1

CBL Anxiety Disorders

CBL Seminars: Anxiety Disorders

3rd Year Medical Students

2

CBL Seminars: Anxiety/School Refusal

Addo BoafoM. B., CH.B. (Legon, Ghana)FRCPC (Ottawa)MBA (Leicester, U.K.)Inpatient Psychiatry 6E CHEOAssistant Prof. (U. of O. Dept. of

Psychiatry)

3

CBL Seminars: Anxiety/School Refusal

Caution:Not an extensive review of:1. Childhood Anxiety Disorders2. School Refusal3. Separation Anxiety4. Slides

4

CBL – Anxiety Disorders of Childhood

1. What are the main childhood anxiety disorders?2. What are the main causes of school refusal?3. What are the clinical features of separation anxiety?4. What are the predisposing factors in childhood anxiety disorders?5. Describe possible characteristics of parents of anxious children.6. Discuss the treatment of childhood anxiety disorders using a

biopsychosocial model.7. Describe long-term complications of childhood anxiety disorders.

5

Main Childhood Anxiety Disorders (DSM 5)

1. Anxiety Disorder Due to a General Medical Condition.

2. Substance/Medication Induced Anxiety Disorder

3. Panic Disorder

6

Childhood Anxiety Disorders

4. Separation Anxiety Disorder (75% have school refusal)

5. Social Anxiety Disorder (Social Phobia)6. Specific Phobia

7

Childhood Anxiety Disorders

7. Generalized Anxiety Disorder8. Selective Mutism (considered by some as a variant of social anxiety

disorder)

9. Agoraphobia10. Other Specified Anxiety Disorder11. Unspecified Anxiety Disorder

8

Childhood Anxiety Disorders

No longer considered as Anxiety Disorders in DSM 5:

1. PTSD2. Acute Stress Disorder3. Adjustment Disorder with Anxiety/Anxious Mood4. OCD5. The is no longer Anxiety Disorder NOS (replaced with Other

Specified Anxiety Disorder, and Unspecified Anxiety Disorder)

9

Childhood Anxiety Disorders

1. Developmentally inappropriate2. Duration (prolonged/recurrent)3. Distress factor4. Impaired functioning5. Number of symptoms(Deciding what is an anxiety disorder)

10

Causes/Sources of School Refusal

1. Separation Anxiety Disorder (50%-80%)2. Psychiatric Disorders a. Mood Disorders:

Major depressive Disorder Bipolar disorder

b. Other Anxiety Disorders c. Overt Psychotic Disorder. d. Other psychiatric conditions

11

Causes/Sources of School Refusal

3. Realistic fear of bodily harm in a dangerous school setting (bullying, gangs)

4. Academic Underachievementa. Learning disabilitiesb. Language disordersc. Developmental delay

12

Causes/Sources of School Refusal

5. Autism Spectrum Disorder6. Stressors

13

Signs and symptoms of Sep. Anxiety Disorder

1. Distress on Separation (actual/anticipated)2. Death/Illness3. Lost/Kidnapped4. Cling/Shadow (fear of being alone)5. Sleep times (onset)6. Nightmares7. Physical symptoms on separation (actual/anticipated)

14

Features: Sep. Anxiety Disorder

1. Recurrent excessive distress when separated from home or major attachment figures occurs or is anticipated.

15

Features: Sep. Anxiety Disorder

2. Persistent and excessive worry about losing, or about possible harm befalling, attachment figures

16

Features: Sep. Anxiety Disorder

3. Persistent and excessive worry that an untoward event will lead to separation from a major attachment figure (e.g., getting lost or being kidnapped)

17

Features: Sep. Anxiety Disorder

4. Persistent reluctance or refusal to go to school or elsewhere because of fear of separation

18

Features: Sep. Anxiety Disorder

5. Persistently and excessively fearful or reluctant to be alone or without attachment figures at home or without significant adults in other settings

19

Features: Sep. Anxiety Disorder

6. Persistent reluctance or refusal to go to sleep without being near a major attachment figure or to sleep away from home

20

Features: Sep. Anxiety Disorder

7. Repeated nightmares involving theme of separation

21

Features: Sep. Anxiety Disorder

Repeated complaints of physical symptoms (such as headaches, stomachaches, nausea, vomiting, palpitations, dizziness, faintness) when separation from major attachment figures occurs or is anticipated.

22

Features: Sep. Anxiety Disorder

Other:1. Duration: 4 or more weeks2. Significant Distress or Impairment

(social/academic/occupational, other)3. Does not occur exclusively during the course of a

pervasive dev. disorder, psychosis; and not better accounted for by panic disorder with agoraphobia

4. DSM 5: Can begin after age 18 years. No early/late onset.

23

Predisposing Factors: Childhood Anxiety Disorders (Clinical)1. Early temperamental traits of passivity and

shyness between ages 3-5 years.2. Temperamental trait called Behavioural

Inhibition: a tendency to show fear and withdrawal in new, unfamiliar situations

24

Predisposing Factors: Childhood Anxiety Disorders (Clinical)3. Insecure mother-child attachment in infancy,

toddlerhood and early childhood.4. How parents, in general, respond to potentially

fear-producing situations. This is communicated to the child in explicit or implicit ways.

