Anxiety Disorders

Case: Marcus, 13. Five chapters follow: the case, epidemiology, presentation, functional neuroscience, and treatment.

The case: Marcus, 13

Presenting concern

Marcus is thirteen and in eighth grade. His pediatrician's referral reads: "Two emergency department visits in six weeks for chest pain, palpitations, and shortness of breath. ECG, electrolytes, glucose, thyroid function, and hemoglobin normal both times. No asthma. Now missing school on days with assemblies or timed tests. Mother describes him as a lifelong worrier. Please assess for anxiety."

Marcus, seen alone, said: "It feels like my heart is about to stop and I'm the only one who knows. Everyone says it's fine, and I believe them for about an hour." Asked about the worrying: "Not big things. Whether the bus will be late. Whether the door is locked. Whether my mom got to work. I know it's stupid, I just have to check."

Developmental and family history

Milestones were typical. His mother describes a slow-to-warm toddler who watched other children for a long time before joining. Between five and six he was frightened of dogs and refused to visit an uncle who kept one; after a summer of weekly visits, the dog first leashed and later loose in the yard, the fear resolved and has not returned. From about age nine he asked long chains of "what if" questions at bedtime, and falling asleep has taken an hour or more since age ten. He rechecks homework and asks teachers to confirm instructions.

His parents separated two years ago; his father lives nearby and has him on weekends. His mother works rotating shifts as a pharmacy technician and had "panic attacks in my twenties" that stopped without treatment. An older sister, sixteen, is well. Marcus drinks one energy drink most mornings. No history of trauma, substance use, or medical illness.

The two attacks

The first attack occurred during a timed math quiz. Within a minute his heart was pounding, his hands tingled, the room seemed "far away," and he thought he was having a heart attack. He walked out before the teacher could respond and was found in the corridor, pale and sweating. The second came three weeks later while he was watching television at home in the evening, with nothing in particular on his mind; the sequence was identical.

Since then he sits nearest the door in every class, carries a water bottle, and asks to go to the nurse most days; the nurse records normal pulse and blood pressure each time. He stopped basketball: "If my heart goes fast I won't know if it's real." He will not attend assemblies. He texts his mother at every period change and again at 8:10 each morning.

Observations in session

Marcus chose the chair nearest the door and glanced toward it when the conversation turned to the quiz. He spoke fluently and apologized for "wasting your time." Describing the first attack, he put a hand to his chest, his breathing became shallow, and he asked whether it could be his heart "even though they said no." A minute later he could say that the emergency doctors were probably right.

Asked what he fears at an assembly, he did not mention being looked at; he described being in the middle of a row and unable to get out. He does not mind reading aloud in English "unless my voice goes weird, then everyone would know." The 8:10 text is because his mother drives on the highway and "the news is always about crashes." The period-change texts are different: "So I know she'd pick up."

Collateral

His math teacher wrote that Marcus was attentive before the first attack and now "seems to be somewhere else." On the most recent quiz day he asked to go to the nurse before the quiz was handed out, with no visible distress. His mother answers every text immediately "so he doesn't spiral," and reports that he asks "are you sure?" about the stove, the door, and tomorrow's plans twenty or more times an evening. His sister: "He's always been like this. The heart stuff is new."

Marcus denied low mood, loss of interest outside the avoided activities, and thoughts of self-harm. Appetite is unchanged. He sleeps in his own room and stays at his father's without difficulty. An anxiety screening questionnaire was markedly elevated on the panic and generalized anxiety scales and near threshold for separation anxiety.

Epidemiology

The most common class, with the earliest onset

Anxiety disorders were the most prevalent class in the NCS-A: 31.9% of US adolescents aged 13 to 18 had met criteria for one by interview, with a median age of onset of 6, the earliest of any class, and 8.3% had an anxiety disorder with severe impairment [53]. By disorder, specific phobia led at 19.3%, then social phobia 9.1%, separation anxiety disorder 7.6%, agoraphobia 2.4%, panic disorder 2.3% and generalized anxiety disorder 2.2% [53]. Girls had higher rates than boys [53]. A primary-care review summarizes the same picture as nearly 1 in 12 children and 1 in 4 adolescents, and notes the US Preventive Services Task Force recommendation to screen from age 8, with insufficient evidence below that age [39]. Estimates from other settings run wider: a clinical reference gives 5% to 25% for pediatric anxiety disorders worldwide [49].

