Anxiety disorders are prevalent among adolescents. It is estimated that the prevalence of anxiety disorders is 25.1% in adolescents between the ages of 13 to 18 years, and adolescents also have a 5.9% lifetime prevalence of developing a severe anxiety disorder.1 Diagnoses of anxiety disorders include generalized anxiety disorder (GAD), panic disorder, and social anxiety disorder. Anxiety disorders can coexist with other mental health problems in this population, such as major depressive disorder.2 There is a relationship between anxiety disorders and sleep difficulties, which can further affect mental health.3 Adolescents with anxiety disorders are significantly more likely to continue to suffer with these disorders in adulthood.4 Adults with anxiety disorders that started in adolescence can have poor coping skills, chronic stress, less life satisfaction, and poor family relationships.4
GAD occurs in 3% of adolescents and includes excessive worry and anxiety occurring more days than not for at least 6 months.5 Symptoms can include feeling restless, easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbances.6 These adolescents worry about multiple issues and are unable to control their worry. Adolescents with panic disorder experience unexpected panic attacks (an abrupt sense of fear peaking within minutes and quickly resolving, usually within 10 to 15 minutes [though possibly slightly longer in some individuals]) with symptoms that may include palpitations, sweating, trembling, shortness of breath, dizziness, and fears of dying or losing control. Behaviors such as avoiding situations and places where panic attacks occurred may be exhibited by the adolescent.6
Panic disorder has a prevalence of 2% to 3% in adolescents.6 Social anxiety disorder includes symptoms of marked fear or anxiety of scrutiny by others in social situations. These adolescents worry about acting in a way or exhibiting anxiety symptoms that would be evaluated in a negative manner by others.6 This disorder has a prevalence of 7% in children and adolescents, which is comparable to the prevalence in adults.6 Anxiety disorders can impair adolescents' functioning at school, home, and with peers, highlighting the need to address these issues in primary care.
History and physical exam
It is important for the primary care NP to assess the details about adolescents' experience with anxiety. It is important to ask what the anxiety feels like to them. Do they worry about multiple things or are they fearful of certain situations? Are they having physical symptoms such as palpitations, shortness of breath, nausea, and tremors that last for a short period without triggers? The history of present illness needs to include functioning level.
Is the anxiety occurring at home, at school, with peers, or in all of these areas? Is it only in social situations? Is it related to performance (dancing or public speaking)? Is the anxiety interrupting their sleep, ability to complete schoolwork, or tasks at home? Were there any traumatic experiences that occurred before the anxiety symptoms began (for example, bullying or abuse)? Are there other symptoms such as depressed mood, lack of motivation or interest, or suicidal thoughts?
A complete history includes assessing for other comorbid disorders, such as depression or attention-deficit hyperactivity disorder. The NP should also explore for a history of anxiety disorders, either from the patient's own childhood or in a family member. Finally, history of substance use must be examined along with a full review of systems.
Adolescents may present with a medical complaint instead of a psychiatric complaint. The NP needs to consider anxiety if there are unexplained physical complaints, poor school attendance, or parental concerns about anxiety.7 The full medical exam may reveal some medical conditions that can mimic anxiety, such as hyperthyroidism or asthma, or substances that could be causing anxiety, including caffeine, energy drinks, steroids, and decongestants.7 Symptoms of withdrawal from benzodiazepines or cannabis can also exhibit as anxiety.
Using validated screening instruments can help in identifying substantial anxiety disorders and help monitor symptom management. These instruments have been validated in adolescents.8-10 The generalized anxiety disorder 7-item (GAD-7) is a seven-item questionnaire assessing anxiety symptoms on a scale of 0 (not at all) to 3 (nearly every day) over the past 2 weeks.10 Symptoms include restlessness, feeling nervous or anxious, worrying about different things, trouble relaxing, easily annoyed or irritable, and feeling afraid something awful may happen. There is also a rating of how much these symptoms are impairing functioning from not difficultat all to extremely difficult. A cut-off score of 10 or greater indicates the possibility of GAD.
The Panic Disorder Severity Scale for adolescents (PDSS-A) assesses seven symptoms on a 5-point Likert scale from 0 (none) to 4 (extreme). These symptoms include panic frequency, distress associated with panic attacks, severity of anticipatory anxiety, agoraphobia and avoidance, fear associated with the physical symptoms that accompany panic attacks, and work and social impairments related to the disorder. A score of 8 or above indicates the possibility of panic disorder.
