Anxiety Disorders

BACKGROUND

Human beings, like all other organisms, are equipped with systems for the detection of potentially harmful stimuli and for differentiating between that which is harmful and that which is necessary or rewarding. The anxiety system is a critical system that serves to promote the avoidance of risks and harm and is an important part of healthy development. When activated, anxiety impacts the various aspects of functioning, including changes to physiological functioning, cognitive functioning, emotions, and behavior. In concert, these changes can promote avoidance of risk, both imminent and more distal, and help to keep the individual safe and healthy. Risks that can trigger anxiety include not only the risk of physical harm but also psychological risks such as the risk of social humiliation and emotional distress.

Psychopathology, in the context of anxiety, occurs when the anxiety system is chronically and excessively triggered in situations that do not pose a realistic threat to the individual and when regulation of the anxiety system is impaired.

DIAGNOSIS, DEFINITION, AND CLINICAL FEATURES

Classification of anxiety problems into discrete diagnostic categories has evolved steadily with each successive iteration of the Diagnostic and Statistical Manual of Mental Disorders (DSM), with some of the most significant changes occurring specifically in relation to the developmental psychopathology of anxiety.

DSM-III recognized three “phobic disorders” (agoraphobia [with and without panic attacks], social phobia, and “simple” phobias), panic disorder, generalized anxiety disorder, and “atypical” anxiety disorder. Also included among the anxiety disorders in DSM-III and DSM-IV was obsessive compulsive disorder. Additionally, DSM-III classified three anxiety disorders as commonly arising during childhood or adolescence: separation anxiety disorder, shyness disorder, and overanxious disorder.

Subsequent versions of DSM have refined and added to these nosological categories, leading up to the present DSM-5 classification, which includes the following anxiety disorders: separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder (social phobia), panic disorder, agoraphobia, generalized anxiety disorder, and illness anxiety disorder (which is grouped along with other somatic symptom disorders, rather than with the other anxiety disorders). DSM-5 also recognizes substance or medication-induced anxiety disorder,
anxiety disorder attributable to another medical condition, and unspecified anxiety disorder. A brief overview of the central features of the anxiety disorders follows and is summarized in Table 12.1. All the DSM-5 anxiety disorders require that the problem be associated with significant impairment in psychosocial functioning in the domains of social relations, school and academic behavior, family functioning, or another significant area.

Separation anxiety disorder: Separation anxiety is the most frequent anxiety problem in young children but can occur at any point in development (Shear et al., 2006). It is characterized by developmentally inappropriate and impairing fear or anxiety about being separated from caregivers and other attachment figures and by excessive worry about losing them or about coming to harm during a separation (American Psychiatric Association, 2013). Children with separation anxiety disorder exhibit reluctance to separate or be separated, often insist on sleeping together with caregivers, and frequently have nightmares involving the theme of separation.
Selective mutism: Selective mutism is the consistent failure to speak in certain social situations where speech is expected, despite being able to speak in other situations (American Psychiatric Association, 2013).

Specific phobia: Specific phobias are strong fears of particular objects or situations that are excessive or exaggerated in relation to the actual risk these objects or situations pose (American Psychiatric Association, 2013). A child with a specific phobia will almost invariably seek to avoid the feared object or situation or will endure them only with significant fear and distress. In many cases, a child will meet criteria for multiple specific phobias, of different objects or situations. Common phobias include heights, dark, animals
or insects, and needles or blood, but any object can be the focus of a child’s phobia. In children, in particular, the fear response may take the form of clinging to parents or having temper tantrums rather than of behaviors that more obviously denote fear.

TABLE 12.1 DSM-5 Anxiety Disorders and Key Characteristics

DSM-5 Anxiety Disorder	Key Characteristics
Separation Anxiety Disorder	Developmentally inappropriate fear of being separated from caregivers Nightmares with the theme of separation are common
Selective Mutism	Consistent failure to speak in certain situations The child is able to speak in other situations
Specific Phobia	Strong, exaggerated fear of specific objects or situations The child almost always seeks to avoid contact with the phobic object
Social Anxiety Disorder	Fear of negative evaluation by others and avoidance of situations with the potential for social evaluation Can be specific to performance situations only Does not denote a lack of social interest, although social contact can be consistently avoided
Panic Disorder	Recurring panic attacks lead to persistent worry about additional panic attacks Cued panic attacks (that occur with a clearly identifiable trigger) are not symptoms of panic disorder
Agoraphobia	Fear and avoidance of situations from which escape may be difficult in the event of developing panic-like symptoms
Generalized Anxiety Disorder	Persistent worry that is difficult to control The worry can impact sleep, attention, and mood
Illness Anxiety Disorder	Preoccupation with becoming seriously ill The worry is not aligned with actual health or risk of illness

