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Mental Illness and Cognitive Disorders

C H A P T E R

Learning Objectives

After studying this chapter, you should be able to

■ Describe the warning signs of mental illness

■ Identify signs, symptoms, etiology, and treatment of the following:

• Developmental disorders

• Disruptive behavior disorders

• Mood disorders

• Substance use disorders

• Schizophrenia

• Anxiety disorders

• Eating disorders

• Personality disorders

■ Recognize environmental, genetic, and biological factors associated with mental illness

■ Describe diagnostic approaches for mental illness

■ Identify the warning signs of suicide

14 Mental illness is a weakness of character.

Fiction:Mental illness has physical and/or biological causes, just as do the diseases of the other systems discussed in this text. For every 100 peo- ple born, one ends up with schizophrenia, one develops bipolar disorder, and 20 experi- ence some form of depression. Heredity may account for as much as 80% of the risk for these illnesses.

Fact or Fiction?

PET scans of Alzheimer’s suf- ferer’s brain. (Getty Images, Inc.)

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Human Diseases: A Systemic Approach, Seventh Edition, by Mark Zelman, Ph.D., Elaine Tompary, PharmD, Jill Raymond, Ph.D., Paul Holdaway, MA, and Mary Lou Mulvihill, Ph.D. Published by Prentice Hall. Copyright © 2010 by Pearson Education, Inc.

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Post-Traumatic Stress Disorder and Modern Psychiatry

T he human brain has evolved to cope with intermittent ordinary stressors, such as hunger, pain, and isolation, but the brain is not well adapted to handle stressors that are outside the realm of normal human experience. Certainly such extreme stressors

occurred occasionally in the human evolutionary past; however, the modern world presents humans with abundant opportunities to expe- rience extreme stress, the sort of stress associated with post-trau- matic stress disorder. These experiences include war; rape or sexual abuse; being hit or harmed by someone in your family; violent crime; airplane or car crashes; hurricane, tornado, or fire; any event in which you thought you might be killed; or witnessing any of these events. Today we know that post-traumatic stress disorder is a real disorder with severe consequences; to appreciate the significance of this, remember that until recently this disorder and many mental ill- nesses were misunderstood. Prior to the twentieth century, mental illnesses were primarily attributed to human fault and hostility, magic, or divine forces. The mentally ill were treated by confinement in prisons and asylums. Reforms in the treatment of the mentally ill started after the French Revolution with Franz Mesmer, an Austrian physician, who established rapport with patients. Emil Kraepelin began the modern classification of psychiatry in the nineteenth cen- tury. Modern psychiatry, founded in the twentieth century by Sig- mund Freud, is credited with a comprehensive approach to under- standing development, emotion, behavior, and psychiatric illness. Psychological theory, treatment options, and scientific advancements continue to evolve, contributing to further understanding of the bio- logical, chemical, environmental, social, and behavioral mechanisms of mental illness.

Disease Chronicle

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Mental Illness

Mental illness refers to a group of psychiatric dis- orders characterized by severe disturbances in thought, mood, and behavior. Psychiatry is the medical specialty that diagnoses and prescribes medical treatment for mental illness, whereas psychology is the discipline that studies normal and abnormal behavior and applies counseling methods to treat mental illness.

Mental illness affects one of every four Ameri- cans and is associated with social stigma, dis- ability, and death. Many people suffering from mental illness may not look as though they are ill, while others may appear detached and with- drawn from society. Warning signs of mental ill- ness are listed in Box 14–1 �.

Over 200 psychiatric diagnoses for adults and children are categorized in the Diagnostic and Statistical Manual of Mental Disorders, or DSM. The DSM-IV is the most recent edition and is used internationally to classify, assess, and guide treatment for mental illness. Because it is difficult to provide a single definition that accounts for all mental illness, disorders are categorized in the DSM-IV according to groups of symptoms or diagnostic criteria. Psychiatric disorders are assigned a diagnosis in one of five

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axes, and each axis is a grouping of develop- mental, medical, psychosocial, and overall adaptive disorders (Box 14–2 �). All DSM-IV di- agnoses require evidence that the symptoms impair academic achievement, occupational performance, and social relationships.

Causes of Mental Illness

Biological Basis for Mental Illness Current biological theories of mental illness implicate anatomical differences, genes, and chemical messengers or neurotransmitters in mental illness. Anatomical differences such as brain size and altered neural connections de- velop from physical insults to the brain, degen- erative processes, and genes. Genes within the brain’s DNA are inherited from both parents and contain all the necessary information to build the structures that mediate the special- ized function of neurotransmitters.

Neurotransmitters are produced, stored, and released from neurons, or nerves cells, within the central and peripheral nervous system. Volun- tary and involuntary physical and psychological processes, such as heart rate and blood pres- sure, behavior, emotions, mood, sleep, and sex drive, are regulated by intricate neurotransmit- ter activity. Inadequate regulation of neuro- transmitters and excess neurotransmitter activ-

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Box 14–1 � Warning Signs of Mental Illness

• Aggression • Changes in eating or sleeping habits • Confusion • Decline in school or work performance • Depression • Euphoria alternating with depression • Excessive fear • Frequent complaints of physical illnesses • Hearing voices • Substance abuse • Thoughts of suicide • Withdrawal from family and friends

Source: Diagnostic and Statistical Manual Text Revision IV. American Psychiatric Association, 2000.

Box 14–2 � The Five-Axis System of Psychiatric Diagnoses

Axis I: Primary diagnosis (clinical disorders and other conditions that may be a focus of clinical attention)

Axis II: Primary diagnosis (personality disorders, mental retardation, learning disabilities)

Axis III: General medical conditions Axis IV: Psychosocial and environmental problems Axis V: Global assessment of functioning

Primary Psychiatric Diagnosis is indicated on Axis I or II.

Source: Diagnostic and Statistical Manual Text Revision IV. American Psychiatric Association, 2000.

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ity in distinct areas of the brain are associated with mental illness. The regulatory action of neurotransmitters and their associated mental illnesses are listed in Table 14–1 �.

Environment and Mental Illness Environmental causes of mental illness have in- formed the diagnosis and treatment of mental illness for many years. Family interactions, age, gender, race, culture, and socioeconomic status alter biological and psychological vulnerability for mental illness and define learned behaviors, attitudes, and perception of health and illness.

Age and gender are determining factors for some mental health problems and illnesses. Mood disorders such as depression, anxiety disorders, and eating disorders occur more frequently in women, whereas disorders with outwardly di- rected behaviors such as antisocial personality disorder and associated substance abuse are more common in males. Attention deficit hyperac- tivity disorder (ADHD) is a development behav- ioral disorder that appears more commonly in males prior to the age of 7 years. Degenerative disorders involving memory and dementia, such

as Alzheimer’s disease and Huntington’s chorea, occur most commonly among older adults.

Mental illness affects all cultures, races, and socioeconomic classes. Access to medical care and acceptance of psychiatric illness is also in- fluenced by race, cultural beliefs, and socioeco- nomic status. The highest rates of mental illness are found among the lowest socioeconomic classes, which are associated with adverse living conditions, increased social stress, and limited access to medical and psychiatric care.

