|
| ||
| ||
|
Anxiety Disorders | ||
|
Anxiety is a subjective sense of worry, apprehension, fear, and distress that can range from a simple Adjustment Disorder to more debilitating disorders, such as Panic Disorder and Posttraumatic Stress Disorder. Anxiety Disorders can affect a child’s thinking, decision-making skills, and perception of the environment, learning and concentration.
Anxiety is a normal part of development. Most toddlers become fearful when separated from their mother, especially in unfamiliar surroundings. Fears of the dark, monsters, bugs, and spiders are common in 3- to 4-yr-olds. This should not be viewed as evidence of a disorder. However, if manifestations of anxiety become so exaggerated that they greatly impair functioning or cause severe distress, an anxiety disorder should be considered.
| ||
|
Adjustment Disorder | ||
|
An adjustment disorder is a stress-related reaction to a difficult situation that lasts longer than expected or is more excessive than expected.
People normally feel upset or anxious for some degree of time when they develop an illness, get divorced, leave home to go to school, are fired from a job, relocate to a new home, or experience other life-changing situations. However, when a person is struggling with an adjustment disorder, the severity or length of the reaction has gone beyond what’s considered typical given the person’s age, culture, and history.
Adjustment disorder with depressed mood: A person with an adjustment disorder with depressed mood may have mostly a depressed mood, feelings of hopelessness, and crying spells.
There are five major adjustment disorders:
Diagnosis Criteria An adjustment disorder will begin within three months of experiencing a stressful situation and will usually disappear after six months. However, if the stressful situation is ongoing, such as a chronic illness, a difficult divorce, or continuing financial problems, the disorder might last for as long as the situation remains unchanged. It is important not to overlook a physical illness that might mimic or contribute to an adjustment disorder.
Reference Daniel L. Araoz & Marie A. Carrese (1996). Solution-oriented brief therapy for Adjustment disorders: A guide for providers under managed care. New York: Brunner/Mazel, Inc.
| ||
|
Social Anxiety Disorder Social Phobia; Shyness | ||
|
Social anxiety disorder (SAD) is characterized by a strong and persistent fear of social or performance situations in which a person might feel embarrassment or humiliation. These social situations can be so intense that the person gets anxious just thinking about them or goes to great lengths to avoid them.
A person who experiences anxiety in most social and performance situations has a condition known as generalized social anxiety disorder. When a person’s anxiety is connected with specific social situations, such as speaking to strangers, eating at restaurants, or going to parties, it is known as a specific social phobia. The most common specific social phobia is fear of public speaking or performing in front of an audience.
Psychological symptoms of social anxiety:
Diagnostic Criteria The diagnosis of social phobia is usually made on the basis of the person's history and reported symptoms. A semi-structured interview to assess social phobia in children is the Anxiety Disorders Interview Schedule for Children, or ADIS-C.
The Social Anxiety Scale for Children and Adolescents, or LSAS-CA can be administered to diagnose social anxiety. Self-report inventories for children include the Child Depression Inventory, or CDI, and the Social Phobia and Anxiety Inventory for Children, or SPAI-C. Parents can be asked to complete the Child Behavior Checklist (CBL), and teachers may be given the Teacher's Report Form (TRF).
Intervention Treatment for social anxiety disorder (SAD) depends on the severity of the person’s emotional and physical symptoms and how well he or she functions daily. Both medication and therapy have been shown effective in treating SAD. Generalized SAD responds best to a combination of medication and therapy, while therapy alone is often sufficient for specific Social Anxiety Disorder.
Cognitive-behavioral therapy for SAD consists of three main components: cognitive restructuring, exposure and social skills training. Cognitive restructuring works to change maladaptive thought patterns that contribute to the symptoms of anxiety while exposure involves gradually facing feared situations to develop confidence. Although not necessary for everyone, social skills training can be helpful for those who lack specific social skills. In addition to receiving professional treatment, a person with SAD can do a number of things to help cope with symptoms. Some of these include practicing relaxation exercises, getting enough sleep, and eating a well-balanced diet.