Social anxiety disorder (social phobia): Social anxiety disorder involves persistent fear or anxiety relating to social situations that present the opportunity for real or perceived evaluation by others (American Psychiatric Association, 2013). Children with social phobia fear that they will be negatively evaluated for their performance or behavior and may fear that their anxious expression itself will contribute to this negative evaluation. For example, a child with social phobia may fear being ridiculed for blushing or stammering because of the anxiety. Social phobia leads to avoidance of social situations and interactions but does not reflect a lack of social interest in children. In most cases, children with social phobia will fear a broad range of social-evaluative situations, but in some cases the fear may be focused only on situations that involve actual performance, such as public speaking in front of an audience or classroom. Of note for developmental psychopathology, the anxiety must extend to situations that involve peers, rather than being limited to interactions with adults alone. Also of note in the context of children, shyness is a common trait in developing youth and does not necessarily indicate the presence of social phobia. Only a minority of shy children will meet the diagnostic criteria for social phobia.
Panic disorder: Panic disorder occurs when a child experiences recurring and unexpected panic attacks and becomes persistently concerned about the possibility of experiencing additional attacks in the future, usually leading to behavioral changes in the child (American Psychiatric Association, 2013). Panic attacks are brief but intense surges in fear or anxiety and are considered unexpected when they occur “out of the blue” in the absence of a clear trigger or stimulus. Panic attacks that occur in the context of a clearly identifiable trigger, for example during an encounter with a phobic object, are not symptoms of panic disorder but rather of the specific phobia. This distinction is important because all anxiety disorders can be accompanied by panic attacks, and panic disorder is diagnosed only in the context of unexpected panic attacks.
Agoraphobia: Agoraphobia is persistent anxiety and/or avoidance of situations owing to fears about not being able to easily escape the situation or to receive help in the event of developing panic-like or other incapacitating symptoms (American Psychiatric Association, 2013). Children with agoraphobia fear situations such as public transportation, open or enclosed spaces, crowds, or being alone outside of the home. In contrast to previous iterations of DSM, under DSM-5 agoraphobia is diagnosed separately and irrespectively of the presence of panic disorder. Even a child who has not experienced panic attacks in the past may meet criteria for a diagnosis of agoraphobia. The avoidance of feared situations in agoraphobia can lead to highly impairing isolation and to difficulty functioning outside of the home, including school attendance.
Generalized anxiety disorder: Generalized anxiety disorder is excessive and persistent worry that is difficult to control and that adversely impacts the child’s physical or psychological functioning (American Psychiatric Association, 2013). Children with generalized anxiety disorder may have difficulty sleeping at night, may become overly tired and have difficulty with attention and concentration, and may become restless and irritable. Although less common in preadolescent children than phobias and separation anxiety, generalized anxiety, and symptoms of generalized anxiety disorder, can occur even in young children.
Illness anxiety disorder: Although not grouped with the other anxiety disorders, illness anxiety disorder is an anxiety disorder in which the core diagnostic criteria center on excessive and impairing anxiety and worry (American Psychiatric Association, 2013). Illness anxiety disorder is persistent preoccupation with, and worry about, becoming seriously ill. The anxiety is not aligned with the child’s actual health and risks. Somatic symptoms, such as chronic aches and pains or gastrointestinal distress, may be present but are of only mild intensity. Children with illness anxiety disorder become easily alarmed about their health and may engage in checking behaviors or may seek to avoid contact with doctors because of their fears. Children may also seek excessive reassurance from their parents about their health or help in accessing unnecessary medical examinations (Box 12.1).

BOX 12.1 Case of Separation Anxiety Disorder

Tommy, a 6 ½-year-old boy, was referred by his family physician because of a long-standing pattern of shyness and inhibition that had become dramatically worse on his entering school. He expressed fear that his mother would be harmed or become ill and several times had come home early from school or had tremendous difficulty separating from his mother at the start of school. His mother had a history of anxiety-related difficulties as a child and even at present described herself as rather like Tommy with many worries and concerns about the future.

When left at school, Tommy would quickly begin to complain of headaches or gastrointestinal (GI) upset. He often left the class to go to the nurse’s office because he felt nausea and was afraid he would vomit in the classroom. It was a struggle for his mother to drop him off at school in the morning—he would be reluctant to bring his backpack, would lose his lunch, and would become upset on leaving the car. Tommy had never been willing to take the bus with other children on his street.