Mental Illness in Children and Adolescents Mental illness in childhood can have far-reach- ing academic, social, developmental, and physi- cal consequences. Common complications of childhood-onset mental illness include learning delays and poor performance in school, low self- esteem, impaired relationships with family and friends, and social rejection and withdrawal.

Although many psychiatric disorders begin in childhood, they may not be diagnosed until adulthood. In the United States, about 20% of children and adolescents have a mental disorder.

Table 14–1 � Neurotransmitters, Regulatory Actions, and Associated Psychiatric Disorders

Neurotransmitter Regulatory Action Mental Illness

Dopamine Mood, behavior, thought process, muscle movement, physical activity, heart rate, blood pressure, feeding, appetite, satiety

Schizophrenia, depression, ADHD, bipolar disorder, eating disorder, autism, Tourette syndrome

Norepinephrine Mood, anxiety, vigilance, arousal, heart rate, blood pressure

Depression, anxiety disorders, ADHD, bipo- lar disorder

Serotonin Perception of pain, feeding, sleep–wake cycle, motor activity, sexual behavior, temperature regulation

Depression, aggression, suicidality, bipolar disorder, eating disorders

Acetylcholine Learning, memory, muscle tone Alzheimer’s disease, Parkinson’s disease, Huntington’s chorea, Tourette syndrome

Gamma aminobutyric acid (GABA)

Interacts with a wide range of neurotransmit- ters to enhance inhibition

Anxiety disorders, alcoholism, Tourette syn- drome, sleep disorders

Source: Kaplan, G. B. and Hammer R. P. Brain Circuitry and Signaling in Psychiatry: Basic Science and Clinical Applications. American Psychiatric Association, 2002.

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Some disorders have slightly adapted criteria for children. Unlike adults, children often do not verbalize their feelings and may present with be- havioral problems such as boredom, irritability, and conduct problems. The outcome of child- hood mental illness depends on the ability of the family to cope and seek treatment, the severity of the illness, and the ability of the child to com- pensate for and adapt to mental health deficits.

Diagnostic Tests for Mental Illness

Comprehensive evaluations, including a med- ical history and physical exam, psychosocial history, mental health exam, and family history, are essential for diagnosis of mental illness. A thorough medical history and physical exam should identify physical illnesses and metabolic and hormonal stresses that mimic symptoms of mental illness. A patient history obtained from family and friends with major timelines of life events can help form a diagnosis. Observation of the patient alone or within a family environ- ment is used to assess emotional responses, physical appearance and reactions, speech and language abilities, clinical estimate of intelli- gence, and level of judgment and insight. A number of standardized questionnaires and rat- ing scales supplement the clinical evaluation by providing a systematic review and standard score to describe behaviors and emotions.

Disorders of Infancy, Childhood, or Adolescence

Disruptive Behavior Disorders Disruptive behavior disorders, including conduct disorder and oppositional defiant disorder, are char- acterized by willful disobedience. Conduct disor- ders affect males more often than females and commonly overlap with other psychiatric disor- ders. A single cause cannot be identified; how- ever, many of these children come from unstable or dysfunctional families and are exposed to do- mestic violence, poverty, and shifting parental fig- ures. The risk for disruptive behavior disorders increases with inconsistent parenting and puni-

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tive disciplinary techniques, parental alcohol and drug abuse, and parental antisocial personality disorder. Harsh parental discipline with physical punishment appears to lead to aggressive behav- ior; however, genetic heritability of antisocial and aggressive behaviors has been identified.

Signs include defiance of authority, fighting, school failure, and destruction of property. Dur- ing adolescence, fire setting, theft, sexual pro- miscuity, and criminal behaviors may develop. Treatment involves individual and family coun- seling as well as medication if appropriate.

Attention Deficit Hyperactivity Disorder Attention deficit hyperactivity disorder (ADHD) is characterized by prominent symptoms of inatten- tion and/or hyperactivity and impulsivity. ADHD affects males more often than females and per- sists into adolescence and adulthood. The cause is unknown, but family and twin studies provide evidence of genetic susceptibility, and molecular DNA studies implicate the role of genes in ADHD. Imaging techniques show anatomic and meta- bolic differences in the brains of ADHD subjects compared to non-ADHD subjects.

The DSM-IV defines three subtypes of ADHD: predominantly inattentive, predominantly hyper- active-impulsive, and combined inattentive, hy- peractive, and impulsive. Children with the inat- tentive subtype tend to be described as “spacey” and socially withdrawn, and they have fewer con- duct and behavioral problems than the hyperac- tive-impulsive subtype. The term ADD (attention deficit disorder) was once used to describe chil- dren with these symptoms, but ADD is no longer a DSM diagnosis. Even so, at times ADD is still used informally today to describe children with the predominantly inattentive subtype of ADHD. Hyperactive ADHD children tend to run around excessively, fidget, and have difficulty playing or engaging in quiet activities. Impulsivity in ADHD is characterized by the inability to wait turns, blurting out answers, and interrupting others.

Contrary to common belief, ADHD is not lim- ited to childhood. ADHD has a chronic lifelong course and, if untreated, results in school and work failure, substance use disorders, legal diffi- culties, car accidents and fatalities, and sexual indiscretions. ADHD commonly occurs with de-

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pressive disorders, anxiety disorders, conduct disorder, oppositional defiant disorder, and learning disorders. Like many psychiatric disor- ders, ADHD often requires multimodal treat- ment that may include medication, cognitive-be- havioral therapy, counseling, and collaboration

among a variety of clinical professionals (Table 14–2 �). The majority of children with ADHD are effectively treated with stimulant medications. Stimulant medications are the oldest and most established pharmacological agents in children with ADHD (Table 14–3 �). Behavior therapy can

Table 14–2 � Clinical Specialists in Treatment and Diagnosis of ADHD

Clinical Specialty Can Diagnose Can Prescribe Medication If Needed

Provides Counseling or Training

Psychiatrists Yes Yes Yes

Psychologists Yes No Yes

Pediatricians or Family Physicians Yes Yes No

Neurologists Yes Yes No

Clinical Social Workers Yes No Yes

Source: National Institutes of Mental Health: www.nimh.org

Table 14–3 � Medications Used in Treatment of ADHD

Trade Name Generic Name Approved Age

Adderall amphetamine 3 and older

Concerta (long acting) methylphenidate 6 and older

Cylert* pemoline 6 and older

Dexedrine dextroamphetamine 3 and older

Dextrostat dextroamphetamine 3 and older

Focalin dexmethylphenidate 6 and older

Metadate ER (extended release) methylphenidate 6 and older

Metadate CD (extended release) methylphenidate 6 and older

Ritalin methylphenidate 6 and older

Ritalin SR (extended release) methylphenidate 6 and older

Ritalin LA (long acting) methylphenidate 6 and older

*Because of its potential for serious side effects affecting the liver, Cylert should not ordinarily be considered as first-line drug therapy for ADHD. The Food and Drug Administration recently approved a medication for ADHD that is not a stimulant. The medication Strattera®, or ato- moxetine, works on the neurotransmitter norepinephrine; whereas the stimulants primarily work on dopamine. Both of these neurotransmit- ters are believed to play a role in ADHD. More studies will need to be done to contrast Strattera with the medications already available but the evidence to date indicates that over 70% of children with ADHD given Strattera manifest significant improvement in their symptoms.

