If Your Adolescent Has an Anxiety Disorder: An Essential Resource for Parents Edna B. Foa, Ph.D., Linda Wasmer Andrews OXFORD UNIVERSITY PRESS Foreword The Adolescent Mental Health Initiative (AMHI) was cre- ated by The Annenberg Foundation Trust at Sunnylands to share with mental health professionals, parents, and adoles- cents the advances in treatment and prevention now available to adolescents with mental health disorders. The Initiative was made possible by the generosity and vision of Ambassadors Walter and Leonore Annenberg, and the project was administered through the Annenberg Public Policy Center of the University of Pennsylvania in partnership with Oxford University Press. The Initiative began in 2003 with the convening, in Phila- delphia and New York, of seven scholarly commissions made up of over 150 leading psychiatrists and psychologists from around the country. Chaired by Drs. Edna B. Foa, Dwight L. Evans, B. Timothy Walsh, Martin E. P. Seligman, Raquel E. Gur, Charles P. O’Brien, and Herbert Hendin, these commissions were tasked with assessing the state of scientific research on the prevalent mental disorders whose onset occurs predominantly between the ages of 10 and 22. Their collective findings now appear in a book for mental health professionals and policy makers titled Treating and Preventing Adolescent Mental Health Disorders ix Contents Foreword ix One Introduction: Uneasy Minds 1 How This Book Can Help 3 How This Book Is Organized 5 The People Behind the Book 6 Two Anxiety Disorders: What They Are, Where They Come From 9 Three Snapshots of Anxiety 9 Seven Types of Anxiety Disorders 13 About One Out of Every 20 Teens 19 From Anxiety to Disorder 19 Coexisting Conditions 22 The Psychology of Anxiety 24 The Biology of Anxiety 27 The Genetics of Anxiety 34 Dangers of Doing Nothing 38 Benefits of Getting Help 39 v Chapter One Introduction: Uneasy Minds One mother recalls that her son always seemed to be a little more fearful than most children. “But it really started interfering with his life when he was about 15. He began worrying constantly that his heart would stop beating while he was sleeping.” Another mother says that her daughter “was very, very introverted during her early teens. She avoided all public speaking, including talking in class. She was always too afraid to draw attention to her- self in case she said or did something wrong.” A father says that his 16-year-old son became obsessed with a fear of contamination. Recently, the father was called to pick up the boy from school. The reason? “My son had dropped his lunch on the floor by accident. When he bent down to pick it up, the sleeve of his sweatshirt grazed the floor, and he became petrified. He told me later he just had to go home to ‘sterilize’ himself after that.” A grandmother says that her granddaughter continued to relive the horror of childhood sexual and physical abuse for years afterward. Once the abuse came to light, the girl went to live with her grandparents, where she had a safe, stable home. “But night was still a nightmare for us,” her grandmother says. “She wasn’t able to sleep for more than 45 minutes at a time. Then she would wake up screaming.” These stories sound quite different in some ways, but they all have a common thread running through them: anxiety. 1 2 If Your Adolescent Has an Anxiety Disorder In fact, each of these teenagers has been diagnosed with an anxiety disorder, one of a group of psychological disorders that lead to excessive or irrational anxiety, worry, and fear. On any given day, from 3% to On any given day, 5% of children and adolescents in the from 3% to 5% United States have some type of anxiety dis- of children and order. Without treatment, this kind of dis- adolescents in the order can interfere with their ability to carry United States out everyday tasks, succeed in school, or have some type of make and keep friends. Or it may simply anxiety disorder. cause great distress that saps much of their enjoyment from life. The parents quoted above also share a common bond: No matter how much or how little they already knew about anxi- ety disorders, all struggled to accept and understand what was happening when their child first became ill. “It was really scary,” says the mother of the boy who feared his heart would stop beating. The fact that she is an experienced psychotherapist didn’t change the anguish and helplessness she initially felt when it was her own son who was suffering. If you’ve found yourself in a similar situation, chances are you know these feelings all too well. The good news is that we now know more about treating anxiety disorders than ever be- fore. There aren’t any miracle cures, but there are effective forms of psychotherapy and medication to help your teen feel better. As for your own feelings, we can’t promise that the concerns and frustrations will totally disappear—after all, you’re raising a teenager! But the worries should lessen as your teen’s symp- toms improve, and the sense of helplessness should fade as you take charge of the situation by finding treatment for your child and a support network for yourself. Introduction: Uneasy Minds 3 How This Book Can Help Perhaps you’re just starting to wonder whether your teen might have an anxiety disorder. Or maybe you’ve already begun the pro- cess of seeking a diagnosis and treatment for your teen. In either case, this book provides the practical, reliable information you need to allay your concerns and empower yourself as a parent. “Anxiety disorder” is an umbrella term that covers seven dif- ferent conditions: social anxiety disorder, generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post- traumatic stress disorder (PTSD), separation anxiety disorder, panic disorder, and specific phobias. In this book, we’ll be fo- cusing mainly on the first four, because those are the anxiety disorders that lead to the most trouble during adolescence. By contrast, panic disorder usually begins in adulthood, while sepa- ration anxiety and specific phobias are more prominent in child- hood and usually lessen during adolescence. Of the four disorders highlighted in this book • Social anxiety disorder is quite prevalent, and it typically begins in late childhood or early adolescence. • GAD is also common, affecting at least 2% of all ado- lescents. • OCD is less common, but the symptoms can be espe- cially disruptive to the lives of young people. • PTSD can lead to particularly distressing symptoms as well. In addition, adolescents are at higher risk than other age groups for many of the traumatic events that can give rise to PTSD. The causes, symptoms, and treatments of social anxiety dis- order, GAD, OCD, and PTSD will be described in detail in the chapters to come. Of course, you may be curious about 4 If Your Adolescent Has an Anxiety Disorder separation anxiety disorder, panic disorder, and specific pho- bias, too. If nothing else, you may have heard these terms tossed around casually and wonder what they really