Supervised by: Ellen Froustis MA, MSc. Ellen Froustis is a DPhil. Education candidate at the University of Oxford. She has a Master’s of Education-Special Emphasis School Counselling and a Master’s in Clinical Psychology. As the founder and director of EIMAI, and regional director of Peace Jam Greece, Ellen provides youth leadership development programs, bringing together youth with Nobel Peace Laureates and university students to create positive change in themselves and their communities. Ellen has served as General Secretary of the Greek Adlerian Psychological Association (2012-2016) and Vice President of Habitat for Humanity, Greater Athens (2006-2010). Ellen’s work with youth and schools has been awarded by the Near East Council of Overseas Schools, The Loukoumi Make A Difference Foundation, The Nobel Peace Laureate’s Billion Acts of Peace and Character.Org for best practices in character education.
There are many changes going on in the lives of teenagers from physical, social, emotional, psychological, relational and academic perspectives, all of which can cause anxiety. About one-third of adolescents are said to suffer from anxiety disorders (NIMH, 2022). The Oxford Scholastica intern group explored the research question: “What are some of the major causes of anxiety prevalent in teenagers and effective ways of treating it?” A review of literature identified that the most common types of anxiety disorders are generalised anxiety disorder, school anxiety, social anxiety, social appearance anxiety, adjustment disorder and, less common but more intense, panic disorder. Reviewing treatments from 14 open-access journal articles, CBT was the most common treatment found across anxiety disorders. ACT was commonly used for self-esteem-related anxieties such as social appearance anxiety and adjustment disorder. Self-help methods such as mindfulness-based mediation, EFT, and mandala colouring worked well in the short term but are more effective in combination with psychotherapeutic treatments that address the core of the problem. CBD as a medicinal option is said to be promising, as it is non-addictive and does not have side effects like traditional SSRIs, but needs more research to grow the evidence base. Internet versus therapist-led CBT was also prevalent; however, therapist-led options were more successful in sustaining individuals through therapy, whereas self-led internet modules had higher dropout rates. Overall, access to timely diagnosis and treatment with support from the home and school environment is key to managing anxiety and other mental health disorders in adolescents.
There are many changes going on in the lives of children when they become teenagers from physical, social, emotional, psychological, relational and academic perspectives. There are also many things in the adult world that affect their lives that they have no control over. As a result, adolescents often experience mental health issues, particularly anxiety, as they attempt to manage it all. Approximately 31.9% of U.S. adolescents aged 13-18 have had an anxiety disorder, with a higher rate observed in female adolescents (38.0%) than adolescent males (26.1%) (NIMH, n.d.). In the UK, results from a national survey of 2,395 British teenagers aged 13-19 found that 27% felt ‘nervous, anxious or on edge’ most or nearly all the days of the previous fortnight (Mental Health Foundation, 2022). In Europe, anxiety and depression account for more than half (55%) of the nine million adolescents (aged 10 to 19) (UNICEF, 2021).
When anxiety is not temporary due to normal stressful situations that get resolved, it can turn into disorders, where anxiety is experienced frequently, interrupting normal daily functioning. The most common type of anxiety disorders that adolescents experience are generalised anxiety disorder, social anxiety disorder, separation anxiety disorder and panic disorder, to name a few. Based on a U.S. survey by NCS-A, the prevalence of each anxiety disorder amongst 10,123 adolescents was: 9.1% for social anxiety disorder, 7.6% for separation anxiety disorder, 2.3% for panic disorder, and 2.2% for generalised anxiety disorder. Specific phobias (fears of specific situations or objects) however, were overwhelmingly as high as 19.3% (Siegel & Dickstein, 2011).
The main difference between normal stress, anxiety and anxiety disorder is whether it is a healthy reaction or a pathological one. Brief anxiety and stress are normally regarded as healthy emotions that alert people that something important must be managed, such as passing an important exam or meeting a close deadline for an assignment. If the task or situation is managed well, resilience occurs, and we build a capacity to manage more things (Perry and Winfrey, 2021). We see this in athletics, academic work, high-risk professions and so on.
Some individuals who experience frequent excessive anxiety beyond their capacity to manage it may develop anxiety disorders that can result in avoidance of stressful situations. Anxiety disorders are a type of mental illness characterised by apprehension, vulnerability, tension and dread (Achint, 2022). In this situation, people develop negative and ineffective reactions to a situation, whether a threat is real or perceived, causing anxiety during their everyday lives. It is estimated that up to 33.7% of the population are influenced by an anxiety disorder during their lifetime (Borwin and Michaelis, 2015).
Stress and anxiety produce physiological reactions, which is why people feel distress. From a biological view, as explained by Wlassoff (2017), the cortex’s older regions, where emotion processing predominates, are where anxiety happens. The “limbic system” is the collective name for several anatomical brain parts. The hippocampus is a key component of the limbic system and is essential for controlling the hypothalamic-pituitary-adrenal (HPA) axis and the stress response. Neurogenesis and hippocampus expansion are both crucial for the growth of resilience to stress and anxiety. The amygdala, however, may be the most important component of the limbic system that is fundamental to the control of emotions. The amygdala has been demonstrated to be hyperactive in anxiety disorders and is crucial for the generation of fear and anxiety-related memories. It has strong connections to the hippocampus, thalamus, and hypothalamus, among other brain regions. Most anxiety disorder cases develop in childhood, where the long-term and repetitive experience of anxiety leads to changes in specific brain structures that can be observed using neuroimaging. Functional magnetic resonance imaging (fMRI) studies on generalised anxiety disorder (GAD) have shown a higher level of activity in the ventrolateral prefrontal cortex. Furthermore, a significant level of activity is seen in the amygdala, especially when a person is told to focus on their stress, as well as changes in the cingulate cortex and insular cortex (Wlassoff, 2017).
