1

ANXIETY DISORDERS IN
CHILDREN & ADULTS
THEORY
DIAGNOSIS
TREATMENT
2
Pharmacological response to
medications designed to treat anxiety
disorders is NOT evidence or proof of
ETIOLOGY.
3
FEAR VERSUS ANXIETY
FEAR

OBJECTIVE

PAST EXPERIENCE
WITH STRESSOR

KNOWN PROBALITY
OF HARM
ANXIETY

SUBJECTIVE

FUTURE ORIENTED


UNKNOWN HOW ONE
WILL BE HARMED
4
NORMAL VERSUS ABNORMAL ANXIETY
LEVEL OF ANXIETY

SOME LEVEL OF ANXIETY NECESSARY TO
CREATE MOTIVATION

HIGH LEVELS OF ANXIETY RESULT IN
INTERFERENCE WITH PERFORMANCE

HIGH LEVELS OF ANXIETY RESULT IN HIGH
LEVEL OF COGNITIVE & PHYSIOLOGICAL
AROUSAL






5
NORMAL VERSUS ABNORMAL ANXIETY
JUSTIFICATION

ANY LEVEL OF ANXIETY WOULD BE
CONSIDERED ABNORMAL IF NO
RATIONAL JUSTIFICATION EXISTS FOR
THE SITUATION TO TRIGGER ANXIETY.

PERCEPTION OF THE EVENT AS
THREATENING TO THE INDIVIDUALS
SAFETY IS KEY.
6
NORMAL VERSUS ABNORMAL ANXIETY
INTERFERENCE IN FUNCTIONING

ANXIETY IS ABNORMAL IF IT CAUSES ANY
IMPAIRMENT IN FUNCTIONING IN ANY LIFE
AREA:
(1) SOCIAL
(2) OCCUPATIONAL
(3) PHYSICAL
(4) RECREATIONAL

7
PREVALENCE & INCIDENCE
OF ANXIETY DISORDERS
MOST COMMON MENTAL DISORDER IN UNITED
STATES.

15%-TO-17% OF ADULT POPULATION SUFFER
FROM 1 OR MORE ANXIETY DISORDERS.
23 MILLION HAVE ONE FORM OF THE 6 ANXIETY
DISORDERS

5% -TO-10% OF SCHOOL AGE CHILDREN HAVE
AN ANXIETY RELATED DISORDER.
8
PREVALENCE & INCIDENCE
OF ANXIETY DISORDERS
26% SUFFER FROM 2 OR MORE
INDEPENDENT ANXIETY DISORDERS.

19% SUFFER FROM ONLY 1 ANXIETY
DISORDER.

55% SUFFERED FROM MULTIPLE
DISORDERS, ONE OF WHICH HELPED
CAUSE THE OTHERS.
9
ANXIETY DISORDERS
Generalized Anxiety
Disorder

Panic Disorder

Obsessive-Compulsive
Disorder

Post-Traumatic Stress
Disorder

Specific Phobia

Social Phobia

Agoraphobia w/o
Panic Attacks

Agoraphobia with
Panic Attacks
10
ANXIETY DISORDERS
Anxiety Disorder Due to a General
Medical Condition

Substance Induced Anxiety Disorder

Anxiety Disorder NOS

Mixed Anxiety-Depressive Disorder
11
GENERALIZED ANXIETY DISORDER

THEORY
DIAGNOSIS
TREATMENT
12
Epidemiology of Generalized Anxiety Disorder
One-year prevalence rate is approximately 3%
of adults.

Life-time prevalence rate approximately 5%.

25% of GAD patients present with comorbid
condition:
Depression
Panic Disorder
Substance abuse
Hypochondriasis
Personality Disorder

13
Epidemiology of Generalized Anxiety Disorder
Half of pts presenting for treatment report onset in
childhood or adolescence.

In children, Over-anxious Disorder of Childhood

Gender ratio is approximately 2-to-1 females

Course of disorder is CHRONIC but fluctuates &
often WORSENS during periods of stress.

familial association
14
PSYCHOANALYTIC EXPLANATION OF GAD & PANIC
DISORDERS
INTERNAL CONFLICTS ARE SOURCE OF
BOTH DISORDERS

UNCONSCIOUS IMPULSES THREATEN
EXPRESSION

ANXIETY IS ALARM THAT DEFENSES ARE
ABOUT TO BREAK DOWN.