Sources: National Institutes of Mental Health: www.nimh.org; Food and Drug Administration: www.fda.gov

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improve academic achievement and reduce tar- geted conduct problems, especially in children with a co-occurring conduct disorder.

Developmental Disorders

Mental Retardation Mental retardation is defined by the presence of low intelligence accompanied by deficits in social and language skills and adaptive functioning. The most common biological cause of mental re- tardation is fragile X syndrome, an inherited de- fect of the X chromosome that affects 1 in 4000 males and 1 in 6000 females in the United States. However, in some cases the exact cause cannot be identified. Treatment focuses on occu- pational therapy to maximize the development of cognitive and behavioral skills.

Autistic Disorder Autistic disorders (autism) include deficits in rec- iprocal language and social interactions and are characterized by repetitive stereotyped behav- iors. Autism affects approximately 3.4 in 1000 children in the United States. Autism often goes unrecognized during infancy and first becomes apparent after 3 years of age. The cause of autism is unknown. Central nervous system changes have been postulated, but no definitive links have been made to autism and no genes are yet strongly associated with the disorder.

The concordance rate for autism in twins is about 90%, and the rate of autism is higher in families with a history of language-related disorders.

The most notable deficits in autism are severe deficits in reciprocal social interactions. These include minimal eye contact with caregivers, de- layed language development, and disinterest in social interactions with peers, usually first ob- served during the toddler years. When speech does develop, it usually is illogical and echolike, as words that are heard are repeated. Repetitive and stereotypic behaviors include odd postur- ing, hand flapping, self-injurious behavior, ab- normal patterns of eating and drinking, and un- predictable mood changes.

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Widely accepted as effective when begun early, applied behavior analysis (ABA) has been shown to improve behavior and communication skills. ABA utilizes intensive and frequent one- on-one interaction with a therapist. No medica- tions are approved for treatment of children with autism. Medications for behavior and mood have been used and these include antide- pressants, anxiolytics, and antipsychotics. As with other childhood illnesses, parental guid- ance and assurance is critical for obtaining ap- propriate medical and psychosocial support. In- formed parents contribute to the child’s learning of self-care and adaptive skills and to positive long-term outcomes.

Tic Disorders A tic is a sudden, rapid, involuntary stereotyped movement or vocalization that may be tem- porarily suppressed by conscious efforts. Tics are exacerbated by stress, anxiety, boredom, or fatigue, and typically decrease in severity when the child is concentrating on an enjoyable task. Tics occur more commonly in boys than girls and are presumed to result from a neurotrans- mitter imbalance. Tourette syndrome is a com- mon tic disorder characterized by patterns of motor and vocal tics and affecting 1 to 10 of every 1000 children and adolescents in the United States.

Complications of tic disorders include embar- rassment and impaired self-esteem that results from being teased and rejected by peers and adults. Severe symptoms may interfere with forming intimate friendships. The unemploy- ment rate in adults with tics has been reported as high as 50%.

Transient tics usually do not require treat- ment. Complicated tic disorders require care- fully titrated medication therapy. No medication eliminates tics, but some can modulate tic severity. The dopamine blockers risperidone and haloperidol can reduce the severity of tics.

Dementia Dementia is a degenerative syndrome charac- terized by deficits in memory, language, and mood. The most common form of dementia is

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Alzheimer’s disease, which develops gradually and occurs most commonly after the age of 60 years. Vascular dementia has a more abrupt onset and is caused by physical insults from high blood pressure, diabetes, and strokes. Poor nutrition, head injuries, with chronic alcohol in- take may result in alcohol-related dementia. Parkinson’s disease is a degenerative neurologi- cal movement disorder characterized by demen- tia in late stages of the disease (see Chapter 13).

Alzheimer’s Disease In 1906 Dr. Alois Alzheimer first recorded cer- tain abnormalities in the brain of a woman who died from dementia. Alzheimer’s disease is a de- generative and progressive form of dementia that seriously disrupts daily living activities, be- havior, and mood.

The two most significant risk factors for Alzheimer’s disease are advanced age and fam- ily history. Up to 4.5 million people annually are affected by Alzheimer’s disease in the United States. The prevalence of Alzheimer’s disease in- creases with age, with the risk increasing over age 60, but Alzheimer’s disease is not a normal part of aging. Alzheimer’s affects about 5% of men and women age 65 to 74 and about 50% of those over age 80. Causes remain unknown, but certain mutations in chromosomes and in- heritance of two high-risk genes are associated with a greater risk for developing Alzheimer’s disease.

Alzheimer’s disease can only be diagnosed definitively by autopsy. However, it is important to recognize the disease early, and so a tentative diagnosis is made using a number of different sources of information. The patient, caretakers, and family members should be interviewed to determine the patient’s history, information about the person’s general health, past medical problems, and ability to carry out daily activi- ties. Standard psychological tests are given to assess memory, problem solving, attention, counting, and language. Finally, brain scans (positron emission tomography, or PET scans) can evaluate brain function.

The earliest manifestation of Alzheimer’s dis- ease is loss of short-term memory. Psychosis, aggression, and profound personality changes

are associated with advanced disease. With se- vere disease, judgment is lost, personal care is neglected, and physical illnesses ultimately may lead to death.

Physical findings in Alzheimer’s disease in- clude degeneration of neurons and plaque for- mation on and around neurons. Plaques or de- posits of proteins build up around neurons and interrupt communication between neurons by neurotransmitters. Abnormal collections of proteins form neurofibrillatory tangles that are detected by brain scans. Acetylcholine is the neurotransmitter that is most affected by Alzheimer’s disease. Decreases in acetylcholine are correlated with memory loss. Alterations in norepinephrine, GABA, and serotonin have been documented and may play a role in mood, behavior, and aggression.

Medications can slow the progression of early and middle stages of Alzheimer’s disease, but they do not cure the disease or stop its pro- gression. These medications include Aricept, Exelon, Razadyne, and Namenda. Associated symptoms of depression, aggression, and anxi- ety may be treated with antidepressants and anxiolytics. Social support is needed to improve the quality of life and maximize personal care. Vitamin E may prevent the progression of Alzheimer’s disease by decreasing oxygen-free radicals that accelerate cell death. In spite of treatment, the disease remains progressive, often ending in death 8 to 10 years after onset of symptoms.

Substance Abuse Disorders

Substance abuse disorders include drug and alco- hol abuse and addiction. Drug and alcohol abuse and addiction have many adverse med- ical, emotional, and economic outcomes. Com- monly abused substances include alcohol, co- caine, amphetamines, LSD, PCP, prescription drugs like benzodiazepines and painkillers, bar- biturates, opiates like codeine and morphine, and marijuana (Table 14–4 �). Substance abuse and addiction occur at all ages, affect all socioe- conomic groups, and worldwide are among the most common causes of disability and death.

