Ch #12 Mental Health

Anorexia Nervosa

Anorexia nervosa is characterized by deprivation of food and a body weight of at least 15% below the normal weight for a person's height and age. The DSM—IV classifies anorexia as an eating disorder associated with the following factors: I Refusal to maintain an adequate weight I Intense fear of gaining weight I Distorted body image I In women, three consecutive missed periods without pregnancy Physical symptoms of anorexia nervosa include a significant loss ofweight, a refusal to eat, amenorrhea, and a denial of unusual eating behaviors or weight change. As an anorexic person's metabolism slows to adjust to the lack of nourishment, other symptoms, such as muscle weakness, constipation, brittle hair and nails, lethargy, and a lowering of the body temperature, which causes a constant feeling of coldness and slowness, occur. Psychological symptoms of this eating disorder include a distorted body image, confusion ofselfimage, a sense of being incompetent, depression, and withdrawal from others. Individuals also tend to become socially withdrawn as the disorder progresses. Researchers note that the most notable belief shared by women with anorexia is that weight, shape, or being thin is the predominant reference for establishing personal value or self—worth. Other identified psychological features of the illness include: - A frustration over becoming overweight - A fear of losing control over eating - A loss of judgment relative to the requirement of food as a basic need for the body I An unrealistic sense of body image Women with anorexia often display obsessive-compulsive behaviors, such as obsessing about becoming fat and, consequently, compulsively exercising or practicing odd eating rituals to avoid becoming fat. Other compulsive activities may include constant weighing, looking in the mirror, and taking body measurements. Women with anorexia also are obsessed with food and eating, and will often cook, prepare, and purchase food for others. They will eat in secret and reject food in public. Anorexia nervosa usually strikes in early to late adolescence. A general characteristic of the anorectic personality is a feeling of overall ineffectiveness as a person. The typical anorexic woman is highly critical of herself, has poor self-esteem, and believes that she is quite inadequate in most areas of personal and social functioning. She often feels powerless and unable to control many areas of her life, so she establishes power over her food intake and weight. Because of her perfectionist tendencies, the woman with anorexia believes that the ultimate sign of control is a "perfect" body. Symptoms of depression, with large mood swings, are commonly seen in individuals with the disor- der. The increased risk for heart and kidney failure, suicide, and other serious consequences makes people with anorexia about 10 times more likely to die early than people without this condition.

Binge Eating Disorder

Binge eating disorder (BED) is characterized by compulsive overeating without attempting to purge. Defining factors of BED include recurrent episodes of binge eating at least 2 days per week for a minimum of 6 months, as well as an overall sense of loss of control over the binges. Women with BED also have a preoccupation with food and weight, as well as a distorted body image. Binge eating disorder is different from nonpurging bulimia nervosa, because people with nonpurging bulimia binge after periods of fasting and use excessive exercise as a way to compensate for their binges. Most people who suffer from BED are obese and have a long history of weight fluctuations. Women who suffer from BED are at high risk for medical problems associated with obesity, as well as depression and anxiety due to guilt and feelings of self disgust. Many people with BED have histories of major family dysfunction and childhood abuse.

Bipolar Disorder

Bipolar disorder, sometimes also referred to as manic— depressive disorder, is somewhat like depression in that it affects a person's emotions and ability to function, but bipolar disorder is characterized by shifts in emotion, not by a single mood. A person with bipolar disorder experiences episodes of both mania ("highs") and depression ("lows"). During manic episodes 21 person with bipolar disorder typically has an excess of energy, activity, and restlessness. At this point, a person could feel wonderful and euphoric, or Overly stimulated and easily irritated. Other symptoms of a manic phase include racing thoughts, extreme distractibility, overconfidence, and an increased sex drive. People experiencing depressive episodes typically have deep, persistent feelings of sadness, anxiety, hopelessness, or guilt; they might also have low energy, a reduced sense of pleasure, a lowered sex drive, and thoughts of suicide. In between manic and depressive episodes, a person with bipolar disorder could have extended periods of being within the normal range of moods. People with bipolar disorder are at great risk for abusing alcohol and other drugs and engaging in other self—destructive behaviors. About 2.6% of the adult population (5.7 million people) will be affected by bipolar disorder in any given year. Bipolar disorder typically first appears during a person's 203. Gender differences influence the manifestation of the disease, however, with women typically having more depressed episodes and more rapid cycling between depression and mania than do men.

Bulimia Nervosa

Bulimia nervosa is an eating disorder characterized by cyclic binge eating (bingeing) followed by purging. Prevalence rates for bulimia range from 1% to 16%, with the highest rates occurring in adolescents and young adults. The DSM—I V associates four distinguishing character— istics of bulimia: I Recurrent episodes of binge eating (at least 2 episodes per week for at least 3 months) I A feeling of lack of control over eating behavior during the binge I Regular engagement in purges I Persistent overconcern with body shape and weight Bulimia is a progressive disorder that usually begins with extreme hunger as a result of long periods of food deprivation from fasting or dieting. This hunger is followed by attempts at eating while still trying to control weight. Women with this eating disorder often maintain normal body weight but are extremely dissatisfied with their bodies. Some bulimics have reported that in their preadolescent years, they gained feelings of control and power through this self—denial. The situation progresses to out—of control binges/purges because the artificial elimination methods have relieved the feeling of being "stuffed," and the bulimic believes it is a good way to lose weight. Binges often occur when bulimics feel that they have passed a self-imposed limit on acceptable food intake. Consequently, they feel defeated and generally gorge until they are interrupted or the food runs out. During such hinges, the caloric intake may range from 2,000 to 3,000 calories. Binges generally lasts for less than 2 hours but have been reported to last as long as 8 hours. The binge foods of choice are usually highcalorie, easily ingested "junk" food that requires little preparation and can be obtained while l keeping the binge secret from others. Bulimics mav use l several modes of purging, including induced vomiting, diuretics, laxatives, fasts, enemas, diet pills, chewing for hours and then spitting out the food, and excessive exercise. The number of different methods of purging is a stronger index of the severity of the woman's condition than is the frequency of use of any one type. The binge—purge cycle may occur anywhere from once or twice weekly to several times daily. The cycle often begins in response to a strong emotion, either positive or negative. These emotions can come from a food craving, stress, sleeplessness, anxiety, joy, excitement, physical or emotional pain, helplessness, hopelessness, loneliness, or sadness. After the binge, some women say they initially feel relaxed and soothed, but these feelings turn to shame, guilt, and self—hatred. The women then feel the need to purge to relieve the fear of weight gain and to regain a sense of control and purity. After the purge, bulimics may feel relieved that they have controlled their weight but guilty and negative about succumbing to the cycle again. These feelings of guilt invariably lead the bulimic to perpetuate the behavior. People with bulimia are often independent high achievers and of normal weight. Bulimia has traditionally afflicted adolescent and young adult females from middle—class backgrounds, but it affects other groups of women and men as well. Bulimics are often perfectionist, obsessive-com- pulsive, depressed, intense, insecure, sensitive to rejection, anxious to please, and dependent on others. They may be socially isolated as a result of their all—consuming preoccupation with food and weight and their struggle to hide their eating behavior. The majority of women who suffer from bulimia are aware that their eating habits are abnor- mal, but may believe that they have the ultimate weight control secret of being able to "have their cake and eat it, too." Other factors thought to contribute to the development of bulimia include family problems, maladaptive behavior, self-identity conflicts, history of sexual abuse, and cultural overemphasis on physical appearance. In addition to the psychological problems, bulimia nervosa can cause a variety of physical problems, including hypoglycemia, a slowed metabolism, spontaneous regurgitation, erosion of tooth enamel or tooth loss, bleeding and sores in the mouth and esophagus, and mineral deficiencies. Table 12.4 compares the symptoms of anorexia nervosa with those of bulimia nervosa.

