Anxiety—College Boy Problems

Before I met with Peter, the 21-year old college boy with anxiety, I asked his parents if there was anything they were concerned about. He said, “Well, it would be great if he were a little more outgoing.” I hadn’t seen the boy in a couple of years and didn’t really know him well since he didn’t go to the doctor much. Was he shy?

An hour or so later, with them waiting patiently outside the exam room, I knew he had a full-blown anxiety disorder. Many people have some anxiety in certain situations, like public speaking. Some people have more focused anxiety about specific things, like spiders or heights. Some have anxiety about things that they themselves know intellectually to be fairly harmless to most other people, such as a fear of balloons. Some fears are so unusual that the person is able to talk about them freely, and knows that they are not an issue for everyone else they have ever met, but the fear is quite real to them. Perhaps a great thing about the internet is that it can give this last group of people the ability to connect with the 1 or 2 or 5 other people who share their unusual problem. By example, there is a community, of sorts, for those with a fear of buttons.

He lived at home with his parents. There’s nothing wrong with that, of course. His parents were nice people and nice to him. And they never threatened to kick him out. They probably never would. That’s a nice thing, too.

But he never indicated that there might be advantages to living away from his parents. More than that, he couldn’t fathom why anybody his age would want to move away from home. It wasn’t like he was so emotionally tied to his parents. I had spoken with them, though not about him. They went on vacation, sometimes camping. They went out to the movies sometimes. Most of the time, I learned from Peter, he never wanted to go. I could picture a dysfunctional relationship in which he didn’t want them to leave, but he never objected. He was most comfortable just staying at home. Alone.

He wasn’t psychotic about his anxiety. He didn’t believe (or say he believed) that if he rode the bus then the world would end by a volcano emerging under his suburban town just as a meteor hit the earth causing an rip in the space-time continuum which would provide an attack opportunity for the Monsters from the Id.

Still, I had a bad feeling about where this was heading. Unlike the College Girl I had seen just a day before, he was not tortured by his anxiety. He knew that others weren’t as concerned as he was about many things, but the way he thought was obvious. Every unusual fear was completely reasonable, and he was almost bemused about the mad foolishness he witnessed around him. To him, our riding in vehicles of all kinds appeared like those who walk tightropes over great gorges. He saw that people did it, that they could do it regularly, but you’d have to be positively nuts actually to try it.

This is also how he saw the pursuit of human relationships. This was another big difference with the College Girl. She didn’t have a boyfriend and wanted one. She absolutely did understand why her peers were in or wanted to be in a relationship. She also understood what was keeping her from achieving this goal. She perceived her anxiety as a handicap that she hated, a roadblock she was desperate to overcome and was so far unsuccessful at doing so.

Was he really forthcoming with me? Like every patient, he was entitled to his privacy and owed me no explanation. Some doctors, I know, think that if a patient isn’t open about something, or if a patient fabricates something, then they can’t or shouldn’t help them. It’s certainly an impediment to treatment when a person doesn’t seem to respond to medication that they say they are taking but aren’t. But mostly if patients want me to give them my best advice and they want advice based on some hypothetical situation, that’s what I and they will be stuck with.

Is this denial? Once I saw a child who had been in and out of emergency rooms at least 4 or 5 times over several months. Every time the family went in with him, he had trouble breathing. He was given breathing treatments and medication and sent home to follow up with his primary care physician. They didn’t give him the medication, didn’t make the follow up appointments. They needed a form filled out for school, and the doctor told them that the child had asthma and would benefit from better control of his symptoms. They changed doctors, and came to the practice where I used to work. I told them their child had asthma and would benefit from better control of his symptoms. He went to the ER again, then they asked for their records to be transferred to another practice.

Is it my job to puncture his denial, if it is? Is it my role to judge his life decisions as somehow inadequate, as incompatible with happiness? Is my definition of happiness and success as an adult a reasonable goal? There are societal norms, of course, and he was aware of these. Marriage, family, work, kids, and so on. Certainly here in one of the epicenters of alternative lifestyles, there aren’t a lot of choices that wouldn’t be tolerated. Besides, I lived in Utah for 3 years. In ways that I appreciate more from a distance—topographical, chronological, and metaphorical—some of those people were very much willing to do a lot to live outside of the mainstream. Whether in shallow swamps of consanguine genes or in isolated heavily-armed bunkers waiting for the race-war end-of-times, they were going to do it their way.

Let me be explicit about some of the ethical issues associated with this case.