The Mini Social Phobia Inventory (Mini-SPIN) has three questions that address these statements: Fear of embarrassment causes me to avoid doing things or speaking to people, I avoid activities in which I am the center of attention, and being embarrassed or looking stupid are among my worst fears. Adolescents rate these statements on a 5-point Likert scale from 0 (not at all) to 4 (extremely). A score of 6 or higher has been shown to detect social anxiety disorder. The GAD-7, the PDSS-A, and the Mini-SPIN are all in the public domain (see Anxiety disorders).
Cognitive behavioral therapy (CBT) has been considered effective treatment for anxiety in adolescents.1,11 This type of therapy helps adolescents recognize their negative cognitions about situations and how anxiety affects their behavior. Two examples that may be appropriate for CBT include an adolescent having outstanding grades in school who worries about failing courses or an adolescent who fears embarrassment or judgment from others when speaking in front of a class.
Adolescents who are exploring their sexuality and gender may have anxiety as well, and they would benefit from intensive treatment. If sleep disturbances accompany anxiety, it is important to highlight sleep hygiene, which specifically involves limiting screen time (texting, online gaming, and social media). Adolescents can use deep-breathing exercises in bed to improve sleep onset. The NP can talk with adolescents about decreasing their consumption of caffeine products, especially 6 hours before bed. Exercise also has antianxiolytic properties, which can be used as a mechanism to control anxiety.
Pharmacology may be necessary for adolescents who have severe anxiety symptoms. The Agency for Healthcare Research and Quality's (AHRQ) recent report on anxiety in children included adolescents in its review.1 Based on the evidence, selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) improved primary anxiety symptoms, function, and remission compared with placebo, whereas benzodiazepines did not differ in effect from placebo.1 According to the AHRQ, the evidence on the effectiveness of benzodiazepines remains insufficient to recommend their use for treatment of anxiety in children.1
The combination of CBT and pharmacology reduced primary anxiety symptoms and improved function better than either treatment alone. Specific SSRIs and SNRIs have been studied in adolescents for anxiety disorders and have been used FDA off label.1,12 The SNRI duloxetine is FDA-approved for use in children and adolescents ages 7 to 17 years for the treatment of GAD.12 Duloxetine includes the antidepressant medication box warning for the increased risk of suicidal thinking and behavior in children and adolescents.12 If the NP in primary care does not feel comfortable treating adolescents with anxiety disorders using pharmacotherapy, there needs to be a referral for CBT and a child psychiatric provider for treatment. Group CBT may also be helpful for the adolescent. If primary care NPs decide to start adolescent patients on medications while the patients await psychiatric appointments, the NPs need to be vigilant of any symptom activation or aggression, which may be indicative of a more serious mood disorder.
The NP needs to have an in-depth conversation with parents and patients about anxiety and any treatment recommendations. Parents need to be involved so they can understand possible consequences if the anxiety is not treated adequately. It is also helpful to provide support to adolescents and their families. This can be done in the form of personal support as the NP or collateral support via online resources. One such resource for patients and families is available from the American Academy of Child and Adolescent Psychiatry.13
There is a need to manage anxiety disorders in adolescents, and primary care can be the entry into treatment. Anxiety disorders could be disruptive in the lives of adolescents and continue into adulthood. Through appropriate identification, referrals, and treatments, primary care NPs can improve these adolescents' functioning and overall quality of life.
1. Wang Z, Whiteside S, Sim L, et al Anxiety in Children. Comparative Effectiveness Review No. 192
. AHRQ Publication No. 17-EHC023-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2017.
2. Essau CA, Lewinsohn PM, Lim JX, Ho MR, Rohde P. Incidence, recurrence and comorbidity of anxiety disorders in four major developmental stages. J Affect Disord
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6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
. 5th ed. Washington, DC: American Psychiatric Publishing; 2013.
7. Boydston L, Chih-Jui Hsiao R, Kvarley C. Identifying anxiety disorders in the primary care setting: the first step to effective treatment for adolescents. Contemp Pediatrics
8. Elkins RM, Pincus DB, Comer JS. A psychometric evaluation of the panic disorder severity scale for children and adolescents. Psychol Assess
9. Ranta K, Kaltiala-Heino R, Rantanen P, Marttunen M. The mini-social phobia inventory: psychometric properties in an adolescent general population sample. Compr Psychiatry
10. Tiirikainen K, Haravuori H, Ranta K, Kaltiala-Heino R, Marttunen M. Psychometric properties of the 7-item generalized anxiety disorder scale (GAD-7) in a large representative sample of Finnish adolescents. Psychiatry Res
11. James AC, James G, Cowdrey FA, Soler A, Choke A. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev