The DSM-IV does not specifically address heroin addiction per se, but rather the general category of opioid addiction (304.00 Opioid Dependence, pg. 270 in the DSM-IV). Furthermore, the criteria for opioid dependence fall under the general category of substance dependence (as do all substances, pg. 192 in the DSM-IV).
A cardinal feature of heroin dependence is the withdrawal symptoms experienced when opioid use is abruptly stopped. All the sites above make mention of this, with the exception of site b (which is a site used to get people in touch with treatment options).
My general impression of the sites above is that they focus more on describing how one can spot heroin use. For example, how to tell when one is high (e.g., “the nods,” constricted pupils, etc) or how to tell when one has been using (track marks, burnt spoons, cotton swaps, etc.). Besides site d (which I think is the most comprehensive when its links are also counted) none of the sites really mention the neurological aspects of heroin addiction; that is, how heroin addiction actually changes the brain. I think this is an important aspect of addiction that the public should know about. Most people still view heroin addicts as somehow having no morals are a weak character. They don’t realize that once they have become addicted, it is almost like they cannot help it (due to neurological changes). The sites above focus on the detrimental health effects, such as HIV, hepatitis C, endocarditic, etc. I think this contributes to the overall negative attitude of the general public toward heroin addicts, as well as the view that they are dirty or even subhuman.
I should also mention that I think that the DSM-IV is of only minimal use regarding substance addiction. One or two chapters in a book cannot even come close to capturing the complexities of drug abuse and addiction. From a purely medical standpoint, one can use the DSM-IV to say, “yes, this person shows the signs of addiction.” But that’s pretty much where the usefulness of the DSM-IV ends, in regards to addiction.
As far as searching online for information about medical/psychological problems, I view it as a way to gather general information. Obviously, one should not accept as fact what one reads on the internet. However, one may gather tidbits of information that one could use when approaching a professional about the problem. Furthermore, internet sites may be helpful in directing people toward more comprehensive books and articles about a medical/psychological problem. In short, the web is a good starting point.
FYI: Site e has an interesting (and accurate) description of the history of heroin.
of the Requirements for the Degree of the Substance Abuse and Clinical Counseling program
Eric K. Mason
Dissociative Identity Disorder: A Case Study
In the following paper, I will present a young woman who I believe is suffering from Dissociative Identity Disorder (DID). In addition, I will give a description of DID, its etiology, and its epidemiology. Lastly, I will present information which I believe supports the diagnosis of DID.
DID is, perhaps, the most misunderstood and controversial of all mental disorders. It is both fascinating and tragic at the same time. Perhaps, no disorder has garnered more attention from the media or more disdain from the skeptics.
There is no denying that those with DID experience a myriad of symptoms, and have a very high rate of co-occurring mental disorders. Furthermore, one cannot easily refute that most people presenting with symptoms of DID have suffered physical and/or sexual abuse, as well as other traumatic experiences as children. Although it is generally believed that DID is a rare mental disorder, one study indicates that it has a lifetime prevalence of 1% in the general population (Millon, Blaney, & Davis, 1999).
The young woman described below exhibits many symptoms of DID. I believe she may have a history that would predispose her to develop DID. In addition, she has experienced factors known to precipitate the onset of DID.
The Client/Patient is an 18-year-old female from Germany. She has been living in the U.S. for the last three years. Her mother died four years ago (cause of death unknown). Client witnessed mother’s death. Client’s mother was never very involved in her life. She was raised by her grandmother. She has no prior history of mental illness or any other medical problems.
The client appeared under nourished at the time of the interview. Client fainted during the clinical interview when her hand was placed in cold water. Otherwise, she exhibited good physical strength for her size. Client had a pleasant disposition, is responsive, and seems oriented to time and place.
Client was brought in by her father and grandmother. Father and grandmother complained that client steals and lies, frequently. For example, father reported that she will take money from his pocket and then deny that she had done so. Father stated that client stole a pocketknife from her teacher. Client claimed that she did not steal it, but rather found it. Father and grandmother claimed that client steals money to buy candy from the store. Client will often assert that it was another little girl who actually bought the candy.
Client often behaves like a child much younger than 18. Father reported that client came to him stating that she wanted to be loved and be his baby like the other little girl. Client went on to say “I’m a good girl now, ain’t I? I don’t steal anymore, do I?” Father said she had a peculiar look on her face during this time. Father claimed that the client will change behaviors frequently. For example, client once ran away and claimed that she was whipped excessively at home. However, on other occasions, as stated above, client will seek out father’s love and affection.
Although father claimed that she is not whipped excessively, he does admit to whipping her when she returned home after she ran away. I am not convinced that the client is not physically abused. Family did not seem to be very fond of client. For example, client’s grandmother called her “a terrible little liar.”
Client is frequently interested in things that one would associate with a young child, not an 18-year-old. For example, she reported stealing money from teacher in order to buy candy, ice cream, and rollerskates. Client appeared more gullible than one would expect for an 18-year-old. For example, client stole items and called people “wicked” names when told to by a boy (15) who lives on her street.
During the interview the client talked about her interaction with the aforementioned boy and another girl (11). Client described how the boy tried to get the other girl to go into the bushes with him. Client said that she did not know what this meant, and that the other girl would not tell her. Client said that the boy will say bad names to her and try to get her to steal, but that he is nice to the other girl. Later in the interview, however, client talked about how the boy tries to get her to go out into the bushes with her (after having said that he never tried to get her to do that). Client also stated that the boy had knocked down the other girl and tried to take her clothes off (after having said that he was nice to her). Client went on to say that the other girl told her lots of bad names that that boy taught her (after having stated that the girl does not say bad words).
From the interview provided, I get the impression that the interviewer is having a conversation with two different people. It appears as though the client switches from herself to “the other girl,” about whom she was talking. The other girl then appears to be talking about the “client.” I believe this is why the girl contradicts herself, as described above. Furthermore, I believe this is why the client (18) buys candy, ice cream, and rollerskates (interests more characteristic of an 11-year-old) with the money she steals. This may also explain why she claims not to remember stealing certain items. It is my opinion that the client is suffering from Dissociative Identity Disorder (DID). The so-called other girl (11) is actually an alternate personality/identity.
300.14 Dissociative Identity Disorder
The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).
At least two of these identities or personality states recurrently take control of the person’s behavior.
Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol intoxication) or a general medical condition (e.g., complex partial seizures). Note: In children, the symptoms are not attributable to imaginary playmates or other fantasy play (American Psychiatric Association, 2000).
Dissociative Identity Disorder (DID)
DID, formerly multiple personality disorder, is characterized by the presence of two more distinct personalities residing in an individual (American Psychiatric Association, 2000). “The quiet, careful guy at the lab who is a ‘wild man’ at parties may look to others like a multiple personality, but he sees these ways of being as different aspects of his identity and does not suffer from Dissociative identity disorder” (Maxmen & Ward, 1995). According to the DSM-IV-TR, DID “reflects a failure to integrate various aspects of identity, memory, and consciousness” (American Psychiatric Association, 2000).
The different personalities or identities may vary in age, sex, personal history, and temperament. They usually have different names, as well. The various identities may not have knowledge of one another. They may emerge (i.e., take control of the person) gradually or within seconds. When a new identity takes control, the person’s facial expression may change or rapid eye blinking may occur (American Psychiatric Association, 2000).
Those who have witnessed a person with DID alternate or transition between personalities may report that it is “spooky” or strange to witness, as the newly emerged identity may speak and walk differently. The person’s facial expression may change so dramatically, the person may become unrecognizable to those witnessing the “transformation.” For some, it is an unnerving experience to say the least (Maxmen & Ward, 1995).
People with DID experience frequent gaps in memory. They may disavow behavior witnessed by others. Psychosocial stresses may precipitate the onset of DID (American Psychiatric Association, 2000).
Individuals with DID often report a history of physical and/or sexual abuse (American Psychiatric Association, 2000). People with DID have learned to dissociate as a way to escape from a traumatic reality. Some argue that DID is a coping mechanism or simply a means of survival, as the trauma people with DID have experience is so psychologically and emotionally painful, it could easily lead to psychosis or suicide (Middleton, 2005). Even so, “untreated patients with DID have very high suicide rates, in the order of several thousandfold in excess of the American national average” (Middleton, 2005).
The abusers may deny or distort their abusive behavior, in an attempt to trivialize real abuse as proper punishment (Middleton, 2005). The psychological motivation of abusers time and again is
to evoke protectively in the child the unwanted negative images of the self—to make the abused one feel utterly helpless, humiliated, shamed, violated and abject—and to bring about a near annihilation of the true self of the abused (Middleton, 2005).
It is no wonder then that abuse leads to a damaged sense of self. Abuse perpetuated on children by a caregiver (as is usually the case) is especially traumatic. In order to maintain a bond with their abusive caregivers (as they remain dependent on the very people who abuse them), abused children may learn to block out or dissociate themselves from the abuse, as a means of coping with their emotionally and psychologically conflicting reality (Middleton, 2005).