SINCE NO FOCUS FOR DEFENSE, ANXIETY
SYMPTOMS ARE RESULT OF
UNSUCCESSFUL DEFENSE AGAINST
ANXIETY PROVOKING IMPULSES.
15
COGNITIVE THEORY OF GENERALIZED ANXIETY
DISORDER
Beck (1991) - People with GAD constantly make
unrealistic assumptions that they are in imminent
danger:

a. ANY STRANGE SITUATION SHOULD BE
REGARDED AS DANGEROUS.

b. A SITUATION OR PERSON IS UNSAFE UNTIL
PROVEN SAFE.

c. IT IS ALWAYS BEST TO ASSUME THE WORST.

d. MY SECURITY & SAFETY DEPEND ON
ANTICIPATING & PREPARING MYSELF AT ALL TIMES
FOR ANY POSSIBLE DANGER.




16
GABA & ANXIETY DISORDERS
Research points to a problem in feedback
system can cause fear or anxiety to go
unchecked (Lloyd, 1992).

GABA is released to exert inhibitory action on
excitatory activity of neurons.

A second site on GABA
A
receptor binds with
benzodiazepines.

People with GAD may have ongoing problems
with anxiety feedback system.


17
GABA
A
Receptor with Binding Sites
18
GABA & GENERALIZED ANXIETY DISORDER
19
GABA & ANXIETY DISORDERS
Brain supplies of GABA too low.

May have too few GABA
A
receptors.

GABA
A
receptors do not readily bind
neurotransmitter.

Brain may be releasing an excess of other
chemicals reducing GABA activity at receptor
sites.

20
ASSESSMENT OF GAD
SCREENING TOOLS
Anxiety Screening Questionnaire (15 items)
Primary Care Evaluation of Mental Disorders
(PRIME-MD)
Hamilton Anxiety & Depression Scale
Beck Anxiety Scale
Center for Epidemiological Studies Depression Scale
(CESD)
Hospital Anxiety & Depression Scale
21
ASSESSMENT OF GAD
INTERVIEWING QUESTIONS:

During the past 4 weeks, have you been bothered by
feeling worried, tense, or anxious MOST of the
time?

Are you frequently tense, irritable, and have trouble
sleeping?

If either answered YES, further investigation is
warranted.
22
TREATMENT OF GAD IN PRIMARY CARE
Treatment options Most efficaciously treated by
combination of CBT & Pharmacotherapy

Cognitive-Behavior Therapy
Reframing
Cognitive Restructuring
Identifying Anxiety Triggers
Cognitive Rehearsal
Stress-Inoculation

23
TREATMENT OF GAD IN PRIMARY CARE
Pharmacotherapy

SSRI
Paroxetine (Paxil) only FDA for GAD
Fluoxetine (Prozac)
Sertraline (Zoloft)
Citalopram (Celexa)
Fluvoxamine (Luvox)

See Table 11.4 in Kaplan & Saddock for dosing.


24
TREATMENT OF GAD IN PRIMARY CARE
Pharmacotherapy SSRI

Advantages of SSRI

Few side effects
Not addictive/dependence liability
Treats co-morbid depression
Once daily dosing
Low sedation effect




25
TREATMENT OF GAD IN PRIMARY CARE
Pharmacotherapy SSRI

Disadvantages of SSRI

Patient does not experience symptom attentuation
with single dose

Several weeks to full therapeutic effects

Gastrointestinal and Sexual side-effects common



26
TREATMENT OF GAD IN PRIMARY CARE
SNRI Venaflaxine Hydrochloride (Effexor XR)

Approved by FDA

Reduces symptoms of:
anxious mood
excessive motor tension
restlessness
insomnia
irritablility
poor concentration




27
TREATMENT OF GAD IN PRIMARY CARE
SNRI Venaflaxine Hydrochloride (Effexor XR)

Common side effects:
asthenia somnolence
nausea tremor
constipation abnormal ejaculation/orgasm

Patient does not experience symptom attentuation
with single dose

Several weeks to full therapeutic effects.




28
TREATMENT OF GAD IN PRIMARY CARE
Nonbenzodiazepine agent Buspirone (Buspar)

It is a 5-HT
1A
receptor partial agonist.

