Mental Health Issue Review: Anxiety in Adolescents

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Anxiety

Anxiety, to a certain extent, is a natural and important emotion that helps an individual recognize nearby threats and motivates them to solve everyday problems (Kitchener, Jorm and Kelly, 2013). It only becomes a mental health issue when the frequency and intensity of the anxious feelings increase and start to interfere with the individual’s ability to go about their daily life (National Institute of Mental Health, 2016). Anxiety is an emotion that is characterized by feelings of stress, troubled thoughts, and physical changes in the body, such as heightened heart rate and blood pressure (Kazdin, 2000). Fear and anxiety are often used interchangeably. However, fear is an uncomfortable emotion towards a specific imminent threat, while anxiety is fear over the anticipation of a future known or unknown threat (American Psychiatric Association, 2013). Anxiety may develop gradually or suddenly and excessive stress can often make it worse (Rapoport & Ismond, 1996).

According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013) anxiety disorders are classified as persistent fears that are directed towards different objects or situations that cause a person to go out of their way to avoid them and they can be distinguished from one another depending on the objects or situations that are being avoided because of the individual’s thoughts and beliefs about them. It is the frequency and intensity, rather than the content or number of worries that helps distinguish between high, medium and low levels of anxiety (Beidel & Turner, 2005). There are several types of anxiety disorders mentioned in the DSM-5 (2013), but among these, social anxiety disorder, generalized anxiety disorder (GAD), specific phobia and panic disorders are some of the commonly observed anxiety disorders in adolescents (13-22 years).

Social anxiety manifests from excessive fear of being scrutinized, embarrassed, humiliated, or being negatively evaluated by others in social or performance-related situations (American Psychiatric Association, 2013). It is reported to be the most common anxiety disorder affecting around 5.4% of young Australians (Australian Institute of Health and Welfare, 2011).

Generalized anxiety is an unrealistic fear about one’s health, money, family, studies or work and it can also be accompanied by physical symptoms, feelings of restlessness, excessive fatigue, difficulty in concentrating, feeling irritated for no apparent reason and disturbed sleep patterns (American Psychiatric Association, 2013).

An excessive, irrational fear of a specific object or situation is referred to as specific phobia. Specific phobias are different from GAD as the fear response is towards a specific object. Some of the common feared objects or situations are certain animals: spiders, snakes, insects; natural environment, blood, heights, and enclosed spaces (American Psychiatric Association, 2013).

In panic disorder, the individual changes his or her behaviour in maladaptive ways as they are concerned about experiencing repeated unexpected panic attacks. Panic attacks are feelings of intense fear or discomfort that abruptly arise and reach peak within a few minutes and they are always accompanied by physical symptoms like shaking, dizziness, nausea, difficulty in breathing, rapid heartbeat etc., (American Psychiatric Association, 2013). 

How Adolescents with Anxiety Might Present in Counselling

In 2011, the Australian Institute of Health and Welfare (Young Australians: their health and wellbeing, 2011) reported that anxiety disorders were the most common mental health problems affecting the Australian youth population (aged 16-24). In 2016, the Australian Bureau of Statistics (ABS) reported that 13% of women and 9.4% of men within the age group 15-24 years, experienced anxiety related problems during the year 2014-15.

Adolescents are at that stage of their life, where their mental capacities, identity and emotions are constantly changing and evolving. Individuals experiencing anxiety may present symptoms from each of the 3 main approaches- cognitive, physiological and behavioural.

Cognitive symptoms. Adolescents with anxiety may often present cognitive symptoms of catastrophizing or misinterpreting situations, excessive self-consciousness, intense worry that lasts for days (especially preceding an upcoming event) and the disturbance of their mental processes like thinking, reasoning, planning, problem-solving and recall (Kendal et al., 2004). Adolescents coming in for counselling may often describe feeling constant worry and fear about their future, health, family, social and sexual life along with disturbed sleep along with feelings of irritability, anger, confusion, embarrassment and nervousness over trivial situations (Kitchener, Jorm and Kelly, 2013).

