Mental Illness

Mental, or psychological, illnesses and disorders occur in or relate to the mind. Mental disorders differ from physical (related to the body) disorders because there are usually no physical symptoms of a mental disorder (such as a broken arm or an upset stomach) for a doctor to observe. Mental disorders originate in the mind of an individual and display themselves outwardly through a person's behavior or emotions. When behavior or emotions are deemed "abnormal," a mental illness might be at the root of the problem.

In a world in which cultural and social differences are abundant, particularly as one moves from one country or region to another, it is very difficult to define what is "normal" behavior over what is "abnormal" behavior. However, abnormal behavior has come to be identified through the presence of different coexisting characteristics or conditions:

Infrequency is one facet of abnormal behavior; in other words, a behavior or characteristic exhibited or not exhibited by the majority of people determines normalcy. Another hallmark of abnormal behavior is whether or not the behavior violates social norms; this will differ from culture to culture and therefore allows for a range of differences in behavior. This can present difficulties in definition because while many criminals violate social norms, they are not always deemed to be mentally ill. Another way of identifying abnormal behavior is personal distress and the degree of an individual's suffering. For example, does a person's grief over something fall outside the scope of what is a "normal" level of grief or is it exceeding the average time it takes for an individual to recover from the grief?

Disability and dysfunction are also used to assess an individual's well-being. For example, someone with a great but irrational fear of something might not be able to participate in daily activities or may be experiencing a great deal of personal distress because of this fear. Finally, another factor in determining abnormality of behavior is whether someone's response to a situation is unexpected. For example, thirst is an expected response to not drinking enough fluids, but becoming emotionally distraught over thirst would not be an expected response.

This chapter describes a variety of major mental conditions and disorders. Some are deep-rooted mental illnesses, such as schizophrenia; others are more easily treatable, such as a learning disorder. Most mental disorders are treatable and, like many physical disorders, mental illness is not the result of something a person has or has not done to influence its development. Mental illness, like physical disease, can and does strike people from all walks of life. However, just as medical treatment for physical ailments has improved markedly over time, so has the diagnosis and treatment of mental illness.

CHILDHOOD DISORDERS

The classification of abnormal behavior in childhood depends greatly on development in terms of what is and is not considered normal behavior for a child at a certain age. This often makes it difficult to diagnose certain disorders of childhood as children develop at different rates and only a qualified therapist can make the distinction between what is appropriate and inappropriate behavior. Also, childhood disorders can be a sensitive subject,

particularly learning disorders, as parents and children are afraid of the social stigma (shame) that often comes with a diagnosis. Children and adolescents strive for acceptance, and any indication of being different or being separated into "special" classes can have devastating effects on a child's self-esteem and the reaction of his or her peers to the situation.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) and other sources categorize the following conditions as "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" or simply "Childhood Disorders"; technically, there isn't any difference between these disorders and other mental disorders except for the higher incidence of diagnosis in childhood rather than adulthood.

Attention-Deficit/Hyperactivity Disorder

Attention-deficit/hyperactivity disorder (ADHD) is a disorder that involves difficulty in concentrating and overall inattentiveness. ADHD affects people of all ages but is usually diagnosed in childhood. This condition has received a great deal of attention in the media in the last ten to fifteen years, because there has been a marked increase in the number of diagnoses of this disorder by mental health practitioners in recent years. No longer seen just as a problem centering around hyperactivity, or excessive activity, the focus of ADHD is also on a child's difficulty in concentrating on tasks at hand. While most children have notoriously short spans of attention, children battling ADHD have increased difficulty controlling their level of activity and attention particularly in situations that call for maintaining a certain degree of composure, such as in the classroom or in public places like restaurants.

ADHD makes it difficult for sufferers to sit still or even to stop talking. When they are called upon to be quiet and remain seated, they might squirm, fidget, tap their hands, swing their feet and legs, and make noise. The diagnosis is often difficult to make, as most children can be full of energy, particularly during times of play. However, children suffering from ADHD are disorganized, bossy and ill-mannered more often than the average child. Because of the increased prevalence of this diagnosis in recent years, there has

Attention-deficit disorder can make it difficult for some kids to concentrate in school. (Photograph by

Robert J. Huffman. Field Mark Publications

. Reproduced by permission.)

been the suggestion that children who are appropriately energetic, hard to handle, or suffering from a conduct disorder (see below) are being given a diagnosis of ADHD unnecessarily. This assessment, however, is difficult to quantify or prove. Furthermore, the Council on Scientific Affairs of the American Medical Association has investigated the issue and determined that while there isn't a concern for general overdiagnosis, some students belonging to minority groups are being diagnosed at a disproportionate rate.

SYMPTOMS. According to the DSM, IV some of the symptoms of ADHD include lack of attention to details; difficulty paying attention in school or at play; not paying attention when being spoken to; not following through on instructions or failure to finish things; disorganization, forgetfulness, losing or misplacing important things; fidgeting excessively; difficulty in playing quietly; excessive talking, difficulty in awaiting turn, and a tendency to interrupt others. In order to be diagnosed with ADHD, more than one of these symptoms must be present, and those symptoms must be creating a specific problem for the sufferer (lack of friends, poor performance in school, etc.).

CAUSES. Although there is no known single cause for ADHD, there are theories as to why certain children develop ADHD while others do not. Some experts propose that ADHD is inherited, while others have blamed the development of the disorder on environmental toxins, such as food additives or nicotine while a child is growing in the mother's womb. Psychological causes may include demanding, authoritative parenting that creates stress and triggers the development of ADHD.

