Stephen Soreff, MD
Boston University
Patricia Bazemore, MD
University of Massachusetts Medical School
Anxiety disorders are the most common psychiatric diagnoses in adolescents.1 The Diagnostic and Statistics Manual 4th Edition, Text Revision (DSM IV TR) definitions include the following types: panic disorder without agoraphobia, panic disorder with agoraphobia, social phobia, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), acute stress disorder, social anxiety disorder, and generalized anxiety disorder (GAD).2 An additional diagnostic category, separation anxiety, is listed in the chapter titled “Disorders usually first diagnosed in infancy, childhood, or adolescence.” Major depression is often an important comorbidity.3,4
This array of diagnoses emphasizes the need for a careful and comprehensive clinical assessment prior to treatment. Such an assessment normally includes not only an interview with the adolescent patient, but also meetings with parents, school personnel, employers, and, perhaps, the criminal justice system. Screening tests, such as the Beck Anxiety Inventory, the Social Phobia and Anxiety Inventory (SPAI), Child-Adolescent Suicidal Potential Index (CASPI), and online testing are all available.5-7
PREVALENCE OF ANXIETY DISORDERS IN ADOLESCENCE
How common are anxiety disorders in adolescence? The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that approximately 13% of children and adolescents aged 9-17 years experience an anxiety disorder.8 In a study of 1,723 male high school students in Saudi Arabia using an Arabic version of the Depression, Anxiety, and Stress Scale (DASS), nearly 49% were found to have an anxiety disorder.9 The prevalence rates of specific anxiety disorders are notable, as well. For example, Beeso et al studied the prevalence of social anxiety disorder in 3,021 adolescents aged 14-24 years and found it to be 11%.10 Simple phobia and social phobia were 2 of the 3 most common psychiatric diagnoses in a study of Dutch adolescents.4 Nutter notes that the prevalence of GAD in children and adolescents ranges from 2.9-4.6%. In addition, GAD occurs more frequently in adolescents aged 12-19 years than in younger children.11
In a study examining the incidence of PTSD in a nonclinical adolescent population, Springer reported that a strikingly high 52% of the adolescents were affected.12 Springer also noted that studies of adolescent populations exposed to violence or trauma revealed prevalence rates of severe PTSD ranging from 14.5-27.1%.12 The prevalence of separation anxiety disorder is in the range of 4% in children and adolescents.13
The prevalence of anxiety disorders differs by gender. The data indicate that females have a much higher prevalence of anxiety disorders than males, and this preponderance can be traced back to age 6 years.8,14 Girls report greater severity of PTSD symptoms, whereas boys exhibit greater functional impairment due to anxiety in social and family domains.15
CAUSES OF ANXIETY DISORDERS IN ADOLESCENTS
The origins of anxiety disorders among adolescents have been found in brain activity using functional magnetic resonance imagery (FMRI), medical comorbidities, and family issues. Monk noted that, in adolescents with GAD, activation of the ventrolateral prefrontal cortex was heightened in response to viewing angry faces when compared to healthy adolescents.16 Others have found hyperactivation of the amygdala and insula in patients with social anxiety disorder and specific phobias, as well as underactivation of dorsal and rostral anterior cingulate cortices and the ventromedial prefrontal cortex in patients with PTSD.17 Certain medical conditions are also related to anxiety. For example, adolescents with asthma experience an increase in anxiety and depressive disorders compared to others without asthma.18
Family issues, such as physical abuse and violence in the home, lead to increased risk for anxiety disorders.19 In a study of 8,984 Norwegian adolescents (aged 13-19 y), those with a family history of divorce and parental distress were more vulnerable to symptoms of anxiety than those without such distress.20 These effects were more marked in females than males. Vazsonyi looked at 6,935 adolescents from Hungary, the Netherlands, Switzerland, and the United States and found that increased anxiety occurred in the presence of extreme maternal and paternal closeness to the adolescent, suggesting possible overinvolvement or intrusiveness between a parent and adolescent.21 Decreased anxiety followed parental support and approval.21
ANXIETY DISORDERS IN ADOLESCENTS: IDENTIFICATION AND TREATMENT
Implications
The presence of an anxiety disorder is not only a cause for concern; it also has significant clinical implications. Many of these disorders persist into young adulthood. For example, OCD in youths is often persistent. In a 2-7–year follow-up of 54 children and adolescents with OCD, only 3 subjects (6%) were noted to obtain complete remission.22 Looking at an adult population with various anxiety disorders, nearly one half had had a diagnosis of a psychiatric disorder in adolescence. And of that half, one third had an anxiety disorder by age 15 years.23 In one study of adolescents with PTSD, 48% showed no significant remission of PTSD into adulthood.24 In about one third of youth with separation anxiety disorder, the condition persists into adulthood.13
An adolescent with an anxiety disorder is predisposed to later mental health problems, including addictions. For example, early symptoms of generalized anxiety were associated with early initiation of alcohol use.25 The presence of anxiety in adolescents heightens the risk of recurrent anxiety or depressive disorders during early adulthood.26 Finally, anxiety disorders correlate with later suicidal thoughts and behavior27 as well as the risk of completed suicide.28
The persistence of anxiety disorders into adulthood and the consequential risk for depression, alcohol use, and suicidal behavior underscore the need for early detection and effective intervention.
