Psychiatric Annals

CME Article 

Anxiety Disorders in Adolescents

Anh Truong, MD; Ali Hashmi, MD; Sophia Banu, MD; Laurel Williams, DO

Abstract

Anxiety disorders are highly prevalent in adolescents and remain significantly undertreated. Appropriate screening, diagnosis, and treatment of adolescent anxiety disorders is important, as early intervention may prevent or reduce risk for other psychiatric disorders and functional impairment in adulthood. Screening should be done by mental health and primary care providers routinely to identify adolescents with anxiety disorders or those at risk of developing anxiety disorders. Several studies have evaluated the utility of therapy and medications in the management of adolescent anxiety disorders, and the most effective treatment continues to be cognitive-behavioral therapy (CBT) in combination with selective serotonin reuptake inhibitors. To provide greater access to care and reduce barriers to treatment, novel interventions including Internet-delivered CBT and applied games have been developed and show promising results in early studies. This article reviews the most common anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, with specific attention to how presentation and treatment may differ in adolescents. [Psychiatr Ann. 2019;49(6):251–255.]

Abstract

Anxiety disorders are highly prevalent in adolescents and remain significantly undertreated. Appropriate screening, diagnosis, and treatment of adolescent anxiety disorders is important, as early intervention may prevent or reduce risk for other psychiatric disorders and functional impairment in adulthood. Screening should be done by mental health and primary care providers routinely to identify adolescents with anxiety disorders or those at risk of developing anxiety disorders. Several studies have evaluated the utility of therapy and medications in the management of adolescent anxiety disorders, and the most effective treatment continues to be cognitive-behavioral therapy (CBT) in combination with selective serotonin reuptake inhibitors. To provide greater access to care and reduce barriers to treatment, novel interventions including Internet-delivered CBT and applied games have been developed and show promising results in early studies. This article reviews the most common anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, with specific attention to how presentation and treatment may differ in adolescents. [Psychiatr Ann. 2019;49(6):251–255.]

For mental health professionals who treat adolescents, anxiety disorders represent perhaps the biggest area of opportunity for practice improvement. With an estimated lifetime prevalence of 31.9%, anxiety disorders are the most common psychiatric disorders among adolescents in the United States, even though only 18% of adolescents with an anxiety disorder receive evidence-based treatment.1 These disorders tend to emerge during early childhood and peak during adolescence. Anxiety disorders in childhood or adolescence strongly predict the presence of the same condition later in life, underscoring the importance of early diagnosis and intervention.2

The age of onset of anxiety disorders is often determined by retrospective methods, which large prospective studies are lacking.3 Most of the data on the prevalence of adolescent mental health disorders comes from one large, nationally representative epidemiological study, the National Comorbidity Survey Replication Adolescent Supplement, which surveyed 10,148 adolescents age 13 to 17 years.1 The median age of onset of anxiety disorders was 6 years compared to 11 years for behavior disorders, 13 years for mood disorders, and 15 years for substance use disorders. Rates of anxiety disorders showed a female predominance, with higher rates of treatment in females as well. Among adolescents, racial and ethnic minority groups receive lower rates of treatment than their white counterparts.1

Anxiety disorders are highly comorbid with other anxiety disorders as well as mood disorders. Longitudinal studies have shown that childhood anxiety disorders are associated with poorer outcomes in young adulthood including suicidality, medical health, interpersonal outcomes, and financial health.4

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) in adolescents is defined as excessive worry and anxiety about several events or activities, occurring more days than not for at least 6 months. This worry or anxiety is difficult to control and causes an impairment in social, occupational, and other areas of functioning. In adolescents, GAD is associated with one or more of the following six symptoms including restlessness, feeling keyed up or on edge, easy fatigability, problems with concentration, irritability, muscle tension, and sleep disturbances.5

Separation Anxiety Disorder

Separation anxiety disorder (SAD) is defined as a syndrome that consists of age-inappropriate and excessive anxiety regarding separation from caregivers or from home, which leads to dependency on parents and caregivers at a time when independence is expected.6 Extreme distress occurs upon separation of the adolescent from caregivers.

