Anxiety Disorders

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Chapter 23 Anxiety Disorders

Anxiety, defined as dread or apprehension, is a normal phenomenon. Anxiety by itself is not considered pathologic, is seen across the lifespan, and can be adaptive (e.g., the anxiety one might feel during an automobile crash). Anxiety has both a physiologic component, mediated by the autonomic nervous system, and a cognitive and behavioral component, expressed in worrying and wariness. Anxiety disorders are characterized by pathologic anxiety in which anxiety becomes disabling, interfering with social interactions, development, and achievement of goals or quality of life, and can lead to low self-esteem, social withdrawal, and academic underachievement. Diagnosis of a particular anxiety disorder in a child requires significant interference in the child’s psychosocial and/or academic or occupational functioning, which can occur even with subthreshold symptoms that do not meet criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

Separation anxiety disorder (SAD), childhood-onset social phobia or social anxiety disorder, generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), phobias, post-traumatic stress disorder (PTSD), and panic disorder are all defined by the occurrence of either diffuse or specific anxiety, often related to predictable situations or cues. Anxiety disorders are the most common psychiatric disorders of childhood; they occur in 5-18% of all children and adolescents, prevalence rates comparable to physical disorders such as asthma and diabetes. Anxiety disorders are often comorbid with other psychiatric disorders (including a 2nd anxiety disorder); significant impairment in day-to-day functioning is common. High levels of fear in adolescence are also a significant risk factor for experiencing later episodes of major depression in adulthood. Anxiety and depressive disorder in adolescence predict increased risk of anxiety and depressive symptoms (including suicide attempts) in adulthood, underscoring the need to diagnose and treat these underreported, yet prevalent, conditions early.

Because anxiety is both a normal phenomenon and, when highly activated, strongly associated with impairment, the pediatrician must be able to differentiate normal anxiety from abnormal anxiety across development. Anxiety has an identifiable developmental progression for most children; most infants exhibit stranger wariness or anxiety beginning at 7-9 mo of age. Behavioral inhibition to the unfamiliar (withdrawal or fearfulness to novel stimuli associated with physiologic arousal) is evident in approximately 10-15% of the population at 12 mo of age and is moderately stable. Most children who show behavioral inhibition do not develop impairing levels of anxiety. A family history of anxiety disorders and maternal overinvolvement or enmeshment predicts later clinically significant anxiety in behaviorally inhibited infants. The infant who is excessively clingy and difficult to calm during pediatric visits should be followed for signs of increasing levels of anxiety.

Preschoolers typically have specific fears related to the dark, animals, and imaginary situations, in addition to normative separation anxiety. Preoccupation with orderliness and routines (just right phenomena) often takes on a quality of anxiety for preschool children. Parents’ reassurance is usually sufficient to help the child through this period. Although most school-aged children abandon the imaginary fears of early childhood, some replace them with fears of bodily harm or other worries (Table 23-1). In adolescence, general worrying about school performance and worrying about social competence are common and remit as the teen matures.

Table 23-1 CRITERIA FOR DIAGNOSIS OF SPECIFIC PHOBIA

SPECIFY TYPE:

From Kliegman RM, Marcdante KJ, Jenson HB, et al, editors: Nelson essentials of pediatrics, ed 5, Philadelphia, 2006, Elsevier/Saunders, p 92.

Genetic or temperamental factors contribute more to the development of some anxiety disorders, whereas environmental factors are closely linked to the cause of others. Specifically, behavioral inhibition appears to be a heritable tendency and is linked with social phobia, generalized anxiety, and selective mutism. OCD and other disorders associated with OCD-like behaviors, such as Tourette syndrome and other tic disorders, tend to have high genetic risk as well (Chapter 590.4). Environmental factors, such as parent-infant attachment and exposure to trauma, contribute more to SAD and PTSD. Parental anxiety disorder is associated with an increased risk of anxiety disorder in offspring. Differences in the size of the amygdala and hippocampus are noted in patients with anxiety symptoms.