Interventions
The interventions for adolescents with an anxiety disorder must be both specific and comprehensive. The treatments for various anxiety disorders, including indications for hospitalization and medications, are detailed in the appropriate anxiety disorder categories found in the “Developmental & Behavioral” articles within the Pediatrics section of www.eMedicine.com.29 These articles include the following anxiety disorders in adolescents articles: generalized anxiety, obsessive-compulsive disorder, panic disorder, separation anxiety and school refusal, and social phobia.
In 1999, the Psychotherapy Task Force of the American Academy of Child and Adolescent Psychiatry (AACAP) said,
Psychotherapy is and must remain a core skill and central to the practice of child and adolescent psychiatry. The psychotherapies remain essential treatment modalities for children’s cognitive, emotional and behavioral problems. Additionally, psychotherapy knowledge and skills inform all psychiatric clinical activities, including diagnostic assessment, pharmacotherapy, and consultation to agencies, schools, and other physicians, as well as collaboration with and supervision of staff and trainees.30
One particularly effective nonpharmacological treatment is cognitive-behavioral treatment (CBT). This has been used successfully for adolescents with social anxiety disorder, social phobia, and GAD.31 CBT has 6 components: psychoeducation, somatic management techniques, cognitive restructuring, problem-solving, exposure, and relapse prevention. Psychoeducation involves providing a context to the nature of anxiety. Somatic management techniques include relaxation exercises and diaphragmatic breathing. Cognitive restructuring embodies the idea of anxiety-causing thoughts and ways to deal with them. Problem-solving allows the adolescent to discover and use tools to identify and deal with problems. Exposure occurs in a progressive controlled form, with gradual experience with feared objects or situations. Relapse prevention provides a tapering of therapy and the use of diaries.31
Pharmacological treatment remains one of the most effective interventions for the treatment of anxiety disorders. According the AACAP’s Practice Parameter for the Assessment and Treatment of Children and Adolescents with Anxiety Disorders, medications are indicated “when anxiety disorder symptoms are moderate or severe or impairment makes participation in psychotherapy difficult, or psychotherapy results in a response.”32 Generally, the use of medication when combined with psychotherapy or CBT leads to better results than pharmacological interventions alone.3 Selective serotonin reuptake inhibitors (SSRIs) are now the pharmacological intervention of choice in adolescent anxiety disorders.33 Effective for GAD, social phobia, and social anxiety disorder, SSRIs have replaced tricyclic antidepressants (TCAs) because of SSRIs’ safer profile in case of overdose and fewer adverse cardiovascular effects.34
SSRIs with evidence of efficacy in anxiety disorders in adolescents include fluoxetine, sertraline, paroxetine, and fluvoxamine.32 Extended-release venlafaxine has proved effective for patients with GAD and social phobias.3 Benzodiazepines have not been found effective in the treatment of adolescent anxiety disorders, and adverse effects can include aggressiveness, irritability, and sedation.32,34
Several issues must be addressed when using SSRIs. The US Food and Drug Administration (FDA) now requires a black box warning for SSRIs that deals with the potential dangers of increased incidence of suicide and deepening depression. While these concerns apply primarily to the prescription use of SSRIs to treat depression, careful monitoring is still needed when SSRIs are prescribed to treat anxiety.32,34 In general, adolescents with anxiety disorders should be symptom-free for 1 year while taking an SSRI before termination of pharmacologic treatment is considered.34 Specific dosage schedules do not exist for the use of SSRIs in adolescents, and the general practice is to start them at low dosage and gradually increase.32 A 4-week trial on a particular SSRI should be considered before switching to another SSRI.32
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