Our Mental Health - Mood Disorders: Life Out Of Control

Some important dates the treatment of depression and mood/anxiety disorders:

Mid 19th to the early 20th century: reports of childhood-onset "circular insanity" or "mania and melancholia" are common in European psychiatric literature.

1930s. Freud dominates psychiatric thought. The standard psychoanalytic theory dictates that classical depressive syndrome could not occur in children before puberty.

1942: Carl Rogers publishes Counseling and Psychotherapy, suggesting respect and non-judgmental approach to therapy is the foundation for effective treatment of mental health issues.

1952: The Diagnostic and Statistical Manual of Mental Disorders (DSM) is first published.

1960s: Articles begin to appear in medical literature to suggest that adult manic-depressive adults have been ill since adolescence.

1968: The second edition of the DSM is published.

1970: Lithium is approved by the FDA to treat mania.

1970: The mass deinstitutionalization of mental hospitals begins ("mainstreaming").

1979: National Alliance for the Mentally Ill is founded.

1980: The Mental Health Systems Act is passed, dramatically increasing federal funding for mental health programs.

1980: Bipolar disorder replaces manic-depressive disorder as a diagnostic term. Other mental disorders that are included in the third edition of the DSM: bulimia, post-traumatic stress disorder, panic disorder, and anxiety disorder.

1988: Prozac is invented.

1992: The term binge-eating disorder is officially introduced.

1994: Childhood mood disorders are included in the DSM IV.

1997: Researchers identify genetic links to bipolar disorder, suggesting that the disorder is inherited.

The standard manual used for diagnosis of mental disorders in the United States is the Diagnostic and Statistical Manual of Mental Disorders (DSM). The first edition was published in 1952 by the American Psychiatric Association. It was published as a way to encourage physicians to use the same standards to diagnose mental illness. It was not until the third edition in 1980, however, that the DSM actually published clear criteria for diagnosing mental disorders (the first two editions had been heavy on Freudian theory). Criteria used to define mental disorders are based on the majority view of psychiatrists and other mental health professionals.

The DSM features descriptions of more than 300 mental disorders. Every edition includes new disorders, or refined definitions of those included earlier. It was in 1980 that a number of new mood and anxiety disorders received official classification: bulimia, post traumatic stress disorder, anxiety disorder, panic disorder, and bipolar disorder. With these disorders given official classification, the National Institute of Mental Health (NIMH) now estimates that more than 19 million adults between 18 and 54 suffer from some sort of diagnosable disorder:

What are these new mood and anxiety disorders? The estimated annual numbers are Estimated Number of 18-54 Year Olds With Disorder Annually shown above. Social anxiety disorder — often referred to with its telling acronym, SAD, is the third largest mental health care problem in the world. Social anxiety, according to the Social Anxiety Association, is the "fear and anxiety of being judged and evaluated by other people." People with SAD are often perceived as "shy, quiet, backward, withdrawn, inhibited, unfriendly, nervous, aloof or disinterested." Those with the disorder experience constant, intense anxiety in the face of public speaking, meeting people in authority or potential criticism. Their hearts beat faster, they can't breathe, or their bodies ache in these situations. SmithKline Beecham marketed Paxil, the first drug ever approved for social phobia, with the slogan "Imagine being allergic to people."

More than 5 million Americans allergic to people? Another 4 million people have something called Generalized Anxiety Disorder (called GAD for short). The possibility of experiencing deep anxiety can happen across the life cycle, according to government statistics, but the highest risk occurs between childhood and middle age. There are, of course, numerous gradations of shyness; many people get nervous at job interviews or while making a speech. The qualifier here seems to be the intensity of the anxiety. But the line between anxiety and dysfunctional thinking is certainly a thin one — and open to interpretation.

Doctors had begun to make distinctions between patients with unexpected anxiety attacks and patients with other anxiety disorders as early as the 1960s. Panic disorder received official recognition by the mental health community when included in the DSM in 1980. Panic disorder typically develops in late adolescence or early adulthood. Roughly 1 in 3 people with panic disorder develop agoraphobia. Agoraphobia is often defined as a fear of public places. It turns out that there's more to it. Those with the condition become afraid of being in any place or situation from which it might be difficult to escape — or where they might not be able to get help in the event of a panic attack. It is the fear of having fear, in a sense — and being unable to find help.

The first symptoms of obsessive-compulsive disorder generally appear in childhood or adolescence. Worries and doubts so overwhelm sufferers that their regular lives are impaired. Some people with OCD have described it as having "mental hiccups." Common obsessions include fear of germs, imagining having harmed oneself or others, excessive or intrusive thoughts (usually about sex or religion), and a need to have things "just so." Those with OCD are then compelled to perform some act in order to relieve the anxiety. They wash hands repeatedly, for instance, to get rid of germs.

As already stated, the mental health community continually renames conditions as it comes to understand them better. Post traumatic stress disorder (PTSD) is often seen as an attempt at describing the plight of some Vietnam veterans. PTSD is, at least in some circles, a more precise explanation of the difficulties of shell-shocked soldiers in World War I or those with combat stress or battle fatigue in subsequent wars. Those with PTSD experience sleep deprivation, depression, guilt at having survived battles, and a number of related issues (alcohol abuse, for example). But has the disorder taken on a life of its own? The ailment can be assigned to anyone who has difficulty coping with life after some traumatic event: violent assault, rape, robbery, terrorism, natural or human-made disasters. Eric Dean points out in his book Shook Over Hell: Post-Traumatic Stress, Vietnam and the Civil War, how far off some of the comparisons are. He quotes sources that suggest some professional football players who find their careers suddenly ended as having "developed post-traumatic stress disorders comparable to those experienced by Vietnam veterans." According to one study, 60% of men and 50% of women will experience a traumatic event in their lifetime. Some wont be able to cope with trauma or with loss. Do they have post-traumatic stress?

