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Module 11: Emotional Health, and Abnormal Behavior
This Module contains 6 Lessons:
Lesson 1: Personality and personality types
Lesson 2: Emotional health and mental/emotional disorders
Lesson 3: Stigma of Mental Illness
Lesson 4: Suicide
Lesson 5: Mental illness in children and adolescents
Lesson 6: Cultural diversity and Mental Illness
Students will be able to identify and distinguish between various forms of mental illness.
Personality: A User Guide
Dr Daniel Nettle, The Open University, Creative Commons Attribution-NonCommercial-ShareAlike 2.0 License,
We are all familiar with the idea that different people have different personalities, but what does this actually mean? It implies that different people behave in different ways, but it must be more than that. After all, different people find themselves in different circumstances, and much of their behavior follows from this fact.
However, our common experience reveals that different people respond in quite remarkably different ways even when faced with roughly the same circumstances. Abbey might be happy to live alone in a quiet and orderly cottage, go out once a week, and stay in the same job for thirty years, whilst Beth longs for exotic travel and needs to be surrounded by vivacious friends and loud music. Charlie goes through a string of divorces from marriages that seemed solid, whilst Derek stays in one that seems unlikely for most of his life. Erica loves walking and landscape paintings, whilst Fran likes abstract art, punk rock and bungee jumping.
In all of these cases, we feel that it cannot be just the situation which is producing the differences in behavior. Something about the way the person is ‘wired up’ seems to be at work, determining how people react to situations, and, more than that, the kind of situations they get themselves into in the first place. This is why personality seems to become stronger as we get older; when we are young, our situation reflects external factors such as the social and family environment we were born into. As we grow older, we are more and more reaping the consequences of our own choices (living in places we ourselves have chosen, doing jobs that we were drawn to, surrounded by people like us whom we have sought out). Thus, personality differences that might have been very slight at birth become dramatic in later adulthood.
Personality, then, seems to be the set of enduring and stable dispositions that characterize a person. These dispositions come partly from the expression of inherent features of the nervous system, and partly from learning. Researchers sometimes distinguish between temperament, which refers exclusively to characteristics that are inborn or directly caused by biological factors, and personality, which also includes social and cultural learning. Nervousness might be a factor of temperament, but religious piety is an aspect of personality (overlaid, perhaps, on some temperamental foundation).
The discovery that temperamental differences are real is one of the major findings of contemporary psychology. It could easily have been the case that there were no intrinsic differences between people in temperament. That is to say, it might have been the case that all humans were basically running the same software, which would mean that given the same learning history, the same dilemmas, they would all respond in much the same way. Yet we now know that this is not the case.
Personality measures turn out to be good predictors of your health, your sexual promiscuity, your likelihood of divorce, how happy you typically are – even your taste in paintings. Personality is a much better predictor of these things than social class or age. The origin of these differences is in part innate. That is to say, when people are adopted at birth and brought up by new families, their personalities are more similar to their blood relatives than to the ones they grew up with. The differences begin to emerge early in life and are surprisingly stable across the decades. This is not to say that people cannot change, but major change is the exception rather than the rule.
Personality differences tend to manifest themselves through the quick, gut-feeling, intuitive and emotional systems of the human mind. The slower, rational, deliberate systems show less variation in output from person to person. Deliberate rational strategies can be used to over-ride intuitive patterns of response, and this is how people wishing to change their personalities or feelings have to go about it.
So what are the major ways personalities can differ? The dominant approach is to think of the space of possible personalities as being defined by a number of dimensions. Each person can be given a location in the space by their scores on all the different dimensions. Virtually all theories agree on two of the main dimensions, though they differ on how many additional ones they recognize.
Learning Activity 1.1:
Big 5 Personality Test
for yourself and for someone else you know.
Compare yourself to this person on each of five basic personality dimensions.
What aspects of personality does this experience tell you about?
Do the results describe your personality accurately?
Do these personality traits accurately predict your behavior in various situations?
An instantly recognizable dimension is neuroticism or negative emotionality, known as N by psychologists. The mind is equipped with systems for protecting itself from harmful things, like physical danger, disease, humiliation, and loss. These systems are driven by emotions like anxiety, fear and shame. It seems that in some people, the systems are a little more easily set off than others. Such people are high on the N dimension. They are worriers, prone to anxieties and fears. Low N scorers are laid back and un-phased by things. High scorers are vulnerable to depression, anxiety and panic, as well as physical ill health from all that stress. They are at high risk for divorce and likely to report themselves as unhappy at any given moment.
If you think of your friends, you will probably find it easy to rank them in terms of the N dimension. The adjective ‘neurotic’ has even entered everyday speech! This is probably because variation in negative emotion systems is a deep biological characteristic of humans, and even of other mammals. Animal breeders have long known that it is very easy to produce more or less fearful horses or dogs by selective breeding, and they have exploited this for producing military and working animals. We know from laboratory rats that you can produce a fearful and anxious strain in a few generations by breeding from the most fearful individuals.
Another key dimension is extraversion or positive emotionality (E). This is commonly used to mean sociability, but to psychologists it means something broader. The mind also contains systems for identifying rewarding things in the environment – food, comfort, mates, kin – and seeking them out. It is thought that brain circuits using the chemical dopamine function to make these positively rewarding stimuli ‘attention grabbing’ (you know the attention grabbing potential of a piece of chocolate cake or a nice looking person). Now these systems seem to be a little more responsive in some people than others.
High E scorers, not surprisingly, go out more, talk more, want to be famous more, have more sexual partners, and drink and take more drugs than low E scorers. Low E scorers are often more content with relatively quiet, self-contained jobs or hobbies whose rewards maybe longer coming. Extraverts generally describe themselves as happier than introverts, though there is a significant group of happy introverts who have strong, self-contained interests and vocations.
Extraversion and neuroticism are the two most broadly accepted dimensions of personality. Other influential proposals include Openness (with high scorers interested in art and abstract ideas, low scorers practical and down to earth), Conscientiousness (with high scorers methodical and dutiful, low scorers more distractible), and Agreeableness (with high scorers cooperative and trusting, and low scorers more aggressive and hostile). Together these make up the ‘big five’, or OCEAN (Openness, Conscientiousness, Extraversion, Agreeableness, Neuroticism).
People often ask what is the optimum personality profile to have. There is no simple answer to this question. It is certainly true that some extremes carry some risks. Low agreeableness is associated with violence, whilst high neuroticism is associated with the risk of depression and anxiety. However, all the systems whose operation is reflected in personality differences are there for a reason. Anxiety and fear are good things to have (at least a little), because the world actually is full of dangerous things. There is evidence that at least some high N scorers do well at college because they strive hard to avoid failure, and people who get convicted of traffic offenses may be less neurotic than those who do not (and therefore, presumably, less fearful to the danger of getting caught).
The balance between the different systems is probably all. If you are an extreme introvert, you might want to challenge yourself to experience the rewards of greater spontaneity and exchange; if you are an extreme extravert, you might want to teach yourself to undertake a long and lonely project that will ultimately be very rewarding. As human beings, we have the unique ability to look in at our personality from the outside and decide what we want to do with it.
Learning Activity 1.2:
Watch this video titled:
Trait Assessment Testing
and take the ungraded quiz.
Lesson 2: Emotional health and mental/emotional disorders
Dedicated to Public Domain 2012, National Institutes of Health
Information about Mental Illness and the Brain
Defining Mental Illness
We can all be “sad” or “blue” at times in our lives. We have all seen movies about the madman and his crime spree, with the underlying cause of mental illness. We sometimes even make jokes about people being crazy or nuts, even though we know that we shouldn’t. We have all had some exposure to mental illness, but do we really understand it or know what it is? Many of our preconceptions are incorrect. A mental illness can be defined as a health condition that changes a person’s thinking, feelings, or behavior (or all three) and that causes the person distress and difficulty in functioning. As with many diseases, mental illness is severe in some cases and mild in others. Individuals who have a mental illness don’t necessarily look like they are sick, especially if their illness is mild. Other individuals may show more explicit symptoms such as confusion, agitation, or withdrawal.
There are many different mental illnesses, including depression, schizophrenia, attention deficit hyperactivity disorder (ADHD), autism, and obsessive-compulsive disorder. Each illness alters a person’s thoughts, feelings, and/or behaviors in distinct ways. In this module, we will at times discuss mental illness in general terms and at other times, discuss specific mental illnesses. Not all brain diseases are categorized as mental illnesses.
Disorders such as epilepsy, Parkinson’s disease, and multiple sclerosis are brain disorders, but they are considered neurological diseases rather than mental illnesses. Interestingly, the lines between mental illnesses and these other brain or neurological disorders is blurring somewhat. As scientists continue to investigate the brains of people who have mental illnesses, they are learning that mental illness is associated with changes in the brain’s structure, chemistry, and function and that mental illness does indeed have a biological basis. This ongoing research is, in some ways, causing scientists to minimize the distinctions between mental illnesses and these other brain disorders.
Optional Learning Activity: Wellbeing Self-assessment
. This tool uses WEMWBS, a scale which is often used by scientists and psychologists to measure wellbeing. To get your wellbeing score, go through the statements and check the box that best describes your thoughts and feelings over the last two weeks.
National Health Service, United Kingdom,
Neurosis vs. Psychosis
Two generic psychiatric terms for mental states are neurosis and psychosis. Neurosis is a term no longer used medically as a diagnosis for a relatively mild mental or emotional disorder that may involve anxiety or phobias but does not involve losing touch with reality. Psychosis refers to a serious mental disorder in which a person loses contact with reality and experiences hallucinations or delusions.
Disturbances of perception and thought process fall into a broad category of symptoms referred to as psychosis. The threshold for determining whether thought is impaired varies somewhat with the cultural context. Like anxiety, psychotic symptoms may occur in a wide variety of mental disorders. They are most characteristically associated with schizophrenia, but psychotic symptoms can also occur in severe mood disorders. One of the most common groups of symptoms that result from disordered processing and interpretation of sensory information are the hallucinations.
Hallucinations are said to occur when an individual experiences a sensory impression that has no basis in reality. This impression could involve any of the sensory modalities. Thus hallucinations may be auditory, olfactory, gustatory, kinesthetic, tactile, or visual. For example, auditory hallucinations frequently involve the impression that one is hearing a voice. In each case, the sensory impression is falsely experienced as real. A more complex group of symptoms resulting from disordered interpretation of information consists of delusions. A delusion is a false belief that an individual holds despite evidence to the contrary. A common example is paranoia, in which a person has delusional beliefs that others are trying to harm him or her. Attempts to persuade the person that these beliefs are unfounded typically fail and may even result in the further entrenchment of the beliefs. Hallucinations and delusions are among the most commonly observed psychotic symptoms.
Symptoms generally involve the experience of something in consciousness that should not normally be present. For example, hallucinations and delusions represent perceptions or beliefs that should not normally be experienced. In addition to hallucinations and delusions, patients with psychotic disorders such as schizophrenia frequently have marked disturbances in the logical process of their thoughts. Specifically, psychotic thought processes are characteristically loose, disorganized, illogical, or bizarre. These disturbances in thought process frequently produce observable patterns of behavior that are also disorganized and bizarre. The severe disturbances of thought content and process that comprise the positive symptoms often are the most recognizable and striking features of psychotic disorders such as schizophrenia or manic depressive illness.
Mental Illness in the Population
Many people feel that mental illness is rare, something that only happens to people with life situations very different from their own, and that it will never affect them. Studies of the epidemiology of mental illness indicate that this belief is far from accurate. In fact, the surgeon general reports that mental illnesses are so common that few U.S. families are untouched by them.
Mental Illness in Adults
Even if you or a family member has not experienced mental illness directly, it is very likely that you have known someone who has. Estimates are that at least one in four people is affected by mental illness either directly or indirectly.
Consider the following statistics to get an idea of just how widespread the effects of mental illness are in society:
According to recent estimates, approximately 20 percent of Americans, or about one in five people over the age of 18, suffer from a diagnosable mental disorder in a given year.
Four of the 10 leading causes of disability—major depression, bipolar disorder, schizophrenia, and obsessive-compulsive disorder—are mental illnesses.
About 3 percent of the population have more than one mental illness at a time.
About 5 percent of adults are affected so seriously by mental illness that it interferes with their ability to function in society. These severe and persistent mental illnesses include schizophrenia, bipolar disorder, other severe forms of depression, panic disorder, and obsessive-compulsive disorder.
Approximately 20 percent of doctors’ appointments are related to anxiety disorders such as panic attacks. Eight million people have depression each year.
Two million Americans have schizophrenia disorders, and 300,000 new cases are diagnosed each year.
Warning Signs for Mental Illness
Each mental illness has its own characteristic symptoms. However, there are some general warning signs that might alert you that someone needs professional help. Some of these signs include marked personality change, inability to cope with problems and daily activities, strange or grandiose ideas, excessive anxieties, prolonged depression and apathy, marked changes in eating or sleeping patterns, thinking or talking about suicide or harming oneself, extreme mood swings—high or low, abuse of alcohol or drugs, and excessive anger, hostility, or violent behavior.
A person who shows any of these signs should seek help from a qualified health professional. Diagnosing Mental Illness Mental Health Professionals To be diagnosed with a mental illness, a person must be evaluated by a qualified professional who has expertise in mental health. Mental health professionals include psychiatrists, psychologists, psychiatric nurses, social workers, and mental health counselors. Family doctors, internists, and pediatricians are usually qualified to diagnose common mental disorders such as depression, anxiety disorders, and ADHD. In many cases, depending on the individual and his or her symptoms, a mental health professional who is not a psychiatrist will refer the patient to a psychiatrist. A psychiatrist is a medical doctor (M.D.) who has received additional training in the field of mental health and mental illnesses. Psychiatrists evaluate the person’s mental condition in coordination with his or her physical condition and can prescribe medication. Only psychiatrists and other M.D.s can prescribe medications to treat mental illness.
Mental Illnesses are Diagnosed by Symptoms
Unlike some disease diagnoses, doctors can’t do a blood test or culture some microorganisms to determine whether a person has a mental illness. Maybe scientists will develop discrete physiological tests for mental illnesses in the future; until then, however, mental health professionals will have to diagnose mental illnesses based on the symptoms that a person has. Basing a diagnosis on symptoms and not on a quantitative medical test, such as a blood chemistry test, a throat swab, X-rays, or urinalysis, is not unusual. Physicians diagnose many diseases, including migraines, Alzheimer’s disease, and Parkinson’s disease based on their symptoms alone. For other diseases, such as asthma or mononucleosis, doctors rely on analyzing symptoms to get a good idea of what the problem is and then use a physiological test to provide additional information or to confirm their diagnosis.
When a mental health professional works with a person who might have a mental illness, he or she will, along with the individual, determine what symptoms the individual has, how long the symptoms have persisted, and how his or her life is being affected. Mental health professionals often gather information through an interview during which they ask the patient about his or her symptoms, the length of time that the symptoms have occurred, and the severity of the symptoms. In many cases, the professional will also get information about the patient from family members to obtain a more comprehensive picture. A physician likely will conduct a physical exam and consult the patient’s history to rule out other health problems. Mental health professionals evaluate symptoms to make a diagnosis of mental illness. They rely on the criteria specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; currently, the fourth edition), published by the American Psychiatric Association, to diagnose a specific mental illness.
For each mental illness, the DSM-IV gives a general description of the disorder and a list of typical symptoms. Mental health professionals refer to the DSM-IV to confirm that the symptoms a patient exhibits match those of a specific mental illness. Although the DSM-IV provides valuable information that helps mental health professionals diagnose mental illness, these professionals realize that it is important to observe patients over a period of time to understand the individual’s mental illness and its effects on his or her life.
The Causes of Mental Illnesses
At this time, scientists do not have a complete understanding of what causes mental illnesses. If you think about the structural and organizational complexity of the brain together with the complexity of effects that mental illnesses have on thoughts, feelings, and behaviors, it is hardly surprising that figuring out the causes of mental illnesses is a daunting task. The fields of neuroscience, psychiatry, and psychology address different aspects of the relationship between the biology of the brain and individuals’ behaviors, thoughts, and feelings, and how their actions sometimes get out of control. Through this multidisciplinary research, scientists are trying to find the causes of mental illnesses. Once scientists can determine the causes of a mental illness, they can use that knowledge to develop new treatments or to find a cure.