TREATMENTS. ADHD has been treated effectively with certain drugs, including Ritalin, a stimulant that helps improve concentration, behavior, and directed activities. However, Ritalin's effectiveness has not been proven for the long term and some researchers have suggested that Ritalin actually hampers a child's creativity. Operant conditioning (see Chapter 15: Mental Health Therapies) has also been successful in helping those with ADHD. This therapy, which centers on rewarding good behavior, supports the belief that ADHD means that a child has a lack of basic skills to help him or her be effective, rather than the belief that a child simply has too much energy.

Conduct Disorder

Although conduct disorders cover a wide array of "bad" behaviors, the underlying principle of the diagnosis is that an individual exhibits inappropriate behaviors that violate the basic rights of other people. These are behaviors that fall outside the scope of normal childhood pranks and mischief; rather, conduct disorder includes behavior that is often vicious, and sufferers typically display no remorse (regret or guilt for having done something wrong), something that links conduct disorder to antisocial personality disorder or psychopathy (see section on Personality Disorders below).

In addition to the dysfunctional behaviors they exhibit, people with conduct disorders do not possess a great deal of empathy (understanding of other people's feelings) for others. Sufferers may also mistakenly think others are behaving aggressively toward them when they are not. Although an individual might seem to have a tough exterior, that person may in fact have low self-esteem, another feature common to those with conduct disorder. Recklessness, angry outbursts, and the tendency to get easily frustrated are also common traits of this problem.

SYMPTOMS. The DSM, IV splits conduct disorder into four categories: aggression toward people and animals (bullying, fighting, use of weapons, physical cruelty to both, stealing, and forced sexual contact); destruction of property (setting fires and destroying property deliberately through another method); deceitfulness or theft (breaking and entering, lying, covert stealing[e.g., forging a check]); and serious violations of rules (staying out past curfew at a young age, running away from home, and cutting school).

CAUSES. Just as with ADHD, there is no known single cause for conduct disorders, but there are theories as to why certain children develop conduct disorders while others do not. One theory is that conduct disorder may be an inherited ailment. Another possibility is that there is a lack of moral awareness in the family of origin of a person suffering from conduct disorder. In general, children learn what is right and wrong and refrain from breaking the boundaries of decency because they have been taught that it is wrong to hurt others. If, for whatever reason, these lessons are not learned in the home, a conduct disorder, and even more ominous psychological problems could develop. Furthermore, a child may witness disordered conduct from his or her parents and learn aggressive, improper behavior. Other researchers have postulated that children prone to developing conduct disorder could have flawed thinking processes. That is, very aggressive children may perceive an otherwise harmless event (for instance, being last in a line) as a slight, place unusual importance on the event, and hold a grudge because of the occurrence.

TREATMENTS. The most successful treatments of conduct disorders involve treating not just the child (or adult) but rather those around him or her as well (family and, in some cases, friends). Cognitive therapy, a form of therapy in which a therapist helps a patient become aware of maladaptive thinking and flawed belief systems and helps change beliefs that can interfere with healthy living (see Chapter 15: Mental Health Therapies), may also improve behavior as can teaching children moral reasoning skills.

Oppositional Defiant Disorder

Children often disobey their parents or teachers, particularly when they are extremely young, as a way of asserting their independence. However, when a child consistently is disobedient, disrespectful, hostile, and defiant toward parents, teachers, and other figures of authority for a period of six months, the child might be diagnosed with oppositional defiant disorder (ODD), a disorder that is not uncommon. Stubbornness and an unwillingness to deal rationally with others when there is disagreement are also signs of ODD.

Because defiant behavior is common in the development in both very young children and teenagers, it is cautioned that mental health practitioners make this diagnosis very carefully. Interestingly, more boys tend to suffer from ODD than girls do in the years before puberty; however, when adolescence arrives, both girls and boys are diagnosed at about the same rate.

The presence of this disorder is marked by a frequent loss of temper, arguing with adults, behaving annoyingly on purpose, blaming others for errors, anger, resentment, and spitefulness or vindictiveness. To be properly diagnosed with ODD, several of these characteristics must be noted for an extended period of time and these behaviors must prevent the child from performing properly at school or relating to family and friends.

While ODD may share similarities with both ADHD and conduct disorder, there are differences. Conduct disorder usually manifests itself in physical violence while ODD usually does not. ODD differs from ADHD in that the bratty behavior seen in ODD seems to be conscious and planned while ADHD suffers seem unable to control their actions. Treatment for ODD often involves cognitive therapy and operant conditioning therapy featuring a system of rewards.

Learning Disorders

Learning disorders refer to developmental problems relating to speech, motor, and academic or language skills that are not linked to a physical disorder or mental retardation (see section below). The presence of a learning disability is not a reflection of how intelligent an individual is. In fact, people with learning disabilities are often of average or above-average intelligence, but there is a problem in development or processing that prevents that person from performing at proper levels. Most often, parents and teachers become aware of learning disorders through a child's results on standardized academic tests administered by the school. It is believed that learning disorders may be inherited, particularly dyslexia (see Reading Disorder below).

The treatment of learning disorders focuses on instruction in the area in which there are problems. The most effective programs are those that give children a chance to make small steps toward progress that can help restore self-esteem and confidence.

Learning disorders are broken down into three separate diagnoses: reading disorder, mathematics disorder, and disorder of written expression; there is also a generalized diagnosis (Learning disorder not otherwise specified) to address problems in all three areas or a combination of two areas.

READING DISORDER. A reading disorder is commonly known as dyslexia (pronounced dis-LEX-ee-a). Dyslexia comes from the Greek words "dys" (meaning poor or inadequate) and "lexis" (which refers to words or language). Dyslexia is a disorder that centers on difficulties with word recognition. Sufferers most often add, omit, or transpose (change the sequence of) letters in a word (for example, mistaking "sing" for "sign" or "left" for "felt"). All of these symptoms manifest themselves in problems with reading aloud, comprehending what is read, and spelling words correctly. Dyslexia can also affect mathematical skills, causing the person to add, omit, or transpose numbers.

