This case leads nicely into a discussion about how to approach the treatment of an anxiety disorder. The first step is to determine a specific diagnosis and determine the level of impairment of the symptoms. If the impairment is mild-moderate, one could start with a therapy approach and determine if medication treatment is needed in the future.

If the impairment is moderate-severe, the standard of care is to begin therapy and medication treatment concurrently. Medication treatment should minimally involve an approach to treat the underlying anxiety – first line would be an SSRI medication.

Other options, if that doesn’t work, could include: SNRIs, Remeron, and Buspar. For many patients, it is helpful to initially prescribe an adjunctive medication to provide some relief for their anxiety while the primary medication is “kicking in”. These include: Buspar (which can be useful for the underlying anxiety management as well as for acute anxiety management), Vistaril, Propranolol, and the benzodiazepines.

Some providers may consider low doses of the atypical antipsychotics, but the concern about that practice is that the patient is still exposed to the possible metabolic side effects of that class of medications even at low doses, as many of the metabolic side effects of antipsychotics are dose-independent. For patients for whom they are effective, these adjunctive medications yield benefits more quickly than the traditional anti-anxiety medications.

In many cases, these medications can be tapered off once the base medication has fully “kicked in”.  Buspar is typically dosed 7.5 mg bid and increased by 5 mg every 2-3 days as tolerated up to 30 mg bid. Onset of action may take 2 weeks. It is relatively well tolerated with less cognitive impairment than benzodiazepines. Major side effects include dizziness, fatigue, and nausea. Vistaril is typically dosed 25-50 mg bid-tid on a prn basis. It is less sedating than Benadryl, therefore is better tolerated during the daytime. Propranolol is typically dosed 20-40 mg if used on a prn basis and 20 mg bid-tid titrated up to 40 mg bid-tid as tolerated and needed if used on a standing basis.

We hope this extensive discussion about this case and the thinking process that occurred in the background was helpful for other similar cases you might encounter in your practice.

First, it is important to determine what makes anxiety clinically significant. Anxiety is an expected, normal, transient response to stress and can be helpful with the warning of danger or coping with the stress. Clinically significant anxiety is an excessive response to external stress or related to an unidentifiable trigger. It is persistent rather than transient. It causes functional impairment, by exceeding the patient’s ability to cope with the stress and/or leading to avoidance behaviors.

General symptoms of anxiety in children include many worries about things before they happen, constant worries or concerns about family, school, friends or activities, fears or embarrassment or making mistakes, low self-esteem and lack of self-confidence. There are often somatic complaints as well, like stomachaches, headaches, and sleep disturbance, as well as a desire to avoid school and friends.

Specific symptoms of separation anxiety include constant thoughts and intense fears about the safety of parents and caregivers, refusing to go to school, frequent stomachaches and other physical complaints, extreme worries about sleeping away from home, being overly clingy, panic or tantrums at times of separation from parents, trouble sleeping or nightmares, and refusing to sleep without parents.

Specific symptoms of a phobia include extreme fear about a specific thing or situation (ex. dogs, insects, needles) and the fears cause significant distress and interfere with usual activities (ex. child refuses to go to the park because of a fear of seeing a dog).

Specific symptoms of social anxiety include fears of meeting or talking to people, avoidance of social situations despite a desire to attend, and few friends outside the family.

Anxiety disorders have a high rate of co-morbidity with other psychiatric disorders, primarily mood disorders, ADHD and other disruptive behavior disorders, and substance use disorders. It is therefore important to assess for these co-morbidities. To complicate things further, there can be some overlap with the specific symptoms of anxiety and other psychiatric disorders. For example, patients with Generalized Anxiety Disorder may “obsess” about daily worries, patients with Autism Spectrum Disorders have rituals, and patients with Major Depressive Disorder may ruminate or “obsess” over negative self-thoughts, but it does not mean that these patients also have Obsessive-Compulsive Disorder.

Early awareness and treatment of anxiety can prevent future difficulties, such as loss of friendships, failure to reach social and academic potential, substance misuse, and feelings of low self-esteem. It is important for primary care providers to be comfortable with assessing for anxiety in pediatric patients and linking families to appropriate resources when needed. Further information about treatment of anxiety symptoms in young patients will be addressed in a future e-weekly publication.