His teacher reported that when he was in school and working, his academic abilities appeared to be at age level. She was, however, concerned that his degree of difficulty with separation and his numerous physical complaints were taking a toll on his peer relationships and would eventually also impact his academic progress.

His mother noted that Tommy had a long history of anxiety-related difficulties, falling asleep only when one his parents (usually his mother) was in bed with him. He often woke during the night and would come into his parents’ bed complaining of nightmares.

Although he would play with children in the neighborhood, Tommy wanted his mother to stay around, and he refused to join a soccer club because of fear of the separation it would cause. His parents also had difficulty leaving him with a babysitter.

Tommy and his parents engaged in a course of treatment focused both on his anxiety and, for his parents, on ways to help him cope more effectively and reduce their accommodation of his symptoms. Issues for the parents included a careful review of ways in which their behavior had frequently supported Tommy’s anxiety and lack of independence. For Tommy, a course of CBT was helpful, combined with the work with his parents. Although he remained a somewhat anxious child, he began to be able to attend school on a regular basis and became more independent at home as well. His sleeping difficulties decreased. After Tommy had completed his treatment, his mother chose to pursue treatment for her own long-standing anxiety difficulties, which had seemed to play some role in Tommy’s problems.

Reprinted with permission from Volkmar, F. R., & Martin, A. (2011). Essentials of Lewis’s child and adolescent psychiatry (1st ed., p. 156). Lippincott Williams & Wilkins/Wolters Kluwer.

Anxiety disorders are associated with impaired functioning in children’s social functioning with relatives and peers, their academic performance and achievement, their physical and mental health, their individual functioning through disrupted routines, including eating and sleep, and with high levels of personal distress (Higa-McMillan et al., 2016; Langley et al., 2013).

Impairment is not limited to the child alone. Family functioning in families of children with anxiety disorders is likewise impaired. One process that is particularly relevant to the developmental aspects of childhood anxiety is that of family accommodation (Jones et al., 2015; Kagan et al., 2017; Lebowitz et al., 2013; Norman et al., 2015; Reuman & Abramowitz, 2017; Thompson-Hollands et al., 2014). Family accommodation refers to the many ways in which parents modify their own behaviors to help their child avoid or alleviate anxiety. Children’s natural reliance on caregivers for protection and regulation, and caregivers’ powerful motivation to respond protectively to cues of childhood fear and distress
contribute to the almost ubiquitous presence of family accommodation among parents of children with elevated anxiety levels. The need to maintain regular overall family functioning also contributes to high levels of family accommodation, because a child’s anxiety can, when not accommodated, interfere with schedules and with the performance of everyday tasks. Thus, for example, an anxious child may have difficulty going to sleep alone, leading to parental accommodation because parents need to ensure proper sleep for the child and other family members. Likewise, parents may accommodate an anxious child by driving them to school in the morning instead of making use of the school bus, because of the need to ensure that the child arrives at school on time and that they can arrive at work on time.

Over 95% of parents of anxious children engage in regular accommodation of the child’s anxiety symptoms. Despite being well intentioned and aimed at reducing the child’s anxiety in the short term, family accommodation is consistently linked to higher levels of anxiety over time and to poorer overall functioning and can contribute to worse treatment outcomes (Kerns et al., 2017; Reuman & Abramowitz, 2017; Settipani, 2015; Storch et al., 2015; Zavrou et al., 2018). High levels of family accommodation also contribute to significant burden and distress for the parents and can result in high levels of intrafamilial conflict affecting all family members, including the siblings of the anxious child (Box 12.2).

BOX 12.2 Case of Generalized Anxiety

Todd, an 11-year-old boy, in the 5th grade, was referred for assessment by his primary care provider owing to symptoms she suggested might reflect an anxiety disorder. The third and final child, and only son, of professional parents, his school work began to deteriorate and had become a subject of concern to his parents. A successful participant in the martial arts and music, Todd had always been popular at school, although this year, in his private school, the level of work dramatically increased and the school shifted from what had been narrative reports to an actual report card, where he was getting B’s and C’s. His parents were puzzled because not only his previous narrative reports but also periodic achievement testing had suggested higher levels of academic ability. His parents initially presented their worry to the pediatrician that he had developed learning problems, but in her discussions with Todd the pediatrician noted that he complained of many worries and concerns. Although he had many physical complaints, the physical examination, including an ECG, had been unremarkable.

During the psychiatric assessment and over several sessions, Todd acknowledged being more worried about school this year, in part because he had also begun to feel pressure from his parents about college; in addition, they had suggested that he take an additional language in school. Todd had a number of somatic complaints (headaches, recurrent aches/pains), and his parents reported that he was more irritable at home. He indicated that his worries had gradually increased but had been noteworthy over the last six months.