MATHEMATICS DISORDER. While math can be difficult for many people, some children have difficulties that go beyond the normal scope. The problem can be as serious as someone being unable to recognize mathematical symbols and numbers to having difficulty following the proper steps in solving a mathematical equation. The degree of the difficulty is the key to making a diagnosis of mathematics disorder.

DISORDER OF WRITTEN EXPRESSION. This disorder centers on problems with writing skills. This, obviously, can affect many areas of academics, as can a reading disorder. Poor handwriting as well as difficulty with

Dyslexia is a learning disorder that centers on difficulties with word recognition. For example, "I surfed the net" can look like "I surfed the ten" to a sufferer of dyslexia. (Photograph by

Robert J. Huffman. Field Mark Publications

. Reproduced by permission.)

punctuation, grammar, and spelling are common. While many young people may have difficulties with some or all of these things, what makes a diagnosis necessary is the degree to which the problem interferes with academic achievement.

Mental Retardation

Mental retardation is a condition of below-normal mental ability or intelligence due to disease, injury, or genetic defect. The average person has an intelligence quotient (IQ) between 70 and 130, with the majority of the population having IQs between 85 and 115. (IQ is the measure of one's intelligence as based on intelligence tests and the intelligence of the general population; see Chapter 11: Mental Health for more information on IQ.) Those suffering from some degree of mental retardation have IQs below 70 and as low as 20. Accompanying a low level of intelligence is trouble with adaptive behavior or functioning (skills such as dressing oneself, being socially responsive, understanding certain abstract concepts like time and money, etc.). These conditions are usually discovered prior to the age of eighteen.

CAUSES. Often, there is no identifiable biological cause for mental retardation, especially in the cases of mildly or moderately mentally retarded individuals.

This child exhibits the outward physical signs of Down syndrome. (Photograph © 1996

Sean O'Brien. Custom Medical Stock Photo

. Reproduced by permission.)

However, in the cases of more severe mental retardation, genetic, or birth, defects—such as Down syndrome—can be the cause. Down syndrome usually causes people to have moderate to severe retardation. Furthermore, Down syndrome sufferers share certain physical characteristics that have become hallmarks of the disorder including oval, upward-slanting eyes; fine straight hair; and a stocky build and short stature. Other complications, including infectious diseases—such as encephalitis (swelling of the brain) and meningococcal meningitis (swelling of the lining around the brain or spinal cord)—can sometimes also cause mental retardation.

TREATMENTS. Treatment of mental retardation varies to the degree of retardation. Residential treatment, that is treatment in live-in residences, is very popular. Sometimes a patient will develop enough skills to move into a group home, which features a homey setting, living with patients at similar levels of functioning. Operant conditioning is often employed as well as certain cognitive therapies (see Chapter 15: Mental Health Therapies). Whatever the case, working with individuals to bring them to the highest level of functioning possible will benefit them; of course, compassion and protection are the key to helping these individuals lead comfortable, happy lives.

There are four major diagnoses relating directly to mental retardation:

MILD MENTAL RETARDATION. The IQ range for this diagnosis is between 50 and 55 to 70. Oftentimes, these individuals are not diagnosed as mentally retarded until later in their development because they are usually able to learn at a sixth-grade level. People who are mildly mentally retarded can usually hold jobs and often marry and successfully raise children. Approximately 85 percent of mentally retarded people have been diagnosed in this category.

MODERATE MENTAL RETARDATION. Ten percent of the mentally retarded are diagnosed with an IQ range of 35-40 to 50-55. Physical problems, including brain damage, are often present and tasks such as running or grasping things can be extremely difficult. Many people in this category live with their families or in supervised group homes with a great deal of success.

SEVERE MENTAL RETARDATION. Approximately three to four percent of individuals with mental retardation are at this level, with an IQ range of 20-25 to 35-40. Birth defects are often present and communication skills are limited. Although they may be able to do certain tasks under supervision, often they are unable to function independently in any capacity.

PROFOUND MENTAL RETARDATION. One to two percent of the mentally retarded have IQs falling below 20-25. These individuals require supervision for their entire lives. Because of physical deformities and other problems, people in this range often have a short life span.

Autism

Autism is a developmental disorder marked by the inability to relate socially to others and by severe withdrawal from reality. Language limitations and the extreme desire for things to remain constant are common traits of autism. Autistic children and adults seem to "look through" people and very often avoid eye contact. More often than not, they are unresponsive to touch and are unable to accept and display affection. An interest in ritual and repetitive body movements, such as rocking back and forth, and of repeating certain words or phrases, are also usually present. In many cases, speech is absent and, when it is present, autistic individuals are often unable to hold a conversation with others. In some cases, those with autism may form strong attachments to inanimate (nonliving) objects, such as keys or even a refrigerator.

Another aspect of autism is that while many suffering from the disorder are mentally retarded to some degree (approximately 80 percent), they also may display almost incredible skill in other areas, such as mathematics. This facet of autism has prompted the use of the term idiot savant. A savant is one with detailed knowledge in a specialized field, such as math or science. Some people suffering from autism may also have exceptional memories or have a profound physical grace. Others with autism may, however, exhibit awkward physical affectations and posture and may not possess any outstanding, savant-like abilities.

