University students represent a specific population with concerns, burdens and worries that differ from other age and occupation groups. Experiences of students, although often exciting, invigorating and empowering, can also be stressful, anxiety producing and may trigger various forms of psychopathology. Students face multiple stressors such as academic overload, constant pressure to succeed, competition with peers, lack of leisure time and less time to spend with their families. Moreover, they are concerned about the future and in some parts of the world have serious financial problems [1••]. Therefore, various forms of psychopathology are more frequently present among them than in other populations.
The health of university students has been the subject of increasing focus in recent years. Studies confirm that multiple protective and risk factors are involved in the psychological well being and distress of university students [2••]. As they belong to a vulnerable age group, students frequently come to college with already existing mental health problems . These problems can become overt at different times in their studies, sometimes during transition from undergraduate to graduate programs, or even upon graduation [4•].
Students are regarded as the national capital and the top investment for the future. However, in the contemporary demanding and globalized world, they are no longer protected by their original mission of studying. Therefore, university education should provide a good atmosphere, cultivating a healthy personality in students and mental health promotion activities [5••].
Personality of university students
Numerous studies confirm that differences among individuals are influenced by various factors such as past and present life experiences, personal and professional environment as well as the ability to cope with life stressors . In relation to university students, it has been shown that their personality is affected by the economic, political, traditional and cultural background, as well as by the objective and subjective inner forces within any student as an individual [5••].
The question is why the university students' personality is an important issue. We believe that personality is a key factor in both vulnerability and resilience. The fact is that many students are not successful. There is no doubt that, among many variables such as social, institutional and university background, psychological features are an important factor influencing their academic achievement . Furthermore, we assume that analysis of students' personality is pertinent, particularly in understanding their selection of the academic majors. Some authors advocate that personality traits of university students should be professionally assessed at the beginning of their academic studies and used for proper guidance throughout the academic years, and for counseling, if necessary, during this sensitive period . Personality types of university students contribute to interindividual differences and a mismatch between personality and career choice may take place . Therefore, a better understanding of the personality profile can help in better academic and career choice as well as in prevention of mental health problems in the future .
Mental health affects the level of personal development and any knowledge that helps psychological adjustment to university life could promote personal qualities in university students [5••]. It has been shown that neurotic students have a tendency to dislike oral examinations, whereas extroverts and agreeable individuals would be more likely to prefer them . However, other authors have reported that, regardless of their personality, students generally express dislike for oral examinations and prefer continuous assessment, the more so if they are emotionally stable [9,10].
It is well known that personality traits and characteristics of coping styles are closely correlated. In the light of the multiple stressors that students face, the question of coping styles and defense mechanisms influencing psychological health is particularly important. It has been shown that the majority of students employ rational coping styles such as problem solving, help seeking, rationalization and the use of cognitive coping skills even in the face of pressure or difficulty. Extroversion has a direct positive effect on mature coping styles, which has been directly related to comparatively good mental health [11•]. Exploring the relationship between emotions and thinking styles among university students, Zhang [12•] found a strong and positive correlation.
Intellectual styles as the preferred ways of processing information and dealing with tasks have a special importance for university students because they influence their academic achievement. It has been shown that legislative, hierarchical, global and liberal thinking styles, which are more creativity generating, positively contributed to students' psychosocial development, including their sense of purpose .
Risk factors for psychopathology
Mental health problems can have a profound impact on university students' functioning. At the individual level, they can affect all aspects of physical, emotional, cognitive and interpersonal functioning. They also have a negative impact on the academic performance – students with higher levels of psychological distress have higher test anxiety and lower self-efficacy [2••]. Furthermore, students with mental health problems influence many other people on campuses, including roommates, classmates, faculty members and staff.
It has been shown that students with a high degree of consciousness, public or private, have a higher tendency toward social phobia . When the public self-consciousness is too high, the difficulty in interpersonal relationships may emerge and self-esteem may decrease, leading to various mental health problems.
Some personality traits might predict psychopathology in the student population. The personality trait of shyness, for example, either alone or in combination with varying levels of sociability, has been recognized as a reliable predictor of various forms of psychopathology, including substance abuse and mood disorders . On the other hand, perfectionism, a common trait among students with high grades, might predict anxiety symptoms, whereas the accompanying loneliness adds to the incremental validity to predict depression and anxiety symptoms [16•].
It has been widely accepted that hopelessness is the most important risk factor for suicide, but, as a marker of pessimism, it is also related to a wide range of psychopathologies. Spirituality, on the other hand, has been negatively correlated with hopelessness and positively correlated with preference for group counseling modalities .
Psychopathology of university students
After the Virginia Tech tragedy, when on 16 April 2007 one student murdered 32 fellow students and faculty members, eventually committing suicide, psychopathology among students became a burning issue. Such tragedies are highly complex and linked to many causal factors. It is a fact that aggression is on the rise in the modern world and that it has become a global phenomenon. The age of the student population is the age of reason, but it can also trigger the manifestation of severe personality disorders and severe mental disorders.
Mild, moderate and severe levels of stress and even burnout have been documented in university students [18•]. Family and interpersonal problems, ‘Monday morning examinations’, outside class assignments and financial concerns were identified as the most common stress triggers [4•]. Living in areas of conflict, many students worldwide experience serious traumas and develop posttraumatic stress disorder .
It has been shown that learning disabilities, self-injury incidents, eating disorders, alcohol problems, illicit drug use and sexual assaults within campuses represent the most common psychological problems among university students . About 15–20% students feel impaired by examinations . As a result of test-related anxiety, a whole spectrum of problems can occur, such as delay and dropout from studying, and even suicidal behavior. Test anxiety may be caused by avoidant personality traits and a tendency to procrastination, but also by some severe mental health problems .