For instance, some adolescents may show tendencies of perfectionism, such as repeatedly redoing assignments until they are satisfied with it or meticulously completing their homework. They may often talk about having thoughts of “what if…”-statements regarding a wide range of situations-in which they often exaggerate the possibility of consequences to a terrible degree, while also underestimating their own ability to cope with the inconvenient situations (Albano, Chorpita & Barlow, 2003). The clients may often express thoughts like, “I’m going crazy”; “People are judging me”; “I feel like I’m dying”, etc., which are common among individuals experiencing anxiety.

Physiological Symptoms. When a threat is detected, i.e. when an individual feels fearful or anxious, cortisol and epinephrine are released into the brain (Wood & McLeod, 2008). These biological effects then present themselves as physical symptoms such as increased heart rate and blood pressure, increase in muscle tension, excessive perspiration and changes in body temperature or trembling of hands. In counselling, the individual may talk about experiencing nausea, blurred vision, chills, shortness of breath, stomach pains, hot flashes, headaches, dizziness or body pain, which can be anxiety presenting itself physically (Beidel & Turner, 2005). A study done in 1997, by Tracey, Chorpita, Douban and Barlow discovered that young adolescents with general anxiety (within their sample size) often experienced several physical symptoms such as restlessness (74%), irritability (68%), trouble concentrating (61%), disturbed sleep (58%), headaches (36%), muscle tension (29%) and stomach pains (29%).

Behavioural Symptoms. When an individual is faced with circumstances that cause fear or worry within them, they start to avoid or escape these situations to lessen their feelings of anxiety or fear. This behaviour is then negatively reinforced by the fear being reduced by the individual’s avoidance behaviours (Borkovec, Alcaine, & Behar, 2004). The counsellor may notice (based on what is told to them by the client) that the client often participates in obsessive or compulsive behaviours; avoids or escapes from certain situations that are stress provoking; keeps silent and tries to hide in the background; always needs to be accompanied by someone when going to unfamiliar places or places that make them feel uncomfortable or even using alcohol to help calm their nerves (Sanders & Wills, 2002). These behaviours can indicate the counsellor that the client may be suffering from anxiety. Clients with anxiety related issues often require validation and approval from others as to not feel fearful or embarrassed about the decisions they make. Hence, clients might often ask for repeated reassurance when they successfully perform a task. (Eisen & Kearney, 1995).

Anxiety is a complex multifaceted network of all these components, which are all joint together by cause and effect to each other. An individual’s thoughts, feelings, physiology, behaviour and the social and physical environment they live in, all interact with one another in multiple ways and each play a role of their own in producing different anxiety problems (Sanders &Wills, 2002). Anxiety can sometimes be more prevalent in some individuals than others based on several factors such as: genetic vulnerability (e.g. if other family members experienced anxiety or anxiety related disorders); gender (females are known to be more prone to anxiety); personality (e.g. shyness, inhibition, withdrawal, sensitive emotional nature); parenting-styles (e.g. being raised by over protecting and controlling care givers or experiencing traumatic or hostile life experiences) (Merikangas, 2005; Rapee, 2012). Anxiety can also be transmitted through modelling leading to childhood anxiety. Thus, Adolescents most likely to present with anxiety are those who grew up with anxious parents (Maid, Smokowski & Bacallao, 2008). Prevalence of anxiety may be higher in individuals who come from high pressure environments where success and achievement are valued the most and/or those who come from backgrounds of low income, education and dysfunctional family environments (Lawrence et al., 2015; Rapoport & Ismond, 1996).

Issues Counsellors Can Address and What Symptoms Indicate Need for Referral

Counselling developed around the 20th century to help individuals cope with the complex, busy and constantly changing world we live in. People can cope with these problems most of the time by either talking to family, friends, religious leaders, etc. But sometimes, talking to them isn’t always helpful and some issues may be too embarrassing for the individual to talk about. This is where a counsellor comes in. Counsellors are people trained to listen to the individual’s difficulties and work together with them to help the individual understand and resolve their problems (McLeod, 2013). Diagnosing or labelling people is not the job of the counsellor, instead it is to help make their client feel heard and understood, while working with whatever makes the most sense for their client. The American Counselling Association website (2013) defines counseling as, “Counselling is a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals.”