Marcus, at 13 with generalized worry and panic attacks, sits in the two smallest categories of the NCS-A list. That is worth noticing: the disorders that bring adolescents to a psychiatrist are not the most prevalent ones, and specific phobia, the most prevalent, is the one Marcus outgrew.

Separation anxiety, social anxiety, panic

Separation anxiety disorder is described as the most frequently diagnosed childhood anxiety disorder, accounting for about half of anxiety-related referrals, with a population prevalence near 4% and 7.6% in pediatric clinical samples; among children and adolescents the rate is given as 5.3% with no gender difference, highest at ages 6 to 9 (7.2%), a mean onset near 6, school refusal in about 75%, and persistence into adulthood in about one third of untreated cases; remission has been reported in 53% at 3.9 years and 63% at 4.31 years, and heritability estimates span 21% to 74% [49]. The same reference attributes a population-attributable risk of suicidality of 7% to 10% to anxiety disorders in adolescents [49].

A 2024 meta-analysis of 38 studies estimated the global prevalence of social anxiety disorder at 4.7% in children, 8.3% in adolescents and 17% in youth, which the authors describe as a progressive increase across developmental stages; confidence intervals and per-group study counts are not in the abstract [50]. For panic disorder, a qualitative study of adolescents' lived experience states a prevalence of around 1% to 3% of the adolescent population without giving its source [45]; the NCS-A's 2.3% lifetime figure is the better-documented number [53].

Trends and disparities

In a repeated school survey of 37,360 adolescents in one Wisconsin county, the proportion meeting anxiety screening criteria rose from 34.1% (95% CI 33.4–34.9) in 2012 to 44.0% (43.2–44.7) in 2018 [41]. The rise was not even: the gap between girls and boys widened, as did the gap between sexual-minority and heterosexual youth, while Black youth did not increase at the same rate as White youth [41]. These are screening-positive rates, higher than the diagnostic rates above, and the authors themselves note that prior trend studies were limited by sampling and measurement.

Culture shapes what anxiety looks like when reported. In a comparison of Mexican, Mexican American and European American families, Mexican and Mexican American children reported more physiological and worry symptoms than European American children, and Mexican American parents offered more somatic interpretations of ambiguous situations [47]. The authors present this as a difference in reporting and interpretation, not in disorder rates [47]. A study of panic symptoms across racial groups in students was listed but its content could not be retrieved [46].

Risk factors and their designs

The primary-care review names parental psychiatric history, socioeconomic stressors, exposure to violence and trauma as risk factors [39]. Among 125 treatment-seeking children with specific phobia, child negative affectivity as rated by mothers predicted poorer post-treatment severity, and an interaction between parental overprotection and negative affectivity predicted post-treatment fearfulness, in different directions for mothers and fathers; the authors note that up to one third of youth show no significant change after brief intensive treatment [52]. A review of family-based treatment found interventions superior to no treatment and comparable or superior to individual treatment, with possible advantages in some populations such as autism, and describes familial factors as strong contributors to onset and persistence [42]. The dedicated review of risk factors covers temperament, parenting, environment and cognitive factors [43]. In a study of 28,698 Iranian children and adolescents aged 6 to 18, anxiety disorders were present in 13.2% of boys and 15.1% of girls, a rare large non-Western figure in this list [40]; the instrument and the prevalence period should be stated alongside those numbers when they are used.

