1
COVERING LETTER
To,
Hatta Sidi , MBBS MMed DipSHC.
Editor, ASEAN Journal of Psychiatry
Professor of Psychiatry, Department of Psychiatry,
Universiti Kebangsaan Malaysia Medical Center (UKMC) 56000 Cheras, Kuala Lumpur,
Malaysia.
Sub: Submission of Manuscript for publication
Dear Sir,
We intend to publish an article entitled [A CLINICAL STUDY OF
SUBSYNDROMAL
ANXIETY SYMPTOMS IN CHILDREN AND ADOLESCENTS FROM
INDIAN CHILD AND ADOLESCENT CLINIC ]
A NORTH
” in your esteemed journal as a
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Yours’ sincerely,
1.DR SATYAKAM MOHAPATRA 2.DR VIVEK AGARWAL3. DR. PRAVAT SITHOLEY4. DR AMIT ARYACorresponding contributor: DR SATYAKAM MOHAPATRA, MD
Senior resident
Mental health institute
S.C.B. medical college
Cuttack
3
Odisha, India, 753007
E mail id- satyakgmu@gmail.com
Mobile no- +918895293997
4
ACKNOWLEDGEMENT
A CLINICAL STUDY OF SUBSYNDROMAL ANXIETY SYMPTOMS IN CHILDREN
AND ADOLESCENTS FROM
A NORTH INDIAN CHILD AND ADOLESCENT
CLINIC
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NAMES
1.DR. SATYAKAM MOHAPATRA 2.DR. VIVEK AGARWAL3. DR. PRAVAT SITHOLEY4. DR. Amit Arya-
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A CLINICAL STUDY OF SUBSYNDROMAL ANXIETY SYMPTOMS IN CHILDREN
AND ADOLESCENTS FROM
A NORTH INDIAN CHILD AND ADOLESCENT
CLINIC
AUTHORS
1.DR. SATYAKAM MOHAPATRA, MD
Department of psychiatry
King George’s Medical University
Lucknow
Uttar pradesh
India
Present address- DR. SATYAKAM MOHAPATRA
Senior resident
Mental health institute
S.C.B. medical college
Cuttack
Odisha,
India
753007
7
2.DR. VIVEK AGARWAL, MD
Associate professor
Department of psychiatry
King George’s Medical University
Lucknow
Uttar pradesh
India
3. DR. PRABHAT SITHOLEY, MD
Ex- head and professor
Department of psychiatry
King George’s Medical University
Lucknow
Uttar pradesh
India
4. DR. AMIT ARYA, MD
Assistant professor
Department of psychiatry
8
King George’s Medical University
Lucknow
Uttar pradesh
India
CORESSPONDING AUTHOR
DR SATYAKAM MOHAPATRA, MD
Present address-Senior resident
Mental health institute
S.C.B. medical college
Cuttack
Odisha,
INDIA
753007
E mail id- satyakgmu@gmail.com
Mobile no- +918895293997
Total number of words-1037
9
Number of words in the abstract- 240
Numbers of references-07
Tables- 01
Figures-nil
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A CLINICAL STUDY OF SUBSYNDROMAL ANXIETY SYMPTOMS IN CHILDREN
AND ADOLESCENTS FROM
A NORTH INDIAN CHILD AND ADOLESCENT
CLINIC
ABSTRACT
Background & objectives: Though anxiety disorders are one of the most common group of
psychiatric disorders among children and adolescents, the frequency of subsyndromal forms of
anxiety in children and adolescents is unknown and under-diagnosed . No study is done in
India on subsymdromal anxiety symptoms in children and adolescents. Therefore, this study was
planned with the aim to identify subsymdromal anxiety symptoms in children and adolescents
and elicit their phenomenology and impairment.
Methods: Patients between age group 6 to 16 years attending child and adolescent psychiatry
clinic were screened by Screen for child anxiety related emotional disorders (SCARED) scale.
Those patients having anxiety symptoms, but not fulfilling criteria for any anxiety disorder their
phenomenology was assessed by SCARED scale. Impairment due to anxiety symptoms was
assessed by Children’s global assessment scale (CGAS).
