Overcoming Emotional and Psychological Problems

A nyone, at any time, can develop an emotional problem. You begin to feel sad, angry, alone, or just frustrated by the problems of everyday life. You lose sleep, become irritable, or simply want to "pull the covers over your head." Ordinarily, simply "venting"--talking with your spouse or a clergyman, friend, or co-worker--is enough to put you in a better frame of mind.

But if things don't turn around, and your ability to function diminishes each day, you may be suffering from something more than a temporary emotional upset. You may have a condition that needs professional treatment.

If so, you will not be alone. According to the National Institute of Mental Health, more than 41 million Americans--nearly 1 in 5--experience a mental disorder at some point in their lives.

• More than 7 million children and adolescents suffer from psychological problems such as hyperactivity, autism, and conduct disorders.
• Severe clinical depression, needing professional treatment, strikes more than 10 million people during the course of their lives.
• Each year, more than 18 million Americans are affected by the most common of all mental problems: anxiety disorder.
• Nearly 14 million Americans abuse alcohol or illicit drugs to the point of dependence each year.
• More than 1.5 million people have schizophrenia and need hospitalization or long-term treatment.
• Perhaps as many as 14 percent of our elderly suffer from some degree of dementia, or loss of mental function.

Studies conducted by the Institute of Medicine show that direct expenditures on health care for mental illness total more than $23 billion a year; substance abuse adds another $17 billion.

But that's only a fraction of the true cost. If mental illness goes undiagnosed, the personal and social consequences can be severe. Suicide is the eighth leading cause of death in the United States and the third leading cause among adolescents and young adults. And the lost workdays, accidents, crime, and reduced productivity that can be traced to untreated mental illness have been estimated to cost us upwards of $250 billion a year.

Much of this suffering and expense could be reduced by early detection and prompt treatment. But unfortunately, as few as one in four who need help seek it. Less than a third of those suffering from depression look for treatment; and less than 10 percent of the children who need help receive it.

Ironically, 80 percent of those suffering from mental illness can be treated effectively with medication and therapy on an outpatient basis.

What Do We Mean by
Mental Illness?

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Mental illness is a broad, umbrella-term for a wide range of disorders that can strike anyone. Even today, the term "mentally ill" carries with it a heavy burden of social stigma, embarrassment, and fear. The idea of "losing your mind" remains a terrifying thought.

Yet, given today's improved diagnostic and therapeutic techniques, such fears are usually misplaced. With earlier detection, better diagnosis, and faster, more effective treatment, millions of the "mentally ill" are now able to lead satisfying, productive lives.

Amazingly, only 40 years ago more than a half million profoundly ill people were beyond help, languishing in huge mental hospitals where they were managed with restraints, confinement, and sedation. The stigma attached to "mental illness" was enormous--few people would admit that they or any member of their family suffered from any kind of psychiatric disease.

As a result, most of those who were "neurotic" or "phobic" went untreated, leading lives of hidden desperation. For those who did seek help, psychiatric treatment consisted almost entirely of "talk therapy," or psychoanalysis. The most seriously ill psychotic patients were simply warehoused in the hospitals.

In those days, health-care experts predicted that the number of people confined to mental institutions would more than double in the next few decades. Yet by the mid-1970s the number of psychiatric inpatients had actually dropped by half!

What had happened? Why were they wrong?

The answer is simple. For decades, researchers had concentrated on development of medications to cure infections, heart disease, cancer, and other illnesses, while mental disorders were ignored. But in 1952, chlorpromazine (Thorazine) was tried in schizophrenic patients at low doses. People who suffered from delusions, hallucinations, paranoia, and other symptoms improved almost immediately. For the first time, psychiatrists realized that medication could be a partner with other forms of therapy for mental illness. Once the pharmaceutical floodgates opened, psychiatry changed overnight. A new age of "biopsychiatry" was born that led to tremendous strides in the diagnosis and treatment of mental illness.

Major Types of Mental Illness

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Today, psychiatrists use everything from blood tests and brain scans to complete physical exams and family histories to aid in the diagnosis of mental disorders. Targeting an emotional disorder for accurate treatment is a complicated task, so mental health professionals have created a unique system to help pin down ambiguous psychiatric problems. Hundreds of types of mental illness are cataloged in a book known as The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Published by the American Psychiatric Association and currently in its fourth edition, DSM-IV, like Physicians' Desk Reference, is the "bible" of its discipline. Understanding that the mind is, in effect, an organ system like the heart or kidneys and, like these organs, can develop a disease, was an important breakthrough in diagnosis and treatment.

