How To Identify and Overcome Problematic Teen Anxiety

Written by: Anne Marie Albano, Ph.D., ABPP and Muniya Khanna, Ph.D.

Anxiety is an alert system

Anxiety is something that we all deal with. In fact, anxiety is an important alert system that, when used for its original purpose, keeps us alive and thriving.

Anxiety only becomes a problem when it starts taking over our lives, interfering with our thoughts and activities, and making the experience of being human less enjoyable. Anxiety can be especially difficult when it manifests in ways that are out of proportion to the event or task we are anxious about. For instance, anxiety becomes an issue when it manifests not in a gentle reminder to finish a term paper but in a debilitating stomach ache that won’t abate until the paper is done. Similarly, frequency matters. If your teen experiences a stomach ache before a big sporting event that is probably not a sign of anything amiss. But if they experience a stomach ache before soccer practice every day, all year, it might be time to seek help.  

Anxiety can be particularly tricky to recognize when it occurs in adolescents and young adults because most of them don’t have the same tools and awareness that adults have. Undiagnosed anxiety shows up in the offices of pediatricians and family doctors all the time, usually in the form of physical symptoms. Most commonly, these include chronic nausea, functional abdominal pain, cyclical vomiting, headaches, and fatigue, among others. Because it isn’t always easy to distinguish between a stomach ache that stems from anxiety and a stomach ache that stems from a virus, it can be hard to diagnose it or know how to best help.  

Because anxiety disorders are extremely prevalent, they should always be ruled out. In fact, 15% of adolescents struggle with excessive anxiety, a percentage that rises to 22% in young adults. And since it can be hard to spot, it’s up to caregivers—including parents, pediatricians, clinicians, teachers, babysitters, and relatives—to help teens identify when they’re suffering from anxiety and assist them in finding treatment.  

The psychological vs. the physical 

It’s common to think of anxiety as a mental ailment. And while it is psychological at its root, anxiety is not just a state of mind. It is actually very much tied to the nervous and hormonal systems of the body. When we’re stressed, our bodies release hormones that create an anxious response and manifest in physical sensations. This can lead to panic attacks, stomach aches, headaches, fatigue, muscle pain, chills, faintness, and chest pain, as well as a variety of other seemingly mysterious physical symptoms. 

It’s important to remember that while these symptoms are very much real, they are rooted in the mind. This means that they are not a sign of a “more serious” physical ailment or disease, which is good news. But, conversely, it also means that they cannot be easily “cured” with medication or procedures that address these physical symptoms. Instead, these symptoms need to be conceptualized as an interaction between the mental, behavioral and physical attributes of anxiety.  

How do I know if it’s anxiety? 

It can be hard for anyone, no matter their age, to distinguish between a physical ailment and one that stems from anxiety. However, because a teenager with anxiety is even less likely to approach their caregivers for help, recognizing their anxiety can be challenging. Caregivers are sometimes thrown off by their teen’s anxiety because the worries “mature” into anxious thoughts that seem more practical. These may include anxieties about performance, self-worth, identity, and social status, among others.  

It should be noted that a single or passing symptom is not an indicator of a clinical anxiety disorder. Instead, look for significant or growing changes in your teen’s behavior and be sure to ask other trusted adults—like teachers or coaches—if they’re noticing similar behaviors outside of the home. It’s important to distinguish between behaviors that are cropping up as a result of a stressful time (think: midterms, graduation, or finals) or whether they seem to be interfering more consistently.  

Studies have shown that caregivers are often better able to detect externalizing behaviors (such as acting out or arguing), as opposed to internalized behaviors (like worrisome thoughts or a low mood). This can make it difficult for caregivers to spot a teenager with anxiety. With this in mind, here are some of the teen-specific signs and symptoms to look for: 

• Recurring fears and worries about routine parts of everyday life 
• Irritability 
• Trouble concentrating 
• Extreme self-consciousness or sensitivity to criticism 
• Withdrawal from social activity 
• Avoidance of difficult or new situations 
• Chronic complaints about stomach aches or headaches 
• Drop in grades or school refusal 
• Repeated reassurance-seeking 
• Sleep problems 
• Substance use 

Common expressions of anxiety in teens 

In its most basic sense, anxiety is an umbrella term that encompasses many different expressions. And while it isn’t always easy—or even important—to diagnose the specific kind of anxiety a teenager is suffering from, it can be useful to have a general idea of the ailment. The most common expressions of anxiety that start to develop in teens include but are not limited to: 

• Social anxiety is more than just momentary jitters or stage fright. It usually shows up as a strong and continual fear of situations that require some sort of performance or social engagement. Those experiencing social anxiety may worry about being judged or humiliated, and often end up avoiding these situations all together. 
• Generalized Anxiety Disorder (GAD) is characterized by intense worry about everyday issues and, as a rule, lasts longer than six months. The teen experiencing GAD will most likely feel the need to be in control, make constant plans, and ask many questions about how an upcoming event or situation will play out. They usually have a hard time being flexible and may feel drained, experience restlessness, seem irritable, have trouble sleeping and concentrating, and feel overwhelmed. 
• Panic attacks often seem to occur at random and can be characterized by dizziness, trembling, heart palpitations, nausea, stomach ache, and other intense physical symptoms. If a teenager experiences a panic attack, they may feel like they are “going crazy” and worry that it will continue happening. Unfortunately, the anticipatory worry that it will occur again often leads to it actually happening again. Panic attacks turn into Panic Disorder when someone repeatedly worries that a panic attack will happen, changes their behavior to ward it off, and then experiences recurrent attacks. 