Help-seeking

Prevalence and treatment are far apart. Among 138 English primary-school children aged 7 to 11 who met interview criteria for an anxiety disorder, 64.5% of parents had contacted a professional, 38.4% reported that the child had received professional support, 2.2% reported cognitive behavioral therapy and 1.4% medication [44]. First contact was most often school staff (58.7%), then a general practitioner (37.7%), then a mental-health specialist (27.5%). Help-seeking was associated with the parent's perceived need (OR 4.23), the parent's own contact with a specialist (OR 2.63) and family impairment (OR 1.14), and not uniquely with the child's symptom severity or diagnosis [44]. Marcus reached a clinic through his pediatrician after two emergency visits in six weeks, while the school nurse was already seeing him most days; in the study, school staff were the most common first contact and a general practitioner the second.

What this case cannot establish

Base rates place generalized and panic presentations at the rare end of a common class. They do not say which of Marcus's two exits from class is the more prognostic, or whether his outcome will resemble the specific-phobia sample in which up to one third showed no significant change after brief treatment [52].

Source status

#53 from the article text; #39, #42, #45, #47 from published abstracts; #41 and #44 from open-access full text; #49 from the live StatPearls chapter (its author line and update date differ from the reference as supplied); #50 and #52 from the publisher's abstract pages. #38, #40, #43 and #46 abstracts recovered in the citation check of 2026-10-05; the age band drawn in figure ANX.2 from [38] still needs its full-text passage.

Figures for this chapter

Presentation

Fear, anxiety, and panic as three observations

Fear is a response to a threat that is present. Anxiety is a response to a threat that is predicted. A panic attack is an abrupt surge of fear that peaks within minutes, with or without a trigger. Marcus shows all three. In the corridor after the quiz he was afraid of something happening to him then. At the assembly hall door he anticipates something that has not happened. Watching television, a surge arrived without any prediction at all.

The phrase "he's anxious" covers a sensation (a pounding heart), an interpretation (a heart attack), and a way of participating (sitting by the door). Each is recorded separately rather than letting the behavior stand in for the whole.

Worry: what Marcus does with unresolved outcomes

The generalized pattern has been present for years. Its content is ordinary: the bus, the door, the stove, tomorrow's plan, his mother's drive. What makes it a disorder is that it is hard to stop, occupies most days, and has physical accompaniments; for Marcus, an hour of delayed sleep onset and twenty "are you sure?" questions an evening. He describes the worry as something he "has to" do until the question is settled.

Worry in childhood commonly attaches to performance, punctuality, and the safety of family members, and its content shifts as the child's world enlarges [38]. Marcus's rechecking of homework and requests that teachers confirm instructions are the school-facing side of the same pattern. The rechecking is not obsessive-compulsive in form: no intrusive thought is being neutralized, there is no ritual, and the question ends when someone answers it. Checking driven by worry and compulsive checking look alike on a report card, and neither is defined by what ends it. Compulsions need not follow a fixed count, and reassurance seeking in generalized anxiety can recur despite an answer. The two differ in function, rigidity, intrusiveness, and relation to a feared consequence [169].

Panic: the attack and the month that follows

A panic attack is defined by its abruptness and its cluster: palpitations, sweating, trembling, shortness of breath, chest discomfort, tingling, dizziness, unreality, and fear of dying or losing control [111]. Marcus's two attacks had most of these. The first came during a timed quiz, a plausible trigger. The second came at rest. An attack without an identifiable cue is what turns recurrent attacks into a disorder, together with a month or more of persistent concern about further attacks or behavior change because of them. In Marcus the behavior change is the more striking half of that criterion.

Adolescents who have experienced panic describe the attacks as overwhelming, describe feeling misunderstood by others, and describe how fear of the next attack reorganized school and social life [45]. Marcus's "I believe them for about an hour" is that experience compressed. The normal ECG does not settle his interpretation, which is about the next surge, not the last one. The panic symptoms endorsed differ across racial groups in a student sample [46], and families from different cultural backgrounds differ in how readily children report somatic symptoms and interpret ambiguous events as threatening [47], so the household's explanation is asked for. His mother's own history of panic, and her "so he doesn't spiral," are part of the explanation Marcus has inherited.

Protective action: what each behavior protects against

Sitting by the door, the nurse visits, stopping basketball, refusing assemblies, and the texts are all visible. What they protect against has to be asked; each behavior is anchored to a specific predicted threat, and the threats differ.

