The first day of seventh grade found Katherine huddled on the floor of her bathroom, clutching the toilet.
When she wasn’t throwing up she was crying, doubled over in pain.
By eighth grade, her stomach cramps and vomiting were more frequent and worse.
Finally, after Katherine had missed nearly three weeks of school, and completed a battery of medical tests, she and her mom realized what was going on — this was anxiety.
For Katherine, a high-achieving, A-minus-is-barely-acceptable, reading-at-a-college-level-while-still-in-middle-school student, the pressures to live up to a growing set of expectations were wreaking havoc.
“I need to be perfect,” says the now 15-year-old who agreed to speak on condition of just using her first name. “I need to be good, I need to be smart, and pretty and everything. I need to be all of it.”
In her mind, society expects nothing less than perfection from her.
From all girls.
Since the women's liberation movement of the 1960s, society has tried to break through glass ceilings and level the playing field between boys and girls, says Stephen Hinshaw, a professor of psychology at the University of California, Berkeley, listing policies like Title IX, college admission changes and increasing STEM involvement among girls through things like all-girl coding camps.
And girls have stepped up — outperforming boys in elementary school, out-graduating young men in high school, out-enrolling men in college and out-achieving men in advanced degrees.
For the first time, more than half of all medical school students in 2017 were women, and as of 2016, 11.2 percent of women ages 25 to 29 had a master’s degree or higher, compared to 7.2 percent of men.
On the outside, young women are excelling.
But on the inside, many feel like they’re imploding.
Nearly 38 percent of teen girls have an anxiety disorder, compared to 26 percent of boys, according to the National Institute of Mental Health.
More than two-thirds of antidepressants prescribed for teens are for girls, and girls comprise more than 90 percent of hospital admissions for eating disorders, says the Anxiety and Depression Association of America.
“(We’re) caught in a cycle of neurotic perfectionism,” says Richa Bhatia, a board certified psychiatrist in San Mateo, California, and former faculty member at Harvard Medical School.
Girls internalize this message and many strive to be top achievers in school and sports, as well as the “good girl” and the “mom friend,” who takes care of everyone else. In addition, many girls long to be beautiful, sexy, social media mavens who make all this work look effortless.
Needing to be competitive, nurturing and flawless is what Hinshaw refers to as the “triple bind” — a trio of unhealthy, stereotypical expectations that are “physically and psychologically impossible."
Yet when girls try and fail, they blame themselves, he says, not the unrealistic expectations.
Experts don’t know whether these expectations are creating anxiety in teens, or simply fueling pre-existing insecurities and triggering genetic predispositions.
For Katherine, it’s probably a mix of both. Anxiety runs in her family, and she’s insecure about her body. She lists her complaints: “‘You have a zit here, and here and here, and you’re not as skinny as you should be, your legs are too long, you’re too skinny — there’s so many things wrong about you,’” she finishes.
Even compliments and well-meaning praise from friends and teachers add to her anxiety, as she’s told she’s “friends with everyone,” “so perfect,” and “super smart.”
“When that’s all you hear,” she says, “then it just becomes something that’s not a compliment anymore — it’s an expectation.”
Growing up girl
Anxiety disorders — the kind that are derailing teens at unprecedented rates — are gender blind, yet many experts worry society is reinforcing damaging stereotypes that add to girls’ lists of unrealistic expectations.
From a young age, girls are conditioned to please others, says Rachel Simmons, co-founder of Girls Leadership, a national nonprofit, and author of “Enough As She Is: How to Help Girls Move Beyond Impossible Standards of Success to Live Healthy, Happy and Fulfilling Lives.”
Boys will be boys, but girls are encouraged to practice caregiving with dolls and kitchen sets. They are praised for being polite and well-behaved.
“Girls are trained to start looking at others before they think of themselves,” says Simmons. “That’s the foundational thing from which body image and other problems stem.”
And years later, when girls are still focused on earning praise and taking care of everyone but themselves, those strengths can become stumbling blocks.
