Mental Health Section

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There is a very real danger inherent in this book: you may try to skip from addiction to higher consciousness without taking care of your mental health. You would not be alone. Ignorance, denial, stigma -- these characterize America's attitude toward mental health. We either don't know about it, don't want to know about it, or, if we have to admit a problem, are ashamed and humiliated. According to statistics endorsed by the government, mental disorders are substantially more common than addiction, costing society almost three times as much. Furthermore, mental illness complicates addiction, making it orders of magnitude more difficult to treat.

Fortunately, there is a growing wave of public interest in mental health and in the disorders that keep us from achieving our full potential. This interest is driven largely by increasing realization of the prevalence of mental health problems. The table below summarizes the results of two large national studies included in the U.S. Surgeon General's Report on Mental Health. Listed are the percentages of the U.S. population, between the ages of eighteen and fifty-four, that experience a clinically diagnosable mental disorder in any given year. Note that people often have multiple disorders, so the totals are not simple sums.

Percentage of Population with Anxiety Disorders:
simple phobia
social phobia
generalized anxiety disorder
panic disorder
obsessive-compulsive disorder


Percentage of Population with Mood Disorders:
major depressive episode
unipolar major depression
bipolar I
bipolar II
nonaffective psychosis
antisocial personality disorder
anorexia nervosa
severe cognitive impairment
Percentage of Population with any Disorder

According to these figures, this year, one-fifth of us will have a mental disorder. For most people, the mental dysfunction or distress will not last for years, nor will it be devastatingly catastrophic. Only 7 percent of the population has significant functional impairment that lasts longer than a year. A little under 3 percent are the most seriously affected. Their illnesses -- such as schizophrenia, bipolar mood disorder, and obsessive-compulsive disorder -- are severe, persistent, debilitating, and often lifelong.

The table does not include all the reasons people see a mental health professional. In fact, a little less than half of the 15 percent of Americans who seek help each year from a mental health clinic do so for a reason either not in the table or not clearly defined. A major omission in the table -- one that will be included in the next study -- is borderline personality disorder, which is thought to apply to between 1 and 2 percent of the general population. Also not in the table is the 6 percent of the population that is addicted but has no mental illness; the 3 percent of Americans who have both mental disorders and addiction is included.

Where to Go for More Information

Before going into the specifics, let's list sources of general information on mental illness. The first places to look are the National Institute of Mental Health (NIMH) and the National Alliance for the Mentally Ill (NAMI). NAMI provides referrals, NIMH doesn't; both provide information. Here are the addresses and Web sites:

National Institute of Mental Health
NIMH Public Inquiries
6001 Executive Boulevard, Rm. 8184, MSC 9663
Bethesda, MD 20892
301-443-4513 (8:30-5:00 EST M-F)

National Alliance for the Mentally Ill
Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201
800-950-6264 (10-5 EST M-F)

Particularly useful are NAMI's “fact sheets” for each mental disorder. These include a summary for each illness, with information on how to get  treatment and where to find support. I encourage you to carefully go through the fact sheets for any disorders that might apply to you or your family. In addition, I recommend browsing book reviews—on this site and elsewhere—and getting a copy of the best-reviewed, most recent general-interest book on mental health.

Note that some feel NIMH and NAMI are excessively drug-oriented. To get a (not unbiased) psychiatric perspective that counterbalances that of the pharmaceutical industry, read Your Drug May Be Your Problem, by Peter Breggin and David Cohen.

Also worth reading is the U.S. Surgeon General's Report on Mental Health, currently available at the Surgeon Generals website:

Click on "Reports and Publications." The 1999 report is a research-based yet readable description of the causes and treatments of mental illness. You can request a printed copy by calling 800-789-2647.

A Canadian psychiatrist has built an outstanding site with concise but complete information on all common mental disorders:

This site has an interactive diagnostic feature, now located at, and although self-diagnosis can be risky, within the limits of a computer program, this seems to be accurate and worth the fee charged.

If you are looking for a self-help group to help you deal with mental health problems, consider Mental Health America (formerly known as the National Mental Health Association).

For further resources, the following clearinghouse, as well as the one listed in the previous section, may be useful:

National Mental Health
Consumers' Self-Help Clearinghouse
800-553-4539 (9-5 EST M-F)

Thirty-Second Primer on Mental Health

Mental health and mental illness exist on a continuum: optimal mental health, ordinary mental health, mental health problems, and mental illness. The farther to the right on the continuum (toward mental illness), the more scientists have studied, and therefore, the more we know. According to the Surgeon General, researchers know quite a lot about treating mental illness but little about promoting mental health. The Surgeon General's report doesn't even consider optimal mental health. Obviously, this is a gap that needs to be filled.