The Biology of Mental Illnesses
Most scientists believe that mental illnesses result from problems with the communication between neurons in the brain (neurotransmission). For example, the level of the neurotransmitter serotonin is lower in individuals who have depression. This finding led to the development of certain medications for the illness. Selective serotonin reuptake inhibitors (SSRIs) work by reducing the amount of serotonin that is taken back into the presynaptic neuron. This leads to an increase in the amount of serotonin available in the synaptic space for binding to the receptor on the postsynaptic neuron. Changes in other neurotransmitters (in addition to serotonin) may occur in depression, thus adding to the complexity of the cause underlying the disease. Scientists believe that there may be disruptions in the neurotransmitters dopamine, glutamate, and norepinephrine in individuals who have schizophrenia. One indication that dopamine might be an important neurotransmitter in schizophrenia comes from the observation that cocaine addicts sometimes show symptoms similar to schizophrenia. Cocaine acts on dopamine-containing neurons in the brain to increase the amount of dopamine in the synapse.
Risk Factors for Mental Illnesses
Although scientists at this time do not know the causes of mental illnesses, they have identified factors that put individuals at risk. Some of these factors are environmental, some are genetic, and some are social. In fact, all these factors most likely combine to influence whether someone becomes mentally ill. Environmental factors such as head injury, poor nutrition, and exposure to toxins (including lead and tobacco smoke) can increase the likelihood of developing a mental illness. Scientists understand that mental illnesses are associated with changes in neurochemicals. For example, in people who have depression, less of the neurotransmitter serotonin (small circles) is released into the synaptic space than in people who do not have depression. Certain medications called selective serotonin reuptake inhibitors (SSRIs) relieve symptoms of depression by causing an increase in the amount of serotonin in the synaptic space. Social factors also present risks and can harm an individual’s, especially a child’s, mental health. Social factors include severe parental discord, death of a family member or close friend, parent’s mental illness, parent’s criminality, overcrowding, economic hardship, abuse, neglect, and exposure to violence.
Treating Mental Illnesses
At this time, most mental illnesses cannot be cured, but they can usually be treated effectively to minimize the symptoms and allow the individual to function in work, school, or social environments. To begin treatment, an individual needs to see a qualified mental health professional. The first thing that the doctor or other mental health professional will do is speak with the individual to find out more about his or her symptoms, how long the symptoms have lasted, and how the person’s life is being affected. The physician will also do a physical examination to determine whether there are other health problems. For example, some symptoms (such as emotional swings) can be caused by neurological or hormonal problems associated with chronic illnesses such as heart disease, or they can be a side effect of certain medications. After the individual’s overall health is evaluated and the condition diagnosed, the doctor will develop a treatment plan. Treatment can involve both medications and psychotherapy, depending on the disease and its severity.
Medications are often used to treat mental illnesses. Through television commercials and magazine advertisements, we are becoming more aware of those medications. To become fully effective, medications for treating mental illness must be taken for a few days or a few weeks. When a patient begins taking medication, it is important for a doctor to monitor the patient’s health. If the medication causes undesirable side effects, the doctor may change the dose or switch to a different medication that produces fewer side effects. If the medication does not relieve the symptoms, the doctor may prescribe a different medication. Sometimes, individuals who have a mental illness do not want to take their medications because of the side effects. It is important to remember that all medications have both positive and negative effects. For example, antibiotics have revolutionized treatment for some bacterial diseases. However, antibiotics often affect beneficial bacteria in the human body, leading to side effects such as nausea and diarrhea.
Psychiatric drugs, like other medications, can alleviate symptoms of mental illness but can also produce unwanted side effects. People who take a medication to treat an illness, whether it is a mental illness or another disease, should work with their doctors to understand what medication they are taking, why they are taking it, how to take it, and what side effects to watch for. Occasionally, the media reports stories in which the side effects of a psychiatric medication are tied to a potentially serious consequence, such as suicide. In these cases, it is usually very difficult to determine how much suicidal behavior was due to the mental disorder and what the role of the medication might have been. Medications for treating mental illness can, like other medications, have side effects. The psychiatrist or physician can usually adjust the dose or change the medication to alleviate side effects.
Psychotherapy is a treatment method in which a mental health professional (psychiatrist, psychologist, or other mental health professional) and the patient discuss problems and feelings. This discussion helps patients understand the basis of their problems and find solutions. Psychotherapy may take different forms. The therapy can help patients change thought or behavior patterns, understand how past experiences influence current behaviors, solve other problems in specific ways, or learn illness self-management skills.
Psychotherapy may occur between a therapist and an individual; a therapist and an individual and his or her family members; or a therapist and a group. Often, treatment for mental illness is most successful when psychotherapy is used in combination with medications. For severe mental illnesses, medication relieves the symptoms and psychotherapy helps individuals cope with their illness. Just as there are no medications that can instantly cure mental illnesses, psychotherapy is not a one-time event. The amount of time a person spends in psychotherapy can range from a few visits to a few years, depending on the nature of the illness or problem. In general, the more severe the problem, the more lengthy the psychotherapy should be.
Impact of Mental Illness
The high incidence of mental illness has a great impact on society. Treatment, including psychotherapy and medication management, is cost-effective for patients, their families, and society. The benefits include fewer visits to other doctors’ offices, diagnostic laboratories, and hospitals for physical ailments that are based in psychological distress; reduced need for psychiatric hospitalization; fewer sick days and disability claims; and increased job stability. Conversely, the costs of not treating mental disorders can be seen in ruined relationships, job loss or poor job performance, personal anguish, substance abuse, unnecessary medical procedures, psychiatric hospitalization, and suicide. Major mental disorders cost the nation at least $193 billion annually in lost earnings alone, according to a 2008 study funded by the National Institutes of Health’s National Institute of Mental Health (
Mental Health and Disabilities
OpenStax College. 2012.
Health in the United States
. Connexions, May 18, 2012.
The treatment received by those defined as mentally ill or disabled varies greatly from country to country. In post-millennial America, those of us who have never experienced such a disadvantage take for granted the rights our society guarantees for each citizen. We do not think about the relatively recent nature of the protections, unless, of course, we know someone constantly inconvenienced by the lack of accommodations or misfortune of suddenly experiencing a temporary disability.
People with mental disorders (a condition that makes it more difficult to cope with everyday life) and people with mental illness (a severe, lasting mental disorder that requires long term treatment) experience a wide range of effects.According to the National Institute of Mental Health (NIMH), the most common mental disorders in the United States are anxiety disorders. Almost 18 percent of American adults are likely to be affected in a single year, and 28 percent are likely to be affected over the course of a lifetime (National Institute of Mental Health 2005). It is important to distinguish between occasional feelings of anxiety and a true anxiety disorder. Anxiety is a normal reaction to stress that we all feel at some point, but anxiety disorders are feelings of worry and fearfulness that last for months at a time. Anxiety disorders include obsessive compulsive disorder (OCD), panic disorders, posttraumatic stress disorder (PTSD), and both social and specific phobias.The second most common mental disorders in the United States are mood disorders; roughly 10 percent of American adults are likely to be affected yearly, while 21 percent are likely to be affected over the course of a lifetime (National Institute of Mental Health 2005).
Major mood disorders are depression, bipolar disorder, and dysthymic disorder. Like anxiety, depression might seem like something that everyone experiences at some point, and it is true that most people feel sad or “blue” at times in their lives. A true depressive episode, however, is more than just feeling sad for a short period. It is a long-term, debilitating illness that usually needs treatment to cure. And bipolar disorder is characterized by dramatic shifts in energy and mood, often affecting the individual’s ability to carry out day-to-day tasks. Bipolar disorder used to be called manic depression because of the way that people would swing between manic and depressive episodes.Depending on what definition is used, there is some overlap between mood disorders and personality disorders, which affect nine percent of Americans yearly. The American Psychological Association publishes the Diagnostic and Statistical Manual on Mental Disorders (DSM), and their definition of personality disorders is changing in the fifth edition, which is being revised in 2011 and 2012. In the DSM-IV, personality disorders represent “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it” (National Institute of Mental Health). In other words, personality disorders cause people to behave in ways that are seen as abnormal to society but seem normal to them. The DSM-V proposes broadening this definition by offering five broad personality trait domains to describe personality disorders, some related to the level or type of their disconnect with society. As their application evolves, we will see how their definitions help scholars across disciplines understand the intersection of health issues and how they are defined by social institutions and cultural norms.
Another fairly commonly diagnosed mental disorder is Attention-Deficit/Hyperactivity Disorder (ADHD), which statistics suggest affects nine percent of children and eight percent of adults on a lifetime basis (National Institute of Mental Health 2005). ADHD is one of the most common childhood disorders, and it is marked by difficulty paying attention, difficulty controlling behavior, and hyperactivity. According to the American Psychological Association (APA), ADHD responds positively to stimulant drugs like Ritalin, which helps people stay focused. However, there is some social debate over whether such drugs are being overprescribed (American Psychological Association). In fact, some critics question whether this disorder is really as widespread as it seems, or if it is a case of overdiagnosis.Autism Spectrum Disorders (ASD) have gained a lot of attention in recent years. The term ASD encompasses a group of developmental brain disorders that are characterized by “deficits in social interaction, verbal and nonverbal communication, and engagement in repetitive behaviors or interests” (National Institute of Mental Health).
Optional Learning Activity:
Is ADHD a valid diagnosis and disease? Some think it is not.
discusses this history of the issue:
The Americans with Disabilities Act requires that access be provided to everyone. Disability refers to a reduction in one’s ability to perform everyday tasks. The World Health Organization makes a distinction between the various terms used to describe handicaps that’s important to the sociological perspective. They use the term impairment to describe the physical limitations, while reserving the term disability to refer to the social limitation.
Before the passage of the Americans with Disabilities Act (ADA) in 1990, Americans with disabilities were often excluded from opportunities and social institutions many of us take for granted. This occurred not only through employment and other kinds of discrimination, but through casual acceptance by most Americans of a world designed for the convenience of the able-bodied. Imagine being in a wheelchair and trying to use a sidewalk without the benefit of wheelchair accessible curbs. Imagine as a blind person trying to access information without the widespread availability of Braille. Imagine having limited motor control and being faced with a difficult-to-grasp round door handle. Issues like these are what the ADA tries to address. Ramps on sidewalks, Braille instructions, and more accessible door levers are all accommodations to help people with disabilities.
People with disabilities can be stigmatized by their illness. Stigmatization means that their identity is spoiled; they are labeled as different, discriminated against, and sometimes even shunned. They are labeled and ascribed a master status, becoming “the blind girl” or “the boy in the wheelchair” instead of someone afforded a full identity by society. This can be especially true for people who are disabled due to mental illness or disorders. As discussed in the section on mental health, many mental health disorders can be debilitating, affecting a person’s ability to cope with everyday life. This can affect social status, housing, and especially employment. According to the Bureau of Labor Statistics (2011), people with a disability had a higher rate of unemployment than people without a disability in 2010: 14.8 percent to 9.4 percent. This unemployment rate refers only to people actively looking for a job. In fact, eight out of 10 people with a disability are considered “out of the labor force;” that is, they do not have jobs and are not looking for them. The combination of this population and the high unemployment rate leads to an employment-population ratio of 18.6 percent among those with disabilities. The employment-population ratio for people without disabilities was much higher, at 63.5 percent (U.S. Bureau of Labor Statistics 2011).
What are the most commonly diagnosed mental disorders in the United States?
ADHD Mood disorders Autism spectrum disorders Anxiety disordersAnswerD
Lesson 3: Stigma of Mental Illness
The Stigma of Mental Illness
Attitudes Toward Mental Illness, 2007,
and SAMHSA's Resource Center to Promote Acceptance, Dignity and Social Inclusion Associated with Mental Health,
Words can hurt. Many derogatory words and phrases are used in relation to mental illness. However, these words maintain the stereotyped image and not the reality about mental illness. Try not to use these words, and encourage students not to use them. It is more appropriate to refer to “a person who has a mental illness” when speaking about someone.
“Mentally ill people are nuts, crazy, wacko.” “Mentally ill people are morally bad.” “Mentally ill people are dangerous and should be locked in an asylum forever.” “Mentally ill people need somebody to take care of them.” How often have we heard comments like these or seen these types of portrayals in movies, television shows, or books? We may even be guilty of making comments like them ourselves. Is there any truth behind these portrayals, or is that negative view based on our ignorance and fear?
Stigmas are negative stereotypes about groups of people. Common stigmas about people who are mentally ill are
Individuals who have a mental illness are dangerous.
Individuals who have a mental illness are irresponsible and can’t make life decisions for themselves.
People who have a mental illness are childlike and must be taken care of by parents or guardians.
People who have a mental illness should just get over it.
Each of those preconceptions about people who have a mental illness is based on false information. Very few people who have a mental illness are dangerous to society. Most can hold jobs, attend school, and live independently. A person who has a mental illness cannot simply decide to get over it any more than someone who has a different
disease such as diabetes, asthma, or heart disease can. A mental illness, like those other diseases, is caused by a physical problem in the body.
Stigmas against individuals who have a mental illness lead to injustices, including discriminatory decisions regarding housing, employment, and education. Overcoming the stigmas commonly associated with mental illness is yet one more challenge that people who have a mental illness must face. Indeed, many people who successfully manage their mental illness report that the stigma they face is in many ways more disabling than the illness itself. The stigmatizing attitudes toward mental illness held by both the public and those who have a mental illness lead to feelings of shame and guilt, loss of self-esteem, social dependence, and a sense of isolation and hopelessness. One of the worst consequences of stigma is that people who are struggling with a mental illness may be reluctant to seek treatment that, in most cases, would significantly relieve their symptoms.
Providing accurate information is one way to reduce stigmas about mental illness. Advocacy groups protest stereotypes imposed upon those who are mentally ill. They demand that the media stop presenting inaccurate views of mental illness and that the public stops believing these negative views. A powerful way of countering stereotypes about mental illness occurs when members of the public meet people who are effectively managing a serious mental illness: holding jobs, providing for themselves, and living as good neighbors in a community. Interaction with people who have mental illnesses challenges a person’s assumptions and changes a person’s attitudes about mental illness.
Stigma and Illness
Stigma has been defined as an attribute that is deeply discrediting. This stigmatized trait sets the bearer apart from the rest of society, bringing with it feelings of shame and isolation. Often, when a person with a stigmatized trait is unable to perform an action because of the condition, other people view the person as the problem rather than viewing the condition as the problem. More recent definitions of stigma focus on the results of stigma—the prejudice, avoidance, rejection and discrimination directed at people believed to have an illness, disorder or other trait perceived to be undesirable. Stigma causes needless suffering, potentially causing a person to deny symptoms, delay treatment and refrain from daily activities. Stigma can exclude people from access to housing, employment, insurance, and appropriate medical care. Thus, stigma can interfere with prevention efforts, and examining and combating stigma is a public health priority.
The Substance Abuse and Mental Health Services Administration (SAMHSA) and the CDC have examined public attitudes toward mental illness in two surveys. In the 2006 HealthStyles survey, only one-quarter of young adults between the ages of 18–24 believed that a person with mental illness can eventually recover (HealthStyles survey). In 2007, adults in 37 states and territories were surveyed about their attitudes toward mental illness, using the 2007 Behaviorial Risk Factor Surveillance System Mental Illness and Stigma module. This study found that -
78% of adults with mental health symptoms and 89% of adults without such symptoms agreed that treatment can help persons with mental illness lead normal lives.
57% of adults without mental health symptoms believed that people are caring and sympathetic to persons with mental illness.
Only 25% of adults with mental health symptoms believed that people are caring and sympathetic to persons with mental illness.
These findings highlight both the need to educate the public about how to support persons with mental illness and the need to reduce barriers for those seeking or receiving treatment for mental illness.
Challenging Stereotypes about Mental Illness
Challenging Stereotypes: An Action Guide
, Substance Abuse and Mental Health Services Administration,
Recovery from mental illness is a complex process. As with all serious illness, the well-being of recovering individuals is affected by the attitudes that surround them. Despite increasing sensitivity about most disabilities, mental illness all too often remains a target for ridicule and misrepresentation in advertising, entertainment, and the mainstream media.
Most of what we know as individuals comes not from personal experience, but from the stories that surround us from birth. In the past it was families, religious institutions, schools, and respected members of the community who instilled cultural attitudes. “Today, this is done by the mass media,” says George Gerbner, founder of the Cultural Environment Movement, and a researcher whose career includes 30 years of monitoring the cultural impact of television on society. Television is, in Gerbner’s words, “the wholesale distributor of the stigma of mental illness.” His research has shown that characters portrayed on television as having mental illnesses have four times the violence rate and six times the victimization rate of other characters. Gerbner notes that “Violence and retribution are shown as inherent in the illness itself and thus inescapable. No other group in the dramatic world of television suffers and is shown to deserve such a dire fate.”
