William T. O’Donohue, Lorraine T. Benuto and Lauren Woodward Tolle (eds.)Handbook of Adolescent Health Psychology201310.1007/978-1-4614-6633-8_32© Springer Science+Business Media New York 2013
Anxiety in Adolescence
(1)
Department of Psychology, Oklahoma State University, 107 Whitehurst, Stillwater, OK 74078, USA
Abstract
Anxiety disorders are some of the most commonly occurring psychological disorders, and risk for the development of these conditions greatly increases during adolescence. Despite this, the literature examining these conditions among adolescents is still relatively sparse. This chapter provides an overview of the characteristics of anxiety disorders during this time period, with a particular focus on panic disorder (with or without agoraphobia), social anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and specific phobia. Etiological factors for anxiety disorders during adolescence are discussed, including biological, interpersonal, and cognitive risk factors. In addition, core fears and issues related to the assessment of each disorder are reviewed. The efficacy of cognitive-behavioral therapies and psychotropic medications during adolescents also is briefly presented. The chapter concludes with suggestions for future research examining anxiety disorders among adolescence.
Introduction
Adolescence is a time of substantial change both physiologically and psychologically. It also is a period of time when individuals are particularly vulnerable to developing symptoms of anxiety disorders (Costello & Angold, 1995). This increased risk for the development of anxiety is likely due in part to the numerous transitions during this period. As a result, adolescence is a particularly important time regarding the development of psychopathology. This period often sets the stage for future beliefs about the self and others, developmental concerns, and interpersonal relationships, which all are factors that are important to the development of anxiety. Therefore, an accurate understanding of the vulnerability factors and the features of anxiety disorders is important for mental health professionals. The goal of this chapter is to review important areas associated with the epidemiology, etiology, assessment, descriptive psychopathology, and treatment of anxiety disorders. This chapter will review these disorders briefly with a focus on adolescence, and will conclude with comments for future research with individuals and adolescents suffering from anxiety disorders.
Description
Anxiety disorders are one of the most prevalent psychiatric disorders, with lifetime prevalence rates of up to 31 % in the population (Kessler, 1995). The main anxiety disorders that could be the focus of attention for clinicians and researchers include panic disorder (PD), agoraphobia, social anxiety disorder (SAD), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), acute stress disorder (ASD), and specific phobias (SP). PD is the fear of experiencing out of the blue physical sensations of anxiety (known as panic attacks). Agoraphobia is characterized by anxiety of places where escape may be difficult in the event that an individual has a panic attack. SAD is an excessive fear of being negatively evaluated in social or performance situations. GAD is characterized by excessive and uncontrollable worry that leads to somatic and cognitive symptoms of anxiety. OCD is characterized by obsessions, which are intrusive and distressing thoughts and images that cause anxiety, and compulsions, which are thoughts or behaviors designed to reduce this anxiety. PTSD is characterized by intrusive thoughts about a past trauma, avoidance of such thoughts, emotional numbing, and physical sensations of anxiety. ASD also involves anxiety about a trauma, although can only be diagnosed within the first month following the event. Specific phobias are excessive fears of particular objects or situations.
Diagnosing the anxiety disorders during adolescence is particularly difficult. The Diagnostic and Statistical Manual (DSM) places the eight above mentioned disorders in their own section, adding anxiety disorders due to a medical condition or a substance, and a Not Otherwise Specified category for clinically impairing symptoms that do not meet full criteria for any of the other disorders (American Psychiatric Association, 2000). This presumes that most of the anxiety disorders develop during adulthood, as there is a separate section in the DSM for disorders that are usually diagnosed during childhood. One of these disorders, separation anxiety disorder, is rarely diagnosed during adolescence (Wicks-Nelson & Israel, 2009). In fact, it is often difficult to determine whether one should draw on what we know about adults with anxiety disorders, or what we know about childhood anxiety among this population. Indeed, it is important to note that not very much research has focused on anxiety during adolescence, and much of the literature that does combines the functioning of adolescents with children. This is surprising, as several studies suggest that anxiety disorders are the most common disorder diagnosed during adolescence (Anderson, 1994; Kim-Cohen et al., 2003). Additionally, there are marked developmental differences between even young and older adolescents, and thus more research is needed to examine how anxiety and its related disorders present during this period.
