When it comes to mental health,

 what’s normal?

Mental Health Overview for Care Providers.

Author: Mark Parkinson RPh:  President  AFC CE

Credit Hours 4- Approximate time required: 240 min. 

Educational Goal: 

To give a basic overview of the most common Mental Health Issues for Care givers.

Educational Objectives:          

1. Understand the difficulties in mental health issues.

2. Explain the Basics of Mental health

3. Provide a description of the 10 most common mental illnesses

4. Provide some care giver tips for caring for mental health patients


1. Read the course materials.  2. Click on exam portal [Take Exam].  3. If you have not done so yet fill in Register form (username must be the name you want on your CE certificate).  4. Log in  5. Take exam.  6. Click on [Show Results] when done and follow the instructions that appear.  7. A score of 70% or better is considered passing and a Certificate of Completion will be generated for your records. 



  The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.



When it comes to mental health, what’s normal?

Mental Health Overview for Care Providers


     When it comes to mental health, who is normal and who is crazy?  That is a hard question to answer. Aren’t we all a bit off center in some way? Despite our differences, we can, for the most part, fit into society and function well.  Unfortunately, there are those who are so far off center that they have difficulty functioning and need help fitting in.  Some of these individuals cannot even live by themselves and wind up in your care homes. Caregivers to these needy people would be wise to have at least a basic understanding of what their clients face. Hopefully by the end of this lesson, you will have a better understanding of some of the most common of society’s mental health problems.

Basic Understanding

What is Mental Health?

     As care providers you are totally involved in the physical health of your patients. You watch their hygiene, give them their medicine, control their diet, fight off any physical illnesses that crop up, make sure they get enough of what they need, etc. Most of you have got a pretty good handle on your patients’ physical health. But what about their mental health?  You may not be used to thinking in such terms.  What is mental health? “Mental health is how we think, feel and act as we cope with life. It also helps determine how we handle stress, relate to others and make choices.” National Institutes of Health, Medline Plus.  When a body doesn’t function normally, we say it is in poor health. When a mind doesn’t function normally, we say that person has a mental illness.

The Difficulty in Diagnosing Mental Illness

     Our mind is one of our most complex structures, with millions of brain cells with trillions of connections to each other.  Those connections can be affected by the way we were born (congenital), environmental assaults (alcohol, drugs, toxins), and outside stresses (emotional abuse, traumatic events, overwhelming stressors) or chemical imbalances. If there are enough changes in our brain cells we begin to think and act abnormally. If the abnormality starts to interfere with normal functioning it is said to be a mental illness. Of course it is not that simple. There is almost limitless variety in brain cell connection structures from one person to another.   In addition the specifics of most mental illness can’t be seen or seen only intermittently. It’s easy to see measle spots but can you tell the difference between having a tired down day and major depression disorders? Add to all the above the fact that the mental health patient themselves are probably unaware that there is a mental health issue. They have learned to compensate for their difficulties, thus hiding the true nature of what is going on. These and other factors make mental illness one of the most challenging areas of concern in health care today.

History of Mental Health Care

     It seems to be in society’s nature to try to force its members to comply to a set standard of behaviors so everyone gets along with each other.  If a member of that society does not comply with its expectations, it has a tendency to push them out of the way until that person decides to come into compliance with normal societal behaviors.  It seems a logical way of handling aberrant behaviors. Unfortunately, logic breaks down when that person has difficulty or cannot change their behaviors. It has been a sad fact for most of human history that mental health patients have been looked down upon, shunned, mistreated, institutionalized, and even punished because of their abnormal behavior. 

     In ancient times, mental illness was viewed as spiritual in nature and the afflicted person was thought to be possessed by demons. Treatments involved trying to exorcise the evil spirit or punish the patient to purge the evil spirit. In medieval to colonial times, doctors tried to balance the humors of the body and mind by bloodletting, burning, or whipping the patient.  In post-colonial Darwinian times, mental illness was view as uncontrolled, animalistic behaviors. Treatments involved imprisonment in asylums and restraints until the person got their inner animal under control.   As modern medicine started to evolve, doctors tried to find purely physical causes for mental illness. Treatments involved extremes like electric shock therapy and lobotomy (cutting away parts of the brain).

     This seems barbaric to us now, but doctors simply did the best they could with the limited knowledge they had at the time.  Even now most individuals have very little understanding of what mental illness is and shun those who suffer, expecting them to behave themselves in public. Unfortunately, it is a normal human reaction to avoid things we find disturbing.  As caregivers, you are hampered by these same human prejudices and lack of knowledge. You may need to change your reactions to mental illness.  By educating yourselves about mental illness, you can fight against these tendencies and become better caregivers to those who need your care.  


What really is Mental Illness?

     Medical science has been trying to answer that question for a long time.  The answer keeps changing as our understanding improves. Shortly after World War II, the U.S. Army tried to standardize the classification of mental diseases. That first attempt has morphed over the years into to the American Psychiatric Association’s DMS IV (Diagnostic and Statistical Manual of Mental Disorders 4th edition). In 2013, they plan to update it to DMS 5.

     In the U.S., the DMS IV is now the generally accepted authority concerning mental health issues. In the DMS IV, there are more than 300 recognized types of mental disorders. There is still considerable debate whether this is the most accurate or appropriate approach to mental illness.  It is argued that there is still considerable social bias involved that clouds effective therapy. But, for the foreseeable future, it will be the gold standard in mental health issues.


How is DSM IV Used?

     Unlike other medical diagnosis systems, mental illness has a multitude of contributing factors that affect the patient’s mental illness. The DSM IV system tries to address all of the contributing factors to the problem. It uses a multiaxial (multidimensional) approach, assessing five different dimensions of a mental illness.

Axis I- Clinical Syndromes

This refers to the primary mental issue, similar to a regular diagnosis, for example,  Bipolar, Major Depression, Panic Disorders.