The portrayal of mental illness in the movies is similarly distorted. In the late 1980s, Steven E. Hyler of Columbia University and his colleagues identified six categories of psychiatric characters in films: homicidal maniac, narcissistic parasite, seductress, enlightened member of society, rebellious free spirit, and zoo specimen. Hyler concluded concluded that these predominantly negative stereotypes had a damaging effect on the viewing public and on the patients themselves, their family members, and policy makers.2 More recently, Otto F. Wahl of George Mason University, an authority on public images of mental illness, found that in the decade from 1985 to 1995, Hollywood released more than 150 films with characters who have mental illnesses, the majority of them killers and villains.3 There can be no doubt that Hollywood stereotypes are a large part of what people know, or think they know, about people with psychiatric vulnerabilities. Newspaper reports about mental illness are often more accurate than the characters one sees in TV entertainment and movies. Still, people with psychiatric histories generally are reported negatively. In 1991, researchers Russell E. Shain and Julie Phillips, using the United Press International database from 1983, found that 86 percent of all print stories dealing with former mental patients focused on violent crime.4 A 1997 British study found similarly skewed stories, and a 1999 German study concludes that selective reporting about mental illness causes audiences to distort their view of the “real world.”6 Media stereotypes of persons with mental illness as villains, failures, buffoons — together with the misuse of terms like “schizophrenia” and“psychotic” in negative contexts — have farreaching consequences. On the most deeply personal level, biased stereotypes damage the sense of self-worth of millions of persons diagnosed with serious psychiatric illnesses. On the social and economic levels, negative stereotyping may result in large-scale discrimination against an entire class of people in the areas of housing, employment, health insurance, and medical treatment.
Increasingly, the media are doing better work; at times, their efforts are excellent. Diana Ross’s moving and realistic portrayal of schizophrenia in Out of Darkness, an ABC television drama, was praised by mental health activists. “Good" characters with mental illness are appearing from time to time in prime-time television entertainment. In an outstanding documentary for Dateline NBC, John Hockenberry followed for two years the uneven course of recovery of a young man with schizophrenia.
Feature stories about the achievements of individuals diagnosed with mental illness — such as Newsweek’s account of Tom Harrell,9 a jazz trumpet star; The San Diego Union-Tribune’s account of pro golfer Muffin Spencer-Devlin;10 and a New York Times business section feature about John Forbes Nash, Jr., the winner of a Nobel Prize for economics11 — also help shatter stereotypes. A New York Times Magazine cover story, for example, brought new understanding to a highly publicized homicide when it chronicled a young man’s search for help in a crumbling mental health system. And increasingly, people with first-hand experience of mental illness are writing books, appearing on television news and talk shows, producing documentaries and radio programs, and contributing articles to the print media. The disparity between mental illness as it is perceived by much of the public and mental illness as it is lived and experienced is a gulf to be bridged. In his 1999 landmark report to the Nation on mental illness and health, Surgeon General David Satcher called on America to tear down the barriers of prejudice that block access to services and recovery.13 Nothing short of a national commitment to de-stigmatize mental illness will achieve this goal.
Learning Activity 3.1:
Take action to reduce stigma about mental illness.
You can promote fair, accurate, and balanced portrayals of mental illness in the media. Your voice does make a difference. Whether you handwrite it, type it, or e-mail it, it’s your passion and knowledge that persuade, that get your letters read (and published), and that change hearts and minds.
Challenging Stereotypes: An Action Guide
to help decrease the barriers of prejudice toward people who have mental illnesses by calling attention to media portrayals of mental illness that are stigmatizing, stereotyping, and/or inaccurate.
The Roots of Stigma
US Surgeon General,
Stigmatization of people with mental disorders has persisted throughout history. It is manifested by bias, distrust, stereotyping, fear, embarrassment, anger, and/or avoidance. Stigma leads others to avoid living, socializing or working with, renting to, or employing people with mental disorders, especially severe disorders such as schizophrenia (Penn & Martin, 1998; Corrigan & Penn, 1999). It reduces patients’ access to resources and opportunities (e.g., housing, jobs) and leads to low self-esteem, isolation, and hopelessness. It deters the public from seeking, and wanting to pay for, care. In its most overt and egregious form, stigma results in outright discrimination and abuse. More tragically, it deprives people of their dignity and interferes with their full participation in society.
Explanations for stigma stem, in part, from the misguided split between mind and body first proposed by Descartes. Another source of stigma lies in the 19th-century separation of the mental health treatment system in the United States from the mainstream of health. These historical influences exert an often immediate influence on perceptions and behaviors in the modern world.
Public Attitudes About Mental Illness: 1950s to 1990s
Nationally representative surveys have tracked public attitudes about mental illness since the 1950s (Star, 1952, 1955; Gurin et al., 1960; Veroff et al., 1981). To permit comparisons over time, several surveys of the 1970s and the 1990s phrased questions exactly as they had been asked in the 1950s (Swindle et al., 1997).
In the 1950s, the public viewed mental illness as a stigmatized condition and displayed an unscientific understanding of mental illness. Survey respondents typically were not able to identify individuals as“mentally ill” when presented with vignettes of individuals who would have been said to be mentally ill according to the professional standards of the day. The public was not particularly skilled at distinguishing mental illness from ordinary unhappiness and worry and tended to see only extreme forms of behavior—namely psychosis—as mental illness. Mental illness carried great social stigma, especially linked with fear of unpredictable and violent behavior (Star, 1952, 1955; Gurin et al., 1960; Veroff et al., 1981).
By 1996, a modern survey revealed that Americans had achieved greater scientific understanding of mental illness. But the increases in knowledge did not defuse social stigma (Phelan et al., 1997). The public learned to define mental illness and to distinguish it from ordinary worry and unhappiness. It expanded its definition of mental illness to encompass anxiety, depression, and other mental disorders. The public attributed mental illness to a mix of biological abnormalities and vulnerabilities to social and psychological stress (Link et al., in press). Yet, in comparison with the 1950s, the public’s perception of mental illness more frequently incorporated violent behavior (Phelan et al., 1997). This was primarily true among those who defined mental illness to include psychosis (a view held by about one-third of the entire sample). Thirty-one percent of this group mentioned violence in its descriptions of mental illness, in comparison with 13 percent in the 1950s. In other words, the perception of people with psychosis as being dangerous is stronger today than in the past (Phelan et al., 1997).
The 1996 survey also probed how perceptions of those with mental illness varied by diagnosis. The public was more likely to consider an individual with schizophrenia as having mental illness than an individual with depression. All of them were distinguished reasonably well from a worried and unhappy individual who did not meet professional criteria for a mental disorder. The desire for social distance was consistent with this hierarchy (Link et al., in press).
Why is stigma so strong despite better public understanding of mental illness? The answer appears to be fear of violence: people with mental illness, especially those with psychosis, are perceived to be more violent than in the past (Phelan et al., 1997).
This finding begs yet another question: Are people with mental disorders truly more violent? Research supports some public concerns, but the overall likelihood of violence is low. The greatest risk of violence is from those who have dual diagnoses, i.e., individuals who have a mental disorder as well as a substance abuse disorder (Swanson, 1994; Eronen et al., 1998; Steadman et al., 1998). There is a small elevation in risk of violence from individuals with severe mental disorders (e.g., psychosis), especially if they are noncompliant with their medication (Eronen et al., 1998; Swartz et al., 1998). Yet the risk of violence is much less for a stranger than for a family member or person who is known to the person with mental illness (Eronen et al., 1998).
In fact, there is very little risk of violence or harm to a stranger from casual contact with an individual who has a mental disorder
. Because the average person is ill-equipped to judge whether someone who is behaving erratically has any of these disorders, alone or in combination, the natural tendency is to be wary. Yet, to put this all in perspective, the overall contribution of mental disorders to the total level of violence in society is exceptionally small (Swanson, 1994).
Because most people should have little reason to fear violence from those with mental illness, even in its most severe forms,
is fear of violence so entrenched? Most speculations focus on media coverage and deinstitutionalization (Phelan et al., 1997; Heginbotham, 1998). One series of surveys found that selective media reporting reinforced the public’s stereotypes linking violence and mental illness and encouraged people to distance themselves from those with mental disorders (Angermeyer & Matschinger, 1996). And yet, deinstitutionalization made this distancing impossible over the 40 years as the population of state and county mental hospitals was reduced from a high of about 560,000 in 1955 to well below 100,000 by the 1990s (Bachrach, 1996). Some advocates of deinstitutionalization expected stigma to be reduced with community care and commonplace exposure. Stigma might have been greater today had not public education resulted in a more scientific understanding of mental illness.
Stigma and Seeking Help for Mental Disorders
Nearly two-thirds of all people with diagnosable mental disorders do not seek treatment (Regier et al., 1993; Kessler et al., 1996). Stigma surrounding the receipt of mental health treatment is among the many barriers that discourage people from seeking treatment (Sussman et al., 1987; Cooper-Patrick et al., 1997). Concern about stigma appears to be heightened in rural areas in relation to larger towns or cities (Hoyt et al., 1997). Stigma also disproportionately affects certain age groups, as explained in the chapters on children and older people.
The surveys cited above concerning evolving public attitudes about mental illness also monitored how people would cope with, and seek treatment for, mental illness if they became symptomatic. (The term “nervous breakdown” was used in lieu of the term “mental illness” in the 1996 survey to allow for comparisons with the surveys in the 1950s and 1970s.) The 1996 survey found that people were likelier than in the past to approach mental illness by coping with, rather than by avoiding, the problem. They also were more likely now to want
social supports (e.g., self-help groups). Those who now sought
support increasingly preferred counselors, psychologists, and social workers (Swindle et al., 1997).
tigma and Paying for Mental Disorder Treatment
Another manifestation of stigma is reflected in the public’s reluctance to pay for mental health services. Public willingness to pay for mental health treatment, particularly through insurance premiums or taxes, has been assessed largely through public opinion polls. Members of the public report a greater willingness to pay for insurance coverage for individuals with severe mental disorders, such as schizophrenia and depression, rather than for less severe conditions such as worry and unhappiness (Hanson, 1998). While the public generally appears to support paying for treatment, its support diminishes upon the realization that higher taxes or premiums would be necessary (Hanson, 1998). In the lexicon of survey research, the willingness to pay for mental illness treatment services is considered to be“soft.” The public generally ranks insurance coverage for mental disorders below that for somatic disorders (Hanson, 1998).
There is likely no simple or single panacea to eliminate the stigma associated with mental illness. Stigma was expected to abate with increased knowledge of mental illness, but just the opposite occurred: stigma in some ways intensified over the past 40 years even though understanding improved. Knowledge of mental illness appears by itself insufficient to dispel stigma (Phelan et al., 1997). Broader knowledge may be warranted, especially to redress public fears (Penn & Martin, 1998). Research is beginning to demonstrate that negative perceptions about severe mental illness can be lowered by furnishing empirically based information on the association between violence and severe mental illness (Penn & Martin, 1998). Overall approaches to stigma reduction involve programs of advocacy, public education, and contact with persons with mental illness through schools and other societal institutions (Corrigan & Penn, 1999).
Ironically, these examples also illustrate a more unsettling consequence: that the mental health field was adversely affected when causes and treatments were identified. As advances were achieved, each condition was transferred from the mental health field to another medical specialty (Grob, 1991). For instance, dominion over syphilis was moved to dermatology, internal medicine, and neurology upon advances in etiology and treatment. Dominion over hormone-related mental disorders was moved to endocrinology under similar circumstances. The consequence of this transformation, according to historian Gerald Grob, is that the mental health field became over the years the repository for mental disorders whose etiology was unknown. This left the mental health field “vulnerable to accusations by their medical brethren that psychiatry was not part of medicine, and that psychiatric practice rested on superstition and myth” (Grob, 1991).
These historical examples signify that stigma dissipates for individual disorders once advances render them less disabling, infectious, or disfiguring. Yet the stigma surrounding
mental disorders not only persists but may be inadvertently reinforced by leaving to mental health care only those behavioral conditions without known causes or cures. To point this out is not intended to imply that advances in mental health should be halted; rather, advances should be nurtured and heralded. The purpose here is to explain some of the historical origins of the chasm between the health and mental health fields.
Stigma must be overcome. Research that will continue to yield increasingly effective treatments for mental disorders promises to be an effective antidote. When people understand that mental disorders are not the result of moral failings or limited will power, but are legitimate illnesses that are responsive to specific treatments, much of the negative stereotyping may dissipate. Still, fresh approaches to disseminate research information and, thus, to counter stigma need to be developed and evaluated. Social science research has much to contribute to the development and evaluation of anti-stigma programs (Corrigan & Penn, 1999). As stigma abates, a transformation in public attitudes should occur. People should become eager to seek care. They should become more willing to absorb its cost. And, most importantly, they should become far more receptive to the messages that are the subtext of this report: mental health and mental illness are part of the mainstream of health, and they are a concern for all people.
Violence and Mental Illness: The Facts
Violence and Mental Illness: The Facts, Substance Abuse & Mental Health Services Administration Center for Mental Health Services,
The discrimination and stigma associated with mental illnesses largely stem from the link between mental illness and violence in the minds of the general public
, according to the U.S. Surgeon General (DHHS, 1999). The belief that persons with mental illness are dangerous is a significant factor in the development of stigma and discrimination (Corrigan, et al., 2002). The effects of stigma and discrimination are profound. The President’s New Freedom Commission on Mental Health found that, “Stigma leads others to avoid living, socializing, or working with, renting to, or employing people with mental disorders - especially severe disorders, such as schizophrenia. It leads to low self-esteem, isolation, and hopelessness. It deters the public from seeking and wanting to pay for care. Responding to stigma, people with mental health problems internalize public attitudes and become so embarrassed or ashamed that they often conceal symptoms and fail to seek treatment (New Freedom Commission, 2003).”
This link is often promoted by the entertainment and news media.
For example, Mental Health America, (formerly the National Mental Health Association) reported that, according to a survey for the Screen Actors’ Guild, characters in prime time television portrayed as having a mental illness are depicted as the most dangerous of all demographic groups: 60 percent were shown to be involved in crime or violence. Also most news accounts portray people with mental illness as dangerous (Mental Health America, 1999). The vast majority of news stories on mental illness either focus on other negative characteristics related to people with the disorder (e.g., unpredictability and unsociability) or on medical treatments. Notably absent are positive stories that highlight recovery of many persons with even the most serious of mental illnesses (Wahl, et al., 2002). Inaccurate and stereotypical representations of mental illness also exist in other mass media, such as films, music, novels and cartoons (Wahl, 1995).
Most citizens believe persons with mental illnesses are dangerous.
A longitudinal study of Americans’ attitudes on mental health between 1950 and 1996 found, “the proportion of Americans who describe mental illness in terms consistent with violent or dangerous behavior nearly doubled.” Also, the vast majority of Americans believe that persons with mental illnesses pose a threat for violence towards others and themselves (Pescosolido, et al., 1996, Pescosolido et al., 1999).
As a result, Americans are hesitant to interact with people who have mental illnesses.
Thirty-eight percent are unwilling to be friends with someone having mental health difficulties; sixty-four percent do not want someone who has schizophrenia as a close co-worker, and more than sixty-eight percent are unwilling to have someone with depression marry into their family (Pescosolido, et al., 1996).
But, in truth, people have little reason for such fears.
In reviewing the research on violence and mental illness, the Institute of Medicine concluded, “Although studies suggest a link between mental illnesses and violence, the contribution of people with mental illnesses to overall rates of violence is small,” and further, “the magnitude of the relationship is greatly exaggerated in the minds of the general population” (Institute of Medicine, 2006). For people with mental illnesses, violent behavior appears to be more common when there’s also the presence of other risk factors. These include substance abuse or dependence; a history of violence, juvenile detention, or physical abuse; and recent stressors such as being a crime victim, getting divorced, or losing a job (Elbogen and Johnson, 2009).
“Research has shown that the vast majority of people who are violent do not suffer from mental illnesses (American Psychiatric Association, 1994).”
“. . . [T]he absolute risk of violence among the mentally ill as a group is still very small and . . . only a small proportion of the violence in our society can be attributed to persons who are mentally ill (Mulvey, 1994).”
In a 1998 study that compared people discharged from acute psychiatric inpatient facilities and others in the same neighborhoods, researchers found that “there was no significant difference between the prevalence of violence by patients without symptoms of substance abuse and the prevalence of violence by others living in the same neighborhoods who were also without symptoms of substance abuse (Steadman, Mulvey, Monahan, Robbins, Applebaum, Grisso, Roth, and Silver, 1998).”
