3.1

• ▪ Common Signs and Symptoms

• ▪ Diagnostic Tests

• ▪ Common Mental Health Diseases and Disorders

  • Developmental Mental Health Disorders

  • Substance-Related Mental Disorders

  • Organic Mental Disorders

  • Psychosis

  • Mood or Affective Disorders

  • Dissociative Disorders

  • Anxiety Disorders

  • Somatoform Disorders

  • Personality Disorders

  • Gender Identity Disorder

  • Sexual Disorders

  • Sleep Disorders

• ▪ Trauma

  • Grief

  • Suicide

• ▪ Rare Diseases

• ▪ Mental Health Disorders in the Older Adult

• ▪ Summary

• ▪ Review Questions

• ▪ Case Studies

• ▪ Bibliography

Addiction (p. 536)

Affect (p. 545)

Anorexia nervosa (p. 533)

Bulimia (p. 533)

Circadian rhythm (p. 546)

Compulsion (p. 548)

Delirium tremens (DTs) (p. 537)

Delusions (p. 540)

Dependency (p. 536)

Euphoric (p. 539)

Hallucinations (p. 537)

Hallucinogenic (p. 540)

Intoxicated (p. 536)

Mania (p. 547)

Mood (p. 545)

Obsession (p. 548)

Organic (p. 542)

Tolerance (p. 536)

Withdrawal (p. 536)

Upon completion of the chapter, the learner should be able to:

• 1. Define the terminology common to mental health disorders.

• 2. Identify the important signs and symptoms associated with mental health disorders.

• 3. Describe the common diagnostic tests used to determine the type and/or cause of mental health disorders.

• 4. Identify common mental health disorders.

• 5. Describe the typical course and management of the common mental health disorders.

• 6. State the mental health disorders found in the older population and the effects of these disorders.

M ental health disorders are some of the most difficult diseases to diagnose and understand. Symptoms can range from mild behavior changes to severe personality disturbances. Because of the variety of symptoms, the difficulty in diagnosing some disorders, and the lack of understanding of the physiologic cause, many mental health disorders are misdiagnosed and can go untreated for years. Although some mental health problems are not yet well understood, many more are relatively easy to diagnose and treat.

for mental health disorders, there are only a few common signs and symptoms. Typically symptoms of mental health problems begin with behavioral changes. These are often slow developing and very subtle, so symptoms might not be noticed early in the development of a disorder, and many of the symptoms, such as forgetfulness, anxiety, or temper tantrums, are attributed to age, stress, or other illnesses. Typical symptoms of each mental health problem are discussed with the specific disorder.

A variety of diagnostic tests is used to determine the specific mental health problem. When symptoms first appear, the physician usually orders physiologic assessments such as laboratory tests, brain scans, electroencephalograms (EEGs), and magnetic resonance imaging (MRI) scans to determine whether the cause is an organic problem; then the individual might be referred to a psychiatrist for psychological testing to determine a diagnosis. These tests can include an aptitude test, personality test, and several others, depending on the symptoms presented and the severity of the symptoms.

Mental health disorders range from mild to severe. A few disorders have a genetic base, others are due to behavior choices, and some are of unknown cause. Early diagnosis and treatment are essential to assist the individual either to overcome the disorder or to improve the quality of life.

Developmental mental health disorders are those usually discovered during infancy, childhood, or adolescence. These disorders might diminish or worsen as the child matures. Developmental disorders that are carried into adulthood can be mild, allowing the involved individual to function in an adult role, or be so severe that institutionalization is necessary.

INTELLECTUAL DISABILITY

▪ DESCRIPTION. Intellectual disability is a condition of decreased intelligence leading to a decrease in the ability to learn, socialize, and mature. Intellectual disability varies in degrees from mild and moderate to severe and profound.

▪ ETIOLOGY. The cause of intellectual disability is often unknown. Known causes fall into two categories: genetic and acquired (Table 21-1). Some types of intellectual disability can be avoided by providing prenatal care.

▪ SYMPTOMS. Affected children might not show signs of intellectual disability until entry into school. Difficulty learning and keeping up with other children of the same age can be indicative of this disorder.

▪ DIAGNOSIS. Diagnosis is confirmed on the basis of observation and IQ testing. IQ testing is a controversial issue today because many feel this testing is culturally biased. If testing is used, the most common types are the Wechsler and Stanford-Binet systems. IQ scores of 90 to 109 are considered normal intelligence. Scores of 71 to 89 are considered borderline in intellectual functioning. Scores below 70 indicate profound disability with an inability to perform the simplest tasks of daily living.

▪ TREATMENT. Treatment of intellectually disabled individuals varies with the amount of disability. Many mildly disabled individuals grow up and find employment in a suitable occupation and lead fairly normal lives. Others might need special, dependent-living facilities, but very few are disabled to the level of needing institutionalization.

▪ PREVENTION. Many cases are not preventable, but one common cause that can be prevented is fetal alcohol syndrome. Prenatal care, education, and encouragement to avoid alcohol when pregnant are helpful measures to prevent intellectual disability due to this cause.

   Another preventable cause is kernicterus, a brain damage that occurs when a baby has too much bilirubin in the blood, causing excessive jaundice. Treatment of kernicterus can prevent intellectual disability.

ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD)

▪ DESCRIPTION. ADHD is a mental health disorder characterized by an inability to concentrate, hyperactivity, and impulsiveness.

▪ ETIOLOGY. The cause of ADHD is unknown, but there does appear to be a familial pattern. This behavior can be apparent at any age but is usually observed before the age of 7, becoming more obvious in school situations.

▪ SYMPTOMS. Examples of ADHD behavior include forgetfulness, not appearing to listen, difficulty in remaining seated or waiting one's turn, squirming, excessive running, climbing, talking, inability to complete detailed work, messy work, and an inability to organize. These behaviors tend to become more exaggerated in a group situation.

▪ DIAGNOSIS. Diagnosis is made on the basis of observation of the age-inappropriate behavior. It is now recognized that in many youngsters with this condition, the hyperactivity component might not be a major factor (especially in girls), and the term attention-deficit disorder (ADD) would serve better, but ADHD has become the accepted diagnosis.

▪ TREATMENT. Treatment of ADHD with amphetamines has shown varying degrees of effectiveness. Behavior modification by rewarding appropriate behavior also has been successful.

▪ PREVENTION. Preventive measures to reduce the incidence of ADHD are not known at this time. Early detection and treatment can reduce the symptoms.

EATING DISORDERS

▪ DESCRIPTION. An eating disorder is a compulsion to eat, or avoid eating, that affects the mental and physical condition of the individual. Eating disorders have a negative impact on all aspects of the individual's life, including school, work, and personal relationships. These disorders affect approximately 5 in 100 females in the United States. Two common eating disorders are anorexia nervosa and bulimia.

• ▪ Anorexia (AN-oh-RECK-see-ah; an = without, orexia = appetite) nervosa is a disorder of self-imposed starvation resulting from a distorted body image (Figure 21-1).

• ▪ Bulimia (boo-LIM-ee-ah) is a disorder characterized by episodes of binge eating (an intake of approximately 5,000 calories in 1 to 2 hours) followed by activities to negate the calorie intake by purging.

▪ ETIOLOGY. The exact cause of these eating disorders is not known. It is thought that one factor relates to the great emphasis Americans place on the thin, perfect, female body. To obtain this ideal figure, many females go to dieting extremes.

▪ SYMPTOMS. The effects of these disorders can range from decreased energy levels, growth retardation, and menstrual dysfunction to more severe effects such as cardiac disturbances, delayed puberty, personality changes, inability to perform activities of daily living, and death. The affected female's excessively thin body often appears prepubescent in shape, which can help reduce stress by decreasing the fears of growing up, sexuality, and developing a sexual identity.

   The term anorexia is a misnomer because the appetite is not diminished, but the affected individual simply refuses to eat from fear of becoming fat. The typical characteristics of an individual with anorexia nervosa include:

• ▪ Adolescent female

• ▪ Meticulous, high achiever

• ▪ Distorted body image (feels fat no matter how thin)

• ▪ Intense fear of becoming fat

• ▪ Performs excessive exercise

   Affected individuals often come from families exhibiting conspicuous togetherness characterized by over-protectiveness and conflict avoidance. The mother is often controlling and domineering, whereas the father is distant and uninvolved. The family unit often fails to support the idea that the adolescent female is competent and able to function in an independent way.

   Bulimic individuals exhibit purging behaviors including self-induced vomiting or excessive laxative use. Excessive vomiting often leads to electrolyte imbalances and erosion of the teeth.

   Individuals affected with bulimia are usually older than anorexics, more obese, and experience a wide fluctuation in weight. Bulimic individuals, like anorexics, tend to have perfectionist personalities and a dread of becoming fat.

▪ DIAGNOSIS. Eating disorders are diagnosed by physical examination, diet history, and reports from the affected individual, family, and close friends.

▪ TREATMENT. Anorexia and bulimia are both classified as psychiatric disorders. Treatment of either is often difficult and lengthy, involving both restoring normal nutrition and resolving psychological problems.

   Early intervention is critical to prevent severe complications, and the entire family must be involved in the individual's recuperation plan. Usually, this can be accomplished on an outpatient basis, but in severe cases, the individual might need hospitalization for treatment or forced feedings until stable.