Ana Homayoun, an educational consultant in the San Francisco Bay area, has met with hundreds of young women who seek external validation by “filling the box” of societal expectations instead of nurturing their own values.
This leads girls to work harder, yet never feel they’ve done enough, she says.
“It is no coincidence that today’s girls are more anxious and struggle with greater rates of mental health issues than ever before,” she writes in her book, "The Myth of the Perfect Girl.”
Looking back, Katherine can see glimpses of her anxiety as early as 6 or 7, when she’d get nervous about playing hide-and-seek.
Jump rope was worse.
What if she timed it wrong and the rope slapped her in the face? What if she got tangled and fell?
The potential of failure was frightening.
But school offered a place where she could excel.
In first grade, Katherine won first place in a district-wide writing contest. In third grade, she filled a composition notebook with ideas for a book plot, and by fourth and fifth grade, she was already reading at a high-school level, devouring thick novels in an evening.
Teachers praised her and showed her work as the good example.
But in sixth grade, she was picked on by other girls, laughed at for wearing the same shoes every day, called too skinny, then too fat.
Administrators mistakenly blamed her for the bullying and suddenly, the girl nicknamed “Sunshine” began emotionally withdrawing.
Katherine grew scared of talking with adults and worried more how others saw her.
She stopped raising her hand in class.
“If I’m wrong, then that’s awkward,” she says, “and shows that I don’t know what I’m doing.”
Boys and girls
When stressed, many girls cry and try harder to please, while boys often act out or give up.
In fact, for decades, “fight or flight” was the predominant stress response theory.
However, in the late '90s, Dr. Shelley Taylor and her team of UCLA researchers discovered that females have an extra stress response — “tend and befriend,” says Regan Gurung, a professor of psychology and human development at the University of Wisconsin-Green Bay, and a postdoctoral student in Taylor’s lab at the time.
This additional stress response proved more compatible with women’s historical responsibilities; primarily caregivers, they couldn’t abandon a baby when overwhelmed.
Instead, they cared for children and sought support from surrounding women, says Gurung, activities that produce oxytocin to calm mother, baby and friend.
This theory doesn’t mean women will never fight, flee or freeze, says Gurung, but it explains why women under stress may seek out female companionship.
“Even if a girl wants to be alone,” Gurung says, “spending time with other girlfriends is probably one of the best things she can do for her coping.”
However, friends may also increase anxiety if the group is filled with “mean girls” who argue, compare and compete.
“Girls seem to be more injured by meanness because they really care about relationships and friendships,” says Lisa Damour, psychologist and author of "Untangled: Guiding Teenage Girls through the Seven Transitions into Adulthood." She calls this “interpersonal sensitivity.”
Knowing this, parents can step in and ask their daughter, “Is this relationship energizing or draining for you?” and let them know sometimes it's OK to walk away.
During a recent visit to her South Jordan home, Katherine is draped on the couch, Snapchatting with friends while we talk.
Snapchat photos disappear within seconds, but Instagram posts remain and are more stressful, she says.
“What do I caption it? How do I filter it?”
Katherine knows Instagram is a curated world, which is why her pinned post shows her on her bed with her dog, makeup-less.
“Stop comparing ourselves based on the pics posted on social media,” she implores in the caption. “Be happy with yourself 100 percent of the time and your life will be 100 percent better.”
She believes that — yet still edits her pictures to make herself look more tan.
While there’s nothing new about women competing and comparing everything from hair color to shoe size, social media has made this an around-the-clock activity.
“Girls are conscious of how they look all the time now,” says Damour.
One study found Instagram use was associated with greater self-objectification, and “fitspiration” posts — images promoting fitness — were associated with greater body image concerns.
Social media is different from magazines, which have limited pages, and TV which shows people from different angles, says study author Jasmine Fardouly, a researcher at Australia’s Macquarie University.
