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About
People with anxiety disorders experience persistent fear, worry, or dread, which is out of proportion to the circumstances, causes them significant distress and/or interferes with their daily functioning.
There are a number of different types of anxiety disorders, including:
- Specific phobia (also known as simple phobia)
- Social anxiety disorder (also known as social phobia)
- Panic disorder
- Agoraphobia
- Generalized anxiety disorder
In the most recent update to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) (1), separation anxiety disorder and selective mutism were added to anxiety disorders. Obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) were removed from anxiety disorders and are recognized in the DSM-5 as separate disorders on their own (1). Due to the recency of these changes, the findings from existing research on anxiety disorders would likely have included OCD and PTSD.
Common symptoms of anxiety disorders are:
Emotional changes:
- persistent worrying and excessive fears
- increased irritability
Cognitive changes:
- difficulty concentrating and paying attention
- easily distracted
Behavioural changes:
- avoidance of feared situations
- social isolation or being withdrawn
- excessive shyness
- inability to relax
- problems with work, social or family life
Physical changes:
- poor sleep
- Muscle tension
- somatic (body) complaints
Onset of anxiety disorders in young people
Anxiety disorders are the most common mental health problem experienced by young Australians. Anxiety disorders are estimated to affect 1 in 5 females aged 16-24 years, and nearly 1 in 10 males of the same age (2). The most common anxiety disorders reported by young Australians are social anxiety disorder (5.4%) and post-traumatic stress disorder (7.7%) (2).
Overall, about half of people with anxiety disorders experience their first symptoms by the age of 11 years, which is significantly younger than for most other mental health problems (3). However, the typical age of onset varies between the different types of anxiety disorders: specific phobia and separation anxiety disorder often occur at a younger age than panic disorder, generalised anxiety disorder and post-traumatic stress disorder (4).
Anxiety disorders in young people rarely occur in isolation, and studies have found associations with other mental disorders, with depression in particular having high comorbidity (5). Anxiety disorders during adolescence are strong predictors of the subsequent onset and persistence of other mental and substance use disorders, and is associated with considerable burden of disease (6,7). These include drug and alcohol misuse, and reduced educational and occupational attainment.
Risk factors
A number of factors have been found to increase the likelihood that a person will have an anxiety disorder (5,8,9). They include:
- Genetic vulnerability (for example, anxiety disorders in other family members)
- Temperament style characterized by shyness, inhibition, and withdrawal
- Overprotective/over controlling parenting style, or negative/critical parenting style
- Adverse or traumatic life experiences
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
Australian Institute of Health and Welfare 2011. Young Australians: their health and wellbeing 2011. Cat. no. PHE 140 Canberra: AIHWKessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005)
Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593-602.Kessler, R. C., Amminger, G. P., Aguilar‐Gaxiola, S., Alonso, J., Lee, S., & Ustun, T. B. (2007).
Age of onset of mental disorders: a review of recent literature. Current Opinion in Psychiatry, 20(4), 359.Rapee, R. M., Schniering, C. A., & Hudson, J. L. (2009).
Anxiety disorders during childhood and adolescence: Origins and treatment. Annual Review of Clinical Psychology, 5, 311-341.Kessler, R. C., Ruscio, A. M., Shear, K., & Wittchen, H. U. (2010).
Epidemiology of anxiety disorders. In behavioural neurobiology of anxiety and its treatment (pp. 21-35). Springer Berlin Heidelberg.Woodward, L. J., & Fergusson, D. M. (2001).
Life course outcomes of young people with anxiety disorders in adolescence. Journal of the American Academy of Child & Adolescent Psychiatry, 40(9), 1086-1093.Merikangas, K. R. (2005).
Vulnerability factors for anxiety disorders in children and adolescents. Child and Adolescent Psychiatric Clinics of North America, 14(4), 649-679.Rapee, R. M. (2012).
Family factors in the development and management of anxiety disorders. Clinical Child and Family Psychology Review, 15(1), 69-80.