There are three neurotransmitter systems that are most implicated when clinically effective medicines are prescribed to treat anxiety. These three are (1) GABA, especially the benzodiazepine receptor complex; (2) Noradrenaline, especially within the locus coeruleus; and (3) Serotonin, in the amygdala and dorsal raphe nuclei (Wlassoff, 2017).
In addition to medication, some of the treatments that are available for stress and anxiety are self-help methods, such as mindfulness/meditation, breathwork, emotion-focused therapy (EFT) and therapist-led treatments, such as cognitive behavioural therapy (CBT), exposure therapy, acceptance and commitment therapy (ACT), to name a few. How and when we use each one of them depends on the type of anxiety disorder that someone has. For example, CBT has been found to be a very effective method for treating symptoms of generalised anxiety disorder (GAD) (Lewis et al., 2012), and ACT is very effective in self-esteem-related issues, such as social appearance anxiety (Shepherd et al., 2020).
When anxiety is due to traumatic stress, it can have life-long consequences because the brain develops a sensitivity to even the slightest stressors, causing anxiety in situations that people with a stable development might not see as threatening (Teicher et al., 2016). The earlier anxiety is treated in young people, the better the outcome. They can better learn how to manage both the real and perceived sources of their distress (Perry and Winfrey, 2021). In trying to understand all the ways that anxiety affects adolescents and how it best can be treated, we explored the following research question: “What are some of the major causes of anxiety prevalent in teenagers and effective ways of treating it?”
This review of literature examines prevalent anxiety disorders in adolescents and the most effective methods of coping with them and treating them. They include: generalised anxiety disorder, school anxiety, social anxiety, social appearance anxiety, adjustment disorder, and panic disorder. Comparisons will be made across psychotherapeutic treatments, but also self-help methods, which will later be discussed.
Students have always understood the anxiety of taking exams, feeling “butterflies” in their stomach or drawing a blank and forgetting answers to test questions that had been studied. School anxiety is a condition that can affect students of all ages. It can manifest as an excessive fear of school and the activities associated with it, such as taking tests, making friends, or speaking in public, such as during class presentations. School refusal, an emotional and behavioural response to school anxiety, is not a recognised mental health diagnosis. However, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) notes that it can be associated with several other diagnoses, including social anxiety, generalised anxiety, or even specific phobias, with different symptoms for each. (APA, 2013). The symptoms can be behavioural – such as refusing to go to school – emotional – such as feeling sad or fearful – and physical – such as having a headache or stomach ache.
School anxiety can interfere with one’s academic life and performance and can be quite prevalent, even if it has not been diagnosed. A study by Mazzone et. al (2007) on the prevalence of school anxiety among high school students in Italy showed that there was an abnormally high level of self-reported anxiety. This rose with age from elementary school through high school and was negatively correlated with academic achievement.
Treatment for school anxiety includes, most commonly, cognitive behavioural therapy (CBT), dialectical behavioural therapy (DBT) or, in severe cases, medication is prescribed such as selective serotonin reuptake inhibitors (Wlassoff, 2017; Herzig-Anderson et al., 2012). Other techniques can be used to lower anxiety such as mindfulness, yoga and other self-help techniques such as colouring mandala art (Sherrell, 2022). In a study by Rose & Lomas (2020), 150 students between the ages of 17 and 18 who were taking their final exams filled out questionnaires about their levels of state anxiety (STAI) and mindfulness (SMS) both before and after spending 12 minutes free-drawing, colouring a mandala, or doing both while listening to recorded mindfulness instructions. Prior to and immediately after the 12 minute colouring intervention, their heart rate (HR) was monitored. Although the results are not yet conclusive, based on early data, it appears that mandala colouring reduced the students’ heart rates and anxiety levels. This means students can self-soothe and distract their anxious thoughts before important school tests through mandala colouring, which is becoming more accessible, with more books on the market these days.
Aside from self-help for normal school anxiety, researchers have also explored providing interventions in schools. A study by Herzig-Anderson et al. (2012) applied empirically established anxiety disorder treatments in schools to adolescents who would not otherwise receive care or essential interventions. A comparison of the effectiveness of interventions was made between CBITS (Cognitive-Behavioural Intervention for Trauma in Schools) and SASS (Skills for Academic and Social Success). After the treatment interventions, 80% of the control group continued to meet the criteria for an anxiety disorder, versus only 25% of the CBT group and 94% of the SASS group. This indicates the importance of establishing stress and anxiety interventions in schools and supplementing them with changes in rules and policies that create unnecessary stress for students, keeping in mind the impact of trauma on the lives of students and the need to support them to manage their behavioural and emotional responses to stressful situations in schools.
