Once you have identified that your adolescent patient has an anxiety disorder, it's time to assess the depth of the problem to discover the best treatment.
Anxiety disorders are very common in adolescents and are associated with considerable distress and impairment in adaptive function. Because teenagers often present their anxiety symptoms to pediatricians, it is important for primary care providers to incorporate assessment and treatment of anxiety disorders into their practice. Unexplained physical complaints, problems with school attendance, and parental concerns about social isolation or irritability suggest the possibility of an anxiety disorder.
We discussed the epidemiology of anxiety disorders in adolescents in last month's issue of Contemporary Pediatrics. Fortunately, there is increasing evidence of very effective treatments.
Assessing anxiety disorders in the primary care setting
The clinical interview is the most important diagnostic tool in the assessment of anxiety. Multiple sources are ideal1,2; parents may provide more reliable information about how their child is functioning at home and at school, but a teenager is likely to have the best sense of his or her own internal experience.1
Adolescents should be given the opportunity to meet with the provider alone for at least part of the interview. It is best if the limits of confidentiality are explained upfront, and it is understood ahead of time that safety issues will need to be shared with a caregiver. Collateral information from the school may provide another perspective.
It is best to start with open-ended questions about how things are going in general at home, at school, or with friends. From there, inquiry should get more specific: Does the adolescent or do the parents think there are problems with worries, stress, nervousness, or anxiety? This should be followed by more targeted questions regarding specific features of anxiety disorders commonly seen in adolescents.3 Explore when the symptoms first started, whether they have occurred before, and what effect they are having on the adolescent's ability to function in the various environments of his or her life.
Additionally, a prior treatment history, including therapy, medications, and complementary or alternative treatments, should be obtained. Inquire about family history of anxiety and other mental health disorders, including depression and substance-use disorders.
Many psychiatric disorders share key features with anxiety and should therefore be considered in the differential diagnosis.1-6 For example, difficulty concentrating, irritability, and sleep disturbance are diagnostic criteria of both pediatric major depression and general anxiety disorder (GAD).3 Hyperarousal and irritability occur in some anxiety disorders such as posttraumatic stress disorder (PTSD) or may be caused by a disruptive behavior disorder such as attention-deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder.5
Adolescents with autism spectrum disorders (ASDs), especially those who are considered to be "higher functioning," can be misdiagnosed as having social phobia (SP).4 To attempt to discriminate among them, one can ask whether the adolescent has been able to make age-appropriate relationships with familiar people. Additionally, the restrictive, repetitive behaviors of ASDs can be confused with obsessive-compulsive disorder (OCD).7
Adolescents who are suspected of having an anxiety disorder should be assessed for core symptoms from other psychiatric categories.2 In particular, the adolescent should be asked about depressed mood. Inquire about current or past thoughts of suicide or nonsuicidal, self-injurious behavior and whether he or she has ever engaged in self-harm.
Although anxiety is much more likely to be comorbid with depression than a bipolar spectrum disorder, screening for symptoms suggestive of a previous manic or hypomanic episode is important because it may affect the decision to start medications.1 Exploring potential manic symptoms may not be completely straightforward because adolescents with anxiety disorders may have significant irritability, problems sleeping and concentrating, and restlessness. Therefore, it is helpful to be alert for features of mania that are more unique to the diagnosis, such as inflated self-esteem, decreased need for sleep (which must be distinguished from insomnia), and an increase in goal-directed or high-risk behaviors.3
Adolescents should be asked about the use of medications, supplements, and illicit substances that may cause elevated anxiety or mimic core features of various anxiety disorders.1-6 In particular, there should be a screen for the potential influence of drugs such as caffeine and activating substances of abuse such as amphetamines or cocaine. To complicate matters, an adolescent may have discovered that certain substances provide some degree of short-term relief from his or her anxiety. Alcohol use should be assessed1 and the patient asked whether he or she has used any other drugs or medications to manage anxiety.