People with psychiatric disabilities are far more likely to be victims than perpetrators of violent crime (Appleby, et al., 2001). Researchers at North Carolina State University and Duke University found that people with severe mental illnesses—schizophrenia, bipolar disorder or psychosis—are 2 ½ times more likely to be attacked, raped or mugged than the general population (Hiday, et al., 1999).
People with mental illnesses can and do recover. People with mental illnesses can recover or manage their conditions and go on to lead happy, healthy, productive lives. They contribute to society and make the world a better place. People can often benefit from medication, rehabilitation, talk therapy, self help or a combination of these. One of the most important factors in recovery is the understanding and acceptance of family and friends.
“Most people who suffer from a mental disorder are not violent — there is no need to fear them. Embrace them for who they are — normal human beings experiencing a difficult time, who need your open mind, caring attitude, and helpful support (Grohol, 1998).”
Learning Activity 3.2:
Personal Stories about Mental Illness
Read a few of the personal stories about mental illness at
Talk with someone you know who is dealing with mental illness. Get to know his or her story, too.
How does knowing these stories help you to better understand mental illness?
Lesson 4: Suicide
Suicide and Self-harm
MedlinePlus, NLM, NIH,
Suicide is among the most common causes of death in the United States. People may consider suicide when they are hopeless and can't see any other solution to their problems. Often it's related to serious
, or a major stressful event.
People who have the highest risk of suicide are white men. But women and teens report more suicide attempts. If someone talks about suicide, you should take it seriously. Urge them to get help from their doctor or the emergency room, or call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255).
Therapy and medicines can help most people who have suicidal thoughts. Treating mental illnesses and substance abuse can reduce the risk of suicide.
Learning Activity 4.1:
Watch this video - Schramm: Break the silence for suicide attempt survivors | Video on TED.com at
Suicidal behavior is complex. Some risk factors vary with age, gender, or ethnic group and may occur in combination or change over time.
Suicide is a major, preventable public health problem. In 2007, it was the tenth leading cause of death in the U.S., accounting for 34,598 deaths. The overall rate was 11.3 suicide deaths per 100,000 people. An estimated 11 attempted suicides occur per every suicide death.
In 2007, suicide was the third leading cause of death for young people ages 15 to 24.
As in the general population, young people were much more likely to use firearms, suffocation, and poisoning than other methods of suicide, overall. However, while adolescents and young adults were more likely to use firearms than suffocation, children were dramatically more likely to use suffocation.
There were also gender differences in suicide among young people, as follows:
Nearly five times as many males as females ages 15 to 19 died by suicide.
Just under six times as many males as females ages 20 to 24 died by suicide.
What are the risk factors for suicide?
Research shows that risk factors for suicide include:
depression and other mental disorders, or a substance-abuse disorder (often in combination with other mental disorders). More than 90 percent of people who die by suicide have these risk factors.
prior suicide attempt
family history of mental disorder or substance abuse
family history of suicide
family violence, including physical or sexual abuse
firearms in the home, the method used in more than half of suicides
exposure to the suicidal behavior of others, such as family members, peers, or media figures.
However, suicide and suicidal behavior are not normal responses to stress; many people have these risk factors, but are not suicidal. Research also shows that the risk for suicide is associated with changes in brain chemicals called neurotransmitters, including serotonin. Decreased levels of serotonin have been found in people with depression, impulsive disorders, and a history of suicide attempts, and in the brains of suicide victims.
Public health approaches to preventing suicide include establishing telephone crisis hot lines, restricting access to suicide methods (for example, firearms), counseling media to reduce “copycat” suicides, screening teens for risk factors of suicide, and training professionals to improve recognition and treatment of mood disorders. Research about the effectiveness of these methods indicates that the screening and training strategies are more helpful for preventing suicides among young people than the other methods are.
Lesson 5: Mental Illness in Children and Adolescents
Mental Illness in Children and Adolescents
Mental illness is not uncommon among children and adolescents. Approximately 12 million children under the age of 18 have mental disorders. The National Mental Health Association has compiled some statistics about mental illness in children and adolescents:
Mental health problems affect one in every five young people at any given time.
An estimated two-thirds of all young people with mental health problems are not receiving the help they need.
Less than one-third of the children under age 18 who have a serious mental health problem receive any mental health services.
As many as 1 in every 33 children may be depressed. Depression in adolescents may be as high as 1 in 8.
Suicide is the third leading cause of death for 15- to 24-years-olds and the sixth leading cause of death for 5- to 15-year-olds.
Schizophrenia is rare in children under age 12, but it occurs in about 3 of every 1,000 adolescents.
Between 118,700 and 186,600 youths in the juvenile justice system have at least one mental illness.
Of the 100,000 teenagers in juvenile detention, an estimated 60 percent have behavioral, cognitive, or emotional problems.
Child Mental Health
It's easy to know when your child has a fever. A child's mental health problem may be harder to identify, but you can learn to recognize the symptoms. Pay attention to excessive anger, fear, sadness or anxiety. Sudden changes in your child's behavior can tip you off to a problem. So can behaviors like exercising too much, or hurting or destroying things.
Some common mental health problems in children are
Attention deficit hyperactivity disorder
Mental health problems can disrupt daily life at home, at school or in the community. Without help, mental health problems can lead to school failure, alcohol or other drug abuse, family discord, violence or even suicide. However, help is available. Talk to your health care provider if you have concerns about your child's behavior.
The Consequences of Not Treating Mental Illness
Most people don’t think twice before going to a doctor if they have an illness such as bronchitis, asthma, diabetes, or heart disease. However, many people who have a mental illness don’t get the treatment that would alleviate their suffering. Studies estimate that two-thirds of all young people with mental health problems are not receiving the help they need and that less than one-third of the children under age 18 who have a serious mental health problem receive any mental health services. Mental illness in adults often goes untreated, too. What are the consequences of letting mental illness go untreated?
The consequences of mental illness in children and adolescents can be substantial. Many mental health professionals speak of accrued deficits that occur when mental illness in children is not treated. To begin with, mental illness can impair a student’s ability to learn. Adolescents whose mental illness is not treated rapidly and aggressively tend to fall further and further behind in school. They are more likely to drop out of school and are less likely to be fully functional members of society when they reach adulthood. We also now know that depressive disorders in young people confer a higher risk for illness and interpersonal and psychosocial difficulties that persist after the depressive episode is over. Furthermore, many adults who suffer from mental disorders have problems that originated in childhood. Depression in youth may predict more severe illness in adult life. Attention deficit hyperactivity disorder, once thought to affect children and adolescents only, may persist into adulthood and may be associated with social, legal, and occupational problems. Mental illness impairs a student’s ability to learn. Adolescents whose mental illness is not treated rapidly and aggressively tend to fall further and further behind in school.
In children, depression lasts an average of seven to nine months with symptoms similar to those in adults. Symptoms in children may include
loss of interest in activities they used to enjoy,
feelings that they are unloved,
hopelessness about the future,
thoughts of suicide,
trouble concentrating, and
lack of energy.
Children and adolescents with depression are more likely than adults to have anxiety symptoms and general aches and pains, stomachaches, and headaches. The majority of children and adolescents who have a major depressive disorder also have another mental illness such as an anxiety disorder, disruptive or antisocial behavior, or a substance-abuse disorder. Children and adolescents who suffer from depression are more likely to commit suicide than are other youths. As in adults, episodes of depression are likely to recur.
Depression in Children and Adolescents
About 11 percent of adolescents have a depressive disorder by age 18 according to the National Comorbidity Survey-Adolescent Supplement (NCS-A). Girls are more likely than boys to experience depression. The risk for depression increases as a child gets older.
Because normal behaviors vary from one childhood stage to another, it can be difficult to tell whether a child who shows changes in behavior is just going through a temporary “phase” or is suffering from depression.
In the past, people believed that children could not get depression. Teens with depression were often dismissed as being moody or difficult. It wasn’t known that having depression can increase a person’s risk for heart disease, diabetes, and other diseases. Today’s most commonly used type of antidepressant medications did not exist. Selective serotonin reuptake inhibitors (SSRIs) resulted from the work of the late Nobel Laureate and NIH researcher Julius Axelrod, who defined the action of brain chemicals (neurotransmitters) in mood disorders.
We now know that youth who have depression may show signs that are slightly different from the typical adult symptoms of depression. Children who are depressed may complain of feeling sick, refuse to go to school, cling to a parent or caregiver, or worry excessively that a parent may die. Older children and teens may sulk, get into trouble at school, be negative or grouchy, or feel misunderstood.
Depressed teens with coexisting disorders such as substance abuse problems are less likely to respond to treatment for depression. Studies focusing on conditions that frequently co-occur and how they affect one another may lead to more targeted screening tools and interventions.
With medication, psychotherapy, or combined treatment, most youth with depression can be effectively treated. Youth are more likely to respond to treatment if they receive it early in the course of their illness.
Although antidepressants are generally safe, the U.S. Food and Drug Administration has placed a “black box” warning label—the most serious type of warning—on all antidepressant medications. The warning says there is an increased risk of suicidal thinking or attempts in youth taking antidepressants. Youth and young adults should be closely monitored especially during initial weeks of treatment.
Years of basic research are now showing promise for the first new generation of antidepressant medications in 2 decades, with a goal of relieving depression in hours, rather than weeks. Such a potential breakthrough could reduce the rate of suicide, which is consistently one of the leading causes of death for young people. In 2007—the most recent year for which we have statistics—it was the third leading cause of death for youth ages 15 to 24.
Is it safe for young adults to take antidepressants?
It may be safe for young people to be treated with antidepressants. However, drug companies who make antidepressants are required to post a "black box" warning label on the medication. A "black box" warning is the most serious type of warning on prescription drugs.
It may be possible that antidepressants make children, adolescents, and young adults more likely to think about suicide or commit suicide. In 2007, the FDA said that makers of all antidepressant medications should extend the warning to include young adults up through age 24.
People of all ages taking antidepressants should be watched closely, especially during the first weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. Families and caregivers should pay close attention to the patient, and report any changes in behavior to the patient's doctor.
Suicide in Childhood and Adolescence
Children and adolescents who are suicidal report feelings of depression, anger, anxiety, hopelessness, and worthlessness. They feel helpless to change frustrating circumstances or to find a solution for their problems. In addition to depression, family conflicts and suicidal death of a relative, friend, or acquaintance are risk factors for suicide among children and adolescents. In the case of another person’s suicide, children or teens may need intervention to prevent feelings of guilt, trauma, or social isolation. Programs offered by school professionals that address these concerns can be extremely helpful for identifying grieving youths who may need help.
Anxiety can be a normal reaction to stress. It can help us deal with a tense situation, study harder for an exam, keep focused on an important speech. In general, it can help us cope. But when anxiety becomes an excessive, irrational dread of everyday situations, it has become a disabling condition. Examples of anxiety disorders are obsessive compulsive disorder, post-traumatic stress disorder, social phobia, specific phobia, and generalized anxiety disorder. Symptoms of many of these disorders begin in childhood or adolescence.
In the past, the brain areas and circuitries underlying symptoms of anxiety disorders were unknown, and no targeted psychotherapies for anxiety disorders existed. Fortunately, today s large, national survey of adolescent mental health reported that about 8 percent of teens ages 13-18 have an anxiety disorder, with symptoms commonly emerging around age 6. However, of these teens, only 18 percent received mental health care.
Attention deficit hyperactivity disorder (ADHD) is the most commonly diagnosed behavioral disorder of childhood. In any six-month period, ADHD affects an estimated 4.1 percent of youths ages 9 to 17. Boys are two to three times more likely than girls to develop ADHD. Although ADHD is usually associated with children, the disorder can persist into adulthood. One researcher estimated that as many as two-thirds of the children he evaluated with ADHD continued to have the disorder in their twenties, and that many of those who no longer fit the clinical description of ADHD nonetheless had significant problems at work or in other social settings.
The symptoms of ADHD
The three predominant symptoms of ADHD are impaired ability to regulate activity level (hyperactivity), to attend to tasks (inattention), and to inhibit behavior (impulsivity).Individuals who have ADHD may display predominantly hyperactive/impulsive behavior, predominately inattentive behavior, or a combination of both. Children and adolescents with ADHD
are often unpopular among their peers,
have trouble in school,
have higher injury rates than their peers,
have difficulty paying attention to details,
are easily distracted,
find it difficult and unpleasant to finish their schoolwork,
put off things that require continued mental effort,
make careless mistakes,
appear not to listen when spoken to, and
fail to follow through on tasks.
The DSM-IV specifies several conditions in addition to the symptoms listed above before making a diagnosis of ADHD. For a diagnosis of ADHD, the behaviors must
appear before age seven,
continue for at least six months,
be more frequent or severe than in other children of the same age, and
cause dysfunction in at least two areas of life, such as school, home, work, or social settings.
The diagnosis of ADHD can be made reliably using well-tested diagnostic interview methods. However, as of yet, there is no independent valid test for ADHD.
Among children, ADHD frequently occurs along with other learning, behavior, or mood problems such as learning disabilities, oppositional defiant disorder, anxiety disorders, and depression.
The causes of ADHD
The exact causes of ADHD are unknown; however, research has demonstrated that factors that many people associate with the development of ADHD do not cause the disorder. For example, ADHD is not caused by minor head injuries, damage to the brain from complications during birth, food allergies, excess sugar intake, too much television, poor schools, or poor parenting. No single cause of ADHD has been discovered. Rather, a number of significant risk factors affecting neurodevelopment and behavior expression have been implicated. Events such as maternal alcohol and tobacco use that affect the development of the fetal brain can increase the risk for ADHD. Injuries to the brain from environmental toxins such as lack of iron have also been implicated.
A variety of medications and behavioral interventions are used to treat ADHD. The most widely used medications are methylphenidate (Ritalin), D-amphetamine, and other amphetamines. These drugs are stimulants that affect the level of the neurotransmitter dopamine at the synapse. Nine out of 10 children improve while taking one of these drugs.
In addition to the well-established treatments described above, some parents and therapists have tried a variety of nutritional interventions to treat ADHD. A few studies have found that some children benefit from such treatments. Nevertheless, no well-established nutritional interventions have consistently been shown to be effective for treating ADHD.
Autism spectrum disorder (ASD) is a range of complex neurodevelopment disorders, characterized by social impairments, communication difficulties, and restricted, repetitive, and stereotyped patterns of behavior. Autistic disorder, sometimes called autism or classical ASD, is the most severe form of ASD, while other conditions along the spectrum include a milder form known as Asperger syndrome, and childhood disintegrative disorder and pervasive developmental disorder not otherwise specified (usually referred to as PDD-NOS). Although ASD varies significantly in character and severity, it occurs in all ethnic and socioeconomic groups and affects every age group. Experts estimate that six children out of every 1,000 will have an ASD. Males are four times more likely to have an ASD than females.
What are some common signs of autism?
The hallmark feature of ASD is impaired social interaction. As early as infancy, a baby with ASD may be unresponsive to people or focus intently on one item to the exclusion of others for long periods of time. A child with ASD may appear to develop normally and then withdraw and become indifferent to social engagement.
Children with an ASD may fail to respond to their names and often avoid eye contact with other people. They have difficulty interpreting what others are thinking or feeling because they can’t understand social cues, such as tone of voice or facial expressions, and don’t watch other people’s faces for clues about appropriate behavior. They lack empathy.
Many children with an ASD engage in repetitive movements such as rocking and twirling, or in self-abusive behavior such as biting or head-banging. They also tend to start speaking later than other children and may refer to themselves by name instead of “I” or “me.” Children with an ASD don’t know how to play interactively with other children. Some speak in a sing-song voice about a narrow range of favorite topics, with little regard for the interests of the person to whom they are speaking.
Children with characteristics of an ASD may have co-occurring conditions, including Fragile X syndrome (which causes mental retardation), tuberous sclerosis, epileptic seizures, Tourette syndrome, learning disabilities, and attention deficit disorder. About 20 to 30 percent of children with an ASD develop epilepsy by the time they reach adulthood.
Lesson 6: Cultural Diversity and Mental Illness
Overview of Cultural Diversity and Mental Health Services
US Surgeon General,
The U.S. mental health system is not well equipped to meet the needs of racial and ethnic minority populations. Racial and ethnic minority groups are generally considered to be underserved by the mental health services system. A constellation of barriers deters ethnic and racial minority group members from seeking treatment, and if individual members of groups succeed in accessing services, their treatment may be inappropriate to meet their needs.
Awareness of the problem dates back to the 1960s and 1970s, with the rise of the civil rights and community mental health movements and with successive waves of immigration from Central America, the Caribbean, and Asia. These historical forces spurred greater recognition of the problems that minority groups confront in relation to mental health services.