Emotion-focused therapy (EFT) is another form of treatment that has not been extensively explored until recently but might be especially helpful for students struggling with anxiety due to a possible negative school environment. A recent study by O’Connell et al. (2020) focused on the school environment by offering students the opportunity to have individual sessions with their student council in order to experience the effects of EFT over a brief period of time. Overall, 15 participants, who all experienced symptoms of GAD, took part in this experiment and had around 8 sessions each. At the beginning of each session, the participants filled out two tests, the GAD-7 and the Penn State Worry Questionnaire – Past Week (PSWQ-PW), in order to track the changes experienced during the course of this experiment. In this study, the main technique used was the Empty Chair Technique. Since GAD is characterised by extreme worry, this technique was used so the participants could properly put in words what it was that was causing them to worry so that they can feel the effects of this worry and be able to experience helpful emotions in order to diminish their worries.
As talking about emotions is often a stressful or even shameful thing for teenagers, a technique such as this one offers the perfect way for them to express themselves in a safe environment. The results speak for themselves. At their pre-test, their GAD-7 results were an average of 13.13, which dropped to 6.39 at their post-test. A significant decrease was also observed in their PSWQ-PW scores. Pre-test scores indicated an average of 66.47, which fell to 47.07 at the end of their sessions. The qualitative analysis also showed exciting results. Positive changes in the categories of decreased anxiety, improved confidence, increased resilience, and better self-awareness were noted.
This shows that EFT could be an effective therapy alongside others such as CBT if more studies are conducted over longer times along with actually diagnosed participants. This study only contained people who experienced symptoms of GAD but hadn’t actually been diagnosed. If EFT were to be offered at schools, it might provide more safe spaces for students who struggle with anxiety disorders but have no way to express themselves.
Social anxiety disorder affects more than 19 million people in America today. It is the third most prevalent mental health disorder in the nation and the most prevalent anxiety disorder (Polaris Teen Center, 2019). It has an estimated lifetime prevalence of 12% (Kessler et al., 2005). Social anxiety disorder (SAD) becomes apparent in adolescence and affects one out of every three adolescents between the ages of 13 and 18 (Lewis et al., 2021). People with clinically heightened social anxiety avoid social events out of fear of being scrutinised by others, which causes distress and dysfunction (Leigh and Clark, 2018). Although they may be aware of the unreasonableness or irrationality of their worries, they may still feel helpless to overcome them.
The causes, symptoms, and impact of social anxiety disorder vary from person to person. However, some common situations that people with this disorder tend to have trouble with are: talking to strangers, speaking in public, dating, making eye contact, going to social gatherings, eating in front of others, starting conversations, and going to school or work. Some of the most common physical symptoms of social anxiety disorder are blushing, nausea, excessive sweating, trembling or shaking, difficulty speaking, dizziness or light-headedness, and a rapid heart rate (Leigh and Clark, 2018).
However, those that face social anxiety disorder aren’t only limited to physical symptoms – they face a number of psychological symptoms as well, such as worrying intensely about social situations, stressing for days or weeks before an event, avoiding social situations, worrying about embarrassing themselves in a social situation, hesitance to talk to others, extreme self-consciousness, and missing school or work because of anxiety. Some more intense cases of social anxiety can cause people to have more extreme psychological symptoms, such as worrying about asking a question or even eating in public. It is unclear what specifically causes social anxiety. The theory that it is brought on by a confluence of genetics and environmental factors is supported by current research. Negative experiences such as criticism, bullying, family conflict, sexual abuse, and emotional abuse can also cause a social anxiety disorder (Higuera, 2016).
A study conducted by Goldin and Gross (2010) focused on the effects of mindfulness-based stress reduction (MBSR) on emotion regulation in social anxiety disorder. Mindfulness-based stress reduction is an eight-week evidence-based program that delivers intensive, secular mindfulness training to those who are struggling with stress, anxiety, depression, and pain. It is a well-known method that has been proven to reduce symptoms of stress, anxiety, and depression. The study focused on MBSR-related changes in the brain-behaviour indices of emotional reactivity and control of negative self-beliefs in SAD patients since the disorder is characterised by emotional and attentional biases as well as exaggerated negative self-beliefs. Sixteen patients went through a functional MRI while responding to negative self-beliefs and regulating negative emotions using different types of “attention deployment emotion regulation” such as breath-focused attention and distraction-focused attention. After the MBSR, 14 of 16 patients took neuroimaging assessments. In comparison to pre-treatment, those who completed MBSR showed a reduction in anxiety and depression symptoms, as well as an improvement in self-esteem. In the breath-focused attention task, patients also showed decreased negative emotion experience, reduced amygdala activity, and “increased activity in brain regions implicated in attentional deployment”. In SAD patients, MBSR training may improve emotional regulation while lowering emotional reactivity (Goldin and Gross, 2010). These adjustments may make it easier for individuals with SAD to reduce avoidance behaviours, clinical symptoms, and instinctive emotional reactions to negative self-beliefs.
While MBSR is the only method mentioned in detail for reducing SAD, there are a variety of other techniques such as cognitive behavioural therapy, emotion-focused therapy, and guided self-help that are recommended for reducing social anxiety and its symptoms.
Social Appearance Anxiety
Social appearance anxiety (SAA) is a type of anxiety prevalent among teenagers. SAA causes distress amongst those who perceive their physical image as negative. SAA is often related to different types of anxiety when one is coming to adulthood, such as poor body and life satisfaction, substance and alcohol abuse, and loneliness, to name a few. Poor self-esteem is at the root of SAA, which can often result in social anxiety as well.
