A 17-year-old girl is brought to the office by her mother, who says that the patient has become increasingly irritable and difficult to get along with since the academic year began 7 months ago. The mother says, "She reacts negatively whenever I try to reassure her that everything is okay. Just last week, she got upset when I complimented her outfit." The mother observes that her daughter always seems on edge and sleeps poorly. The patient says she lies awake at night reviewing conversations she had with peers at school and ruminating about whether she said the right thing. She also worries about maintaining her grades and getting into college and has concerns about her appearance and clothes. She recently met a boy she likes but is afraid of being rejected by him due to her acne. The patient wishes she could change but says, "I can't help it; I am always thinking too much." During the day, she feels tired and has difficulty concentrating. Which of the following is the most likely diagnosis?
Generalized anxiety disorder in children & adolescents | |
Clinical |
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Associated |
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Treatment |
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Differential |
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SNRI = serotonin-norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor. | |
This patient's irritability, feeling on edge, sleep disturbance, impaired concentration, fatigue, and excessive worry about multiple issues are consistent with generalized anxiety disorder (GAD), a common anxiety disorder in children and adolescents. Although adolescents may sometimes be moody, argumentative with their parents, and preoccupied with appearance and social acceptance, experiencing sleep disturbance, fatigue, and poor concentration and being consistently on edge are not typical and should not be dismissed as normal (Choice C). Patients with GAD experience anxiety as overwhelming and difficult to control. As in this patient, anxiety is pervasive, causes distress, and interferes with daily functioning.
Although 6 months' duration is required for diagnosis, most patients report a lifelong history of anxiety and typically experience worsening symptoms during periods of increased stress. Treatment of GAD in adolescents consists of cognitive behavioral therapy; pharmacotherapy with selective serotonin reuptake inhibitors is reserved for severe cases.
(Choice A) This patient's anxiety is generalized and not exclusively focused on a specific body part or perceived physical defect, as is the case in body dysmorphic disorder. Her appearance concerns are just one of multiple worries, which is characteristic of GAD.
(Choice D) Although this patient is preoccupied with worry, her thoughts are not described as intrusive or involuntary in nature, which would be expected of obsessions in obsessive-compulsive disorder (OCD). Patients with OCD try to neutralize their obsessions with compulsive, ritualistic behavior, which is not apparent in this case.
(Choice E) In social anxiety disorder, symptoms occur exclusively in response to social interactions in which the patient fears negative evaluation by others. This patient's anxiety is more pervasive and extends beyond concerns about social acceptance (eg, grades, getting into college). Her anxiety is prevalent in the home setting, as well as at school.
Educational objective:
Although concerns about social acceptance and appearance are typical of adolescence, pervasive and overwhelming anxiety requires further assessment. Generalized anxiety disorder is characterized by excessive anxiety lasting ≥6 months with edginess, fatigue, difficulty concentrating, irritability, muscle tension, and sleep disturbance.