Psychiatric Evaluation for Adolescent Anxiety
Begin with systematic screening using validated tools—specifically the GAD-7 for adolescents or SCARED (parent and child versions)—followed by a structured diagnostic interview to confirm the specific anxiety disorder subtype, assess severity, rule out medical mimics (particularly hyperthyroidism and cardiac conditions), screen for comorbidities and suicide risk, and develop a biopsychosocial formulation. 1
Initial Screening and Symptom Identification
Deploy standardized screening instruments before or during the initial visit to systematically identify anxiety concerns rather than relying on spontaneous report alone, which is unreliable given that adolescents frequently underreport psychological distress 1, 2
Use the GAD-7 (freely available at https://www.phqscreeners.com) for teens, with scores of 10-14 indicating moderate-severe anxiety and 15-21 indicating severe anxiety requiring immediate intervention 1, 3
Alternatively, use the SCARED (Screen for Child Anxiety Related Emotional Disorders) in both parent and child versions (https://www.pediatricbipolar.pitt.edu/resources/instruments) to capture broader anxiety symptomatology 1
Obtain multi-informant data from the adolescent, parents, teachers, and other collateral sources, as anxiety presentations vary across settings and adolescents may minimize symptoms 4, 5
Structured Diagnostic Assessment
Conduct a structured or semi-structured interview to enhance diagnostic accuracy over unstructured clinical interviews, which are vulnerable to information collection biases 1
Consider the K-SADS-PL DSM-5 (freely available) as it includes comprehensive sections for panic, agoraphobia, separation anxiety, social anxiety, selective mutism, specific phobia, and generalized anxiety disorders, plus screening questions for comorbidities 1
The proprietary ADIS (Anxiety Disorders Interview Schedule) is the research gold standard but requires purchase and training; reserve for complex cases or research settings 1
Confirm the specific anxiety disorder diagnosis: separation anxiety (developmentally inappropriate distress about separation from caregivers), social anxiety (excessive fear of negative peer evaluation), generalized anxiety (chronic pervasive worry about multiple topics with physical symptoms), panic disorder (recurrent unexpected panic attacks with anticipatory anxiety), specific phobia (excessive fear of specific objects/situations), or selective mutism (absence of speech in certain social situations) 1, 6, 4
Critical Medical Rule-Outs
Order thyroid function tests (TSH, free T4) to exclude hyperthyroidism, which mimics anxiety with tachycardia, tremor, heat intolerance, and irritability 6, 3, 4
Obtain ECG if palpitations, chest pain, or syncope are present to rule out cardiac arrhythmias or structural heart disease that can present as anxiety 6, 3
Screen for substance use (stimulants, caffeine, cannabis) and withdrawal states that produce anxiety and irritability 4
Consider hypoglycemia in patients with diabetes or eating disorders presenting with anxiety-like symptoms 4
Mental Status Examination
Document specific anxiety signs: poor eye contact, shy demeanor, clinginess, tremor, fidgetiness/restlessness, "nervous" habits (nail-biting, hair-pulling), hypervigilance, poverty of or pressured speech, perseverative or ruminative thought processes, worry- or fear-laden thought content, distractibility, irritability/agitation 1, 4
Recognize these signs are nonspecific and may be absent even in severe anxiety; they are adjunctive to other diagnostic information, not diagnostic themselves 1
Comorbidity Screening (Essential—Not Optional)
Screen for depression systematically, as 50-60% of adolescents with anxiety have comorbid depression, and this combination carries the highest suicide risk 6, 4
Assess for ADHD, which commonly presents with low frustration tolerance, emotional dysregulation, and secondary anxiety about academic/social failures 4
Evaluate for other anxiety disorders, as multiple anxiety disorders frequently co-occur 1, 6
Screen for eating disorders, substance use disorders, and trauma history (PTSD), particularly in maltreated youth who may exhibit post-traumatic rage triggers 4
Consider autism spectrum disorder in adolescents with extreme frustration when routines are disrupted or sensory overload occurs 4
Suicide Risk Assessment (Mandatory)
Directly assess suicidal ideation, plans, intent, and prior attempts, as 24% of anxious adolescents report suicidal ideation and 6% have made suicide attempts 6, 4
The highest suicide risk occurs in generalized anxiety disorder plus comorbid depression; this combination requires immediate psychiatric referral 6, 4
Immediate psychiatric referral is required for: suicidal ideation with plan/intent, self-harm behaviors, risk of harm to others, psychotic symptoms, or severe agitation requiring one-to-one observation 6, 3, 4
Biopsychosocial Formulation
Assess biological vulnerabilities: family history of anxiety disorders (inherited brain structure/function vulnerabilities), temperament characterized by negative affectivity or behavioral inhibition, autonomic hyperreactivity, chronic medical conditions, and developmental/acquired brain insults 1
Evaluate psychological factors: insecure attachment patterns, maladaptive cognitive schemas, information-processing errors (catastrophizing, overgeneralization), negative self-evaluations, and disconnects between feelings and behaviors 1
Document contextual factors: current stressors, environmental supports, cultural/spiritual/gender/sexual orientation considerations, developmental history, educational functioning, family dynamics, and social relationships 1
Identify precipitating and perpetuating factors: recent life events that triggered symptom onset, ongoing stressors maintaining symptoms, and avoidance behaviors that reinforce anxiety 1
Functional Impairment Assessment
Document specific impairments in academic performance (declining grades, school refusal), peer relationships (social withdrawal, isolation), family functioning (increased conflict, dependence), and daily activities (sleep disturbances, somatic complaints interfering with routines) 4, 5
Clinically significant anxiety must cause distress or functional impairment; symptoms without impairment do not meet diagnostic criteria 4
Common Pitfalls to Avoid
Do not dismiss symptoms as "just teenage drama" or normal adolescent stress; anxiety disorders are distinct from developmentally typical worries by their excessive intensity, duration (≥6 months), uncontrollability, and functional impairment 4, 2
Do not rely solely on observable signs in the mental status exam, as many anxious adolescents appear calm or well-controlled in clinical settings but experience severe internal distress 4
Do not overlook medical mimics by attributing all symptoms to psychiatric causes; always rule out hyperthyroidism and cardiac conditions first 6, 4
Do not miss comorbidities, particularly depression, ADHD, eating disorders, and substance use, which dramatically alter treatment planning and prognosis 6, 4
Do not skip trauma screening, especially in youth with maltreatment backgrounds who may present with anxiety plus irritability/rage 4
Initial Management Decisions Based on Severity
For mild to moderate anxiety: initiate cognitive-behavioral therapy (CBT) as monotherapy, with 12-20 sessions typically required 6, 5
For severe anxiety: initiate combination treatment with both CBT and an SSRI (sertraline starting at 25 mg daily, target 25-200 mg/day) from the outset, as combination therapy is superior to either treatment alone 6, 5, 7
CBT should include core components: psychoeducation about anxiety, behavioral goal-setting, self-monitoring, relaxation techniques, cognitive restructuring, graduated exposure, and problem-solving/social skills training 6
Avoid benzodiazepines as first-line or long-term treatment due to dependence risk and cognitive impairment 6