• Agoraphobia is the fear of not being able to leave or escape a situation without being publicly embarrassed in the case of a panic attack. It commonly manifests as avoidance of certain situations or places and is often characterized as a “shrinking” of one’s world. 
• Obsessive Compulsive Disorder (OCD) can occur in teens and kids alike, and is characterized by recurrent, intrusive thoughts, images, and impulses that often cause distress. The teen experiencing these thoughts may come up with coping mechanisms and behaviors to alleviate these thoughts, such as hand washing, praying, counting, and silently repeating words, among others. 

Other forms of anxiety: 

The following forms of anxiety may occur in teens, but often manifest for the first time at earlier developmental stages or after specific traumatic events: 

• Separation anxiety is a common—and developmentally normal—sensation that usually occurs in babies and toddlers who are between 6 and 18 months old. Separation Anxiety Disorder (SAD), however, can manifest in older children and teenagers and is often characterized by a deep, sometimes debilitating fear of being separated from their caregiver. This may worry about getting lost, being kidnapped, or their caregiver dying. Because of this, your child may refuse to go to school or go away to college, attend field trips, or avoid social events without their parents or “safety person” (a good friend) like birthday parties and sleepovers.  
• Specific phobias can fixate on a wide range of objects or situations. While many people have fears—common ones in adolescents include a fear of vomiting, doctors, injections, as well as dogs, heights, deep water, etc.—the person experiencing a phobia will spend an excessive amount of energy worrying about the particular object or situation they find triggering. They will often noticeably disrupt their lives trying to avoid it. Both SAD and specific phobias tend to be especially obvious to caregivers who are tasked with managing their child’s anxious behaviors and/or reassuring their child that situations are safe.  
• PTSD is usually the result of a traumatic event, such as a car accident, assault, or natural disaster. It usually manifests in the person continually “re-experiencing” the event, either in dreams or waking life. Common reactions include an overwhelming sense of fear, agitation, helplessness, or horror. There is also significant avoidance of places, people or events that remind the teenager of their traumatic event. It can occur in anyone at any age. 

There are a plethora of specific expressions of anxiety and not all of them are easily categorized. Some, like OCD, may warrant specialized treatments. But, during diagnosis, the through line that every caregiver should be looking for is a teen with an overly sensitive internal alarm that often rings when there is no present danger or cause for real distress. 

Seeking treatment 

The great news about undiagnosed symptoms that may be stemming from anxiety is that they are both common and treatable. Anxiety can be helped by working with a counselor or starting therapy, becoming acquainted with progressive relaxation techniques and meditation, or making lifestyle changes.  

When it comes to diagnosis, caregivers should be on the lookout for whether their child is experiencing the same symptoms repeatedly, in similar circumstances. For instance, does the teenager experience stomach aches before social events? Do they complain of a headache before school every morning? Do they always complain of nausea before sleepovers, exams, or their friends’ birthday parties? Adolescents who are experiencing anxiety often have a strong and persistent need for predictability, perfection, and planning. They also usually try to avoid discomfort. Be on the lookout for patterns in your teen’s complaints.

Checklist for when to seek help 

• PERSISTENCE: Does the symptom manifest in a range of situations throughout the day? Does it occur on most days? Has it lasted weeks or months? Does it seem unrelated to a specific environmental stressor, such as the lead-up to the SAT or a big soccer game? 
• UNCONTROLLABLE: When your teen attempts to manage anxiety-producing situations, are they able to cope? Do they possess a range of skills that help them push through the anxiety and manage the situation? 
• AVOIDANCE: Is the symptom interfering with your teen’s daily life? Are they withdrawing from or avoiding activities that challenge them, such as school, field trips, birthday parties, sleepovers, family functions, and sporting events? If they are able to face their fear, some amount of anxiety is expected—but it may be a red flag if the anxiety remains prevalent once they are involved in the activities they were formerly worried about.
• INTENSE AND OVERWHELMING: Is your teen overly stressed? Are they losing sleep or experiencing physical symptoms like headaches and stomach aches? Is this the amount of stress you would anticipate a teen might feel in this situation or does it seem out of proportion when compared to other teens their age? 