Psychologically sound and healthy individuals may take the notion of selfhood for granted, but it is an essential aspect of healthy human functioning, without which one’s daily functioning would be severely hindered. Selfhood allows one to differentiate him- or herself from others and the environment. In other words, it serves as boundary between the self and the rest of the world. It serves as a guide for how one represents him- or herself to others and the environment, as well (Middleton, 2005).
Furthermore, a good sense of selfhood allows one to distinguish the past from the present, as well as the capacity to recall one’s life logically and relatively chronologically. Self-hood enables one to live for him- or herself independently and free of toxic, enmeshed relationships. This in turn, allows one to be at peace with him- or herself and to develop self-esteem, as well as an overall sense of wellbeing (which is an essential aspect of an emotionally and psychologically healthy individual (Middleton, 2005). Interestingly enough, Middleton points out that selfhood enables one to cope with traumatic experiences, so that he or she may move on with his or her life (2005).
People with DID lack a true sense of selfhood. They, therefore, lack many or most of the positive aspects of a well-defined sense of self. It is not surprising that people with DID have difficulties in nearly every aspect of their lives (e.g., vocational and financial difficulties, social and familial problems, legal troubles, substance abuse and other mental disorders, etc.) (Middleton, 2005).
Comorbidity is a significant problem of people living with DID. People with DID regularly have had or will develop other mental disorders at some point in their lifetimes. Common cooccuring disorders run the gamut from mood, anxiety, and psychotic disorders to substance abuse, somatoform, and eating disorders (Millon, et al., 1999). “Moreover, borderline personality disorder has been diagnosed in almost 70% of a series of clinically diagnosed DID subjects” (Millon, et al., 1999). Like DID, Borderline personality disorder (BPD) is frequently diagnosed in individuals with a traumatic/abusive childhood. Those dually diagnosed with DID and BPD are more likely to have been more severely abused than those diagnosed with only DID (Millon, et al., 1999).
Clinicians are frequently unaware that they’re treating a [person with DID], since these patients are tough to detect. One psychiatrist reported that seven years had passed before he realized his patient had this disorder. Few enter treatment complaining of multiple personalities, and if they come at all, it’s usually for depression (Maxmen & Ward, 1995).
In short, DID “rarely occurs as an isolated condition” (Millon, et al., 1999). In regards to DID, comorbidity is more often the rule than the exception. Differential diagnose is, therefore, extremely important when considering a diagnosis of DID (Millon, et al., 1999).
People with DID are prone to establishing abusive relationships with others (American Psychiatric Association, 2000). In addition to having real physical ailments (as they are prone to self-mutilation), they may exhibit psychosomatic symptoms (Middleton, 2005).
DID has been found in cultures throughout the world. For example, DID has been documented in Australia, India, New Zealand, North America, South America, Turkey, France, Belgium, Scotland, Scandinavia, England, Japan, the United States, and Germany. Although DID is found all over the world, in may be expressed differently depending on the cultural context. For example, in traditional cultures, alternate personalities often manifest as god, ghost, deceased family members, or nonhuman entities. The manifestation of such alternate personalities is in line with the cultural values of some traditional societies. Although psychopathology may be universal, it always occurs within the context of a culture. One cannot deny the interplay that occurs between culture and nearly every aspect of human life, including psychopathology (Shumaker & Ward, 2001).
DID appears to be more prevalent in individualistic cultures, such as the United States, Germany, and Finland, than collectivistic cultures. Most Western cultures are individualistic in nature, while Eastern cultures are more collectivistic (Shumaker & Ward, 2001). However, a recent study indicated that DID was on the rise in Japan. Between 1919 and 1990 there were only five documented cases of DID. A dramatic increase in DID occurred between 1991 and 1997, with 30 cases being documented (Uchinuma & Sekine, 2000).
In addition, DID is more prevalent in cultures that tend to be relatively more tolerant of child abuse (Middleton, 2005). Although Western cultures typically hold a harsh opinion of child abusers, they are generally not really severely punished. Rates remain high in the West, despite increasing efforts to improve detection and early intervention of physical, sexual, psychological, and emotional abuse of children (Steinberg, 2005).
DID is three to nine times more prevalent in females than males (American Psychiatric Association, 2000). However, this disparity narrows between the sexes among incarcerated individuals—reflecting the greater likelihood that prison inmates were abused as children. DID usually shows up during adolescents and rarely develops after the age of 40 (Maxmen & Ward, 1995). It tends to be chronic and recurrent. DID, “and the proliferation of new identities, often continues for life, making this condition the worst of the dissociative disorders” (Maxmen & Ward, 1995).
Justification for Diagnosis
I would like to point out that after making the initial diagnosis of DID, I would investigate further in order to gain more evidence to substantiate my claim. A fully detailed description of the methods for more thoroughly investigating DID is beyond the scope of this paper, but they include things like semi-structured diagnostic interviews (the Dissociative Disorders Interview Schedule) and screening tests, such as the Dissociative Experiences Scale. A diagnoses of DID is more or less done on an exclusionary basis, meaning that other seemingly similar disorders, such as schizophrenia (for which DID is frequently—albeit wrongly—diagnosed as), must be first systematically ruled out before it is given (Maxmen & Ward, 1995).
If I could not substantiate my claim relatively quickly, one option would be to defer the diagnosis of DID or, perhaps, give a diagnosis of Dissociative Disorder, Not Otherwise Specified (DDNOS). DDNOS is often used by clinicians as an initial diagnosis until they can more thoroughly substantiate a diagnosis of DID (Maxmen & Ward, 1995). That being said, I will now provide justification for why I believe that the young woman described above does, in fact, have DID.
This particular client exhibits many symptoms of DID. For example, the client disavows certain behaviors, apparently having no recollection of pervious events that were witnessed by others. She may claim to have found items that were known by others to have been stolen by her. The client will persistently deny that she stole the items, even in the face of proof that she did, in fact, steal the items.
In addition, the client has stolen money from her father in order to purchase candy. I find that stealing money to buy candy to be rather uncharacteristic of an 18-year-old. It seems to me that an 18-year-old would be more interested in stealing money to purchase more age-appropriate items. At times, the client has claimed that another little girl was actually responsible for purchasing the candy. The family is convinced that she is simply a pathological liar.
People with DID usually have no recollection of events that took place while an alternate personality or identity was in control. I believe that the client has an alternate identity, which takes on the persona of a little girl. I think that this alternate identity is responsible for the thefts witnesses by others. Furthermore, I think this explains why the client apparently buys candy with the money she steals, instead of more age-appropriate items.
Client’s father reported that her behaviors shift dramatically from time to time for no apparent reason. He stated that she once ran away and refused to come home. Upon returning, client told father that she wanted him to love her like he did the other girl. Furthermore, client’s father claimed that she has a strange look about her during these shifts in behavior.
When different identities emerge in people with DID, it usually proceeded by rapid blinking or a change in facial expressions. Witnesses often say that people with DID have an overall strange look about them when they are shifting from one identity to another. I believe that the client’s strange facial expression (described by the father), which co-occurred with a shift in her behavior, is actually the emergence of alternate identity. This would also explain the dramatic shifts in her behavior, as well as her request that her father love her like he does the other girl. I believe the other girl, of whom she spoke, is actually an alternate identity.
On one occasion, when the client ran away, she claimed that she was whipped excessively at home. The father denies that this is the case. However, one would expect him to deny it, as abusers usually do. Although the father claimed that he does not whip her, he admitted to whipping the client after she returned home from running away. This is an obvious contradiction, which, I believe, reveals that he does in fact whip her—perhaps, excessively. Obviously, this suspicion would have to be substantiated before I could make this claim with any level of real confidence.
It would appear that the client has not had an extremely stable childhood. Her mother and apparently her father were not very involved in her life growing up, as she was predominantly raised by her grandmother. It sounds as if the client’s grandmother does not hold her in high regard, as the grandmother commented that the client was “a terrible little liar.” Such a statement may indicate the presence of emotional or psychological abuse.
Furthermore, the client appeared undernourished at the time of the interview. This may be evidence of neglect and/or abuse at home. However, under normal circumstances one would expect an 18-year-old to be capable of attaining nourishment for herself by whatever means necessary (perhaps her alternate identities are stealing for this very reason), though the client’s circumstances appear to be by no means normal. The client’s undernourished appearance could be the result of an eating disorder, which co-occur with DID at a very high rate (Maxmen & Ward, 1995). Of course, these suspicions would have to be further substantiated, as well.
Approximately 90% of people suffering from DID were abused and/or experienced a traumatic childhood (Millon, et al., 1999). A history of abuse appears to be the overwhelmingly consistent feature of those with DID (Okugawa, 2005). Although I cannot yet make this claim unequivocally, I believe there is some reason to expect that the client at the very least experienced a difficult childhood, if not an abusive and/or traumatic one.
Further evidence for a diagnosis of DID appeared during the diagnostic interview. During the interview it seemed as if the clinician was having a conversation with two different people. Although the client appeared to be rambling and contradicting herself, I believe that the interviewer was actually witnessing the emergence of one of the client’s alternate identities.
Furthermore, during the interview, the client claimed not to be aware of the sexual innuendo of the boy who lives on her street. This is rather unusual for most 18-year-olds (especially considering she is of normal intelligence). I believe that when she made this claim, one of her alternate identities was in control, probably the little girl described above.
