Cambridge Independent Neuroscience and Psychiatry Services
Anxiety Disorders
Why do we get anxious?

Everyone gets anxious at times and the symptoms of anxiety, such as breathing faster or feeling your heart beating faster, are designed with a purpose.  

Imagine yourself swinging above a river or lake and then seeing a crocodile in the water.
You are likely to feel anxious with physical changes (symptoms) such as feeling your heart race or a dry mouth.  These symptoms of anxiety that you feel, will be because your heart and lungs are making changes to enable you to perform and get to a place of safety.  These physical changes and what you experience as anxiety symptoms are designed to save your life in certain circumstances. 

In some cases, individuals feel anxious constantly or have severe episodes of anxiety, without there being any real danger or risk, and these symptoms interfere with general daily functioning; these presentations can sometimes be referred to as anxiety disorders.  Research indicates that the prevalence for different anxiety disorders in children vary between 1-8%, some say 15-20%.  As with Depression, most children and young people do not ask for help. 

It is important to treat anxiety disorders early, because it is likely to become more difficult to treat, the longer you wait and the prognosis deteriorates.  Anxiety disorders usually do not resolve on their own. 

What are some of the signs of anxiety disorders?

Physical (health/medical) symptoms
Presentation usually relate to autonomic symptoms and motor tension, for example:

Increased respiration, heart rate, palpitations (awareness of heart beating), shortness of breath, dizziness
Epigastric (stomach) and chest pain, sweating, blushing, dry mouth, feeling of being 'choked'
Frequency (urinating often), urgency (feeling you 'have to go' urgently)
Nausea, diarrhoea, constipation, lack of appetite, insomnia, poor concentration, impulsive behaviour
Muscle tightening, fidgeting, hyperactivity, headaches and tremors (shaking)

Psychological symptoms
Avoiding the situation that causes stress or rapidly exiting rapidly from a scary situation
Anticipatory anxiety or constant worry / apprehension or heightened startle response
Feeling you are going 'crazy', 'mad' or going to die or that you, your life or 'things' are unreal
Fear of losing control or feeling you are losing control
Daydreams of scary memories, nightmares and flashbacks - reliving past events as if real
Detachment, emotional numbness or no interest in social interaction, relationships or previous interests
Not enjoying things you previously found enjoyable

What causes anxiety disorders or excessive anxiety?

The causes are often complex and a direct cause is not always clear.  It is often helpful to consider predisposing, precipitating and maintaining risk factors as well as protective factors. 

Protective factors:  
This list will not prevent anxiety disorders completely, but will lower the risk and improve prognosis. 

Engagement in enjoyable and regular group activities with friends or adults with similar interests
Many interests that are enjoyed regularly such as horse riding, swimming, boxing or cooking
Positive and supportive relationships with other children or young people, adults and family
Positive and supportive environment at home, at school and/or in the community
Certain personality traits (not taking life too seriously, not being too hard on yourself)
Good coping or defense mechanisms (sports, humour, friends)

This list is not comprehensive. 

Risk factors:
Genetic factors (family history of mental illness or anxiety)
Certain personality traits (sensitive, anxious, needing to get things 'just right', hard on oneself) 
Medical problems, illness or disorders
Social environment at home, at school and/or in the community
Major life events and trauma including traumatic events during early childhood and early adulthood
Stressors - chronic (such as bulling at school) and acute (death in the family or sudden change) 
Other existing mental health difficulties e.g. Depression or neurodevelopmental problems e.g. ADHD

This list is not comprehensive.  

Medical problems and medications that can cause anxiety symptoms:
Trauma, toxins (such as mercury) or nutrition deficiencies (such as Vit B12)
Infections especially chronic infections
Inflammatory disease (such as related to Lupus Erythematosus)
Neurological causes such as migraine or epilepsy (remember not all epilepsy presents with convulsions)
Cardiovascular or cardiopulmonary causes
Endocrine causes (such as related to adrenal or pituitary gland, thyroid, or parathyroid hormone)
Biochemical and haematological causes (such as relating to glucose levels and anaemia) 
Neoplasms (some tumours produce adrenaline)
Medications (such as some antibiotics, sympathomimetics and vasopressors)

This list is not comprehensive.

Many medical disorders or side effects of medications can cause anxiety symptoms and look like anxiety disorders in children and young people where no anxiety disorders exist (differential diagnoses).  Child Psychiatrists are medical doctors, so should be able to advise you and liaise with your GP to ensure that medical causes are excluded, before mental health causes are considered.  

How are anxiety disorders diagnosed?

Child Psychiatrists meet with children with various degrees of anxiety every day.  Many children present with anxiety, but no anxiety disorder.  Many medical disorders and mental illness or neurodevelopmental disorders can present similar to anxiety disorders.  Through a detailed assessment, including a psycho-social history, it becomes clear whether a diagnosis of a anxiety disorder is appropriate.