The DSM-IV breaks psychiatric illness into more than two dozen categories and over 100 sub-categories, each with its own unique set of symptoms. When a patient's symptoms fit within the DSM-IV criteria, a psychiatrist can pinpoint a specific diagnosis. Among the major categories of mental illness listed in the DSM-IV are the following:

• Anxiety Disorders (phobias, panic disorder, post-traumatic stress disorder, obsessive-compulsive disorder)
• Mood Disorders (depression, manic-depressive disorder)
• Schizophrenia
• Developmental Disorders (learning disorders, retardation, autism)
• Disruptive Behavior Disorders (attention deficit hyperactivity disorder, conduct disorder)
• Substance Abuse Disorders (alcoholism, drug dependence)
• Delusional Disorders (delusional paranoia)
• Sexual Disorders
• Sleep Disorders
• Impulse Control Disorders (kleptomania, pyromania)
• Dissociative Disorders (multiple-personality disorder)
• Eating Disorders (anorexia, bulimia)
• Organic Mental Disorders (Alzheimer's disease and other psychiatric diseases that result from metabolic problems in the brain or from substance abuse)

Perhaps the most important step in diagnosing any mental illness is for the patient and the family to actually seek help. As with a physical illness, the earlier an emotional or psychiatric problem is detected, the more likely and the easier is the cure. Unfortunately, psychiatric symptoms are far easier to ignore or misinterpret than physiological symptoms. While the criteria for disorders like cancer, arthritis, and high blood pressure are precisely defined, psychological symptoms (e.g., "the blues") are often ambiguous. Coupled with the stigma or "denial" that is common in questions of mental health, this may make an accurate diagnosis harder to achieve.

Still, the meaning of certain specific sets of symptoms is relatively clear. Here's a closer look at the most prevalent types of mental illness.

Anxiety Disorders

Almost everybody gets anxious. Most of us feel nervous before a test or an important business meeting. The "butterflies" that we all experience from time to time are so common that we tend to ignore them. Yet, for more than 18 million Americans, "anxiety" is so severe that it interferes with their daily functioning.

Actually, a genuine anxiety disorder is marked not by anxiety, but by outright fear. While anxiety is a form of mental tension that we can't really put our finger on, fear is easily recognized. Its symptoms are well known: shakiness, trembling, aching muscles, sweating, chills, dizziness, pounding heart, dry mouth, a lump in the throat.

If you are diagnosed with an anxiety disorder, you suffer from one or more of a group of problems including generalized anxiety disorder, phobias, panic disorders, obsessive-compulsive disorder, and post-traumatic stress disorder.

Phobias are the most common of the anxiety disorders. An estimated 5 to 12 percent of the population suffer a psychological and physiological reaction to a place, a situation, or an object that interferes with daily life. The "phobic reaction" is almost a reflex. The victim is filled with dread, horror, and terror. He begins to gasp for breath, shake, and often flees. Some people will go miles out of their way to avoid a phobic situation.

There are hundreds of phobias. For instance, there is "agoraphobia," a phobia that is widely misunderstood. Most think that an "agoraphobic" is simply afraid to leave home. In fact, his real fear is of being alone in public places from which he thinks escape would be difficult or help unavailable if he were hurt or trapped. As a result, agoraphobics stay home rather than risk the terror they've come to expect.

Likewise, people with social phobias aren't antisocial. Rather, they fear that they will do something in a public place that will cause them humiliation. They fear "being watched" while doing almost anything--eating a meal, standing in line at the bank, making small talk at the beach. To some extent, almost everyone has social phobias--nervousness in front of an audience is the most common. However, most of us can cope and get on with it. Someone with a social phobia will, like an agoraphobic, go to any length to avoid placing himself in an "unsafe" situation.

"The Simple Phobias": Make a list of just about anything--dogs, cats, snakes, mice, bats, spiders, insects, dark rooms, heights, closed spaces--and you will find someone with a phobic reaction to it.

Panic Disorder: A panic attack is one of the most frightening of all psychological events.

Imagine that you are walking down the street one day, feeling fine, when, out of the blue, you are overcome by an intense fear and foreboding unlike anything you've ever felt before. You are literally frozen to the sidewalk, unable to move. And then it gets worse. You start to shake, sweat, gasp for air. You are sure you are having a heart attack and that you will die the next instant. People stop and stare; some even offer to help. But you can't move or respond. The weight on your chest is growing heavier, and you are now just waiting to die.

And then, as suddenly as it started, it stops. Gone. Since you feel so good, you carry on, ignoring the event--except that you now avoid the street where it happened.

A week goes by and nothing happens, and then another week. You've almost forgotten about the attack completely when, without warning, it hits you again, this time far more intensely. Your body is tingling. You're overcome with nausea. You are so out of control you think you're going insane. If you don't continue to ignore what's happened and instead call a psychiatrist, chances are you'll be told that you are one of nearly 3 million Americans who suffer from the relatively common form of anxiety called "panic disorder," and that the attacks are every bit as real as they seem.

Panic disorder, many researchers think, may be partly a result of genetics--it does run in families--or may be caused by disturbances of the neurotransmitters that form the brain's chemical messenger system. Panic attacks may also be signs of underlying physiologic illness. Researchers often refer to panic attacks as "impostors," because their symptoms may actually be caused by heart disease, thyroid imbalances, or respiratory problems. In fact, more than 40 medical problems can cause panic-like symptoms.