Lifestyle changes for social anxiety disorder (social phobia) can be most helpful. Though they aren’t enough to overcome social anxiety disorder, they can support your overall treatment progress. The lifestyles tips that are also good for one’s health are: 1. Avoid or limit caffeine (coffee or energy drinks which act as stimulants and increase anxiety symptoms); 2. Drink only in moderation and – even better – not at all (alcohol increases your risk of having an anxiety attack); 3. Quit smoking if you do smoke; and 4. Get a good night’s sleep (being well rested will help one stay calm in social situations).
Etiology There is some evidence that social anxiety can be inherited. A genetic locus on human chromosome 3 that is linked to agoraphobia and two genetic loci on chromosomes 1 and 11q were linked to panic disorder. Because social phobia has some traits in common with panic disorder, it is likely that there are also genes that govern a person’s susceptibility to social phobia.
A person’s temperament (natural predisposition) can also be a broad vulnerability factor in the development of anxiety and mood disorders, including social phobia. More specifically, children who manifest behavioral inhibition in early infancy are at increased risk for developing more than one anxiety disorder in adult life. Behavioral inhibition refers to a group of behaviors that are displayed when the child is confronted with a new situation or unfamiliar people (e.g., crying, and general irritability, followed by withdrawing, seeking comfort from a familiar person).
The development of social phobia is also influenced by parent-child interactions in a patient's family of origin. For instance, it is highly likely that the children of depressed parents may acquire certain attitudes and behaviors from their parents that make them more susceptible to developing social phobia.
| ||
|
Separation Anxiety Disorder |
||
|
Separation anxiety disorder is a persistent, intense, and developmentally inappropriate fear of separation from a major attachment figure (usually the mother). Affected children desperately attempt to avoid such separations. When separation is forced, these children are distressfully preoccupied with reunification. Common symptoms of separation anxiety disorder are:
Worries and Fears:
Refusal and Sickness
Causes of separation anxiety disorder include:
Differential Diagnosis Like social phobia, separation anxiety disorder often manifests as school (or preschool) refusal, and children often develop somatic complaints.
| ||
| Specific Phobias | ||
|
A specific phobia is an extreme fear of a specific object or situation that is out of proportion to the actual danger or threat. In addition, a person with a specific phobia could be distressed about having the fear, or experiences significant interference in his or her day-to-day life because of the fear.
There are a multitude of specific phobias consisting of anything that someone could fear. However, some phobias are much more common than others. Here are ten of the most common specific phobias.
Acrophobia—Fear of Height: Acrophobia is a generalized fear of all heights. This distinguishes it from aerophobia (fear of flying) and other more specified phobias. Acrophobia is to be distinguished from vertigo, which is a physical condition that causes dizziness or disorientation when looking down from a great height
Claustrophobia—Fear of Enclosed Spaces: can range from mild to severe. In severe cases, the sufferer may develop anxiety from simply closing a bedroom door.
Nyctophobia—Fear of the Dark: This fear is common and generally transient in children. If it persists for longer than six months and causes extreme anxiety, however, it may be diagnosed as a phobia. It is less common in adults.
Ophidiophobia—Fear of Snakes: Ophidiophobia refers specifically to snakes. If other reptiles are also feared, then the more general herpetophobia (fear of reptiles) is used. People who suffer from this phobia are not only afraid of touching snakes. They also show fear when viewing pictures of snakes or even talking about them.
Arachnophobia—Fear of Spiders: This is a common insect phobia. Sufferers generally fear spider webs and other signs that a spider may be in the vicinity. They also fear pictures of spiders.
Trypanophobia—Fear of Injection of medical needles: A more general fear of non-medical needles is known as aichmophobia.
Astraphobia—Fear of Thunder and Lightning: This is a common fear among children. If it is severe and continues for longer than six months, however, then a phobia may be diagnosed.
Nosophobia—Fear of Having a Disease: This is the irrational fear of developing a specific disease. Hypochondrias is is a related disorder marked by the persistent fear of having an unspecified disease.
Mysophobia AKA Germophobia—Fear of Germs: This is an intense fear of becoming contaminated by germs. It is related to obsessive-compulsive disorder, which is often marked by repetitive hand-washing. However, for OCD sufferers the focus is on the act of hand-washing itself, while mysophobia sufferers wash hands to remove the contamination.