What about phobias? Over 6 million people between 18 and 54 — more than 4% of the age group — have a specific phobia regarding an object or situation. We all have such fears — we avoid freeways where we've had an accident. But the key, of course, is that some fears take on an irrational intensity. The fear is exaggerated in relation to the actual threat. Fear then comes to disrupts the sufferer's life.

Research (Ost & Hugdahl) suggests that half of all people with phobias have never had a painful experience with the object that they fear. Martin Seligman (1971) argues that we may be "prepared" to learn certain phobias. People learned to avoid snakes, rats, and heights to evade the potential dangers that they pose. Man survived as a species, and the fear has been passed on in our genes. Specific phobias are generally treated with behavioral therapy. The patient is exposed to the object of his fear in safe surroundings. In "flooding," a patient is exposed to the trigger until the fear goes away. The patient may be trained to substitute a feeling of calm and relaxation for the fear and panic. This is called "counter conditioning." A patient may be gradually introduced to the object of his fear. This is called "systematic desensitization."

More than 2 million Americans suffer from bipolar disorder — the old manic- depression. Those with the disorder experience sudden and sharp mood swings, from abysmal "lows" to exuberant "highs." These phases can last for months. The shifts often become more dramatic with time (roughly 8 to 10 years are thought to elapse from onset of the disorder to diagnosis). People may be deeply depressed, or have grandiose thoughts, pick fights, drive indiscriminately or be hypersexual.

The illness was thought to affect only adults, but there has been a disturbing rise in the number of children and adolescents diagnosed as bipolar. Indeed, in a generation, Time reports, the average age of onset has fallen from early 30s to the late teens. Children diagnosed with the illness exhibit a variety of symptoms: hyperactivity, a fascination with blood and gore. Giddy mood states, complaints of boredom, and poor handwriting are all included on The Bipolar Child 's checklist of possible behavior for bipolar children. Some of these symptoms, of course, are exhibited by every child at some point. But where's the line between normal development and a child potentially at risk? As well, some symptoms are so generic that that the child can be misdiagnosed. Is a hyperactive child bipolar or is he suffering from attention deficit hyperactivity syndrome? Or is he just an energetic child? One study suggests that 15% of those with ADHD actually are bipolar. The distinction is important; Ritalin is a useful treatment for attention deficit syndrome but has sent some bipolar children into emotional tailspins.

What causes bipolar disorder? As with many of these illnesses, researchers simply don't know. There is certainly evidence of genetic predisposition to the illness. Researchers have just begun to solve some of the riddles of how the brain functions. Some scientists point to something in "modern lifestyles": a child overcome by a stressful home, difficulties in school, etc. Any recreational drug that disrupts body chemistry may trigger those with a genetic predisposition. How is the illness usually treated? Anticonvulsants and antipsychotics are very useful. Lithium is still an effective tool. Those who are bipolar also receive intensive therapy.

Why were these disorders included in the updated version of the DSM in 1980? The manual is used as a tool to diagnose mental disorders. The inclusion of all these new ailments speaks to something that may have happened in society in the preceding years. Were counselors and clinicians suddenly besieged by a sudden number of deeply anxious people? It's tempting to point to a bad economy, a high suicide rate, or the rise of "dys- functional" families as a potentially easy answer to this question. Were they visited by the millions of mentally ill who were being moved out of institutions? Did mental health officials start seeing a dramatic rise in depressed teenagers, or young women who had stopped eating? Considering the violent crime rate in the 1970s, were doctors seeing patients who were stressed over being victimized?

The issue of cost is an additional consideration. If these conditions were legitimized, would it be easier for mental health organizations to obtain vital dollars to treat them? In the coming years, managed care would further complicate the issue of the mentally ill being able to afford to get treatment.

Are we just giving new names to old problems? In some cases, No. Scientists are making significant discoveries that warrant tailoring standard definitions. For example, another term included in the 1980 DSM was Pervasive Developmental Disorder, which is used to suggest the multi-faceted issues around autism and its related disorders (a topic addressed later in this chapter).

But one might argue that the labels are getting out of control. Is social anxiety just a fancy term for shyness? What one calls a bipolar of bipolar child, another calls a classic case of "the terrible twos." Is a victim of a traumatic incident suffering from post- traumatic stress disorder or is he just traumatized? Are doctors — with the best of intentions — misdiagnosing marginal patients? Some disorders have such generic symptoms, one might fear this is the case. Why do we have so many organizations to address the needs of sufferers? The Social Anxiety Institute, the Social Anxiety Network, Social Phobia/Social Anxiety Association, the Child and Adolescent Bipolar Foundation, and the Depressive and Manic Depressive Association are but a few. Does an official organization make us feel better about our dysfunction? Does having "a name for it" perhaps absolve us of being responsible for our behavior — or our pain?

Data from the National Institute of Mental Health show that more than 19 million Americans between 18 and 54 have some diagnosable (there's that word again) disorder. But what of the younger and older age groups? Are we even more troubled than we realize?

Sources: Chart figures come from the National Institute of Mental Health located at http://www.nimh.nih.gov; Ost Hugdahl & Martin Seligman theories on phobias taken from http://www.phobialist.com; "What is OCD?" at http://www.ocfoundation.org. "Social Phobia Fact Sheet." Retrieved from http://www.socialphobia.org; Kluger, Jeffrey and Sora Song. "Young and Bipolar." Time, August 19, 2002, p. 38. Fay Flam. "Gene Plays Role in Anxiety, Scientists Discover." Knight-Ridder/Tribune News Service, July 18, 2002.