Platforms like Instagram offer an endless stream of perfectly posed and edited images that people interact with by liking or commenting — making even celebrities feel closer and more relatable: “If you feel like they are much more like you,” she says, “you might think you should look that way.”
And there’s more at stake than just wanting nice abs.
A famous 1998 study involved researchers asking young women to take a math test wearing either a bikini or a sweater. Girls wearing sweaters were more comfortable and less focused on their bodies, and as a result, far outperformed their bikini-clad counterparts.
More recent research found that teens who “perceive” themselves to be overweight don’t do as well in school.
“If you’re preoccupied with your appearance, you’re less likely to invest in other aspects of your personality and skills,” Fardouly says.
Body insecurity is a real thing for Katherine. She picks out her outfits the night before and each morning FaceTimes with friends while they get ready, asking about hairstyles and which bracelets to wear.
“It’s like having your own personal stylist,” she tells her mom, Natalie, in the car on the way home from running errands.
“It’s called insecurity with making a choice,” Natalie retorts.
“Yeah, that too,” Katherine agrees.
What’s at stake
But if anxiety isn’t taken seriously, and without healthy coping skills, girls, more than boys, turn to self-harm to numb their pain.
A recent study found nearly 24 percent of girls, compared to just over 11 percent of boys, reported non-suicidally hurting themselves — often by cutting, burning, scraping or picking at their own skin — at least once in the last year.
Most girls self-harm in places easy to hide — upper thighs, upper arms, stomach — because they often feel ashamed of their behavior.
“What are you doing?!” Alexandria remembers thinking as she stared down at her bleeding wrist, where she’d just dug into it with a pen. “You’re crazy. You promised you wouldn’t do this.”
But two days later, overwhelmed by homework, thoughts of her ailing grandfather and the constant feelings of anxiety-produced inadequacy, the 23-year-old did it again.
Though difficult, experts say being open and honest about mental health struggles is the best way to heal.
“When we don’t name the things we feel strongly about, we feel shame,” says Simmons. “Shame silences people. When young people realize they are not alone, there is a very powerful healing effect.”
For parents, this means being “persistent but gentle” in keeping the lines of communication open, says Hinshaw, noting the power of dinner-table conversations.
A few days after her self-harm, Alexandria rolled up her long-sleeve shirt and showed her parents the fresh scars.
Her mom cried. Her dad looked sad.
Not disappointed sad, she clarified, but sad that she’d felt the need to hurt herself.
They reassured her they still loved her, and talked about how to handle the next stressful situation.
“Let someone know,” Patty Taylor, an American Fork-based licensed clinical psychologist, tells teens.
As adolescents strive for independence, it may be harder to open up and be vulnerable with difficult things, she says, especially for girls already seeking external validation.
Besides telling her parents, Alexandria has visited a counselor, talks to close friends, and uses the CalmHarm app.
Now, when anxiety prompts a panic attack, she bargains with her brain: “I don’t have time right now. You can panic in three hours.”
In three hours, she’s often forgotten what triggered her in the first place.
If that doesn’t work and she feels her heart start racing, she finds five things she can see, four things she can feel, three things she can smell, two things she can hear and one thing she can taste — grounding her mind through her senses.
“I’m getting to the point where it’s OK to make mistakes, as long as you learn from them,” she says. “Despite how the world may beat me down, or how I may beat myself down, I’m going to get back up at the end of the day, going to try again tomorrow and that’s enough.”
While experts avoid sweeping generalities for something as individualized as anxiety, nearly all of them agree that sleep is a critical — and missing factor — in the well-being of today’s teenagers.
Psychologist Damour believes the lack of sleep, due to increasingly busy schedules and late-night technology use, is the most powerful biological explanation for rising anxiety rates among teenage girls, who need more sleep than any other demographic.
“Sleep is the glue that holds human beings together,” she says simply.
When teens are sleep deprived, not only is it harder to remember the information they’ve been cramming in their late-night study sessions, says Hinshaw, but it’s also harder to remember anything positive, and negative emotions more easily float to the surface.
