The DSM-5 is expected to place obsessive-compulsive disorder and posttraumatic stress disorder into their own diagnostic categories, removing them from the family of anxiety disorders, according to Dr. Daniel S. Pine.
Setting trauma-related and obsessive-compulsive spectrum disorders off on their own makes sense because the "longitudinal outcomes, comorbidities, familial aggregations, and underlying biology" suggest the conditions are different from anxiety disorders, said Dr. Pine, chief of the section on development and affective neuroscience at the National Institute of Mental Health in Bethesda, Md.
Dr. Daniel S. Pine
This new approach also makes sense because the disorders that will be left in the anxiety category – generalized, social, separation, panic, and phobic anxieties – are pretty much treated the same way. "Nothing in the treatment literature suggests we should approach any of these [problems] differently from any of the others," Dr. Pine said at a psychopharmacology update sponsored by the American Academy of Child and Adolescent Psychiatry.
Overall, such problems "are incredibly common [in children]. One in three will, some time in their adolescence, have an anxiety disorder." They go away in most, but the minority in whom they persist "account for the majority of chronic mood and anxiety disorders" in adults, he said.
It’s probably the same for "substance abuse, conduct problems, personality disorders, eating disorders, mood disorders," and other problems. Children who don’t overcome those issues are the "precursors for adults who have a problem," Dr. Pine said.
"The hope of neuroscience is that it will give us better clues about" which anxious children will progress, he said. "We’re very bad at predicting that right now." Children who are worse seem to do worse over time, but beyond that, gender, age, type of anxiety disorder, and other factors do not seem to predict persistence into adulthood, he said.
As with adults, selective serotonin reuptake inhibitors (SSRIs) "are extremely good" for treating anxiety in children, and "there’s particularly good" evidence for fluvoxamine, fluoxetine, paroxetine, and sertraline. Across studies, the number needed to treat is about three, which is "about as good a treatment as we can get," he said, noting that SSRIs are "much better treatments" for anxiety than for depression (J. Am. Acad. Child Adolesc. Psychiatry 2003;42:415-23).
But because anxiety disorders are transient in most children and the effect of SSRIs on developing brains is unknown, children "deserve a trial off medication" after a year of treatment, he said.
There’s also "very good evidence" that cognitive-behavioral therapy (CBT) helps anxiety, too, though it might be a bit slower than SSRIs. Combining the two also is a possibility. In one 12-week study (N. Engl. J. Med. 2008;359:2753-66), it was clear that combination treatment was the best, Dr. Pine said.
Despite the value of treating anxiety with SSRIs, it is important to remain vigilant of the increased risk of suicidal ideations and attempts that accompany use of these medications in children and adolescents. "You really are obliged to spend a fair amount of time reviewing with parents the nature of that risk," he said.
Dr. Pine said that he had no financial disclosures.