Adolescent psychopathology is an area that is often in need of research

 

 

 

Analysis of Research Regarding Adolescent Generalized Anxiety Disorder

 

Kristy Suriano

Department of Education

 

 

Adolescent psychopathology is an area that is often in need of research.  Although various studies have concluded that 15-22 percent of children have mental health problems and need treatment (Costello, 1990; Tuma, 1989), much of the previous outcome research has focused exclusively on the adults and the available treatments that have been proven effective for this population.  However, researchers have acknowledged the paucity of adolescent treatments and have begun to focus on adolescents and their psychopathology.  The following is a presentation of several of the available studies regarding adolescent generalized anxiety disorder.           

Many school-aged children are treated today for externalizing issues, such as attention deficit disorder, while the students who deal with internalization issues are often overlooked.  According to Werry (1986), 10-20 percent of school aged children are in need of treatment for internalization problems which includes anxiety, isolation, depression, and self-consciousness.  While the internalization problems are often grouped together, the need to examine each individually is crucial.  An example of internalization disorders are anxiety disorders.  Anxiety disorders have a myriad of subtypes of disorders that are often categorized and researched separately. “However, there is considerable overlap in symptoms among the various DSM anxiety disorders (e.g., avoidant disorder and social phobia, overanxious disorder and generalized disorder); and as a result, two or more of the disorders can be diagnosed in a particular child or adolescent at the same time” (Ollendick & King, 1994, p. 918). Nevertheless, the need to focus and divide the anxiety disorders into separate categories will help to diagnose an adolescent and move on to further treatment.  The DSM IV denotes one category of an anxiety disorder as generalized anxiety.  This disorder is typically viewed as an adult disorder, yet children and adolescents can and do suffer with it (Ollendick & King, 1994).  Although many of the anxiety disorders do exist in adolescents, the present review focuses on generalized anxiety disorders (GAD) and the outcome research that has been effective in helping adolescents deal with this disorder. 

Generalized anxiety disorder is an excessive and uncontrollable worry about daily activities.  This continuous worry impedes everyday functioning and can manifest into physical symptoms.  “Worry has been defined as a chain of thoughts that are negative in content, predominantly verbal, and aimed at problem solving” (Wells, 2002, p. 179, as cited in Borkovec, Robinson, Pruzinsky, & DePree, 1983).  The excessive amount of worry associated with GAD is also mostly uncontrollable and often non-discriminatory of the topic of worry.  As opposed to an adolescent with social anxiety who fears social situations, an adolescent with GAD worries about many different situations (not discriminatory of one particular situation) as well as about worry itself.  Worry about worry is known as meta-worry or Type 2 worry in which the person is overly concerned about their worry (Wells, 1994).  A negative belief about worry itself is also a central feature of GAD, which includes negative self statements, automatic thoughts, and negative misinterpretations. 

Additional behaviors associated with an adolescent diagnosed with GAD includes worry about family, health, finances as well as more mundane issues such as car repairs, being late for school, or even chores or other responsibilities.  The focus of worry can shift often, while the intensity, duration, and frequency of the worry are disproportionate to the issue itself.  Worry also interferes with the adolescents’ ability to concentrate and to perform daily tasks (Anxiety Disorder Association of America, 2002).  Although in “normal” development adolescents may have worries, yet “concern arises when childhood fears and worries become so severe as to interfere with appropriate activities or have a negative impact of the child’s relationships” (Kane & Kendall, 1989, p. 500).  The DSM IV system of classification may help to determine adolescents who have abnormally intense worries beyond the “normal” developmental stressors.  Constant worry also may lead to physical symptoms such as nausea, jumpiness, gastrointestinal discomfort, perspiration, and fatigue (Kendall, Chu, Pimentel, & Choudhury, 2000). 

