Anxiety Disorders Have Been Increasingly

¶ … anxiety disorders have been increasingly cited by healthcare practitioners as being one of the most serious health problems, exceeding even physical medical conditions, facing adolescents and young adults in the United States. The purpose of this study was to provide a critical review of the relevant peer-reviewed literature concerning anxiety disorders among adolescents and young adults in general and in the United States in particular to determine its prevalence, diagnosis, treatment and implications for clinicians and to apply these findings to an individual case of anxiety disorder in an adolescent client. Although anxiety is a natural human emotion that affects everyone from time to time, for most people the condition is temporary and resolves itself in short order. In some others, though, anxiety can become a lingering and persistent condition in ways that make normal functioning difficult or even impossible. The research showed that adverse health consequences of untreated anxiety can range from milder manifestations of the problem such as poor relationships with peers and a negative impact on academic outcomes to life-threatening conditions such as increased suicidal behaviors. Fortunately, there are some diagnostic tools and treatments available for anxiety disorders among adolescents and young adults that have been shown to be effective in helping young people overcome this potentially serious condition.

Effective Treatment of Anxiety for Adolescents and Young Adults

Introduction

One of the unfortunate consequences of the human condition is the universality of anxiety disorders. Indeed, people of all ages and walks of life will typically experience the adverse effects of anxiety at some point in their lives, but for most people, the effects are transient and do not result in significant adverse mental health conditions. For some young people, though, the powerful effects of unrelenting anxiety can create a wide range of healthcare issues that, left untreated, can even become life threatening. Furthermore, because of the lack of relevant life experiences and inadequately developed coping skills among younger people, the adverse effects of anxiety can be even more significant for adolescents and young adults. When combined with the substance-abusing behaviors that are characteristic of the experimental phases of life for many adolescents and young adults, anxiety disorders can produce even more serious healthcare concerns. Fortunately, some effective treatments have been identified for the treatment of anxiety disorders in adolescents and young adults, including clinical interventions such as cognitive-behavioral therapies as well as physical fitness regimens that are designed to counter the negative effects of an increasingly sedentary lifestyle that is conducive to the onset of anxiety disorders. To determine the definition, diagnostic criteria, causes, symptoms and treatment of anxiety disorders in adolescents and young adults, this paper provides a review of the relevant peer-reviewed literature, followed by a summary of the research in the conclusion and implications for clinicians in the application section.

Review of the Relevant Literature

Definition and Diagnosis of Anxiety

Life in the 21st century is certainly no piece of cake, and it is little wonder than so many young people are anxious about their current lives as well as what the future holds for them. Indeed, following the terrorist attacks of September 11, 2001, young people today are confronted with a constant barrage of alternating color-coded threat levels, many observers are predicting the end of the world in 2012 and popular media sources such as the History Channel have contributed to a culture of fear in the United States today. As a result, the prevalence of anxiety disorders among adolescents and young adults is truly staggering and its impact can be long-lasting and interfere with an individual's ability to function normally throughout the lifespan. In this regard, McLoone, Hudson and Rapee (2006) report that, "Research suggests that adolescents with anxiety disorders face an increased risk of experiencing anxiety, depression, illicit drug dependence, and educational underachievement in early adulthood. These risks remain even when socio-familial and individual factors are controlled" (p. 219). In fact, anxiety disorders represent some of the most common and serious issues facing young people today. For instance, according to Mcloone and her associates, "Given the frequency and potential negative consequences of anxiety disorders, it is no surprise that anxiety disorders have been named as one of the greatest health problems (exceeding most physical health problems) in terms of global burden of disease" (2006, p. 219). Taken together, the foregoing observations concerning the prevalence and significant adverse impact of anxiety on young people should represent a call to action for clinicians seeking to treat this population, but there are some significant constraints and obstacles involved in accurately diagnosing an anxiety disorder in general and in younger people in particular that must be taken into account in a clinical setting.