1. If the patient doesn’t think it’s a problem, is it a problem? Before there were Wall Street executives who didn’t take any responsibility in their congressional testimony, there was a panel of Tobacco CEOs who swore under oath that they didn’t believe that smoking caused health problems. That seemed sleazy and dishonest. But if a patient says that they are just fine with what they are doing, does it matter if they are in denial or are out of touch with reality?  Does the doctor have an obligation to do more than educate, inform, and offer help?

2. Is Peter hurting anyone else by his inattention to his anxiety disorder? Sure, his parents had dreams for him that might be difficult to achieve. But who among us has parents who have always thought that we would be exactly who we are now? I am, to be blunt, worried that what appears typical enough at the moment—a college kid living at home while attending a decent and popular local institution—could become more cumbersome as the years go by. Do his parents deserve a life of their own, without their kids? Do their kids owe them the freedom gained by moving the heck out of the house at some point? And the parents aren’t my patient, so should I care what they need?

3. I want to repeat that last part. The parents aren’t my patient. This is an easy issue for some of the patients I see. I have a patient who’s nearly 30 now, severely developmentally delayed. I have autistic kids who are technically autistic adults. It’s an easy issue for them because they have legal guardians and decision-makers. Not Peter—he’s warm and smart and going to college. But in some ways, obviously from these essays, I think of him as having a handicap. It’s not politically-correct, I know, to use that term at all. But there’s something about him, that is with him in every setting, that often interferes with his achievement of some of his own goals. It interferes, in my professional opinion, with his ability to meet some criteria of independent—if not happy, perhaps—adulthood. The Americans with Disabilities Act of 1990 says a covered disability is a physical or mental impairment that substantially limits a major life activity. What, if anything, should I tell his parents? That their kid is sick and needs to have medication spiked into his orange juice? I want to tell them everything. They are his best advocates, they know something isn’t right. He gets along well with them. Shouldn’t they be there to encourage him to seek the help I think he needs? A lot of parents read this, and would probably agree. But what about when you were 20—would you have wanted your doctor calling your parents?

Anxiety--College Boy

Peter was at college here in Berkeley, and needed a physical exam form filled out for a summer job he had applied for. He came in with his parents. I asked them if they were worried about anything in particular and they said that he had been very healthy. But they wished he'd get out more. Maybe be a little more...outgoing. He looked very relieved when his parents left the room.

"Gosh," I said, "I thought they'd never leave!" He smiled briefly. I asked how college was going, if he had a major.

He said, politely enough, looking at the floor, "It's going OK. Don't have a major." Didn't I recall that he was interested in Economics? "Yes, but I didn't get a good feeling from those people." Meaning, I took it, from those in that department. How about people in other departments? I told him I thought there was a lot to be said about finding a group where you feel like you fit in. "Maybe, but I don't fit in." Still no eye contact.

"You haven't made a lot of new friends?"

"None, really."

"Are you in touch with your friends from high school?"

"I had two friends in high school but they are going to college in Hayward [Cal State]." It is a sad fact of suburban life that the logistics of socialization are often very cumbersome for children. (This is very different from my experience growing up where public transport was great and cheap.) But he was 21, not 14. What about borrowing a car from his parents? "I don't drive."

"Why not? Didn't they have driver education in your high school?"

"Yes but I stopped taking it after the first day. It was just too dangerous." But his mom and dad drove, I pointed out. "But I won't drive with them at night. Anything could happen. No," he added for emphasis, "I definitely don't want to drive."

Most 16-year-olds have, at least in their minds, cut from magazines the photos of the cars they want to have. A car, or access to one, or even without access but having a driving license, meant adulthood, liberation from the control of their parents, freedom. Most American teenagers have much clearer dreams of owning their own car than they have of owning their own home someday. I think that this is less prevalent among those growing up in urban settings. (A wealthy high-school classmate of mine had his own car, but I don't know where he drove it (let alone parked it) and neither I nor most of my other classmates were envious.) But this is California, where having a car or wanting one is or should be considered an essential developmental milestone, like walking or potty training. When he said that he didn't want to learn to drive, whatever alarms were not already ringing for me started to go off. "What about going to Hayward on BART?" [Bay Area Rapid Transit--a not very extensive system, but fast and reasonably comfortable and clean.  And ] I knew he lived in a town with a station.

"That goes under the Bay!" he explained as if I has somehow been misinformed about this fact.  But it didn't between Berkeley and Hayward.

At some point, I stood up to wash my hands and examine him. I went to put my stethoscope on his chest, but stopped. "Gosh, Peter. Have you been gardening? Working with paint solvents?" His hands were red, very dry-looking and irritated. He denied this but said that he washed his hands a lot. Mine were not so raw, and I typically washed them 20 times a day, sometimes more.

"I know. I'm a bit of a germophobe."

