Anxiety Disorders in Adults & Pediatrics (FL INITIAL Autonomous Practice - Pharmacology)

Separation anxiety disorder is characterized by a non-developmentally appropriate excessive fear that a child experiences when separating from the individuals to which the child is attached (APA, 2022; Melnyk & Lusk, 2022). Is it just being away from their caregivers that gives these children anxiety? No, not always. These children can experience a persistent fear that harm might come to their attachment figures or that events could occur that could lead to the loss of or separation from their guardians (APA, 2022). With this fear comes a reluctance to leave the side of a caregiver. Although this anxiety disorder is more commonly experienced in childhood, it can still be expressed in adulthood when a history of childhood separation anxiety disorder exists (APA, 2022).

What diagnostic features might a child exhibit who is suffering from a separation anxiety disorder? The following features could be present and must be persistent, excessive, and distressing (APA, 2022):

• Distress when getting ready to or currently experiencing separation
• Worry that something bad might happen to a major attachment figure
• Concern about an unpleasant event (accident, illness, getting lost, being kidnapped)
• Refusal to separate
• Fear of being alone
• Refusal of sleeping without a figure of attachment
• Nightmares about being separated
• Complaints of physical symptoms (headaches, stomachaches, vomiting, nausea)

Separation anxiety in children can lead to school attendance refusal, which could ultimately impact academic performance. Children refusing to go to school can become very angry and possibly aggressive towards the individual, forcing the separation (APA, 2022).

The child or adolescent experiencing separation anxiety disorder must be experiencing this fear and/or avoidance for at least four weeks to be diagnosed with this.

Selective mutism is an anxiety disorder that is characterized by a failure to speak when there is an expectation to speak, such as in social situations like school (APA, 2022). These children have the ability to speak and do speak in other situations, such as at home with their families (APA, 2022).

What diagnostic features might a child who is exhibiting selective mutism exhibit? The following features could be present and must be persistent, excessive, and distressing (APA, 2022):

• Failure to speak in specific situations
• The situation/place in which they refuse to speak is leading to interference with achievement/communication

The child or adolescent demonstrating selective mutism must exhibit these diagnostic features for at least four weeks to be diagnosed with this. It does not meet the criteria if the child is choosing not to speak only in the first month of school. The failure to speak cannot be attributable to a lack of knowledge or a lack of the known spoken language (APA, 2022).

The refusal to speak in places such as school can interfere with normal social communication and can really have a deleterious effect on the child's academic achievement.

Children, adolescents, or adults with specific phobias are afraid or anxious about a specific object or situation (APA, 2022). Although we all have fears, more often seen in children, this fear that is experienced is out of proportion to the actual risk imposed by that object or situation (APA, 2022).

The prevalence in children ranges from 3% to 9% across various countries and approximately 16% among adolescents (APA, 2022). Specific phobia typically develops in early childhood, with the majority of cases presenting prior to the age of 10 years (APA, 2022). Even though most specific phobias begin in childhood and adolescence, it is quite possible for a specific phobia disorder to emerge at any age, often as the result of traumatic experiences (APA, 2022).

What diagnostic features might an individual demonstrate who is exhibiting a specific phobia? The following features could be present and must be persistent, excessive, and distressing (APA, 2022):

• Fear of a specific object or situation (in children, we see crying, tantrums, clinging, and/or freezing)
• The object or situation always elicits this response
• The object or situation is avoided
• Anxiety is out of proportion to the danger posed by the object or situation

The individual demonstrating a specific phobia must be exhibiting these diagnostic features for at least six months to be diagnosed with this.

What sort of phobias exist? This can really be anything. More common examples, however, include (APA, 2022):

• Environment (heights, water, storms)
• Animals (insects, dogs, spiders, snakes)
• Blood-related (needles)
• Situational (flying, enclosed spaces)

Social anxiety disorder is characterized by an individual feeling very anxious about and avoiding social interactions (APA, 2022). It can even involve situations where the individual may feel like they or their behavior might be scrutinized in some way (APA, 2022). Social interactions can be meetings with unfamiliar people, situations where they can and will be observed eating or drinking, or especially circumstances in which the individual is performing in front of others (APA, 2022). These individuals have an overwhelming fear of being embarrassed, humiliated, or rejected by others (APA, 2022). For children, the key part of this diagnosis is that the anxiety must occur in peer settings, specifically not just around adults (APA, 2022).