Etiological Factors
Adolescence represents a period of significant change in several domains that result in the individual increasing their independence from their parents and building their sense of self and way of relating to others. These changes, however, can result in high levels of stress for the adolescent, which in turn can set the stage for psychopathology. How these changes relate to the development of anxiety among adolescents will be discussed in the following section.
Biological Factors
There are extensive biological changes that occur during puberty, mostly involving increased hormone levels via the hypothalamus and the pituitary gland. These hormones result in increased height and weight, changes in the body’s composition of fat and muscle, and maturation of the reproductive organs. Some studies indicate that the timing of puberty can increase risk of developing anxiety disorders. Specifically, research has suggested that individuals who experience puberty earlier than their peers are more likely to experience symptomatology compared to peers who develop “on time” or later, particularly among girls (Reardon, Leen-Feldner, & Hayward, 2009). Moreover, the physical changes associated with puberty also may increase risk for anxiety. Females tend to experience increases in the amount of fat compared to males (who experience increases in muscle growth), in addition to growth of the hips and breasts. As a result, body image becomes particularly important for girls, and can result in increased stress and lower self-esteem.
A few studies have begun to examine the effects of pubertal hormones on the development of internalizing disorders. There is some evidence that the hormones that result in puberty may have a relationship with the development of anxiety disorders. For example, one study suggested that hormones released by the adrenal and gonadal systems (which are related to puberty) may increase risk for anxiety among boys, but not girls (Susman et al., 1991). Additionally, cortisol, a hormone that is produced in response to stress and arousal, and is released from the adrenal glands, is increasingly being studied in its relationship with psychopathology. Although it is clear that cortisol is a biological marker of the stress response, its relationship with psychopathology may depend on a number of factors, including the severity and duration of the symptoms. Within the anxiety disorders, some evidence suggests that cortisol is related to PTSD, although the data are equivocal regarding its relation to the other anxiety conditions (Reardon et al., 2009). Given the relatively small number of studies examining this issue, more research is needed in order to draw strong conclusions within this area.
Interpersonal Stress
One robust predictor of the development of anxiety disorders has been the relationship functioning of parents and children. Specifically, several studies suggest that the children of anxious parents are at a greater risk for developing an anxiety disorder compared to those whose parents do not meet criteria for an anxiety diagnosis (Beidel & Turner, 1997; Kearney, Sims, Pursell, & Tillotson, 2003). Other studies have found evidence that attachment patterns during early childhood are predictive of the development of anxiety disorders during adolescence (Muris, Mayer, & Meesters, 2000; Warren, Huston, Egeland, & Sroufe, 1997). Parenting behaviors that are risk factors for anxiety disorders include overprotection, control, rejection, and lack of warmth (McLeod et al., 2007). Thus, parenting behavior that interferes with adolescents’ attempts to develop into relatively independent young adults increases risk for the development of anxiety (Davila, La Greca, Starr, & Landoll, 2010).
Moreover, during adolescence peer relationships become more important to an individual’s functioning than parental relationships (Larson, 1983). Difficulties in the development of close relationships can lead to chronic stress, which leaves the individual vulnerable to the developmentt of psychopathology. How adolescents function within these relationships can not only affect their future relationship development but also can impact the development of their anxious symptoms (Davila et al., 2010). Thus, positive peer relationships can protect adolescents against the development of anxiety disorders, whereas problematic relationships can increase risk for the development of anxiety (La Greca & Harrison, 2005).
It is important to note that adolescence is a period of time where many sex differences emerge in risks for psychological disorders. With most of the anxiety disorders, females have higher prevalence rates and tend to report more impairment as a result of their symptoms (Chapman, Mannuzza, & Fyer, 1995). One reason why girls are more at risk for the development of anxiety (and depressive) disorders is due to their vulnerability to stress. Particularly, several studies have suggested that girls are more focused on their relationship functioning, and thus are more vulnerable to experiencing stress within these relationships (e.g., Rudolph, 2002). This increased stress results in problematic ways of relating to others, leading to internalizing symptoms characterized by anxiety and depression (Rose & Rudolph, 2006; Rudolph, 2002). Thus, relationship stress is an important vulnerability factor to consider when working with adolescents, particularly for girls.
