or tongue, and if the child can understand when others are speaking to them. generally, cognitive behavioral therapy (cbt) is the recommended approach for treating selective mutism, but prospective long-term outcome studies are lacking. diagnosis the diagnosis of anxiety disorders is made by symptoms, triggers, and a person's personal and family histories. there are no objective biomarkers or laboratory tests that can diagnose anxiety. it is important for a medical professional to evaluate a person for other medical and mental causes for prolonged anxiety because treatments will vary considerably. numerous questionnaires have been developed for clinical use and can be used for an objective scoring system. symptoms may be vary between each subtype of generalized anxiety disorder. generally, symptoms must be present for at least six months, occur more days than not, and significantly impair a person's ability to function in daily life. symptoms may include: feeling nervous, anxious, or on edge; worrying excessively; difficulty concentrating; restlessness; irritability. questionnaires developed for clinical use include the state-trait anxiety inventory (stai), the generalized anxiety disorder 7 (gad-7), the beck anxiety inventory (bai), the zung self-rating anxiety scale, and the taylor manifest anxiety scale. other questionnaires combine anxiety and depression measurement, such as the hamilton anxiety rating scale, the hospital anxiety and depression scale (hads), the patient health questionnaire (phq), and the patient-reported outcomes measurement information system (promis). examples of specific anxiety questionnaires include the liebowitz social anxiety scale (lsas), the social interaction anxiety scale (sias), the social phobia inventory (spin), the social phobia scale (sps), and the social anxiety questionnaire (saq-a30). differential diagnosis anxiety disorders differ from developmentally normal fear or anxiety by being excessive or persisting beyond developmentally appropriate periods. they differ from transient fear or anxiety, often stress-induced, by being persistent (e.g., typically lasting 6 months or more), although the criterion for duration is intended as a general guide with allowance for some degree of flexibility and is sometimes of shorter duration in children. the diagnosis of an anxiety disorder requires first ruling out an underlying medical cause. diseases that may present similar to an anxiety disorder, including certain endocrine diseases (hypo- and hyperthyroidism, hyperprolactinemia), metabolic disorders (diabetes), deficiency states (low levels of vitamin d, b2, b12, folic acid), gastrointestinal diseases (celiac disease, non-celiac gluten sensitivity, inflammatory bowel disease), heart diseases, blood diseases (anemia), and brain degenerative diseases (parkinson's disease, dementia, multiple sclerosis, huntington's disease). several drugs can also cause or worsen anxiety, whether in intoxication, withdrawal, or from chronic use. these include alcohol, tobacco, cannabis, sedatives (including prescription benzodiazepines), opioids (including prescription painkillers and illicit drugs like heroin), stimulants (such as caffeine, cocaine and amphetamines), hallucinogens, and inhalants. prevention focus is increasing on prevention of anxiety disorders. there is tentative evidence to support the use of cognitive behavioral therapy and mindfulness therapy. a 2013 review found no effective measures to prevent gad in adults. a 2017 review found that psychological and educational interventions had a small benefit for the prevention of anxiety. research indicates that predictors of the emergence of anxiety disorders partly differ from the factors that predict their persistence. perception and discrimination stigma people with an anxiety disorder may be challenged by prejudices and stereotypes that the world believes, most likely as a result of misconception around anxiety and anxiety disorders. misconceptions found in a data analysis from the national survey of mental health literacy and stigma include (1) many people believe anxiety is not a real medical illness; and (2) many people believe that people with anxiety could turn it off if they wanted to. for people experiencing the physical and mental symptoms of an anxiety disorder, stigma and negative social perception can make an individual less likely to seek treatment. there are two prevalent types of stigmas that surround anxiety disorders: public and self-stigma. public stigma in this context is the reaction that the general population has to people with an anxiety disorder. self-stigma is described as the prejudice which people with mental illness turn against themselves. there is no explicit evidence that announces the exact cause of stigma towards anxiety, however there are three highlighted perspectives. the macro, intermediate, and micro levels. the macro level marks society as whole with the influence from mass media. the intermediate level includes health care professionals and their perspective. the micro level details the individuals contributions to the process through self-stigmatization. stigma can be described in three conceptual ways: cognitive, emotional, and behavioural. this allows for differentiation between stereotypes, prejudice, and discrimination. treatment treatment options include lifestyle changes, therapy, and medications. there is no clear evidence as to whether therapy or medication is most effective; the specific medication decision can be made by a doctor and patient with consideration to the patient's specific circumstances and symptoms. if while on treatment with a chosen medication, the person's anxiety does not improve, another medication may be offered. specific treatments will vary by subtype of anxiety disorder, a person's other medical conditions, and medications. lifestyle and diet lifestyle changes include exercise, for which there is moderate evidence for some improvement, regularizing sleep patterns, reducing caffeine intake, and stopping smoking. stopping smoking has benefits in anxiety as large as or larger than those of medications. omega-3 polyunsaturated fatty acids, such as fish oil, may reduce anxiety, particularly in those with more significant symptoms. psychotherapy cognitive behavioral therapy (cbt) is effective for anxiety