He was attending college locally. So I asked him if BART was uncomfortable for him, why wasn’t it a problem taking the public transit bus to school?  He told me that he walked to his college campus, about 3 miles or so from his home. He admitted that not using public transportation was a real barrier to making and sustaining new friendships at college.

Continuing in this line, I was worried about what would come next. As I would ask any patient his age, I asked if he was dating anyone. I assumed that this would be logistically difficult for him, given his transportation constraints. He said he wasn’t in a way that concerned me. Sometimes I get a disappointed response, when the college kid wished they were dating somebody. Sometimes it’s a blissful yes they are. He looked at me at me with an odd expression of confusion. Now I was confused about why he was confused. I asked him to clarify what he was thinking.

He told me that he wasn’t dating and convincingly claimed not to know why people did. Let me be really clear here:  I asked about just dating, nothing more intimate. Yes, he knew classmates in high school went on dates or wanted to and talked about it.  He knew they did in college. I asked if he knew how his parents met. Like most of us, their relationship started with dating. But he didn’t really see why people did this. There were so many obstacles that he pointed out. Getting together in a certain place and time, which is a key part of the definition of a ‘date,’ is very difficult if one of the people has to be within walking distance of their home. Holding hands seemed unappealing to him, and kissing appeared positively unhygienic. I asked if he would like someday to have a family of his own and a mate. He said that he would but he didn’t know and couldn’t picture what kind of a person that would be or how he would get to there from where he was.

I spent about an hour with him, much of it trying to figure out the level of isolation to which he was willing to subject himself.

I told him he had anxiety. I recommended many things, including trying some medication. I was willing to work with him in any way that I could. He was willing to commit only to think about these choices, or if he wanted to do anything at all. So deeply did he see his perspective as an accurate view of the world that he didn’t see it as a problem in his life. I asked about continuing to live with his parents, and he didn’t see a problem with that, or limiting for school or work to a walking-radius around his parents’ house in Berkeley. Gently, I tried to point out that it might be difficult to meet somebody under these circumstances, but he was blind to this. He didn’t try to reconcile his dream of having a family with his disinterest in looking for somebody with whom to start that family.

Anxiety—College Girl

Not feeling well for a weekend, getting through a really busy spell in your work, maybe just being exhausted and not getting a good night's sleep. Those are common reasons why people stop their regular daily exercise routine. It's not like they make a decision that the exercise they've been doing isn't a good idea, or even that they hadn't been enjoying it. But somehow the routine is broken. It's really hard to get started again. When you do restart, what came easily when you stopped is really difficult. It will take time to work up to your former level of fitness.

I got unusually tired and wasn't feeling well. My closest friend called and told me she had cancer.  Suddenly, the effort that was required to keep this up just didn't seem so important. A series of moving patient encounters, together with a surprising amount of encouragement from readers both locally and around the world combined to get me off my lazy behind. My 2-month sabbatical from this blog, I hope, is over.



Jessica came to my office by herself last week.  She was 18 now, and starting college.  She’s been seeing me since she was a girl, and though I knew we got along well enough, I never got the feeling that she was entirely comfortable.  This visit might be the first time I saw her without her mother.  She had always been thin, but my perceptive assistant noted to me that she had lost about 10 pounds since the last time she’d been in the office.

She said that she wanted me to take a look at something on the skin of her leg.  It had started as a bump a few weeks ago, about the size, she said, of a ‘mosquito bite.’  Maybe it was a little itchy at first, but she didn’t remember it being very annoying.  After some time, she wasn’t exactly sure how long, the bump went away and an area of the surrounding skin on her leg was red.  It wasn’t painful or bothersome.  Over the last couple of days, the redness has decreased and there was a very small amount of skin peeling.  When I asked, she said that it looked like it was getting better.  It didn’t hurt, itch, burn, bleed, ooze, or interfere with anything she did or wore.  I asked to see it.  A little above her knee was an area about the size of a quarter with some faint pinkness and a few skin flakes.  I asked if I could touch it, and found that it wasn’t warm, firm, soft, raised, or bumpy.  She said that it didn’t hurt when I touched or pressed on it.  There were no other such lesions on her.  I was not very worried about it, whatever it was originally—and told her so.  She should call right away, however, if it didn’t continue to improve a little every day. 

I will inject as an aside that I believe the rapport that a patient—even a little kid—has with her doctor can be really important.  It is very hard to establish that relationship with 6-minute visits.  There are lots of other impediments established by current care standards.  If you see a different doctor every time, if the doctor never seems interested in other symptoms you might be living with, if you’re made to feel like just another hot-stamped drop-shipped cog delivered through optimized just-in-time-supply-chain management into the inflexible assembly line of efficient health care designed to achieve least-common-denominator-acceptable outcomes for your particular diagnosis code in order to achieve maximal reimbursement from a 3rd-party-payer at whose toll-free-number you cannot ever reach a human, then you probably won’t really feel relaxed with your doctor.  My patients of all ages, I hope, know that’s not how I work.