More effective in reducing cognitive symptoms than
somatic symptoms of GAD.

Less addictive potential associated with its use.

Indicated if patient has co-morbid substance use
disorder.






29
TREATMENT OF GAD IN PRIMARY CARE
Nonbenzodiazepine agent Buspirone (Buspar)

Patients who had used benzodiazepines are not
likely to respond to Buspirone.

Lack or absence of anxiolytic effects (muscle
relaxation & sense of well being) may be contributing
factor.

Effects take 2-to-3 weeks to become evident.






30
Treatment of GAD
BENZODIAZEPINES
ALPRAZOLAM XANAX
CHLORDIAZEPOXIDE LIBRIUM
CLONAZEPAM KLONOPIN
CLORAZAPATE TRANZENE
DIAZEPAM VALIUM
LORAZEPAM ATIVAN
OXAZEPAM SERAX
PRAZEPAM CENTREX

31
TREATMENT OF GAD IN PRIMARY CARE
Pharmacotherapy Benzodiazepines

Advantages

Therapeutic effect in single dose

Time to full therapeutic effect in days.

Anxiolytic effect of medications helps reduce somatic
symptoms of GAD



32
TREATMENT OF GAD IN PRIMARY CARE
Pharmacotherapy Benzodiazepines

Disddvantages

Impaired alertness & motor performance
High addictive or dependence liability
Does not treat co-morbid depression
Requires several doses per day
High sedation effect
Memory impairment



33
TREATMENT OF GAD IN PRIMARY CARE
Pharmacotherapy Benzodiazepines

Most common clinical mistake is to routinely continue
treatment INDEFINITELY.

Treatment may be minimum of 6 months-to-1 year
so consideration of other medications who seem
warranted.

Start treatment with benzodiazepine & buspirone &
taper off benzodiazepine when buspirone reaches
maximum effect ( 2-to-3 weeks).


34
PANIC DISORDER

THEORY
DIAGNOSIS
TREATMENT
35
Epidemiology of Panic Disorder
One-year prevalence rate is approximately
1.5% of adults.

Life-time prevalence rate approximately 3.5%.

Panic Disorder patients present with comorbid
condition:
Major Depression GAD
Substance abuse OCD
Specific Phobia Agoraphobia
Social Phobia PTSD

36
Epidemiology of Generalized Anxiety Disorder
Typically onset between adolescence & mid-30s.

Females 3X more likely to have PD with agoraphobia
Males 2X more likely to have PD W/O agoraphobia

Course of disorder is CHRONIC but waxing & waning.

1
st
degree biological relatives are 8 times more likely
to develop panic disorder.

If onset before age 20, 20 times more likely
37
NOREPINEPHERINE & PANIC DISORDERS
Research has focused upon abnormal
norepinepherine activity in locus coeruleus.

Function of locus coeruleus is to send
messages to amygdala (limbic system) that is
known to trigger emotional reactions.

Studies have indicated that locus coerulus is
involved in activating certain behaviors such
as increased vigilance.


38
NOREPINEPHERINE & PANIC DISORDERS
Over-activity in nordrenergic system has been
linked to panic disorder.

Stimulation of locus coerulus in both animal &
human studies trigger panic symptoms.

Noradrenergic over-activity may be result of
fewer GABA
A
receptor sites and lower GABA
levels in occipital cortex of panic disorder
patients. (Malizia, 1998; Goddard, 2001)

39
NOREPINEPHERINE & PANIC DISORDERS
Anti-depressant drugs act to restore
appropriate norepinepherine activity in locus
coerulus & helps to reduce symptoms of
disorder.

80% will experience some significant
improvement.

40% reach full recovery or improve markedly;
20% show NO improvement.

40
LOCUS COERULUS & PANIC DISORDER
41
ASSESSMENT OF PANIC DISORDER
SCREENING TOOLS
Anxiety Screening Questionnaire (15 items)
Primary Care Evaluation of Mental Disorders
(PRIME-MD)
Hamilton Anxiety & Depression Scale
Beck Anxiety Scale
Center for Epidemiological Studies Depression Scale
(CESD)
Hospital Anxiety & Depression Scale
Panic Disorder Self-Test (www.adaa.org)
42
TREATMENT OF GAD IN PRIMARY CARE
Cognitive Behavior Therapy

Stress-inoculation
Reframing
Cognitive Restructuring
Relaxation Training
Progressive Relaxation
Deep breathing
Positive Imagery



43
TREATMENT OF GAD IN PRIMARY CARE
Pharmacotherapy

SSRI
Paroxetine (Paxil) only FDA for GAD
Fluoxetine (Prozac)
Sertraline (Zoloft)
Citalopram (Celexa)
Fluvoxamine (Luvox)

See Table 11.4 in Kaplan & Saddock for dosing.


