Clinical Formulation of Anxiety D/O
Stressful/traumatic life events
Parenting behaviors (overprotective, high rejection, modeling anxious thoughts)
social skills deficits
Social
dry mouth, nausea, diarrhea, heartburn, headache, somnolence, insomnia, dizziness, vivid dreams, changes in appetite, wt loss/gain, fatigue, nervousness, tremor, bruxism, diaphoresis
MC adverse effects
speech usually normal at home, absence of speech in certain social situations with speech in others
selective mutism
preschool, early school age
10-60mg pediatric dosing
CYP450-2D6 substrate *significant interaction
Generally avoided in youth due to discontinuation syndrome (MC), weight gain, and anticholinergic effects
increased risk of SI compared to other SSRIs
Paroxetine (Paxil)
FDA indication for treatment of GAD in 7-17 yo
Duloxetine
Insecure attachment
maladaptive cognitive schemas
information processing errors
negative self-evaluation
Psychological
behavioral activation, mania/hypomania, seizures, abnormal bleeding, serotonin syndrome
black box warning risk of suicidal thinking and behavior through 24yo 1% rate NNH=143
high margin of safety in overdose
Serious side effects
Excessive uncontrollable worry about everyday situations
perfectionistic, seek reassurance, high internal distress
Generalized Anxiety Disorder (later adolescent/early adults)
25-200mg pediatric dosing
CYP450-2D6;1A2
Higher drug-drug interactions
Discontinuation syndrome (less common)
Fluvoxamine (Luvox)
high strength of evidence against CBT: improved global function
moderate strength of evidence against CBT: response, remission, improved anxiety symptoms
SSRIs
family history of anxiety
brain lesions, chronic medical conditions
autonomic hyperreactivity
negative affectivity temperament
behavioral inhibition
sleep/eating issues
Biological
No FDA approval, but substantial empirical support for effectiveness and safety for:
Fluoxetine, fluvoxamine, paroxetine, sertraline
excessive worry/fear of negative evaluation by others in a socal situation
won't answer questions or read in class, shy, won't attend parties, refusal to eat in public places
Social anxiety
later school age, early adolescence
10-40mg pediatric dosing
CYP450-2C19;2D6,3A4
Can cause QT prolongation, avoid in long QT, least drug-drug interaction
Citalopram (Celexa)
Escitalopram (Lexapro) Less risk of QT prolongation (5-20mg)
Associated with greater risk of suicide than other SNRIs, overdose fatalities, and discontinuation syndrome
Venlafaxine (including desvenlafaxine)
Peer rejection
inappropriate expectations for achievement
lack of support/opportunities for competency development
poor fit in a given environment
Social
CBT + SSRI preferentially over either alone
youth w combo treatment had higher rates of remission vs CBT, SSRI or placebo alone at 12 and 24 wks, naturalistic follow up - no long term maintenance of initial superiority of combo over monotherapy (2 studies w conflicting evidence)
CAMS study - child-adolescent anxiety multimodal study
combined treatment
Developmentally inappropriate, excessive worry or distress w separation from primary caregiver
Worry about parent's safety, cant sleep/bathe alone, nightmares about separation, somatic complaints
Separation anxiety
preschool, early school age
25-200mg pediatric dosing
CYP450-2C19; 2D6, 3A4
Can be more sedating, consider dosing QHS; give with food to increase absorption by 40%, helps w GI discomfort. possible discontinuation syndrome (less common)
Sertraline (Zoloft)
screening psychiatric assessment of children and adolescents should routinely screen for presence of obsessions and/or compulsions or repetitive behaviors, even when not part of presenting complaint as symptoms may vary in severity and intensity over time
Clinical Practice Guidelines
Disconnects between feelings/behaviors
Ego deficits
internalized object relation issues
unconscious conflicts
affect management instability
Psychological
high strength of evidence against placebo for primary anxiety symptoms, increased fatigue/somnolence
paradoxical effect of noradrenergic medications
sufficient data - venlafaxine and duloxetine (only SNRI FDA approved GAD in 7-17yo)
recurrent unexpected abrupt fear or discomfort assoicated w physical and cognitive symptoms; attacks commonly seen in adolescence (low prevalence before age 14, <0.04%)
panic disorder
later adolescent/early adults
10-60mg pediatric dosing
CYP450-2D6 substrate *signficant interaction
Can be activating, consider AM dosing
long half life w least risk of discontinuation syndrome
Fluoxetine (Prozac)
Hepatic failure (abdominal pain, hepatomegaly, increased LFTs), cholestatic jaundice, Stevens-Johnson and erythema multiforme - Discontinue and do not restart if jaundice or rash is reported
Duloxetine