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Defining Phycological Health

DEFINING PSYCHOLOGICAL HEALTH Psychological health (or mental health) can be defined either negatively, as the absence of sickness, or positively, as the presence of wellness. The vast majority of people do not Page 60suffer from mental illness, yet all of us have to deal with stress, interpersonal conflicts, and difficult emotions. Psychological health refers to the extent to which we are able to function optimally in the face of these challenges, whether or not we have a mental illness. Positive Psychology In his book Toward a Psychology of Being, psychologist Abraham Maslow adopted a perspective that he called "positive psychology." Maslow developed a hierarchy of needs (Figure 3.1): The most important kind is the satisfaction of physiological needs; following this is a feeling of safety, a state of being loved, maintenance of self-esteem, and finally, self-actualization. FIGURE 3.1 Maslow's hierarchy of needs. source: Maslow, A. 1970. Motivation and Personality, 2nd ed. New York: Harper & Row. When urgent (life-sustaining) needs—such as the need for food and water—are satisfied, less basic needs take priority. Maslow's conclusions were based on his study of a group of visibly successful people who seemed to have lived, or to be living, at their fullest. He suggested that these people had fulfilled a good measure of their human potential and achieved self-actualization. Self-actualized people all share certain qualities: Realism. Self-actualized people know the difference between what is real and what they want. As a result, they can cope with the world as it exists without demanding that it be different; they know what they can and cannot change. Just as important, realistic people accept evidence that contradicts what they want to believe. Acceptance. Self-accepting people have a positive but realistic self-concept, or self-image. They typically feel satisfaction and confidence in themselves, and thus they have healthy self-esteem. Self-acceptance also means being tolerant of your own imperfections—an ability that makes it easier to accept the imperfections of others. Autonomy.Autonomous people can direct themselves, acting independently of their social environment. Autonomy is more than physical independence. It is social, emotional, and intellectual independence, as well. Authenticity. Self-actualized people are not afraid to be themselves. Sometimes, in fact, their capacity for being "real" may give them a certain childlike quality. They respond in a genuine, or authentic, spontaneous way to whatever happens, without pretense or self-consciousness. Capacity for intimacy. People capable of intimacy can share their feelings and thoughts without fear of rejection. They are open to the pleasure of physical contact and the satisfaction of being close to others—but without being afraid of the risks involved in intimacy, such as the possibility of rejection. (Chapters 4 and 5 discuss intimacy in more detail.) Creativity. Creative people continually look at the world with renewed appreciation and curiosity. Such buoyancy can enhance creativity. Self-actualization is an ideal to strive for rather than something most people can reasonably hope to achieve. Maslow himself believed it was achieved quite rarely. Still, fulfilling your own potential is a goal that everyone can work toward. Influenced by the work of Abraham Maslow, psychologist Martin Seligman suggests that the goal of positive psychology is "to find and nurture genius and talent" and "to make normal life more fulfilling" rather than just to identify and treat illness. In other words, it means being able to define positive goals and identify concrete, measurable ways of achieving them. You can develop happiness in any number of ways. The keys are to focus on work and activities you enjoy and to develop a supportive network of friends and family. © Ciaran Griffin/Getty Images RF According to Seligman, happiness can come to us through three equally valid dimensions: The pleasant life. This life is dedicated to maximizing positive emotions about the past, present, and future, and to minimizing pain and negative emotions. The engaged life. This life involves cultivating positive personality traits (such as courage, leadership, kindness, and Page 61integrity) and actively using your talents. "Engagement" also involves cultivating a capacity to "live in the moment" and immerse yourself fully in your activities. A key to being engaged and successful in life is the positive personality trait of emotional intelligence. An emotionally intelligent person can identify and manage his or her own emotions and respond to the emotions of others. People with higher emotional intelligence can perceive their own emotions and can also channel them to reach their intended goals. Psychologists and educators believe that emotional intelligence is not as rooted as abstract intelligence and that it can be learned. The meaningful life. Another road to happiness entails working with others toward a meaningful end. Many people find meaning in their connections with and service to families, friends, religious institutions, social causes, and/or work. The happiness to be found by following this path is strongest when meaning comes from more than one source. Seligman and his colleagues are developing methods of assessing these ways of life and of teaching people how to become happier by adopting one or more of them. They need not be mutually exclusive. Not everyone accepts the ideas of positive psychology—or even the concept of psychological health—because they involve value judgments that are inconsistent with psychology's scientific status. Defining psychological health requires making assumptions and value judgments about what human goals are desirable, and some people think these are matters for religion or philosophy. Positive psychology has also been criticized as promoting a shortsighted denial of reality and unwarranted optimism. In particular, therapists guided by existential philosophy believe that psychological health comes from acknowledging and accepting the painful realities of life. QUICK STATS 48.4% of college students report having sought counseling in their lives. —Penn State Center for Collegiate Mental Health Annual Report on Student Counseling Centers, 2015 What Psychological Health Is Not We can define normal body temperature because a few degrees above or below this temperature means physical sickness, but we cannot measure psychological health this way. Your ideas and attitudes can vary tremendously without impeding your ability to function well or causing you to feel emotional distress. Moreover, psychological diversity—the understanding, acceptance, and respect for how much individuals differ in psychological terms—is actually a valuable asset; encountering a wide range of ideas, lifestyles, and attitudes broadens our perspectives and helps us solve problems of the social world. Psychological health does not mean being "normal": What is considered healthy for one person may be quite different for someone else. Not seeking help for personal problems does not prove you are psychologically healthy, any more than seeking help proves you are mentally ill or unhealthy. Unhappy people may avoid seeking help for many reasons, and severely disturbed people may not even realize they need help. Further, we can't say people are "mentally ill" or "mentally healthy" based solely on the presence or absence of symptoms. Consider the symptom of anxiety, for example. Anxiety can help you face a problem and solve it before it becomes too big. Someone who shows no anxiety may be refusing to recognize problems or to do anything about them. A person who is anxious for good reason is likely to be judged more psychologically healthy in the long run than someone who is inappropriately calm. Finally, we cannot judge psychological health from the way people look. All too often, a person who seems to be okay and even happy suddenly takes his or her own life. At an early age, we learn to conceal our feelings and even to lie about them. We may believe that our complaints put unfair demands on others. Although maintaining privacy about emotional pain may seem to be a virtue, it can also be an impediment to getting help. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Have you ever had a reason to feel concerned about your own psychological health? If so, what was the reason? Did your concern lead you to talk to someone about the issue, or to seek professional help? If you did, what was the outcome, and how do you feel about it now?

getting help

GETTING HELP Knowing when you need help dealing with a mental health problem is usually not as difficult as deciding which self-help method or which mental health professional to choose. Self-Help A smart way to begin helping yourself is by finding out what you can do on your own. For example, certain behavioral and cognitive approaches can be effective because they all involve becoming more aware of self-defeating actions and ideas and combating them in some way: being more assertive; communicating honestly; raising your self-esteem by counteracting the negative thoughts, people, and actions that undermine it; and confronting, rather than avoiding, the things you fear. Although information from books in the psychology or self-help sections of libraries and bookstores can be helpful, you should avoid any that make fantastic claims or deviate from mainstream approaches. Some people find it helpful to express their feelings in a journal. Grappling with a painful experience in this way provides an emotional release and can help you develop more constructive ways of dealing with similar situations in the future. Research indicates that using a journal in this way can improve physical as well as emotional wellness. For some people, religious belief and practice may promote psychological health. Religious organizations provide a social network and a supportive community, and religious practices, such as prayer and meditation, offer a path for personal change and transformation. Peer Counseling and Support Groups Sharing your concerns with others is another helpful way of dealing with psychological health challenges. Just being able to Page 82share what's troubling you with an accepting, empathetic person can bring relief. Comparing notes with people who have problems similar to yours can give you new ideas about coping. Individual therapy is just one of many approaches to psychological counseling. © Tom M Johnson/Getty Images Many colleges offer peer counseling through a health center or through the psychology or education department. Volunteer students specially trained in maintaining confidentiality are usually those who offer counsel. They may steer you toward an appropriate campus or community resource or simply offer a sympathetic ear. Many self-help groups work on the principle of bringing together people with similar problems to share their experiences and support one another. Support groups are typically organized around a specific problem, such as eating disorders or substance abuse. Self-help groups may be listed online or in the campus newspaper. Professional Help Sometimes trying self-help or talking to nonprofessionals is not enough, especially if you might have a mental illness. Overcoming the stigma about seeking help is a first step. In many communities and cultures, great shame and stigma are associated with talking to a mental health professional; in others, there is much less. You may someday find yourself having to overcome your own reluctance, or that of a friend, about seeking help.Page 83 A person has many options when seeking professional help (see the box "Choosing and Evaluating Mental Health Professionals"). For students, the student health center is a great start. The professionals there have extensive experience evaluating and working with people who have all sorts of needs, from the stress of adjusting to college life and dealing with relationships, to severe mental illnesses. Pediatricians and primary care providers can also make referrals. CRITICAL CONSUMER: Choosing and Evaluating Mental Health Professionals Mental health workers belong to various professions and have different roles. Psychiatrists are medical doctors. They are experts in deciding whether a medical disease lies behind psychological symptoms, and they are usually involved in treatment if medication or hospitalization is required. Clinical psychologists typically hold a doctoral degree (PhD); they are often experts in behavioral and cognitive therapies. Other mental health workers include social workers, licensed counselors, and clergy with special training in pastoral counseling. In hospitals and clinics, various mental health professionals may join together in treatment teams. In choosing a mental health professional, financial considerations are important. Research the costs and what your health insurance will cover. City, county, and state governments may support mental health clinics for those with few financial resources. Some on-campus services may be free or offered at very little cost. The cost of treatment is linked to how many therapy sessions will be needed, which in turn depends on the type of therapy and the nature of the problem. Getting this information before you start treatment is important. Many mental health professionals do not accept health insurance payments and only accept direct payments from patients. Psychological therapies focusing on specific problems may require weekly visits for a period of 8-24 sessions, depending on the type of therapy. Therapies based on CBT, DBT, and ACT are often time limited, and your therapist can tell you how many sessions to expect. Therapies aiming for psychological awareness and personality change, such as psychodynamic therapies, can last months or years. Deciding whether a therapist is right for you will require meeting the therapist in person. Before or during your first meeting, find out about the therapist's background and training: Does she or he have a degree from an appropriate professional school and a state license to practice? Has she or he had experience treating problems similar to yours? How much will therapy cost? You have a right to know the answers to these questions and should not hesitate to ask them. After your initial meeting, evaluate your impressions: Does the therapist seem like a warm, intelligent person who would be able to help you and seems interested in doing so? Are you comfortable with the therapist's personality, values, and beliefs? Is he or she willing to talk about the techniques in use? Do these techniques make sense to you? If you answer yes to these questions, this therapist may be satisfactory for you. If you feel uncomfortable—and you're not in need of emergency care—it's worthwhile to set up one-time consultations with one or two others before you make up your mind. Take the time to find someone who feels right for you. Later in your treatment, evaluate your progress: Are you being helped by the treatment? If you are displeased, is it because you aren't making progress, or because therapy is raising difficult, painful issues you don't want to deal with? Can you express dissatisfaction to your therapist? Such feedback can improve your treatment. The most important predictor of whether your therapy will be helpful is how much rapport you feel with your therapist at the first session. This has been shown to be true no matter what model of psychotherapy the therapist is practicing. You have to like your therapist and feel that she or he will be able to help you—if you do, there's a good chance that it will be helpful. If you sense that your therapy isn't working or is actually harmful, thank your therapist for her or his efforts, and find another. It's extra work for you, but it's important for your health. Many kinds of professionals are trained to evaluate people's psychological and psychiatric needs and to provide treatment. Psychotherapists, for example, come from a variety of backgrounds and include licensed social workers or family and marital therapists (with master's degrees); specially trained nurses with advanced degrees; psychologists (with doctorates); and psychiatrists, who have medical degrees and thus can prescribe medication. Many national organizations have websites that may be useful in finding help. Here are some examples: Anxiety and Depression Association of America—adaa.org Depression and Bipolar Support Alliance—dbsalliance.org National Alliance on Mental Illness—nami.org National Association of Social Workers—socialworkers.org American Psychological Association—apa.org American Psychiatric Association—psychiatry.org Professional help is appropriate in any of the following situations: Depression, anxiety, or other emotional problems interfere seriously with school or work performance or in getting along with others. Suicide is attempted or is seriously considered (see the warning signs listed earlier in the chapter). Symptoms such as hallucinations, delusions, incoherent speech, or loss of memory occur. Alcohol or drugs are used to the extent that they impair normal functioning during much of the week, that finding or taking drugs occupies much of the week, or that reducing their dosage leads to psychological or physiological withdrawal symptoms. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Are you open to discussing the intimate details of your life, your emotions, your fears, your deepest thoughts? Have you ever truly opened up to another person in this manner? Would you be open to this kind of sharing if it meant getting help for a psychological disorder?

