a case study on anxiety disorders

Module 4: Anxiety Disorders

Case studies: examining anxiety, learning objectives.

• Identify anxiety disorders in case studies

Case Study: Jameela

Jameela was a successful lawyer in her 40s who visited a psychiatrist, explaining that for almost a year she had been feeling anxious. She specifically mentioned having a hard time sleeping and concentrating and increased feelings of irritability, fatigue, and even physical symptoms like nausea and diarrhea. She was always worried about forgetting about one of her clients or getting diagnosed with cancer, and in recent months, her anxiety forced her to cut back hours at work. She has no other remarkable medical history or trauma.

For a patient like Jameela, a combination of CBT and medications is often suggested. At first, Jameela was prescribed the benzodiazepine diazepam, but she did not like the side effect of feeling dull. Next, she was prescribed the serotonin-norepinephrine reuptake inhibitor venlafaxine, but first in mild dosages as to monitor side effects. After two weeks, dosages increased from 75 mg/day to 225 mg/day for six months. Jameela’s symptoms resolved after three months, but she continued to take medication for three more months, then slowly reduced the medication amount. She showed no significant anxiety symptoms after one year. [1]

Case Study: Jane

Jane was a three-year-old girl, the youngest of three children of married parents. When Jane was born, she had a congenital heart defect that required multiple surgeries, and she continues to undergo regular follow-up procedures and tests. During her early life, Jane’s parents, especially her mother, was very worried that she would die and spent every minute with Jane. Jane’s mother was her primary caregiver as her father worked full time to support the family and the family needed flexibility to address medical issues for Jane. Jane survived the surgeries and lived a functional life where she was delayed, but met all her motor, communication, and cognitive developmental milestones.

Jane was very attached to her mother. Jane was able to attend daycare and sports classes, like gymnastics without her mother present, but Jane showed great distress if apart from her mother at home. If her mother left her sight (e.g., to use the bathroom), Jane would sob, cry, and try desperately to open the door. If her mother went out and left her with a family member, Jane would fuss, cry, and try to come along, and would continually ask to video-call her, so her mother would have to cut her outings short. Jane also was afraid of doctors’ visits, riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was too afraid to take part in her gymnastics performances.

Jane also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say “ow, ow” if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties. [2]

• Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. ↵
• Hirshfeld-Becker DR, Henin A, Rapoport SJ, et alVery early family-based intervention for anxiety: two case studies with toddlersGeneral Psychiatry 2019;32:e100156. doi: 10.1136/gpsych-2019-100156 ↵
• Modification, adaptation, and original content. Authored by : Margaret Krone for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Treatment of anxiety disorders. Authored by : Borwin Bandelow, Sophie Michaelis, Dirk Wedekind. Provided by : Dialogues in Clinical Neuroscience. Located at : http://Treatment%20of%20anxiety%20disorders . License : CC BY: Attribution

“I Don’t Want to Bother You” – A Case Study in Social Anxiety Disorder

• First Online: 29 March 2023

Cite this chapter

• Katharine E. Daniel 3 &
• Bethany A. Teachman 3  

Part of the book series: CBT: Science Into Practice ((CBT))

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Gi, a 34-year-old second-generation Korean American man, presented to treatment with pronounced and longstanding anxiety in many social situations, which significantly impaired his functioning (e.g., his perceived ability to run errands in crowded stores and care for his ill father). Gi engaged in cognitive behavior therapy (CBT) via telehealth during the COVID-19 pandemic. Key cognitions and biased cognitive processes that were maintaining his anxiety included a judgment that others frequently reject him, an assumption that if he expressed his own needs, then he would be unreasonably burdening others, and a core belief that he was incompetent, along with a pervasive tendency to make negative interpretations about his abilities in most social situations. He experienced marked functional improvements and reduced anxiety throughout his 17-session course of treatment. Gi’s case and treatment are detailed throughout this chapter to illustrate how individual CBT for social anxiety disorder can be implemented. Special discussion of how the clinician continuously and collaboratively modified her case conceptualization and intervention approaches with reference to aspects of Gi’s identities and in response to her own missteps are offered throughout.

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Daniel, K.E., Teachman, B.A. (2023). “I Don’t Want to Bother You” – A Case Study in Social Anxiety Disorder. In: Woud, M.L. (eds) Interpretational Processing Biases in Emotional Psychopathology . CBT: Science Into Practice. Springer, Cham. https://doi.org/10.1007/978-3-031-23650-1_16

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Case-based learning: anxiety disorders

There are many types of anxiety disorders with varying levels of severity. Pharmacists should know the treatment options that are available and how to support patients. 

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Anxiety is a common mental health condition that affects approximately 6.6% of the population in England each week, along with one in six adults experiencing or being identified as having a common mental health condition per week [1] , [2] . Data suggest that women are almost twice as likely to be diagnosed with anxiety compared with men; however, the reason for this is unclear [3] , [4] . Although a large number of people are affected by mental health conditions (e.g. anxiety or depression), only 39% of adults aged 16–74 years are accessing treatment for them [5] .

Mental health conditions typically worsen over time and can negatively impact on social activities, relationships, career performance, academic work and general quality of life [6] . As such, patients that present with conditions, such as generalised anxiety disorder (GAD), are frequently seen in the community, with pharmacists having the opportunity to significantly impact on the patient’s quality of life by providing information on the treatment options that are available [7] . While occasional anxiety is a normal aspect of day-to-day life, persistent symptoms can indicate the possible presence of an anxiety disorder, which can often be debilitating. Anxiety has also been known to precipitate physiological responses, such as tachycardia and hyperhidrosis [8] . ’Functional impairment’ is a term that is often used to describe the degree to which an illness can limit a person’s ability to carry out some of their normal daily tasks; anxiety can affect this to differing degrees [9] .

There are multiple factors that could predispose or potentially encourage the manifestation of anxiety, which are often attributable to a combination of genetic and environmental factors [10] . In addition, studies suggest that alcohol and illicit drug use, particularly the use of stimulants and hallucinogens, are associated with higher rates of incidence [11] , [12] . Instances of childhood abuse and sexual abuse are also identified as potential causative factors for anxiety and depression [13] . However, there is a broad range of patients affected by anxiety, for whom there is often an unknown cause.

Types of anxiety

Anxiety disorder is an inclusive term for several disorders, including:

• Panic disorder;
• Selective mutism;
• Separation anxiety;
• Social anxiety disorder [14] .

The most common types of anxiety disorder include:

• Social anxiety disorder — this is considered to be the most common form of anxiety; in up to 50% of cases, it is present in individuals by age 11 years [15] . Symptoms include a persistent fear of social performance, panic attacks and a large fear of humiliating oneself in public [15] ;
• Phobic disorder — this broadly refers to a fear of places, situations, objects and animals. For example, agoraphobia is often considered to be simply a fear of open spaces, but it is far more serious and can include a fear of being in a place that individuals will find difficult to escape from or receive aid if things go wrong [16] .

Avoidance behaviour is common to both social anxiety disorder and phobic disorder, with patients actively trying not to encounter the feared stimulus (e.g. avoiding going outside, such as in cases of agoraphobia) [17] , [18] , [19] . This behaviour can hugely impact on a patient’s ability to maintain functional capacity.

Symptoms and diagnosis

Symptoms may involve feelings of restlessness, palpitations, problems with concentrating, uncontrollable worry, sleep disturbances and general irritability [6] .

Diagnosis of anxiety would initially be made by a GP following a comprehensive review of the following:

• Symptomatic presentation of the patient;
• Frequency of symptoms;
• Degree of severity of distress;
• Functional impairment.

History of substance misuse, comorbidities and past medical history should be considered as part of a holistic approach to diagnosis [20] .

In addition, differential diagnoses must be considered before a formal diagnosis is made. Anaemia and hyperthyroidism are two conditions that must be ruled out and/or treated as they can both manifest symptoms of anxiety disorders [21] , [22] . Blood analysis and further tests may be necessary to ensure a correct diagnosis is made [22] , [23] . As stated by the National Institute for Health and Care Excellence (NICE), diagnostic tools, such as the Diagnostic and Statistical Manual of Mental Disorders , can be utilised for anxiety disorders [21] . The criteria include a minimum of six months of incessant and uncontrollable worries, disproportionate to actual risk, and three of the following symptoms:

• Being easily fatigued;
• Irritability;
• Muscle tension;
• Poor concentration;
• Restlessness/nervousness;
• Sleep disturbance [21] .

The ‘International Classification of Diseases, 10th revision’, a disease classification tool, offers a similar criteria [21] . There are also other resources available to healthcare professionals to work through with patients, such as the GAD-7 questionnaire for anxiety and the personal health questionnaire-9 (PHQ-9) for depression [21] . Questions typically ask how frequently certain symptoms have occurred in the preceding two weeks. Both GAD-7 and PHQ-9 allow assessors to distinguish between anxiety and depression, and provide an indication as to the severity of presentation, which can guide therapy. These are typically asked by a GP during an initial consultation with the patient and may include questions such as: ‘Over the past two weeks, how often have you been bothered by feeling nervous, anxious or on edge?’ [24]

The GAD-7 questionnaire can also be used as a tool to determine the severity of its presentation, with scores of 5 and above, 10 and above, and 15 and above (out of a possible 21) referring to mild, moderate and severe anxiety, respectively [25] . Higher scores are strongly associated with functional impairment, although individual characteristics of presentation will affect how the patient is treated.

Pharmacological treatment

For patients with mild anxiety, pharmacotherapy is not recommended. However, as per NICE guidelines, pharmacological treatment is recommended where significant functional impairment exists [26] . First-line drug treatment involves selective serotonin reuptake inhibitors (SSRIs; e.g. sertraline or fluoxetine) [26] .

SSRIs are widely used for GAD and are often well tolerated. In addition, they are considered to be safer in overdose than most other similarly indicated medicines, because they carry a lower risk of cardiac conduction abnormalities and seizures [27] , [28] , [29] . Selective serotonin–noradrenaline reuptake inhibitors (SNRIs; e.g. duloxetine and mirtazapine) are a suitable alternative; pregabalin is a tertiary option if the others are unsuitable or poorly tolerated [26] .

It is important to manage the patients’ expectations with pharmacological therapies. Providing a clear message that it could take between four and six weeks before the patient notices a benefit from their medicine is essential, as this will help ensure that they take their medication as directed. Patients should also be made aware of side effects and the withdrawal process (e.g. associated side effects) prior to commencing therapy [26] .

Common side effects of SSRIs include abnormal appetite, arrhythmias, impaired concentration, confusion, gastrointestinal discomfort and sleep disorders [27] . The incidence of side effects is reported to be highest within the first two weeks of starting treatment [30] . Although most common side effects tend to improve over time, sexual dysfunction can persist [31] . There is an increased risk with SSRIs in certain patient groups (e.g. young adults, children and patients with a previous history of suicidal behaviour) of suicidal ideation and self-harm; therefore, initiation of SSRIs must be reviewed weekly in those under aged under 30 years for the first four weeks of treatment. If the risk of recurrent suicidal behaviour is a concern, the healthcare professional may want to seek advice from the local crisis or home-based treatment team; SSRIs generally have a better safety profile than other drugs used for anxiety, but may require frequent monitoring in this case [32] , [26] .

SSRIs are one of several classes of medicines that pose a risk for long QT syndrome, which occurs as a result of a prolonged QT interval on the electrocardiogram measurements of the heart. This can lead to torsades de pointes (a specific type of abnormal heart rhythm) and possible sudden cardiac death [33] [34] , [35] .

It is important that SSRIs are withdrawn slowly to minimise the occurrence of SSRI discontinuation syndrome — an abrupt cessation of treatment that can cause a combination of psychological and physiological symptoms; the most common including nausea, dizziness, headache and lethargy [36] . Tapering drug doses slowly over several weeks will mitigate the effects of the withdrawal and minimise unnecessary re-initiation of the SSRI [37] .

Considerations for selective serotonin reuptake inhibitors and selective serotonin–noradrenaline reuptake inhibitors

Serotonin syndrome is a serious side effect that can occur with the use of SSRIs and SNRIs. It occurs as a result of overactivation of the 5-HT1A and 5-HT2A receptors, precipitated by serotonergic drug use [38] . Symptoms typically range from confusion and agitation to more serious symptoms, such as seizures, arrhythmias and loss of consciousness [31] . The risk of the syndrome is higher if patients are taking other medicines that can increase serotonin levels in the brain, such as tramadol and metoclopramide. Taking 5-HT1F agonists, which include sumatriptan, or a combination of medicines with the same effect, can also increase risk [39] .

If a decision is made to initiate an SSRI, despite the associated risk, patients should be provided with suitable information concerning the syndrome, which can be found on or printed from the NHS website [31] . If a patient experiences symptoms of serotonin sydrome, they should be advised to contact their GP surgery immediately. If this is unavailable, they should call NHS 111 for advice.

Alongside serotonin syndrome, SSRIs have been known to contribute to inappropriate antidiuretic hormone secretion, which is related to hyponatremia and has symptoms including headache, insomnia, nervousness and agitation [40] . 

Patients with anxiety disorders should be monitored as frequently as the severity of the disorder demands, which is essential to protect patients and improve their quality of life. Guidance from the British National Formulary states that patients being initiated on an SSRI should be reviewed every one to two weeks after initiation, with response being assessed at four weeks to determine whether continuation of the drug is suitable [27] . NICE guidelines expand on this by encouraging three-monthly reviews of drug therapy to assess clinical effectiveness [20] .

Non-pharmacological treatment

Patients should be advised to minimise alcohol intake and make time for activities they find relaxing. They should also be encouraged to exercise every day, aiming to do 150 minutes of moderate-intensity exercise (e.g. walking or cycling) per week as exercising has been shown to improve mental health [41] , [42] . A study has demonstrated that those who exercise had 43.2% fewer days of poor mental health, with team sports having the largest association with reduction in mental health burden [43] .

Psychological treatment

Cognitive behavioural therapy (CBT) is a common psychological treatment used for those with anxiety. This therapy aims to transform negative thinking into more structured thought patterns, which then assist the patient in making changes to their thought processes to encourage positive thinking. CBT is suitable for patients that present with ongoing anxiety and does not look at patient history [34] . This type of treatment may be useful for patients with mild anxiety, as an addition to medicine or for those who do not wish to take medicine. It can be conducted individually or as part of a group.

Guided self-help — a process by which a patient is able to work through a course with the support of a trained therapist — and counselling are other treatments available through the NHS that may benefit patients with mild anxiety or as an adjunct to prescription medicines [44] .

Specialist referral and suicide risk

Specialist referral should be considered if patients:

• Have not responded to initial therapy;
• Have comorbidities, such as alcohol or substance misuse;
• Are at significant suicide risk.

Healthcare professionals should always assess suicide risk by discussing the patients’ feelings about self-harm openly and considering other contributing factors, such as the use of prescribed or illicit drugs. Healthcare professionals must take opportunities to make interventions — for example, referring patients for urgent mental health assessment or in the case of serious concerns, calling emergency services [23] .

