Recognizing Mental Illness

By Dan Blair, a marriage counselor and family counselor.

Just as recognizing when to go to the doctor or emergency room is essential, so is being able to recognize mental illness. In addition to being able to recognize when illness may be affecting a loved one, I think of “first responders,” those who run toward someone who needs help, as seen in the video from the Boston marathon bombing. Response makes a difference. Moreover, mental illness is more common than you think. People are more comfortable, though, talking about physical illness. I’ve heard plenty of times someone say, “I came down with a little cold.” Rarely, do I hear, “Yeah, I caught a little depression last night and stayed home from work today.” Reducing stigma leads to better response and ability to recognize mental illness.

One of the ways stigma can be seen is the questioning of someone’s capability, when many people accomplish a great many things with mental illness. Paul Gottlieb, a long-time Publishing Executive said:

“Where I worked, if you had a heart problem or cancer, you’d never find a more sympathetic, supportive group of people . . . but for years I had to be secretive about my mental illness because I was in control of millions of dollars of the corporation’s assets, and I couldn’t run the risk of having my judgment mistrusted.”

The second way stigma can be detected is through statements like, “Depression is his excuse for laziness.” In other words, “It’s a choice.” This view underestimates how powerful the symptoms can be. There are bio-chemical and physiological realities creating symptomology.

Mental illness is due to genetic vulnerabilities and excessive stress on your system. Any one can get it, any time. Almost half the population will experience it at some point, and one quarter is experiencing it now. Most people do not seek help. Untreated, mental illness is associated with cutting with 25 years off your life. Not many of us are trained to recognize and help.

The initial response to mental illness is not diagnosis, treatment, or solving one’s problems, unless you are a professional working with a client. Mental illness is a diagnosable illness affecting thinking, emotions and behavior. It is also disruptive to daily activities, work and satisfying relationships. Most people need to be understood and helped. Keeping four steps in mind is helpful.

The first step to keep in mind throughout all these steps is looking for any risk of harm. If you can foresee any clear or imminent danger due to the person’s intentions, move through the other four steps listed here, but make sure the fourth step includes a hand-off to someone responsible to assess risk of harm.

The second step allows for getting at the truth of what is happening by not criticizing, suggesting solutions, or cutting them off. These common responses actually create more heat than light, and you may find you are “spinning your tires.” So give them space to talk without jumping in or rescuing them.

The third step paves the way for help by offering hope. You can say things like, “I understand.” “You feel anger,” or “You’re scared.” Maybe “That sounds like grief” is appropriate. Other affirmations include, “Others have felt this way” and “There are options.”

We want to involve them in the decision-making process without taking away their right to self-determination. Give options and ask which option is the best for now. Refer to the county mental health and referral line, or other local resources.

Each mental illness has characteristics and if enough criteria are met and a thorough assessment has been completed to rule out other causes, a diagnosis may be applicable so that evidence-based treatment can be offered. We all meet some of the criteria some of the time. Many celebrities and historical figures have made contributions to society maybe in part because of a mental illness. No one should be discounted.

Mood Disorders affect emotions, thoughts, behavior, medical issues, and the workplace. Emotions include sadness, usually mixed with guilt, anxiety, anger, or lack of emotion. All are marked with a sense of hopelessness, which makes the emotions more difficult to bear. Thoughts are self-critical, self-blaming, pessimistic, impairing concentration, creating indecisiveness, and can lead to thoughts of suicide. Behavior observations include social withdrawal, neglecting important responsibilities, loss of interest or motivation that used to be interesting and motivating, lethargy, and increased substance use. Physical symptoms may be endless fatigue, loss of sleep or appetite, excessive sleep or appetite, and other medical symptoms. 69 percent of people with depression go to their physician but only report physical symptoms. In the workplace there may be decreased productivity, loss of morale, lack of cooperation, and increased accidents and absenteeism.

Four types of mood disorders include, among other variations, major depression, bipolar, postpartum, and seasonal. (Most people generally feel better in better weather, but for some the dark winter months are especially brutal.) A manic episode is the other side of a depressive episode. Vacillating combinations of the two make up different forms of bipolar disorder. The first three or four symptoms may sound good, but the list goes downhill from there. Symptoms include increased energy, elated mood, less need for sleep, rapid thinking and speech, lack of inhibition and insight, along with grandiosity and irritability. The crash after a manic episode along with depression itself can be associated with thoughts of suicide. Most people may briefly think of suicide when things are bad, but it is usually dismissed. The risk is higher for those who cannot get the thought out of their mind. When those thoughts turn to a plan, it gets more dangerous.

Here’s some initial response to someone who referenced thoughts of suicide:

• Ask, “Do you ever, or are you thinking of suicide?” Be direct; you’re not going to give them an idea that they haven’t thought of before. A direct response will hopefully give a direct answer.
• The next step is to talk about a possible plan. You can ask, “Have you decided how you would?” “When?” “How have you prepared for that?”
• A past history of attempts or attempts among the family or friends also increases the risk. Ask, “Have you ever tried before? Or, have you known anyone to try?”
• Many suicides are completed under the influence. Make sure you ask, “Any substance use while thinking about suicide?”