The next few sections review the current understanding of common mental disorders. To oversimplify for the sake of clarity, mental disorders can be, somewhat irreverently, categorized as follows: you are either scared, depressed, crazy, or hard to get along with -- or a combination of these. There are, of course, dozens of rare disorders that don't fit under these headings, and there are physically induced problems, like sleep apnea and Alzheimer's, but these we won't consider here.


These are called anxiety disorders. They include:

  • Generalized anxiety disorder -- constant anxiety with no apparent cause.
  • Panic attack -- sudden extreme anxiety, often so strong you think you are going to die. It may be cued by the environment, or it may have no external cause.
  • Phobia -- intense fear of specific objects or events, such as snakes, heights, social situations, and traveling or being in public without a companion (agoraphobia).
  • Post-traumatic stress disorder -- stress from intensely traumatic past events, such as physical or sexual abuse, a car accident, or war, the terror of which haunts you in the present.
  • Obsessive-compulsive disorder -- endless intrusive repetitive thoughts that cause overwhelming anxiety (obsession), and/or ritualized compulsive behaviors, such as hand washing or checking the stove, done sometimes for hours a day, to prevent an imagined calamity (compulsion).

One more disorder should be added. Although not traditionally categorized as an anxiety disorder, somatization disorder is common among adult children of alcoholics, especially women with severe, early-onset, alcoholic fathers. It is estimated that 7 to 8 percent of women seeking help from a mental health clinic have somatization disorder. It is characterized by a series of physical complaints for which no medical cause can be found. Somatization disorder is probably due to the body constantly maintaining a state of hypervigilance; like a steam engine running under too much pressure, the body -- under intense mental pressure -- continually breaks down. Symptoms can include: pain in different parts of the body; gastrointestinal discomfort, such as irritable bowel syndrome or nausea; sexual or menstrual problems; and neurological impairment -- in balance, muscles, sight, hearing, touch, or memory.

There is little information on how to treat this. Recovery, Inc., as well as the tools in this book, should prove useful.

To learn more about anxiety disorders, contact:

Anxiety Disorders Association of America

For information on post-traumatic stress disorder: (click on link for PTSD brochure)

For information on obsessive-compulsive disorder try the following sites:

The National Institute of Health's OCD site

UCLA Anxiety Disorders Clinic

Obsessive-Compulsive Foundation


Since just about everyone experiences depression, there is no need to explain what it is. It becomes a clinically diagnosable disorder when it is severe (you may be suicidal), is not related to life events, lasts a long time, or is preceded or followed by an extreme and imbalanced high (mania). Here are the different so-called mood disorders:

· Major depressive episode -- your depression either has no cause or lasts longer than the cause warrants. Major depressive episodes can be recurrent, but in most cases are not. A single major depressive episode is the most common -- and most easily treated -- mental disorder.
· Dysthymia -- chronic, for some even lifelong, low-grade depression.
· Bipolar (formerly called manic-depressive illness) -- this is a cyclic mood disorder. To be diagnosed as bipolar, you must have had at least one manic phase. Typically, your moods go way up -- and stay up -- and way down -- and stay down. However, your moods don't have to alternate consistently and repeatedly, and there are disorders that cycle rapidly with less extreme peaks and troughs. Bipolar mood disorder is of two forms: bipolar I and bipolar II. The difference is in the mania; the high in bipolar II isn't as high, disabling, or uncomfortable as in bipolar I.

To learn more about mood disorders:

Depression and Bipolar Support Alliance
800-826-3632 (8:30-5:00 EST M-F)

Crazy (Distorted Reality)

Alcohol can make you crazy. Dedicated use can result in delirium on withdrawal -- the infamous DTs, which are rare, but can be deadly without medical treatment. Alcohol can cause dementia; 5 to 10 percent of all cases of dementia are alcohol induced. And it can cause psychosis. However, the purpose of this section is not addiction related; it is to make sure everyone is aware of schizophrenia, a common and very debilitating mental illness. Many schizophrenics use addiction to escape their mental discomfort, but addiction is not their primary problem.