CAUSES. Autism was originally thought to be the result of emotionally distant parenting but this has not been proven. However, a specific biological cause also has not been found. Still, it is believed that autism has its origins in biology, and studies of twins have indicated that autism may be genetic. It is difficult to confirm this, however, because of the rarity of autism (two to five births in 10,000) and the fact that persons with autism rarely have children. Most of the symptoms of autism are usually present and a diagnosis made by the time a child reaches toddler age.

TREATMENT. Treatment for autism is not always effective. However, operant conditioning and modeling (see Chapter 15: Mental Health Therapies) have proven to be successful in enabling parents to, at the very least, bring their child into social situations without the child acting out. Some therapists have had success in using intense behavioral therapy as well.

Tourette's Disorder

Usually diagnosed before a person reaches the age of eighteen, the main feature of Tourette's disorder is the presence of multiple motor tics and at least one vocal tic (a tic is a quirk of behavior or speech that happens frequently). Examples of such tics include frequent eye blinking, throat clearing, sniffing, repeating words or sounds over and over, or coprolalia (repeatedly saying obscenities). Such symptoms must be exhibited for more than a year, without a lapse in symptoms exceeding three months in a row, and the condition must have a negative effect on one area of functioning (social, educational, professional, etc.). More common in males than females, the average onset age of Tourette's is seven.

SYMPTOMS. Symptoms accompanying Tourette's range from obsessions and compulsions (see section on Anxiety Disorders below), to hyperactivity, social discomfort, and depression. Social problems and depression may stem from embarrassment over a sufferer's inability to control his or her actions. Exaggerated behaviors not uncommon to Tourette's, such as head banging, knee bending, head jerking, and picking the skin, can cause injury and/or illness.

CAUSES. Tourette's disorder is genetic in origin. While not all individuals who inherit the predisposition toward Tourette's will develop the disorder, 70 percent of females and 99 percent of men carrying the genes will develop it.

TREATMENTS. Tourette's is often treated with prescription drugs, which can help to lessen the presence of tics and other symptoms.

Stuttering

Many people have heard another person stutter; what might strike many people is the number of individuals who have outgrown or overcome stuttering. Stuttering is a disturbance in verbal fluency of speech; for example, a stutterer might repeat whole words several times before being able to move on to the next word in the sentence ("I want to go-go-go-go to the movies."). Another sign may be a person's consistent difficulty in pronouncing certain consonants, or having long pauses between words in a sentence.

Stuttering is frustrating because, like Tourette's, it separates people from others by hampering easy communication. It can also affect learning, as a child may be embarrassed to ask or answer questions in class because of fear of classmates' teasing. Furthermore, stuttering can become worse when one is nervous, which can prevent a stutterer from answering difficult questions or doing any type of public speaking.

Stuttering affects more males than females and usually is present at or around the age of five. It has been estimated in the DSM, IV that eighty percent of stutterers recover, with sixty percent overcoming their stutter through no apparent reason. Speech-language pathologists (see Chapter 7: Health Care Careers) perform therapy with stutterers to help them overcome the disorder.

MOOD DISORDERS

Mood disorders cause a disturbance in mood (state of mind) and include depression and bipolar disorders. Mood disorders can be devastating as, depending on their severity, they can emotionally paralyze people, rendering them unable to work or attend classes or even enjoy the most basic things. Mood disorders can also disrupt appetite and sleep patterns and an individual's sense of well-being. It is not known why some people suffer from mood disorders while others do not.

Major Depression

Major depression, the condition of feeling deep and constant sadness, is one of the most common mental disorders. It strikes almost one in five people at some point. More common in women than in men, depression tends to recur, making it a lifelong battle for some people. Depression, too, has become more common over the last few decades. This may be attributable to social changes that have occurred simultaneously (society moving at a faster pace, individuals bearing more stress as life becomes increasingly urbanized, and many institutions—church, family, cultural customs—that once acted as support systems no longer as common). It may also be that people are more aware of the symptoms of depression and are more willing to seek treatment than in the past.

SYMPTOMS. There are several possible symptoms of depression, whether it be a major depressive episode (which lasts approximately up to two weeks) or major depressive disorder (of longer duration and higher rate of return of the depression). Symptoms can include: constant feelings of sadness, emptiness, or irritability; a lack of pleasure in activities, even those that once brought enormous pleasure; a noticeable drop or increase in weight; the inability to sleep; extreme exhaustion; feelings of worthlessness; an inability to make decisions or concentrate on performing tasks; and thoughts of death and suicide. In order for a diagnosis of depression to be made, none of these symptoms can be caused by drugs or a medical disorder (there are separate categories of depression that are caused by illness or substance abuse) and a diagnosis should not be made if an individual is mourning the very recent loss of a loved one.

CAUSES. Many different theories account for the development of depression, depending upon the therapist's school of thought. Psychoanalysts (see Chapter 15: Mental Health Therapies) believe that the seeds of depression are sown in early childhood when something goes wrong with one stage of development or another. Cognitive therapists, such as Aaron Beck, believe that an individual battling depression has a faulty perception of the world, tending to view things negatively, and this impacts the person and his or her

Mood disorders can make a person unable to enjoy the company of others, which brings on feelings of isolation. (Photograph by

Robert J. Huffman. Field Mark Publications

. Reproduced by permission.)

A diagnosis of major depression should not be made if a person is mourning the recent death of a loved one, which is perfectly normal. (Photograph by

Robert J. Huffman. Field Mark Publications

. Reproduced by permission.)

reactions to different situations later in life, increasing susceptibility to developing depression. Behavioral therapists believe that depression may strike individuals who do not have strong social support and whose depression further deepens their isolation from others. There are also those who attribute depression to biological causes, including the possibility that it is inherited or caused by a chemical imbalance in the brain.