Axis II- Development Disorders and Personality Disorders

This lists any personality disorder that may be shaping the way the patient is responding to the Axis I issue, for example, Mental Retardation, Paranoia, Antisocial Disorders.

Axis III -Physical Condition

This refers to contributing physical conditions that can affect the Axis 1 diagnosis, for example brain injury, HIV/AIDS, severe Asthma, Cancer.

Axis IV –Psychosocial Stressors

This refers to outside stresses the patient has had or is now experiencing. for example,  death of a loved one, unemployment, divorce.

Axis V- Level of Functioning

This is numerical ranking of how well the patient is functioning despite the mental illness. It uses the Global Assessment of Functioning (GAF) scale of 100 to 0. Using GAF 100 represents no impairment with a gradual decline to GAF 1-10, in which the patient is a persistent danger to themselves or others.

 The multi-axial system of the DSM-IV tries to address "the whole person." It is designed to help the mental health professional intervene successfully in an emotional or psychiatric disorder by considering all conditions that affect the patient’s mental health. 

By now you might be thinking, “Why did he write such a lengthy introduction? Just tell us about the disorders already”. What I am trying to convey is there is no clear cut definitions, no easy understandings, just broad categories in which patients’ disorders might fall.  Even when a mental illness has been diagnosed, there are other matters to consider, like severity and functionality.  The only certain reality is that mental health understanding and treatment will change in the future. There will always be a need for a greater amount of patience and understanding on the part of mental health caregivers.


All that said and done, let’s talk about what medical science knows so far.


Mental Illness: The Big Picture



     Mental health issues might be more common than you think. According to an article published in the Archives of General Psychiatry, “ Lifetime prevalence estimates are as follows: anxiety disorders, 28.8%; mood disorders, 20.8%; impulse-control disorders, 24.8%; substance use disorders, 14.6%; any disorder, 46.4%.... CONCLUSIONS: About half of Americans will meet the criteria for a DSM-IV disorder sometime in their life.”

     In another article, the School of Social Work- University of Washington stated, “Mental disorders are common in the United States and internationally. An estimated 26.2 % of Americans ages 18 and older – about 1 in 4 adults – experience a mental disorder in a given year…. This figure translates to 57.7 million people. “Most of these people can cope without any help, but the article continues “the main burden of illness is concentrated in a much smaller portion – about 6 %, or 1 in 17 experience a serious mental illness.” The article continued to say about half of those who suffer have two or more disorders, complicating therapy and compounding the seriousness of the issue.


     Mental illness is often first seen during adolescence or young adulthood, but all ages are at risk. It appears that the young and the old are particularly susceptible. The World Health Organization reported that four out the 10 leading causes of disability in the U.S. are related to mental disorders.



     The severity of a condition is measured by how much it interferes with normal functioning. Just as with most things in life, mental health issues are not black and white, but several shades of gray.  The severity of a condition can range from a mild inconvenience to a total debilitation of functioning and cycle back and forth. Most severe cases have two or more mental illnesses to contend with. The severity of the condition can change over time. For example, some contributing conditions can be resolved or the patient’s ability to cope can fluctuate over time. It is not uncommon for a mental illness to be a lifelong challenge. 



     There has been considerable advancement in the science of mental health.  Research confirms that mental illness is a serious medical condition. Mental illness is not a result of an individual’s poor character and cannot be overcome through sheer will power and right thinking. But mental illness is not a purely physical condition, either and, cannot be cut out or drugged away.  


     Greater understanding has led to more effective treatments. One of the most significant advances is how medical professionals view the resolution of mental illness. We no longer try to “cure the illness.” Instead, there is a focus on the whole person and their mental functionality.  With this change of focus, between 70 and 90 percent of serious mental health patients have significant reduction of symptoms and improved quality of life. The most effective mental health therapies are a combination of pharmacological and psychosocial treatments accompanied with supports. Caregivers can play a vital role in the support system of mental health patients.


     The following mental health diseases are presented in no particular order. Most  were selected because you, the caregiver, requested to know more about them.


Mental Disorders


Bipolar Disorder


     Bipolar disorder is a mental illness that causes extreme mood swings to be experienced by the patient. It is also known by its common name of manic depression. This is a cyclic illness characterized by a high (mania) phase and a low (depression) phase, with normal behaviors in between. Each swing through the different phases can last from weeks to months, seriously affecting the patient and those around him. Onset of the disease is often in the teens or early adulthood but can be seen in all ages. Ninety percent of suffers experience their first episode before the age of 50. It is thought to be caused by a chemical imbalance in the brain and may be an inherited tendency.



    Cycles may start with either a manic or depressive phase.



     In mania, the classic symptoms are heightened mood (either euphoric or irritable), flight of ideas, pressure of speech, increased energy, decreased need for sleep, and hyperactivity. Parts of this phase can be enjoyed by the patient and those around them, especially when they are happy and get a lot accomplished. Unfortunately, the condition can also progress to the point of fragmentation of thoughts, poor decision making, risky behaviors, and even delusions. In the absence of developed speech patterns as in mental retardation or youth, symptoms can be expressed as purposeless activity

Manic episodes are often preceded by symptoms warning of an impending cycle. They can last from a few days to a few months. The symptoms are mild and often transitory with indistinct manic symptoms. At times, however, no prodromal warning signs may occur, and the episode starts quite abruptly. When this occurs, patients often wake up during the night full of energy and vigor—the so-called “manic alert.”



     During this “Down” phase, the patient often feels depressed, irritable, and fault finding with themselves and those around them. The patient lacks energy and thoughts become slow and sluggish. The ability to concentrate and comprehend alternatives may become impaired. Patients often feel a need for increased hours of sleep lasting from 10 to 18 hours a day. Even with the extra sleep, they still wake up exhausted. Appetite may increase. This, coupled with lack of exercise, can lead to dramatic weight gain. There are those, though, who are affected in just the opposite, with insomnia and loss of appetite. Symptoms gradually subside in each cycle. Afterward, the patient often feels guilty and is full of self-reproach for his lack of self-control.



