A Problem of Anxiety in Adolescents

As the stigma associated with mental health is slowly being broken, many individuals are beginning to realize that mental illness is not defined by an age.  Many clinicians are beginning to see patients at younger ages that are suffering from symptoms and disorders that are usually thought to only affect adults.  One of the most common mental illnesses that clinicians are treating in adolescents is anxiety disorders.  These disorders have a global prevalence in adolescents from fifteen percent to over thirty percent (Tassin, Reynaert, Jacques, & Zdanowicz, 2014).

  Globally, the prevalence for anxiety disorders in adults is between ten percent and twenty percent (Tassin, Reynaert, Jacques, & Zdanowicz, 2014).  Among adolescents, the two most frequently treated anxiety disorders are social phobias and generalized anxiety disorders.  While the root cause of anxiety disorders is unknown, these disorders are likely due to a combination of genetic, environmental, psychological and developmental issues.  These disorders are currently being treated between a combination of psychotherapy and pharmacological therapy.

Types of Anxiety Disorders

Many individuals are quick to classify themselves as having anxiety.  Unfortunately, there is a lack of knowledge among the general population that there are a number of different anxiety disorders affecting the population, specifically adolescents.  Social phobias, generalized anxiety disorder, panic disorder, and separation anxiety disorder are among the most treated anxiety disorders in the adolescent population (Parekh, 2017).

Social Anxiety Disorder

Social anxiety disorder is one of the most commonly diagnosed psychiatric disorders seen in adolescents.  According to Parekh (2017), individuals suffering from social anxiety disorder have anxiety and discomfort being in social situations.  Many times, these individuals feel embarrassed, judged, isolated and looked down upon in social situations.  Individuals suffering with social anxiety disorder often go to great lengths to avoid being put in these situations.  In adolescents, kids may try to avoid going to school or choosing to not participate in sports or activities where the spotlight will be put on them.  Other examples are children being afraid to speak in front of people or meeting new kids.

Social anxiety disorder is complex in adolescents in that the disorder is usually associated with another psychological issue that children might be facing.  According to Tassin, Reynaert, Jacques and Zdanowicz (2014), there is a high correlation between body dysmorphic disorder and social anxiety disorder in adolescents and teenagers.  The way adolescents and teens view their bodies significantly correlates with their self-esteem (Tassin, Reynaert, Jacques, & Zdanowicz, 2014).  Adolescents suffering from negative body issues are highly likely to develop some sort of social anxiety due to the way they feel about themselves.

In today's society, social media has become a widely used platform to connect individuals from every walk of life.  From socializing, to forming friendships, to even dating, social media is the go-to for many individuals.  Social media has become increasingly popular among adolescents and teenagers.  Instagram, snapchat, Facebook and YouTube are being used by younger and younger children.  One of the main problems associated with social media is that everything is done behind a screen.  The art of human to human communication and interaction is being lost.  Children are accustomed to being able to sit behind a screen and create friendships but lack true social skills that are required to exist in the world.  In this sense, social media is leading to social anxiety disorder in adolescents.  Because these social skills are lost, this leads to increased anxiety when placed in social situations.  If children are not learning social skills at a young age, then they are being set up to fail as adults.  Going to school, holding a job, and even simple tasks, such as going to the grocery store, all require social skills.  While social media is a powerful tool, overuse can lead to serious problems in the future.  According to Caplan (2007), there is a correlation between excessive internet use with social anxiety and loneliness.