models of human nature and therapeutic change

MODELS OF HUMAN NATURE AND THERAPEUTIC CHANGE Human problems such as the psychological disorders discussed in this chapter can be evaluated from at least four perspectives: biological, behavioral, cognitive, and psychodynamic. Each perspective has a distinct view of human nature, and from those views of human nature come distinct therapeutic approaches. The Biological Model The biological model emphasizes that the mind's activity depends entirely on an organic structure, the brain, whose composition is genetically determined. The activity of neurons, mediated by complex chemical reactions, gives rise to our most complex thoughts, our most ardent desires, and our most pathological behaviors. As an organ, the brain responds well to healthy lifestyle behaviors such as maintaining a nutritious diet and exercising. (See the box "Does Exercise Improve Mental Health?") When true mental health issues arise, however, drug therapies can help. TAKE CHARGE: Does Exercise Improve Mental Health? Since 1995, more than 30 major population-based studies (involving 175,000 Americans) have been published on the association between physical activity and mental health. The overall conclusion is that exercise—even modest activity such as taking a daily walk—can help combat a variety of mental health problems and contribute to psychological health. For example, studies found that regular physical activity protects against depression and the onset of major depressive disorder; it can also reduce symptoms of depression in otherwise healthy people. Other studies found that physical activity protects against anxiety and the onset of anxiety disorders (such as specific phobia, social phobia, generalized anxiety, and panic disorder); it also helps reduce symptoms in people affected with an anxiety disorder. Physical activity can enhance feelings of well-being in some people, which may provide some protection against psychological distress. Overall, physically active people are about 25-30% less likely to feel distressed than inactive people. Regardless of the number, age, or health status of the people being studied, those who were active managed stress better than their inactive counterparts. Researchers have also looked at specific aspects of the association between activity and stress. For example, one study found that taking a long walk can be effective at reducing anxiety and blood pressure. Another showed that a brisk walk as short as 10 minutes can leave people feeling more relaxed and energetic for up to two hours. People who took three brisk 45-minute walks a week for three months reported that they perceived fewer daily hassles and had a greater sense of general wellness. Physical activity also helps you sleep better, and consistently sound sleep is critical to stress management and mental health. According to the National Sleep Foundation, about two-thirds of Americans have trouble sleeping at least a few nights a week, and 41% say they have difficulty sleeping virtually every night. There are about 70 known sleep disorders, and disordered sleep is associated with a variety of physical and neurological problems, including health problems related to stress. Although only a few small-scale studies have examined the relationship between physical activity and sleep, most experts have concluded that regular activity promotes better sleep and provides some protection against sleep interruptions such as insomnia and sleep apnea. Consistent, restful sleep is now regarded as a protective factor in disorders such as depression, anxiety, obesity, and heart disease. sources: Physical Activity Guidelines Advisory Committee. 2008. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: U.S. Department of Health and Human Services (http://www.health.gov/paguidelines/); Loprinzi, P. D., & Loenneke, J. P. (2015). Engagement in muscular strengthening activities is associated with better sleep. Preventive Medicine Reports, 2, 927-929. Pharmacological Therapy The most important kind of therapy inspired by the biological model is pharmacological, or medication treatment. A list of some of the popular medications currently used for treating psychological disorders follows. All require a prescription from a psychiatrist or other medical doctor. All have received U.S. Food and Drug Administration approval as being safe and more effective than a placebo. However, as with all pharmacological therapies, these drugs may cause side effects. For example, the side effects of widely used antidepressants range from diminished appetite to loss of sexual pleasure. In addition, a patient may have to try several drugs before finding one that is effective and has acceptable side effects. Antidepressants. One group is called selective serotonin reuptake inhibitors (SSRIs) because of one of their actions; this group includes Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), Celexa (citalopram), and Lexapro (escitalopram). Another group is Page 78called serotonin and norepinephrine reuptake inhibitors (SNRIs) and includes Effexor (venlafaxine), Pristiq (desvenlafaxine), and Cymbalta (duloxetine). Antidepressants that do not fit into these groups include Wellbutrin (bupropion), Remeron (mirtazapine), Brintellix (vortioxetine), Viibryd (vilazodone), and Fetzima (levomilnacipran). Another group is called the tricyclics after their chemical structure; it includes Aventyl (nortriptyline) and Elavil (amitriptyline), although these medications are used only infrequently as they may have more side effects than newer antidepressants and can be fatal in overdose due to their effects on heart rhythms. No one antidepressant is known to be better than another, and they are often chosen based on their side effects (or lack thereof). Surprisingly, these antidepressants are as effective in treating panic disorder and certain kinds of chronic anxiety as they are in treating depression. Some also alleviate the symptoms of OCD. For more information, see the National Institute of Mental Health's "Mental Health Medications" website at http://www.nimh.nih.gov/health/publications/mental-health-medications/index.shtml. Mood stabilizers. Lithium carbonate, Depakote (valproic acid), and Lamictal (lamotrigine) are prescribed as mood stabilizers. They are taken to prevent mood swings that occur in bipolar disorder and schizoaffective disorder. Lamictal is used primarily to prevent depression, Depakote to prevent mania, and lithium to prevent both. Antipsychotics. Older antipsychotics include Haldol (haloperidol) and Prolixin (fluphenazine); newer antipsychotics (sometimes called "atypical antipsychotics") are Clozaril (clozapine), Zyprexa (olanzapine), Risperdal (risperidone), Seroquel (quetiapine), Abilify (aripiprazole), Geodon (zisprasidone), Latuda (lurasidone), and Saphris (asenapine). The drugs reduce hallucinations and disordered thinking in people with schizophrenia, bipolar disorder, and delirium, and they have a calming effect on agitated patients. Anxiolytics(antianxiety agents)and hypnotics(sleeping pills). One of the largest and most prescribed classes of anxiolytics is the benzodiazepines, a group of drugs that includes Valium (diazepam), Librium (chlordiazepoxide), Xanax (alprazolam), and Ativan (lorazepam). Dalmane (flurazepam), Restoril (temazepam), and Halcion (triazolam) are benzodiazepines that have been prescribed as sleeping aids, but newer non-benzodiazepine hypnotics such as Sonata (zaleplon), Ambien (zolpidem), and Lunesta (eszopiclone) are more commonly prescribed. Stimulants. Ritalin (methylphenidate) and Adderall (dextroamphetamine and amphetamine) are most commonly used to treat ADHD in children and less often in adults. Drugs of this type are also marketed under the names Dexedrine, Concerta, Focalin, Vyvanse, Daytrana, and Metadate. They are also used against daytime sleepiness in adults, as are purified caffeine (e.g., NoDoz), Provigil (modafinil), and Nuvigil (armodafinil). An antidepressant-like drug called Strattera (atomoxetine) is used to treat ADHD, and two antihypertensive medications (medications that lower blood pressure)—Kapvay (clonidine) and Intuniv (guanfacine)—also work to treat ADHD. Pharmacological therapy (medication) is a common form of treatment for many psychological disorders. Medications can be very effective, but they have risks and side effects, and they do not work for all patients. © Comstock Images/PictureQuest Issues in Drug Therapy The discovery that many psychological disorders have a biological basis in disordered brain chemistry has led to a revolution in the treatment of many disorders, particularly depression. The new view of depression as based in brain chemistry has also lessened the stigma attached to the condition, leading more people to seek treatment. Antidepressants are now among the most widely prescribed drugs in the United States. The development of effective drugs has provided relief for many people, but the wide use of antidepressants has also raised many questions. Critics of drug therapy ask whether the new drugs are really better than the old ones or are just being marketed Page 79by drug companies because their patents on old drugs have run out. Critics also say that the efficacy of antidepressants has been exaggerated by drug company-sponsored research and that psychological treatments of depression are usually just as good. Research indicates that, for mild cases of depression, psychotherapy and antidepressants are about equally effective. For major depression, combined therapy is significantly more effective than either type of treatment alone. Therapy can help provide insight into factors that precipitated the depression, such as high levels of stress or a history of abuse. A therapist can also provide guidance in changing patterns of thinking and behavior that contribute to the problem. The Behavioral Model The behavioral model focuses on what people do—their overt behavior—rather than on brain structures and chemistry or on thoughts and consciousness. This model regards psychological problems as "maladaptive behavior" or bad habits. When and how a person learned maladaptive behavior is less important than what makes it continue in the present. Behaviorists analyze behavior in terms of stimulus,response, and reinforcement. The essence of behavior therapy is to discover what reinforcements keep an undesirable behavior going and then to try to alter those reinforcements. For example, if people who fear speaking in class (the stimulus) remove themselves from that situation (the response), they experience immediate relief, which acts as reinforcement for future avoidance and escape. To change their behavior, fearful people are taught to practice exposure—to deliberately and repeatedly enter the feared situation and remain in it until their fear begins to abate. A student who is afraid to speak in class might begin his behavioral therapy program by keeping a diary listing each time he makes a contribution to a classroom discussion, how long he speaks, and his anxiety levels before, during, and after speaking. He would then develop concrete but realistic Page 80goals for increasing his speaking frequency and contract with himself to reward his successes by spending more time in activities he finds enjoyable. Behavioral therapy can help people overcome many kinds of fears, including that of public speaking. © Yuri Arcurs/Getty Images Although exposure to the real situation works best, exposure in your imagination or through the virtual reality of computer simulation can also be effective. For example, in the case of someone who is afraid of flying, a simulated scenario would likely be vivid enough to elicit the fear necessary to practice exposure techniques. The Cognitive Model The cognitive model emphasizes the effect of ideas on behavior and feeling. According to this model, behavior results from complicated attitudes, expectations, and motives rather than from simple, immediate reinforcements. Cognitive therapy tries to expose and identify false ideas that produce feelings such as anxiety and depression. For example, a student afraid of speaking in class may harbor thoughts such as "If I begin to speak, I'll say something stupid; if I say something stupid, the teacher and my classmates will lose respect for me; then I'll get a low grade, my classmates will avoid