What are the signs and symptoms of anxiety in teenagers?

Signs of Anxiety in Teenagers

Teenagers with anxiety present with excessive, uncontrollable worry about everyday situations (school performance, social interactions, future events) that persists most days for at least 6 months, accompanied by physical symptoms like headaches, muscle tension, restlessness, gastrointestinal distress, and heart palpitations, plus behavioral changes including avoidance, irritability, and functional impairment in school or social settings. 1

Core Symptom Categories

Anxiety in adolescents manifests across three primary domains that should all be assessed 2:

Psychological/Cognitive Symptoms

• Excessive, uncontrollable worry about multiple everyday situations (grades, timing of tasks, social evaluation, physical appearance, future events) 1, 3
• Social and existential concerns that are developmentally typical for adolescents but become pathological when excessive 1
• Fear of negative evaluation by peers in social situations 1
• Worry- or fear-laden thought content, perseverative or ruminative thinking 1
• Difficulty concentrating or distractibility 1
• Poor insight and judgment regarding the excessiveness of worries 1

Physical/Somatic Symptoms

• Headaches and muscle tension 2
• Gastrointestinal distress (stomach aches, nausea) 2
• Heart palpitations 2
• Restlessness or feeling keyed up 1, 2
• Fatigue 2
• Sleep disturbances 3
• Tremor, fidgetiness 1
• Shortness of breath, dizziness 4
• Diaphoresis (sweating) 5

Behavioral/Observable Signs

• Avoidance behaviors (avoiding school, social situations, specific activities) 1, 6
• Poor eye contact, shy demeanor 1
• Clinginess or seeking excessive reassurance 1
• Irritability and agitation 1
• Tantrums or emotional outbursts 5
• "Nervous" habits (nail biting, hair pulling) 1
• Hypervigilance 1
• Poor engagement or uncooperativeness 1
• Fastidious or disheveled appearance 1

Disorder-Specific Presentations

Different anxiety disorders have distinct presentations in teenagers 1:

Generalized Anxiety Disorder (Most Common)

• Chronic, pervasive worry about multiple topics beyond any single concern 3, 6
• Physical symptoms dominate: tension, restlessness, gastrointestinal issues 2
• Difficulty controlling the worry 1

Social Anxiety Disorder

• Excessive fear of negative evaluation by peers 1
• Avoidance of social situations, school presentations, eating in front of others 1
• May present as selective mutism (absence of speech in social situations despite speaking at home) 1

Panic Disorder

• Recurrent unexpected panic attacks with abrupt surge of intense fear 1
• Physical manifestations: palpitations, chest discomfort, shortness of breath, dizziness 1, 4
• Anticipatory anxiety about future attacks 4

Separation Anxiety Disorder

• Developmentally inappropriate distress about separation from parents/caregivers 1
• School refusal, reluctance to be alone 1

Functional Impairment Indicators

Clinically significant anxiety must cause distress or functional impairment 1:

• Declining academic performance or school avoidance 5
• Withdrawal from peer relationships and social activities 5
• Interference with family functioning 5
• Inability to participate in age-appropriate activities 1
• Marked distress that affects daily functioning 2

Critical Distinction from Normal Development

Adolescent anxiety disorders must be distinguished from normative developmental fears 1:

• Normal adolescent concerns include social acceptance, physical appearance, academic performance, and existential questions 1
• Pathological anxiety is characterized by excessive intensity, duration (≥6 months), uncontrollability, and functional impairment 1, 2
• The worry is disproportionate to actual threat and cannot be dismissed by reassurance 1

Red Flags Requiring Immediate Attention

Certain presentations demand urgent psychiatric evaluation 6:

• Suicidal ideation or self-harm behaviors 6
• Severe agitation or inability to function 6
• Comorbid depression (present in 56% of anxious adolescents and significantly increases suicide risk) 7
• Psychotic symptoms 6
• Substance use as self-medication 1

Screening Approach

Systematic screening is recommended for all adolescents 8 years and older 5:

• Use validated tools like GAD-7 (scores ≥10 indicate moderate-severe anxiety requiring intervention) 6
• SCARED (Screen for Child Anxiety Related Emotional Disorders) - teen and parent versions 1
• Spence Children's Anxiety Scale - teen and parent versions 1
• Multi-informant approach: obtain reports from teenager, parents, and teachers 2

Common Pitfalls to Avoid

• Missing medical mimics: Always rule out hyperthyroidism, hypoglycemia, cardiac arrhythmias, asthma, and caffeine excess before confirming anxiety disorder 3, 7
• Overlooking comorbidities: 56% have comorbid depression; also assess for ADHD, eating disorders, substance use 7
• Dismissing symptoms as "just teenage drama": Persistent symptoms with functional impairment require intervention 1, 5
• Relying solely on observable signs: Mental status findings (tremor, fidgetiness, poor eye contact) are nonspecific and may be absent; focus on reported symptoms and functional impairment 1
• Missing trauma history: Sexual harassment, assault, and trauma are common underlying triggers, especially in adolescent girls 7