Anxiety Disorders in Adolescents and Young Adults: Diagnosis and Treatment

Introduction

Anxiety disorders have been increasingly cited by healthcare practitioners as one of the most serious health problems facing adolescents and young adults in the United States — a burden that, in terms of global disease impact, exceeds even many physical medical conditions. 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, in order to determine the 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 quickly. In some individuals, however, anxiety can become a lingering and persistent condition that makes normal functioning difficult or even impossible. The research showed that adverse health consequences of untreated anxiety can range from milder manifestations — such as poor peer relationships and a negative impact on academic outcomes — to life-threatening conditions such as increased suicidal behavior. Fortunately, there are 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.

One of the unfortunate consequences of the human condition is the universality of anxiety disorders. 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 outcomes. 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. Because of the lack of relevant life experience and inadequately developed coping skills among younger people, the adverse effects of anxiety can be even more significant for adolescents and young adults.

Definition and Diagnosis of Anxiety

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 this population, including clinical interventions such as cognitive-behavioral therapies as well as physical fitness regimens 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 and implications for clinicians.

Life in the 21st century presents considerable challenges, and it is little wonder that so many young people experience anxiety about their current lives as well as what the future holds. The prevalence of anxiety disorders among adolescents and young adults is truly staggering, and their 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). Anxiety disorders represent some of the most common and serious issues facing young people today. 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). These observations represent a call to action for clinicians seeking to treat this population, but significant constraints and obstacles exist in accurately diagnosing an anxiety disorder in younger people.

There are subjective assessments involved in diagnosing anxiety in adolescents and young adults. 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. For a diagnosis of generalized anxiety disorder to be appropriate, anxiety must be almost always present following exposure to a phobic stimulus or feared situation, and the resulting condition must persist for at least six months. Anxiety disorders also frequently involve physical symptoms, particularly during the most salient period of exposure to a phobic stimulus or feared situation. Typical symptoms that can help identify anxiety disorders in young people include restlessness, fatigue, difficulty concentrating, irritability, muscle tension, nausea, and sleep disturbances (McLoone et al.). Because everyone exhibits such symptoms from time to time — especially adolescents and young adults — it is important to differentiate a transient episode of irritability from symptoms that are characteristic of anxiety disorders. 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 accurately diagnosing anxiety disorders in young people, clinicians will likely be confronted with a number of other behavioral issues that may further complicate the picture. 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). Young people may have problems with eating disorders, substance abuse, or other behavioral conditions that contribute to their anxiety disorder but make distinguishing one disorder from another problematic. 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 predictive of alcohol disorders in early young adulthood" (p. 767). Furthermore, both prescription drugs (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). Adolescents and young adults who engage in substance-abusing behaviors and subsequently develop anxiety-related disorders may find themselves trapped in a vicious cycle later in life. 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 involving major depressive episodes are also frequently diagnosed in adolescents who suffer from anxiety disorders (Stanard, 2000). 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 is congruent with findings presented by Armstrong, Dedrick, and Greenbaum (2003). Based on their analysis of 292 participants in the longitudinal National Adolescent and Child Treatment Study, Armstrong and her associates determined that substance abuse was the most common diagnosis for 17- to 25-year-old participants, followed by diagnoses of anxiety and depressive disorders; criminal behaviors were also shown to be higher for this population. Anxiety and depression represent the most prevalent problems facing young adults attending college, ranking 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 when most people engage in exploratory behaviors and test their limits in ways that may contribute to their propensity to develop anxiety disorders. 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). 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 agree that these are distinct disorders and should be diagnosed and treated as such. 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 people tend to experience change with age, shifting from the specific to the more abstract. McLoone and her associates also note that "the prevalence of anxiety disorders 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. Stanard emphasizes that "the presence of other psychiatric disorders in the adolescent increases 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). Anxiety disorders among adolescents 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 can be especially difficult because of a powerful reluctance among adolescents to share their problems with others. 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 are certainly not unique to younger people, but they appear more pronounced in this segment of the population, making the use of appropriate diagnostic tools and techniques all the more important.

In some cases, 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. Hurley (2007) emphasizes that "because it is necessary for the patient to report internal complex perceptions, it is difficult to diagnose 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 some adolescents and young adults may verbalize such apprehensions readily, others may be reluctant for the reasons noted above or may be unable to do so by virtue of an intellectual disability. 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). Young people with an intellectual disability may be particularly susceptible to anxiety disorders because of their inability to process events in a healthy fashion, and these constraints may also contribute to anxiety disorders remaining undiagnosed in this population. 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 accurate and timely diagnosis requires significant feedback from the sufferer, young people with anxiety disorders who are intellectually disabled are clearly at a disadvantage. 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. A study by Turchik and her associates (2007) determined that one commonly used tool, the Child Behavior Checklist, is not particularly effective at predicting anxiety disorders; however, it has been found useful in ruling out anxiety disorders among adolescents. The Ohio Youth Problems, Functioning, and Satisfaction Scales (commonly referred to as the Ohio Scales) are intended to identify changes in behavior over time 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. Their analysis 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 to confirm or rule out a diagnosis of anxiety disorder. Turchik et al. report that "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 for identifying anxiety disorders in adolescents and young adults, it is equally important for the treating clinician to recognize the causes of this disorder that are particularly prevalent among younger people.

Conclusion

The research showed that adverse health consequences of untreated anxiety can range from milder manifestations of the problem — such as poor peer relationships and a negative impact on academic outcomes — to life-threatening conditions such as increased suicidal behavior. While anxiety disorders in adolescents and young adults are among the most prevalent and serious health problems facing this population, effective diagnostic tools and evidence-based treatments exist. Cognitive-behavioral therapy and physical fitness interventions have demonstrated particular efficacy. Clinicians working with adolescents and young adults should be alert to the high rates of comorbidity associated with anxiety disorders, use both parent and patient reports in the diagnostic process, and consider multidisciplinary treatment approaches that address the full range of contributing factors. Early identification and intervention remain critical to preventing the long-term consequences of untreated anxiety in this vulnerable population.