The prevalence of GAD might also have to do with parents or grandparents who have similar anxiety-related disorders. One example is demonstrated by Last, Phillips, and Statfeld (1987) who examined the prevalence of adolescents with separation anxiety disorders (SAD) and overanxious disorders (OAD) with mothers who have also been diagnosed with SAD or OAD.  The presence of depression and a panic disorder or agoraphobia in a parent adds an additional risk of an adolescent to acquire an anxiety disorder and depression (Weissmann, Leckman, Merikangas, Gammon, and Prusoff, 1984, as cited in Kendall, 1994).  This example of mothers with SAD and OAD also applies to a more generalized anxiety and patterns of interaction with their children. Adults with GAD might displace their anxiety onto their children.  Adolescents who have physical complaints may be subtly encouraged to continue these behaviors if their parents continue to be insistent upon repeated medical evaluation of anxiety-related somatic complaints such as abdominal pains or headaches (Carr, 1999).  Additionally, parents who are overly worried about their own health may displace their anxiety onto their children.  These studies demonstrate that parental psychopathology and mental illness may be associated with an adolescent’s anxiety disorder.

Generalized anxiety is often not a confined disorder and adolescents may experience a variety of additional stressors or psychological difficulties that complicate their already existing anxiety. The issue of comorbidity, “the co-occurance of one or more disorders in the same child or adolescent at the same time,” may possess significant implications for treatments, in that adolescents with comorbid disorders may have different treatment needs than those adolescents with a single disorder” (Ollendick & King, 1994, p. 919). Research has demonstrated that 12 percent of adolescents with anxiety disorders are comorbid with depression, 15 percent with oppositional defiant disorder, 14.8 percent with conduct disorder, and 17 percent with attention-deficit/hyperactivity disorder (Brady & Kendall, 1992, Carr, 1999, Kendall, Kortlander, Chansky, & Brady, 1992).  Additionally, 33 percent of the cases of overly anxious, depressed and separation anxious adolescents had a concurrent psychiatric disorder of dysthymia (Kovacs, Paulauskas, Gastonis, & Richards, 1988, as cited in Ollendick & King, 1994).   Although most commonly associated with generalized anxiety disorder are other, more specific, anxiety disorders (in 50-75 percent of cases), GAD can be coupled with several other psychopathological disorders. Most often, patterns of comorbidity with anxiety disorders, depression and disruptive disorders seem to be the rule rather than the exception (Ollendick & King, 1994).  Additionally, adolescents who are comorbid often report more general psychopathology than those with pure anxiety disorders alone (Bernstein, 1991, as cited in Ollendick & King, 1994).  The existence of comorbid diagnosis reveals the need for treatment “to be applied somewhat flexibly based on a number of factors and symptoms (Kendall, Chu, Pimentel, Choudhury, 2000).

 

Generalized anxiety disorder and cognitive-behavioral therapy

The literature and current research on the treatment of anxiety disorders with adolescents is growing.  However, as mentioned previously, many of the studies are conducted with adults and then applied to adolescents.  Although many of these general treatments are proven to be effective with adolescents, all treatments must take into consideration the adolescent’s age, sex, age of onset of disorder, duration of disorder, comorbidity, family dysfunction, socioeconomic status, as well as several other aspects. 

