儿童和青少年中的强迫症和社交焦虑障碍课件

儿童和青少年中的 强迫症和社交焦虑障碍,OCD And Social Anxiety Disorder In Children And Adolescents John T. Walkup, MD,Financial Disclosure Statement John T.Walkup,MD,Consultant Janssen Pharmaceutica Inc,Solvay Pharmaceuticals Grants/Research Support GlaxoSmithKline,Lilly Research Laboratories,Pfizer Inc,Solvay Pharmaceuticals,Wyeth-Ayerst Laboratories,Introduction,Review -OCD -social anxiety disorder Review recently published RUPP anxiety treatment study for -separation anxiety disorder -social anxiety disorder -generalized anxiety disorder,Obsessive-Compulsive Disorder Controlled Trials,Clomipramine-DeVeaugh-Geiss et al,1992 Fluoxetine-Riddle et al,1992 Sertraline-March et al,1998 Fluvoxamine-Riddle et al,2001 Paroxetine-data analysis Fluoxetine-data analysis Paroxetine ii-study under way Foa and March-study under way,Sertraline In Childhood OCD,Double-blind,placebo-controlled,12-week,multisite trial N=187;age=6-7 year;sertraline200mg/d Sertralineplacebo Mild side effects Similar profile of response as clomipramine March et al.JAMA,1998;280:1752.,Fluvoxamine In Childhood OCD,Double-blind,placebo-controlled,multisite trial N=120;age=8-17 years;fluvoxamine 50-200mg/d Fluvoxamineplacebo Mild side effects Riddle et al.J Am Acad Child Adolesc Psychiatry.2001;40:222.,Paroxetine In Childhood OCD,Double-blind,placebo-controlled,multisite trial 16 weeks open-label treatment and 16 weeks double-blind treatment N=375;mean age=12 years;paroxetine 10-60mg/d Mild side effects Emsile et al.presented at the American Psychiatric Association Meeting.Chicago.IL.2000.,Long-Term Treatment Of OCD In Children And Adolescents,Leonard et al,1991 DeVeaugh-Geiss et al,1992 Walkup et al,1999 Wagner et al,1999,Desipramine Substitution During Long-Term Treatment With Clomipramine,Double-blind desipramine substitution(8 months) N=26 on long-term clomipramine for OCD Results Leonard et al.Arch Gen Psychiatry.1991;48:922.,Fluvoxamine In Childhood CD: long-Term Treatment,Multisite,long-tterm,open-label trial N=98,ages 8-17 years;fluvoxamine200 mg/d Adverse events:hyperactivityin children;somnolenceadolescence Walkup et al.Presented at the Annual Meeting of the American Academy of Child and Adolescent Psychiatry.1999.,Sertraline In Childnood OCD: Long-Term Trial,Multicenter,long-term,open-label,extension trial N=137;sertraline-120mg/d Significant reduction in mean CY-BOCS from beginning of extension(17.0)to end(10.8) Adverse vents:hyperkinesia,headache,insomnia,GI distress Wagner et al.Presented at NCDEU 39th Annual Meeting Boca Raton.Florida;June 1-4,1999.,When To Discontinue Therapy For OCD?,Plan discontinuation trial After a stable response After a trial of CBT It may be sooner than you think During a nonstressful period Never in winter? Is summer camp better?,Social Anxiety Disorder Controlled Trials,Paroxetine-study under way Beidel and Sallee,Controlled Trials: Sparation Anxiety Disorder,Social Anxiety Disorder,Generalized Anxiety Disorder,Research units of pediatric psychopharmacology -Columbia/Johns Hopkins site-fluvoxamine -Pittsburgh site-fluoxetine,Pharmacology Of Pediatric Anxiety Diagnostic Issues,High degree of comorbidity (Biederman et al.1995;Gurley et al.1996) -social phobia,generalized anxiety disorder,separation anxiety disorder -but not panic disorder,PTSD or OCD Prior studies target disorders as a group(Birmaher et at.1994;Barrett et al.1996;Fairbanks et al.1996;Kendall et al.1995),The Research Units Of Pediatric Psychopharmacology Anxiety Group,Johns Hopkins University:John Walkup,MD;Mark Riddle,MD;Michael Labellarte,MD Columbia University at NYSPI:Daniel Pine,MD;Laurence Greenhill,MD;Rachel Klein,PhD;Mark Davies,MPH;Michael Sweeney,PhD New york University:Howard Abikoff,PhD;Sabine Hack,MD;Pbrian Klee,MD University of California,Los Angeles:James McCracken,MD;Lindsay Bergman,PhD;John Piacentini,PhD Duke University:John March,MD MPH;Scott Compton,PhD Nathan Kline Institute:James Robinson,Med;Thomas OHara;Sheryll Baker,PhD National Institute Mental Health:Benedetto Vitiello.MD;Louise Ritz,MBA;Margaret Roper,MPH,Study Methodology: Subject Criteria,Diagnosis and other inclusion criteria -SAD,SoAD,GAD;ages 6-17 y -PARSmoderate severity -CGAS69 Exclusion criteria -Other serious psychiatric disorders -Conditions know to be responsive to SSRIs -Past SSRI failure -Need for stimulants PARS=Pediatric anxiety rating scale. RUPP.In press.,Study Methodology: Measures,Primary outcome measures: -continuous:PARS development and reliability testing -categorical:CGI-I definition of responder Secondary outcome measures: -MASC,SCARED(parent,child) -CGAS,HAM-A,CGI-S RUPP,In press,Study Methodology: Procedures,3-week open psychoeducational phase:-exclude responders to intervention 8-week parallel-group study: -randomization at NIMH(50/50) -continue psychosocial intervention -dosing:start at 25mg,increase to 250 mg(6-12years old)or 300mg(13-18 years old)by week 6 -weekly:PARS,CGI-S&I,adverse effects,side effects RUPP,In press.,SSRIs:Complications Of Treatment,Activation Bipolar switching Celebration Dimensional issues and comorbidities Disorders Evolving psychopathology Frontal-lobe symptoms-apathy Gastrointestinal symptoms Hey!,SSRIs:Dosing In Children And Adolescents,Fluoxetine 10-20mg/day Par