me, and life will be hell." In cognitive therapy, these ideas will be examined critically. If the student prepares, will he or she really sound stupid? Does every sentence said have to be exactly correct and beautifully delivered, or is that an unrealistic expectation? Will classmates' opinions be completely transformed by one presentation? Do classmates even care that much? And why does the student care so much about what they think? People in cognitive therapy are taught to notice their unrealistic thoughts and to substitute more realistic ones, and they are advised to repeatedly test their assumptions. The Psychodynamic Model The psychodynamic model also emphasizes thoughts. Proponents of this model, however, do not believe thoughts can be changed directly because they are fed by other unconscious ideas and impulses. Symptoms are not isolated pieces of behavior but the result of a complex set of wishes and emotions hidden by active defenses (see Table 3.2). In psychodynamic therapy, patients speak as freely as possible in front of the therapist and try to gain an understanding of the basis of their feelings toward the therapist and others. Through this process, patients gain insights that help them overcome their maladaptive patterns. Current therapies of this type tend to focus more on the present (the here and now) than on the past, and the therapist tries to facilitate self-exploration rather than providing explanations. Evaluating the Models Ignoring theoretical conflicts among psychological models, therapists have recently developed pragmatic cognitive-behavioral therapies (CBTs) that combine effective elements of both models in a single package. For example, the package for treating social anxiety emphasizes exposure as well as changing problematic patterns of thinking (see the Behavior Change Strategy "Dealing with Social Anxiety" at the end of the chapter). Combined therapies have also been developed for panic disorder, obsessive-compulsive disorder, generalized anxiety disorder, and depression. These packages, involving 10 or more individual or group sessions with a therapist and homework between sessions, have been shown to produce significant improvement. Drug therapy and CBTs are also sometimes combined, especially in the case of depression. For anxiety disorders, both kinds of therapy are equally effective, but the effects of drug therapy last only as long as the drug is being taken, whereas CBTs produce longer-term improvement. For schizophrenia, drug therapy is a must, but a continuing relationship with therapists who give support and advice is also indispensable. Psychodynamic therapies have been attacked as ineffective and endless. Of course, effectiveness is hard to demonstrate for therapies that do not focus on specific symptoms. But common sense tells us that being able to open yourself up and discuss your problems with a supportive but objective person who focuses on you and lets you speak freely can enhance your sense of self and reduce feelings of confusion and despair.Page 81 Other Psychotherapies In addition to existing forms of treatment, newer psychotherapies such as dialectical behavior therapy (DBT) have become available. Developed by Marsha Linehan, DBT is used to treat borderline personality disorder and chronic suicidal behavior, but it has since been expanded to treat other disorders, such as drug addiction and eating disorders. This therapy uses the principles of standard CBT by encouraging distress tolerance and acceptance of painful feelings and emotions through mindfulness (mindful awareness, discussed in Chapter 2), originally derived from Buddhist meditation and other Eastern practices. Mindfulness aims to allow a person to be aware of feelings rather than react to them, and to learn techniques to regulate emotions, by decreasing the intensity of emotional reactions. Mindfulness is practiced in group and individual therapy, often involving the use of workbooks and homework between sessions. Another newer therapy called acceptance and commitment therapy (ACT) is a scientifically studied psychological intervention that uses acceptance and mindfulness strategies, together with commitment and behavior change strategies, to increase psychological flexibility. Psychological flexibility is the process of embracing the present moment fully as a conscious human being, and then changing or continuing your behavior in the service of your own chosen values. It was developed in the 1980s by psychologists Steven C. Hayes, Kelly G. Wilson, and Kirk D. Strosahl. QUICK STATS 28,200 psychiatrists and 173,900 psychologists were practicing in the United States in 2014. —Bureau of Labor Statistics, 2015

Psychological Disorders

PSYCHOLOGICAL DISORDERS All of us feel anxious at times. In dealing with anxiety, we may avoid doing something we want to do or should do. Most of us have periods of feeling down when we become pessimistic, less energetic, and less able to enjoy life. Many of us are bothered at times by irrational thoughts or odd feelings. Such feelings and thoughts can be normal responses to the ordinary challenges of life, but when emotions or irrational thoughts interfere with daily activities and rob us of peace of mind, they can be considered symptoms of a psychological disorder. Psychological disorders are generally the result of many factors. Genetic differences, which underlie differences in how the brain processes information and experiences, are known to play an important role, especially in certain disorders such as autism, schizophrenia, and bipolar disorder. However, exactly which genes are involved, and how they alter the structure and chemistry of the brain, is still under study. A dysfunctional interaction between neurotransmitters and their receptors is associated with some psychiatric disorders (Figure 3.2). The trouble begins when neurotransmitters (chemicals that transmit messages between nerve cells) misfire and the nerve cells do not communicate properly. FIGURE 3.2 Nerve cell communication. Nerve cells (neurons) communicate through a combination of electrical impulses and chemical messages. Neurotransmitters such as serotonin and norepinephrine alter the overall responsiveness of the brain and are responsible for mood, levels of attentiveness, and other psychological states. Many psychological issues are related to problems with neurotransmitters and their receptors, and drug treatments frequently target them. For example, some antidepressant drugs increase levels of serotonin by slowing the resorption (reuptake) of serotonin. Learning and life events are important, too: Although one identical twin is often at higher risk of having a disorder if the other has it, the two don't necessarily have the same psychological disorders despite having identical genes. Some people have been exposed to more traumatic events than others, leading either to greater vulnerability to future traumas or, conversely, to the development of better coping skills. Further, what your parents, peers, and others have taught you Page 69strongly influences your level of self-esteem and how you deal with frightening or depressing life events (see the box "Ethnicity, Culture, and Psychological Health"). DIVERSITY MATTERS: Ethnicity, Culture, and Psychological Health Cultures develop unique ideas about mental health—about what is normal and what is problematic, how symptoms should be interpreted and communicated, whether treatment should be sought, and whether a social stigma is attached to a particular symptom or disorder. Based on their various environmental, cultural, and socioeconomic backgrounds, cultures perceive—categorize and interpret—psychological disorders differently. Climate and geography, as well as other environmental factors, such as diet, contribute to a group's health. These culturally distinct ideas change as the group comes into contact with other groups. For example, Asian immigrants to the United States have often come from collectivist cultures that anticipate and care for the needs of each other, so that individuals don't need to request support. In U.S. cultures, usually no group is expected to look after the needs of an individual; rather, individuals or their close families are responsible for seeking help for themselves. For this reason Asian immigrants appear to have more trouble than European Americans asking for explicit social support. The process by which individuals and groups adapt to each other's cultures, called acculturation, is an important influence on health. This adaptation ideally represents an exchange between both cultures, so that they learn how to do things a new way. Acculturation, however, often applies only to immigrants' adopting influences from a dominant culture. When a dominant group takes over the resources of a minority group—for example, a government enforces an English-only policy on bilingual speakers, thereby increasing the difficulties of the immigrants seeking help—then the socioeconomic status of the adapting group often decreases. As the following examples show, this status change may then further affect the psychological health of the group. Arctic Native Populations Studies of native populations around the Arctic (e.g., in northern Canada, Greenland, and Scandinavia) reveal many cases of elevated and chronic stress, accompanied by high blood pressure and cardiovascular risk. This chronic stress is linked to 50 years of rapid socioeconomic change: The population has experienced long-term unemployment, contamination of food, and a multitude of other acculturation problems. As they have acculturated, indigenous people have suffered discrimination, loss of traditional values, and lack of control over their resources. Because they live in climates with less light during winter months, they also experience seasonal affective disorder, a form of depression. Cultural expressions of their high levels of anxiety and depression include increased incidence of suicide and violence. Adolescents, in particular, among Alaska Natives and Greenland Inuit, have recently had a high number of suicides. In these populations, levels of injury and violence reach two to four times as high as national averages. Latinos in the United States Latinos in the United States generally are healthier than other U.S. racial and ethnic groups, for example, in mortality rates for adults and newborn babies. Still, mortality rates, incidence of chronic illness, and some mental health conditions such as depression vary within the U.S. Latino population, depending on Latino origin or cultural heritage (e.g., Mexican, Puerto Rican, or Cuban). One of the largest immigrant groups in the United States is from Mexico. Surprisingly, surveys show that these immigrants are psychologically healthier than their own children born in the United States. The children, who have acculturated into the dominant society—or acquired some knowledge of its language, food choice, dress, music, sports, etc.—are more likely to suffer from problems with depression, substance abuse, poor diet, and birth outcomes (e.g., prematurity, low birthweight, and teen pregnancy). Reasons for the negative effects of acculturation may be the stresses of cultural conflicts around ideas of individuality, interpersonal relationships, and what it means to succeed. Access to processed American foods high in simple sugars and excess fat may also prevail over the diets of their parents, which tend to be higher in fiber, protein, and vegetables and fruits. Despite these problems, second-generation Americans nevertheless tend to have higher rates of insurance coverage and access to health care. Their greater facility with English is correlated with higher frequencies of general physical, vision, and dental check-ups. Regardless of one's generation, other factors affect immigrants' health outcomes living in the U.S.: education, wealth, occupational and language skills all influence their lifestyles, as well as the policies of the government and attitudes of Americans already here. sources: Fisher, E. B. 2014. Peer support in health care and prevention: Cultural, organizational, and dissemination issues. Annual Review of Public Health 35: 363-383; Leyse-Wallace, R. 2013. Nutrition and Mental Health. Boca Raton, FL: CRC Press; Snodgrass, J. J. 2013. Health of indigenous circumpolar populations. Annual Review of Anthropology 42: 69-87; Brick, K., et al. 2011. Mexican and Central American immigrants in the United States. Washington, D.C: Migration Policy Institute; Lara, M., et al. 2005. Acculturation and Latino health in the United States: A review of the literature and its sociopolitical context. Annual Review of Public Health 26: 367-397. This section examines some of the more common psychological disorders, including anxiety disorders, mood disorders, and schizophrenia. Table 3.3 shows the likelihood of these disorders occurring during a lifetime. VITAL STATISTICS Table 3.3 Prevalence of Selected Psychological Disorders among Americans MEN WOMEN DISORDER LIFETIME PREVALENCE (%) LIFETIME PREVALENCE (%) Anxiety Disorders Specific Phobia 6.7 15.7 Social phobia 11.1 15.5 Panic disorder 2.0 5.0 Generalized anxiety disorder 3.6 6.6 Obsessive-compulsive disorder 1.7 2.8 Posttraumatic stress disorder 5.0 10.4 Mood disorders Major depressive episode 11.2 20.7 Manic episode 1.4 1.9 Schizophrenia and related disorders 0.8 0.4 sources: Centers for Disease Control and Prevention. 