     A more rare form Bipolar episodes is called a Mixed-Manic episode. During this kind of episode the patient feels both manic and depressive symptoms either together or in very quick cycles.




     The goal of Bipolar therapy is to balance the brain chemicals that control mood. This is often accomplished with mood stabilizers like lithium, valproic acid, and carbamazipine. Other medications can be added to control symptoms, like antipsychotics and sleeping aids. A psychiatrist made need to be consulted. Counseling can help with stress, family concerns, and relationship problems.




     Bipolar disorder is a lifelong condition with time between relapses from weeks to decades. Up to 10- 20 percent of bipolar patients contemplate or commit suicide. Because of the euphoria, added accomplishments, and normal times between episodes many patients are resistant to ongoing therapy. Despite all this, the condition will not get better on its own. The patient is always at risk for another mood swing episode. Without medication, the condition will only get worse over time.


Major Depressive Disorder




     Major depressive disorder is a clinical mood disorder that is an all-encompassing low mood. It is characterized by feelings of sadness, loss, anger, or frustration. In order for a depression to be called major depressive disorder, the episode must interfere with activities of daily living for two weeks or longer. It is different from the normal, reactive or chemically induced depression in that it appears to originate in an imbalance of chemicals or improper processes in the brain. The true cause of the disorder is still unknown but it can run in families.


     It is estimated that about 5 percent of the general population could be afflicted by the disorder. Depressive events are episodic in nature as shown by a gradual increase of depression symptoms that could last for months. Generally, the patient returns to normal functioning. Twice as many adult females are affected as men. 




     Though not all patients have them, the basic pattern to major depression symptoms are: a down mood, loss of energy, difficulty in concentrating manifesting in impaired decision making and memory loss, loss of interest in favorite activities, insomnia, and loss of appetite, though there are a minority who experience just the opposite, continual pessimism, agitation with self and others, and non-descriptive suicidal thoughts.


Special caregiver considerations

     There are a few symptom patterns that are of clinical significance to caregivers.

1. Patients lack the energy and focus to act on suicidal thoughts, but when they start to feel better they gain those abilities. Caregivers should be more alert to potential suicides as the patient gets better.

2. Some patients experience their worst symptoms in the morning and gradually improve throughout the day.

3. It may appear that some events triggered an episode, but in reality it was the depressive episode that caused the major event. For example, a loss of job or divorce seemed to make a person depressed but in reality they were caused when the patient started to experience the depression symptoms first.

4. In the worst cases, activities of daily living become more difficult if the patient has to make choices, for example what to wear and what to eat.

5. The loss of interest in favorites makes food taste like “cardboard,” contributing to the lack of eating.

6. The lack of movement and proper eating habits commonly lead to constipation.

7. Headaches are a common complaint.




     Antidepressant medication is the gold standard for therapy. Psychological counseling by itself appears to be less effective. There are many antidepressant medications the doctors can choose from. Depending on how often a depressive episode occurs, the patient may have to take them for the rest of their lives. 




     It is not clear what causes Major Depression and its occurrence is episodic. Depressive events can occur even in childhood. As of yet, there is no cure. Once an event occurs, the patient will always be at risk for another. Fortunately, for most sufferers, depression can be controlled. The patient can lead a normal life, though they may have to be on long-term antidepressant therapy.


Autism (Autism Spectrum Disorders)



     Autism is a group of developmental disorders of the brain that affects nerve cells and how they are connected to each other. It alters the way information is processed in the brain. Those who have Autism Spectrum Disorders are characterized by impaired or underdeveloped social interactions and communication skills and are often accompanied by severely restricted interests and or repetitive behavioral issues.


     Autism affects each patient differently along an entire spectrum of behaviors. Each case can be mild to severe. The major types of Autism are 1. Classic or Typical Autism or just Autism, 2. Asperger Syndrome 3. Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS) or Atypical Autism.


     The exact causes of the disorders are not well understood but start before the age of three. Science has identified some inheritable genetic factors, spontaneous gene mutations, and defects cause by certain toxins and some chemicals. It is generally accepted that autism is probably caused by a combination of factors.


Special caregiver considerations

At one time, it was feared that some vaccinations and poor parenting skills contributed to the risk of the disorder, but studies have proven otherwise.





    In typical care-home environments disruptive behaviors are usually dealt with by helping the patient alter their behaviors. Unfortunately, Autistic patients may not be able to. It is helpful to understand which behaviors are related to the disability.

According to the NIH Medline Plus website:

 “People with autism may:

  • Be overly sensitive in sight, hearing, touch, smell, or taste (for example, they may refuse to wear ‘itchy’ clothes and become distressed if they are forced to wear the clothes)
  • Have unusual distress when routines are changed
  • Perform repeated body movements
  • Show unusual attachments to objects

The symptoms may vary from moderate to severe.

Communication problems may include:

  • Cannot start or maintain a social conversation
  • Communicates with gestures instead of words
  • Develops language slowly or not at all
  • Does not adjust gaze to look at objects that others are looking at
  • Does not refer to self correctly (for example, says ‘you want water’ when the child means ‘I want water’)
  • Does not point at objects when attempting to direct others attention to objects (occurs in the first 14 months of life)
  • Repeats words or memorized passages, such as commercials
  • Uses nonsense rhyming

Social interaction:

  • Does not make friends
  • Does not play interactive games
  • Is withdrawn
  • May not respond to eye contact or smiles, or may avoid eye contact
  • May treat others as if they are objects
  • Prefers to spend time alone, rather than with others
  • Shows a lack of empathy

Response to sensory information:

  • Does not startle at loud noises
  • Has heightened or low senses of sight, hearing, touch, smell, or taste
  • May find normal noises painful and hold hands over ears
  • May withdraw from physical contact because it is over-stimulating or overwhelming
  • Rubs surfaces, mouths or licks objects
  • Seems to have a heightened or low response to pain


  • Doesn't imitate the actions of others
  • Prefers solitary or ritualistic play
  • Shows little pretend or imaginative play


  • ‘Acts up’ with intense tantrums
  • Gets stuck on a single topic or task (perseveration)
  • Has a short attention span
  • Has very narrow interests
  • Is overactive or very passive
  • Shows aggression to others or self
  • Shows a strong need for sameness
  • Uses repetitive body movements”

source- http://www.nlm.nih.gov/medlineplus/ency/article/001526.htm


Asperger’s Syndrome

     Asperger syndrome usually present with milder autistic symptoms.  Those with Asperger’s  do not have problems with intellectual disabilities but may face some social challenges and unusual behaviors or interests. Clumsiness may also be a factor. 


