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Understanding Chronic Mental Illness
What is Chronic Mental Illness?
Chronic mental illness is a persistent alteration in a person's thinking, feeling and/or behavior, which creates significant difficulties in functioning normally; socially, with their families, at work or at leisure.
Chronic mental illness is persistent. In most cases it is with a person, either in an acute phase or in remission for most of their lives. Although consistent, appropriate treatment; i.e. staying on medication, getting regular check-ups, attending therapy and/or support groups, can minimize its disorganizing effects, a person must deal with their illness day to day for the long term.
Chronic mental illness is pervasive. Since it is a significant alteration in a person's sense of perception, i.e. the way they view themselves in their environment, unlike other types of transitional emotional problems, it tends to affect a person's functioning in several if not all areas of their life.
There are three major types of chronic mental illness.
- Problems primarily with thinking - schizophrenia;
- Problems primarily with emotions - affective disorders;
- Problems primarily with behaviors - personality disorders.
While we tend to separate these diagnostic categories for clarification, in reality they many times overlap and intermix. It's rare for instance to find a person diagnosed with schizophrenia who does not also have some problems with their emotions and behaviors.
What is Schizophrenia?
Much of what is understood today as schizophrenia has its roots in the 1800's by a German psychiatrist, Kraeplin who noted that it usually started in late adolescence or early twenties and was usually accompanied by a list of common symptoms. He also noted it usually demonstrates a deteriorating course.
It is generally accepted today, that schizophrenia is a medical, physiological disorder although it is believed that a person's environment may have a role in how and when it emerges. While the way it specifically works is not yet known, it is believed to be associated with an imbalance of "neurotransmitters" or those chemicals and substances which regulate the structure of thinking in the brain. Many different studies have shown that there seems to be a genetic component to schizophrenia.
The Personal Experience of Schizophrenia
Distraction.
Schizophrenia is usually experienced first as the frightening realization that your mind is not entirely under your control. Distraction or the loss of ability to focus attention is usually the first indicator. From the book
Schizophrenia and the Family, the following examples may help describe a schizophrenic's experience:
"I jump from one thing to another, if I am talking to someone, they only need to cross their legs or scratch their heads, and I am distracted and forget what I was saying."
"I am speaking to you now, but I can hear noises going on next door and in the corridor. I find it difficult to shut these out and it makes it more difficult for me to concentrate on what I am saying to you. Often the silliest little things that are going on seem to interest me, but I find myself attending to them and wasting a lot of time this way."(P.87.)
Overload.
One of the things we take for granted about our miraculous psychological functioning is the automatic ability to "filter out" huge amounts of distracting, unwanted internal and external stimuli or "noise." This automatic function appears somewhat impaired in schizophrenics.
"It's like being a transmitter. The sounds are coming through to me but I feel my mind cannot cope with everything It's difficult to concentrate on any one sound. It's like trying to do two or three different things at one time."
"My brain after a very short time became sore trying to handle all this information with a real physical soreness as if it had been rubbed with sandpaper until it was raw. It felt like a bleeding sponge. I had very little ability to sort the relevant from the irrelevant. The filter had broken down. Completely unrelated events became intricately connected in my mind." (pp. 87,88.)
Sensitivity.
When the filtering mechanism breaks down, the schizophrenic is likely to be extremely sensitive to everyday, common stimuli we take for granted:
"I have noticed that noises all seemed to be louder to me than they were before. It's as though someone has turned up the volume..."
"Colors seem brighter now, almost as if they are luminous. When I look around me it's like a luminous painting. I'm not sure if things are solid until I touch them."(p. 88).
Misperceptions.
With greater distraction or decreased ability to attend accurately to one's internal and external environment, an overload of stimulation, and a decreased ability to filter out unwanted "noise," we can begin to appreciate how a Schizophrenic can misperceive reality to the point of having delusions and hallucinations:
"Everything is in bits...It's like a photograph that's torn in bits and put together again...If you move it's frightening. This picture you had in your head is still there but it's broken up."
"That's the horror! that's the horror of the great big open space! It's like something gone mad about the place. I could never walk in the streets. Never! It's a terrifying place, isn't it? Soon as the houses lift off buildings on both sides of the road, as if it's flat and you could see right over it like a mad horse or something...it would look mad and terrifying, like it would hurt something." (pp. 88,89.)
Symptoms of Schizophrenia
General appearance.