TREATMENTS. Depression has been treated with success with cognitive therapy and interpersonal therapy (a therapy that focuses on how a person interacts with others and which instructs him or her how to interact more

Kurt Cobain, lead singer of the band Nirvana, committed suicide in 1994 while at the peak of a successful career. (Photograph ©

Ken Settle

. Reproduced by permission.)

effectively). Drug therapies have also worked well in treating depression. Antidepressants, such as Tofranil and Elavil, as well as Prozac, have been effective in alleviating the symptoms of depression. Drug therapies are most beneficial when they are accompanied by sessions with a therapist who can help an individual better understand depression and how he or she is reacting to the medication.

Bipolar Disorder

Bipolar disorders are marked by extreme highs and extreme lows in mood. Similar to depression in that they include the occurrence of major depressive episodes, bipolar disorders are also accompanied by manic episodes or hypomanic episodes. A manic episode is when a person is in an intense emotional state of elation (extreme happiness) and overactivity in which he or she is abnormally energetic and talks in an almost stream-of-consciousness way, with ideas and grandiose plans being shared (however implausible they may seem). Examples of other symptoms of a manic episode include an inflated sense of self, a reduced need for sleep, and engaging in reckless activities (for example, irresponsible sexual behavior or excessive spending). A hypomanic episode is similar to a manic episode though not as extreme.

Bipolar I disorder is marked by manic episodes accompanied by major depressive episodes. Bipolar II disorder has major depressive episodes at its center which are accompanied by at least one hypomanic episode.

Bipolar depression also differs from major depression, which is also known as unipolar depression, in that it strikes males and females at the same rate. Typically, bipolar depression is treated with drugs and counseling. As with major depression, there exists a genetic correlation.

PSYCHOTIC DISORDERS

Psychotic disorders, including schizophrenia, center around psychoses, which refer to mental disorders that involve a dramatic impairment in thinking,

such that an individual is almost completely out of contact with reality. Most often this means that a person is experiencing hallucinations, or having delusions. Hallucinations are the perception of things that aren't present (seeing things, hearing things, etc.); delusions are false or irrational beliefs that an individual holds in spite of proof that those beliefs are untrue. It is these qualities that render psychotic disorders frightening and mysterious, especially for those afflicted by them.

Schizophrenia

Schizophrenia, perhaps the most severe psychotic disorder, is still not fully understood by the mental health community. When it strikes, more often than not, sufferers need to be on medication for the rest of their lives in order to keep the disorder under control. Furthermore, many schizophrenics are unable to resume normal lives; this tragedy is compounded by the fact that schizophrenia often develops when individuals are in their late teens through mid-thirties. This means that some persons could have been working toward building a full life only to find themselves in jeopardy of losing everything they have worked for.

SYMPTOMS. Symptoms of schizophrenia include having scattered, disorganized thoughts. People with schizophrenia will lose their train of thought when conversing with others, often bringing up completely different issues and causing others to become confused. Delusions are another symptom of schizophrenia. Delusions can include anything from a person's belief that others are plotting against him or her, or that a person's food is being poisoned because someone is trying to kill him or that another person can read his mind. Hallucinations often accompany delusions as well. Many times, schizophrenics hear strange voices inside their heads. Naturally, this is extremely disturbing and feeds a schizophrenic's fear.

Other symptoms include a lack of motivation to engage in normal daily activities, such as maintaining one's hygiene or doing chores. Also, although schizophrenics will tend to speak, they will have less to say; their conversations may be repetitive and nonsensical. The inability to experience pleasure, known as anhedonia, may also be present, as may problems with a person's affect (an individual's emotional response and demeanor); often times, a schizophrenic's affect may be flat (lacking in emotional response) or inappropriate (for example, laughing upon hearing that someone has died).

CAUSES. There is no single, definitive answer as to why some people develop schizophrenia. It is believed that it is genetic and that if a person has a schizophrenic relative in his or her family, there is an increased incidence of the person developing schizophrenia. Studies on families and twins have supported the genetic link, although the statistics are not very high, meaning that there may be schizophrenia in a family's gene pool, but the likelihood of someone developing it isn't all that great. Among twins with schizophrenia, the incidence of both having the disorder is quite high in identical twins (almost 44.30 percent according to one 1987 study); further, fraternal (nonidentical) twins also have an increased risk, although it's not as high as in identical twins.

It has also been suggested that chemical imbalances in the brain could account for the development of schizophrenia, something that certain researchers believe may also be inherited as well. Finally, psychological stress has been identified as being a possible cause.

TREATMENTS. Schizophrenia is almost always treated with antipsychotic drugs, such as Thorazine, which reduce psychotic symptoms, particularly because hallucinations and delusions can cause schizophrenics to engage in behaviors that make them a risk to themselves and even others around them. Medication is usually successful in suppressing symptoms but, alone, it is not enough. Therapy is a necessary ingredient in treatment to help the individuals accept and cope with their situations and understand the importance of continuing to take medication even if they feel "cured." Therapy can also be useful in helping a schizophrenic's family understand the patient's plight and contribute to helping manage and maintain a person's plan of care.

ANXIETY DISORDERS

Anxiety, the unpleasant feeling of fear and apprehension, is something that most people experience at one point or another in their lives. People have anxious feelings about taking tests, speaking in public, interacting with the opposite sex, making new friends and acquaintances, traveling to strange places, or personal situations (for example, money, job, family, etc.). Anxiety of this nature is completely normal, as long it does not prevent people from going ahead and doing these activities anyway, facing their minor fears or worries and moving forward.