In regards to the little girl, the client makes reference to interactions between herself, the boy (described above), and the little girl. She seems to intermix and intertwine the actions of the little girl with herself. For example, in one instance stating that she (the client) said bad words and not the other girl, but in another instance say that the other girl said bad words and not her. Perhaps, in the second instance “the other girl” (the little girl) had emerged as the controlling identity and was actually speaking of the client as “the other girl.” This may explain the apparent contradictions the client made during the interview described above.
The client’s father reported that her strange behaviors did not begin until she moved to the United States from Germany, shortly after the death of her mother. The client reportedly witnessed the death of her mother (who “fell over dead next to her”). Psychosocial stressors have been shown to precipitate the onset of DID for those susceptible to the disorder. Moving, especially to a foreign country which speaks a different language and has different customs, is extremely stressful. Moving to a new country, in conjunction with witnessing the death of her mother, may have been enough to push her over the edge—leading to the development of a full-blown case of DID.
Other factors that support the diagnosis of DID are as follows: The client is female, under the age of 40, and comes from a Western culture with previously documented cases of DID. DID is much more prevalent (four to nine times) in females than males. There are few cases in which DID developed in individuals over the age of 40. The client is from Germany and lives in the U.S. They are both Western cultures where child abuse is more or less tolerated, and where DID has been documented relatively frequently.
Lastly, during the interview, when the client’s hand was placed in cold water, she fainted. This may be indicative of psychosomatic symptoms. According to Maxmen and Ward, psychosomatic symptoms are common in people with DID (1995).
DID, also known as multiple personality or split personality disorder, has a notorious and somewhat controversial history. DID has garnered attention from Hollywood,..
*The criteria used for alcohol dependence are the same as those used for all substances*
Criteria for Substance Dependence:
Recurrently problematic and frequent substance use, which leads to clinical and serious impairment or distress. Three or more of the following must occur within a 12 month period as a result of substance use.
Tolerance, as described by the following criteria:
The need for more and more of the amount of the substance in order to become intoxicated or achieve the desired effects.
Noticeable decrease in the effectiveness of the substance when the same amount is used.
Withdrawal, as described by the following criteria:
Typical withdrawal symptoms for the particular substance (see alcohol withdrawal below on page 2).
Substance is taken (or one that is similar) in order to avoid or relieve negative symptoms associated with nonuse of the substance.
The substance is used in greater amounts and for a longer period time than was originally intended.
A firm desire to reduce or control the amount of substance use, possibly with many unsuccessful attempts to do so.
A lot of time is spent in obtaining and using the substance, as well as in recovering from its effects (e.g., going out of town to go on a bender, chain-smoking, working extra hours to earn money to buy the substance, days spent recovering from a bender, etc.).
Substance use significantly interferes with social, occupational, or recreational activities.
Substance is still used even when one has knowledge that the substance use was the likely cause of a physical and/or psychological problem(s), or when one has knowledge that substance use exacerbated a physical and/or psychological problem(s) (e.g., continued drinking despite cirrhosis of the liver.)
With Physiological Dependence: evidence of tolerance and/or withdrawal
Without Physiological Dependence: no evidence of either tolerance or withdrawal
Early Full Remission: When criteria of substance abuse or dependence is no longer met for at least one month, but less than 12 months.
Early Partial Remission: When full criteria for substance abuse or dependence has not been met (but one or more criteria have) for at least one month, but less than 12 months.
Sustained Full Remission: No criteria for substance abuse or dependence have been met for at least 12 months.
Sustained Partial Remission: When full criteria for substance abuse or dependence has not been met (but one or more criteria have) for at least 12 months.
On Agonist Therapy: For those using agonist medications to aid in recovery.
In a Controlled Environment: For those in an environment where access to substances is restricted and no criteria for substance abuse or dependence has been met for at least a month.
291.81 Alcohol Withdrawal
Criteria A: Abstinence (or reduction) from alcohol use
Criteria B: Two or more of the following symptoms, starting within several hours to a few days after one has cut down or stopped consuming alcohol.
increased hand tremor
nausea or vomiting
transient visual, tactile, or auditory hallucinations or illusions
grand mal seizure
Criteria C: The above symptoms cause significant problems in social, occupation, and/or other areas of functioning.
Criteria D: The above symptoms are not a result of a medical condition or another mental disorder.
With Perceptual Disturbances: Used when hallucinations occur, but the individual is aware that they are caused by alcohol withdrawal (termed, intact reality testing). When the individual is not aware that the hallucinations are the result of withdrawal, a diagnosis of Substance-Induced Psychotic Disorder, With Hallucinations may be given.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders: DSM-IV-TR (4th ed. tr.). Arlington: Amer. Psychiatric Assn.
There are more English synonyms for “drunk” than any other word.
Arabs were the first to distill alcohol in 600 A.D.
1990 per capita consumption of alcoholic drinks in the U.S. was 39.5 gallons
Alcohol is the most serious drug problem for all industrialized nations
Alcoholism is a illness of normal people
The typical alcohol is in his or her mid-thirties and has a good job, home, and family (i.e., not a “bum”)
Mortality rates are twice as high for male alcoholics and three times as high for females alcoholics than their nonalcoholic counterparts
Half of all hospital admissions, homicides, and car accidents are alcohol related
A quarter of all suicides involve alcohol
Alcoholism plays a major role in 20% of all divorces
1 out of 10 U.S. adults is an alcoholic (14 million total)
Men are three times more likely than women to become alcoholics
A quarter of alcoholics developed alcoholism before they were 20
A family history of alcoholism puts one at a much greater risk of alcoholism (i.e., there appears to be a very strong genetic component to alcoholism)
The DSM-IV list 13 mental disorders associated with alcohol
Alcoholics typically suffer from apprehension, agitation, dysphoria, guilt, remorse, despair, hopelessness, futility, self-deprecation, and insomnia
Maxem, J. S., & Ward, N. G. (1995). Essential Psychopathology and its Treatment. (2nd.). New York: W.W. Norton and Company.
Military personnel or embassy officials and their families must contend with certain life stressors, which make their experiences unique from many perspectives. For example, military personnel and their families must relocate often, as they are frequently deployed to various bases around the country. At times, the military requires military personnel to move abroad to bases outside of the United States. Frequent moves, which require military personnel and their families to uproot and leave behind friends and family on a regular basis, can be stressful and problematic for many individuals. Moving out of the country may multiply this stress exponentially, as families are forced to adapt to a foreign culture (Lee, 2007).
Moving abroad forces one to go through the process of cultural transition. Cultural transition involves a great amount of change. Change, even when it viewed positively, is generally stressful for those experiencing it. Studies using Holmes’ and Rahe’s Social Readjustment Scale have indicated that the drastic life change that occurs when one relocates from one country to another is so great that it may put one at risk for major illness or depression (Lee, 2007).
Immigrants, refugees, international students, military personnel, business assignees, and Peace Corps volunteers are all affected by [the cultural transition] process. It is estimated that 2-10% of business people on foreign assignments have adjustment difficulties and 33% of their families return to the United States earlier than planned. Similarly, 15-25% of international students have been reported to experience significant adjustment difficulties and as many as 35-40% of Peace Corps volunteers in some years terminate prematurely (Lee, 2007).
Unlike business people and Peace Corps volunteers, military personnel and their families do not have a choice when it comes to moving abroad or coming home early. They must go where their orders dictate them to or they may face court marshal. Counselors may help military personnel and their families deal with acculturative stress (culture shock) by providing education about the cultural transition process prior to their departure. For example, counselors may brief them on the types of feelings they may experience as they are go through the cultural transition process—letting them know that such feelings are a normal part of cultural transition. In addition, many individuals experience reentry shock, stress that occurs as individuals try to readjust to their native culture, when returning home. Therefore, counseling may also be advisable when military personnel and their families return home (Lee, 2007).
Sometimes military personnel must deploy and leave their families behind. When a member of the armed services is deployed overseas without his or her family, it likely places a great deal of stress on his or her family. Members of such families may be forced to take on additional familial roles as a result of the deployment, as well as experience greater financial insecurity. Such burdens inevitably produce mental and emotional strain on even the most resilient families. Although deployment into non-combat areas may be very stressful for military families, when a family member is deployed into a combat zone, however, there is little doubt that families experience greater and more intense stress.
It is well known that stress often causes or precipitates mental illness. Military families probably experience stress more often, as a result of frequent military deployments. I, therefore, believe that mental health difficulties may be more prevalent in military families than in the general population.
Mother Absence in Military Families
Since the U.S. military became an all-volunteer military in 1973, it has found filling its ranks to be evermore challenging. As a result, the military has increasingly allowed more women to serve in roles that were traditionally reserved for men. In 1972, women comprised less than two percent of the military. As of 1992, women made up more than 12 percent of the military. This percentage is probably much higher as of 2008, and will surely continue to grow in future years (Applewhite and Mays, 1996).
Operation Desert Storm was the first recent military conflict in which women were allowed to directly engage in combat. During Operation Desert Storm, women combatants were helicopter, airplane, and jet pilots (Applewhite and Mays, 1996). However, the present war in Iraq and Afghanistan has seen women combatants on the ground fighting along side men. Although the idea of women ground troops was once very controversial, it has become an acceptable practice in recent years.