Students could be at risk for illicit substance use because of the social climate of university life such as peer pressure, change in life structure and reduced parental supervision [21••]. Cannabis and amphetamine use are most common, with a prevalence of cannabis use of 5.9–7.7% and its lifetime use of 40–49% . Although it is accepted that most students drink for social reasons, the underlying psychological problems should not be neglected. It has been shown that, among students admitted to health services for alcohol intoxication, nearly one-third had previously been seen in mental health units and many of them had symptoms of anxiety or depression prior to their most recent drinking episode .
It is widely accepted that deliberate self-harm is yet another major problem among young people and it has been identified as one of the key mental health problems affecting students. A high correlation was found between self-harm and depressed mood, difficulties of sexual identity, alcohol and illicit drug use [23••]. Students with problems in academic life, in family relationships, in anger expression, and with interpersonal insensitivity, introversion and loneliness are at higher risk of suicide [24•,25].
It is well known that age and sex are factors strongly contributing to the onset of eating disorders, whereas the ‘studying stage’ represents the stage of vulnerability along a developmental continuum. As for the specific forms of behavioral patterns, it has been found that self-esteem represents the most important factor predicting the drive for thinness and body dissatisfaction of female graduate students . Of course, the idealization of beauty and eternal youth in the mass media should not be neglected either.
Attention deficit hyperactivity disorder (ADHD) might be a risk factor for poor adjustment in adult life, irrespective of the presence of full symptoms in adulthood. This disorder is closely related to the satisfaction of students with their life .
It seems that the education process of the health professions brings a considerable amount of stress (academic overload, working with cadavers, constant pressure of maintaining good grades, etc.). The psychological distress was significantly greater in the sample consisting of medical students – 76% of medical students scored above the threshold in terms of psychological distress compared with their peers [28••]. There is a tendency of medical students to diagnose themselves with diseases they are studying – ‘medical school syndrome’, also called ‘medical students’ disease’ or ‘medical studentitis’ [29•]. It seems that the exposure to specific knowledge provides a framework for identifying previously neglected bodily feelings, which, in addition to the existing stress, may cause various somatic sensations, especially in narcissistic and passive–aggressive individuals. The imagined health problems can cause anxiety, influencing students' mental health in general.
Strategies to overcome problems
Within the majority of universities, there are counseling centers with the primary aim of assisting students to define and accomplish their personal, academic and career goals. When students receive help for their psychological problems, it can have a positive impact on their personal well being and academic success .
The most common strategies that students use to cope with stress are exercising, spending time with family and friends, watching TV and drinking alcohol . It has been found that maintaining the quality and quantity of sleep is important for mental health, especially for female students, because sleep fluctuates throughout their menstrual cycle . Furthermore, the role of physical activity cannot be underestimated as a moderator of the health–illness relationship [31•]. Student athletes had significantly higher levels of self-esteem and social connectedness, as well as lower levels of depression, than nonathletes .
It is important to promote coping with stigma, because it can be one of the reasons for avoiding help seeking when mental health problems appear. It was shown that perceived stigma was higher among male, younger and more religious students as well as those coming from poor families [33••].
Mental health professionals, particularly those working at universities, should help new students to enroll into programs that are congruent with their personalities in order to adjust academically and to have proper performance results . University administration should make an effort to alleviate stress by actions such as elimination of Monday morning examinations, expanding wireless Internet, increasing teaching by the experienced professors, improving gym facilities and so on. [4•]. Some medical schools, trying to improve their students' mental and emotional well being, adopt strategies intended to lessen potentially traumatic stressors, such as encouraging students to record their emotional responses in curriculum journals [29•].
The psychoeducation groups can be helpful to students who have difficulties in controlling and expressing anger by working on anger management and expression skills [24•]. Teaching self-esteem skills is also important because it is well known that self-esteem is central to sound mental health and prevention of various mental disorders. Furthermore, peer education is one of the most effective ways to promote mental health and prevent problems . A better student–instructor relationship was a significant contributor to school completion , especially for at-risk students . A good relationship with teachers encourages autonomy, clarifies the role expectations and helps in more engaged academic work and students' self-determination [37••], which contributes to psychological well being. Involvement of students in academic activities induces positive psychological state, physical resource, resilience and stress coping strategies [37••].
Promoting healthy lifestyles and creating youth friendly services within campuses or universities, with special emphasis on mental health issues, along with promoting peer education and peer counseling are productive and effective means to improve students' involvement, learning and achievement. The students' environment can also be helpful in reducing sources of stress. This should include redesigning courses and timetables, particularly for the freshmen, providing more structure and direct support for the development of academic skills. Developing a more supportive learning environment in which seeking support for academic difficulties is seen as ‘normal’ is important as well as continuous online guidance for students and staff . Further research aimed at understanding the role of personality in the development of burnout syndrome in students would help to detect those with mental health problems prior to matriculation and target interventions toward those at highest risk [28••].
There is a need for institutional policy and national programs for mental health promotion of university students in order to prevent mental health disorders, which are frequent at this vulnerable age when a pursuit of identity is typical but when people are also burdened with a plethora of problems. Students need access to more immediate and accessible forms of information and support as well as a continuous partnership with and support from the academic staff .
University students often experience stress that can have adverse emotional, academic and health outcomes. Their personality characteristics are closely correlated to coping styles to overcome everyday life challenges. The development of successful coping behaviors is likely to reduce stress and enables students to solve problems, while maintaining psychological balance and well being. Counseling services at universities need to address problems of students' mental health and conduct active outreach campaigns. University students are jewels and the future of each nation, but they are also a vulnerable population prone to development of psychopathology. Therefore, not only mental health professionals but also society as a whole should implement pertinent programs of mental health promotion and care.
References and recommended reading
Papers of particular interest, published within the annual period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 81).
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