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Symptoms of drug and alcohol dependence include compulsive use, physical and psycho- logical cravings and dependence, tolerance, and withdrawal. The addict cannot function without the use of drugs and/or alcohol, and daily activ- ities center on obtaining the substance. The key sign of substance abuse is persistent use that is physically damaging and continues in spite of adverse medical, social, economic, and legal consequences.

Some signs and symptoms are specific to the type of substance abused and include behav- ioral and physical changes. Long-term alcohol abuse and addiction are characterized by denial and attempts to hide the addiction and tem- porarily lead a functional life. A patient history reveals a pattern of alcohol use to maintain nor- mal functioning and the inability to refrain from drinking or becoming intoxicated. The physical effects of long-term alcohol abuse include mal-

nutrition, cirrhosis, neuropathy, brain damage, and cardiomyopathy. See Chapter 9 for more on the physical effects of alcohol addiction.

Behavioral and physical changes accompa- nying addiction and abuse involving other substances also depend on the type of sub- stance abused, and this lies beyond the scope of this text.

Causes and risk factors that lead to sub- stance abuse include stressful events, un- treated mental illness, genetic predisposition, and, in children and adolescents, peer pressure, poor self-esteem, depression, and even bore- dom. Legitimate medicinal use of drugs rarely leads to abuse or addiction. Underlying addic- tion and abuse are seeming alterations in the dopamine reward centers of the brain where al- cohol or drugs simulate pleasure and reward in susceptible individuals. Family and twin studies have implicated genes in addiction.

Table 14–4 � Commonly Abused Drugs

Stimulants

Cocaine

Street Names

Coke, snow, crack, crank

Amphetamines

Amphetamine sulfate

Methamphetamine

Dextramphetamine sulfate

Bennies, grennies, cartwheels

Speed, meth, crystal

Hearts, oranges, dexies

Hallucinogens

LSD (lysergaic acid diethylamide) PCP, angel dust, rocket fuel, elephant tranquilizer, peace pill

Depressants

Alcohol

Benzodiazepines

Barbituates

Opiates

Beer, wine, distilled drinks like whiskey, gin, vodka

Dolls, yellow jackets

Barbs, downers, reds

Heroin: junk, horse, H, smack; Morphine: M, morph

Cannabinoids

Marijuana Pot, grass, weed, reefer, joint, THC

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Treatment of Alcohol and Substance Abuse Treatment of alcohol abuse and addiction must include total abstinence from drinking. Sup- portive individual and group therapy and coun- seling, including Alcoholics Anonymous (AA), is effective for some alcoholics. Medical treatments such as acamprosate (Campral) reduce craving for alcohol and are effective at reducing relapses when used in combination with supportive ther- apy. Treatment of other types of substance abuse and addiction depends on the type of substance but must also include a treatment plan that leads to complete abstinence.

Schizophrenia

Schizophrenia is a complex mental illness that affects over 1% of the U.S. population. The onset of schizophrenia is often first noted in late teenage years or early adulthood. Signs and symptoms of schizophrenia include hallucina- tions, delusions, disordered thinking, move- ment disorders, flat affect, social withdrawal, and cognitive deficits. These symptoms fall into three categories: positive, negative, and cogni- tive, and include fairly complex and pervasive disturbances in behavior and thinking (Box 14–3 �). The suicide rate among schizophrenics is 10%, and the average life expectancy is lower than that of the general population.

Schizophrenia diagnosis is based on a de- tailed history and family interviews. Medical causes such as tumors or endocrine disorders may be ruled out. The pattern of characteristic signs and symptoms are key to diagnosis. The characteristic signs of schizophrenia are a gradual withdrawal from people, activities, and social contacts, with increasing concern for ab- stract and sometimes eccentric ideas. Some patients experience only a single episode and remain symptom free for most of their lives. The course of the illness can fluctuate over many years and can get worse if episodes reoc- cur. Depression, anxiety, suspiciousness, diffi- culty in concentrating, and restlessness are

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among the early symptoms of schizophrenia, and they intensify or diminish as the illness progresses.

Disturbances in perception, or hallucinations, and false beliefs, or delusions, are reflected in behavior and thoughts that are vague and de- tached from reality. Schizophrenics may experi- ence auditory or visual hallucinations in which they may hear or see things that are not pre- sent. Delusions are commonly persecutory (be- lief that they are being watched, followed, or plotted against), grandiose (belief that they have special powers, influence, or wealth), or somatic (physical belief that something is rotting inside their bodies).

Affect, or “feeling tone,” refers to the outward expression of emotion. The schizophrenic affect may be extremely unstable, with rapid shifts from sadness to happiness for no obvious rea- son, or it may be flattened, with no signs of emotion in tone of voice or facial expression. Pa- tients may state that they no longer respond to life with normal intensity or that they are “los- ing their feelings.”

Motor disturbances in schizophrenia may be catatonic or rigid, or disorganized or agitated. Catatonic features may range from a total re- duction in movement, or “zombie-like state,” to a wild, aggressive, and agitated state. Disorga- nized conduct is usually blunted or dull, bear- ing no relationship to social signals. The causes of schizophrenia are complex and include ge- netics and environment. While schizophrenia occurs in 1% of the population, it occurs in 10% of those who have a first-degree relative with schizophrenia and occurs at a high rate among identical twins. In spite of these obser- vations of genetic risk for developing schizo- phrenia, no genes have been definitively linked to schizophrenia. Environmental risks include exposure to viruses or malnutrition in the womb, problems during birth, and psychosocial factors, like stressful environmental conditions. Levels of the neurotransmitters dopamine and glutamate and changes in brain metabolism and structure point to the biological basis for schizophrenia.

Treatment includes antipsychotic medica- tions such as risperidone and olanzapine.

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Box 14–3 � Signs and Symptoms of Schizophrenia

Positive Symptoms

Positive symptoms are easy-to-spot behaviors not seen in healthy people and usually involve a loss of contact with real- ity. They include hallucinations, delusions, thought disorder, and disorders of movement. Positive symptoms can come and go. Sometimes they are severe and at other times hardly noticeable, depending on whether the individual is receiv- ing treatment.

• Hallucinations • Delusions • Thought disorders • Disorders of movement

Negative Symptoms

The term negative symptoms refers to reductions in normal emotional and behavioral states.

• Flat affect (immobile facial expression, monotonous voice) • Lack of pleasure in everyday life • Diminished ability to initiate and sustain planned activity • Speaking infrequently, even when forced to interact. • Neglect basic hygiene • Need help with everyday activities

Cognitive Symptoms

Cognitive symptoms are subtle and are often detected only when neuropsychological tests are performed.

• Poor “executive functioning” (the ability to absorb and interpret information and make decisions based on that infor- mation)

• Inability to sustain attention • Problems with “working memory” (the ability to keep recently learned information in mind and use it right away)

Source: Diagnostic and Statistical Manual Text Revision IV. American Psychiatric Association, 2000 and the National Institute of Mental Health, www.nimh.gov

Treatment must include illness management therapy, psychosocial therapy, and cognitive behavioral therapy and must often include fam- ily therapy.