During Operation Desert Storm, almost 37,000 children were separated from either both parents or their only parent. In other words, these children were left without their sole caretaker(s) as a result of the war. Out of all the single parents in the military, women comprise 35 percent (Applewhite and Mays, 1996).
Depending on a child’s developmental stage, he or she may respond to separation from his or her mother differently. According to Stolz, when a child is separated from his or her mother during infancy, he or she may become fearful, nervous, and shy. Many of these children develop an anxious belief that their mothers may never return (Applewhite and Mays, 1996).
Furthermore, a child’s sex may determine his or her reaction to the absence of his or her mother. Although boys tended to have more negative reactions to the absence of their mother as a result of a military deployment than girls, boys responded even more negatively when their fathers were absent as the result of a military deployment (Applewhite and Mays, 1996).
Father Absence and Mental Illness
Father absence has notoriously contributed to mental health difficulties in children—especially in males. Father absence is an increasing phenomenon in American society. Children who have fathers in the military may be forced to deal with the absence of a father figure more often than children in the general population (Ryan-Wenger, 2001).
Absence of a father reportedly contributes to lower scores on achievement tests, lower mathematical ability, and higher rates of emotional difficulties. Although a “child’s sex, socio-economic status, presence of siblings, type of absence, time of onset and duration” all appear to play an important role in determining how the child reacts to paternal absence, the probability of developmental and emotional difficulties appears to increase when the child’s is father absent (Ryan-Wenger, 2001). For example, paternal absence earlier in life is associated with aggressive behaviors, depression, irritability, and impulsiveness in children (Ryan-Wenger, 2001).
In short, fathers appear to play an important role in a child’s development. Father absence is associated with developmental delays, mental health difficulties, and, overall, maladjustment in children. Although children in the military may have caring fathers, they are forced to deal with paternal absence more frequently than most children (Ryan-Wenger, 2001).
Military Deployment into Combat Zones and its Effects on Military Families
The possibility of being deployed into a combat zone is an ongoing stressor that military personnel and their families must deal with constantly. Certainly, this possibility is a stressor during peacetime; however, with the United States currently engaged in combat in Afghanistan and Iraq, military personnel who are not already deployed in combat zones surely live with a heightened sense of stress that they may soon be deployed to these combat zones. Indeed, the families of military personnel are under greater amounts of stress, as they also live with the constant threat that their loved ones could be deployed to combat zones. Such stress certainly places a great deal of strain on the family unit.
Although maternal and paternal absence is difficult for most children, when their parent is deployed into a combat zone, they likely experience even more stress. These children must deal with the fact that their parent may be killed or wounded, in addition to the difficulties associated with the absence of the parent. As a result, these children probably experience more mental and emotional difficulties than children whose parents are deployed into non-combat zones (Ryan-Wenger, 2001).
There are 3.36 million children who have parents in the armed forces. Although the U.S. is currently at war, these children must deal with the possibility of war even when the U.S. is not at war. This ongoing stress is associated with mental and emotional difficulties in many children who have parents in the military (Ryan-Wenger, 2001). Furthermore, spouses of deployed soldiers may fail to recognize their children’s own distress, as they are dealing with their own difficulties of having a husband or wife deployed overseas. Such unintentional neglect may compound the child’s distress even further. (Murray and Kuntz, 2002)
Since the U.S. is currently at war, however, it is important that research is conducted in this area to help these 3.36 million children cope with the stress they must face as the result of possible deployment of family members into a combat zone (Ryan-Wenger, 2001). The ongoing war on terror, a war that may continue well into the future, will ensure that many of these 3.36 million children continue to experience this high-intensity stress. The notion of an ongoing war with no real end in sight is unprecedented in American history, which puts mental health practitioners in a unique situation. To be sure, mental health practitioners will encounter more frequently children with emotional and mental health issues as a result of this unprecedented struggle (Murray and Kuntz, 2002).
With the Unites States currently at war in Afghanistan and Iraq, military families are forced to deal with the frequent deployment of their family members into combat zones. Repeatedly having to deal with stress on such an intense level surely results in more mental health related difficulties in these families. In addition to experiencing stress as a result of a military deployment, when a family members is injured, killed, or becomes mentally ill as a result of his or her deployment, military families are forced to deal with a great deal of change and uncertainly that undermines familial structure. Likewise, such change may result in the development of mental illness in some family members. When military personnel become mentally ill, as a result of a deployment (e.g., PTSD), the mental illness may become transferred onto other family members. For example, the spouse of a depressed combat veteran may also become depressed, which may, in turn, affect the mental health of their children.
As a consequence of the United States’ current wars, those working in the mental health field may more frequently encounter individuals who are experiencing mental health issues. Indeed, the war on terror is a military conflict, seemingly with no end in sight. Many American families will surely be affected by such foreign policy. In order to help these families cope with mental health difficulties, it is essential that more research is conducted in this area.
When military personnel are deployed into combat zones, the psychological stress under which they must live dramatically increases the likelihood that they (and their families) will develop a psychological disorder. The most common disorders that afflict military personnel are Post-Traumatic Stress Disorder (PTSD), depression, Substance Use Disorders (SUD’s), as well as anxiety disorders, such as Generalized Anxiety Disorder (GAD). Suicidal ideation may occur without the presence of a psychological disorder, but it it most often a “byproduct” of a psychological disorder.
The stress and anxiety of having their loved one deployed into a combat zone may lead the spouses and children of military personnel to become depressed, as well as develop anxiety disorders and SUD’s. The spouses and children of military personnel are also at risk of developing symptoms of PTSD via a phenomenon known as secondary traumatization. Although not a psychological disorder, interpersonal conflict increases significantly for combat veterans and their families. These issues are explored in more detail below (Renshaw, Rodrigues, & Jones, 2008).
Posttraumatic Stress Disorder
Post-Traumatic Stress Disorder (PTSD) is the psychological disorder that most frequently affects combat veterans (Brinker, 2007). PTSD may occur in individuals who have been exposed “to a severe and extraordinary stressor: a massive fire, hurricane, holocaust, rape, mugging, military combat, or terrorist bombing” (Maxmen & Ward, 1995). In contrast to a normal response to a severe stressor, in which one’s response to it dissipates and diminishes (i.e., the psychological stress experienced by the individual decreases), a diagnosis of PTSD requires that one’s response does not dissipate or diminish over time, but remains at the level at which one experienced the stressor. In fact, those with PTSD often experience greater levels of psychological stress long after the severe stressor (i.e., their psychological stress worsens over time) (Million, Blaney, & Davis, 1999).
Hours to months after experiencing the traumatic event, clients with PTSD may begin to alternate between the two stages of PTSD—namely, intrusion and avoidance. The avoidance stage is usually first to appear. During this stage clients attempt to minimize, deny, and forget their psychological stress (Maxmen & Ward, 1995). Behaviorally, they may “lose interest in life, display constricted affect, daydream, and abuse drugs or alcohol” (Maxmen & Ward, 1995).
In the intrusion stage, clients repeatedly re-experience (against their will) the traumatic event. They may be hypervigilant and flooded with unwanted images connected to the traumatic event (e.g., hallucinations, nightmares, mental images, etc.). They may cry frequently, become agitated and angry easily, as well as develop somatic anxiety. Clients in the intrusion stage are often unable to think about anything else, as they compulsively relive the traumatic event (Maxmen & Ward, 1995).
In addition to psychological symptoms, combat veterans with PTSD frequently display poorer general physical health than combat veterans without a PTSD diagnosis. These veterans often report health problems, complain of somatic symptoms, visit their doctors more frequently, and miss more days of work. A recent study, which controlled for demographic variables, risky behaviors (such as smoking and drug use), environmental contaminates (such as exposure to chemicals and toxins), revealed that Afghani and Iraqi war veterans with PTSD had more physical health problems than Afghani and Iraqi war veterans without PTSD (Jakupcak, 2008).
Veterans with PTSD over and over again present to primary care physicians with physical illness, rather than with psychological complaints. As is the case with most all mental disorders, there is a stigma attached to PTSD—especially within the military culture. Veterans may, therefore, prefer to disclose (consciously or unconsciously) physical health difficulties over psychological troubles. It is important for health care providers to be aware of the link between physical health, mental health, and PTSD. The more health care providers who are aware of this link, the greater the likelihood that veterans with PTSD will get the mental health care they deserve (Jakupcak, 2008).
Although the lifetime prevalence rates of PTSD for the general population are relatively low at 8%, for those who have experienced a traumatic event, the rates are much higher. Combat veterans are unique in that they represent a large group that has experienced traumatic events, which are similar (i.e., the tragedies of war). Veterans of the Gulf War (a brief war in which casualties were low) have a lifetime prevalence rate for PTSD of 19%, more than double that of the general population (Brinker, 2007). For those veterans with extreme traumatic experiences, PTSD is virtually a guarantee. For example, veterans who were captured while fighting in the Pacific theater during World War II have shown lifetime rates higher than 90% (Dikel, 2005).
