Asian Journal of Psychiatry 8 (2014) 84–88
Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
A clinical study of anxiety disorders in children and adolescents from North Indian children and adolescents clinic Satyakam Mohapatra *, Vivek Agarwal, Prabhat Sitholey, Amit Arya Department of Psychiatry, King George’s Medical University, U.P. (Formerly C.S.M. Medical University), Lucknow, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 July 2013 Received in revised form 20 November 2013 Accepted 15 December 2013
Background and objectives: Anxiety disorders are the most common group of psychiatric disorders in children and adolescents. But few studies on specific anxiety disorders in children and adolescents are available in India. Therefore, this study was planned to identify anxiety disorders in children and adolescents in an Indian psychiatry outpatient setting and elicit its phenomenology and co-morbidities. Methods: 1465 persons were screened using screen for child anxiety related emotional disorders (SCARED) scale. The screen positive patients were assessed and diagnosis of anxiety disorders was established according to DSM-IV-TR. Detailed assessment of the phenomenology of anxiety disorders was done by K-SADS-PL. Results: 42 (2.86%) patients had different anxiety disorders. Out of which 16 (38.1%) patients had obsessive compulsive disorder, 10 (23.81%) patients with specific phobias, 6 (14.29%) patients with generalized anxiety disorder, 4 (9.52%) patients with social anxiety disorder and 3 (7.14%) patients each with separation anxiety disorder and panic disorder. Co-morbidities were found in 54% of patients with anxiety disorders. Dissociative disorder, specific phobias and social anxiety disorder were the common co-morbidities. Interpretation and conclusion: Anxiety disorders are less commonly found in clinic settings (2.86%). No case of posttraumatic stress disorder or acute stress reaction was found in this study. ß 2013 Elsevier B.V. All rights reserved.
Keywords: Anxiety Children Adolescents
1. Introduction Anxiety disorders are the most common group of psychiatric disorders in children and adolescents. Anxiety disorders usually remain undiagnosed in children and adolescents owing to the internalized nature of its symptoms (Tomb and Hunter, 2004). Various epidemiological studies done in children and adolescents in India have reported prevalence of anxiety disorders ranging from 1.3% to 4.2% (Indian Council of Medical Research, 2001; Margoob, 1996; Chadda and Saurabh, 1994; Hackett et al., 1999; Sidana et al., 1998). Anxiety is associated with substantial negative effects on children’s social, emotional and academic success (Essau et al., 2000). Longitudinal data of children and adolescents with anxiety disorders indicate that anxiety disorders can be chronic and disabling, and they can increase risk of co-morbid disorders (Pine et al., 1998). Anxiety is considered to be a universal phenomenon existing across cultures, although its contexts and manifestations are influenced by cultural beliefs and practices
* Corresponding author. Tel.: +91 8895293997. E-mail addresses: [email protected], [email protected] (S. Mohapatra). 1876-2018/$ – see front matter ß 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2013.12.005
(Good and Kleinman, 1985). Identifying and treating children and adolescents with anxiety disorders would reduce the burden of this disorder and may help in better management of the co-morbid conditions in these patients. Studies on obsessive compulsive disorder (Khanna and Srinath, 1988) and post-traumatic disorder (Khan and Margoob, 2006) in children and adolescents are done in India. Another study on social anxiety disorder in adolescents (Mehtalia and Vankar, 2004) also done in India. But no study was available in India assessing all anxiety disorders in children and adolescents. Therefore this study was planned in a psychiatry outpatient setting of a university department of psychiatry in northern India with the aim to identify anxiety disorders in children and adolescents and elicit their phenomenology and comorbidities. 2. Materials and method This cross-sectional, clinic based study was carried out at Department of Psychiatry, K. G. Medical University, Lucknow from August 2010 to July 2011. The study was approved by the institutional ethics committee. Inclusion criteria were: (i) patients with age between 6 and 16 years, (ii) diagnosis of non-psychotic psychiatric disorder. Exclusion criteria included patient with a
S. Mohapatra et al. / Asian Journal of Psychiatry 8 (2014) 84–88
severe physical disorder or condition requiring priority medical management. All patients attending child and adolescent psychiatry OPD were screened for selection criteria. IQ assessment of the patients was done by the clinical psychologists by using Raven’s progressive matrices (Raven et al., 2003) as a part of routine clinical evaluation. All selected patients were screened by screen for child anxiety related emotional disorders (SCARED) scale (Birmaher et al., 1995). The screen positive patients (patients with score more than 25 on SCARED scale) were assessed and diagnosis of anxiety disorders was established according to diagnostic and statistical manual of mental disorders, fourth edition, text revision (DSM-IV-TR) (American Psychiatric Association, 2000). Detailed assessment of the phenomenology of anxiety disorders was done by Kiddie – Schedule for Affective disorders and Schizophrenia – present and lifetime version (K-SADS-PL) (Kaufman et al., 1997). Both the process of screening by SCARED scale and subsequent evaluation by KSADS-PL were done by the same rater. Diagnosis of co-morbid disorders was made by using diagnostic and statistical manual of mental disorders, fourth edition, text revision (DSM-IV-TR). Impairment due to anxiety disorder was assessed by children’s global assessment scale (CGAS) (Shaffer et al., 1983). 