Depression

Depression is a medical illness affecting the mind as well as the body. Usually triggered by stressful life events, depression is characterized by persistent, inescapable feelings of sadness. These emotions are often accompanied by feel ings of inadequacy and hopelessness, physical exhaustion; and other symptoms (Table 12.1). Symptoms of depres sion are so intense that they usually disrupt a person's basic activities, including eating, sleeping, maintaining relation- ships, and taking pleasure in life. People with depression often feel undesirable and inadequate. They anticipate rejection and dissatisfaction from their interactions and experiences, and they blame themselves when their negative expectations are fulfilled. People with depression often know their feelings are unhealthy and unproductive, and want desperately to feel better, but are unable to do so. This inability to "snap out of it" makes them feel even more weak and inadequate. Feelings of hopelessness and worthlessness also make people with depression unlikely to seek professional help. Less than one—third of people with depression seek help from a mental health professional. Depression often coexists with other physical and mental illnesses. Among the elderly, for example, depression is often mistaken for, or present with, Alzheimer's disease. Medical conditions, such as thyroid disease, multiple scle- rosis, and cancer, also increase a person's risk of getting depression. Depression also may arise as a response to a serious illness, a consequence of substance abuse, or a side effect of certain medications. In addition, depression frequently accompanies chronic diseases, including coronary heart disease, diabetes, stroke, cancer, and HIV/AIDS. Hormonal shifts during reproductive-related events and their link to mental illness have been the subject of much controversy. For example, it was previously believed that hormones were solely responsible for depression during premenstrual syndrome (PMS); however, research now shows that hormones may trigger, but are not solely responsible for, PMS-related depression. Severe depression during PMS, called premenstrual dysphoric disorder (PMDD), affects 3% to 7% of menstruating women. Postpartum depression is a type of depression that affects 10% to 15% of all new mothers. This condition is different from the "baby blues," or postpartum blues, which occurs in the first 10 days after delivery and are quite common and typically mild. Postpartum depression typically begins 3 to six 6 after delivery and is much more severe (Table 12.2), although less severe than postpartum psychosis. Postpartum depression is more common in women with a history of depression, marital issues, lack of social sup- port, or a history of negative life experiences. Although it often goes unnoticed and untreated, postpartum depression can greatly affect the mother and child as well as damage the relationship between the parents. For women who are already at risk, menopause can be another hormone—related event that can trigger depression. Levels of the neurotransmitter serotonin are lower in people with major depression. Medications that boost levels of serotonin, called selective serotonin reuptake inhibitors (SSRIs), can often relieve symptoms of depression. One study found that men's brains make 52% more serotonin than do women's brains, possibly explaining why depression can manifest diflerently in men and women. Genetics also play a major role in depression. Someone with a family history of depression is significantly more likely to develop depression than someone with no family history of the disease. Studies have shown that children with one depressed parent are two to three times more likely to experience depression by age 18 than are children without depressed parents. The risk doubles if both parents suffer from depression. Seasonal shifts in daylight hours, which affect a person's circadian rhythm or sleep—wake cycle, can cause a particular form of depression called seasonal affective disorder (SAD). Seasonal affective disorder often affects women in their reproductive years, producing symptoms such as increased appetite, lethargy, and carbohydrate cravings. Researchers believe the cause of SAD may be related to melatonin disturbances. Therapeutic doses of bright light in the morning can help to relieve this condition. Depression is the most common mood disorder among women and is about twice as common in women as it is in men. Depression affects 1 in 10 women at any given moment, but more than 1 in 5 women will experience at least one depressive episode during their lives. Adolescent females have especially high rates of depression, Before puberty, boys are more likely than girls of the same age to be diagnosed with depression or depressive symptoms. After puberty, however, girls are far more likely to be diagnosed with depression. Between the ages of 30 and 44—typically the years of childbearing and childrearing—rates of depression are three times greater for women than they are for men. Elderly women, especially women who are widowed, are in poor physical health, or have lost some or all of their independence, are also at risk for developing depression. Medical illness and the effects of multiple medications in the elderly make diagnosing depression especially diflicult. Rates of depression vary significantly by race/ ethnicity and socioeconomic characteristics (see Figures 12.1 and 12.2). People of color are significantly more likely to be depressed than White people. Education, employment status, and poverty are also predictors for depression. People without a high school diploma are 2.5 times more likely to be depressed than people who have gone to college; people who are unemployed or unable to work are 3 to 5 times more likely to be depressed than people who work, and people living in poverty are about twice as likely to be depressed as people who are not poordul The reasons for these correlations are complex and not fully understood. However, these higher rates of depression can be traced in part both to reduced access to health care and other resources, and to increased vulnerability to negative life events and the stress resulting from this vulnerability. Researchers are examining whether the higher rates of depression in women truly represent a greater incidence of depression or whether the rates reflect gender-based differences in the acknowledgment of mental illness or ability to recognize symptoms. Rates of depression in men may be underestimated because women are more likely than men to discuss feelings associated with being depressed, to admit to feeling depressed, and to seek help. Men are also more likely to direct negative feelings outward rather than inward, toward the self. (These same tendencies make men more likely to engage in self-destructive behaviors such as substance abuse and violent behavior directed at others.) In Amish culture, where women's roles as mothers and homemakers are more highly valued than in US. society as a whole and society frowns on self—destructive "macho" behaviors and alcohol consumption, rates of depression are equal for men and women. Women also have higher rates of victimization from physical abuse, sexual harassment, and rape. Acts of violence such as these not only cause trauma, but foster low self—esteem, a sense of helplessness, social isolation, and, ultimately, depression. Being a caregiver for young children, aging parents, or ill family members—roles often filled by women—also has been noted as a risk factor for depression.

Dysthymia

Dysthymia is a milder but persistent form of depression. Even though dysthymia's symptoms are less severe than other forms of depression, dysthymia is still a serious, debilitating disease. It is diagnosed when symptoms last at least 2 years in adults or 1 year in adolescents and chil dren. People with dysthymia exhibit a depressed mood and at least two other symptoms of depression, such as poor appetite, overeating, sleep difficulties, or low self—esteem. Dysthymia often begins in childhood or adolescence, but Can occur at any age. Because it often develops at a young age, the depressed state becomes integrated within the woman's personality, often not only affecting her self- esteem and motivation, but also her ability to live a satisfying life and function normally. Dysthymia affects about 1.5% of the adult population (about 3.3 million adults) in any given year.