*Do not leave alone until notifying a responsible party. Try to involve the person in the decision of what should be done. If aggressive or in possession of a weapon, call police. There’s a lot more we can talk about this scary subject, and I urge you to do some reading on the subject.

Anxiety Disorders are difficult to bear and are among the most common. Cardiovascular symptoms include rapid or pounding heartbeat and/or chest pain. Respiratory symptoms include rapid and shallow breathing. Neurological symptoms include tingling, numbness, sweating, dizziness, and headaches. Gastrointestinal symptoms include stomach pain, frequent voiding, dry mouth, and difficulty swallowing. Psychological symptoms include a racing mind, feeling unsure, sleep disturbance, and vivid dreams. Behavioral symptoms include avoidance behavior, especially of one’s triggers; obsessive thinking where you cannot get the thoughts out of your mind, and compulsive behaviors meant to soothe the anxiety but are never quite enough. Like many mental health illnesses, these symptoms could also be due to medical conditions, medications and substance use.

A particularly difficult episode is the panic attack. It feels like you are about to die, though without actual danger. Still, the symptoms may be due to a medical condition, so check for medical alert bracelet and seek medical assistance, especially if there is no history of panic attacks. Then it may be a medical condition. Remain calm and patient for the person, acknowledging that the terror feels real. Don’t dispute it. Reassure that he or she is safe, that this will pass, or that help is on the way. After a panic attack, offer help in getting more information on panic attacks.

Psychotic episodes include a temporary loss of contact with reality. Accompanying signs may be irritability, suspiciousness, lack of emotion or inappropriate emotion. Episodes found in schizophrenia, bipolar disorder, psychotic depression, or may be substance-induced.

Imagine trying to have a conversation with someone or concentrate on your work, while someone else sitting next to you was speaking in your ear the following statements over and over:

• Why is he talking to you?
• Is he looking at you?
• You are a failure.
• You are nothing.
• Why did she say that?

You can see how disruptive and disturbing that would be. Hallucinations can occur through every one of your senses.

When approaching someone who may be having a psychotic episode let the person know you are concerned and want to help. State the specific behaviors that concern you. Don’t touch without permission. Allow the person to talk about his or her experiences and beliefs if they want. Remain calm, talk concisely and don’t criticize. Avoid nervous behavior. Also, maintain safety and an access to an exit.

Hand-in-hand with mental health disorders is substance use disorders. Signs include an increased use of a substance over time. Have you notice someone who used to drink this much, and that used to be enough, now drinking more or more frequently, or harder drinks? Studies show that desirable effects of drinking are obtained early on, and then it’s downhill from there. In fact, some studies have shown that when people think they are drinking alcohol, they act accordingly drunk, even when given a placebo. Another sign is giving up important activities and relationships. How does the substance use affect one’s own values? Like the saying goes, sometimes you don’t know how much you’ve got, until it’s gone. Furthermore, another indication is the difficulty in controlling use, crossing one’s own boundaries. This is promising to yourself, “Only one, maybe two drinks per hour.” Then when the time comes, you think, “Forget that. Maybe next time.” Use is then continued use despite mounting problems. The thought may be, “I might as well.” Though one’s job or marriage may be in jeopardy, people rely on their own rationales to drink or drug. Moreover down this path is increased tolerance. The person with tolerance may feel okay to drive, but he or she is just as impaired as someone at the same blood alcohol level without tolerance. At serious levels, symptoms of withdrawal appear like anxiety, irritability, depression, sweating, tremors, hallucinations and more in the face of not using. Common substances include alcohol, tobacco, marijuana, heroin (and other opioids), sedatives and tranquilizers, cocaine, amphetamines and methamphetamines, ecstasy (and other hallucinogens) and inhalants.

Call 911 if you encounter . . .

• Irregular, shallow or slow breathing or pulse
• Cold, clammy, pale or bluish skin
• Continually vomiting
• Seizure activity
• Delirium tremens

*Stay calm and ensure safety. It can be quite scary.

Eating Disorders are also very dangerous. Three types of eating disorders include Anorexia Nervosa, a fear of weight, loss of menstrual periods.

Bulimia Nervosa involves overeating and purging. Binge eating occurs without compensatory behaviors meant to “make up” for it. Eating disorders involve the overvaluation of body shape and weight, and a disturbance of eating habits or weight control behavior along with elements of perfectionism. It results in impairments to physical, psychological and social health and obsessive-compulsive patterns around food selection, preparation, eating, or exercise. There is also evidence of vomiting or laxative use. Effects of eating disorders include weight loss fluctuations, sensitivity to cold, changes or loss of menstrual periods and dental deterioration.