Differential Diagnoses (problem that can look similar to anxiety disorders in children):
Mood disorders such as Depression or Bipolar Disorder
Psychotic disorders such as Schizophrenia
Developmental disorders and neurodevelopmental disorders such as ADHD and Autism Spectrum Disorder
Adjustment and Separation Disorder
Abuse and attachment disorders, difficulties

This list is not comprehensive. 

It is also important to know that different anxiety disorders can also look alike in children and young people (be differential diagnoses).  Anxiety disorders such as PTSD or OCD in children often present rather different to the disorders in adults and assessment and diagnosis can be complex. 

Children with anxiety disorders are more vulnerable to develop other mental health problems (complications) sometimes present with comorbidities (two or more disorders presenting together).  

Child Psychiatrists assess for comorbidities that can occur with anxiety or anxiety disorders such as:
Depression (up to 30%)
Tic disorders (up to 30%)
ADHD (up to 10%)
Specific developmental disabilities or problems (24%)
Other anxiety disorders (up to 20%)
Enuresis and encopresis (more or less 4%)

This list is not comprehensive. 

How are anxiety disorders treated?

Early treatment is essential and directly related to outcome or prognosis.  It is essential to ensure that the diagnosis is accurate and that possible medical causes as well as mental health comorbidities and complications have been considered. 

Comprehensive treatment packages (psychotherapy, family therapy or support, liaison with Education and social intervention with or without medication), tailored to individuals unique needs, are most often required. 

Management/treatment recommendations may include medication (usually SSRIs such as Fluoxetine), but will almost certainly always include recommendations of social intervention and therapeutic intervention. 

Individual therapy, such as Cognitive Behavioural Therapy (CBT) can be offered.  This can give children and young people the opportunity to discuss worries, think about strategies to manage anxiety and learn tools to manage anxiety.  Family work is also often helpful.  Type of therapeutic intervention is usually related to presentation, personalty and temperament as well as patient preference.  Some children and adults presenting with anxiety disorders or anxiety enjoy and respond well to CBT, others do not.  Your specialist will be able to advise you. 

Therapeutic options often helpful for Anxiety Disorders (and Depression) include cognitive behavioural therapy (CBT), cognitive analytical therapy (CAT), psychodynamic therapy, creative therapies, group therapy and systemic family therapy.  Therapy usually last between 6-8 weeks (such as CBT) or longer. Therapy sessions are usually scheduled to last 45 minutes.  

Social intervention is almost always an essential component of treatment and recommendations may vary. Most specialists agree that regular normative, enjoyable, meaningful, physical and non-physical activities after school hours with non-delinquent peers and adults with similar interests, offer children the opportunity to learn new skills, experience a sense of achievement and develop from an emotional, social, cognitive and physical point of view.  Environment in the community, at school, work or at home is also relevant.  

Practical and social recommendations may appear like simple solutions, but can inspire, support or maintain positive outcomes.  An example - We were asked to assess the mental health of 100 unaccompanied minors; most witnessed their loved ones tortured and killed, and were tortured and enslaved themselves.  Some children presented with anxiety disorders, including PTSD, and some children presented with Depression and PTSD.  Most children were treated/managed through practical/social intervention, not medication, and positive outcomes were identified in more than 95% of the children.     Less that 10% of children were started on medication.  The practical intervention included connecting children to religious leaders (as they requested), community elders, employment or education opportunities (also as they requested).  Many individuals who have experienced significant trauma say that the most helpful part of treatment was, having a 'safe space' where they could talk (or not talk) with someone that they 'connected' with, being busy (with what they enjoyed, with their goals) and having a sense of belonging (being welcomed in the community and feeling accepted).  

Risk assessment, along with assessing for comorbidities and complications, throughout treatment or follow up, remain essential in all follow up appointments in mental health.  

Medication may be indicated if psychological therapies fail, when impairment and distress are disabling (usually when children or young people are unable to engage in therapy) or when children or young people refuse to engage in therapy.  Please see Depression for more information on SSRI's (medication often used for anxiety disorders).

Most psychiatrists absolutely avoid sedatives or tranquillisers, such as diazepam, and other serious medication such as beta blockers for anxiety disorders or panic in adults and especially in children and young people in the community, because the possible benefits very seldom outweighs the possible risks. Sedatives and tranquillisers can lead to significant rebound anxiety, dependence in a short period of time, and can interfere significantly with therapeutic progress and prognosis.  Beta blockers can have significant cardiac side-effects and can significantly affect mood.  The medication of choice to treat anxiety disorders is antidepressant medication, such as Fluoxetine (SSRI).


Obsessive Compulsive Disorder (OCD)
Research indicates that 30-50% of adult diagnoses of OCD had an onset in childhood (50% had significant symptoms relating to OCD).  Research indicates an incidence of 1-2% and a lifetime prevalence of 2-3%.

More or less 50% of people we see comment on a precipitating stressful event.  Most people delay asking for help (some adults wait 5-10 years), which has a negative impact on prognosis.  Medication is sometimes indicated; more or less 60% of people present with a significant improvement on medication.  