Eating Disorders

Eating disorders are serious mental illnesses characterized by dysfunctional eating patterns. But an eating disorder is much more than an unhealthy eating habit or a desire "not to eat." Like other mental illnesses, eating disorders have biological and environmental causes, distinct symp- toms, and harmful consequences for the body. People with eating disorders are also likely to have other mental illnesses, including depression, anxiety disorders, and substance—abuse problems. At some point in their lives, between 0.5% and 3.7% of women will have anorexia, and between 1.1% and 4.2% of women will have bulimia. Eating disorders are treatable, but success requires the person to acknowledge the seriousness of the issue and seek professional medical help. There is no single explanation for why an eating disorder evolves. Eating disorders often begin with dieting; however, before dieting, other factors have already affected a person's mindset. Some women may have a biological vulnerability to eating disorders. Levels of neurotransmitters and hormones that affect one's mood, appetite, and eating behavior may be altered in women with eating disorders. For example, the hormone serotonin, which creates feelings of satiety after eating, may be present at lower levels in women with bulimia. Therefore, these individuals tend to not feel as satisfied after eating and may binge as a result. Poor self—image, depression, anxiety, loneliness, and certain familv and personal relationships may contribute to the development of an eating disorder, too. The smesses associated with adolescent and adult life also can precipitate anorexia or bulimia. Our culture, with its unrelenting idealization of thin- mess, "the perfect body," and its presentation of weight loss as an accomplishment, is also partly to blame. Consider the rise in pro-eating-disorder websites that share information among those with eating disorders on how to better meet their disordered goals of weight loss and behavior control. Women (and men) use personal blogs and webpages such as Pinterest to share photographs, stories, and techniques in an effort to create a sense of support and community among people of like thinking. Many health professionals, however, believe these websites encourage harmful eating habits and have mounted campaigns with Internet service providers to have the sites removed. Eating disorders have harmful consequences for the mind and the body. People with eating disorders are more likely to Suffer from other mental illnesses; they can also develop health complications including dental problems kidney failure, and heart conditions. The female athlete triad is a particularly harmful interrelationship between disordered eating, amenorrhea (the absence of a regular menstrual cycle in a woman of repro- ductive age), and osteoporosis. The triad usually begins with disordered eating. Poor nutrition and intense athletic training cause weight loss and a decrease in or shut—down of estrogen production. These stresses on the body lead to a cessation of the menstrual cycle. The final condition in the triad, osteoporosis, may follow if estrogen levels remain low and the woman's diet is lacking in calcium and vitamin D. Although the triad can occur in any athlete, those at greatest risk are endurance athletes such as distance swimmers and runners, and athletes in sports where slim appearance is highly valued, such as gymnasts and figure skaters.

Generalized Anxiety Disorders

Generalized anxiety disorder (GAD) is characterized by chronic and exaggerated worry and tension that lasts for at least 6 months. People with GAD may worry about disasters befalling themselves or their loved ones, or about routine events of everyday life. 'lhis constant worrying eventually affects the body in many ways, producing symptoms such as an inability to relax, nausea, muscle tension or pain, trembling, or having to go to the bathroom frequently. The worrying can also interfere with concentration and memory. The severity of GAD varies from person to person: It can be relatively mild, or the anxiety can be intense and disabling enough to prevent a person from carrying out daily activities, holding ajob, or interacting with others. Generalized anxiety disorder currently affects 6.8 million adults in the United States, two-thirds of whom are women.

Mood Disorders

Mood disorders (also known as affective disorders) are mental disorders characterized by extreme disturbances of mood, the dominant emotion (or emotional tendency) a person feels at any given moment. Many factors including genetics, out—of—balance neurotransmitters, a person's life experiences, and other environmental factors can contrib- ute to a mood disorder or influence how a given disorder progresses. Depression and dysthymia are associated with persistent sadness, whereas bipolar disorder is associated with rapid mood changes or sustained elevations in mood.

Introduction

Mental health is at least as important as physical health for a happy, meaningful life. Poor mental health can interfere with maintaining relationships, having a sense of satisfaction in one's self and one's work, and functioning in day-to-day life. Mental illnesses can dull or block even our basic interests in food, sleep, and sexual contact. So how should a topic as important, yet as nebulous, as "mental health" be defined? One definition of mental health is "how we think, feel, and act as we cope with life." By this definition, good mental health could be considered a state of well—being that allows a person to be productive, have fulfilling relationships, adapt to changes, and cope with difficult circumstances. Mental disorders can be defined as health conditions marked by changes or abnormalities in mood, thinking, or behavior (or a combination of the three) that produce distress or impair functioning. Making more specific definitions without going into extensive detail is difficult. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM—IV-TR), the manual the American Psychological Association uses to classify mental disorders, uses more than 140 words to define "mental disorder," and 943 pages (17 major drag- nostic classes along 5 axes) to define every recognized mental disorder. Defining terms like "mental health," "mental disorders," and "mental illness" is also difficult because the distinction between mental and physical health is largely artificial. The brain governs our ability to think, feel, and respond— everything we think of as "mental health." But the brain, like any other organ, requires nutrients and oxygen. It can be damaged or otherwise affected by nutritional deficiencies, thyroid problems, tumors, or physical trauma. Mental health also influences physical health. Depression, for example, makes people less likely to exercise, more likely to engage in substance abuse, and less able to take good care of themselves, greatly increasing their risk for heart disease and other conditions. The environment also affects a person's mental health. Just as if you restrict a person's vitamin C intake, that person will be very likely to develop scurvy even if that person is otherwise "healthy," if you prevent a person from getting enough oxygen, he or she will have a panic attack, even if that person is otherwise a brave, disciplined person in good mental health. Social context also influences how cultures conceptualize mental health. The DSM once, but no longer, classified homosexuality as a mental illness. Today, suicide is considered the ultimate symptom of mental illness, but in feudal Japan, this act was expected of an honorable person under some circumstances. Freud said the mark of a mentally healthy individual was the ability to love and to work, but even this definition carries certain social judgments about what is important for a good life. Finally, mental health is difficult to define because it is a matter of degree. People normally considered "mentally healthy" may engage in behaviors that, if taken further, are associated with mental illness. A woman may be considered mentally healthy, and even sensible, for washing her hands several times a day during cold or flu season, but if that same woman washes her hands 30 or 40 times a day and her hand washing interferes with her ability to work, she could be diagnosed with obsessive—compulsive disorder (OCD). Drawing a line between the mentally healthy and people with mental disorders requires a judgment call that may vary from person to person. (Similarly, people have different definitions about at what point water turns from "hot" to "cold," even if everyone agrees that boiling water is hot and ice is cold.) Mental illness is extremely common. Just as a person's physical health varies throughout his or her lifetime, so, too does his or her mental health. Most people with mental disorders are otherwise normal people who love and are loved, and who contribute to society. People with mental illnesses can be politicians, artists, bus drivers, accountants, doctors, or any other profession. They may seek treatment and recover fully, or they may cope with their disorder as best they can by themselves. In some cases, the perspectives people gain from dealing with mental illness may be of great value to society; some historians have argued that Abraham Lincoln and Winston Churchill were better lead ers because of their depressive tendencies. Half of all Americans experience mental illness in their lifetimes, but most of these people will not seek professional treatment. Many factors contribute to this lack of care. Sometimes good mental health care is not available or affordable, or people do not know where they can find it. The stigma associated with mental illness—many people are afraid to seek help because they are afraid of being thought of as "crazy"—prevents people from seeking needed care. Even as science continues to make enormous strides in mapping the brain and understanding cognitive function, the basic problem of improving access to mental health care remains one of the major health challenges of the 21st century.