Pervasive Developmental Disorder – Not Otherwise Specified (PDD-NOS)
     There are those who have some but not all of the symptoms of Classic Autism and Asperger syndrome. They are placed in the category of PDD-NOS. People with PDD-NOS usually have fewer and milder symptoms that may cause only social and communication challenges.



   As of yet, there is no medicine that alters the course of the disorder. However,  early intervention can greatly enhance a patient’s abilities.


Special caregiver consideration

  Because the patient has physical disabilities that affect their behaviors, it is important that caregivers carefully control the patient’s environment and make adjustment in the home as required. Expecting a patient to alter his behavior may be problematic.





     Schizophrenia is a group of severe mental disorders that impairs the brain from interpreting its surroundings normally. It may result in the patient experiencing hallucinations, delusions, and disordered thoughts that result in unusual behaviors. It is the mental disease that is the closest to the classic term craziness. Left untreated, it is severely debilitating because the patient cannot perceive that anything is wrong.  Symptoms first appear most commonly between the ages of 16 to 30. 




   The causes of Schizophrenia are not completely understood, but there is a strong correlation with abnormal functioning of certain neurons or their associated neurotransmitter chemicals. The symptoms of Schizophrenia have been grouped into three broad categories.

Positive- Positive symptoms are those that most individuals do not normally experience but are present in people with schizophrenia. In other words, they are definite sign of the disease. They include hallucinations (perceiving things that no one else can- ex. hearing voices), delusions (believing ideas that are not true- ex. mind control with magnets), thought and movement disorders (disorganized patterns –ex garbled sentences or made-up words and repeating certain movement over and over again).

Negative- Negative symptoms are disruption of normal functioning, or an absence of regular behavior. They include flat affect (the person’s face does not move or they talk in a monotone voice), lack of pleasure in activities, speaking very little.


Special caregiver consideration

Negative symptoms lead the patient to appear lazy or sloppy. Often they need help with activities of daily living.


Cognitive- Cognitive symptoms are impaired mental functioning. They include reduced ability to understand information and using that information to make decisions, trouble focusing or paying attention, and reduced short-term memory.




     Treatments for Schizophrenia focus on eliminating the symptoms of the disease not the disease itself. Treatments include antipsychotic medications and various psychosocial treatments. Positive symptoms are more responsive to medication therapy.


     Older first-generation drugs are called typical antipsychotics and usually are associated with more side effects. Newer second-generation drugs are called atypical antipsychotics. They generally have fewer side effects but are more expensive.   Regardless of the drug, the side effects can include drowsiness or dizziness, blurred vision, rapid heartbeat, skin rashes, and sensitivity to the sun.


Special caregiver consideration

1. Long-term use especially with first generation drugs can lead to tardive dyskinesia (TD). TD causes muscle movements the patient can’t control. They include facial tics, tongue rolling, tremors, and unusual walking gate. It is important for the caregiver to promptly report these side effects to the doctor. Discontinuation of the drug can lead to a recovery from TD, but sometimes the effect is permanent.  Discontinuation of an antipsychotic medicine should be done gradually.


 2. Treatment can sometimes be problematic because the patient does not recognize that he needs help. Those who are unwilling or unable can get long-acting depot shots of certain medications. These drugs are usually second-line therapy but certainly are a treatment option for caregivers who have difficulty treating residents.




     Even though Schizophrenia has been categorized as one of the most debilitating  diseases, medication and therapy can help the patient lead a normal life. Continuing research has led to a better understanding of the condition, the patients, and therapies. Because of its unpredictable nature and lack of perception on the part of the patient, therapy usually has to be lifelong. 


Panic Attack Disorders




     "One day, without any warning or reason, I felt terrified. I was so afraid, I thought I was going to die. My heart was pounding and my head was spinning. I would get these feelings every couple of weeks. I thought I was losing my mind. The more attacks I had, the more afraid I got. I was always living in fear. I didn't know when I might have another attack. I became so afraid that I didn't want to leave my house."

     The above quote describes the anxiety disorder called panic attacks. They are episodic events that can appear without warning and last for several minutes, sometimes longer. The disorder is twice as common in women as it is in men. Symptoms usually begin before age 25, but may occur in the mid-30s.



     Panic attacks appear suddenly and usually peak in 10 to 20 minutes. Some symptoms may last longer. A diagnosis of panic attack can be made in the presence of four or more of the following symptoms: chest pain or discomfort, dizziness or faintness, fear of dying, fear of losing control or impending doom, feeling of choking, feelings of detachment, feelings of unreality, nausea or upset stomach, numbness or tingling in the hands, feet, or face, palpitations, fast heart rate, or pounding heart, sensation of shortness of breath or smothering, sweating, chills, or hot flashes.


Special caregiver consideration     

     Many first-time patients think they are having a heart attack and go to the emergency room for treatment. As the panic attacks increase in frequency, many patients alter their behavior that negatively affects their normal functioning.




     Panic attack can appear without warning but some triggers can be identified and avoided. The goal of therapy is to maintain normal functioning despite the occurrence of attacks. Cognitive-behavioral therapy and medication have been reported to have the best results.  Commonly used long-term medications are SSRI antidepressants, (fluoxetine- Prozac). They may take several weeks to reach full effect. Short-term treatments are usually anti-anxiety benzodiazepines, (diazepam- Valium). Cognitive behavior therapy is a psychotherapy especially useful for treating panic disorder. It teaches a person different ways of thinking, behaving, and reacting to situations that help him or her feel less anxious and fearful.