Individuals can experience cognitive and physical symptoms of anxiety ranging from mild to severe (American Psychiatric Association, 2013). Severe mental health issues or mental illnesses cannot be treated by counsellors, especially when medical aid is necessary in order to control the symptoms. However, mild/moderate symptoms can be addressed in therapy. A counsellor can work with adolescents experiencing problems such as time management, test anxiety, procrastination, nervousness, worry, phobias, stage fright, issues with anger, etc. There are many tests and rating scales that are available for use to measure the severity of anxiety such as theHospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983), Depression and Anxiety Stress Scale (DASS) (Lovibond & Lovibond, 1995), Clinical Outcomes in Routine Evaluation(CORE) (Kessler & Mroczek, 1992), etc. Along with the counsellor’s own evaluation of the individual’s mental health, these tests can help give an idea of how severe the symptoms may be and whether a referral will be required or not. Some of the warning signs of severe anxiety are mutism i.e. inability to speak in some situations, panic attacks that occur more than once a week, experiencing severe anxiety about multiple things, having intrusive thoughts that disturb the individual, repeating behaviours with the intention of lessening the feeling of anxiety. These are severe symptoms of mental health issues and illnesses and a counsellor will need to refer the client on to someone more qualified to help the client with these issues.

However, a counsellor can also work in collaboration with a psychiatrist or other medical professional to ensure that the client is given a more holistic service.

Counselling Techniques

There are many different counselling techniques and therapies that counsellors can use to help an individual discover the primary cause of their fears or worries; learn how relax; look at situations in more positive ways and develop methods of better coping and problem solving. The type of therapies and techniques used by a counsellor may change from client to client, depending on what suits the client best as different types of anxiety require different kinds of therapy and approaches. E.g. A client with social anxiety may require a different treatment approach compared to a client who has claustrophobia (fear of closed spaces).

Cognitive behavioural therapy. It is one of the most broadly used therapy for anxiety related issues (especially in adolescents) as it is a time-sensitive, goal-oriented and structured form of psychotherapy that takes a hands-on, practical approach to solve problems (Butler, Fennell, Robson & Gelder, 1991; Hofmann & Bögels, 2006; Hofmann & Scepkowski, 2006). The aim of cognitive behavioural therapy (CBT) is to change the negative thought patterns and/or behaviours that causes anxiety within an individual and to teach them skills to modify these dysfunctional thoughts and behaviours (Clark & Beck, 2011; Hope, Burns, Hayes, Herbert & Warner, 2010; Piet, Hougaard, Hecksher & Rosenberg, 2010; Sanders & Wills, 2002). Individual therapy, group therapy and cognitive-behavioural therapy via electronic/technological devices (eCBT ) are the three main ways in which CBT can be implemented. Compared to individual and group CBT, eCBT is more well-liked among adolescents as it is more easily accessed, maintains confidentiality and safety for the user and therapist (Spek et al., 2006; Spurgeon & Wright, 2010). Also, therapies that are mediated electronically help save time and costs of travelling to and from therapy. The drawback of the above cited CBT studies, is that most of their conclusions state that CBT was not always effective in all age groups as younger adolescents found it difficult to comprehend the therapy method. Studies also show that a substantial number of individuals do not respond to CBT (Barlow, Gorman, Shear, & Woods, 2000), but the ones on which the therapy was effective, many of the individuals end up relapsing (Brown & Barlow, 1995). When working with adolescents, counsellors need to be creative and engaging in their CBT delivery skills so as to prevent the youths from feeling bored or disinterested.

Accepting and commitment therapy. This therapy (ACT; Hayes, Strosahl, & Wilson, 1999) is a mixture of mindfulness and acceptance, which help target avoidance behaviours that individuals with anxiety use. Rather than seeking different methods to change the feelings, ACT helps the individuals understand that it is okay to feel anxious and to accept it as part of their internal experience (Hayes, Strosahl, & Wilson, 1999). ACT’s main aim is to teach individuals to foster acceptance of problematic negative thoughts and feelings that cannot be controlled and commit to taking actions to live a life of one’s own choices rather than trying to get rid of unpleasant emotions that get in the way of reaching these goals (Eifert et al., 2009; Hayes, Strosahl, & Wilson, 1999). This way adolescents struggling with anxiety can learn skills to accept and understand their discomforting thoughts and feelings, instead of controlling, managing or avoiding them. Even though ACT can help with reducing stress, worry, irritability, etc., the studies mentioned above do not show overall anxiety reduction in the individual.

