From the Editor

“The disintegration of Jake’s life took him by surprise.”

This quotation is from a long, moving essay about a young patient with a big problem. The piece begins with Jake in his junior year of high school with much on his plate: three Advanced Placement courses, a spot on the cross-country team, invitations to Model U.N. conferences – and significant anxiety.

The essay explores his anxiety, and the anxiety of teens like Jake.

The essay, which recently ran in The New York Times Magazine, traces the struggles of Jake, and the writer puts these problems in a larger context.

Teen anxiety: A growing problem?

In this Reading, we review this essay.


Teens and Anxiety 

“Why Are More American Teenagers Than Ever Suffering From Severe Anxiety?”

Benoit Denizet-Lewis

The New York Times Magazine, 11 October 2017

The disintegration of Jake’s life took him by surprise. It happened early in his junior year of high school, while he was taking three Advanced Placement classes, running on his school’s cross-country team and traveling to Model United Nations conferences. It was a lot to handle, but Jake — the likable, hard-working oldest sibling in a suburban North Carolina family — was the kind of teenager who handled things. Though he was not prone to boastfulness, the fact was he had never really failed at anything.

Not coincidentally, failure was one of Jake’s biggest fears. He worried about it privately; maybe he couldn’t keep up with his peers, maybe he wouldn’t succeed in life. The relentless drive to avoid such a fate seemed to come from deep inside him. He considered it a strength.

Jake’s parents knew he could be high-strung; in middle school, they sent him to a therapist when he was too scared to sleep in his own room. But nothing prepared them for the day two years ago when Jake, then 17, seemingly ‘ran 150 miles per hour into a brick wall,’ his mother said. He refused to go to school and curled up in the fetal position on the floor. ‘I just can’t take it!’ he screamed. ‘You just don’t understand!’

Jake was right — his parents didn’t understand. Jake didn’t really understand, either. But he also wasn’t good at verbalizing what he thought he knew: that going to school suddenly felt impossible, that people were undoubtedly judging him, that nothing he did felt good enough. ‘All of a sudden I couldn’t do anything,’ he said. ‘I was so afraid.’ His tall, lanky frame succumbed, too. His stomach hurt. He had migraines. ‘You know how a normal person might have their stomach lurch if they walk into a classroom and there’s a pop quiz?’ he told me. ‘Well, I basically started having that feeling all the time.’

news_denizet-lewis_large_0Benoit Denizet-Lewis

So begins an essay by Denizet-Lewis.

He notes the following:

  • “Over the last decade, anxiety has overtaken depression as the most common reason college students seek counseling services.”
  • “In its annual survey of students, the American College Health Association found a significant increase — to 62 percent in 2016 from 50 percent in 2011 — of undergraduates reporting ‘overwhelming anxiety’ in the previous year.”
  • “Surveys that look at symptoms related to anxiety are also telling. In 1985, the Higher Education Research Institute at U.C.L.A.began asking incoming college freshmen if they ‘felt overwhelmed by all I had to do’ during the previous year. In 1985, 18 percent said they did. By 2010, that number had increased to 29 percent. Last year, it surged to 41 percent.”
  • Anxiety if the most common mental-health disorder in the United States, affecting nearly one-third of both adolescents and adults, according to the National Institute of Mental Health.”

What enlivens this essay is the journey that Jake takes, from his first difficulties to three hospitalizations to care at Mountain Valley, a residential treatment facility for acutely anxious adolescents where Jake learns mindfulness and “equine therapy” (Mountain Valley costs $910 a day).

But what happened to Jake that he got so anxious? Arguing that anxiety is on the rise, the writer discusses several possible explanations. Helicopter parents? He weighs this.

‘Teenagers used to tell me, ‘I just need to get my parents off my back,’’ recalls Madeline Levine, a founder of Challenge Success, a Stanford University-affiliated nonprofit that works on school reform and student well-being. ‘Now so many students have internalized the anxiety. The kids at this point are driving themselves crazy.’

He explores social media.

Anxious kids certainly existed before Instagram, but many of the parents I spoke to worried that their kids’ digital habits — round-the-clock responding to texts, posting to social media, obsessively following the filtered exploits of peers — were partly to blame for their children’s struggles.

These things are complicated: Jake, for the record, is a “remarkably minimalist emailer and texter…”

The writer discusses different treatments, including CBT, noting a New England Journal of Medicine study showing that CBT and meds were superior to either modality alone.

We eventually catch up with Jake who is now an undergraduate at the University of North Carolina.

I was curious how much of Jake’s newfound contentment had to do with being at U.N.C., with getting into his dream school. After all, a major component of his treatment at Mountain Valley was learning to accept that his value didn’t depend solely on academic achievement. How would he have reacted if his application was one of the 74 percent that U.N.C. rejected last year?

It was clear that Jake had thought about the question. ‘I would have been disappointed, but I really think I would have been O.K.,’ he told me. ‘There are other schools in the world where I would have been happy. I definitely wouldn’t have believed that a couple years ago, but a lot’s changed.’

A few thoughts:

  1. This is a good essay.
  1. While it isn’t from a journal, the essay does a nice job of incorporating the literature.
  1. Of course, the larger question remains: why are teens suffering from anxiety in increasing numbers? There are lively explanations offered in this piece. The Atlantic recently published a very provocative essay suggesting that our iPhones are our undoing. In “Have the Smartphones Destroyed a Generation?” Jean M. Tweng argues that smartphones are deeply problematic. She draws from the literature:

All screen activities are linked to less happiness, and all nonscreen activities are linked to more happiness. Eighth-graders who spend 10 or more hours a week on social media are 56 percent more likely to say they’re unhappy than those who devote less time to social media.

But is that causation or correlation?

You can find the full essay here:

  1. But is the basic assumption – that there is rising mental illness in adolescents – correct? Is it possible that we are simply more aware of mental illness in youth? Large epidemiologic studies are mixed. Olfson et al., in a New England Journal of Medicine paper, found that “The percentage of young people with more severe mental health impairment (CIS score ≥16) declined from 12.8% in 1996–1998 to 11.9% in 2003–2005 to 10.7% in 2010–2012…”

That paper was considered in a past Reading, which you can find here:

  1. On a related note, for the adult psychiatrists among us, it’s not clear that – despite the popular press portrayal – illnesses like depression are more prevalent. The University of Calgary’s Scott Patten has published on this. See, for example, his recent Journal of Affective Disorders paper, “Why is major depression prevalence not changing?”

You can find it here:


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.