44
Pharmacotherapy of Panic Disorder
SSRI
Paroxetine (Paxil)


Fluvoxamine (Luvox)


Sertraline (Zoloft)

DOSE
5-10 mg start
20-60 mg maintenance

12.5 mg start
50-125 mg maintenance

12.5 25 mg start
100-150 mg maintenance
45
Pharmacotherapy of Panic Disorder
TCA
Clomipramine
(Anafrinil)


Imipramine (Tofranil)




DOSE
5-12.5 mg start
50-125 mg maintenance


10-12.5 mg start
150-500 mg maintenance


46
Pharmacotherapy of Panic Disorder
Benzodiazepines
Alprazolam (Xanax)


Clonazepine (Klonopin)


Lorazepam (Ativan)




DOSE
.25-.5 mg tid start
.5-2 mg tid maintenance

.25 -.5 mg bid start
.5-2 mg bid maintenance

25 -.5 mg bid start
.5-2 mg bid maintenance
47
OBESSIVE-COMPULSIVE DISORDER

THEORY
DIAGNOSIS
TREATMENT
48
OBSESSIONS
INTRUSIVE THOUGHTS WISHES THAT
CANNOT BE IGNORED, DISMISSED OR
RESISTED.

COMMON THEMES:
CONTAMINATION ORDERLINESS
VIOLENCE SEXUALITY
49
COMPULSIONS COMMON FORMS
These behaviors or mental acts either are
not connected in a realistic way with
what they are designed to neutralize or
prevent or are clearly excessive:

cleaning hand washing
ordering checking
touching counting
repeating words silently praying

50
COMMOM OBSESSIONS & COMPULSIONS
51
52
ASSESSMENT OF OCD
SCREENING TOOLS
Yale-Brown Obsessive Compulsive Scale (YBOCS)
Anxiety Screening Questionnaire (15 items)
Primary Care Evaluation of Mental Disorders
(PRIME-MD)
Hamilton Anxiety & Depression Scale
Beck Anxiety Scale
Center for Epidemiological Studies Depression Scale
(CESD)
Hospital Anxiety & Depression Scale

53
PSYCHOANALYTIC VIEW OF
OBSESSIVE-COMPULSIVE DISORDER
OCD develops when child comes to fear his own ID
impulses & uses EDMs as counter-thoughts or
compulsive actions to lessen resulting anxiety.
Three ego-defenses are common in OCD:

isolation- isolates & disowns undesirable/unwanted
thoughts & experiences them as intrusions

undoing - Individual engages in acts that implicitly
cancel out their undesirable impulses.

reaction formation - Takes on lifestyle that directly
opposes their unacceptable impulses.




54
SEROTONIN & OBSESSIVE-CONPULSIVE DISORDER
Serotonin plays role in operation of orbital
region & caudate nuclei.

Low levels of serotonin disrupts functioning.

Research has found:
Reducing serotonin activity results in an
increase of OCD symptoms.
Low levels of serotonin are related to high levels
of OCD symptoms.
Increasing serotonin levels reduces symptoms.


55
56
57
58
PHOBIC DISORDERS:
SPECIFIC PHOBIA
SOCIAL PHOBIA
AGORAPHOBIA

THEORY
DIAGNOSIS
TREATMENT
59
SPECIFIC PHOBIA
A. Marked & persistent fear that is excessive or
unreasonable, cued by presence or
anticipation of a specific object or situation.

