Most cases of generalized anxiety, panic disorder, and social phobia first appear in adolescence or earlier. Anxiety develops out of fundamental human survival responses, mediated by the serotonergic and noradrenergic systems, involving avoidance of harm and escape from danger, and ensuring that helpless infants maintain close contact with adults. Canadian Pharmacy prednisone
When this natural anxiety system is activated inappropriately or responds excessively, or when its signals are misinterpreted, people react with a fight or flight response, instinctive avoidance of danger, and catastrophic worrying. Various anxiety disorders result from this response and are generally well recognized by family physicians. When the symptoms of anxiety disorders in adolescents are behavioural, however, they can be less readily recognizable. Anxious adolescents can be challenging for parents, doctors, and schools to manage because of their unique combination of defiance and avoidance. Common behavioural manifestations of anxiety disorders in adolescents will be reviewed, as well as effective management strategies based on recent pharmacologic and behavioural research.
Quality of evidence and literature search
Current literature (January 1980 to March 2000) was searched via MEDLINE using the MeSH headings Anxiety and Anxiety Disorders focusing on psychology, diagnosis, epidemiology, and both pharmacologic and nonpharmacologic treatment. Articles were selected based on quality of research design and clinical relevance. Official diagnostic criteria based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), current practice parameters from the American Academy of Child and Adolescent Psychiatry, and recent textbooks by recognized experts were reviewed. Experience from clinical assessment, treatment, and outreach programs in the British Columbia Children’s Hospital’s Mood and Anxiety Disorders Clinic was integrated with research evidence and expert consensus guidelines to provide a practical perspective.
Prevalence of anxiety disorders in adolescents. The core diagnostic criteria for common anxiety disorders in adolescents are the same as for adults. Panic disorder is characterized by the occurrence of one or more panic attacks with at least 4 weeks of impairment due to worry about attacks or avoidance of situations that cause panic; as a result, many people become agoraphobic. Generalized anxiety disorder is characterized by at least 6 months of worrying about many issues, accompanied by somatic complaints, sleep problems, fatigue, and irritability. Social phobia is characterized by tremendous anxiety about scrutiny by others in various situations. The threshold for this disorder has been debated, as anxiety about speaking in public is very common; hence the term “generalized social phobia” is now used to indicate those who have broad social anxieties resulting in seriously impaired function. Separation anxiety disorder, characterized by refusal to separate from parents (usually mothers) results in clinging behaviour and school avoidance and often an insistence on sleeping with others. While more common among children, separation anxiety disorder can occur among teenagers in association with panic attacks. Obsessive compulsive disorder (OCD) is characterized by either obsessions or compulsions taking up at least 1 hour daily and impairing functioning. The threshold for this diagnosis needs to be carefully applied; subclinical OCD symptoms are present in up to 19% of adolescents. The prevalence of anxiety disorders in adolescence varies from 5% to 17% in epidemiologic studies, a variation explained by changes in diagnostic criteria for childhood anxiety disorders, multiple comorbid disorders, and method of ascertainment, which can affect the threshold for diagnosis. For example, the reported rate of generalized anxiety disorder (formerly overanxious disorder) ranges from 2.6% to 10.8%. Summarizing more than a dozen epidemiologic studies of the past decade suggests a reasonable estimate for prevalence in adolescence would be 1% for panic disorder, 3% to 4% for generalized anxiety disorder, 3% to 5% for generalized social phobia, and 1°% to 2°% for OCD. canada pharmacy mall
Presentations of anxiety in adolescence. Diagnostic criteria do not describe what an anxious teen actually looks like. Teenagers sometimes present to family physicians with somatic or insomnia complaints that are readily recognizable as symptoms of anxiety. Frequently, however, it is parents who complain that the adolescent either exhibits uncontrolled behaviour at home or is not attending school. These behavioural manifestations represent aspects of the instinctive fight or flight response to the frightening experience of physical and psychological anxiety. Many teenagers have had symptoms of chronic anxiety because an associated lack of effective parental authority develops when parents perpetually avoid upsetting anxious children to prevent emotional and behavioural crises. These children are “demanding, intrusive, and in need of constant attention,… leading to resentment and conflict in the family.”
While surprisingly little research has specifically examined relationships between oppositional defiant disorder and anxiety disorders, these features emerge in case studies and textbooks: “conflicts with his parents over school attendance led to tantrums, with screaming, crying, and turning over and breaking furniture.” Rates of anxiety disorders in young people with oppositional and conduct disorders are high, and trait anxiety is associated with conduct problems. Extensive research on the problem of school avoidance, in most cases representing an anxiety disorder, reflects a common manifestation of this oppositional quality in anxious teenagers.
Adolescents with generalized anxiety or persistent panic disorder tend to have a long-standing history of anxiety and chronic irritability. Acute rage can occur in the context of spontaneous panic attacks, but more often occurs when stresses build up. Triggers can be social pressures, life changes, new situations, or performance demands, usually related to school.