Research documents that many members of minority groups fear, or feel ill at ease with, the mental health system. These groups experience it as the product of white, European culture, shaped by research primarily on white, European populations. They may find only clinicians who represent a white middle-class orientation, with its cultural values and beliefs, as well as its biases, misconceptions, and stereotypes of other cultures.
Research and clinical practice have propelled advocates and mental health professionals to press for “linguistically and culturally competent services” to improve utilization and effectiveness of treatment for different cultures. Culturally competent services incorporate respect for and understanding of, ethnic and racial groups, as well as their histories, traditions, beliefs, and value systems. Without culturally competent services, the failure to serve racial and ethnic minority groups adequately is expected to worsen, given the huge demographic growth in these populations predicted over the next decades.
Introduction to Cultural Diversity and Demographics
The Federal government officially designates
major racial or ethnic minority groups in the United States: African American (black), Asian/Pacific Islander, Hispanic American (Latino),and Native American/American Indian/Alaska Native/Native Hawaiian (referred to subsequently as “American Indians”). There are many other racial or ethnic minorities and considerable diversity within each of the four groupings listed above. The representation of the four officially designated groups in the U.S. population in 1999 is as follows: African Americans constitute the largest group, at 12.8 percent of the U.S. population; followed by Hispanics (11.4 percent), Asian/Pacific Islanders (4.0 percent), and American Indians (0.9 percent). Hispanic Americans are among the fastest-growing groups. Because their population growth outpaces that of African Americans, they are projected to be the predominant minority group (24.5 percent of the U.S. population) by the year 2050.
Racial and ethnic populations differ from one another and from the larger society with respect to culture. The term “culture” is used loosely to denote a common heritage and set of beliefs, norms, and values. The cultures with which members of minority racial and ethnic groups identify often are markedly different from industrial societies of the West. The phrase “cultural identity” specifies a reference group—an identifiable social entity with whom a person identifies and to whom he or she looks for standards of behavior. Of course, within any given group, an individual’s cultural identity may also involve language, country of origin, acculturation, gender, age, class, religious/spiritual beliefs, sexual orientation, and physical disabilities. Many people have multiple ethnic or cultural identities.
The historical experiences of ethnic and minority groups in the United States are reflected in differences in economic, social, and political status. The most measurable difference relates to income. Many racial and ethnic minority groups have limited financial resources. In 1994, families from these groups were at least three times as likely as white families to have incomes placing them below the Federally established poverty line. The disparity is even greater when considering extreme poverty—family incomes at a level less than half of the poverty threshold—and is also large when considering children and older persons. Although some Asian Americans are somewhat better off financially than other minority groups, they still are more than one and a half times more likely than whites to live in poverty. Poverty disproportionately affects minority women and their children. The effects of poverty are compounded by differences in total value of accumulated assets, or total wealth.
Lower socioeconomic status—in terms of income, education, and occupation—has been strongly linked to mental illness. It has been known for decades that people in the lowest socioeconomic strata are about two and a half times more likely than those in the highest strata to have a mental disorder. The reasons for the association between lower socioeconomic status and mental illness are not well understood. It may be that a combination of greater stress in the lives of the poor and greater vulnerability to a variety of stressors leads to some mental disorders, such as depression. Poor women, for example, experience more frequent, threatening, and uncontrollable life events than do members of the population at large. It also may be that the impairments associated with mental disorders lead to lower socioeconomic status.
Cultural identity imparts distinct patterns of beliefs and practices that have implications for the willingness to seek, and the ability to respond to, mental health services. These include coping styles and ties to family and community, discussed below.
Cultural differences can be reflected in differences in preferred styles of coping with day-to-day problems. Consistent with a cultural emphasis on restraint, certain Asian American groups, for example, encourage a tendency not to dwell on morbid or upsetting thoughts, believing that avoidance of troubling internal events is warranted more than recognition and outward expression. They have little willingness to behave in a fashion that might disrupt social harmony. Their emphasis on willpower is similar to the tendency documented among African Americans to minimize the significance of stress and, relatedly, to try to prevail in the face of adversity through increased striving.
Culturally rooted traditions of religious beliefs and practices carry important consequences for willingness to seek mental health services. In many traditional societies, mental health problems can be viewed as spiritual concerns and as occasions to renew one’s commitment to a religious or spiritual system of belief and to engage in prescribed religious or spiritual forms of practice. African Americans and a number of ethnic groups, when faced with personal difficulties, have been shown to seek guidance from religious figures.
Many people of all racial and ethnic backgrounds believe that religion and spirituality favorably impact upon their lives and that well-being, good health, and religious commitment or faith are integrally intertwined. Religion and spirituality are deemed important because they can provide comfort, joy, pleasure, and meaning to life as well as be means to deal with death, suffering, pain, injustice, tragedy, and stressful experiences in the life of an individual or family. In the family/community-centered perception of mental illness held by Asians and Hispanics, religious organizations are viewed as an enhancement or substitute when the family is unable to cope or assist with the problem.
Culture also imprints mental health by influencing whether and how individuals experience the discomfort associated with mental illness. When conveyed by tradition and sanctioned by cultural norms, characteristic modes of expressing suffering are sometimes called “idioms of distress”. Idioms of distress often reflect values and themes found in the societies in which they originate.
One of the most common idioms of distress is somatization, the expression of mental distress in terms of physical suffering. Somatization occurs widely and is believed to be especially prevalent among persons from a number of ethnic minority backgrounds (Lu et al., 1995). Epidemiological studies have confirmed that there are relatively high rates of somatization among African Americans. Indeed, somatization resembles an African American folk disorder identified in ethnographic research and is linked to seeking treatment.
A number of idioms of distress are well recognized as culture-bound syndromes and have been included in an appendix to DSM-IV. Among culture-bound syndromes found among some Latino psychiatric patients is
ataque de nervios,
a syndrome of “uncontrollable shouting, crying, trembling, and aggression typically triggered by a stressful event involving family. . . ” . A Japanese culture-bound syndrome has appeared in that country’s clinical modification of ICD-10.
is an intense fear that one’s body or bodily functions give offense to others. Culture-bound syndromes sometimes reflect comprehensive systems of belief, typically emphasizing a need for a balance between opposing forces (e.g., yin/yang, “hot-cold” theory) or the power of supernatural forces. Belief in indigenous disorders and adherence to culturally rooted coping practices are more common among older adults and among persons who are less acculturated. It is not well known how applicable DSM-IV diagnostic criteria are to culturally specific symptom expression and culture-bound syndromes.
Family and Community as Resources
Ties to family and community, especially strong in African, Latino, Asian, and Native American communities, are forged by cultural tradition and by the current and historical need to assist arriving immigrants, to provide a sanctuary against discrimination practiced by the larger society, and to provide a sense of belonging and affirming a centrally held cultural or ethnic identity.
Among Mexican-Americans and Asian Americans relatively high rates of marriage and low rates of divorce, along with a greater tendency to live in extended family households, indicate an orientation toward family. Family solidarity has been invoked to explain relatively low rates among minority groups of placing older people in nursing homes.
The relative economic success of Chinese, Japanese, and Korean Americans has been attributed to family and communal bonds of association. Community organizations and networks established in the United States include rotating credit associations based on lineage, surname, or region of origin. These organizations and networks facilitate the startup of small businesses.
There is evidence of an African American tradition of voluntary organizations and clubs often having political, economic, and social functions and affiliation with religious organizations. African Americans and other racial and ethnic minority groups have drawn upon an extended family tradition in which material and emotional resources are brought to bear from a number of linked households. According to this literature, there is “(a) a high degree of geographical propinquity; (b) a strong sense of family and familial obligation; (c) fluidity of household boundaries, with greater willingness to absorb relatives, both real and fictive, adult and minor, if need arises; (d) frequent interaction with relatives; (e) frequent extended family get-togethers for special occasions and holidays; and (f) a system of mutual aid”.
Families play an important role in providing support to individuals with mental health problems. A strong sense of family loyalty means that, despite feelings of stigma and shame, families are an early and important source of assistance in efforts to cope, and that minority families may expect to continue to be involved in the treatment of a mentally ill member (Uba, 1994). Among Mexican American families, researchers have found lower levels of expressed emotion and lower levels of relapse. Other investigators have demonstrated an association between family warmth and a reduced likelihood of relapse.
Epidemiology and Utilization of Services
One of the best ways to identify whether a minority group has problems accessing mental health services is to examine their
of services in relation to their
for services. As noted previously, a limitation of contemporary mental health knowledge is the lack of standard measures of “need for treatment” and culturally appropriate assessment tools. Minority group members’ needs, as measured indirectly by their prevalence of mental illness in relation to the U.S. population, should be proportional to their utilization, as measured by their representation in the treatment population. These comparisons turn out to be exceedingly complicated by inadequate understanding of the prevalence of mental disorders among minority groups in the United States. Nationwide studies conducted many years ago overlooked institutional populations, which are disproportionately represented by minority groups. Treatment utilization information on minority groups in relation to whites is more plentiful, yet, a clear understanding of health seeking behavior in various cultures is lacking.
The following paragraphs reveal that disparities abound in treatment utilization: some minority groups are underrepresented in the outpatient treatment population while, at the same time, overrepresented in the inpatient population. Possible explanations for the differences in utilization are discussed in a later section.
The prevalence of mental disorders is estimated to be higher among African Americans than among whites. This difference does not appear to be due to intrinsic differences between the races; rather, it appears to be due to socioeconomic differences. When socioeconomic factors are taken into account, the prevalence difference disappears. That is, the socioeconomic status-adjusted rates of mental disorder among African Americans turn out to be the same as those of whites. In other words, it is the lower socioeconomic status of African Americans that places them at higher risk for mental disorders.
African Americans are underrepresented in some outpatient treatment populations, but overrepresented in public inpatient psychiatric care in relation to whites. Their underrepresentation in outpatient treatment varies according to setting, type of provider, and source of payment. The racial gap between African Americans and whites in utilization is smallest, if not nonexistent, in community-based programs and in treatment financed by public sources, especially Medicaid and among older people . The underrepresentation is largest in privately financed care, especially individual outpatient practice, paid for either by fee-for-service arrangements or managed care. As a result, underrepresentation in the outpatient setting occurs more among working and middle-class African Americans, who are privately insured, than among the poor. This suggests that socioeconomic standing alone cannot explain the problem of underutilization.
African Americans are, as noted above, overrepresented in inpatient psychiatric care. Their rate of utilization of psychiatric inpatient care is about
that of whites. This difference is even higher than would be expected on the basis of prevalence estimates. Overrepresentation is found in hospitals of all types except private psychiatric hospitals. While difficult to explain definitively, the problem of overrepresentation in psychiatric hospitals appears more rooted in poverty, attitudes about seeking help, and a lack of community support than in clinician bias in diagnosis and overt racism, which also have been implicated. This line of reasoning posits that poverty, disinclination to seek help, and lack of health and mental health services deemed appropriate, and responsive, as well as community support, are major contributors to delays by African Americans in seeking treatment until symptoms become so severe that they warrant inpatient care.
Finally, African Americans are more likely than whites to use the emergency room for mental health problems. Their overreliance on emergency care for mental health problems is an extension of their overreliance on emergency care for other health problems. The practice of using the emergency room for routine care is generally attributed to a lack of health care providers in the community willing to offer routine treatment to people without insurance.
Asian Americans/Pacific Islanders
The prevalence of mental illness among Asian Americans is difficult to determine for methodological reasons (i.e., population sampling). Although some studies suggest higher rates of mental illness, there is wide variance across different groups of Asian Americans. It is not well known how applicable DSM-IV diagnostic criteria are to culturally specific symptom expression and culture-bound syndromes. With respect to treatment-seeking behavior, Asian Americans are distinguished by extremely low levels at which specialty treatment is sought for mental health problems. Asian Americans have proven less likely than whites, African Americans, and Hispanic Americans to seek care. One national sample revealed that Asian Americans were only a quarter as likely as whites, and half as likely as African Americans and Hispanic Americans, to have sought outpatient treatment. Asian Americans/Pacific Islanders are less likely than whites to be psychiatric inpatients. The reasons for the underutilization of services include the stigma and loss of face over mental health problems, limited English proficiency among some Asian immigrants, different cultural explanations for the problems, and the inability to find culturally competent services. These phenomena are more pronounced for recent immigrants.
Several epidemiological studies revealed few differences between Hispanic Americans and whites in lifetime rates of mental illness. A recent study of Mexican Americans in Fresno County, California, found that Mexican Americans born in the United States had rates of mental disorders similar to those of other U.S. citizens, whereas immigrants born in Mexico had lower rates. A large study conducted in Puerto Rico reported similar rates of mental disorders among residents of that island, compared with those of citizens of the mainland United States.
Although rates of mental illness may be similar to whites in general, the prevalence of particular mental health problems, the manifestation of symptoms, and help-seeking behaviors within Hispanic subgroups need attention and further research. For instance, the prevalence of depressive symptomatology is higher in Hispanic women (46%) than men (almost 20%); yet, the known risk factors do not totally explain the gender difference. Several studies indicate that Puerto Rican and Mexican American women with depressive symptomatology are underrepresented in mental health services and overrepresented in general medical services.
American Indians/Alaska Natives have, like Asian Americans and Pacific Islanders, been studied in few epidemiological surveys of mental health and mental disorders. The indications are that depression is a significant problem in many American Indian/Alaska Native communities. One study of a Northwest Indian village found rates of DSM-III-R affective disorder that were notably higher than rates reported from national epidemiological studies. Alcohol abuse and dependence appear also to be especially problematic, occurring at perhaps twice the rate of occurrence found in any other population group. Relatedly, suicide occurs at alarmingly high levels. Among Native American veterans, post-traumatic stress disorder has been identified as especially prevalent in relation to whites. In terms of patterns of utilization, Native Americans are overrepresented in psychiatric inpatient care in relation to whites, with the exception of private psychiatric hospitals.
Barriers to the Receipt of Treatment
The underrepresentation in outpatient treatment of racial and ethnic minority groups appears to be the result of cultural differences as well as financial, organizational, and diagnostic factors. The service system has not been designed to respond to the cultural and linguistic needs presented by many racial and ethnic minorities. What is unresolved are the relative contribution and significance of each factor for distinct minority groups.
Among adults, the evidence is considerable that persons from minority backgrounds are less likely than are whites
outpatient treatment in the specialty mental health sector. This is not the case for emergency department care, from which African Americans are more likely than whites to seek care for mental health problems, as noted above. Language, like economic and accessibility differences, can play an important role in why people from other cultures do not seek treatment.
The reasons why racial and ethnic minority groups are less apt to seek help appear to be best studied among African Americans. By comparison with whites, African Americans are more likely to give the following reasons for not seeking professional help in the face of depression: lack of time, fear of hospitalization, and fear of treatment. Mistrust among African Americans may stem from their experiences of segregation, racism, and discrimination. African Americans have experienced racist slights in their contacts with the mental health system, called “microinsults” by Pierce (1992). Some of these concerns are justified on the basis of research, cited below, revealing clinician bias in overdiagnosis of schizophrenia and underdiagnosis of depression among African Americans.
Lack of trust is likely to operate among other minority groups, according to research about their attitudes toward government-operated institutions rather than toward mental health treatment per se. This is particularly pronounced for immigrant families with relatives who may be undocumented, and hence they are less likely to trust authorities for fear of being reported and having the family member deported. People from El Salvador and Argentina who have experienced imprisonment or watched the government murder family members and engage in other atrocities may have an especially strong mistrust of any governmental authority. Within the Asian community, previous refugee experiences of groups such as Vietnamese, Indochinese, and Cambodian immigrants parallel those experienced by Salvadoran and Argentine immigrants. They, too, experienced imprisonment, death of family members or friends, physical abuse, and assault, as well as new stresses upon arriving in the United States.
American Indians’ past experience in this country also imparted lack of trust of government. Those living on Indian reservations are particularly fearful of sharing any information with white clinicians employed by the government. As with African Americans, the historical relationship of forced control, segregation, racism, and discrimination has affected their ability to trust a white majority population.
The stigma of mental illness is another factor preventing African Americans from seeking treatment, but not at a rate significantly different from that of whites. Both African American and white groups report that embarrassment hinders them from seeking treatment. In general, African Americans tend to deny the threat of mental illness and strive to overcome mental health problems through self-reliance and determination. Stigma, denial, and self-reliance are likely explanations why other minority groups do not seek treatment, but their contribution has not been evaluated empirically, owing in part to the difficulty of conducting this type of research. One of the few studies of Asian Americans identified the barriers of stigma, suspiciousness, and a lack of awareness about the availability of services. Cultural factors tend to encourage the use of family, traditional healers, and informal sources of care rather than treatment-seeking behavior, as noted earlier.