Two pairs of observations look alike and differ functionally. The first pair is the two exits from math class. During the first attack, Marcus left with the surge already under way: escape from an alarm. On the most recent quiz day he asked for the nurse before the quiz was handed out, with no visible distress: avoidance of a predicted alarm. The teacher's record shows two absences. The second pair is the two kinds of text. The period-change text, "so I know she'd pick up," keeps an escape route open. The 8:10 text checks that his mother survived her commute. One is a safety behavior belonging to panic; the other is a worry about harm to an attachment figure.

Observation	What Marcus perceives	What he interprets	What he does	Pattern it points to
Middle of a row at assembly	Enclosed space, no exit	"If it starts I can't get out"	Refuses to attend	Panic with agoraphobic avoidance
Reading aloud in English	His voice may shake	"Everyone would know"	Attends unless symptomatic	Panic; social anxiety only if fear of scrutiny extends beyond symptoms
8:10 text	Mother on the highway	"The news is always about crashes"	Checks she arrived	Generalized worry about harm to family; consider separation anxiety
Nurse visit before quiz	Anticipation, no symptoms	"It will happen if I stay"	Leaves before the quiz	Avoidance learned from the first attack

Differentials among the anxiety disorders

Anxiety disorders are the most common class of mental disorder in adolescents and have the earliest onset [53]. They co-occur often enough that the task is to describe which patterns are present and which is primary rather than to select one label [38, 40].

Separation anxiety disorder requires distress about separation itself: reluctance to be away from home or attachment figures, nightmares about separation, physical symptoms at the point of parting [49]. Marcus sleeps alone, stays at his father's, and leaves the house without protest. His worry about his mother's commute has the same form as his worry about the stove and belongs, on present evidence, to the generalized pattern. The near-threshold score is a reason to re-examine this if school avoidance grows or he begins to resist leaving her.

Social anxiety disorder centers on fear of scrutiny and humiliation across ordinary interactions and performance. Marcus does not fear being watched at the assembly; he fears being unable to leave. His concern about reading aloud is that visible symptoms would reveal an attack, a fear of the attack's consequences rather than of evaluation as such. Social anxiety disorder is common in adolescence [50] and a slow-to-warm temperament is a recognized precursor [43], so the question stays open.

Specific phobia is circumscribed and cue-bound. Marcus's childhood fear of dogs had that form, resolved with repeated exposure, and has not returned. Parent overprotection and child negative affectivity interact in specific phobia [52]; both recur across the anxiety disorders. His current fear of bodily sensations is not a phobia of an external object; it is a fear of his own alarm.

Depression is not present: mood is not low, interest is preserved outside the avoided activities, and the sleep disturbance is onset delay rather than early waking. Childhood anxiety disorders predict later depression [38], so the absence is a baseline, not a guarantee. Medical contributors have been assessed; the energy drink is noted for later.

Developmental context and the route to the clinic

Fear content follows a developmental sequence: separation and animal fears in early childhood, harm and performance fears in the school years, social-evaluative fears in adolescence, with panic and generalized anxiety tending to emerge later than separation anxiety and specific phobia [38]. Marcus's dog fear at five, worry at nine, and panic at thirteen follow that ordering, which makes each age-typical in content and atypical in intensity and persistence, not one disorder unfolding. A behaviorally inhibited temperament and a parent with an anxiety history are among the best-replicated risk factors for pediatric anxiety disorders [43].

Most children with anxiety disorders do not reach professional support, and parental recognition that the problem needs help often waits for visible impairment [44]. Four years of bedtime worry produced no referral. Two emergency visits did.

What this case cannot establish

One interview and one set of collateral cannot establish whether the generalized worry predisposed Marcus to panic or the two arose independently; whether the near-threshold separation score reflects an emerging disorder or a single worry topic; whether the energy drink contributed to either attack; whether his mother's immediate replies maintain the pattern or are a reasonable response to it; or whether his fear of reading aloud would outlast the panic. Each observation is a sample under particular conditions, and the meaning of each behavior was obtained by asking, not by watching.