Generalized Anxiety Disorder

According to Kolos and Walkup (2012), pediatric generalized anxiety disorder is reported in over ten percent of children.  The onset of the disorder is usually around eight and a half years and usually occurs in girls more than boys (Kolos, 2012).  According Reynolds & Kamphaus (2013), the Diagnostic and Statistical Manual of Mental Disorders requires that an individual has excessive anxiety and worry for most days for at least six months, as well as, finding it difficult to control that worry.  In adolescents, only one of the following items is required for a diagnosis of generalized anxiety disorder: restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, or sleep disturbance (Reynolds & Kamphaus, 2013).  All of these symptoms that an individual is having usually causes significant impairment in daily functioning and cannot be explained better by another medical disorder.  In adolescents, determining that the child is experiencing generalized anxiety disorder versus some other medical disorder can be difficult.  The requirements by the Diagnostic and Statistical Manual of Mental Disorders are often synonymous with other psychiatric illnesses such as attention-deficit hyperactivity disorder (ADHD).  With ADHD in adolescents, there are often signs of difficulty concentrating, irritability, restlessness and sleep disturbance.

According to Kolos and Walkup (2012), scales from the Diagnostic and Statistical Manual of Mental Disorders generally cannot distinguish children that have generalized anxiety disorder versus other similar anxiety disorders.  Due to the nature of children being relatively poor-historians, the assessment for these patients usually involves family members as well as teachers.  Often times these individuals are able to articulate specific ways they see the child worry in day to day life.  The parents are often able to give better examples of when the child has been exhibiting certain symptoms such as headaches, being restless, being tense, having gastrointestinal issues and feeling unease (Kolos & Walkup, 2012).

Panic Disorder

Panic attacks are experienced by almost one-fourth of the population; out of these individuals suffering from panic attacks, nearly five percent meet the criteria for panic disorder (Elkins, Pincus, & Comer, 2014).  Even though panic disorder usually onsets in early adulthood, the rates of this disorder are shown to be increasing throughout childhood and adolescence.  The age of adolescence is especially vulnerable to developing panic disorder; according to Elkins, Pincus and Comer (2014), the rates of panic disorder are shown between one percent and two percent in samples taken from communities of adolescents, between two percent and six percent of outpatient psychiatric clinic samples and fifteen percent in inpatient adolescent samples.

Adolescents suffering from panic disorder may experience symptoms of panic attacks such as trouble breathing, chest pain, feeling like their heart is skipping beats, shaking and trouble speaking.  In adolescents, the first occurrence of a panic attack is very scary because children are usually not aware of what is actually happening to their bodies.  Panic disorder usually co-exists with social anxiety disorder in the pediatric population.  Children may experience panic attacks when put in certain social situations such as school, public speaking, playing sports and being in crowded parks and restaurants.  These panic attacks enhance the sense of fear that children might already have about certain situations and make them even more prone to isolating themselves.  According to Elkins, Pincus and Comer (2014), panic disorder must be addressed in childhood, because if left untreated can lead to suicidal ideation, depression and a reduced quality of life in adulthood.

Separation Anxiety Disorder

Separation anxiety disorder is seen in adolescents who show immense fear and anxiety beyond which is normal for the child's developmental level (Bernstein & Pataki, 2018).  These symptoms are seen when the child is expecting separation from the figure whom the child is closest to, whether it be a parent, grandparent or primary caretaker.  Separation anxiety disorder affects children younger than eighteen years of age and usually persists for at least four weeks but generally longer (Bernstein & Pataki, 2018).  In adults, if separation anxiety disorder is being considered, typical symptoms will last around at least six months. (Bernstein & Pataki, 2018).  According to Bernstein and Pataki (2018), separation anxiety disorder usually coexists with adolescents suffering from panic disorder and panic attacks are likely to occur when the child is being separated from their caretaker.

According to the Diagnostic and Statistical Manual of Mental Disorders, three of the following symptoms must be observed for a child to meet the criteria of having separation anxiety disorder: distress when leaving major attachment figures, immense worry about losing major attachment figures, immense worry about a tragic even occurring that would take them away from their major attachment figure, refusing to go to school or away from home, extreme fear of being alone without their major attachment figure, excessive fear of sleeping away from home or somewhere without their major attachment figure, nightmares associated with being away from their major attachment figure, physical symptoms such as headaches, gastrointestinal upset, vomiting and sweating when being taken away from their major attachment figured (Bernstein & Pataki, 2018).

