Anxiety

Anxiety Disorder

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Anxiety Disorder

  • See Also
  1. Anxiety Secondary Cause
  2. Anxiety Symptoms
  3. Generalized Anxiety Disorder
  4. Obsessive Compulsive Disorder
  5. Body Dysmorphic Disorder
  6. Panic Disorder
  7. Social Anxiety Disorder (Social Phobia)
  8. Acute Stress Disorder
  9. Post-Traumatic Stress Disorder
  10. Excessive Worry
  11. Anxiety Non-pharmacologic Management
  12. Anxiety Pharmacologic Management
  • Definitions
  1. Anxiety Disorder
    1. Excessive Worry, anxiety or fear out of proportion to a situation, event, person, object or threat
    2. Physical manifestations are typically Sympathetic Nervous System driven (e.g. Palpitations, diaphoresis)
    3. Timing varies from persistent (e.g. Generalized Anxiety Disorder) to severe, brief episodes (e.g. Panic Attack, Specific Phobia)
    4. May manifest avoidance of specific activities, or interactions with objects or people
  • Epidemiology
  1. Anxiety Disorder Incidence (U.S.): 16%
  2. Family physicians treat 90% of anxiety patients
    1. Refer <10% of patients to psychiatry
  3. Childhood
    1. Childhood Prevalence worldwide: 6.5%
    2. Childhood Prevalence in U.S.
      1. Children age 3 to 17 years: 8%
      2. Children with behavioral problems: 36%
      3. Adolescents 13 to 17 years old: 7% formally diagnosed (estimated to be as high as 25%)
      4. Most common diagnoses include Specific Phobias, Social Anxiety Disorder and Separation Anxiety Disorder
    3. References
      1. Ghandour (2019) J Pediatr 206:256-67 +PMID: 30322701 [PubMed]
      2. Polanczyk (2015) J Child Psychol Psychiatry 56(3): 345-65 [PubMed]
  4. Elderly have lower Incidence of anxiety
    1. Elderly women more affected than men
    2. Often associated with depression
  • Pathophysiology
  1. Hyperarousal state
    1. Those with anxiety perceive a higher risk or fear in low risk situations
    2. Specific CNS circuits are activated with fear or noxious stimuli
  2. Begins in Brainstem reticular formation
    1. Locus Ceruleus (Secretes Norepinephrine)
    2. Dorsal and medial raphe nuclei (Secretes Serotonin)
  • Risk Factors
  • Children and Adolescents
  1. Lower socioeconomic status
  2. Exposure to Violence or Trauma
  3. Family History
  4. Parental anxiety
  5. Social Media engagement (esp. body image, Cyberbullying)
  6. Covid19 Pandemic
  • Types
  • Primary Anxiety Disorder
  1. Generalized Anxiety Disorder
  2. Panic Disorder
  3. Social Anxiety Disorder
  4. Separation Anxiety Disorder
  5. Obsessive Compulsive Disorder (OCD)
  6. Post-Traumatic Stress Disorder (PTSD)
  7. Phobias (e.g. Social Phobia)
  • History
  1. Medical history
  2. Psychiatric history
  3. Family History of Anxiety Disorder and other mental health disorders
  4. Prior mental health management
  5. Medications (including over-the-counter and Herbals)
  6. Substance Use (e.g. Caffeine, Alcohol, Tobacco, Marijuana, Cocaine, Methamphetamine) by patient and close contacts
  7. Trauma History
  8. Psychosocial stressors
  9. Social functioning with others (e.g. parents, children, teachers, bosses, coworkers, peers and friends)
  10. Educational and work performance
  11. Self harm and Suicidal Ideation, planning or preparation
  12. Support people and resources
  • Findings
  • Signs and Symptoms
  1. See Anxiety Symptoms
  2. Excessive Worry, anxiety or fear out of proportion to a situation, event, person, object or threat
  3. Timing varies from persistent (e.g. Generalized Anxiety Disorder) to severe, brief episodes (e.g. Panic Attack, Specific Phobia)
  4. Physical manifestations are typically Sympathetic Nervous System driven
    1. Palpitations
    2. Diaphoresis
    3. Chest Pain
    4. Nausea
    5. Faintness
    6. Muscle tightness
  5. May manifest avoidance of specific activities, or interactions with objects or people
    1. Children may cry or throw tantrums or cling to those they see as protective (e.g. parents)
  6. Anxiety Disorders often persist and may progress to significant functional impact
    1. Social and relationship
    2. Education and work
  • Differential Diagnosis
  • Psychiatric Conditions
  1. See Anxiety Secondary Causes
  2. Mania or Bipolar Disorder
  3. Personality Disorder (Anxious cluster)
    1. Obsessive Compulsive Personality disorder
    2. Avoidant Personality Disorder
    3. Dependent Personality disorder
    4. Passive-Aggressive Personality Disorder
  4. Anxiety Adjustment Disorder
    1. Appropriate response to a life stressor
  5. Schizophrenia
  6. Somatoform Disorder
  1. No laboratory tests are required (perform only as indicated by history or exam)
  2. Common Studies
    1. Serum Chemistry profile
      1. Serum Glucose
      2. Serum Calcium
      3. Serum Phosphate
    2. Thyroid Stimulating Hormone (TSH)
    3. Urine Drug Screen
  3. Studies if specifically indicated
    1. Serum Cortisol
    2. Urine Catecholamines
  1. No diagnostic tests are required (perform only as indicated by history or exam)
  2. Common Studies
    1. Electrocardiogram (EKG)
  3. Studies if specifically indicated
    1. Electroencephalogram (EEG)
    2. Vestibular testing
    3. Echocardiography
  • Evaluation
  1. See Anxiety Scales
  2. Adult Scales
    1. Generalized Anxiety Disorder Scale (GAD-7)
    2. Short Health Anxiety Inventory (SHAI)
    3. PROMIS Emotional Distress-Anxiety Short Form for adults
    4. Severity Measure for Generalized Anxiety Disorder - Adults
    5. Hamilton Anxiety Scale (HAM-A)
    6. Zung Self Rating Scale for Anxiety
    7. Beck Anxiety Scale
  3. Pediatric Scales
    1. Screen for Child Anxiety Related Emotional Disorders (SCARED, ages 8 to 18 years)
    2. Spence Children's Anxiety Scale (SCAS, ages 8 to 15 years)
    3. Preschool Anxiety Scale (PAS, ages 30 months to 6.5 years)
  • Management
  1. See Anxiety Medications
  2. See Anxiety Non-pharmacologic Management
  3. Treatment is specific for the Anxiety Disorder
    1. Generalized Anxiety Disorder
    2. Panic Disorder
    3. Obsessive Compulsive Disorder (OCD)
    4. Post-Traumatic Stress Disorder (PTSD)
    5. Social Phobia
  • Prognosis
  1. Anxiety in children in teens often persists (including into adulthood) and is associated with frequent relapses
    1. Ginsburg (2018) J Am Acad Child Adolesc Psychiatry 57(7):471-480 +PMID: 29960692 [PubMed]
  • References
  1. Kowalchuk (2022) Am Fam Physician 106(6): 657-64 [PubMed]
  2. Walley (1994) Am Fam Physician 50(8): 1745-53 [PubMed]