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    anxiety in children

    look for books about anxiety disorders in children

    Main > Diseases and Conditions > Anxiety Disorders

    Childhood and Adolescent
    Anxiety Disorders

    by William T. Goldman, MD
    Anxiety symptoms and disorders are the number one health problem in America, ranging from a simple Adjustment Disorder to more difficult and debilitating disorders such as Panic Disorder and Posttraumatic Stress Disorder. According to the most recent data, the lifetime prevalence for anxiety disorders as a whole in adults is about 25%; the frequency in children is unknown, but felt to be significantly underreported and under-diagnosed. More specifically Social Anxiety Disorder has a lifetime risk of 17%, while Panic Disorder occurs in approximately 1-3% of the adult population.
      
      


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    Although quite common, Anxiety Disorders in children often are overlooked or misjudged, despite them being very treatable conditions with good, persistent medical care. What does seem to be developing in the medical literature is the consensus that many “adult” psychiatric disorders likely have their first (although perhaps subtle or ignored) manifestations in childhood, and that if left untreated these anxiety disorders in children likely progress to adult versions.

    Symptoms of Anxiety Disorders

    Anxiety is a subjective sense of worry, apprehension, fear and distress. Often it is normal to have these sensations on occasion, and so it is important to distinguish between normal levels of anxiety and unhealthy or pathologic levels of anxiety. The subjective experience of anxiety typically has two components: physical sensations (e.g., headache, nausea, sweating) and the emotions of nervousness and fear. Anxiety disorders, when severe, can affect a child's thinking, decision-making ability, perceptions of the environment, learning and concentration. It raises blood pressure and heart rate, and can cause a multitude of bodily complaints, such as nausea, vomiting, stomach pain, ulcers, diarrhea, tingling, weakness, and shortness of breath, among other things.

    Types of Anxiety Disorders

    Diagnosis of normal versus abnormal anxiety depends largely upon the degree of distress and its effect on a child's functioning in life. The degree of abnormality must be gauged within the context of the child's age and developmental level. The specific anxiety disorder is diagnosed by the pattern and quality of symptoms as follows:

