These mental health states have been summarized in order to provide some understanding of the categories of the DSM V [American Psychiatric Association] and ICD-11 [World Health Organization]
Each description listed below is followed by an overview of the solutions recommended by the National Institute for Health and Care Excellence [NICE] based upon the research evidence for effective therapy.
All therapy begins with a comprehensive Assessment. It is often the case that people experience a combination of the following categories of mental health difficulties.
Assessment is followed by a Formulation, an individual understanding of your experiences.
This is followed by a Treatment process tailored to your unique experience and need.
Depression can be thought of as the body going into basic survival mode in the face of overwhelming feelings of sadness and anomie, which is feeling completely disorientated and lost.
Depression can be caused by life events such as a loss, bereavement or series of bereavements. It can also be the result of feelings of anger at something or someone else, which is difficult to accept because the anger is at odds with the person’s values or their view of themselves.
Depression is often accompanied by anxiety. The experience of anxious feelings may generate or exacerbate feelings of worthlessness because the person has not been able to function and may have become isolated.
Symptoms of depression include low mood, not experiencing enjoyment or happiness, feelings of hopelessness, lethargy, lack of concentration, difficulty getting to sleep, disturbed sleep, early-morning waking, lack of appetite, low self-esteem, low self-confidence and a negative outlook of self and for the future. Depression can lead to thoughts that life is not worth living and self-harm and/or suicidal ideas or actions.
Treatment Solutions for Depression
The first step in the treatment for depression is called ‘Behavioural Activation’. This pays attention to re-introducing structure into the day, both waking and sleeping, healthy eating and also waking up the body with activity such as regular exercise. Treatment includes coaching to help motivation and to enable a rested full night’s sleep. When you are feeling stronger and more optimistic then we explore the difficulties that caused the low mood, your thoughts and feelings about this and how to move forward.
Anxiety is a physiological reaction to the experience of fear.
It can be illustrated by the scenario of a Cave Person coming across a Sabre Toothed Tiger. Our Mind-Body System is the same as the Cave Person’s System.
Danger is detected and adrenaline is released to generate energy and strength in the body so that the person can fight or run away [flight]. The heart beats faster in order to send oxygen around the body at a faster rate. Oxygen enters the muscles and the brain at an optimum rate and thus the person is able to fight or run away from the danger. The digestive system shuts down because this is not necessary for fight or flight, which causes butterflies in the stomach or a sudden feeling of sickness and a dry mouth. The eyes focus into pinpoint accuracy of vision. Hairs stand on end to allow the body to allow heat to escape.
A third adaptive mechanism in the face of danger is to freeze because a predator may detect prey by movement. In anxiety this is experienced as not being able to engage in anything.
If the person does fight or run away from the danger then the energy generated is used up and there is no experience of discomfort, but only of tiredness or exhaustion afterwards.
However, if the fear is generated by thinking or belief then the physical process is exactly the same. Adrenaline is released but is not used up by the actions of fighting or running away.
The body continues to produce an ever-increasing amount of oxygen. Oxygen into the brain causes dizziness and then headache. The ongoing pinpoint accuracy of vision is experienced as eyestrain developing into a headache.
Oxygen’s energy into the muscles keeps building up causing discomfort, shaking and then cramp. The person also experiences the discomfort and embarrassment of all-over the body sweating including clammy hands and feet. If the anxiety is prolonged then the excessive oxygen in the system causes an in-balance with carbon dioxide causing a gasping for air. The person feels that they cannot breathe and then the thought that they are going to die keeps the adrenaline and anxiety flowing.
Anxiety is extremely uncomfortable and thus the individual begins a pattern of avoidance of people or situations that could cause the same feelings to be repeated. It is often the case that the person develops a series of safety-seeking behaviours to ward off feelings of anxiety, such as carrying water everywhere or only going out with someone else, so that they feel protected. People can experience intrusive thoughts or images of danger and the fearful expectation of the next catastrophe. This causes hyper-vigilance, which is keeping a constant lookout for anticipated catastrophe and negative predictions that bad things will happen.