A recent study of 88,235 veterans who served in the war in Iraq indicated that 69.6% of reservists experienced traumatic, combat-related events, while 66.5% of active soldiers reported similar experiences (Milliken, Auchterlonie, & Hoge, 2007). Although we do not yet know the total number of combat veterans who will be affected by PTSD as a result of their traumatic experiences in Afghanistan and Iraq (as the wars are ongoing), the above figures indicates that there is a high potential that many of these combat veterans may have to deal with symptoms of PTSD long after the fighting has stopped.
Delayed-Onset Posttraumatic Stress Disorder
Clinicians providing mental health services to veterans should be aware that clients who do not currently display symptoms of PTSD may later develop PTSD. This phenomenon is known as Delayed-Onset Posttraumatic Stress Disorder (Andrews, 2007). “The DSM-IV-TR describes delayed onset as a specifier for PTSD indicating that at least 6 months have passed between the traumatic event and the onset of the symptoms” (Andrews, 2007). There is no real consensus on the prevalence of Delayed-Onset PTSD, but some studies estimate that it compromises up to 68% of current PTSD cases (Andrews, 2007).
Reportedly, Delayed-Onset PTSD is high among those who have experienced combat. It has been hypothesized that the symptoms of PTSD are often not expressed while one is still in a combat zone, as they are not an adaptable response to war (i.e., the expression of PTSD may put one at greater risk when one is still engaged in war). PTSD symptoms may, therefore, be unconsciously suppressed until it is safe to express them (e.g., when the soldier has returned home) (Andrews, 2007).
Furthermore, physical injuries may retard the development of PTSD for several months. In other words, soldiers preoccupied with their physical injuries may only begin to express symptoms of PTSD once their physical wounds have healed. The current conflicts, in which the U.S. is engaged, have seen more soldiers surviving injuries that in earlier conflicts would have resulted in death. This is, in part, thanks to advances in medicine and quick evacuation of wounded soldiers. Many of these wounded soldiers may express symptoms of PTSD after their wounds have healed. Military studies indicate that Delayed-Onset PTSD is common among combat veterans returning from the wars in Afghanistan and Iraq (Andrews, 2007).
Subthreshold PTSD is a phenomenon experienced by many veterans returning from the wars in Afghanistan and Iraq. Subthreshold PTSD occurs when an individual has some symptoms of PTSD, but not enough to be diagnosed with PTSD. Like those diagnosed with PTSD, these individuals regularly have other complicating factors, such as substance abuse, unemployment, and interpersonal conflict. Furthermore, they are more like to have physical health problems, as well.
The risk of suicide is elevated for individuals with Subthreshold PTSD. Since the beginning of the wars in Afghanistan and Iraq, it has become apparent that more and more veterans are choosing to commit suicide. There is little doubt that this increase in suicides is the result of mental disorders, such as PTSD and depression, which were precipitated by veterans’ traumatic experiences in Afghanistan and Iraq.
Tragically, veterans with Subthreshold PTSD may go unnoticed by mental health professionals, as they may initially come across as asymptomatic. It is imperative that mental health professionals remain vigilant and consider the possibility of Subthreshold PTSD, especially in regards to clients with traumatic experiences (such as combat veterans). There appears to be a dearth of research on Subthreshold PTSD. Indeed, more research is needed on Subthreshold PTSD in combat veterans in order to ensure that they receive proper mental health care.
Posttraumatic Stress Disorder and Substance Use Disorders
Substance use disorders (SUD) are common among people with PTSD, with some studies indicating a comorbid prevalence rate of 30-59%. These individuals tend to have worse psychological symptoms and treatment outcomes than people with PTSD or SUD alone. Furthermore, individuals with SUD-PTSD are more likely to relapse after receiving treatment than those with only SUD. It is believed that people with PTSD have a greater likelihood of developing a SUD, as they may use drugs and alcohol to self-medicate their PTSD symptoms (Norman, 2006).
As is the case with the general population, there is a high rate of alcohol and drug abuse among veterans with PTSD (Taft, 2007). For those with combat-related PTSD, alcohol and drug abuse is especially high. Unfortunately, treatment outcomes for these veterans are particularly poor (Rotunda, O’Farrel, Murphy, & Babey, 2007).
It is imperative for clinicians to recognize PTSD symptoms in veterans, especially those who have experienced combat. Since it is well known that those with PTSD often use alcohol and drugs as a way of self-medicating their symptoms, it is important to ensure that veterans get proper treatment for their PTSD as means of preventing the development of a SUD (especially, considering that treatment outcomes are better for veterans with PTSD alone than veterans with SUD-PTSD). In addition, veterans with SUD-PTSD are more likely to have occupational problems, aggressive tendencies, and experience more interpersonal conflict (Taft, 2007).
Interpersonal Conflict and PTSD
A recent study found that spouses of combat veterans with PTSD reported higher levels of psychological stress and marital dissatisfaction than did spouses of combat veterans without PTSD (Renshaw, Rodrigues, & Jones, 2008). Several studies have indicated that wives of veterans with PTSD often present with feelings of tension, depression, anxiety, low self-esteem, self-blame, and loss of control, all of which were absent or existed at significantly lower levels before their husband became PTSD symptomatic. Such negative feelings are likely the result of the rigidity, conflict and violence, low levels of cohesiveness, reduction of personal intimacy and self-expression, as well as enmeshment that frequently characterize families in which one spouse has PTSD (Dekel, 2005).
Spouses of combat veterans with PTSD who perceived that their spouse (the combat veteran) did not experience significant levels of trauma reported the highest level of marital dissatisfaction, according to one study. In other words, does who felt that their spouses should not show signs of PTSD (because they perceived their traumas to be insignificant) were most likely to report marital discord. Perhaps, spouses who held perceptions that their wives or husbands were involved in highly traumatic events were more likely to be empathetic and compassionate and, therefore, more likely to endure the negative effects of their spouse’s PTSD (Taft, 2008). Such findings highlight the interplay between mental illness, perception, and interpersonal functioning.
Both male and female veterans, who experienced high levels of combat, reported high levels of PTSD symptoms, which was also associated with poorer family functioning. However, female veterans with PTSD reported the highest levels of family maladjustment (Taft, 2009). Perhaps, this is due to the reality that many women fulfill central roles in their families. Women with PTSD may be unable to fulfill these roles as well as they once could. Indeed, more research may need to be conducted in this area.
Many other factors may contribute to interpersonal conflict for individuals with PTSD. In addition to the “standard” PTSD symptoms, which by themselves surely cause stress in interpersonal relationships, those with PTSD are more likely to abuse drugs and alcohol, be unemployed, as well as have elevated rates of anger and aggression. A recent study by Jakupcak revealed that veterans with PTSD displayed higher rates of anger, hostility, and aggression (2007). According to the study,..
Media and more specifically the movie industry has created a royally skewed picture of mental disorders. This skewed view becomes more evident when considering the group of mental disorders called personality disorders. Upon hearing the term personality disorder one starts to think of the many examples of movies that have made the antisocial personality disorder (or better known as Psychopathy) and multiple personality disorder (which by the way is not considered a personality disorder and is categorized as a dissociative disorder) their main story telling device. This example should be more than enough to show the distorted and unscientific view of personality disorders prevalent among the general public, exacerbated by the media’s portrayal of such disorders.
To have a better understanding of personality disorders it would be useful to first reference the DSM-5. According to the DSM-5 a personality disorder is a pattern of experience and behavior that differs greatly from what is culturally expected from an individual, it is enduring and inflexible and is pervasive and can cause distress or impairment (American Psychiatric Association, 2013, p. 645). What this means in layman terms is that a personality disorder is just like any other mental disorder in that it causes distress and impairment, but it differs from any other mental disorder in that it is stable over time meaning even when symptoms are treated, it is still there and the symptoms will resurface again. That is why the prevalent view is that these disorders are not treatable, but the symptoms can be dealt with (either through medication or therapy) and the daily life of the individual could become manageable. In a way it seems like the symptoms are a part of the individual’s personality, it is just the way they are, and that is why they are called personality disorders. The DSM-5 categorizes personality disorders as such: Avoidant Personality Disorder; Borderline Personality Disorder; Narcissistic Personality Disorder; Obsessive-Compulsive Personality Disorder; Schizotypal Personality Disorder; Antisocial Personality Disorder; Dependent Personality Disorder; Histrionic Personality Disorder; Schizoid Personality Disorder; and Paranoid Personality Disorder (American Psychiatric Association, 2013).
The global prevalence rate of personality disorders stands at about 6% of the world population (Tyrer et al., 2010). This prevalence doesn’t seem to show a systematic difference among different cultures, ethnicities and countries. Thailand, a south East Asian nation with the capital city of Bangkok, falls into the same prevalence brackets. In total, Asia seems to have the same prevalence rates when it comes to personality disorders, still there are some inconclusive evidence that the prevalence maybe lower than the global average (Bernier, Kim and Sen, 2014).
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Bernier G.‐L., Kim Y.‐R., and Sen P. (2014), A systematic review of the global prevalence of personality disorders in adult Asian populations, Personality and Mental Health, 8, 264–275, doi: 10.1002/pmh.1270
Tyrer, P., Mulder, R., Crawford, M., Newton-howes, G., Simonsen, E., Ndetei, D., … Barrett, B. (2010). Personality disorder: a new global perspective. World Psychiatry, 9(1), 56–60.