Cost is yet another factor discouraging utilization of mental health services. Minority persons are less likely than whites to have private health insurance, but this factor alone may have little bearing on access. Public sources of insurance and publicly supported treatment programs fill some of the gap. Even among working class and middle-class African Americans who have private health insurance, there is underrepresentation of African Americans in outpatient treatment. Yet studies focusing only on poor women, most of whom were members of minority groups, have found cost and lack of insurance to be barriers to treatment. The discrepancies in findings suggest that much research remains to be performed on the relative importance of cost, cultural, and organizational barriers, and poverty and income limitations across the spectrum of racial and ethnic and minority groups.
Advocates and experts alike have asserted that bias in clinician judgment is one of the reasons for overutilization of inpatient treatment by African Americans. Bias in clinician judgment is thought to be reflected in overdiagnosis or misdiagnosis of mental disorders. Since diagnosis is heavily reliant on behavioral signs and patients’ reporting of the symptoms, rather than on laboratory tests, clinician judgment plays an enormous role in the diagnosis of mental disorders. The strongest evidence of clinician bias is apparent for African Americans with schizophrenia and depression. Several studies found that African Americans were more likely than were whites to be diagnosed with schizophrenia, yet less likely to be diagnosed with depression.
In addition to problems of overdiagnosis or misdiagnosis, there may well be a problem of underdiagnosis among minority groups, such as Asian Americans, who are seen as “problem-free”. The presence and extent of this type of clinician bias are not known and need to be investigated.
Improving Treatment for Minority Groups
The previous paragraphs have documented underutilization of treatment, less help-seeking behavior, inappropriate diagnosis, and other problems that have beset racial and ethnic minority groups with respect to mental health treatment. This kind of evidence has fueled the widespread perception of mental health treatment as being uninviting, inappropriate, or not as effective for minority groups as for whites. The Schizophrenia Patient Outcome Research Team demonstrated that African Americans were less likely than others to have received treatment that conformed to recommended practices. Inferior treatment outcomes are widely assumed but are difficult to prove, especially because of sampling, questionnaire, and other design issues, as well as problems in studying patients who drop out of treatment after one session or who otherwise terminate prematurely. In a classic study, 50 percent of Asian Americans versus 30 percent of whites dropped out of treatment early. However, the disparity in dropout rates may have abated more recently. One of the few studies of clinical outcomes, a pre- versus post-treatment study, found that African Americans fared more poorly than did other minority groups treated as outpatients in the Los Angeles area. Earlier studies from the 1970s and 1980s had given inconsistent results.
There is mounting awareness that ethnic and cultural influences can alter an individual’s responses to medications (pharmacotherapies). The relatively new field of ethnopsychopharmacology investigates cultural variations and differences that influence the effectiveness of pharmacotherapies used in the mental health field. These differences are both genetic and psychosocial in nature. They range from genetic variations in drug metabolism to cultural practices that affect diet, medication adherence, placebo effect, and simultaneous use of traditional and alternative healing methods. Just a few examples are provided to illustrate ethnic and racial differences.
Pharmacotherapies given by mouth usually enter the circulation after absorption from the stomach. From the circulation they are distributed throughout the body (including the brain for psychoactive drugs) and then metabolized, usually in the liver, before they are cleared and eliminated from the body. The rate of metabolism affects the amount of the drug in the circulation. A slow rate of metabolism leaves more drug in the circulation. Too much drug in the circulation typically leads to heightened side effects. A fast rate of metabolism, on the other hand, leaves less drug in the circulation. Too little drug in the circulation reduces its effectiveness.
There is wide racial and ethnic variation in drug metabolism. This is due to genetic variations in drug-metabolizing enzymes (which are responsible for breaking down drugs in the liver). These genetic variations alter the activity of several drug-metabolizing enzymes. Each drug-metabolizing enzyme normally breaks down not just one type of pharmacotherapy, but usually several types. Since most of the ethnic variation comes in the form of inactivation or reduction in activity in the enzymes, the result is higher amounts of medication in the blood, triggering untoward side effects.
For example, 33 percent of African Americans and 37 percent of Asians are slow metabolizers of several antipsychotic medications and antidepressants (such as tricyclic antidepressants and selective serotonin reuptake inhibitors). This awareness should lead to more cautious prescribing practices, which usually entail starting patients at lower doses in the beginning of treatment. Unfortunately, just the opposite typically had been the case with African American patients and antipsychotic drugs. Clinicians in psychiatric emergency services prescribed more oral doses and more injections of antipsychotic medications to African American patients. These are the kinds of experiences that likely contribute to the mistrust of mental health services reported among African Americans.
Psychosocial factors also can play an important role in ethnic variation. Compliance with dosing may be hindered by communication difficulties; side effects can be misinterpreted or carry different connotations; some groups may be more responsive to placebo treatment; and reliance on psychoactive traditional and alternative healing methods (such as medicinal plants and herbs) may result in interactions with prescribed pharmacotherapies. The result could be greater side effects and enhanced or reduced effectiveness of the pharmacotherapy, depending on the agents involved and their concentrations. Greater awareness of ethnopsychopharmacology is expected to improve treatment effectiveness for racial and ethnic minorities.
The term “Latino(a)” refers to all persons of Mexican, Puerto Rican, Cuban, or other Central and South American or Spanish origin.
Acculturation refers to the “social distance” separating members of an ethnic or racial group from the wider society in areas of beliefs and values and primary group relations (work, social clubs, family, friends). Greater acculturation thus reflects greater adoption of mainstream beliefs and practices and entry into primary group relations.
, National Institutes of Mental Health,
Anxiety Disorders affect about 40 million American adults age 18 years and older (about 18%) in a given year,1 causing them to be filled with fearfulness and uncertainty. Unlike the relatively mild, brief anxiety caused by a stressful event (such as speaking in public or a first date), anxiety disorders last at least 6 months and can get worse if they are not treated. Anxiety disorders commonly occur along with other mental or physical illnesses, including alcohol or substance abuse, which may mask anxiety symptoms or make them worse. In some cases, these other illnesses need to be treated before a person will respond to treatment for the anxiety disorder.
Effective therapies for anxiety disorders are available, and research is uncovering new treatments that can help most people with anxiety disorders lead productive, fulfilling lives. If you think you have an anxiety disorder, you should seek information and treatment right away.
This lesson will:
describe the symptoms of anxiety disorders,
explain the role of research in understanding the causes of these conditions,
describe effective treatments,
help you learn how to obtain treatment and work with a doctor or therapist, and
suggest ways to make treatment more effective.
The following anxiety disorders will be discussed:
obsessive-compulsive disorder (OCD),
post-traumatic stress disorder (PTSD),
social phobia (or social anxiety disorder),
specific phobias, and
generalized anxiety disorder (GAD).
Each anxiety disorder has different symptoms, but all the symptoms cluster around excessive, irrational fear and dread.
“For me, a panic attack is almost a violent experience. I feel disconnected from reality. I feel like I’m losing control in a very extreme way. My heart pounds really hard, I feel like I can’t get my breath, and there’s an overwhelming feeling that things are crashing in on me.”
“It started 10 years ago, when I had just graduated from college and started a new job. I was sitting in a business seminar in a hotel and this thing came out of the blue. I felt like I was dying.”
“In between attacks there is this dread and anxiety that it’s going to happen again. I’m afraid to go back to places where I’ve had an attack. Unless I get help, there soon won’t be anyplace where I can go and feel safe from panic.”
Panic disorder is a real illness that can be successfully treated. It is characterized by sudden attacks of terror, usually accompanied by a pounding heart, sweatiness, weakness, faintness, or dizziness. During these attacks, people with panic disorder may flush or feel chilled; their hands may tingle or feel numb; and they may experience nausea, chest pain, or smothering sensations. Panic attacks usually produce a sense of unreality, a fear of impending doom, or a fear of losing control.
A fear of one’s own unexplained physical symptoms is also a symptom of panic disorder. People having panic attacks sometimes believe they are having heart attacks, losing their minds, or on the verge of death. They can’t predict when or where an attack will occur, and between episodes many worry intensely and dread the next attack.
Panic attacks can occur at any time, even during sleep. An attack usually peaks within 10 minutes, but some symptoms may last much longer.
Panic disorder affects about 6 million American adults1 and is twice as common in women as men.2 Panic attacks often begin in late adolescence or early adulthood,2 but not everyone who experiences panic attacks will develop panic disorder. Many people have just one attack and never have another. The tendency to develop panic attacks appears to be inherited.3
People who have full-blown, repeated panic attacks can become very disabled by their condition and should seek treatment before they start to avoid places or situations where panic attacks have occurred. For example, if a panic attack happened in an elevator, someone with panic disorder may develop a fear of elevators that could affect the choice of a job or an apartment, and restrict where that person can seek medical attention or enjoy entertainment.
Some people’s lives become so restricted that they avoid normal activities, such as grocery shopping or driving. About one-third become housebound or are able to confront a feared situation only when accompanied by a spouse or other trusted person. 2 When the condition progresses this far, it is called agoraphobia, or fear of open spaces.
Early treatment can often prevent agoraphobia, but people with panic disorder may sometimes go from doctor to doctor for years and visit the emergency room repeatedly before someone correctly diagnoses their condition. This is unfortunate, because panic disorder is one of the most treatable of all the anxiety disorders, responding in most cases to certain kinds of medication or certain kinds of cognitive psychotherapy, which help change thinking patterns that lead to fear and anxiety.
Panic disorder is often accompanied by other serious problems, such as depression, drug abuse, or alcoholism.4,5 These conditions need to be treated separately. Symptoms of depression include feelings of sadness or hopelessness, changes in appetite or sleep patterns, low energy, and difficulty concentrating. Most people with depression can be effectively treated with antidepressant medications, certain types of psychotherapy, or a combination of the two.
“I couldn’t do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good luck number and one wasn’t. It took me longer to read because I’d count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn’t add up to a ’bad’ number.”
“I knew the rituals didn’t make sense, and I was deeply ashamed of them, but I couldn’t seem to overcome them until I had therapy.”
“Getting dressed in the morning was tough, because I had a routine, and if I didn’t follow the routine, I’d get anxious and would have to get dressed again. I always worried that if I didn’t do something, my parents were going to die. I’d have these terrible thoughts of harming my parents. That was completely irrational, but the thoughts triggered more anxiety and more senseless behavior. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me.”
People with obsessive-compulsive disorder (OCD) have persistent, upsetting thoughts (obsessions) and use rituals (compulsions) to control the anxiety these thoughts produce. Most of the time, the rituals end up controlling them.
For example, if people are obsessed with germs or dirt, they may develop a compulsion to wash their hands over and over again. If they develop an obsession with intruders, they may lock and relock their doors many times before going to bed. Being afraid of social embarrassment may prompt people with OCD to comb their hair compulsively in front of a mirror-sometimes they get “caught” in the mirror and can’t move away from it. Performing such rituals is not pleasurable. At best, it produces temporary relief from the anxiety created by obsessive thoughts.
Other common rituals are a need to repeatedly check things, touch things (especially in a particular sequence), or count things. Some common obsessions include having frequent thoughts of violence and harming loved ones, persistently thinking about performing sexual acts the person dislikes, or having thoughts that are prohibited by religious beliefs. People with OCD may also be preoccupied with order and symmetry, have difficulty throwing things out (so they accumulate), or hoard unneeded items.
Healthy people also have rituals, such as checking to see if the stove is off several times before leaving the house. The difference is that people with OCD perform their rituals even though doing so interferes with daily life and they find the repetition distressing. Although most adults with OCD recognize that what they are doing is senseless, some adults and most children may not realize that their behavior is out of the ordinary.
OCD affects about 2.2 million American adults,1 and the problem can be accompanied by eating disorders,6 other anxiety disorders, or depression.2,4 It strikes men and women in roughly equal numbers and usually appears in childhood, adolescence, or early adulthood.2 One-third of adults with OCD develop symptoms as children, and research indicates that OCD might run in families.
The course of the disease is quite varied. Symptoms may come and go, ease over time, or get worse. If OCD becomes severe, it can keep a person from working or carrying out normal responsibilities at home. People with OCD may try to help themselves by avoiding situations that trigger their obsessions, or they may use alcohol or drugs to calm themselves.
OCD usually responds well to treatment with certain medications and/or exposure-based psychotherapy, in which people face situations that cause fear or anxiety and become less sensitive (desensitized) to them. NIMH is supporting research into new treatment approaches for people whose OCD does not respond well to the usual therapies. These approaches include combination and augmentation (add-on) treatments, as well as modern techniques such as deep brain stimulation.
Post-Traumatic Stress Disorder
“I was raped when I was 25 years old. For a long time, I spoke about the rape as though it was something that happened to someone else. I was very aware that it had happened to me, but there was just no feeling.”
“Then I started having flashbacks. They kind of came over me like a splash of water. I would be terrified. Suddenly I was reliving the rape. Every instant was startling. I wasn’t aware of anything around me, I was in a bubble, just kind of floating. And it was scary. Having a flashback can wring you out.”
“The rape happened the week before Thanksgiving, and I can’t believe the anxiety and fear I feel every year around the anniversary date. It’s as though I’ve seen a werewolf. I can’t relax, can’t sleep, don’t want to be with anyone. I wonder whether I’ll ever be free of this terrible problem.”
Post-traumatic stress disorder (PTSD) develops after a terrifying ordeal that involved physical harm or the threat of physical harm. The person who develops PTSD may have been the one who was harmed, the harm may have happened to a loved one, or the person may have witnessed a harmful event that happened to loved ones or strangers.
PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes.
People with PTSD may startle easily, become emotionally numb (especially in relation to people with whom they used to be close), lose interest in things they used to enjoy, have trouble feeling affectionate, be irritable, become more aggressive, or even become violent. They avoid situations that remind them of the original incident, and anniversaries of the incident are often very difficult. PTSD symptoms seem to be worse if the event that triggered them was deliberately initiated by another person, as in a mugging or a kidnapping.
Most people with PTSD repeatedly relive the trauma in their thoughts during the day and in nightmares when they sleep. These are called flashbacks. Flashbacks may consist of images, sounds, smells, or feelings, and are often triggered by ordinary occurrences, such as a door slamming or a car backfiring on the street. A person having a flashback may lose touch with reality and believe that the traumatic incident is happening all over again.
Not every traumatized person develops full-blown or even minor PTSD. Symptoms usually begin within 3 months of the incident but occasionally emerge years afterward. They must last more than a month to be considered PTSD. The course of the illness varies. Some people recover within 6 months, while others have symptoms that last much longer. In some people, the condition becomes chronic.
PTSD affects about 7.7 million American adults,1but it can occur at any age, including childhood. Women are more likely to develop PTSD than men,8 and there is some evidence that susceptibility to the disorder may run in families.9 PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders.
Certain kinds of medication and certain kinds of psychotherapy usually treat the symptoms of PTSD very effectively.
Social Phobia (Social Anxiety Disorder)
“In any social situation, I felt fear. I would be anxious before I even left the house, and it would escalate as I got closer to a college class, a party, or whatever. I would feel sick in my stomach-it almost felt like I had the flu. My heart would pound, my palms would get sweaty, and I would get this feeling of being removed from myself and from everybody else.”
“When I would walk into a room full of people, I’d turn red and it would feel like everybody’s eyes were on me. I was embarrassed to stand off in a corner by myself, but I couldn’t think of anything to say to anybody. It was humiliating. I felt so clumsy, I couldn’t wait to get out.”
Social phobia, also called social anxiety disorder, is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. People with social phobia have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. They can worry for days or weeks before a dreaded situation. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends.
While many people with social phobia realize that their fears about being with people are excessive or unreasonable, they are unable to overcome them. Even if they manage to confront their fears and be around others, they are usually very anxious beforehand, are intensely uncomfortable throughout the encounter, and worry about how they were judged for hours afterward.
Social phobia can be limited to one situation (such as talking to people, eating or drinking, or writing on a blackboard in front of others) or may be so broad (such as in generalized social phobia) that the person experiences anxiety around almost anyone other than the family.
Physical symptoms that often accompany social phobia include blushing, profuse sweating, trembling, nausea, and difficulty talking. When these symptoms occur, people with social phobia feel as though all eyes are focused on them.
Social phobia affects about 15 million American adults.1 Women and men are equally likely to develop the disorder,10 which usually begins in childhood or early adolescence.2 There is some evidence that genetic factors are involved.11 Social phobia is often accompanied by other anxiety disorders or depression,2,4and substance abuse may develop if people try to self-medicate their anxiety.
Social phobia can be successfully treated with certain kinds of psychotherapy or medications.