Mood Disorders

Mood disorders are characterized by marked pe- riods of sadness and euphoria. While it is nor- mal for people to experience ups and downs, those who have major depression or bipolar disor- der experience debilitating symptoms that result

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in vocational failure, social withdrawal, and dysfunctional relationships.

Major Depression Complaints of sadness and hopelessness are commonly expressed by depressed individuals. Major depression occurs at any age and, if un- treated, may result in suicide. At least one de- pressive episode affects up to 80% of the U.S. population annually. Women are diagnosed with major depression about twice as often as men. Depression in the elderly is often masked by

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concurrent physical illness and is attributed to normal aging processes. Poor performance in school, irritability, loss of appetite, social with- drawal, and pretending to be sick are signs of depression in children.

A major depressive disorder consists of at least one episode of serious mood depression ac- companied by a number of changes in behavior. Complaints frequently include a loss of interest and pleasure, and withdrawal from activities. Feelings of guilt, worthlessness, anxiety, and shame are reported because individuals with major depression view their illness as a moral deficiency. Physical symptoms that suggest emotional distress include unexplained weight loss or weight gain, disturbed sleep, decreased energy, poor eye contact, monosyllabic speech, and indifference to pleasure or joy.

Subcategories of depression include seasonal affective disorder, postpartum depression, dys- thymia, and premenstrual dysphoric disorder. Sea- sonal affective disorder is believed to be due to decreased sunlight exposure during the winter months. Postpartum depression usually occurs 2 weeks to 6 months following the birth of a child. Persistent care of the newborn, sleep de- privation, social stresses, and hormonal changes all play a role in the development of postpartum depression. Chronic depression or dysthymia is diagnosed when symptoms persist for more than 2 years. Cyclic depressive symp- toms prior to menstruation may occur regularly for some women.

Heredity is currently the most important pre- disposing factor for major depression. The risk for major depression is higher in families with a history of mood disorders. Depression in a parent contributes to depression in genetically vulnerable children. While stressful life events trigger sadness, despair, and grief, stressful factors alone do not cause major depression (Box 14–4 �).

The most prominent theory for depression fo- cuses on regulatory disturbances in neuro- transmitters. The neurotransmitters serotonin, norepinephrine, and dopamine are widely dis- tributed in the central nervous system and are implicated in regulation of mood, arousal, movement, and sleep. Medications that increase

serotonin, norepinephrine, and dopamine effec- tively reduce symptoms of depression.

Major depression may occur with a number of physical and psychological disorders. Physi- cal disorders such as thyroid disease or Cush- ing’s disease induce depression by altering hor- mone levels. Chronic heart disease or cancer produce depressive symptoms from associated disability, fatigue, and physical pain. Direct physical causes of depression include HIV infec- tions and seizure disorders that damage the brain and central nervous system. Psychological disorders such as anxiety disorders, eating dis- orders, and developmental disorders are often referred to as co-morbid disorders because they commonly occur with major depression.

Various prescription medications and sub- stance abuse induce depression by altering brain function and regulation of hormones and neurotransmitters. Heart medications, for ex- ample, alter neuronal responses to norepi- nephrine, leading to fatigue and depressive symptoms. Corticosteroid medications induce behavioral changes, psychosis, and major de- pression especially in susceptible individuals.

Box 14–4 � Symptoms of Major Depression

• Prolonged sadness or unexplained crying spells • Significant changes in appetite and sleep patterns • Irritability, anger, worry, agitation, anxiety • Pessimism, indifference • Loss of energy, persistent lethargy • Unexplained aches and pains • Feelings of guilt, worthlessness, and/or

hopelessness • Inability to concentrate • Indecisiveness • Inability to take pleasure in former interests • Social withdrawal • Excessive consumption of alcohol or use of chem-

ical substances • Recurring thoughts of death or suicide

Source: Diagnostic and Statistical Manual Text Revision IV. American Psychiatric Association, 2000.

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Alcoholic beverages as well as many commonly abused substances depress the central ner- vous system.

A trial of antidepressant medication that re- stores regulation of norepinephrine, dopamine, and/or serotonin is indicated for most cases of major depression. These drugs elevate the lev- els of these neurotransmitters; the drugs are commonly called selective serotonin reuptake inhibitors (SSRIs), noreprinephrine reuptake inhibitors (NRIs), serotonin and norepineph- rine reuptake inhibitors (SNRIs), and dopamine agonists. Optimal reduction of symptoms is usually noticed 14 to 21 days after starting medication. Psychosocial treatment is often re- quired to improve social functioning and to change depressive thought processes. De- pression that is resistant to drug treatment may respond to electroconvulsive therapy, in which electrodes apply current to the brain. Severe depression may be accompanied by psy- chosis, which requires the use of antipsychotic medications.

Bipolar Disorder Bipolar disorder, or manic-depressive illness, is a mood disorder that causes unusual shifts from depression to mania, or an overly elevated, ener- getic, irritable mood. Periods of highs and lows are called episodes of mania and depression. Bipolar disorder affects more than 2 million American adults annually. Bipolar disorder typically devel- ops in late adolescence or early adulthood. How- ever, some people have their first symptoms dur- ing childhood, and some develop them late in life. Bipolar disorder is often not recognized as an ill- ness, and people may suffer for years without a diagnosis or proper treatment (Box 14–5 �).

Mania can vary from extreme elation, hyper- activity, and irritability to extreme aggression, with little need for sleep, and risky behaviors that are later regretted. An overly enthusiastic mood at times may attract others; however, mood shifts with delusions may lead to alien- ation of friends and family and to irresponsible behaviors such as spending one’s life savings or engaging in sexual indiscretions.

A distinct period of an abnormally elevated mood that is not induced by the physiologic ef-

fects of a drug substance followed by a distinct period of depression is central to diagnosis of a bipolar disorder. Different categories of bipolar disorder are determined by patterns of symp- toms or severity of highs and lows. Bipolar I dis- order is associated with periods of intense mania and depression that last for several weeks. Bipolar II disorder is associated with less severe episodes of mania, but depression may continue for several weeks. A chronic fluctuat- ing mood, with mild symptoms of both depres- sion and mania, or cyclothymic disorder, often is undiagnosed and may eventually result in a more severe form of bipolar disorder.

The causes of bipolar disorder are unclear, though genetic, biochemical, and environmental causes have been identified. Like other mental illnesses, several genes acting together may ulti- mately identify patients who will develop bipolar disorder. Bipolar disorder runs in families, and stressful experiences may trigger some symp- toms. Changes in neurotransmitter regulation that lead to bipolar disorder may be affected by the presence of another illness, stress, sub- stance abuse, changes in diet and exercise, and hormonal changes.

Box 14–5 � Symptoms of Mania

• Increased physical and mental activity and energy • Heightened mood, exaggerated optimism and

self-confidence • Excessive irritability, aggressive behavior • Decreased need for sleep without experiencing

fatigue • Grandiose delusions, inflated sense of self-

importance • Racing speech, racing thoughts, flight of ideas • Impulsiveness, poor judgment, distractibility • Reckless behavior such as spending sprees, rash

business decisions, erratic driving, and sexual indiscretions

• In the most severe cases, delusions and hallucinations

Source: Diagnostic and Statistical Manual Text Revision IV. American Psychiatric Association, 2000.

