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Written by Dennis A Nutter, Jr   
Saturday, 21 July 2007
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Anxiety Disorder:Generalized Anxiety
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Synonyms and related keywords: anxiety disorder, generalized anxiety, overanxious disorder, overanxious reaction, generalized anxiety disorder of childhood, generalized anxiety disorder, GAD
AUTHOR INFORMATION
Author: Dennis A Nutter, Jr, MD, Consulting Staff, Department of Psychiatry, Northeast Georgia Medical Center
Coauthor(s): Lene Holm Larsen, PhD, Instructor, Department of Child and Adolescent Psychiatry, Children's Memorial Hospital of Chicago; Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Dennis A Nutter, Jr, MD, is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, North Carolina Medical Society, and Society for Research in Child Development
Editor(s): Chet Johnson, MD, Medical Director, Child Development Unit, Professor, Department of Pediatrics, University of Kansas Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Caroly Pataki, MD, Associate Program Director, Clinical Associate Professor, Department of Psychiatry and Biobehavioral Sciences, Division of Child and Adolescent Psychiatry, Neuropsychiatric Institute and Hospital, UCLA; Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine; and Murray M Kappelman, MD, Professor, Departments of Pediatrics and Psychiatry, University of Maryland School of Medicine

INTRODUCTION
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.

    * Anxiety is a serious problem in children and adolescents. We now understand that, in addition to deleteriously affecting the child's social and academic functioning (Pine, 1997), anxiety can cause serious long-term consequences. Many children with one of the anxiety disorders suffer intermittently for the rest of their lives. Other serious psychiatric conditions, such as major depressive disorder and substance misuse; these are closely associated with pediatric anxiety if not treated in a timely and effective manner.

    * 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.

Age: The age of onset varies. GAD is more common in adolescents and older children than in young children. In addition, affected adolescents and older children tend to have more symptoms than affected younger children.

CLINICAL
History: An evaluation for GAD should include data gathering through diagnostic interviews with the child and parent, direct observation, and questionnaires. Family history of anxiety and mood disorders, the child's early temperament and adjustment to school, and life stressors or disruptions are among important factors to consider in GAD.

    * Structured interviews yielding DSM-IV diagnoses, such as the Diagnostic Interview Schedule for Children (DISC) and the Anxiety Disorders Interview Schedule for DSM-IV Child and Parent Versions (ADIS-C/P), can be employed.

    * 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:

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

          o Difficulty controlling the worry

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

          o 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

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

          o 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.

Research has demonstrated an association between parents with anxiety disorders and children with behavioral inhibition. The tendency of anxiety to occur in families also has been established. Anxious parents may genetically predispose their children to anxiety, model anxious behavior, and behave and/or parent in ways that encourage and maintain anxious behavior in the child. Environmental factors, such as other parental emotional problems, disrupted attachment, stressful life events, and traumatic experiences, also may place the child at risk for developing GAD. The role of the family in understanding child anxiety is important, particularly in situations in which the needs of younger children who are developmentally limited in their ability to benefit from direct individual intervention are considered.

DIFFERENTIALS
Author Information Introduction Clinical Differentials Workup Treatment Medication Follow-up Miscellaneous Bibliography

Anxiety Disorder: Obsessive-Compulsive Disorder
Anxiety Disorder: Panic Disorder
Anxiety Disorder: Separation Anxiety and School Refusal
Anxiety Disorder: Social Phobia and Selective Mutism
Anxiety Disorder: Specific Phobia
Anxiety Disorder: Trichotillomania
Asthma
Attention Deficit Hyperactivity Disorder
Child Abuse & Neglect: Posttraumatic Stress Disorder
Eating Disorder: Anorexia
Hyperthyroidism
Hypothyroidism
Mood Disorder: Bipolar Disorder
Mood Disorder: Depression
Mood Disorder: Dysthymic Disorder
Obstructive Sleep Apnea Syndrome
Oppositional Defiant Disorder
Peptic Ulcer Disease
Personality Disorder: Avoidant Personality
Somatoform Disorder: Hypochondriasis
Somatoform Disorder: Somatization
Thyroiditis


Other Problems to be Considered:

Substance-induced anxiety disorder, anxiety disorder due to a general medical condition, an adjustment disorder, or psychotic disorder also should be considered.

Distinguishing anxiety from developmentally appropriate fears is important. Throughout childhood and early adolescence, children experience various transitory fears occurring concurrently with their ability to recognize and understand potential dangers in their environment. A progression occurs from immediate, tangible fears (eg, separation from caregiver, strangers) to anticipatory, less tangible fears (eg, bad dreams, getting hurt, school failure). Children are expected to overcome and resolve these fears as part of the developmental process.

Distinguishing anxiety from realistic worry is also imperative. Worry can be thought of as feeling uneasy or concerned about something. It represents an internal representation of a realistic threat. For example, a child with a learning disability may worry about an upcoming examination, or a child with a medical condition may worry about an upcoming surgery. This kind of worry is expected to be specific to a situation, and it is expected to subside once the situation has passed; thus, the temporal requirement for GAD diagnosis (6 mo) is not met.


WORKUP
Lab Studies:

* Consider urine drug screening, thyroid-stimulating hormone level assessment, and less common laboratory tests based on history and physical findings.


TREATMENT
Medical Care: Behavioral and cognitive-behavioral therapies are among the most researched and promising treatments for childhood anxieties. Behavioral techniques (eg, relaxation training, modeling, imagining and visualizing, in vivo exposure) and cognitive techniques (eg, identifying and modifying self-talk, challenging irrational beliefs) often are used in combination with psychoeducation and contingency maintenance. Typically, children are taught to recognize early physiologic and cognitive signs of anxiety and to develop and implement coping techniques. The importance of parental participation in the treatment process recently has received attention. Adding a family component focused on techniques such as contingency management, communication, and problem solving to individual child cognitive-behavioral therapy has produced favorable long-term treatment benefits in several clinical trials (eg, Barrett, 1996; Last, 1998; Silverman, 1999).

For a more detailed review of current integrated cognitive-behavioral therapies for children with anxiety disorders, see Kendall et al (2000). Practically speaking, less successful real-world treatments are frequently encountered because of a dearth of qualified child therapists and a failure to recognize the importance of directly or indirectly (family component) treating parental anxiety. Several cognitive-behavioral therapy books, such as Helping Your Anxious Child: A Step-By-Step Guide for Parents by Sue Spence and Keys to Parenting Your Anxious Child (Barron's Parenting Keys) by Katharina Manassis, MD, are readily available for parents and their children to work with at home and at school.

Surgical Care: Children with an anxiety disorder are particularly likely to benefit from age-appropriate preoperative preparation including relaxation practice for elective procedures.

Consultations: Early referral to a psychologist, psychiatrist, or behavioral-developmental pediatrician for evaluation and treatment can alleviate symptoms and stress that may be the early manifestations of a more severe disorder. Family therapy referral also may be indicated, but that may be best managed by the mental health professional or the developmental and behavioral pediatrician who performs the consultative evaluation.

Diet: Limiting caffeine intake is appropriate.

Activity: Regular exercise promotes a sense of well-being that is particularly beneficial in individuals with anxiety and mood disorders.


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