   Several clinics in the United States specialize in treating eating disorders. The use of antidepressant medications can be beneficial. Death from starvation is often due to compromised cardiac function.

▪ PREVENTION. There is no known prevention for eating disorders. Educational programs that promote health and early identification of these disorders are helpful, and early treatment is the best course to prevent progression of the disorder and potential complications.

TIC DISORDERS

▪ DESCRIPTION. Tic disorders include a variety of conditions characterized by sudden, rapid muscle movement or vocalization.

▪ ETIOLOGY. The cause of tics is unknown, but there is some evidence that maternal emotional stress during pregnancy might play a part in development. Tic tends to develop in children ages 5 to 10 years. Tics are irresistible but tend to increase with stress and decrease with sleep or preoccupation with another activity.

▪ SYMPTOMS. Examples of tics include eye blinking, facial grimacing, neck or shoulder jerking, throat clearing, snorting, and grunting, to name just a few.

▪ DIAGNOSIS. Physical examination is typically all that is needed for diagnosis.

▪ TREATMENT. Treatment depends on how this condition is affecting the individual's life. Medication and psychotherapy are used only if the condition is having a major impact on school, job, and other life activities. Dopamine blocker medications such as risperidone and pimozide are used to treat tics, but these are not always successful.

▪ PREVENTION. There are few preventive measures for tic disorders, but avoiding emotional stress during pregnancy might be helpful. Because tic disorders appear more often when individuals are stressed, avoiding or minimizing stress can also aid in prevention of symptoms.

ENURESIS

▪ DESCRIPTION. Enuresis (EN-you-REE-sis), commonly called bedwetting, is a condition of urinary incontinence after the age of bladder training (usually considered as 5 years of age). Enuresis is more common in males than in females and commonly affects firstborn children.

▪ ETIOLOGY. The cause of enuresis is unknown, but it does have familial tendencies and is thought by some to be due to inadequate or poor attempts at toilet training.

▪ SYMPTOMS. The only symptom is involuntary bedwetting that occurs at least twice a month.

▪ DIAGNOSIS. A physical examination is usually completed to rule out any physical conditions. A bedwetting diary outlining dates of wetting episodes along with time of meals, fluid intake, and sleep time can be helpful.

▪ TREATMENT. Treatment involves encouraging the child to participate in planning and carrying out a program to reduce and finally eliminate the episodes. Planning might include restriction of fluids after the evening meal, bladder training to help enlarge the capacity of the bladder, urinating before bedtime, and awakening the child during the night to void. Reprimanding, ridiculing, and shaming the child should be avoided because these activities tend to make the condition worse.

▪ PREVENTION. Getting plenty of sleep and developing a habit of using the bathroom at scheduled times during the day and evening hours might prevent some episodes of bedwetting.

Alcohol affects the teenage brain differently than the adult brain. Many teens are the size of adults and thus might be expected to react to alcohol in the same way, but their brains are different, so they react to alcohol differently. The Centers for Disease Control and Prevention (CDC) has reported that 25% of teens use alcohol and participate in binge drinking. This is dangerous behavior. A researcher noted that the teen brain has less white matter, and thus, the teen cannot make judgments and decisions as the adult can. Teens have a greater tendency to make quick decisions and engage in impulse-driven behaviors. This might be why there are many more fatal car accidents and dangerous sexual encounters in the teen population. Ongoing research is looking at all aspects of teen behavior, and new recommendations for caution might be forthcoming soon.

Source: Paturel (2011).

Substance-related mental disorder is now the diagnosis used in place of the term drug addiction. The annual cost of substance abuse in the United States has been estimated at more than $193 billion a year (Substance Abuse and Mental Health Services Administration, 2011). It is a national problem that needs continued investigation, education, and monitoring.

   Common terms used in substance-related mental disorders include addiction, dependency, tolerance, and withdrawal. Addiction means a physical and or psychological dependence on a substance. Dependency is a psychological craving for a substance that might or might not be accompanied by a physical need. Tolerance is the ability to endure a larger amount of a substance without an adverse effect or the need for a larger amount or dose of the drug to attain the same effect. Withdrawal is the unpleasant physical and psychological effects that result from stopping the use of the substance after an individual is addicted.

ALCOHOLISM

▪ DESCRIPTION. Alcoholism, a physical and mental dependence on a regular intake of alcohol, is one of the most common mental disorders, with approximately 10% of the population affected. It is a chronic, progressive, and often fatal disease. Onset of alcoholism is often insidious, beginning in the teen years. Excessive use can be related to stress, depression, or some other stressful life event.

   Alcoholism is a major drug problem that causes approximately 100,000 deaths per year and adversely affects the physical, mental, social, and spiritual health of the affected individual. Chronic alcoholism causes physical damage to nearly every organ system. Some of the common problems include heart disease, hypertension, cirrhosis, pancreatitis, peripheral neuropathy, and gastrointestinal problems (including an increased risk of stomach and esophageal cancer).

   Mental disorders include anxiety, depression, insomnia, impotence, and amnesia. These physical and mental problems, along with the associated accidents, injuries, and violence associated with alcoholism, can be psychologically, socially, and economically devastating to affected individuals and their families.

▪ ETIOLOGY. The cause of alcoholism is unknown. There is no universally accepted explanation for alcoholism, although recent research points toward a biological explanation or at least a genetic predisposition. Other causal factors can include depression, poverty, peer pressure, and condoning of substance abuse by peers and family members. Individuals raised in homes in which both parents are alcoholics are at very high risk for also becoming alcoholics.

   Alcohol is absorbed in the mouth and small intestine and is broken down by the liver. A normal-sized individual can metabolize or break down approximately 30 milliliters of alcohol, or 1 ounce of whiskey, every 90 minutes. If taken in higher amounts or consumed more frequently, alcohol causes a sedative effect and can depress breathing and lead to death.

▪ SYMPTOMS. An individual is intoxicated when the blood alcohol level reaches 0.10% or more. Four to 6 hours after intoxication occurs, the individual experiences a hangover with symptoms of nausea, vomiting, fatigue, sweating, and thirst. The primary cause of a hangover is the accumulation of alcohol in the blood and hypoglycemia.

Family therapy may be an effective alternative treatment for drug abuse in adolescents and adults. Researchers have found that family-based therapy programs show the best effects with both the families and young drug abusers. Drug abuse affects the entire family and causes distress and disruptions to all members. The family-based treatment regimen is recommended as an alternative modality for drug abuse. These programs have proven to be an effective approach to treating drug abusers and helping families of abusers.

Source: Rowe (2012).

   Alcoholics become physically dependent on alcohol and can experience symptoms of withdrawal if alcohol is withheld for 24 to 48 hours. Symptoms of withdrawal include hallucinations (a false sensation of sight, touch, sound, or feel), tremors of the hands, mild seizures, and delirium tremens (DTs).

   Symptoms of delirium tremens can include agitation, memory loss, anorexia, seizures, and hallucinations. DTs usually last 1 to 5 days and can be fatal if not properly treated. Treatment for withdrawal includes tranquilizers, anticonvulsive medication, adequate nutrition, and antiemetic (anti = against, emetic = nausea or vomiting) medications.

   The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines problem drinking as more than 7 drinks per week for women and more than 14 drinks per week for men. Diagnosis is frequently difficult because affected individuals are often embarrassed and not forthcoming with information. A history of alcohol abuse is often obtained from family members. Blood tests including blood alcohol and liver enzymes can be helpful.

▪ TREATMENT. Treatment of chronic alcoholism includes rehabilitation designed to meet the alcoholic's physical and psychological needs and supports total abstinence from alcohol. Many alcoholics have found success with self-help groups.

MARIJUANA ABUSE

▪ DESCRIPTION. Marijuana is a mixture of the dried leaves and flowers of an Indian hemp plant, Cannabis sativa (Figure 21-2). This mixture is crushed and rolled into cigarettes or joints. It can also be smoked in a pipe.

   Hashish, a resin from the flowering top of the hemp plant, is thought to be four to eight times stronger than marijuana. Both marijuana and hashish usually produce a euphoric effect or sense of well-being. This effect is immediate and lasts approximately 2 to 3 hours.

▪ ETIOLOGY. All forms of marijuana are mind-altering because they contain delta-9-tetrahydrocan-nabinol (THC), the active chemical in the plant. THC disrupts the nerve cells in the brain, making it difficult to problem-solve, remember events, and participate in activities with normal skill and coordination. THC is absorbed by fatty tissue in the body and can be detected in urine samples for weeks after use.

▪ SYMPTOMS. The short-term effects of marijuana use include memory loss, slowed ability to learn, distorted perception, loss of coordination, and increased heart rate. Long-term effects of use include the short-term effects as well as problems in the respiratory, immune, and reproductive systems.

   True tolerance does not develop with marijuana use, but chronic use can lead to a psychological dependence. Marijuana use has not been proven to lead to the use of hard drugs, but users often experiment with other drugs.

   Beneficial uses of marijuana include a lowering of intraocular pressure in glaucoma patients and relief of nausea and vomiting in individuals on chemotherapy.