Relaxation techniques. These techniques help in reducing overall arousal in individuals with anxiety. Adolescents learn to become more aware of their feelings of stress and tension present in their bodies and then use various relaxation methods to decrease these uncomfortable feelings. General arousal and body tension are common symptoms of anxiety and therefore relaxation training is frequently taught to individuals with anxiety. Some common relaxation techniques used on adolescents are deep breathing exercises, guided imagery, mindfulness, meditation and progressive muscle relaxation (PMR). Jacobson’s (1948) PMR teaches individuals how to tense and relax muscles throughout their body. This helps decrease overall body tension, anxiety and stress levels. Studies show that PMR helps decrease the physical symptoms of anxiety like heart rate, blood pressure, headaches, etc. (Dalfsen, J.O.Y., 1986). Breathing retraining is another strategy that helps individuals relieve anxiety and panic symptoms as this technique helps the body relax and prevent it from going into hyperventilation or panic attacks during situations of stress and worry, by teaching the clients diaphragmatic breathing exercises (Levitt, Hoffman, Grisham, & Barlow, 2001).  

Mindfulness-Based Stress Reduction Training (MBRS) is another type of relaxation technique used mostly in individuals with social anxiety (Bögels & Voncken, 2006; Piet et al., 2010). Mindfulness teaches an individual to focus on their inner capacities in order to develop insight, awareness, wisdom and control (Kabat-Zinn, 1990; Tory, 2003). Individuals learn to look within themselves by paying attention to all aspects of their lives that they would normally overlook and this helps them move towards a path of self-understanding and healing (Kabat-Zinn, 1990). The abovementioned studies all demonstrate mindfulness based stress reduction as being useful in helping individuals lessen their anxiety, but many of the studies use inappropriate or inadequate statistics, have limited generalizability and also have a lack of active control groups. Bishop (2002) in his study says that mindfulness based stress reduction needs to be studied more as the studies do show it to be an effective method to manage anxiety and stress. 

Systematic desensitization. This behavioural technique was developed by Wolpe (1958) and it helps in alleviating types of anxiety, fears and phobias. It is a type of gradual exposure based on classical conditioning that pairs anxiety inducing stimuli with relaxation and it has been successful in treating anxiety (especially generalized anxiety) in adolescents (Kane & Kendall, 1989). This is three step method that involves identifying what causes anxiety or fear, constructing a hierarchy of items that cause fear or anxiety, teaching the client relaxation techniques and then pairing the learnt relaxation methods with gradual exposure to the hierarchy items (from least intense to most intense) (Wolpe, 1958). Exposures may start off with being imaginal and then proceed to in vivo. This method creates discomfort among the individuals at the beginning, but by placing themselves in anxiety aggravating situations, their anxiety levels start to dissipate (Falsetti & Davis, 2001; Persons, 2001). Silverman and Kearney (1991) state that this form of exposure to anxiety is most frequently used when treating childhood anxiety.

Exercise. Studies show that exercise is very effective in maintaining mental fitness and it helps reduce stress. It can help lower fatigue, improve attentiveness and boost overall cognitive functioning (Stonerock, Hoffman, Smith, & Blumenthal, 2015). Physical activities like exercise produce endorphins in the brain which are natural pain killers that help improve sleep and decrease stress (Stonerock et al., 2015). Although exercise may have a positive effect on some people, it may backfire and lead to an even worse mental health issue for others. The study conducted by Stonerock et al. (2015) shows that even though numerous studies show positive results for exercise as a treatment for anxiety, many of them had methodological limitations and were conducted on small sample studies with inadequate fitness levels. They all stated that exercise may be useful as a treatment for anxiety, but they still lack a lot of data and definite conclusions (Stonerock, Hoffman, Smith, & Blumenthal, 2015).

While anxiety is one of the most prevalent and pressing issues that the youth in Australia face, there is limited research supporting the treatment plans and its effectiveness. Hence, as counsellors we should encourage further research in this direction and actively take up on ourselves to work towards minimizing anxiety.

References

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Appendix

Study Guide

  • Describe the difference between stress, fear, and anxiety.