Legal Dimensions

Most people with mental disorders are law-abiding citizens. With access to proper treatment, people with mental disorders are not more likely to commit crimes than the general population. However, if mental illnesses are left untreated or are not treated properly, a correlation between mental illness and crime does exist, especially among individuals with psychotic and mood disorders. Many people are not identified as suffering from a mental disorder during the legal and criminal process. The Bureau of Justice Statistics estimates that more than half of prison and jail inmates suffer from at least one mental disorder, most often mania, depression, and psychotic disorders. Female inmates are more likely to have some form of mental illness than male inmates: 73% of women in state prisons, 61% of women in federal prisons, and 75% of women in jails had a significant mental disorder. Less than one—third of prisoners who had a mental health problem had received treatment since they were incarcerated. These numbers likely reflect both a link between untreated mental disorders and crime as well as increased rates of mental illness that result from the trauma related to committing a crime, going to trial, and adjusting to a life in prison. Mentally ill homeless people also create legal and ethical dilemmas for society. During the 1980s, thousands of mentally ill people became homeless after cuts in federal and state funding to inpatient mental facilities and outpatient mental health clinics. These funding cuts forced facilities to release thousands of patients who were not capable of caring for themselves, and also removed a source of mental health care for thousands of others who were caring for themselves but were economically vulnerable. With- out appropriate care and access to consistent medications and treatment, and with continued exposure to the stress of living on the street, over time many mentally ill homeless people have become less healthy, both mentally and physically. For this and other reasons, homeless people with mental disorders have a high incidence ofarrests and encounters with the law for threatening behavior, substance abuse, or other disorderly conduct. 'lhey also face numerous health problems that develop from their unhealthy living conditions. The connection between the inability of many mentally ill people to access appropriate care and the incidence of criminal behavior underscores the continued need for social programs that improve the quality of life for the mentally ill in the United States.

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is an anxiety dis- order in which a person develops intense, persistent fears, worries, or superstitions (obsessions), and uses specific rituals (compulsions), often repeated over and over again . on a daily basis, for relief. One of the classic obsessions in OCD is an overwhelming fear of germs; a woman with this obsession might wash her hands dozens of times a day, or be afraid to touch a doorknob or any item that someone else has touched. Other obsessions include fear of social embarrassment, thoughts about having harmed a loved one, worries about having forgotten something or left something out of place, and intrusive sexual thoughts. The ritual adopted to find relief varies from person to person, but some common themes emerge. Rituals often involve repeatedly checking, counting, or touching things in a specific pattern or order. The rituals are distracting and time-consuming and do not actually bring pleasure, just, at most, short-lived relief from symptoms. Slightly more than 2 million adults in the United States have OCD, which affects men and women in equal numbers. Obsessive—compulsive disorder usually appears in the first 20 to 30 years of a person's life, often appearing in childhood. It also runs in families, suggesting that genetics can predispose a person to the disorder.

Other Phobias

People can develop phobias about specific animals, objects, places, or events other than social interactions. Phobias may involve heights, closed spaces, flying, spiders, elevators, the sight of blood, or other things or situations. A phobia involves more than a moderate level of fear—a person can be afraid of any of the previously men tioned things without having a phobia. Phobias involve powerful, overwhelming fear that occurs not only when the object of the phobia appears, but also often when it is merely even thought about. Phobias can be especially disabling if the object of the phobia is common or difficult to avoid in a person's daily life. About 20 million US adults, including 14 million women, have a phobia of some kind.

Social Phobia

Phobias are intense fears of something that poses little or no threat. A person with social phobia, or social anxiety disorder, experiences a powerful, lasting fear of interacting with other people. People with this mental disorder become very self-conscious in social settings, often imagining that they are being watched or judged, or that they are doing something embarrassing. A social phobia may create anxiety surrounding all human interactions, or it may be limited to specific situations, such as eating or drinking in public, or speaking in front of a group. Anxiety can last for days or weeks before a social event and can continue after. Fifteen million US. adults experience social phobia; about half of them are women.

Post-traumatic Stress Disorder

Posttraumatic stress disorder (PTSD), also referred to as posttraumatic stress injury, is an extremely debilitating disorder that occurs after an exposure to a terrifying event involving w'olent harm or the threat of violent harm. PTSD can result from situations such as armed combat, a car accident, sexual assault, mugging, or natural disaster. A person can develop PTSD if he or she was threatened directly, or if he or she witnessed a threat to a friend or family member. People with PTSD may be easily startled or may be constantly anxious and hyper-vigilant. Situations that remind them of the traumatic event can trigger "flash—backs" in which they relive part or all of their experience. Flashbacks can also occur in dreams or for no apparent reason while the person is awake. People with PTSD can also become emotionally numb, unable to maintain personal relationships or take pleasure from daily life. People with PTSD may become violent or aggressive; they may also become depressed, or turn to substance abuse for relief. PT SD was originally identified in male Vietnam veterans, but PTSD is a major public health concern for women as well. Women are more than twice as likely as men to develop PT SD after exposure to a traumatic event, in part because they are more likely to blame themselves. Women are also more likely than men to be victims of sexual assault, a major trigger event for PTSD. Women are more likely to experience PT SD if they have more than one traumatic experience, had or have a mental disorder before the trauma, or do not have good social support. One bit of good news for women, however, is that they tend to recover from PTSD more easily than men, because they are more I likely to be comfortable talking about their feelings and difficult personal issues. At least 7.7 million US. adults have PTSD, but this number maybe an underestimate. Over the past decade, millions of women have been sub- ject to traumatic events that have made them more vulnerable to PTSD. Hundreds of thousands of women and have lost their jobs, homes, or financial security as a result of the 2007—2008 global economic crisis. Women living in and around New Orleans have had their lives, homes, and families ravaged by the flooding of (and slow government response to) Hurricane Katrina; one study found that almost one in four residents of Mississippi directly affected by Hurricane Katrina exhibited some signs of PTSD. Women veterans have had to adjust to coping with daily life after returning from the wars in Iraq and Afghanistan—about one out of seven military personnel who have experienced combat in Iraq are women. Women soldiers are much more likely than men to be victims of sexual assault or violence from their fellow soldiers and from superior ofiicers. Although a male soldier may have to deal with significant stress from fighting enemy combatants, he might be able to have a deep sense of trust around his fellow troops; a woman who has been sexually assaulted not only has to deal with the direct trauma of the experience, but can never fully relax.