2011. Mental illness surveillance among adults in the United States. MMWR 60 (Suppl.): 1-29; Kessler, R. C., et al. 2005. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCSR). Archives of General Psychiatry 62(6): 617-627; Kessler, R. C., et al. 1994. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry 51(1): 8-19; Kessler, R. C., et al. 1995. Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry 52(12): 1048-1060; Plassman, B. L., et al. 2007. Prevalence of dementia in the United States: The aging, demographics, and memory study. Neuroepidemiology 29: 125-132; Kukull, W. A., et al. 2002. Dementia and Alzheimer's disease incidence. Archives of Neurology 59 (Nov.): 1737-1776. Anxiety Disorders Fear is a basic and useful emotion. Its value for our ancestors' survival cannot be overestimated. For modern humans, fear motivates us to protect ourselves and to learn how to cope with new or potentially dangerous situations. We consider fear to be a problem only when it is out of proportion to real danger. Anxiety is another word for fear, in particular, fear that is not in response to any definite threat. It becomes a disorder when it occurs almost daily or in life situations that recur and cannot be avoided, interfering with your relationships and the ability to function in social and professional situations. Specific Phobia The most common and understandable anxiety disorder, called specific phobia, is a fear of something definite like lightning, a particular type of animal, or a place. Snakes, spiders, and dogs are commonly feared animals; high or enclosed spaces are often frightening places. Sometimes, but not always, these fears originate in bad experiences, such as being bitten by a snake. Social Phobia The 15 million Americans with social phobia fear humiliation or embarrassment. Fear of speaking in public is perhaps the most common phobia of this kind. Extremely shy people can have social fears in almost all social situations. People with these kinds of fears may not continue in school as far as they could and may restrict themselves to lower-paying jobs in which they do not have to come into contact with new people. Panic Disorder People with panic disorder experience sudden unexpected surges in anxiety, accompanied by symptoms such as rapid and strong heartbeat, shortness of breath, loss of physical equilibrium, and a feeling of losing mental control. Such attacks usually begin in a person's early twenties and can lead to a fear of being in crowds or closed places or of driving or flying. Sufferers fear that a panic attack will occur in a situation from which escape is difficult (in an elevator), where the attack could be incapacitating and result in a dangerous or embarrassing loss of control (driving a car or shopping), or where no medical help would be available if needed (alone away from home). Fears such as these lead to avoidance of situations that might cause trouble. The fears Page 70and avoidance may spread to a large variety of situations until a person is virtually housebound, a condition called agoraphobia. People with panic disorder can often function normally in feared situations if with someone they trust. Panic disorder is different from an occasional panic attack, which affects about 40 million American adults age 18 and older every year. This occasional attack of overwhelming Page 71anxiety may have no obvious antecedent and usually resolves in an hour or less. Generalized Anxiety Disorder A basic reaction to future threats is to worry about them. Generalized anxiety disorder (GAD) is a diagnosis given to people whose worries about multiple issues linger more than six months. Worries may involve family, other relationships, work, school, money, and health. The GAD sufferer's worrying is not completely unjustified—after all, thinking about problems can result in solving them. But this kind of thinking seems to just go around in circles, and the more you try to stop it, the more you feel at its mercy. The end result is a persistent feeling of nervousness, often accompanied by depression. QUICK STATS 8 million American adults suffer from posttraumatic stress disorder. —U.S. Department of Veterans Affairs, 2015 Obsessive-Compulsive Disorder Someone diagnosed with obsessive-compulsive disorder (OCD) struggles with obsessions, compulsions, or both. Obsessions are recurrent, unwanted thoughts or impulses. Unlike the worries of GAD, they are not ordinary concerns but improbable fears such as of suddenly committing an antisocial act or of having been contaminated by germs. Compulsions are repetitive, difficult-to-resist actions usually associated with obsessions. A common compulsion is hand washing, associated with an obsessive fear of contamination by dirt. Other compulsions are counting and repeatedly checking whether something has been done—for example, whether a door has been locked or a stove turned off. People with OCD feel anxious, out of control, and embarrassed. Their rituals can occupy much of their time and make them inefficient at work and difficult to live with. Posttraumatic Stress Disorder (PTSD) People who suffer from posttraumatic stress disorder are reacting to severely traumatic events (events that produce a sense of terror and helplessness) such as physical violence to themselves or their loved ones. Trauma occurs in personal Page 72assaults (rape, military combat), natural disasters (floods, hurricanes), and tragedies (fires, airplane or car crashes). Symptoms include reexperiencing the trauma in dreams and in intrusive memories, trying to avoid anything associated with the trauma, and numbing of feelings. Hyperarousal (being on edge or easily startled), sleep disturbances, and other symptoms of anxiety and depression also commonly occur. Such symptoms can last months or even years. The symptoms of PTSD must last at least a month for the diagnosis to be made. Those whose symptoms have lasted only a month before resolving are considered to have acute stress disorder. PTSD symptoms often decrease over time, but up to one-third of PTSD sufferers do not fully recover. Recovery may be slower in those who have previously experienced trauma or who suffer from ongoing psychological problems. A study by the U.S. Department of Veterans Affairs National Center for PTSD found that, as a result of the Boston Marathon bombing in April 2013, many Boston-area military veterans diagnosed with PTSD experienced flashbacks, unwanted memories, and other psychological effects. The study raised awareness of the effects that tragic events such as terror attacks and mass shootings have on people directly involved but also on those with PTSD and other preexisting psychological conditions. The researchers urged health care systems to be prepared in the future to provide treatment for individuals either directly or indirectly affected by such tragedies. Treating Anxiety Disorders Therapies for anxiety disorders range from medication to psychological interventions concentrating on a person's thoughts and behavior. Both drug treatments and cognitive-behavioral therapies are effective in panic disorder, OCD, and GAD. Specific phobias are best treated without drugs. Attention-Deficit/Hyperactivity Disorder Attention-deficit/hyperactivity disorder (ADHD) is one of the most common disorders of childhood and adolescence. The main features of ADHD are inattention, hyperactivity, and/or impulsivity. Because these behaviors are normally found in children, attention must be paid to the persistence and severity of the symptoms. They may go misdiagnosed for a time: The impulsive child may be labeled a "discipline problem." An inattentive child may be described as "unmotivated" or "unintelligent." A diagnosis of ADHD is made only if the individual exhibits a persistent pattern of these behaviors; the behaviors must also interfere with the individual's functioning or development, as well as negatively affect school performance, peer relationships, or behavior at home. Inattention includes failure to pay close attention to details; tendency to make careless mistakes; trouble holding attention; failure to listen when spoken to directly; inability to follow through on or complete a task; avoidance of activities that require sustained effort; and tendency to get easily distracted. Hyperactivity and impulsivity include a tendency to fidget or squirm; inability to stay seated when expected; inability to play quietly; tendency to be high energy, to talk excessively, and to interrupt others; and inability to wait his or her turn. To be diagnosed, a person must have symptoms of ADHD before age 12 (even if an adult at first diagnosis). There must also be evidence that the ADHD behaviors are present in two or more settings—for example, at home, school or work; with friends and family; and in other activities. Someone who can pay attention at work but is inattentive only at home usually wouldn't qualify for a diagnosis of ADHD. ADHD has no cure, and scientists are still working on treatments. They are using tools such as brain imaging to find ways to prevent it. The use of medications is controversial. At best it can relieve some symptoms of the disorder. Other treatments include psychotherapy, education and training, and a combination of treatments. Mood Disorders We've all experienced sadness and feeling "down" or elated or irritable, but sometimes these feelings can be persistent or severe and interfere with life functioning. The two main types of mood disorder, major depressive disorder and bipolar disorder (what used to be called manic-depression) are together the most common mental disorders in the United States. Depression Depression differs from person to person but includes the following symptoms that persist most of the day and last more than two consecutive weeks: A feeling of sadness and hopelessness or loss of pleasure in doing usual activities (anhedonia) Poor appetite and weight loss or, alternatively, increased eating compared to usual Insomnia or disturbed sleep, including waking up and being unable to fall back to sleep or sleeping more than normal Decreased energy Restlessness or, alternatively, slowed thinking or activity Thoughts of worthlessness and guilt Trouble concentrating or making decisions Thoughts of death or suicide A person experiencing depression may not have all of these symptoms but must have depressed mood or anhedonia and at least four other symptoms. Sometimes instead of poor Page 73appetite and insomnia, the opposite occurs—eating too much and sleeping too long. Thus depression may contribute to weight gain in young women. People can have multiple symptoms of depression without feeling depressed, although they usually experience a loss of interest or pleasure. (See the box "Are You Suffering from a Mood Disorder?") ASSESS YOURSELF: Are You Suffering from a Mood Disorder? You should be evaluated by a professional if you've had five or more of the following symptoms for more than two weeks or if any of these symptoms causes such a big change that you can't keep up your usual routine. When You're Depressed ______ You feel sad or cry a lot, and it doesn't go away. ______ You feel guilty for no reason; you feel you're no good; you've lost your confidence. ______ Life seems meaningless, or you think nothing good is ever going to happen