Sometimes, though, some people find that they are paralyzed by their anxiety about a situation or a thing and cannot act. Instead of doing what they know they should, they retreat and avoid the situation entirely. This might not seem too harmful if it is a case of a person being afraid, for example, of tigers. As long as he or she doesn't live in an area populated by such animals, the situation might never present a problem. However, what happens if individuals have extreme anxiety in social situations to the point that they avoid interacting with others entirely? Or, what if people are so afraid of germs that they cannot stop compulsively cleaning themselves to the point that they are unable to engage in normal activities for fear of contamination? It is at this point that individuals must seek professional help in order to conquer their fears so that they can live normal, full lives.

Phobias

Phobia is a form of an anxiety disorder that involves intense and illogical fear of an object or situation. Usually, the individual is aware that the fear is out of proportion to the danger of the thing they fear. In other words, someone being afraid of skydiving or rock climbing wouldn't have a phobia; both of these activities carry high risks for injury or death. However, someone who has never had a negative experience with a dog but is afraid of dogs has a phobia. And, even allowing for the fact that a person has had a negative experience with the thing or situation feared, the presence of a phobia is indicated if the level of fear is out of proportion with the threat the situation or object presents.

The most common phobia is agoraphobia, the fear of public places. This is a phobia that can impair a person's ability to connect with others, to attend

Don't look down! The fear of heights, called acrophobia, is a common phobia. (Photograph by

Robert J. Huffman. Field Mark Publications

. Reproduced by permission.)

school, and to hold a job. People with severe agoraphobia will not only avoid crowds and busy places, some may refuse to leave their homes entirely. Other common phobias include the fear of heights, called acrophobia, and claustrophobia, which is the fear of closed spaces (such as elevators or overly crowded rooms that leave little personal space).

TREATMENTS. Treatments for phobias usually involve confronting the fear in some way. Behavioral therapists (see Chapter 15: Mental Health Therapies) may use a variety of techniques that involve visualization or actual contact with the object or situation around which the phobia centers. The thinking behind this, for certain schools of therapies, is that it will desensitize the phobic to the phobia. For example, flooding, a behavioral technique, involves exposing a phobic person to the cause of the phobia in an extreme way; however, this can cause the phobic serious initial discomfort, at the very least, and many therapists shy away from therapies that could potentially traumatize a patient.

Operant conditioning is also used in similar ways. Cognitive therapists will work with phobics using cognitive therapies alone (without some type of exposure to the source of the phobia), but this is usually effective only in the case of social phobics. Furthermore, social phobics have responded well to behavioral techniques that involve acquiring better social skills so that they feel more comfortable in social situations. Drugs have also been used to lessen a phobic's anxiety but drugs only mask the fear and will not solve the problem in the long term.

WHAT ARE YOU AFRAID OF?

For every fear, it seems there is a phobia. Listed below are just some phobias, from the common to the plain weird.

Phobia	Meaning
Ailurophobia	The fear of cats
Bibliophobia	The fear of books
Coulrophobia	The fear of clowns
Didaskaleinophobia	The fear of going to school
Entomophobia	The fear of insects
Glossophobia	The fear of speaking
Heliophobia	The fear of the sun
Ichthyophobia	The fear of fish
Lachanophobia	The fear of vegetables
Myctophobia	The fear of darkness
Nosocomephobia	The fear of hospitals
Ophidiaphobia	The fear of snakes
Pantophobia	The fear of everything
Rupophobia	The fear of dirt
Sophophobia	The fear of learning
Triskadekaphobia	The fear of the number 13
Urophobia	The fear of urine or urinating
Xenophobia	The fear of strangers or foreigners
Zoophobia	The fear of animals

Panic Attacks and Disorder

A panic attack can accompany several different anxiety disorders, so in and of itself, a panic attack is not a separate disorder. Essentially, a panic attack is a short period involving intense feelings of fear or discomfort along with several telltale symptoms. These symptoms include an irregular or accelerated heart rate or a pounding of the heart; sweating, discomfort or pain in the chest; a feeling of choking or not being able to breathe properly; trembling, feelings of detachment, of things being "unreal," and/or of impending doom. People experiencing panic attacks have described feeling as though they would lose control completely or were about to have a heart attack or stroke.

Panic attacks can be caused by certain situations, such as being in a strange place, or while a person is relaxing or even sleeping. If panic attacks continue to occur when there is no apparent stressor (stress-inducing event), an individual might be diagnosed with having panic disorder. Panic disorder is a reasonably common ailment, affecting two percent of men and five percent of women. It may begin in adolescence and the disorder is inherited. Biological theories as to the disorder's origin have been put forth as have theories that suggest that panic disorders and agoraphobia are solely psychological in origin. Furthermore, one set of researchers has even suggested that the agoraphobia that so often coexists with panic disorders isn't really a fear of public places but rather a fear of losing control and having a panic attack in a public place.

Certain drugs, such as antidepressants, have been used to treat people with panic disorder and agoraphobia with some success; however, the drugs are merely a temporary measure as people's symptoms will return when they stop taking the drugs. A better approach in terms of a cure might be methods used by cognitive and behavioral therapists, which have proven to help lessen the severity of the disorder.

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) involves obsessions (repeating thoughts, impulses, or mental images that are irrational and which an individual cannot control) and compulsions (habitual behaviors or mental acts an individual is driven to perform in order to reduce stress and anxiety brought on by obsessive thoughts or because individuals believe those behaviors or acts will prevent a certain calamity from occurring [for example, believing that a certain behavior will prevent a car accident]). While almost every person may have behavioral quirks or strong preferences (cracking one's knuckles, or wanting things to be kept neat), obsessions and compulsions are different in that they prevent people from living normal lives because they take up an inordinate amount of time.