3. Results A total of 1465 persons were screened. Out of which 42 (2.86%) patients had different anxiety disorders. Mean age of patients with anxiety disorders was 12.5 2.34 years. Majority 26 (62%) patients were in adolescent (13–16 years) age group. 35(84%) had the onset of symptoms before 13years of age. Mean age of onset of anxiety disorder was 10.4 1.05 years. Mean age of recognition of symptoms by caregiver was 11.2 1.15 years. Majority of patients were female patients 26 (62%). Majority of patients belong to urban area 29 (69.08%). 23 (55%) patient’s parents were 10th class pass or above educated. 26 (62%) of patient’s parents were employed. Majority of patient’s monthly family income is above 6000 rupees per month 25(60%). Thirty-seven (88.46%) patients were students. Mean IQ of subjects was 95.24 1.69. 6 (14.29%) patients had family history of psychiatric disorders. Out of which 4 (66.67%) patients had family history of obsessive compulsive disorder and 2 (33.33%) each patients had family history of generalized anxiety disorder and bipolar affective disorders. Most common first care providers were faith healer (a type of care provider who used to treat/cure illness or disability by recourse to divine power, without the use of medicines) (33.26%), followed by local practitioner (a type of care provider who was either qualified in other discipline of medical sciences like ayurvedic, homeopathic or unani medicine or nonqualified village/local health care providers/quacks) (26.58%) and general medical practitioner (a type of care provider who was a qualified allopathic medical practitioner) (24.57%), while first contact with psychiatrist (type of care provider who was having postgraduate in discipline of psychiatry) was made by 15.59% of patients. Majority (53.76%) of patients were referred to the study center by previous care providers, followed by family members of patient with psychiatric disorder in neighborhood (19.52%) and self-referral (26.72%). Among 42 patients with anxiety disorders obsessive compulsive disorder was the most common anxiety disorder 16 (38.95%) followed by specific phobias 10 (23.81%), generalized anxiety disorder 6 (14.29%), social anxiety disorder 4 (9.52%) and 3 (7.14%) patients each with separation anxiety disorder and panic disorder (Tables 1 and 2). Co-morbidities were found in 22 (53%) of patients with anxiety disorders. Among them majority 14 (64%) patients had one
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Table 1 Numbera of subjects with anxiety disorders. Anxiety disorders
N (42)
Obsessive compulsive disorder Specific phobias Generalized anxiety disorder Social anxiety disorder Separation anxiety disorder Panic disorder
16 10 6 4 3 3
a
(38.95%) (23.81%) (14.29%) (9.52%) (7.14%) (7.14%)
Not mutually exclusive.
Table 2 Phenomenologya of different anxiety disorders. Anxiety symptoms
N
%
Obsessive compulsive disorder (N = 16) Compulsions Washing and cleaning Checking Repeating rituals Obsessions Contaminations Aggressive thoughts Religious thoughts
16 14 9 8 14 14 11 9
100% 87.5% 56.25% 50% 87.5% 87.5% 68.75% 56.25%
4 3 2 1 10 10
40% 30% 20% 10% 100% 100%
Specific phobias (N = 10) Fear of darkness Fear of blood Fear of insects Fear of animals Avoidance of the situation Physiological symptoms of anxiety on exposure to the situation Generalized anxiety disorder (N = 6) Inability to control worry Excessive need for reassurance Physiological symptoms of anxiety Social anxiety disorder (N = 4) Fear of reading aloud in front of class Writing on the blackboard while others watching Answering questions in class in front of others Physiological symptoms of anxiety to the feared social situation Separation anxiety disorder (N = 3) Excessive distress upon separation Excessive distress in anticipation of separation Physical symptoms (headache, stomachache) on school separation days Nightmares (something bad happening to parents) Panic disorder (N = 3) Palpitation Fear of dying Fear of having another attack a
5 4 3
83.33% 66.67% 50%
4 4 4 3
100% 100% 100% 75%
3 3 2
100% 100% 66.67%
2
66.67%
3 3 3
100% 100% 100%
Not mutually exclusive.
co-morbid psychiatric illness and 8 (37%) patients had more than one co-morbid psychiatric illness. Dissociative disorder 8 (36.36%) is the most common co-morbid psychiatric illness followed by specific phobias 5 (22.73%), social anxiety disorder 4 (18.18%), 1 (2.38%) each with separation anxiety disorder, panic attacks, ADHD, depression and nocturnal enuresis. Among the anxiety disorders obsessive compulsive disorder had maximum co-morbid psychiatric illness 8 (37%) followed by specific phobias 6 (27%) and generalized anxiety disorder (14%). Most of the subjects had moderate difficulty in functioning (Mean C-GAS score 49 6.21). Impairment due to anxiety disorders was more in obsessive compulsive disorder (Mean C-GAS score 46 6.21) while it was less in panic disorder (Mean C-GAS score 54).