25

Predisposing Factors: Childhood Anxiety Disorders (Clinical)5. One or both parents may have intense concerns

about the hazards of separation. This is communicated to the child directly or indirectly.

6. Family accommodation: facilitating avoidanceFailure to accommodate: child becomes angry or abusive and anxiety symptoms worsen.

26

Predisposing Factors: Childhood Anxiety Disorders (Clinical)7. Role reversal in the family, with the

child/adolescent carrying too much power and the parents, for example, unable to influence a return to school.

8. Abuse and Trauma

27

Treatment of Childhood Anxiety Disorders (biopsychosocial model)1. Take a good history, with collateral information.2. Do a good mental status examination.3. Physical Examination and Relevant laboratory Studies.4. Get input from interdisciplinary team: (psychology, social work,

occupational therapy, school teacher, frontline (nurses, child and youth counsellors).

5. Assess Suicide Risk

28

Treatment: Biopsychosocial Model6. Rule out Substance/Medication induced anxiety disorder.7. Rule out anxiety disorder due to a medical condition.8. Determine if there is more than one anxiety disorder. Anxiety triad (GAD,

Social Anxiety Disorder, and Separation Anxiety Disorder), Panic Features.

9. Determine if there is a co-morbid Psychiatric Disorder10. Determine if there is a co-morbid Medical Disorder.

Treatment of Anxiety Disorders

In general: 1. School interventions 2. Talk therapy 3. Possibly a Medication.

29

30

Treatment: Biopsychosocial Model A. Cognitive-Behavioural Therapy (CBT)1. Shortest duration of treatment (mean 6 mo)2. Best outcome: about 50-60% efficacy rate.

3. Training and certification needed.4. Could be in individual/family/group forms

31

Treatment: Biopsychosocial Model CBT’s six essential components:1. Psychoeducation2. Physiologic management3. Cognitive Restructuring

32

Treatment: Biopsychosocial ModelCBT4. Problem solving skills5. Exposure6. Relapse prevention

33

Treatment: Biopsychosocial Model

School InterventionsMay involve:1.Addressing bullying, teasing, violence, abuse2.Appropriate remediation and placement.3.School psychoeducation4.Others

34

Treatment: Biopsychosocial Model

PsychotropicsRemember:1.Psychoeducation of family and child/adolescent is very important.2.Informed consent is needed.3.Need monitoring strategies for outcome and side effects.

35

Treatment: Biopsychosocial Model Reasons to use medications as an add-on1. Level of functional impairment is moderate to

severe and need to prevent further loss.2. Facilitate or hasten positive outcomes of

behavioural interventions.

36

Treatment: Biopsychosocial Model

Psychotropics: 1. SSRIs seem to be the treatment of choice for most

pervasive and impairing anxiety disorders in youth.2. TCAs are a second-line treatment due to side effects

and less overall efficacy.3. Benzodiazepines are less commonly used due to risk of

dependency, better alternatives, disinhibition.4. Atypical antipsychotics may have a role.

37

Treatment: Biopsychosocial ModelTreatment by Disorder TypeSocial anxiety disorderPanic DisorderGADAgoraphobiaSeparation Anxiety DisorderConsider:1.CBT2.Antidepressant3. Possible addition of benzodiazepine, atypical antipsychotics.

38

Treatment: Biopsychosocial Model

NB: “Anxiety Triad” : GAD, Separation A. Disorder, & Social Anxiety DisorderSpecific PhobiaConsider:1.CBT2.PRN benzodiazepine

39

Treatment: Biopsychosocial ModelSelective Mutism:Consider:1. Variety of Cognitive approaches: positive reinforcers, modeling, systematic

desensitization, in vivo exposure, in vivo graded exposure.2. Antidepressants may help.

Clinical Course of Anxiety Disorders in youth:

About half of treated patient were in remission after an average of 6 years.

40

Complications (Anxiety Disorders)1. Development of Mood Disorders (Depression)2. Substance Use (street drugs/alcohol) Disorders3. Prescription Medication abuse4. Suicide ideation/attempts5. Impaired school/work/relationship performance6. Isolation/Social withdrawal7. Sleep disorders8. Physical Health (stomach

cramps/diarrhea/headaches/cardiovascular symptoms)9. Others

41

References

1. Reinblatt, SP & Walkup (2005) Psychopharmacological Treatment of Pediatric Anxiety Disorders. Child Adolesc. Psychiatric Clin N Am, 14: 877-908.

2. Practice Parameters for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders (1997). J. Am. Acad. Child Adoles. Psychiatry, 36; 10 Supplement (69S-83S)

42

References

3. Fremont WP (2003). School Refusal in Children and Adolescents. Am Fam Physician, 68: 1555-60, 1563-4.