There are some subjective assessments involved in the diagnosis of anxiety in adolescents and young adults, but Mcloone et al. indicate that anxiety disorders are typically characterized by an irrational dread of a situation or stimulus that is unreasonably excessive for an individual's age but does not quantify these in any fashion. In addition, Mcloone et al. emphasize that for a diagnosis of generalized anxiety disorder to be appropriate, anxiety is almost always present following an exposure to a phobic stimulus or a feared situation, and here at least the guidance is quantifiable in that the resulting condition must persist for at least 6 months in order to qualify as an anxiety disorder. In addition, there are some physical manifestations of anxiety that can help guide the clinician in diagnosis. For example, anxiety disorders frequently involve physical symptoms, particularly during the most salient period of exposure to a phobic stimulus or feared situation. Finally, some of the typical symptoms of anxiety that can help identify anxiety disorders in young people include restlessness, fatigue, difficulty in concentrating, irritability, muscle tension, nausea, or sleep disturbances (Mcloone et al.). Because it is reasonable to posit that everyone exhibits these symptoms from time to time, though (especially adolescents and young adults), it is important to differentiate a transient episode of say, irritability, with those symptoms that are characteristic of anxiety disorders. In this regard, in order for a diagnosis of anxiety to be appropriate, the affected individuals must experience interference with their daily functioning as a result of heightened worry, physical symptoms, or anxious behaviors (Mcloone et al.).

When it comes to accurately diagnosing anxiety disorders in young people, though, clinicians will likely be confronted with a number of other behavioral issues that may further confound the picture. In this regard, Mcloone et al. emphasize that, "Despite the anxiety disorders having distinct diagnostic criteria, there is a great deal of overlap in presenting profiles and anxiety disorders are characterized by high levels of comorbidity" (2006, p. 220). Indeed, young people may have problems with eating disorders, substance abuse or other behavioral conditions that will contribute to their anxiety disorder but will make distinguishing one disorder from another problematic. For example, according to a study by Kelly, Donovan, Cornelius, Bukstein, Delbridge and Clark (2003), "Substance use disorders, especially cannabis use disorders, are prevalent among adolescents" (p. 616). Although physical injuries are not as prevalent with cannabis abuse as with alcohol abuse (Kelly et al., 2003), D'Amico and her associates (2005) emphasize that, "Psychiatric distress is associated with an alcohol use disorder, with mental disorders at age 15 leading to elevated risk of cannabis use at age 18 and anxiety disorders during adolescence [that are] predictive of alcohol disorders in early young adulthood" (p. 767). Furthermore, both prescription (such as asthma inhalers and diet pills) and nonprescription drugs (such as decongestants and caffeine in coffee, chocolate and carbonated drinks) can produce symptoms that mimic anxiety, complicating an accurate diagnosis (Kalapatapu & Schmetzer, 2008). What is known for certain, though, is that adolescents and young adults who engage in substance-abusing behaviors and subsequently develop anxiety-related disorders may find themselves trapped in a vicious circle later in life as well. For example, D'Amico and her associates emphasize that, "Young adults who have experienced mental-health or conduct problems early in life may also be at risk through this same process, engaging in high levels or problematic patterns of substance use when they leave their parents' home, which continues into later adulthood" (p. 767).

Besides eating and substance abuse disorders, personality disorders that involve major depressive episodes are also frequently diagnosed in adolescents who suffer from anxiety disorders (Stanard, 2000). In fact, as Turchik, Karpenko and Ogles (2007) emphasize, "It is important to keep in mind that comorbidity is more a rule than an exception in children and adolescents who present to outpatient clinical settings" (p. 120). This observation is congruent with the findings presented by Armstrong, Dedrick and Greenbaum (2003) as well. Based on their analysis of 292 adolescent and young adult participants in the longitudinal National Adolescent and Child Treatment Study, Armstrong and her associates determined that substance abuse was the most common diagnosis for the study's participants (17- to 25-year-olds), followed by diagnoses of anxiety and depressive disorders; in addition, criminal behaviors were also shown to be higher for this population. Likewise, anxiety and depression represent the most prevalent problems facing young adults attending college, with these two conditions being ranked first and third, respectively, among college students seeking counseling services (Mccarthy, Fouladi, Juncker & Matheny, 2006).