“When you add to the triple bind sleep deprivation,” he says, “It’s putting gas on a fire that’s already out of control.”
Poor sleep may prompt tired teens to perk up with caffeinated drinks and sugar-laden or processed foods, which provide quick energy, but a later crash.
“If your body is metabolically compromised, you’re going to feel it in your mind,” says Lisa Feldman Barrett, a Northeastern University psychology professor with appointments at Harvard Medical School and Massachusetts General Hospital.
When girls feel crummy, they’re more likely to internalize those messages and believe they’re bad, while boys take the negative messages and believe something’s wrong with the world, she says.
Barrett encourages parents to remind their teens that feeling unpleasant may simply be a sign they need a nutritious meal, some exercise and 42 more hours of sleep.
Compassion and courage
Because anxiety is a normal biological feeling, girls shouldn't want or expect it to disappear forever. Experts say the trick is learning how to control and manage anxiety that becomes overwhelming.(see sidebar)
For some girls, it's helpful to do something that makes them anxious — dancing, public speaking, acting — as a way to teach their brain the difference between real risk and imagined, over-estimated risk. Often, telling themselves they're "excited" instead of "nervous" or "anxious" can make a big difference in their body's response.
Other girls say they need quiet time alone — away from the demands of friends and social media to focus on their own feelings and desires. Some take naps, others do meditation or yoga.
For some, talking with parents, friends or a counselor is helpful, and many find that the combination of therapy and medication helps to quiet the buzzing in their brain.
Other girls go running, play with animals, listen to music or hike in the mountains — just something to get them outside their own minds.
While each girl is different, experts say everyone can benefit from practicing self-compassion — the idea of treating yourself as kindly as you try to treat other people, says Bhatia.
The idea stems from ancient Buddhist teachings, but unlike “self-esteem,” it doesn’t require being better than others or being perfect, says Kristin Neff, a professor at the University of Texas at Austin, who first used the term in psychological literature in 2003.
“So much of teens’ self esteem is tied up in looking perfect and getting perfect grades and getting likes on Instagram,” says Neff. “But what happens when they don’t meet those standards?”
Instead of blaming, Neff teaches teens to tell themselves, “You tried your best. You’re only human and a lot of people struggle with this,” accompanied by some form of soothing self-touch, such as hands on the heart or arms wrapped around the belly.
Haylee Bladen, founder of WholeKids Emotional Wellness based in Sandy, teaches girls to repeat empowering phrases to themselves in stressful moments.
“We say ‘I am a light, and I believe in myself’ to get them feeling it,” says Bladen. “It’s a really cool thing to watch, to see them stand in their power. It’s powerful stuff. You can see a change in their body language and their faces.”
Her workshops also involve guided imagery, breathing, meditation, mindfulness and temporary distraction skills — “real tools you can use to bring your (stress) levels down and function well,” she says.
For Bladen, courage doesn’t mean not being scared. It means overcoming fear and learning you are strong enough to deal with challenges.
Katherine’s next big challenge is high school.
But for now, it’s a warm Friday afternoon and she and her mom are shopping.
Along with glittery mechanical pencils and school notebooks, Katherine picked out a new lamp, a decorative globe and some fake succulents to update her room.
In a way, the Target run embodies growing up, moving from the familiar middle school to the giant high school where Katherine is sure she’ll take a wrong turn in the winding hallways.
There will be new stressors: AP world history and honors classes but also new excitement: driver’s ed, new friends, school dances and football games.
There’s also the very real possibility that she’ll start the year off in the bathroom again — sick with anxiety.
“I just try not to think about it,” she says. “I’m not worrying about it, cause I’m actually terrified.”
Yet eighth grade ended better than seventh grade. She threw up less, and on the days when she felt nauseated, instead of checking out of class, she'd stay in her seat, breathing deeply and focusing on her family and friends.
"I realized what it was," she says of her anxiety, "and decided I needed to fight back."