II. Definitions
- Anxiety Disorder
- Excessive Worry, anxiety or fear out of proportion to a situation, event, person, object or threat
- Physical manifestations are typically Sympathetic Nervous System driven (e.g. Palpitations, diaphoresis)
- Timing varies from persistent (e.g. Generalized Anxiety Disorder) to severe, brief episodes (e.g. Panic Attack, Specific Phobia)
- May manifest avoidance of specific activities, or interactions with objects or people
III. Epidemiology
- Anxiety Disorder Incidence (U.S.): 16%
- Family physicians treat 90% of anxiety patients
- Refer <10% of patients to psychiatry
- Childhood
- Childhood Prevalence worldwide: 6.5%
- Childhood Prevalence in U.S.
- Children age 3 to 17 years: 8%
- Children with behavioral problems: 36%
- Adolescents 13 to 17 years old: 7% formally diagnosed (estimated to be as high as 25%)
- Most common diagnoses include Specific Phobias, Social Anxiety Disorder and Separation Anxiety Disorder
- References
- Elderly have lower Incidence of anxiety
- Elderly women more affected than men
- Often associated with depression
IV. Pathophysiology
- Hyperarousal state
- Those with anxiety perceive a higher risk or fear in low risk situations
- Specific CNS circuits are activated with fear or noxious stimuli
- Begins in Brainstem reticular formation
- Locus Ceruleus (Secretes Norepinephrine)
- Dorsal and medial raphe nuclei (Secretes Serotonin)
V. Risk Factors: Children and Adolescents
- Lower socioeconomic status
- Exposure to Violence or Trauma
- Family History
- Parental anxiety
- Social Media engagement (esp. body image, Cyberbullying)
- Covid19 Pandemic
VI. Types: Primary Anxiety Disorder
VII. History
- Medical history
- Psychiatric history
- Family History of Anxiety Disorder and other mental health disorders
- Prior mental health management
- Medications (including over-the-counter and Herbals)
- Substance Use (e.g. Caffeine, Alcohol, Tobacco, Marijuana, Cocaine, Methamphetamine) by patient and close contacts
- Trauma History
- Psychosocial stressors
- Social functioning with others (e.g. parents, children, teachers, bosses, coworkers, peers and friends)
- Educational and work performance
- Self harm and Suicidal Ideation, planning or preparation
- Support people and resources
VIII. Findings: Signs and Symptoms
- See Anxiety Symptoms
- Excessive Worry, anxiety or fear out of proportion to a situation, event, person, object or threat
- Timing varies from persistent (e.g. Generalized Anxiety Disorder) to severe, brief episodes (e.g. Panic Attack, Specific Phobia)
- Physical manifestations are typically Sympathetic Nervous System driven
- Palpitations
- Diaphoresis
- Chest Pain
- Nausea
- Faintness
- Muscle tightness
- May manifest avoidance of specific activities, or interactions with objects or people
- Children may cry or throw tantrums or cling to those they see as protective (e.g. parents)
- Anxiety Disorders often persist and may progress to significant functional impact
- Social and relationship
- Education and work
IX. Differential Diagnosis: Psychiatric Conditions
- See Anxiety Secondary Causes
- Mania or Bipolar Disorder
-
Personality Disorder (Anxious cluster)
- Obsessive Compulsive Personality disorder
- Avoidant Personality Disorder
- Dependent Personality disorder
- Passive-Aggressive Personality Disorder
-
Anxiety Adjustment Disorder
- Appropriate response to a life stressor
- Schizophrenia
- Somatoform Disorder
X. Lab: Evaluation for Anxiety Secondary Causes
- No laboratory tests are required (perform only as indicated by history or exam)
- Common Studies
- Serum Chemistry profile
- Thyroid Stimulating Hormone (TSH)
- Urine Drug Screen
- Studies if specifically indicated
- Serum Cortisol
- Urine Catecholamines
XI. Diagnostics: Evaluation for Anxiety Secondary Causes
- No diagnostic tests are required (perform only as indicated by history or exam)
- Common Studies
- Electrocardiogram (EKG)
- Studies if specifically indicated
- Electroencephalogram (EEG)
- Vestibular testing
- Echocardiography
XII. Evaluation
- See Anxiety Scales
- Adult Scales
- Generalized Anxiety Disorder Scale (GAD-7)
- Short Health Anxiety Inventory (SHAI)
- PROMIS Emotional Distress-Anxiety Short Form for adults
- Severity Measure for Generalized Anxiety Disorder - Adults
- Hamilton Anxiety Scale (HAM-A)
- Zung Self Rating Scale for Anxiety
- Beck Anxiety Scale
- Pediatric Scales
- Screen for Child Anxiety Related Emotional Disorders (SCARED, ages 8 to 18 years)
- Spence Children's Anxiety Scale (SCAS, ages 8 to 15 years)
- Preschool Anxiety Scale (PAS, ages 30 months to 6.5 years)
XIII. Management
- See Anxiety Medications
- See Anxiety Non-pharmacologic Management
- Treatment is specific for the Anxiety Disorder
XIV. Prognosis
- Anxiety in children in teens often persists (including into adulthood) and is associated with frequent relapses