Social and Psychosocial Factors

Social and psychosocial factors change throughout a woman's lifetime and influence the way a woman views her, self and interacts with others. Women with low incomes; low levels of education; and who work in difficult, stressful, and low-status jobs have higher rates of mental illness than do women who have a higher socioeconomic status, higher education level, and higher-status job. These higher rates likely result from a combination of the undervalued or nonvalued roles that these women fill and the financial diliiculties that accompany such roles. Women in roles that society does not highly value, such as full—time homemakers, often suffer from low self—esteem. Women who are trying to fill multiple roles as career women, mothers, and caretakers often feel overwhelmed, which may lead to low self—esteem, increased stress, and, in some cases, depression. Societal expectations and the way parents treat their children also influence mental health. Modern American society, for example, expects men to be aggressive, independent, stoic, and strong, and women to be passive, dependent, emotional, and weak. Consequently, many parents interact with girls and boys differently, parents may encourage girls to be delicate, nurturing, nonaggressive, and sensitive to the feelings of others, and teach boys to be assertive, aggressive, and dominant. For many women, aggression can turn inward, resulting in aggression directed at themselves rather than at others, and manifested as depression or another mental illness. As children reach puberty, gender differences, both physically and culturally, become more apparent. A girl's success often comes from popularity and attractiveness, while a boy's success is often based on athleticism and academic achievement. Factors such as these lead many girls to base their self-esteem on their physical appearance and body weight. These pressures, along with the physical and hormonal changes of puberty and other stressors, make adolescence an especially difficult period. Research shows that at all grade levels, girls continue to receive less attention than boys in academic settings. Girls generally make better grades than boys do, but despite this academic success, girls experience more internal costs— worry, anxiety, and depression. As the authors of one study note, "Although girls may have the edge over boys in terms of their performance in school, this edge is lost when it comes to the experience of internal distress." Another study showed that women tend to attribute their successes to luck and their failures to lack of ability, whereas men tend to attribute their successes to ability and their fail- tires to bad luck. During and after adolescence, girls must create an identity for themselves, deal with their sexuality, make education and career choices, and become independent. For adolescents, risk factors for mental disorders include lack of parental support, sexual abuse, low self-esteem, and weak relationships with friends or family. Some teens may not exhibit obvious signs ofemotional distress and may express their lack ot'mental wellness through substance abuse, disordered eating, behavior problems, and sexual promiscuity. Teenage girls are more likely than teenage boys to experience depression. Studies show that female high school students have significantly higher rates of anxiety disorders, eating disorders, and adjustment disorder than their male counterparts, who have higher rates of disruptive behavior disorders, attention deficit disorder, autism, and learning disabilities. Early adulthood brings many decisions, including those concerning career choices, relationships such as marriage or intimate partnerships, and childbearing. Reproductive events at this time in a woman's life, such as pregnancy, child care, infertility, or the decision not to have children, may create personal stress and relationship tension. Many women also experience increased independence at this time in their lives, as well as increased financial obligations and responsibilities at work and at home. All of these factors can affect a woman's mental health. Many women begin to experiment with recreational drug use during adolescence and early adulthood. Among women with mental health disorders, substance abuse is a common occurrence. Substance abuse may occur when these women attempt to self-medicare and cope, or from the fact that their mental disorders inhibit their reasoning skills. The prolonged use of illicit drugs can put People at higher risk for developing mental disorders and can make existing disorders worse, causing people to self-medicate with drugs more intensely or more frequently. This pattern creates a vicious cycle in the relationship between drug use and mental disorders. Studies have shown that between 30% and 60% of drug abusers have mental health disorders; depression and attempted suicide are especially common among female substance abusers. For many of these abusers, their depressive symptoms predated their use of alcohol and other drugs. Rates of drug abuse or dependence among anorexics range from 5% to 19%; among bulimics, these rates are significantly higher, ranging from 8% to 36%. These women may abuse cocaine, heroin, or methamphetamines to lose weight because these substances act as appetite suppressants. Between 30% and 60% of patients with bipolar disorder also have a substance abuse problem. In fact, substance abuse is more likely to be present with bipolar illness than with any other disorder. Individuals with bipolar disorder who abuse drugs or alcohol may have an earlier onset and worse course of illness than those Who do not. As women reach midlife, many continue to deal with career issues and financial burdens while struggling to balance their many roles of mother, wife, daughter, friend Sibling, employer, employee, and self. Women also may be, dealing with stress from growing children and aging parents. The support and joy that good relationships ofier a woman are often important counterbalances to the stress of managing her everyday life. As she nears late adulthood, a woman may be fortunate enough to feel satisfied with her accomplishments and be financially secure. Women who struggle with retirement issues, physical health, unaccomplished areas of their lives, ill parents, or adult children with difficulties, however, may feel overwhelmed byvstressors not fully within their control. Depression and dementia resulting from Alzheimer's disease (Chapter 11) are serious mental health issues afiect- ing the elderly. A majority of people with Alzheimer's disease are women, in part because women constitute a largervpercentage of the elderly population than men. Depression is widely underdiagnosed and undertreated in the elderly population. One in every 14 Americans age 65 or older currently has a diagnosable depressive illness. Older adults in the United States are also about 40% more likely to com- mit suicide than the general population. Poor physical health, limited independence, loss of pri- vacy and freedom, and loss of one's partner or friends all contribute to stress and poor mental health in older women. Cognitive impairments in the elderly often result from some form of dementia, but may also result from severe depression. In many cases, depression occurs concurrently with chronic medical conditions such as heart disease, diabetes, cancer, and dementia. Because of the common occurrence of depression in the elderly, many healthcare providers, as well as patients and caregivers, believe that symptoms of depression are a normal part of aging or a normal consequence of chronic disease. Depression in older women can lead to disorientation, loss of short term memory, verbal difficulty, and inappropriate reasoning skills. Personality changes also may result from dementia or depression or from a decrease in overall physical health. Discrimination—being singled out by others based on sexual, ethnic, or physical characteristics, including the presence of a mental disorder—is another risk factor for mental illness that women of all age groups experience. Discrimination can affect any aspect of a woman's life, including her work, marriage, and social status. Both mental and physical abuse put women at high risk for developing depression, posttraumatic stress disorder, or obsessive-compulsive disorder. Many people with mental disorders suffered from childhood abuse or traumas, and their dis- orders represent a response to their repressed emotions. This factor may partly account for women's increased incidence of certain mental disorders, because women are at a higher risk of being victimized through rape, abuse, and sexual harassment. Other reasons that women suffer from mental disorders may relate to their individual personality traits. Women who are prone to pessimistic thinking, have low self—esteem, feel they have little control over life events, and worry excessively are at higher risk for depressive and anxiety disorders. Many women also have a heightened sense of sympathy and empathy, which leaves them more vulnerable to suffering from depression after tragic events, even if they were not directly affected by the events themselves.

Stress

Stress is the physical, mental, or emotional response that a person experiences when subjected to any type of stressor, a situation that produces tension or requires a difficult decision. Stressors can range from daily hassles to life—altering events, and people experience and react to them in different ways. Today's women face special stressors. A national recession, along with continuing high rates of unemployment, have increased financial insecurity and made it harder for women to earn a living wage. More women, especially those with young children, are becoming members of the paid workforce. However, women continue to do more housework and spend more time caring for dependent family members than men, often creating a "second shift" after a woman returns from her day job. Domestic chores, child care, and running errands can sap women of their energy and cause stress that affects both their home life and their work life. Acute stress can be helpful for energizing and motivating a person, but chronic stress can overload a person and cause emotional symptoms such as edginess and distorted thinking. Chronic stress also can lead to physical symptoms such as increased heart rate and blood pressure, and lowered immune defense to common colds and other illnesses. Women and men often perceive, evaluate, and respond to stress in different ways. Men may respond positively with physical activity, but negatively through aggression and substance abuse. In contrast, women often internalize their stress, which can cause feelings of failure and self—blame. People adopt different strategies to cope with the stress in their lives. Because stress levels change over time, individuals may adjust their coping mechanisms accordingly. Positive ways of coping with stress include relaxation techniques; supportive, positive interactions with friends and family, and exercise (see the It's Your Health boxes in this chapter). People with better coping skills are less distressed overall and suffer from less pain, anxiety, depression, illnesses, and "burnout."

Schizophrenia

Psychosis is a severe mental disorder characterized by loss of contact with reality and severe personality changes. Although mood disorders primarily affect how a person feels, psychosis disorders primarily affect how a person thinks and perceives the world. Schizophrenia, a type of psychosis, represents an extraordinarily complex group of disorders and is the most chronic and disabling of the severe mental disorders. Many subtypes of schizophrenia exist, each of which is characterized by specific symptoms and a certain degree of disease severity. Although the word "schizophrenia" comes from the Greek word for "split," it does not mean that a schizophrenic person has a "split" or multiple personality. Instead, this meaning describes the splitting of coherent thoughts in those who suffer from the illness. Schizophrenia afflicts about 2.4 million U.S. adults (about 1% of the adult population), with men and women being affected equally. Gender differences are apparent in the development of the disease, however. Men are more likely to be affected between the ages of 16 and 25, whereas women are more likely to have a disease onset between the ages of 25 and 30. Women typically start with a milder form of the disease, experiencing more mood symptoms than psychoses. A significant proportion of women with schizophrenia experience an increase in symptoms during pregnancy and the postpartum period. Living with schizophrenia can be terrifying. People With schizophrenia experience hallucinations (usually voices and other sounds, but also smells and sights that are not there) and delusions (beliefs that are not true, such as that people are reading the person's mind, planning to harm or trap the person, or controlling the person's thoughts). To the person experiencing them, these hallucinations and delusions appear utterly real. These and other symptoms can appear suddenly or gradually over a period of years. Other symptoms of schizophrenia include disordered thinking, difficulty interacting with others, and difficulty thinking clearly. Some women with schizophrenia may experience symptoms for years or decades at a time, whereas others may experience random episodes of symptoms through— out life. Treatments for schizophrenia are improving and can provide some relief, but most people with schizophrenia experience symptoms throughout their lives. Fewer than half of people with schizophrenia get adequate treatment. New medications that cause fewer side effects have been developed over the last decade. A newly developed class of drugs, the atypical antipsychotics, are more effective than older types of drugs, but have much more severe side effects. Psychotherapy and support groups also may help some patients. Schizophrenia is a diflicult disease; only 1 in 5 people recovers completely and 1 in 10 eventually takes his or her own life.