Upon examining several previously performed research studies and illustrated treatments, many of the authors (Ollendick & King, 1994; Kazdin & Weisz, 1998; Kendall, 1994; Kane & Kendall, 1989) seem to have reported that some forms of cognitive-behavioral interventions are necessary in the treatment of generalized anxiety disorder. Although each author describes his/her own version of restructuring thoughts or changing behaviors, there are common features involving education and behavioral exposure.  Kazdin and Weisz (1998) believe that as part of the educational element of treatment, adolescents must learn about the biological arousal that is associated with their anxious feelings.  They may essentially begin to identify their own distinctive pattern of behaviors, such as abdominal pain, sweating, dry mouth, and eventually learn specific skills (such as relaxation) to manage their biological responses to anxiety.  Upon identifying behaviors related to anxiety, adolescents may begin to test and modify negative cognitions that are also associated with anxiety.  Finally, it is an essential component of cognitive-behavior therapy for the adolescent to gain exposure to the anxiety-related object(s). “Therapists work with children, and sometimes with their family members, to set up encounters with anxiety-arousing events and situations, typically low grade at first but often progressing to highly anxiety arousing (e.g. speaking in front of a group)” (Kazdin & Weisz, p. 23).  Adolescents are encouraged to challenge their anxiety-related causes by in vivo or imagination.  In vivo or using one’s imagination entails placing the adolescent in a fear evoking situation.  When the adolescent is in this situation either through imagination or real exposure, the counselor can help the client acclimate to the distressing situation as well as provide opportunities for the adolescent to practice his/her coping skills.  Exposure to anxiety-related stimuli can be done gradually, where the adolescent can develop mastery over time, or by flooding, in which the adolescent participates in repeated and prolonged exposure to the stimuli until his/her anxiety diminishes.   It is important to note that flooding is typically used in concurrence with response prevention, in which the adolescent is not permitted to avoid the anxiety-related stimuli (Kendall, Chu, Pimentel, and Choudhury, 2000).

Session exercises and homework related to these activities may also encourage the reduction of anxiety.  Kane and Kendall (1994) follow a similar pattern for reducing adolescent generalized anxiety.  The authors break the previous sections of CBT into four major components:

a)      recognizing anxious feelings and somatic reactions to anxiety,

b)      clarifying cognitions in anxiety-provoking situations (i.e. unrealistic or negative attributions or expectations)

c)      developing a plan to cope with the situations (i.e. modifying anxious self-talk into coping self-talk as well as determining what coping actions might be effective?)

d)      evaluating the success of the coping strategies and self-reinforcement as appropriate (p. 501- 502)

 

Aside from the cognitive training strategies listed above, Kane and Kendall suggest using behavioral strategies such as modeling, role playing, and relaxation training.  It is crucial to first help the adolescent gain and master the skills needed to reduce anxiety and then practice these skills through imaginal or in vivo experiences.  During the sessions, social reinforcement by the therapist and family members included in the training of such skills should be used to reward and encourage the adolescent.

            Another important aspect of using cognitive-behavioral therapy with anxiety disorders in adolescents is the concept of self-talk.  Self-talk is simply the things that adolescents say to themselves when they are feeling anxious and often includes the adolescent’s acknowledgment and expectations of him/herself.  The expectations and attributions are often negative and at times are perfectionist standards of performance.  Kendall, Chu, Pimentel, and Choudhury (2000) have stated that “the way one thinks about things affects what he or she might feel or do in that situation” (p. 263-264).  One technique used to introduce the concept of self-talk and allow the student to begin to alter his/her cognitions is the idea of cartoons.  The cartoons can appear on a paper with empty thought bubbles for the adolescent to fill in their own thoughts.  At first, the bubble can be filled with non-threatening scenes and eventually move towards more anxiety-provoking situations.  The adolescent can also begin to generate anxiety-reducing (coping) thoughts for the characters. The therapist may also ask questions to help the adolescent generate self-coping statements.  “The therapist guides the child through an empirical, hypothesis-testing process in which both work to challenge the assumptions and beliefs that lead to anxiety and distress” (Kendall, Chu, Pimentel, and Choudhury, p. 264).  Positive self-talk is also a way in which adolescents can gain confidence and practice being in an environment that is less anxiety filled.  Consequently, using the cognitive-behavioral therapy plan, an adolescent is now able to recognize his/her physical symptoms of anxiety, recognize negative self-talk, use relaxation techniques and use positive self-talk to help him/her gain more control over his/her anxiety. 