It is natural and normal for people to feel worried and anxious sometimes. This rather unsavory sensation keeps one on their toes and generally more aware of what needs to be done to get through that feeling. Now try to imagine having that feeling of “worry” all day, every day. How life would be like? Can the individual live a “normal” life, or concentrate on a specific task, be it work or school, to accomplish it to the best of their abilities?
The answer to the above questions is a resounding “No”, and that is what separates normal everyday worriers from “pathological” worrying. This is where Anxiety Disorders come in, and that is why the diagnosis is available. Being worried always and in a disease like manner is not healthy and it certainly disrupts the daily life of the individual and impairs their normal functioning.
These individuals are sometimes informally called “worrywarts” because they just cannot stop worrying about things that may seem trivial to healthy individuals, things such as expecting a disaster in any situation, constant worrying about family members, friends, work, school. In more severe cases these worries extend to even the miniscule details of everyday life such as an appointment with a hairdresser, going out to buy groceries or folding laundry. These individuals seem restless and unsettled and may involuntarily cause negative reactions in others.
Several causes have been proposed for the generalized anxiety disorder, such as genetic factors, brain chemistry imbalance at the nerve endings connecting regions of the brain associated with emotion and thinking, and environmental factors such as traumatic experiences.
The official diagnosis criteria outlined in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are as follows:
“A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
The individual finds it difficult to control the worry.
The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past 6 months):
Note: Only one item required in children.
Restlessness, feeling keyed up or on edge.
Being easily fatigued.
Difficulty concentrating or mind going blank.
Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).
The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
The disturbance is not better explained by another medical disorder.” (American Psychiatric Association, 2013).
The global average prevalence of anxiety disorders was at 7.3% with African cultures having the lowest prevalence at 5.3% and the Euro/Anglo cultures having the highest at 10.4% (Baxter et al., 2013). It has also been shown that anxiety disorders are more prevalent in women, especially Caucasian women in developed countries compared to their counterparts in developing countries. In comparison to those data points, in Thailand, a South East Asian nation, in the capital city of Bangkok the prevalence of anxiety disorders was at 1.4%, according to the Thai National Mental Health Survey 2013 (Sooksompong et al., 2016) which falls on the lower end of the spectrum.
Treatment considerations for Anxiety Disorders include medication (e.g. antidepressants and anxiolytics) and therapy. A combination of both is the preferred method to consider a bio-psychosocial model of the individual.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Baxter, A., Scott, K., Vos, T., & Whiteford, H. (2013). Global prevalence of anxiety disorders: A systematic review and meta-regression. Psychological Medicine, 43(5), 897-910. doi:10.1017/S003329171200147X
Sooksompong, S., Kwansanit, P., Supanya, S., Chutha, W., Kittirattanapaiboon, P., Udomittipong, D., Piboonarluk, W., & Saengsawang, S. (2016). The Thai National Mental Health Survey 2013: Prevalence of Mental Disorders in Megacities: Bangkok. Journal of the Psychiatric Association of Thailand, 61(1), 75-88. Retrieved from https://www.tci-thaijo.org/index.php/JPAT/article/view/54842
Mental disorder is described as the emergence of maladaptive behavior or thought and cognition patterns that impairs the normal everyday functioning of the individual. It is apparent that not every concern related to mental health will be considered a “disorder” or in simpler terms a “disease”. For example it may have happened that at some point you felt sad like the world was ending or really nervous that your stomach was churning, still those can be “normal” happenings of everyday life, meaning that they are limited in duration, and serve a necessary function. The function of sadness could be to help you process and come to terms with the loss of a loved one, the anxiety could be to keep you alert and focused on an important task so you could do it successfully. The disorder designation is used when that sadness or anxiety hinders your life functioning and you cannot be productive anymore and manage your life adequately.
Having that explanation in mind, mental disorders, as categorized by the World Health Organization’s International Classification of Disease (ICD) and the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), are of several kinds. Those are Mood Disorders, Anxiety Disorders, Personality Disorders, Trauma- and Stressor-Related Disorders, Eating Disorders, Schizophrenia Spectrum and Other Psychotic Disorders, Dissociative Disorders, Somatic Symptoms and Related Disorders, Sleep-Wake Disorders, Sexual Disorders, Neurodevelopmental and Conduct Disorders, Substance Use and Addictive Disorders, and Neurocognitive Disorders.
The chances of being diagnosed with a mental disorder can depend on one’s gender, socio-cultural background, and genetic factors and so on and so forth. But the prevalence of mental disorders, in simpler terms, ranges from the not-so-serious to the serious psychotic cases, with the most common types of mental disorders around the globe being Mood Disorders (e.g. Depression), Anxiety Disorders (e.g. Generalized Anxiety Disorder, OCD), and Substance Use Disorders (e.g. drug and alcohol addiction).
Women tend to have a higher rate of Mood and Anxiety disorders compared to men, and men have a higher chance of having a substance abuse disorder. Geographically speaking, North and South East Asia and Sub-Saharan-Africa have a lower reported prevalence of mental disorders compared to other regions, while English speaking countries have the highest prevalence rates (Steel et al., 2014). Thailand being a South East Asian country follows the trends, according to the Thai National Mental Health Survey 2013, in the capital city of Bangkok, the prevalence of mental disorders was at 9.3%, with Substance use disorders having the highest prevalence with 5.6%, followed by Impulse control disorders at 1.6%, Anxiety disorders at 1.4% and Mood disorders at 0.4% (Sooksompong et al., 2016). This geographic disparity could be explained by the cultural practices and beliefs of those regions and how they view a healthy mind and its associated ailments. This point is further discussed in the “Culture-Bound Pathologies” section.
Humans over the course of their evolution, have been and ever more become a social creature, and working within this social paradigm requires an understanding of others, of self in association to others, and what happens in social interactions. This understanding and ability to interact with the environment is called social cognition (Lieberman, 2007). In this sense identifying and interpreting emotions, or having the capacity to understand one’s own or other’s mental state is social cognition (Comparelli et al., 2013). Now the question may come up why social cognition is being talked about here when the topic is supposed to be culture bound syndromes in the broader discussion of psychopathologies. Social cognition is being discussed here to provide a working foundation on the role of culture in the formation and shaping of cognition in individuals and consequently the pathologies that may arise because of those said cultural influences.
The Role of Social Cognition
Research has shown that there are in fact cultural differences in social cognition, there is a culture factor at play in how people understand themselves and others and their environment, for example it’s been shown that children in the US develop this understanding earlier that two individuals may possess totally different beliefs from one another, while children in China develop the understanding earlier that two individuals, with no regard for their beliefs, could be informed or ignorant about certain facts (Wellman, Fang, Liu, Zhu, & Liu, 2006). Other similar studies have shown that Japanese children, compared to their western counterparts, develop the false belief skills later but were better adapted at interpreting situations that strongly depended on inference of implicit social information (Naito and Koyama, 2006). The cultural differences go deep, all through an individual’s life, shaping the thought process of the individual and the way they perceive the world around them, for example studies have shown that when asked to comment about something Japanese participants tend to mention and focus on contextual information and relationships more than American participants do (Matsuda & Nisbett, 2001).
Research has also shown that there are cultural variations in the psychopathologies such as Schizophrenia, for example schizophrenic patients in developing countries seem to recover quicker, and familial interdependency was one of the important protecting factors (Singh, Harley, & Suhail, 2013). When it comes to symptoms of schizophrenia, research again shows a cultural difference, for example western patients tend to have more religious delusions, delusional guilt and delusions of grandeur and persecution when compared to Asian and African patients (Tateyama, Asai, Hashimoto, Bartels, & Kasper, 1998; Veling, Hoek, Selten, & Susser, 2011). Tactile hallucinations occur more frequently in patients from Africa and the Middle East, while European patients report more visual hallucinations (Ndetei & Vadher, 1984).
Coming back to the issue of culture specific pathologies now should make more sense, as the role of culture in the way an individual’s brain works is clearer now. Each culture and their perception of the self, of others and of the environment also plays a huge role in how that culture understands and reacts to symptoms and disorders that deviate from what it considers to be “normal”. One should have in mind that this “normal” is totally arbitrary, where something could be considered “normal” in one culture, while it is not “normal” in another (Koelkebeck et al., 2016).
Culture-bound syndromes or pathologies are clinical presentation forms of symptoms that are culturally distinctive (Kirmayer, 2001). In simpler terms these are symptoms of psychopathologies that are dependent on and only observed in specific socio-cultural environments. Individuals from those environments have a higher tendency to show said symptoms. The prevalent culture and practices of that environment plays a central role in the emergence of those symptoms. There are some well-studied examples such as Koro, Amok, Dhat, Taijin kyofusho and hikikomori, which will be discussed in detail later on.