All of these symptoms must cause extreme distress in every day functioning in order for a child to meet the criteria of separation anxiety disorder.  According to Bernstein and Pataki (2018), an astounding three fourths of children who present with social anxiety disorder refuse to attend school.  Due to the nature of separation anxiety disorder with children being avoidant to change and scared to be left away from caretakers, it is important that children be evaluated for autism spectrum disorder in order to select the correct diagnosis.

Treatment of Anxiety Disorders

Diagnosis and treatment can be difficult when it comes to anxiety disorders.  If anxiety is suspected, the first step is to visit a provider to be evaluated.  Many parents and caretakers are often unaware of how serious the anxiety disorder might be affecting their child.  They might notice a few signs and symptoms here and there such as their child not wanting to attend school or their child being nervous about attending a sleepover, so it is extremely important that they watch their children closely and note these signs and symptoms their children are experiencing.  Even though anxiety disorders can all be closely related, they each possess unique characteristics.  Children can be poor historians, so in order for a provider to get a good baseline for a diagnosis, parents are strongly included in the evaluation process, especially for younger children.

Most anxiety disorders are treated with a combination of therapies in order to increase the likelihood of positive outcomes.  Medication, as well as psychotherapy, is used to help those dealing with the disorders.  Medication alone will not cure anxiety disorders, but it provides great relief to the symptoms being experienced by the one suffering with anxiety.  There are a few types of different medications that are used to treat adolescents with anxiety.  Selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) are considered first-line pharmacological therapy for treating anxiety disorders in children and adolescents.  In combination with these medications, a form of therapy known as cognitive behavioral therapy (CBT) is used with adolescents to teach them ways to cope with anxiety.

Selective Serotonin Reuptake Inhibitors

Serotonin is a powerful chemical produced by nerve cells in the body.  This chemical has a major impact on almost every major function of the body such as sleeping, eating and digestion.  Along with these functions, serotonin plays a vital role in stabilizing mood and emotions (Scaccia, 2017).  Individuals with decreased levels of serotonin are likely to experience signs and symptoms associated with anxiety and depression.  There are natural ways to increase the serotonin levels in the body before beginning or in combination with pharmacological measures.  Exposure to sunlight and bright lights help boost the body's level of serotonin.  Regular exercise and a healthy diet can play a positive role in regulating emotions and increasing mood in patients suffering from anxiety.

According to Kodish, Rockhill and Varley (2011), positive results have been seen from clinical trials involving the use of selective serotonin reuptake inhibitors in children and adolescents.  These drugs that target serotonin reuptake have shown great benefit in relieving symptoms primarily associated with anxiety disorders.  While these drugs are approved to primarily treat depression in children and adults, the use to treat anxiety has proved extremely beneficial.  Common selective serotonin reuptake inhibitors that are used in adolescents to alleviate symptoms of social anxiety disorder, generalized anxiety disorder and panic disorder are Prozac (fluoxetine), Zoloft (sertraline) and Lexapro (escitalopram) (Kodish, Rockhill, & Varley, 2011).

Serotonin and Norepinephrine Reuptake Inhibitors

Another class of drugs that also works on serotonin, as well as norepinephrine, is serotonin and norepinephrine reuptake inhibitors (SNRIs).  These are antidepressant drugs that are also used to treat symptoms of anxiety disorders.  According to Kodish, Rockhill and Varley (2011), an SNRI known as Effexor XR (venlafaxine) was examined in two eight-week randomized controlled trials in children suffering from generalized anxiety disorder.  The children in the trial that received the drug showed to greater responses compared with the placebo.  Another sixteen-week trial was done examining children who suffered from social anxiety disorder.  The results of this trial also yielded a great response to those receiving the drug versus the placebo.

