Anxiety in AdolescentsDr. David Wood

Dr. Matthew Tolliver

11/8/18

Anxiety in Adolescents

• We have no financial disclosures.• We do present products that are non-profit in nature.

13 November 2018 David L. Wood, MD, MPH

Types of Anxiety Disorders DSM V1. Anxiety Disorders (separation anxiety disorder, selective mutism, specific phobia, social phobia, panic disorder, agoraphobia, and generalized anxiety disorder).2. Obsessive-Compulsive Disorders (obsessive-compulsive disorder, body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder).3. Trauma and Stressor-Related Disorders (reactive attachment disorder, disinhibited social engagement disorder, PTSD, acute stress disorder, and adjustment disorder).

Lifetime Prevalence of Anxiety Disorders in Adolescence

• National Comorbidity Survey-Adolescent Supplement– 36% of adolescents meet critera for anxiety

disorders• Social Phobia 9%; Specific phobia 19%; PTSD

5%; Separation Anxiety 7%; • Females 50% higher than males• 8.3% overall with severe impairment and/or

distress• Median age of onset: 6 years (13 for depression)

Merikangas KR, et. Al. J Am Acad Child Adolesc Psychiatry. 2010 October ; 49(10): 980–989

Merikangas KR, et. Al. J Am Acad Child Adolesc Psychiatry. 2010 October ; 49(10): 980–989

How Anxiety is Manifested

• Feeling of a sense of dread• Have fears of impending doom• Experience a sense of suffocation• Anticipation of unarticulated catastrophe• Loss of control over their breath, swallowing,

speech, and coordination

Physical Symptoms of Anxiety• Twitching or trembling • Muscle tension • Headaches • Sweating • Dry mouth • Difficulty swallowing • Abdominal pain (may be the only symptom of stress

especially in a child)• Visual symptoms

Additional Physical Symptoms of Anxiety

• Dizziness • Rapid or irregular heart rate• Rapid breathing • Diarrhea or frequent need to urinate• Fatigue • Irritability, including loss of your temper • Sleeping difficulties and nightmares • Decreased concentration • Sexual problems

Physical Reaction to Anxiety

Effects of Anxiety (to name a few)

• School failure

• Absenteeism

• Classroom disruption

• The inability to complete basic tasks

• Family stress

• Impaired social relationships

• Substance Use

Relationship between Anxiety, Chronic Illness and Well-Being

Belazs, et. Al. Int. J. Environ. Res. Public Health 2018, 15, 1698

Screening for and Treatment of Anxiety in Primary Care

Citation: Child & Adolescent Psychiatric Disorders & Psychosocial Aspects of Pediatrics, Hay, Jr. WW, Levin MJ, Deterding RR, Abzug MJ. Current Diagnosis & Treatment: Pediatrics, 24e; 2018. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=2390&sectionid=189073651 Accessed: September 17, 2018Copyright © 2018 McGraw-Hill Education. All rights reserved

Treatment algorithm for children and adolescents with anxiety

• RCT for child and adolescent anxiety (n = 488)– Most had multiple anxiety dx

• CBT Alone vs. CBT + Sertraline vs. Sertraline Alone vs. Placebo

• % Very Much or Much Improved at 4, 8 and 12 weeks:– Combined: 80.7%– CBT: 59.7%– Sertraline: 54.9%– Placebo: 23.7%

Child Adolescent Multimodal Study (CAMS)—Good News!

Walkup JT. 2008 NEJM. RCT of Childhood Anxiety

• 319 Youth followed up 4-12 years after RCT– Data on 224 with 3 or more f/u years

• 22% in Remission• 30% chronically ill with anxiety• 48% relapsed

• Treatment responders + Males + Younger were less likely to be in chronically ill group

• A dx of social phobia, lower family functioning and negative life events more likely to be in chronically ill group

Child Adolescent Multimodal Study (CAMS)—Bad News!

Ginsberg GS. J Am Acad Child Adolesc Psychiatry 2018;57(7):471–480.

Treatment - CBT• CBT has a strong evidence base for

treating adolescent anxiety

(Kendall & Peterman, 2015) (Oar, Johnco, & Ollendick, 2017)

Anxietybc.com

Self Help for Anxiety

(SAM) App

Acceptance and Commitment Therapy (ACT)

• Acceptance and Commitment Therapy versus Cognitive Behavior Therapy for Children With Anxiety: Outcomes of a Randomized Controlled Trial

• 193 children randomized to 10 weeks of CBT, ACT, or waitlist

• Similar improvements on the Anxiety Disorders Interview Schedule

Hancock, Swain, Hainsworth, Dixon, Koo, & Munro (2018)

ACT Model

• Open up• Be Present• Do What Matters

(Hayes, Strosahl & Wilson, 2012)