To understand schizophrenia, we need to start with psychosis, which is a mental illness in its own right. Psychosis distorts reality. Unlike delirium -- which is brief, typically has a known cause, and may include some awareness that things are not right -- a psychosis blends the real and the imaginary into a seamless, more permanent reality where the person has no insight into their problem.

Psychosis can include:

  • delusions
  • hallucinations
  • disorganized speech
  • disorganized behavior
  • no fizz in one's personality, with little or no emotions, speech, or motivation

Hallucinations and delusions are the most common symptoms. A person who is psychotic may, to give a few examples, have a delusional belief, thinking they are Jesus Christ's wife; they may be paranoid -- the police are secretly conspiring to kill them; and there are the classic cases of schizophrenics who hear voices convincing them to engage in bizarre behaviors, such as taking off their clothes and wandering the streets.

A psychotic person can, with treatment, usually return to function in the work-a-day world; a schizophrenic frequently cannot. Schizophrenic patients, by definition, have multiple or severe psychoses, with some symptoms present for at least six months. Schizophrenia can begin imperceptibly and grow slowly. Once it starts, it is usually a lifelong illness. In many cases, it can be successfully treated, but not cured, with medication. Remember, those with schizophrenia often cannot recognize their own problem. You have to recognize it and get them help.

The National Alliance for the Mentally Ill is your best resource on schizophrenia. (Mail and phone contact information is above).

Hard to Get Along With

If you have had substantial, lifelong difficulty interacting with others, you may have a personality disorder. There are ten of them. The two most likely to go along with addiction are antisocial and borderline.

Antisocial personality disorder is a pattern of behavior that usually starts in childhood. A person with antisocial personality disorder continually violates the rights of others. They may lie, steal, break the law, and, by their aggressiveness and violence, may endanger themselves and others. Typically, these behaviors result in repeated arrests. Substance abuse and drug dealing often go along with this disorder. Most psychiatrists consider antisocial personality disorder untreatable. About three-fourths of the hard-core prison population receive the diagnosis; one of its characteristics is lack of regret for wrongdoing. Antisocial personality disorder is certainly hard to treat, but it isn't impossible. Consider the substantial reduction in recidivism for inmates who learn to meditate.

Borderline personality disorder (BPD) afflicts emotionally highly sensitive children who grew up in emotionally invalidating environments. Seventy-five percent of people with BPD were abused, either sexually or physically, as children. Note that a child can have BPD and not have been abused (sometimes it is precipitated by adoption), so not all parents of BPD sufferers can be accused of abuse.

According to DSM-IV (The Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association), people with borderline personality disorder have "a pervasive pattern of instability of interpersonal relationships, self-image, and [emotions], and marked impulsivity beginning in early adulthood and present in a variety of contexts."

People with BPD find it difficult to regulate their emotions. Small bumps on the road of life -- things that would briefly annoy someone else -- jolt a person with BPD into hours of anger or paranoid fear. Their behavior tends to be compulsive and inappropriate, including eating disorders, overspending, gambling, compulsive sex, and substance abuse. They lack a clearly defined sense of self, tending to change their colors to blend into their environment. They may chronically feel empty or bored, in some cases suicidal; self-inflicted injury is possible. They see everything as either black or white: they deify the people around them, or alternatively, irrationally devalue them. Their partner may be considered ideal one moment and fatally flawed the next -- or valued in the beginning of the relationship and seen as worthless in the end. People with BPD are hypersensitive to rejection and will do anything to avoid perceived abandonment. Often they are constantly angry or irritable.

"Borderline personality disorder" is somewhat of a misnomer. At the time the phrase was coined, people with BPD were thought to be on the borderline between psychotic and neurotic disorders. Most researchers would now like the name changed to something indicating emotion dysregulation.

Until recently, the treatment of personality disorders hasn't had much attention. Borderline personality disorder, like antisocial personality disorder, was thought to be untreatable -- or at least too difficult to be worth the effort. However, Marsha Linehan, a psychology professor at the University of Washington, pioneered a successful form of therapy she calls Dialectical Behavior Therapy. Dr. Linehan has trained counselors, and her books are considered the most authoritative in the field. Clinical trials demonstrated that Dialectical Behavior Therapy is effective and enables clients to progress substantially. However, recovery from all personality disorders is a slow process. They are, by definition, collections of traits that tend to remain fixed throughout a person's life.