Cognitive Factors
Cognitive vulnerabilities include ways the individual thinks about themselves and about their world. Specific cognitive vulnerabilities include biases in attention (how one views the world and reacts to threat), interpretation of events, and memory processes. Attentional biases are characterized by excessive focus on perceived threatening or anxiety-provoking stimuli. These biases result in individuals focusing on anxiety-provoking stimuli over neutral or positive stimuli, which serve to maintain their anxious symptoms. Interpretation biases result in the individual inferring negative meanings from ambiguous events. Finally, memory biases involve excessive recall of perceived negative past events. There is considerable evidence of anxiety being associated with biases of attention and interpretation (e.g., Schultz & Heimberg, 2008), although whether anxiety is associated with biases of memory may depend on the specific disorder (Coles & Heimberg, 2002).
Another cognitive factor that has been found to be important to the development of anxiety disorders is anxiety sensitivity. Anxiety sensitivity represents a fear of consequences of experiencing anxiety, such as fear of panic symptoms, mental incapacitation, and others noticing one’s anxiety (Reiss, 1991). Studies have suggested that high levels of anxiety sensitivity predict the development of panic attacks and anxiety symptoms prospectively, even when controlling for baseline anxiety symptoms (Hayward, Killen, Kraemer, & Taylor, 2000; Schmidt et al., 2010). Studies also have found evidence of anxiety sensitivity representing a risk factor for anxiety disorders among adolescents (e.g., Anderson & Hope, 2009).
Comorbidity
Among most DSM diagnoses, comorbidity (i.e., where an individual meets criteria for two or more disorders at the same time) is the rule rather than the exception. Thus, when seeing an adolescent with symptoms resembling anxiety, it is important to consider other possible diagnoses. First, individuals who meet DSM criteria for one anxiety disorder are more likely to also meet criteria for another anxiety disorder. Second, depression also exhibits high comorbidity levels with the anxiety disorders. Several studies have suggested a strong relationship between being diagnosed with an anxiety disorder and major depressive disorder (Kessler et al., 1994). Third, anxiety also has been shown to increase risk for substance use disorders. For example, research suggests that individuals often use substances to cope with their anxious symptoms (e.g., Kushner, Sher, & Beitman, 2004). Finally, anxiety disorders also are associated with increased risk for developing eating disorders, particularly among adolescent females (Babio, Canals, Pietrobelli, Perez, & Arija, 2009). Because individuals with eating disorders are less likely to seek treatment, a careful assessment procedure including a physical examination may be useful in distinguishing between anxiety and eating pathology.
As a result of the high levels of comorbidity, it is recommended that clinicians conduct a thorough assessment with adolescents seeking treatment for anxiety. In some cases, approaches effective in treating anxiety also have been useful in treating comorbid cases, although at times comorbidity can negatively impact treatment outcome (e.g., Heimberg & Becker, 2002). Therefore it is important to have a broad understanding of the specific features associated with the anxiety disorders.
Assessment
Assessment of anxiety disorders (and other psychological disorders) is a complex process. The major concerns include focusing on nomothetic assessments with documented psychometric properties, while considering idiographic aspects of the individual patient. In terms of anxiety disorders, examination of an individual’s behavior without considering their specific fears can lead to an inaccurate diagnosis. For example, during the assessment phase a clinician may learn that a patient avoids social situations because they make them anxious. However, determining whether this patient is avoiding this situation because they will be negatively evaluated (and thus are experiencing symptoms of SAD) or because they are scared they might have a panic attack (and thus are experiencing symptoms of PD) is an important distinction. Among adolescents, another consideration includes the relationship the adolescent has with his/her parents. Although it is very important for clinicians to focus on the needs of his/her patients, adolescents still are too young to consent to treatment without their parents. Therefore, including the parents during the assessment phase, and determining before treatment the extent that parents will be involved, is essential, regardless of the individual’s diagnosis.