    • Generalized Anxiety Disorder. Defined as excessive worry, apprehension, and anxiety occurring most days for a period of 6 months or more that involves concern over a number of activities or events. The person has difficulty controlling the anxiety, which is associated with the following: restlessness, feeling “keyed up” or on edge; being easily fatigued; difficulty concentrating or having the mind go blank; irritability; muscle tension; difficulty falling asleep or staying asleep, or restless sleep. The anxiety causes significant distress and problems functioning.
    • Panic Disorder. Panic Disorder is different from Panic Attacks; panic attacks are defined as sudden, discrete episodes of intense fear and/or discomfort accompanied by 4 out of 13 bodily or cognitive symptoms, often manifesting with an intense desire to escape, feeling of doom or dread, and impending danger. These symptoms peak within 10 minutes, and often subside within 20-30 minutes. The 13 symptoms are: heart palpitations or fast heart rate; sweating; trembling or shaking; shortness of breath or smothering; choking sensation; chest discomfort or pain; nausea or abdominal distress; feeling dizzy, lightheaded, faint or unsteady; feelings of unreality or being detached from oneself; fear of losing control or going crazy; fear of dying; numbness or tingling sensations; chills or hot flashes. Panic Disorder consists of recurrent unexpected panic attacks with inter-episode worry about having others; the panic attacks lead to marked changes in behavior related to the attacks. Panic attacks are frequently associated with Agoraphobia (anxiety and avoidance of situations from which escape might be difficult or help might not be available).
    • Obsessive-Compulsive Disorder. Defined by persistent Obsessions (intrusive, unwanted thoughts, images, ideas or urges) and/or Compulsions (intense uncontrollable repetitive behaviors or mental acts related to the obsessions) that are noted to be unreasonable and excessive. These obsessions and compulsions cause notable distress and impairment and are time consuming (more than one hour a day). The most common obsessions concern dirt and contamination, repeated doubts, need to have things arranged in a specific way, fearful aggressive or murderous impulses, and disturbing sexual imagery. The most frequent compulsions involve repetitive washing of hands or using handkerchief/tissue to touch things; checking drawers, locks, windows, and doors; counting rituals; repeating actions; and requesting reassurance.
    • Posttraumatic Stress Disorder. A person is exposed to a traumatic event in which he or she experiences, witnesses, or is confronted by an event or events that involved actual or perceived threat of death or serious bodily injury, and the person’s response involves intense fear, helplessness, or horror. The traumatic event is continually re-experienced in the following ways: recurrent and intrusive distressing remembrances of the event involving images, thoughts, or perceptions; distressing dreams of the event; acting or believing that the traumatic event is recurring; intense anxiety and distress to exposure to situations that resemble the traumatic event; bodily reactivity on exposure situations that resemble the traumatic event. The person avoids situations associated with and remind him of the traumatic event, leading to avoidance of thoughts, feelings or conversations associated with the trauma; activities, places, or people that remind him of the traumatic event; inability to remember details of the event; markedly diminished participation and interest in usual activities; feeling detached and estranged from others; restricted range of emotional expression; sense of a foreshortened future or lifespan; persistent signs of physiologic arousal, such as difficulty falling asleep or staying asleep, irritability or anger outbursts, difficulty concentrating, excessive vigilance, and exaggerated startle response. The above symptoms persist for more than one month and cause significant distress and impairment of functioning.
    • Acute Stress Disorder. A person is exposed to a traumatic event in which he or she experiences, witnesses, or is confronted by an event or events that involved actual or perceived threat of death or serious bodily injury, and the person’s response involves intense fear, helplessness, or horror. The traumatic event is continually re-experienced in the following ways: recurrent and intrusive distressing remembrances of the event involving images, thoughts, or perceptions; distressing dreams of the event; acting or believing that the traumatic event is recurring; intense anxiety and distress to exposure to situations that resemble the traumatic event; bodily reactivity on exposure situations that resemble the traumatic event. The person avoids situations associated with and remind him of the traumatic event, leading to avoidance of thoughts, feelings or conversations associated with the trauma; activities, places, or people that remind him of the traumatic event; inability to remember details of the event; markedly diminished participation and interest in usual activities; feeling detached and estranged from others; restricted range of emotional expression; sense of a foreshortened future or lifespan; persistent signs of physiologic arousal, such as difficulty falling asleep or staying asleep, irritability or anger outbursts, difficulty concentrating, excessive vigilance, and exaggerated startle response. The above symptoms persist for less than one month and cause significant distress and impairment of functioning.
    • Social Phobia. Persistent and significant fear of one of more social situations in which a person is exposed to unfamiliar persons or scrutiny by others and feels he or she will behave in a way that will be embarrassing or humiliating. Exposure to the feared social situations almost always causes significant anxiety, even a panic attack despite the fact that the anxiety is seen as excessive and unreasonable. This belief may lead to avoidance of such situations or endurance under extreme distress, leading to marked interference in the person’s functioning and routine.
    • Specific Phobia. Persistent and significant fear that is recognized as unreasonable and excessive that is triggered by the presence or perception of a specific feared situation or object; exposure to this situation or object immediately provokes an anxiety reaction. The distress, avoidance, and anxious anticipation of the feared situation or object significantly interfere with a person’s normal functioning or routine. Animal Type: animals or insects; Natural Environmental Type: storms, heights, water, etc.; Blood-Injection-Injury Type: getting injections, seeing blood, seeing injuries, watching or having invasive medical procedures; Situational Type: elevators, flying, driving, bridges, escalators, trains, tunnels, closets, etc.
    • Adjustment Disorder with Anxiety (with or without depressed mood). When the development of emotional and/or behavioral symptoms occur within 3 months in response to an identifiable stressor. These symptoms and behaviors cause marked distress in excess of that which could be expected and results in significant occupational, social, or academic performance. Once the initiating stressor has ceased, the disturbance does not last longer than 6 months.
    • Anxiety Disorder Due to a General Medical Condition. When the physiologic consequences of a distinct medical condition is judged to be the cause of prominent anxiety symptoms.
    • Drug-Induced Anxiety Disorder. When the physiologic consequences of the use of a drug or medication is judged to be the cause of prominent anxiety symptoms.
    • Anxiety Disorder Not Otherwise Specified. When the prominent symptoms of anxiety and avoidance exist but do not fully meet the above diagnostic criteria.

    Etiology/Causes of Anxiety

    • Psychological. Anxiety can result when a combination of increased internal and external stresses overwhelm ones normal coping abilities or when ones ability to cope normally is lessened for some reason.
      • Psychodynamic: When internal competing mental processes, instincts and impulses conflict, causing distress.
      • Behavioral: Anxiety is a maladaptive learned response to specific past experiences and situations that becomes generalized to future similar situations.
      • Spiritual. When people experience a profound, unquenchable emptiness and nothingness to their lives, often leading to distress concerning their mortality and eventual death.
    • Genetic. Studies show 50% of patients with Panic Disorder have at least one relative affected with an anxiety disorder. There is a higher chance of an anxiety disorder in the parents, children, and siblings of a person with an anxiety disorder than in the relatives of someone without an anxiety disorder. Twin studies demonstrate varying but important degrees of genetic contribution to the development of anxiety disorders.
    • Biologic. Evidence exists that supports the involvement of norepinephrine, serotonin, and GABA. In some cases there appears to be a dysregulation of the noradrenergic and serotonergic neural systems, two systems that are complexly interrelated in the brain. Theories and some experimental evidence suggest abnormal functioning in the brain's GABA receptors. Brain imaging and functional studies have shown some evidence of abnormal function is several regions of the brain.
    • Medical. Illnesses such as cardiovascular disease (mitral valve prolapse, arrhythmias), lung disease, certain tumors (pheochromocytoma), endocrine disorders (hyperthyroidism), infections, and neurologic disease can all cause anxiety disorders. Therefore it is important to see your doctor in order to exclude medical diseases as potential causes or contributors to anxiety disorders.