Figures for this chapter

Functional neuroscience

Prediction and protective action

A brain that waited for harm to arrive before responding would not last long. Threat is predicted from cues, from context, and from the body's own signals, and action is taken to prevent it. This is the function anxiety serves, and in Marcus it is running on the wrong evidence. The question is what his brain is predicting, from what, and what his protective actions do to the evidence.

Functional layer

Representing threat

A threat representation is information held about what is dangerous, how likely and costly the harm is, and whether one could cope. It is a Representation. Marcus holds at least three: a fast heartbeat warns of cardiac catastrophe; an enclosed place is somewhere escape may be impossible; an unresolved outcome (the stove, the door, the highway) is harm waiting to happen. The first was learned in two episodes six weeks ago. The third has been accumulating since he was nine.

A representation need not be endorsed at every moment to guide behavior. Marcus can say that the emergency doctors were right and, a minute earlier, ask whether it could still be his heart. What varies is access, not existence.

Prediction error and what counts as evidence

A threat prediction error is the difference between predicted and encountered threat. It is a Process. The learning rule from the Depressive Disorders module (Jonah) applies with the sign reversed: expected threat moves toward encountered threat by a fraction of the difference. Every quiz day without an attack is, in principle, such a difference.

The rule has a condition: the outcome must be credited to the situation. If Marcus went to the nurse, the absence of an attack is credited to the nurse. If he sat by the door, to the door. If his mother replied "ok," to the reply. The prediction "if I stay in the middle of the room it will happen" is never tested and cannot be corrected; each normal reading at the nurse's office means "not this time" rather than "not because of that." The problem is credit assignment, not the learning rate.

Avoidance learning: reactive escape and instrumental avoidance

Avoidance learning is the Process by which actions that reduce expected threat are strengthened by the relief they produce. The two exits from math class are its two forms. During the first attack Marcus left with the surge already under way: reactive escape from an alarm in progress. On the most recent quiz day he asked for the nurse before the quiz was handed out: instrumental avoidance, selected on a prediction. Escape ends an aversive state and teaches that leaving works. Avoidance prevents the test of the prediction and teaches that the prediction was worth acting on.

Laboratory avoidance paradigms show that avoidance persists long after the threat is removed, because omission of harm after avoidance carries no information about whether harm would have occurred [170]. Stopping basketball is the same arrangement: Marcus has removed the one setting in which exertion could show that a fast heart is not a failing one.

Safety learning is new learning, not erasure

Safety learning is the Process by which a cue that once predicted threat comes to predict its absence. It produces a safety representation that competes with the threat representation rather than replacing it. In conditioning experiments, a tone paired with shock comes to elicit freezing; presented repeatedly without shock, freezing declines; tested in a new context, after a delay, or after a reminder, freezing returns [171]. In these experiments, a second representation was learned alongside the first, and which controls behavior depends on context and time.

Safety must be learned where it is needed, not only in the clinic. Return of fear after a break is expected, not evidence that nothing was learned. And a safety signal is not a safety representation: his mother's "ok" reduces anxiety now and prevents learning that the period would have passed safely without it. Contrast the dog. Weekly visits, leashed then loose, same yard, one summer, produced a safety representation that has held seven years. Same brain, different learning arrangement.

Interoceptive appraisal: sensing and interpreting the body

Two operations act on bodily signals. Interoceptive detection is a Capacity: sensing the heartbeat. Interoceptive appraisal is a Process: assigning meaning to what was sensed. Whether Marcus's detection is unusually accurate is unknown; what has changed is the appraisal. A racing heart during basketball once meant "I am running"; the same signal now cues the cardiac threat representation. Appraisal raises arousal, arousal strengthens the signal, and the stronger signal confirms the appraisal. The second attack, at rest, is that loop starting from a fluctuation with no external cause.