Obsessions can include thoughts ranging from a person constantly thinking about becoming "contaminated" with germs and avoiding shaking hands with others because of that fear, to a person being convinced that he has left his front door unlocked. The compulsions accompanying these obsessions can include things such as someone repeatedly washing hands for fear of germs, or checking repeatedly (sometimes a certain number—for instance, three times) to see if they have indeed locked the front door. Unlike preferences, a compulsion is something that is viewed as not being part of someone's personality but rather irrational behavior that a person is unable to stop. Due to the nature of this disorder, it can separate people from others, rendering afflicted individuals unable to participate in everyday activities because their obsessions and compulsions prevent them from doing so.

CAUSES. There are many theories surrounding the development of OCD. Behavioral and cognitive therapists believe that the behaviors and thinking related to OCD are learned and reinforced. For example, a person may have the irrational belief that she has not locked her door; by going back to check whether or not it is indeed locked, she is able to relieve the stress that is related to her worries. Some therapists have also pointed to the fact that a lot of the problem stems from the fact that those suffering from OCD simply cannot remember whether or not they did something. There can also be organic (relating to the body) causes for OCD, such as head injuries and brain tumors as well as chemical imbalances in the brain.

TREATMENTS. Treating OCD is not an easy task. One of the most successful therapies involves placing a person in a situation that usually triggers his anxiety, but the patient is not allowed to engage in the compulsive behavior that is the typical response. The idea is that eventually the stress from not performing the compulsive behavior will lessen over time to the point where the person no longer feels compelled to do it.

Prescription drugs have also proven successful in reducing a person's obsessive thoughts and compulsive behaviors; this approach will not necessarily resolve the problem entirely but will free a person to live a normal life while confronting the issues appropriately through therapy.

Post-Traumatic Stress Disorder

Every day, people experience traumatic events, anything from being in a car accident to being robbed or even witnessing such an event happening to someone else. While people may survive these events (which involve intense fear and a feeling of helplessness), and their physical wounds may heal, they can still carry emotional scars. When an individual experiences emotional aftereffects from a traumatic event days, months, or even years after the actual event, this is known as post-traumatic stress disorder (the prefix "post" means after or later). Many of these individuals, even much later, will relive the event, become extremely upset and/or have nightmares about the event. They will also try to avoid things that remind them of the trauma. Finally, they may also be plagued by sleep disruptions, have difficulty concentrating, and startle easily and dramatically.

Post-traumatic stress disorder received a great deal of attention in the years following the Vietnam War (1954–75), as it had after World Wars I (1914–17) and II (1939–45), the Korean Conflict (1950–53) and, in fact, even after earlier conflicts such as the American Civil War (1861–65), because of the emotional scars that those who had served in a war often seemed

Post-traumatic stress disorder affected many students (pictured at a memorial service) and adults alike after the 1999 Columbine High School shootings in Littleton, Colorado. (Photograph by

David Zalubowski. AP/Wide World Photos

. Reproduced by permission.)

to display. In fact, PTSD was originally called "shell shock" (in reference to the ammunition used during times of war). It is now known that those who have witnessed or participated in any type of traumatic event—such as being involved in the search-and-rescue or recovery missions for the victims of plane crashes in which hundreds of people perish—are now known to be potential sufferers from PTSD. What is mysterious about PTSD is why it affects only certain people and not all of those experiencing similar events or even the same event.

TREATMENTS. Great strides have been made in treating PTSD through group therapy. Talking in a group to others who have experienced similar events and have been suffering from them continuously can be very helpful because patients can feel that they are not alone in their feelings and that there are people who understand the intensity of their traumatic experience. Most therapies, in groups or single client therapy, usually will involve confronting the event in some way. Stress management and medication have also been used with some success.

People who have lived through traumatic events should be encouraged to seek at least brief therapy to ensure that PTSD won't develop years later.

OTHER TYPES OF MENTAL DISORDERS

There are a number of other mental or psychological disorders that afflict millions of people each day. These can range from disorders most often appearing in old age, such as Alzheimer's disease, to gender-identity disorders, in which people wish to be members of the opposite sex. Eating disorders are also a common mental illness. [For more information on eating disorders, see Chapter 13: Eating Disorders.]

What follows is a small sampling of other common psychological disorders.

Somatoform Disorder

Sometimes people will complain of pain or discomfort that lingers but, when these individuals seek medical treatment, doctors can find no physical cause for the symptoms. When this persists, and the pain and discomfort prevent a person from participating in day-to-day life, a mental health professional may diagnose that person with pain disorder, which is just one of several somatoform disorders. Somatoform disorders are psychological disorders that manifest themselves physically without the presence of a true physical ailment.

Somatoform disorders can include conversion disorders, which can result in sudden loss of vision (once called hysterical blindness) or paralysis. People have also been known to lose their senses of hearing and smell as well. Another somatoform disorder is body dysmorphic disorder (BDD). While many people would like to change something about themselves (such as being more muscular, having smaller ears, having straight or curly hair, being taller or shorter, etc.), people with BDD grossly exaggerate what they perceive to be flaws with themselves and spend hours obsessing about these so-called flaws. Some BDD sufferers even take measures to act upon their impulses by picking at their skin (if they think they have too many blemishes) or getting plastic surgery unnecessarily.

As with many other mental disorders, there is no single theory that can account for why certain people develop somatoform disorders while others do not. Oftentimes, a person will recover suddenly from the problem while others require therapy. Behavior therapists will use techniques that center around making it appealing for a person to abandon his or her symptoms. Other therapists have used techniques similar to those used on people with phobias, wherein the patient will be exposed to the cause of the stress in order to diminish its effect.