Two methods that would be quite helpful to cope with SAA are improving self-esteem through talk therapies and maintaining cohesion and contact with family and/or peers. Cohesion with family and peers may lead to a decrease in the development of social anxiety as well as SAA. Cohesion with family and peers is helpful because it provides support for adolescents who struggle with SAA by giving them an available resource to deal with problems and a sense of being important to others (Antonietti et al., 2020).
Acceptance and commitment therapy (ACT) has also been found to be useful for treating SAA. In a study by Shepherd et al. (2020), three independent case studies used ACT to treat SAA. Each case received a number of sessions, and after each session, patients were given a questionnaire to fill out. After a month, the only data available were for two cases. The sessions of ACT had worked and helped the patients with SAA. No negative outcomes were found at the end of the study (Shepherd et al., 2020).
Social appearance anxiety has also been studied cross-culturally. Apprehension or worry about the adequacy of one’s physical appearance and about how others evaluate it is a social problem that also has emerged in recent years in Asian countries. According to the 2021 Chinese Youth Campus Media Study on social appearance anxiety, 87% of teenagers reported having appearance anxiety (Ke and Mingyang, 2022). Moreover, data from Weibo, the largest national social platform in China, reported that the number of searches and readings on “appearance anxiety” exceeded 3 billion.
Social appearance anxiety manifests as a lack of self-confidence in one’s appearance, feeling less attractive than others, constantly looking in the mirror and comparing one’s appearance to others, and having a high concern about perceived physical and facial defects that will receive negative attention from others and be laughed at. People with SAA spend a lot of money on cosmetics, have a desire to correct physical or facial features with plastic surgery, avoid social interactions because of appearance, feel nervous and anxious, have difficulty concentrating, and feel vulnerable when “face-to-face” with others. Communicating with text and voice messages “without face-to-face communication” is more comfortable (Lyness, n.d.).
There are many causes of developing appearance anxiety, which can be due to negative life experiences such as childhood teasing, humiliation, neglect or abuse. It can also be due to personal character traits, such as perfectionism. Social norms that project the importance of appearance further sustain this form of anxiety in three ways.
Firstly, an individual’s perception of mainstream aesthetics is formed by continuous processes of social integration and social consciousness that form a sense of unity from mainstream society, and highlight certain social attributes that are particular to a culture. Appearance anxiety is formed under the oppression of mainstream aesthetics, and it is inseparable from the social system, social environment and the interaction between individuals and society (Yan, 2022).
The prevalence of appearance anxiety also can be regarded as a reflection of the emotional state of youth in the face of the uncertainty and competitive pressures of modern society. This is also validated by perceptions of adults and messages they pass on to youth about the adult world. According to a Korean media survey, 56% of people believe that the statement that “appearance affects employment” is true; 75% of people admit that they judge people by their appearance when evaluating each other, and 85% of people think that appearance affects interpersonal relationships (Ke and Mingyang, 2022).
Sadly, it is also confirmed by labour statistics. There appears to be a strong correlation between appearance and total lifetime labour income (Robins et al., 2011). According to the China Labour Dynamics Survey, the average income of the sample was 34,666.8 yuan. In comparison, the income of people who were considered aesthetically pleasing and above the social aesthetic standard was 37,398.78 yuan. Their salary was 9.5% higher than the salary of those who only met social aesthetics standards and 17.73% higher than those considered below social aesthetics standards (Wang et al., 2017). Therefore, there are many explicit social messages on the importance of attractiveness.
Secondly, due to the abundance in people’s lives, the pursuit of beauty (and the consumption of non-necessities) raises and helps to sustain an emphasis on beauty as a social norm (Ke and Mingyang, 2022). Thirdly, the internet and social media create an atmosphere of social comparison, raise attention to appearance, and increase the availability of beauty products. The beauty industry influences consumers to think that improving their personal image through makeup, medical aesthetics, and weight loss is a way to gain greater acceptance and competitiveness. As a result, young people often relieve appearance anxiety through the use of beauty and non-surgical medical products such as makeup, skincare, and weight loss products. Therefore, it can be said that “the materialised demand spawned by market commercial value” can contribute to appearance anxiety (Yan, 2022).
Taking China as an example, a palm-sized face, big eyes, double eyelids, a high nose bridge, fair skin, and a thin body are the mainstream aesthetics in the current Chinese society. From popular challenges launched on Internet social platforms, such as “putting coins on your collarbone”, “touching your navel to your back.” achieving an “A4 waist-size”, to the promotion of “white and thin” aesthetics, the public is unconsciously attracted to this trend (Yan, 2022). Especially with the development of beauty and cosmetic technology in recent years, the view of aesthetics has become more narrow, encouraging less confidence in young people’s natural appearance and a greater preoccupation with appearance anxiety. When one’s individual cognition is influenced by the group consensus about standards of appearance, it is greatly sustained by the internet and further supported by one’s consumption power. Therefore, appearance anxiety has become a major social problem and warrants greater attention.