SYNTHETIC CANNABIS ABUSE

▪ DESCRIPTION. Synthetic cannabis, or “fake weed,” also known as “K2” and “Spice,” is a psychoac-tive designer drug made from a mixture of herbal and spice plants sprayed with chemicals that mimic the effects of marijuana. This designer drug began selling in 2000. It was originally thought that these blends achieved an effect through a mixture of legal herbs, but chemical analysis of the ingredients showed that these blends actually contained synthetic cannabinoids that acted on the body in a similar way as marijuana.

   In an effort to continue legal sales in the United States, a large variety of synthetic cannabinoids were sold under various brand names and marketed as herbal incense online and in head shops. The Synthetic Drug Abuse Prevention Act of 2012 banned synthetic compounds commonly found in synthetic marijuana, making them a controlled substance and therefore illegal to possess or use in the United States.

▪ SYMPTOMS. Symptoms and side effects mimic those of marijuana.

COCAINE ABUSE

▪ DESCRIPTION. Cocaine is one of the most addictive drugs abused by individuals. It is estimated that one in two Americans between the ages of 25 and 35 has tried cocaine, and 3.6 million Americans are regular cocaine users (National Institute on Drug Abuse, 2009).

   Cocaine is a powerful stimulant that accelerates the central nervous system and an anesthetic that numbs whatever part of the body it touches. The anesthetic properties of powdered cocaine make it an ideal legal medication for patients undergoing nasal surgery.

   Effects of the drug include increased blood pressure, dilated pupils, increased heart rate, hyperstimulation, reduced fatigue, and a high associated with pleasure. The length of the effect depends on the route of administration and amount used.

   Cocaine is obtained from either the leaves of the coca plant found in South America or synthetic production. Cocaine is a pure white powder referred to as coke. It is quite expensive at $100 per gram.

   The powder form of cocaine is commonly cut into lines, or doses, with a razor blade and snorted (drawn up) through the nose with a straw or tightly rolled dollar bill (Figure 21-3). Drug paraphernalia include a piece of glass or mirror and a razor blade. Snorting produces a slower response than injecting, with effects lasting approximately 20 minutes. Complications of snorting cocaine include disintegration of the mucous membrane of the nose and ulceration through the nasal septum.

   Cocaine powder can also be mixed with water, heated to help with the dissolving process, and injected. Drug paraphernalia, in this case, includes syringes, spoons, and straws. Injecting cocaine and sharing needles increase the risk of human immunodeficiency virus (HIV).

   Another form of cocaine is called crack or free-base. Crack cocaine is currently made by heating a mixture of powder cocaine, water, and ammonia or baking soda, causing the material to precipitate into a hardened form of small chips or chunks. Historically, this process involved the use of ether and other flammable bases rather than ammonia and baking soda. Processing with the ether method is very dangerous due to the flammability of this product.

   Crack cocaine is four to five times stronger, and much more addictive, than powder cocaine. Crack is smoked rather than snorted or injected. Manufacturing and smoking crack cocaine is called freebasing. When smoked, crack reaches the brain within seconds, giving an intense high, or rush, to the body. The high lasts approximately 5 to 15 minutes and then fades into a restless desire for more of the drug.

   Crack is sold by the size of the rock and ranges from $5 to $40. This cost is initially less expensive than powdered cocaine, but the intense addiction this drug causes leads to increased use and cost. Addiction often leads to theft, prostitution, and dealing to obtain the money needed to purchase more cocaine.

   Crack cocaine is usually smoked with marijuana, tobacco cigarettes, or in a glass pipe. Overdosing with crack is more common than with powder cocaine. In some instances, death has occurred with the first dose taken. However, most deaths associated with the drug are related to overdosing, mixing the drug with other drugs or alcohol, or both.

   When mixed with alcohol, the liver combines the drugs, creating a third substance called cocaethylene, which intensifies the euphoric (sense of well-being) effects of cocaine but increases the risk of sudden death.

▪ TREATMENT. Treatment for cocaine addiction includes behavior modification along with some pharmacologic agents. Recent research in antiaddiction medications is aimed at development of opioid receptor blocking. Infants born to cocaine-using mothers are often addicted and exhibit low birth weight, hyper-activity, tremors, and frantic sucking activities.

METHAMPHETAMINE ABUSE

Methamphetamine is a white, odorless powder that acts as an addictive, potent stimulant that affects the central nervous system. It is one of the most abused drugs. It is popular among the young because it is relatively cheap to purchase and is easily produced in home laboratories. It can be taken by mouth, injected, smoked, or sniffed.

   The effects of the drug include decreased appetite, decreased fatigue, anxiety, and a general euphoric state. After the initial rush, the effects can last up to 8 hours. Long-term use has many negative consequences including severe dental problems called “meth mouth,” extreme weight loss, anxiety, confusion, insomnia, mood disturbances, and violent behavior.

   Repeated abuse of methamphetamine can lead to addiction accompanied by chemical and molecular changes in the brain. Chronic users can develop psychotic features including visual and auditory hallucinations, paranoia, and delusions. A common delusion involves insects crawling under the skin.

ECSTASY (MDMA) ABUSE

▪ DESCRIPTION. Ecstasy (MDMA, 3,4-methyl-enedioxymethamphetamine) is a synthetic, psycho-active drug similar to the methamphetamine. Street names are Ecstasy, Adam, beans, and love drug. Ecstasy is an illegal psychedelic stimulant that produces an energizing effect and distortions in time and perception.

▪ SYMPTOMS. Ecstasy primarily affects the brain and may cause persistent memory problems. It also can affect the body's ability to regulate temperature, leading to hyperthermia. Other symptoms may include increased heart rate and blood pressure, muscle tension, involuntary teeth clenching, nausea, confusion, depression, sleep problems, drug craving, and severe anxiety.

CAFFEINE AND NICOTINE ABUSE

Two of the most common addicting substances in our society are caffeine and nicotine (Figure 21-4). Caffeine is a stimulant found in coffee, chocolate, tea, cola drinks, and some over-the-counter medications. Caffeine causes vasoconstriction and, over a long period of time, can lead to circulatory problems.

   Individuals addicted to caffeine often experience severe withdrawal headaches, anxiety, drowsiness, fatigue, and nausea. Caffeine tends to cause breast tenderness in females and intensify the symptoms of premenstrual syndrome (PMS). Caffeine is the cheapest and most abused drug in the United States.

   Tobacco use in this country is on the rise, especially among the teen population. Cigarettes are the most widely used drug by adolescents, despite widespread knowledge of the devastating effects of nicotine on the cardiovascular and respiratory systems. Nicotine is a stimulant that narrows blood vessels and raises the heart rate and blood pressure. It has been theorized that nicotine is as addictive as cocaine. Symptoms of withdrawal include depression, irritability, anger, anxiety, and an increase in appetite and weight gain.

   Smoking during pregnancy can result in spontaneous abortion and premature birth. Nicotine patches that reduce nicotine intake gradually have been successful in helping millions of affected individuals quit smoking.

Antidepressants decrease brain levels of dopamine, a brain chemical of pleasure that plays an important role in creativity and love/romance.

SEDATIVES OR DEPRESSANTS ABUSE

Drugs in this category are commonly antianxiety medications (Librium or Valium), barbiturates (Nembutal and Seconal), and hypnotics (Dalmane and Placidyl). Individuals addicted to these medications can use as much as 65 milligrams of Valium or 600 milligrams of Seconal a day.

   The most severely abused group of sedatives or depressants is the barbiturates. Street names for these drugs include downers or barbs, or they might be known by the color of the capsules (reds, yellow jackets, or rainbows). These medications are often prescribed to treat insomnia, hypertension, and seizure disorders. Barbiturates distort mood, leading to euphoria; slow down reaction times, causing an increase in automobile and home accidents; and, in some cases, cause hallucinations.

   Taking barbiturates with alcohol potentiates, or enhances, the effect of alcohol. Addiction and tolerance to barbiturates develop quickly and commonly lead to overdosing of barbiturates, causing a slowing of the heart and breathing that often results in death. Barbiturate use is one of the main causes of accidental death and is the most common method of suicide. Sudden withdrawal from barbiturates also can be life-threatening. It is recommended that withdrawal be conducted under the guidance of a physician. Affected individuals are usually hospitalized and the drug is withdrawn slowly to prevent nausea, delirium, and seizures.

   A nonbarbiturate sedative, methaqualone (Quaalude), was introduced in the United States in the mid-1960s and was marketed as having no effect on sleep patterns and little potential for abuse. Since that time, it has been discovered that Quaalude, commonly called ludes, does interfere with rapid eye movement (REM) sleep and does cause psychological and physical dependence. Withdrawal symptoms can last 2 to 3 days and can include insomnia, anxiety, nausea, hallucinations, and nightmares.

AMPHETAMINE ABUSE

Amphetamines are stimulant drugs that cause a release of the body's natural epinephrine, leading to an increase in heart rate, respiration, and digestion. Commonly, amphetamines are called speed, uppers, bennies, and pep pills. These drugs are often used by obese individuals to lose weight, by truck drivers to stay awake, and by college students to stay alert for studying. Amphetamines are addictive and do lead to tolerance. Chronic use often leads to an opposite effect, that is, to drowsiness. Depression and suicide can result from sudden withdrawal.