Anxiety sensitivity is the Representation that the sensations of anxiety are themselves dangerous. It has been proposed as a specific vulnerability for panic in adolescents, and catastrophic misinterpretation of bodily sensations is the core of cognitive models of the disorder [48]. Adolescents' own accounts of panic describe loss of control and fear of dying [45], appraisals as much as sensations. Once the surge subsides, Marcus produces the benign interpretation. At the peak he cannot reach it. Knowing the heart is fine is a capacity; using that knowledge while it pounds is access under a particular State.

Attention and the body

Attentional selection toward threat is a Process with two separable components, orienting toward threat-relevant input and difficulty disengaging once it is found [172]. Marcus's glances at the door are orienting. His monitoring of his heartbeat is the same operation turned inward; it increases detection of ordinary fluctuations, which feeds appraisal. Attention here is part of the mechanism, not only a symptom.

Uncertainty and worry

Uncertainty tolerance is a Capacity: how much unresolved outcome information a child can hold without acting to resolve it. The Representation that unresolved outcomes are unacceptable has been proposed as central to generalized anxiety [173]. Worry is the Process that runs on it: verbal simulation of outcomes until something counts as resolution. Reassurance seeking is its interpersonal form. Each "are you sure?" resolves the immediate uncertainty, which is why it is asked again.

Worry is slow, verbal, and costs Marcus an hour of sleep; panic is fast, somatic, and over in minutes. They share the protective function. Tolerating one uncertainty, such as who wins a game, does not establish the capacity across domains.

State: arousal, sleep, and caffeine

A State is a condition that changes access to capacities. An energy drink most mornings and an hour of sleep lost to worry each raise baseline arousal, increasing the fluctuations available for appraisal. Neither causes panic disorder. A State that increases detection is not a Representation that assigns danger; the two are addressed differently.

Construct	Kind	What it names in Marcus
Threat representation	Representation	Fast heart means cardiac catastrophe; enclosed places mean no escape
Threat prediction error	Process	The uncredited mismatch on each safe quiz day
Avoidance learning	Process	Reactive escape (first exit) versus instrumental avoidance (nurse before quiz)
Safety learning	Process	What the dog summer produced and the texts prevent
Interoceptive appraisal	Process	"My heart is going to stop"
Anxiety sensitivity	Representation	Sensations of anxiety are themselves dangerous
Uncertainty tolerance	Capacity	What "are you sure?" twenty times an evening reveals
Arousal	State	Energy drink, lost sleep

Circuits, development, and genes

Distributed systems for predicted threat

These operations are implemented by interacting systems. The amygdala participates in acquiring and expressing learned threat responses; ventromedial prefrontal regions in retaining safety learning; the hippocampus supplies context that determines which representation controls behavior; the insula represents interoceptive state; brainstem and hypothalamic outputs help produce the surge Marcus feels [174, 175, 176]. A "fear circuit" label adds little unless it specifies what is represented and when it controls behavior.

Rodent extinction experiments relate the return of extinguished fear to hippocampal context signals and to prefrontal-amygdala interaction, and human imaging has reported analogous patterns during extinction recall [174, 176]. This is why exposure that succeeds in one room may not transfer to another. Insular activity has been related to bodily attention and to anxiety, while findings on heartbeat perception accuracy in anxious groups are mixed [175]; Marcus's difficulty could lie in detection, appraisal, or attention, and a group result does not say which.

Development

Work in mice and humans has reported attenuated extinction learning in adolescence compared with childhood and adulthood, and human imaging has reported developmental change in amygdala-prefrontal coupling [177, 178]. The coupling difference is a developmental group finding, not a predictor of an individual's response to treatment. If the pattern holds, exposure at thirteen needs to be planned for retention, with repetition across contexts and time. The developmental ordering of fear content, separation and animal fears early and panic later, tracks the same maturation [38].

Temperament is the earliest visible marker. Behavioral inhibition in toddlerhood, the slow-to-warm pattern Marcus's mother describes, predicts later anxiety disorders, social anxiety in particular [43]. Parental anxiety, overcontrolling or accommodating parenting, and stressful life events are further replicated risk factors [43], and parent overprotection interacts with child negative affectivity in specific phobia [52]. Whether his mother's panic history reaches Marcus through shared genes, through watching her, or through how she answers his texts cannot be separated within one family.