B. Exposure to phobic stimulus almost
invariably provokes an immediate anxiety
response

C. Person recognizes that the fear is excessive
or unreasonable.

60
SPECIFIC PHOBIA
.





Animal Type

Natural Environment Type (heights,
storms, water)

Blood Injection Injury type

Situational Type (airplanes, elevators,
enclosed places)


61
AGE OF ONSET OF PHOBIA
62
PSYCHOANALYTIC MODEL OF PHOBIC
REACTIONS
PHOBIAS ARE EXPRESSIONS WISHES/
FEARS WHICH ARE UNACCEPTABLE TO
EGO

UNCONSCIOUS CONFLICT IS DISPLACED
TO EXTERNAL OBJECT OR SITUATION

PHOBIA IS LESS THREATENING TO
PERSON THAN THE RECOGNITION OF THE
UNCONSCIOUS IMPULSE
63
PSYCHOANALYTIC MODEL OF PHOBIC
REACTIONS
PHOBIA IS ONLY A SYMPTOM OF UNDERLYING
CONFLICT.

LEVEL OF PHOBIC FEAR INDICATES
STRENGTH OF CONFLICT.

ONCE UNDERLYING CONFLICT IS DISPLACED
ONTO EXTERNAL SITUATION, CONFLICT
CAN BE CONTROLLED SIMPLY THROUGH
AVOIDANCE.


64
SOCIAL PHOBIA
LIFE TIME PREVALENCE 11% MALES
15% FEMALES
ONSET IN ADOLESCENCE

COMMON IN FAMILIES WHO :
USE SHAME AS CONTROL TECHNIQUE

STRESS IMPORTANCE OF OPINIONS OF
OTHERS
65
SOCIAL PHOBIA
CAN BE DIVIDED INTO 3 TYPES:

PERFORMANCE

LIMITED INTERACTIONAL

GENERALIZED
66
SOCIAL PHOBIA
PERFORMANCE

EXCESSIVE ANXIETY OVER ACTIVITIES
PLAYING INSTRUMENT
SPEAKING IN PUBLIC
EATING IN RESTAURANT
USING PUBLIC RESTROOM
67
LIMITED INTERACTIONAL

EXCESSIVE FEAR ONLY IN SPECIFIC
SOCIAL or VOCATIONAL SITUATIONS

ex. INTERACTING WITH AUTHORITY FIGURE
GOING OUT ON A DATE
SOCIAL PHOBIA
68
SOCIAL PHOBIA
GENERALIZED

EXTREME ANXIETY DISPLAYED IN
MOST SOCIAL SITUATIONS

MAY RESULT IN AVOIDANCE OF ALL
SOCIAL INTERACTION
69
AGORAPHOBIA
Anxiety about being in places or situations from
which:

escape might be difficult (or embarrassing)
OR
help may not be available in the event of having
an unexpected or situationally predisposed
Panic Attack or panic like symptoms.




70
AGORAPHOBIA
Agoraphobic fears typically involve characteristic
clusters of situations that include:

being outside home alone

being in a crowd or standing in line

being on bridge

traveling in bus, train, or automobile.
71
AGORAPHOBIA
LIFE TIME PREVALENCE 5% OF
MALES & 12% OF FEMALES.

DEVELOPS IN 50% OF PANIC
DISORDERS

FAMILY & TWIN STUDIES INDICATE 3-
TO-5 TIMES GREATER RISK FOR
PANIC DISORDER/ AGORAPHOBIA
THAN IN GENERAL POPULATION
72
AFFECTS 1/2 OF VICTIMS BY AGE 8

SOME MAY HAVE BEEN BORN WITH
TENDENCY TOWARDS EXTREME SHYNESS

1-IN-5 DEMONSTRATED CONSISTENT FEAR &
DISTRESS IN NOVEL SITUATIONS AS EARLY
AS 8 WEEKS OF AGE.

DISORDER THOUGHT TO OCCUR MORE
OFTEN IN FEMALES BUT MALES
POST-TRAUMATIC STRESS DISORDER IN
CHILDREN
73
POST-TRAUMATIC STRESS DISORDER
MUST EXPERIENCE TRAUMATIC EVENT

INTRUSIVE RE-EXPERIENCING OF
EVENT
(DREAMS, FLASHBACKS, IMAGES,
THOUHGTS, RECOLLECTIONS)

AVOIDANCE OF STIMULI ASSOCIATED
WITH EVENT

74
PERCENTAGE OF INDIVIDUALS DX WITH PTSD
75
POST-TRAUMATIC STRESS DISORDER
NUMBING OF RESPONSIVENESS TO THE
WORLD & RESTRICTION OF AFFECT

SYMPTOMS OF INCREASED AROUSAL
EXAGGERATED STARTLE REACTION
HYPERVIGILANCE
DIFFICULTY CONCENTRATING
INSOMINIA
NIGHTMARES

76
POST-TRAUMATIC STRESS DISORDER
PTSD can occur at any age even childhood.

In young people, the response may be
expressed as agitated behavior.