again. ______ You have a negative attitude a lot of the time, or it seems as if you have no feelings. ______ You don't feel like doing a lot of the things you used to like—music, sports, being with friends, going out, and so on—and you want to be left alone most of the time. ______ It's hard to make up your mind. You forget lots of things, and it's hard to concentrate. ______ You get irritated often. Little things make you lose your temper; you overreact. ______ Your sleep pattern changes: You start sleeping a lot more or you have trouble falling asleep at night; or you wake up really early most mornings and can't get back to sleep. ______ Your eating patterns change: You've lost your appetite or you eat a lot more. ______ You feel restless and tired most of the time. ______ You think about death or feel as if you're dying or have thoughts about suicide. When You're Manic or Hypomanic ______ You feel abnormally good or confident, like you're "on top of the world." ______ You get unrealistic ideas about the great things you can do—things that you really can't do. ______ Thoughts go racing through your head, you jump from one subject to another, and you talk a lot. ______ You're starting multiple projects at the same time—doing too many things at once. ______ You do risky things that may be out of character—spending much more money than usual, having more sex with more partners, driving recklessly, and so on. ______ You're so energized that you don't need much sleep. ______ You're so abnormally irritable that you can't get along at home or school or with your friends. If you are concerned about depression or manic behavior in yourself or a friend, or if you are thinking about hurting or killing yourself, talk to someone about it and get help immediately. In some cases, depression is a clear-cut reaction to a specific event, such as the loss of a loved one or a failure in school or work, whereas in other cases no trigger event is obvious. Regardless of the reason, severe symptoms should be taken seriously. Someone who has symptoms of major depression for more than two weeks, even if it is in reaction to a specific event, should consider treatment. One danger of severe depression is suicide, which is discussed later in this chapter, but the overall impact of depression on general health and ability to function, with or without suicidal thoughts, can be devastating. The National Institutes of Health estimates that depression strikes nearly 6.7% of Americans annually—20% of people have it in their lifetime—making depression the most common mood disorder. Depression affects the young as well as adults; about 3% of adolescents aged 13-18 suffer a major depressive episode each year, and nearly 50% of college students report depression severe enough to hinder their daily functioning. Depression tends to be more severe and persistent in blacks than in people of other races. Despite this, only about 60% of blacks affected by depression receive treatment for it. Almost twice as many women as men have serious depression. Overall, about three times as many women as men attempt suicide, but women's attempts are less likely to be lethal. Why women have more depression than do men is a matter of debate. Some experts think much of the difference is Page 74the result of reporting bias: Women are more willing to admit experiencing negative emotions, being stressed, or having difficulty coping. Women may also be more likely to seek treatment. Other experts point to biologically based sex differences, particularly in the level and action of hormones. It may also be that men are more likely than women to have symptoms such as anger or irritability when they are depressed, leading them to be misdiagnosed or for the diagnosis to be missed. In addition, women's social roles and expectations often differ from those of men. Women may put more emphasis on relationships in determining self-esteem, so the deterioration of a relationship is a cause of depression that can hit women harder than men. Culturally determined gender roles are more likely to place women in situations where they have less control over key life decisions, and lack of autonomy is associated with depression. Although treatments are highly effective, only about 35% of people who suffer from depression currently seek treatment. Treatment for depression depends on its severity and on whether the depressed person is suicidal. The best initial treatment for moderate to severe depression is probably a combination of drug therapy and psychotherapy. Newer prescription antidepressants work well, although they may need several weeks to take effect, and patients may need to try multiple medications before finding one that works well. If someone is severely depressed and at risk of suicide, hospitalization for more intensive treatment to ensure the patient's safety is sometimes necessary. Antidepressants work by targeting key neurotransmitters in the brain, including serotonin. When you take an antidepressant, your levels of serotonin increase. This increase has been revealed to help depression and other bodily conditions that serotonin influences, including mood, sexual desire and function, appetite, sleep, memory and learning, temperature regulation, and some social behavior. When women take antidepressants, they may need a lower dose than men; at the same dosage, blood levels of medication tend to be higher in women. An issue for women who may become pregnant is whether antidepressants can harm a fetus or newborn. The best evidence indicates that the most frequently prescribed types of antidepressants do not cause birth defects, although some studies have reported withdrawal symptoms in some newborns whose mothers used certain antidepressants. Electroconvulsive therapy (ECT) is effective for severe depression when other approaches have failed, including medications and other electronic therapies. In ECT, an epileptic-like seizure is induced by an electrical impulse transmitted through electrodes placed on the head. Patients are given an anesthetic and a muscle relaxant to reduce anxiety and prevent injuries associated with seizures. ECT usually includes three treatments per week for two to four weeks. For patients with seasonal affective disorder (SAD)—a type of depression—the treatment involves sitting with eyes open in front of a bright light source every morning. For patients with SAD, depression worsens during winter months as daylight hours diminish. Light therapy may work by extending the perceived length of the day and thus convincing the brain that it is summertime even during the winter months. The American Psychiatric Association estimates that 10-20% of Americans suffer symptoms that may be linked to SAD. SAD is more common among people who live at higher latitudes, where there are fewer hours of light in winter. QUICK STATS 51% of all suicides in the United States are committed with a firearm—more than 21,000 per year. —National Center for Health Statistics, 2016 Bipolar Disorder People who experience mania, characteristic of a severe mood disorder called bipolar disorder, undergo discrete periods of time when they may be restless, have excess energy or activity, feel rested with less sleep than usual, and speak rapidly. They may feel elevated (that is, much better than normal) or abnormally irritable. These feelings are often accompanied by impulsive behavior without regard for the consequences—for example, spending too much money or engaging in risky sexual activity. When such episodes are severe (requiring hospitalization, for example, or producing severe consequences), they are known as manic episodes, and the person who experiences them has what is known as bipolar I disorder. If such episodes of elevation or irritability are not so severe as to significantly impair functioning, they are known as hypomanic episodes. If hypomania alternates with periods of depression, that person is diagnosed with what is known as bipolar II disorder. People with bipolar disorder typically have periods of both mania or hypomania and depression, and the periods of depression can be persistent and severe. Bipolar disorder typically begins in the late teens through the twenties. Many people with bipolar disorder also struggle with substance and alcohol use disorders and anxiety. Suicide rates are high in bipolar disorders, especially early in life. This syndrome affects men and women equally. Antimanic drugs include lithium (a salt that calms manic episodes), mood stabilizers, and antipsychotic medications. For people who have recurrent episodes of mania or depression, continued, lifelong medication treatment is recommended. Specific medications to treat bipolar depression may also be prescribed.Page 75 Schizophrenia Schizophrenia is a devastating mental disorder that affects a person's thinking and perceptions of reality. People with schizophrenia frequently develop paranoid ideas and false beliefs (delusions), or may have auditory hallucinations (hearing "voices"). People with schizophrenia are often convinced that the voices they hear are "real." The disease can be severe and debilitating or so mild that it's hardly noticeable. Although people are capable of diagnosing their own depression, they usually don't diagnose their own schizophrenia because they often can't see that anything is wrong. This disorder is not rare; in fact, 1 in every 100 people has schizophrenia, most commonly starting in adolescence, which is perhaps what is most tragic and disturbing about the disease—that it starts to affect people in the prime of their lives. Scientists are uncertain about the exact causes of schizophrenia. Researchers have identified possible chemical and structural differences in the brains of people with the disorder as well as several genes that appear to increase risk. Schizophrenia is likely caused by a combination of genes and environmental factors that occur during pregnancy and development. For example, children born to older fathers have higher rates of schizophrenia, as do children with prenatal exposure to certain infections or medications. Some general characteristics of schizophrenia include the following: Disorganized thoughts. Thoughts may be expressed in a vague or confusing way. Inappropriate emotions. Emotions may be either absent or strong but inappropriate. Delusions. People with delusions—firmly held false beliefs—may think that their minds are controlled by outside forces, that people can read their minds, that they are great personages like Jesus Christ or the president of the United States, or that they are being persecuted by a group such as the CIA. Paranoid delusions can give people the feeling that they are in grave danger of being harmed. Auditory hallucinations. People with schizophrenia may hear voices when no one is present. Sometimes these voices tell them to do things (like harm themselves or others), belittle and criticize them, or give individuals a running commentary on someone's thoughts and behaviors. These voices can seem very real to the person hearing them and therefore are quite terrifying. Deteriorating social and work functioning. Social withdrawal and increasingly poor performance at school or work may be so gradual that they are hardly noticed at first, but over time people suffering from the disease fall far behind their peers—and far behind others' earlier expectations. None of these characteristics is invariably present. Some schizophrenic people are quite logical except on the subject of their delusions. Others show disorganized thoughts but no delusions or hallucinations. A schizophrenic person needs help from a mental health professional. Suicide is a risk in schizophrenia, and expert treatment can reduce that risk and minimize the social consequences of the illness by shortening the period when symptoms are active. The key element in treatment is regular medication. At times medication is like insulin for diabetes—it makes the difference between being able to function or not. Sometimes hospitalization is required temporarily to relieve family and friends. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Have you ever wondered if you were depressed? Try to recall your situation at the time. How did you feel, and what do you think brought about those feelings? What, if anything, did you do to bring about change and to feel better?

