Discussed below are mental health disorders and conditions of mood, stress, and anxiety. These are all conditions in which the perception of reality is not lost, and the person is aware of the symptoms and their impact. These conditions were earlier called neurotic disorders or neurosis as opposed to psychosis or psychotic disorders like schizophrenia where insight and the connect with reality is lost. However, this term has been dropped now, as the so-called neurotic disorders can sometimes also manifest psychosis-like symptoms. Also, certain conditions called dissociative disorders lie in between the spectrum of neurosis and psychosis.
A person may suffer from two or more conditions at the same time, where it is possible that one led to or worsened the other. For example, anxiety and depression are often seen together, or a person with PTSD or an eating disorder may develop depression, or depression may lead to a binge-eating disorder, or anxiety may over time manifest as a social phobia, OCD, or somatic disorder. It is also important to understand past stressors, traumatic events, family life, socio-cultural and occupational factors, as having important roles to play in the development of these conditions along with biological, genetic, or personality and temperamental predisposition.
Substance abuse (alcohol, narcotic or recreational drugs) can often be the cause of the mental health condition, or can also be associated with and sometimes be the result of the particular mental health condition as a coping measure. Substance abuse must be diagnosed and managed after a careful history is taken while treating any mental illness. Substance abuse has been recognized as a separate category in the classification of mental disorders.
Everyone goes through periods or episodes of sadness, and low moods due to specific situations, causes and events. When such moods are persistent or occur frequently over a period of time, the person is said to be depressed or have depression.
To qualify as major depressive disorder (clinical depression), 5 or more of the symptoms below should be present of which at least one of the symptoms should be the first or second one mentioned. If <5 but 2-4 symptoms below are present then it is said to be minor depressive disorder. The duration of these symptoms should be a minimum of 2 weeks:
- Feeling sad, tearful, empty, irritable, or hopeless for most of the day
- Loss of interest in daily routine activities or those of prior interest
- Disturbed sleep patterns (too much or too little, difficulty in sleeping or waking too early)
- Change in appetite or 5% weight gain/loss
- Difficulty in concentration or decreased work performance
- Low energy and easy fatigue
- Physical agitation or completely reduced physical activity.
- Low self-esteem, guilt, blame, worthlessness
- Feelings of hopelessness, thoughts of death, and suicide
If 2 or above symptoms of depression are present for the past 2 years or more, with the symptom-free period not being more than 2 months at a time, then it is called persistent depressive disorder (dysthymia).
Major Depression episodes may sometimes be further described as being of specific subtypes (specifiers) based on associated features like:
- Melancholic: Negative emotions – excess guilt, early morning awakening and symptoms more prominent in mornings, loss of appetite, physical agitation, or marked retardation.
- Psychotic: With delusions, hallucinations, dissociation along with feelings of worthlessness and guilt.
- Atypical: Increased sleep, weight gain, increased appetite, lethargy with arms/legs feeling heavy, but with significant brightening and mood elevation due to positive events.
- Seasonal: Episodes occur at a similar time every year (seasonal affective disorder -SAD, occurs annually in fall/winter)
- Catatonic features: Immobility, rigidity, stupor, becoming mute, or sometimes marked physical agitation.
Depression is a unipolar mood disorder. It is seen more commonly in women than men. Defined periods of depression occur after a specific event like the death of a dear one, or loss of a relationship, job, or finances.
Depression after delivery occurs in some mothers after childbirth which manifests with the symptoms of depression described above along with the inability to bond with the baby. Mild symptoms lasting under 2 weeks are called baby blues, while severe, constant, and more prolonged symptoms are called postpartum depression. Some may also experience delusions and hallucinations (postpartum psychosis).
Premenstrual dysphoric disorder is another specific depressive disorder recognized in women that manifests in the week preceding menstruation. Symptoms include those of depression above, with anxiety, irritability, mood swings, and physical signs like breast tenderness and bloating.
As the name suggests, in this disorder the affected individual experiences both manic or hypomanic episodes, and depression (manic depressive illness). Bipolar disorders are more common in men.
A manic episode is characterized by features lasting at least a week, like inflated self-esteem and grandiosity, increased talking and fast speech, racing thoughts and ideas, high energy levels and decreased need for sleep, easy distractibility, and indulging in increased sometimes purposeless or reckless activities/sprees. When such features occur to a lesser degree of intensity (below the full threshold of mania) for at least 4 days or more it is called a hypomanic episode.
In Bipolar type 1, the episode of mania should last at least a week, or be severe enough to need hospitalization. Manic episodes may sometimes have psychotic features like delusions (manic psychosis). This occurs along with periods of depression lasting at least 2 weeks that occur apart from or can sometimes coexist with mania. In Bipolar type 2, there is hypomania with clinical depression.