On the other hand, there are some people who are less traditionally “attractive” because of inherent physical defects or they are disfigured because of accidents. These people are easily isolated from society, not accepted by society, and can even be discriminated against. Living with the pressure of having a disfigured face for a long time, combined with their own mirror and spotlight effects, they are extremely prone to anxiety, depression and other psychological problems. Take school bullying as an example. A recent 2019 survey on school bullying in Japan revealed that 62.7% of young people with flawed appearance reported being ridiculed, molested, abused, and said to be made to feel uncomfortable. Nearly 13.6% reported being ignored by groups or ostracised, and 3% experienced cyberbullying via mobile phones and computers. In addition to appearance anxiety, these people may even suffer from a social anxiety disorder and selective mutism (Ministry of Education, Sports, Science and Technology of Japan, 2019)
Research on treatments has discovered that acceptance and commitment therapy (ACT) is generally considered useful for treating distress associated with appearance anxiety. It is the most representative experiential behavioural therapy in the new generation of CBT. It helps clients increase their mental flexibility and engage in a worthwhile, meaningful life through processes of mindfulness, acceptance, cognitive defusion, self-contextual explicit values and committed action, and flexible and diverse therapeutic techniques. After the ACT intervention, academics used questionnaires and patient feedback for assessment. Fortunately, all patients’ functional impairments were reduced, and appearance anxiety had less of an impact on their daily lives; also, they were living more rewarding and meaningful lives. No negative effects were found (Laura et al., 2020).
While some teenagers experience anxiety due to high expectations from the adult world about their appearance, others experience anxiety due to major life transitions or adjustments that can cause adjustment disorder (AD). An adjustment disorder is a stress-related disorder that is prevalent in adolescence due to certain events that commonly occur around this stage of life, like moving off to college, getting a new job, and dealing with friendship or relationship issues. These events can cause a negative impact on behaviour, such as skipping class, vandalising property, and being defiant to authority figures, as opposed to depressive symptoms like adults may experience due to transitions (Hull, 2022). Some other symptoms include difficulty sleeping, lack of appetite, anger and/or crying spells, and stomach aches (Hull, 2022). Adjustment disorders tend to be short-term; however, they can be described as a “gateway” disorder that can lead to more grievous conditions like major depressive disorder (MDD) and other anxiety disorders such as obsessive-compulsive disorder (OCD).
In a study by Gradus et al. (2014), it was reported that 111,844 adults and children in Denmark sought inpatient or outpatient care related to severe stress or a potential diagnosis of adjustment disorder between 1995 and 2011. When diagnosed, adjustment disorder was the most prevalent of the diagnoses (64%) among those 15 and younger, with other disorders either being secondary to the primary diagnosis or no specified stress disorder identified (Gradus et al., 2014).
Treatments for adjustment disorder might include psychotherapy, CBT, self-help groups or group therapy, and sometimes medication. Coming up with successful coping mechanisms with CBT and other treatments might reduce the effects that impact the everyday life of teens with adjustment disorder (The Recovery Village, n.d.).
As of late, internet treatments have been used more and more. A study by Rachyla et al. (2018) studied the effectiveness of internet-based cognitive behavioural therapy (ICBT) and self-help for adjustment disorders. They used a randomised control trial (RCT) and split the people into two groups for the experiment. One had a brief weekly telephone support program (n=34), and the other was put onto a waiting list (n=34) or the control group. To measure the effectiveness, they used two categories of primary outcomes, consisting of Beck’s anxiety and depression inventory, and five categories of secondary outcomes: AD symptoms, post-traumatic growth, positive and negative effects, and quality of life. The ICBT group had a substantially larger improvement in these categories, with follow-ups around every 3 months following the ICBT phone calls, to see if the people were still using their self-help from their ICBT, which they were. The research confirmed that using online therapist support, although a minimal and brief self-help intervention, is more helpful in resolving these symptoms compared to just the passage of time.
Another study by Hancock et al. (2018) wanted to examine the differences between a newer type of therapy,ACT, and CBT. They used 193 children aged 7-17 years old with a variety of anxiety disorders, and split them into groups for a randomised controlled trial (RCT). Two groups had a 10-week group-based program of either ACT or CBT, and another was a 10-week waitlist control. For the program, there were ten 90-minute sessions (once per week) where both parents and children came in and worked on skills as a group and separately. The ACT program was based more on building a better relationship with the patient’s beliefs using a different approach to psycho-educational methods rather than solely CBT concepts. The CBT program sought to restructure the belief altogether using common CBT methods. The results of this study showed, after the pre- and post-treatment interviews and a follow-up 3 months later, that the statistics for both therapies were practically equivalent, demonstrating the effectiveness of both in helping with anxiety disorders such as adjustment disorder.
Although panic disorder in adolescence has a lower rate, with a prevalence of around 1%, 10-15% of adolescents receive a panic disorder diagnosis (Pincus et al., 2010), which negatively impacts people’s quality of life and disrupts everyday activities. Panic disorder is distinguished by irregular, unpredicted panic attacks that occur without an obvious prompt. Panic attacks are defined by the rapid onset of intense fear (typically peaking within 10 minutes) with at least four physical and psychological symptoms, according to the DSM-5 diagnostic criteria (Locke et al., 2015), such as a racing heart, chest pain, breathing difficulties and other anxiety-related physiological symptoms (Achint, 2022). After the first attack, patients become hyper-aware and afraid of subsequent sudden attacks. They change their behaviour by avoiding places or situations that may result in future attacks, perpetuating the cycle.