Political Dimensions

The National Institute of Mental Health (NIMH) is the largest research organization in the world dedicated to improving mental health. Part of the National Institutes of Health, which itself is part of the federal government, the NIMH researches new ways to understand the mind, brain, and behavior; examine, treat, and prevent mental disorders; and promote and maintain good mental health. The Substance Abuse and Mental Health Services Administration (SAMHSA), another agency of the federal government, is responsible for preventing death and preventing, treat- ing, and rehabilitating disability caused by mental illness and substance abuse. Whereas the NIMH tends to focus more on research and furthering scientific understanding, SAMHSA focuses on aid and research that more directly helps people who suffer from poor mental health or substance abuse. Federal, state, and local policies and laws have enormous, far-reaching effects on mental health. The connections between the two are not always obvious, however. If more elfective drug—enforcement laws are enacted, they could reduce rates of underage drinking and illegal drug use among pregnant women, which in turn could prevent cases of mental illness resulting from fetal exposure to drugs and alcohol. An overseas conflict that sends US. armed forces into combat will inevitably increase rates of posttraumatic stress disorder (PTSD) as those troops react to injuries and their experiences on the battlefield. A program offering low—interest loans to small businesses could reduce rates of depression if it lifted large numbers of people out of poverty and reduced the stresses and risk factors associated with living under the poverty line. Laws and policies affect the affordability of mental health care. For years, people who had health insurance often found that the plans charged more for mental health services than for other services, or that the plans did not cover mental health services at all. This discrepancy often resulted in people being unable to afford mental health care and contributed to the false idea that mental health services are either unimportant or a luxury. In 2008, Congress passed legislation requiring health insurance plans that offered mental health services to give those services the same coverage they otter for other physical health services; however, this law only affected insurance plans that offered mental health coverage to begin with. Preventing mental illnesses can minimize suffering and loss of productivity associated with the disorders, and eliminate the costs of diagnosing and treating the disorders after they develop. Simple, cost—effective ways to prevent mental illness include enacting policies to reduce head injuries by mandating the use of motorcycle helmets; reducing childhood exposure to lead by replacing old plumbing in public schools; and preventing fetal exposure to alcohol, tobacco, and other drugs by offering rehabilitation programs for pregnant women. Programs that support good parenting, such as ample maternity and paternity leave programs, providing classes and support to new parents, have espe cially powerful mental-health—promoting effects for both children and parents.

Nutrition

The food that people eat can also affect their mental health. Certain foods tend to increase stress levels, whereas others help to calm the physiological effects of stress. "Food stressors" include chocolate, caffeine, sugar, and alcohol. Foods that can provide a calming effect include water, vegetables, fruit, and oil-rich fish. Eating regular, health- ful meals also appears to have a positive effect on mental health. The effects of nutrition on mental health are considered secondary, however, to other physiological and environmental factors.

Treatment

The good news is that treating mood disorders can provide great benefits, allowing people to live satisfying, functional, and healthy lives. The bad news, however, is that mood disorders have no "quick fix." Between 70% and 80% of people who experience one episode of depression will experience depression again at some point in their lives; bipolar disorder typically requires ongoing treatment for a person to stay within a stable mood range. Short—term treatments for either of these illnesses are unlikely to be effective. For both depression and bipolar disorder, the earlier a person seeks treatment, the better chance that person will have of making a recovery and of preventing further episodes. Mood disorders can be treated with medications, psychosocial treatment (some form of "talk therapy"), or both of these forms used together. A combined approach usually works better than either form used alone. Medications are a powerful, yet imperfect tool to treat people with mood disorders. Medications can gradually bring a person with depression or bipolar disorder back into a normal range of moods, but they may take days or even weeks to have any noticeable effects. Individuals respond differently to treatments and treatments may have side effects, so a person with a mood disorder taking medications should work with his or her psychiatrist to find the specific pharmaceutical drug and dosage that provides the most benefit while reducing Side effects to a low, or at least acceptable, level. Because some medications for depression or bipolar disorder may affect fetal development, a woman with a mood disorder should talk with her psychiatrist about her medication routine ifshe is pregnant or wishes to conceive. Antidepressant medications attempt to restore a depressed person's levels of neurotransmitters, particu- larly serotonin, norepinephrine, and dopamine, to a normal level. There are several types of antidepressant medications. The two newest, most commonly used types are called selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIS). Older forms of antidepressants, including tricyclics or monoamine oxidase inhibitors (MAOIS), are more likely to have side effects, though these medications may be best for some individuals. Possible side effects of antidepressant medications include headaches, nausea, insomnia, constipation, and reduced sexual desire and function. Bipolar disorder is usually treated with one or more of several kinds of medications known as "mood stabilizers." Mood-stabilizing drugs include lithium and several classes of anticonvulsant drugs. These drugs help to keep a person's mood within a consistent, central range. To be effective, these drugs should be taken on a regular basis. Sometimes a person with bipolar disorder can "feel" a mood shift approaching; if a person notices this and talks with his or her psychiatrist, a temporary change in his or her treatment plan can often prevent an episode from occurring. Psychosocial treatment for depression can provide benefits on either a short-term (around 10—20 weeks) or a continuous basis, depending on the individual's needs and desires. The two most popular forms of psychotherapy used to treat depression are cognitive behavioral therapy (CBT) and interpersonal therapy (IPT). Cognitive behavioral therapy teaches a depressed person to recognize patterns of thinking and behaving that contribute to depression, and helps that person find new thoughts and behaviors that support recovery, while IPT helps people to understand and improve their own personal relationships and interactions with other people. Psychotherapy is often the best treatment option for people with mild to moderate depression; for people with major depression, psychotherapy can be combined with antidepressant medications. For people with bipolar disorder, psychosocial treatment includes: I Cognitive behavioral therapy, which helps patients to recognize and change harmful thought patterns and behaviors associated with the disorder I Psychoeducation, which teaches patients (and sometimes relatives or loved ones) about the effects, treatment, and management of bipolar disorder - Family therapy, which works on improving family interactions to improve harmful relationships or patterns of interaction that contribute to or result from the patient's symptoms I Interpersonal and social rhythm therapy, which helps patients improve their personal interactions and establish regular daily routines.

