Multiple empirically supported treatments (ESTs), including behavioral and phar- macological treatments, are available for adults with anxiety disorders, and these interventions are reviewed elsewhere in this volume (see Chaps. 12 and 13). EAs would have been included in the treatment trials that established the efficacy of these ESTs. However, we are aware of no systematic effort to explore EA as a pre- dictor or moderator of treatment response in these trials. This omission is problem- atic, as EAs experience unique biological, psychological, and social changes that may impact their response to behavioral and pharmacological interventions. Below we discuss factors to consider when developing, testing, or delivering interventions to EAs with anxiety disorders.
Treatment Engagement and Retention EAs are notoriously challenging to engage and retain in mental health treatment, which appears to prevent many from receiving ESTs for anxiety disorders. Data from the NESARC indicate that only 16% of college students with a past-year anxiety disorder diagnosis received mental health treatment [45]. This treatment rate is much lower than the rate observed for college students with a past-year mood disorder diagnosis (34%; [45]), which sug- gests that EAs with anxiety disorders face unique barriers to accessing care.
Commonly cited barriers to mental health treatment among college students include (1) the belief that stress is normal in college, (2) perceived lack of need for treat- ment, (3) the belief that the symptoms will improve naturally, and (4) perceived lack of time for treatment [66]. Thus EAs with persistent worry, social fears, or panic attacks may view these experiences as normative during an unstable life stage and be reticent to invest time and energy in mental health treatment. These barriers may also explain why EAs drop out of mental health treatment at rates higher than other age groups [67].
Targeted strategies are needed to reduce barriers to accessing and utilizing men- tal healthcare among EAs with anxiety disorders. For example, public education programs about anxiety disorders could reduce the perception among EAs that clinical anxiety is “normal stress.” In addition, brief prevention and early interven- tion programs could be used to reach EAs during the initial stage of an anxiety disorder, before symptoms become entrenched. These brief programs might be more acceptable to EAs than the lengthy treatment regimens needed to address chronic disorders. Prevention programs for anxiety in childhood and adolescence have received preliminary empirical support [68] and should be studied in EAs.
Programs that target specific risk factors for anxiety (i.e., selective prevention pro- grams) or subclinical anxiety symptoms (i.e., indicated prevention programs) are likely to be most effective from a public health perspective. For example, cognitive behavioral and mindfulness-based interventions are both effective for reducing stress in university students [69] and could be studied as indicated prevention pro- grams for anxiety among EAs. Internet- and mobile-based prevention and early
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intervention programs could also be used to overcome time and logistic barriers to care, though more research on these programs is needed [70].
Clinicians treating EAs with anxiety disorders can also use evidence-based strat- egies to target patient engagement and treatment adherence. For example, research- ers have developed a transdiagnostic intervention to increase EAs’ motivation for treatment entitled Motivational Enhancement Therapy for Treatment Attrition (MET-TA; [71]). MET-TA was designed to address barriers to treatment retention among EAs, including poor working alliance and lack of knowledge about the struc- ture and length of treatment [71]. To address these barriers, the MET-TA protocol prescribes the use of motivational interviewing techniques to explore the following themes during initial treatment sessions: (1) patient’s reasons for seeking therapy, (2) patient’s goals for therapy, (3) psychoeducation about the structure and length of therapy, (4) strategies to mitigate potential barriers to treatment engagement, and (5) a concrete plan to prevent early termination [71]. MET-TA was found to be feasible in an initial pilot trial; however, more research is needed to determine whether it is efficacious for reducing treatment attrition among EAs [71]. Nevertheless, the MET-TA protocol nicely illustrates the potential of motivational techniques to assess and mitigate EAs’ barriers to treatment retention. The MET-TA protocol could also be beneficial for helping EAs explore motivation for pursuing age- appropriate goals that are challenging due to anxiety (e.g., interacting with profes- sors, applying for jobs). Helping EAs approach these goals in treatment is important in order to reduce the likelihood that anxiety symptoms will thwart the achievement of developmental milestones.
Social Factors in Treatment Clinicians treating EAs with anxiety disorders should also consider the role of social factors in maintaining their patients’ symp- toms. If left unaddressed, these social factors can interfere with treatment response and lead to dropout. As noted, EA is a period of social transition, during which time individuals establish independence from the family of origin and move toward com- mitment in a long-term romantic relationship. EAs with anxiety disorders may pres- ent for treatment at different stages of this developmental process, with some still living with their parents and others struggling to navigate the nascent stages of mari- tal relationships. Clinicians should therefore evaluate each patient’s social context by asking questions about his or her living situation, frequency of contact with other individuals, and quality of relationships with family, friends, and romantic partners.
Following this assessment, clinicians can reference the child anxiety literature as well as the adult anxiety literature to formulate whether and how social factors may be maintaining symptoms.
