Managing adolescent anxiety
The essential first step is to gain teenagers’ cooperation through developing rapport. This is difficult at first, as anxious teenagers are practised at resistance, but the fact that you have taken time to listen through the assessment has a remarkable effect. Before engaging in more specific treatments (Table 2), such factors as sleep routines, regular eating patterns, exercise, and a balance of activities should be addressed. Most teenagers can accept that anxiety symptoms will be worsened by sleep deprivation and lack of fuel. Convincing them to exercise can be challenging, but you can emphasize that simply taking a break and walking the dog can help produce physical relaxation. Buy Metaxalone 400 mg
Table 2. Management of adolescent anxiety
Basics: sleep, eating, exercise, schedule
Avoid alcohol and drugs
Parent or family counseling
Individual or group counseling
Mandatory attendance at school
Develop areas of success
Cognitive behavioural therapy: education, examination, experimentation, exposure
Medications: primarily selective serotonin reuptake inhibitors
Coping rather than cure
Patterns of avoidance through excessive TV watching, video games, or staying up late take some creativity to manage. Rather than becoming yet another adult insisting on compliance, engage teenagers’ interest by suggesting that they try some “experiments.” A similar approach should be taken with substance abuse. If you insist that they stop, they could simply stop telling you that they are using. You can encourage them to observe the effects for themselves and let you know what they find out. In other words, keep this discussion open. generic Carisoprodol online
Psychoeducation. Psychoeducation regarding the pathogenesis of anxiety symptoms is crucial. Excessive anxiety, especially if it is likely to be a lifelong tendency, cannot and should not be entirely eliminated by avoidance or even by medications. Anxiety needs to be understood and mastered. Teenagers will be quite interested in an explanation of the physiologic mechanism of specific anxiety symptoms and in how the mind elaborates on these symptoms to produce cycles of avoidance or phobias. Discussing the perfectionism, procrastination, paralysis pattern, or how chronic anxiety is physically exhausting and produces irritability, will demonstrate to teenagers that you have some understanding of what is going on. If they simply begin to observe some of these patterns, they will be on the way to making changes. buy generic Tramadol
Similarly, parents need education about behavioural aspects of anxiety, including rages and avoidance, as they are often also caught up in ineffective cycles of anger and frustration. There is a need for consistent, calm, and structured parenting; conflict resolution strategies; and communication with their teenagers. It is also important to address other family stresses, such as marital conflict, to which teenagers could be responding. At times, a family therapy approach is most helpful to re-establish calm, effective communication and healthier parenting strategies. Further, it is likely that at least one of the parents also suffers from anxiety. Addressing the parent’s coping skills or anxiety symptoms will usually improve teenagers’ functioning. Encourage parents to check the local library for books or websites to better understand and manage anxiety. buy cheap levitra
Specific psychosocial treatments. Individual or group counseling for teenagers should focus on skills development, including social skills, structuring time, handling homework, and learning specific cognitive and behavioural strategies for preventing catastrophic thinking and avoidance. Cognitive behavioural therapy (CBT) strategies are effective, are easy to learn,21 and can be taught in small doses by family physicians during frequent short visits. These strategies are harder to practise, however, and teenagers should be approached with an attitude of curiosity and humour to encourage new attitudes and behaviours. The CBT therapist is primarily a coach, taking an active role familiar to physicians trying to change other health behaviours. canadian generic viagra
Key words are education, examination, experimentation, and exposure. Cognitive behavioural therapy requires education about physiologic anxiety, cognitive catastrophization, and avoidance; examination of one’s own habits in these routines; some experiments with new ways of thinking and behaving; and exposure to anxiety-provoking situations to practise and reinforce these strategies. An example would be an adolescent who is avoiding school because of anxiety about rejection by peers leading to physical anxiety symptoms and angry irritability with parents. Education includes pointing out the connection between worry and physical symptoms, and how avoidance perpetuates this by making it worse the next time. Some distraction or relaxation strategies can be suggested. Examination of unjustified negative predictions about social contacts can be followed by suggested experiments, such as making eye contact or making a friendly comment. Teenagers should be reminded of the need to practise exposure to feared situations between appointments. canadian health care + tramadol
Casually encouraging language should be used: “find out which things work best for you”; “what’s so bad about taking a risk; it can’t be worse than you’ve already imagined it….”; “maybe it won’t work, but what’s to lose in trying?” Tap into teenagers’ creativity and sense of humour. Stress and anxiety management books can be recommended for those who like to read. School counselors, local health departments, and mental health agencies often run groups for teenagers to help develop these skills. Teenagers who have a fixed pattern of negative thoughts and avoidance will need referral to psychologists or psychiatrists for more intensive treatment. canadian pharmacy topamax
Role of family physicians. To what degree can family physicians manage these problems? Family physicians are essential in evaluating potential medical factors, in undertaking psychoeducation, in initiating pharmacotherapy when indicated, and in referring patients to specialized resources. While family physicians are often frustrated with the difficulty of accessing mental health resources and specific CBT treatments, they should be reassured that a recent study of school avoidance showed a supportive psychoeducational approach was as effective as CBT and more accepted by young people. buy cialis professional
Strategies listed in Table 2 reflect common sense and can be reinforced by many adults in teenagers’ support networks. Support networks can be strengthened by involving extended family members, mental health workers, family services, or a youth worker. When resources are scarce, supportive counseling could be available through a parent’s employee assistance program, an ethnic community, or a religious organization. Referral to a psychologist or psychiatrist for further assessment and treatment should be arranged if no progress occurs after several sessions of intervention. Finally, consider having a community health nurse or mental health outreach worker visit at home to assess very resistant teenagers who are inaccessible because they are refusing to attend appointments. cialis super active
School interventions. For most anxious adolescents, school is a great stressor because of the social environment and performance demands. Ask parents to maintain close contact with the school, and beware of facilitating school avoidance with medical excuses. Learning supports should be put into place to adjust academic workload if indicated, to address specific learning disabilities, and to help teenagers develop schedules, prioritizing work and avoiding procrastination by breaking up projects into small chunks. Parents can help by hiring a tutor. School-based counseling might facilitate attendance. Some teenagers need smaller classes, “support block,” or special program placement. cymbalta canadian pharmacy
Ideally, because of the exposure principle, school attendance should be mandatory. As this is effectively unenforceable, we have to compromise and be creative. If all else fails, less preferable options include part-time attendance and home schooling so that at least basic academics are completed. Some young people with social phobias bypass the social complexities of high school through home schooling, but go on to attend post-secondary programs—so be patient. female pink viagra
Pharmacotherapy. What is the role of medication? Medication options (Table 3) should be considered by family physicians when anxiety impairs adolescents’ psychosocial and academic functioning. Pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) is increasingly used for anxiety disorders due to demonstrated efficacy in controlled trials involving anxious adults and open trials involving teenagers. Several controlled trials are currently under way in children and adolescents. In adults, we have level 1 evidence for the efficacy of SSRIs in panic disorder, social phobia, OCD, and even generalized anxiety disorder. Canadian Imipramine and buspirone are also effective for generalized anxiety in adults. In children and adolescents, we have level 1 evidence that OCD is responsive to clomipramine, generic fluvoxamine, and canadian sertraline and that canadian fluoxetine is also effective in selective mutism, thought to be variant of social phobia.