People suffering from schizophrenia especially if it is chronic, tend to share similar peculiarities in their appearance including:
- Disheveled. Clothes may be dirty or crumpled and may not coordinate very well. Personal hygiene may be poor.
- Disorganized. There may be a sense of disharmony in appearance and presenting behavior.
- Distracted. There is usually a sense of internal preoccupation and inattention to external surroundings.
General behavior.
Contrary to popular belief, schizophrenics are rarely violently agitated. They tend to show the following behaviors:
- Introversion. Usually very wrapped up in their own thoughts, fantasies, or internal reality. May talk to themselves, laugh inappropriately, or carry on one sided conversations.
- Inappropriateness. Do not follow generally accepted social cues. May seem rude, thoughtless or at times bizarre.
- Impaired psychomotor behavior. There may be marked decrease in reactivity to the environment, a reduction of spontaneous movement. At times "posturing" may be observed.
Content of thought.
The major disturbance in the content of what is thought are delusions. Delusions are beliefs which the schizophrenic hold to be absolutely true despite there being no evidence (from our perception) that they could be true. No amount of trying to convince the schizophrenic otherwise or talk them out of their delusion will produce any results other than convincing them we just don't understand them. Some of the more common delusions are:
- Hyper religious. The belief that theirs and others thoughts, feeling, behaviors, life circumstances are under the direct influence or control of a deity - to a much greater degree and prevalence than what is generally accepted by most religions.
- Paranoid. The belief that a person(s) is spying, following, and planning, to harm them despite concrete evidence to the contrary.
- Grandiose. The belief in having unlimited power, great beauty, skills, wealth or good luck far beyond what is considered acceptable.
- Thought broadcasting, insertion or withdrawal. The belief or experience that one's thoughts as they occur are being broadcasted to the external world, that thoughts which do not belong to the person are being inserted into their brain, or that thoughts are being taken or withdrawn.
Form of thought.
This refers not to the content, or what is thought, but to the process, or how thoughts unfold.
- Loosening of associations is the most common disturbance in this form of thought. It is when ideas shift from one subject to another, completely unrelated or only slightly related, without the speaker being aware that the topics are unrelated.
- Rambling. When the associations are so loose that no sense can be made at all and is considered incoherent.
- Tangential. When one thought is only slightly connected to another but causes a shift in speech in that direction.
- Circumstantial. When speech circles around and around the topic but never really addresses it.
- Poverty of thought. When the form of speech is intact but conveys little information because it is vague, overly abstract or repetitive.
Perception.
The major disturbances in perception are various forms of hallucinations:
- Auditory. May be a single or multiple voice heard outside of the head. The voices may be familiar and may make insulting comments about the person. Command hallucinations direct the person to perform some kind of behavior and may be of concern.
- Tactile. Usually involves an electrical, tingling, or burning sensation upon the skin.
- Somatic. The sense that something may be rotting inside the person's stomach.
- Visual hallucinations rarely occur by themselves. They are often associated with medical problems.
Affect.
Affect is a word for emotional expression. In schizophrenia there are two kinds of affect:
- Flat. Where a person shows virtually no expression of feeling or emotion. The voice is usually monotonous and the face immobile.
- Inappropriate. Where the expression of emotion clearly does not fit the situation, e.g. laughing at a funeral.
In summary, schizophrenia is best understood as a physiological disorder which diminishes a person's ability to attend properly to their external environment. This is generally because of distraction or loss of ability to focus attention, an overload of stimuli, sensitivity and misperceptions. This in turns leads to peculiarities in appearance and behavior, difficulties in controlling the form and content of thoughts, which may be evidenced by delusions and/or hallucinations.
What is an Affective Disorder?
Major affective disorders are severe disturbances of feelings or emotions. They are generally more intense and persistent than our occasional ups and downs. They can be severe enough to affect a person's thinking and behavior. As with schizophrenia, affective disorders are believed to have a strong biochemical, genetic component. They also respond significantly to medication.
There are generally two kinds of affective disorders;
Major Depressive Disorder and Bipolar or Manic Depressive Disorder. Either of these disorders can be accompanied by psychotic symptoms as well.
Major Depressive Disorder
There are basically two kinds of depressive disorders: reactive and endogenous. Reactive depressions are what most of us experience at some time in our lives. They are a depressive reaction to a particular life event. They are generally short- lived and while they are uncomfortable, they are usually manageable.