     If panic attacks are common, the patient should avoid alcohol and stimulants like caffeine or illegal drugs. The nicotine in cigarettes is also a strong trigger of panic attacks. These substances may trigger or worsen panic attack symptoms.




     Due to the unpredictable nature of the disorder, the possibility of an attack is ever present.  Fortunately, most patients respond quite well to treatment.





     Phobias are a type of anxiety disorder where there is a persistent fear of an object or a situation usually greater than the danger that actually exists. When forced to confront the fear, the patient becomes quite distressed, which can even trigger a panic attack.




     The patient has a fear of an item or event that is not based in reality. Since these are irrational fears, one could literally have a phobia concerning every single object and situation that exists. Here is a very abbreviated list.


Acrophobia- Fear of heights

Agoraphobia- Fear of open spaces or of being in crowded, public places like markets, fear of leaving a safe place

Autophobia- Fear of being alone or of oneself

Bacteriophobia- Fear of bacteria

Chiraptophobia- Fear of being touched

Enochlophobia- Fear of crowds

Gelotophobia- Fear of being laughed at

Gerascophobia- Fear of growing old

Hydrophobia- Fear of water

Iatrophobia- Fear of going to the doctor or of doctors

Lygophobia- Fear of darkness

Misophobia or Mysophobia- Fear of being contaminated with dirt or germs

Nosocomephobia- Fear of hospitals

Panophobia or Pantophobia- Fear of everything




     Medication is of limited use. Antidepressants and short-term anti-anxiety drugs are used but by themselves cannot resolve the issue. Psychotherapy is the first-line therapy with either cognitive behavioral therapy or systematic desensitization therapy or both. A course of 10 to 20 visits with a therapist is typical. 




     If the patient is cooperative with therapy, the outlook for normal functioning is quite good.


Eating Disorders



     Eating is a basic human need but it is more than just satisfying a physical desire. Strong emotional responses can be tied to the experience of eating. In some ways, it’s our way of controlling our environment or at least our reaction to what is going on around us.  Eating disorders are illnesses where there is a severe disturbance in thoughts and emotions that lead to out-of-control eating patterns that can cause harm.  Victims of these disorders become obsessed and distressed with food and body weight. They also can lose proper perspective about the consequences of their actions.


     The main types of eating disorders are Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder. The exact cause of these disorders is not fully understood. It is believed to be combination of genetic, biological, and environmental factors. It has been described as “Genetics loads the gun but circumstances pull the trigger.”  They frequently coexist with other illnesses such as depression, substance abuse, or anxiety disorders. Many sufferers can trace the onset of their disorder to a severe emotional event, like mental abuse, sexual trauma, or severe peer pressure.

     Overwhelmingly, more young women are diagnosed with these conditions than men. It is thought to be in part due to bias on the part of doctors and society. Men who have the symptoms are often diagnosed with other conditions instead of an eating disorder, such as depression or obsessive compulsive disorder.




Anorexia Nervosa

    Anorexia Nervosa is characterized by the patient’s extreme thinness, at least 15 percent underweight, obsessing about thinness, distorted feeling about self-esteem and body image, intense fear of gaining weight, and denial about the consequences of their eating habits.

These lead sufferers to weigh themselves repeatedly, portion food carefully, and eat very small quantities of only certain foods. Some people with anorexia nervosa may also engage in binge-eating followed by extreme dieting, excessive exercise, self-induced vomiting, and/or misuse of laxatives, diuretics, or enemas.


Bulimia Nervosa

     Bulimia Nervosa sufferers have frequent bouts of overeating. They feel ashamed of their behavior and binge in private. Often they feel a lack of control over these episodes and stop only when they are interrupted or become sick. These binges are followed by compensating behaviors, like vomiting, laxatives, and excessive exercise.   Unlike anorexia nervosa, people with bulimia nervosa usually maintain a normal weight, some are slightly overweight. But like people with anorexia nervosa, they often fear gaining weight, want desperately to lose weight, and are intensely unhappy with their body size and shape.


Binge-Eating Disorders

      Binge Eating Disorders occur when people lose control over their eating habits, but binges are not followed by compensating behaviors. This results in obesity.

     As a group sufferers of eating disorders often report feeling powerless about their socioeconomic environment, and view eating, dieting, exercise, and purging as an  empowering means of controlling their circumstances. The consequences of these behaviors are detrimental to the health of the patient and can be life-threatening. Uncontrolled eating disorders can lead to amenorrhea, tooth erosion from stomach acid, osteoporosis, scurvy, kidney failure, electrolyte imbalance, dehydration, chronically inflamed sore throat, GERD, uncontrolled bowels, cardiac problems, brain atrophy, and suicide.  



     Eating disorders are real, treatable medical illnesses. Successful therapy includes both the physical needs of the body and the emotional needs of the patient. Efforts to achieve and maintain a proper weight is just the first step. Psychotherapy can help the individual identify and address the underlying emotional problem that causes or contributes to the abnormal eating behavior.




Uncontrolled eating disorders can be a serious health problem. Fortunately, therapy has been shown to be quite effective. Individual or group psychotherapy is key to recovery and relapse prevention. An important note is sufferers of eating disorders have the third highest rate for self-abuse and suicide.


Special caregiver consideration

     Some antidepressants like Prozac, used to treat the underlying depression and to help reduce the binge cycle, have been linked to an increased suicide risk in teens and young adults. Caregivers are cautioned to monitor their patients for thought of suicide after therapy is started.  