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S. Mohapatra et al. / Asian Journal of Psychiatry 8 (2014) 84–88
4. Discussion Though anxiety disorders are the most common psychiatric disorder in children and adolescents, but in our study out of 1465 screened patients 42 (2.86%) patients had different anxiety disorders. This finding is supported by an epidemiological study conducted by Indian Council of Medical Research at two-centres (Bangalore and Lucknow) (Indian Council of Medical Research, 2001). Studies at Bangalore Centre and Lucknow Centre were community based study and clinic based study respectively. This study showed that anxiety disorders were more common in Bangalore centre (3.93%) as compared to Lucknow centre (2.32%). So anxiety disorders are less commonly found in clinic setting. This low frequency of anxiety disorders in child and adolescent age group can also be explained by the fact that in India children emotional disorders are less readily recognized and treated (Chacko, 1967). Children are mostly taken to indigenous healers and parents do not consider these problems as emotional disorders and also seek treatment for the same. The mean age of patients with anxiety disorders was 12.5 2.34 years. Majority 26 (62%) patients were in adolescent (13–16 years) age group. 35 (84%) subjects had the onset of symptoms before 13 years of age, but seek treatment for the first time in adolescent age. Study by Malhotra (2009) showed that disorders of emotions with onset specific to childhood according to ICD-10 classificatory system were more common (82%) in adolescent age group. Another study by Margoob (1996) also revealed that anxiety disorders are more common (80%) in adolescent age group. This can be explained by the fact that with increasing scholastic demands and expectations from the child and the consequent stress on studies may be responsible for more anxiety in adolescent age group. Majority of patients were female patients 26 (62%). This is in accordance with most previous studies (Campbell and Rapee, 1994; Costello et al., 2003; Last et al., 1996). Indian studies also revealed similar facts. Study done by Chadda and Saurabh (1994) showed that anxiety symptoms were common in female population (1.55%) as compared to males (0.77%). Another study by Margoob (1996) done in Kashmir showed that anxiety disorders were common (80%) in female patients. Majority of patients belong to urban area 29 (69.08%). This finding is also supported by Margoob (1996), which showed that 80% patients of anxiety disorders belong to urban area. One reason for predominant urban population in our study may be that the child and adolescent psychiatry clinic was in urban area (Lucknow). This might had caused a referral bias. Another reason of over representation of urban subjects in our study could be due to more awareness in the urban areas compared to rural population. Among 42 patients with anxiety disorders obsessive compulsive disorder was the most common 16 (1.09%) anxiety disorder followed by specific phobias 10 (0.68%), generalized anxiety disorder 6 (0.41%), social anxiety disorder 4 (0.27%) and separation anxiety disorder and panic disorder each 3 (0.21%). In previous Indian studies by Indian Council of Medical Research (2001) specific phobias (Bangalore centres – 2.9% and Lucknow centers – 1.98%) were most common anxiety disorders in children and adolescents. In our study in patients with obsessive compulsive disorder compulsions (100%) were present more commonly as compared to obsessions (87.5%). A study by Khanna and Srinath (1988), from India also showed that compulsions (86%) more frequent compared to obsessions (62%). In our study most common obsession were contaminations 14 (87.5%), aggressive thoughts 11 (68.75%), religious thoughts 9 (56.25%), symmetry 8 (50%), sex 3 (18.75%). These findings were supported by another study by Reddy et al. (2003) which showed that contamination obsessions
were the commonest (62%), followed by obsessions related to aggression (57%), symmetry (34%), sex (22%), religion (22%). Most common compulsions in our study were washing and cleaning 14 (87.5%), checking 9 (56.25%), repeating rituals 8 (50%), ordering 8 (50%), counting 4 (25%). Study by Reddy et al. (2003) showed that cleaning and washing was the commonest (69%) followed by repeating (52%), checking (47%), ordering (29%), counting (15%). The phenomenology of OCD in our study is also similar to that reported in a group of 70 patients at the National Institute of Mental Health (NIMH) in USA (Swedo et al., 1989). In our study specific phobias were present in 10 (0.68%) patients. Phobias in children may be particularly under recognized because their presentation may be regarded as mere fears or may be misdiagnosed because of symptom overlap with other anxiety disorders. Predominant type of phobias is fear of darkness, fear of blood, fear of insects and fear of animals. Study by Essau et al. (2000) showed that natural environment (darkness) and animal phobia were the most common types of phobias in children and adolescents. Other studies (King, 1993; Silverman and Rabian, 1993; Strauss and Last, 1993) also have same findings. As the sample size of subjects with specific phobias in our study is low, so to compare the type of specific phobias of children with that of the adolescents does not have any significance. 