“I’m scared to death of flying, and I never do it anymore. I used to start dreading a plane trip a month before I was due to leave. It was an awful feeling when that airplane door closed and I felt trapped. My heart would pound, and I would sweat bullets. When the airplane would start to ascend, it just reinforced the feeling that I couldn’t get out. When I think about flying, I picture myself losing control, freaking out, and climbing the walls, but of course I never did that. I’m not afraid of crashing or hitting turbulence. It’s just that feeling of being trapped. Whenever I’ve thought about changing jobs, I’ve had to think, ‘Would I be under pressure to fly?’ These days I only go places where I can drive or take a train. My friends always point out that I couldn’t get off a train traveling at high speeds either, so why don’t trains bother me? I just tell them it isn’t a rational fear.”
A specific phobia is an intense, irrational fear of something that poses little or no actual danger. Some of the more common specific phobias are centered around closed-in places, heights, escalators, tunnels, highway driving, water, flying, dogs, and injuries involving blood. Such phobias aren’t just extreme fear; they are irrational fear of a particular thing. You may be able to ski the world’s tallest mountains with ease but be unable to go above the 5th floor of an office building. While adults with phobias realize that these fears are irrational, they often find that facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety.
Specific phobias affect an estimated 19.2 million adult Americans1 and are twice as common in women as men.10 They usually appear in childhood or adolescence and tend to persist into adulthood.12 The causes of specific phobias are not well understood, but there is some evidence that the tendency to develop them may run in families.
If the feared situation or feared object is easy to avoid, people with specific phobias may not seek help; but if avoidance interferes with their careers or their personal lives, it can become disabling and treatment is usually pursued.
Specific phobias respond very well to carefully targeted psychotherapy.
Generalized Anxiety Disorder (GAD)
“I always thought I was just a worrier. I’d feel keyed up and unable to relax. At times it would come and go, and at times it would be constant. It could go on for days. I’d worry about what I was going to fix for a dinner party, or what would be a great present for somebody. I just couldn’t let something go.”
When my problems were at their worst, I’d miss work and feel just terrible about it. Then I worried that I’d lose my job. My life was miserable until I got treatment.
“I’d have terrible sleeping problems. There were times I’d wake up wired in the middle of the night. I had trouble concentrating, even reading the newspaper or a novel. Sometimes I’d feel a little lightheaded. My heart would race or pound. And that would make me worry more. I was always imagining things were worse than they really were. When I got a stomachache, I’d think it was an ulcer.”
People with generalized anxiety disorder (GAD) go through the day filled with exaggerated worry and tension, even though there is little or nothing to provoke it. They anticipate disaster and are overly concerned about health issues, money, family problems, or difficulties at work. Sometimes just the thought of getting through the day produces anxiety.
GAD is diagnosed when a person worries excessively about a variety of everyday problems for at least 6 months. People with GAD can’t seem to get rid of their concerns, even though they usually realize that their anxiety is more intense than the situation warrants. They can’t relax, startle easily, and have difficulty concentrating. Often they have trouble falling asleep or staying asleep. Physical symptoms that often accompany the anxiety include fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, nausea, lightheadedness, having to go to the bathroom frequently, feeling out of breath, and hot flashes.
When their anxiety level is mild, people with GAD can function socially and hold down a job. Although they don’t avoid certain situations as a result of their disorder, people with GAD can have difficulty carrying out the simplest daily activities if their anxiety is severe.
GAD affects about 6.8 million American adults,1 including twice as many women as men. The disorder develops gradually and can begin at any point in the life cycle, although the years of highest risk are between childhood and middle age.2 There is evidence that genes play a modest role in GAD.
Other anxiety disorders, depression, or substance abuse often accompany GAD, which rarely occurs alone. GAD is commonly treated with medication or cognitive-behavioral therapy, but co-occurring conditions must also be treated using the appropriate therapies.
Treatment of Anxiety Disorders
In general, anxiety disorders are treated with medication, specific types of psychotherapy, or both. Treatment choices depend on the problem and the person’s preference. Before treatment begins, a doctor must conduct a careful diagnostic evaluation to determine whether a person’s symptoms are caused by an anxiety disorder or a physical problem. If an anxiety disorder is diagnosed, the type of disorder or the combination of disorders that are present must be identified, as well as any coexisting conditions, such as depression or substance abuse. Sometimes alcoholism, depression, or other coexisting conditions have such a strong effect on the individual that treating the anxiety disorder must wait until the coexisting conditions are brought under control.
People with anxiety disorders who have already received treatment should tell their current doctor about that treatment in detail. If they received medication, they should tell their doctor what medication was used, what the dosage was at the beginning of treatment, whether the dosage was increased or decreased while they were under treatment, what side effects occurred, and whether the treatment helped them become less anxious. If they received psychotherapy, they should describe the type of therapy, how often they attended sessions, and whether the therapy was useful.
Often people believe that they have “failed” at treatment or that the treatment didn’t work for them when, in fact, it was not given for an adequate length of time or was administered incorrectly. Sometimes people must try several different treatments or combinations of treatment before they find the one that works for them.
Medication will not cure anxiety disorders, but it can keep them under control while the person receives psychotherapy. Medication must be prescribed by physicians, usually psychiatrists, who can either offer psychotherapy themselves or work as a team with psychologists, social workers, or counselors who provide psychotherapy. The principal medications used for anxiety disorders are antidepressants, anti-anxiety drugs, and beta-blockers to control some of the physical symptoms. With proper treatment, many people with anxiety disorders can lead normal, fulfilling lives.
Antidepressants were developed to treat depression but are also effective for anxiety disorders. Although these medications begin to alter brain chemistry after the very first dose, their full effect requires a series of changes to occur; it is usually about 4 to 6 weeks before symptoms start to fade. It is important to continue taking these medications long enough to let them work.
Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other neurotransmitters, helps brain cells communicate with one another.
Fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and citalopram (Celexa®) are some of the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. Venlafaxine (Effexor®), a drug closely related to the SSRIs, is used to treat GAD. These medications are started at low doses and gradually increased until they have a beneficial effect.
SSRIs have fewer side effects than older antidepressants, but they sometimes produce slight nausea or jitters when people first start to take them. These symptoms fade with time. Some people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the dosage or switching to another SSRI.
Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD. They are also started at low doses that are gradually increased. They sometimes cause dizziness, drowsiness, dry mouth, and weight gain, which can usually be corrected by changing the dosage or switching to another tricyclic medication.
Tricyclics include imipramine (Tofranil®), which is prescribed for panic disorder and GAD, and clomipramine (Anafranil®), which is the only tricyclic antidepressant useful for treating OCD.
Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. The MAOIs most commonly prescribed for anxiety disorders are phenelzine (Nardil®), followed by tranylcypromine (Parnate®), and isocarboxazid (Marplan®), which are useful in treating panic disorder and social phobia. People who take MAOIs cannot eat a variety of foods and beverages (including cheese and red wine) that contain tyramine or take certain medications, including some types of birth control pills, pain relievers (such as Advil®, Motrin®, or Tylenol®), cold and allergy medications, and herbal supplements; these substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help lessen these risks. MAOIs can also react with SSRIs to produce a serious condition called “serotonin syndrome,” which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions.
High-potency benzodiazepines combat anxiety and have few side effects other than drowsiness. Because people can get used to them and may need higher and higher doses to get the same effect, benzodiazepines are generally prescribed for short periods of time, especially for people who have abused drugs or alcohol and who become dependent on medication easily. One exception to this rule is people with panic disorder, who can take benzodiazepines for up to a year without harm.
Clonazepam (Klonopin®) is used for social phobia and GAD, lorazepam (Ativan®) is helpful for panic disorder, and alprazolam (Xanax®) is useful for both panic disorder and GAD.
Some people experience withdrawal symptoms if they stop taking benzodiazepines abruptly instead of tapering off, and anxiety can return once the medication is stopped. These potential problems have led some physicians to shy away from using these drugs or to use them in inadequate doses.
Buspirone (Buspar®), an azapirone, is a newer anti-anxiety medication used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an anti-anxiety effect.
Beta-blockers, such as propranolol (Inderal®), which is used to treat heart conditions, can prevent the physical symptoms that accompany certain anxiety disorders, particularly social phobia. When a feared situation can be predicted (such as giving a speech), a doctor may prescribe a beta-blocker to keep physical symptoms of anxiety under control.
Before taking medication for an anxiety disorder:
Ask your doctor to tell you about the effects and side effects of the drug.
Tell your doctor about any alternative therapies or over-the-counter medications you are using.
Ask your doctor when and how the medication should be stopped. Some drugs can’t be stopped abruptly but must be tapered off slowly under a doctor’s supervision.
Work with your doctor to determine which medication is right for you and what dosage is best.
Be aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.
Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor, to discover what caused an anxiety disorder and how to deal with its symptoms.
Cognitive-behavioral therapy (CBT) is very useful in treating anxiety disorders. The cognitive part helps people change the thinking patterns that support their fears, and the behavioral part helps people change the way they react to anxiety-provoking situations.
For example, CBT can help people with panic disorder learn that their panic attacks are not really heart attacks and help people with social phobia learn how to overcome the belief that others are always watching and judging them. When people are ready to confront their fears, they are shown how to use exposure techniques to desensitize themselves to situations that trigger their anxieties.
People with OCD who fear dirt and germs are encouraged to get their hands dirty and wait increasing amounts of time before washing them. The therapist helps the person cope with the anxiety that waiting produces; after the exercise has been repeated a number of times, the anxiety diminishes. People with social phobia may be encouraged to spend time in feared social situations without giving in to the temptation to flee and to make small social blunders and observe how people respond to them. Since the response is usually far less harsh than the person fears, these anxieties are lessened. People with PTSD may be supported through recalling their traumatic event in a safe situation, which helps reduce the fear it produces. CBT therapists also teach deep breathing and other types of exercises to relieve anxiety and encourage relaxation.
Exposure-based behavioral therapy has been used for many years to treat specific phobias. The person gradually encounters the object or situation that is feared, perhaps at first only through pictures or tapes, then later face-to-face. Often the therapist will accompany the person to a feared situation to provide support and guidance.
CBT is undertaken when people decide they are ready for it and with their permission and cooperation. To be effective, the therapy must be directed at the person’s specific anxieties and must be tailored to his or her needs. There are no side effects other than the discomfort of temporarily increased anxiety.
CBT or behavioral therapy often lasts about 12 weeks. It may be conducted individually or with a group of people who have similar problems. Group therapy is particularly effective for social phobia. Often “homework” is assigned for participants to complete between sessions. There is some evidence that the benefits of CBT last longer than those of medication for people with panic disorder, and the same may be true for OCD, PTSD, and social phobia. If a disorder recurs at a later date, the same therapy can be used to treat it successfully a second time.
Medication can be combined with psychotherapy for specific anxiety disorders, and this is the best treatment approach for many people.
How to Get Help for Anxiety Disorders
If you think you have an anxiety disorder, the first person you should see is your family doctor. A physician can determine whether the symptoms that alarm you are due to an anxiety disorder, another medical condition, or both.
If an anxiety disorder is diagnosed, the next step is usually seeing a mental health professional. The practitioners who are most helpful with anxiety disorders are those who have training in cognitive-behavioral therapy and/or behavioral therapy, and who are open to using medication if it is needed.
You should feel comfortable talking with the mental health professional you choose. If you do not, you should seek help elsewhere. Once you find a mental health professional with whom you are comfortable, the two of you should work as a team and make a plan to treat your anxiety disorder together.
Remember that once you start on medication, it is important not to stop taking it abruptly. Certain drugs must be tapered off under the supervision of a doctor or bad reactions can occur. Make sure you talk to the doctor who prescribed your medication before you stop taking it. If you are having trouble with side effects, it’s possible that they can be eliminated by adjusting how much medication you take and when you take it.
Most insurance plans, including health maintenance organizations (HMOs), will cover treatment for anxiety disorders. Check with your insurance company and find out. If you don’t have insurance, the Health and Human Services division of your county government may offer mental health care at a public mental health center that charges people according to how much they are able to pay. If you are on public assistance, you may be able to get care through your state Medicaid plan.
Ways to Make Treatment More Effective
Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common. Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a mental health professional.
Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided. Check with your physician or pharmacist before taking any additional medications.
The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one’s symptoms. Family members should not trivialize the disorder or demand improvement without treatment. If your family is doing either of these things, you may want to show them this booklet so they can become educated allies and help you succeed in therapy.
A diagnosis of mental illness is rarely simple and straightforward. There are no infallible physiological tests that determine whether a person has a mental illness. Diagnosis requires that qualified healthcare professionals identify several specific symptoms that the person exhibits. Each mental illness has characteristic signs and symptoms that are related to the underlying biological dysfunction.
Depression, or depressive disorders, is a leading cause of disability in the United States as well as worldwide. It affects an estimated 9.5 percent of American adults in a given year. Nearly twice as many women as men have depression. Epidemiological studies have reported that up to 2.5 percent of children and 8.3 percent of adolescents in the United States suffer from depression.
The symptoms of depression
Depression is more than just being in a bad mood or feeling sad. Everyone experiences these feelings on occasion, but that does not constitute depression. Depression is actually not a single disease; there are three main types of depressive disorders. They are major depressive disorder, dysthymia, and bipolar disorder (manic-depression).
While some of the symptoms of depression are common during a passing “blue mood,” major depressive disorder is diagnosed when a person has five or more of the symptoms nearly every day during a two-week period. Symptoms of depression include a sad mood, a loss of interest in activities that one used to enjoy, a change in appetite or weight, oversleeping or difficulty sleeping, physical slowing or agitation, energy loss, feelings of worthlessness or inappropriate guilt, difficulty concentrating, and recurrent thoughts of death or suicide.
When people have depression, their lives are affected severely: they have trouble performing at work or school, and they aren’t interested in normal family and social activities. In adults, an untreated major depressive episode lasts an average of nine months. At least half of the people who experience an episode of major depression will have another episode of depression at some point.
Dysthymia is less severe than major depressive disorder, but it is more chronic. In dysthymia, a depressed mood along with at least two other symptoms of depression persist for at least two years in adults, or one year in children or adolescents. These symptoms may not be as disabling, but they do keep affected people from functioning well or feeling good. Dysthymia often begins in childhood, adolescence, or early adulthood. On average, untreated dysthymia lasts four years in children and adolescents.
A third type of depressive disorder is bipolar disorder, also called manic-depression. A person who has bipolar disorder alternates between episodes of major depression and mania (periods of abnormally and persistently elevated mood or irritability). During manic periods, the person will also have three or more of the following symptoms: overly inflated self-esteem, decreased need for sleep, increased talkativeness, racing thoughts, distractibility, increased goal-directed activity or physical agitation, and excessive involvement in pleasurable activities that have a high potential for painful consequences.
While in a manic phase, adolescents may engage in risky or reckless behaviors such as fast driving and unsafe sex. Bipolar disorder frequently begins during adolescence or young adulthood. Adults with bipolar disorder often have clearly defined episodes of mania and depression, with periods of mania every two to four years. Children and adolescents with bipolar disorder, however, may cycle rapidly between depression and mania many times within a day. Bipolar disorder in youths may be difficult to distinguish from other mental illnesses because the symptoms often overlap with those of other mental illnesses such as ADHD, conduct disorder, or oppositional defiant disorder.
The causes of depression (depressive disorders)
Depression, like other mental illnesses, is probably caused by a combination of biological, environmental, and social factors, but the exact causes are not yet known. For years, scientists thought that low levels of certain neurotransmitters (such as serotonin, dopamine, or norepinephrine) in the brain caused depression. However, scientists now believe that the interplay of factors leading to depression is much more complex. Genetic causes have been suggested from family studies that have shown that between 20 and 50 percent of children and adolescents with depression have a family history of depression and that children of depressed parents are more than three times as likely as children with nondepressed parents to experience a depressive disorder. Abnormal endocrine function, specifically of the hypothalamus or pituitary, may play a role in causing depression. Other risk factors for depressive disorders in youths include stress, cigarette smoking, loss of a parent, the breakup of a romantic relationship, attention disorders, learning disorders, abuse, neglect, and other trauma including experiencing a natural disaster.
A variety of antidepressant medications and psychotherapies are used to treat depression. The most effective treatment for most people is a combination of medication and psychotherapy. Many of us are aware that medications are available to treat depressive disorders—we see the ads on television and in magazines. Up to 70 percent of people with depression can be treated effectively with medication.
Medications used to treat depressive disorders usually act on the neurotransmission pathway. For example, some medications affect the activity of certain neurotransmitters, such as serotonin or norepinephrine. Different depressive disorders require different medication therapies. For example, individuals who have bipolar disorder are often treated with a mood-stabilizing drug, such as lithium, during their manic phase and a combination of mood-stabilizer and antidepressant medications during their depressive phase.