So when I told her to call right away if it didn’t improve, my hand was not on the doorknob.  I didn’t even stand up to go.  I simply asked her, “What else hurts?”

“Nothing much,” she said thoughtfully.  “I mean, you know, except for the stomach aches.”  I resisted the urge to smack myself in the head.  Only gradually had I come to realize that bald as I am, a good smack might leave a red mark that could last an afternoon.  Somehow, it was not as satisfying to smack myself on, for example, the ankle.  I didn’t say or do anything except pay attention.  “Sometimes they’re really bad.”  With that her eyes filled with tears and so did mine.  The exam rooms are stocked with tissues, but only one box.  We shared.

She had been having abdominal pain for at least several months.  It was very worrisome for her.  She was afraid she had an ulcer caused by her anxiety.  Anxiety?  Forget the mosquito bite—what happened to the abdominal pain? 

About an hour later, I had learned that she had a couple of jobs that she couldn’t keep because of her anxiety about many, many things.  She had no problem with the academics of college but being in a classroom was a problem and if the classroom were filled with busy, social, chatting, comfortable peers it was an awful experience.   She had sought professional help for this, I was relieved to learn.  But the medication she was prescribed wasn’t helping her—and she was afraid of bringing this up.  I offered to make that call, but she declined for now.  She felt hopeless about the anxiety because the medication didn’t work.  She said that she was worried that her abdominal pain could be something serious.  Right after she said that, she said that it’s her fault because she probably has an ulcer that’s caused by her anxiety.

Here’s what I told her.  Neither the anxiety nor the abdominal pain were her fault.  This I backed up with a short neurophysiologic explanation of how the amygdala communicating with the prefrontal cortex can give the uncomfortable sensations associated with anxiety.  I told her that though it does indeed seem like she has an anxiety disorder, people with anxiety disorders can get just as sick as people without. 

I explained the curious history of peptic ulcer disease.  For more than 100 years, an entire field of medical knowledge was based on the belief that it was somehow caused by intense or anxious or angry or unstable personalities.  Idioms like Type-A Personality entered the daily lexicon largely based on this medical belief.  It was all crap.  Ulcers are usually caused by a bacterial infection in the stomach, which is typically successfully treated with antibiotics and Pepto-Bismol.  (Even happy little kids can get ulcers, by the way, though this is quite unusual.)

I told her that it would be a medical error to assume that her anxiety had been the cause of her symptoms.  It didn’t help, of course.  But I suggested an alternative way of looking at her pain.  Suppose there were some reasonable explanation for the pain and other symptoms that she described.  Maybe when the pain was bad, she would become worried about it and if it were something serious.  This, I pointed out explicitly, would be just how people without an anxiety disorder would think about it.  If the pain continued, a person would be increasingly worried.  As the worry increased, their senses would be focused on the pain, observing it carefully for changes.  With this concentration, continued pain would be sharply perceived and the worry would just continue in an accelerating spiral.  She had not looked at it that way.  Besides, I said, I would really like to relieve that pain if I could.  She deserved and needed the workup I would do for any young woman with chronic abdominal pain.

I informed her that though she might not have been helped by her treatment so far, there are many other treatments available.  None of them works with everybody, but all of them work with some people.  There’s at least a dozen medications she hasn’t tried.  Has she tried a workbook?  She said she had one but she didn’t want to do it because it might not help.  She had not seen that she was too anxious to try an anxiety treatment.  Maybe yoga, maybe hypnosis, I suggested.  She hadn’t thought of those.  I didn’t promise to make her better.  But I promised I would try and I wouldn’t give up.  I don’t know if that will be enough, but it’s all I had to offer.  Well, that and calling the shrink.  For now, I’m working on the stomach aches.

By complete coincidence I have had a series of patients with anxiety issues.  Maybe there were more of them out there than I knew about, and maybe I wasn’t asking enough or the right questions.  With teenagers, I screen everyone for depression.  I get the feeling that’s not enough.  I’ll write more about these young people.

The poster pictured above, stolen from the internet, is from a movie I have not seen.   It’s apparently being shown as a double feature with Libidoland, by the same filmmakers.  Not sure what to make of that.  The tag line for Anxiety Acres is:  “When Casey moved Kevin to the country, she hoped he’d find peace and quiet; instead he found new things to worry about: zombies, hitchhikers, and chocolate cake.”  Who doesn’t worry about zombies, hitchhikers, and chocolate cake?

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