6 (14.29%) patients were with generalized anxiety disorder. Most common symptoms were inability to control worry 5 (83.33%), excessive need for reassurance 4 (66.67%), physiological symptoms of anxiety 3 (50%), preoccupation with appropriateness of past behavior 3 (50%), over concern about competence 3 (50%), physical symptoms on school separation 3 (50%). This is consistent with the finding of the study done by Wagner (2001) which showed that unlike adults with this disorder, children and adolescents usually do not realize that their anxiety is more intense than the situation warrants. Children and adolescents with GAD often require frequent reassurance from the adults in their lives, they excessively worry about a variety of events, including those in the past, present, and future. In our study patients with social anxiety disorder presented with most common complaints of fear of reading aloud in front of class and writing on the blackboard while others watching 4 (100%), answering questions in class in front of others (100%), starting a conversation with unknown people 4 (100%) and avoidance of the above situations 4 (100%). In the study by Mehtalia and Vankar (2004) showed that fear of doing things when people might be watching (51.8%), fear of talking to strangers (33.3%) were common complaints among adolescents with social anxiety disorders. Chandler (1993) also pointed out that reading aloud in front of class, joining in on a conversation, speaking to adults, writing on the blackboard were the common presenting complaints of children and adolescents with social anxiety disorder. In patients with separation anxiety disorders in our study presented with complaints of excessive distress upon separation 3 (100%) and excessive distress in anticipation of separation 3 (100%). Bell-Dolan et al. (1990) showed similar features mentioning that key feature of separation anxiety disorder is excessive anxiety about separation from primary attachment figures (e.g. parents, grandparents). Children with SAD fear that harm will come to themselves or their attachment figures when separated. In our study nightmares (something bad happening to parents) and physical symptoms (headache and stomach ache) on school separation days were two other important findings. Bell-Dolan et al. (1990) also found in their study that recurrent nightmares characterized by separation themes were commonly found in children and adolescents with separation anxiety disorders. Livingston et al. (1988) pointed out that in children and adolescents present with physical symptoms like nonspecific complaints of stomachaches or headaches on separation.
S. Mohapatra et al. / Asian Journal of Psychiatry 8 (2014) 84–88
In patients with panic disorders in our study palpitations, tremors, fear of dying, fear of having another attack were present in all patients. Kearney et al. (1998) also found same findings in his study. Symptoms like choking, chest pain, depersonalization and numbness were less commonly found in our subjects which matches with the findings of study by Von Korff et al. (1985). Anxiety disorders in children and adolescents have consistently been reported as having high rates of co-morbidity with both externalizing and internalizing psychiatric disorders. In our study, co-morbidities were found in 53% of patients with anxiety disorders. Among them majority (64%) patients had one comorbid psychiatric illness and 37% patient had more than one comorbid psychiatric illness. Dissociative disorder 8 (36.36%) is the most common co-morbid psychiatric illness. But this is in contrast to most of the previous studies (Costello et al., 1996; Cohen et al., 1993), which showed that second anxiety disorder, depressive disorder, or disruptive behavior disorder were common co-morbid psychiatric disorders. This can be explained by the fact that most of these studies on anxiety disorders in children and adolescents were done on western population, where prevalence of dissociative disorder is less compared to India (Chaudhury et al., 2007). Childhood anxiety disorders are also associated with significant impairment, causing distress that interferes with school performance, family, and social functioning (Ialongo et al., 1994). In our study most of the patients had moderate difficulty in functioning (Mean C-GAS score 49 6.21). Impairment due to anxiety
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disorders was more in obsessive compulsive disorder (Mean C-GAS score 46 6.21). But Cohen et al. (1993) showed that simple phobia has more impairment as compared to other anxiety disorders. The result of our study can be explained by the fact that patients with obsessive compulsive disorder have highest number of co-morbidities. The limitations of the study included a larger sample size would have made our study more comprehensive and robust. The comorbidities could have been assessed by tools like MINI-KID, but we have assessed by using only DSM-IV TR. We have not evaluated a small number (for example 10%) of screen negative subjects by using KSADS-PL. Though we have assessed impairment due to different anxiety disorders, but we have not assessed severity of anxiety and its impact on functioning. In our study no case of post-traumatic stress disorder or acute stress disorder was found. In summary, our study showed that anxiety disorders in children and adolescent are still less commonly found in clinic settings in India. The phenomenology of anxiety disorders in children and adolescent was similar to those seen in the western countries.
Conflict of interest None declared.
