1 CBL Anxiety Disorders  CBL Seminars: Anxiety Disorders  3 rd Year Medical Students

2 CBL Seminars: Anxiety/School Refusal  Addo Boafo  M. B., CH.B. (Legon, Ghana)  FRCPC (Ottawa)  MBA (Leicester, U.K.)  Inpatient Psychiatry 6E CHEO  Assistant Prof. (U. of O. Dept. of Psychiatry)

3 CBL Seminars: Anxiety/School Refusal  Caution: Not an extensive review of: 1. Childhood Anxiety Disorders 2. School Refusal 3. Separation Anxiety 4. 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 Disorder 8. Selective Mutism (considered by some as a variant of social anxiety disorder) 9. Agoraphobia 10. Other Specified Anxiety Disorder 11. Unspecified Anxiety Disorder

8 Childhood Anxiety Disorders No longer considered as Anxiety Disorders in DSM 5: 1. PTSD 2. Acute Stress Disorder 3. Adjustment Disorder with Anxiety/Anxious Mood 4. OCD 5. The is no longer Anxiety Disorder NOS (replaced with Other Specified Anxiety Disorder, and Unspecified Anxiety Disorder)

9 Childhood Anxiety Disorders 1. Developmentally inappropriate 2. Duration (prolonged/recurrent) 3. Distress factor 4. Impaired functioning 5. 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 Underachievement a. Learning disabilities b. Language disorders c. Developmental delay

12 Causes/Sources of School Refusal 5. Autism Spectrum Disorder 6. Stressors

13 Signs and symptoms of Sep. Anxiety Disorder 1. Distress on Separation (actual/anticipated) 2. Death/Illness 3. Lost/Kidnapped 4. Cling/Shadow (fear of being alone) 5. Sleep times (onset) 6. Nightmares 7. 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 weeks 2. 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 avoidance Failure 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 Model 6. 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 Disorder 10. 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. Psychoeducation 2. Physiologic management 3. Cognitive Restructuring

32 Treatment: Biopsychosocial Model  CBT 4. Problem solving skills 5. Exposure 6. Relapse prevention

33 Treatment: Biopsychosocial Model School Interventions May involve: 1. Addressing bullying, teasing, violence, abuse 2. Appropriate remediation and placement. 3. School psychoeducation 4. Others

34 Treatment: Biopsychosocial Model Psychotropics Remember: 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-on 1. 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 Model Treatment by Disorder Type  Social anxiety disorder  Panic Disorder  GAD  Agoraphobia  Separation Anxiety Disorder Consider: 1. CBT 2. Antidepressant 3. Possible addition of benzodiazepine, atypical antipsychotics.

38 Treatment: Biopsychosocial Model NB: “Anxiety Triad” : GAD, Separation A. Disorder, & Social Anxiety Disorder Specific Phobia Consider: 1. CBT 2. PRN benzodiazepine

39 Treatment: Biopsychosocial Model Selective 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) Disorders 3. Prescription Medication abuse 4. Suicide ideation/attempts 5. Impaired school/work/relationship performance 6. Isolation/Social withdrawal 7. Sleep disorders 8. 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: 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: ,