Answering the above questions honestly can help you determine whether or not your teen’s anxiety seems to be fleeting—a mere rock in the road—or if it needs to be addressed. Answering “yes” to the questions above may mean that your teen could benefit from professional treatment or support. 

Discrepancies in diagnosis and treatment 

Caregivers should also be aware that there is a much higher rate of diagnosis and treatment of anxiety in white teens versus LGBTQ and minority teens. Yet statistics show that teenage girls, LGBTQ youth, and people of color actually experience rates of anxiety that are just as high—if not higher—than their white male counterparts. 

Statistics from a 2022 survey show that 73% of LGBTQ youth reported experiencing symptoms of anxiety. And, according to a 2022 survey by the AKKOMA project, feeling  anxiety, worry, and nervousness were the most common symptoms of anxiety reported by youth of color, with African American adolescents being most concerned with decision making and worrying that bad things can happen to them; whereas Latino/e youth reported struggling with decision making; and Asian American, Pacific Islander, and Native American youth reported high avoidance of situations prompting worry. In prior studies, female teens have proven to have more anxiety than male teens. In fact, studies have shown that as early as age six, girls are already twice as likely to have experienced an anxiety disorder as their male counterparts.  

Because treatment rates do not reflect the aforementioned statistics, it’s clear that anxiety disorders are being severely overlooked in all of these populations. That means that, as a caregiver, you should be particularly thoughtful when assessing your teen’s mental and emotional state. Be aware that your teen’s identity may—intentionally or unintentionally—be a factor in how their doctor diagnoses them. 

Getting support from medical professionals 

If you suspect that your teen may be suffering from anxiety, a visit to the pediatrician or family doctor can be the perfect opportunity to discuss your observations with a professional. Together, you can decide which tests to run to rule out medical reasons for headaches, stomach aches and fatigue. This will help you better assess anxiety as the root cause of these complaints.  

However, it’s important to remember that even when these symptoms are due to anxiety, that does not mean they aren’t physically real and unpleasant. Providers can help validate that these symptoms are uncomfortable and that the best way to help reduce them is to learn and practice anxiety management skills. 

In the meantime, it could be helpful to discuss things like your teen’s schedule, current academic stressors, and social concerns with your provider. They can help you identify the areas where it could be beneficial to add support to your teen’s environment—and where there might need to be more acute treatment recommendations. 

Tips for caregivers 

If you’re a caregiver currently in the midst of a marathon of visits to different doctors and specialists, we sympathize with you. It can be hard to help your teenager when you don’t know what’s wrong, but it’s important to step back, reset, breathe, and trust the doctors. Remind yourself that it’s good news when a pediatrician says they haven’t yet found anything concerning or concrete.  

As the doctor continues to listen to your concerns, take a minute to examine your own anxiety. Ask yourself what you are worried about when it comes to your teen’s anxiety. Go through the checklist we shared above and determine whether or not this current situation seems like it might just be a blip—something your teen can adapt to if they are given the opportunity, time, space, and support—or if it’s a more serious issue that could be helped by talking to a therapist or setting up an appointment with Lumate.   

Cognitive-Behavioral Therapy (CBT) 

When it comes to treating anxiety, therapy can be a gamechanger—especially when it is short-term, targeted, solution-oriented, and active. Cognitive-Behavioral Therapy (CBT) is a “talk therapy” or psycho-social approach that focuses on minimizing the symptoms of disorders like depression and anxiety, and it has actually been shown to be just as effective, if not more effective, than other forms of therapy and medications.  

So how does it work? At its root, CBT is about changing thinking patterns and shifting behaviors that maintain anxious symptoms. Patients work with a therapist in a collaborative way to focus on the present, increase their awareness of anxious thoughts, and then incorporate skills that can help shift these thoughts. Some therapists might engage in role play with their patients to help them prepare for anxiety-inducing interactions. Others might focus on relaxation techniques that help the patient calm their body and nervous system. These processes teach the patient to face their fears rather than avoid them and give them tools they can practice in between sessions. A pivotal aspect of CBT for anxiety involves helping the teenager approach, rather than avoid, the people, places or situations they’re afraid of. This is done in guided partnership with the therapist so that the teenager can enjoy a wider range of common adolescent experiences.  

It might be helpful to think of CBT as physical therapy for the nervous system: it has a beginning and an end date, gives patients skills they can use for the rest of their lives, and strengthens the mental muscles that help keep anxiety in check. Most importantly, CBT has helped many adolescents become happy, independent, high-functioning people who aren’t reliant on mental health professionals forever.  

Moving forward 

It’s important to remember that anxiety is a common, self-protective feature that has evolved over centuries. And it’s normal to be uncomfortable sometimes. Just because your teenager feels uncomfortable does not mean that something is “wrong.” Life can be challenging. The important thing is to help them focus on strengthening their minds, grounding themselves, and managing their health and wellness so that they are able to ride out the uncomfortable times and meet their challenges head-on. And if you need support, Lumate is here to help.