The prevalence of social anxiety disorder in young adolescents (age 13 to 17 years) is roughly half that of those in adults (APA, 2022). There is also a higher rate of social anxiety among women when compared to men, and the difference in rates among genders is more pronounced in adolescents and young adults (APA, 2022).

What diagnostic features might an individual demonstrate who might have social anxiety disorder? The following features could be present and must be persistent, excessive, and distressing (APA, 2022):

• Anxiety about one or more social situations/interactions
• Fear that they will demonstrate anxiety symptoms that could embarrass them
• Social situations almost always cause anxiety (crying, freezing, clinging, failing to speak)
• Avoidance of social situations or situations endured with intense signs of anxiety
• Fear is out of proportion with the actual threat of a social situation

The individual showing signs of social anxiety disorder must be exhibiting these diagnostic features for at least six months to be diagnosed with this.

Although panic attacks can occur in children, the prevalence of panic disorder is quite low before 14 years of age (APA, 2022). The rates increase during adolescence and peak in adulthood (APA, 2022). Adolescents who suffer from multiple panic attacks and are anxious about having future panic attacks can be diagnosed with panic disorder (APA, 2022).

What exactly are the signs and symptoms of a panic attack? Panic attacks have an abrupt onset and then reach a peak within just a few minutes. Panic attacks are accompanied by at least 4 of the following symptoms (APA, 2022; Melnyk & Lusk, 2022):

• Sweating
• Trembling/shaking
• Palpitations, pounding heart, or increased heart rate
• Feeling smothered
• Feeling choked
• Chest pain
• Nausea
• Lightheadedness
• Depersonalization/derealization
• Chills/heat sensations
• Paresthesias
• Fear of going crazy
• Fear of death

There must be at least one of the attacks followed by at least one month of persistent worry about having another attack and/or avoidance behaviors to avoid a future attack (APA, 2022).

The panic attacks themselves can either be unexpected (no trigger), expected (known trigger), or even, less commonly known, nocturnal (waking from sleep in a full-blown panic attack). The biggest concern about those who suffer from panic disorder is that their fear of having another panic attack will result in their purposeful avoidance of places and situations where they have had a panic attack before, thinking something about that place or situation might be a trigger. This avoidance can lead to agoraphobia, which can severely impact the individual's ability to function.

It is important to note that we cannot assume that their initial attack is not a cardiac issue. Especially in the case in which the individual or their families have some sort of cardiac history to be concerned about, it is best to rule out a cardiac issue by at least completing a 12-lead electrocardiogram (EKG), which could capture possible ischemia or an arrhythmia pointing to something more cardiac in nature.

Generalized anxiety disorder, or GAD, is characterized by persistent and excessive worry that the individual has trouble controlling (APA, 2022). GAD is the existence of this overwhelming anxiety or worry paired with three or more of the following symptoms (APA, 2022; Melnyk & Lusk, 2022):

• Muscle tension
• Becoming easily fatigued
• Irritability
• Restlessness
• Having difficulty falling or staying asleep

For children who are experiencing GAD, only one bulleted item listed above is required for diagnosis (APA, 2022). These children and adolescents with GAD have an excessive concern about their competence in school punctuality, they hold perfectionist ideals with a desire to excel, and they generally lack overall self-confidence (APA, 2022). They also tend to be overzealous in attempting to gain reassurance and approval from others regarding their performance (APA, 2022). The somatic complaints, as listed above, are quite common physical demonstrations of the stress and anxiety endured by their minds.

Any aged individual suspicious of GAD must be exhibiting these diagnostic features more daysthan not for at least six months to be diagnosed with this.