Meeting life's challenges with a positive self concept

Page 62 MEETING LIFE'S CHALLENGES WITH A POSITIVE SELF-CONCEPT Life is full of challenges—large and small. Everyone, regardless of heredity and family influences, must learn to cope successfully with new situations and new people. For emotional and mental wellness, each of us must continue to cultivate an adult identity that enhances our self-esteem and autonomy. We must also learn to communicate honestly, handle anger and loneliness appropriately, and avoid being defensive. Growing Up Psychologically Our responses to life's challenges influence the development of our personality and identity. Psychologist Erik Erikson proposed that development proceeds through a series of eight stages that extend throughout life. Each stage is characterized by a conflict or turning point—a time of increased vulnerability as well as increased potential for psychological growth (Table 3.1). Table 3.1 Erikson's Stages of Development AGE CONFLICT IMPORTANT PEOPLE TASK Birth-1 year Trust vs. mistrust Mother, father, or other primary caregiver In being fed and comforted, developing the trust that others will respond to your needs 1-3 years Autonomy vs. shame and self-doubt Parents In toilet training, locomotion, and exploration, learning self-control without losing the capacity for assertiveness 3-6 years Initiative vs. guilt Family In playful talking and locomotion, developing a conscience based on parental prohibitions that are not too inhibiting 6-12 years Industry vs. inferiority Neighborhood and school In school and playing with peers, learning the value of accomplishment and perseverance without feeling inadequate Adolescence Identity vs. identity confusion Peers Developing a stable sense of who you are—your needs, abilities, interpersonal style, and values Young adulthood Intimacy vs. isolation Close friends, sex partners Learning to live and share intimately with others, often in sexual relationships Middle adulthood Generativity vs. self-absorption Work associates, children, community Doing things for others, including parenting and civic activities Older adulthood Integrity vs. despair Humankind Affirming the value of life and its ideals source: Erikson, E. 1963. Childhood and Society. New York: Norton. The successful mastery of one stage is a basis for mastering the next, so early failures can have repercussions in later life. Fortunately, life provides ongoing opportunities for mastering these tasks. For example, although the development of trust begins in infancy, it is refined as we grow older. We learn to trust some people outside our immediate family and to identify others as untrustworthy. Developing an Adult Identity A primary task beginning in adolescence is the development of an adult identity: a unified sense of self, characterized by attitudes, beliefs, and ways of acting that are genuinely our own. People with adult identities know who they are, what they are capable of, what roles they play, and their place among their peers. They have a sense of their own uniqueness but also appreciate what they have in common with others. They view themselves realistically and can assess their strengths and weaknesses without relying on the opinions of others. Achieving an identity also means that we can form intimate relationships with others while maintaining a strong sense of self. Our identities evolve as we interact with the world and make choices about what we'd like to do and whom we'd like to model ourselves after. Developing an adult identity is particularly challenging in a heterogeneous, secular, and relatively affluent society like ours, in which many roles are possible, many choices are tolerated, and ample time is allowed for experimenting and making up your mind. This idea of a core self may seem contradictory to the idea that we are always changing. We show different sides of ourselves, not just as we pass through different ages, but also from one day to the next, depending on whom we're with or the environment we're in. Early identities are often modeled after parents and adult caregivers—or the opposite of parents, in rebellion against what they represent. Over time, peers, rock stars, sports heroes, and religious figures are added to the list of possible role models. In high school and college, people often join cliques that assert a certain identity, such as "jocks," "nerds," or "slackers." Although much of our identity is internal—a way of viewing ourselves and the world—certain aspects of it can be external, such as styles of talking and dressing, ornaments like earrings, and hairstyles. Early identities are rarely permanent. A hardworking student seeking approval one year can turn into a dropout Page 63devoted to sleeping all day and partying all night the next year. At some point, however, most of us adopt a more stable, individual identity that ties together the experiences of childhood and the expectations and aspirations of adulthood. Erikson's theory does not suggest that one day we suddenly assume our final identity and never change after that. Life is more interesting for people who continue evolving into more distinct individuals, rather than being rigidly controlled by their pasts. Identity reflects a lifelong process, and it changes as a person develops new relationships and roles. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Write down times when you felt Free Aloof Angry Generous Happy Talkative For each moment you recall, who were you with when you felt those ways? What had recently happened in your life? Where were you? Did you feel most "yourself" in any of those moments? Which? Developing an adult identity is an important part of psychological wellness. Without a personal identity, we begin to feel confused about who we are. Erikson called this situation an identity crisis. Until we have "found ourselves," we cannot have much self-esteem because a self is not firmly in place. Developing Intimacy People with established identities can form intimate relationships and sexual unions characterized by sharing, open communication, long-term commitment, and love. Those who lack a firm sense of self may have difficulty establishing relationships because they feel overwhelmed by closeness and the needs of another person. As a result, they experience only short-term, superficial relationships with others and may remain isolated. Developing Values and Purpose in Your Life Erikson assigned his last two stages, generativity versus self-absorption and integrity versus despair, to middle adulthood and older adulthood, respectively. But these stages concern values that need to be addressed by young people and reexamined throughout life. Values are criteria for judging what is good and bad, and they underlie our moral decisions and behavior. The first morality of the young child is to consider "good" to mean what brings immediate and tangible rewards, and "bad" to mean whatever results in punishment. An older child will explain right and wrong in terms of authority figures and rules. But the final stage of moral development, one that not everyone attains, is being able to conceive of right and wrong in more abstract terms such as justice and virtue. As adults we need to assess how far we have evolved morally and what values we have adopted. Without an awareness of our personal values, our lives may be hurriedly driven forward by immediate desires and the passing demands of others. Living according to values means Considering your options carefully before making a choice Choosing among options without succumbing to outside pressures that conflict with your values Making a choice and acting on it rather than doing nothing Your actions and how you justify them proclaim to others what you stand for. Achieving Healthy Self-Esteem Having a healthy level of self-esteem means regarding your self—which includes all aspects of your identity—as good, competent, and worthy of love. It is a critical component of wellness. Developing a Positive Self-Concept Ideally a positive self-concept begins in childhood, based on experiences both within the family and outside it. Children need to develop a sense of being loved and being able to give love and to accomplish their goals. If they feel rejected or neglected by their parents, they may fail to develop feelings of self-worth. They may grow to have a negative concept of themselves. Another component of self-concept is integration. An integrated self-concept is one that you have made for yourself—not someone else's image of you or a mask that doesn't quite fit. Important building blocks of self-concept are the personality characteristics and mannerisms of parents, which children may adopt without realizing it. Later they may be surprised to find themselves acting like one of their parents. Eventually such building blocks may be reshaped and integrated into a new, individual personality. Another aspect of self-concept is stability. Stability depends on the integration of the self and its freedom from contradictions. People who have gotten mixed messages about themselves from parents and friends may have contradictory self-images, which defy integration and make them vulnerable to shifting levels of self-esteem. At times they regard themselves as entirely good, capable, and lovable—an ideal self—and at other times they see themselves as entirely Page 64bad, incompetent, and unworthy of love. Neither of these extreme self-concepts allows people to see themselves or others realistically, and their relationships with other people are filled with misunderstandings and ultimately with conflict. A positive self-concept begins in infancy. The knowledge that he's loved and valued by his parents gives this baby a solid basis for lifelong psychological health. © Purestock/PunchStock RF The concepts we have about ourselves and others are an important part of our personalities. And all the components of our self-concepts profoundly influence our interpersonal relationships. Meeting Challenges to Self-Esteem As an adult, you sometimes run into situations that challenge your self-concept. People you care about may tell you they don't love you or feel loved by you, for example, or your attempts to accomplish a goal may end in failure. You can react to such challenges in several ways. The best approach is to acknowledge that something has gone wrong and try again, adjusting your goals to your abilities without radically revising your self-concept. Less productive responses are denying that anything went wrong and blaming someone else. These attitudes may preserve your self-concept temporarily, but in the long run they keep you from meeting the challenge. The worst reaction is to develop a lasting negative self-concept in which you feel bad, unloved, and ineffective—in other words, to become demoralized. Instead of coping, the demoralized person gives up (at least temporarily), reinforcing the negative self-concept and setting in motion a cycle of bad self-concept and failure. In people who are genetically predisposed to depression, demoralization can progress to additional symptoms, which are discussed later in the chapter. Notice Your Patterns of Thinking One method for fighting demoralization is to recognize and test the negative thoughts and assumptions you may have about yourself and others. Note exactly when an unpleasant emotion—feeling worthless, wanting to give up, feeling depressed—occurs or gets worse, to identify the events or daydreams that trigger that emotion, and to observe whatever thoughts come into your head just before or during the emotional experience. Keep a daily journal about such events. Avoid Focusing on the Negative Imagine that you are waiting for a friend to meet you for dinner, but he's 30 minutes late. What kinds of thoughts go through your head? You might wonder what caused the delay: Perhaps he is stuck in traffic, you think, or needs to help a roommate who has the flu. This kind of reaction is healthy for several reasons: You aren't jumping to a conclusion or blaming your friend for a failure. After all, he probably hasn't forgotten about you or decided to ditch you. You are being reasonable by giving your friend the benefit of the doubt. Things happen. Your friend probably has a good reason for not being there. He deserves a chance to explain and may need your help dealing with the situation that made him late. You avoid personalizing the situation in such a way that you feel hurt or betrayed. Jumping to a negative conclusion (such as "He isn't coming because he doesn't really like me") can make you feel bad unnecessarily. The same thing happens if you place blame—either on your friend or yourself—without knowing all the facts. By contrast, people