In the UK, area-specific community programmes and the charity  Anxiety UK  can provide patients with further advice on managing their anxiety. However, many primary care networks are now recruiting social prescribers, who will have the ability to direct patients to attend local groups that are more suited to individual needs. Community pharmacists are also likely to be aware of local support networks.

Case studies

Case study 1: a woman taking interacting medicines

Joanne*, a woman aged 65 years, approaches the pharmacy counter. She is concerned about heart palpitations she has been experiencing recently.

After inviting Joanne into the consultation room, you ask her if she is taking any medicines. She says that she is taking amitriptyline for the pain in her legs. She has also recently started taking a new medicine and states that she is on other medicines, but cannot recall the names. You ask for permission to view her summary care record and note that there is furosemide on her list of medicines. She was started on citalopram two weeks prior and was prescribed a seven-day course of clarithromycin three days ago.

You are concerned that Joanne is experiencing long QT syndrome, since the selective serotonin reuptake inhibitor (SSRI) citalopram is a risk factor for QT prolongation — as are the tricyclic antidepressant amitriptyline and the antibiotic clarithromycin [33] , [45] , [46] . In addition, furosemide can also precipitate hypokalaemia, which has been known to affect the QT interval [47] .

Advice and recommendations

You advise Joanne to stop taking the citalopram that has been prescribed to her until she can see a GP, which is a matter of urgency, as you believe it could be related to the medicines she is taking. You advise that she should try and get a same-day appointment if possible. The GP will likely request an electrocardiogram and stop the SSRI if results demonstrate long QT syndrome.

Case study 2: a man with concerns about his medicine

Gareth*, an investment banker aged 52 years, attends the pharmacy and asks to purchase sildenafil over the counter, owing to his erectile dysfunction. He is referred to you and you sit with him in the consultation room.

During the consultation, you begin to ask questions about his history and whether the erectile dysfunction is a new condition that he is experiencing. He states that he has been worried about it for the last couple of months. You then discuss his lifestyle and ask him questions about his medicines, in which he states he started taking a new medicine, fluoxetine, several months ago. He has been under significant stress at his workplace and was started on fluoxetine owing to his anxiety.

You consider the following:

• The erectile dysfunction that Gareth is experiencing could be related to the stress he is experiencing as part of his work;
• The possibility there could be an underlying reason for the problem related to his general health;
• That the prescribed fluoxetine may be causing his erectile dysfunction because this is a side effect of selective serotonin reuptake inhibitors [48] .

You explain your rationale with Gareth and indicate that you do not think it is appropriate to sell him sildenafil now. You suggest he goes back to his GP to discuss the symptoms that he has been having. The GP may decide to try an alternative medicine, but, given that he has been taking the fluoxetine for a few months, he should not discontinue it until advised to do so by his GP. You explain that if his GP advises him to stop the medicine, there will be a specific withdrawal process to minimise the side effects and that you would be able to advise him on this.

Case study 3: a man who is displaying symptoms of moderate anxiety

Anton*, a university graduate aged 21 years, attends the pharmacy and asks to speak to the pharmacist in private. He states he is worried about heart palpitations that he has been experiencing. He is visibly sweating and looks on edge.

You invite Anton into the consultation room and ask him about his symptoms. He states that he has started a new job and that the palpitations start when he is feeling anxious. His symptoms are occurring most days of the week and he says it makes him “feel on edge”. He adds that he does not want to socialise with his co-workers. It is starting to affect his sleep and he does not know what to do. He also states that he has occasional pain in his chest.

Treatment options

Anton is demonstrating symptoms of moderate anxiety, given his desire to avoid socialising, and has a degree of functional impairment. However, as he has potential cardiac symptoms, these issues could be related to another condition.

When questioned, he confirms he has no other problems with his health, but you feel the patient needs further investigation — for example, an electrocardiogram test to measure the electrical activity of his heart to rule out underlying cardiac problems. His presentation concerns you and you feel he needs to see a doctor today to assess the differential diagnosis, as you are worried about his chest pain and palpitations.

You encourage Anton by saying that it is great that he felt he could talk to a pharmacist about this, but explain that he would benefit from a consultation with a GP. You explain that his symptoms could be related to anxiety and that you think he may need something to help him manage. He agrees to let you contact his local practice. As you have a good relationship with the practice, you manage to secure an appointment for him to see a GP that day. If a GP appointment had been unavailable, you could have telephoned NHS 111 for Anton to seek access to support.

*All cases are fictional

Useful resources

• NHS: Do I have an anxiety disorder?

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[29] Yekehtaz H, Farokhnia M & Akhondzadeh S. Cardiovascular considerations in antidepressant therapy. J Tehran Heart Cent 2013;8(4):169–176. PMID: 260058484

[30] Warden D, Trivedi MH, Wisniewski SR et al. Early adverse events and attrition in selective serotonin reuptake inhibitor treatment: a suicide assessment methodology study report. J Clin Psychopharmacology 2010;30(3):259–266. doi: 10.1097/JCP.0b013e3181dbfd04

[31] NHS. Antidepressants. 2018. Available at: https://www.nhs.uk/conditions/antidepressants/ (accessed May 2020)

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[48] Montejo-Gonzalez AL, Llorca G, Izguierdo JA et al . SSRI-induced sexual dysfunction: fluoxetine, paroxetine, sertraline and fluvoxamine in a prospective, multicentre and descriptive clinical study of 344 patients. J Sex Marital Ther 1997;23(3):176–194. doi: 10.1080/00926239708403923

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Generalized Anxiety Disorder Case Study: James

A paper on case studies.

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Generalized anxiety disorder, (GAD) is a traumatic illness, and is hard to understand unless you are experiencing it yourself. While specific anxiety disorders are complicated by panic attacks or other features of the disorder, GAD has no specific focus. (Durand, 2007 p.130). The person constantly worries about everyday life; not being able to figure out what to do with their worries. All the while making themselves and everyone around them miserable. (p.130). The worries seem to take over control of one's life, almost to the point of not being able to function at all.

It seems that GAD tends to run in families based on studies conducted, and seems to happen more to women than men. (Durand, 2007 p.132). And evidence shows that GAD may be proved to be just as heritable, the same as other anxiety disorders. (p.133). The textbook states that this disorder originated in 1980, however therapists were working with patients with anxiety way before the criteria was developed. (p.133). For many years, clinicians believed that people who were generally anxious just didn't seem to have anything specific to focus on, thus calling it the 'free floating' disorder. (p.133).

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) has specific criteria that characterized GAD. As stated in our textbook, the features are:

• Excessive anxiety and worry for 6 months or more about a number of events or activities. • Difficulty in controlling the worry. • At least three of these symptoms: (1) restlessness of feeling all keyed up; (2) becoming fatigues easily; (3) difficulty concentrating; (4) irritability; (5) muscle tension; (6) sleep disturbance. • Significant distress or impairment. • Anxiety is not limited to one specific issue. (Durand, 2007 p.131).

Generalized anxiety disorder has been studied using various criteria. The National Comorbidity Survey (NCS) focused on noninstitutionalized American civilians ages 15 to 54. The results were reported and found there was a clear predominance of women with GAD, with a 2:1 female/male ratio. It was lowest among the younger age group but increased with age. (NA, 1997). 'There was a significant regional difference in GAD as well, with a higher lifetime prevalence in the Northeast than in other parts of the country.' (1997). Studies have shown that many people could not really pinpoint a clear age of onset of GAD or an onset dating back to childhood. (Barlow, 1993 p.156). There have also been twin studies which conclude that GAD is somewhat greater for identical female twins than for non-identical twins, but only if one twin already had generalized anxiety disorder. (Durand, 2007 p.132). But later researched showed that what seemed to be inherited was the ability to become anxious rather than GAD itself. (p.132). It's amazing to know that people with GAD seem to show less responsiveness on most physiological measures, such as heart rate, blood pressure, skin conductance and respiration rate than do people with other anxiety disorders. (p.133).

Although it seems to prove that GAD is quite common, I am amazed that more people don't have this disorder. I think that many people have general anxieties on a daily basis, but most people are able to handle them successfully. I did not realize that most people with GAD have usually had symptoms of anxiety or feelings of being worried throughout life, but just didn't know when it all started. The criterion has changed over the years as well as doctors have become more knowledgeable about this disorder. I first had knowledge of this disease in 1997 when I noticed strange things happening.

He was not really watching as he stared directly at the television set. I would notice that he had no expressions at all; nothing during the humorous scenes, or the dramatic ones. He once told me that it was as if he was someone else, watching himself try to crawl out of his own skin. That was 10 years ago when I was married to this man who was suffering from generalized anxiety disorder. I didn't understand and I really didn't want to. I thought he was just being lazy and unmotivated. Although this disorder seems to be simple to others, it is quite alarming to the person who is suffering from it, and the onset is rather quick, whereas, treatments are difficult. Everyone experiences anxiety, but in most people, it does not last for months at a time.

The case study I am choosing is about James who is a doctor suffering from generalized anxiety disorder. At 31 years of age and living in New York, he is unemployed because of his constant anxiety, even at the thought of working. He now lives with his parents off a small trust fund set up for him by an uncle. Although he was an overachiever throughout his academic career, James is having a hard time keeping it together, while his parents are somewhat supportive but disappointed with his medical career. Let's see what we can learn about this horrible and crippling disorder. 'Generalized anxiety disorder is associated with irregular neurotransmitters in the brain. Neurotransmitters are chemicals that carry signals across nerve endings. Neurotransmitters that seem to involve anxiety include norepinephrine, GABA (gamma-aminobutyric acid), and serotonin.' (na, 2001). So it was thought that reduced levels of GABA initiated excessive anxiety, although neurotransmitters are much to complex to be interpreted that simply. (Durand, 2007 p.45).

The brain is a very fascinating and intricate part of who we are and if the brain is not functioning properly, then our reactions to certain situations are not in balance. This is why some people still believe that undeniable psychological disorders are said to be caused by biochemical imbalances. (Durand, 2007 p.50). So in James' case, his brain was not functioning right and he was experiencing an unnatural balance of change within his various neurotransmitters, causing him to become anxious, easily irritated, distracted and quite tense. He also complained of headaches, body aches and pains and always feeling tired.

Genetics does play a major role is determining whether a person will or will not have a psychological disorder. The textbook states that the research is beginning to acknowledge genes that relate to some psychological disorders. (Durand, 2007 p.70). I feel that genetics does contribute to some disorders, but I also think that the environment and society can cause debilitating stress to induce certain disorders, such as anxiety. If the gene linked to the disorder is dormant, a stress related incident can bring it to the surface, thus bringing on the disorder. My research has shown that there are brain abnormalities indicated with generalized anxiety disorder. A study of 30 patients displayed that compared to 20 healthy volunteers, 11 patients had significant brain abnormalities mainly in the right temporal lobe. (Nutt, 2003 p.209). The temporal lobe controls the processes of recognizing various sights and sounds and long term memory storage. (Durand, 2007 p.48). However there are two temporal lobes on each side of the brain, located at the level of the ears. The lobes help a person distinguish one sound from another as well as one smell from the other. The right lobe controls visual memory while the left lobe controls verbal memory. (Johnson, 2006) So this would explain why James kept making mistakes because he was probably having a hard time remembering simple procedures.

The first thing James would need to do would be to seek professional help and see if he has this disorder, although being a medical doctor, he may have self diagnosed himself, however he should see a psychiatrist. There are no laboratory tests that can determine if a person has anxiety or a mental illness, but a doctor will perform a battery of tests to weed out other illnesses, such as an overactive thyroid gland, which can produce anxiety and its symptoms. (NA, 2007 WebMD). James' next plan of attack would be to discuss the different types of medications that are available for providing relief from this disorder. Since James has generalized anxiety disorder, which has been called a 'free-floating' disorder because of his constant worrying and nervousness, as stated earlier, he would need a medication that treats low levels of GABA. (Roberts, ch.17 p.6). The textbook states that the drub benzodiazepine (minor tranquilizers) is the most frequently prescribed. (Durnad, 2007 p.134). The drug is used for short-term relief and can be hard to stop taking because of dependence issues. One such drug in particular is called Xanax, which is shown to enhance the function of GABA in the brain. It also slows down the central nervous system. This drug is extremely addicting; it's the drug my ex-husband did not want to give up, so we got a divorce.

There is also evidence that antidepressants can be used for GAD and may be a better choice. (p.134) The most common antidepressants are prozac and zoloft. 'These drugs are shown to affect the concentration and activity of the neurotransmitter serotonin, a chemical in the brain thought to be linked to anxiety disorders.' (na, 2004). Some of these drugs that I have researched for GAD, are also used for treating migraines, because I was prescribed some for headaches. No wonder I was always in a good mood, even though it felt like my head was about to explode.

Because the drugs prescribed for this disorder are recommended to be taken for short periods of time, therapy should be initialized as well. The side effects of these drugs are: Xanax (benzodiazepines): drowsiness, fatigue, decreased concentration, confusion, blurred vision, pounding or irregular heartbeat, impaired coordination, short term memory problems, dizziness. (Smith et al, 2006).

Prozac (Selective Serotonin reuptake inhibitors): nausea, insomnia, headaches, decreased sex drive, dizziness, weight gain or loss, nervousness, sweating, drowsiness/fatigue, dry mouth, diarrhea or constipation, skin rashes. (Smith et al, 2006) These medications offer so many side effects, it's a wonder anyone wants to take them at all. But I guess for the person who is suffering from anxiety attacks or generalized anxiety disorder, the side effects may be a welcomed relief There are also natural remedies to help with GAD such as valerian root and kava kava, which has been treating anxiety for years, but the results are not well documented. (Smith et al, 2006) Some natural remedies can actually make anxiety worse and taking supplements may interact with the prescription anxiety medications, so it's a good idea to discuss this with a doctor.

Another approach to treatment is to help James with therapy sessions to try to figure out why he is experiencing all this anxiety and worry. One session may include showing James pictures of things that may make him anxious and then teaching him how to relax deeply to fight his tension. It's called cognitive behavioral treatment, developed in the early 1990s, and is quite successful; however we need both medications and therapy to treat GAD. (Durand, 2007 p.134).

Acupuncture, which is one medical treatment that does no harm to the body, only releases energy and gets it moving in the system; (NA, 2007) biofeedback, which is the ability to allow the patient hear or see feedback of their body's physiological state while relaxing;(Grohol, 2004) and hypnotherapy shown as an appropriate treatment modality for those individuals who are highly suggestible, have also been used to treat anxiety. (Grohol, 2004).

So which treatments work the best? That is hard to say because everyone is different and will react differently to each treatment. As stated in the textbook, a combined treatment of therapy and medications suggested there were no advantages for both, and that people did better in the long run when having psychological treatments only. (Durand, 2007 p.144). So it's suggested to start with psychological treatment first and then followed by drug treatments for the patients who are not responding to therapy. (p.144).