HALLUCINOGEN ABUSE

Hallucinogens, also called psychedelic drugs, commonly produce hallucinations. These drugs cause a heightened and distorted response to visual, auditory, and tactile stimuli and induce the affected individual to see flat objects take on shape, stationary objects to move, and colors to become more vivid. Hallucinogenic drugs include lysergic acid diethylamide (LSD), mescaline, and phencyclidine (PCP).

LSD is the most commonly abused drug in the hallucinogenic (producing psychedelic or bizarre alterations in mental functioning) class. It is a colorless, tasteless, and odorless synthetic substance primarily produced in illegal laboratories. It can be added to the food or drink of an unsuspecting victim or to chewing gum, hard candy, postage stamps, or stickers. LSD is a very potent drug; an amount of drug visible to the eye is enough to cause an 8-hour hallucination.

   With LSD, the heart rate increases, pupils dilate, blood pressure increases, and appetite diminishes. Delusions, hallucinations, and abnormal thought processes can cause temporary or permanent mental changes. Controversy exists over whether LSD might also cause chromosomal damage. Surprisingly, LSD is not addictive. It appears that this drug is abused to escape reality rather than to help cope with reality. Abusers of LSD do have a high tendency to abuse marijuana, barbiturates, and amphetamines.

   The danger of this drug lies in the fact that the activities of an individual under the influence of LSD are totally unpredictable. The person might attempt to fly or exhibit episodes of violence and self-destruction. Flashbacks (recurrence of a trip) can occur months after the drug was taken because it is stored in fat tissue and might be released at a later time.

Mescaline is similar to LSD but much weaker. It is an active chemical found in the Mexican peyote cactus that also can be produced synthetically (Figure 21-5). Native Americans use this cactus as part of their traditional religious ceremonies.

PCP, also known as angel dust, peace pill, and peace weed, is a depressant that was introduced in the 1950s as an animal tranquilizer. Its use has since been abandoned because of unpredictable side effects. PCP is easily produced in illegal laboratories and can be taken as pills or injections or by snorting or smoking. Danger lies in the poor and varied quality of the product sold on the street. PCP can cause memory lapses lasting for several days. Other symptoms are coma, convulsions, and respiratory arrest.

NARCOTIC ABUSE

Narcotics are depressants that are primarily prescribed as analgesics or painkillers. Demerol, methadone, morphine, heroin, and opium are classified as narcotics and are commonly abused. Narcotics lower blood pressure and slow nerve and muscle action and the rate of the heart and breathing. Physical and psychological dependence and tolerance rapidly develop with the use of narcotics. Overdose symptoms include slurred speech, confusion, staggering, coma, and respiratory arrest.

Opium is an air-dried, milky residue obtained from the unripe opium poppy. References to opium smoking are common in Oriental history, and some people in Asian countries still smoke opium. Users in the Western countries, including the United States, prefer opium derivatives such as morphine and heroin. Opium contains approximately 10% morphine. Heroin is a derivative of morphine but is approximately eight times stronger. Heroin is very addictive and is commonly called smack and horse. Heroin is the narcotic most widely used by narcotic addicts today.

Heroin is a fine white powder that is usually mixed with water and injected intravenously in a process called mainlining. It also can be snorted or smoked. Heroin use usually gives a rush, or intense feeling of well-being, followed by a sleepy, drowsy state. Withdrawal from heroin without medical treatment is called going cold turkey. Withdrawal is often uncomfortable but not usually life-threatening. Symptoms of withdrawal include sweating, shaking, diarrhea, vomiting, and sharp pain and cramps in the stomach and legs.

Abuse of opium-based drugs is increasing, and researchers are continuing to search for effective treatment measures. Chinese medicines such as WeiniCom (also known as Xuan Xia) have been used as an alternative treatment for opium addictions for centuries and also in conjunction with traditional treatments. Another herbal product used for opium addiction is kratom, which comes from a leaf of a tree found in Southeast Asia. The problem is that most of these herbs have not been well-researched to determine their effectiveness, toxicity, and therapeutic dosages.

Source: Ward et al. (2011).

INHALANT ABUSE

Inhalants are chemicals that produce a vapor that can be inhaled and that produce a mind-altering effect. Young people are more likely to abuse inhalants than adults and often treat the use of inhalants as a game or a way to get a cheap high. This is a very dangerous activity and has caused death in many adolescents.

   Inhalants include over 1,000 legal substances, including glue, spray paint, hair spray, nail polish, lighter fluid, and gasoline. These substances commonly contain harmful hydrocarbons and an oily base that, when inhaled, coats the inner lining of the lungs. Inhalant abuse refers to intentionally breathing the vapors of a substance to get high. This intentional breathing in is commonly called huffing, snuffing, or bagging. The effect is similar to alcohol intoxication.

   Bagging is the most dangerous because it entails placing a plastic bag over the head to get a longer effect. Using inhalants over a period of time can result in permanent brain, heart, kidney, and liver damage. Some products, such as paint and gasoline, contain lead and can lead to death from lead poisoning.

   Inhalant abuse is the third most common substance abused by individuals aged 12 to 14 years, surpassed only by alcohol and tobacco. Symptoms of inhalant abuse include spots or sores around the mouth, a glassy-eyed look, fumes on the breath or clothing, anxiety, and loss of appetite.

ANABOLIC STEROID ABUSE

Anabolic steroids are the synthetic derivatives of testosterone, the male hormone. They are widely abused by athletes and others trying to promote growth of skeletal muscle and increase lean body mass. From the fitness craze of the 1980s, the use of anabolic steroids has increased significantly in young males and even in females who want to develop athletic, lean bodies.

   Steroids are taken orally or injected. They do produce increases in muscle strength, lean body mass, and improved performance over periods of time, but the long-term effects are dangerous. The side effects include shrinking of the testes, reduced sperm count, infertility, and baldness in males; and growth of facial hair, changes in menstruation, enlargement of the clitoris, and a deepened voice in females.

   A spectrum of behaviors is exhibited by people on anabolic steroids that range from being somewhat more assertive, to being frankly aggressive, to displaying what is described as “roid rage.” Roid rage is commonly thought to account for some instances of road rage because this activity is not uncommon for those on steroids. A variety of extreme behaviors is exhibited by those on anabolic steroids.

   Adolescents or preteen children can experience accelerated puberty changes and growth cessation from premature skeletal maturation. Other effects reported include mood swings, depression, and irritability.

Organic mental disorders are those associated with some type of known physical cause. These disorders affect the cognitive abilities—the abilities to think, remember, and make judgments by the affected individual. These disorders can be temporary or permanent.

DEMENTIA

▪ DESCRIPTION. Dementia is common in the elderly; it was called senility in the past and thought to be caused by aging. Dementia is a progressive deterioration of mental abilities due to physical changes in the brain. The most common form of dementia is Alzheimer's disease. It accounts for 50%–75% of all cases of dementia.

▪ ETIOLOGY. We now know that dementia is not part of the normal aging process but, rather, is caused by a variety of medical conditions. Factors important in determining whether dementia will occur in an individual include nutritional status, family history, chronic diseases, and general state of health. Causes of dementia are listed in Table 21-2. Dementia might or might not be reversible, depending on cause.

▪ SYMPTOMS. Symptoms often develop gradually and show a progressive deterioration of cognitive or mental abilities, including severe memory loss, disorientation, impaired judgment, and the inability to learn new information. An affected individual might lose items, get lost when driving even in familiar areas, get confused in conversations, and lose the ability to perform common tasks such as balancing a checkbook. As the disease progresses, symptoms become more noticeable. Symptoms of dementia can become severe enough to interfere with the individual's ability to care for himself or herself.

▪ DIAGNOSIS. The diagnosis of dementia requires a thorough medical, physical, and neurologic examination. The American Psychiatric Association has established two criteria to support the diagnosis of dementia. The first is loss of memory. The second is the loss of one of the following functions: language, motor activity, recognition, and executive function (unable to plan, organize, or think abstractly).

▪ TREATMENT. Treatment focuses on correction of all reversible factors. These include correcting drug doses, ensuring that prescribed medications are being taken correctly, withdrawing misused drugs, treating depression and other medical conditions, and ensuring proper nutrition and hydration.

▪ PREVENTION. Researchers have found that activity in the elderly reduces the risk of dementia. Activities such as reading, playing musical instruments, dancing, playing board games, and doing puzzles are beneficial.

DELIRIUM

▪ DESCRIPTION. Delirium is not a disease but a clinical syndrome, or set of symptoms, that might result from a disease. Thorough assessment is necessary to distinguish it from other psychiatric disorders. Deliriums commonly affect 1 in 10 hospitalized patients and as many as 80% of those in intensive care units. Delirium is more common in the elderly and, although it is not a disease in and of itself, those who have it usually do not do as well as those with the same illness who do not have delirium.

▪ ETIOLOGY. Delirium is an acute condition that can develop suddenly or over a period of days. There are a variety of causes of delirium, including medications, alcohol, fever, dehydration, or physical illness. Causes of delirium are also listed in Table 21-2.

▪ SYMPTOMS. The classic symptom of delirium is a fluctuating level of consciousness with periods of calmness and extreme anxiety. The affected individual is often frightened and disoriented in place and time and has illusions, hallucinations, and incoherent speech. Individuals with delirium expend great amounts of energy, continually wandering and performing aimless activities.