Teenagers’ experience with panic disorder can be dreadfully overwhelming and unpleasant, which includes feeling misunderstood, feeling different or abnormal, and having a negative self-concept. Notably, a negative social relationship in the school environment can be particularly damaging (Baker et al., 2022). There are three approaches to treating panic disorder: education, medication and psychotherapy. Compassion and listening while educating young people about their condition, including standard recommendations of lifestyle adaptations, can help reduce anxiety in panic disorder. Medication can help to reduce symptoms of distress during a panic attack but it can also have side effects. Psychotherapy, such as CBT, to understand the underlying issues in one’s life, and applied relaxation techniques are considered the best treatment for panic disorder (Locke et al., 2015).
In the study by Baker et al. (2022), the aim was to examine teenagers’ panic disorder experiences. In order to test this aim, researchers found eight teenagers between the ages of 11-18 years who had a DSM-5 diagnosis of panic disorders. Each of them had one-to-one, semi-structured interviews. They asked questions about the participant’s experience of having a panic attack, the causes and how panic had influenced their life. Researchers gained a new view into teenagers’ experience of panic disorder, and found that negative social interactions with teachers and schoolmates were peculiarly damaging. Teenagers must access evidence-based and timely treatment, and also, educators must increase awareness and understanding of panic disorders in school.
A study by Lewis et al. (2012) aimed to investigate the effectiveness, cost-efficiency and acceptability of self-help interventions for anxiety disorder. To test this aim, the researchers mainly selected and searched for RCTs of self-help interventions from different studies. The researchers defined self-help as bringing about self-change through healthy practices. The researchers concluded that self-help is most effective in panic disorder and social phobias.
In the study of Hardway et al. (2016), the researchers assumed that an 8-day intensive treatment for panic disorder in teenagers would be beneficial in reducing symptoms of depression. Researchers placed 57 adolescents aged 11 to 18 who finished intensive treatment for PD. During the 8-day treatment, 27 teenagers were randomly assigned to complete the adolescent intensive panic treatment (AIP) without parental involvement, and 30 participated in AIP with parental involvement. Results showed that age and parental involvement were key to reducing adolescent mental health distress. For younger participants, parental involvement in treatment was more effective. For older participants, parent involvement was less important.
Common Treatment Methods for Anxiety
Aside from psychotherapeutic methods for handling anxiety, there are many self-help methods such as books, DVDs, CDs and websites. Since anxiety has become very common among adolescents, it is very important to address the issue and make psychotherapy more accessible. Many psychotherapists and psychiatrists have published books and articles and made videos on how someone can help themselves to deal with anxiety. Many people see improvement after the treatments. Self-help methods have been shown to be most effective for treating social anxiety and panic disorders. (Lewis et al., 2012). Although they are useful and powerful methods, not everyone has the self-discipline to do them. CBT and ERP are the two most common therapies that can be effective even when they are self-administered. To calm an anxious mind, one can also meditate and use mindfulness. The best results come when the therapy methods are combined.
In a study by Titov et al. (2008), the aim was to find out how self-help CBT methods compare to therapist-guided CBT. Ninety-eight adults diagnosed with social anxiety (38 males and 60 females) were randomly divided into three groups. One group received online clinical-assisted computerised CBT (CaCCBT); a second group received self-guided computerised CBT (CCBT), and the third group were waitlisted as a control group. Each person filled out a questionnaire before and after the experiment was conducted. The CaCCBT group and CCBT group both had to pass six online courses, had access to forums and had to do their assignments. The only difference was that the CaCCBT group had access to a therapist and could talk to a therapist online regularly, while the CCBT group did not. Although the dropout rate in the CCBT group was very high (67%), those that did complete all six lessons showed improvement in their self-confidence and social anxiety. Despite the fact that the CCBT has been found to be effective, the success rate in the CaCCBT group (77%) was drastically higher than in the CCBT group.
In a study by Tolin et al. (2007), 41 adults that were diagnosed with OCD (by Y-BOCS scale) were divided into two groups. The aim of the study was to determine how self-administered CBT and ERP compare to therapist-administered CBT and ERP. The self-administered group had 20 participants, and the therapist-administered group had 21 participants. In the therapist-administered condition, the therapist collected a detailed assessment of the patient’s symptoms and made a treatment plan. Then the ERP began, and the therapy took 11 to 13 sessions. There was a relapse prevention component (1 to 2 sessions) after ERP was complete, where the therapist helped the patient prepare to manage his or her symptoms without relying on the therapist. The patient was instructed in “normal” behaviour. During ERP, the fear level would be monitored by a therapist using the SUDS scale. Patients in the self-administered ERP group met with a study clinician who provided them with information about their condition and a brief explanation of their ERP therapy. Participants of self-administered ERP were given the book “Stop Obsessing!” (Foa and Wilson, 2001), which provides information and instructions for self-administered ERP. The participants of the group were instructed to read the book and follow its tips and routine over a 6-week period. Seventeen people completed the assignments in each group. The success rate of self-administered ERP was 17%, and 35% in the therapist-administered condition. It is yet again shown that self-administered therapy can be beneficial if one is motivated to work, but therapist-administered therapy is more effective.
Antidepressant and anti-anxiety medications, such as benzoamines, selective serotonin and noradrenaline reuptake inhibitors, are often prescribed to lower the sensations of anxiety (NHS, n.d.). These usually have side effects and can be addictive. Newer studies are exploring the effectiveness of CBD, which is the non-psychotomimetic and non-addictive component of the cannabis sativa plant.
