Amy Merker, M.D.

In order to merit this diagnosis, a person must have at least five of the following symptoms nearly every day for at least two weeks: Sad mood, tearfulness, psychomotor retardation, decreased energy, diminished interest or pleasure, insomnia, poor appetite, weight loss, poor concentration, feelings of worthlessness, hopelessness, or excessive guilt, and suicidal ideation.

This is the most common type of major depression. However, there is also an atypical type of major depression where individuals' experience increased sleep and appetite, rather than decreased.

Both of these disorders are considered Unipolar mood disorders because there is only one direction the mood tends to swing to. The other type of Major Affective Disorder is called Bipolar Disorder because the persons' mood tends to swing in two directions, (thus it is called Bi because of the two poles). Major Depression and Bipolar Disorder are differentiated by whether or not an individual has ever had a manic episode. The person with a major depressive illness has recurrent depressive episodes throughout their life, whereas the Bipolar patient, or Manic Depressive as they once were called, have periodic depressive episodes and have had at least one manic episode in their lifetime.

• Definition of a Manic Episode: One or more distinct periods, (few days-weeks), with a predominantly elevated, explosive or irritable mood, and at least three of the following symptoms: increase in activity or physical restlessness, more talkative--difficult to interrupt, jumping from one topic to another very rapidly, (flight of ideas or loose associations), inflated self-esteem, (delusions of grandeur), decreased need for sleep, (can stay up for 3-4 nights cleaning etc.), easily distracted, excessive involvement in activities with a high potential for painful consequences--like buying sprees, foolish business investments, or sexual indiscretions, i.e., poor judgment.

• People with a Bipolar Disorder may even become psychotic during a manic episode. In other words, they may lose touch with reality. They may hallucinate or experience delusions.

• Definition of a Delusion: A "fixed false belief which no amount of objective evidence will change."

These individuals are usually quite ill. This is considered a psychotic disorder. In other words they are out of touch with reality. They experience delusions and or hallucinations. We have already discussed delusions.

• Definition of a Hallucination: A false sensory perception in the absence of any external stimuli, not merely a misinterpretation of something that is really there, (i.e., not an illusion).

• Most common auditory hallucination

• Disorders of thinking

• Loose associations or flight of ideas

The predominant symptom in this group of disorders is obviously anxiety. These folks are considered neurotic, not psychotic because they are in touch with reality.

This category includes:

Panic Disorders with or without Agoraphobia, Obsessive-Compulsive Disorder, Social Phobia, PTSD, and Generalized Anxiety Disorder.

• Panic Disorders consist of sudden distinct episodes of extreme anxiety which include four or more of the following symptoms: Shortness of breath, heart palpitations, chest pain, dizziness, sweating, shaking, or a fear of loosing control or dying. These individuals may also have agoraphobia and are afraid to leave their homes. Agoraphobia means literally fear of open spaces. These people often find it very difficult to be in a crowd. For example they may get overwhelmed and experience a panic attack in a grocery store.
  

• Obsessive Compulsive Disorder is characterized by recurrent obsessions or intrusive, unwanted thoughts, or compulsions, which are repetitive behaviors or mental acts which the person feels driven to perform in response to and obsession or according to certain rules or rituals. The individual realizes these thoughts or actions are abnormal or excessive, but feels unable to control them. They are a significant source of distress to the individual or interfere with social functioning. In other words, these are more than merely excessive worries about real life problems.

We all have certain personality traits that we have developed over the years. These are enduring, ingrained patterns of perceiving and relating to the environment and ourselves. When these personality traits become inflexible and maladaptive and cause either significant impairment in social or occupational functioning they constitute a personality disorder. Examples include:

• Narcissistic, Paranoid, Avoidant, Dependent, Anti-social, Histrionic, Schizoid, Passive-Aggressive, and Borderline Personality Disorder.

A pattern of pathologic use involves intoxication throughout the day, the inability to stop or cut down, or black outs.The difference between alcohol or substance abuse verses dependence is that someone has become dependent if they have developed tolerance or withdrawal symptoms. Tolerance is the need for markedly increased amounts of the substance to achieve intoxication. Withdrawal symptoms include tremor, nausea, agitation and seizures.

It is also important to determine if they have had to miss work because of their abuse and if they have had any legal problems, such as an OMVI.

Intense fear of getting fat

Disturbance of body image - Think they are fat even when thinWeight loss of at least 25% of original body weight

Refusal to maintain body weight over a minimal normal weight for age and heightNo known physical illness that would account for weight lossAmenorrhea

Recurrent episodes of binge eating - rapid consumption of large amounts of food in a discrete period of time, and a sense of lack of control over eating, (often eat in secret)

Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, fasting or excessive exerciseThe binge eating and compensatory behavior both occur at least twice a week for 3 months

Preoccupation with weight and shapeNot due to any physical disorder

The RED FLAGS to look for in discerning if someone needs professional help are:

1. Suicidal Ideation

   This must be asked directly if you suspect someone may have thoughts about hurting themself. It's important to get them to verbalize these thoughts, since they are less likely to act on them if they talk about it. Ask them if they have thought of a plan. Also ask them if they've ever had these thoughts before or ever made a suicide attempt in the past. If they say I wish I were dead, this is not taken nearly as seriously as if they say I'm thinking about taking an overdose. If they have a plan it must be taken seriously and you should take them to Harding Emergency Services, Riverside E.R., or a Community Mental Health Center.

2. Need for Medication

   If an individual is psychotic, significantly depressed, or experiencing O.C.D., they ought to be referred for an evaluation by a psychiatrist in order to determine if they need medication. Individuals with symptoms of Major Depression, Bipolar Disorder, and in some cases Dysthymic Disorder will likely need anti-depressant medication.

   People with O.C.D., Panic Disorder with or without agoraphobia may benefit from medication.

   Obviously those with a schizophrenic illness will need an anti-psychotic.

3. Need Hospitalization

   If suicidal or homicidal they need to be admitted. These days that is about the only way to get someone admitted to the hospital. If they are psychotic and unable to care for themselves then they may also be admitted.

4. Need for Detox

If they are dependent on drugs or alcohol they may need to be hospitalized in order to be detoxed. This is because if someone who is dependent on alcohol stops drinking cold turkey they are at risk for withdrawal seizures. In the hospital their vital signs can be monitored closely and they can be administered medication which can prevent withdrawal seizures.

It is helpful to look at hurting people in terms of these types of symptoms. If you suspect someone is depressed, for example, you may want to inquire about their sleeping and eating patterns in order to assess the severity of their depression. It is also crucial to ask if they have had any thoughts about suicide. If so, ask if they have a plan or a history of attempts.

If you are living in a ministry house and you notice food continues to disappear, you may have a bulimic living among you. You will need to directly confront them about their binging and purging, since secrecy is paramount to the bulimic and openness is key to their recovery.Obviously if someone becomes delusional or begins hearing voices, you would want them evaluated as soon as possible.Your job as leaders is to encourage them to see a professional. You can take them to Riverside's E.R. (566-5000), Harding Hospital Emergency Services (785-7400), or a Community Mental Health Center such as North Central on High Street just south of Campus. You could try to contact me or Dr. Larry Pfahler, who is a Christian psychiatrist in Worthington and has a practice called Alpha Psychiatric Care with several psychologists and social workers.

Go to Servanthood 2 Class Notes

Read More in "When to Refer People for Professional Help" by Jeff Gordon, M.D.