who are demoralized tend to use all-or-nothing thinking. They overgeneralize from negative events. They overlook the positive and jump to negative conclusions, minimizing their own successes and magnifying the successes of others. They take responsibility for unfortunate situations that are not their fault, then jump to more negative conclusions and more unfounded overgeneralizations. Patterns of thinking that make events seem worse than they are in reality are called cognitive distortions. Develop Realistic Self-Talk When you react to a situation, an important piece of that reaction is your self-talk—the statements you make to yourself inside your own mind. To Page 65pick up on our earlier example, suppose your friend is late for a dinner date. As you wait for your friend to arrive, your self-talk has a profound effect on your reaction to his lateness. Someone who is demoralized or wrestling with a poor self-concept might immediately react with negative self-talk: "He isn't coming. It's my fault; he probably doesn't like me because I'm boring. I bet he's with someone else." In your own fight against demoralization, you may find it hard to think of a rational response until hours or days after the event that upset you. Responding rationally can be especially hard when you are having an argument with someone else, which is why people often say things they don't mean in the heat of the moment or develop hurt feelings even when the other person had no intention of hurting them. Once you get used to noticing the way your mind works, however, you may be able to catch yourself thinking negatively and change the process before it goes too far. This approach to controlling your reactions is not the same as positive thinking—which means substituting a positive thought for a negative one. Instead you simply try to make your thoughts as logical and accurate as possible, based on the facts of the situation as you know them, and not on snap judgments or conclusions that may turn out to be false. Demoralized people can be tenacious about their negative beliefs—so tenacious that they make their beliefs come true in a self-fulfilling prophecy. For example, if you conclude that you are so boring that no one will like you anyway, you may decide not to bother socializing. This behavior could make the negative belief become a reality because you limit your opportunities to meet people and develop new relationships. For additional tips on changing distorted, negative ways of thinking, see the box "Realistic Self-Talk." TAKE CHARGE: Realistic Self-Talk Do your patterns of thinking make events seem worse than they truly are? Do negative beliefs you have about yourself become self-fulfilling prophecies? Substituting realistic self-talk for negative self-talk can help you build and maintain self-esteem and cope better with the challenges in your life. Here are some examples of common types of distorted, negative self-talk, along with suggestions for more accurate and rational responses: COGNITIVE DISTORTION NEGATIVE SELF-TALK REALISTIC SELF-TALK Focusing on negatives Babysitting is such a pain in the neck; I wish I didn't need the extra money so bad. This is a tough job, but at least the money's decent and I can study once the kids go to bed. Expecting the worst I know I'm going to get an F in this course. I should just drop out of school now. I'm not doing too well in this course. I should talk to my professor to see what kind of help I can get. Overgeneralizing My hair is a mess and I'm gaining weight. I'm so ugly. No one would ever want to date me. I could use a haircut and should try to exercise more. This way I'll start feeling better about myself and will be more confident when I meet people. Minimizing It was nice of everyone to eat the dinner I cooked, even though I ruined it. I'm such a rotten cook. Well, the roast was a little dry, but they ate every bite. The veggies and rolls made up for it. I'm finally getting the hang of cooking! Blaming others Everyone I meet is such a jerk. Why aren't people friendlier? I am going to make more of an effort to meet people who share my interests. Expecting perfection I cannot believe I flubbed that solo. They probably won't even let me audition for the orchestra next year. It's a good thing I didn't stop playing when I hit that sour note. It didn't seem like anyone noticed it as much as I did. Believing you're the cause of everything Tom and Sara broke up, and it's my fault. I shouldn't have insisted that Tom spend so much time with me and the guys. It's a shame Tom and Sara broke up. I wish I knew what happened between them. Maybe Tom will tell me at soccer practice. At any rate, it isn't my fault; I've been a good friend to both of them. Thinking in black and white I thought that Mike was really cool, but after what he said today, I realize we have nothing in common. I was really surprised that Mike disagreed with me today. I guess there are still things I don't know about him. Magnifying events I stuttered when I was giving my speech today in class. I must have sounded like a complete idiot. I'm sure everyone is talking about it. My speech went really well, except for that one stutter. I bet most people didn't even notice it, though. Page 66 Psychological Defense Mechanisms—Healthy and Unhealthy We are always trying to manage our feelings, even if we aren't aware we are doing it. We try to manage uncomfortable feelings through what are called psychological defenses. By using defense mechanisms, we change unacceptable feelings (like shame or anger or anxiety) into ones with which we are more comfortable. Table 3.2 lists some standard defense mechanisms. Defense mechanisms can be healthy and adaptive—such as humor and altruism—but sometimes they are what are called maladaptive. For example, it would be maladaptive to displace your anger at your teacher by yelling at your roommates because doing so doesn't help your relationship with your teacher or your roommates. The drawback of many defenses is that they make feelings better temporarily but don't address underlying causes. Table 3.2 Defense and Coping Mechanisms MECHANISM DESCRIPTION EXAMPLE Projection Reacting to unacceptable impulses by denying their existence in yourself and attributing them to others A student who dislikes his roommate feels that the roommate dislikes him. Repression Keeping an unpleasant feeling, idea, or memory out of awareness The child of an alcoholic, neglectful father remembers only when her father showed consideration and love. Denial Refusing to acknowledge to yourself what you really know to be true A person believes that smoking cigarettes won't harm her because she's young and healthy. Displacement Shifting your feelings about a person to another person A student who is angry with one of his professors returns home and yells at one of his housemates. Dissociation Detaching from a current experience to avoid emotional distress Rather than listen to his angry father, Beethoven composes a piece in his mind. Rationalization Giving a false, acceptable reason when the real reason is unacceptable A shy young man decides not to attend a dorm party, telling himself he'd be bored. Reaction formation Concealing emotions or impulses by exaggerating the opposite ones A person who dislikes children frequently buys expensive gifts for, and speaks with enthusiasm about, the children of her friends. Substitution Replacing an unacceptable or unobtainable goal with an acceptable one A man in love with an unavailable partner throws himself into training for a marathon. Acting out Engaging in an action that makes an unacceptable feeling go away A person who feels disrespected and devalued gets into a fight at a bar with a stranger. Humor Finding something funny in unpleasant situations A student whose bicycle has been stolen thinks how surprised the thief will be when he or she starts downhill and discovers the brakes don't work. Altruism Serving others without expecting anything in return A person who grew up in an upper-class neighborhood volunteers at a foundation that helps people get out of poverty. Recognizing our own defense mechanisms can be difficult because we are not aware of them, as they occur unconsciously. But we all have some inkling about how our minds operate. By remembering the details of conflict situations, a person may be able to figure out which defense mechanisms she or he used in successful or unsuccessful attempts to cope. Recall a psychologically stressful situation and view yourself as an objective outside observer would; now analyze your thoughts and behavior in that situation. Having insight into what strategies you typically use can lead to new, more rewarding and effective ways of coping. Being Optimistic Most of us have a predisposition toward optimism or pessimism. Pessimism is a tendency to focus on the negative and expect an unfavorable outcome; optimism is a tendency to emphasize the hopeful and expect a favorable outcome. Pessimists not only expect repeated failure and rejection but also accept it as deserved. They do not see themselves as capable of success and irrationally dismiss any evidence of their own accomplishments. This negative point of view is learned, typically at a young age from parents and other authority figures. Optimists, by contrast, consider bad events to be temporary and consider failure to be limited and look forward to new pursuits. You can learn to be optimistic by recording adverse events in a diary, along with the reactions and beliefs with which you met those events. By doing so, you learn to recognize and dispute the false, negative predictions you generate about yourself, like "The problem is going to last forever and ruin everything, and it's all my fault." Refuting such negative self-talk frees energy for realistic coping.Page 67 Maintaining Honest Communication Another important area of psychological functioning is communicating honestly with others. It can be very frustrating for us and for people around us if we cannot express what we want and feel. Others can hardly respond to our needs if they don't know what those needs are. We must recognize what we want to communicate and then express it clearly. Some people know what they want others to do but don't state it clearly because they fear denial of the request, which they interpret as personal rejection. Such people might benefit from assertiveness training: learning to insist on their rights and to bargain for what they want. Assertiveness includes being able to say no or yes depending on the situation. Communicating your feelings appropriately and clearly is important. For example, if you tell people you feel sad, they may have various reactions. If they feel close to you, they may express an intimate thought of their own. Or they may feel guilty because they think you're implying they have caused your sadness. They may even be angry because they feel you expect them to cheer you up. Depending on your intention and your prediction of how a statement will be taken, you may or may not wish to make it. For example, if you say, "I feel like staying home tonight," you may also be implying something different. You could really mean "Don't bother me." Or you mean that you're open to a negotiation: "I would be willing to do something else if the conditions are right." Although keeping your real thoughts and feelings to yourself may help you avoid a confrontation (or even a discussion) with someone, it is unfair because you are not really being clear about what you want. Good communication means expressing yourself clearly. You don't need any special psychological jargon to communicate effectively. Dealing with Loneliness It can be hard to strike the right balance between being alone and being with others. Some people are motivated to socialize from fear of being alone. If you discover how to enjoy being by yourself, you'll be better able to cope with periods when you're forced to be alone—for example, when you are no longer in a romantic relationship or when your usual friends are away on vacation. Unhappiness with being alone may come from interpreting it as a sign of rejection—that others are not interested in spending time with you. Before you reach such a conclusion, be sure that you give others a real chance to get to know you. Examine your patterns of thinking: You may harbor unrealistic expectations about other people—for example, that everyone you meet must like you and, if they don't, you must be flawed. You might also consider the possibility that you expect too much from new acquaintances, and, sensing this, they start to draw back, triggering feelings of rejection. Not everyone you meet is suitable and willing to have a close or intimate relationship. Feeling