According to Armstrong and her associates (2003), adolescence and young adulthood is a period in life when most people engage in explorative behaviors and test their limits in ways that may contribute to their propensity to develop anxiety disorders. In this regard, Armstrong and her associates note that, "From their late teens to their early twenties, young adults experience dramatic changes across all realms of development. . . . During this stage of development, young adults are more likely to engage in substance abuse, drive while intoxicated, and have unprotected sex" (p. 66). Likewise, D'Amico, Ellickson, Collins, Martino and Klein (2005) report that, "Although the majority of people have reduced their substance use by the mid-20s, many young adults continue to use substances at significant levels and may go on to develop substance-use disorders (SUDs) in adulthood" (p. 766). Although anxiety disorders can contribute to depression and may produce similar or even identical symptoms, most authorities seem to agree that these are distinct disorders and should be diagnosed and treated as such. Indeed, Lerner, Safren, Henin, Warman, Heimberg and Kendall (1999) point out that, "Although some have argued that anxiety and depression are variants of the same disorder in children and adolescents, others have posited that anxiety and depression are distinct syndromes with unique characteristics" (p. 82).

According to Mcloone et al. (2006), the types of anxieties that people tend to experience change as they grow older, shifting from the specific to the more abstract with age. In addition, Mcloone and her associates note that, "The prevalence of anxiety disorders also differs by gender, with epidemiological surveys showing that females are around one and a half to two times more likely to have an anxiety disorder than males" (2006, p. 219). The consequences of an untreated anxiety disorder in adolescents or young adults can be severe, persistent and even life-threatening. In this regard, Stanard emphasizes that, "The presence of other psychiatric disorders in the adolescent increase the risk factor for the development of depression and associated suicidal risk. Adolescents diagnosed with a personality disorder are 10 times more likely to commit suicide than those who are not" (p. 204). In fact, anxiety disorders among adolescents in particular are one of the warning signs for suicide that clinicians are advised to monitor in this population (Muehlenkamp, Ertelt & Azure, 2008). According to Muehlenkamp and her associates, "Suicide remains a significant cause of death in the United States, particularly among youth. Suicide is the third leading cause of death among 15 to 19-year-olds" (2008, p. 105).

Identifying such behaviors and disorders among young people in order to diagnose an anxiety disorder, though, can be especially difficult among adolescents because of a powerful reluctance to share and reveal their problems with others. In this regard, Lerner et al. point out that, "Self-report assessment of anxiety and depression in adolescents has limitations. It may be difficult to determine the extent to which adolescents are able or willing to report anxious or depressive symptoms. Older children with anxiety disorders may be inhibited by concerns about self-presentation and negative evaluation by others" (1999, p. 92). Such inhibitions about revealing one's inner-most thoughts and fears are certainly not unique to younger people, but they do appear to be more pronounced in this segment of the population, making the use of appropriate diagnostic tools and techniques all the more important.

In some cases, though, adolescents and young adults who suffer from an intellectual disability may not have developed the cognitive abilities needed to adequately communicate the requisite diagnostic criteria to clinicians that can aid in the diagnosis of an anxiety disorder. In this regard, Hurley (2007) emphasizes that, "Because it is necessary for the patient to report internal complex perceptions, it is difficult to anxiety disorders in people with intellectual disability. The diagnosis of three anxiety disorders requires that the patient be able to verbalize his or her feelings and perceptions of worry, apprehension, or impending doom" (p. 26). While it may be a simple matter for some adolescents and young adults to verbalize such apprehensions in a clinical setting, others may be reluctant for the reasons noted above or they may be unable to do so by virtue of an intellectual disability. For example, Hurley adds that, "These perceptions require a moderate level of awareness wherein one can reflect upon his or her reflections, a higher cognitive capacity that typically arises in puberty with increasing development of the frontal lobe and executive control systems" (p. 26). It is reasonable to suggest that young people with an intellectual disability may be particularly susceptible to anxiety disorders because of their inability to process events that confront them in a healthy fashion, and these constraints may also contribute to the existence of an anxiety disorder remaining undiagnosed in this population. In this regard, Hurley advises that, "People with intellectual disability suffer from psychiatric illness at a rate that is thought to be much higher than the general population. Yet, anxiety disorders have only rarely been reported" (p. 26). Because the accurate and timely diagnosis of anxiety disorders requires significant feedback from the sufferer, young people with anxiety disorders who are intellectually disabled are clearly at a disadvantage. For example, according to Hurley:

It is unclear to what extent most people with intellectual disability achieve this level of cognitive capacity. Thus, it is possible that individuals with intellectual disability and great anxiety cannot communicate their symptoms or understand them sufficiently so that the anxiety is recognized by others and/or interpreted correctly by diagnosticians. It is for these reasons that much of the field of psychiatric illness and intellectual disability uses behavioral equivalents of diagnostic criteria. (p. 27)