Appendix A. Pathway of care of patients with anxiety disorders
Patients screened for selection criteria
Phenomenology of anxiety disorders was done by KSADS-PL
All selected patients screened by SCARED scale for anxiety disorders
Screen positive patients (patients with score more than 25 on SCARED scale) diagnosed for different anxiety disorders by DSM-IV TR
Co morbid psychiatric disorders assessed by DSM-IV TR and impairment due to anxiety disorders assessed by CGAS
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Contents lists available at ScienceDirect
Asian Journal of Psychiatry journal homepage: www.elsevier.com/locate/ajp
A clinical study of anxiety disorders in children and adolescents from North Indian children and adolescents clinic Satyakam Mohapatra *, Vivek Agarwal, Prabhat Sitholey, Amit Arya Department of Psychiatry, King George’s Medical University, U.P. (Formerly C.S.M. Medical University), Lucknow, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 July 2013 Received in revised form 20 November 2013 Accepted 15 December 2013
Background and objectives: Anxiety disorders are the most common group of psychiatric disorders in children and adolescents. But few studies on specific anxiety disorders in children and adolescents are available in India. Therefore, this study was planned to identify anxiety disorders in children and adolescents in an Indian psychiatry outpatient setting and elicit its phenomenology and co-morbidities. Methods: 1465 persons were screened using screen for child anxiety related emotional disorders (SCARED) scale. The screen positive patients were assessed and diagnosis of anxiety disorders was established according to DSM-IV-TR. Detailed assessment of the phenomenology of anxiety disorders was done by K-SADS-PL. Results: 42 (2.86%) patients had different anxiety disorders. Out of which 16 (38.1%) patients had obsessive compulsive disorder, 10 (23.81%) patients with specific phobias, 6 (14.29%) patients with generalized anxiety disorder, 4 (9.52%) patients with social anxiety disorder and 3 (7.14%) patients each with separation anxiety disorder and panic disorder. Co-morbidities were found in 54% of patients with anxiety disorders. Dissociative disorder, specific phobias and social anxiety disorder were the common co-morbidities. Interpretation and conclusion: Anxiety disorders are less commonly found in clinic settings (2.86%). No case of posttraumatic stress disorder or acute stress reaction was found in this study. ß 2013 Elsevier B.V. All rights reserved.
Keywords: Anxiety Children Adolescents
1. Introduction Anxiety disorders are the most common group of psychiatric disorders in children and adolescents. Anxiety disorders usually remain undiagnosed in children and adolescents owing to the internalized nature of its symptoms (Tomb and Hunter, 2004). Various epidemiological studies done in children and adolescents in India have reported prevalence of anxiety disorders ranging from 1.3% to 4.2% (Indian Council of Medical Research, 2001; Margoob, 1996; Chadda and Saurabh, 1994; Hackett et al., 1999; Sidana et al., 1998). Anxiety is associated with substantial negative effects on children’s social, emotional and academic success (Essau et al., 2000). Longitudinal data of children and adolescents with anxiety disorders indicate that anxiety disorders can be chronic and disabling, and they can increase risk of co-morbid disorders (Pine et al., 1998). Anxiety is considered to be a universal phenomenon existing across cultures, although its contexts and manifestations are influenced by cultural beliefs and practices
* Corresponding author. Tel.: +91 8895293997. E-mail addresses: [email protected], [email protected] (S. Mohapatra). 1876-2018/$ – see front matter ß 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.ajp.2013.12.005
(Good and Kleinman, 1985). Identifying and treating children and adolescents with anxiety disorders would reduce the burden of this disorder and may help in better management of the co-morbid conditions in these patients. Studies on obsessive compulsive disorder (Khanna and Srinath, 1988) and post-traumatic disorder (Khan and Margoob, 2006) in children and adolescents are done in India. Another study on social anxiety disorder in adolescents (Mehtalia and Vankar, 2004) also done in India. But no study was available in India assessing all anxiety disorders in children and adolescents. Therefore this study was planned in a psychiatry outpatient setting of a university department of psychiatry in northern India with the aim to identify anxiety disorders in children and adolescents and elicit their phenomenology and comorbidities. 2. Materials and method This cross-sectional, clinic based study was carried out at Department of Psychiatry, K. G. Medical University, Lucknow from August 2010 to July 2011. The study was approved by the institutional ethics committee. Inclusion criteria were: (i) patients with age between 6 and 16 years, (ii) diagnosis of non-psychotic psychiatric disorder. Exclusion criteria included patient with a
S. Mohapatra et al. / Asian Journal of Psychiatry 8 (2014) 84–88