Results: Out of 1465 screened patients 21(1.43%) patients had anxiety symptoms. Mean age of
patients with anxiety symptoms was 11.4±1.8years. Majority of patients were females patients
15(71%).
4(19.05%) patients had family history of psychiatric disorders. Mean score of anxiety
symptoms on SCARED scale was 18.24±2.51. Most of the subjects had some difficulty in
functioning (Mean C-GAS score -65±3.78).
Interpretation & conclusion: The significant prevalence of sub-syndromal anxiety symptoms,
the significant psychosocial impairment associated with it and the possible chronicity of its
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course should make the sub-syndromal anxiety symptoms a matter for serious consideration by
both clinicians and researchers.
Key words- anxiety, subsyndromal , children , adolescents.
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1.Introduction
The specification of diagnostic algorithms and cut off scores for different psychiatric disorders
has led to the new controversy as to whether the sub-threshold/subsyndromal symptoms are a
clinical problem at all, or separate phenomenon in their own right, or a minor form of major
psychiatric disorder1. Though anxiety disorders are one of the most common group of
psychiatric disorders among children and adolescents, the frequency of subsyndromal forms of
anxiety
in children and adolescents is unknown. Unfortunately, these are often significantly
underreported and under-diagnosed and difficult to recognize. Great Smoky Mountains Study2
showed that subsyndromal anxiety symptoms in children and adolescents quadrupled the
likelihood
of developing of anxiety disorders in the future. This study also revealed that
children and adolescents with subsyndromal forms of anxiety were twice as likely to have
impaired functioning compared to those with no symptoms. Typically, the best predictor of later
psychopathology2, including anxiety disorders , is earlier psychopathology. If symptoms of
anxiety in children and adolescents are predictive of disorders and impairment, then treatment
of
subsyndromal forms of anxiety in children and adolescents may be one of the few options
for reducing the chronicity of anxiety disorder.
No study is done in India on subsymdromal
anxiety symptoms 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 subsymdromal anxiety symptoms in children and adolescents and elicit their
phenomenology and impairment.
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2. Material and Method
This cross-sectional, clinic based study was carried out at Department of Psychiatry, King
Goerge’s medical university , Lucknow from August 2010 to July 2011 . The study was
approved by the institutional ethics committee. Inclusion criteria were, (i) non psychotic patients
between 6 to 16 years of age , (ii) availability of at least one reliable informant who may be a
parent or guardian of the subject, (iii) informed consent of the parent or guardian of the patient.
Exclusion criteria included, (i) patients with psychotic illness, (ii) patient with a severe physical
disorder or condition requiring priority medical management, (iii) Parents or guardians not
willing to give informed consent, (iv) non-availability of a reliable informant,(v) mental age <6
years.
All patients attending
child and adolescent psychiatry OPD were screened for selection
criteria. IQ assessment of the patients were done by the clinical psychologists by using Raven’s
Progressive Matrices3. All selected patients were screened by screen for child anxiety related
emotional disorders (SCARED) scale4 . Those
patients having anxiety symptoms, but not
fulfilling criteria for any anxiety disorder their phenomenology was assessed by screen for child
anxiety related emotional disorders (SCARED) scale. Impairment due to anxiety symptoms was
assessed by children’s global assessment scale (CGAS)5.
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3.Results
A total of 1465 persons were screened. Out of which
21(1.43%) patients had anxiety
symptoms. Mean age of patients with anxiety symptoms was 11.4±1.8years. Majority 15(71%)
patients were in childhood (6 -13 years) age group. 19(90%) had the onset of symptoms before
13years of age. Majority of patients were females patients 15(72%). Majority of patients belong
to urban area 15(71%). Eighteen (86%) patients were students. Mean IQ of subjects was
92.24±1.82.
4(19.05%) patients had family history of psychiatric disorders. Out of which
2(50%) patients had family history of
generalized anxiety disorder and 1(25%) each patients
had family history of major depressive disorder and bipolar affective disorders. Mean score of
anxiety symptoms on scared was 18.24±2.51.