Triskaidekaphobia—Fear of Number 13: There is some controversy regarding triskaidekaphobia, as many experts see it as a superstition rather than a legitimate phobia. Nonetheless, triskaidekaphobia is so pervasive in Western culture that it has actually influenced the modern world.
Differential Diagnosis Specific phobias are to be distinguished from Delusional Disorder; e.g., a person who avoids an elevator because of a conviction that it has been sabotaged and who does not recognize that this fear is excessive and unreasonable. Also, the content of phobias as well as their prevalence varies according to culture and ethnicity. For example, fears of magic or spirits are present in many cultures and should be considered a Specific Phobia only if the fear is excessive in the context of the culture and causes significant impairment or distress.
| ||
|
Generalized Anxiety Disorder (GAD) | ||
|
Generalized anxiety disorder (GAD) is a persistent state of heightened anxiety and apprehension characterized by excessive worrying, fear, and dread. Physical symptoms can include tremor, sweating, multiple somatic complaints, and exhaustion.
Symptoms and Signs of GAD The main characteristics of GAD are exaggerated anxiety and worry (apprehensive expectations) about a number of events or activities such as work or school performance, that a person finds difficult to control.
The anxiety and worry is associated with some of the following symptoms.
Other physical symptoms that are associated with GAD include:
Differential Diagnosis GAD is diagnosed in children and adolescents who have prominent and impairing anxiety symptoms that are not focused enough to meet criteria for a specific disorder such as social phobia or panic disorder. GAD is also an appropriate diagnosis for children who have a specific anxiety disorder, such as separation anxiety, but also have other significant anxiety symptoms above and beyond those of the specific anxiety disorder. GAD shouldn’t be confused with attention-deficit/hyperactivity disorder (ADHD) because GAD can cause difficulty with paying attention and can also result in psychomotor agitation (ie, hyperactivity). A key difference is that children with ADHD tend to be no more prone to worries than children without ADHD, whereas children with GAD have many distressing worries.
Etiology Genes are in part responsible for GAD; however, research suggests that while genes predispose a person to GAD, his or her environment could also be a trigger that sets it off. Stressful experience can intensify GAD. Serotonin and norepinephrine, two brain neurotransmitters, are thought to be linked to GAD, as well as to other anxiety disorders and depression. Often, depression accompanies anxiety disorders, and can be another indicator of anxiety.
Interventions Because the focus of symptoms is diffuse, GAD is especially challenging to treat with behavioral therapy. Progressive muscle relaxation therapy along with cognitive-behavior therapy is often more appropriate. Both children and adults who have severe GAD or who do not respond to psychotherapeutic interventions may need anxiolytic drugs.
| ||
|
Obsessive-Compulsive Disorder (OCD) | ||
|
Obsessive-compulsive disorder (OCD) is characterized by obsessions, compulsions, or both. Obsessions are irresistible, persistent ideas, images, or impulses to do something. Compulsions are pathologic urges to act on an impulse, which, if resisted, result in excessive anxiety and distress. The obsessions and compulsions cause great distress and interfere with academic or social functioning. Diagnosis is by history. Treatment is with behavioral therapy and SSRIs.
Symptoms and Signs The main characteristics of OCD are obsessions and/or compulsions.
Common obsessive thoughts in OCD include:
Common compulsive behaviors in OCD include:
Obsessions are recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety and distress.
The thoughts, impulses, or images are not simply excessive worries about real-life problems. The person attempts to ignore or suppress such intrusive thoughts, impulses, or images, or to neutralize them with some other thoughts or actions, such as rituals.
Compulsions are repetitive behaviors (e.g., hand washing to avoid disease, checking things such as whether the front door is locked) or mental acts (e.g., praying, counting, repeating words to oneself) that the person feels driven to perform in response to an obsession.