Some show rapid cycling with multiple (at least 4) mania and depression episodes in a year, while some show mixed episodes of rapidly alternating or intermixed mania and depression episodes lasting at least a week.
Cyclothymia is a milder form of bipolar disorder where there are multiple hypomanic and depressive episodes over a 2-year period, but not meeting the intensity of either mania or clinical depression. However, such cases do often develop into bipolar 1 or 2 disorder.
STRESS AND TRAUMA DISORDERS
Stress is a part of day-day life and can affect a person both psychologically and physically. Episodic acute stress occurs on many days in response to a particular stressful situation or accumulated stress, causing symptoms like irritation, anxiety, palpitation, muscle tension, and feeling tired. Ongoing daily stress lasting beyond a month, makes it chronic stress. Long-term chronic stress can increase the risk of developing conditions like depression and anxiety, as well as high BP, cardiovascular disease, weight gain, lowered immunity, and other medical conditions. Stress is also associated with increased rates of alcohol and substance abuse. Chronic stress management is central to the modern lifestyle.
However, psychological disorders described here are caused by a specific episode or disturbing traumatic event causing intense stress. These are:
It is seen after an unsettling event like the loss of a loved one, relationship breakdown (divorce, separation, etc.), loss of job, change of residence or environment, financial loss, illness, etc. It usually begins within 3 months of the event and subsides in 6 months, beyond which an alternate diagnosis is considered.
Symptoms can range from low depressive moods, emotional instability, irritability, anxiety, difficulty in focusing, sleep disturbances, and appetite changes. Treatment is family-social support, counseling, and reassurance, and where needed short course of medicines for sleep and depression.
Acute Stress Disorder
This is seen after a traumatic life-threatening or intense physical-emotional event. It begins within 2 weeks and lasts for at least 3 days to 1 month. Presentation and symptoms include numbness, dissociative amnesia (blocking out disturbing memories of the traumatic event), depersonalization (disconnect with self), derealization (disconnect with surroundings), flashbacks (replaying/re-living the trauma), being hypervigilant, and getting startled easily. These symptoms are similar to PTSD and that becomes the diagnosis if these symptoms last beyond 1 month.
Post-Traumatic Stress Disorder
It refers to the psychological condition developed due to a traumatic life-threatening or intense physical-emotional event. These can include battle, shootout, explosion, major accident-injury, natural calamity or rape/sexual assault, and involves experiencing such events directly, or witnessing/learning of the experience of a loved one, or as part of the line of duty (firemen, police, army, etc).
Symptoms usually begin within 2 weeks, however can sometimes come in as late as 6 months or more (delayed onset PTSD). Symptoms should last for a month or more to be called PTSD. Acute PTSD lasts for up to 3 months, thereafter it is called chronic PTSD. Complex PTSD may be diagnosed in adults or children who have repeatedly experienced traumatic events, such as violence, neglect, or abuse.
The following features and symptoms define this condition:
- Intrusive thoughts and feelings of the event as distressing recurrent memories causing psychological and physiological distress, nightmares, dissociative experiences, or flashbacks.
- Persistently avoidance of thoughts, memories, situations, activities, conversations, places, and objects linked to the event/s.
- Negative thoughts and distorted interpretations around the event like shame, guilt, fear, blame, and anger, along with the inability to remember important aspects of the event due to block out (dissociative amnesia), as well as lack of interest and detachment from social/pleasurable activities and positive emotions.
- Altered reactivity and arousal manifested as sleep disturbances, hypervigilance and always being alert/guarded, getting easily startled, emotional angry outbursts, reckless destructive behavior, and difficulty in focusing.
ANXIETY AND RELATED DISORDERS
Anxiety refers to worrying about what has not yet happened or issues that are yet to come. Everyone goes through periods of anxiety that may sometimes be quite intense. These could be related to situations, events, and circumstances in life. However, when anxiety is persistent and begins to interfere with daily activities, sleep, occupational and social functioning, or impacts physical health, then it is wise to consult a doctor. Anxiety and depression often co-exist. Anxiety and panic can often present with physical signs like palpitations, sweating, breathlessness, etc. that may appear like other physical illnesses.
The following are recognized and classified as anxiety and related disorders. The characteristics of each are given below:
GENERALIZED ANXIETY DISORDER
This refers to general and constant feelings of worry that are persistent (for more days than not, over 6 months or more), that the person is unable to control, and is causing impairment of personal, social, and occupational functioning. The associated symptoms include:
- difficulty in concentrating
- getting fatigued easily
- restlessness and feeling on the edge
- sleep disturbances (difficulty falling or staying asleep)
- muscle tension.
