Mental Health Issues and the University Student

14. Anxiety

Anxiety and fear are universal human emotions, with significant adaptive functions in our lives. But surveys of college students suggest that in the past decade or two, more are experiencing problematic anxiety. Nearly half of students in the 2011 National College Health Assessment Survey reported ex­ periencing “overwhelming anxiety” within the past year.1 Some of these were likely facing developmentally normal or short-lived situational anxiety, but others may have been suffering from an anxiety disorder. Clearly anxiety, or stress, as a presenting concern in counseling centers is on the rise, endorsed by 63% of counseling center patients in 2001, compared with only 36% in 1988.2 It has become the most commonly cited concern among counseling center clients. Untreated, anxiety can become a chronic, debilitating problem. But most anxiety disorders as well as more self-limited developmental anxieties respond well to treatment, especially in emerging adults, who rapidly grasp the concepts of what causes anxiety and how to most effectively approach rather than avoid the problems it can cause. Chapter 14 Anxiety Anxiety  127 Diagnosis: Regular Worry versus a Disorder Mike is a 24-year-old African American second-year medical student from Seattle who comes in complaining of declining academic performance and concerns about whether he has chosen the right profession. He describes feeling a constant sense of dread about school, racing thoughts, difficulty falling asleep, and frequent stomach disturbances. It’s hard to face the day. He can’t stop obsessing about whether he should be in medical school or not and often thinks about this question while on hospital rounds, causing him to miss questions that the attending physician directs to him. His mind often goes blank during presentations, and his hands tremble if he’s holding notes, making him feel unprepared and embarrassed. He’s been told to “relax” by several supervisors and has tried to, but to no avail. He was an excellent student as an undergraduate but has not been able to make honors in any of his medical school courses thus far, and he feels ashamed and demoralized by this. He’s most afraid that he will fail to take proper care of his patients and flunk out. Academic demands occasionally trigger anxiety for most students, but when anxiety is sustained and debilitating, an anxiety disorder may be to blame. Among American adults, anxiety disorders are the most common psychiatric illnesses, with a prevalence rate of 13% to 18%.3 There’s less data on the rate of all anxiety disorders among college students. One study found that in a sample of nearly 3,000 undergraduate and graduate students at a large midwestern university , 4.2% screened positive for either generalized anxiety disorder (GAD) or panic disorder based on the PHQ-9 questionnaire, with GAD being the more common diagnosis.4 In this study, more women than men suffered from anxiety (mirroring the general population), and more than a third who had anxiety also had some form of depression. One-fifth of those who screened positive for GAD also had suicidal thoughts. Students frequently use the word “stress” to describe anxiety, though at times it may also refer to depressive symptoms. It’s important to get a clear picture of exactly what they mean. Do they feel nervous, tense, afraid, anxious? Is there a sense of physical restlessness or irritability? How long and in what contexts have they been noticing this? Mike also uses the word “obsessing,” as students frequently do, but it’s helpful to distinguish between occasional irrational worries or constant excessive worries about usual life events, which more typically suggest generalized anxiety, and true obsessive thoughts, which 128  Clinical Challenges are intrusive, often ego-dystonic, sometimes bizarre or embarrassing, and more commonly accompanied by compulsions. In DSM-5, obsessive-compulsive disorder is separated from the anxiety disorders chapter. Had Mike described a constant thought that he might harm his patients, for example, or intrusive images of actually harming patients, an OCD-spectrum diagnosis may have been more likely. Other psychiatric conditions can cause or mimic anxiety. The complaint of “racing thoughts” is common among students, and it’s important to clarify whether this is an anxiety symptom or a manic or hypomanic one. A newly emerging psychosis can also cause significant anxiety. Anxiety disorders have high rates of comorbidity with other psychiatric problems—especially, for college students, substance abuse. Mike describes uncertainty over career choice, a...