Avoidance of anxiety can lead to family and social difficulties such as isolation, the loss of friendships and social standing, and/or difficulty going to work or study. This can result in low self-confidence and self-worth.
It is often the case that the distress of anxiety causes the memory of distressing events to block out better memories. This may contribute to a distorted view of self, which can result in overwhelming feelings of guilt and shame. Anxiety over time causes an increasing feeling of powerlessness and vulnerability.
The following Anxiety States represent the various ways that people try to maintain control as the anxiety progressively dominates their actions, views, decisions and lifestyle.
Panic attacks are experienced as extreme discomfort as the anxious feelings grow until the person hyperventilates, feeling that he/she cannot breathe, feels faint and shaky and often thinks that they are going to die. The person also experiences profuse sweating and subsequent headache and exhaustion.
Panic Disorder is the fear of having another panic attack after the experience of the first. This fear causes hyper vigilance, which is constantly looking out for danger, and also a growing avoidance of going anywhere or doing anything that may bring on another panic attack. Another common feature of having panic disorder is the fear associated with not feeling in control of thoughts and emotions, which can be caused by not being able to identify the triggers, which cause the anxious feelings.
Panic Disorder can occur when the first panic attack takes place in a public place and the person experiences embarrassment as well as the symptoms of panic. In addition to the symptoms of panic disorder the person also avoids any situation that may cause embarrassment. This results in avoiding social activity, which may include going to work or study, hobbies, pastimes or enjoying time with friends and family.
The avoidance of social situations can cause loss of confidence, a very critical view of self and lowered mood. The person adopts Safety Seeking Behaviours to pre-empt further attacks of panic, such a only going out if someone is with them or always carrying a drink.
Phobia is the name given to a fear of a specific object or experience. Common phobias are fear of driving, travel, dogs, spiders, high places, injections, vomiting and enclosed spaces. A phobia can arise because of feeling intense fear and feeling a loss of control in relation to the object. In children a phobia can be generated by witnessing the fearful response of an adult and may be maintained because the object of the fear is consistently avoided.
Posttraumatic Stress Disorder (PTSD)
PTSD is the name given to clusters of symptoms of intrusions, hyper-arousal and avoidance. These become apparent after a person has experienced a traumatic event or bereavement. The symptoms include those of re-experiencing the event, (as if suddenly transported back to the moment), intrusive thoughts or images that cause sudden and extreme fear, sleep disturbance, nightmares, hyper vigilance (constantly looking out for danger) and avoiding any situation which may trigger fear. These symptoms impact upon the person’s functioning, self-concept and enjoyment of life.
Complex Posttraumatic Stress Disorder (Complex PTSD)
Complex PTSD describes PTSD that has had a severe impact upon the person’s functioning, self-concept and enjoyment of life. This may be because the trauma was severe and impacted upon the person’s sense of self; and/or because the person experienced a series of traumatic events thus amplifying the experience of anxiety; and/or because the symptoms of PTSD remained untreated over a long period of time. In children and young people this can impact upon their emotional and social development.
Obsessional Compulsive Disorder (OCD) and Pure OCD
Obsessions are thoughts which are repetitive and seem to be outside of the person’s control. They generate anxious feelings that can range from discomfort to panic. The feelings can be relieved by repetitive and/or excessive behaviours – compulsions - such as washing hands over and over. The reason the compulsion provides relief is because the repetitive behaviour uses up the energy that the anxiety has generated and also distracts from the intensity of the thought. For example ‘I won’t get sick if my hands are clean’. People who experience OCD sometimes find that they repeat cycles of behaviour. This is because the compulsive actions have used up the anxious energy but before the person can move onto to do something else further intrusive thoughts generate another burst of anxious energy, which drives the urge to wash their hands again.
OCD ranges from mild symptoms to severe. The severity can be caused either due to the length of time the symptoms of OCD have remained untreated or because of the severity of the event(s) from which the anxiety developed. Over time because the anticipated disaster has not happened the person carrying believes they have successfully averted the potential catastrophe by carrying out the rituals and thus the obsessions and compulsions become progressively entrenched.
Pure OCD describes the experience of those who predominantly experience obsessional thinking with the rituals integrated into the pattern of thoughts.
