Anxiety Disorders

BACKGROUND

Description and Occurrence

A variety of anxiety disorders can occur in people with mental retardation, including Generalized Anxiety Disorder, Panic Disorder, Social Anxiety Disorder, phobias and Obsessive Compulsive Disorder (OCD). The identification of anxiety disorder in people with developmental disabilities can be elusive if the approach is purely probing for anxiety symptoms with the patient. In people with communication difficulties and difficulty with verbally expressing emotional states the diagnosis must be postulated from observations made by primary caretakers. For example caretakers may describe social avoidance, withdrawal, escalation of behaviors in new settings, increase in reparative actions or stereotypes, persistence on sameness in environment, and signs of autonomic arousal. Some genetic syndromes include a behavioral phenotype consistent with an anxiety disorders (e.g., Prader Willi syndrome and OCD ; Fragile X and anxiety/social withdrawal). The prevalence of anxiety disorders has been estimated at 10 – 25% in persons with mental retardation and is thought to be equally prevalent in males and females.

Characteristic Features

Condensed Diagnostic and Statistical Manual of Mental Disorders Ed. IV (DSM-IV) Criteria

Generalized Anxiety Disorder

Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
The person finds it difficult to control the worry.
The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children.
- Restlessness or feeling keyed up or on edge
- Being easily fatigued
- Difficulty concentrating or mind going blank
- Irritability
- Muscle tension
- Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

Panic Disorder

A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

Palpitations, pounding heart, or accelerated heart rate
Sweating
Trembling or shaking
Sensations of shortness of breath or smothering
Feeling of choking
Chest pain or discomfort
Nausea or abdominal distress
Feeling dizzy, unsteady, lightheaded, or faint
Derealization (feelings of unreality) or depersonalization (being detached from oneself)
Fear of losing control or going crazy
Fear of dying
Paresthesias (numbness or tingling sensations)
Chills or hot flashes

Obsessive-Compulsive Disorder

Either obsessions or compulsions:

Obsessions as defined by (1), (2), (3), and (4):

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 or distress
The thoughts, impulses, or images are not simply excessive worries about real-life problems
The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

Compulsions as defined by (1) and (2):

Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

Diagnostic Considerations

Given the range of anxiety disorders that can occur in people with mental retardation, a careful assessment for these disorders must be attempted. Factors which can impact the expression of an anxiety disorder include comorbid mood disorder, association with a genetic syndrome and its behavioral phenotype, medication induced and psychosocial stress factors (e.g., loss of caregiver, changes in living situation). The work-up should also rule out any other causes, such as hyperthyroidism, that can masquerade as mental illness. The evaluation for anxiety disorders should include interview with family/caregivers/educational or vocational staff, direct observation of behavior and impact on ability to function, functional behavioral assessment, medication and side effects evaluation, medical history/physical exam, and an assessment of communication skills. The physician or other primary care provider must determine developmental age, as it is well known that behavior is developmental. What is “normal” for a two-year old could be problematic for a ten-year-old child. If this is not taken into consideration, one can make an inaccurate diagnosis.

MEDICAL MANAGEMENT CONSIDERATIONS

The treatment needs to involve psychosocial treatment preferably by a multidisciplinary team. The team will need to assess functional analysis of behavior, support services of caregivers, environmental modifications, cognitive-behavioral therapy, client and/or caregiver education, and consider psychopharmacological interventions. In some situations heightened levels of anxiety associated with anxiety disorders can present with severe self-injurious behaviors or aggression. Therefore, assessing safety of the person or others must be the first consideration. If safety cannot be adequately secured in their current setting, acute treatment modalities need to be considered such as hospitalization or 1:1 staffing.

Medication Management

Medications can be an important component of the treatment of anxiety disorders, some examples are listed below:

Selective Serotonin Reuptake Inhibitors – for generalized anxiety disorder (Paxil or Paxil CR), panic disorder (Paxil, Zoloft), social phobia (Paxil) and OCD (Paxil, Prozac, Zoloft; Zoloft in children)
Buspirone (Buspar) and venlafaxine (Effexor) – FDA-approved for the treatment of generalized anxiety disorder
Benzodiazepine – for short term relief of anxiety symptoms, be aware that some individuals respond negatively to benzodiazepines manifested by disinhibited behaviors
Atypical antipsychotics such as risperidone (Risperdal) are potent second-line anxiolytics that may also facilitate sleep

REFERENCES

Aman, M.G., Collier-Crespin, A., Lindsay, R.L. (2000). Pharmacotherapy of Disorders in Mental Retardation. European Child and Adolescent Psychiatry 9, Supplement 1:I, 98-107.

