Anxiety in Adolescents Dr. David Wood Dr. Matthew Tolliver 11/8/18
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§ionid=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: [email protected]
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).