▪ DIAGNOSIS. Diagnosis is made after a thorough medical history and physical and mental status examinations. The most important activity is determining the cause of the delirium. Tests can include blood and urine test, computerized tomography (CT), MRI, EEG, electrocardiogram (ECG), and lumbar puncture.

▪ TREATMENT. A calm, quiet atmosphere along with simple, clear communication, especially from family members, might help with symptoms. Physical restraints might be needed to keep the individual safe. Prompt and effective treatment of the cause often reverses the symptoms of delirium.

▪ PREVENTION. Prevention is focused on avoiding or treating the causes.

ALZHEIMER'S DISEASE

▪ DESCRIPTION. Alzheimer's disease is a progressive and irreversible form of dementia. Alzheimer's accounts for 50% of all dementias and commonly occurs after age 65 but can occur as early as age 40.

▪ ETIOLOGY. The cause of Alzheimer's is unknown, but theories include an inherited chromosomal defect, viral infection, a deficiency in neurochemicals in the brain, and an immunologic defect. Interestingly, postmortem studies have revealed a high level of aluminum in the brain and a higher incidence of a serious head injury. Physical changes noted during autopsy include brain plaques and neuronal tangles.

▪ SYMPTOMS. Symptoms begin with mild memory loss and progress to impaired mental function, personality changes, and speech and language problems. In the final stage, the affected individual is often depressed and paranoid and might have hallucinations. At this stage, the individual with Alzheimer's depends on another individual for total care and might need institutionalization. Death usually occurs in 10 to 15 years from onset and is usually due to complications of immobility.

▪ DIAGNOSIS. A thorough medical history involving family members and physical examination of the individual are needed along with testing to rule out other conditions. Test can include hearing exam, blood sugar levels, thyroid level, screening for depression, cognitive testing, and brain scanning with MRI or positron emission tomography (PET). Alzheimer's can usually be diagnosed with 80%-90% accuracy. The only definitive diagnosis is postmortem brain tissue examination.

▪ TREATMENT. Treatment is aimed at relieving symptoms and managing behavior problems. (See Chapter 15, “Nervous System Diseases and Disorders,” for more information.)

▪ PREVENTION. Research suggests that preventing or slowing the symptoms of Alzheimer's can be accomplished by lifestyle changes including:

• ▪ Wearing helmets and seatbelts and preventing falls to protect the brain from jarring or injury.

• ▪ Staying active with family and friends.

• ▪ Exercising your body and your brain.

• ▪ Eating a healthy diet.

Psychosis is a term describing conditions characterized by a disintegration of one's personality and a loss of contact with reality. Psychotic individuals have delusions, hallucinations, impaired communication skills, and an inability to deal with life's demands. These mental disturbances might or might not have a physical or structural change in the brain. One of the most common psychotic disorders is schizophrenia.

SCHIZOPHRENIA

▪ DESCRIPTION. Schizophrenia, meaning split mind, is a serious type of psychosis. It is not a split-personality disorder.

▪ ETIOLOGY. Various theories exist as to the cause of schizophrenia, including genetics, brain biochemical disorders, and structural alterations. It is generally agreed that schizophrenics have a genetic vulnerability because an individual with a schizophrenic parent, sibling, or other close relative has an increased possibility of becoming schizophrenic. Another theory suggests that schizophrenic individuals were deprived of meaningful relationships with family members during childhood years. This theory is supported by the fact that most schizophrenics felt that as children, they were unloved, unwanted, and unimportant.

▪ SYMPTOMS. This disorder often appears in individuals aged 16 to 25 and is more common in females than in males. Schizophrenics lose touch with reality and act on imagined or fantasized reality. Specific symptoms include delusions, hallucinations, flat tone of voice, incoherent speech, bizarrely disorganized behavior such as lack of speech, unresponsiveness, and muscular rigidity.

▪ DIAGNOSIS. Verbal screening tests are used to help determine the diagnosis. If one or more of the symptoms persist for 6 or more months, the diagnosis may be confirmed.

▪ TREATMENT. Drug treatment is the primary therapy. Studies indicate, however, that an integrated approach, using a variety of therapies, prevents relapses better than routine care (medication, monitoring, and access to rehabilitation programs).

▪ PREVENTION. There is no known way to prevent schizophrenia. Activities that reduce or prevent relapses include recognizing the first signs of relapse so early intervention is possible, reducing stress, avoiding alcohol and illegal drugs, and taking medications as prescribed.

DELUSIONAL DISORDERS

▪ DESCRIPTION. Delusional disorders are characterized by a firm belief in a delusion in an otherwise normally adjusted and balanced personality. The delusions often center on feelings of persecution and grandiosity and often involve romance, religion, and politics. These delusions often develop slowly and involve a false interpretation of an actual occurrence. Delusional individuals become firmly convinced that something is true no matter how convincing evidence is to the contrary. Types of delusional disorders affecting the thinking of affected individuals include the following:

• ▪ Grandiose—an inflated sense of self-worth, power, and knowledge.

• ▪ Jealous—belief that their sexual partner is unfaithful.

• ▪ Erotomanic—belief that someone of higher status is in love with them.

• ▪ Persecutory—seeing suspicious actions and having feelings that people are spying on them with harmful intentions.

• ▪ Somatic—belief that they have a physical disease or disorder.

   People with delusional disorder can often continue to socialize and function normally apart from their delusion. This ability to function in society is unlike other psychotic disorders. This disorder is more common in women and tends to occur in middle to late life.

▪ ETIOLOGY. The exact cause is not known, although genetic, biological, environmental, and psychological factors are thought to be involved.

▪ SYMPTOMS. Nonbizarre delusion is the most common symptom. Other symptoms include an irritable, angry, or low mood and hallucinations of sight, hearing, or things that are not really there.

▪ DIAGNOSIS. After a thorough medical and physical examination, if there is no physical reason for the condition, referral to a psychiatrist or psychologist is needed. A diagnosis is made if the individual has nonbizarre delusions for at least 1 month.

▪ TREATMENT. The most common medications used to treat delusional disorders are antipsychotics. These disorders are usually chronic, but if properly treated, many get relief from symptoms. Unfortunately, many will not seek help because they do not recognize that they are ill. Without treatment, these disorders can last a lifetime.

▪ PREVENTION. There is no known way to prevent delusional disorders, although treatment can improve the individual's life.

A study found that individuals who believe they are always treated unfairly are 55% more likely to have a heart attack. The authors recommended that these individuals focus on getting over the idea that life isn't fair.

Mood or affective disorders are those that involve the emotions (mood) and the outward expression of those emotions (affect). Mood ranges on a spectrum with extreme depression at one end and extreme elation or happiness at the other.

   Individuals normally experience times of sadness and moments of joy. When these emotions are not appropriate to the events of life, last for an inappropriate length of time, or are extreme in nature, mood disorders might be suspected. Some individuals with mood disorders can have extreme depression, whereas others will exhibit both extreme depression and extreme elation at alternating times (bipolar disorder).

DEPRESSION

▪ DESCRIPTION. Depression is a prolonged feeling of extreme sadness or unhappiness, despair, and discouragement. It is different from grief, which is a realistic sadness related to a personal loss. Prolonged grief might become depression because depression is often associated with loss of a loved one, possessions, self-esteem, and youth.

▪ ETIOLOGY. The cause of depression can include genetic, biological, and environmental factors. In some cases, the cause can be singular, whereas in others, it might be multifactorial. In some cases, the cause is never known.

   For some, the cause appears to be due to a decrease in chemicals in the brain known as neurotransmitters. These chemicals typically affect mood and appear to play a part in depression. Causes of depression include:

• ▪ Heredity—Certain types of depression run in families.

• ▪ Personality—People who are negative thinkers, are pessimistic, have low self-esteem, or are ineffective stress managers.

• ▪ Situations—Difficult life events, including death of family members or a friend, loss of job, or loss of financial status.

• ▪ Medical conditions—Heart disease, stroke, diabetes, cancer, menopause, or Parkinson's and Alzheimer's diseases.

• ▪ Medication—Birth control pills, prednisone, and medications for hypertension.

• ▪ Substance abuse—Although depression can lead to substance abuse, it is now realized that substance abuse can also lead to depression.

• ▪ Diet—Deficits in folic acid, B12, and some vitamins.

• ▪ Gender—Females are more at risk.

• ▪ Age—The elderly are more often affected.

• ▪ Status—Lower socioeconomic status.

• ▪ Weight—Obesity.

• ▪ Social isolation—Living alone, recently widowed.

▪ SYMPTOMS. A depressed individual often exhibits the following characteristics:

• ▪ Feels rejected, helpless, and worthless

• ▪ Is indecisive and disinterested in surroundings

• ▪ Does not enjoy pleasurable events

• ▪ Has a low energy level; always feels fatigued

• ▪ Is unable to sleep or sleeps excessively

• ▪ Might cry easily and often

• ▪ Might have thoughts of suicide

   Depression more commonly occurs during critical periods along the life cycle, including adolescence, menopause, and old age.

▪ DIAGNOSIS. A thorough history and physical examination are completed to rule out other conditions. Tests might include blood test, X-rays, MRI, or CT scan. A psychological questionnaire can also be helpful in diagnosis.