Symptoms:  Individuals experience unpleasant and repetitive thoughts or impulses that is resisted, unsuccessfully.  Individuals
 often feel compelled to act in a specific way or by a specific rule (opening and closing drawers or taps, or switching light switches on and off, or any other 'ritual'), that has no specific, realistic or rational purpose.  This is done to avoid disaster or a negative outcome. 

Assessment for OCD can be challenging, especially in young children.  Ask a specialist for advice. 

Post Traumatic Stress Disorder (PTSD)
PTSD can be a complex diagnosis to make.  Please seek help from professionals with comprehensive training and experience to consider this diagnosis in children and young people.   

Research indicates that PTSD rates after traumatic events can be as high as 25-30%, some say 60%. Lifetime prevalence for PTSD is more or less 1-8%.  PTSD can occur soon after or 30 years after a traumatic event.  PTSD can be divided into complex and simple PTSD.  Responses after trauma can be dependent on many factors, not only the severity or intensity of the traumatic event and context (ABC) of the event, but also factors such as the interpretation of, or meaning assigned to the event, premorbid personality, social support and most importantly, the responses of loved ones and the community after the event or events. 

Early and effective treatment packages by experienced professionals are required.
Symptoms:  Presentations vary.  Individuals may repeatedly relive stressful experiences, in the form of flashbacks (reliving it as it if is currently happening and real), daydreams or nightmares.  Young children can indicate this through play and older children can indicate this through repetitive topics of conversation relating to trauma.  Individuals can appear or feel 'unreal', 'blank', numb and completely detached (emotional blunting or unresponsiveness).  Individuals can lose interest in previous interests (anhedonia) or social interaction or relationships and struggle to sleep.  Avoiding situations or stimuli where symptoms or memories are precipitated can occur.  An exaggerated startle response or hypervigilance can also be seen.  Children and adults can present with poor concentration, impulsive, hyperactive, bizarre, defiant or aggressive behavioural changes, as well as personality changes.  

Many children, young people or adults do not talk about their symptoms; they disengage and withdraw from the world (friends, family, school, employment) or present with aggression.  

Risk assessment and management is very important in PTSD, as with most mental health diagnoses. 

Generalised Anxiety Disorder
GAD usually occurs in late adolescent to early adulthood.  Research indicates a prevalence of more or less 4%.  As with all anxiety disorders, it is important to rule out medical causes. 
Symptoms:  Constant apprehension (worry and poor concentration), largely non-specific or unfocused, and interfering significantly with daily functioning and causing significant distress.  Autonomic symptoms and symptoms relating to motor tension, such as hyperactive and impulsive behaviour, are common.   

Panic Disorder
Panic Disorder usually occurs in late adolescence (age 15 more or less) to early adulthood.  Research indicates a prevalence of <1% in children under 12 and more or less 3% in children of 12 and older. 
As with all anxiety disorders, early diagnosis and treatment are relevant in prognosis.  
Symptoms:  Recurrent attacks of panic, during which an individual feels he/she is going to die or 'go insane' or lose control, when there is no real risk.  The attack begins suddenly and lasts minutes.  The individual experiences intense anxiety symptoms such as sweating, shortness of breath and palpitations.  There is often no anxiety between the attacks and the attacks are not predictable or precipitated by a particular situation or fear.  individuals usually exit the situation quickly, and avoid certain places or contexts because of fear of another panic attack. 

Social Phobia
Social Phobia most often occurs between age 15-20.  Research indicates that the prevalence is likely more or less 7%.     

Symptoms:  Individuals experiences panic in particular social circumstances such as eating in public, speaking in public, general interaction with people or groups of people, or any other 'performance situations'.  These circumstances are avoided and extreme anxiety is felt when it is anticipated. 

Young people with social phobias, as with most anxiety disorders, are vulnerable to develop depression. Early treatment is important to avoid complications.  

Agoraphobia usually occurs between late adolescence (age 15) and early adulthood.  Research indicates a prevalence of <1% in children under 12 and 4% in children 12 and older.   
Symptoms:  Individuals experience panic in particular circumstances such as in crowds, public places, travelling away from home or travelling alone.  These circumstances are avoided and extreme anxiety is felt when it is anticipated.

Early treatment is important and relates directly to prognosis.  

Please see Helpful Links for (mostly non-medical) support for children, young people and families.   

The content of these pages is intended for general information purposes only.  These pages do not constitute any form of consultative or diagnostic tool or process.  The assessment, diagnosis and treatment of mental health difficulties, particularly in children, is a complex and specialised process and should only be undertaken by individuals with appropriate training and sufficient experience, such as qualified mental health professionals.  If you are concerned about the mental health of a young person, please seek appropriate advice from your General Practitioner, local Child and Adolescent Mental Health Service or Social Care.  Research findings and conclusions can vary between sources, and can change over time. 
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