            The cognitive-behavioral model also connects to another model, which includes parental involvement, and can be used in conjunction with CBT to further aid the adolescent in overcoming his/her generalized anxiety.  Although CBT focuses primarily on the individual and his/her pattern of thinking and behavior, parents and other family members or close friends are encouraged to participate by taking a supportive role.  In dealing with adolescents, parents are usually involved from the onset and must be active in making decisions for treatment plans.   Information is provided to the parents so that their understanding of their adolescent’s disorder is complete and they will be able to discuss any concerns about their adolescent.  The parent’s role may take several forms such as: being informed and thus, can explain certain aspects of GAD and the process to their child; being actively involved in one or several of the therapy sessions and encourage their child to continue facing their anxiety-related stimuli; or be observant to their child’s behavior at home and complete checklists such as the Child Behavior Checklist (Achenback & Edelbreck, 1983, as cited in Eisen & Silverman, 1993) the Parent Weekly Records, or the Parent Ratings of Severity (Eisen & Silverman, 1993).  In general, the parent’s role is two-fold.  First, they can become knowledgeable about the disorder and the techniques utilized by the therapist. Second, parents can focus on helping the adolescent practice these techniques at home or in any anxiety-related situation. It is crucial to note, however, that “given the important role that parents can play in their child’s treatment, therapist should be aware of the particular problems that families of anxious children may be experiencing” (Kendall, Chu, Pimentel, and Choudhury, 2000, p. 272).  These problems may include parents with anxiety disorders, over-protectiveness, or excessive guilt about the adolescent’s disorder.  Therapist would have to carefully deal with these issues in another manner. 

The evidence that has demonstrated the effects of CBT for adolescent generalized anxiety has been and currently is encouraging.  Controlled and randomized clinical trials have shown valuable effects at posttreatment. Support for CBT includes evidence that has shown that many pertinent studies conducted have:

 

1.                            focused on cases serious enough to warrant formal diagnosis, based on standardized assessment procedures, and cases involving comorbid conditions

2.                            included assessment of clinical significance, and striking reductions have been shown in the percentage of treated youth who qualify for anxiety diagnoses

3.                            tracked treated youth over longer posttreatment follow-up periods that most studies have shown that gains made by treated youth hold up well

4.                            suggested that reductions in children’s anxious self-talk do indeed mediate change in anxiety associated with the treatment.

5.                            been supported by studies conducted in the United States, Australia and multicultural areas (Kazdin & Weisz, 1998, p. 23).

 

 

Generalized anxiety disorder and psychoanalytic therapy

The psychoanalytic perception of generalized anxiety disorder is that the defense mechanisms one develops as a young child are used to keep unacceptable emotional and/or psychological responses- such as sadness, sexual impulses, or feelings of anxiety- from entering a conscious state.  Thus, the unacceptable feelings and related anxiety become “transformed into neurotic anxiety and expressed as an anxiety disorder” (Carr, 1999, p. 427). The psychoanalytic view of anxiety is that an adolescent displaces his/her anxiety upon a substitute object, which is a symbol of the real anxiety that is felt.  “In generalized anxiety disorders, the defenses break down and the person becomes overwhelmed with anxiety as the unacceptable impulses continually intrude into consciousness and seek expression” (Carr, 1999, p. 427).  The overwhelming anxiety of the environment is placed upon almost every object. 

One of the more popular case studies conducted in psychology emphasized anxiety in children.  The case of Little Hans performed by Sigmund Freud was described as a fear Hans had in leaving the safety of his home and parents upon witnessing a violent scene in the street.  Freud interpreted Hans’s fear using the Oedipal model in which Freud believed that Hans would not return to the street because of his own unconscious feelings of violence and competitiveness towards his father. This early study was believed to be true, yet there was or is no empirical evidence for the reason why Hans would not leave his house.  Therefore, although significant in the history of anxiety disorders, the psychoanalytic view does not employ as much empirical background as cognitive behavioral therapy in pursuit of treatments for anxiety disorders.

Two early American behaviorists conducted an experiment to counter Freud’s explanation of the development of fear.  Watson and Raynor (1924) described their work with another child, Little Albert, whom they taught to fear a rabbit after repeated pairings of the rabbit and a loud noise.  Thus, the behaviorists demonstrated that fear can be classically conditioned within a human.  However, Dadds (1995) notes that “attempts to replicate Watson and Raynor’s demonstration of phobias learned in a laboratory have largely been unsuccessful” (p. 62).  Despite the failure to replicate the experiments conducted by Freud, Watson and Raynor, these case studies have been highly influential as landmarks in the developments in clinical psychiatry and psychology (Dadds).