Review of last year’s psychological testing revealed above-average intelligence and even somewhat higher achievement scores. Todd’s mother, an attorney, reported a history of depression and anxiety and was currently taking an SSRI with good effect.

Todd was referred for a course of group CBT, with good results. In addition, his parents and school were encouraged to review his academic load and discontinue the additional course work. There was also an opportunity to discuss with his parents the possibility that increased expectations and premature worries about college might contribute to his anxiety. Follow-up in several months revealed that Todd was doing well in school and at home with no apparent recurrence of anxiety-related symptoms.

Reprinted with permission from Volkmar, F. R., & Martin, A. (2011). Essentials of Lewis’s child and adolescent psychiatry (1st ed.). Lippincott Williams & Wilkins/Wolters Kluwer.

EPIDEMIOLOGY AND DEMOGRAPHICS

Taken together as a group, the anxiety disorders comprise the most common forms of developmental psychopathology (Achenbach et al., 1995; Costello et al., 2011; Merikangas et al., 2010), with onset that occurs early in life and with prevalence rates that are estimated to be as high as one third of youth by adulthood. Anxiety disorders are also commonly comorbid, both with other anxiety disorders and with nonanxiety psychopathology, in particular mood disorders (Cummings et al., 2014; Garber & Weersing, 2010; Lamers et al., 2011).

The National Comorbidity Survey Replication Adolescent Supplement (NCSA) surveyed a nationally representative sample of youth between the ages of 13 and 17, using structured interviews and confirmed the high prevalence of anxiety disorders (Kessler et al., 2009). Specific phobias were the most common anxiety disorders, followed by social anxiety disorder and separation anxiety disorder. As has been the case in some other studies, anxiety disorder prevalence in the NCSA was higher for females than for males, but this finding has not been consistent in the literature (Perou et al., 2013). Other demographic variables such as race and ethnicity have not been reliably found to predict risk of anxiety disorders (Wren et al., 2007).

Anxiety disorders in youth are more common among children of anxious parents than among those of nonanxious parents (Li et al., 2008). This is partly explained by genetic heritability, but nongenetic factors also contribute to anxiety heritability. For example, highly anxious parents may model more anxious or avoidant behavior and may exacerbate a tendency toward anxiety in children by providing high levels of family accommodation.

ETIOLOGY AND PATHOGENESIS

The precise etiology and pathogenesis of anxiety disorders in children is far from well-understood. A large number of psychological, biological, and environmental factors have been convincingly linked to the development of anxiety in children and these factors interact with each other, and very likely with other as yet unidentified factors, in complex ways (Newman et al., 2013). Even approximating a cohesive mapping of these complex relations requires additional long-term research effort. It goes almost without saying that identifying the etiology and pathogenesis of a specific child’s anxiety problem is as yet not possible. Even when a particular psychological trigger for a child’s anxiety is seemingly apparent, or when a deficit is identified in a particular physiological system, or when heredity is likely a significant contributor to a child’s problem, it is generally a false conclusion to assume that the child’s anxiety problem is actually explained by any one of these factors. The issue of heredity itself is complex, because it can include both genetic and nongenetic cross-generational transmission (Domschke & Maron, 2013; Eley, 1999; Eley et al., 2015).

Taking an historical perspective on psychological explanations for anxiety in children, some of the earliest theories were informed by psychoanalytic theory. The seminal example for this approach is that of “Little Hans,” a case study in child phobia described by Freud in 1909 (Freud, 1928). Hans was a five-year-old boy with a phobia of horses. Hans’ fear soon generalized, as is common in phobic disorders, to a fear of leaving the house at all because of the high prevalence of horses typical of the time. Freud posited that the fear of horses was a symbolic representation of an underlying fear of castration by the father, linked to Hans’ Oedipal desire for his mother.

The emergence of behavioral learning theories of psychology during the early 20th century directed attention to the role of classical and operant conditioning as a basis for explaining the etiology of childhood anxiety disorders. The seminal experiment here was the case of “Little Albert,” described by Watson in 1920 (Ollendick & Muris, 2015). Albert was a nine-month-old baby who was shown various stimuli, including a white rat, a rabbit, and a monkey, that initially did not evoke a fear response in him. After Watson paired the rat with a sudden loud noise that startled Albert, he began to show signs of fear in response to the rat, and his fear generalized to other similar stimuli. This was interpreted as evidence that childhood fears are learned responses that emerge in response to the ongoing processes of learning and conditioning.

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