How does environment influence our behavior? Do we imitate what we see around us? Are we simply looking for acceptance, thereby, acting or saying what we think society expects? Who decides what acceptable behavior is? Although the environment may affect a person's behavior, there are many other elements to explore that influence the way we are.

James is coping with generalized anxiety disorder, as was stated earlier. At 31, he is allowing this disorder to control his life which is leading to being emotionally and physically drained. Although he realizes that he is an intelligent and capable person, he knows to avoid any situation that may exacerbate the anxieties that he is experiencing. With minimal support from his family and friends, James feels that he is dealing with this all alone and just wants to lead a normal life. Perhaps the stress and strain of becoming a doctor led to James' anxiety disorder as it may have been dormant within his genetic makeup, and is now just surfacing.

Many people develop generalized anxiety disorder (GAD) during adolescence, but do not seek professional help until they are adults. (NA, 2001). When they do finally get help, they claim they have been anxious and nervous all their lives. (2001). These people cannot just 'get over it' but society seems to not grasp that concept. Some of the environmental influences that could lead to general anxiety are: • Work. This would affect James immensely because his whole life has been based around his becoming a doctor. Even his father wanted him to follow in his footsteps and have a prestigious career. • School. Although James did not experience anxieties until after he graduated from medical school, I'm sure he still felt anxious with tests and schoolwork. • Relationships. This would be dealing with James' parents as they are somewhat supportive but disappointed that his career has not been progressing. He also lost his relationship with his girlfriend of three years because of the stress. • Health. Because James is dealing with this disorder, his health is rapidly declining. He is having headaches, body aches and pains and is always tired. His emotional health is affected as well with feelings of laziness and worthlessness. • Financial. James is realizing that if he cannot work, he cannot earn a paycheck. He is living off a small trust fund set up for him by his great uncle, but that won't last forever. All of these things are considered threats and can cause James to worry excessively which is interfering with his life.

Is the environment to blame for James' anxiety or is it more biological? I think that genetics and the environment work together to produce this disorder. I feel that if a person is genetically prone to have anxiety and fear; if the person never leaves the house, then what does he/she have to worry about? The environment has to play a role in the mobility of this disorder. If James were to isolate himself from the world, he would still have anxiety; however he would not be able to face his fears, thus restricting his life. His thought process would be 'what if this happened, or what if that happened?' He would always be having threatening thoughts and images playing over and over in his mind. (Alloy, 2006 p.189).

Our textbook states that GAD generally runs in families, which I mentioned earlier. (Durand, 2007 p.132). With all the research and studies that are performed, it will show that generalized anxiety disorder is inherited. So genetics and biology has to be the most important because people who aren't suffering from anxiety will react more favorable to a stressful situation, than someone who is suffering from GAD. It seems that we all have to face the same environmental influences, but the threat of each situation interacts with the biological aspect of a person, thus bringing on the symptoms of the disorder. (p.133).

James needs to be treated by a psychiatrist, not a family physician. He needs to be seen by someone who deals with psychological disorders daily and is educated with the treatments available. Psychological treatments work better in the long run and work just as well as prescription medication. Our textbook states that, 'as we learn more about generalized anxiety, we may find that helping people with this disorder to focus on what is actually threatening is useful.' (Durand, 2007 p.134).

Research has indicated that psychological treatments work very well for children who suffer from GAD. (Durand, 2007 p.135). But I feel that unless a child is diagnosed early in life, the treatments won't be as effective. I'm sure that James was experiencing some form of anxiety as a child, but children are difficult to diagnose, and if the parents don't know what to look for, they won't know the child needs help. But children respond to cognitive-behavioral treatments along with family therapy. (p.135).

I feel that psychosocial treatments would be the best way to start with a patient. In James' case, I think he should start with therapy for at least three months. He needs to confront the fear, phobias and anxieties head on to figure out what's making him feel emotionally and physically drained. I would also suggest to James that he should educate and read everything he can on this disorder. Having this knowledge will benefit him so he may get the most out of his treatments. If I had a disorder, I would want to know everything about it. And I would be asking a million questions. Sometimes I feel that everyone in society could use some form of therapy to deal with the stressors of life.

Next, I would try medications in addition to therapy to help James with possible other symptoms of GAD, such as depression. (Smith et al, 2006). The medication, however, would only be used on a temporary basis, as addiction can occur. My ex-husband was on medication for his GAD, but he was not seeing anyone for therapy. I think that was the biggest problem. He was increasing his dosage without telling his doctor, thus becoming extremely dependent on the drugs. As a doctor, James should know that some of the medications used for GAD are very addictive and hopefully would only be used as directed.

There are certain beliefs about thoughts and thought processes that are included in cognitive forms. (Papageorgiou, 2004 p.228). 'There are two types of worries; Type 1 and Type 2. Type 1 worries deal with external daily events such as the welfare of a partner, and non-cognitive internal events such as concerns about bodily sensations. Type 2 worries are focused on the nature and occurrence of thoughts themselves such as worrying that worry will lead to insanity. It's basically worry about worry.' (Wells, 1997 p.202). The cognitive model claims that the varieties of worry are typically type 2 worries in which the patients negatively appraise the activity of worrying. (p 202). I feel that the cognitive psychological model best applies to understanding and treating this disorder. I believe that by using cognitive therapies and similar research studies, we can begin to know what it takes to treat the people who are suffering with better results now and in the future. There are new medications that can help people with GAD, but there are side effects that may be too harsh or severe. I believe that more psychosocial therapies may need to be developed in order to help these people, so they can live a normal life without medications, because of the problems they present to the body.

I believe that James could once again become a successful doctor if and when he gets his generalized anxiety disorder under control. The treatments are available; all he has to do is seek them out. I feel that with therapy coupled with medications would benefit James tremendously. Eventually he will be able to stop taking the medications and perhaps enjoy a fairly normal life. The good news is that only 4% of the population meets the criteria for GAD during a given one-year period. However it is still one of the most common anxiety disorders. (Durand, 2007 p.132). . My research for this paper has helped me so far in understanding what a person is going through with crippling anxiety. It's not something that a person can just 'get over' and I know I wanted to tell my ex-husband that many, many times. However, he became addicted to the prescriptions drugs, and became a drug addict in about two weeks. Because of my first hand experience with this disorder, I chose to do my projects on it.

References N.A. (1997) Retrieved Oct. 20, 2007 from The Natural History of Generalized Anxiety Disorder website: www.medscape.com N.A. (2001). Retrieved Sept. 16, 2007 from General Anxiety Disorder website: http://www.mentalhealthchannel.net N.A. (2004). Retrieved Sept. 13, 2007 from Anxiety Disorders Association of America website: http://www.adaa.org N.A. (2007) Retrieved Sept. 17, 2007 from Anxiety Panic Guide website: http://www.webmd.com N.A. (2007). Retrieved Oct. 21, 2007 from Acupuncture for Generalized Anxiety Disorder website: www.revelutionhealth.com Barlow, D. (1993) Clinical Handbook of Psychological Disorders: A step-by-step treatment Manual 3rd ed. Guilford Press Retrieved Oct. 20, 2007 from libsys.uah.edu. Durand, V. & Barlow, D. (2007) Essentials of Abnormal Psychology: Mason, OH. Thomson/Wadsworth Publishing. Grohol, J. (2004) Retrieved Oct. 20, 2007 from generalized anxiety disorder treatment website: www.psychentral.com/disorders Johnson, G. (2006) Retrieved Sept. 15, 2007 from A Guide to Brain Anatomy website: http://www.waiting.com/brainanatomy Nutt, D. & Ballenger, J. (2003). Anxiety Disorders. Malden, Ma: Blackwell Publishers Retrieved Sept. 18, 2007 from Net library search: libsys.uah.edu Papageorgiou, C. & Wells, A. (2004). Depressive Rumination Nature, Theory and Treatment. Hoboken, NJ: John Wiley & Sons, LTD. Roberts, M. (nd). Introductory Guide to Psychology Kaplan University Class SS-124 Alloy, L. & Riskind, J. (2006). Cognitive Vulnerability to Emotional Disorders. Mahwah, NJ: Lawrence Erlbaum Associates Inc. Smith, M., Kemp, G., Larson, H., Jaffe, J., Segal, J. (2006). Retrieved Oct.8, 2007 from Anxiety Attacks and Disorders website: http://www.helpguide.org Wells, A. (1997). Cognitive therapy of Anxiety Disorders: A practice manual and conceptual guide. Chichester, NY: John Wiley & Sons, LTD.

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Anxiety Disorders

We all experience anxiety. For example, speaking in front of a group can make us anxious, but that anxiety also motivates us to prepare and practice. Driving in heavy traffic is another common source of anxiety, but it helps keep us alert and cautious to avoid accidents. However, when feelings of intense fear and distress become overwhelming and prevent us from doing everyday activities, an anxiety disorder may be the cause.

Anxiety disorders are the most common mental health concern in the United States. Over 40 million adults in the U.S. ( 19.1% ) have an anxiety disorder. Meanwhile, approximately  7%  of children aged 3-17 experience issues with anxiety each year. Most people develop symptoms before age 21.

Anxiety disorders are a group of related conditions, each having unique symptoms. However, all anxiety disorders have one thing in common: persistent, excessive fear or worry in situations that are not threatening. People typically experience one or more of the following symptoms:

Emotional symptoms:

• Feelings of apprehension or dread
• Feeling tense or jumpy
• Restlessness or irritability
• Anticipating the worst and being watchful for signs of danger

Physical symptoms:

• Pounding or racing heart and shortness of breath
• Sweating, tremors and twitches
• Headaches, fatigue and insomnia
• Upset stomach, frequent urination or diarrhea

Types Of Anxiety Disorders

There are many types of anxiety disorders, each with different symptoms. The most common types of anxiety disorders include:

Generalized Anxiety Disorder (GAD)

GAD produces chronic, exaggerated worrying about everyday life. This worrying can consume hours each day, making it hard to concentrate or finish daily tasks. A person with GAD may become exhausted by worry and experience headaches, tension or nausea.

Social Anxiety Disorder

More than shyness, this disorder causes intense fear about social interaction, often driven by irrational worries about humiliation (e.g. saying something stupid or not knowing what to say). Someone with social anxiety disorder may not take part in conversations, contribute to class discussions or offer their ideas, and may become isolated. Panic attacks are a common reaction to anticipated or forced social interaction.

Panic Disorder

This disorder is characterized by panic attacks and sudden feelings of terror sometimes striking repeatedly and without warning. Often mistaken for a heart attack, a panic attack causes powerful physical symptoms including chest pain, heart palpitations, dizziness, shortness of breath and stomach upset. Many people will go to desperate measures to avoid an attack, including social isolation.

We all tend to avoid certain things or situations that make us uncomfortable or even fearful. But for someone with a phobia, certain places, events or objects create powerful reactions of strong, irrational fear. Most people with specific phobias have several things that can trigger those reactions; to avoid panic, they will work hard to avoid their triggers. Depending on the type and number of triggers, attempts to control fear can take over a person’s life.

Other anxiety disorders include:

• Agoraphobia
• Selective mutism
• Separation anxiety disorder
• Substance/medication-induced anxiety disorder, involving intoxication or withdrawal or medication treatment

Scientists believe that many factors combine to cause anxiety disorders:

• Genetics.   Studies support the evidence that anxiety disorders “run in families,” as some families have a higher-than-average amount of anxiety disorders among relatives.
• Environment.  A stressful or traumatic event such as abuse, death of a loved one, violence or prolonged illness is often linked to the development of an anxiety disorder.

Physical symptoms of an anxiety disorder can be easily confused with other medical conditions, like heart disease or hyperthyroidism. Therefore, a doctor will likely perform an evaluation involving a physical examination, an interview and lab tests. After ruling out an underlying physical illness, a doctor may refer a person to a mental health professional for evaluation.

Using the Diagnostic and Statistical Manual of Mental Disorders (DSM) a mental health professional is able to identify the specific type of anxiety disorder causing symptoms as well as any other possible disorders that may be involved. Tackling all disorders through comprehensive treatment is the best recovery strategy.

Different anxiety disorders have their own distinct sets of symptoms. This means that each type of anxiety disorder also has its own treatment plan. But there are common types of treatment that are used.

• Psychotherapy , including cognitive behavioral therapy
• Medications , including antianxiety medications and antidepressants
• Complementary health approaches , including stress and relaxation techniques

Related Conditions

Anxiety disorders can occur along with other mental health conditions, and they can often make related conditions worse. So, talk with a mental health care professional if you are experiencing anxiety and any of the following:

• Substance Use
• Attention Deficit Hyperactivity Disorder ( ADHD )
• Eating Disorders
• Trouble Sleeping

Reviewed December 2017

Once it is clear there is no underlying physical condition present or medication side effect causing your anxiety, then exploring options for mental health treatment is essential.

The types of treatment proven to be most effective for many people experiencing an anxiety disorder involve a combination of psychotherapy and medication. Your preferences in a treatment plan are essential, however, so discuss the best approaches and options with your treatment team.

Co-occurring conditions, like depression, are common when a person has anxiety. Be sure to work with your treatment team to make sure these other conditions are not overlooked.

Psychotherapy

Cognitive Behavioral Therapy (CBT)  is the most researched  psychotherapy  for anxiety disorders. In general, CBT focuses on finding the counterproductive thinking patterns that contribute to anxiety. CBT offers many constructive strategies to reduce the beliefs and behaviors that lead to anxiety.

CBT is also effective when delivered outside of the traditional in-person setting. Working with a therapist using  telehealth technology  — like video or phone calls or online learning modules that teach CBT concepts —  can be just as effective  as traditional face-to-face therapy.

CBT has the largest research base to support its effectiveness, though it can be difficult to figure out which therapists are trained in CBT. There is no single national certification program for this skill. Ask your therapist how they approach treating anxiety and their trainings in these approaches.

Exposure Response Prevention  is a psychotherapy for specific anxiety disorders like phobias and social anxiety. Its aim is to help a person develop a more constructive response to a fear. The goal is for a person to “expose” themselves to that which they fear, in an attempt to experience less anxiety over time and develop effective coping tools.

Some people find that medication is helpful in managing an anxiety disorder. Talk with your health care provider about the potential benefits, risks and side effects.

• Anti-anxiety medications . Certain medications work solely to reduce the emotional and physical symptoms of anxiety. Benzodiazepines can be effective for short-term reduction of symptoms, but can create the risk of dependence when used for a long time. Be sure to review these potential risks if you select these medicines.  Click here  for more information on these medications.
• Antidepressants . Many antidepressants may also be useful for treating anxiety. These can also be useful if your anxiety has a co-occurring depression. Be sure to check our  Medication page  for more information.