A study by Nobuo Masataka (2019) examined the effects of cannabidiol (CBD) in teenagers who suffer from social anxiety disorder (SAD). The experiment was conducted for four weeks with a total of 37 teenagers, who were then split into two groups. The first group (n=17) received CBD, while the other group (n=20) received a placebo, which in this case, was olive oil. The participants underwent both pre- and post-intervention testing to better compare the changes they experienced. They took the Fear of Negative Evaluation Test (FNE) and the Liebowitz Social Anxiety Scale (LSAS), which are used to assist the diagnosis of SAD by taking a look at situations that cause a person the most anxiety. After the post-intervention tests, it was found that there was a significant decrease in anxiety within the first group receiving CBD. Their average FNE score dropped from 24.4 to 19.1, and their average LSAS score also showed change, falling from 74.2 to 62.1. This, in turn, shows that CBD could provide an excellent and non-addictive treatment for teenagers struggling with SAD. The researcher also found it effective for the treatment of generalised anxiety disorder (GAD), in another research study (Blessing et al., 2015).
To conclude, anxiety disorders typically faced by adolescents are often treated with medication or evidence-based methods such as CBT, ACT, EMDR, and EFT. There are also self-help methods, such as MBSR and mindfulness meditation which are useful to de-escalate anxiety symptoms in the moment (Edenfield & Saeed, 2012). As managing anxiety can be a daily challenge, alternative forms of self-help therapy are being used and studied, such as online computer-assisted forms of CBT and apps and even alternative medicines, such as CBD. A review and assessment of these therapies are made below.
A brief review of studies exploring treatment methods for adolescent anxiety discussed above were searched through open-access psychology journals such as Frontiers in Psychology, Research Gate, Google Scholar and Social Science Research Network. We searched terms such as “anxiety”, “anxiety disorders”, “adolescent anxiety”, “treatment for anxiety”, “school anxiety”, “social anxiety disorder”, “SAD”, “social appearance anxiety”, panic disorder, “self-help treatments for anxiety” and “adjustment disorder”, “generalised anxiety disorder”, “GAD”.
Table 1, below, shows the 14 studies reviewed:
|Authors||Year of publication||Type Of Anxiety||Type Of Treatment||Results|
|Rose and Lomas||2020||School anxiety||12 min of either (1) free drawing, (2) mandala colouring,||Heart rate remained lower after using the mandala colouring method.|
|Herzig-Anderson, Colognori, Fox, Stewart, and Masia- Warner||2012||School anxiety||School-Based Anxiety Treatments||BCASS: 80% of the control group continued to meet criteria for an anxiety disorder after treatment, versus only 25% of the CBT group. SASS: 94% respondent to treatment|
|Shepherd, L., Turner, A., Reynolds, D.P., Thompson, A.R.||2020||Social appearance anxiety (SAA)||ACT, CBT, Mindfulness||All patients experienced a decrease in SAA and no negative effects were found.|
Vera Gergov,Nina Lindberg,Jari Lahti,Jari Lipsanen,Mauri Marttunen
Generalised anxiety disorder
|Psychotherapy vs. art vs. occupational therapy||All therapies showed significant reduction of symptoms within the first 6 months (no differences between therapy forms).|
|Edenfield & Saeed||2012||Generalised anxiety disorder||Mindfulness Meditation||Moderately effective for improving anxiety.|
|Goldin & Gross||2010||Social anxiety||Mindfulness- Based Stress Reduction (MBSR)||After 8 weeks, MBSR reduced anxiety and depression symptoms, and improved self-esteem. In the breath-focused attention task, patients also showed decreased negative emotion experience, reduced amygdala activity, and “increased activity in brain regions implicated in attentional deployment.” In SAD patients, MBSR training may improve emotional regulation while lowering emotional reactivity.|
|2019||Generalised anxiety disorder / social anxiety disorder||CBD vs. paroxetine||CBD was effective in treating GAD and SAD, and was almost as effective as paroxetine (an SSRI).|
O’Connell, Kent, Robinson, Rashleigh & Timulak
|2020||Generalised anxiety disorder||EFT||Very effective over a short period of time.|
Tolin,Hannan, Maltby, Diefenbach, Worhunsky, & Brady
|2007||Obsessive compulsive disorder in patients with prior experience w/ Medication||Self-Directed vs. Therapist- Directed CBT||Therapist-Directed CBT was more effective, however those committing to the self-directed CBT also improved.|
Titov, Andrews, Isabella Choi, Schwencke, & Mahoney
|2008||Social phobia||Guided vs Unguided Internet-Based CBT||Therapist guided internet-based CBT was more effective than unguided CBT, although a subgroup of the unguided CBT participants also showed improvements.|
Hardway, Pincus, Gallo, & Cormer
|2015||Panic disorder||Adolescent Intensive Panic treatment (AIP) with vs. without family participation||AIP and AIP+FAM alleviated adolescents’ overall symptoms of depression, especially in the areas of negative mood, interpersonal problems, anhedonia, and negative self-esteem.|
|2021||Adjustment disorder||Self-help interventions for AD through internet||Internet-controlled CBT showed significant improvement in adjustment disorder symptoms.|
Dixon, Koo, & Munro
|2018||Social anxiety disorder, generalised anxiety disorders, panic disorder||Acceptance and commitment therapy and cognitive behavioural therapy||Both CBT and ACT treatments had similar outcomes, so ACT could be a viable treatment option.|
Adrian Schønning, Tine Nordgreen
|2021||Panic disorder, social anxiety disorder||Internet-delivered CBT||People who engaged in the modules had improvements in symptoms. Disengagement due to motivation was a challenge for some.|
Of the 14 studies reviewed, the most common treatment tested for adolescent generalised anxiety disorder, school anxiety, social anxiety, adjustment disorder, and panic disorder was by far CBT. ACT was a common therapy for self-esteem issues such as social appearance anxiety as it focuses on self-acceptance and self-compassion. Self-help methods such as using mandala art, EFT, and mindfulness-based mediation worked well in the short term. CBD as a medicinal option is promising but needs more research to grow the evidence base. Computer- versus therapist-led CBT was also tested, and indicated that therapist-led options were more successful in sustaining individuals through therapy, whereas self-led internet modules appeared less effective primarily due to the self-motivation needed to complete the full modules and assignments.