A common misconception about this class of drugs is the action of onset.  Many people believe that as soon as a pill is taken, that results will be seen.  This is one of the downfalls associated with SSRI's.  It can take weeks or even months before the patient might notice some change in how they are feeling and to note a decrease in the symptoms they have been experiencing.  Titrating dosages is necessary with these forms of drugs in order to reach therapeutic levels.

While SSRIs and SNRIs can prove very beneficial in treating anxiety disorders in children, there is an extreme concern for the negative effects associated with these potent drugs.  Antidepressants carry a black-box warning from the Food and Drug Administration (FDA), in that these drugs may increase or potentiate the thoughts of suicidal thinking.  Due to the nature of these drugs causing this problem, it is strongly encouraged that parents keep a close eye on their children when starting these medications as well as seeking therapy if they feel they are seeing negative mood changes.  If suicidal thoughts occur in children and adolescents after taking these drugs, it is imperative that caretakers seek medical attention immediately for their child to be evaluated.  These thoughts can occur due to the nature of the SSRIs activation which leads to an increase in anxiety, impulsivity, and emotions in the beginning of treatment (Kodish, Rockhill, & Varley, 2011).

Too much serotonin does not equate to quicker outcomes.  An increase above normal levels of serotonin leads to a potential life-threatening condition known as serotonin syndrome.  Serotonin syndrome can occur when a new medication is started or there is an increase in a dosage.  Parents and caretakers are strongly urged to watch for the following signs and symptoms in their children: diarrhea, twitching muscles, muscle stiffness, tachycardia, high fever, increased blood pressure and even seizures (Scaccia, 2017).  There is not a definitive test for serotonin syndrome, but a provider can perform an exam to make the diagnosis.  Serotonin syndrome symptoms will usually disappear within a couple of days once the medication is changed.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is a form of psychotherapy used in children, adolescents, teenagers and adults.  This form of therapy is focused on identifying negative or faulty thinking patterns and correcting them with better more positive ways of viewing situations.  According to Hofmann, Asnaani, Vonk, Sawyer and Fang (2012), cognitive behavioral therapy proves to be very beneficial when used as a first line therapy for anxiety disorders.  Medication alone will not eradicate the feelings of anxiety completely so children need to be equipped with another tool to deal with their thoughts, feelings and emotions.

Cognitive behavioral therapy was initially developed by Aaron T. Beck in 1964 (Fenn & Byrne, 2013).  In CBT, individuals are taught the following: to be aware of negative thoughts, to recognize the way these negative thoughts affect behavior and actions, to realize the cause of the negative thoughts, to change these thoughts to more positive realistic ways to reacting and to identify reasons that may cause negative thinking initially (Fenn & Byrne, 2013).  Along with cognitive behavioral therapy, teaching adolescents to develop and utilize coping skills is a prominent way to deal with symptoms of anxiety.  Coping skills for adolescents can involve taking a walk, taking a deep breath, meditating, counting to ten or enjoying something relaxing such as music.  All of these coping skills help take away the immediate thoughts of feeling anxious when placed in a situation that the child might feel uncomfortable.

Conclusion

Anxiety disorders are often misunderstood in adolescents; it is hard for many individuals to understand the "why" behind kids having symptoms of anxiety. Numerous parents and caretakers tend to miss the signs and symptoms their child must be exhibiting, or these signs and symptoms are mistaken for some other behavioral problem.  Through advances of medicine and therapy, adolescents no longer have to be forgotten when it comes to finding the right treatment for suffering with anxiety disorders.  Important signs and symptoms to watch for are wanting to miss school, constantly being scared to perform in front of others, consistently refusing to be away from home and not developing relationships with peers.

Pharmacological therapy is extremely beneficial in treating anxiety disorders in adolescents, but it is not the cure.  If providers feel it necessary to begin adolescents are psychotropic medication, caretakers need to take the time and effort to monitor their children closely for adverse effects that could potentially prove to be fatal.  Psychotherapy should be used as a first line in understanding where the anxiety is coming from and ways that might be best to cope with those feelings and emotions.

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