Obsessive-Compulsive Disorder (OCD)



     Obsessive- Compulsive Disorder is an anxiety disorder where intrusive thoughts are experienced by the patient. It causes uneasiness, fear, worry, and apprehension. These thoughts are hard or impossible to control or ignore. To relieve the distress, the patient will perform rituals that temporarily reduce the anxiety the intrusive thoughts produce -obsessions. The patient is most often aware that the obsessions are not based in reality but feels compelled to act on them anyway- compulsions.

     "I couldn't do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good luck number and one wasn't. It took me longer to read because I'd count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn't add up to a 'bad' number."

"Getting dressed in the morning was tough, because I had a routine, and if I didn't follow the routine, I'd get anxious and would have to get dressed again. I always worried that if I didn't do something, my parents were going to die. I'd have these terrible thoughts of harming my parents. I knew that was completely irrational, but the thoughts triggered more anxiety and more senseless behavior. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me. I knew the rituals didn't make sense, and I was deeply ashamed of them, but I couldn't seem to overcome them until I got treatment."




     Those who suffer from OCD experience thoughts or images about things like fear of germs or dirt, acts of violence, hurting themselves or loved ones, sexual acts or conflicts with religion. Typical rituals include hand washing, locking and unlocking doors, hoarding, repetitive acts, ordering, and counting. What sets these symptoms apart from normal actions is that the patient feels no pleasure when performing the rituals, only temporary anxiety relief. They feel that they must act or they experience significant distress. According to diagnostic criteria, the patient will spend at least one hour a day on these thoughts and actions.




     A combination of psychotherapy and medication has proven to be the most effective treatment for OCD. Psychotherapy may include cognitive behavior therapy and antidepressants and tricyclic antidepressants. Clomipramine is particularly effective but side-effect management may be required.  




     It is unclear why OCD happens. There may be inherited aspects, physical or chemical damage, or an imbalance in neurotransmitters. Brain scans have shown that the OCD brain functions differently. Therapy has been shown to be effective at reducing symptoms so the patient can regain control of their life. Medication usually takes longer to see the effects, up to three months. Patients should be counseled that when they start to feel better, they should continue to see the medical professional regularly for at least 12 months and notify them if symptoms start to return. Fortunately patients can go on for many years before their symptoms reappear, and some may not get symptoms again.


Post-Traumatic Stress Disorder (PTSD)



     Post-Traumatic Stress Disorder is an abnormal response to a stressful event and is classified as a panic disorder. When a person experiences a traumatic event, the body copes with the situation by feeling shock, anger, fear, panic, and even guilt. Over time, these feelings will naturally fade. For some, though, these feeling continue or even get stronger until they interfere with normal living. An example of this is a young World War II paratrooper who was so traumatized by the events of the D-Day invasion that he became temporarily blind. PTSD has also been called shell shock and battle fatigue.




     Anyone who experiences a traumatic event can develop PTSD. It depends on their genetics, coping skills, social support network, neurotransmitters, and hormonal make up.  Symptoms last at least one month and are often grouped into three categories. Reliving - flashbacks, nightmares, hallucinations, and distressed feeling around reminders of the event. Avoiding- staying clear of people places and things are reminders of the trauma. Increased arousal-  excessive emotions, problems relating to others - including feeling or showing affection, difficulty falling or staying asleep, irritability, outbursts of anger, difficulty concentrating, and being "jumpy" or easily startled. In PTSD, these symptoms are felt to the point of impairment. The person may also suffer physical symptoms, such as increased blood pressure and heart rate, rapid breathing, muscle tension, nausea, and diarrhea.




     From a medical perspective, treatment could be summed up as “medicine controls the symptoms and counseling heals.” A wide variety of mental health drugs are available to the doctor. Selection of which medicine is used depends on the predominant symptoms.


     Similarly, a variety of psychotherapies could also be utilized, including: Cognitive behavioral therapy- recognizing and change thought patterns that lead to troublesome emotions, feelings, and behavior Exposure therapy- reliving the traumatic experience (done in a well-controlled and safe environment). The goal is to help the person confront the fear and gradually become more comfortable with situations that are frightening the patient and causing anxiety. This has been very successful  PTSD treatment. Psychodynamic therapy- focusing on helping the person examine personal values and the emotional conflicts caused by the traumatic event. Family therapy- may be useful because the behavior of the person with PTSD can have an effect on other family members. Group therapy- may be helpful by allowing the person to share thoughts, fears, and feelings with other people who have experienced traumatic events. Eye Movement Desensitization and Reprocessing (EMDR)- is a complex form of psychotherapy that was initially designed to alleviate distress associated with traumatic memories but is now also used to treat phobias.




     In most cases, symptoms start to appear within three months after the traumatic event. A few do not have symptoms until years later. Depending upon severity, some people recover within six months, while others suffer much longer. Without treatment, the patient could develop other conditions, like depression, other anxiety disorders, and alcohol or substance abuse. Early recognition and treatment leads to better outcomes. Post-trauma counseling has been proven to be effective in reducing the occurrence of PTSD.



Generalized Anxiety Disorder



     Generalized anxiety disorder (GAD) is a pattern of uncontrollable constant worry and anxiety that interferes with normal functioning over a long period of time that is not attributed to another disorder or condition (for example,  worry about phobias, about being fat- anorexia. chemical abuse, etc.). It affects twice as many women as men with onset happening from youth to old age. The median age of onset is 31. There is some evidence that the elderly may be more susceptible to GAD as indicated in the increased use of anti-anxiety drugs in this portion of the population.  Long-term, constant worry can have a negative effect on the general health of the patient.  For example, constant worry and stress reduces the immune system, leads to teeth grinding, increases blood pressure, tends to upset bowels, or leads to constipation.




     By definition, GAD is anxiety and worry that is associated with at least three of the following six symptoms (with at least some symptoms present for more days than not for the previous six months). Note: Only one symptom is required in diagnosis for children.