pressure to have such a relationship may lead you to connect with someone whose interests and needs are remote from yours or whose need to be cared for leaves you with little time of your own. You may have traded loneliness for potentially worse problems. College offers many antidotes to loneliness in the forms of clubs, organized activities, sports, and just hanging out with friends. © Hero Images/Getty Images Loneliness is a passive feeling state. If you decide that you're not spending enough time with people, change the situation. College life provides many opportunities to meet people. If you're shy or introverted, you may have to push yourself to join a group. Look for something you've enjoyed in the past or in which you have a genuine interest. Dealing with Anger Anger is a part of the array of normal emotions, yet it is often confusing and difficult to deal with. Some people feel that expressing anger is beneficial for psychological and physical health. However, if angry words or actions damage relationships or produce feelings of guilt or loss of control, they do not contribute to psychological wellness. It is important to distinguish between a destructive expression of anger and a reasonable level of self-assertiveness. At one extreme are people who never express anger or any opinion that might offend others, even when their own Page 68rights and needs are being jeopardized. They may be trapped in unhealthy relationships or chronically deprived of satisfaction at work and at home. If you have trouble expressing your anger, consider training in assertiveness and appropriate expressions of anger to help you learn to express yourself constructively. At the other extreme are people whose anger is explosive or misdirected—such expression of anger can signal a condition called intermittent explosive disorder (IED). It may also be a symptom of a more serious problem—angry outbursts, for instance, are associated with posttraumatic stress disorder. Explosive anger may also happen during periods of intoxication with alcohol or drugs such as amphetamines or cocaine. Explosive anger or rage, like a child's tantrum, renders an individual temporarily unable to think straight or to act in his or her own best interest. During an IED episode, a person may lash out uncontrollably, hurting someone else physically or verbally, or destroying property. Anyone who expresses anger this way should seek professional help. Some studies have suggested that overtly hostile people seem to be at higher risk for heart attacks. Managing Your Anger If you feel explosive anger coming on, consider the following two strategies to head it off. First, try to reframe what you're thinking at that moment. You'll be less angry at another person if there is a possibility that his or her behavior was not intentionally directed against you. Imagine that another driver suddenly cuts in front of you. You would certainly be angry if you knew the other driver did it on purpose, but you probably would be less angry if you knew he simply did not see you. If you're angry because you've just been criticized, avoid mentally replaying scenes from the past when you received other unjust criticisms. Think about what is happening now, and try to act differently than you would have in the past—less defensively and more analytically. Second, until you're able to change your thinking, try to distract yourself. Use the old trick of counting to 10 before you respond, or start concentrating on your breathing. If necessary, cool off by leaving the situation until your anger has subsided. This does not mean that you should permanently avoid the sensitive topics. Return to the matter after you've had a chance to think clearly about it. QUICK STATS In 2014, an estimated 43.6 million adults age 18 and older in the United States had a mental illness. This number represented 18.1% of all U.S. adults. —National Institute of Mental Health, 2015 Dealing with Anger in Other People Anger can be infectious, and it disrupts cooperation and communication. If someone you're with becomes very angry, respond "asymmetrically" by reacting not with anger but with calm. Try to validate the other person by acknowledging that he or she has some reason to be angry: "I totally get that this is making you mad," or "If I were you, I'd be upset, too." This does not mean apologizing if you don't think you're to blame, or accepting verbal abuse. It means that you have considered the other's perspective and that you understand why she might be angry. Finally, if the person cannot be calmed, it may be best to disengage, at least temporarily. After a time-out, you may have better luck trying to solve the problem rationally. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Think about the last time you were truly angry. What triggered your anger? How did you express it? Do you typically handle your anger in the same manner? How appropriate does your anger-management technique seem?

suicide

SUICIDE In the United States, suicide is the second leading cause of death for young people aged 15-24 and the 10th leading cause for people of all ages. In 2013, among adults age 18 and over, 1.1% made suicide plans, and 0.6% went ahead and attempted it. (see Figure 3.3 for data on suicidal thoughts). Suicide rates vary by race or ethnicity: Among adolescents and young adults, the suicide rate is highest among American Indians or Alaska Natives; among adults, non-Hispanic whites have the highest suicide rate. The suicide rate among men is still more than three times higher than that among women, but the gap has narrowed in recent years. Overall, non-Hispanic white men aged 45-54 have the highest suicide rate. Suicidal thoughts are highest among adults reporting two or more races, followed by American Indians/Alaskan Natives. [D] FIGURE 3.3 Percentages of Americans age 18 and over having suicidal thoughts in the past year. source: Centers for Disease Control and Prevention. 2015. Suicide. Facts at a Glance. National Center for Injury Prevention and Control. Atlanta, GA (http://www.cdc.gov/violenceprevention/pdf/suicide-datasheet-a.pdf). Suicide rarely occurs without warning signs (see Table 3.4). About 60% of people who kill themselves are depressed. The more symptoms of depression a person has, the greater the risk. A threat of suicide should not be taken as only a cry for help but also as a possible future occurrence. Here are specific warning signs: Any mention of dying, disappearing, jumping, shooting oneself, or other types of self-harm. Changes in personality, including sadness, withdrawal, irritability, anxiety, fatigue, indecisiveness, or apathy. A sudden, inexplicable brightening of mood (which can mean the person has decided to attempt suicide). A sudden move to give away important possessions, accompanied by statements such as, "I won't be needing these anymore." An increase in reckless behaviors. Table 3.4 Myths about Suicide: Don't Be Misled MYTH FACT People who really intend to kill themselves do not let anyone know about it. This belief can be an excuse for doing nothing when someone says he or she might attempt suicide. In fact, most people who eventually follow through with suicide have talked about doing it. People who made a suicide attempt but survived did not really intend to die. This belief may be true for certain people, but people who seriously want to end their lives may fail because they misjudge what it takes. Even a pharmacist may misjudge the lethal dose of a drug. People who succeed in suicide really wanted to die. We cannot be sure of that either. Some people are only trying to make a dramatic gesture or plea for help but miscalculate. People who really want to kill themselves will do it regardless of any attempts to prevent them. Few people are single-minded about suicide even at the moment of attempting it. People who are quite determined to take their lives today may completely change their minds tomorrow. Suicide is proof of mental illness. Many suicides are carried out by people who do not meet ordinary criteria for mental illness, although people with depression, schizophrenia, and other psychological disorders have a much higher than average suicide rate. People inherit suicidal tendencies. Certain kinds of depression that lead to suicide do have a genetic component. But many examples of suicide running in a family can be explained by factors such as psychologically identifying with a family member who kill themselves, often a parent. All suicides are irrational. By some standards, all suicides may seem "irrational." But many people find it at least understandable that someone might want to attempt suicide—for example, when approaching the end of a terminal illness or when facing a long prison term. Page 76In addition to warning signs, certain risk factors increase the likelihood that someone will attempt suicide (see the box "Deliberate Self-Harm"). Protective factors decrease the likelihood. Risk factors and protective factors can be intrapersonal,social/situational, or cultural. WELLNESS ON CAMPUS: Deliberate Self-Harm In general, people want to be well and healthy and to protect themselves from harm. But many individuals—predominantly in their teens and adolescence—do deliberately harm themselves, although in a nonfatal way. A common method of self-harm involves people cutting or burning their own skin, leaving scars that they hide beneath their clothes. Self-cutting and other self-injurious behaviors are not aesthetically motivated. Many people who engage in these behaviors report seeking the physical sensations (including pain) produced by a self-inflected injury, which may temporarily relieve feelings of tension, perhaps through a release of endorphins. In 2011, a research group led by Alicia Meuret, an associate professor of psychology at Southern Methodist University, conducted surveys on more than 550 college students and found that over 20% had engaged in self-injury at some point, which is consistent with prevalence estimates in other studies on college populations. In examining differences between self-injurers and noninjurers, individuals who had recently engaged in self-harm were significantly more depressed, anxious, and disgusted with themselves. Compared to noninjurers, self-injurers were roughly 4 times more likely to report a history of physical abuse and 11 times more likely to report a history of sexual abuse. Self-injury is not the same as a suicide attempt, but individuals who repeatedly hurt themselves are more likely than the general population to kill themselves. In any case, self-injury should be taken seriously. Treatment usually includes group therapy, individual therapy, medication (e.g., antidepressants), or stress reduction and management skills. The following are key risk factors: A history of previous attempts A sense of hopelessness, helplessness, guilt, or worthlessness Alcohol or other substance use disorders Serious medical problems Mental disorders, particularly mood disorders such as depression and bipolar disorder Availability of a weapon Family history of suicide Social isolation A history of having been abused or neglected A current or past experience of being a victim of bullying, in person or online The following are key protective factors: Strong religious faith or other cultural prohibition on suicide Connection to other people, including family that is supportive Engagement in treatment in which the person is getting help Connection with one's own children (or even pets) Lack of access to lethal means (guns, pills, railroad tracks) Page 77If you are severely depressed or know someone who is, expert help from a mental health professional is essential. Don't be afraid to discuss the possibility of suicide with someone you fear is suicidal. You won't give them an idea they haven't already thought of. Ask direct questions to determine whether someone seriously intends to kill themselves. Encourage your friend to talk and to take positive steps to improve his or her situation. You can call the National Suicide Prevention Lifeline at 800-273-TALK (8255). Trained crisis workers are available to talk 24 hours a day, 7 days a week. If you think someone is in immediate danger, do not leave him or her alone. Call for help or take him or her to an emergency room. Most communities have emergency help available, often in the form of a hotline telephone counseling service run by a suicide prevention agency. Firearms are used in more suicides than homicides. Among gun-related deaths in the home, 83% are the result of suicide, often by someone other than the gun owner. If you learn someone at high risk for suicide has access to a gun, try to convince him or her to put it in safekeeping.