Although more common in adulthood, the twelve-month prevalence is 0.9% among adolescents (APA, 2022). Oftentimes, adults who experience GAD have a history of experiencing this intense anxiety back in their childhoods. In fact, many individuals with GAD report that they have experienced anxiety and felt nervous for all of their lives (APA, 2022). Women and adolescent girls are actually at least two times as likely as men and adolescent boys to experience GAD (APA, 2022). It is also interesting to note that one-third of the risk of GAD is genetic, meaning that a family history of GAD carries a significant weight to the risk of GAD in future generations (APA, 2022).

The main goals of the treatment for anxiety are to:

1. Decrease or eliminate the symptoms
2. Improve overall quality of life
3. Improve overall functioning

What is the best first step? EDUCATION. Teaching about what anxiety is, why it is, how common it is, and what we can do about it is so helpful for our patients. Why does it behoove us to capture anxiety in children and adolescents when they are younger? First, pediatric anxiety disorders are often associated with increased difficulty in school performance, peer relationships, and issues juggling a full schedule with school, homework, and extracurriculars. When left untreated, anxiety disorders tend to worsen and are likely to persist into adulthood. With persistence into adulthood, anxiety is likely to be associated with more mental health issues, including depression, substance use disorders, suicidal behavior, and occupational impairment (UpToDate, 2023a).

After providing psychoeducation, first-line treatment options for anxiety include (UpToDate, 2023a):

1. Therapy (primarily CBT)
2. Medication
3. A combination of therapy and medications

We will now review each of these components.

Cognitive behavioral therapy, or CBT, is considered the first-line nonpharmacological treatment option for GAD (APA, 2017b; Psychology Today, 2022). It has been shown to benefit all of those who suffer from anxiety and depressive disorders (APA, 2017b). Research has shown that the benefits of CBT can last longer than the effects of medications for anxiety. In fact, CBT has been shown to significantly reduce symptoms, even showing a benefit persisting up to 12 months after treatment is received (APA, 2017b).

CBT is a form of psychological treatment that is based on a few core principles (APA, 2017b):

1. Psychological issues are partially based on unhelpful ways of thinking.
2. These problems are partially based on learned patterns of these unhelpful behaviors.

CBT helps by breaking down the things that make us scared or anxious, putting them into clear focus and perspective to figure out why we have the reaction that we do, rationalizing our knee-jerk responses, and then working to help change our response and negative thought patterns going forward to improve the way we feel overall (APA, 2017b).

The goal of CBT is to become aware of our thoughts, intervene in real-time to acknowledge our negative thoughts, and then improve our thought patterns for our futures (APA, 2017b).

In anxiety, we also can have these "cognitive distortions" that require cognitive restructuring to change these patterns of thought. Some of these cognitive distortions can include (Garey, 2023):

• All or Nothing Thinking: This is also referred to as black-and-white thinking or dichotomous thinking. Good or bad, success or failure, this cognitive distortion allows no middle area. It is a common thought pattern in those who are perfectionists.
• Overgeneralization: This is when one negative event or detail is thought to be a universal truth about one's whole life.
• Fortune-Telling: This is generally a pessimistic thought pattern where one can feel that negative events are going to happen in the future regardless of what one does.
• Mind-Reading: This is when one makes the assumption that others are thinking negatively about them.
• Catastrophizing: This is taking something negative or some type of problem and blowing it out of proportion, assuming it is the worst ever.

In order to work on cognitive restructuring, patients are asked to challenge these cognitive distortions. What is the worst thing that can happen? And if that is the worst thing, can I handle that? Most likely, yes. What are the chances my fear will come true? The chances are really not as high as you think.

One great tool used often in CBT is the "Evidence For vs. Evidence Against" technique (Simmons & Griffiths, 2017). Although some different, fancy worksheets exist out there, these can simply be drawn as a T-table with "Evidence For" on the left side and then "Evidence Against" on the right side.

To best use this table, one is asked to consider the anxiety-provoking thought. Then, they are asked to make a list on the left side of the table that would be the evidence that this anxiety-provoking thought/event would come true. Then, one is asked to fill out the right side of the table with the evidence that that anxiety-provoking thought is likely not to come true. For example, let's say that the thought is, "If I do not pass this one exam, I will never be a nurse.". Now, let's try to complete the table, really considering what evidence we have "for" and "against" that thought.