Still recent literature shows that these symptoms are spreading from their “native” socio-cultural habitat into other, unfamiliar, parts of the world, for example recent studies have found cases of hikikomori (which is a syndrome native to Japan) in the US, India, and Korea, which seems to be a recent phenomenon (Teo et al., 2015; Kato, Kanba, & Teo, 2018). The reverse also holds true, for example western interpretations and symptoms of depression and anorexia nervosa were not present in Hong Kong before the advent of internet and international mass media. It was after being exposed to international, and particularly western media that reporting of similar cases started (Watters, 2011).
It seems as though people were not aware of such feelings or discomforts, and suddenly they found it. That is why some have started questioning the nature of culture-bound syndromes, while acknowledging the socio-cultural roots of said symptoms. They propose that with the availability of information for the average individual, these symptoms do not remain culture-bound for long, which calls into question the usage of “bound” in the name (Balhara, 2011; Ventriglio, Ayonrinde, & Bhugra, 2016). Maybe it would be better to call them “culturally influenced syndromes” or something to that effect. It should be noted that more research and evidence is needed in this regard, and the changes made in the DSM-V paves the way for cultural awareness in the field of psychology and psychiatry (Kato & Kanba, 2016). Alas this word is still in common use, and for that reason it is being used here.
With all that being said, here, a number of Asian culture-bound symptoms will be discussed to give a better understanding of the nature of such pathologies.
We start the discussion with hikikomori. Hikikomori (a syndrome native to Japan) as defined by Japan’s Ministry of Health, Labour and Welfare is “a situation where a person without psychosis is withdrawn into his/her home for more than six months and does not participate in society such as attending school and/or work” (Kato, Kanba, & Teo, 2018).
Hikikomori may be comorbid with various psychiatric disorders, including avoidant personality, social anxiety disorder and major depression, kin addition, autistic spectrum disorders and latent or prodromal states of schizophrenia may have some overlapping symptomatology with hikikomori.
The socio-cultural roots of this syndrome can be traced to the concept of “amae” (presuming and depending upon, and endlessly seeking, another person’s help and affection) and shame. In fact in Japanese language the verb “amaeru” (which amae is derived form) means “depend on the benevolence of others”.
Parent‐child relationships in Japan have always been less oedipal than in Western societies and marked by an extremely prolonged and close bond to the mother, which may result in difficulty to become independent. Especially in hikikomori, the development of basic interpersonal skills during the early stages of life seems to be insufficient, which can induce vulnerability to stress in later school/workplace environments and lead to escape from social situations (Kato et al., 2016). Others have suggested that hikikomori could be because of “a lack of enthusiasm, especially among the young, for entering fully into the life of a community whose purposes they don’t understand or have much sympathy for” (Harding, 2018).
As previously mentioned Hikikomori does not seem to be “bound” to just Japan anymore. Cases have been reported from different countries with completely different ideologies and cultural make up, such as the US and Spain. There has been recent studies that show some form of biological predisposition for this syndrome, which could be the common factor between individuals from different socio-cultural backgrounds (Hayakawa et al., 2018).
Now, we get to Dhat, a very interesting culture-bound syndrome observed in the Indian subcontinent. It is characterized by “male patients fear the loss of power due to the belief of losing their semen through premature ejaculation or from passing semen in their urine”. It is also reported from many other geographical regions such as – Central Asia, China, Russia, America, and Europe. In Asian countries of Sri Lanka and China, the effects of semen loss are described under the names of “Prameha” and “Shen K’uei,” respectively. The patients with Dhat syndrome commonly present with a features of depression, anxiety, multiple nonspecific somatic symptoms, sexual dysfunction, fatigability, and impairment of concentration, which are all attributed to semen loss (Kar and Sarkar, 2015).
So why semen loss would be so important for this individuals that it can create anxiety and depression? The answer lies in the cultural beliefs. The term “Dhat” was derived from songskrito and the ancient Vedic depiction of body fluids called “dhatus” and among the seven different body fluids (dhatus) mentioned in veda; semen is perceived to be most precious one, so leaking this most precious liquid, can make the individual fearful, and even traumatized. The effect of culture is most evident yet again.
Koro is described as “a culture-bound syndrome that involves a belief that one’s penis is shrinking or retracting into abdomen that would eventually cause death or bodily harm, along with anxiety, avoidance behavior and psychosocial complications” (Garg, Das, and Kumar, 2018). It has been reported in in China, East Asia and North-Eastern India as well as among western patients (Garg, Kumar, and Sharadhi, 2017). And there are numerous reports of its observation from around the world in culturally and geographically diverse populations and as part of other psychiatric illnesses (El-Badri and Leathart, 2017). Just like Dhat, Koro is also gender specific, which yet again has roots in its native socio-cultural environment. The emphasis on the “male sex” and “male sexual prowess” and the ability “to father a child” in Asian cultures is considered as the root cause (Elghazouani and Barrimi, 2018). And as mentioned earlier it is not that “bound” anymore as there are reports of cases from diverse cultural backgrounds.
Both Dhat and Koro are male gender specific syndromes with Hikikomori being gender neutral. Now we discuss a female gender specific culture-bound syndrome. That syndrome being Devaki. Devaki refers to the “depression and anxiety that is observed in pregnant women with previous fetal loss due to spontaneous abortions and these women’s identification with a mythological figure – Devaki” (Nath et al., 2015). In other words, the usual fears and anxieties of an expecting mother with history of spontaneous abortions, takes a pathological turn and the expecting mother starts identifying with a cultural mythical figure.
To have a better understanding of this cultural syndrome one should consider two important cultural factors. One has to know what motherhood means in that culture and who Devaki was in the myths. “Queen Devaki, who in Hindu religious mythology had suffered seven losses of newborns who were killed by the tyrant King Kansa (as legend had prophesied that the king would be killed by the son born to Devaki). However the eighth child, Krishna was saved by Devaki’s husband who relocated him elsewhere before Kansa could get his hands on the child.” (Nath et al., 2015).
This shows why women would identify with Devaki. It is giving them hope that maybe, just like Devaki, they will be rewarded too for their sufferings in becoming a mother. The other important issue of what motherhood means in that culture, can be answered by looking at family dynamics in that culture. Motherhood is not simply giving birth, it’s a role and a duty that every woman carries with themselves, and failing at that could lead to a loss of meaning in life. Now the reasons for these women identifying with a mythical figure should be clear. Devaki is different from other culture-bound syndromes we talked about, in that it is female gender specific and it ties in with a very specific mythological figure. Logically it follows that the prevalence of this syndrome in other cultures would be low to nonexistent. The author could not find other studies pointing to the existence of this pathology in individuals from other cultures.
Another female gender specific culture bound syndrome is “Hwa-Byung” which is predominantly observed in Korean women. The word is a combination of “Hwa” meaning “anger” and “byung” meaning “disease”. It manifests in the form of a group of psychosomatic symptoms developed, including depression, anxiety, panic, and lumps in the upper chest, palpitations, or feelings of impending doom. It is the result of suppressing years of anger, frustration, hate, animosity, and other negative feelings toward their family or significant others. When these feelings go unexpressed for a long time (sometimes 30 to 40 years), the aforementioned psychosomatic symptoms develop. It can go undiagnosed or mistakenly diagnosed as clinical depression or anxiety (Choi & Yeom, 2011).
The underlying cultural root cause of this syndrome is the role traditional Korean women are supposed to play as mothers. The culture being “collectivistic” puts an enormous amount of emphasis on maintaining harmony in the family and greater social interactions. Women are considered as the tent pole in keeping balance and harmony, and thus any expression of discomfort or dissatisfaction is heavily stigmatized and frowned upon (Choi & Yeom, 2011).
Amok which has been documented in a number of Southeast Asian cultures is defined as an acute outburst of unrestrained violence, associated with (indiscriminate) homicidal attacks, preceded by a period of brooding and ending with exhaustion and amnesia (Heine, 2015). It is a mostly gender-specific syndrome, occurring primarily in males and is hypothesized to be caused by stress, lack of sleep, and alcohol consumption. Amok is mainly observed in Malaysia and the Malay culture. One theory posits that the prevalence of Amok in Malay culture is caused by the general attitude expected from an individual in that culture, as in in mostly rural areas people are expected to be passive and non-confrontational. Somewhat similar to the Korean “Hwa-Byung” syndrome, when people do not find culturally sanctioned ways to express their anger and frustration, they may finally explode in an uncontrollable burst of anger and aggression (Heine, 2015). Running Amok still occurs in Southeast Asian cultures and the rate has increased in the latter half of the 20th century. Most cases of running Amok end up being killed in action, and the few cases that survive exhibit a divergent set of symptoms that leads to them being diagnosed with a variety of mental disorders including schizophrenia, endogenous depression, and epilepsy (Heine, 2015). One could argue that similar behavior can be observed in Western societies, especially the mass killings that happen in the US, but one big differentiator remains that those mass killings tend to be more premeditated.
In conclusion, these culture-bound syndromes should be considered and studied with greater detail. Not all culture-bound syndromes have been recognized by and included in the DSM and they are still misdiagnosed and are considered as cultural variations of universal pathologies. Understanding the underlying cultural cause can help greatly in differentiating cultural variations from true culture-bound syndromes. Recognizing these pathologies and educating the mental health professionals on their root causes will greatly help the average individual seeking help in any mental health setting, be it in their native country or as immigrants in another country.