▪ TREATMENT. Treatment of depression can include psychotherapy and antidepressant medications. The majority of individuals with serious depression will show improvement in only a few weeks. Depression is often untreated, with only one in every three affected individuals seeking assistance.

▪ PREVENTION. Prevention might not be possible, but activities that reduce risk of developing depression and help prevent recurrence include eating a balanced diet, exercising regularly, getting adequate sleep, avoiding drugs and alcohol, seeking help with the first symptoms of depression, and taking medications as prescribed.

SEASONAL AFFECTIVE DISORDER (SAD)

▪ DESCRIPTION. SAD, also called winter depression, is a depressive condition that occurs more commonly during the winter months. Onset of depression typically begins in the fall, becomes progressively worse through the winter months, and clears or improves in the spring. SAD tends to recur each year with the change of seasons.

▪ ETIOLOGY. The cause of SAD is thought to be related to an increase in the melatonin hormone, which is released by the pineal gland during dark hours and is suppressed by light. Increased amounts of melatonin cause drowsiness and fatigue, so individuals with SAD are thought to be affected by high levels of melatonin.

   Another theory suggests that SAD is caused by a delay in the individual's circadian rhythm (a normal 24-hour cycle of biological rhythms including sleep, metabolism, and glandular secretions), causing a type of hibernation.

▪ SYMPTOMS. Symptoms include chronic fatigue, excessive sleep, and excessive eating with weight gain. SAD occurs more commonly in women and those living at higher latitudes with shorter daylight hours.

▪ DIAGNOSIS. Diagnosing SAD is difficult because many other types of depression and mental health conditions have similar symptoms. Diagnosis depends on the individual having bouts of depression for at least 2 consecutive years during the same season, the symptoms resolving for a period of time, and the absence of other explanations for the mood change.

▪ TREATMENT. Medications to treat SAD may include some serotonin reuptake inhibitors. Daily exposure to bright light during the winter months has also improved depression in individuals affected by SAD (Figure 21-6).

▪ PREVENTION. There is no way to prevent SAD, although steps to manage symptoms include starting treatment before symptoms would normally appear and continuing treatment past the time the symptoms usually disappear.

BIPOLAR DISORDER (MANIC DEPRESSIVE)

▪ DESCRIPTION. Bipolar disorder is a type of depression in which extreme depression and mania (extreme elation or agitation) occur. The mania is not truly a state of happiness but rather a state of elated depression. Affected individuals experience a normal state of depression but also exhibit dramatic swings between extreme depression and extreme mania.

▪ ETIOLOGY. The cause of bipolar disorder is unknown. Current theories suggest genetics and a biochemical deficiency in the brain.

▪ SYMPTOMS. Symptoms of extreme depression have already been discussed. Symptoms of mania include:

• ▪ Feelings of euphoria

• ▪ Increased energy, activity, and restlessness

• ▪ Rapid thoughts and racing speech

• ▪ Unrealistic beliefs in one's abilities

• ▪ Extreme irritability

• ▪ Unusual behavior and denial that anything is wrong

▪ DIAGNOSIS. Bipolar disorder is difficult to diagnose because individuals do not seek medical treatment in the manic phase, only in the depressed stage. A history of the condition often reveals only symptoms of depression, not of mania. There is no blood test to help with diagnosis. A mood disorder questionnaire (MDQ) is a checklist that aids the physician in identifying symptoms and thus diagnosis.

▪ TREATMENT. Current treatment includes psychotherapy and lithium medication to control mood swings.

▪ PREVENTION. Bipolar disorder cannot be prevented. Taking prescribed medications can control mood swings.

▪ DESCRIPTION. Dissociative disorders are characterized by escape of reality in involuntary and unhealthy ways ranging from suppressing memories to assuming alternate identities. These disorders commonly develop in reaction to a trauma and include psychogenic amnesia, psychogenic fugue, depersonalization disorder, and multiple personality.

• ▪ Psychogenic amnesia is characterized by a sudden loss of memory that is more than simple for-getfulness. This disorder tends to occur after a major stress event and is considered to be a way of escape.

• ▪ Psychogenic fugue is characterized by suddenly leaving home, traveling some distance, forgetting one's identity and past, and often changing one's name. Fugue usually occurs after a major natural disaster such as an earthquake or during wartime. This disorder often lasts only a few days but can last for several months.

• ▪ Depersonalization disorders often occur following severe depression, stress, fatigue, or recovery from drug addiction. The affected individuals feel disconnected from mind and body and can feel like they are viewing life from a distance. Often, individuals feel that they are losing their minds.

• ▪ Multiple personality is a rare disorder characterized by exhibition of two or more distinct personalities. The dominant personality determines the actions and activities of the affected individual. The dominant personality is usually not aware of the secondary personality(ies), but the secondary personality(ies) are aware of the dominant personality. Change from one personality to another usually occurs quite suddenly and usually follows a stressful event.

▪ ETIOLOGY. These disorders commonly develop during childhood as a mechanism for coping with trauma that includes physical, sexual, or emotional abuse and a frightening home environment. Adults rarely develop these disorders.

▪ SYMPTOMS. Symptoms include memory loss (amnesia), depression, anxiety, blurred sense of identity, and a sense of being detached from self (depersonalization).

▪ DIAGNOSIS. Physical exam to rule out conditions such as head trauma, brain diseases, and sleep disorders is needed. A mental health professional might use medication and hypnosis to identify alternate personalities to confirm diagnosis.

▪ TREATMENT. Psychotherapy, also known as talk therapy, is the primary treatment for this disorder. This course of therapy is often long and difficult but frequently very effective.

▪ PREVENTION. Protecting children from physical, sexual, and emotional trauma is the best prevention. If children are traumatized, seeking professional help immediately is a preventive measure.

▪ DESCRIPTION. Normally, anxiety is a temporary response to stress, but for some individuals, anxiety becomes a chronic problem. Affected individuals often experience anxiety that is exaggerated or of inappropriate proportion to the situation. Anxiety disorders, previously known as neuroses, represent the largest group of mental health disorders in the United States.

▪ ETIOLOGY. The cause of anxiety disorders might be related to genetic factors, severe stress, biochemical alterations, and, in some cases, physical causes such as hyperthyroidism.

▪ SYMPTOMS. Symptoms of each type of anxiety disorder, including generalized anxiety, panic, phobia, obsessive-compulsive, and post-traumatic stress, are covered in the following list.

• ▪ Generalized anxiety disorder, also called excessive worry, is a continuous state of mild to intense anxiety. The anxiety is not related to a specific event and, for this reason, is often called free-floating anxiety. This state of constant anxiety often leads to physical symptoms including dry mouth, nausea and vomiting, diarrhea, and muscle aches.

• ▪ Panic disorder is a state of extreme, uncontrollable fear commonly called a panic attack. Onset of an attack is usually sudden and peaks in 10 minutes or less and can include a feeling of impending doom and a need to escape. Other symptoms include diaphoresis, chest pain, increased pulse, nausea, and dissociation (the feeling that the incident is happening to someone else).

• ▪ Phobia disorder is the most common anxiety disorder. A phobia is an intense and irrational fear of an object, situation, or thing, resulting in a strong desire to avoid the feared stimulus. The affected individual usually realizes that the phobia is irrational but is still unable to control the fear. There are over 700 known phobias (see Table 21-3 for a partial listing of these). Fears of spiders, snakes, and enclosed areas are some of the more common phobias.

• ▪ Obsessive-compulsive disorder (OCD) is an anxiety disorder with two distinct parts. Obsession is repetition of a thought or emotion. Compulsion is a repetitive act the affected individual is unable to resist performing. With OCD, the individual is unable to stop the thought or the action. Behavior becomes ritualistic, and thoughts or attempts to stop the thought or action bring about extreme anxiety. This behavior becomes very time-consuming, usually taking more than an hour a day, and can become so disruptive that the individual is unable to perform daily activities or hold a job. Examples of compulsive activities include hand washing, cleaning objects, checking an object, and locking and unlocking locks.

• ▪ Post-traumatic stress disorder (PTSD) develops as a response to a psychologically distressing event the individual could not control and is outside the normal range of human experience. This disorder is a new addition to anxiety disorders and was observed frequently in Vietnam veterans.

   In addition to war, individuals who are victims of rape, child incest, or abuse or survive natural disasters or acts of violence are often affected. Police and firemen are at great risk for PTSD. The feelings and fears associated with the trauma do not normally diminish with the passing of time. Affected individuals often relive this trauma for weeks, months, or years in painful recollections or dreams and frequently go to extremes to avoid any reminder of the trauma.

   Symptoms can occur immediately or not arise for months after the trauma. Symptoms include:

• ▪ Flashbacks with the individual reliving the traumatic event

• ▪ Difficulty developing and maintaining relationships

• ▪ Irritability and agitation

• ▪ Depression

• ▪ Social withdrawal

• ▪ Drug dependency

▪ DIAGNOSIS. A thorough medical and physical exam is necessary to rule out other conditions. Diagnosis is made by confirming a history of symptoms without other causes or conditions.

▪ TREATMENT. Hypnosis, stress reduction, relaxation therapy, physical exercise, and biofeedback can be used to treat the condition, depending on severity and cause.

▪ PREVENTION. Education on stress and stress reduction techniques, along with a good support system, might prevent this condition.