Table 3. Medications for adolescent anxiety
|MEDICATION CLASSSelective serotonin reuptake inhibitors||INDICATIONSObsessive compulsive disorder (level 1) Social phobia (level 2) Generalized anxiety (level 3) Panic disorder (level 3)||ADVANTAGESTreats comorbid depression Well tolerated||DISADVANTAGESSexual side effects Occasional behavioural disinhibition or amotivational state|
|Generic Imipramine||Attention deficit disorder(level 1)
School phobia (level 1) Generalized anxiety disorder
|Treats comorbid attention deficit hyperactivity disorder Inexpensive||Anticholinergic and cardiac side effects|
|Buspirone||Generalized anxiety disorder(level 2)||Well tolerated||No effect on depression Subtle effects|
|Benzodiazepine||Panic disorder (level 1) Generalized anxiety disorder(level 2)||Rapid onset||Behavioural side effects Cognitive impairment|
Clonazepam has been shown to be superior to placebo in adolescent panic disorder but is associated with problems of irritability and disinhibition at doses of 2 mg or more daily. We also have level 2 evidence from open trials involving young people for the efficacy of buspirone and generic fluoxetine in generalized anxiety.
Considering the high comorbidity with depression, the most common medications prescribed for adolescent anxiety are SSRIs, especially generic paroxetine if getting to sleep is a concern. Initial medication dose should be low (eg, 10 mg of paroxetine or 50 mg of sertraline) to minimize the transient exacerbation of anxiety seen in many of these patients or the effect of anxiety sensitivity, which causes them to overreact to or misinterpret somatic sensations (such as jitteriness, nausea, or dizziness). Dose-finding studies in adult anxiety disorders, however, demonstrate that the effective dose is often at least 40 mg of fluoxetine or canadian paroxetine. In younger people, a limiting factor is dose-related behavioural activation, and in the longer term, the high rate of anorgasmia is definitely upsetting to teenagers. In generalized anxiety, buspirone or generic venlafaxine are alternatives that could have fewer sexual side effects.
For those with attention problems as well as anxiety, a combination of SSRIs and stimulants can be considered. Because of demonstrated efficacy in both attention deficit hyperactivity disorder in young people and anxiety in adults, cheap imipramine is an option, although limited by side effects. After conflicting results from several placebo-controlled trials on imipramine’s effect on school avoidance, a recent study found imipramine 75mg combined with CBT to be significantly more effective than placebo with CBT. Clinical practice suggests that the antidepressant serotonin and noradrenaline reuptake inhibitor (SNRI) cheap venlafaxine is a better tolerated option, although controlled research is lacking at present.
Although SSRIs are becoming valuable in relatively quickly improving symptoms and functioning in anxious young people, several problems remain. First, anxiety tends to be chronic, so symptoms return quickly when medication is tapered, and hence long-term treatment is common. Second, symptoms of avoidance require additional behavioural interventions. Third, an anxious teenager might be returned to school with an SSRI, but if learning disabilities are not addressed, school failure and secondary avoidance will recur. Longer-term studies involving adults with anxiety disorders have clearly shown that the best outcomes are with a combination of CBT and medications, and that medications rarely eliminate anxiety symptoms—even with optimal treatment. Anxious patients need to learn to tolerate physiologic anxiety and to develop skills to overcome avoidance symptoms in order to prevent long-term impairment of social and occupational function.
Anxious teenagers sometimes hide behind aggression or defiant avoidance behaviour, which can be as frustrating for physicians as for families. Although medications can reduce symptoms and hence the intensity of behavioural problems, habitual patterns of avoidance in particular require teenagers’ cooperation in practising exposure. It is helpful to follow adolescents’ interests to find areas for success—a job, hobbies, sports, mentoring—to keep them functioning as well as possible. Physicians and families need to maintain a calm and practical approach; it is rare for anxiety to go away completely. Even with optimal medication management and psychotherapeutic supports, longitudinal research in both adults and children indicates that anxiety will be chronic and recurrent. Hence, teaching teenagers to cope effectively is a more realistic goal than attempting to cure anxiety. Fortunately, the skills gained in coping with anxiety as adolescents will better equip patients to manage future symptoms of anxiety.