Medications usually lead to relief from the symptoms of depression within six to eight weeks. If one drug doesn’t relieve symptoms, doctors can prescribe a different antidepressant drug. As with drugs to treat other mental illnesses, patients are monitored closely by their doctor for symptoms of depression and for side effects. Patients who continue to take their medication for at least six months after recovery from major depression are 70 percent less likely to experience a relapse. Psychotherapy helps patients learn more effective ways to deal with the problems in their lives. These therapies usually involve 6 to 20 weekly meetings. These treatment plans should be revised if there is no improvement of symptoms within three or four months.
The combination of medications and psychotherapy is effective in the majority of cases and represents the standard care; however, doctors can employ other methods. One therapy that is highly effective when antidepressants and psychotherapy are not effective is electroconvulsive therapy (ECT), or electroshock therapy. ECT is not commonly used in children and adolescents. When ECT is performed, the individual is anesthetized and receives an electrical shock in specific parts of the brain. The patient does not consciously experience the shock. ECT can provide dramatic and rapid relief, but the effects usually last a fairly short time. After ECT, individuals usually take antidepressant medications.
A few years ago, the herbal supplement St. John’s wort received great attention in the media as an over-the-counter treatment for mild to moderate depression. However, many of the claims did not have good scientific evidence to back them up. The effectiveness and safety of St. John’s wort remain uncertain, and its use is generally not recommended.
Coping with depression
People who have depression (or another depressive disorder) feel exhausted, worthless, helpless, and hopeless. These negative thoughts and feelings that are part of depression make some people feel like giving up. As treatment takes effect, these thoughts begin to go away.
Some strategies that can help a person waiting for treatment to take effect include setting realistic goals in light of the depression and assuming a reasonable amount of responsibility; breaking large tasks into small ones, setting some priorities, and doing what one can as one can; trying to be with other people and to confide in someone—it is usually better than being alone and secretive; participating in activities that may make one feel better; getting some mild exercise, going to a movie or a ball game, or participating in religious, social, or other activities; expecting one’s mood to improve gradually, not immediately (feeling better takes time); postponing important decisions until the depression has lifted and discussing big decisions with family or friends who have a more objective view of the situation; remembering that positive thinking will replace the negative thinking that is part of the depression as one’s depression responds to treatment; and letting one’s family and friends help.
Learning Activity 2.1:
Watch this video:
Sherwin Nuland on electroshock therapy | Video on TED.com
Surgeon and author Sherwin Nuland discusses the development of electroshock therapy as a cure for severe, life-threatening depression -- including his own.
Schizophrenia affects approximately 1 percent of the population, or 2.2 million U.S. adults. Men and women are equally affected. The illness usually emerges in young people in their teens or twenties. Although children over the age of five can develop schizophrenia, it is rare before adolescence. In children, the disease usually develops gradually and is often preceded by developmental delays in motor or speech development. Childhood-onset schizophrenia tends to be harder to treat and has a less favorable prognosis than does the adult-onset form. The symptoms of schizophrenia. There are many myths and misconceptions about schizophrenia.
Schizophrenia is not a multiple or split personality, nor are individuals who have this illness constantly incoherent or psychotic. Although the media often portray individuals with schizophrenia as violent, in reality, very few affected people are dangerous to others. In fact, individuals with schizophrenia are more likely to be victims of violence than violent themselves. Schizophrenia has severe symptoms. A diagnosis of schizophrenia requires that at least two of the symptoms below be present during a significant portion of a one-month period: delusions (false beliefs such as conspiracies, mind control, or persecution); hallucinations (usually voices criticizing or commenting on the person’s behavior); disorganized speech (incomprehensible or difficult to understand); grossly disorganized or catatonic behavior; and negative symptoms such as flat emotions, lack of facial expressions, and inattention to basic self-care needs such as bathing and eating.
However, the presence of either one of the first two symptoms is sufficient to diagnose schizophrenia if the delusions are especially bizarre or if the hallucinations consist of one or more voices that keep a running commentary on the person’s behavior or thoughts. The DSM-IV specifies additional criteria for a diagnosis of schizophrenia: occupational dysfunction, persistence of the disturbance for at least six months, exclusion of a mood disorder, exclusion of a substance-abuse or medical condition that causes similar symptoms, and consideration of a possible pervasive developmental disorder. The course of schizophrenia varies considerably from one individual to the next. Most people who have schizophrenia experience at least one, and usually more, relapses after their first psychotic episode. Relapses are periods of more intense symptoms of illness (hallucinations and delusions). During remissions, the negative symptoms related to emotion or personal care are usually still present. About 10 percent of patients remain severely ill for long periods of time and do not return to their previous state of mental functioning. Several long-term studies found that as many as one-third to one-half of people with schizophrenia improve significantly or even recover completely from their illness.
The causes of schizophrenia
Like the other mental illnesses discussed here, scientists are still working to determine what causes schizophrenia. Also like the other mental illnesses, genetic and environmental factors most likely interact to cause the disease. Several studies suggest that an imbalance of chemical neurotransmitter systems of the brain, including the dopamine, GABA, glutamate, and norepinephrine neurotransmitter systems, are involved in the development of schizophrenia. Family, twin, and adoption studies support the idea that genetics plays an important role in the illness. For example, children of people with schizophrenia are 13 times more likely, and identical twins are 48 times more likely, to develop the illness than are people in the general population. Scientists continue to look at genes that may play a role in causing schizophrenia. One gene of interest to scientists who study schizophrenia codes for an enzyme that breaks down dopamine in the synapse.
There is no cure for schizophrenia; however, effective treatments that make the illness manageable for most affected people are available. The optimal treatment includes antipsychotic medication combined with a variety of psychotherapeutic interventions. Since the 1950s, doctors have used antipsychotic drugs, such as chlorpromazine and haloperidol, to relieve the hallucinations and delusions typical of schizophrenia. Recently, newer (also called atypical) antipsychotic drugs such as risperidone and clozapine have proven to be more effective. Early and sustained treatment that includes antipsychotic medication is important for long-term improvement of the course of the disease. Patients who discontinue medication are likely to experience a relapse of their illness. People who manage schizophrenia best combine medication with psychosocial rehabilitation (life-skills training). Therapies that combine family and community support, education, and behavioral and cognitive skills to address specific challenges help schizophrenic patients improve their functioning and the quality of their lives.
Samantha is scared to death of flying. She never flies anymore, even though her children live more than 2000 miles away. She used to start dreading a plane trip a month before she was due to leave. She felt awful when the airplane door closed; she felt trapped. Her heart pounded, and she dripped with sweat.
In any social situation, Tamara felt fear. She would be anxious before she even left the house, and it escalated as she got closer to a college class, a party, or whatever. She felt sick in her stomach. It almost was like she had the flu. Her heart pounded, her palms would get sweaty, and she had this sense of being removed from herself and from everybody else.
Sue was raped when she was 25 years old. For a long time, she spoke about the rape as though it was something that happened to someone else. She was very aware that it had happened to her, but there was just no feeling. Then she started having flashbacks. They kind of came over her like a splash of water. She felt terrified. Suddenly, she was reliving the rape. Every instant was startling. She wasn't aware of anything around her. She was in a bubble, just kind of floating. The rape happened the week before Thanksgiving, and she feels fearful every year around the anniversary date.
Anxiety is a normal reaction to stress. It helps you deal with a tense situation in the office, study harder for an exam, or keep focused on an important speech. In general, it helps you cope. But when anxiety becomes an excessive, irrational dread of everyday things, it can be disabling. Anxiety disorders affect about 40 million American adults age 18 years and older (about 18 percent). It's not the same as the mild stress you may feel when you have to speak in public, or the butterflies you may feel in your stomach when going on a first date. Anxiety disorders can last at least six months and can get worse if they are not treated. The five major types of anxiety disorder are:
Generalized anxiety disorder
Post-traumatic stress disorder
Social phobia (social anxiety disorder)
Generalized Anxiety Disorder
All of us worry about things like health, money, or family problems at one time or another. But people with GAD are extremely worried about these and many other things, even when there is little or no reason to worry about them. They may be very anxious about just getting through the day. They think things will always go badly. At times, worrying keeps people with GAD from doing everyday tasks.
People with GAD:
Worry very much about everyday things for at least six months, even if there is little or no reason to worry about them
Can't control their constant worries
Know that they worry much more than they should
Have a hard time concentrating
Are easily startled
Have trouble falling asleep or staying asleep
Common body symptoms are:
Feeling tired for no reason
Muscle tension and aches
Having a hard time swallowing
Trembling or twitching
Feeling out of breath
Having to go to the bathroom a lot
GAD develops slowly. It often starts during the time between childhood and middle age. Symptoms may get better or worse at different times, and often are worse during times of stress. People with GAD may visit a doctor many times before they find out they have this disorder. They ask their doctors to help them with the signs of GAD, such as headaches or trouble falling asleep, but don't always get the help they need right away. It may take doctors some time to be sure that a person has GAD instead of something else.
People with panic disorder have sudden attacks of terror. These attacks include:
A pounding heart
Dizziness Feeling overly warm or chilled
Tingling or numb hands
Nausea, chest pain, or smothering sensations
Panic attacks usually produce a sense of unreality, a fear of impending doom, or a fear of losing control. A fear of one's own unexplained physical symptoms is also a sign of panic disorder. People having panic attacks sometimes believe they are having heart attacks, losing their minds, or are dying. They can't predict when or where an attack will occur, and, between episodes, many worry a lot and fear the next attack. Panic attacks can occur at any time, even during sleep. An attack usually peaks within 10 minutes, but some symptoms may last much longer. People who have full-blown, repeated panic attacks can become very disabled by their condition and should seek treatment before they start to avoid places or situations where panic attacks have occurred. For example, if a panic attack happened in an elevator, someone with panic disorder may develop a fear of elevators that could affect the choice of a job or an apartment. This fear could also restrict where that person can seek medical attention or enjoy entertainment.
Post-traumatic stress disorder
PTSD starts after a scary ordeal that involved physical harm or the threat of physical harm. The person who develops PTSD may have been the one who was harmed, the harm may have happened to a loved one, or the person may have witnessed a harmful event that happened to loved ones or strangers. PTSD can cause many symptoms.
These symptoms can be grouped into three categories:
1. Re-experiencing symptoms:
Flashbacks — reliving the trauma over and over, including physical symptoms like -
A racing heart or sweating
Re-experiencing symptoms may cause problems in a person's everyday routine. They can start from the person's own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger symptoms.
2. Avoidance symptoms:
Staying away from places, events, or objects that are reminders of the experience
Feeling emotionally numb
Feeling strong guilt, depression, or worry
Losing interest in things that were enjoyable in the past
Having trouble remembering the dangerous event
Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car.
3. Hyperarousal symptoms:
Being easily startled
Feeling tense or "on edge"
Having difficulty sleeping
Having angry outbursts
It's normal to have some of these symptoms after a dangerous event. Sometimes people have very serious symptoms that go away after a few weeks. This is called acute stress disorder, or ASD. When the symptoms last more than a few weeks and become an ongoing problem, they might be PTSD. Some people with PTSD don't show any symptoms for weeks or months.
Social phobia, also called social anxiety disorder, is diagnosed when people become very anxious and self-conscious in everyday social situations. People with social phobia have a strong fear of being watched and judged by others. They embarrass easily. Social phobia can happen in one kind of situation, such as talking to people, eating or drinking, or writing on a blackboard in front of others. Or, it may be so broad that the person experiences anxiety around almost anyone other than family members. Physical symptoms include:
When these symptoms occur, people with social phobia feel as though everyone is watching them. A specific phobia is an intense, irrational fear of something that poses little or no actual danger. Some of the more common specific phobias are fears of:
Dogs Injuries involving blood
These fears are irrational. For example, you may be able to ski the world's tallest mountains with ease but be unable to go above the fifth floor of an office building. Adults with phobias know that these fears are irrational but they often find that facing, or even thinking about facing their fears brings on a panic attack or severe anxiety. Treatments Yes, there are treatments that can help people with anxiety disorders. There is no cure for anxiety disorder yet, but treatments can give relief to people who have it and help them live a more normal life. The first step is to go to a doctor or health clinic to talk about your symptoms. The doctor will do an exam to make sure that another physical problem isn't causing the symptoms. The doctor may make a referral to a mental health specialist.
Doctors may prescribe medication to help relieve anxiety disorders. It's important to know that some of these medicines may take a few weeks to start working. In most states only a medical doctor (a family doctor or psychiatrist) can prescribe medications. The kinds of medicines used to treat anxiety disorders are listed below. Some are used to treat other problems, such as depression, but also are helpful for anxiety disorders:
Selective serotonin reuptake inhibitors (SSRIs) are a kind of antidepressant for treating depression and anxiety disorders. However, a number of research studies show that certain antidepressants, such as some of the SSRIs (see box at right) have been used relatively safely during breastfeeding. You should discuss with your doctor whether breastfeeding is an option or whether you should plan to feed your baby formula. Although breastfeeding has some advantages for your baby, most importantly, as a mother, you need to stay healthy so you can take care of your baby.
Before taking medication for an anxiety disorder:
Ask your doctor to tell you about the effects and side effects of the drug.
Tell your doctor about any alternative therapies or over-the-counter medications you are using.
Ask your doctor when and how the medication should be stopped.
Some drugs can't be stopped abruptly but must be tapered off slowly under a doctor's supervision. Work with your doctor to determine which medication is right for you and what dosage is best. Be aware that some medications are effective only if they are taken regularly and that symptoms may come back if the medication is stopped.
Personality disorders are long-term patterns of thoughts and behaviors that cause serious problems with relationships and work. People with personality disorders have difficulty dealing with everyday stresses and problems. They often have stormy relationships with other people. The exact cause of personality disorders is unknown. However, genes and childhood experiences may play a role. Symptoms vary widely depending on the specific type of personality disorder. Treatment usually includes talk therapy and sometimes medicine.
What is borderline personality disorder?
Borderline personality disorder is a serious mental illness marked by unstable moods, behavior, and relationships. In 1980, the
Diagnostic and Statistical Manual for Mental Disorders, Third Edition
(DSM-III) listed borderline personality disorder as a diagnosable illness for the first time. Most psychiatrists and other mental health professionals use the DSM to diagnose mental illnesses. Because some people with severe borderline personality disorder have brief psychotic episodes, experts originally thought of this illness as atypical, or borderline, versions of other mental disorders. While mental health experts now generally agree that the name "borderline personality disorder" is misleading, a more accurate term does not exist yet. Most people who have borderline personality disorder suffer from:
Problems with regulating emotions and thoughts
Impulsive and reckless behavior
Unstable relationships with other people
People with this disorder also have high rates of co-occurring disorders, such as depression, anxiety disorders, substance abuse, and eating disorders, along with self-harm, suicidal behaviors, and completed suicides. According to data from a subsample of participants in a national survey on mental disorders, about 1.6 percent of adults in the United States have borderline personality disorder in a given year. Borderline personality disorder is often viewed as difficult to treat. However, recent research shows that borderline personality disorder can be treated effectively, and that many people with this illness improve over time.
What are the symptoms of borderline personality disorder?
According to the DSM, Fourth Edition, Text Revision (DSM-IV-TR), to be diagnosed with borderline personality disorder, a person must show an enduring pattern of behavior that includes at least five of the following symptoms:
Extreme reactions—including panic, depression, rage, or frantic actions—to abandonment, whether real or perceived
A pattern of intense and stormy relationships with family, friends, and loved ones, often veering from extreme closeness and love (idealization) to extreme dislike or anger (devaluation)
Distorted and unstable self-image or sense of self, which can result in sudden changes in feelings, opinions, values, or plans and goals for the future (such as school or career choices)
Impulsive and often dangerous behaviors, such as spending sprees, unsafe sex, substance abuse, reckless driving, and binge eating.
Recurring suicidal behaviors or threats or self-harming behavior, such as cutting Intense and highly changeable moods, with each episode lasting from a few hours to a few days
Chronic feelings of emptiness and/or boredom Inappropriate, intense anger or problems controlling anger
Having stress-related paranoid thoughts or severe dissociative symptoms, such as feeling cut off from oneself, observing oneself from outside the body, or losing touch with reality.
Seemingly mundane events may trigger symptoms. For example, people with borderline personality disorder may feel angry and distressed over minor separations — such as vacations, business trips, or sudden changes of plans —from people to whom they feel close. Studies show that people with this disorder may see anger in an emotionally neutral face and have a stronger reaction to words with negative meanings than people who do not have the disorder.
Contemporary Health Issues
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