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