Utilizing this table is helpful for those with anxiety to physically write out and challenge those cognitive distortions that one might be having that lead to rumination, obsession, and other anxiety symptoms such as problems sleeping. In more cases than not, individuals are able to see that there is more evidence that their thoughts are not true and that their anxious thoughts and fears are simply giving them a hard time. This is one tool that can be used in CBT to help manage symptoms of anxiety. There are many more available out there!

Although a perfectly thorough review of the pharmacological treatment options for anxiety is outside of the realm of this course, we will review the most common first-line treatment for anxiety disorders.

For the treatment of anxiety disorders, research has demonstrated that psychotherapy is more effective than medications alone and that adding in medications does not substantially improve outcomes from therapy alone (APA, 2017a). It has been found that when treating depression, a combination of both psychotherapy and psychotropics for treatment performs significantly better in improving function and quality of life when compared to each treatment (Kamenov et al., 2017). If psychotherapy requires a bit more momentum, the option of psychotropic medications can be very helpful! The general "rule of thumb" here is for those with mild anxiety, it is recommended that we do more "watchful waiting," give some management tips, and possibly refer them to therapy if they are interested. For more moderate anxiety, CBT plus medication is often recommended. For severe anxiety, CBT plus medication is even highly recommended. Therapy can always be started first, and then medication can be added later if desired.

Just as there is a stigma in relation to therapy or "seeing a shrink," psychotropic medications also receive their own share of shame. Although not for everyone, many patients do so well on medications that work in their bodies to potentiate and increase the level of neurotransmitters that, when deficient, can be responsible for many mental health struggles.

Much like those who struggle with symptoms of attention deficit hyperactivity disorder (ADHD) and require the help of stimulants to increase their focus and motivation, anxiety could very well be treated effectively by selective serotonin reuptake inhibitors (SSRIs). In fact, these are considered the first-line treatments for anxiety (APA, 2022).

Why SSRIs? SSRIs are known commonly as antidepressants that block the reuptake and recycling of the neurotransmitter serotonin, which allows more serotonin to be available in the brain (Cleveland Clinic, 2022). Low serotonin levels are implicated in several mental health disorders, including (Cleveland Clinic, 2022):

• Anxiety
• Depression
• Suicidal thoughts/behavior
• Panic disorders
• Phobias
• Post-traumatic stress disorder (PTSD)

What does serotonin do exactly? Serotonin within the brain helps regulate mood (Cleveland Clinic, 2022). It's our "feel good" neurotransmitter (Cleveland Clinic, 2022)! At normal, higher levels, we are all able to focus, be more emotionally stable, and overall calmer and happier (Cleveland Clinic, 2022). Serotonin also plays a role in the quality of our sleep, wound healing, bone health, digestion, and sexual health (Cleveland Clinic, 2022).

What causes lower levels of serotonin? Sometimes, the body is not producing enough, and other times, it is not using it effectively. In other cases, the serotonin receptors are not working like they are supposed to (Cleveland Clinic, 2022).

How can the levels of serotonin be increased so that our mood can improve and our body can have it for other bodily functions? Getting more sunlight, more exercise, lowering your stress levels, and even eating foods like salmon, eggs, pineapples, cheese, and nuts can help increase natural serotonin levels (Cleveland Clinic, 2022). There is also the option of SSRIs, which is the first-line psychotropic treatment for several mental health disorders (Cleveland Clinic, 2022).

SSRIs are non-addictive, quite well-tolerated, and, after a period of generally 4-6 weeks, have been shown to increase serotonin levels enough for people to notice a difference in their overall mood and a decrease in their symptoms (Cleveland Clinic, 2022).

For our children and adolescents, the following table will give you an idea of a few SSRIs that can be used and their appropriate doses for this age group.

(UpToDate, 2023a; UpToDate, 2023b; Stahl, 2019)

Please note: With the exception of escitalopram, antidepressants are not approved by the United States Food & Drug Administration (FDA) for the treatment of anxiety disorders in children (Stahl, 2019). However, it is used for GAD as an off-label use option. For example, fluoxetine is FDA-approved for major depressive disorder for ages 8+ and obsessive-compulsive disorder (OCD) for ages 7+ but is also often given off-label for ages 7+. Sertraline is FDA-approved for OCD in children but is also often given off-label for anxiety for ages 6+ (Stahl, 2019).

