Primary Anxiety Disorders

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Pediatric patients may present with a history of preexisting anxiety disorder or develop an anxiety disorder after a medical illness is diagnosed. Because anxiety disorders often present with physical symptoms, particularly complex diagnostic issues can be gener ated in children and adolescents with comorbid medical conditions that may also be associated with somatic symptoms. The psychological symptoms of anxiety are routinely associated with physical signs of autonomic activity (e.g., palpitations, shortness of breath, tremulousness, flushing, faintness, dizziness, chest pain, dry mouth, muscle tension). The most common somatic symptoms reported by children and adolescents with DSM-IV-TR anxiety disorders (i.e., social, separation, and generalized anxiety disorders) were as follows: restlessness (74%), stomachaches (70%), blushing (51%), palpitations (48%), muscle tension (45%), sweating (45%), and trembling/shaking (43%) (Ginsburg et al. 2006).

Several subtypes of anxiety disorders are seen in the medical setting (see Figure 7-1). We describe the following DSM-IV-TR anxiety disorders (American Psychiatric Association 2000) as "primary" to the extent that they are not specifically a psychological or physical reaction to a physical illness or substance (see left-hand column of Figure 7-1). Separation anxiety disorder involves inappropriate and excessive anxiety concerning separation from caregivers and/ or home and is particularly common in younger children admitted to the hospital. Generalized anxiety disorder presents with a pattern of excessive anxiety and worry for 6 months or longer that is associated with symptoms of restlessness, fatigue, difficulty with concentration, irritability, muscle tension, and sleep disturbance and may also be heightened during the stress of an inpatient admission. Obsessive-compulsive disorder in the physically ill child may include obsessive preoccupation or fears about physical illness and/or aspects of the medical setting (e.g., contamination fears). Specific phobias may be particularly problematic in the pediatric setting in patients with fears about needlesticks and blood. Patients with claustrophobia similarly may have difficulties with procedures such as magnetic resonance imaging or the need for protective isolation due to an infectious disease or immunosuppression. Social phobia, characterized by anxiety in response to social or performance situations, may contribute to children having difficulty actively engaging with medical personnel around treatment and/or limit their adherence to recommendations.

Panic disorders can overlap and blend with the symptoms of the accompanying general medical condition. The hallmark of these disorders is the presence of panic attacks, in which a sudden onset of intense psychological fear co-occurs with various unpleasant physical symptoms. Panic disorders may

Table 7-1. Psychological sources of anxiety associated with pediatric physical illness

Source of anxiety

Factors to consider

Illness diagnosis

Patients often experience symptoms of anxiety around the time of diagnosis of a physical illness. Individuals with a family history of a specific medical condition may experience anxiety symptoms due to excessive fear that they will be affected. This fear can cause elevated symptoms of anxiety related to routine pediatric appointments during the period between the initial evaluation of a symptom and its diagnosis. Anxiety may also occur when a patient has an abnormal laboratory test that does not lead to a diagnosis but that does require follow-up or monitoring.

Physical integrity

Beginning around age 4 or 5 years, children become more concerned about bodily injury and are more cognitively aware of the physical effects of illness; as a result, they frequently experience anxiety. Fears about amputation, loss of vision, and/or pain are common and understandable. Adolescents in particular may worry about the cosmetic effects of an illness or treatment due to excessive concerns about social stigma.

Hospital anxiety

Hospitalized children have to adjust to the presence of pediatric staff and to disruptions to their daily routine. These children may experience anxiety about the presence of hospital staff, particularly when the staff become associated with stressful medical procedures or the delivery of disturbing medical information. Children under age 4-5 years are particularly prone to separation anxiety. Patients who have not adhered to their medical treatment or who have engaged in risk-taking behaviors may conceal important medical information because of anticipatory anxiety about the potential disapproval of their physicians.

Impact of illness

Children frequently report symptoms of anxiety related to the impact of the illness and its treatment on their own lives and on family members. They may be concerned about missing school or falling behind academically. Adolescents may be particularly troubled by their separation from peers as well as by feeling "different" from others. Children may feel guilty about their need for increased parental attention and assistance. Some children report worries about the financial impact of their illness on the family because their parents have to take time off from work or because of the costs of treatment.

Prognosis and death

Patients may experience anxieties about their prognosis and death that can be based on both realistic and unrealistic appraisals of their illness. Children can develop symptoms of anxiety related to fears about the recurrence of an illness such as cancer. Such fears are not necessarily assuaged by a favorable statistical prognosis. A family history of medical illness or knowledge of the death of a family member or peer can influence these fears. Children may also report concerns about the emotional impact of their death on parents or siblings.

present either with or without agoraphobia (i.e., anxiety about, or avoidance of, places or situations from which escape may be difficult). Studies of adult patients have shown that individuals with panic attacks are high utilizers of medical care (Barsky et al. 1999). This is particularly true for patients who experience chest pain and who repeatedly present at emergency rooms or are referred for diagnostic workups. However, when symptoms of agoraphobia are also present, patients may have particular difficulty participating in treatment within the medical setting and adhering to follow-up appointments.

Acute stress disorder and posttraumatic stress disorder (PTSD) are characterized by the reexperiencing of a traumatic event accompanied by avoidance of related stimuli and physiological symptoms of increased arousal (see Tables 7-2 and 7-3). These two disorders are differentiated primarily by the duration of the associated symptoms and, depending on the context in which they arise, may be considered a primary anxiety disorder or a psychological reaction to a physical illness. Patients presenting in the medical setting as a direct result of a traumatic event can experience acute stress disorder symptoms that may or may not persist. Furthermore, patients can be struggling with symptoms connected with a trauma unrelated to their presenting medical issue (e.g., a history of physical or sexual abuse) or develop

Table 7-2. DSM-IV-TR diagnostic criteria for acute stress disorder

A. The person has been exposed to a traumatic event in which both of the following were present:

(1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

(2) the person's response involved intense fear, helplessness, or horror

B. Either while experiencing or after experiencing the distressing event, the individual has three (or more) of the following dissociative symptoms:

(1) a subjective sense of numbing, detachment, or absence of emotional responsiveness

(2) a reduction in awareness of his or her surroundings (e.g., "being in a daze")

(3) derealization

(4) depersonalization

(5) dissociative amnesia (i.e., inability to recall an important aspect of the trauma)

C. The traumatic event is persistently reexperienced in at least one of the following ways: recurrent images, thoughts, dreams, illusions, flashback episodes, or a sense of reliving the experience; or distress on exposure to reminders of the traumatic event.

D. Marked avoidance of stimuli that arouse recollections of the trauma (e.g., thoughts, feelings, conversations, activities, places, people).

E. Marked symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hypervigilance, exaggerated startle response, motor restlessness).

F. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

G. The disturbance lasts for a minimum of 2 days and a maximum of 4 weeks and occurs within 4 weeks of the traumatic event.

H. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition, is not better accounted for by brief psychotic disorder, and is not merely an exacerbation of a preexisting Axis I or Axis II disorder.

symptoms of medical traumatic stress as a reaction to the current physical illness or treatment being received, as discussed further in the following section.

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