Here are some good sites on BPD. Check their lists of links for further resources. As with all the disorder-specific sites, e-mail lists and chat rooms are especially useful. The first site has a searchable directory of counselors. The last site, BPDCentral, helps nonborderlines deal with family members who have BPD. It is run by Randi Kreger, one of the authors of Stop Walking on Eggshells: Coping When Someone You Love Has Borderline Personality Disorder.

Mental Health and Addiction

It is generally agreed that as much as 50 percent of the mentally ill have a substance abuse problem. For example, 30 percent of bipolar I patients are alcoholic, over 50 percent of those with BPD are substance abusers, and 50 to 60 percent of cocaine or crack addicts have a mood disorder. A diagnosis of both addiction and mental illness is called a dual diagnosis. Most addicts -- two-thirds -- do not have dual diagnoses, but one-third do. If you've had an addiction, you owe it to yourself to get a mental health checkup. Do it merely as a precaution. Addiction is often the presenting symptom, and is quite rightfully treated first. Addiction creates its own temporary mood and anxiety disorders, as well as exaggerating existing personality disorders, but addiction itself is not always the deepest underlying cause.

Symptoms that should alert you to the need for assistance are:

  • any persistent or severe mental or emotional distress
  • consistently being unhappy to the point where you don't look forward to the next day
  • disturbances in sleep patterns
  • decreased functioning -- or greater difficulty than those around you -- in job performance, social interaction, or family life
  • others complaining about you -- that you talk too loud or too fast, are irritable or unreliable, are too introspective, or don't respect other people's boundaries

How to Get Help

Beware: the Surgeon General found a big gap between what researchers know works and what practitioners in the field actually do. Psychiatrists are often out of date. Furthermore, for many therapists, if they don't know how to treat a problem (e.g., psychiatrists and BPD), that problem doesn't exist. Psychiatrists are taught to prefer a diagnosis they know they can successfully work with. All therapists and counselors have a favorite therapeutic approach, but for some it is their inevitable tool; and if all you've got is a hammer . . .

The best way to find a mental health professional is by referral. If you don't know who to ask, here are a few possibilities. SAMHSA can locate mental health treatment facilities, consumer groups, and state resources:
800-789-CMHS (8:30-5:00 EST M-F)

The Association for Cognitive and Behavioral Therapies lists its members by state and specialty:
212-647-1890 (9:30-5:00 EST M-F)

You can e-mail or call the American Psychiatric Association:
888-357-7924 (8:30-6:00 EST M-F)

Or call the American Psychological Association at 800-964-2000 (8-5 PST M-F). They will connect you to a state association for a local referral.

Experts recommend interviewing at least three potential therapists. Make sure they understand addiction. Find out how many people with your mental disorder they have treated. Ask about credentials, training, specialty, success rates, preferred treatment methods, length of treatment, availability, and, of course, cost. You should feel comfortable with them and they should feel compassionate and empathic toward you.

After you have given yourself a general education and received a professional diagnosis, get in touch with self-help and consumer groups -- people who have your specific problem and are looking for the most effective way to deal with it. Then, get another professional diagnosis. Without a second opinion, you risk misdiagnosis and mistreatment, wasting mountains of time and money, while filling your body with needless drugs.

Drugs are a contentious issue, with no end to the debate. More and more disorders are being treated without drugs. Two of the most resistant mental disorders are BPD and obsessive-compulsive disorder (OCD). Even these, in many cases, can be healed without medication. Marsha Linehan's approach to BPD is not drug based. Jeffrey Schwartz, a psychiatrist at the UCLA School of Medicine, has developed a nonmedicinal four-step self-treatment method for OCD (described in his book, Brain Lock: Free Yourself from Obsessive-Compulsive Behavior). However, both Dr. Linehan and Dr. Schwartz are not afraid to have patients take drugs. Dr. Schwartz considers medication necessary -- sometimes -- to reduce overwhelming symptoms, so the person can focus on changing their behavior. He calls the drugs training wheels.

So if you must temporarily take drugs --under the close and continued supervision of a skilled, preferably holistic or integrative, psychiatrist -- because your symptoms are severe or your disorder is chronic and because nonpharmacological approaches have failed or are insufficient, then do what you have to do. If the psychopharmacological approach works, use it. However, don't trust any doctor who, after a brief office visit, gives you drugs and a bill, and thinks his job is over. And,on the other hand, don't trust someone who never recommends medication to any of her clients, is unaware of therapies targeted to your disorder, and wants you to come chat twice a week, for the rest of your life, at $250 an hour. Get specific treatment for your specific problems.

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