Complementary Health Approaches

More and more people have started using  complementary and alternative treatments  along with conventional treatment to help with their recovery. Some of the most common approaches for treating anxiety include:

• Self-management strategies , such as allowing for specific periods of time for worrying. Someone who becomes an expert on their condition and its triggers gains more control over their day.
• Stress and Relaxation Techniques  often combine breathing exercises and focused attention to calm the mind and body. These techniques can be an important component in treating phobias or panic disorder.
• Yoga . The combination of physical postures, breathing exercises and meditation found in yoga have helped many people improve the management of their anxiety disorder.
• Exercise . Aerobic exercise can have a positive effect on your stress and anxiety. Check with your primary care doctor before beginning an exercise plan.
• Surviving the Bed Shortage in Mental Health Treatment Facilities: A Teenager’s Experience

If you, a family member or friend is experiencing symptoms of an anxiety disorder, there is help. NAMI is here to provide you with support and information about community resources for you and your family.

Find education programs and support groups  at your local NAMI . Contact the NAMI HelpLine at 1-800-950-NAMI (6264) or  [email protected]  if you have any questions about anxiety or want help finding support and resources.

Helping Yourself

Anxiety disorders can impact even the smallest details of life. It’s important to get help and learn how to remain resilient during difficult times. Here are some ways you can help yourself move forward:

• Become an expert.  Learn about medication and  treatment options . Keep up with current research. Build a personal library of useful websites and helpful books.
• Know your triggers and stressors.  If large groups make you nervous, go to a park and sit on an out-of-the-way bench. If taking a walk outdoors reduces your anxiety before a big meeting, schedule a 10-minute walk before the meeting starts. Being mindful of triggers and stressors will help you live your life with fewer limitations.
• Partner with your health care providers.  Actively participate in your treatment by working with mental health care professionals to develop a plan that works for you. Talk with them about your goals, decide on a recovery pace you’re comfortable with and stick to your plan. Don’t quit when something doesn’t go well. Instead, talk to your doctor or therapist about possible changes.
• Get healthy.  Studies have reported that 30 minutes of vigorous, aerobic exercise can eliminate symptoms, while low-key activities like meditation, yoga or Tai Chi relieve stress. Regular exercise can reduce many symptoms. Diet is also an important factor, so try to eat healthy, balanced meals and pay attention to food sensitivities. In some people, certain foods or additives can cause unpleasant physical reactions, which may lead to irritability or anxiety.
• Avoid drugs and alcohol.  These substances may  seem  to help with anxiety at first, but can disrupt emotional balance, sleep cycles and interact with medications. Coffee, energy drinks and cigarettes worsen anxiety.
• Find support.  Share your thoughts, fears and questions with others. NAMI offers  support groups and education programs , as well as online discussion communities.

Learn more about  managing your mental health and finding support  while living with mental illness.

Helping A Family Member Or Friend

Learn about your loved one’s triggers, stressors and symptoms. By being informed and aware, you may help prevent an increase in symptoms. Look for things like rapid breathing, fidgeting or avoidance behaviors. Discuss your friend or family member’s past experiences with them so they can recognize the signs early as well.

• Play a role in treatment.  Increasingly, mental health professionals are recommending couple or family-based treatment programs. And on occasion, a therapist might enlist a loved one to help reinforce behavior modification techniques with homework. Ultimately, the work involved in recovery is the responsibility of the person with the disorder, but you can play an active, supportive role.
• Communicate.  Speak honestly and kindly. Make specific offers of help and follow through. Tell the person you care about her. Ask how she feels and don’t judge her for her anxious thoughts.
• Allow time for recovery.  Understanding and patience  need to be balanced  with pushing for progress and your expectations.
• React calmly and rationally.  Even if your loved one is in a crisis, it’s important to remain calm. Listen to him and make him feel understood, then take the next step in getting help.

Find out more about  taking care of your family member or friend  (without forgetting about yourself!).

• Tips For Easing Back-to-School Anxiety
• Being Queer is Joyful

Know the warning signs of mental illness

Learn more about common mental health conditions

NAMI HelpLine is available M-F, 10 a.m. – 10 p.m. ET. Call 800-950-6264 , text “helpline” to 62640 , or chat online. In a crisis, call or text 988 (24/7).

• Open access
• Published: 17 April 2024

How much do adverse childhood experiences contribute to adolescent anxiety and depression symptoms? Evidence from the longitudinal study of Australian children

• Berhe W. Sahle 1 ,
• Nicola J. Reavley 1   na1 ,
• Amy J. Morgan 1   na1 ,
• Marie Bee Hui Yap 1 , 2   na1 ,
• Andrea Reupert 3   na1 &
• Anthony F. Jorm 1   na1  

BMC Psychiatry volume  24 , Article number:  289 ( 2024 ) Cite this article

472 Accesses

Metrics details

This study aims to: (i) examine the association between adverse childhood experiences (ACEs) and elevated anxiety and depressive symptoms in adolescents; and (ii) estimate the burden of anxiety and depressive symptoms attributable to ACEs.

Data were analyzed from 3089 children followed between Waves 1 (age 4–5 years) and 7 (16–17 years) of the Longitudinal Study of Australian Children. Logistic regression was used to estimate the associations between ACEs and child-reported elevated anxiety and depressive symptoms at age 16–17. Anxiety and depressive symptoms were measured using the Children’s Anxiety Scale and Short Mood and Feelings Questionnaire, respectively. The punaf command available in STATA 14 was used to calculate the population attributable fraction (PAF).

Before the age of 18 years, 68.8% of the children had experienced two or more ACEs. In the analysis adjusted for confounding factors, including co-occurring ACEs, both history and current exposure to bullying victimisation and parental psychological distress were associated with a statistically significant increased likelihood of elevated anxiety and depressive symptoms at age 16–17. Overall, 47% of anxiety symptoms (95% CI for PAF: 35–56) and 21% of depressive symptoms (95% CI: 12–29) were attributable to a history of bullying victimisation. Similarly, 17% (95% CI: 11–25%) of anxiety and 15% (95% CI: 4–25%) of depressive symptoms at age 16–17 years were attributable to parental psychological distress experienced between the ages of 4–15 years.

The findings demonstrate that intervention to reduce ACEs, especially parental psychological distress and bullying victimisation, may reduce the substantial burden of mental disorders in the population.

Peer Review reports

Introduction

Mental disorders remain a major cause of morbidity, mortality, and economic burden worldwide [ 1 , 2 ]. The lifetime prevalence of having one or more mental disorders by the age of 75 years is estimated to be up to 47% [ 3 ]. Despite an increase in the availability of treatment in many countries, there is little evidence that the burden of mental illness is decreasing [ 4 , 5 , 6 ]. Moreover, the global economic burden of mental disorders is predicted to rise to $16 trillion by 2030, primarily due to early onset of mental illness and lost productivity across the life course [ 4 ].

There is growing evidence that the lack of emphasis on prevention and early intervention underlies the lack of improvements in the population burden of mental disorders [ 5 , 6 ]. While increasing access to mental health services is central to improving population mental health, even if all those requiring treatment obtained it, approximately 60% of the burden of mental disorders would not be averted [ 7 ]. This underscores the importance of prevention of mental disorders with accumulating evidence pointing to the benefits of preventive interventions that aim to reduce risk factors and enhance protective factors [ 1 , 5 ]. Making progress in this area requires us to target the biggest contributors to mental disorders in order to have a major impact on the population prevalence and burden of disease [ 8 ]. These include adverse childhood experiences (ACEs) [ 8 ].

ACEs are defined as exposures to traumatic experiences during childhood (0–17 years). They include childhood maltreatment, maladaptive parenting practices (e.g., harsh discipline, aversiveness, over-involvement or parent-child conflict), household dysfunction (e.g., substance or alcohol misuse, family violence, and parental separation/divorce), violence and socio-economic adversity [ 9 , 10 ]. Globally, ACEs are prevalent, with three in five adults having experienced at least one ACE and a quarter of adults having experienced at least three [ 11 , 12 , 13 ]. ACEs are associated with an increased prevalence of physical and mental health problems across the life course, including mental health disorders, suicidal behaviours, unhealthy lifestyle behaviours and chronic non-communicable diseases [ 14 , 15 ]. For example, children exposed to four or more ACEs have four times higher odds of having anxiety or depressive disorders, compared with children who were not exposed to any ACEs [ 14 ]. Furthermore, there is evidence that ACEs and their negative effects can be transmitted from one generation to the next, leading to their intergenerational transmission [ 16 ]. In this study we defined ACEs as stressful and potentially traumatic events occurring in childhood or adolescence that can negatively impact health and well-being. ACEs include financial hardship, family drug or alcohol abuse, marital separation, verbal or physical interpersonal conflict, unsafe neighbourhood, parental psychological distress, death of family member, and bullying victimisation [ 14 , 17 ].

ACEs are common globally, however, the prevalence of specific types of ACEs and their contribution to the risk of mental disorders varies across and within populations [ 15 , 18 ]. Therefore, intervention efforts need to prioritise those ACEs with the largest potential population benefits in terms of preventing poor mental health outcomes. Calculating the population attributable fraction (PAF) of each ACE can inform action in this area. The PAF combines the prevalence of a risk factor and the strength of association with an outcome, allowing us to measure the proportion of an outcome that would have been prevented in a population over a given period of time by reducing the population’s exposure to a risk factor to a theoretically minimal risk.

Previous studies on the association between ACEs and common mental disorders have a number of limitations, as they are largely focused on individual types of ACEs, such as child maltreatment or bullying [ 18 , 19 , 20 , 21 ] This approach has been employed despite the frequent co-occurrence of multiple forms of ACEs in certain families, which can have an additive or multiplicative impact on a range of health outcomes. Second, most of the studies examining the links between ACEs and mental disorders involve adults and are based on cross-sectional designs or retrospective assessment of exposure to ACEs in childhood [ 14 , 15 ]. In addition to the inherent limitations of retrospective assessment, onset of mental disorders in adulthood is likely to be confounded by exposure to a wide range of life events after childhood. Prospective longitudinal studies that include exposure to multiple ACEs across childhood are required to better understand the PAF of ACEs on mental disorders.

Using data from the Longitudinal Study of Australian Children (LSAC), this study examines the association between a range of ACEs and elevated depression and anxiety symptoms, in order to estimate the PAF of anxiety and depressive symptoms associated with ACEs. The LSAC is a large, community-based cohort of Australian children that investigates the effect of children’s social, economic and cultural environments on their wellbeing over the life course [ 22 ]. The LSAC provides an excellent opportunity to identify which ACEs are associated with the largest burden from mental disorders in the Australian population.

Data source

This study analysed seven waves of data from the LSAC. Details of the study design, sampling, recruitment, and data collection for LSAC have been described previously [ 22 ]. LSAC commenced in 2004 (Wave 1) with a nationally representative sample of 10,090 children drawn from two cohorts of Australian children. Cohort B (“Birth”) includes 5107 children aged 3–19 months and Cohort K (“Kindergarten”) includes 4983 children aged 4 to 7 years at Wave 1. Data have been collected biennially. Overall, LSAC collects data from multiple informants, including children, parents, teachers and childcare workers. Variables collected include family demographics, finances, health status, health behaviour and risk factors, relationships, parenting, long-term chronic conditions, and children’s social and emotional outcomes, via face-to-face interview, self-administered questionnaire, child self-report interview, computer-assisted telephone interview, and observations made by interviewers.

We analysed ACEs reported between Waves 1 and 7 of the K-cohort of the LSAC survey, and anxiety and depressive symptoms reported by the child at Wave 7. Our analyses focus on children’s self-reported anxiety and depressive symptoms in the most recent wave because children are deemed to become more reliable reporters of their own mental health as they get older [ 23 ].

Anxiety symptoms were assessed based on the 8-item Children’s Anxiety Scale (CAS-8) derived from the Spence Children’s Anxiety Scale short form. Children are asked to rate on a 4-point scale (1 = Never, 4 = Always), the frequency with which they experience symptoms of anxiety such as: ‘I worry about things’; ‘I feel afraid’; and ‘I feel nervous’. The CAS-8 has demonstrated good reliability as an indicator of anxiety symptoms. Total scores of ≥ 13 for males and ≥ 16 for females are considered indicative of elevated or clinical levels of anxiety [ 24 ].

Depressive symptoms were assessed using the Short Mood and Feelings Questionnaire (SMFQ). The SMFQ is a 13-item self-report measure of depressive symptoms for children aged 8–16 years. Assessed over the last two weeks, items include, ‘I felt miserable or unhappy’, ‘I didn’t enjoy anything at all’, and ‘I felt I was no good at all’. Response options are true (= 2), sometimes true (= 1), and not true (= 0). Total SMFQ scores range from 0 to 26, and a score of 11 or higher has been shown to have a high sensitivity and specificity in identifying those who meet criteria for a diagnosis of major depressive disorder [ 25 ]. In this study, scores of 11 or higher were considered indicative of elevated depressive symptoms.

In each Wave of the LSAC, parents were asked six questions relating to their experience of stressful financial events that occurred in the year preceding the survey. A count of the number of stressful financial events (0–6) was used to indicate the extent of financial hardship, with higher values indicating higher levels of financial stress. Financial stress was dichotomized as having parent 1 and/or parent 2 have at least 1 financial stress vs. neither parent has financial stress.

Parental psychological distress was assessed for each parent at all Waves using the 6-item Kessler Psychological Distress Scale (K-6). Parents reported on a five-point rating scale the extent to which they experience symptoms of psychological distress, such as feeling nervous, hopeless, restless, extremely sad, and worthless over the previous four weeks. Responses were summed and a cut-off point of 13 and above was used for the assessment of probable clinical-level psychosocial distress [ 26 ]. Parental psychological distress was dichotomized as: parent 1 and/or parent 2 have psychological distress, or neither parent has psychological distress.

Hostile parenting, which refers to parenting behaviour that expresses hostility, aggression, irritability, and anger towards a child, was assessed through reports by both parents in Waves 3 and 4 [ 27 ]. Hostile parenting behaviours were reported on a frequency rating scale (never/almost never; rarely; sometimes; often; always/almost always) to a battery of 4-questions relating to how parents had been feeling or behaving with the child during the preceding four weeks. Item scores were averaged to give overall scores for hostile parenting with higher values indicating higher levels of hostile parenting. Hostile parenting was dichotomized as: parent 1 and/or parent 2 have hostile parenting score in the top 10% vs. neither parent has hostile parenting score in the top 10% [ 28 ].

Bullying victimisation between Waves 1 and 4 was reported by the child’s mother and is based on a single question asking whether the child has been picked on or bullied by other children. At Waves 5, 6, and 7, children were asked (on a 4-point rating scale) the following question to assess whether they have experienced bullying: Please indicate if any of the following statements happened during the past 30 days at school: (i) Kids hit or kicked me on purpose; (ii) Kids grabbed or shoved me on purpose; (iii) Kids threatened to hurt me or take my things; (iv) Kids said mean things to me or called me names; (v) Kids tried to keep others from being my friend; (vi) Kids did not let me join in what they were doing; (vii) Kids sent me a mean text message/email; or posted mean things about me on the Internet. Those children who responded ‘never’ to all seven questions were categorised as “not victims of bullying” or otherwise as “bullying victims”.