TABLE I. PHENOMENOLOGY OF ANXIETY SYMPTOMS
ANXIETY SYMPTOMS
N(21)
%
Feeling of nervousness
14
67%
Frightened for no reason
8
38%
Worry about sleeping alone
7
33%
Afraid to be alone in the house
7
33%
Stomach ache at school
11
53%
Worry about going to school
10
48%
Nightmares that something is happening to me
5
24%
Worry about sleeping alone
6
29%
Headache when at school
8
38%
Do not like to be away from home
7
33%
15
Shy with unknown people
8
38%
Heart beats first when frightened
5
24%
Nervous with unknown people
12
58%
Difficult to breath when frightened
4
19%
*Not mutually exclusive
Most of the subjects had some difficulty in functioning (Mean C-GAS score -65±3.78).
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4.Discussion- In our study out of 1465 screened patients 21 (1.43%) patients had anxiety
symptoms not fulfilling criteria for any anxiety disorder. Though no Indian data is available
regarding frequency of subsyndromal anxiety symptoms in children and adolescents, but while
comparing with the frequency of anxiety disorders in children and adolescents from
epidemiological study conducted by
the
Indian Council of Medical Research6 at two centres
Bangalore (3.93%) and Lucknow (2.32%) , it can be concluded that subsyndromal anxiety
symptoms are significantly present in Indian children and adolescents population. This study is
a clinic based study. So the frequency of subsyndromal
anxiety symptoms in children and
adolescents may be more in community setting.
Though anxiety disorders in children and adolescents are associated with significant impairment
in functioning7 but in our study most of the subjects of subsyndromal anxiety symptoms also
had some difficulty in functioning (Mean C-GAS score -65±3.78). This finding is supported by
Great Smoky Mountains Study2 on subsyndomal anxiety symptoms which revealed that
children and adolescents only with symptoms of anxiety were twice as likely to have impaired
functioning compared to those with no symptoms. Thus, in this study, subsyndromal anxiety
symptoms were associated with children and adolescents' impaired ability to function well at
home, at school, and with peers.
Great Smoky Mountains Study2 on subsyndomal anxiety symptoms also revealed that children
and adolescents with anxiety disorders show clinical symptoms of anxiety even at times when
they would not meet formal diagnostic criteria of any anxiety disorders. This study also showed
that subsyndromal anxiety symptoms quadrupled the likelihood that children and adolescents
without a previous history of anxiety disorders would develop anxiety disorders in future.
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The significant prevalence of sub-syndromal anxiety symptoms, the significant psychosocial
impairment associated with it and the possible chronicity of its course should make the subsyndromal anxiety
symptoms a matter for serious consideration by both clinicians and
researchers. Thus, there is a need to give research-based recognition to sub-syndromal anxiety
symptoms along with their associated repercussions and a comprehensive strategy including
guidelines for addressing this matter from the management point of view.
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5. References
1.Ram D , Ram D.Subsyndromal states in bipolar disorder. Indian J Psychiatry. 2010 52(4):
367–370
2.Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of
psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry. 2003;60:837–844 .
3.Raven J, Raven JC, Court JH. Manual for Raven’s progressive matrices and vocabulary scales.
San Antonio, TX: Harcourt Assessment; 2003.
4.Birmaher,B. Khetarpal,S. Brent, D.Cully, M.Brent, D.& McKenzie, S et al . Screen for Child
Anxiety Related Emotional Disorders (SCARED).Child Psychiatry Department, Western
Psychiatric Institute and Clinic, 1995.
5.Shaffer D, Gould MS, Brasic J, et al. A children's global assessment scale (CGAS). Archives
of General Psychiatry, 1983, 40, 1228-1231.
6.Indian Council of Medical Research. Epidemiological study of child and adolescent psychiatric
disorders in urban and rural areas. 2001
7.Ialongo N , Edelsohn G, Larsson L, Crockett L, & Kellam S et al , The significance of self
reported anxious symptoms in prediction to anxious symptoms and adaptive functioning in fifth
grade .Journal of child psychology and Psychiatry and allied disciplines, 1994: 36, 427-43.