Differential Diagnosis While the onset of obsessive-compulsive disorder usually occurs during adolescence or young adulthood, younger children sometimes have symptoms that look like OCD. However, the symptoms of other disorders, such as ADD, autism, and Tourette’s syndrome can also look like obsessive-compulsive disorder. It is also important to note that OCD is an anxiety disorder, and in children, the symptoms of anxiety usually change over time. So a child with OCD symptoms will not necessarily suffer from OCD symptoms as an adult.
Intervention Most cases of OCD have no clear etiology. However, a few cases are thought to be associated with group A β-hemolytic streptococcal infections. This syndrome is called pediatric autoimmune neuropsychiatric disorder associated with streptococcus (PANDAS). PANDAS should be considered in all children with a sudden onset of severe OCD-like symptoms because early antibiotic treatment may prevent or attenuate long-lasting impairment.
| ||
|
Acute Stress Disorder | ||
|
Acute stress disorder (ASD) is a brief period (about 1 mo) of intrusive recollections (e.g., flashbacks and nightmares), dissociation, avoidance, and anxiety occurring within 1 mo of a traumatic incident. If the symptoms persist over one month after the traumatic event it is likely that the person is experiencing PTSD-like symptoms.
| ||
|
Posttraumatic Stress Disorders (PTSD) | ||
|
Posttraumatic stress disorder (PTSD) is caused by a psychologically traumatic event involving actual or threatened death or serious injury to oneself or others. PTSD causes recurring, intrusive recollections of an overwhelming traumatic incident that persist for over 1 month, as well as emotional numbing and hyperarousal.
Emotional numbing and hyperarousal are common. Emotional numbing includes the following:
Hyper arousal symptoms include the following:
Children with PTSD have intrusive recollections that cause them to re-experience the traumatic event. The most dramatic kind of recollection is a flashback. Flashbacks may be spontaneous but are most commonly triggered by something associated with the original trauma. Traumatic events commonly associated with these disorders include assaults, sexual assaults, car accidents, dog attacks, injuries (especially burns) and war atrocities. In young children, domestic violence is the most common cause of PTSD.
Differential Diagnosis Post-traumatic Stress Disorder is a condition that is different from anxiety disorder, which lacks the presence of a stressor, or adjustment disorder or acute stress disorder. A stressor is generally an event of a serious, unusual nature that an individual or group of individuals experience. The stressors that cause PTSD, adjustment or acute stress disorders may be traumatic or relatively minor. Stressors' most crucial link to their pathogenic potential is their perception by the person as stressful.
Diagnotic Criteria Diagnosis of Acute stress disorder (ASD) and PTSD is based on a history of severely frightening and horrifying trauma followed by re-experiencing, emotional numbing, and hyper arousal. These symptoms must be severe enough to cause impairment or distress.
| ||
|
Panic Attack | ||
|
The main feature of panic attack is a discrete period of intense fear or discomfort that is accompanied by somatic or cognitive symptoms: e.g., palpitations, pounding or accelerated heart, sweating, sensations of shortness of breath or smothering, feeling of choking, chest pain or discomfort, feeling unsteady, lightheaded or faint, and fear of losing control.
Panic Attack occurs in the context of several different Anxiety Disorders: e.g., Panic Disorder, Specific phobia, Social Phobia, Post-Traumatic Stress Disorder, and Acute Stress Disorder. In determining the differential diagnostic significance of the panic attack, it is important to consider the context in which the Panic Attack occurs: There are three characteristic types of panic attacks: unexpected (uncued) Panic Attacks, situationally bound (cued Panic Attacks), and situationally predisposed Panic Attacks.
| ||
|
Panic Disorder | ||
|
Panic disorder is characterized by recurrent, unexpected (out of the blue), frequent panic attacks, which lead to significant change in behavior (e.g., avoidance). Panic attacks per se are discrete spells lasting about 20 minutes; during attacks, children experience somatic symptoms, cognitive symptoms, or both. Some persons feel that the attacks indicate the presence of an undiagnosed, life-threatening illness (e.g., heart attack), this in spite of confirmed expert opinion. Others fear that the Panic Attacks are an indication they are losing control.