Verbal inter-parental conflict was assessed in all Waves by asking mothers to rate on a 5-point scale about how often they and their partners engage in disagreements (e.g. ‘‘How often is the conversation awkward or stressful?”). Verbal inter-personal conflict was present if mothers responded “often” or “always” to at least one of the four items [ 29 ].

Physical inter-parental conflict was measured at all Waves, by asking mothers to rate on a 5-point scale “How often do you have arguments with your partner that end up with people pushing, hitting, kicking or shoving?’’. A response of “sometimes’’, ‘‘often’’ or ‘‘always’’ represented presence of physical inter-parental conflict [ 29 ].

Parent alcohol or substance use problem was assessed by asking the mother if either of the parents had an alcohol or drug problem (Yes/No) in the last year.

Unsafe neighbourhood was defined as “disagreement” or “strong disagreement” with the statement “This is a safe neighbourhood”.

Data analysis

We estimated the prevalence of the ACEs across the seven Waves, and the prevalence of elevated anxiety and depressive symptoms at Wave 7. We then used logistic regression models to estimate the Odds Ratios (ORs) ± 95% Confidence Interval (CI) of having elevated anxiety or depressive symptoms among those who experienced ACEs compared to those who did not. We ran two separate regression models to compare the: (i) cross-sectional associations between ACEs and elevated anxiety and depressive symptoms at age 16–17 (Wave 7), and (ii) history of exposure to ACEs between ages 4–15 (Waves 1–6) and elevated anxiety and depressive symptoms at age 16–17. In our analyses, where we explored the associations between the prior history of ACEs and depressive and anxiety symptoms at Wave 7, we excluded individuals with elevated anxiety and depressive symptoms in the preceding wave (Wave 6). A cumulative ACE score was calculated based on report of the first exposure to individual ACEs across any of the six follow up waves (1 = yes, 0 = no), and then grouped into categories: 0, 1, 2, and 3 or more. PAFs for anxiety and depressive symptoms due to ACEs significantly associated ( P  < 0.05) with elevated anxiety and depressive symptoms were estimated based on the respective prevalence rates of ACEs and the ORs. The punaf command available in STATA 14 was used to calculate the population attributable fraction (PAF) from the final multivariable logistic regression model. Ethics approval was not required for this because it uses de-identified publicly available data from the LSAC survey.

Characteristics of study participants

A total of 3089 children (51% males) responded to Wave 7 of the LSAC survey and were included in this study. Aged 16–17 years, most children (95.9%) were born in Australia and only 9.8% spoke a language other than English at home. Table  1 presents a summary of sociodemographic and other background characteristics of the study population.

Prevalence of ACEs and elevated anxiety and depressive symptoms

Before the age of 18 years, 68.8% of the children had experienced two or more ACEs. Bullying victimisation (54.1%) and exposure to verbal or physical interparental conflict (23.4%) were the most commonly reported ACEs. About a quarter of the parents (23.4%) had experienced two or more (2.1%) financial stresses (e.g., could not pay mortgage or rent on time) and 13.8% had psychological distress. Children had a mean of 2.4 ACEs (SD = 1.3) across the seven Waves. The number of ACEs was comparable in both males and females, but was higher in children of parents who were unemployed or who lived in disadvantaged areas. Table  2 and Supplementary File Table S1 ) show the prevalence of ACEs between Waves 1 and 7 of the LSAC.

30% of children reported elevated depressive symptoms and 16.1% reported elevated anxiety symptoms at age 16–17 years. The prevalence of both elevated depressive symptoms (36.4% vs. 26.6%) and elevated anxiety (17.6% vs. 14.5%) symptoms was higher in females than males.

Cross-sectional association between ACEs and anxiety and depressive symptoms

Table  3 shows the cross-sectional association between ACEs and elevated anxiety and depressive symptoms at Wave 7 and the corresponding PAF. After adjusting for potential confounding factors, elevated anxiety and depressive symptoms were significantly higher in children who reported being bullied by other children, and children whose parents experienced psychological distress. Children who reported being bullied by other children (OR = 2.91, 95% CI: 2.23–3.80) and whose parents had psychological distress (OR = 1.90, 95% CI: 1.20–2.99) had greater odds of having elevated anxiety symptoms. Similarly, bullying victimisation (OR = 1.76, 95% CI: 1.28–2.41) and parental psychological distress (OR = 1.86, 95% CI: 1.23–2.79) were independently associated with increased odds of elevated depressive symptoms. Furthermore, a larger total number of ACEs experienced by children was associated with greater odds of elevated depressive or anxiety symptoms. The odds of elevated anxiety symptoms were 2.27, 3.69 and 4.88 times higher in children who reported one, two and three or more ACEs, respectively, compared to those who reported no ACEs. Similarly, children who reported one, two, and three or more ACEs had 1.52, 2.02 and 2.76 times greater odds of elevated depressive symptoms. The association between several other ACEs, including household alcohol or drug abuse, unsafe neighbourhood, and household financial stress, and elevated anxiety and depressive symptoms did not persist after adjusting for potential confounding factors.

Overall, 47% of anxiety symptoms (95% CI for PAF: 40–57) and 21% (95% CI for PAF: 33–45) of depressive symptoms were attributable to bullying-victimisation. A small but significant proportion of anxiety (PAF: 6%, 95% CI: 3–9) and depressive (PAF: 5%, 95% CI: 2–8) symptoms were attributable to parental psychological distress.

Association between history of ACEs and elevated anxiety and depressive symptoms

We analysed the association between exposure to ACEs between Wave 1 (4–5 years) and Wave 6 (14–15 years) and elevated anxiety and depressive symptoms at Wave 7 (16–17 years) (Table  4 ). Bullying victimisation (OR = 1.49, 95% CI: 1.06–2.09) and parental psychological distress (OR = 1.84, 95% CI: 1.24–2.75) were associated with a statistically significant increased odds of elevated anxiety symptoms. Similarly, the odds of elevated depressive symptoms were significantly higher for bullying victimisation (OR = 1.78, 95% CI: 1.24–2.56) and parental psychological distress (OR = 1.41, 95% CI: 1.05–1.91). Children who reported two, three and four or more ACEs had 1.34, 2.75 and 2.53 times greater odds of elevated anxiety, compared to those who reported no ACEs. Similarly, children who reported two, three, and four or more ACEs had 1.43, 1.81 and 1.84 times greater odds of elevated depressive symptoms compared to those who reported no ACEs. However, the increased odds of elevated anxiety and depressive symptoms in children exposed to only one ACE did not reach statistical significance. There was no significant interaction between sex of child and ACEs for elevated depressive or anxiety symptoms. The PAFs of anxiety symptoms associated with ACEs ranged from 6% for financial stress to 15% for parental psychological distress. The PAFs of depressive symptoms associated with bullying victimisation and parental psychological distress were 17% and 15% respectively (Table  4 ).

Our findings of the associations between ACEs and elevated depressive symptoms did not substantially change when the cut-off for elevated depressive symptoms was defined as the top 10% of the SMFQ score, and anxiety symptoms as CAS-8 of ≥ 18 for males and ≥ 21 for females (Supplementary File Table S2 ).

Using a large population-based cohort of Australian children, this study explored the prevalence of a comprehensive list of ACEs and their contribution to the risk of anxiety and depressive symptoms in the population. While ACEs were highly prevalent across all demographic characteristics, bullying victimisation and parental psychological distress were the major contributors to elevated anxiety or depressive symptoms independent of demographic characteristics and coexisting ACEs. The findings strengthen evidence that a substantial burden of anxiety and depressive symptoms in adolescence may be preventable through evidence-based interventions targeting bullying victimisation and parental psychological distress.

A key finding of this study is that even though most of the ACEs were associated with anxiety and depressive symptoms in the individual analyses, after adjusting for potential confounding factors including other ACEs, only bullying victimisation and parental psychological distress remained significant. Previous studies have focused on the association between individual ACEs and mental illness, often without accounting for the effect of co-occurring ACEs, even though most children experience multiple ACEs [ 15 , 30 ]. In those studies focusing on a single type of ACE, it is not possible to assess whether observed associations represent the downstream effect of other ACEs or are linked to other co-occurring ACEs [ 31 ]. Differences in the prevalence of ACEs across populations [ 32 ], and variations in access to health and social services that could moderate the impact of ACEs on mental disorders [ 33 ], may also partly explain why some ACEs were not significantly associated with anxiety and depressive symptoms in those studies.

It has been consistently reported that ACEs are common across all population groups, although the prevalence rates vary across populations and according to the definition of ACEs [ 32 ]. Our findings that two out of three Australian children had experienced two or more ACEs before the age of 18 years is comparable with data from previous studies in other countries [ 32 , 34 , 35 ]. A recent meta-analysis of 96 studies reporting the prevalence of ACEs in school-aged youth (≤ 18 years) found that two thirds of youth experience ACEs no matter where they reside across the world [ 32 ]. There was no sex difference in the prevalence of ACEs in this study. Despite the importance of disaggregating the prevalence rates of ACEs by population characteristics, the gender-specific prevalence rate of ACEs is not commonly reported in the literature [ 32 ].

Our findings of the extent to which bullying victimisation contributes to elevated anxiety and depressive symptoms are in line with the literature [ 30 ]. For example, a birth cohort study from United Kingdom found that 29.2% (95% CI:10.9–43.7) of depression diagnosis at age 18 years was attributable to bullying victimisation at the age of 13 years [ 30 ]. Findings from the World Mental Health Surveys showed that parental mental illness was strongly associated with a range of mental health problems in offspring, with a PAF of 13% for anxiety disorders and 10% for mood disorders [ 36 ]. Although previous studies have found that both bullying victimisation and parental psychological distress contribute to the risk of anxiety disorders and depression in adolescents, the PAFs may vary across studies mainly due to difference in the prevalence rates of bullying victimisation and parental mental illness. A recent global study of more than 317,000 adolescents (12–17 years) from 83 countries found that the prevalence of bullying victimisation varies across countries, ranging between 8% and 45% [ 37 ]. Similarly, the burden of psychological distress varies substantially across population groups [ 38 ].

In light of the significant burden of anxiety disorders and depression in adolescence, our findings have important implications for policy and health promotion interventions. Given that bullying victimisation and parental psychological distress are the major contributors to elevated anxiety and depressive symptoms in adolescence, intervention programs that show evidence of reducing rates of these ACEs are likely to have substantial population benefits over time. A meta-analysis of 14 randomized clinical trials of anti-bullying school programs found a significant reduction in bullying and improvement in attitudes against bullying [ 39 ]. Another meta-analysis of 53 different anti-bullying programs demonstrated that school-based anti-bullying programs result in a 20% decrease in bullying victimisation [ 40 ]. However, it has also been demonstrated that these programs have greater impact in younger children and their effectiveness decreases with age [ 39 , 41 ]. The substantial burden of elevated anxiety and depressive symptoms attributable to parental psychological distress, and existing evidence of clustering of ACEs in families [ 13 , 42 ], suggest that children whose parents have elevated psychological distress constitute an essential target group for preventive interventions. There is evidence to show that preventive interventions such as mental health treatment for parents, parenting support and family-focused interventions result in small but significant improvements in child mental health outcomes and a reduction in the risk of intergenerational impacts of parental mental illness [ 43 ].

This study has some limitations that should be considered when interpreting the findings. One of the major limitations is that data on child maltreatment, a key ACE that is strongly associated with poor mental health outcomes [ 15 ], was not collected in the LSAC. Some of the variables included in the analyses, including depressive symptoms, bullying victimisation and hostile parenting, lack validated measures and thresholds for objectively defining risk, and were therefore defined based on commonly used definitions from previous studies. However, sensitivity analyses conducted with a higher threshold level for indicating elevated depressive symptoms largely support these findings. Given the underrepresentation in the LSAC sample of children from families with a lower socioeconomic status, Aboriginal and Torres Strait Islander families, and children born overseas, the current findings may underestimate the association between ACEs and mental disorders in these subgroups of the Australian population. Although ACEs were collected prospectively in each wave, anxiety and depressive symptoms were not assessed in earlier waves, thereby limiting longitudinal analyses.

In this large population-based cohort study of Australian adolescents, two-thirds of children were reported as having experienced two or more ACEs before age 18 years. Between 13 and 47% of the burden of depressive or anxiety symptoms at age 16–17 years could be attributed to bullying victimisation, and between 6 and 15% to parental psychological distress. The findings suggest that interventions targeting these ACEs, as the major contributors to elevated anxiety and depressive symptoms in adolescence, may reduce the substantial burden of mental disorders in the population.

Data availability

The authors do not have permission to share data. LSAC data can be requested through an application to the Australian Data Archive Dataverse at the Australian Government Department of Social Services ( https://dataverse.ada.edu.au/ ).

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Acknowledgements

This study is based on data set from the Longitudinal Study of Australian Children. The study is conducted in partnership with the Department of Social Services (DSS), the Australian Institute of Family Studies (AIFS) and the Australian Bureau of Statistics (ABS). The findings and views reported in this paper are those of the authors and should not be attributed to the DSS, the AIFS or the ABS.

This study is funded by NHMRC and Beyond Blue co-funded Centre of Research Excellence in Childhood Adversity and Mental Health (#1153419). The funders had no role in study design or preparation of this report.

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Nicola J. Reavley, Amy J. Morgan, Marie Bee Hui Yap, Andrea Reupert and Anthony F. Jorm contributed equally to this work.

Authors and Affiliations

Centre for Mental Health, Melbourne School of Population and Global Health, University of Melbourne, 207 Bouverie Street, Carlton, Melbourne, VIC, 3010, Australia

Berhe W. Sahle, Nicola J. Reavley, Amy J. Morgan, Marie Bee Hui Yap & Anthony F. Jorm

School of Psychological Sciences and Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia

Marie Bee Hui Yap

Faculty of Education, Monash University, Melbourne, VIC, Australia

Andrea Reupert

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BWS, NJR, AJM, MBHY, AR, AJF contributed to the design of the study. BWS did the analyses and wrote the draft report. NJR, AJM, MBHY, AR, AJF contributed to critically revising the consecutive drafts. All authors reviewed the study findings and approved the final version before submission.

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Distribution of adverse childhood experiences in Wave 7 of the K-cohort of Longitudinal Study of Australian Children; Supplementary file Table S2: Association between adverse childhood experiences prior to Wave 7 and anxiety and depressive symptoms at Wave 7 in the K-cohort

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Sahle, B.W., Reavley, N.J., Morgan, A.J. et al. How much do adverse childhood experiences contribute to adolescent anxiety and depression symptoms? Evidence from the longitudinal study of Australian children. BMC Psychiatry 24 , 289 (2024). https://doi.org/10.1186/s12888-024-05752-w

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DOI : https://doi.org/10.1186/s12888-024-05752-w

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Potential of niacin skin flush response in adolescent depression identification and severity assessment: a case-control study

Affiliations.