Suicide

The taking of one's own life can be considered the most harmful symptom of mental illness. There are almost always warning signs that a person is at risk of suicide. More than 90% of people who kill themselves have depression, another diagnosable mental illness, or a substance abuse disorder. Adverse life events like a death in the family, a relationship breakup, or financial ruin, along with other risk factors, also may make a person more likely to take his or her own life. However, suicide is not a normal or acceptable response to stress. Many people have considered suicide at some point in their lives when they were depressed or experienced something very bad; however, most would never act on these thoughts, and are thus not considered suicidal. Risk factors for someone committing suicide include the following: - Adverse life events along with other factors such as depression I Prior suicide attempt I Family history ofmental disorder or substance abuse I Family history of suicide I Family violence, including physical or sexual abuse I Firearms in the home I Incarceration I Exposure to suicidal behavior of others, including family members, peers, and even the media Although more women than men report attempts at suicide, more men complete the act. Suicide is the 11th leading cause of death in the United States—the 9th leading cause of death for males, and the 16th leading cause of death for females. For many people, an attempt at suicide is a "cry for help." In adults, the strongest risk factors for attempting suicide are depression, substance abuse, and separation or divorce. Risk factors for children and adolescents include depression, substance use, and aggressive behavior. Friends and family members of people with known depression or with one of the risk factors mentioned earlier should pay close attention to their loved ones. If they demonstrate suicidal behaviors or discuss suicidal wishes, seek professional psychiatric, social work, or medical help immediately. Suicide has become a major problem in many devel oping countries and Eastern European countries. Among rural communities in China and many former Soviet bloc countries, it is one of the leading causes ofdeath for young women. Preventive interventions for suicide are often intensive. They typically require learning new coping skills, recognizing the underlying factors causing distress, and receiving appropriate treatment for existing mental and substance abuse disorders.

Anxiety Disorders

Anxiety is an adaptive mental function that helps us live safe, productive lives. At healthy levels, anxiety can motivate a person to study for a test, look both ways before crossing the street, double—check that the front door is locked, or refrain from stealing or committing some other crime. Anxiety disorders occur when anxiety grows to unhealthy levels, or when anxiety appears in situations in which no risks exist. People with anxiety disorders often know that the worries, fears, or behaviors caused by the disorders are unhelpful and unrealistic, but this knowledge does not eliminate the symptoms (see Table 12.3). Anxiety disorders include generalized anxiety disorder (GAD), social phobias (also known as social anxiety disorder), specific phobias, panic disorder, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder. Anxiety disorders affect about 40 million American adults (about 1 out of 5 adults) during a given year. Women are two to three times more likely than men to suffer from anxiety disorders. People with an anxiety disorder are disproportionately likely to experience some form of depression, another anxiety disorder, or engage in substance abuse in efforts to self-medicare. Anxiety disorders usually appear early as compared to other mental illnesses: Three-fourths of people with an anxiety disorder experience their first symptoms before they turn 21.

Biological Factors

Biological factors vary among mental illnesses, but they often include genetic predisposition to a disease, abnormal brain structure or function, irregular levels or activity of neurotransmitters or hormones, head or brain injuries, or prenatal exposure to illegal drugs or alcohol. Many studies have examined patterns in twins and families to determine genetic factors that create vulnerability to certain types of mental illness. Most people with mental disorders have a history of mental illness in their family, providing evidence of a genetic link. Other studies have found that if one identical twin has a mental illness, the other one often has the same illness. The influence of hormones during reproductive-related events is another important biological factor in women's mental health. Although studies have produced conflicting findings, it appears that changes in hormone levels affect mental well—being and may be a factor in depression during premenstrual syndrome, postpartum depression, and postpartum psychosis. Brain structure and function, as well as neurotransmitter levels, also have been studied to identify gender-related differences and differences between people with and without mental illness.

Factors Affecting Mental Health

Biological, psychosocial, and environmental factors, and even the food a person eats, all influence mental health. Genetics, for example, clearly predispose some people to mental illness. Studies following separated identical twins find that if one twin has bipolar disorder, the other twin has about a 59% chance of also developing the disease—- clearly greater than the proportion of bipolar disorder in the general population. Yet genes are clearly not the only factor: Since identical twins share the same genetic code, some other factor in their environment is responsible for the other 41%. Psychosocial and cultural factors influence how a woman views herself, responds to stress, interacts, and is treated by other people. Factors such as low self—esteem and experiences such as abuse or trauma, all of which women are more likely than men to experience, can make a person more vulnerable to mental illness.

Dissociative Disorders

Dissociative disorders develop as an unconscious way to protect oneself from emotional traumas by detaching from a part of one's personality. These disorders occur as a response to a severe childhood trauma. While the created defense appears helpful to the individual, it is actually detrimental to the process of recovery. Several types of dissociative disorders exist, with the most common being dissociative identity disorder, also known as multiple personality disorder. Dissociative identity disorder is associated with early childhood abuse and usually begins in late adolescence or early adulthood. The disorder is progressive and often coexists with personality disorders. Women with this disorder are unable to process their thoughts, feelings, memories, and actions into a complete and single state of consciousness. Signs of dissociative identity disorder include amnesia, detachment from reality, and detachment from oneself through deperson alization. People with dissociative identity disorder often hurt themselves intentionally in acts of self-mutilation. Treatment includes psychotherapy to integrate the various personalities and to resolve feelings surrounding the traumatic event. Dissociative amnesia, another form ofa dissociative disorder, is loss of memory resulting from trauma. Depending on the form ofdissociative amnesia, either some or all of the experiences from various time periods are blocked out. Therapy is used to help the person adjust to the current situation rather than to resolve the past.

Economic Dimensions

In addition to their harmful effects on individual health, mental illnesses carry a great economic cost. One major study found that lost earnings from serious mental illnesses cost Americans $193 billion a year. This estimate does not include the billions of dollars spent on medical care such as medications, clinic visits, and hospital visits; nor does it include the time and resources spent by families and caregivers of people with mental illnesses or the cost of social problems such as increased crime and threats to public safety. Treating mental illness is often a costly undertaking. Prescription drugs can be very expensive, especially for people who don't have health insurance or who are underinsured. Because individual responses to medications vary and medications sometimes have serious side effects, time and medical care must often be spent on determining, often by trial and error, the correct medication and dosage for a person's individual needs. Inpatient and outpatient mental healtheare services are also expensive and require commitments of time and resources for patients and facilities providing care. Because people with serious mental illnesses sometimes have difficulty holding down jobs for long periods of time, they are at increased risk for being both uninsured and economically vulnerable.

Treatment

Like many other mental illnesses, anxiety disorders can be treated with medications, psychotherapy, or a combination of the two, depending on individual needs and preferences. Without treatment, people with anxiety disorders may find themselves making serious life decisions based on their likelihood of encountering a phobic or anxiety—producing object or situation. Treatment can provide great benefits for people living with anxiety disorders, but time and effort are necessary to see improvements; people sometimes believe that they can't be treated, or that the treatment doesn't work for them, when more time or an adjustment to the treatment is all that is needed. Commonly prescribed medications for anxiety disorders include antidepressants, anti-anxiety medications, and beta blockers, a type of drug originally developed to treat heart conditions. Cognitive behavioral therapy can help people with anxiety disorders learn to recognize and change thoughts and behaviors associated with the disorder. Another form of therapy used for anxiety disorders is called exposure/ response therapy. Exposure/ response therapy aims to desensitize sufferers to their fears by supporting them in staying calm while gradually confronting more and more anxiety-producing situations. Certain forms of group therapy can also help people with anxiety disorders, especially people with PTSD or social phobia. Ifa person with an anxiety disorder is experiencing another form ofmental illness or has a substance abuse problem, these issues will also need to be treated

Epidemiological Data

More than one out of four American adults—about 58 million people—experience a diagnosable mental disorder in a given year. About 13 million, or 1 out of 17 American adults, will suffer from a severe mental illness that seriously disrupts their day-to—day activities, and about half the people who have one mental disorder also have at least one other. Taken together, mental illnesses are responsible for 4 of the top 10 causes of disability. Among adults ages 15—44, mental illnesses cause more death and injury than cancer. Men and women are equally likely to suffer from mental disorders, but the frequencies of specific mental disorders vary by gender. Men and women may also experience the same disorder in different ways, including the average age that disorders appear, frequency of psychotic symptoms, course of disease progression, social adjustment, and long—term outcome. Variations in mental illnesses may be partially a result of distinct brain structures and the presence of different brain hormones in males and females, which cause neurons to act tiiflereiitlyr. Evidence shows that the development of brain hemispheres differs by gender, possibly resulting in males and females using their brains in different ways when decoding words, deciphering emotion, and performing other basic tasks. Other differences in how men and women experience mental illness may be due to how men and women cope with problems, View themselves, and express emotions. The Gender Dimensions box lists gender differences in common mental health disorders.