    Anxiety Treatments

    • Psychological Treatments
      • Cognitive-Behavioral Therapy: addresses underlying “automatic” thoughts and feelings that result from thoughts, as well as specific techniques to reduce or replace maladaptive behavior patterns
      • Psychotherapy: Centers on resolution of conflicts and stresses, as well as the developmental aspects of an anxiety disorders solely through talk therapy
      • Behavioral Therapies: focus on using techniques such as guided imagery, relaxation training, progressive desensitization, flooding as means to reduce anxiety responses or eliminate specific phobias
    • Psychopharmacological Treatments
      • Benzodiazepines: Long-acting are best (Klonopin, Ativan, Valium, Librium, Serax) to quickly reduce the symptoms of an anxiety disorder. However, if used long term the result may be that tolerance develops.
      • Serotonergic Agents: newer antidepressants act as antianxiety agents as well, with excellent tolerability and effectiveness. Takes 4 to 6 weeks for full response (Luvox, Prozac, Zoloft, Paxil).
      • Tricyclic Antidepressants (TCAs): older antidepressants with more side effects typically than the serotonergic agents, but also effective. Takes 4 to 6 weeks for full response (Tofranil, Elavil, Pamelor, Sinequan)
      • Combination Serotonin/Norepinephrine Agents: new medications such as Effexor, Serzone, and Remeron, also with excellent tolerability and effectiveness. Takes 4 to 6 weeks for full response.
      • Antihistamines: older medications used for mild to moderate anxiety for many years. These, like the benzodiazepines, work fairly quickly (Atarax, Vistaril).
      • Buspirone (BuSpar): a new serotonergic combination agonist/antagonist. Is nonaddicting, but may take 2 to 4 weeks for full effect.
      • Major Tranquilizers (also called neuroleptics): medications that act on a variety of neurotransmitter systems (acetylcholine, dopamine, histamine, adrenergic). Most are somewhat sedating, and have been used in situations where anxiety is severe enough to cause disorganization of thoughts and abnormal physical and mental sensations, such as the sense that things around you aren't real (derealization) or that you are disconnected with your body (derealization). Commonly used neuroleptics include: Zyprexa, Risperdal, Seroquel, Mellaril, Thorazine, Stelazine, Moban, Navane, Prolixin, and Haldol.
    • Environmental Treatments
      • Avoidance or minimization of stimulants. No caffeine, minimize use of asthma medications if possible (bronchodilators, theophylline), avoid use of nasal decongestants, some cough medications, and diet pills.
      • Good sleep habits. Getting adequate, restful sleep improves response to interventions to treat anxiety disorders.
      • Reduction of stressors. Identify and remove or reduce stressful tasks or situations at home, school and work.

     

    Support: Where to look for help.

    There are several convenient sources of information and support, many of which can be found on the internet or in your community's libraries. Below are several good internet starting points. Additionally, your physician, nurse, pastor or counselor can be good sources of information.

    • The Anxious Child: Article from the American Academy of Child and Adolescent Psychiatry about anxiety in children.
    • Childhood Mental Health Resources: A guide to your children's mental health, with links to information about depression, anxiety disorders, ADHD, bipolar disorder and behavioral problems.
    • Anxiety Disorders Association of America: Descriptions and treatment guides for different types of anxiety disorders. Includes message boards and chat.
    • Anxiety Disorders: Information about anxiety disorders from the National Institute of Mental Health, including quick facts, treatments and where to get help.
    • Anxieties.com: "A free internet self-help site for persons suffering from anxiety, panic attacks, phobias, obsessive-compulsive disorder - OCD, fear of flying and post traumatic stress disorder - PTSD"
    • Mental Health Net: the most comprehensive source of online mental health information, news and resources.
    • Online Psych: Online Psych gives you a variety of interactive tests, quizzes, and surveys to challenge, inform, intrigue, and educate you. You'll find everything from online screening tests for mental health issues to fun surveys about relationships.
    • Medication Effective in Treating Anxiety Disorders in Children and Adolescents : a press release that describes a 'multi-site study to evaluate treatments for anxiety disorders in children and adolescents, funded by the National Institute of Mental Health (NIMH), found that a medication {Fluvoxamine} was more than twice as effective as the placebo, or sugar pill.'

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