• 1 Department of Psychosomatics, School of Medicine, Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, West second Section, 1st Ring Road, 610041, Chengdu, Sichuan, China.
• 2 Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China.
• 3 Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders, Ministry of Education, Shanghai Jiao To ng University, Shanghai, China.
• 4 Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, No. 33, Section 2, Furong Avenue, Wenjiang District, 611135, Chengdu, Sichuan, China.
• 5 School of Nursing, Chengdu Medical College, Chengdu, China.
• 6 Department of Psychosomatics, School of Medicine, Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, West second Section, 1st Ring Road, 610041, Chengdu, Sichuan, China. [email protected].
• 7 Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China. [email protected].
• PMID: 38632560
• PMCID: PMC11025263
• DOI: 10.1186/s12888-024-05728-w

Background: The diagnosis of adolescent Depressive Disorder (DD) lacks specific biomarkers, posing significant challenges. This study investigates the potential of Niacin Skin Flush Response (NSFR) as a biomarker for identifying and assessing the severity of adolescent Depressive Disorder, as well as distinguishing it from Behavioral and Emotional Disorders typically emerging in childhood and adolescence(BED).

Methods: In a case-control study involving 196 adolescents, including 128 Depressive Disorder, 32 Behavioral and Emotional Disorders, and 36 healthy controls (HCs), NSFR was assessed. Depressive symptoms were measured using the Patient Health Questionnaire-9 (PHQ-9) and anxious symptoms with the Generalized Anxiety Disorder 7-item scale (GAD-7). Pearson correlation analysis determined the relationships between NSFR and the severity of depression in DD patients. Receiver Operating Characteristic (ROC) was used to identify DD from BED integrating NSFR data with clinical symptom measures.

Results: The adolescent Depressive Disorder group exhibited a higher rate of severe blunted NSFR (21.4%) compared to BED (12.5%) and HC ( 8.3%). Adolescent Depressive Disorder with psychotic symptoms showed a significant increase in blunted NSFR (p = 0.016). NSFR had negative correlations with depressive (r = -0.240, p = 0.006) and anxious (r = -0.2, p = 0.023) symptoms in adolescent Depressive Disorder. Integrating NSFR with three clinical scales improved the differentiation between adolescent Depressive Disorder and BED (AUC increased from 0.694 to 0.712).

Conclusion: The NSFR demonstrates potential as an objective biomarker for adolescent Depressive Disorder, aiding in screening, assessing severity, and enhancing insights into its pathophysiology and diagnostic precision.

Keywords: Adolescent depressive disorder; Behavioral and emotional disorders typically emerging in childhood and adolescence; Biomarker; Niacin skin flush response; Precision diagnosis.

© 2024. The Author(s).

• Anxiety Disorders / psychology
• Case-Control Studies

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• 2022NSFSC1550/the Youth Fund Project of Sichuan Provincial Science and Technology Department

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Case report: From anxiety disorders to psychosis, a continuum in transitional age youth?

1 Faculty of Medicine, Université Libre de Bruxelles, Brussels, Belgium

2 Child and Adolescent Psychiatry Department, Queen Fabiola Children's University Hospital, Brussels, Belgium

3 Child and Adolescent Team, Mental Health Service at Université Libre de Bruxelles, Brussels, Belgium

Simone Marchini

4 Child and Adolescent Psychiatry Department, Erasme Hospital, Brussels, Belgium

Hélène Nicolis

Véronique delvenne, associated data.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Introduction

To date, among individuals meeting ultra-high risk criteria for psychosis, the relationship between the presence of anxiety disorders and the risk of psychotic transition raises several unanswered questions.

Case description

This case report describes the clinical progression of a 17-year-old male initially presenting anxious symptoms meeting the DSM-V criteria for panic disorder. The patient also reported social withdraw, mild depressive symptoms, insomnia and fatigue. Over a 6 month period, a gradual onset of subthreshold psychotic symptoms suggested a prodromal phase of a psychotic disorder.

Diagnostic assessment and therapeutic intervention

A detailed assessment of UHR criteria for psychosis was performed. The overall level of social and occupational functioning was assessed by the SOFAS, which showed a 35% drop over a 12 months period. The CAARMS, has also been administered. The patient met the diagnostic criteria for UHR, APS group. The care plan included psychiatric follow-up, pharmacologic treatment, individual psychological follow-up and individual and familial psychoeducation. Over a 6 months period, the patient did not experienced a first psychotic episode and presented a partial improvement of psychotic symptoms.

The DSM-V categorical approach does not seem to adapt well to early clinical presentations in transitional age youth. A transdiagnostic and dimensional approach allows to better identify at-risk patients of psychiatric disorders and implement early intervention strategies.

As the onset of most psychiatric disorders typically occurs during late adolescence and early adulthood, transitional age youth (TAY) are an at-risk population in terms of mental health ( 1 ). Early intervention in mental health is crucial, as it seems promising in modifying long-term outcomes and reducing illness severity ( 2 ).

Recent research recognizes that current categorical frameworks for classification and treatment in psychiatry are inadequate, particularly in TAY. Trans-diagnostic clinical staging models have gained prominence, by allowing a multidimensional assessment and taking into account a continuum of illness ( 3 ).

Categorical diagnosis such as anxiety and schizophrenia have been considered as completely distinct entities for years, even if the comorbidity between them has long been recognized. Regarding schizophrenia, the initial diagnosis frequently occurs at the time of the first psychotic episode. However, the diagnosis is often preceded by a prodromal phase where several symptoms gradually emerge. Early symptoms may be non-specific and include anxiety, as well as depressed mood, social withdrawal and academic difficulties. Non-specific symptoms may be followed by the basic symptoms, subtle subclinical disturbances in cognition, perception, language, emotional reactivity and stress tolerance. Later, these abnormalities become more pronounced and subthreshold positive symptoms of psychosis also emerge ( 4 ). The broad range of symptoms present in these early stages of schizophrenia include a wide variety of anxiety symptoms and comorbid entities are often present ( 5 ). Thus, the identification of anxiety symptoms seems to be an essential step in the assessment of a potential prodromal phase, in particular, when evaluating a patient also presenting impaired cognitive or social functioning. Recent epidemiological studies also show that anxiety disorders, such as social anxiety disorder, panic disorder and obsessive-compulsive disorder, are more common among people diagnosed with psychotic disorders compared to the general population ( 6 ).

Current research establishes a new paradigm for schizophrenia prodrome, which is currently considered a flexible entity where symptoms can completely disappear, persist or progress in several possible directions. The term ultra-high risk (UHR) for psychosis has therefore been used to designate individuals who potentially present prodromal symptoms and may benefit from early intervention strategies ( 7 ). Most evidence-based recommendations for UHR point out cognitive-behavioral therapy (CBT) as the most efficacious intervention, improving social functioning, allowing reduction of psychotic symptomatology and preventing or delaying transition to psychosis. Studies on the benefit/ risk balance of antipsychotic medication were not conclusive and existing clinical guidelines do not recommend systematic antipsychotic use ( 8 , 9 ).

To date, among UHR individuals, the relationship between the onset of anxiety symptoms and the risk of psychotic transition raises several unanswered questions and remains a topic of scientific interest. This case report presents the clinical situation of a 17-year-old adolescent complaining with anxious symptoms meeting the DSM-V criteria for panic disorder [300.01 (F41.0)]. The progressive emergence of prodromal symptoms, possibly suggesting a psychotic disorder, led to reflexions about anxiety disorders and psychosis as comorbid conditions or manifestations of the same clinical entity. The authors propose to include some considerations about the clinical and epistemological complexity of these categorical diagnoses. A trans-diagnostic dimensional approach is preferable in order to comprehensively assess the ever-changing clinical presentation and to provide appropriate care.

We describe the clinical case of a white Caucasian 17-year-old male adolescent referred to an outpatient child and adolescent mental health service in the Brussels urban area, Belgium, after an initial psychological assessment in a private outpatient clinic. At the time of the first psychiatric assessment, the patient was the main requester of the consultation. He presented, for about 3 months, panic attacks, characterized mainly by trembling, palpitations, a sensation of shortness of breath and a fear of losing control, without a trigger factor. These episodes, which had increased in frequency and intensity since their onset, were accompanied by a persistent worry of further panic attacks and an increase in social withdrawal that had been gradually increase in intensity over about 3 years. This posture described by the patient as voluntary self-isolation and avoidance of interactions with peers and family, was not associated with fear or anxiety related to social interactions. The patient also reported mild depressive symptoms, a sleep disorder characterized by initial insomnia, and fatigue.

Early childhood development was described as normal by parents and there was no history of perinatal complications. The patient received speech therapy, from age 3 to, for speech delay (first words at 24-months old) and articulation disorders. He took his first steps at around 12 months of age. Social interactions with peers were spontaneous during childhood and early adolescence. Regarding scholar functioning, no learning difficulties had ever been reported and he was attending, at the time of the first consultation, the last year of secondary school.

Prior to the onset of symptoms, there were no known family stressors or any significant life events, apart from the emigration of the family, from another European country, 7 years later, for professional reasons. Family psychiatric history was also not relevant.

His medical history included a primary spontaneous pneumothorax at the age of 16. He was admitted to hospital for 1 week and a chest tube was inserted, without complications. Physical examination (including cardiovascular screening) was normal, with a body mass index of 19 kg/m 2 . All laboratory results (blood and urine tests) were within normal limits. There was no history of alcohol, tobacco or drug use and he had not been on any medications.

Intelligence quotient (IQ) was assessed using the Wechsler Intelligence Scale for Adults, 4 th Edition ( 10 ) and revealed a very superior IQ (140, percentile >99).

At the time of the first psychiatric assessment, Beck Depression Inventory II (BDI-II), was administered to measure the severity of depressive symptoms ( 11 , 12 ). The patient scored for “mild depression” (score: 19). The Panic Disorder Severity Scale (PDSS), was also administered ( 13 , 14 ). This self-report scale, assessing the severity of panic attacks and panic disorder symptoms, revealed a moderate intensity of symptoms (score: 12). Initial assessment outcomes are described in Table 1 . The patient met the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) criteria for panic disorder [300.01 (F41.0)] ( 15 ).

Initial assessment results.

BDI-II, Beck Depression Inventory, second version; IQ, Intelligence Quotient; PDSS, Panic Disorder Severity Scale; PRI, Perceptual Reasoning Index; PSI, Processing Speed Index; VCI, Verbal Comprehension Index; WAIS-IV, Wechsler Adult Intelligence Scale, fourth edition; WMI, Working Memory Index.

Pharmacologic and psychotherapeutic treatment options were discussed with the patient and parents ( 16 ). Since the patient was not motivated to start CBT, a selective serotonergic reuptake inhibitor, Sertraline 50 mg per day, was initiated, with a substantial improvement of anxiety and depressive symptoms, over a 3 months period. No unexpected side effects were described.

Approximately 6 months after starting antidepressant treatment, parents reported a more pronounced decrease in social functioning, despite continued pharmacologic treatment and complete remission of panic attacks. In particular, parents observed a global decrease in social interactions, including family interactions, and the onset of clinophilia. The patient additionally reported aboulia and concentration problems related to school but only a slight drop in school results was observed at this stage. Besides, the patient reported, for the first time, having, for about 4 months, subthreshold psychotic symptoms, such as suspiciousness ideas, visual distortions, and subjective changes in speech, such as thought blockage and intrusive thoughts. These recent symptoms caused a significant distress and fear to “go crazy”.

Figure 1 shows a timeline of psychiatric symptoms and pharmacologic treatment.

Simplified timeline of psychiatric symptoms and pharmacologic treatment.

Diagnostic assessment, therapeutic intervention

Further clinical evaluation was performed and included a detailed assessment of UHR criteria for psychosis as showed in Table 2 . The 16-item Version of the Prodromal Questionnaire (PQ-16), a routine screening tool for UHR of developing psychosis ( 17 ) was administered and showed a total score of 11 points (above the distress threshold of 6 or more points). The overall level of psychosocial functioning was assessed by the Social and Occupational Functioning Assessment Scale (SOFAS) ( 18 ), showing a sustained 35% drop in SOFAS score over a 12 months period. The Comprehensive Assessment of at Risk Mental States (CAARMS), was also administered. The CAARMS is a semi-structured assessment tool used by mental health professionals to identify help-seeking youth who are at UHR of psychosis and to identify the onset of the first episode of psychosis ( 19 ). Patient presented subthreshold intensity and frequency scores on non-bizarre ideas subtest and perceptual abnormalities subtest. Based on both SOFAS and CAARMS scores, the patient met the diagnostic criteria for UHR, attenuated psychosis group (APS). He did not met the diagnostic criteria for brief, limited intermittent psychotic symptoms (BLIPS), neither trait vulnerability criteria ( 20 ). Based on presenting clinical features and the clinical staging model of mental disorders, the patient was assigned a stage 1b ( 21 ).

UHR for psychosis assessment results.

APS, Attenuated Psychotic Syndrome; CAARMS, Comprehensive Assessment of At Risk Mental States; PQ-16, Prodromal Questionnaire, 16-item; SOFAS, Social and Occupational Functioning Assessment Scale; UHR, Ultra-High Risk for Psychosis.

In line with recent recommendations for UHR patients ( 8 , 9 ), information about the diagnosis and early intervention strategies was provided and an individualized and multidisciplinary care plan was proposed. The patient still refused CBT and the follow-up included regular psychiatric monitorisation and supportive therapy, every 2–4 weeks. In order to better manage comorbid symptoms, sertraline was increased to 100 mg per day. Antipsychotic treatment was not initiated since the patient did not present severe and/ progressive UHR symptomatology ( 9 ). Both individual and family psychoeducational approaches were started even if evidence in UHR patient is still lacking and they focused on enhancing the understating of psychotic and non-psychotic symptoms, psychoeducation about the nature of anxiety and stress, engagement in treatment and increase adherence to treatment.

Over a 6 months period after the diagnosis and about a year after the onset of APS, a partial improvement of APS was observed by the clinician and the patient. The patient did not experienced a first psychotic episode over the same period.

During the initial psychiatric evaluation and the psychiatric follow-up, even if the patient was seeking care, he had a hard time in the therapeutic alliance and in explaining the symptoms, because of fear of stigmatization and of being diagnosed with a serious chronic disease. He also presented some difficulties in understanding the implications of the diagnosis and the therapeutic objectives, and in accepting the therapeutic strategies (CBT and pharmacological treatment). Both individual and family psychoeducational sessions were, according to the patient, unproductive at first, because he presented lack of motivation, but after that period, essential in order to finally understand available treatments and reduce stress and anxiety.

CARE case report guidelines were followed in the redaction of all sections the manuscript ( Table 3 ).

CARE case report guidelines.

n/a, non-applicable.