Assessment
Formal systems for the diagnosis of mental illness (DSM-5 (1)) (ICD-10; see F40-F48) define a number of different types of anxiety disorder, including:
- Specific phobia: Significant and excessive fear or anxiety about a specific object or situation that when faced, provokes intense fear, anxiety, or avoidance (symptoms last at least 6 months)
- Social anxiety disorder: Significant and excessive avoidance of, and fear or anxiety about social situation(s) where there is possible scrutiny and negative evaluation by others (symptoms last at least 6 months)
- Subtype: Performance only (if the fear is restricted to public speaking/performance)
- Panic disorder: Recurrent, unexpected panic attacks (a sudden, intense fear or discomfort that peaks within minutes. Includes symptoms like heart palpitations, trembling, fear of losing control), followed by at least 1 month of persistent worry about additional panic attacks and/or significant maladaptive behaviour changes related to panic attacks (e.g. avoidance of situations where they might have a panic attack)
- Agoraphobia: Significant and excessive avoidance of, and fear or anxiety about being in situations that might cause panic, helplessness, or embarrassment (e.g. being outside of the home alone, using public transportation) (symptoms last at least 6 months)
- Generalized anxiety disorder: Significant and excessive anxiety and worry (apprehension about something in the future) about a number of events or activities that the person finds difficult to control (symptoms occur more days than not for at least 6 months)
- *Obsessive-compulsive disorder: recurrent and persistent obsessions (intrusive and unwanted thoughts, urges, and impulses) and/or compulsions (repetitive and excessive behaviours or mental acts in response to the obsession, with the aim of preventing/reducing anxiety or the occurrence of some feared event)
- *Posttraumatic stress disorder: exposure to actual/threatened danger (e.g. death, serious injury), followed by (1) intrusive symptoms (e.g. recurrent nightmares, flashbacks), (2) persistent avoidance of stimuli associated with the traumatic event(s), (3) negative alterations in mood and cognition (e.g. feelings of detachment or dissociative amnesia), and (4) arousal and reactivity associated with the traumatic event(s) (e.g. hypervigilance, exaggerated startle response) (symptoms last at least 1 month)
- Separation anxiety disorder: developmentally inappropriate and excessive fear or anxiety regarding separation from an attachment figure (symptoms last at least 4 weeks in adolescents and 6 months in adults)
- Selective mutism: persistent failure to speak in social situations where there is an expectation for speaking (e.g. at school, at work), despite speaking in other situations (symptoms last at least 1 month outside of the first month of school)
Common to all the disorders is the experience of significant distress or functional impairment as a result of the symptoms.
* In its own category and not grouped under anxiety disorders in the DSM-5 (1).
Assessment Tools
To decide whether a young person may be experiencing an anxiety disorder, an assessment is required. A comprehensive assessment involves asking questions about a range of aspects of a person life including their:
- Home and environment;
- Education and employment;
- Activities;
- Drugs and alcohol;
- Relationships and sexuality;
- Conduct difficulties and risk-taking;
- Anxiety and eating;
- Depression symptoms and suicide risk;
- Psychosis and mania symptoms
For more information, see psychosocial assessment interview.
There are several assessment tools available to assess or screen for anxiety disorders. These include the Beck's Anxiety Inventory (BAI) (2), the Depression Anxiety Stress Scales (3), the Hamilton Anxiety Scale (HAM-A) (4), and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) (5). These questionnaires are not a diagnostic tool but rather to assist with identifying when a more detailed assessment is warranted.
References
1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
2. Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: psychometric properties. Journal of Consulting and Clinical Psychology, 56(6), 893.
3. Lovibond, S.H. & Lovibond, P.F. (1995). Manual for the Depression Anxiety Stress Scales. (2nd. Ed.) Sydney: Psychology Foundation. ISBN 7334-1423-0.
4. Hamilton, M. A. X. (1959). The assessment of anxiety states by rating. British Journal of Medical Psychology, 32(1), 50-55.
5. Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Fleischmann, R. L., Hill, C. L., ... & Charney, D. S. (1989). The Yale-Brown obsessive compulsive scale: I. Development, use, and reliability. Archives of General Psychiatry, 46(11), 1006-1011.
Treatment
Early detection and treatment of anxiety disorders can reduce their adverse effects. Early intervention is particularly important as these disorders often become apparent at critical stages of development in childhood, adolescence and early adulthood.
The management plan developed for a young person with anxiety will be dependent upon a range of factors including:
- The severity of symptoms
- Health services available, both in terms of actual services to refer to and the skills and experiences of workers involved
- Other presenting health issues
- Support network available, including family and friends, or school supports
- The young persons' preference for a particular treatment approach
The foundation for any helping relationship is establishing a therapeutic alliance, openly discussing the problem, and having a collaborative approach. Other helpful strategies that can be introduced within this helping relationship include skill development around problem solving, stress management, activity planning, and psychoeducation. A range of simple, guided self-help techniques for managing anxiety disorders has also been shown to be effective (1).