Dissociative Disorder

When someone dissociates, it means that a certain behavior or part of the personality becomes removed from the rest of his or her consciousness. This can be something as harmless as becoming preoccupied while listening to a song on a portable stereo while walking and then not remembering which route was taken upon arriving at a destination. However, dissociation can also be a very serious problem and several disorders are attached to this phenomenon.

DISSOCIATIVE AMNESIA. Dissociative amnesia, which occurs when a person cannot remember personal information, such as where a person has been, who a person is, or even entire conversations. Often this is prompted by a stressful event, such as abuse, a traumatic experience similar to those detailed in the section on PTSD, or the death of a loved one. Memory loss is the primary symptom of this disorder, which is more common among young adults.

DISSOCIATIVE FUGUE. Dissociative fugue (pronounced fyoog) is a particularly disturbing mental phenomenon as it involves one or more instances of a person leaving their normal, everyday life for a period of time and taking up a new life, with no recollection of their former life. Like dissociative amnesia, fugues are often triggered by traumatic events and are often fueled by unfulfilled wishes. An individual in the midst of a fugue will often leave home, abandoning all aspects of his or her life, and assume a new identity in another place. A fugue can last hours or days or longer.

DISSOCIATIVE IDENTITY DISORDER. Dissociative identity disorder, or DID (formerly known as multiple personality disorder, or MPD), involves an individual having two or more identities or personalities that are in control of an individual's behaviors and thoughts at different times. A controversial diagnosis (as it violates the basic belief that only one person can inhabit a body), people diagnosed with DID will often have a variety of personalities that are very different from one another and that may be in opposition to one another. For example, one personality may require an individual to wear glasses in order to see clearly, while another personality will not wear glasses. Or one personality may be left-handed whereas the other(s) are right-handed. DID usually begins in childhood and is often the result of severe trauma or an individual's repressing, or keeping back, strong feelings and desires.

Because of the association of the concept of repression (holding back painful memories) with dissociative disorders, psychoanalytic therapists seem to have good success in treating these disorders (for an explanation of the principles of psychoanalysis, see Chapter 15: Mental Health Therapies). Hypnosis may be also be used by psychoanalysts to help uncover forgotten memories in order to get to the root of why individuals disconnect from themselves.

Personality Disorders

People have different personalities (one's behavioral and emotional traits). Many people, however, share a type of personality, which means they have certain tendencies. For example, an individual who is sensitive to criticism might have an avoidant personality type. This is perfectly acceptable unless that person's behavior is extreme, thereby presenting problems in personal relationships and the ability to function in society. If one avoids people in social and work-related situations out of fear of being criticized or rejected; shies away from getting close to other people for fear of being made fun of; has low self-esteem; and is painfully shy and standoffish, that person might have an avoidant personality disorder. In other words, the difference between a personality type and a personality disorder is that the disorder separates people from others and the separation can prevent them from being happy and successful.

There is a wide range of personality disorders. There is the histrionic personality disorder, in which an individual needs to be the center of attention; behaves inappropriately (making sexual comments, for example); wears revealing clothes; is overly dramatic; is easily influenced by other people or events; and exaggerates how emotionally close one actually is to another person.

Dependent personality disorder is marked by an overwhelming need for advice and reassurance from others; being unable to disagree with others for fear he or she will no longer be liked; having a lack of initiative and self-direction; and showing an unusual need for close relationships along with a fear of being alone.

Other personality disorders include the paranoid personality disorder (which involves constant distrust and suspicion of other people; thinks others are "out to get them."). There is also the schizoid personality disorder (in which people are removed from social contact with others and have problems experiencing and expressing emotion). Another is the borderline personality disorder (wherein an individual is unstable in relationships with others, has poor self-image and extremist thinking, and is very impulsive). Lastly, there is the narcissistic personality disorder (wherein an individual is overly conceited, having an abnormal need for admiration and lack of empathy for others).

Personality disorders are treated differently, depending upon which type of disorder is present. The difficulty lies in the fact that personality disorders carry risks with them that can affect treatment and a person's personal safety. For instance, people with severe personality disorders often engage in high-risk behavior, such as excessive drinking or taking illegal drugs. Furthermore, they are particularly vulnerable to psychiatric breakdowns, are less likely to take medications prescribed to them in the proper manner, and have a hard time taking responsibility for their behavior or trusting their mental health care provider.

FOR MORE INFORMATION

Books

Cush, Cathie. Depression (Teen Hot Line). Raintree/Steck Vaughn, 1994.

Friedland, Bruce. Personality Disorders (Psychological Disorders and Their Treatment). Chelsea House, 1991.

Ingersoll, Barbara D. Distant Drums, Different Drummers: A Guide for Young People with ADHD. Cape Publications, 1995.

Klebanoff, Susan and Ellen Luborsky. Ups and Downs: How to Beat the Blues and Teen Depression. New York: Price Stern Sloan, Inc. 1999.

Levine, Mel, Melvin D. Levine, and Ann Jennings. Keeping a Head in School: A Student's Book About Learning Abilities and Learning Disorders. Educator's Publishing Service, Inc., 1991.

Roleff, Tamara L., ed. Suicide: Opposing Viewpoints. Greenhaven Press, 1997.

Sebastian, Richard. Solomon H. Snyder and Dale C. Garell, eds. Compulsive Behavior (Encylopedia of Health Series: Psychological Disorders and Their Treatment). Chelsea House, 1993.

Web sites

American Psychiatric Association. [Online] http://www.psych.org (Accessed July 28, 1999).

American Psychological Association. [Online] http://www.apa.org/ (Accessed July 28, 1999).

OC Foundation of California. [Online] http://www.ocdhelp.org/faq.html (Accessed July 28, 1999).

Yellow Ribbon Suicide Prevention Program. [Online] http://www.yellowribbon.org (Accessed July 28, 1999).