Patients must have three of the following symptoms for at least 4 weeks: excessive distress when separation occurs or is anticipated; worry about attachment figures getting hurt; refusal to go to school or other places because of fear of separation; reluctance to be alone; refusal to sleep alone or away from home; nightmares about separation; and repeated complaints of physical symptoms when separation from a major attachment figure occurs or is anticipated.5 Adolescents may refuse to engage in developmentally appropriate activities like attending camp, sleeping over at a friend's home, or traveling to school activities independently.

Social Anxiety Disorder (Social Phobia)

The hallmark of social anxiety disorder (social phobia) is an excessive fear of humiliation in social situations in which one may be negatively evaluated or scrutinized by others. This is accompanied by avoidance of the situation or endurance of the situation with significant distress. These symptoms must last for greater than 6 months.5 The lifetime prevalence of social phobia is 8.6% in adolescents.7

Adolescents with social phobia may appear shy or submissive. They often present with poor or inadequate eye contact, rigid body posture, and are often soft-spoken. They also may present with higher rates of avoidance. In adolescence, academic and social responsibilities begin to shift from parent to adolescent, and activities become more self-directed. They may have more social and academic responsibilities including group assignments, oral presentations, dating, and club involvement, which can present more opportunities for avoidance of these activities. In turn, this may lead to academic decline, school refusal, and social withdrawal.8 This functional impairment, particularly within social and academic domains, increases with age.9

Panic Disorders with or Without Agoraphobia

Panic disorder with or without agoraphobia (PDA) occurs commonly in adolescents and young adults and can be debilitating.10 The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),5 defines a panic attack as an abrupt surge of intense fear or discomfort that peaks within minutes and during which four or more of the following symptoms are present: palpitations or tachycardia; sweating; trembling or shaking; shortness of breath or choking; chest pain; nausea or abdominal discomfort; dizziness or lightheadedness; chills or warmth; paresthesias; derealization or depersonalization; and fear of losing control or “going crazy” or of dying. Accordingly, panic disorder is diagnosed in the presence of recurrent or unexpected panic attacks followed by at least 1 month or more of persistent concerns or worries about having additional attacks or a significant maladaptive behavioral change in response to the attacks (avoidance of certain places and situations).

Research has identified several risk factors for panic attacks and panic disorder in adolescents and young adults including female sex, familial psychopathology (especially panic, anxiety, and depressive disorders), certain temperaments and personality traits, poor coping skills and low self-esteem, and unfavorable parental rearing styles.11 Left untreated, PDA places people at risk for continuing mental health problems as well as reduced quality of life in adulthood.12

Ruling out medical etiologies is essential before making the diagnosis of PDA. Medical causes can include thyroid or parathyroid abnormalities, cardiac arrhythmias, vestibular disorders, asthma, and neuroendocrine tumors such as pheochromocytomas. Collaboration with a pediatrician or subspecialist is essential, as is thorough medical testing, including physical examination, appropriate laboratory tests, and electrocardiogram. Once medical causes are ruled out, it is also important to assess whether the attacks are associated with specific stimuli. Nocturnal panic attacks are usually pathognomonic for PDA.

The essential feature of agoraphobia, according to the DSM-5,5 is marked by intense fear or anxiety triggered by real or anticipated exposure to a wide range of situations. Symptoms often begin after a catastrophic stress such as parental loss or exposure to a life-threatening or similar situation that engenders overwhelming feelings of helplessness. Agoraphobia often has an onset in late adolescence or early adulthood. Panic disorder and agoraphobia are often comorbid, although either can be diagnosed independently of the other.

