Anxiety Disorder: Generalized Anxiety

Background: Generalized anxiety disorder (GAD) was introduced in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), replacing overanxious disorder of childhood (Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition [DSM-III-R]). GAD is associated with persistent, excessive, and unrealistic worry that is not focused on a specific object or situation.

Children with GAD worry more often and more intensely than other children in the same circumstances. They may worry excessively about their performance and competence at school or in sporting events, about personal safety and the safety of family members, or about natural disasters and future events.

The focus of worry may shift, but the inability to control the worry persists. Because children with GAD have a hard time “turning off” the worrying, their ability to concentrate, process information, and engage successfully in various activities may be impaired. In addition, problems with insecurity that often result in frequent seeking of reassurance may interfere with their personal growth and social relationships. Further, children with GAD often seem overly conforming, perfectionistic, and self-critical. They may insist on redoing even fairly insignificant tasks several times to get them “just right.” This excessive structuring of one's life is used as a defense against the generalized anxiety related to the concern about the individual's overall and specific performance.

Pathophysiology: Little empiric data are available regarding the physiologic indicators of anxiety in children (Barrios, 1988; Beidel, 1988). The high cost, lack of normative data, idiosyncratic patterns, and high sensitivity of cardiovascular and electrodermal measures in children contribute to the difficulties in physiologic assessment of anxiety in children (Kendall, 2000).

Frequency:

• In the US: Prevalence for children and adolescents ranges from 2.9-4.6%. GAD is more common in adolescents (aged 12-19 y) than in children (aged 5-11 y).

• Internationally: Worldwide prevalence of GAD is unknown.

Mortality/Morbidity:

• Deaths related to GAD in childhood and adolescence are related more to comorbid conditions such as depression than to GAD. Children and adolescents with both depression and an anxiety disorder tend to have more severe forms of depression; therefore, GAD should be viewed as a risk factor for morbidity and mortality.
  
  
• Anxiety disorders have a high rate of comorbidity. Children with GAD are also likely to meet criteria for other anxiety disorders and, to a lesser degree, for a depressive or disruptive behavior disorder.

• Anxiety disorders tend to be unstable over time. That is, a child may struggle with anxiety for a long period, but it may not necessarily be a result of the same specific anxiety disorder.

• GAD also may co-occur with conditions associated with stress, such as irritable bowel syndrome and headaches. The long-term physiologic effects of stress are more likely to cause nonpsychiatric gastrointestinal, cardiovascular, or other sequelae later in life.

Race: Specific racial or cultural group prevalence rates are not available.

Sex: In childhood, the sex distribution tends to be equal for females and males. In adolescence, a female-to-male ratio of 6:1 has been suggested; however, epidemiologic study results vary.

• Questionnaires such as the Revised Children’s Manifest Anxiety Scale (RCMAS), the Multidimensional Anxiety Scale for Children (MASC), and the Screen for Child Anxiety Related Emotional Disorders (SCARED) child and parent versions can be used to further assess anxiety symptoms.

• The DSM-IV requires the following to satisfy a diagnosis of GAD:

• Excessive anxiety and worry, occurring more days than not for at least 6 months, about a number of events or activities

• Difficulty controlling the worry

• One of the following symptoms in association with the worry: restlessness, fatigue, poor concentration, irritability, muscle tension, or sleep disturbance

• Focus of worry that is not confined to features of another Axis I diagnosis, eg, worry about having a panic attack, social embarrassment, or separation from caregiver

• Clinically significant distress or impairment experienced in social, school, or other important areas

• Disturbance not due to a substance or general medical condition and does not occur exclusively during a mood disorder, a psychotic disorder, or associated with a pervasive developmental disorder

Physical: Children with GAD may experience somatic symptoms such as shortness of breath, rapid heart beat, sweating, nausea or diarrhea, frequent urination, cold and clammy hands, dry mouth, trouble swallowing, or a “lump in the throat.” Problems with muscle tension also can occur, including trembling, twitching, a shaky feeling, and muscle soreness or aches. Patients often complain of stomachaches and headaches. Despite these symptoms, few findings are noted on physical examination.

Excessive laboratory exclusion of somatic complaints is to be avoided; however, careful interview and physical examination assessment of stress-related symptoms should be repeated if the psychological diagnostic picture is unclear.

Causes: Multiple factors are thought to contribute to the development of GAD and to the broad category of anxiety disorders. Biological, familial, and environmental factors are considered important. Behavioral inhibition (Kagan, 1989), an early temperament associated with aversion to novel situations, has been found to be associated with later development of anxiety disorders.

• A cognitive-behavioral approach is likely to be most beneficial. Treatment should consist of individual sessions with family involvement to support the treatment process. Cognitive therapy features may be incorporated into an eclectic approach by highly skilled and experienced therapists.

• Psychodynamic therapies, including play therapy, are time-honored modalities, but most outcomes research has focused on the brief or intermediate therapies, which are more structured.

In/Out Patient Meds:

• For patients for whom medication is prescribed, regular appointments with a child and adolescent psychiatrist or developmental-behavioral pediatrician are necessary for the duration of treatment.

Deterrence/Prevention:

• Consistent, stable, supportive home environment

• Parenting practices that promote self-confidence, self-esteem, and effective coping skills

• Minimal number of psychosocial stressors or traumatic events

• Adaptive problem solving and coping skills modeled by parents and other significant people in the child’s life

• Psychoeducation

Complications:

• Comorbid depression and other comorbid conditions

• School truancy and withdrawal from other age-appropriate activities

• Strained family relationships when the child’s anxiety contributes to irritability, noncompliance, demanding behavior, and/or chronic reassurance seeking

• “Self-medication” leading to substance abuse by adolescents

• Parents’ inability to help in the child’s treatment or to model adaptive coping/anxiety management because of their own untreated anxiety (or other psychiatric condition)

Prognosis:

• Prognosis is good when treatment is implemented early and effectively. However, the child remains at risk of developing GAD or other anxiety disorders. For example, Last and colleagues in 1996 reported an 80% recovery rate from overanxious disorder during a 3- to 4-year follow-up period. However, 35% of the children developed a new psychiatric disorder in the same interval.

Patient Education:

• Psychoeducation should be part of the treatment process. Patients and parents should have a good understanding of the contributing and maintaining factors of anxiety. Also, they should be clear regarding treatment goals, processes, and expectations.

Medical/Legal Pitfalls:

• Failure to diagnose and, thus, failure to treat the disorder