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR). Washington DC: American Psychiatric Association

Jellinek, M., Patel, B.P., Froehle, M.C. (2002). (Eds.) Bright Futures in Practice: Mental Health (vols. I & II). Arlington, VA: National Center for Education in Maternal and Child Health.

Kaplan, H.I., Sadock, B.J. (1995). (Eds.) Comprehensive Textbook of Psychiatry/VI, Volume 2, 6^th edition. Baltimore: Williams & Wilkins.

Linna, S.L., Moilanen, I., Ebeling, H., Piha, J., Kumpulainen, K., Tamminen, T., Almqvist, F. (1999). Psychiatric Symptoms in Children with ntellectual Disability. European Child & Adolescent Psychiatry, 8, Supplement 4, IV/77-IV82.

Masi. G., Brovedani, P., Mucci, M., Favilla, L. (2002). Assessment of Anxiety and Depression in Adolescents with Mental Retardation. Child Psychiatry and Human Development, 32(3), 227-237.

Masi, G., Favilla, L., Mucci, M. (2000). Generalized Anxiety Disorder in Adolescents and Young Adults with Mild Mental Retardation. Psychiatry, 63(1), 54-64.

Rush AJ, Frances A (2000) (Eds), Treatment of psychiatric and behavioral problems in mental retardation. American Journal of Mental Retardation 105:3, 1-71

Szymanski, L., King, B.H. (1999). Practice Parameters for the Assessment & Treatment of Children, Adolescents, & Adults with Mental Retardation and Comorbid Mental Disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 38(12), supplement, 5S-31S.

RESOURCES FOR FAMILIES

American Academy of Child and Adolescent Psychiatry

3615 Wisconsin Avenue N.W.

Washington, D.C. 20016-3007

202-966-7300

http://www.aacap.org

The Arc (formally Association for Retarded Citizens)

500 East Border Street, Suite 300

Arlington, Texas 76010

617-261-6003

800-433-5225

Home

California Department of Developmental Services

P.O. Box 944202

Sacramento, CA 94244-2020

916-654-1690

http://www.dds.ca.gov

California Regional Centers 915-654-1958,

http://www.dds.ca.gov/rc/RCInfo.cfm

California Alliance for the Mentally Ill

1111 Howe Avenue, Suite 475

Sacramento, CA 95825-8541

916-567-0163

800-950-NAMI

Fax: 916-567-1757

[email protected]

http://www.nami.org

http://namicalifornia.org

National Mental Health Association Information Center

2001 North Beauregard Street, 12^th floor

Alexandria, VA 22311

703-684-7722

800-969-6642

Fax: 703-684-5968

[email protected]

http://www.nmha.org

Association of University Centers on Disabilities

8630 Fenton Street, Suite 410

Silver Spring, MD 20910-3803

301-588-8252

http://www.aucd.org

The National Association for the Dually Diagnosed

132 Fair Street

Kingston, NY 12401

800-331-5362

http://www.thenadd.org

Project MED (Medical Education for Consumers)

http://www.projectmed.org

The Tarjan Center for Developmental Disabilities at UCLA

http://www.tarjancenter.ucla.edu

California Mental Health and Developmental Disabilities Center

http://www.mhddc.ucla.edu

American Psychiatric Association

1400 K Street N.W.

Washington, DC 20005

888-337-7924

http://www.psych.org

ADVISORY COMMITTEE

Theodore A. Kastner, M.D., M.S.

Leonard Magnani, M.D., Ph.D.

Felice Weber Parisi, M.D., M.P.H.

Terrance D. Wardinsky, M.D.

PUBLICATION INFORMATION

Funded by a grant from the California Department of Developmental Services

For more information, contact:

Center for Health Improvement

1330 21st Street, Suite 100

Sacramento, CA 95814

(916) 901-9645

This document does not provide advice regarding medical diagnosis or treatment for any individual case, and any opinions or statements contained in this document are not intended to serve as a standard of medical care. Physicians are encouraged to view the considerations presented in this document in light of evolving scientific information. This document is not intended for use by the layperson. Reproduction of this document may be done with proper credit given to California Department of Developmental Services and the Center for Health Improvement.