Genes

Anxiety disorders are moderately heritable, and genome-wide studies in predominantly adult samples identify many common variants of small effect that overlap across anxiety, depression, and neuroticism [179, 180]. Genetic liability is a population statement. It does not identify which of Marcus's representations was inherited or which treatment will help him.

Moving between levels of evidence

A conditioning experiment tests a specified learning operation under controlled conditions. A developmental imaging study describes a distribution across ages. A risk-factor review describes associations across children. Connecting any of these to Marcus's fear of the middle of a row requires an additional inference, made explicit in the functional account.

What this case cannot establish

The case cannot establish whether Marcus's interoceptive detection is heightened, ordinary, or reduced; whether his safety learning is atypical for his age or simply has not been arranged; whether caffeine and lost sleep changed the frequency of attacks or only the conditions of the two that occurred; or whether the generalized intolerance of uncertainty and the panic-specific anxiety sensitivity are one representation or two. Every construct above was inferred from what Marcus said and did. None was measured, and a behavior that fits a construct does not demonstrate the mechanism it is named after.

Figures for this chapter

Treatment

What Marcus and his family want

Marcus wants to play basketball again and to stop "waiting for it." His mother wants him in school on assembly days and asks, in the first session, whether she is making it worse by answering the texts. These are different goals from "fewer panic attacks," and they can be measured: minutes on the court, assemblies attended, quizzes taken in the room, texts sent. Participation is what matters to him, and it can improve before the attacks stop.

Assessment before treatment

The medical workup is complete, and the normal results are not repeated as reassurance; they are recorded and the conversation moves to what the attacks mean. The energy drink is stopped and sleep onset tracked, because both raise the arousal from which the appraisal loop starts. Caffeine-challenge studies show that caffeine, largely at high doses, can provoke panic attacks in adults with panic disorder [181]. They do not establish what an energy drink most mornings does at thirteen. A standardized child and parent anxiety questionnaire provides a baseline and is repeated during treatment [39]. The interview has asked how the household explains the attacks, because families from different cultural backgrounds differ in how children report somatic symptoms and interpret ambiguous events [47], and the plan is built on a shared explanation.

Cognitive behavioral therapy built around exposure

Cognitive behavioral therapy is the first-line psychological treatment for pediatric anxiety disorders, with trial evidence for reduction in symptoms and impairment across generalized, separation, and social anxiety [39]. For panic in adolescents, adapted protocols including intensive formats delivered over days rather than months have been evaluated [48]. The component that acts on the functional account is exposure. The account explains how to arrange it; the trials establish that it works.

Psychoeducation comes first: the surge is time-limited, the sensations are those of a fear response and not of cardiac failure, and the body cannot sustain the peak for long. This supplies a competing appraisal, not access to it at the peak, which is why exposure follows.

Interoceptive exposure produces the feared sensations deliberately: running in place, breathing through a straw, spinning in a chair, then holding still while the heart pounds and nothing else happens. The aim is a new representation, "this sensation is tolerable and passes," learned in the presence of the sensation. Basketball becomes an interoceptive exposure with a purpose Marcus values.

Situational exposure follows a hierarchy Marcus builds: the door seat, then a middle seat; a quiz day without the nurse; an assembly on the aisle, then in the middle of a row. Each step is repeated across days and settings because safety learning is context-bound. A step repeated in three rooms teaches more than one passed once.

Safety behaviors are removed as part of exposure, not afterward. The water bottle, the door seat, and the period-change texts each let the safe outcome be credited to something other than the situation; removing them allows the prediction error to count. Here the two kinds of text separate: the period-change text is dropped as a panic safety behavior, while the 8:10 text is addressed with the worry.

For the generalized worry, the exposure is to not knowing. Marcus leaves the door unchecked, does not confirm tomorrow's plan, and waits until evening to hear about his mother's commute. Reassurance seeking is the interpersonal form of worry, so its removal requires his mother's participation.