Often there is a “perfectionism, procrastination, paralysis” pattern. A perfectionist cannot stand “losing face”; hence facing discipline, disappointing others, or any kind of embarrassment leads to a crisis. Excessively high expectations lead to procrastination, as it is no use starting something if it is not going to be good enough. As the work piles up, it becomes harder and harder to start, and paralysis sets in. As a deadline looms or a parent pushes for action, there is a crisis and a “meltdown” with extreme rage or inability to function. Parents become frustrated and angry with the teenager’s refusal to cooperate with expectations. At this point the teenager sometimes expresses feelings of hopelessness and thoughts of suicide. Some more explosively express their anxiety and frustration through verbal or physical aggression toward family members. It is necessary to distinguish anxious teenagers from those having primary conduct or defiance problems. The latter are more likely to be truant in the company of friends and to be violating other rules, such as curfews, while anxious teenagers remain at home when absent from school and are often socially isolated. buy Levaquin 500 mg
Temperamentally avoidant and socially phobic teenagers can present a more low-key chronic avoidance gradually worsens in adolescence. Avoidant teenagers withdraw from stressful activities, such as homework or school, and even from recreational activities and peers. Prolonged absence from school has secondary consequences for academic and social development. These teenagers are often emotionally dependent, with many somatic complaints. When teenagers become housebound, they sometimes develop a fear of being alone, forcing a parent to become housebound with them. Socially phobic teenagers often complain of chronic symptoms of fatigue or develop secondary depression. Often, symptoms improve dramatically over the summer when social pressure is off. Social phobia can be hard to detect without more information from parents because teenagers sometimes appear quite confident in one-to-one situations with adults while being reluctant to admit that they cannot tolerate peer scrutiny, rejection, or judgment. Boys, especially, tend to deny anxiety because it is too embarrassing. buy omnicef antibiotics
Comorbidity and complications. Anxiety disorders are highly comorbid and frequently complicated by the time they are seen for assessment ( Table 1). Many teenagers have multiple anxiety disorders. Others also have learning-related problems that can promote school avoidance. Eventually one third to half of anxious adolescents develop a major depressive episode or the chronic minor depression known as dysthymia. A very common complication of anxiety disorders is school failure due to poor concentration, incomplete work, and not attending school. Finally, adolescent girls’ eating disorders are associated with anxiety, as controlling eating can be a way of controlling an overwhelming world. buy Strattera 25 mg
Table 1. Comorbidity and complications of adolescent anxiety
One third to half develop major depression
One third have attention deficit hyperactivity disorder; one quarter have learning disorders
Substance abuse is common, especially cannabis dependence
School failure is caused by incomplete work or failure to attend
Eating disorders are common
Unfortunately, anxious teenagers often become substance abusers, usually, it seems, as a form of self-medication. Alcohol abuse can occur, as it does in adults, but cannabis abuse and dependence are pattern that more common among teenagers in school. Many of these teenagers report that marijuana makes them feel calmer and more able to be around other people, so they are prone to use it daily, even during school hours. Being anxious, they are also sensitive to somatic and psychological withdrawal symptoms, such as nausea, irritability, and nervousness (which themselves resemble anxiety disorders), and tend to use drugs more frequently to control these symptoms as well. Daily use profoundly affects school performance through well-documented impairment of attention and memory; school failure becomes another stressful complication. Marijuana use produces resistance to treatment with some medications as well as adverse drug interactions. In addition to viewing substance abuse as a complication of anxiety disorders, differential diagnosis when evaluating anxiety symptoms must include substance-induced anxiety disorder due to cannabis, caffeine, ampheta¬mines, and other drugs.
Family physicians might have to assess patients over several appointments. Anxiety problems are complex and usually subacute or chronic. Taking some time will result in more accurate assessment and effective interventions. Taking time also helps build rapport with an adolescent. Begin with a medical history and examination to ensure anxiety symptoms are not caused by some easily identifiable factor, such as medication effects due to bronchodilators, a general medical condition (such as hyperthyroidism), common substances (such as caffeine), or simply sleep deprivation. Acute stressors should be identified, including changes, losses, family conflict, and crises in peer relationships. Celecoxib 200 mg online
Specific symptoms to be clarified include panic attacks, obsessions, compulsions, depressed mood, insomnia, changes in appetite, impaired daily functioning, and suicidal thoughts or attempts. After assuring teenagers of confidentiality, detailed substance use histories must be obtained. While this part of the interview should be done with the teenager alone, parents also need to be interviewed at some point for behavioural observations, school history, past history, and family history. A longitudinal history should emphasize such features as anxious or shy temperament, prior symptoms, perfectionism, obsessive traits, and a history of learning or attention problems. In taking a family history, probe beyond diagnosed psychiatric disorders to include family members with undiagnosed chronic anxiety, avoidance, agoraphobia, or transient panic attacks. A strong family history of multiple anxiety disorders gives a valuable clue that behavioural problems are driven by anxiety. Imitrex migraine