Differential Diagnosis The Panic Attack is not due to caffeine intoxication or illicit drugs. It is neither the result of a delusional disorder or physiological conditions such as hyperthyroidism. In some cultures witchcraft or magic can produce panic attack-like symptoms. In western cultures persons affected develop ritualistic behavior to reduce the fear and counteract the Panic Attacks. Panic disorder can occur with or without agoraphobia.
| ||
|
Agoraphobia | ||
|
Agoraphobia is a persistent fear of having a panic attack or panic-like symptoms in a situation that is perceived to be difficult (or embarrassing) from which to escape. These situations can include, but are not limited to, wide-open spaces, crowds, or uncontrolled social conditions. Avoidance behaviors are considered agoraphobia if they greatly impair normal functioning, such as going to school, visiting the mall, or doing other typical activities.
| ||
|
Episodic Paroxysmal Anxiety Floating Anxiety | ||
|
The essential features are recurrent attacks of severe anxiety (panic) which are not restricted to any particular situation or set of circumstances, and which are therefore unpredictable. The main symptoms are sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization) are common. There is also the fear of dying, or losing control.
| ||
|
Substance-Induced Anxiety Disorder | ||
|
The essential features of Substance-Induced Anxiety Disorder are prominent anxiety symptoms that are due to the direct physiological effects of a substance: i.e., a drug or abuse of one, a medication, or toxin exposure. The symptoms may involve prominent anxiety, panic attacks, phobias, or obsessions and compulsions. The symptoms must cause significant distress or impairment in social, occupational, or other important areas of functioning.
| ||
|
Selective Mutism Elective Mutism (ICD-10) | ||
|
Selective Mutism is a condition occurring in childhood. It is characterized by a consistent failure to speak in specific social situations in which there is an expectation for speaking. Children with this disorder have the ability to both speak and understand language, but fail to use this ability.
The main characteristics are:
Differential Diagnosis The main feature is anxiety. This anxiety, which causes avoidance, seems closest to the definition of social anxiety disorder, which needs to be differentiated from selective mutism. Usually selective mutism lasts for only a few months (transient selective mutism), but sometimes it can continue for years (persistent selective mutism). It can also continue through to the teenage years and adulthood. If so, it is likely that selective mutism would turn into social anxiety. Other social-emotional disturbances are often present: e.g., social withdrawal and oppositional behavior.
Other disorders need to be ruled out before offering a diagnosis of selective mutism: e.g., communication disorder (e.g. stuttering or other similar speech disorders); autism or pervasive developmental disorders; receptive and expressive language disorders, or schizophrenia.
Etiology There is no single cause of selective mutism. As with other forms of anxiety, some children may be more likely to have this problem if anxiety or extreme shyness runs in the family, or if they are born with a shy nature. Beyond genetics, in some families where adults are anxious, children may learn to feel socially anxious by watching the way adults react and behave. Upsetting or stressful events such as divorce, the death of a loved one, or frequent moves may trigger selective mutism in a child who is prone to anxiety. Teachers and counselor should also consider cultural issues, such as recently moving to a new country and speaking another language, which can trigger selective mutism-like behaviors.
Intervention Selective Mutism should be diagnosed and treated as quickly as possible. Treatment for Selective Mutism focuses on lowering the anxiety that the child has for speaking in a particular setting. Treatment does not focus on the speaking itself, nor should anyone’s attention. Instead, behavioural therapy, cognitive behavioural therapy and play therapy will often be used in treatment plans and medication may be used also. In some cases family therapy may be recommended as well.
References Cunningham, C.E., & Vanier, M. K. (2005). Helping your child with selective mutism: Practical steps to overcome a fear of speaking. Oakland, CA: New Harbinger Publications.Shipon-Blum. (2003).The ideal classroom setting for the selectively mute child. Published by Selective Mutism Anxiety Research Center.Kearney, C. (2010). Mutism and their parents: A guide for school-based professionals. New York: Oxford University Press.
Books for children Understanding Katie: "a day in the life of …" book one. Dr. Elisa Shipon-Blum. Childhood Anxiety Network, Inc., 2001 Cat's got your tongue? - a story for children afraid to speak. Charles E. Schaefer. Magination Press, 1992. My Friend Daniel Doesn't Talk / by Sharon Longo. Speechmark Publishing Ltd, 2006.
| ||