Separation anxiety disorder (SAD) is one of the most common childhood anxiety disorders with a prevalence of 3.5-5.4%. Approximately 30% of children presenting to an outpatient anxiety disorder clinic have SAD as a primary diagnosis. Separation anxiety is developmentally normal when it begins about 10 mo of age and tapers off by 18 mo. By 3 yr of age, most children can accept the temporary absence of their mother or primary caregiver.

SAD is more common in prepubertal children, with an average age of onset of 7.5 yr. Girls are more commonly affected than boys. SAD is characterized by unrealistic and persistent worries about separation from the home or a major attachment figure. Concerns include possible harm befalling the affected child or his or her primary caregivers, reluctance to go to school or to sleep without being near the parents, persistent avoidance of being alone, nightmares involving themes of separation, numerous somatic symptoms, and complaints of subjective distress. The 1st clinical sign might not appear until 3rd or 4th grade, typically after a holiday or a period where the child has been home because of illness, or when the stability of the family structure has been threatened by illness, divorce, or other psychosocial stressor.

Symptoms vary depending on the child’s age: Children younger than 8 yr often have associated school refusal and excessive fear that harm will come to a parent; children 9-12 yr have excessive distress when separated from a parent; and those 13-16 yr often have school refusal and physical complaints. SAD may be more likely to develop in children with lower levels of psychosocial maturity. Parents are often unable to be assertive in returning the child to school. Mothers of children with SAD often have a history of an anxiety disorder. In these cases, the pediatrician should screen for parental depression or anxiety. Often referral for parental treatment or family therapy is necessary before SAD and concomitant school refusal can be successfully treated.

Comorbidity is common in SAD. In children with comorbid tic disorders and anxiety, SAD is especially associated with tic severity. SAD is a predictor for early onset of panic disorder. Children with SAD compared to those without SAD are 3 times more likely to develop panic disorder in adolescence.

When a child reports recurring acute severe anxiety, antidepressant or anxiolytic medication is often necessary. Controlled studies of tricyclic antidepressants (imipramine) and benzodiazepines (clonazepam) show that these agents are not generally effective. Data support the use of cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) (see Table 19-4). One controlled trial of 488 children, 7-17 yr, which included children with a primary diagnosis of SAD, compared 12 wk of treatment with CBT, the SSRI, sertraline, their combination, and placebo. Nearly 81% of those treated with combination therapy improved, 55% for SSRI alone, 60% for CBT. All treatments were superior to placebo (24% response rate). The SSRI was well tolerated and had few side effects; adverse events, including suicidal and homicidal ideation, did not differ between the SSRI and placebo groups. There was no attempted suicide among the 488 children. CBT was associated with less insomnia, fatigue, sedation, and restlessness than SSRI. Combining SSRI with CBT may be the best approach to achieving a positive response; long-term SSRI treatment can provide additional benefit.

Childhood-onset social phobia (social anxiety disorder) is characterized by excessive anxiety in social settings (including the presence of unfamiliar peers, or unfamiliar adults) or performance situations, leading to social isolation (Table 23-2) and is associated with social scrutiny and fear of doing something embarrassing. Fear of social settings can also occur in other disorders, such as GAD. Avoidance or escape from the situation usually dissipates anxiety in social phobia (SP), unlike GAD, where worry persists. Children and adolescents with SP often maintain the desire for involvement with family and familiar peers. When severe, the anxiety can manifest as a panic attack.

Table 23-2 CRITERIA FOR DIAGNOSIS OF SOCIAL PHOBIA

SPECIFY IF

Generalized: if the fears include most social situations (e.g., initiating or maintaining conversations, participating in small groups, dating, speaking to authority figures, attending parties). Note: Also consider the additional diagnosis of avoidant personality disorder

From Kliegman RM, Marcdante KJ, Jenson HB, et al, editors: Nelson essentials of pediatrics, ed 5, Philadelphia, 2006, Elsevier/Saunders, p 93.

SP is associated with a decreased quality of life, with 38% of SP patients not graduating from high school. SP is associated with increased likelihood of having failed at least one grade. Its onset is typically during or before adolescence and is more common in girls. A family history of SP or extreme shyness is common. About 70-80% of patients with SP have at least one comorbid psychiatric disorder.

Social effectiveness therapy for children (SET-C), alone or with SSRIs, is considered the treatment of choice for SP (see Table 19-4

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