1. Restlessness or feeling keyed up or on edge

2. Easily fatigued

3. Difficulty concentrating or mind going blank

4. Irritability

5. Muscle tension

6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)




     Unfortunately, GAD is quite hard to treat. Often the patient will go to their regular medical doctor who prescribes anti-anxiety drugs. This is no more than a short- term fix, a chemical crutch. The patient starts to rely on the medication to cope with life and becomes addicted, both chemically and behaviorally. This pattern is often seen in the elderly. Those patients who included psychotherapy in there treatments showed a marked reduction in the use of anti-anxiety drugs. Effective psychotherapy could include; relaxation-based treatments or biofeedback, cognitive therapy, relaxation training, anxiety management training, or some combination of these procedures in groups session or alone. Course of therapy can be 12 weeks with follow up every few months.




     As of yet there remains a need for greater understanding of what causes GAD. A patient can maintain a functional life most effectively with a combination of psychotherapy and medication, though it is more difficult if there are addiction issues to contend with.


Personality Disorders



     There are those individuals who never seem to fit into regular society. They just seem “wrong-headed,” to the point where one would have to wonder how they function day to day. If you were to look closer, some of these individuals could be diagnosed with a mental illness called a Personality Disorder.


     Those who suffer from Personality Disorders experience rigid and inflexible thought patterns. They find it difficult to react to the changes and demands of life. This thinking and behavior can lead to significant limitations in relationships and social situations. Often they have a narrow view of life, blaming their troubles on others because they believe their way of thinking is normal.




     There are many types of personality disorders, each with their own signs and symptoms. The three main groupings are, Cluster A- Odd or eccentric behavior, Cluster B- Dramatic, emotional or erratic behavior, and Cluster C- Anxious, fearful behavior. 


An example of each are;


Cluster A

 Paranoid Personality Disorder. The patient interprets the actions of others as deliberately threatening or demeaning. They usually are untrusting, unforgiving, and prone to anger or have aggressive outbursts without justification. They perceive others as unfaithful, disloyal, condescending, or deceitful. They may also be frequently jealous, guarded, secretive, and scheming, and may appear to be emotionally “cold” or excessively serious.


Cluster B

Borderline Personality Disorder. These patients have extreme "black and white" thinking. They experience instabilities in relationships, self-image, identity, and behavior. This often leads to self-harm and impulsivity.


Cluster C

Avoidant Personality Disorder.  These personalities are often hypersensitive to rejection and are unwilling to become involved with others unless they are sure of being liked. They experience excessive social discomfort, timidity, and fear of criticism that leads them to avoid social or work activities that involve interpersonal contact.




     Here again, medication helps manage symptoms and psychotherapy heals. The goals of psychotherapy are to: 1. Help the patient see the unconscious conflicts that are contributing to or causing their symptoms, 2. Help the patient  become more flexible with their behavior patterns that interfere with everyday living, and 3. Help the patient recognize the effects of their behavior on others.




     The more that is learned about personality disorders, the more effective therapy becomes.  There is a strong causal relationship between child abuse and neglect and the development of the disorder. Genetic and other factors may also make a person more vulnerable to these diseases.  Unfortunately, diagnosing and treating personality disorders is difficult because of the many factors involved, but a fulfilling life can be achieved with help.


Attention Deficit Hyperactivity Disorder (ADHD and ADD)



     Attention Deficit Hyperactivity Disorder has been classified as a brain development disorder where portions of the brain that control the attention attributes develop at a slower rate or have incomplete development. The result is the patient has trouble remaining focused, is easily distracted, and can be impulsive and hyperactive. 



     Diagnosis can be hard because most symptoms are seen as regular activities in normal children and adults. Each person has their own unique manifestation of conditions but there are three main subgroups: Predominantly hyperactive-impulsive, Predominantly inattentive, Combined hyperactive-impulsive and inattentive. According to the DSM-IV, a diagnosis can be made if there is a manifestation of symptoms that causes a significant impairment for at least six months.


Those symptoms can include:


Inattentive- being easily distracted, missing details, forgetting things, and frequently switching from one activity to another. Difficulty maintaining focus on one task. Becoming bored with a task after only a few minutes, unless doing something enjoyable.  Difficulty focusing attention on organizing and completing a task. Difficulty learning something new or trouble completing or turning in homework assignments. Patients often lose things. They don’t seem to listen when spoken to, daydream, become easily confused, and move slowly. Difficulty processing information as quickly and accurately as others. Struggle to follow instructions.

Hyperactive- fidget and squirm in their seats. Talk nonstop.  Dash around, touching or playing with anything and everything in sight.  Trouble sitting still during dinner, school, and story time. Constantly in motion. Difficulty performing quiet tasks or activities.

Impulsivity-  very impatient. Blurting out inappropriate comments, showing their emotions without restraint, and acting without regard for consequences. Difficulty waiting for things they want or waiting their turns in games.




The goal of therapy is not to eliminate symptoms but to reduce the impairment the patient experiences. The most effective long-term therapies are a combination of stimulant medications to increase brain level function and behavioral therapies that enable compensating coping skills. 




     ADHD can't be cured but it can be successfully managed. Treatments therapies are partnerships among the patient who learns coping skills, medical professionals who provides the medication and helps manage side effects, and family/caregiver/mental health professionals who provide training and behavioral support.


Special caregiver note

     There is some controversy in the use of addicting stimulant drugs in patients who are children. Long-term studies have shown that addiction is a risk but usually not an issue with proper management. Some studies have shown that without these medications, patients tend to develop substance abuse issues later in life as they try to cope with their impairments.



Caregiver Frustration


     When I owned and operated my care homes, one of the most challenging aspects of In Home Care was mental health issues. From depression to dementia, it’s just harder to deal with residents in your homes who have impaired ability to reason and think. It is frustrating when your patients don’t think and act the way you expected them to, and you can’t apply normal reasoning to them. I can remember thinking, “I can’t get them act right-no matter what I say. Now what am I going to do? I wish I could just lock them up so I don’t have to deal with them anymore.”