Any psychotropic medications prescribed for children should be started at the lowest dose (even half the initial dose at first if very medication-naïve) and then increased slowly and gradually over time, depending on symptoms and side effects (Stahl, 2019).

For adults, the same above table is applicable. Of course, as mentioned, these are just a few of the SSRIs and antidepressants, in general, that are available for treatment.

The general side effects of SSRIs include (UpToDate, 2023a; UpToDate, 2023b; Melnyk & Lusk, 2022):

• Nausea
• Vomiting
• Anorexia
• Diarrhea
• Headache
• Trouble sleeping
• Drowsiness 

The main side effects (the first four) occur because one of the main sites of serotonin receptors is in the stomach (Stahl, 2019; UpToDate, 2023b). In fact, 95% of serotonin receptors are in the gut (Stahl, 2019; UpToDate, 2023b). When serotonin levels increase in the brain when SSRIs are taken, they also increase in the stomach. When this happens, patients can commonly experience gastrointestinal side effects (Stahl, 2019; UpToDate, 2023b). The good thing, however, is that these side effects generally subside within the first few days once the body acclimates to the higher levels of serotonin in the stomach. Other long-term side effects that can occur with SSRIs include weight gain and sexual dysfunction (Stahl, 2019; UpToDate, 2023b).

Family/patient/caregiver teaching is very important when a new SSRI is started. SSRIs do not immediately stop or reduce symptoms (Stahl, 2019; UpToDate, 2023b). As mentioned above, it is a gradual process as serotonin levels increase, which generally takes about 4 to 6 weeks (Stahl, 2019; UpToDate, 2023b). Another very important thing to mention is the Black Box warning that SSRIs contain regarding the possibility of increased suicidal ideation (Stahl, 2019; UpToDate, 2023b).

Other serotonin-increasing medications can also include serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine. SNRIs increase levels of norepinephrine in addition to serotonin, which is the neurotransmitter that plays a role in attention, motivation, emotions, and memory storage (Endocrine Society, 2022). Low levels of norepinephrine are also implicated in several mental health conditions, including anxiety (Endocrine Society, 2022). There are several other second-line and third-line options for treatment that are available for treatment for these mental health conditions that have been mentioned, as well as many others that have not been.

There are so many different ways to do some breathwork. Counting and box breathing are just two examples. Box breathing is a powerful breathing technique that includes breathing in for four seconds, holding for four seconds, exhaling for four seconds, and then holding again for four seconds (Swiner, 2023). In this way, imagine drawing a square, with each side being four seconds!

Those with anxiety often complain of body pain and soreness. This can be due to the common anxiety manifestation in the body in the form of tension. Those with anxiety typically can find their neck, back, and even their jaws tensed up, even when just sitting and doing a calm activity. This constant tensing of their muscles leads to this soreness they experience. Just acknowledging this muscle tension, taking a deep breath, mindfully relaxing those muscles, or even getting a massage can help with the physical symptoms of anxiety.

Individuals who suffer from anxiety will often explain what they are experiencing in their brains as non-stop thoughts and ideas flying around and popping up, sometimes keeping them up at night. They might also describe the desire to just "turn their brain off." In order to do that, it really helps to write down those ideas so that the individual knows they are in a safe place and not to be forgotten later. This "brain dump" can be done on any piece of paper or, even better, in a notebook kept right at the bedside. Right before bed, a few moments can be taken to write down every thought, idea, or concern that comes to mind. These things are then written down, contained, and no longer distracting the person from resting and relaxing. A "brain dump" can be really beneficial immediately before going to bed or really whenever someone with anxiety is struggling with racing thoughts.

We have already talked about CBT at length; however, even simple talk therapy without the employment of skills for a specific mode of therapy can be extremely beneficial to those with anxiety (UpToDate, 2021). Having someone to talk to and vent to, who is specifically there to listen to you, talk you through experiences in your life, and help YOU help YOURSELF, can be invaluable!