            With understanding of the psychoanalytic view of anxiety disorders, a counselor must then initiate treatment with an adolescent using individual psychodynamic psychotherapy.  The overall goal of this type of therapy is to discover the defense mechanism being used, interpret the concealed feelings that are being repressed (held back) and understand the associated neurotic anxiety.  The therapist brings to the adolescent’s attention the parallel between his/her relationship to the therapist, past relationships with parents and present relationships with other significant people in his/her life.  This type of therapy is reported as being “clinically useful when working with anxious children” because often times children say that they are worried about one thing when in fact, they are anxious about something else (Carr, 1999, p. 427).  However, the psychoanalytic theory for treatment of generalized anxiety disorder is not empirically supported by many studies.  Carr reports that “there is no evidence to support the idea that all anxiety disorders represent displacement of anxiety associated with psychosexual developmental conflicts” (p. 427).

 

Summary and Future Research

The use of cognitive-behavioral therapy with adolescents who have generalized anxiety disorder has been the main focus of much of the literature and outcome research and appears to be the most effective in the clinical studies.  CBT is not only effective for short term improvement, but for long-term cognitive and behavioral change in adolescents as well. Several therapeutic techniques such as educating the adolescent about his/her disorder, modeling, in vivo and imaginal exposure, relaxation techniques self-reinforcement, and self-talk, have demonstrated through clinical trials positive results in the area of adolescent anxiety disorders.  Early intervention through knowledge about the symptoms and the genetic factors that pertain to generalized anxiety disorder can also aid in discovering the patterns of onset.  “Such vulnerabilities, combined with environmental adversities (e.g. parental psychopathology, marital discord, parent-child interactions, peer rejection, and school failure) could occasion the emergence of such [a] disorder” (Ollendick & King, 1994, p. 924).

            Among the variety of counseling/therapeutic theories and strategies that are available to use to treat generalized anxiety disorder, the psychoanalytic theory has proposed that anxiety is a result of unacceptable feelings and impulses.  Displacement is the key defense mechanism that is used by adolescents to substitute the unacceptable impulse for another object which he/she is frightened. The main treatment using the psychoanalytic theory, as stated previously, is psychodynamic psychotherapy.  Interpreting the defense, the hidden feelings which are being repressed, and the associated neurotic anxiety are therapeutic ways to discover the true reason for anxiety. Although the psychoanalytic therapy may help to uncover hidden anxiety, there is no evidence to convey the fact that anxiety disorders are representations of displacement of anxiety associated with psychosexual conflicts.  Therefore, the therapist who employs the psychoanalytic theory and outcome strategies to treat generalized anxiety disorder should be directed to the existing literature and empirical studies that directly demonstrate the positive outcomes found in treating adolescents with the cognitive-behavioral method and theory. In sum, while the psychoanalytic theory can be clinically useful in some cases and has been influential in the history of psychology, the outcome research has confirmed more efficient ways to treat generalized anxiety disorders.

            Future research in the area of treating generalized anxiety disorder can be directed towards using a developmental perspective within the cognitive-behavioral structured therapy.  One of the most distinguishing characteristics of adolescence is change and therefore the concept of development implies “systematic and successive changes over time in an organism” (Lerner, 1986, as cited in Ollendick & King, 1994, p. 924).  Changes that occur during adolescence have a direct or indirect impact on development.

Developmental psychopathology is an emerging discipline that must play an essential role in the evolution of such disorders.  In addition to focusing on development, future studies can be directed towards increasing the number of studies conducted with adolescents who have generalized anxiety comorbid with other pathologies. These studies should provide more focused ways to treat adolescents as well as a more defined theory of preventative measures that can be taken with the adolescent population.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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