Endogenous, or major depressive disorders are quite different. It is because of this difference that it is sometimes difficult to understand how a person can get that depressed over what may (to us) seem like a minor event. Major depressive episodes are severe psychological and physical responses that may or may not be precipitated (triggered) by a particular stressor or situation. They usually continue long after the precipitating event and are quite resistant to improving, even if the person is in therapy. Many times there is a history of depression and/or suicide in the person's biological family.
Symptoms of Major Depressive Episode:
Major depressive episodes are considered to be a biochemical disorder and are usually accompanied by a number of specific symptoms including:
- Depressed mood. This usually means more than feeling down, or "blue." Some people have described it more as a "black mood," which can become so severe that "time stands still."
- Insomnia or hypersomnia. The person usually experiences waking up several times in the early morning and is unable to go back to sleep; or may sleep an excessive amount.
- Lack of appetite or excessive appetite. There is usually excessive weight loss or gain several weeks after the depressive episode has started.
- Lack of energy and motivation. Many depressed people state they feel as though someone has "pulled their plug."
- Anhedonia, or lack of pleasurable feelings. A depressed person may state that they have no sense of feeling good, life feels completely gray.
- Decreased ability to concentrate or think clearly. Many times significant indecisiveness is apparent.
- Recurrent thoughts of death or suicide.
In addition to the above symptoms, a severely depressed person may also experience psychotic symptoms. These symptoms are usually limited to mood congruent delusions and hallucinations. Unlike those in schizophrenia, these delusions and hallucinations are present only when there is a severely depressed mood and their content is usually consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism or deserved punishment.
Bipolar Disorders
Bipolar, or manic depressive disorder is another affective disorder, which is believed to have a strong biochemical, genetic component. Bipolar disorders also respond significantly to medication.
The essential feature of a bipolar disorder is the presence of one or more manic or hypomanic episodes (usually with a history of major depressive episodes). A person with bipolar disorder can present with either mania or depression, but usually has a history of having both. There is usually a cycling between mania and depression, which can take days, weeks, even months to complete a cycle.
The essential feature of a manic episode is a distinct period during which the predominant mood is elevated, expansive, or irritable, and there are associated symptoms of the manic syndrome. The disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to require hospitalization to prevent harm to self or others.
Symptoms of the Manic Syndrome
- A distinct period of abnormally and persistently elevated, expansive, or irritable mood. The elevated mood may be described as euphoric, good, cheerful or high. The expansive quality of the mood is characterized by unceasing and unselective enthusiasm for interacting with others. The mood may become irritable when the person is thwarted or discouraged.
- Inflated self-esteem or grandiosity. The person may display uncritical self-confidence and give sweeping advice in matters he has no knowledge.
- Decreased need for sleep. May stay awake most of the night, in some cases may not sleep for days.
- Pressured speech. The person may display loud, continual and rapid speech, not allowing anyone else to talk. Often it is full of jokes, puns, play on words and amusing irrelevancies. If the mood is irritable the speech may be marked by complaints, hostile comments, and angry tirades.
- Flight of ideas. Along with the pressured speech, there will be a "racing of thoughts" which the person cannot slow down or stop. When the flight of ideas is severe, speech may be disorganized and incoherent.
- Distractibility. Also part of pressured speech and flight of ideas is distractibility, which is evidenced by rapid changes in speech or activity.
- Increase in activity. This often involves excessive planning of, and participation in, multiple activities. Usually, there is an increase of sociability, expansiveness, unwarranted optimism, grandiosity, and lack of judgment. This can lead to buying sprees, reckless driving, foolish business ventures, and sexual behavior unusual for the person.
As with major depressive episode, a person in a manic episode may also experience psychotic symptoms. These are again, mood congruent hallucinations and/or delusions. With manic episode hallucinations and delusions may take a grandiose theme; i.e. hearing God's voice, or believing they are on a special, personal mission from God.
What is a Personality Disorder?
Personality disorders are considered here as a chronic mental illness because they can cause significant and sustained impairment. The Diagnostic and Statistical Manual of Mental Disorders-IV distinguishes between personality traits and personality disorders.
Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself, and are exhibited in a wide range of important social and personal contexts. It is only when personality traits are inflexible and maladaptive and cause either significant functional impairment or subjective distress that they constitute personality disorders. The manifestations of personality disorders are often recognizable by adolescence or earlier and continue throughout most of adult life, though they often become less obvious in middle or old age.
