According to the National Institute of Mental Health 25% of teenagers will at one point or another be diagnosed with an anxiety disorder and 6% will be considered severe. Research over the last 80 years suggests either an increase in anxiety among teens or better recognition of a condition that’s existed all along. Either way, over my 26 years of practice, I’ve never seen quite as many teens and young adults suffering such a broad range of anxieties. Are teens really more anxious today than in past years, and if so, is that due to changing expectations, cultural dynamics, social media, or some other factors? When should parents let teens struggle through the normal angst of adolescence and start looking for help?
In this segment of Up to Date with Steve Kraske, I discuss what’s behind this wave of anxiety and more importantly, what parents can do to help both in terms of psychotherapy and medication management.
Three Forms of anxiety
Generalized Anxiety Disorder
Excessive anxiety or worry for months and face several anxiety-related symptoms including:
- Restlessness or feeling wound-up or on edge
- Being easily fatigued
- Difficulty concentrating or having their minds go blank
- Muscle tension
- Difficulty controlling the worry
- Sleep problems (difficulty falling or staying asleep or restless, unsatisfying sleep)
Recurrent unexpected panic attacks, which are sudden periods of intense fear that may include palpitations, pounding heart, or accelerated heart rate; sweating; trembling or shaking; sensations of shortness of breath, smothering, or choking; and feeling of impending doom. Clients often feel they are about to die, particularly if this is the first time they’ve had an attack. Symptoms include:
- Sudden and repeated attacks of intense fear
- Feelings of being out of control during a panic attack
- Intense worries about when the next attack will happen
- Fear or avoidance of places where panic attacks have occurred in the past
Social Anxiety Disorder
A marked fear of social or performance situations in which they expect to feel embarrassed, judged, rejected, or fearful of offending others. Symptoms include:
- Feeling highly anxious about being with other people and having a hard time talking to them
- Feeling very self-conscious in front of other people and worried about feeling humiliated, embarrassed, or rejected, or fearful of offending others
- Being very afraid that other people will judge them
- Worrying for days or weeks before an event where other people will be
- Staying away from places where there are other people
- Having a hard time making friends and keeping friends
- Blushing, sweating, or trembling around other people
- Feeling nauseous or sick to your stomach when other people are around
Teens may experience any of these forms of anxiety, as well as some that are specific to certain situations, such as school, body image, performance, etc. However, they are particularly susceptible to social anxiety because social situations are so much a part of daily teen life.
We often expect to see teens with self-consciousness, worries about body image, and concern about what others think of them. But today, our staff are increasingly seeing death anxiety, gender dysphoria presenting as anxiety, fearfulness over parent absence, and health anxiety. While there’s no one thing to which we can assign this increase in anxiety, common themes including the rancorous political climate which teen and young adult culture finds anathema to long cherished beliefs in LGBTQ+ rights, environmental protection, and social justice. Additionally, extensive involvement in social networking seems to be driving a lot of teen anxiety as kids are never out of touch with their peer group and thus always “on stage,” increasing the time available for performance anxiety and self-consciouness.
All things being equal, the best treatment for teen anxiety combines several forms of psychotherapy with medication management. While a key factor in recovery often involves changing the circumstances that lead up to anxious episodes, teens may also have to change out the respond to and approach those same circumstances. In other words, help your teen change what he or she can change and learn to accept what he cannot.
I am particularly excited about ACT, an evidence based form of therapy that derives from Cognitive Behavioral Therapy but extends it to include meditation and mindfulness. I’ve attended trainings in ACT from the leaders in the field in November 2016 and July 2017 and believe it holds greater promise for treating teens than past methods, which they tend not to like too much. We also use varying forms of exposure therapy which helps desensitize teens upsetting stimuli and unhelpful thoughts underlying anxiety disorders.
Evaluation for an anxiety disorder often begins with a visit to a primary care provider. However, we believe it’s best to start that journey with a licensed mental health provider as soon as possible. Medication for anxiety without psychotherapy is only half the battle. That’s not just a policy at this office, but a finding in research.
Some research suggests several factors which increase the likelihood of your teen having problems with anxiety. These include:
- Shyness, or behavioral inhibition, in childhood (which is not the same thing as introversion).
- Being female
- Having few economic resources
- Living in a divorced family or one in which a parent has died (we treat many of these cases)
- Exposure to stressful life events in childhood
- Anxiety disorders diagnosed in a close biological relatives
- Parental history of psychological disorders.
Exposure therapy focuses on confronting the fears underlying an anxiety disorder in order to help people engage in activities they have been avoiding. Exposure therapy is used along with relaxation exercises and/or imagery. One study, called a meta-analysis because it pulls together all of the previous studies and calculates the statistical magnitude of the combined effects, found that cognitive therapy was superior to exposure therapy for treating social anxiety disorder.
CBT may be conducted individually or with a group of people who have similar problems. Group therapy is particularly effective for social anxiety disorder. Often “homework” is assigned for participants to complete between sessions.
Medication won’t cure anxiety disorders but it can help make them more manageable by relieving symptoms. In nearly every case, we attempt to avoid specific anti-anxiety medications like those in the class known as benzodiazepines because they tend to build dependency and have a limited duration of impact. Instead, many of the SSRIs like Zoloft, Lexapro, and Effexor, provide longer term relief with out dependency. On the downside, they can take several weeks to start working and may cause side effects, most notably those related to sexual desire and performance. While some parents might think those are neat side effects for teens, we don’t and we monitor kids on these medications closely for any negative impact. We strongly urge any teen who is considering medication to be an active member of the treatment team and our nurse practitioner (Dr. Kelsey Daugherty) won’t prescribe against the will of any minor.
There’s a lot more to know about anxiety than I can cram into this space, or our hour of radio time, but hopefully this will get you started. Check out a practice in your area that specializes in both teens and anxiety management and see what they might have to offer. If you do your homework your child will stand to benefit from all that treatment has to offer.