severe physical disorder or condition requiring priority medical management. All patients attending child and adolescent psychiatry OPD were screened for selection criteria. IQ assessment of the patients was done by the clinical psychologists by using Raven’s progressive matrices (Raven et al., 2003) as a part of routine clinical evaluation. All selected patients were screened by screen for child anxiety related emotional disorders (SCARED) scale (Birmaher et al., 1995). The screen positive patients (patients with score more than 25 on SCARED scale) were assessed and diagnosis of anxiety disorders was established according to diagnostic and statistical manual of mental disorders, fourth edition, text revision (DSM-IV-TR) (American Psychiatric Association, 2000). Detailed assessment of the phenomenology of anxiety disorders was done by Kiddie – Schedule for Affective disorders and Schizophrenia – present and lifetime version (K-SADS-PL) (Kaufman et al., 1997). Both the process of screening by SCARED scale and subsequent evaluation by KSADS-PL were done by the same rater. Diagnosis of co-morbid disorders was made by using diagnostic and statistical manual of mental disorders, fourth edition, text revision (DSM-IV-TR). Impairment due to anxiety disorder was assessed by children’s global assessment scale (CGAS) (Shaffer et al., 1983). 3. Results A total of 1465 persons were screened. Out of which 42 (2.86%) patients had different anxiety disorders. Mean age of patients with anxiety disorders was 12.5 2.34 years. Majority 26 (62%) patients were in adolescent (13–16 years) age group. 35(84%) had the onset of symptoms before 13years of age. Mean age of onset of anxiety disorder was 10.4 1.05 years. Mean age of recognition of symptoms by caregiver was 11.2 1.15 years. Majority of patients were female patients 26 (62%). Majority of patients belong to urban area 29 (69.08%). 23 (55%) patient’s parents were 10th class pass or above educated. 26 (62%) of patient’s parents were employed. Majority of patient’s monthly family income is above 6000 rupees per month 25(60%). Thirty-seven (88.46%) patients were students. Mean IQ of subjects was 95.24 1.69. 6 (14.29%) patients had family history of psychiatric disorders. Out of which 4 (66.67%) patients had family history of obsessive compulsive disorder and 2 (33.33%) each patients had family history of generalized anxiety disorder and bipolar affective disorders. Most common first care providers were faith healer (a type of care provider who used to treat/cure illness or disability by recourse to divine power, without the use of medicines) (33.26%), followed by local practitioner (a type of care provider who was either qualified in other discipline of medical sciences like ayurvedic, homeopathic or unani medicine or nonqualified village/local health care providers/quacks) (26.58%) and general medical practitioner (a type of care provider who was a qualified allopathic medical practitioner) (24.57%), while first contact with psychiatrist (type of care provider who was having postgraduate in discipline of psychiatry) was made by 15.59% of patients. Majority (53.76%) of patients were referred to the study center by previous care providers, followed by family members of patient with psychiatric disorder in neighborhood (19.52%) and self-referral (26.72%). Among 42 patients with anxiety disorders obsessive compulsive disorder was the most common anxiety disorder 16 (38.95%) followed by specific phobias 10 (23.81%), generalized anxiety disorder 6 (14.29%), social anxiety disorder 4 (9.52%) and 3 (7.14%) patients each with separation anxiety disorder and panic disorder (Tables 1 and 2). Co-morbidities were found in 22 (53%) of patients with anxiety disorders. Among them majority 14 (64%) patients had one
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Table 1 Numbera of subjects with anxiety disorders. Anxiety disorders
N (42)
Obsessive compulsive disorder Specific phobias Generalized anxiety disorder Social anxiety disorder Separation anxiety disorder Panic disorder
16 10 6 4 3 3
a
(38.95%) (23.81%) (14.29%) (9.52%) (7.14%) (7.14%)
Not mutually exclusive.
Table 2 Phenomenologya of different anxiety disorders. Anxiety symptoms
N
%
Obsessive compulsive disorder (N = 16) Compulsions Washing and cleaning Checking Repeating rituals Obsessions Contaminations Aggressive thoughts Religious thoughts
16 14 9 8 14 14 11 9
100% 87.5% 56.25% 50% 87.5% 87.5% 68.75% 56.25%
4 3 2 1 10 10
40% 30% 20% 10% 100% 100%
Specific phobias (N = 10) Fear of darkness Fear of blood Fear of insects Fear of animals Avoidance of the situation Physiological symptoms of anxiety on exposure to the situation Generalized anxiety disorder (N = 6) Inability to control worry Excessive need for reassurance Physiological symptoms of anxiety Social anxiety disorder (N = 4) Fear of reading aloud in front of class Writing on the blackboard while others watching Answering questions in class in front of others Physiological symptoms of anxiety to the feared social situation Separation anxiety disorder (N = 3) Excessive distress upon separation Excessive distress in anticipation of separation Physical symptoms (headache, stomachache) on school separation days Nightmares (something bad happening to parents) Panic disorder (N = 3) Palpitation Fear of dying Fear of having another attack a
5 4 3
83.33% 66.67% 50%
4 4 4 3
100% 100% 100% 75%
3 3 2
100% 100% 66.67%
2
66.67%
3 3 3
100% 100% 100%
Not mutually exclusive.
co-morbid psychiatric illness and 8 (37%) patients had more than one co-morbid psychiatric illness. Dissociative disorder 8 (36.36%) is the most common co-morbid psychiatric illness followed by specific phobias 5 (22.73%), social anxiety disorder 4 (18.18%), 1 (2.38%) each with separation anxiety disorder, panic attacks, ADHD, depression and nocturnal enuresis. Among the anxiety disorders obsessive compulsive disorder had maximum co-morbid psychiatric illness 8 (37%) followed by specific phobias 6 (27%) and generalized anxiety disorder (14%). Most of the subjects had moderate difficulty in functioning (Mean C-GAS score 49 6.21). Impairment due to anxiety disorders was more in obsessive compulsive disorder (Mean C-GAS score 46 6.21) while it was less in panic disorder (Mean C-GAS score 54).
