Anxiety Disorders in Adolescents: Identidication and Treatment

March 12, 2008
Stephen Soreff

Stephen SoreffStephen Soreff, MD
Boston University




Patricia BazemorePatricia 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

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  
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



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.


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 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

Rynn MA, Riddle MA, Yeung PP, Kunz NR. Efficacy and safety of extended-release venlafaxine in the treatment of generalized anxiety disorder in children and adolescents: two placebo-controlled trials. Am J Psychiatry. 2007;164(2):290-300.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision. Washington, DC: American Psychiatric Association; 2000.

Soreff S, Bazemore P. Depression and Anxiety Feature Series 2, issue 6. Comorbidity of major depressive disorder and anxiety disorders. 2007. eMedicine from WebMD Web site. Available at: Accessed November 21, 2007.

Verhulst FC, van der Ende J, Ferdinand RF, Kasius MC. The prevalence of DSM-III-R diagnoses in a national sample of Dutch adolescents. Arch Gen Psychiatry. 1997;54(4):329-36.

Clark DB, Turner SM, Beidel DC, Donovan JE, Kirisci L, Jacob RG. Reliability and validity of the Social Phobia and Anxiety Inventory for adolescents. Psychol Assess. 1994;6(2):135-40.

Farvolden P, McBride C, Bagby RM, Ravitz P. A Web-based screening instrument for depression and anxiety disorders in primary care. J Med Internet Res. 2003;5(3):e23.

Pfeffer CR, Jiang H, Kakuma T. Child-Adolescent Suicidal Potential Index (CASPI): a screen for risk for early onset suicidal behavior. Psychol Assess. 2000;12(3):304-18.

SAMHSA children’s mental health facts children and adolescents with anxiety disorders. National Mental Health Information Center. Available at: Accessed 11/21/07.

Al-Gelban KS. Depression, anxiety and stress among Saudi adolescent school boys. J R Soc Health. 2007;127(1):33-7.

Beesdo K, Bittner A, Pine DS, et al. Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry. 2007;64(8):903-12.

Nutter DA, Larsen LH. Anxiety disorder: generalized anxiety. eMedicine from WebMD. Updated September 18, 2006. Available at: Accessed November 21, 2007.

Springer C, Padgett DK. Gender differences in young adolescents’ exposure to violence and rates of PTSD symptomatology. Am J Orthopsychiatry. 2000;70(3):370-9.

Shear K, Jin R, Ruscio AM, Walters EE, Kessler RC. Prevalence and correlates of estimated DSM-IV child and adult separation anxiety disorder in the National Comorbidity Survey Replication. Am J Psychiatry. 2006;163(6):1074-83.

Lewinsohn PM, Gotlib IH, Lewinsohn M, Seeley JR, Allen NB. Gender differences in anxiety disorders and anxiety symptoms in adolescents. J Abnorm Psychology. 1998;107(1):109-17.

Pat-Horenczyk R, Abramovitz R, Peled R, Brom D, Daie A, Chemtob CM. Adolescent exposure to recurrent terrorism in Israel: posttraumatic distress and functional impairment. Am J Orthopsychiatry. 2007; 77(1):76-85.

Monk CS, Nelson EE, McClure EB, et al. Ventrolateral prefrontal cortex activation and attentional bias in response to angry faces in adolescents with generalized anxiety disorder. Am J Psychiatry. 2006;163(6):1091-7.

Etkin A, Wager TD. Functional neuroimaging of anxiety, a meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia. Am J Psychiatry. 2007;164(10):1476-88.

Goodwin RD, Fergusson DM, Horwood LJ. Asthma and depressive and anxiety disorders among young persons in the community. Psychol Med. 2004;34(8):1465-74.

Pelcovitz D, Kaplan SJ, DeRosa RR, Mandel FS, Salzinger S. Psychiatric disorders in adolescents exposed to domestic violence and physical abuse. Am J Orthopsychiatry. 2000;70(3):360-9.

Størksen J, Røysamb E, Holmen TL, Tambs K. Adolescent adjustment and well-being: effects of parental divorce and distress. Scand J Psychol. 2006;47(1):75-84.

Vazsonyi AT, Belliston LM. The cultural and developmental significance of parenting processes in adolescent anxiety and depression symptoms. J Youth Adolesc. 2006;35(4):491-505.

Wagner KD. Chapter 36: Treatment of childhood and adolescent disorders—obsessive-compulsive disorder. In: Schatzberg AF, Nemeroff CB, eds. Essentials of Clinical Psychopharmacology, Second Edition. Arlington: American Psychiatric Publishing, Inc. 2006.

Gregory AM, Caspi A, Moffitt TE, Koenen K, Eley TC, Poulton R. Juvenile mental health histories of adults with anxiety disorders. Am J Psychiatry. 2007;164(2):301-8.

Perkonigg A, Pfister H, Stein, MB, et al. Longitudinal course of posttraumatic stress disorder and posttraumatic stress disorder symptoms in a community sample of adolescents and young adults. Am J Psychiatry. 2005;162(7):1320-7.

Kaplow JB, Curran JP, Angold J, Costello EJ. The prospective relation between dimensions of anxiety and the initiation of adolescent alcohol use. J Clin Child Psychol. 2001;30(3):316-26.

Pine DS, Cohen P, Gurley D, Brook J, Ma Y. The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Arch Gen Psychiatry. 1998;55(1):56-64.

Horesh N, Apter A. Self-disclosure, depression, anxiety, and suicidal behavior in adolescent psychiatric inpatients. Crisis. 2006;27(2):66-71

Boden JM, Fergusson DM, Horwood LJ. Anxiety disorders and suicidal behaviours in adolescence and young adulthood: findings from a longitudinal study. Psychol Med. 2007;37(3):431-40.

Pediatrics: Development and Behavior. eMedicine from WebMD Web site. Accessed December 20, 2007.

Ritvo R, Al-mateen C, Ascherman L, et al. Report of the Psychotherapy Task Force of the American Academy of Child and Adolescent Psychiatry. J Psychother Pract Res. 1999;8(2):93-102.

Velting ON, Setzer J, Albano AM. Update on and advances in assessment and cognitive-behavioral treatment of anxiety disorders in children and adolescents. Prof Psychol Res Pr. 2004;35(1):42-54.

Connolly SD, Bernstein GA. Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry. 2007; 46(2): 267-83.

Hammerness PG, Vivas FM, Geller DA. Selective serotonin reuptake inhibitors in pediatric psychopharmacology: a review of the evidence. J Pediatr. 2006, 148(2):158-65.
Reinblatt SP, Riddle MA. The pharmacological management of childhood anxiety disorders: a review. Psychopharmacology (Berl). 2007;191(1):67-86.

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