The emotional and physical responses for all three states are similar. Subtle and not-so-subtle differences between stress, anxiety and fear can be observed. These three states are important for an individual as they help prepare their body to react to forthcoming threats.

Stress is the body’s reaction to pressures of life and to events or situations that upset the normal balance in life. Stress can be caused by something physical that is caused by the external world, or by something that is generated emotionally inside an individual. The feelings of stress are often described as being overwhelmed, worried or tired (Selye, 1956; Daines, B., Gask, L., & Howe, A., 2007).

Fear is the emotional response towards a certain or known threat. It is the perception of danger. This emotion helps the body deal with the threats and remain in a state of flight-fight-freeze to keep itself safe. Fear and anxiety are closely related and each can trigger the other (e.g. A past fear can be a trigger for anxiety in the present). When experiencing fear, individuals often also experience physical reactions that are categorized under anxiety (Daines, B., Gask, L., & Howe, A., 2007).

Fear can cause anxiety and anxiety can cause fear. Anxiety is an emotion that is characterized by feelings of stress, troubled thoughts, and physical changes in the body, such as heightened heart rate and blood pressure (Kazdin, 2000). Fear and anxiety are often used interchangeably. However, fear is an uncomfortable emotion towards a specific imminent threat, while anxiety is fear over the anticipation of a future known or unknown threat that is almost always accompanied by feelings of impending doom (American Psychiatric Association, 2013). Anxiety may develop gradually or suddenly and excessive stress can often make it worse (Rapoport & Ismond, 1996).

In short, fear is directed at a clear and present object, anxiety is a state of being constantly fearful or anxious about future uncomfortable situations- it is a vague tense feeling of dread and stress is when there is pressure put upon a person’s physical and mental states (also see, Sanders & Wills, 2003).

  • How is that anxiety and phobias are maintained? What keeps anxiety and phobia going?

Anxiety is a feeling of worry, nervousness or unease about something known or unknow that may happen in the future. Whereas phobias are an extreme, irrational fear towards a particular object or situation. Environmental situations like work, performance roles and relationships can play a significant role in causing an individual to feel continuous anxiety or phobia. Anxious feelings, thoughts, behaviours, fears and physiology interact with each other and create a never-ending cycle of ongoing anxiety and/or phobia (Sanders & Wills, 2002). As anxiety is worry of a potential threat that may happen, the individual stats paying attention to possible signs of threats and then tries to see if they can cope with the threat. When anxious symptoms are noticed by the individual, they automatically think they won’t be able to cope with the situation and this leads to them feeling more anxious. When an individual with a phobia sees, or is reminded to the object/ situation that created fear in them, their body goes into flight-flight-freeze mode, which results in them experiencing many different sensations. This feeling then confirms to them that they are in danger (Sanders & Wills, 2003).

Activity

  1. Find three apps on the Google Play Store, the Apple App Store, or the Windows App Store that are helpful for individuals managing their anxiety.
  2. Smiling Mind
  3. SAMApp
  4. Anxiety Free
  5. Use one of these apps over the next week. What changes did you notice in your mood?

I used the Smiling Mind App which is an app that uses mindfulness to help decrease anxiety. Listening to the daily mindfulness sessions and following the exercises really helped reduced my anxiety and stress. It calmed me down and helped me feel more relaxed so I could concentrate better on my work. I found that I often feel really irritated and angry at myself and let my emotions get the best of me and following the daily meditation at night before bed, really helped me calm my nerves and helped me sleep better.

  • What support groups are available in your local community for individuals suffering from anxiety related issues?
  • Monash Counselling Services at Campus Centre
  • Mental Health Online

This website provides online information, assessments, referrals and treatment for anxiety and depressive problems. There are treatment programs (either free online self-help guides or weekly help from a professional at a cost) that are available for anxiety related problems and disorder.

  • Lifeline 24-Hour Counselling and Crisis Support Chat

Trained volunteer counsellors are available 24 hours a day, 7 days a week for help people suffering from mental health problems.

Phone: 131114 Website: www.lifeline.org.au/crisischat

  • Mental Illness Fellowship of Australia
  • This is a not-for-profit, self-help, support and advocacy organization that is dedicated to helping people with serious mental illnesses, their family and friends. Website: www.mifa.org.au/

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