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Medical treatment of bipolar disorder is com- plex. Patients often require prolonged treatment with medications called mood stabilizers, such as lithium or certain antiepileptic medications, anti- depressants, sedative medications or “sleep aids,” and major tranquilizers or antipsychotic medica- tions. Family and individual patient counseling improves social functioning by providing psycho- logical support and treatment that stabilizes ex- treme characteristics of mania or depression.

Anxiety Disorders

Anxiety disorders include a number of disorders in which the primary feature is abnormal or in- appropriate anxiety that interferes with daily school, work, recreational, and family activities. Anxiety is a normal phenomenon in which our mind and body reacts to flee from danger, also known as “fight or flight.” Heart rate, respiratory rate, blood pressure, and muscle tension in- creases at the onset of a stressful event. Symp- toms of anxiety become a problem when they occur without any recognizable cause or when the cause does not require an intense response.

Anxiety disorders affect adults and children and may persist for many years without proper treatment. As with many other mental illnesses, family and friends often label those that suffer anxiety disorders as weak and unable to “snap out of their condition.” Some people’s lives be- come so restricted that they avoid normal, every- day activities such as grocery shopping or dri- ving. In some cases, they become housebound.

The genetic basis for anxiety disorders origi- nates from family studies. Anxiety disorders are common among relatives of affected individuals. The risk for phobias is greater in relatives of in- dividuals with both depression and panic disor- der. In cases of PTSD, genetic factors may ex- plain why only certain individuals exposed to trauma develop PTSD.

Head injuries, an overactive thyroid gland, car- diovascular disease, respiratory disease, altered regulation of neurotransmitters, and certain medications may cause anxiety disorders. Indi- viduals with anxiety disorders are more sensitive to medications that increase heart rate, blood pressure, and fear behaviors. Abnormal neuro- transmission of the neurotransmitter serotonin

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as a cause of obsessive-compulsive disorder (OCD) is recognized by a reduction of symptoms with medications that increase serotonin.

Types of Anxiety Disorders

Physical symptoms and behaviors vary slightly with each subtype of anxiety disorder. Panic dis- order, generalized anxiety disorder, phobic dis- orders, social phobia, obsessive compulsive dis- order, and post-traumatic stress disorder share the common theme of excessive, irrational fear.

Panic Disorder A panic attack involves a sudden onset of fear and terror accompanied by physical symptoms in vital organs such as the heart and lungs. Shortness of breath, chest pains, and pal- pitations peak within 10 minutes and usually re- solve within 30 to 60 minutes. Because of the un- predictability of a panic attack, people who have them develop anticipatory anxiety, or a persistent pattern of worry regarding when and where the attack will take place. Physical complaints often lead patients to seek emergency medical care.

Generalized Anxiety Disorder Severe persistent worries that are out of proportion to the circum- stance describe a typical day for sufferers of gen- eralized anxiety disorders. Common worries re- lated to work, money, health, and safety are difficult to control. Additional complaints of rest- lessness, fatigue, muscle tension, impaired con- centration, and disturbed sleep may often be misdiagnosed as depression.

Phobic Disorders An irrational fear of something, or a specific phobia, that poses little or no danger is the most common type of anxiety disorder. Some phobias, such as a fear of the dark, of strangers, or of large animals, begin in childhood and disap- pear with age. Hyperventilation, or rapid breath- ing, may accompany a fear of heights, flying, closed spaces, insects, and rodents. Although adults with phobias realize that these fears are irrational, they often find that facing the feared object or situation brings on a panic or severe anxiety attack.

Social Phobia Social phobia involves excessive worry and self-consciousness in everyday social situations. Intense fears of being humiliated in social situations interfere with ordinary activi-

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ties. Physical symptoms that accompany social anxiety include blushing, profuse sweating, nau- sea, and difficulty talking.

Obsessive-Compulsive Disorder Anxious, irrational thoughts and images, also known as obsessions, lead to the need to perform rituals to prevent or get rid of the obsessive stimulus. Rituals are pat- terns of irrational behaviors, or compulsions, that provide temporary relief from the anxiety. Obsessions centered on cleanliness and fear of germs, for example, may lead to compulsive hand washing. Other rituals may include the need to repeat certain words and phrases to ward off danger, or repetitive counting of objects. Patients with obsessive-compulsive disorder (OCD) are aware that their compulsion and corresponding ritual is irrational but cannot stop it. OCD af- fects both men and women, and symptoms may ease over time with appropriate treatment.

Post-traumatic Stress Disorder Exposure to an overwhelming traumatic incident such as the events of September 11, 2001, or encounters of trauma such as rape, violence, child abuse, or war, may lead to symptoms and diagnosis of post- traumatic stress disorder (PTSD). Victims of trauma develop persistent frightening thoughts and memories months or years after the event. The traumatic event is repeatedly experienced as nightmares and flashbacks or numbing recollec- tions of the event throughout the day. The indi- vidual avoids reminders of the event, startles or feels frightened easily, and may feel detached and numb. PTSD sufferers may lose interest in things they used to enjoy, avoid affection, and become ir- ritable or aggressive. Individuals with PTSD often feel guilty about surviving the event or about be- having destructively, as in case of veterans of war.

Imaging techniques have focused on the role of brain structures that mediate communication and process information to memory. The amygdala is an almond-shaped structure located deep within the brain, and it may play a role in fear and phobias. The hippocampus is a structure of the brain that processes and stores informa- tion to memory. The size of the hippocampus ap- pears smaller in post-traumatic stress disorder, which may explain the memory deficits and flashbacks in individuals with PTSD.

Treatment of Anxiety Disorders Anxiety, as a learned response to a stimulus and corresponding biochemical changes in brain chemistry, responds to treatment with medica- tions and psychotherapy. Medications that in- crease serotonin are effective in the treatment of OCD, though psychotherapy is often required to gain understanding of underlying emotional con- flict. Antianxiety medications that increase the ef- fect of the neurotransmitter gamma aminobutyric acid (GABA) have a calming effect and work quickly. The use of antianxiety medications is limited, however, by their potential for addiction.

Eating Disorders

Eating disorders involve serious disturbances in eating behavior. Fashion trends, ad campaigns, social attitudes, and athletics promote leaner body weight and a preoccupation with body shape and weight. Extreme attitudes surround- ing weight and food, combined with psychologi- cal and medical complications, define the disabil- ities that meet the criteria for eating disorders.

Symptoms of Eating Disorders Anorexia nervosa and bulimia nervosa occur pri- marily in young women who develop a paralyzing fear of becoming fat. In anorexia nervosa, fear of obesity causes excessive restriction of food, re- sulting in emaciation. Bulimia involves massive binge eating followed by purging or excessive di- eting and exercise to prevent weight gain.

Anorexia Nervosa Anorexia means “lack of ap- petite.” Ironically, individuals with anorexia ner- vosa are hungry and yet are preoccupied with di- eting and limiting food intake to the point of starvation. There is an intense fear of gaining weight or becoming fat even though anorectics be- come dangerously thin. The process of eating be- comes an obsession, with rituals centered on meal plans, calorie counts, compulsive exercise, and self-induced vomiting despite little food intake.