Barriers to Proper Care


     My frustrations led me to inappropriate thoughts. These people needed me and my caregiving abilities or they wouldn’t have been in my home in the first place. What helped me turn the corner to proper caregiving was to start to understand what was really going on in their heads and what was going on in mine.  You can “turn the corner” to proper caregiving by identifying barriers to proper care and working to remove them.


Patient Barriers

     Patients who suffer with mental illness are not stubborn or lazy or grouchy or have other personality flaws. It is an illness that has its roots in a medical condition. The patient has an impairment that prevents them from acting normally. 

-Impaired ability to communicate

-Impaired ability to change behaviors

-Impaired ability to understand what is going wrong in them

What may be one of the biggest barriers of all is the fear of being stereotyped as a “crazy person.” It leads the patient to avoid medical providers and be uncooperative with  therapy.


Caregiver Barriers:

     Caregivers have their own set of baggage that throws up barriers to proper care.

-Lack of knowledge/training

-Unrealistic expectations

-Being unprepared for the challenges of care, both mentally and physically.

Stereotyping, not seeing the patient as a person- just the stigma of “being crazy” prevents proper caregiving.


Mental Health Caregiver Techniques


     This article is not a training manual for mental health caregiving that lists all to “dos and don’ts” of in-home care. But I would like to give a few pointers that might smooth the way to proper care for your patients with mental illness issues.


Reflective Practices

     The “Practice” of In Home Care giving is how you apply your beliefs, abilities, and resources to meet the needs of the patient.  A “Reflective Practice” is to regularly review your past experiences –describe, analyze, evaluate- and use the information to change future practices.


     A few questions you might ask yourself and your staff are: What stereotyping is shown in your behavior? How unprepared is your home?  Are you professional enough to get past all the difficulties? Are you willing to learn new ways of caring? What was your internal dialog when you last approached the patient? Were you able to provide empathic, compassionate care to this individual? Did you show an unconditional positive attitude toward your patient with a mental illness?

In other words “The first barriers to care to remove are the ones you threw up yourself.”


Develop a Plan of Action:

     Find what works, break it down into repeatable steps, write it down in a way that can be used for training, follow the steps, and always improve.

You might find the following a useful part of your plan.

  1. Find out what the diagnosis is.
  2. Educate yourself on the illness
  3. Find out what the goals of therapy are
  4. Find out what information and observations the doctors and mental health

professionals want about the patient and develop methods for getting it to them.

  1. Collect information from family and friends about what has worked in the past.
  2. Decide what to do in advance about difficulties and dangerous circumstances that

might arise. (examples: What to do if the patient doesn’t follow therapy. How and when to place the patient in the hospital- even against their will.)

  1. Provide an orientation for the new move-ins. Include house rules, patient rights,

boundaries and expectations (both yours and theirs).


Compliance with Therapy:

     Treatments are partnerships between the patient, doctor, and caregiver. The best outcomes happen when all understand their part and work as a team. It is vital that early identification of symptoms and consistent follow-through is achieved.

Ideas for the Patient:

  1. Keep a journal. Keeping track of the patient’s personal life can help identify what is causing stress and what seems to make them feel better. 
  2. Be prepared for the patient’s doctor visits. Write down some notes to take with them.

Thing to write down include:

       - Symptoms experienced and how intense they were.

- Any special events that triggered the symptoms like events, dreams, and


- Any questions for the doctor.

- What causes them stress.

  1. Take a trusted family member or friend if possible with them to the doctor visits.


Suggestions for the Caregiver


     Take good caregiver notes. Patients are impaired from seeing things correctly. You can provide proper perspective to the information mental health professionals receives. You can also provide vital information, such as a list of medications and health conditions the patient has or has developed since their last visit.


     Be prepared for down turns and have an action plan in place.

Watch for and make note of: marked changes in personality, eating or sleeping patterns, inability to cope with problems or daily activities, strange or grandiose ideas, excessive anxiety, prolonged depression or apathy, thinking or talking about suicide, extreme mood swings or excessive anger, or violent behavior.

Always remember: Many people who have mental illness consider their symptoms a normal part of life. Patients often avoid treatment out of shame or fear. Confronting patients directly about their delusions or hallucinations rarely works because their illness prevents them from seeing them as anything but real.  


     Laws vary from state to state, and it can be difficult to force a person with a mental disorder into treatment or hospitalization. But when a person becomes dangerous to himself or herself, or to others, caregivers may have to call the police to take their patients to the hospital. Contacting the police and hospital before hand and asking about proper procedures can really make a difference in a stressful situation.  


Patient Advocacy


    With workloads going up and reimbursement rates going down, sometimes the health system breaks down and patient’s needs are forgotten. Sometimes you have to do battle for your client to get what they need. Being respectful gets more cooperation but sometimes pushing until needs are met is in the best interests of your clients and your business.


Care Coordinator

     The doctor and case workers may be in charge, but in my experience the best outcomes happen when the caregiver takes responsibility. Caregivers are in the best position to ensure that every needful thing is done, that proper follow up is achieved, that different types of care is coordinated, and communication happens between the different members of the healthcare team. Keeping a check list of important items in the patient’s records is very helpful.  Items to include are: immunizations, dental and eye exams, physicals, required blood and other monitoring tests, behavioral, occupational, and physical therapies.




     Understanding mental health and how to care for the mentally ill has been a  challenge throughout the years. For those charged with the care of mental patients, the realization that the illness is both a physical and a psychological impairment has led to more effective and humane treatments. There is more hope than ever before that those who suffer can feel well again.


     For those who cannot make it by themselves in normal society, the support of a Care Home can make all the difference in maintaining therapy. Caregivers who take on the challenge of providing that needed support can best do so if they are properly prepared.


     For caregivers in any setting (Adult Foster Care, Mental Health Homes or Developmentally Disabled), understanding the barriers to proper care and working on removing them is a very effective way to be prepared. Gaining underling knowledge can go a long way in understanding and preparing for the challenges the In Home Care provider may face.






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7. Dr. Brian Burke, Abnormal Psychology, Fort Lewis College


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