Body Dysmorphic Disorder (BDD)
Body Dysmorphic Disorder follows the same pattern of obsessional thinking and compulsive behaviours described for OCD. The obsessional thinking is in relation to how the person perceives the way they look. The obsessional thinking is usually related to a particular area of the body or the face, such as the chin and forehead. In response to the thinking the person can either spend long periods of time examining the area of their body or not looking at the area at all. The discomfort experienced can lead to women not leaving the house without make-up or not leaving the house at all and is often associated with not feeling confident or comfortable with self or other people. The fears become associated with beliefs about other people seeing the person as they really are. For example the person may believe that no one would want to be with them, that they could be mocked or ridiculed or find themselves alone. What is seen in the mirror or changes according to mood, with less distortion reported if the person is feeling ok.
BDD can be caused by trauma, sometimes even a chance remark, which has resonated with vulnerability in the person’s self-esteem. It can also be caused by the experience of prolonged negativity undermining the individual’s self-worth. In addition to feeling at ease with their body or face, treatment explores issues around self-perception and self-concept.
A lack of nutrition or healthy eating patterns can cause severe physical problems such as heart attack, loss of fertility, permanent damage to bone density and severe dental problems. An appointment with the GP is essential.
Anorexia Nervosa is an over-evaluation of the importance of shape and weight and an attempt to keep control of these. As a result of judging self-worth according to shape and weight, the person actively keeps a low body weight [BMI of 17.5 or below] by eating only small amounts irregularly, engaging in driven exercise and sometimes using laxatives.
As body weight drops the brain goes into basic survival mode, reducing creative and complex thought processes. This contributes to the lack of objective perception about food and exercise and increasing preoccupation with weight and shape. The person also experiences distortion of perception such as seeing a fat body when looking at self.
Bulimia Nervosa is an over-evaluation of the importance of shape and weight and keeping control of these. Distress, habitual behaviour or anxieties in relation to self-worth result in the person finding him/herself having episodes of ‘binge eating’ at which time he/she feels out of control. In order to control weight the person engages in weight control rituals such as vomiting.
Other eating difficulties have similar symptoms to those above but do not meet the diagnostic criteria for either. Binge eating is the result of satisfying emotional distress to mask symptoms of depression and/or anxiety. The resulting weight gain causes further loss of self-esteem and escalation of symptoms.
Children sometimes engage in restricted eating which may be due to family stress in relation to food, a developmental disorder, or it may be because as a young child he/she did not assimilate a variety of textures and tastes.
Treatment Solutions for Anxiety
People who experience anxiety often have symptoms of depression also. This is because the effect of anxious symptoms on lifestyle, confidence and a negative view of self may cause a drop in mood, optimism and ability to enjoy life. Treatment sessions begin with paying attention to re-introducing structure into the day, both waking and sleeping, healthy eating and also energizing the body with activity such as regular exercise.
Developing emotional regulation skills using posture, breathing and relaxation enable sleep and help to increase confidence. An increased ability to manage emotions fosters an improved experience of life. This improved experience allows an alternative understanding and view of anxiety – that anxiety is generated through the mind/body system and that the individual can manage this system to gradually retrieve previous activities, relationships and lifestyle.
Individuals experience anxiety in different ways. The development of anxiety can be dependent upon life events and the way that the anxiety was reinforced over time. Treatment is responsive to the nature of the anxiety, what has worked previously for the individual. The therapist helps the person to explore the fears or other considerations that stand in the way of the person being able to do the things that have been avoided. These could be at work, in relation to domestic activities, social activities or relationships.
After the person is feeling stronger in their ability to manage emotions and an increased engagement in their life and relationships, then therapy moves on according to the Individual Formulation. This may include gradual exposure; trauma processing; and coaching to support ERP [Exposure to uncomfortable anxious feelings and Response Prevention]. Response prevention is resisting urges to carry out excessive unhelpful behaviours, rumination or obsessional or ritualistic thinking.
Programmes include emotional regulation, pain management, gradual exposure to fear, trauma processing, cognitive work (helpful and unhelpful patterns of thinking) and relapse prevention.