College Students and Anxiety

What is Disordered Anxiety? Types of Anxiety Disorders

How do we know when we cross the line between “normal” anxiety and disordered anxiety?

Guidance for making this distinction can be found in diagnostic systems used by psychiatrists and psychologists, such as the Diagnostic and Statistical Manual of Mental Illness (DSM-5-TR) or the World Health Organization ICD-11 system. In general, anxiety is considered disordered when it meets the following criteria:

• The anxiety is not warranted by the situation.
• The anxiety is preventing a person from carrying out normal daily living.

A student who treats an upcoming exam as if it were a life-threatening emergency is probably experiencing a level of anxiety that is no longer rational. If that anxiety interferes with the student’s ability to get to class, finish homework, eat normally, enjoy a movie with friends, and otherwise take care of everyday life, we will become increasingly concerned for that student’s well-being.

One of the interesting aspects of disordered anxiety is that it does not affect reality testing, at least in adults. Adults experiencing disordered anxiety are typically aware that their level of anxiety is disproportionate to their situation, yet they feel the anxiety nonetheless. A person who is unrealistically afraid of heights understands at some level that they are perfectly safe while looking down from a window in a high-rise building, yet their negative emotional response remains. Children, however, do not have this luxury. Their anxiety is accompanied by full confidence in its validity.

Anxiety disorders take several forms, and many individuals experience more than one form. Variants include generalized anxiety disorder, panic disorder, specific phobias, agoraphobia, social anxiety disorder, and separation anxiety disorder.

Generalized anxiety disorder is usually diagnosed when a person is in an ongoing state of worry. The worry can be unfocused or it can relate to generally minor things, such as getting tasks done on time or upcoming appointments. It is common for individuals with this diagnosis to experience fatigue, difficulty concentrating, and poor sleep. Because maintaining a state of “yellow alert” for long periods of time requires resources, these symptoms are not surprising. A student in this state would be compromising the cognitive and physical resources needed to succeed academically. Across all adults, about 2 percent experience generalized anxiety disorder, but this number is likely to be higher among college students.

Panic disorder is diagnosed when a person experiences repeated panic attacks and then begins to worry about having more panic attacks. A panic attack resembles the fight-or-flight response in the absence of an emergency. The system simply turns on when the situation doesn’t warrant it, such as when a person is enjoying a lunch with friends. In other cases, a person might experience a panic attack in particular, usually benign, situations like being in a crowd. Because the physical symptoms seem so out of place, people might assume they are having a heart attack or other medical emergency, which only makes the negative emotional state worse. 

Having experienced one or a few panic attacks is surprisingly common. When I ask my college students anonymously if they have had such an experience at least once, over half say that they have. Having a few panic attacks does not meet the criteria for the disorder, however. The population rate for panic disorder is 2 to 3 percent, with a typical onset between the ages of 20 and 24 years. This, of course, coincides with the age of many college students, so many individuals experience panic disorder initially during their college experience.

One of the great challenges of panic disorder is that it is embarrassing, and the emerging adults who make up the bulk of the college student population are still more sensitive to social pressures than they will be a few years later. This makes panic disorder a substantial risk factor for social withdrawal. The individual might fear going to class or out with friends due to the possibility of having a panic attack.

Specific phobias, or unrealistic fears of specific objects or situations, are the most common of the anxiety disorders, affecting between 8 and 12 percent of adults. People have phobias regarding animals (spiders, snakes, etc.), situations (high places, enclosed places, open water, etc.), and sight of blood or injury. 

It is interesting to note that people do not experience phobias related to harmless objects or situations. Nobody has a coffee cup phobia or a chair phobia. Instead, phobias appear to be exaggerated responses to things that have some realistic connection to danger. Spiders and snakes can kill. What makes phobic responses disordered is that the fear is not proportional to the actual risk presented by the animal or situation. 

People often go to great lengths to avoid the focus of their phobias. They book their vacations many months (or even years) in advance to ensure rooms on the second floor of a hotel instead of on a higher floor. Blood-injury phobias can interfere with a person’s seeking appropriate medical treatment. These phobias can be so physically powerful that they actually induce fainting. This is one of the reasons why the rest of us must be bundled into padded chairs for a simple blood draw. Over the years, I have learned to edit the images I show to my behavioral neuroscience students and to provide appropriate warnings. These steps help me avoid having students faint at their desks.

Agoraphobia is named after the Athenian agora, or marketplace, and refers to a fear of being out in the open. Between 1 and 3 percent of adolescents and adults experience this disorder. Like the specific phobias, this fear has a certain basis in logic. 

Being out in the open for our ancestors probably meant a certain amount of danger. In today’s world, however, agoraphobia can interfere with an individual’s use of public transportation, standing in line, or being in a crowd. If you have attended or visited a large university, you know that these activities are important parts of everyday campus life. The person who is unable to manage these situations is at a distinct disadvantage.

Social anxiety disorder is characterized by worry about being judged negatively in social situations. People with this disorder loathe public speaking, worry about meeting new people, and avoid eating or drinking in public. If this sounds like a prescription for making college unbearable, you are probably correct. This type of anxiety disorder can affect as many as 7 percent of adults.

Finally, separation anxiety disorder is diagnosed when people have extreme concerns about being physically away from those to whom they are attached. This disorder affects one to 2 percent of the population and typically begins in childhood. Children with separation anxiety disorder have difficult leaving the parent to attend regular school. Symptoms, however, can continue into adulthood, making leaving home to attend college a very difficult task.

It is unclear whether any of these categories is more responsible than others for the observed increases in college student anxiety reported by Mary Duffy and her colleagues. Measures used with college populations tend to be more general, such as the GAD-7 scale. This scale asks if individuals have felt certain symptoms over the past two weeks, such as “worrying too much about different things.” 

It is possible, though, that some types of anxiety disorder would make it too difficult to attend college in the first place. More research is needed before we can make definitive conclusions about the types of anxiety affecting college students.

Sources of Student Anxiety

We really don’t know why Duffy and colleagues saw a big increase in student anxiety starting in 2013. Why didn’t this happen in 2009, when economic pressures were dire? The year 2013 has its own share of challenges, from the Boston Marathon terrorist attack to Ed Snowden letting the American people know their government was spying on them to a huge tornado in Oklahoma. But as years go, this one seems about as anxiety-provoking as most.

Many psychologists yearn to blame social media use for the increasing anxiety seen in young people. However, this issue is difficult to tease apart as most of the data are correlational. If we observe that anxious individuals spend more time on social media, what have we learned? It may well be true that social media causes anxiety, but it is equally plausible that anxious people might be more attracted to social media use. As with any correlation, there might also be multiple third factors predicting both social media use and anxiety, such as low self-esteem.

Other possible risks for college anxiety include sleep disruption and loneliness. Sleep disruption among college students is almost a rite of passage. Dorms and other student housing do not provide very restful environments and the “all nighter” is a very poorly advised strategy that just won’t go away. When people are already tired, it makes it difficult to keep challenges in perspective.

Loneliness is extremely common among college students, especially those who have moved away from home to attend. Loneliness is an evolutionary signal that our social connectivity needs repair. When our ancestors experienced social isolation and loneliness, they really were in danger, so it should not be surprising that we still respond to any glitches in our social networks with anxiety.