Screening and Evaluation

Given the high prevalence of anxiety disorders in adolescents, routine screening for anxiety disorders in primary care and mental health settings is recommended using multiple informants given that different aspects of dysfunction will be uncovered based on the informant. The gold standard for diagnosis of anxiety disorders continues to be a comprehensive clinical interview. The Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Version is the most frequently used semi-structured interview for research.

There are several self-report measures to screen and monitor for symptoms of anxiety in children and adolescents. The Screen for Child Anxiety Related Disorders (SCARED) is used for screening, whereas the Revised Children's Manifest Anxiety Scale and Multidimensional Anxiety Scale for Children (MASC) are used for monitoring symptoms. If adolescents screen positive for symptoms of anxiety, a full diagnostic evaluation should be pursued. Both the MASC and SCARED have adolescent and parent rating versions, which may help monitor treatment progress.13

Additionally, a thorough review of medications and substances is necessary. Adolescents need to be screened for use of illicit substances, marijuana, cocaine, anabolic steroids, hallucinogens, phencyclidine, and other newer drugs of abuse) as well as albuterol, oral steroids, pseudoephedrine, stimulants, antidepressants, dietary supplements, and environmental toxins such as lead, arsenic, and organophosphates.

Treatment

Treatment options should consider the following: severity of anxiety disorder, level of impairment, comorbid psychiatric conditions, developmental functioning, and access to evidence-based treatment. Psychoeducation regarding treatment options, including cognitive-behavioral therapy (CBT), family interventions, and pharmacological treatment, should be discussed to determine the best fit for each person prior to initiation of treatment.

Cognitive-Behavioral Therapy

Several studies have shown that CBT is an effective treatment for youth with anxiety disorders.14 If more than one anxiety disorder is present, the anxiety disorder causing the most impairment should be targeted first.

CBT for anxiety disorders at its core includes the following elements: psychoeducation, emotion/body regulation, graded exposure to fearful stimuli, identification and removal of negative self-talk, cognitive restructuring, problem-solving skills, and relapse prevention.6 Patients must practice their skills between CBT sessions (homework). Parents must be involved in psychoeducation as well as implementing behavioral reward systems. Depending on the type of anxiety disorder, certain elements are highlighted more than others.

The most empirically supported and disseminated manualized CBT protocol for youth with anxiety disorders is Coping Cats, comprised of 16 sessions, which was designed for children with SAD, GAD, and social phobia. The program showed significant improvement in anxiety symptoms that were maintained at 5-year follow-up assessments.15 This CAT project manual was adapted from Coping Cats to target the adolescent population.

Other therapies may focus more on social skills training, peer sessions, and graded exposure, in addition to core CBT components. In social effectiveness training, group social skills training in conjunction with behavioral therapy is used for children and adolescents with social phobia, and has been found to be effective with improvements maintained 5 years after treatment.16 For panic disorder, panic control treatment for adolescents includes traditional CBT as well as education and exposure to feared bodily sensations like hyperventilation and tachycardia.17

Pharmacological Interventions

Despite the lack of US Food and Drug Administration (FDA)-approved indications for non–obsessive-compulsive pediatric anxiety disorders, several studies have shown selective serotonin reuptake inhibitors (SSRIs), including fluoxetine, fluvoxamine, paroxetine, and sertraline, to be effective for treatment of adolescent anxiety disorders compared to placebo.18,19

Walkup et al.19 from the Child/Adolescent Anxiety Multimodal Study (CAMS) examined the efficacy of sertraline, CBT, a combination of sertraline and CBT, or placebo in a randomized control trial with 488 children and adolescents age 7 to 17 years with GAD, SAD, and social phobia. This study found that the combination of sertraline plus CBT was more effective than either treatment alone or placebo in reducing severity of anxiety. There was also no significant difference between CBT and SSRI monotherapy. This supports recommendations that CBT and SSRI are to be used in combination and as first-line treatments for adolescent anxiety disorders.