mean, scientifi- cally speaking. So we’ve also provided briefer descriptions of these three disorders in Chapter 2. Throughout the book, you’ll find straightforward, scientifi- cally sound answers to the questions that parents of teens with anxiety disorders most often ask. For example: • What’s the difference between everyday anxiety and an anxiety disorder? • If my teen has an anxiety disorder, is it my fault? • What are the warning signs to watch for? • What type of therapy helps with anxiety disorders? • What are the pros and cons of medication? • Will insurance cover the costs of treatment? • How can I help my teen succeed in school? • What does the future hold for my teen? • Where can I find further support and education for myself? No book can take the place of professional diagnosis and treatment by a qualified mental health care provider. But this book can arm you with the facts you need in order to choose a qualified professional in the first place. And once you’ve found the right person to provide a diagnosis and treatment, this book can help you and your teen make The more you know, the the most of that opportunity. The more you know, the better equipped better equipped you’ll be you’ll be to ask critical questions, to ask critical questions, make informed decisions, and, make informed decisions, when necessary, advocate for your and, when necessary, teen effectively with the insurance advocate for your teen. company or school system. Introduction: Uneasy Minds 5 How This Book Is Organized In Chapter 2 of this book, you’ll find an introduction to all seven types of anxiety disorders. Here’s where you’ll learn what distinguishes one disorder from another and why they all rep- resent some form of dysfunctional anxiety. If you’ve ever won- dered what a phobia or panic attack really is, this chapter will help you clarify the true meaning of these widely used—but sometimes misused—terms. In Chapters 3 through 6, you’ll find in-depth discussions of the four anxiety disorders that are especially relevant to adoles- cents: social anxiety disorder, generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), and post- traumatic stress disorder (PTSD). These chapters describe the symptoms, risk factors, causes, diagnosis, and treatments of each disorder. They also discuss ways that parents can help with the day-to-day management of symptoms at home and school. Since you may just want to read about your own teen’s disorder, we’ve made sure that each of these chapters can stand alone as a guide to that particular condition. You can skip the chapters that don’t apply to your teen. Or if you prefer to read the book straight through, you can skip the few sections that are, of necessity, repeated from one chapter to the next. In particular, the sec- tion called Medication Therapy is similar for all the disorders. You might want to read through it once carefully and then skim over it in the remaining chapters. In Chapter 7, you’ll find a close-up look at treatment and recovery issues that are relevant to all kinds of anxiety disor- ders. There’s a general discussion of the pros and cons of therapy and medication as well as suggestions for helping your teen get the most benefit from whatever treatment option is chosen. In addition, there are practical pointers on dealing with managed care companies and your teen’s school. 6 If Your Adolescent Has an Anxiety Disorder In Chapter 8, we tie things up with suggestions for standing up to stigma and empowering your teen. At the back of the book, you’ll find an appendix of diagnostic criteria, a glossary, and a list of additional resources you may want to consult. All in all, we’ve tried to provide the information that a concerned, involved parent is most likely to need. We’ve tried to paint a realistic portrait of what it’s really like to raise an adolescent with an anxiety disorder. At times, you may feel stressed-out, worried, confused, frustrated, discouraged— or all of the above. There’s no denying that your role as a mom or dad can be a very challenging one. Ultimately, though, there are many good reasons for feeling Excellent treatments, optimistic. Excellent treatments, in- including specifically cluding specifically targeted therapies targeted therapies and and new medications, are now avail- able, and most teens with anxiety dis- new medications, are orders can be helped to feel better. now available, and You can play a pivotal role in that most teens with anxiety process by supporting your teen at disorders can be helped home and seeking professional care to feel better. when it’s needed. The People Behind the Book In 2003, the Adolescent Mental Health Initiative, a project spearheaded by the Annenberg Foundation Trust at Sunnylands, convened a blue-ribbon commission of the nation’s leading authorities on adolescent anxiety disorders. The result was a professional report that summarized the state of the science in this area. The book in your hands draws heavily on the commission’s report to present you with the most up-to-date, authoritative information currently available. Introduction: Uneasy Minds 7 The lead author of this book was chair of the commission. Dr. Foa is a professor of clinical psychology in psychiatry at the University of Pennsylvania, where she also directs the Center for the Treatment and Study of Anxiety. She is internationally recognized for her research on the causes and treatment of anxi- ety disorders, including OCD, PTSD, and social anxiety dis- order. A therapeutic program she developed for trauma victims has been highly influential in the treatment of PTSD. Dr. Foa has published several books and over 250 articles and book chapters, and she has lectured extensively around the world. Over the years, she has received many honors, including an honorary doctorate from the University of Basel in Switzerland and the Distinguished Scientist Award and Distinguished Sci- entific Contributions to Clinical Psychology Award, both from the American Psychological Association. Two of Dr. Foa’s colleagues at the University of Pennsylvania contributed their considerable insights and expertise to this book as well. Martin E. Franklin, Ph.D., is an associate professor of clinical psychology in psychiatry at the University of Pennsyl- vania School of Medicine and clinical director of the Center for the Treatment and Study of Anxiety. Moira A. Rynn, M.D., is an assistant professor of psychiatry and medical director of the Mood and Anxiety Disorders Section at the University of Pennsylvania School of Medicine. We would like to express our appreciation to Dr. Franklin and Dr. Rynn for their help in reviewing and providing feedback on the scientific dimensions of the book. The second author of this book is a journalist who has spe- cialized in mental health issues for more than two decades. Her most important contribution to the project was to interview parents of adolescents with anxiety disorders from across the United States and beyond. These mothers and fathers—and