Through a review of the literature of 14 studies, we explored the research question: “What are some of the major causes of anxiety prevalent in teenagers and effective ways of treating them?”. We found that the most prevalent anxiety disorders that teens suffered were: generalised anxiety disorder, school anxiety, social anxiety, social appearance anxiety, adjustment disorder and to a smaller, but more stressful degree, panic disorder.
In identifying the most common treatments and their effectiveness, we found that CBT was the most common treatment used across all anxiety disorders because it focuses on irrational thinking and core beliefs, and helps teens differentiate between real and perceived sources of stress, anxiety and underlying beliefs about them. It helps young people to find new ways of looking at the situation, which makes the source of anxiety less threatening, and changes core beliefs about their ability to manage their source of stress. CBT also educates about how anxiety works in the brain and how cognitive distortions elevate fear and panic responses that lead to undesired behaviours such as avoidance or panic. Lastly, it also teaches self-help techniques that can lower one’s distress in the moment, such as mindfulness-based stress reduction techniques, breathing techniques and even tapping, which are emotion-focused techniques.
ACT has similar traits to CBT and is a common therapy for self-esteem issues such as social appearance anxiety or even adjustment disorder, as it also focuses on creating greater awareness about one’s self-worth and works on developing self-acceptance and self-compassion. Self-help methods such as using mandala colouring, EFT, and mindfulness-based mediation, which often accompany therapist-led therapies, work well in the short run to lower distress, but work best in combination with therapy to change dysfunctional thinking patterns.
We did not specifically focus on medication as treatment, as they have proven effective and already have widespread use in lowering anxiety levels. However, without targeting the root cause of anxiety, medication is a temporary solution and has many side effects. We did explore one medicinal alternative, CBD, as it is being used more and more for various physical and mental health issues. We found that it does provide relief, similarly to traditional medicines, but without side effects and addictive properties. This makes it a promising alternative to these commonly used medications in combination with proper talk therapies such as CBT, ACT or others. However, more research is needed to grow the evidence base about its usefulness.
Computer or internet CBT was also prevalent, indicating that therapy can be more affordable and accessible to more people. In comparing internet-based and therapist-led CBT options, however, therapist-led treatment was more successful. Self-led internet modules appeared less effective primarily due to the self-motivation needed to complete the full modules and assignments, which participants in studies did not always have.
Lastly, we paid particular attention to the study on school anxiety that tested treatments in a school setting (Herzig-Anderson, 2012). We assessed that it would be beneficial for school environments to be more aware of mental health issues young people are facing and offer in-school treatments to help students manage anxiety, panic attacks and other issues.
Strengths and Limitations
Strengths of this review of literature included an exploration of diverse types of anxiety disorders often experienced by young people. Our analysis of treatment therapies, therefore, allowed us to examine to what degree specific types of therapies are more common and effective. Limitations of this study include primarily identifying full-text articles from open access journals, which means that an extensive search was not undertaken in many psychological databases that need a subscription. Therefore, there were many more studies not reviewed for this research.
However, given the limited timeframe of four weeks to write a review of literature with open-access journal articles, we were able to make assessments in relation to common anxieties experienced by adolescents and effective treatment methods. Consideration of future research would be to conduct a full systematic review and further explore the progress of new and upcoming treatment methods as well as more cross-cultural research.
Due to time constraints, we did not focus explicitly on the types of biases that occurred in each of the research studies reviewed. Therefore, we recognise broadly that small samples cannot be generalised to the greater population and that randomised control trials are the most statistically valid, providing that experimenter bias is minimised at each stage of the research process. Participant bias can also skew results either because participants consciously or unconsciously align with the research aims, or fill out self-reports in a way that shows the social desirability effect: over or under-reporting their condition to appear in a better light.
To conclude, anxiety is a widespread mental health challenge for young people as the world around them has many more problems that impact them and is more competitive than earlier generations. Therefore, schools and parents must be more aware of how to support young people. It is also important that therapy is both accessible and affordable so that all young people can address their issues earlier than later. Finally, with more internet based therapies available and self-help methods, it is promising that young people can have access to and take more control over their mental distress, as long as they are able to seek professional help to guide them to evidence-based practices. Overall, access to timely diagnosis and treatment with the support from the home and school environment is key to managing anxiety and other mental health disorders in adolescents.
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