Unlike the two chronic mental illnesses already described, schizophrenia and affective disorders, there is little research to support the idea that personality disorders are genetically predisposed or biochemical related. It is more likely personality disorders are a result of sustained environmental distress and family dysfunction.
However, unlike other emotional problems that may have their origins in family dysfunction, personality disorders are a result of significant and sustained impairment that renders the dysfunction many times as ego syntonic. This means the impaired perception and relating to oneself and their environment, regardless of how unrealistic (in the view of others) it may be, seems normal - the way things should be, to the personality-disordered person.
It is for these reasons personality disorders are considered a chronic mental illness. The impairment is significant enough, especially in the Borderline, Antisocial and Schizotypal personality disorders to require occasional to frequent psychiatric hospitalization. It is also chronic enough, so that even when a person with a personality disorder enters treatment with the intent to modify dysfunctional traits, he/she may be unable to do so despite great effort.
Specific Personality Disorders
While it is difficult for even an experienced therapist to diagnose specific personality disorders, and it can be questioned how useful this type of "labeling" really is, it is necessary to have some familiarity with the basic types or "clusters" of personality disorders.
In the DSM-IV the personality disorders have been grouped into three clusters. The first cluster, referred to as cluster A, includes Paranoid, Schizoid, and Schizotypal personality disorders. People with these disorders often appear odd or eccentric. Cluster B includes Antisocial, Borderline, Histrionic, and Narcissistic personality disorders. People with these disorders often appear dramatic, emotional, or erratic. Cluster C includes Avoidant, Dependent, Obsessive Compulsive, and Passive Aggressive personality disorders. People with these disorders often appear anxious or fearful.
Cluster A
In this first cluster, people with this basic type of personality disorder are often mistaken for schizophrenics. This is because their behavior can be quite odd, erratic and confusing. Many times they appear disheveled, poorly dressed and/or groomed and seem very much caught up in their own world, or very suspicious. They may at times be talking to themselves and seem disorganized in their behavior.
In talking with them (if they will talk to you), you may find they have odd ideas and beliefs. In trying to relate to them, you will find them distant emotionally, at times with a "vacant" feeling about them. They may present as cold, disinterested. You would get the feeling, it would take a long time before they would trust you enough to "let you in" to their world.
Despite the similarities to schizophrenics in presentation and behavior, the essential difference is that there is a distinct absence of hallucinations, fixed delusions, or impaired reality testing. As eccentric as these people may present, they are (usually) quite in touch with reality.
The main reason a person with a Cluster A personality disorder would present for counseling would probably be because of discomfort in interpersonal relationships. Although they tend to avoid personal relationships, they are often the target of criticism at work or misunderstanding in personal relationships.
Because they do present eccentric and are usually outside the "mainstream" of social contexts, they are often aggravated or shunned by others. In personal relationships, if they do get emotionally involved, they can display an intense, almost desperate dependency. This often precipitates a disruption in the relationship and can produce panic, disorganization and even temporary psychotic decomposition.
Cluster B
This second cluster of personality disorders are not as easily identified as those of Cluster A. They usually do not display eccentric or odd behavior, abnormalities in appearance, and in fact may present as quite "normal." In some contexts they may even appear "slick" in their appearance and "smooth" in their speech and may hold positions of authority. Some personality disorders within this cluster may "prey" upon others who are unaware or unsuspecting of their genuine motives or intentions.
In interpersonal relationships, cluster B personality disorders tend to be "chameleons." They are able to rapidly assimilate what others may expect of them and assume the appropriate "shape and color," to fit perceived expectations. They are often very skilled in perceiving the needs of others, and assuming the appearance of caring for or taking care of those needs.
Intrapersonally, this cluster of personality disorders often feels very empty or barren. Many complain of chronic boredom. They may attempt to escape this emptiness by "thrill seeking." This may take the form of performing dangerous and/or illegal behaviors, drug and alcohol abuse, and deviant sexual relationships. They generally have significant difficulties or are incapable of forming mutually caring, respectful relationships.
Possibly the best phrase that can describe this cluster of personality disorders is "stable instability." There is a stable and consistent pattern of instability: in self-image, in affect, in interpersonal relationships, and in the ability to control their own behavior. In one context they may appear smooth, controlled and appropriate, while in another display intense rage, dependency, anxiety, threatens suicide or harm to others.