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4. Discussion Though anxiety disorders are the most common psychiatric disorder in children and adolescents, but in our study out of 1465 screened patients 42 (2.86%) patients had different anxiety disorders. This finding is supported by an epidemiological study conducted by Indian Council of Medical Research at two-centres (Bangalore and Lucknow) (Indian Council of Medical Research, 2001). Studies at Bangalore Centre and Lucknow Centre were community based study and clinic based study respectively. This study showed that anxiety disorders were more common in Bangalore centre (3.93%) as compared to Lucknow centre (2.32%). So anxiety disorders are less commonly found in clinic setting. This low frequency of anxiety disorders in child and adolescent age group can also be explained by the fact that in India children emotional disorders are less readily recognized and treated (Chacko, 1967). Children are mostly taken to indigenous healers and parents do not consider these problems as emotional disorders and also seek treatment for the same. The mean age of patients with anxiety disorders was 12.5 2.34 years. Majority 26 (62%) patients were in adolescent (13–16 years) age group. 35 (84%) subjects had the onset of symptoms before 13 years of age, but seek treatment for the first time in adolescent age. Study by Malhotra (2009) showed that disorders of emotions with onset specific to childhood according to ICD-10 classificatory system were more common (82%) in adolescent age group. Another study by Margoob (1996) also revealed that anxiety disorders are more common (80%) in adolescent age group. This can be explained by the fact that with increasing scholastic demands and expectations from the child and the consequent stress on studies may be responsible for more anxiety in adolescent age group. Majority of patients were female patients 26 (62%). This is in accordance with most previous studies (Campbell and Rapee, 1994; Costello et al., 2003; Last et al., 1996). Indian studies also revealed similar facts. Study done by Chadda and Saurabh (1994) showed that anxiety symptoms were common in female population (1.55%) as compared to males (0.77%). Another study by Margoob (1996) done in Kashmir showed that anxiety disorders were common (80%) in female patients. Majority of patients belong to urban area 29 (69.08%). This finding is also supported by Margoob (1996), which showed that 80% patients of anxiety disorders belong to urban area. One reason for predominant urban population in our study may be that the child and adolescent psychiatry clinic was in urban area (Lucknow). This might had caused a referral bias. Another reason of over representation of urban subjects in our study could be due to more awareness in the urban areas compared to rural population. Among 42 patients with anxiety disorders obsessive compulsive disorder was the most common 16 (1.09%) anxiety disorder followed by specific phobias 10 (0.68%), generalized anxiety disorder 6 (0.41%), social anxiety disorder 4 (0.27%) and separation anxiety disorder and panic disorder each 3 (0.21%). In previous Indian studies by Indian Council of Medical Research (2001) specific phobias (Bangalore centres – 2.9% and Lucknow centers – 1.98%) were most common anxiety disorders in children and adolescents. In our study in patients with obsessive compulsive disorder compulsions (100%) were present more commonly as compared to obsessions (87.5%). A study by Khanna and Srinath (1988), from India also showed that compulsions (86%) more frequent compared to obsessions (62%). In our study most common obsession were contaminations 14 (87.5%), aggressive thoughts 11 (68.75%), religious thoughts 9 (56.25%), symmetry 8 (50%), sex 3 (18.75%). These findings were supported by another study by Reddy et al. (2003) which showed that contamination obsessions
were the commonest (62%), followed by obsessions related to aggression (57%), symmetry (34%), sex (22%), religion (22%). Most common compulsions in our study were washing and cleaning 14 (87.5%), checking 9 (56.25%), repeating rituals 8 (50%), ordering 8 (50%), counting 4 (25%). Study by Reddy et al. (2003) showed that cleaning and washing was the commonest (69%) followed by repeating (52%), checking (47%), ordering (29%), counting (15%). The phenomenology of OCD in our study is also similar to that reported in a group of 70 patients at the National Institute of Mental Health (NIMH) in USA (Swedo et al., 1989). In our study specific phobias were present in 10 (0.68%) patients. Phobias in children may be particularly under recognized because their presentation may be regarded as mere fears or may be misdiagnosed because of symptom overlap with other anxiety disorders. Predominant type of phobias is fear of darkness, fear of blood, fear of insects and fear of animals. Study by Essau et al. (2000) showed that natural environment (darkness) and animal phobia were the most common types of phobias in children and adolescents. Other studies (King, 1993; Silverman and Rabian, 1993; Strauss and Last, 1993) also have same findings. As the sample size of subjects with specific phobias in our study is low, so to compare the type of specific phobias of children with that of the adolescents does not have any significance. 