Psychiatric clinical cases are often characterized by interactions and overlaps between different diagnostic entities. Initially, this clinical case met the DSM-V criteria for panic disorder. However, the evolution of the disease has raised questions regarding a possible schizophrenia prodrome. Non-specific negative symptoms, including sleep disturbances, depressed mood, fatigue and social withdrawal were already present at the time of initial clinical presentation. Still, it was the gradual onset of positive symptoms, the attenuated psychotic symptoms, in particularly persecutory ideas and visual perceptual abnormalities, that suggested a prodromal phase of a psychotic disorder.

The DSM-V categorical approach, usually applied in clinical practice and research, is based on a list of signs and symptoms drawing a clear line between normality and psychopathology, according to a defined threshold ( 15 ). This approach is being increasingly criticized by scientific community for multiple reasons such as the excessive comorbidity between syndromes and the lack of emphasis on developmental, social, cultural and environmental context. Dimensional approaches seem to better adapt to TAY psychopathology, often characterized by early clinical presentations which include non-specific or subthreshold intensity/frequency symptoms and by the high incidence of comorbid disorders ( 22 ). In recent years, trans-diagnostic clinical staging models have gained importance, by allowing a multidimensional assessment while considering illness as a dynamic continuum from its absence to its most extreme expression ( 3 ). This broader strategy to identify at-risk patients may ultimately permit to recognize early stages of severe mental disorders, offering new management strategies tailored to patient's clinical stage, preventing the onset and/or progression of mental disorders ( 23 ). More specifically, with regard to psychotic disorders, UHR criteria represents a milestone in early detection and intervention field. The prodromal phase, previously described retrospectively, is now approached as a prospective phase. Moreover, UHR individual have a high risk to develop psychotic disorders but this pathway is neither inevitable nor the only diagnostic possibility ( 2 ). Recent scientific efforts permitted to develop clinical criteria and tools to identify UHR individuals, including the SOFAS and the CAAMS. The use of these standardized instruments can be extremely helpful to enable an early transdiagnostic approach but also to complement differential diagnosis evaluations.

More studies are needed to better identify risk and protective factors involved in transition from UHR to first episode of psychosis and schizophrenia. In this particular situation, authors questioned whether these two clinical entities are comorbid disorders or dimensional manifestations of a same disorder and whether the presence of an anxiety disorder could increase the risk of psychotic transition in UHR individuals. Prospective studies conducted in UHR individuals have found high prevalence of psychiatric comorbidities, in particular depressive (between 31 and 34%) and anxiety disorders (between 28 and 39%) ( 24 , 25 ). A study on 509 UHR individuals revealed that comorbid anxiety and depressive disorders do not appear to have an effect on the risk of psychotic transition ( 26 ). Conversely, a recent study showed that, in individuals presenting psychotic experiences, non-psychotic comorbidity increases the risk of psychotic transition ( 27 ). Furthermore, in adolescents and young adults, the presence of psychotic symptoms is frequent in depressive and anxiety disorders ( 28 ).

There is still limited knowledge of the mechanisms involved in the simultaneous presence of psychotic and anxiety symptoms, including if the treatment of anxiety disorders could decrease the frequency and intensity of subthreshold psychotic symptoms and the risk of psychotic transition. Additionally, in TAY, it is particularly important to take into account developmental, social, cultural and environmental contexts. According to cohort studies, individuals who develop schizophrenia in adulthood often show developmental abnormalities in early childhood, such as speech and motor disorders and social adjustment difficulties ( 29 ). However, there are many common risk factors between psychotic and anxiety symptoms ( 30 ). Nevertheless, the knowledge of identified risk factors may provide additional clues and guide diagnostic reasoning.

Individualized and multidisciplinary assessment and management, according to the clinical stage, should be offered to the patient and the family, ideally in a specialized center. However, to date, in Brussels, Belgium, there is no service or program specifically design to UHR patients, despite scientific evidence showing the role of these structures in reducing the risk of psychotic transition and reducing the duration of untreated psychosis, compared to conventional services ( 31 ). There is, therefore, a substantial difficulty in access to current treatment strategies. Antipsychotic medication prescription to UHR patients is not recommended in clinical practice guidelines based on the current evidence. Nevertheless, pharmacological treatment of comorbidities (principally depressive and anxiety disorders) and CBT seem to decline the rate of psychotic transition ( 32 ).

In conclusion, this case report illustrates frequent difficulties on psychiatric clinical practice, particularly in transition age youth. In UHR individuals, psychiatric comorbidities, including anxiety disorders, are common and may be responsible for additional distress. The DSM-V categorical approach does not seem to adapt well to TAY psychopathology, often characterized by early clinical presentations, non-specific and/or subthreshold symptoms. A transdiagnostic and dimensional approach could better identify at-risk patients of psychiatric disorders and allow a personalized targeted-care.

Data availability statement

Ethics statement.

Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.

Author contributions

JR and SM contributed to the manuscript draft and research on the topic. JR was responsible for the psychiatric assessment and follow-up of the patient. HN provided clinical advice to JR. HN and VD reviewed the case report and article as senior authors. All authors approved the submitted version.

This study is part of the University Chair Psychiatry in Transition in a World in Transition (Université Libre de Bruxelles, Brussels, Belgium), supported by the Julie Renson Fund, the Queen Fabiola Fund and the King Baudouin Foundation. Apart from the financial contribution in research activities, the funding institutions have no role in data collection, diagnostic assessment, or therapeutic strategies.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

• Open access
• Published: 23 April 2024

Prevalence of anxiety, depression, and post-traumatic stress disorder among Omani children and adolescents diagnosed with cancer: a prospective cross-sectional study

• Laila S. Al-Saadi 1 ,
• Moon Fai Chan 1 ,
• Amal Al Sabahi 2 ,
• Jalila Alkendi 2 ,
• Nawal Al-Mashaikhi 3 ,
• Hana Al Sumri 1 ,
• Amal Al-Fahdi 4 &
• Mohammed Al-Azri 1  

BMC Cancer volume  24 , Article number:  518 ( 2024 ) Cite this article

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Children and adolescents diagnosed with cancer often experience psychological distress, encompassing anxiety, depression, and post-traumatic stress disorder (PTSD). This study aimed to evaluate the prevalence of these conditions among Omani children and adolescents diagnosed with cancer, alongside identifying contributing factors.

A prospective cross-sectional study was conducted from October 2021 to June 2023 among a cohort of Omani children and adolescents (6–18 years old) diagnosed with cancer at three primary cancer referral centres in Oman. Validated Arabic-language versions of the Screen for Child Anxiety Related Disorders, the Center for Epidemiologic Studies Depression Scale for Children, and the Impact of Event Scale-Revised instruments were used to assess symptoms of anxiety, depression, and PTSD, respectively. An initial assessment (T1) was undertaken within the first 3 months of diagnosis, followed by a second assessment (T2) 3–6 months later.

Of 113 eligible participants, 101 agreed to participate in the study (response rate: 95.6%), with 92 (91.0%) completing both assessments and included in the final analysis. Prevalence rates of anxiety, depression, and PTSD decreased from 43.5%, 56.5%, and 32.6%, respectively, at T1, to 38.0%, 35.9%, and 23.9% at T2. All average scores were below diagnostic cut-off points, except for the depression score at T1. Anxiety and depression scores decreased significantly ( p  = 0.043 and 0.001, respectively) between T1 and T2, as did the overall prevalence of depression ( p  = 0.004). At T1, linear regression analysis showed significant correlations between anxiety scores and the child’s age and PTSD score ( p  < 0.05); these variables were also correlated with depression scores ( p  ≤ 0.001). At T2, significant correlations were observed between anxiety scores and the child’s age and PTSD scores ( p  < 0.001). At both T1 and T2, anxiety, depression, and PTSD scores remained significantly correlated ( p  < 0.001).

Conclusions

Omani children and adolescents recently diagnosed with cancer exhibit a high prevalence of anxiety, depression, and PTSD over time. Age-appropriate communication, ongoing support, and mental health services are recommended to help this patient group cope with their diagnosis and manage their emotional wellbeing. There is a need for future research to determine the effectiveness of specific psychological interventions in reducing the frequency of these disorders.

Peer Review reports

Cancer in childhood and adolescence ranked as the sixth leading contributor to the total global cancer burden in 2019 [ 1 ]. An estimated 429,000 individuals under 19 years of age are diagnosed with cancer every year, with 141–185 cases per million reported worldwide [ 2 , 3 ]. Approximately 100,000 children and adolescents die annually from cancer, with the vast majority of deaths (90%) occurring in low- and middle-income countries (LMICs) [ 1 ]. Furthermore, those diagnosed with cancer in LMICs have a low five-year survival rate of 30%, in stark contrast to high-income countries where survival rates exceed 80% due to significant advances in cancer treatment [ 2 , 3 ].

In Arab countries, over 18,000 children below the age of 15 years are diagnosed with cancer every year, with annual incidence rates ranging from 7.5 to 12.8 cases per 100,000 children, although variations may be due to differences in registration accuracy [ 4 ]. In Oman, approximately 31% of the total population is under 19 years of age [ 5 ]. In 2019, a total of 2,307 patients were diagnosed with cancer, of which 2,089 patients (91.5%) were of Omani nationality and 124 (5.9%) comprised children aged 0 to 14 years [ 6 ]. However, the anticipated total number of annual cancer diagnoses is projected to rise to 8,549 by the year 2040 [ 7 ].

Anxiety, depression, and post-traumatic stress disorder (PTSD) are frequent in children and adolescents with cancer, with pooled prevalence rates of 13.92%, 20.43%, and 20.90%, respectively [ 8 ]. Recent research underscores a higher incidence of anxiety and depression in paediatric cancer patients and the heightened vulnerability of this demographic to post-traumatic stress symptoms, emphasising the need for a nuanced understanding of emotional challenges throughout the cancer diagnosis, treatment, recovery, and survivorship journey [ 9 , 10 , 11 , 12 ]. In itself, a diagnosis of cancer, along with accompanying physical symptoms and treatment side-effects, can lead to excessive tension, discomfort, and fear of death [ 8 , 13 ]. Symptoms of depression, including low mood, despair, guilt, and loss of interest in usual activities, may also challenge patients’ ability to function and adhere to treatment [ 14 ].

As Oman continues to make significant improvements in healthcare delivery and medical treatment, cancer survival rates among children and adolescents have improved. However, the emotional toll of a cancer diagnosis cannot be underestimated, and an understanding of these psychological repercussions is crucial as an essential indicator of patients’ well-being to ensure the provision of comprehensive oncologic care [ 8 ]. Indeed, it has been found that that the activity of making jewelry from beads was effective in reducing the state and trait anxiety levels of children with cancer [ 15 ]. Our study therefore aimed to identify the prevalence of anxiety, depression, and PTSD among Omani children and adolescents diagnosed with cancer and their associated factors, and to describe changes occurring over time.

Study design and setting

A cross-sectional study was conducted targeting all Omani children and adolescents aged six to 19 years diagnosed with any type of cancer between 1st October 2021 and 30th June 2023. The study was conducted at the National Oncology Centre (NOC) of the Royal Hospital, the Paediatric Haematology Unit of the Sultan Qaboos University Hospital (SQUH), and the Sultan Qaboos Comprehensive Cancer Care and Research Centre (SQCCCRC). These centres, located in Muscat, the capital city of Oman, serve as the primary referral cancer centres providing integrated care for cancer patients throughout Oman.

Recruitment of participants

Participants were recruited during their visits to either the outpatient clinics of the three referral centres or upon admission to the oncology/haematology wards. Children and adolescents who were non-Omani or had cognitive and behavioural disorders (as documented in their medical records) were excluded from the study.

Data collection

An Arabic version of the Screen for Child Anxiety Related Disorders (SCARED) tool was used to screen for anxiety symptoms over the past three months [ 16 , 17 ]. It consists of various questions or items related to anxiety symptoms, and individuals are typically asked to respond based on their experiences which is valuable for understanding the child’s mental health status over a recent period [ 16 ]. This child self-report instrument includes 41 items scored on a 3-point scale (from 0 to 2), yielding five factors matching classifications outlined in the Diagnostic and Statistical Manual of Mental Disorder, fifth edition (DSM-IV) [ 16 ]. Overall, a total SCARED score of ≥ 25 may indicate the presence of an anxiety disorder, while scores of > 30 are more specific to anxiety. According to a validation study, internal consistency (Cronbach’s α) for the translated tool is 0.91, ranging between 0.65 and 0.89 for individual subscales [ 16 ].

Depressive symptoms were assessed using an Arabic version of the Center for Epidemiologic Studies Depression Scale for Children (CES-DC) [ 18 , 19 ]. It consists of a series of questions that ask about various feelings and behaviours associated with depression, such as sadness, irritability, changes in appetite or sleep patterns, and feelings of worthlessness [ 19 ]. Respondents rate how often they have experienced each symptom over a specific period, typically within the past week [ 19 ]. This self-report scale consists of 20 items scored on a 4-point scale (from 0 to 3), for a total score ranging from 0 to 60, with higher scores more indicative of depression [ 18 ]. The cut-off CES-DC score is 15, with scores of 15–60 considered indicative of significant symptoms of depression. The Arabic version of the CES-DC has previously demonstrated high internal consistency (Cronbach’s α = 0.90) [ 18 ].

An Arabic version of the Impact of Event Scale-Revised (IES-R) was used to measure symptoms of post-traumatic stress [ 20 , 21 ]. The IES-R is a self-report scale designed to assess current subjective distress for any major life event in children, adolescents, and adults, assessing the core symptom cluster of avoidance, intrusion, and hyperarousal [ 20 , 21 ]. The tool has been also used to evaluate the extent of distress experienced by individuals who have been exposed to a traumatic event such as accidents, natural disasters, combat, or other life-threatening situations [ 21 ]. The scale helps clinicians and researchers understand the psychological impact of these events on individuals [ 20 ]. The tool consists of 22 items scored on a 5-point scale (from 0 to 4), of which 14 items correspond directly to symptom criteria outlined in the DSM-IV. Total scores range from 0 to 88, with a cut-off IES-R score of 33 and above indicative of a probable diagnosis of PTSD [ 20 , 21 ]. According to previous research, the Arabic version of the self-report IES-R scale has demonstrated acceptable internal consistency (Cronbach’s α = 0.94) [ 20 ].

Arabic versions of the SCARED, CES-DC, and IES-R instruments were administered twice to assess for symptoms of anxiety, depression, and PTSD, respectively. The first assessment (T1) was conducted at any time within the first 3 months of diagnosis, while the second assessment (T2) was conducted 3 to 6 months after T1. Research assistants administered the questionnaire to participants aged 6 to 12 years, while the instruments were self-administered by participants aged 12 years or older. In both cases, a research assistant remained available to clarify any questions that the participants might have had during completion. Additional sociodemographic and clinical information was recorded by the researchers based on data gathered from the participants’ medical records or elicited from the children’s parents or primary caregivers at T1. Cancer risk was estimated based on the participant’s age at diagnosis, disease stage, tumour histology, MYCN status (amplified versus nonamplified), and tumour cell ploidy status [ 22 ].

