Keywords
Anxiety, Panic Disorder, Agoraphobia, Generalized Anxiety, Phobia, Mutism
Anxiety disorders are characterized by uneasiness, excessive rumination, and apprehension about the future. The conditions tend to be chronic, recurring, and vary in intensity over time. They affect 5-10% of children and adolescents ( Table 17.1 ) and have a lifetime prevalence of approximately 30%. Some common anxiety disorders are discussed in the following sections. Conditions such as obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are no longer included in the DSM-5 section on anxiety but continue to share a close relationship with anxiety disorders.
| FEATURE | PANIC DISORDER | GENERALIZED ANXIETY DISORDER | SEPARATION ANXIETY DISORDER | SPECIFIC PHOBIA |
|---|---|---|---|---|
| Epidemiology | Prevalence is 0.2-10%; Eight times more common and of early onset in family members of affected individuals than general population. | Prevalence is 2-4%. Sex ratio equal before puberty, but higher in female following puberty. Genetic factors play only a modest role in the etiology. | Prevalence is 3-4% of children and adolescents. The sex ratio is almost equal. Heritability of SAD is greater for girls than for boys. | Prevalence is 5% in children and approximately 16% in adolescence. Sex ratio is 2 : 1 females:males. Increased risk of specific phobias in first-degree relatives of patients with specific phobias. |
| Onset | Average age at onset is 20-24 years; <0.4% onset before 14 years of age. | The average age at onset is 10 years. | The average age at onset is 7 years. | Varies |
| Differential diagnosis | Anxiety disorder due to a general medical condition. Substance-related anxiety disorder due to caffeine or other stimulants. | Other anxiety disorders, OCD, PTSD, and depressive, bipolar, and psychotic disorders. Substance-related (caffeine and sedative-hypnotic withdrawal). | Other anxiety disorders and conduct, impulse-control, and disruptive behavior disorders. | Agoraphobia, panic disorder, OCD, and PTSD. |
| Co-morbidities | Separation anxiety disorder (common). Agoraphobia, substance use, major depression, OCD, and other anxiety disorders. Asthma patients have a high incidence of panic attacks. | Unipolar depression and other anxiety disorders. | GAD and specific phobia. | Depression and other anxiety disorders. |
| Prognosis | Frequently chronic with a relative high rate of suicide attempts and completions. | One study showed that 65% of children cease to have the diagnosis in 2 years. | Variable. The majority of children are not diagnosed with significant anxiety disorders as adults. | Social phobia in childhood may become associated with alcohol abuse in adolescence. |
Panic disorder is the presence of recurrent, unexpected panic attacks. A panic attack is a sudden unexpected onset of intense fear associated with a feeling of impending doom in the absence of real danger and may occur in the context of any anxiety disorder. The individual must experience four or more symptoms (e.g., sweating, palpitations, feeling of choking, chest pain, trembling/shaking, chills, paresthesias, fear of dying, fear of losing control, derealization, dizziness, nausea, or shortness of breath) during the attack. At least 1 month of persistent worrying about having another panic attack and/or a significant behavioral change following an attack (e.g., attempting to avoid another attack, avoidance of triggers such as exercise) is required to make the diagnosis.
Panic disorder often begins in adolescence or early adulthood. Symptom severity varies greatly. In children, the most commonly experienced symptoms include shortness of breath, palpitations, chest pain, a choking sensation, and a fear of losing control or going “crazy.” Symptoms may be brief or may last for prolonged periods of time; however, they generally last less than 15 minutes. Patients may believe that they are experiencing an acute medical condition (e.g., a heart attack).
Agoraphobia is a disorder marked by anxiety or fear of situations where escape is difficult or would draw unwanted attention to the person. This is limited to situations involving two or more of five specific situations: fear/anxiety about the use of public transportation, being in open spaces, being in enclosed spaces, standing in line or being in a crowd, or being outside of the home alone. Agoraphobia is often persistent and can leave people homebound. While agoraphobia does commonly occur with panic disorder, a substantial number of individuals experience agoraphobia without panic symptoms. First onset of agoraphobia is rare in children but more commonly presents in adolescence. Females are approximately twice as likely to experience the disorder. Agoraphobia is a chronic condition. In children, being outside of the home alone and worries regarding becoming lost are common complaints.
Generalized anxiety disorder (GAD) is characterized by 6 or more months of persistent, excessive worry and anxiety about a variety of situations or activities. The worries should be multiple, not paroxysmal, not focused on a single theme and should cause significant impairment. The anxiety must be accompanied by at least one of the following symptoms: restlessness, fatigue, concentration difficulties, irritability, muscle tension, or sleep disturbance. Physiological signs of anxiety are often present, including shakiness, trembling, and myalgias. Gastrointestinal symptoms (nausea, vomiting, diarrhea) and autonomic symptoms (tachycardia, shortness of breath) also commonly coexist. In children and adolescents, the specific symptoms of autonomic arousal are less prominent. Symptoms are often related to school performance or sports. Patients also commonly present with concerns about punctuality and may be perfectionistic. Children with GAD are often exceedingly self-conscious, have low self-esteem, and have more sleep disturbance than patients with other kinds of anxiety disorder. Care must be taken to elicit internalizing symptoms of negative cognitions about the self (hopelessness, helplessness, worthlessness, suicidal ideation), as well as those concerning relationships (embarrassment, self-consciousness) and associated with anxieties. Inquiry about eating, weight, energy, and interests should also be performed to eliminate a mood disorder. GAD is slightly male predominant prior to puberty, but by adolescence, females outnumber males.
Unspecified anxiety disorder is a common condition in clinical practice. This diagnosis is used when there is impairing anxiety or phobic symptoms that do not meet full criteria for another anxiety disorder.
Separation anxiety disorder (SAD) is marked by excessive distress or concern when separating from a major attachment figure ( Table 17.2 ). Most commonly, children and adolescents express vague somatic symptoms (e.g., headaches, abdominal pain, fatigue) in an attempt to avoid going to school or leaving their home. Patients may have a valid or an irrational concern about a parent or have had an unpleasant experience in school, and the prospect of returning to school provokes extreme anxiety and escalating symptoms. Children may refuse to go to school or leave their home. Children with SAD may require constant attention and present with struggles with separation at bedtime. SAD is a strong (78%) risk factor for developing problems in adulthood, such as panic disorder, agoraphobia, and depression. SAD may be highly heritable with community samples estimating such genetic rates as high as 73%.