Obsessive-Compulsive Disorder: This illness is very much what it sounds like. People who have continual, unwanted thoughts that prevent them from functioning properly are considered "obsessed;" to rid themselves of these nagging ideas, they usually develop "compulsions"--rituals they must go through before they can move on to another activity. Compulsive rituals include repetitious washing, repeating certain phrases, completing steps in a process over and over, counting and recounting, checking and re-checking to make sure something hasn't been forgotten, excessive neatness, and hoarding of useless items.

The cause of OCD, as it's called, has remained a mystery, despite theories that link it to other disorders, such as depression. Research on a physical cause of the disorder is on the rise; and several effective medications are available, including Anafranil, Luvox, and Prozac.

Post-Traumatic Stress Disorder: PTSD
was known for years as shell shock or battle fatigue, but we now know that it's not limited to soldiers who've seen too much of war. PTSD is a disorder that can affect anyone who has survived a severe and unusual trauma, such as a hurricane, tornado, flood, or airplane crash. One psychiatrist calls it "aftershock," which is an apt description, because the symptoms of PTSD may surface months after the actual event.

Veterans do remain the main victims of PTSD. The Department of Veterans Affairs estimates that 700,000 to 800,000 of the 3.5 million Vietnam veterans have experienced PTSD. For these vets and other victims, the symptoms are often a "re-experience of the traumatic event . . . also known as flashbacks." In effect, the person replays the emotions he felt during the traumatic event itself. Some of the afflicted develop insomnia, extreme anger, fear and grief, and even an inability to feel any emotions, which leads to withdrawal from society. Some PTSD patients have "survivor's guilt." Others begin to avoid situations that remind them of the traumatic event (flying, for example).

Treating Anxiety Disorders: Anxiety disorders are often treated with a combination of psychotherapy and drugs. Once medication has reduced the symptoms of the various anxiety disorders, psychiatrists use behavioral therapy, psychotherapy, and other forms of therapy that are tailored to the patient's personal needs.

The most commonly prescribed medications for anxiety are the benzodiazepine class of drugs, such as Valium and Xanax, and other tranquilizers such as BuSpar. Recently some psychiatrists have been using beta blockers such as propranolol (Inderal) to curb certain forms of anxiety and phobias. (For more on beta blockers, see the chapter on heart disease.)

Depression

Depression is not just "the blues." Depression is one of the most serious and common of all mental disorders. It is also one of the most treatable--provided the victim seeks treatment. At any time, more than nine million Americans may be suffering from depression. More than 15 percent of Americans are attacked by depression at some time in their lives.

While we've all felt sad at times, we usually get up, go to work, and try to overcome our general discouragement with life. But when these overwhelming feelings of sadness persist--even if for only a few weeks--you may be suffering from a clinical depression, which means you need some professional treatment. Besides a depressed mood or loss of pleasure, symptoms of clinical depression may include appetite and sleep changes, apathy, fatigue, hopelessness, guilt, loss of concentration, and thoughts of suicide.

There are two major kinds of depression: bipolar and unipolar. In bipolar depression, the patient rides a roller coaster of emotions from high to low, leading to the term "manic depression." Unipolar depression, also known as clinical or major depression, lacks bipolar's "highs."

Treating Depression: The American Psychiatric Association estimates that 80 to 90 percent of all depression can be treated. The first step is an accurate diagnosis. Along with a physical and lab tests to rule out causes such as reduced thyroid activity, a complete psychiatric history should be taken. And because depression and other major psychiatric problems are side effects of many medications, a good work-up will also include a review of the patient's medications and any illicit drug use.

Once a diagnosis is made, the basic medications used for depression today are:

• Tricyclic antidepressants such as Elavil, Tofranil, and Pamelor are prescribed for patients who are in despair, feeling helpless, and unable to feel pleasure.
• Serotonin uptake inhibitors such as Prozac, Paxil, and Effexor, all prescribed for uncomplicated depression.
• Monoamine Oxidase (mao) Inhibitors like Nardil and Parnate: These medications are usually used when depressive symptoms are accompanied by symptoms of an anxiety disorder.
• Lithium : This is the most effective drug for manic depression. However, it can also be used to prevent recurring episodes of depression.

When one of these medications is prescribed, follow-up and continued medical supervision are critical. Blood tests and other metabolic studies are often performed on a regular basis to determine the effect of the drug on the patient. This can be a drawn-out process, because most drugs for depression don't relieve symptoms instantly. Often it takes four to six weeks for a medication to become effective.

Other forms of therapy for depression include interpersonal psychotherapy to help broken relationships, cognitive behavioral therapy to help reverse the patient's negative view of himself and the world, and traditional psychoanalysis. Electroconvulsive therapy--known as ECT or shock therapy--has been used effectively in patients who cannot tolerate the side effects of today's medications, who cannot wait for the medications to work, or who are unable to take drugs for other reasons. While controversial, ECT has proved to be a good treatment option.

Next: Anxiety