Most young people with PTSD avoid things
that remind them of what happened.

Many have physical symptoms as well, such as
startling easily.


77
PTSD IN CHILDREN
ETIOLOGICAL FACTORS
Certain PREMORBID personality profiles
& attitudes are more likely to develop
PTSD.

Pre-morbid personality or psychological
difficulties are associated with increase
risk & more severe ASD & PTSD
symptoms:
poor interpersonal relationships
external locus of control
pessimism


78
ETIOLOGICAL FACTORS
NATURE & QUALITY OF SOCIAL SUPPORT
SYSTEM

Person with a strong social support system after a
traumatic event less likely to develop an extended
disorder.

If feels loved/accepted/valued, will be more likely
to recover.

Societal support for appears to be important in
lessening severity & duration of symptoms.
79
ETIOLOGICAL FACTORS
DEGREE OF EXPOSURE & SUBJECTIVE
EXPERIENCE OF THREAT PLAYS CRITICAL
ROLE IN DEVELOPMENT OF PTSD & ASD.

DURATION OF THE EXPOSURE

LEVEL OF INVOLVEMENT

SALIENCE

DEGREE OF HARM EXPERIENCED
80
MIXED ANXIETY & DEPRESSION
SHARED SYMPTOMS

EXCESSIVE WORRY

MOTOR TENSION

EASY FATIGABILITY

DIFFICULTY CONCENTRATING

SOMATIC COMPLAINTS
81
MIXED ANXIETY & DEPRESSION
ANXIETY

SHORTNESS OF
BREATH
CHEST PAIN
NERVOUSNESS
IRRITABILITY
BURNING STOMACH
DIFFICULTY FALLING
ASLEEP
DEPRESSION

DEPRESSED MOOD
ANHEDONIA
WEIGHT LOSS OR
GAIN
SUICIDAL
THOUGHTS
EARLY MORNING
AWAKENING
82
MEDICATIONS THAT REDUCE ANXIETY
AZASPIRONES
BUSPRIONE BUSPAR

BETA BLOCKERS
PROPANOLOL INDERAL
ATENOLOL TENORMIN
83
ANXIETY DISORDERS IN PRIMARY CARE:
GUIDELINES
RECOGNIZE ANXIETY AS CAUSE OF PTs
PRESENTING SYMPTOMS:

LOOK FOR MULTIPLE SYMPTOMS

GREATER # OF PHYSICAL SYMPTOMS, MORE
LIKELY ANXIETY D/O PRESENT

GREATER # OF SOMATOFORM SYMPTOMS,
MORE LIKELY ANXIETY D/O PRESENT
84
ANXIETY DISORDERS IN PRIMARY CARE: GUIDELINES
RECOGNIZE ONLY A SMALL NUMBER OF PTS WITH
ANXIETY SYMPTOMS ARE A RESULT OF GENERAL
MEDICAL CONDITION.

LOOK FOR ANXIETY IN OTHER LIFE AREAS

LOOK FOR TRIGGERS OR AVOIDANCE
(TIME/PLACE/SETTING/CONTEXT)

LOOK FOR MULTIPLE SYMPTOMS

LOOK FOR SOMATOFORM SYMPTOMS

EPIDEMIOLOGY = APPEARS IN YOUNGER PT-->
LESS RISK FOR ILLNESS

85
ANXIETY DISORDERS IN PRIMARY CARE:
GUIDELINES
A SIGNIFICANT # OF PTS WITH ANXIETY SYMPTOMS
HAVE CO-MORBID PSYCHIATRIC DISORDERS.

26% SUFFER FROM 2 OR MORE INDEPENDENT
ANXIETY DISORDERS. 55% SUFFERED FROM
MULTIPLE DISORDERS, ONE OF WHICH HELPED
CAUSE THE OTHERS.

MAJOR DEPRESSION

SUBSTANCE DEPENDENCE/ ABUSE