Other symptoms can include moments of racing thoughts, feeling nervous, palpitations or shortness of breath, dry mouth, and sometimes dissociation, during the course of the day. Other anxiety disorders and substance abuse should be ruled out when making this diagnosis.
Mixed anxiety-depressive disorder (MADD) is a diagnostic category defining patients who suffer from both anxiety and depressive symptoms of limited and equal intensity accompanied by at least some physical symptoms like racing heart (palpitations), feeling breathless, shakiness, slurring, muscle tension, sweating or nausea. These patients do not meet the criteria for specific anxiety or depressive disorders.
Sometimes anxiety may be specific like seen in separation anxiety (severe worry of being separated from loved ones), and in phobias, or anxiety can become extreme and manifest as panic.
A panic attack is an episode of severe intense fear and anxiety that the person finds overwhelming. It is usually accompanied by physical signs like racing heart, rapid breathing, feeling choked, chest pain, sweating, trembling, chills, nausea or sick feeling in the gut, dizziness, numbness, or tingling sensations. The person gets a feeling of losing control, going crazy, or a fear of dying. There may also be feelings of derealization and depersonalization (detachments from reality and oneself respectively). The attack can peak in a few minutes and lasts for 10-30 minutes, rarely up to an hour.
When panic attacks are recurrent and unexpected and are accompanied by a nagging persistent concern of getting a panic attack, that leads to avoiding behaviors, then it is called a panic disorder. Panic disorders significantly affect personal, social, and occupational functioning. Other conditions like phobias and PTSD, along with substance abuse should be ruled out.
This refers to the intense fear of a particular object or situation. To classify as a phobia, the fear should be existing for 6 months or more, be consistent, out of proportion, uncontrollable, significantly impact social and occupational functioning, and lead to avoiding behaviors. Other physical or psychological disorders, and substance abuse, should be ruled out.
Types of phobias include –
- Social phobia (social anxiety disorder): Intense fear of interacting, eating, and speaking in public due to the anxiety of humiliation, embarrassment, negative judgment or rejection.
- Specific phobia: Fear of heights (acrophobia), water, particular animals/insects, flying, closed narrow spaces (claustrophobia), blood, injections, etc.
- Agoraphobia: This is a fear of public places like modes of public transport, parking lots, market places/malls, streets, cinema halls, queues, or just being alone outside the home. The person perceives these places as difficult to escape from or getting into a humiliating or embarrassing situation.
The mental health disorders given below have been removed from the category of anxiety disorders and classified separately. However, anxiety remains the central mechanism in these conditions.
OBSESSIVE-COMPULSIVE DISORDER (OCD)
OCD is characterized by recurrent or persistent thoughts, urges, and actions. The obsession part is the intrusive thoughts, images, and urges, that cause severe anxiety and distress, and are not controllable or suppressible. The compulsion part is the repetitive actions and behavior, that are perceived to suppress or neutralize the obsession.
For qualifying as OCD, the obsessions and compulsions should take up at least an hour in a day, be present for at least 6 months, and adversely impact personal, social, and occupational functioning. Other physical and psychological illnesses and substance abuse should be ruled out.
Common examples of OCD revolve around thoughts of dirt-hygiene, clutter-orderliness, and security, and the compulsions include hand washing, cleaning, checking locks, ordering-arranging, counting, etc. OCD due to superstitious intrusive thoughts and feeling that something bad will happen or some harm will occur if the compulsive acts/rituals/chants etc. are not performed, is called magical thinking OCD.
Other conditions that have been classified under OCD related disorders are:
- Body dysmorphic disorder: Obsession with perceived or imaginary flaws in the body, leading to compulsions like checking in the mirror, dress changes, grooming acts, mental comparisons with others, etc.
- Trichotillomania: Obsession with scalp and body hair as an increased sense of tension, followed by compulsion of pulling out the hair (commonly from scalp, eyebrows, and arms).
- Excoriation disorder: Obsession with skin disease and hygiene leading to the compulsion of skin picking.
- Hoarding disorder: Emotional obsession with possessions, and compulsion of not being able to dispose of, organize, or part with them, leading to extreme and interfering clutter.
These consist of abnormal eating habits resulting from intense anxiety of gaining weight or appearing fat. There is a disturbance in the way body shape is perceived with undue importance given to body weight in self-evaluation and self-esteem. These conditions are postulated to possibly occur due to abnormalities in the satiety and appetite centers of the hypothalamus in the brain. Eating disorders are more common in women.
Anorexia Nervosa: The person is of lower weight than the lower end of normal, and appears thin or even emaciated. There is severe avoidance or restriction (restricting type) of food, or the person may binge-eat and then throw it out (binge eating-purging type) either by inducing vomiting or with laxatives or enemas. Other characteristics include close monitoring of intake and calories, eating very slowly, breaking food into small pieces, not eating in public, or secretly throwing away food.