Statistical analysis

Statistical analysis was performed using SPSS Statistics Software for Windows, version 23 (IBM Corp., Armonk, NY). Descriptive statistics, including percentages, frequencies, means, and standard deviations, were used to delineate the participants’ sociodemographic and clinical characteristics, as well as their average anxiety, depression, and PTSD scores. Paired t-tests and McNemar’s tests were utilised to assess differences in average anxiety, depression, and PTSD scores between the two time points. Analysis of variance and independent sample t-tests were employed to assess variations between the dependent variable (average anxiety, depression, or PTSD scores) and independent variables (sociodemographic and clinical characteristics). Pearson’s Chi-squared test was applied to explore associations between psychological outcomes and sociodemographic and clinical characteristics. Linear regression models were used to investigate correlations between sociodemographic and clinical characteristics and average anxiety, depression, and PTSD scores. The researchers adhered to a significance level of 5% throughout the analysis.

Characteristics of the participants

Out of the 113 Omani children and adolescents diagnosed with cancer during the study period, 101 agreed to participate, yielding a response rate of 95.6%. However, only 92 participants (91.0%) completed both T1 and T2 assessments and were included in the final analysis. Of these, 83 (90.2%) received a new diagnosis of cancer, while nine (9.8%) had suffered relapses. The mean age was 11.4 ± 3.6 years, with a median of 11.0 years. Most participants ( n  = 62; 67.4%) were children (aged 6–12 years). Males ( n  = 52; 56.5%) outnumbered females ( n  = 40; 43.5%). Leukaemia was the most frequent diagnosis ( n  = 38; 41.3%), with most participants receiving chemotherapy as the sole form of treatment ( n  = 56; 60.9%). Most participants were assessed within the first month of diagnosis ( n  = 66; 71.7%), with their cancer diagnosis not being disclosed to them ( n  = 65; 70.7%) [see Table  1 ].

Prevalence of anxiety, depression, and PTSD

Overall, 40 (43.5%) and 35 (38.0%) participants exhibited anxiety symptoms at T1 and T2, respectively, while 52 (56.5%) and 33 (35.9%) reported depressive symptoms and 30 (32.6%) and 22 (23.9%) had probable diagnoses of PTSD. There was a significant reduction in the prevalence of depression between T1 and T2 ( p  = 0.004). Similarly, average scores decreased significantly for both anxiety (23.7 ± 10.6 vs. 21.7 ± 11.0; p  = 0.043) and depression (17.67 ± 10.7 vs. 13.6 ± 8.9; p  = 0.001) during this interval [see Table  2 ].

Factors associated with anxiety, depression, and PTSD

At T1, the univariate analysis revealed a statistically significant increase in average scores for anxiety ( p  = 0.005), depression ( p  < 0.001), and PTSD ( p  < 0.001) as the child’s age advanced. Adolescents (aged 13–18 years) demonstrated significantly increased anxiety ( p  = 0.041), depression ( p  = 0.012), and PTSD ( p  = 0.001) scores compared to children (aged 6–12 years). Participants identified as having a high risk of cancer exhibited significantly increased PTSD scores ( p  = 0.001), while those aware of their cancer diagnosis showed significant increases in both anxiety ( p  = 0.003) and PTSD ( p  = 0.004) scores. Increased anxiety scores correlated with significant increases in both depression ( p  < 0.001) and PTSD ( p  < 0.001) scores; similarly, increased depression scores were associated with higher anxiety ( p  < 0.001) and PTSD ( p  < 0.001) scores, while elevated PTSD scores were associated with significant increases in both anxiety ( p  < 0.001) and depression ( p  < 0.001) scores [see Table  3 ].

At T2, the univariate analysis similarly showed significant increases in anxiety ( p  = 0.001), depression ( p  < 0.001), and PTSD ( p  < 0.001) scores as age increased, with adolescents exhibiting greater ( p  = 0.006), depression ( p  = 0.001), and PTSD ( p  = 0.002) scores compared to children. Participants with a high risk of cancer had significantly higher anxiety ( p  = 0.007) and depression ( p  = 0.007) scores, while those aware of their diagnosis demonstrated significantly higher scores for anxiety ( p  = 0.007), depression ( p  = 0.003), and PTSD ( p  = 0.005). Increased anxiety scores correlated with increased depression ( p  < 0.001) and PTSD ( p  < 0.001) scores, while increased depression scores correlated with increased anxiety ( p  < 0.001) and PTSD ( p  < 0.001) scores. Finally, increased PTSD scores were associated with significant increases in both anxiety ( p  < 0.001) and depression ( p  < 0.001) scores [see Table  4 ].

A linear regression analysis was conducted to establish links between anxiety, depression, and PTSD scores and various sociodemographic, clinical, and psychological factors. At T1, significant correlations were observed between anxiety scores and age (β = 0.762; p  < 0.001), age group (adolescents vs. children; β = -0.217; p  = 0.001), and PTSD scores (β = 0.209; p  = 0.025), with an adjusted R 2 value of 0.861. Depression scores demonstrated significant correlations with age (β = 0.460; p  = 0.001) and PTSD scores (β = 0.488; p  < 0.001), with an adjusted R 2 value of 0.849. Finally, PTSD scores were significantly correlated with cancer risk (β = 0.147; p  = 0.025), anxiety scores (β = 0.287; p  = 0.016), and depression scores (β = 0.604; p  < 0.001), with an adjusted R 2 value of 0.827 [see Table  5 ].

At T2, anxiety scores were found to be significantly correlated with age (β = 0.553; p  < 0.001), age group (adolescents vs. children; β = -0.134; p  = 0.014), and PTSD scores (β = 0.400; p  < 0.001), with an adjusted R 2 value of 0.896. Depression scores were significantly correlated with age (β = 0.297; p  = 0.018) and PTSD scores (β = 0.431; p  < 0.001), with an adjusted R 2 value of 0.837. Finally, PTSD scores showed significant correlations with both anxiety (β = 0.622; p  < 0.001) and depression (β = 0.426; p  < 0.001) scores, with an adjusted R 2 value of 0.839 [see Table  5 ].

To our knowledge, this is the first study conducted in Oman to identify the prevalence of anxiety, depression, and PTSD among Omani children and adolescents diagnosed with cancer, associated factors, and to describe changes occurring over time. Our findings revealed that a high number of children and adolescents with cancer in Oman exhibit symptoms of anxiety (43.5%), depression (56.5%), and PTSD (32.6%) within the first three months of diagnosis. Prevalence rates of these psychological disorders, especially anxiety and depression, were notably higher compared to the pooled rates reported in a recent systematic review and meta-analysis of previous literature (13.92%, 20.43%, and 20.90%, respectively) [ 8 ]. However, these differences might be attributed to variations in the measurement and screening tools used across different studies.

Alternatively, another explanation for the high prevalence rates of anxiety, depression, and PTSD symptoms observed in our study could be linked to the lack of specialized or psychosocial supportive care for cancer patients in Oman, particularly at the time of diagnosis [ 23 ]. This is likely exacerbated by the fact that, in certain Arab cultures, including in Oman, there remains considerable stigma surrounding mental health issues, posing a challenge for individuals to actively seek or obtain psychological support [ 24 , 25 ]. Moreover, limitations in healthcare resources, such as a shortage of mental health professionals, may further hinder access to psychological support services for cancer patients [ 24 ]. Finally, a lack of widespread awareness regarding the significance of psychological support for cancer patients, particularly children and adolescents, could contribute to a shortage of available programs and services [ 26 ].

We also found that symptoms of anxiety, depression, and PTSD among children and adolescents diagnosed with cancer decreased over time; these findings are supported by other longitudinal studies [ 27 , 28 , 29 ]. Other research has shown that a healthy family environment is a strong protective factor against the development of these disorders, as well as improving the quality of life of children and adolescents diagnosed with cancer [ 30 , 31 ]. In Oman, support extended by family members and friends to cancer patients has been observed to significantly reduce mental distress and alleviate the adverse side-effects associated with cancer treatment [ 23 ]. Moreover, cancer patients in Oman have been shown to develop various coping mechanisms and adaptive strategies to deal with the emotional impacts of a cancer diagnosis, including denial, optimism, withdrawal, and a strong reliance on Islamic beliefs and practices [ 32 ]. These factors likely play a role in decreasing psychological distress over time.

The results of our study indicated that the child’s age had a significant impact on their anxiety, depression, and PTSD scores, with adolescents exhibiting a higher likelihood of experiencing these conditions compared to children. Other studies have also highlighted a notable increase in major depressive episodes during the transition to adolescence [ 33 , 34 ]. This finding aligns with the understanding that adolescence is marked by hormonal changes and an enhanced ability to comprehend emotions [ 35 ]. Moreover, adolescents with cancer may face substantial disruptions to their education, potentially missing school due to the demands of treatment and recovery [ 36 ]. Repercussions may extend beyond academic skills, encompassing a range of missed opportunities, such as participation in sports, group activities, excursions, and award ceremonies, as well as the absence of daily structure and routine provided in the scholastic environment [ 37 ]. Prolonged absences from school and limited peer interaction can contribute to the development of emotional, behavioural, and psychological challenges [ 37 , 38 ].

We also found that children and adolescents who were informed of their diagnosis exhibited significantly higher anxiety, depression, and PTSD scores compared to those who remained unaware of their condition. The relationship between disclosure of a cancer diagnosis and mental health outcomes is complex, and individual reactions can vary widely. Some children and adolescents may benefit from being informed, as this allows them to be more actively involved in their own care and treatment decision-making, while others may find comfort in not knowing the full extent of their illness [ 39 ]. Fundamentally, awareness of a cancer diagnosis results in a deeper cognitive understanding of illness severity, the side-effects of treatment, social stigma, and health uncertainties, all of which can increase anxiety and stress [ 40 ]. However, in Omani culture, it is routine for some parents and family members to try to protect their loved ones or keep their hopes up by choosing to withhold knowledge of their diagnosis [ 23 ].

Our findings showed that high-risk patients had significantly higher PTSD scores during the first three months of diagnosis. Patients with more aggressive types of cancer often require more intensive and invasive treatment regimens, such as surgery and radiation, resulting in long periods of hospitalization, all of which may contribute to increased stress, anxiety, and trauma [ 41 ]. Furthermore, the aggressive nature of the cancer and its associated treatment can create a sense of uncertainty about the future, including treatment outcomes and the potential for relapse [ 42 ]. Indeed, the physical and emotional toll of aggressive cancer can be overwhelming as a result of the side-effects of treatment, including changes in physical appearance and disruptions to daily life, factors which can contribute to symptoms of depression [ 43 ].

The results of our study should be considered in the light of certain limitations. Firstly, the study involved a prospective, cross-sectional design in which Omani children and adolescents were screened for symptoms of anxiety, depression and PTSD at two separate time intervals following diagnosis. The length of time between these intervals might not have been adequate to track dynamic changes in anxiety and PTSD over time, thereby limiting our understanding of the long-term psychological effects of cancer diagnoses. An extended study period with more frequent assessments could have potentially enabled a more in-depth exploration of the psychological challenges faced by children and adolescents at different points in their cancer experiences.

Secondly, the information regarding anxiety, depression, and PTSD symptoms was self-assessed by the participants; such self-reporting is susceptible to various biases, including memory recall influenced by the passage of time, emotional states, and individual differences in cognitive processing. Thus, the participants may have unintentionally provided inaccurate or incomplete information regarding their psychological experiences, leading to potential discrepancies between reported and actual symptoms. Finally, we cannot rule out the effect of the confounding variables such as socioeconomic status that are associated with both the independent variable (the factor of interest) and the dependent variable (mental health outcome).

To our knowledge, this is the first study conducted in Oman to identify the prevalence of anxiety, depression, and PTSD symptoms, along with their associated factors, among Omani children and adolescents diagnosed with cancer. The findings indicated that children and adolescents in Oman exhibited high levels of anxiety, depression, and PTSD within the first three months of a cancer diagnosis. Implementing routine screening protocols for psychological symptoms among children and adolescents diagnosed with cancer, particularly within the first three months of diagnosis, is imperative. The early identification of mental health challenges can facilitate timely intervention and support, particularly for adolescents, as they are more likely to suffer from psychological and emotional distress.

Furthermore, integrating mental health services into standard care protocols for paediatric and adolescent cancer patients in Oman could significantly enhance outcomes and support the delivery of holistic care. An urgent need exists for the provision of additional resources and specialised training for healthcare professionals in Oman, enabling them to recognize and address the psychological needs of children and adolescents with cancer. To advance the field, future research should consider employing longitudinal interventional designs, extending assessment durations, and incorporating a more comprehensive set of psychological variables. This approach will bolster the robustness and applicability of findings concerning mental health in the context of cancer. Additionally, longitudinal designs will enable the observation of changes in self-reported symptoms over time, offering a more nuanced understanding of the evolving psychological state of individuals navigating cancer.

Data availability

The datasets supporting the conclusions of this article are available from the corresponding author upon reasonable request.

Abbreviations

Center for Epidemiologic Studies Depression Scale for Children

Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition

Impact of Event Scale-Revised

Low and Middle-Income Countries

V-Myc Avian Myelocytomatosis Viral Oncogene Neuroblastoma-Derived Homolog

National Oncology Centre

Post-Traumatic Stress Disorder

Screen for Child Anxiety Related Disorders

Statistical Package for the Social Sciences

Sultan Qaboos Comprehensive Cancer Care and Research Centre

Sultan Qaboos University Hospital

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Acknowledgements

The authors would like to thank the parents and guardians of the participants for allowing their children to take part in the study. The authors also extend their gratitude to the respective authorities of the NOC, SQUH, and SQCCCRC for permitting this study to be conducted.

The authors received no financial support for the research, authorship, and/or publication of this article.

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Laila S. Al-Saadi, Moon Fai Chan, Hana Al Sumri & Mohammed Al-Azri

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Amal Al Sabahi & Jalila Alkendi

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LA, MFC, AA, JA, NA, AF, and MA contributed to the study conception and design. Data collection was performed by LAS. Data analysis was performed by LA, MFC, and HA. The first draft of the manuscript was written by LAS and MA. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Mohammed Al-Azri .

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The study protocol was approved by the respective local research ethics committees of the NOC, SQUH, and SQCCCRC. All procedures performed in this study were in accordance with the principles of the Declaration of Helsinki and good clinical practice. Written informed consent was obtained from the parents and guardians of the participating children and adolescents. Information requiring participation requirements and the right to refuse was delivered to all participants.

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Al-Saadi, L.S., Chan, M.F., Al Sabahi, A. et al. Prevalence of anxiety, depression, and post-traumatic stress disorder among Omani children and adolescents diagnosed with cancer: a prospective cross-sectional study. BMC Cancer 24 , 518 (2024). https://doi.org/10.1186/s12885-024-12272-z

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Received : 23 January 2024

Accepted : 16 April 2024

Published : 23 April 2024

DOI : https://doi.org/10.1186/s12885-024-12272-z

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