# Situation: A school nurse and the nurses of a pediatric ward follow students with chronic health problems. A 14-year-old girl has missed school often this term because of morning stomachaches and headaches; her examination and tests are normal. For the past 8 months she has worried nearly every day about her grades, her family's money, and her health, and she finds the worry hard to control. She reports muscle tension, poor sleep, and irritability but still enjoys drawing and denies sad mood. Which condition is MOST likely?

> source: MyMerci (mymerci.kr)  
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> language: ko  
> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: A school nurse and the nurses of a pediatric ward follow students with chronic health problems.

A 14-year-old girl has missed school often this term because of morning stomachaches and headaches; her examination and tests are normal. For the past 8 months she has worried nearly every day about her grades, her family's money, and her health, and she finds the worry hard to control. She reports muscle tension, poor sleep, and irritability but still enjoys drawing and denies sad mood. Which condition is MOST likely?

## 보기

1. Separation anxiety disorder
2. Generalized anxiety disorder **✔ 정답**
3. Persistent depressive disorder
4. Somatic symptom disorder

**정답: 2**

## 해설

Excessive, hard-to-control worry about many everyday matters on most days for 6 months or more, with muscle tension, poor sleep, and irritability, is generalized anxiety disorder; physical complaints are common in young people. She keeps her interests and denies sad mood, which argues against depression, and her worries are not centered on separation from caregivers or on the physical symptoms themselves.

## 심화 해설

Core clinical reasoning

The most likely condition is generalized anxiety disorder (GAD). The hallmark is excessive, difficult-to-control worry about multiple everyday domains—grades, family finances, and personal health—occurring on most days for at least 6 months. This adolescent has worried nearly every day for 8 months, which exceeds the 6-month duration threshold. The accompanying symptoms of muscle tension, poor sleep, and irritability are classic autonomic and somatic correlates of chronic worry in GAD.

Key point! The physical complaints—morning stomachaches and headaches with normal examination and tests—do not indicate a separate somatic disorder. In GAD, somatic symptoms frequently lack an identifiable physiologic foundation and are best understood as physical manifestations of persistent anxiety [1]. The worry is not focused on the symptoms themselves, which distinguishes this presentation from somatic symptom disorder.

Why the other options are less likely

| Condition | Why it does not fit this adolescent |
| --- | --- |
| Separation anxiety disorder | Worry is not centered on separation from caregivers or home; her concerns span school performance, family finances, and health. |
| Persistent depressive disorder | She still enjoys drawing and denies sad mood. Anhedonia or depressed mood is required for a depressive diagnosis, and retained interest argues against it. |
| Somatic symptom disorder | Her worry is about multiple life domains, not primarily about the stomachaches or headaches themselves. The physical symptoms are better explained by the anxiety. |

Pathophysiology and clinical presentation in adolescents

In GAD, the worry is generalized and pervasive rather than tied to a specific trigger. The condition involves heightened activity in threat-appraisal circuits, producing a state of general apprehensiveness that persists across situations . In children and adolescents, anxiety disorders are highly prevalent and carry negative long-term consequences when untreated, making early recognition in school and pediatric settings especially important .

The somatic complaints in this case—headache, abdominal discomfort, fatigue, and insomnia—are well documented presenting features of GAD in primary care and school health settings [1]. Because these symptoms have no identifiable physiologic basis, they can lead to extensive but unproductive medical evaluation. The school nurse and pediatric ward nurses are in a key position to recognize the pattern: multiple somatic complaints plus pervasive worry about several life areas, lasting months, without depressed mood or loss of interest.

Watch out! Anxiety disorders frequently co-occur with other conditions. In children with ADHD, up to 60% meet criteria for at least one anxiety disorder, including generalized, social, or separation anxiety . When a student presents with chronic worry and somatic symptoms, assess for comorbid attention or learning difficulties, because untreated anxiety can worsen child and family functioning.

Nursing assessment priorities

A focused nursing history for suspected GAD should explore the content and controllability of worry, its duration and frequency, associated physical symptoms, sleep patterns, and impact on school attendance and social functioning. In this adolescent, the 8-month duration of near-daily worry, the presence of muscle tension and poor sleep, and the preservation of interest in drawing collectively support GAD over a depressive or somatic disorder. The school nurse should also assess safety and functional impairment, including how often stomachaches or headaches lead to missed school days, because school avoidance can reinforce the anxiety cycle.

Early identification matters because GAD is frequently associated with inappropriate consumption of health care resources and delayed effective treatment [1]. Pharmacological and psychological interventions, including cognitive-behavioral approaches, are available, but many patients do not respond to first-line medication, underscoring the value of accurate early diagnosis and appropriate referral .References (research sources)

- [1]An overview of generalized anxiety disorder: disease state--appropriate therapy.Research articleLydiard RB (2000) · DOI: 10.1016/s0149-2918(00)89070-0

## 임상 시나리오

Adolescent GAD RecognitionChronic multi-domain worry with somatic tension
In generalized anxiety disorder, worry is excessive, hard to control, and spans multiple everyday domains for at least 6 months. This patient has worried nearly every day for 8 months about grades, family finances, and health.

Associated symptoms include muscle tension, poor sleep, and irritability. Physical complaints such as morning stomachaches and headaches with normal workup are common somatic manifestations of anxiety, not a separate disorder.

Retained interest in drawing and denial of sad mood argue against depressive disorders. Worry not centered on separation or on the physical symptoms themselves rules out separation anxiety disorder and somatic symptom disorder.

CautionDo not over-investigate normal physical complaints in anxious youth; repeated negative workups can reinforce somatic focus. Assess for co-occurring depression or other anxiety disorders, especially when school absence is prominent.

## 핵심 개념

- **Generalized anxiety disorder** — Excessive, difficult-to-control worry about multiple everyday matters occurring on most days for at least 6 months, accompanied by symptoms such as muscle tension, poor sleep, and irritability.
- **Somatic symptoms in anxiety** — Physical complaints such as stomachaches and headaches that commonly accompany anxiety disorders without an identifiable physiologic cause.
- **Anhedonia** — Loss of interest or pleasure in activities, a core symptom required for depressive disorders.
- **Separation anxiety disorder** — Anxiety disorder characterized by excessive worry about separation from attachment figures or home.
- **Somatic symptom disorder** — Condition in which the individual's worry and distress are focused primarily on the physical symptoms themselves.

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