Cognitive behavioural therapy is the most researched treatment for anxiety in young people, and CBT in various formats (e.g. individual, group, with family involvement, or computerized) have been found to reduce symptoms of anxiety, PTSD, and OCD in this age group (2-5). Other psychological therapies including exposure-based, psychodynamic, narrative, supportive counselling, and eye movement desensitisation and reprocessing (EMDR) have also shown to be effective in reducing symptoms of anxiety and PTSD in children and adolescents (5).
Medication treatments can be effective in reducing the core symptoms of anxiety disorders in children and adolescents (most trials assessed the use of SSRIs (a class of antidepressants) in treating pediatric OCD) (6). However, their use in young people is cautioned given the concerns about increased risk of suicidal ideation and behaviour in children and adolescents using SSRIs (7). There is little evidence on the efficacy of other medications, including anti-anxiety drugs like benzodiazepines (6). Therefore, combined with the concerns of dependency issues with this class of drug, the routine use of benzodiazepines in young people cannot be recommended.
References
1. Cuijpers, P., Donker, T., van Straten, A., Li, J., & Andersson, G. (2010). Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies. Psychological Medicine, 40(12), 1943-1957.
2. James AC, James G, Cowdrey FA, Soler A, Choke A. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD004690. DOI: 10.1002/14651858.CD004690.pub4.
3. Richardson, T., Stallard, P., & Velleman, S. (2010). Computerised cognitive behavioural therapy for the prevention and treatment of depression and anxiety in children and adolescents: a systematic review. Clinical Child and Family Psychology Review, 13(3), 275-290.
4. O'Kearney RT, Anstey K, von Sanden C, Hunt A. Behavioural and cognitive behavioural therapy for obsessive compulsive disorder in children and adolescents. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004856. DOI: 10.1002/14651858.CD004856.pub2.
5. Gillies D, Taylor F, Gray C, O'Brien L, D'Abrew N. Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD006726. DOI: 10.1002/14651858.CD006726.pub2.
6. Ipser JC, Stein DJ, Hawkridge S, Hoppe L. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD005170. DOI: 10.1002/14651858.CD005170.pub2.
7. Hetrick SE, McKenzie JE, Cox GR, Simmons MB, Merry SN. Newer generation antidepressants for depressive disorders in children and adolescents. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD004851. DOI: 10.1002/14651858.CD004851.pub3
Guidelines
The following authoritative guidelines provide evidence-based information about the practical treatment of anxiety disorders:
Australian Guidelines for the Treatment of Acute Stress Disorder and Posttraumatic Stress Disorder. (2013) Australian Centre for Posttraumatic Mental Health (NHMRC approved).
Social anxiety disorder: recognition, assessment and treatment. (2013). NICE CG159. United Kingdom
Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults: Management in primary, secondary and community care. (2011). NICE CG113. United Kingdom
Practice guideline for the treatment of patients with panic disorder, second edition. (2009) American Psychiatric Association. United States of America.
Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. (2007) American Academy of Child and Adolescent Psychiatry - Medical Specialty Society.
Post-traumatic stress disorder (PTSD): The management of PTSD in adults and children in primary and secondary care. 2005; NICE clinical guideline CG26.
Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. (2005) NICE CG31. United Kingdom
More Information
The following selected articles provide more information about anxiety disorders:
Geller, D. A., & March, J. (2012). Practice parameter for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51(1), 98-113.
Reavley, N.J., Allen, N.B, Jorm, A.F., Morgan A.J., Purcell R. A Guide to What Works for Anxiety Disorders. beyondblue: Melbourne, 2010.
AACAP Work Group on Quality Issues. (2010). Practice parameter for the assessment and treatment of children and adolescents with posttraumatic stress disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 49(4), 414-430.
Connolly, S. D., & Bernstein, G. A. (2007). Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 46(2), 267-283.
Hunot V, Churchill R, Teixeira V, Silva de Lima M. Psychological therapies for generalised anxiety disorder. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001848. DOI: 10.1002/14651858.CD001848.pub4
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