For someone with anxiety, it is vital to have a place to put all the reminders, appointments, and daily schedules in a place that is safe, complete, and organized. For students in school who struggle with the overall assignment due dates and exam dates, the best way to organize their thoughts and their school syllabi is to create a semester schedule that merges all deadlines for all courses and extracurricular activities in one place to ensure nothing is missed. Because looking at that full calendar can be overwhelming and could lead to avoidance of tasks, breaking it down into more "bite-sized" pieces, like monthly or weekly calendars of events, can make things feel more manageable. From there, daily checklists can be used to make sure you stay on task and accomplish what needs to be done! There are few things someone with anxiety loves more than a good checklist! Just one task at a time!

Various scents and smells through aromatherapy can do wonders for anxiety (Keohan, 2023). Research has found a huge slew of scents to be calming, specifically for anxiety. For example, lavender oil is said to reduce cortisol levels, heart rate, blood pressure, and skin temperature as well (Keohan, 2023; Gong et al., 2020)! Oils can be used in massage oil, a diffuser, or even in bath water to help someone with anxiety relax. It is important, however, that safe oils are used and attention is taken to who else the oils might be exposed to. Some oil scents can be toxic to children and/or pets.

Epsom salt baths can be an AMAZING form of "therapy" for anxiety! Epsom salt is magnesium sulfate. There is so much research that says that magnesium is such a calming mineral for the body. Those who have anxiety commonly can have a deficiency in magnesium! One study at the University of Birmingham found that taking Epsom salt baths 2-3 times per week significantly increased plasma magnesium levels (Lidicker, 2019). It is important to follow the directions for the specific blend of Epsom salt that is used, as too much can cause its own side effects, and too little will not have any positive effects at all (Lidicker, 2019). The key, too, is to make sure you are soaking long enough in the tub to allow the positive effects of the magnesium to take place. Generally, at least 10 minutes is recommended, but 20 to 30 minutes is even better. Depending on the individual's magnesium level, oral supplementation might be helpful to correct a deficiency as well!

Connectedness with nature has been associated with lower anxiety levels (Mental Health Foundation, 2021). A connectedness with nature can be accomplished by taking a moment to truly appreciate the song of a bird, the bark of a tree, the smell of a flower, or even the feeling of soil and grass beneath our feet. Something called "grounding" can be really beneficial. Grounding describes the action of standing or walking barefoot in the sand at the beach, the grass in the park, the soil in a forest, or even right in your own yard (Schwartz, 2022). The goal is to walk barefoot while paying close attention to how your feet feel in the natural elements on the ground (Schwartz, 2022). The benefits of going barefoot are that it physically feels good, elicits a sensory experience with different textures and temperatures, allows us to center our minds and bodies in the present, and helps decrease stress and lower anxiety (Schwartz, 2022).

Marie explains that she has struggled with anxious feelings since she was eight years old. She is a perfectionist, requiring herself to have straight A's in school and participate in as many extracurriculars as possible. She likes how she is, though, as she feels that constantly pushing herself helps her stay on top of her schoolwork and work toward becoming a pediatric nurse practitioner. Therefore, she has not brought it up before at her primary care office, has never participated in any form of therapy, and has never taken any sort of psychiatric medication. However, over the last three months, she feels she is losing control and is here to ask for help.

Marie continues to explain that at least once per week, she has experienced an "episode," as she calls it. She explains that all of a sudden, she is unable to breathe, her heart is racing, she is frozen still, she is shaking, and she has severe chest pain. She notes that these events are never triggered by anything, as she is normally just quietly taking notes at her desk at school when these episodes suddenly come on. Marie and her mother deny any personal history, nor family history, of cardiac issues. Marie is an otherwise healthy teenage girl who is active in dance four days per week. Marie notes that these episodes last no longer than 5-10 minutes max each time. Marie is now experiencing fear that these episodes will continue to occur, which has resulted in her missing a couple of days of school. Missing these days of school is now, in turn, increasing her level of anxiety.