▪ DESCRIPTION. Somatoform (somato = body) disorders are characterized by physical symptoms that lead one to believe in a physical disease, but no organic or physiologic cause can be found. Additionally, the physical symptoms appear to be associated with unconscious mental factors or conflicts.

▪ ETIOLOGY. The cause of somatoform disorders is not clear. The problem appears to be multifactorial and might include genetic influences, environmental causes, high parental expectations that the child feels pressured to meet, sexual abuse, and a poor ability to express emotions.

▪ SYMPTOMS. The symptoms of somatoform disorders are very real to the affected individual except in the case of factitious disorders (Munchausen and malingering). Individuals with somatoform disorders characteristically are described as frustrated, dependent, emotionally deprived, and resentful of family members and physicians. Somatoform disorders include conversion, hypochondriasis, pain disorder, malingering, Munchausen syndrome, and Munchau-sen by proxy. Each condition is described, along with typical symptoms, in the following list.

• ▪ Conversion disorder, formerly known as hysterical neurosis, is a very striking disorder characterized by dramatic physical symptoms such as paralysis of an arm or leg, blindness, numbness, and deafness. The affected individual usually exhibits a calm, indifferent attitude about the situation. These physical symptoms enable the individual to avoid a stressful or unacceptable situation and, at the same time, gain attention from others who might not usually give them attention.

• ▪ Hypochondriasis is a condition characterized by an abnormal anxiety about one's body and health. Affected individuals are commonly called hypochondriacs. These individuals have an astounding knowledge of medical conditions and are constantly watchful of symptoms. Hypochondriacs have an unrealistic fear that they are ill, despite medical assurance to the contrary. Affected individuals have difficulty establishing and maintaining relationships because so much of their energy and conversation revolve around their perceived illnesses.

• ▪ Pain disorder can occur at any age but commonly occurs in adolescent and young females. This disorder is characterized by pain that does not have a physiologic cause or, if a cause is discovered, the pain is greater than normally expected. This pain causes interference with the individual's social, occupational, and basic activities of life. Longstanding pain often leads to depression and suicide. This condition is not fictitious, as is malingering.

• ▪ Malingering is the fictitious display of symptoms to gain financial or personal reward. Returning to work after a work-related injury commonly leads to malingering. Symptoms are usually exaggerated and fraudulent. Diagnosis is often difficult because many of the symptoms are subjective and difficult to disprove.

• ▪ Munchausen syndrome is a group of disorders in which the affected individuals simulate illness for no other apparent reason than to receive treatment. Often, the individuals will go to extremes to present false tests, for example, scratching or cutting themselves to add blood to urine specimens. An affected person also might self-inject a variety of substances into the blood or tissues to cause an illness. Generally, this individual has an extensive knowledge of diseases, medical treatments, terminology, and hospital routine.

   Affected individuals often present to emergency departments with reports of a variety of symptoms. Multiple tests and procedures are undergone willingly. When testing does not support the stated symptoms, the individual often reports different symptoms. There is usually a history of repeated hospitalizations with undetermined diagnosis. When the behavior is discovered, the confronted individual often becomes hostile and seeks attention at a different facility.

• ▪ Munchausen by proxy is the same disorder except the parent projects the disorder onto a child. The parent might inject the child or otherwise cause illness and then present the child for treatment. Illness commonly tends to be gastrointestinal or genitourinary in nature, and the parent denies any knowledge of the cause of the illness. Munchausen by proxy can be carried to the extreme and actually cause the death of the child.

▪ DIAGNOSIS. A thorough history and physical examination are necessary to rule out other medical or neurologic disorders from somatoform disorders. A history of ongoing symptoms is often the key to diagnosis.

▪ TREATMENT. Because somatoform disorders usually have a long medical history, it is beneficial to develop a long-term relationship with a trusted physician. This aids in diagnosis and often prevents unnecessary tests and treatments.

   Antianxiety and antidepressant medications are sometimes prescribed because these conditions often coexist with somatoform disorders. Psychoanalysis is usually not used, but supportive approaches might be beneficial to reduce symptoms and secure the individual's personality. In some cases, hypnosis might also be helpful. Other therapies that are of some benefit include acupuncture, therapeutic message, homeopathic treatments, hydrotherapy, and meditation, to name a few.

▪ PREVENTION. There is some evidence to suggest that allowing children to express emotional pain without ridicule of being weak or a sissy might be a preventive measure.

▪ DESCRIPTION. An individual's personality is formed during the early years of life and is affected or molded by genetics and environmental factors such as early life experiences. Much of what is learned aids the individual in adapting to life situations. A person might be funny, social, quiet, or reserved, depending on these factors. The basic personality is fixed by adulthood and remains intact throughout life.

   Individuals with personality disorders have traits or factors that make them feel and behave in unacceptable or unsocial ways. This behavior limits relationships and can affect home and work life. A vast number of people have maladaptive patterns of seeing, relating to, and thinking about their environment. These individuals fit on a mental health spectrum at some point between mentally healthy and mentally ill.

▪ ETIOLOGY. The cause of personality disorder can be due to genetics and environmental factors. Although there is no clear-cut cause, it is known that those at risk are children who have:

• ▪ A family history of personality disorders.

• ▪ An alcoholic parent.

• ▪ Been raised in a chaotic or abusive family.

• ▪ Been sexually abused.

• ▪ Suffered some type of head trauma.

▪ SYMPTOMS. Most individuals with personality disorders have disturbances in emotional development, are maladjusted socially, and often have incapacitating, acute episodes of their mental disorder; most believe that others are responsible for their condition.

   Personality disorders include paranoid, schizoid, antisocial, narcissistic, and histrionic behaviors. Each condition is described, along with typical symptoms, in the following list.

• ▪ Paranoid personalities are characterized by traits of jealousy, suspicion, envy, and hypersensitivity. These individuals exhibit extreme mistrust of others and suspect their motives and intents as deliberately harmful to them. Paranoid individuals are often angry, hostile, cold, and unemotional.

• ▪ Schizoid personalities are loners. They lack warm or tender feelings for others and have few friends. The opinions of others have little effect on their feelings, and they have difficulty expressing anger.

• ▪ Antisocial personalities usually are identified in the teen years by troublesome behavior including fighting, stealing, running away, and cruelty. The antisocial individual is selfish, irritable, aggressive, and impulsive. These individuals do not express feelings of guilt and do not learn from mistakes.

• ▪ Narcissistic personalities have an exaggerated sense of self-importance and self-love. They need constant attention and admiration. If criticized, they react with rage or humiliation and lack ability to express empathy.

• ▪ Histrionic personalities are overly dramatic with expressions of emotion. They exhibit theatrical mannerisms and overreact to events. This personality is vain and demanding, needs to be the center of attention, and constantly seeks approval and reassurance.

▪ DIAGNOSIS. There are no specific tests for personality disorders. Diagnosis is usually made by a mental health professional based on evaluation of symptoms and emotional and mental history.

▪ TREATMENT. Treatment of personality disorders includes psychotherapy and drug therapy. Common medications include antidepressants, anticonvulsants, and antipsychotics. Hospitalization might be needed during acute episodes.

▪ PREVENTION. There is no way to prevent personality disorders. Avoiding acute symptoms might be possible by regularly attending counseling sessions and taking medications as prescribed.

Gender identity disorder is a condition in which the person is uncomfortable or distressed with his or her sexual identity. Affected children might state a preference for being the opposite sex, cross-dress, choose members of the opposite sex for best friends, play games stereotypical of the opposite sex, show disgust with their genitals, and express a desire for genitals of the opposite sex.

   In adults, the disorder is characterized by a stated desire to be the opposite sex and a conviction that they have feelings and attitudes of the opposite sex and that they were born the wrong sex. Adults with gender identity try to rid themselves of secondary sex characteristics and might seek hormonal and surgical intervention for a gender reassignment.

▪ DESCRIPTION. Sexual disorders include sexual dysfunction and paraphilias, sexual deviations. Sexual dysfunction is discussed in Chapter 17, “Reproductive System Diseases and Disorders.” Paraphilia is a sexual disorder in which the person experiences repeated and intense sexual arousal from bizarre fantasies, often involving objects or nonconsenting persons. The majority of paraphiliacs are male. Many of these disorders are considered socially unacceptable at the least and criminal at worst.

▪ ETIOLOGY. There are many theories concerning the origin of sexual disorders, but in reality, no one has a certain answer. Some think these are formed during sexual development near or during puberty. The idea is that social development, or how the individual has been treated, has somehow gone off course, leading to the inability to develop relationships. This inability, along with the lack of meaningful relationships, is expressed in the form of sexual disorders.

▪ SYMPTOMS. Sexual disorders include exhibitionism, fetishism, transvestic fetishism, frotteurism, pedophilia, sexual sadism, sexual masochism, and voyeurism. Each condition is described, along with typical symptoms, in the following list.

• ▪ Exhibitionism is a very common disorder and involves a male exposing his genitals to an unsuspecting female.

• ▪ Fetishism involves sexual arousal with a nonliving object.

• ▪ Transvestic fetishism involves arousal by cross-dressing (Figure 21-7).

• ▪ Frotteurism involves sexual arousal from touching or rubbing against a nonconsenting person.