I still clearly remember the example that my professor gave when I was studying for my Master’s degree in Linguistics, to highlight socio-cultural differences and nuances in language use. It was a true story about an immigrant Korean family in the US. One day the mother takes their only child out to go shopping. At one moment, for whatever reason, the child lets go of the mother’s hand and runs into the street, one car hits the child and the child dies. The mother witnessing this scene runs to the child, sits beside the child, hugs the child tightly and starts hitting herself, crying something in Korean language. Police comes in and witnessing the situation and not understanding Korean, they ask for someone to interpret the mother’s words. The interpretation was “I killed my child with my own hands”. The police detains the mother for a few hours until everything becomes clear.
The cultural consideration in this case being that even though the child dying was an accident, for a Korean mother it meant that she has failed to fulfill her duties as a mother and that is the reason she uses that specific wording and blames herself.
I guess the same applies in diagnosing pathologies in specific socio-cultural situations, as we mental health professional should strive not to be like the police in our example.
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During normal daily life, one experiences “good moods” and “bad moods”. Upon hearing a good news, like getting a job we love, we feel elated and are in a good mood for the rest of the day or maybe even for days to come. Similarly at the same time, hearing an unpleasant news, like the loss of a loved one, could put us in a bad mood for the rest of day or even for days to come. The experience of these normal emotions should not be confused with a mood disorder. Professionally, the disorder designation is only used when the everyday emotional state of the individual is affected and that makes them unable to function normally and productively.
Imagine a scenario in which an individual loses someone s/he loves. We can all agree that feeling sad and grieving for a period of time seems “normal”, but the person should still be able to care of themselves and their everyday affairs, and they usually come to terms with the loss and move one with their daily lives. In this scenario, if the individual in unable to move on and the feelings are sadness are with them 24 hours a day and seven days a week, then they would not be able to take care of themselves or go to work or study. In other words their daily routine is interrupted and that makes then unable to adapt to normal daily life challenges.
Our imaginary scenario just described a mood disorder, namely major depressive disorder. The distinction between “just feeling sad” and the “clinical depression” (as it is commonly called) should be clear now. In fact the word depression and its derivatives are so commonly used to refer to the normal and usual experience of sadness and general low mood that a new term had to be used to distinguish the “real” pathology (disorder) cases. That is how the “clinical depression” came to be used.
The official diagnosis criteria outlined in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are as follows:
“1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation.)
Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
Insomnia or hypersomnia nearly every day.
Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide” (American Psychiatric Association, 2013).
According to the DSM-5 to be diagnosed with major depressive disorder 5 (or more) of these symptoms should be present in a 2 week period and should be a sign of a major change from previous functioning patterns.
In other words, major depressive disorder, generally has 2 distinct sets of symptoms, namely the emotional or affective symptoms and the physical or somatic symptoms. Examples of affective symptoms include experiencing generally sad mood for extended periods of time (more than 2 weeks), loss of interest in activities previously enjoyed, feelings of hopelessness and helplessness, low self-esteem and slow self-worth. Examples of somatic symptoms include the afflicted individual feels fatigued and has low energy to cope with daily life demands, experiencing sleep problems, chronic pain usually in the form of headaches, feeling heavy in the chest area, and digestive problems.
Depression is a common affliction across the world, with its lifetime prevalence being in the 10% range, “with higher prevalence in women (14.4%) and in countries with a medium human development index (HDI) (29.2%)” (Lim et al., 2018).
It is interesting to note that representation of depressive symptoms is different across the world, with the more developed, western countries showing the more affective symptoms and the less developed, Asian countries showing more of the somatic symptoms.
As a point of comparison, in Thailand, a South East Asian country, according to the Thai National Mental Health Survey 2013, in the capital city of Bangkok, the prevalence of all mood disorders (major depressive disorder included) was at 0.4% (Sooksompong et al., 2016) which is considerably lower than the global average. The main explanation could be the expression of somatic representations of depression. People feeling depressed, express their situation in more somatic forms, such as experiencing headaches, feeling tired, having trouble breathing and general stomach problems. That is the reason that the individual will seek a physician for their complaints instead of consulting a mental health professional. The social stigma associated with mental health problems should also be noted as an important deterrent in seeking professional help.
Depression, in any form, should be dealt with and professional help should be sought as it can be life threatening in its more severe forms. Fortunately, depression is treatable and the treatments include therapy and medication.
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The worldwide prevalence of Obsessive-Compulsive Disorder is about 1% to 2%. It occurs worldwide, including Bangkok, Thailand, with similar symptoms across multiple cultures. The average age of onset is about 20 years old and usually does not occur after the age of 35. It often affects women more than men.
OCD is often regarded as an anxiety disorder, although DSM-5 places in its own category along with other disorders, such as body dimorphic disorder and hoarding disorder. It is characterized by uncontrollable obsessions and compulsions. Obsessions are considered unwanted thoughts, while compulsions are the behaviors that people engage in to try to get relief from the anxiety-provoking obsessive thoughts. Compulsions are often repetitive and ultimately only provide temporary relief from the unwanted obsessive thoughts.
For example, a person with obsessive thoughts regarding cleanliness (fear of germs or disease) may repetitively wash his or her hands in hopes of satisfying the obsessive thought. However, the compulsions only serve to further engrain the obsessive thinking. In addition, some may avoid people, places, or things that trigger the obsessive thinking. This avoidance behavior can become debilitating, as people with OCD may miss work and avoid other responsibilities.
Only about 20% of people with OCD will improve without treatment. Those with early onset if OCD may have it for a lifetime if they do not seek out psychological treatment. OCD may be exacerbated by co-occuring disorders, such as substance abuse and addiction or depression. Some with OCD may abuse drugs or alcohol in an effort to self-medicate their OCD.
OCD should be taken seriously as about 50% of people with OCD will have suicidal thoughts and 25% will attempt suicide.
OCD usually affects the entire family of those with it and may lead to individual suffering from OCD to become socially isolated as those around him or her have difficulty tolerating his or her behavior.
Recent research has found that OCD occurs more often in those living at higher altitudes, which is believe to be connected less exposure to sunlight. Additionally, “night owls” were found to have higher rates of OCD. Again, this is connected to diminished exposure to sunlight, as these individuals often sleep throughout the day and leads to a disruption in their circadian rhythm.
People who are overly sensitive to anxiety of display a high fear of fear usually have poorer treatment outcomes for OCD.
Person-centered therapy, cognitive behavioral therapy (CBT), and exposure therapy may be effective in improving symptoms of OCD. Medications, such as SSRIs, are also effective in providing relief from OCD.
However, those with a high sensitivity to anxiety may respond well to exposure therapy. Exposure may evoke too much anxiety in these individuals which they may see as failure of treatment. This, in turn, may cause them to drop out of treatment, according to research.
Treatment of OCD is available in Bangkok, Thailand. There are multiple psychologists, counselors, and psychiatrists who are qualified to provide treatment of OCD. Lighthouse Human Services in Bangkok offer psychological treatment for OCD.
Although there are people may grow out of ADHD in some cases, it often persist into adulthood. Indeed, some researchers argue that it is a lifelong disorder that many adults have simply learned to manage and have only learned improved coping skills over time. That is, they have not grown out of it, but there improved coping skills means that ADHD no longer causes significant problems in their lives.
In this regard, ADHD may be considered unique from many other mental health disorders, as it is not episodic. That is, it does not appear for discrete periods of time, such as is the case for some mental disorders like depression or anxiety. Indeed for those who have not learned to cope with it, problems often persist or worsen into adulthood resulting in lifelong impairment from ADHD. Furthermore, at certain transitional points in an adults life, such as when transitioning from high school to university or university to the working world, ADHD symptoms may worsen, complicating the transitional process.
In fact, many people with ADHD go undiagnosed until they reach adulthood. Although the symptoms were always present since childhood, due to the complexities of ADHD as discussed above, many adults did not have their ADHD properly identified as children or adolescents. Later in life, as adults, these individuals usually will recall a lifetime of ADHD symptoms beginning very early in life as children.
As in children and adolescents, comorbidity is very common. Adults with ADHD may also have anxiety disorders, depression, and substance use disorders. Although various treatments may be effective for ADHD in adults, medications remains the most effective treatment option. In addition, it is important to address comorbidities, such as anxiety and depression, as well as family or relationship dysfunction that often results from ADHD.
In some instances, ADHD result in positive effects, according to researchers. In those adults for whom ADHD is advantageous, it appears that these adults have developed unique coping strategies over the years. For example, they have learned to minimize the negative effects of ADHD, while possibly retaining the some of the positive aspects of ADHD. People with ADHD may be more creative and better at multi-tasking.
Nevertheless, adults who are able to learn to cope well with ADHD appear to have certain prognostic factors, which appear to predict better outcomes, such as not having a co-morbid mental health disorder, having strong psychosocial support, and living in a culture where ADHD treatment is readily available. This is illustrates the importance of improving awareness of ADHD in Thailand, as ADHD not only negatively affects children and adolescents, but adults and their families, as well. However, when adequate treatment and understanding is present, positive effects of ADHD may be enhanced, while the negative effects are limited.