The typical anorectic is an adolescent female who has lost 15% of her body weight, fears obe- sity, stops menstruating, and otherwise looks

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healthy. Other notable signs include low blood pressure, decreased heart rate, and edema, or swelling of tissues. Metabolic changes, includ- ing dehydration and depletion of electrolytes (sodium, potassium, and chloride), can result in abnormal heart rhythm, heart failure, sudden cardiac arrest, and death.

Usually described as the honor-roll student or state champion, the individual denies that anything is wrong and typically does not seek medical care until prompted into treatment by friends and family. Depression is common as anorectics withdraw from social affairs involving food and festivities.

Bulimia Nervosa Similar to anorexia nervosa, bu- limics are excessively concerned with body weight and physical shape. Unlike anorectics, bulimics binge by eating an excessive amount of food within a restricted period of time, followed by compensatory purging behavior such as self- induced vomiting or misuse of laxatives or diuret- ics. Rigorous dieting and exercise may also follow binges to prevent weight gain. There is a feeling of loss of control during the binging episode, fol- lowed by intense distress and guilt. Body weight may be normal, which makes it easy for bulim- ics to hide their illness.

The medical consequences of bulimia nervosa can be devastating. Stomach acid and digestive enzymes from vomiting erode tooth enamel and cause injury and inflammation to the esophagus and salivary glands. Severe dental caries and gum disease eventually require removal of teeth. Vomiting and laxative and diuretic abuse lower blood potassium levels, causing muscle cramp- ing and abnormal heart rhythms. In cases of se- vere potassium loss, death may result from car- diac arrest. Prolonged and excessive laxative abuse may severely damage the bowel. If the bowel ceases its function, surgery is required to form a colostomy, an opening from the bowel to the abdominal wall to allow removal of the feces into a bag attached to the outer abdominal wall.

Bulimics are aware of their behavior and feel intense guilt and shame. Bulimics are generally outgoing, impulsive, and prone to depression and alcohol or drug abuse. Unlike anorectics, bulimics are more likely to talk about their illness and des- perately seek help from physicians and friends.

Patterns of psychological and interpersonal is- sues most consistently provide insight into the causes of eating disorders. Low self-esteem and persistent feelings of inadequacy shape attitudes of perfectionism for the anorectic and severe self- criticism for the bulimic. Troubled family rela- tionships, difficulty expressing feelings and emo- tions, and a history of physical or sexual abuse are reported more often in bulimics than anorec- tics. Social attitudes that value thinness and limit beauty to specific body weight and shape influ- ence body image and contribute to extreme diet- ing and exercise for both anorectics and bulimics.

The biological basis for eating behavior in- volves a complex network of brain structures and neurotransmitters. The hypothalamus reg- ulates hunger, monitors fullness of the stom- ach, and determines how much food is eaten. The limbic system influences emotions and se- lection of foods to appease the appetite. The pre- frontal region of the brain controls decisions about when, where, and how to eat. Future studies on the biology of appetite control and behavior may lead to development of new med- ications to treat eating disorders.

Successful treatment of and recovery from eating disorders requires the realization that starvation, binging, and purging is destructive. Medical treatment to restore nutrition and re- place fluids and electrolytes is crucial to prevent death from organ failure. Medication to relieve depression and anxiety may improve mood and thought processes. Group, family, individual, and nutritional counseling provide support to break down delusions that shape eating behav- ior and distortions in body image.

Personality Disorders

Persistent, inflexible patterns of behavior that af- fect interpersonal relationships describe per- sonality disorders. Personality disorders appear in adolescence or early adulthood and remain stable throughout an individual’s lifetime. The DSM-IV describes three major categories of personality disorders based on “clusters” of symptoms.

Personality disorders occur along with med- ical and psychiatric illnesses. Relations with family, friends, and caregivers are often strained

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by inflexible and maladaptive personality char- acteristics. People with severe personality disor- ders are more vulnerable to psychiatric break- downs and are at risk for alcoholism, substance abuse, reckless sexual behavior, eating disor- ders, and violence.

Symptoms of Personality Disorders Cluster A: Paranoid and Schizoid Paranoid Personality The paranoid personal- ity type is indifferent, suspicious, and hostile. His or her relationships are shallow because of a ten- dency to respond to positive acts or kindness with distrust. The paranoid personality type interprets positive statement such as “You look like a million bucks” to mean “My friend is after my money.”

Schizoid Personality People with schizoid per- sonality appear cold and isolated. Often called introverted, schizoid personality types appear self-absorbed and withdrawn. They often deal with their fears through superstitions, magical thinking, and unusual beliefs.

Cluster B: Antisocial, Borderline, Histrionic, and Narcissistic Antisocial Personality Callous disregard for others and manipulation of people for personal gratification characterize antisocial personality types. Antisocial personality may start as a con- duct problem in childhood, manifested as disre- spect for authority and for personal and public property. Adolescents and adults with antisocial personalities are at risk for alcoholism, drug abuse, sexual improprieties, and violence.

Borderline Personality Borderline personality disorders often occur in women who were de- prived of adequate care during childhood. Their moods are unstable and characterized by crisis and anger alternating with depression. Threats of real or imagined abandonment elicit impulsive behaviors such as promiscuity and substance abuse. The individual with a borderline person- ality disorder is vulnerable to brief psychotic episodes, substance abuse, and eating disorders.

Histrionic Personality The histrionic personal- ity is characterized by theatrical and exaggerated emotional behavior. Friendships are initially formed because others are attracted to the histrionic per- sonality’s energetic and entertaining behavior. Hys-

teria and flamboyant behaviors often result in neg- ative responses and feelings of rejection.

Narcissistic Personality The narcissistic per- sonality type has an exaggerated self-image and a tendency to think little of others. Narcissists expect others to admire their grandiosity and feel they are entitled to have their needs attended to. When rejected by others through criticism or de- feat, the narcissist becomes enraged or severely depressed.

Cluster C: Avoidant, Dependent, and Obsessive-Compulsive Avoidant Personality Avoidant personality types appear shy and timid, as if they have a so- cial phobia. They fear relationships, although they have a strong desire to feel accepted. They are hypersensitive to criticism and rejection and are susceptible to depression, anxiety, and anger for failing to develop social relationships.

Dependent Personality Dependent personal- ity types have an extremely poor self-image. They appoint others to make significant decisions out of fear of expressing themselves or offending oth- ers. Extended illness may bring out a dependent personality in adults.

Obsessive-Compulsive Personality The obses- sive-compulsive personality types are depend- able, meticulous, orderly, and intolerant of mis- takes. They are often high achievers, attending to details while failing to complete the task at hand. Individuals with an obsessive-compulsive personality avoid new situations and relation- ships because these new elements cannot be me- thodically controlled.

Treatment of Personality Disorders Most people with personality disorders do not see a need for treatment. Often, secondary med- ical and psychiatric illnesses force persons with personality disorders to seek treatment. Rigid thoughts and behavior often complicate compli- ance with treatment and are frustrating for healthcare providers. Individual, family, and group therapy is required to point out conse- quences of behavior. Antianxiety, antidepres- sant, and antipsychotic medications may be re- quired to treat accompanying symptoms of anxiety, depression, and psychosis.