Bulimia Nervosa: The person is of normal weight (sometimes slightly overweight). There is disproportionally high or excessive and uncontrollable eating within a defined period (of two hours), that involves eating large amounts of food, rapidly, even when not hungry and till uncomfortably full. This is followed by compensatory behavior of eliminating the food that includes inducing vomiting and taking laxatives, enemas or diuretics (purging bulimia) or by heavy exercise, or a period of fasting (non-purging bulimia). Such episodes should occur at least once a week for 3 months to qualify as bulimia nervosa.
Bulimia nervosa differs from the binge eating-purging type of anorexia nervosa in 2 ways – the person having normal weight or being slightly overweight in bulimia as opposed to underweight in anorexia, and that in bulimia the person is often preoccupied with shame and guilt, while in anorexia, the person is often surprised by the concern and attributed seriousness on the condition by others.
Purging type anorexia and bulimia may show puffed cheeks, throat/finger injury, mouth ulcers, and dental decay due to induced vomiting. Such people often disappear to the bathroom after meals. Both bulimia and anorexia can have serious health consequences like malnutrition and vitamin deficiencies, weakness, dizziness, low blood pressure, electrolyte imbalances, heart failure, and heart rhythm problems, hormonal irregularities causing lack of or irregular menses and high-risk pregnancies in women, hair loss, weak bones, swollen joints, constipation, anemia, skin problems, kidney disease, dehydration, and mental slowness, irritability or depression.
Binge-eating disorder: It refers to eating as in bulimia but without compensatory behaviors. Other characteristics include eating without actual hunger, rapid eating, eating till uncomfortably full, eating alone, and feelings of shame, disgust, guilt, and depression. These eating episodes should occur at least once a week for 3 months.
People with eating disorders often do not like to eat in public, and tend to isolate themselves socially. Eating disorders are treated by a combination of nutrition and diet therapy which has a weight-natural approach, along with counseling and psychotherapy techniques.
Others: Feeding disorders may be seen like avoidant-restrictive food intake disorder (extremely picky and selective eating), pica (craving and eating non-nutritious or inedible substances like mud, paper, etc.), and rumination (repeated chewing and re-chewing food brought out from stomach). These disorders are more common in children.
SOMATIC SYMPTOM AND RELATED DISORDERS
‘Soma’ stands for body. This group of diseases may stem from underlying anxiety being transposed from psychological on to physical perception for coping mentally. To call it a somatic symptom or related disorder, the characteristics should be present for a period of 6 months. It is also very important to conduct a thorough medical examination and lab investigations to rule out actual physical disease.
In somatic symptom disorder, the affected person has perceived bodily symptoms or physical problems that cause immense psychological distress and impairment. Even though the medical assessor may not find physical symptoms or disease, people with somatic symptom disorders genuinely believe and cannot help perceiving the symptoms, and are not faking or attempting to deceive.
Such people experience or perceive one or more physical symptoms that they find distressing and disrupting in everyday life. They have immense anxiety and disproportionate, persistent thoughts about the seriousness of these symptoms, and devote excess time and energy to the same. As said before, it is important to rule out a physical illness with a medical examination and lab investigations before making this diagnosis.
Other conditions in this group include illness anxiety (hypochondriasis) which is the preoccupation and anxiety of falling ill or contracting a disease. The affected person does not have any symptoms currently, or have routine mild symptoms. Such people may perform repeated checks and tests for various body parameters or on the other hand completely avoid tests and doctor appointments.
A specific condition called conversion disorder (functional neurological symptom disorder) makes the person perceive neurological symptoms (like not being able to see or hear, feeling paralyzed in a limb, tremor, episodes resembling seizures or losing consciousness, etc.). However, neither is there any underlying neurological disease, nor is the symptom pattern characteristic of any neurological disease.
In factitious disorder, there is actually deception and falsification of physical or psychological symptoms to appear ill or injured. It differs from malingering, as such falsification is done even in the absence of an external reward or benefit. In a rare condition called Munchausen’s syndrome by proxy (factitious disorder imposed on another), the person tries to present someone under their care like a child or elderly as ill. For this they may also inflict symptoms like withholding food or giving certain food items, giving emetics to induce vomiting, or laxatives to induce diarrhea, adding blood to urine or stools, heating up thermometers, and bringing for repeated hospitalization. This can be a very dangerous situation for the one under the care of the affected person.
Read: Awareness, Causes, and Treatment of Mental Health Disorders below:
DSM-V APsA – Classification of Mental Health Disorders