The assessment phase ideally would include clinical interviews, self-report measures, and behavioral assessments across multiple sources (i.e., adolescent, parent, teacher). Among adults, one widely used semi-structured interview for assessment of the anxiety disorders is the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Brown, DiNardo, & Barlow, 1994). The ADIS-IV has been developed for use with children and adolescents, and includes interviews for both the child and the parent (ADIS-C/P; Silverman & Albano, 1996). The ADIS-C/P also includes questions to diagnose related disorders including depression and attention deficit/hyperactivity disorder. Its psychometric properties have been well documented, and it has been used in numerous studies. The full interview takes approximately 2 h, and provides the interviewer with probe questions to differentiate between comorbid conditions. Due to its length, completing the full ADIS can be time consuming, despite its usefulness in differentiating between the different anxiety disorders. Thus, it may be useful to include self-report measures to help determine the specific nature of an individual’s fears.
Each anxiety disorder is characterized by a core fear which leads to some form of avoidance or is endured with considerable distress. This fear guides individuals’ behavior, typically resulting in avoidance of any situation where they may have to experience or approach the feared object/situation. Thus, understanding anxiety disorders revolves around differentiating between the main fear that characterizes each. A brief review of these disorders will follow, with an eye toward identifying the features of each that are characteristic of adolescents.
Panic Disorder and Agoraphobia
The core fear of panic disorder (PD) involves experiencing a panic attack, a discrete period of intense anxiety typically characterized by increased heart rate, chest pressure, difficulty breathing, and other physiological symptoms of anxiety (American Psychiatric Association, 2000). Panic attacks generally only last a few minutes, and typically observers are not aware of the symptoms that the patient is experiencing. However, from the patient’s perspective, these acute anxiety attacks are associated with severe physical and cognitive symptoms of anxiety. Individuals experiencing a panic attack often have catastrophic thoughts about their symptoms. As a result of these fears, individuals with PD have excessive concerns about experiencing future attacks, worry about what these attacks mean about them (e.g., “am I going crazy?”), or change their behavior to avoid having future attacks (e.g., they will avoid exercise or caffeinated drinks; APA, 2000).
A diagnosis of PD can occur either with or without agoraphobia. Agoraphobia involves anxiety about being in a situation where one may not be able to escape in the event that they experience a panic attack (APA, 2000). The additional fears associated with agoraphobia often result in increased avoidance of several situations, including malls, grocery stores, and other situations with large groups of people. Therefore, the symptoms of PD with agoraphobia can result in impairment across a wide variety of situations. Many patients with PD (with or without agoraphobia) will often carry a particular object (e.g., an inhaler, a bottle of pills) around with them to serve as a “safety signal.” A safety signal is something that individuals believe will help them cope with anxiety, and is characteristic of all anxiety disorders. Individuals also can rely on close friends, family, and romantic partners. Thus, these individuals can enter their feared situations as long as they have their “safety person” with them. Although these safety signals can help them to enter situations which they normally would fear, use of safety signals can often interfere with treatment.
PD typically has an age of onset around mid to late adolescence. This disorder occurs in about 1 % of adolescents in the community, and as high as 15 % of adolescents seeking treatment, with at least half percent also meeting criteria for agoraphobia (Essau, Conradt, & Petermann, 1999; Last & Strauss, 1989). Research has suggested that the cognitions experienced by adolescents while panicking are similar to those of adults (Nelles & Barlow, 1988). However, data also suggests that many adolescents with PD either are diagnosed with a different disorder (e.g., depression), or are referred for treatment due to comorbid diagnosis (Doerfler, Connor, Volungis, & Toscano, 2007) such as ADHD and mood disorders.
Social Anxiety Disorder
Social anxiety disorder (SAD) is characterized by excessive fears of being negatively evaluated in social situations (APA, 2000). Most individuals with this disorder will avoid social situations with any chance of ambiguity, or hover on the periphery in order to avoid possible embarrassment. Individuals with SAD frequently use close friends, romantic partners, or family members as safety signals. Therefore, the socially anxious individual can attend parties and other evaluative situations as long as their safety person attends with them (and stays by their side). SAD has a fairly early age of onset with many individuals first experiencing clinically significant symptoms during early to mid adolescence (Mannuzza, Fyer, Liebowitz, & Klein, 1990). Therefore, considering the increasing social pressures faced by adolescents, the early teen years are likely a difficult time for individuals with high levels of social fears.