• ▪ Pedophilia is a condition of being sexually aroused by a child. This disorder occurs primarily in impotent men. Pedophiles usually do not rape the involved child but, more often, want to fondle the child and request the child to fondle them. This activity is criminally classified as child molestation. Homosexuals are usually not child molesters. The usual case is a teen or adult male with a prepubes-cent female.

• ▪ Sexual sadism involves sexual arousal of the sadist when the victim suffers physical or psychological pain.

• ▪ Sexual masochism involves sexual arousal of the masochist when the masochist is humiliated or made to suffer by being beaten or bound.

• ▪ Voyeurism is a common disorder and involves arousal by secretly watching others undress or engage in sexual activity. Voyeurs are commonly called peeping toms.

• ▪ Other paraphilia include arousal with animals (zoophilia), corpses (necrophilia), and obscene telephone calls (scatologia).

▪ DIAGNOSIS. Individuals with sexual disorders are not easily diagnosed, usually due to embarrassment about the condition. Those affected are often found out and reported. After the individual is assessed by a mental health professional, the diagnosis is usually confirmed.

▪ TREATMENT. Professional treatment that assists the affected individual with suppressing the activity is often beneficial. Treatment with androgen (hormones) can influence the frequency and intensity of the episodes.

▪ PREVENTION. There are no clear-cut actions for prevention.

The colder the room you sleep in, the greater is the risk of having bad dreams.

▪ DESCRIPTION. Sleep disorders (somnipathy) are medical disorders of sleep. Some disorders are serious enough to disrupt the individual's ability to function at home and work. These disorders include dyssomnias and parasomnias. Dyssomnias are disorders related to falling asleep and include insomnia, narcolepsy, and sleep apnea. Parasomnias are disorders related to staying asleep and include nightmares, sleep terror, and sleepwalking disorders.

▪ ETIOLOGY. Some causes of sleep disorders are easy to recognize, whereas others are more difficult to determine. Common causes include shift work, anxiety, pain, incontinence, noise, and certain medications.

▪ SYMPTOMS. Sleep disorders include insomnia, narcolepsy, apnea, nightmare, sleep terror, and sleepwalking. Each condition is described, along with typical symptoms, in the following list.

• ▪ Insomnia is the inability to fall or stay asleep. The affected individual might awaken early and feel mentally and physically fatigued. Insomnia commonly affects females and tends to increase in incidence with age. Intake of stimulants such as coffee or tea before bedtime often causes the condition, as do physical disorders such as thyroid conditions. Anxiety and stress also can lead to insomnia. Treatment can include treating physical disorders, removing stress and anxiety, obtaining psychotherapy, and, as a last resort, taking sleeping medications.

• ▪ Narcolepsy is a daily uncontrollable attack of sleep. Affected individuals might fall asleep any time they are sedentary such as driving, studying, reading, or eating. Narcolepsy usually occurs in the late teens or early 20s. Seizure disorder and sleep apnea must be ruled out prior to treatment. Scheduled naps and establishing a sleeping routine will usually resolve the disorder.

• ▪ Sleep apnea is a dyssomnia characterized by short periods of breathlessness during sleep, possibly due to respiratory or neurologic problems. This condition is discussed in Chapter 15.

• ▪ Nightmare disorder is a condition in which the involved individual is awakened by anxiety-provoking dreams. Once awakened, the individual is quickly oriented. Common subjects of nightmares include falling, death, and being attacked. Children usually outgrow this condition, but adults might need treatment with Valium.

• ▪ Sleep terror is an awakening due to nightmares, but individuals are so terrified that they do not become quickly oriented. The individual can be confused and cannot be comforted by family members. Night terrors can be reduced by not allowing the child or affected individual to watch disturbing movies or television programs.

• ▪ Sleepwalking disorder is a condition characterized by the individual getting up at night and walking without awakening. The individual can be awakened, usually with some difficulty but does not remember the episode. The primary concern with sleepwalking is the increased potential for injury to the sleeping individual.

▪ DIAGNOSIS. Most disorders can be diagnosed by a sleep history. Sleep studies including a polysomno-gram, along with medical testing, help the physician confirm the diagnosis.

▪ TREATMENT. When the source of the problem is identified, several treatment options exist, including bright-light therapy, continuous positive airway pressure (CPAP), medications such as melatonin, and surgery.

▪ PREVENTION. Depending on the cause, some activities that might help prevent sleep disorders include:

• ▪ Going to bed at the same time every night.

• ▪ Avoiding caffeine, nicotine, and alcohol late in the day.

• ▪ Avoiding a large meal late in the day.

• ▪ Getting regular exercise.

• ▪ Eating a healthy diet.

• ▪ Creating a routine to wind down just before sleep, such as reading or taking a warm bath.

Grief is a natural process of coping with a loss, such as the loss of a family member or friend or the prospect of one's own impending death. The loss might also be of less weight and include the loss of a body part or body function, a job, or a valued possession.

   No matter the cause, grief is real and is a natural part of life. Grieving is a healthy process. Those unable to grieve and complete the grieving process often have difficulty coping with life.

   People grieve differently in different cultures, and individuals within each culture might grieve differently. Some individuals are very emotional, whereas others remain solemn.

   The normal grieving process passes through several stages that were defined by Dr. Elisabeth Kübler-Ross in the 1970s and remain true today (Table 21-4). Not everyone is able to move through all the steps. Grieving individuals might stop in one stage and need assistance to move on, or they might retreat to a lower stage before moving forward again. The speed at which a person moves through the grieving process is, again, very individual.

   An important aspect of a funeral ceremony is to allow those who are grieving to say good-bye and to have closure of the situation. Individuals who were never allowed to say good-bye to a deceased or missing loved one, such as families of servicemen killed overseas or of missing children or persons, can suffer with extreme depression. Inability to grieve and complete the grieving process can lead to depression, poor coping skills, and the need for psychological counseling.

Suicide was discussed in Chapter 20, “Childhood Diseases and Disorders,” as a major concern for teenagers, but it is also a common problem among individuals with mental health disorders. Depression is a main cause of suicide. Suicidal individuals have feelings of depression, guilt, hopelessness, and helplessness. As previously stated, changes in the life cycle—including aging—can lead to depression and suicide.

   It is estimated that more than one-third of people over age 65 try to commit suicide. Individuals diagnosed with a terminal illness often consider suicide as a means of living the remainder of life with dignity. Widowed, older white men; minority groups; and the unemployed are also at risk.

Several of the disorders discussed in this chapter are considered to be rare but are included to maintain the order of the outline and assist the learner in categorizing mental illnesses. There are, however, many other very rare mental health disorders affecting individuals from children to the older adult population.

There are many mental health disorders that can affect the older adult. Some of these might have begun early in life, whereas others occur very late in life. Some disorders of the neurologic system cause symptoms such as memory lapses, behavior changes, and confusion that mimic symptoms of mental health problems but really are a physiologic or system-specific disorder. Others, such as Alzheimer's disease, although a neurologic system problem, are also considered to be a mental health disorder.

   Many other disorders found in the older adult population are like this. Because of the changes that occur in the aging process, some symptoms seen in the older population might just be normal changes and not related to mental health disorders at all. Unfortunately, older adults are often labeled as having a mental health problem when they are merely dealing with the normal process of aging.

   The most common mental health problems in the older population include depression, insomnia, isolation, stress, and disorders related to or caused by other system diseases. In addition, some individual medications or medication interactions can cause symptoms of mental health problems such as confusion, forgetfulness, dizziness, and speech problems.

Mental health disorders are some of the most misunderstood health problems. Although some are difficult to diagnose and treat, many more can be either controlled or cured with proper diagnosis and intervention.

   Some of the symptoms of mental health problems are very slow to appear and are quite subtle, making it difficult to determine whether a real problem exists. In the older adult, many neurologic disorders and the normal changes occurring in the aging process are often incorrectly attributed to a mental health disorder. Early diagnosis and treatment of any type of mental health disorder are important to assist the affected individual to live a quality life.

Short Answer

• 1. What are some of the common signs and symptoms of mental health disorders?

• 2. What are some common tests used to diagnose mental health problems?

• 3. List some of the treatments used to control or cure mental health disorders.

Matching

• 4. Match the mental health disorder in the left column with the appropriate category in the right column. Items in the right column may be used more than once.

• 5. Match the drugs listed in the left column with the best description in the right column.

▪ Jenny Stanson is a 20-year-old college student who lives with her grandmother. She has noticed that her grandmother seems confused at times, forgets things she has told her, and is often rather short-tempered. This does not seem to be her usual manner and happens only infrequently, but Jenny is concerned. Someone stated her grandmother might be suffering from early Alzheimer's disease. She wants to know what she should do about this. She also wants more information about Alzheimer's disease. How can you help her? What resources might be helpful?

▪ Jim Wolf is a 45-year-old auto-parts store owner who constantly washes his hands. He also continually checks and rechecks parts lists, equipment, and his employees' schedules. His wife, Mary, who works in the business with Jim, has convinced him to seek medical intervention for his problem because his anxiety level has been interfering with his work performance and his ability to sleep. After testing and referral to a psychiatrist, he has been diagnosed with an OCD. What can you tell Jim and Mary about this disorder? Jim asks you if you think he is crazy. How would you respond to that question? What type of treatment might he expect?

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Online Resources

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