disorders and is a first-line treatment. cbt appears to be equally effective when carried out via the internet compared to sessions completed face to face. mindfulness-based programs also appear to be effective for managing anxiety disorders. it is unclear if meditation has an effect on anxiety and transcendental meditation appears to be no different than other types of meditation. a 2015 cochrane review of morita therapy for anxiety disorder in adults found not enough evidence to draw a conclusion. adventure-based counseling can be an effective way to anxiety. using rock-climbing as an example, climbing can often bring on fear or frustration, and tackling these negative feelings in a nurturing environment can help people develop coping mechanisms necessary to deal with these negative feelings. medications first-line choices for medications include ssris or snris to treat generalized anxiety disorder. for adults there is no good evidence supporting which specific medication in the ssri or snri class is best for treating anxiety, so cost often drives drug choice. fluvoxamine is effective in treating a range of anxiety disorders in children and adolescents. fluoxetine, sertraline and paroxetine can also help with some forms of anxiety in children and adolescents. if the chosen medicine is effective, it is recommended that it is continued for at least a year. stopping medication results in a greater risk of relapse. buspirone and pregabalin are second-line treatments for people who do not respond to ssris or snris. pregabalin and gabapentin are effective in treating some anxiety disorders but there is concern regarding their off-label use due to the lack of strong scientific evidence for their efficacy in multiple conditions and their proven side effects. medications need to be used with care among older adults, who are more likely to have side effects because of coexisting physical disorders. adherence problems are more likely among older people, who may have difficulty understanding, seeing, or remembering instructions. in general, medications are not seen as helpful in specific phobia, but a benzodiazepine is sometimes used to help resolve acute episodes. in 2007, data were sparse for efficacy of any drug. cannabis as of 2019, there is little evidence for cannabis in treating anxiety disorders. children both therapy and a number of medications have been found to be useful for treating childhood anxiety disorders. therapy is generally preferred to medication. cognitive behavioral therapy (cbt) is a good first therapy approach. studies have gathered substantial evidence for treatments that are not cbt-based as being effective forms of treatment, expanding treatment options for those who do not respond to cbt. although studies have demonstrated the effectiveness of cbt for anxiety disorders in children and adolescents, evidence that it is more effective than treatment as usual, medication, or wait list controls is inconclusive. like adults, children may undergo psychotherapy, cognitive-behavioral therapy, or counseling. family therapy is a form of treatment in which the child meets with a therapist together with the primary guardians and siblings. each family member may attend individual therapy, but family therapy is typically a form of group therapy. art and play therapy are also used. art therapy is most commonly used when the child will not or cannot verbally communicate, due to trauma or a disability in which they are nonverbal. participating in art activities allows the child to express what they otherwise may not be able to communicate to others. in play therapy, the child is allowed to play however they please as a therapist observes them. the therapist may intercede from time to time with a question, comment, or suggestion. this is often most effective when the family of the child plays a role in the treatment. if a medication option is warranted, antidepressants such as ssris and snris can be effective. fluvoxamine is effective in treating a range of anxiety disorders in children and adolescents. minor side effects with medications, however, are common. epidemiology globally, as of 2010, approximately 273 million (4.5% of the population) had an anxiety disorder. it is more common in females (5.2%) than males (2.8%). in europe, africa and asia, lifetime rates of anxiety disorders are between 9 and 16%, and yearly rates are between 4 and 7%. in the united states, the lifetime prevalence of anxiety disorders is about 29% and between 11 and 18% of adults have the condition in a given year. this difference is affected by the range of ways in which different cultures interpret anxiety symptoms and what they consider to be normative behavior. in general, anxiety disorders represent the most prevalent psychiatric condition in the united states, outside of substance use disorder. like adults, children can experience anxiety disorders; between 10 and 20 percent of all children will develop a full-fledged anxiety disorder prior to the age of 18, making anxiety the most common mental health issue in young people. anxiety disorders in children are often more challenging to identify than their adult counterparts, owing to the difficulty many parents face in discerning them from normal childhood fears. likewise, anxiety in children is sometimes misdiagnosed as attention deficit hyperactivity disorder or, due to the tendency of children to interpret their emotions physically (as stomachaches, headaches, etc.), anxiety disorders may initially be confused with physical ailments. anxiety in children has a variety of causes; sometimes anxiety is rooted in biology, and may be a product of another existing condition, such as autism spectrum disorder. gifted children are also often more prone to excessive anxiety than non-gifted children. other cases of anxiety arise from the child having experienced a traumatic event of some kind, and in some cases, the cause of the child's anxiety cannot be pinpointed. anxiety in children tends to manifest along age-appropriate themes, such as fear of going to school (not related to bullying) or not performing well enough at school, fear of social rejection, fear of something happening to loved ones, etc. what separates disordered anxiety from normal childhood anxiety is the duration and intensity of the fears involved.