6 (14.29%) patients were with generalized anxiety disorder. Most common symptoms were inability to control worry 5 (83.33%), excessive need for reassurance 4 (66.67%), physiological symptoms of anxiety 3 (50%), preoccupation with appropriateness of past behavior 3 (50%), over concern about competence 3 (50%), physical symptoms on school separation 3 (50%). This is consistent with the finding of the study done by Wagner (2001) which showed that unlike adults with this disorder, children and adolescents usually do not realize that their anxiety is more intense than the situation warrants. Children and adolescents with GAD often require frequent reassurance from the adults in their lives, they excessively worry about a variety of events, including those in the past, present, and future. In our study patients with social anxiety disorder presented with most common complaints of fear of reading aloud in front of class and writing on the blackboard while others watching 4 (100%), answering questions in class in front of others (100%), starting a conversation with unknown people 4 (100%) and avoidance of the above situations 4 (100%). In the study by Mehtalia and Vankar (2004) showed that fear of doing things when people might be watching (51.8%), fear of talking to strangers (33.3%) were common complaints among adolescents with social anxiety disorders. Chandler (1993) also pointed out that reading aloud in front of class, joining in on a conversation, speaking to adults, writing on the blackboard were the common presenting complaints of children and adolescents with social anxiety disorder. In patients with separation anxiety disorders in our study presented with complaints of excessive distress upon separation 3 (100%) and excessive distress in anticipation of separation 3 (100%). Bell-Dolan et al. (1990) showed similar features mentioning that key feature of separation anxiety disorder is excessive anxiety about separation from primary attachment figures (e.g. parents, grandparents). Children with SAD fear that harm will come to themselves or their attachment figures when separated. In our study nightmares (something bad happening to parents) and physical symptoms (headache and stomach ache) on school separation days were two other important findings. Bell-Dolan et al. (1990) also found in their study that recurrent nightmares characterized by separation themes were commonly found in children and adolescents with separation anxiety disorders. Livingston et al. (1988) pointed out that in children and adolescents present with physical symptoms like nonspecific complaints of stomachaches or headaches on separation.
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In patients with panic disorders in our study palpitations, tremors, fear of dying, fear of having another attack were present in all patients. Kearney et al. (1998) also found same findings in his study. Symptoms like choking, chest pain, depersonalization and numbness were less commonly found in our subjects which matches with the findings of study by Von Korff et al. (1985). Anxiety disorders in children and adolescents have consistently been reported as having high rates of co-morbidity with both externalizing and internalizing psychiatric disorders. In our study, co-morbidities were found in 53% of patients with anxiety disorders. Among them majority (64%) patients had one comorbid psychiatric illness and 37% patient had more than one comorbid psychiatric illness. Dissociative disorder 8 (36.36%) is the most common co-morbid psychiatric illness. But this is in contrast to most of the previous studies (Costello et al., 1996; Cohen et al., 1993), which showed that second anxiety disorder, depressive disorder, or disruptive behavior disorder were common co-morbid psychiatric disorders. This can be explained by the fact that most of these studies on anxiety disorders in children and adolescents were done on western population, where prevalence of dissociative disorder is less compared to India (Chaudhury et al., 2007). Childhood anxiety disorders are also associated with significant impairment, causing distress that interferes with school performance, family, and social functioning (Ialongo et al., 1994). In our study most of the patients had moderate difficulty in functioning (Mean C-GAS score 49 6.21). Impairment due to anxiety
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disorders was more in obsessive compulsive disorder (Mean C-GAS score 46 6.21). But Cohen et al. (1993) showed that simple phobia has more impairment as compared to other anxiety disorders. The result of our study can be explained by the fact that patients with obsessive compulsive disorder have highest number of co-morbidities. The limitations of the study included a larger sample size would have made our study more comprehensive and robust. The comorbidities could have been assessed by tools like MINI-KID, but we have assessed by using only DSM-IV TR. We have not evaluated a small number (for example 10%) of screen negative subjects by using KSADS-PL. Though we have assessed impairment due to different anxiety disorders, but we have not assessed severity of anxiety and its impact on functioning. In our study no case of post-traumatic stress disorder or acute stress disorder was found. In summary, our study showed that anxiety disorders in children and adolescent are still less commonly found in clinic settings in India. The phenomenology of anxiety disorders in children and adolescent was similar to those seen in the western countries.
Conflict of interest None declared.
Appendix A. Pathway of care of patients with anxiety disorders
Patients screened for selection criteria
Phenomenology of anxiety disorders was done by KSADS-PL
All selected patients screened by SCARED scale for anxiety disorders
Screen positive patients (patients with score more than 25 on SCARED scale) diagnosed for different anxiety disorders by DSM-IV TR
Co morbid psychiatric disorders assessed by DSM-IV TR and impairment due to anxiety disorders assessed by CGAS
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