In the follow-up to CAMS, 319 children from CAMS were observed over the course of 4 years to evaluate anxiety symptoms over time in the CAM Extended Long-Term Study (CAMELS).20 Across all 4 years, 21.7% of youth were in stable remission, 30% were chronically ill, and 48% relapsed. Those who responded initially to acute treatment were more likely to be in remission at follow-up.20 Functional outcomes have also been measured in CAMELS and showed that there were meaningful long-term functional benefits in responders and remitters 3 to 12 years after treatment.21

Although limited, there is also some research that shows that serotonin norepinephrine reuptake inhibitors (SNRIs) may be effective in the treatment of GAD and social phobia in children and adolescents. In particular, duloxetine has been found to be effective for treatment of GAD in youth age 7 to 17 years and is FDA approved for this age range.22 However, the side-effect profile of SNRIs (eg, anorexia, tachycardia, hypertension, somnolence) may limit their use.23,24

In addition, several small open-label trials have looked at benzodiazepines for treatment of adolescent anxiety disorders and found that they did not show greater efficacy compared to placebo.18 They are also not FDA approved for anxiety disorders in children and adolescents. This is particularly important in adolescents with a history of substance abuse as the potential for benzodiazepine abuse must be considered.

Parents and adolescents often have concerns about the duration of treatment with medications, so any initial discussion of pharmacological interventions should include risks of untreated illness versus benefits of long-term treatment. Despite limited research on long-term use of SSRIs for anxiety, some general recommendations can still be made. If patients are asymptomatic at 12 months, a slow taper and then discontinuation can be considered, ideally during periods of reduced stress (eg, summer).

Internet and Computer-Based Interventions

There has been emerging interest in the use of Internet and computer-based interventions for adolescents with anxiety disorders given the frequent barriers to receiving evidence-based treatment (eg, geographic location, nontraditional hours, maintaining treatment integrity, availability of experienced therapists). Recent systematic reviews have found self-directed Internet-delivered CBT (ICBT) in combination with therapist support to be effective for treatment of children and adolescents.25,26

Several promising studies have evaluated the utility of ICBT compared to traditional CBT in adolescents. One randomized controlled trial evaluating online versus clinic-based CBT for adolescents found that online CBT was equally effective in treating adolescent anxiety as compared to face-to-face CBT with 78% of adolescents in the ICBT group no longer meeting criteria for an anxiety disorder at 12-month follow-up compared to 81% in the traditional CBT group.27

Applied games are also novel interventions being evaluated to treat adolescent anxiety disorders. Applied games are video games developed to incorporate CBT techniques into game mechanics, which are actions in a game that are repeated over and over until a skill is learned. These video games teach emotion regulation skills, relaxation training through neurofeedback, exposure training, and attention bias modification. Applied games have also been recently compared to traditional CBT to treat adolescent anxiety disorders and have been found to be equally effective in the treatment of anxiety disorders in children and early adolescents with benefits retained at 6-month follow-up.28 Applied games may also be more engaging and motivating compared to the traditional didactic nature of CBT, making them a promising option for treatment of adolescent anxiety disorders.28

Conclusion

Anxiety disorders remain significantly undertreated in adolescents, despite the availability of effective treatment modalities. According to the small amount of data available from recent studies,19–21 the most effective treatment approach continues to be CBT in combination with SSRIs. Novel interventions including ICBT and applied games show promising results in early studies and may help reduce barriers to treatment. Further research should explore alternative treatment options for patients with anxiety disorders refractory to CBT and SSRIs, as well as ways to further reduce barriers to treatment and provide greater access to care.

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Authors

Anh Truong, MD, is an Assistant Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Ali Hashmi, MD, is an Associate Professor, Department of Psychiatry, King Edward Medical University. Sophia Banu, MD, is an Associate Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine. Laurel Williams, DO, is an Associate Professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine.

Address correspondence to Anh Truong, MD, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, 1977 Butler Boulevard, Suite E4.400, Houston, TX 77030; email: altruong@bcm.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20190507-04

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