Specific relationship factors to address in treatment for EAs with anxiety disor- ders include overprotection, psychological control, criticism, and symptom accom- modation. Parent overprotection has been studied in the child anxiety literature and appears to reinforce anxiety symptoms over time [72]. Though parent/partner over- protection has not been explicitly studied among EAs with anxiety disorders, it is probable that this behavior implicitly undermines EAs’ self-efficacy and impedes recovery. Parent psychological control, which is defined as parental attempts to
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influence children’s behavior through manipulative tactics, has been studied in EAs and is associated with symptoms of both anxiety and depression [33, 73]. In addi- tion, hostility and criticism from romantic partners have been linked with poorer psychotherapy response among adults with anxiety disorders [72, 74, 75].
Psychological control, criticism, and hostility from close others likely cause stress in patients with anxiety disorders, thereby exacerbating their symptoms and under- mining their motivation for change [75]. These social factors are essential to address in treatment, either through a family session or referral for adjunctive family ther- apy, both of which are described below.
Clinicians should also assess and target symptom accommodation when treating EAs with anxiety disorders. Symptom accommodation occurs when close others (e.g., family, romantic partners) modify their behavior in order to prevent or reduce distress in a patient with a psychiatric disorder [76]. With regard to anxiety disor- ders, symptom accommodation often includes involvement in avoidance behaviors (e.g., grocery shopping for a patient with agoraphobia who fears the supermarket) or the provision of reassurance (e.g., assuring a patient with GAD that he will not be fired). If left unaddressed, symptom accommodation can undermine cognitive behavioral therapy for anxiety, as it prevent patients from approaching feared stim- uli and learning they can tolerate the associated distress [72]. Indeed, symptom accommodation is associated with reluctance to seek treatment and treatment resis- tance among youth with obsessive-compulsive disorder [77]. Research on symptom accommodation in EAs is quite limited. However, researchers in one study observed an association between symptom accommodation by family and friends and social anxiety symptoms in college students [78]. More research is needed to explore symptom accommodation as a maintenance factor for anxiety among EAs, as well as strategies to reduce symptom accommodation in this population.
Clinicians who formulate that relationship factors may be maintaining a patient’s symptoms may wish to incorporate the patient’s family or partner into treatment.
However, given that EA is a time when individuals value independence from both family and romantic partners (see [31, 35]), care should be taken to preserve the patient’s autonomy when suggesting involving others in treatment. Clinicians can provide patients with psychoeducation about the interpersonal processes that rein- force anxiety and invite them to observe whether any of these patterns are present in their own relationships. If a patient observes a problematic interpersonal pattern, the clinician can invite relevant family members (with the patient’s permission) for a psychoeducation session to address the unhelpful behavior. However, a single con- joint session may be insufficient to address entrenched interpersonal processes in some families. In these situations, clinicians may choose to refer the patient for adjunctive family therapy. For example, Family Focused Therapy for Anxiety Disorders (FFT-ADs) is a treatment that uses evidence-based assessment and inter- vention tools to reduce anxiety maintenance patterns within a family [75]. The treat- ment length can vary from 1 to 12 sessions and begins with an assessment of family hostility, criticism, and symptom accommodation [75]. The therapist then uses tools such as psychoeducation, communication enhancement training, problem-solving, and systematic reduction of symptom accommodation to help families reduce
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anxiety- maintaining behaviors and enhance motivation for change [75]. FFT-AD has yet to be tested as an adjunct to empirically supported treatments for anxiety disorders [75]. However, the treatment is promising and the strategies that comprise the intervention may be helpful for clinicians working with EAs with anxiety disorders.
Assessment and Treatment of Co-occurring Substance Use Disorders Finally, clinical management of EAs with anxiety disorders should include a thorough psy- chiatric evaluation to assess for the presence of comorbid disorders, particularly substance use disorders (SUDs). In the NCS-R, SUDs were the second most preva- lent class of disorders among EAs (after anxiety disorders), with 22.0% of EAs meeting criteria for a past-year SUD [6]. It is likely that the imbalance between developed limbic regions and immature prefrontal regions, discussed earlier, sets the stage for increased risk for SUDs during EA [79]. In addition, developmental stressors (e.g., college matriculation), reduced parental oversight, and increased environmental exposure to alcohol and drugs likely contribute to increased vulner- ability for SUDs during this life stage [79]. Data from the NCS-R indicate that individuals with anxiety disorders have higher rates of SUDs [80], so EAs with anxiety disorders may be particularly at risk for problematic substance use. Little research exists to guide treatment recommendations for EAs with comorbid anxiety and SUDs. Integrated cognitive behavioral treatments that target anxiety and sub- stance use symptoms simultaneously have been developed for adults, though evi- dence for these treatments is mixed [81, 82]. Instead, experts recommend referring EAs with comorbid anxiety and SUDs for evidence-based SUD treatment if they are willing [79]. On the other hand, if an EA expresses low readiness for SUD treat- ment, it may be useful to first engage the patient in evidence-based treatment for anxiety in order to foster awareness of the connection between emotions and sub- stance use and to build motivation for change [79].