The family's part

Family accommodation, the adjustments parents make to reduce a child's anxiety in the moment, is a treatment target in its own right. Reviews of family-based treatment find that involving parents, especially in reducing accommodation, is supported, while evidence that family-based CBT consistently outperforms child-focused CBT is mixed [42]. The answer to Marcus's mother's question is neither "yes, you are making it worse" nor "no, carry on." Her immediate replies are what a caring parent does after two emergency visits. The plan changes them by agreement and gradually: a delayed reply, then a fixed check-in time, then none during school. Her own panic history is asked about directly, because a parent who shares the child's appraisal of a fast heart will find it hard to hold the line, and because she may want help.

If the 8:10 text proves to be a fear of harm befalling her rather than one worry among many, the exposure shifts toward separation, and treatment for separation anxiety, which also centers on CBT with family involvement, applies [49]. Marcus's father is included so the approach holds across both households.

Medication

Selective serotonin reuptake inhibitors have trial support in pediatric anxiety disorders, and primary care reviews summarize evidence that combining an SSRI with CBT produced higher response rates than either alone in a large multisite trial [39]. The primary report of that trial compared CBT, sertraline, their combination, and placebo in children and adolescents aged 7 to 17 [182]. Medication is considered for Marcus if impairment is severe, if CBT is unavailable or has not produced change after an adequate course, or if the family prefers it. School absence on assembly and quiz days is impairment that lowers the threshold.

Sertraline and fluoxetine are typical choices [39]. Adverse effects requiring monitoring include activation, gastrointestinal symptoms, sleep change, and the class warning regarding suicidal thinking in children and adolescents. The US label ties that warning to close monitoring at initiation and dose changes, while NICE's contact schedule for the first four weeks was written for depression, not anxiety [131, 132]. Reuptake inhibition is established pharmacology; a serotonin deficiency account of Marcus's anxiety is not. The drug may change the State under which exposure takes place, lowering arousal and making the benign appraisal easier to access, but this is how benefit could occur, not evidence that it occurs this way in him. Trial outcomes are symptom scales and global ratings; they do not show that the SSRI altered a threat representation, and a response does not confirm the mechanism.

Benzodiazepines are not used. Small pediatric trials show limited evidence of benefit in anxiety disorders, and a dose acts as a chemical safety signal when it is taken to prevent an attack in a feared situation [183, 184, 170]. Used that way, it lets the safe outcome be credited to the tablet.

School

The school plan replaces the nurse visit with an in-class step: Marcus stays, uses a brief coping routine, and the teacher records whether he stayed. The log is asked to distinguish an exit during symptoms from an exit before them. The seat change and the assembly plan are scheduled with the school counselor. Basketball is re-entered by agreement with the coach, practice before games. The nurse is briefed that normal vital signs, offered as reassurance, have not reduced the fear.

Measuring what changes

Attack frequency, fear of attacks, avoidance, and participation are tracked separately, because they improve at different rates. Attacks may continue while avoidance drops, and that is progress. Return of fear after a school break is expected and met with a planned return to exposure rather than treated as relapse. The questionnaire is repeated at intervals, with the teacher's log, the text count, and sleep-onset time reviewed alongside. Marcus's own criterion, whether he is still "waiting for it," is asked each session.

Why Marcus reached the clinic when he did

Four years of worry produced no referral; two emergency visits did. Parental recognition that a child's anxiety needs help often waits for visible impairment, and most anxious children do not reach services [44]. Panic brought Marcus in. The generalized worry is treated at the same time because it is the older pattern and because reassurance seeking and the safety texts are, functionally, the same protective action.

What this case cannot establish

The case cannot establish which component of treatment will help Marcus, whether he will need medication, or whether reducing his mother's replies will be sufficient or tolerable. If attacks become less frequent, the case cannot show whether that reflects safety learning, lower arousal from stopping caffeine and sleeping longer, medication, or time. A response to treatment does not demonstrate the mechanism the treatment was designed around, and an absence of response does not show the functional account was wrong. The account offers a way to arrange treatment so that the evidence Marcus encounters can count.

Figures for this chapter

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