SAD appears to be a relatively common fear among treatment-seeking adolescents. Research suggests that the period of adolescence is one of the highest risks for the development of social anxiety, particularly for girls (e.g., Wittchen, Stein, & Kessler, 1999). Possible reasons include difficulties with body satisfaction, gender role stressors, or changes in physical development (Nolen-Hoeksema & Girgus, 1994). For example, one study suggested that the onset of puberty predicted increased risk for the development of social anxiety among females, but not males during adolescence (Deardorff et al., 2007). Studies have suggested that social fears can decrease the development of appropriate social skills, friendships, and romantic relationships (Johnson & Glass, 1989; Rubin, LeMare, & Lollis, 1990). In fact, socially anxious adolescents experience rejection by peers, fewer friendships, and poor quality friendships (Inderbitzen, Walters, & Bukowski, 1997; La Greca & Lopez, 1998). Social fears also can impact academics, and future occupational functioning. For example, it is not uncommon for socially anxious adolescents to choose a less prestigious career path just because it will allow them to avoid public speaking or interacting with others.
Generalized Anxiety Disorder
Generalized anxiety disorder (GAD) is characterized by excessive and uncontrollable worries about a number of topics within one’s life (APA, 2000). As a result of these worries, patients will experience several somatic symptoms including muscle tension, restlessness, and difficulty falling asleep. Among adolescents with this disorder, worries typically focus on the future, school and classwork, family relationships, and friend and romantic relationships (Albano & Hack, 2004). Epidemiological studies suggest that GAD typically has an age of onset during late adolescence (Kendler, Neale, Kessler, Heath, & Eaves, 1992). Previous versions of the DSM have diagnosed children and adolescents with excessive worries with overanxious disorder. However, as of DSM-IV, overanxious disorder has been subsumed under the category of GAD.
Based on available data, the features that characterize adolescents with GAD appear to be similar to adults with the disorder. Typical adolescents with GAD will set high achievement goals for their academics, and will frequently worry about not making these achievements. These perfectionistic tendencies can carry over into other areas, such as being on time for appointments and within their friendships. GAD also is associated with difficulties within close relationships. Studies indicate that GAD is associated with a range of problematic interpersonal behaviors, from excessive dependency to cold and hostile personality traits (e.g., Newman & Erickson, 2010). Finally, due to the nature of the disorder, individuals with GAD frequently engage in checking behavior. For example, these individuals might call a close friend just to “check that they are ok.” Therefore, the chronic worry leads to impairment across several domains.
Studies have suggested that similar to adults, adolescents with GAD often experience high levels of comorbid depression (Masi, Favilla, Mucci, & Millipiedi, 2000). Additionally, studies have suggested that adolescents with comorbid GAD and depression are at higher risk for developing suicidal ideation compared to those with either disorder alone (Pawlak, Pascual-Sanchez, Rae, Fischer, & Ladame, 1999; Strauss, Last, Hersen, & Kazdin, 1988). Other studies have suggested that adolescents with GAD may initiate use of alcohol at a lower age compared to their nonanxious peers, perhaps as a self-medication strategy (Clark, Parker, & Lynch, 1999; Kaplow, Curran, Angold, & Costello, 2001).
Obsessive-Compulsive Disorder
The characteristic symptoms of obsessive-compulsive disorder (OCD) are made up of obsessions, or intrusive thoughts or images that cause anxiety or distress, and compulsions, or repetitive behaviors used to reduce anxiety or distress (APA, 2000). Although the focus of the obsessions (to increase anxiety) and the compulsions (to decrease anxiety) remain rather constant, the specific rituals and symptoms vary greatly for each patient. Indeed, there are several areas of obsessions and compulsions that are only somewhat functionally related. For example, upon experiencing an obsession that one’s hand is contaminated or dirty, a typical response is to excessively wash one’s hand. Alternatively, it is not at all uncommon for a patient with OCD to experience obsessions related to a close friend or family member being hurt which leads to a compulsion to count objects in the environment. Although DSM criteria do not require both obsessions and compulsions for a diagnosis, individuals experiencing only one type of symptom are rare (Swedo et al., 1989). In trying to diagnose this disorder, it is important to keep in mind the function of the thoughts and behaviors.
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