Anxiety, somatic complaints, and depressive symptoms in rural adolescents

Journal of Child and Adolescent Psychiatric Nursing, Jul-Sep 2003 by Puskar, Kathryn R, Sereika, Susan M, Haller, Linda L

PROBLEM. Undiagnosed and untreated anxiety in adolescents is often associated with greater rates of mood and behavior problems, somatic complaints, and risk for future psychiatric disorders.

METHODS. A self-report anxiety instrument was administered as part of a community survey of 466 rural adolescents.

FINDINGS. Anxiety symptoms were strongly correlated with both physical complaints and depression. Females had higher scores for total anxiety and the anxiety subtypes of generalized anxiety disorder, separation anxiety disorder, panic disorder, social phobia, and school phobia.

CONCLUSIONS. Implications for nursing practice are provided.

Search terms: Anxiety, depression, youth

The term anxiety can be used to refer to the uncomfortable feeling periodically experienced by people without a psychiatric disorder, to a large array of symptoms that may exist alone or in combination to a degree not sufficient to warrant a diagnosis of anxiety disorder, or to the several specific anxiety disorders now listed in the DSM-IV (American Psychiatric Association, 1994). Anxiety-disorders are a prevalent and disabling form of psychopathology, which in adolescents can be associated with significant functional impairment.

Anxious youngsters have increased rates of behavioral and mood problems; somatic complaints; school difficulties; poorer self-esteem; and greater risks for suicide, substance use, and depression compared with the general population (Anderson, 1994; Birmaher et al., 1997; Kashani & Orvaschel, 1990; Reinherz et al., 1993). In particular, anxiety-disordered adolescents have significantly greater difficulties with both peers and family than do other teens (Kashani & Orvaschel). The presence of one or more anxiety disorders in adolescence is associated with greater risk of developing an anxiety disorder in adulthood (Pollack et al., 1996), and with greater occurrence of major depression in later adolescence (Reinherz et al.). In children who experienced both an anxiety disorder and a depressive episode, anxiety was found to precede depression in two thirds of cases, and to persist beyond the depressive episode (Kovacs, Gatsonis, Paulauskas, & Richards, 1989). Children with anxiety disorders who do not receive treatment may have a chronic course and low remission rate (Bernstein, Borchardt, & Perwien, 1996; Keller et al., 1992), but there is evidence that early treatment of anxiety disorders in children can reduce the tendency toward the development of avoidant coping strategies and co-morbid depression (Pollack et al.).

Even children whose anxiety symptoms are not at the level of disorder can experience increased school, family, and peer difficulties (American Academy of Child and Adolescent Psychiatry, 1993). A study of 62 nonreferred children (Bell-Dolan, Last, & Strauss, 1990) found that children identified as subclinically anxious had higher levels of anxiety, depression, loneliness, and greater family pathology (namely an increase in family history of major depression and/or alcohol dependence in the father) than did the nonanxious children. The authors suggested that the subclinically anxious children may be likely to remain at least slightly elevated in terms of anxiety throughout life, or may be primed to develop an anxiety disorder later in response to a major Stressor (Bell-Dolan et al.).

In summary, the presence of anxiety in adolescents, whether or not at a clinical level, cannot be assumed to be benign, in spite of its prevalence. Although normal youngsters report a high range and rate of anxiety symptoms, these can have important developmental consequences, and clinical levels of anxiety can be associated with substantial impairment and risk for future psychiatric disorders. Recognition of anxiety in schools or other nonpsychiatric settings can be difficult because of the covert nature of many anxiety symptoms. The adolescent with clinically significant anxiety may first present to healthcare providers or to school personnel with somatic complaints; because of the disabling nature of anxiety disorders and their co-morbidity with depression, such complaints should not be treated casually.

Clinically, the association between anxiety in children and somatic complaints, especially headaches and stomachaches, is well documented. In particular, the literature has noted for decades the relationship between somatic complaints and school refusal, an anxiety syndrome (Last, 1991). In spite of this, there has been relatively little systematic investigation of this relationship. Therefore, the research questions of this study are:

1. What is the prevalence of anxiety symptoms in a community sample of rural high school students?

2. What are the relationships among anxiety symptoms, somatic complaints, and depressive symptoms?

3. Controlling for selected demographic (age, gender, grade) characteristics, how do somatic complaints predict anxiety and depression?

Review of the Literature

Several issues have complicated epidemiological investigation of anxiety in children and adolescents. Separation of pathological from normal anxiety can be difficult, given the universality of many anxiety disorder symptoms at different developmental stages. It is not agreed whether children with anxiety disorders experience entirely different types of symptoms, or whether they merely experience the same types of symptoms at greater severity level (Bell-Dolan et al., 1990). However, it is agreed that "normal" youngsters commonly experience symptoms such as fear of separation from a loved one, fear of the dark, school refusal, fear of strangers, fear of social situations, and worry about what others think of them (Anderson, 1994). Sources of data, whether from child self-report instruments, parent interview, teacher report, or clinical interview will yield somewhat different findings (Stavrakaki & Gaudet, 1989). Additionally, the co-morbidity of anxiety disorders with several other disorders, especially depression, presents both epidemiological and clinical challenges. There is evidence that it becomes increasingly harder to differentiate between anxiety and depression when these persist into adulthood (Boyd & Gullone, 1997).