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Anx,ety ,S an emotion expended at one time or another by all human beings. It functions as a biological warning system that alerts an individual to the presence of danger and can also arise as a consequence of loss or psychological conflict. An important distinction to make is between anxiety experienced as a normative reaction to a challenging environment or situation and an anxiety disorder, which is a mental health diagnosis that deviates from the norm. Child and adolescent anxiety disorders are characterized by excessive or developmentally inappropriate anxiety that interferes with psychological, academic, and social functioning (Vasa and Pine 2006).

Symptoms of anxiety are very common in patients and family members in the pediatric setting. Depending on the context and severity, symptoms of anxiety can significantly impair functioning and recovery. Anxiety may also influence aspects of treatment, including adherence. Anxiety is a risk factor for several general medical conditions (e.g., hypertension) and may exacerbate the symptoms of specific illnesses (e.g., asthma, irritable bowel syndrome). Symptoms of anxiety may be secondary to the direct effects of an illness, be a psychological reaction to an illness, indicate the presence of a comor-bid anxiety disorder, or be a combination of all three (see Figure 7-1).

With respect to pediatric psychosomatic medicine, the evaluation and treatment of anxiety depend strongly on consideration of the context in which the symptoms present and the environment in which symptoms are maintained. Biopsychosocial (Engel 1977) and social-ecological (Bronfenbrenner 1979) models that emphasize the interdependent and mutually influencing relationships among biological, psychological, individual, family, and community subsystems are particularly useful frameworks for better understanding anxiety that may arise in the context of pediatric illness (Kazak et al. 2009a). The consultant needs to appreciate that anxiety symptoms may be caused or exacerbated by a child's emotional reaction to an acute hospitaliza-tion and separation from home. However, interpreting physical symptoms such as tachycardia, shortness of breath, or sweating as symptoms of anxiety may or may not be appropriate, depending on the context in which they arise. Specific anxiety symptoms may be present as part of another psychiatric disorder (e.g., depressive or somatoform disorder) or may accompany another disorder as a primary co-morbid anxiety disorder (Shaw and DeMaso 2006). In the pediatric setting, untangling these diagnostic dilemmas and making recommendations are integral to successful clinical care.

Figure 7-1. Classification of anxiety disorders in the medically ill child.

Source. Adapted from Shaw RJ, DeMaso DR: "Anxiety Symptoms and Disorders," in Clinical Manual of Pediatric Psychosomatic Medicine: Consultation With Physically Ill Children and Adolescents. Washington, DC, American Psychiatric Publishing, 2006, p. 122. Copyright 2006, American Psychiatric Publishing. Used with permission.

Figure 7-1. Classification of anxiety disorders in the medically ill child.

Source. Adapted from Shaw RJ, DeMaso DR: "Anxiety Symptoms and Disorders," in Clinical Manual of Pediatric Psychosomatic Medicine: Consultation With Physically Ill Children and Adolescents. Washington, DC, American Psychiatric Publishing, 2006, p. 122. Copyright 2006, American Psychiatric Publishing. Used with permission.

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