• Spending a lot of time going to bathroom

• Isolating self in room and think about bladder

• Disengaged at school

• Drinking 12-15, 500oz bottles of water/day

Brian’s Choice Point

At school, alone at home

“Something is wrong with my bladder” “No one likes me”

• Values: appreciate what you have, stand up for what you believe in

• Goals: drink less water

“Pain” in bladder

What to do with anxious thoughts?Evaluate, analyze, categorize, generate alternative

Non-judgmental, curious stance, move towards values VS

Point: Efforts to struggle against/control anxiety takes up a lot of time & energy and can push us away from our valued directions

It seems like your anxiety

stands in the way, stopping you from going in

your valued

direction

But really, your anxiety is just along for the ride. It shows up. It says “turn right! Turn right!” But

you can still choose to turn left.

Acceptance/Willingness

Point: Avoidance often gets us more stuck

Acceptance/Willingness

Focused ACT (FACT)

• What have you tried?• How has it worked?• What has it cost you?

• What kind of life would you choose if you could choose?

(Strosahl, Gustavsson, & Robinson, 2012)

Identifying Values

1 2 3 4 5 6 7 8 9 10 11

Being a good friend

Genuine

Committed Action(Robinson, Gould, & Strosahl, 2011)

ACT for Adolescents

• BOLD Warrior Skills– Breathing deeply and slowing down– Observing thoughts, emotions, sensations– Listening to your values– Deciding on actions and doing them

“We can spend our whole lives escaping from the monsters of our minds” – Pema Chodron

(Ciarrochi, Hayes, Bailey, & Hayes, 2012, p. 27)

Headspace Meditation Video: https://www.youtube.com/watch?v=t_yXe_6mYTAThree Little Pigs Avoidance: https://www.youtube.com/watch?v=pX8s3If90_E

Medical/Behavioral Partnerships: ACT in Primary Care

• Focus on improving functioning over just symptoms reduction

• Physicians can model mindfulness skills• Brief interventions can help

How is Brian doing?

References• Ciarrochi, J., Hayes, L., Bailey, A., & Hayes, S. C. (2012). Get out of your mind & into your life for teens: A guide to living

an extraordinary life. Oakland, CA: Instant Help books.• Hancock, K. M., Swain, J., Hainsworth, C. J., Dixon, A. L., Koo, S., & Munro, K. (2018). Acceptance and commitment

therapy versus cognitive behavior therapy for children with anxiety: Outcomes of a randomized controlled trial. Journal of Clinical Child and Adolescent Psychology, 47(2), 296-311. doi:10.1080/15374416.2015.1110822

• Hayes, L. L., & Ciarrochi, J. (2015). The thriving adolescent: Using acceptance and commitment therapy and positive psychology to help teens manage emotions, achieve goals, and build connection. Oakland, CA: Context Press, an imprint of New Harbinger Publications.

• Hayes, S., Strosahl, K., & Wilson, K. (2012). Acceptance and commitment therapy: The process and practice of mindful change. New York, NY: The Guilford Press.

• Kendall, P. C., & Peterman, J. S. (2015). CBT for adolescents with anxiety: Mature yet still developing. The American Journal of Psychiatry, 172(6), 519-530. doi:10.1176/appi.ajp.2015.14081061

• Luoma, J. B., Hayes, S. C., & Walser, R. D. (2017). Learning ACT: An acceptance and commitment therapy skills training manual for therapists, second edition. Oakland, CA: Context Press, an imprint of New Harbinger Publications.

• Oar, E. L., Johnco, C., & Ollendick, T. H. (2017). Cognitive behavioral therapy for anxiety and depression in children and adolescents. Psychiatric Clinics of North America, 40(4), 661-674. doi:10.1016/j.psc.2017.08.002

• Robinson, P. J., Gould, D. A., & Strosahl, K. (2011). Real behavior change in primary care: Improving patient outcomes and increasing job satisfaction. Oakland, CA: New Harbinger.

• Strosahl, K., Gustavsson, T., & Robinson, P. A. (2012). Brief interventions for radical change: Principles and practice of focused acceptance and commitment therapy. Oakland, CA: New Harbinger Publications.

• Turrell, S. L., & Bell, M. (2016). ACT for adolescents: Treating teens and adolescents in individual and group therapy. Oakland, CA: Context Press, an imprint of New Harbinger Publications.

THANK YOU

David Wood, MDMatthew Tolliver, PhDPhone: 423-439-6222FAX: 423-439-8066Email: wooddl@etsu.edu

For an appointment with Dr. Wood for an adolescent or young adult call: 423-439-7320

(Hayes, Strosahl & Wilson, 2012)

ACT for Adolescents: DNA-V

(Hayes & Ciarrochi, 2015).

Our “Advisor”is like a GPS

Defusion (Hayes & Ciarrochi, 2015).