Panic Disorder

Panic disorder affects about 6 million U.S adults and is twice as common in women as in men. This disorder is characterized by panic attacks—periods of intense fear accompanied by physical and emotional distress that may last anywhere from 5 to 20 minutes. The panic attacks often strikes without warning. Its symptoms have Often been mistaken for a heart attack, and include a pounding heart, sweating, faintness, dizziness, chest pain, nausea, and emotional symptoms such as a feeling of impending doom or of losing control. In many cases the intensity of the symptoms, as well as their unexplainable nature, makes the panic attacks themselves a major source of anxiety. An initial panic attack usually occurs in a person's 20s. A panic attack may occur during transition periods, times of considerable stress, or crises and often sends the individ- ual to the emergency room. Some women have an isolated attack without ever developing the disorder; nevertheless, repeated panic attacks are a definitive sign of panic disor— der. Panic attacks can be extremely disabling if they occur on a regular basis.

Informed Decision Making

People have different vulnerabilities to mental disorders based on their genetic inheritance, physical condition, social situation, and life experiences, but mental health is a concern for everyone. No one is immune to mental dis orders. Even if you are fortunate enough to never experi- ence one, it is almost certain that you will know and care for someone who has experienced one, has one now, or will have one. Good mental health is more than the absence of mental illness, just as good physical health is more than the absence of disease. There may be no perfect definition of good mental health, but being able to engage in rational thought and decision making; feeling a variety of emotions without being controlled by those emotions; being able to maintain stable, fulfilling relationships; and being able to cope with difficult circumstances are all signs ofa healthy mind. To maintain emotional wellvbeing, it is essential to take care of oneself. Some women tend to put other people's needs before their own. If a woman does this on a consistent basis, it can put her under great stress and make her more likely to experience and suffer from mental illness. Finding appropriate coping mechanisms can help women deal with stressful situations and difficult circumstances, Some good coping mechanisms include taking time to relax, and having a trusted friend, family member, or mentor to talk to. Other basic healthy behaviors, like getting a good night's sleep, eating a nutritious diet, and integrating physical activity into one's daily routine, benefit the mind as well as the body. In particular, regular exercise yields enormous benefits for people suffering from depression and anxiety disorders. The It's Your Health box lists healthful activities that can relieve stress and promote good mental health. If a woman does notice a pattern of disturbing thoughts, finds herself unable to cope with life's daily challenges, or finds herself anxious or unhappy most of the time, she should seek professional help. Seeking help is not always easy. Many people who could benefit from mental health services decide not to seek care out of fear that theywill be labeled "crazy" or "unstable." Other people believe either that "things will get better on their own or that treatment would be useless. Millions of Americans already benefit from (or would benefit from) some form of mental health treatment. Although some mental disorders may go away on their own, others do not, and treatment can often dramatically shorten the course of a disorder. Self-Assessment 12.1 can help a woman determine whether she, or someone she cares about, needs to Seek help. Psychiatrists, clinical psychologists, and social work ers are all trained, certified practitioners who have been educated in helping people with mental health problems. Many colleges and universities have professional mental health services available, or at least can give referrals to nearby services. A good match between a patient and provider that includes mutual trust is key. Asking a mental health provider questions about his or her training, number of years in practice, experience treating someone with a similar problem, fees, types of insurance accepted, and methods of therapy can all help a woman decide whether I that provider is best for her. I There are four basic forms of psychotherapy: I Traditional psychotherapy, which deals with psychosocial aspects of depression and is often referred to as "talk therapy"

Treatment

People with eating disorders are usually intensely securetive about them. However, observant friends and family members often have an idea when an eating disorder is occurring. Many people try to ignore their suspicions so as to protect the privacy of their friend or family member or out of a wish not to interfere. Women with bulimia and BED are often able to identify the disorder themselves. In contrast, women with anorexia are often in denial about their condition and usually are brought to treatment by concerned family members. Many women enter therapy to treat an eating disorder only after being persuaded to do so by people in their lives. It thus becomes extremely important for people to confront the women in their lives when they suspect disordered eating, and to provide them with support in finding the appropriate help. As with all health interventions, sensitivity and care need to be taken when discussing eating disorders with individuals, and one needs to have an understanding of the very central and painful role the disorder may play in an individuals life. Several approaches are used to treat eating disorders, including motivating the patient, enlisting family support, and providing nutrition counseling and psychotherapy. Behavior modification therapy and drug therapy, such as antidepressants, may also be used. Hospitalization may be required for those patients with life-threatening complica- tions or extreme psychological problems. If the patient's life is not in danger, treatment may be provided on an out patient basis and may last for a year or longer. Treatment is often a lengthy and difficult process, with many women suffering from relapses. Stopping the pattern of dysfunctional eating is essential for successfully treating an eating disorder, but this is not the only requirement. Healthful eating habits must be learned and established to replace the harmful behaviors. Additionally, people with eating disorders also need professional help to develop a realistic body image, develop positive self-esteem, and resolve the underlying control issues that may have contributed to the eating disorder.

Personality Disorders

Personality disorders are characterized by distorted and inflexible thoughts and behaviors that make it impossible for a person to live a productive life or establish fulfilling relationships. These types of disorders have created controversy in the field of psychiatry because it is often difficult to decide when the personality style of a person becomes clinically deviant. For a woman to be diagnosed with a personality disorder, she must experience long—term patterns of the distorted thoughts and behaviors and these behaviors must cause interpersonal trouble. Several personality disorders exist (Table 12.5), with histrionic and borderline personality disorders being the most commonly diagnosed in women. People with histrionic personality disorder are deeply emotional, have low self—control, and feel a strong need for attention. People with this mental disorder feel uncomfortable and unappreciated unless they are constantly the center of attention. Because people with this disorder are very sensitive, they can be easily hurt by real or imagined slights. People with histrionic disorder often have a difficult time maintaining stablejobs, living arrangements, and relationships. Additionally, their suggestibility, and need for attention and approval, can lead people with histrionie disorder to engage in risky sexual behaviors. Borderline personality disorder (BPD) is also characterized by instability in moods, relationships, identity, and behavior. People with BPD may develop intense feelings of anxiety, anger, or depression that appear and disappear within several hours. The intensity of these feelings makes people with BPD more likely to hurt themselves, engage in substance abuse, and commit suicide. The same intense, changing emotional pattern also makes it very difficult for people with BPD to build and maintain stable relationships. A combination of environmental and genetic factors likely play a part in whether a person develops histrionic personality disorder or BPD. Many people with personality disorders never enter treatment. Those who do usually seek help for depression or anxiety. Treatment often involves long-term psychotherapy, cognitive behavioral therapy, and/ or family or group therapy. Medications may be given with psychotherapy to relieve symptoms of depression or anxiety.