Cluster C
In this last cluster of personality disorders there is a pervasive pattern of social discomfort, fear of negative evaluation, timidity, and submissive behavior. While people with Cluster A personality disorders tend to be indifferent and aloof to the needs and interactions of others, those from Cluster B tend to be demanding and manipulative, cluster C personality disorders tend to be needy, clinging and dependent.
While most people are concerned about how others evaluate them, people with cluster C personality disorders are easily hurt by criticism and are devastated by the slightest hint of disapproval. They are generally unwilling to enter into relationships unless given an unusually strong guarantee of uncritical acceptance.
This excessive dependence on others leads to difficulty in initiating projects or doing things on one's own. People in this cluster tend to feel uncomfortable or helpless when alone, and will go to great lengths to avoid being alone. They are devastated when close relationships end, and tend to be preoccupied with fears of being abandoned.
People with cluster C personality disorders invariably lack self-confidence, suffer from low self-esteem, are prone to brooding, withdrawal and episodes of depression. They tend to belittle their abilities and assets. They may constantly refer to themselves as "stupid" or "ugly." They may at times seek, or stimulate, overprotection and dominance in others.
Review
Chronic mental illness is a persistent alteration in a person's thinking, feeling and/or behavior, which creates significant difficulties in functioning normally, socially, with their families, at work or at leisure.
There are three major types of chronic mental illness:
- Problems primarily with thinking - schizophrenia;
- Problems primarily with emotions - affective disorders;
- Problems primarily with behaviors - personality disorders.
Schizophrenia
It is generally accepted today that schizophrenia is a medical, physiological disorder although it is believed that a person's environment may have a role in how and when it emerges. While the way it specifically works is not yet known, it is believed to be associated with an imbalance of neurotransmitter or those chemicals which regulate the structure of thinking in the brain. Many different studies have shown that there seems to be a genetic component to schizophrenia.
Schizophrenia is usually first experienced as distraction, or the loss of ability to focus attention to the external environment. Overload or the loss of ability to filter out unwanted "noise" or stimulation also becomes part of, and intensifies distraction. With greater distraction or decreased ability to attend accurately to one's internal and external environment, an overload of stimulation, and a decreased ability to filter out unwanted noise, the schizophrenic becomes increasingly vulnerable to misperceiving reality to the point of having delusions and hallucinations.
This increase of internal noise or distraction and decreased ability to attend to the external environment can lead to a constellation of symptoms including: impairment of general appearance, general behavior, content of thought, form of thought, perception, and affect.
Affective Disorders
Major affective disorders are severe disturbances of feelings or emotions. They are generally more intense and persistent than our occasional ups and downs. They can be severe enough to affect a person's thinking and behavior. As with schizophrenia, affective disorders are believed to have a strong biochemical, genetic component. They also respond significantly to medication.
There are basically two kinds of affective disorders: major depressive disorder and bipolar affective disorder or manic-depressive disorder. Either of these disorders can be accompanied by psychotic symptoms as well.
Symptoms of the major depressive disorder include: depressed mood, insomnia or hypersomnia, lack of appetite or excessive appetite, lack of energy and motivation, anhedonia or lack of pleasurable feelings, decreased ability to concentrate and recurrent thoughts of death or suicide.
The essential feature of a bipolar disorder is the presence of one or more manic or hypomanic episodes (usually with a history of major depressive episodes). A person with bipolar disorder can present with either mania or depression, but usually has a history of having both. There is usually a cycling between mania and depression, which can take days to months to complete a cycle.
Symptoms of the manic syndrome include: a distinct period of abnormally and persistently elevated, expansive or irritable mood, inflated self-esteem or grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in activity.
Personality Disorders
Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself, and are exhibited in a wide range of important social and personal contexts. It is only when personality traits are inflexible and maladaptive and cause either significant functional impairment or subjective distress that they constitute personality disorders.
The manifestations of personality disorders are often recognized-able by adolescence or earlier and continue throughout most of adult life, though they often become less obvious in middle or old age.
In the DSM IV-R the personality disorders have been grouped into three clusters.
The first cluster, referred to as cluster A, includes Paranoid, Schizoid, and Schizotypal personality disorders. People with these disorders often appear odd or eccentric.
Cluster B includes Antisocial, Borderline, Histrionic, and Narcissistic personality disorders. People with these disorders often appear dramatic, emotional, or erratic.
Cluster C includes Avoidant, Dependent, Obsessive Compulsive, and Passive Aggressive personality disorders. People with these disorders often appear anxious or fearful.
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