ANXIETY DISORDERS

Anxiety/fear is a normal part of development, beginn­ing with stranger's anxiety/fear by 6-8 months of age. The term anxiety disorders or neurosis denotes ‘disproportionately excessive anxiety to a real event or undue

anxiety to an imaginary cause'.

a. Phobia, e.g. school phobia (in ~1-2% children) or social phobia, i.e. fear to meet unfamiliar people;

b. Obsessive-compulsive disorder, i.e. repetitive thoughts, acts, rituals, e.g. compulsive hand washing, checking of locks, etc.;

c. Specific anxiety disorders including separation anxiety, i.e. unrealistic worry towards parents or fear of loneliness and post-traumatic stress disorder;

d. Generalized anxiety disorders, more common in adolescents with unrealistic worry for future events,

e.g. academic failure.

Post-traumatic stress disorder (PTSD) is an anxiety disorder seen in all age groups including children, in response to any external event, experienced or witnessed by an individual and perceived as dangerous.

Etiology: Life-threatening situations leading to serious injuries or death, e.g. riots, natural disasters, etc. are frequently associated with PTSD. Younger children, females and individuals with high-anxiety personality trait are at an increased risk of PTSD. Physical/sexual abuse is an important cause of PTSD in children.

Incidence of PTSD depends on the severity of precipitating event. Although only ~1% of exposed adults satisfy the DSM criteria for PTSD, over 15% are estimated to suffer with more non-specific stress behavior for a variable period of time. Children are more vulnerable for PTSD than adults.

Clinical features: PTSD may be acute or chronic.

Acute PTSD is characterized by: (a) recurrent recollections and dreams of the traumatic event, (b) intense anxiety, (c) sleep disturbances with startle reactions, and (d) concentration difficulties.

Chronic PTSD is generally seen in children with prolonged physical/sexual abuse, leading to changes in the attitude towards life, people, future, etc., psychologic numbing, i.e.

Management: Early identification and management of PTSD is essential to prevent long-term psychotic morbidity and includes:

• Initial evaluation to explore the child's understanding, vulnerability and reactions to the traumatic event.

• Psychotherapy to provide the child an opportunity to discuss the event and express his/her feelings of helplessness, sadness or anger. She/he should be helped to understand everyday events and distinguish them from past-trauma.

• Family therapy and parental counseling to make them understand the basis of child's behavior and encourage their participation in day-to-day management.

• Pharmacotherapy with drugs, e.g. benzodiazepines to modify the sleep and arousal behavior, in selected cases.

Stranger anxiety is a normal phase of development to appear at ~6 months and lasts till 15-18 months. During this phase, infants tend to avoid interaction with unfamiliar persons and cry or move away from them, towards the parents. No treatment is required except reassurance to parents and emotional support to the child. However, unusually intense discomfort with excessive crying, psychological distress or persistence of this phase beyond second year of life may be an indication of serious behavioral problem, e.g. separation anxiety disorder. Such cases need psychiatric referral for complete evaluation and interventions, e.g. cognitive behavior therapy.

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