224 Anxiety Disorders
be. The advent of chronic physical disease can be a potent issue for excessive worry in the
elderly. In the frail elderly, worries abou t safety—and especially about falling—may limit
activities. In those with early cognitive impairment, what appears to be excessive worry
about, for example, the whereabouts of things  is probably better regarded as realistic
given the cognitive impairment.
In children and adolescents with generalized  anxiety disorder, the anxieties and wor-
ries often concern the quality of  their performance or competen ce at school or in sporting
events, even when their performance is not being evaluated by others. There may be ex-
cessive concerns about punctuality. They ma y also worry about ca tastrophic events, such
as earthquakes or nuclear war. Children with  the disorder may be overly conforming, per-
fectionist, and unsure of themselves and tend to redo tasks because of excessive dissatis-
faction with less-than-perfect  performance. They are typi cally overzealous in seeking
reassurance and approval and require exces sive reassurance about their performance and
other things they are worried about.
Generalized anxiety disorder may be overdiagnosed in children. When this diagnosis
is being considered in children, a thorough ev aluation for the presence of other childhood
anxiety disorders and other mental disorders should be done to determine whether the
worries may be better explained by one of thes e disorders. Separation anxiety disorder, so-
cial anxiety disorder (social phobia), and obsessive-compulsive disorder are often accom-
panied by worries that may mimic those described in generalized anxiety disorder. For
example, a child with social anxiety disorder  may be concerned abou t school performance
because of fear of humiliation. Worries about illness may also be better explained by sep-
aration anxiety disorder or obsessive-compulsive disorder.