Behavioral equivalents of the diagnostic criteria described above can be identified using a variety of diagnostic tools, but existing instruments vary in their ability to capture this critical information in a viable fashion. For instance, a study by Turchik and her associates (2007) determined that one of the common tools used for diagnostic purposes, the Child Behavior Checklist, is not particularly effective at predicting anxiety disorders; however, this instrument has been found to be useful in ruling out anxiety disorders among adolescents. Likewise, the Ohio Youth Problems, Functioning, and Satisfaction Scales (commonly referred to as the Ohio Scales) are intended to identify changes in behavior over time in adolescents by distinguishing between internalizing and externalizing problems; Turchik and her colleagues report that in the Ohio Scales, externalized behaviors indicate conditions such as hyperactivity, oppositionality, and aggression while internalized disorders are characterized by depression, anxiety, and physical symptoms. The results of an analysis of the efficacy of the Ohio Scales in various diagnostic settings conducted by Turchik and her associates found that, "Youth with mood and anxiety disorders had higher Internalizing scores than youth with other diagnoses" (Turchik et al., 2007, p. 120).

Despite the availability of these diagnostic tools, Lerner and her colleagues (1999) suggest that there is a growing consensus among practitioners that both parents and the patient should be consulted in order to confirm or rule out a diagnosis of anxiety disorder. For instance, Turchik et al. report, "Parents may be more reliable informants than children when queried about children's overt behavior and its interference with functioning. It is now preferred practice to rely on both parent and child report in making diagnostic decisions" (p. 84). While a number of diagnostic tools exist that can be used to identify anxiety disorders in adolescents and young adults, it is important for the treating clinician to recognize some of the causes of this disorder that are particularly prevalent among younger people, and these issues are discussed further below.

Causes of Anxiety in Adolescents and Young Adults

As noted above, adolescence and young adulthood are periods in life when people tend to "sow their oats" by experimenting with different things and testing their limits. While such experimentation can result in risky behaviors, most people manage to endure the rigors of adolescence with few scars to show for their efforts. There are some other issues that are particularly relevant to this period in young people's lives that are not shared by their older counterparts, though, that can contribute to the incidence of anxiety disorders. For instance, according to Stanard (2000), "Research suggests that persistent or escalating stressful events (e.g., disagreements with parents) increase the risk for development of adolescent depression or anxiety" (p. 204). Furthermore, extending the adage that "there is no problem so large that drinking cannot make it worse," the tendency of young people to experiment with various drugs and alcohol during this formative period in their lives can result in substance abusive behaviors that will further exacerbate any anxiety disorders that may already exist (Stanard, 2000). This assertion is highly congruent with the findings of a study by Kelley, Lewis and Sigal (2004) who report, "Substance abuse has been found to accompany various psychiatric disturbances and generally occurs before or as a result of substance abuse in adolescents [with the] prevalence of anxiety disorder ranging from 7% to more than 40%" (p. 67). Although caffeine can produce anxiety-like symptoms in young people, it is also possible that excessive use of caffeine by young people can cause insomnia, and this condition has been found to contribute to a higher incidence of generalized anxiety disorder (Espie, 2002). Moreover, Kelley and her associates note that the prevalence of mood disorders such as depression tend to accompany or follow substance abuse behaviors by adolescents and estimates indicate that up to half of all adolescents who abuse substances will go on to develop a mood disorder that predisposes them to suicidal behaviors. In this regard, Stanard emphasize that, "The most common diagnosis in suicidal adolescents is a mood disorder with or without a substance abuse disorder and/or anxiety disorder" (2000, p. 204). In addition, a study by Bagwell, Molina, Kashdan, Pelham and Hoza (2006) found that problems with peer relations in childhood predicted anxiety disorders among adolescents. Clearly, young people are subject to the same factors that can cause anxiety in people of any age as well as some that are specific to their age that make this population particularly susceptible to the development of anxiety disorders. Therefore, identifying effective treatments for anxiety in adolescents and young adults represents a timely and important enterprise, and these issues are discussed further below.

Treatment of Anxiety in Adolescents and Young Adults