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Suicide

Suicide is almost always associated with mental illness. People consider suicide when they feel hopeless and are unable to see alternative solu- tions to confusion, mental and physical an- guish, and chaos in their life. Risks for suicide include substance abuse, previous suicide at- tempts, a family history of suicide, a history of sexual abuse, and impulsive or aggressive char- acter. More than four times as many men as women die by suicide; however, women attempt suicide more often. Suicidal behavior occurs most often when people experience major losses and stressful events such as divorce, loss of a job, incarceration, and chronic illness.

Unlike physical illnesses, mental illness has no visible wounds and so is associated with social stigma, isolation, and personal faults. Those with mental illness contemplating suicide may talk about their distress at the risk of being judged, ignored, and isolated. Warning signs of suicide include withdrawal, talk of death, giving away cherished possessions, and a sudden shift in mood. A severely depressed person may un- expectedly appear better, or a schizophrenic may progressively develop delusions about death prior to a suicide attempt. A suicide at- tempt or completed suicide is devastating to families, friends, and caregivers, who commonly

▼ experience remorse and guilt for failing to avert the suicide attempt or death.

Age-Related Disorders

Mental illness can occur at any age. Some disor- ders occur first in childhood and adolescence, such as ADHD, conduct disorder, and opposi- tional defiant disorder. Others are developmen- tal disorders usually first recognized in child- hood but continue throughout life; these disorders include mental retardation, autistic disorders, and tic disorders. Some are strongly associated with adolescence, including bulimia nervosa and anorexia nervosa. Other disorders clearly associated with advanced aging include dementia and Alzheimer’s disease. Many other disorders can first occur at any time during adulthood from young adult through advanced age. These include depression, anxiety, schizo- phrenia, and substance abuse disorders.

R E S O U R C E S

Food and Drug Administration: www.fda.gov

National Alliance for the Mentally Ill: www.nami.org

National Institutes of Mental Health: www.nimh.org

World Health Organization: www.who.org

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Suicide Warning Signs Mentally ill people may have self-destructive thoughts and may exhibit suicidal behaviors. Patients with depressive symp- toms in particular are more likely to have suicidal thoughts. Thus it is important for healthcare workers and families of the patient to watch for suicide warning signs. The following are signs of suicidal behavior and require immediate attention:

• Withdrawal and isolation • Depression • Saying good-bye to close friends and family • Giving away or discarding personal possessions • Indirectly expressed suicide messages or wishes • Explicit suicide messages

If you or someone you know exhibits these behaviors, call your doctor, or call 911, or go to a hospital emergency room to get immediate help, or ask a friend or family member to help you do these things. Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889) to talk to a trained counselor.

Source: National Institutes of Mental Health: www.nimh.org

Prevention PLUS!

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DISEASES AT A GLANCE Mental Illness and Cognitive Disorders*

DISORDER ETIOLOGY SIGNS AND SYMPTOMS

Disruptive behavior disorders Genetics, biology, environment Willful disobedience, defiance of authority, aggression

Attention deficit hyperactivity disorder

Genetics, biology, environment Hyperactivity, impulsivity, inattention

Mental retardation Genetics, biology, environment Social language deficits, below-average intelligence

Autistic disorder Genetics, biology, environment, toxins

Reciprocal language deficits, repetitive stereotypical behaviors

Tic disorder Genetics, biology, environment Rapid involuntary repetitive movement or vocalization

Dementia Genetics, biology, environment, toxins

Language, memory, and mood deficits

Substance abuse disorders Genetics, environment Compulsive use, physical and psychological cravings, tolerance, and withdrawal

*Prevention of a disorder and its complications depends on screening and intervention, especially in at-risk persons.

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DIAGNOSIS TREATMENT LIFESPAN

Psychosocial and medical evaluation, psychometric testing; diagnosed in childhood

Cognitive, behavioral psychotherapy, pharmacotherapy: stimulants, atypical antipsychotic medications, mood stabilizers

Onset in early childhood

Psychosocial and medical evaluation, psychometric testing; diagnosed prior to the age of 7, with approximately 50% persistence into adulthood

Cognitive, behavioral psychotherapy, pharmacotherapy: stimulants, atypical antipsychotic medications, certain antidepressants

Onset in early childhood; more prevalent in boys

Psychosocial and medical evaluation, psychometric testing; diagnosed usually before 3 years of age

Behavioral therapy, occupational therapy, social support services

Usually first recognized in childhood

Psychosocial and medical evaluation, psychometric testing; diagnosed usually around 3 years of age

Behavioral therapy, occupational therapy, social support services; pharmacotherapy or other supportive care to manage aggression or self-injurious behavior

Usually first recognized by age 3

Psychosocial and medical evaluation, psychometric testing; diagnosed usually before adulthood

Behavioral therapy; pharmacotherapy: certain antidepressants or atypical antipsychotic medications

Can develop at any age; usually first recognized in childhood and adolescence

Psychosocial and medical evaluation; diagnosed most commonly after age 60

Behavioral, cognitive, family psychotherapy; social supportive care services; pharmacotherapy: memory enhancers, atypical antipsychotic medications, antidepressants, and/or mood stabilizers

Onset in older adults

Diagnosis may follow social, medical, or legal consequences imposing psychosocial evaluation

Behavioral therapy, 12-step programs supporting abstinence (such as Alcoholics Anonymous or Narcotics Anonymous). Pharmacotherapy: antidepressants, atypical antipsychotic medications, or mood stabilizers

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DISEASES AT A GLANCE Mental Illness and Cognitive Disorders (continued)

DISEASE ETIOLOGY SIGNS AND SYMPTOMS

Schizophrenia Genetics, biology, environment Loss of contact with reality, severe disturbance in social functioning, bizarre thoughts, withdrawal from social interactions, hallucinations, delusions

Major depression Genetics, biology, environment Prolonged sadness, significant changes in sleep and appetite, irritability, feelings of guilt and anxiety

Bipolar disorder Genetics, biology, environment Mania (episodic elation, inflated sense of self) alternating with depression

Anxiety disorder Genetics, biology, environment Inappropriate fear response with avoidance of daily work, family, life, school, and recreational activities

Eating disorders Genetics social trends, attitudes, and stresses

Anorexia: persistent dieting, starvation, excessive exercise, body weight less than 15% of ideal body weight Bulimia: binge followed by purging behavior, overuse of laxatives, excessive dieting, body weight normal or thin

Personality disorders Environment Inflexible patterns of behavior with strained relationships; may occur with substance use disorders, reckless sexual behavior, eating disorders and violence

*Prevention of a disorder and its complications depends on screening and intervention, especially in at-risk persons.

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DIAGNOSIS TREATMENT LIFESPAN

Psychosocial and medical evaluation, psychometric testing, unpredictable behavior

Pharmacotherapy: antipsychotic medications primarily, antidepressants occasionally; behavioral therapy, occupational therapy, social support services

Usually first recognized in late adolescence and early adulthood