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1、儿童和青少年中的强迫症和社交焦虑障碍第1页，本讲稿共22页Financial Disclosure Statement John T.Walkup,MDnConsultantnJanssen Pharmaceutica Inc,Solvay PharmaceuticalsnGrants/Research SupportnGlaxoSmithKline,Lilly Research Laboratories,Pfizer Inc,Solvay Pharmaceuticals,Wyeth-Ayerst Laboratories第2页，本讲稿共22页IntroductionnReviewn -OCD
2、n -social anxiety disordernReview recently published RUPP anxiety treatment study forn -separation anxiety disordern -social anxiety disordern -generalized anxiety disorder第3页，本讲稿共22页Obsessive-Compulsive Disorder Controlled TrialsnClomipramine-DeVeaugh-Geiss et al,1992nFluoxetine-Riddle et al,1992nS
3、ertraline-March et al,1998nFluvoxamine-Riddle et al,2001nParoxetine-data analysisnFluoxetine-data analysisnParoxetine ii-study under waynFoa and March-study under way第4页，本讲稿共22页Sertraline In Childhood OCDnDouble-blind,placebo-controlled,12-week,multisite trialnN=187;age=6-7 year;sertraline200mg/dnSe
4、rtralineplacebonMild side effectsnSimilar profile of response as clomipraminenMarch et al.JAMA,1998;280:1752.第5页，本讲稿共22页Fluvoxamine In Childhood OCDnDouble-blind,placebo-controlled,multisite trial nN=120;age=8-17 years;fluvoxamine 50-200mg/dnFluvoxamineplacebonMild side effectsnRiddle et al.J Am Aca
5、d Child Adolesc Psychiatry.2001;40:222.第6页，本讲稿共22页Paroxetine In Childhood OCDnDouble-blind,placebo-controlled,multisite trialn16 weeks open-label treatment and 16 weeks double-blind treatmentnN=375;mean age=12 years;paroxetine 10-60mg/dnMild side effectsnEmsile et al.presented at the American Psychi
6、atric Association Meeting.Chicago.IL.2000.第7页，本讲稿共22页Long-Term Treatment Of OCD In Children And AdolescentsnLeonard et al,1991nDeVeaugh-Geiss et al,1992nWalkup et al,1999nWagner et al,1999第8页，本讲稿共22页Desipramine Substitution During Long-Term Treatment With ClomipraminenDouble-blind desipramine substi
7、tution(8 months)nN=26 on long-term clomipramine for OCDnResultsnLeonard et al.Arch Gen Psychiatry.1991;48:922.第9页，本讲稿共22页Fluvoxamine In Childhood CD:long-Term TreatmentnMultisite,long-tterm,open-label trialnN=98,ages 8-17 years;fluvoxamine200 mg/dnAdverse events:hyperactivityin children;somnolencead
8、olescencenWalkup et al.Presented at the Annual Meeting of the American Academy of Child and Adolescent Psychiatry.1999.第10页，本讲稿共22页Sertraline In Childnood OCD:Long-Term TrialnMulticenter,long-term,open-label,extension trialnN=137;sertraline-120mg/dnSignificant reduction in mean CY-BOCS from beginnin
9、g of extension(17.0)to end(10.8)nAdverse vents:hyperkinesia,headache,insomnia,GI distressnWagner et al.Presented at NCDEU 39th Annual Meeting Boca Raton.Florida;June 1-4,1999.第11页，本讲稿共22页When To Discontinue Therapy For OCD?nPlan discontinuation trialnAfter a stable responsenAfter a trial of CBTnIt m
10、ay be sooner than you thinknDuring a nonstressful periodnNever in winter?nIs summer camp better?第12页，本讲稿共22页Social Anxiety DisorderControlled TrialsnParoxetine-study under waynBeidel and Sallee第13页，本讲稿共22页Controlled Trials:Sparation Anxiety Disorder,Social AnxietyDisorder,Generalized Anxiety Disorde
11、rnResearch units of pediatric psychopharmacologyn -Columbia/Johns Hopkins site-fluvoxaminen -Pittsburgh site-fluoxetine第14页，本讲稿共22页Pharmacology Of Pediatric AnxietyDiagnostic IssuesnHigh degree of comorbidity(Biederman et al.1995;Gurley et al.1996)n -social phobia,generalized anxiety disorder,separa
12、tion anxiety disordern -but not panic disorder,PTSD or OCDnPrior studies target disorders as a group(Birmaher et at.1994;Barrett et al.1996;Fairbanks et al.1996;Kendall et al.1995)第15页，本讲稿共22页The Research Units Of Pediatric Psychopharmacology Anxiety GroupnJohns Hopkins University:John Walkup,MD;Mar
13、k Riddle,MD;Michael Labellarte,MDnColumbia University at NYSPI:Daniel Pine,MD;Laurence Greenhill,MD;Rachel Klein,PhD;Mark Davies,MPH;Michael Sweeney,PhDnNew york University:Howard Abikoff,PhD;Sabine Hack,MD;Pbrian Klee,MDnUniversity of California,Los Angeles:James McCracken,MD;Lindsay Bergman,PhD;Jo
14、hn Piacentini,PhDnDuke University:John March,MD MPH;Scott Compton,PhDnNathan Kline Institute:James Robinson,Med;Thomas OHara;Sheryll Baker,PhDnNational Institute Mental Health:Benedetto Vitiello.MD;Louise Ritz,MBA;Margaret Roper,MPH第16页，本讲稿共22页Study Methodology:Subject CriterianDiagnosis and other i
15、nclusion criterian -SAD,SoAD,GAD;ages 6-17 yn -PARSmoderate severityn -CGAS69nExclusion criterian -Other serious psychiatric disordersn -Conditions know to be responsive to SSRIsn -Past SSRI failuren -Need for stimulantsnPARS=Pediatric anxiety rating scale.nRUPP.In press.第17页，本讲稿共22页Study Methodolog
16、y:MeasuresnPrimary outcome measures:n -continuous:PARSn development and reliability testingn -categorical:CGI-In definition of responder Secondary outcome measures:-MASC,SCARED(parent,child)-CGAS,HAM-A,CGI-SRUPP,In pressn 第18页，本讲稿共22页Study Methodology:Proceduresn3-week open psychoeducational phase:-
17、exclude responders to interventionn8-week parallel-group study:n -randomization at NIMH(50/50)n -continue psychosocial interventionn -dosing:start at 25mg,increase to 250 mg(6-12years old)or 300mg(13-18 years old)by week 6n -weekly:PARS,CGI-S&I,adverse effects,side effectsnRUPP,In press.第19页，本讲稿共22页
18、SSRIs:Complications Of TreatmentnActivationnBipolar switchingnCelebrationnDimensional issues and comorbiditiesnDisordersnEvolving psychopathologynFrontal-lobe symptoms-apathynGastrointestinal symptomsnHey!第20页，本讲稿共22页SSRIs:Dosing In Children And AdolescentsnFluoxetine 10-20mg/daynParoxetine 20-30mg/daynSertraline 25-125mg/daynFluvoxamine 50-150mg/daynCitalopram 20-40mg/day第21页，本讲稿共22页OCD And Social Anxiety Disorder In Children And Adolescents:SummarynDo not minimize anxiety symptom severitynData from numerous controlled trialsnSSRIs are likely to be very helpful第22页，本讲稿共22页