Personality Disorders are among the most difficult to diagnose and treat. A number of criteria need to be met. Narcissistic Personality Disorder involves seeing oneself as superior and justifying incivility. Rules may not been seen as applicable to self. Borderline Personality Disorder involves difficulty controlling emotion and impulsive behavior, losing temper, going from crisis to crisis, and being surprised or defensive when confronted. Antisocial Personality Disorder involves appearing friendly, along with manipulation. One may see asking for favors but no returned favors. Dominating and criticizing others are also possible characteristics. There are a number of other personality disorders.

Many high conflict people are likely to fit the match to a personality disorder. Even carefully planned responses, reasoning, and encouragements have no effect. Usually, consequences are your only option. Bill Eddy, social worker and attorney, suggests:

• Be brief. The usual approach of empathy and understanding may not get you far.
• Instead, be informative, and helpful in some way.
• Maintain friendliness, and stay away from combativeness, unless you want it to be “game on.”
• Be firm. You don’t want to vacillate with high conflict people.

Reducing stigma, recognizing and responding to mental illness along with practicing mental fitness is good practice, but not necessarily preventative. Just as physical illness is unavoidable, aspects of mental illness are common to us all. Here are some quick tips for good practice using “ACES” to develop new brain connections. Each of these items should be on your daily to-do list.

• Accomplishment – daily goals that feel good when accomplished
• Connection – put energy into others and nature to reinforce your brain’s relational circuitry
• Enjoyment – fun, humor, without a specific goal, relaxation to recharge the brain
• Self-Care- exercise, sleep, diet and time set aside to allow emotions. Lots of stress comes from fighting your emotions.

Here are some ideas to practice serenity and reduce anxiety using the A-E Approach.

Acceptance Techniques include acceptance of what you feel and what is real. Some say, “Why accept? Don’t settle for what you feel. You need to fix it, figure it out, or forget about it.” Sometimes we do no need to fix something, figure it out, or forget about it. But your default position can be to accept what you feel without judging, and the reality of what is around you, so you can be kind to yourself. Conversely, experiential avoidance is associated with pathology.
Breathing Techniques. One example is breathing in the words “This too” and breathing out “shall pass.” Others use belly breathing, deep breathing using your diaphragm. Your stomach should extend, not your chest. Others breathe in through the nose and out through the mouth, emphasizing the out breath. “Combat breathing” used by soldiers involves breathing in for four counts, holding for four counts, breathing out for four counts, holding for four counts and repeating. For kids, you can also use balloons, bubbles, or pretend to smell a flower and blow out a candle.
Calming Techniques employing the five senses to relax the body. For sight, pictures, photos, or moving objects can be used. For touch, objects of different textures can be used, or rolling up in a blanket, squeezing a pillow, hugs, massages, baths or showers can be options. Tastes include favorite flavors and textures (crunchy, spicy or sour). Sounds include music or relaxing sounds. Scents include strong or pleasurable smells.
Distraction Techniques are anything that effectively holds your attention for some time until the adrenaline can metabolize. The only caveat is that it should be a healthy distraction and not something that can become an addiction.
Expression Techniques involves different ways to process emotion, or even using “I statements.” Exercise, stretching or other activity can put excess adrenaline to good use.

Strategies for Preventing Alzheimer’s and Nourishing your Brain by Dr. Daniel Amen

1. Regularly eat the best brain foods: blueberries, oranges, beans, broccoli, spinach, pumpkin, oats, soy beans, salmon, lean turkey, yogurt, brazil nuts and walnuts.
2. Take Multi-Vitamins, extra vitamin C and E, and folic acid.
3. Exercise your brain by getting 15 minutes of new learning each day.
4. Get enough sleep. Less than 7 hours per night can decrease the blood flow to the brain.
5. Exercise your body including doing hand-eye coordination exercises.
6. Protect your head from injury. Wear helmets and be sure your kids wear helmets when doing sports.
7. Listen to music and have sex. It’s good for the brain.
8. Avoid toxic substances.

Research on positive psychology has identified traits associated with joy that do not come naturally and may have to go against the grain to be practiced. The brain has been described by researcher Rick Hanson to be wired like Velcro for negativity, and like Teflon for positivity, so change has to be intentional and practiced, as one researcher suggested, every day for six months.

• Avoid dwelling and social comparison; instead dwell on the good, past, present and future
• Forgiveness
• Acts of kindness
• Close relationships
• Spirituality

Current statistics on mental health and substance use can be found:

www.nimh.nih.gov
www.samhsa.gov

References

Amen, Daniel. (2011) The Amen Solution: The Brain Healthy Way to Get Thinner, Smarter, Happier. New York: Three Rivers Press.

Hanson, Rick. (2011). Just One Thing: Developing a Buddha Brain One Simple Practice at a Time. Oakland: New Harbinger.

Kitchener, B.A., Jorm A.F. & Kelly, C.M., Maryland Department of Health and Mental Hygiene, Missouri Department of Mental Health, and National Council for Community Behavioral Healthcare (2009) Mental Health First Aid USA.

Misunderstanding Incivility and How to Stop It © 2013 by Bill Eddy, LCSW, CFLS