Malingering is a condition in which a physical symptom that is under voluntary control is used to gain reward (e.g., money or avoidance of school, jail, or obtaining drugs). The patient has conscious intent in production of symptoms. Symptoms may not lessen when the reward is attained. Malingering is difficult to prove unless the patient is directly observed or confesses.
Anxiety disorders are characterized by uneasiness, excessive rumination, and apprehension about the future. The conditions tend to be chronic, recurring, and vary in intensity over time. They affect 5% to 10% of children and adolescents (Table 17-1). Some common anxiety disorders are discussed in the following sections.
Panic disorder is the presence of recurrent, unexpected panic attacks. A panic attack is a sudden unexpected onsetof intense fear associated with a feeling of impending doomin the absence of real danger. At least 1 month of persistentworrying about having another panic attack is required tomake the diagnosis (Table 17-2). Panic disorder most oftenbegins in adolescence or early adulthood. Symptom severitywaxes and wanes. Characteristic symptoms include shortnessof breath, palpitations, chest pain, a choking or smothering sensation, and a fear of losing control or going “crazy” (Table 17-3). Symptoms generally last approximately 15 minutes andare generally time-limited. It is common for patients to thinkthat they are about to die of a heart attack. Panic attacks areclassified as (1) spontaneous, (2) bound to situations (occurimmediately on exposure), and (3) predisposed to situations(attacks occur while at school, but not every time). Agoraphobia is a condition describing fear of situations where escapeis difficult or would draw unwanted attention to the person.Agoraphobia is often persistent and can leave people homebound. Panic disorder is seen in 95% of patients with agoraphobia. The condition is more common in females. Considerthe diagnosis of a specific phobia (as opposed to agoraphobia)if the avoidance is limited to one or a few specific situationsor social phobia if avoidance is limited to social situations ingeneral.
Generalized anxiety disorder (GAD) is characterized by 6or more months of persistent, out of proportion worry and anxiety that includes a historical diagnosis of overanxious disorderof childhood. The worries should be multiple, not paroxysmal,and not focused on a single theme and should cause significantimpairment (Table 17-4).The anxiety must be accompanied byat least three of the following symptoms: restlessness, easy fatigability, difficulty concentrating, irritability, muscle tension,and disturbed sleep. Physical signs of anxiety are often present,
Epidemiology Prevalence is 0.2%−10%; rates are similar in all racial groups. Half have agoraphobia. Eight times more common and of early onset in family members of affected individuals than general population.
Prevalence is 5%. The Prevalence is around sex ratio is equal. 8%. Twin studies Genetic factors play suggest some genetic only a modest role in role. the etiology.
Prevalence is 2%−4% of children and adolescents. The sex ratio is almost equal. Heritability of SAD is greater for girls than for boys.
Prevalence is 2%. Sex ratio is 2:1 females:males. Increased risk of specific phobias in first-degree relatives of patients with specific phobias.
Onset Average age at onset is The average age at
The average age at 15–19 years; earlier in 25%. onset is 10 years.
onset is 8–9 years.
Differential Anxiety disorder due to a diagnosis general medical condition. Substance-induced anxiety disorder due to caffeine or other stimulants.
ADHD, Attention-deficit/hyperactivity disorder; PTSD, posttraumatic stress disorder.
A. Both (1) and (2) 1.
2.
At least one attack is followed by ≥1 month of one or more of the following: a.
b.