• Anxiety: Patient endorses racing thoughts, rumination of thought, a constant sense of worry, and feeling restless. She rates her anxiety as an 8 out of 10.
• Psychosis: Patient denies auditory hallucinations, visual hallucinations, and paranoia.
• Eating habits: Patient eats three meals a day. She occasionally drinks soda; otherwise, there is no coffee or excessive caffeine.
• Sleep: Patient reports about 6-7 hours of sleep per night on average.
• Exercise: Patient reports dance four days per week, for two hours at a time.
• Current Medications: None.
• Drugs/alcohol use: Patient denies ever having tried any drug or alcohol or having ever smoked/vaped.
• Past psych history: Marie and her mother endorse her history of being an anxious child, but no formal diagnosis has been made in the past.
• Past medical history: Patient reports chronic tonsil stones.
• Social history: Patient is in the 11th grade and works part-time as a tutor. She lives with her parents and three younger male siblings.
• Trauma: Patient denies any form of abuse or traumatizing experiences.
• Hospitalizations/surgeries: Marie denies a history of any hospitalizations. She did have surgery in November 2021 to remove her tonsils.
• Suicidality/self-harm: Patient denies engaging in any self-harm practices and denies suicidal ideation in the past.
• Family psych history: Patient's mother suffers from anxiety and has had postpartum depression. Patient's father has anxiety as well. Brother is on the autism spectrum.

• Physical exam: Within normal limits. Blood pressure: 118/67, heart rate 98, respiratory rate 16, temp 98.6 F.
• Appearance/orientation: Dressed appropriately for the weather. Well-groomed. In good health.
• Mood/affect/behavior: Appears euthymic. Mood is congruent with behavior.
• Speech: Rate and rhythm pressured at times.
• Thought process: Generally organized and circumstantial.
• Cognition: Alert to person, place, and time. Long-term and short-term memory intact.
• Motor Activity: Posture is good, makes eye contact, fidgeting.

Now that we have collected a good history and physical, based on Marie's information, what are you thinking might be going on?

If you are thinking of possible GAD and panic disorder, you are correct!

Based on Marie's presentation, let's give her a GAD-7 to try to get an idea of the severity of her anxiety symptoms. 

• Patient endorses racing thoughts, rumination of thought, a constant sense of worry, and feeling restless.
• GAD-7: 10
• This indicates a likely moderate level of anxiety.

Okay! Let's come up with a plan for her. Because she is experiencing a moderate level of anxiety as well as frequent panic attacks, there is much we can do to get her symptoms under control.

First, we educate about anxiety, the symptoms, and how anxiety can affect the mind and body, and reinforce that Marie is doing the right thing by coming in for help! Next, we can start by recommending some nonpharmacological treatment strategies: relaxation, grounding, talk therapy, journaling, physical activity, and maybe mindfulness. Then, although she does not have a history of cardiac issues and her story is highly consistent, with these being panic attacks, let's order some baseline labs and refer her to cardiology to ensure her heart is not the culprit of the symptoms she is experiencing.

Next, we are going to start Marie on fluoxetine (Prozac) 10 mg every AM for her anxiety. We have picked Prozac because it is known to have a long half-life. Marie is known for having trouble remembering to take her medications in the past. With Prozac having a long half-life, it will stay in her system longer, decreasing the chances of issues with withdrawing from lack of medication if she does happen to forget to take it. We started her on 10 mg because she is psychotropic-naïve (and a pediatric patient), and she is a bit nervous about taking it. Prozac is used off-label for panic disorder in pediatric patients.

Marie and her mother are encouraged to look into getting her a therapist to work with. We explain the benefits of CBT and that we recommend a mental health professional who is able to provide CBT because it is an evidence-based treatment for anxiety.

Additional education that is provided to Marie and her mother includes the medication mechanism of action, being that it takes 4-6 weeks for Prozac to work fully. However, it is explained to Marie and her mother that it could start working for her sooner. The side effects of SSRIs are explained. Marie is encouraged to keep a journal of her panic attacks, their triggers (if any), time of the day they occur, things that help/worsen the situations, and the length of time the symptoms are being experienced.

A follow-up appointment will be scheduled at the desk for four weeks so that we are able to assess progress with her medication, her panic attack journal, and how she is functioning overall.