What is the treatment for a 13-year-old patient with anxiety and diaphoresis (excessive sweating)?

From the Guidelines

For a 13-year-old experiencing anxiety with sweating, I strongly recommend starting with cognitive-behavioral therapy (CBT) as the first-line treatment, as it has considerable empirical support as a safe and effective short-term treatment for anxiety in children and adolescents 1.

Treatment Approach

When considering treatment for anxiety in children and adolescents, it's crucial to prioritize approaches that have the most significant empirical support. According to the clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders published in the Journal of the American Academy of Child and Adolescent Psychiatry in 2020 1, CBT may be considered the first-line treatment, particularly for mild to moderate presentations.

Medication Consideration

If symptoms are more severe or when quality CBT is unavailable, selective serotonin reuptake inhibitor (SSRI) medication, such as fluoxetine (Prozac), can be considered as an alternative treatment option 1. The guideline suggests that combination treatment (CBT and SSRI) may be more effective than either treatment alone for short-term anxiety treatment in children and adolescents.

Addressing Sweating

For the physical symptom of sweating, aluminum chloride antiperspirants like Drysol or clinical-strength over-the-counter antiperspirants containing 20% aluminum compounds can be effective in temporarily blocking sweat ducts. It's essential to apply these at bedtime, wash them off in the morning, and use them daily until improvement is seen, then reduce to 1-2 times weekly for maintenance.

Comprehensive Approach

A comprehensive, evidence-based assessment is crucial to enhance evidence-based treatment outcomes. This includes ruling out other medical causes of sweating, such as hyperthyroidism, and recognizing that treatment may need adjustment based on the individual's response. The treatment plan should be tailored to the individual's needs, considering the depth of the clinical formulation and the breadth of the treatment plan.

Key Points

• CBT as the first-line treatment for anxiety in children and adolescents.
• Consider SSRI medication for more severe symptoms or when CBT is not available.
• Combination treatment may be more effective for short-term anxiety treatment.
• Aluminum chloride antiperspirants for managing excessive sweating.
• Comprehensive assessment to rule out other medical causes and tailor the treatment plan.

From the FDA Drug Label

In lower weight children, treatment should be initiated with a dose of 10 mg/day. Additional dose increases may be considered after several more weeks if insufficient clinical improvement is observed A dose range of 20 to 30 mg/day is recommended. Treatment should be initiated with a dose of 10 mg/day. After 1 week, the dose should be increased to 20 mg/day. In adolescents and higher weight children, treatment should be initiated with a dose of 10 mg/day. After 2 weeks, the dose should be increased to 20 mg/day

For a 13-year-old patient with anxiety and sweating, the recommended initial dose of fluoxetine is 10 mg/day. After 1-2 weeks, the dose can be increased to 20 mg/day if insufficient clinical improvement is observed. The dose range for this age group is 20-30 mg/day 2, 2.

• Initial dose: 10 mg/day
• Dose increase: 20 mg/day after 1-2 weeks if necessary
• Dose range: 20-30 mg/day
• Key consideration: Patients should be periodically reassessed to determine the need for treatment and dosage adjustments should be made to maintain the patient on the lowest effective dosage.

From the Research

Treatment Options for Anxiety and Sweating in a 13-year-old

• Cognitive Behavioral Therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatments for childhood anxiety disorders 3, 4.
• The combination of CBT and SSRI medication has been shown to be the most effective treatment for anxiety in youths ages 7 to 17, compared to either CBT or medication alone 3, 5.
• SSRIs have been established to be safe and efficacious for the treatment of pediatric anxiety and are considered the medications of choice for this population 3.
• CBT has been associated with lower attrition rates compared to pharmacotherapy 4.

Screening and Diagnosis

• The US Preventive Services Task Force recommends screening for anxiety in children and adolescents aged 8 to 18 years, as it has a moderate net benefit 6.
• A comprehensive assessment of child and adolescent anxiety disorders benefits from a multimethod approach to evaluation and diagnosis, including semistructured interviews, child and informant questionnaires, and behavioral observations 3.

Treatment Effectiveness

• Research indicates that CBT plus SSRI medication is the most effective treatment of anxiety for youths ages 7 to 17, compared with either CBT or medication alone 3, 5.
• The combination of CBT and SSRI has been shown to produce greater improvement than either treatment alone, with the fastest response seen in patients who are younger, with milder baseline anxiety/depression symptoms, and depressive disorders 5.
• The superiority of SSRI+CBT for youth with depression and anxiety is further supported, with the added value of CBT occurring late in treatment 5.