Obsessive-Compulsive Disorder, OCD, like other mental illnesses occurs on a continuum, or in layers of complexity. It is based on anxiety that underlies irrational fears and concerns than can only be discharged by carrying out a ritual of activities. We can think of OCD as a two-part problem; the thought or irrational concern is the Obsession, and the implementation of the ritual is the Compulsion. For example, someone may have an unreasonable fear of germs, an obsession, and to make themselves feel better, they wash their hands multiple times, the compulsive ritual.
To some degree OCD is common for many people but it is not a problem that is debilitating. A good case can be made that superstition is based to some degree on this disorder. If there is a concern that walking under a ladder can be disastrous to ones well being, then avoiding walking under one will "protect" the believer. For this type of irrational concern, walking around the ladder will stop something bad from happening. If you ask what may happen if they do not comply, they simply cannot provide a rational answer. But, this suggests some type of learned behavior that provokes compliance.
Numbers also play a large part in the lives of many people. Whether it is a lucky number, or a number to be avoided, numbers have a strong yet unreasonable power in some otherwise rational individuals. Another example of an illness with anxiety as a base is hoarding. The inability to discard even useless items satisfies the anxious individual as having OCD. The following short vignette illustrates the extreme level to which OCD can be seen:
Tom was a male in his mid 40's and lived in a rural area with his parents. He cannot remember a time when life was not controlled by irrational concerns and fears. His life was consumed with numbers and the absolute need to follow a well-learned behavior pattern. When he went through a doorway, he had to enter and return exactly 13 times and if he lost count, he would have to repeat the process. He drank water and when he opened his container, he would have to tap the lid 13 times and then drink 3 times before closing the bottle. His medication was taken at exactly 30 minute intervals with the water ritual. The illness was so pervasive that he had to control his body as well. He was only "allowed" a bowel movement every three days. When challenged to explain any of his patterns he could only say that if he did not follow the ritual, something bad would happen.
Despite the incredible demands of his illness, Tom felt that his life was normal. The thoughts that I had when visiting him were that even with a large number of medications and therapy, his OCD never improved. OCD and brain activity is being investigated as well as the learned behavior and with time, I hope to see Tom gain some control over his own destiny.

Over the next ten years Paul continued to experience bouts of panic but they had become very sporadic. There were times that several weeks would pass but produced no attacks. At other times, the panic would strike again and he would retreat to the learned behavior of returning home for safety. He feared being in public when the attacks occurred and planned his activities around them. He stayed close to home, and began anticipating panic almost continually. He was afraid of fainting, having a heart attack, and losing control of his rational thinking. He even considered suicide as the panic sometimes consumed his thinking.
Paul continued to seek treatment and consulted with at least two more medical doctors and entered therapy with a psychiatrist. But, the diagnosis was always the same; anxiety and panic disorder. But, Paul had adapted to his panic and the anticipation of panic. He could work and at times use sickness to leave work, or use the restroom at work to let the attacks pass. For the entire ten years, Paul was using tranquilizers to just barely function.
And then, one day at work, his heartbeat was so rapid and he was sweating so much, that he felt that a heart attack was imminent. But it felt different than usual and he was  truly afraid that he would die this time. He called a nearby cardiologist and described the symptoms to the nurse and she advised him to either go to the emergency room or to their office right away. Paul feared the hospital and opted for the office visit.
Upon arrival, he was given an EKG, blood was taken, and a stress-test was started but could not be completed. His heart rate was already so high that it exceeded the stress-test parameters. The EKG showed no heart problem, and the cardiologist realized that there was something unusual happening but did not discuss anxiety. He gave Paul a shot using a tranquilizer to slow down the progression of elevated heart rate and advised him to return the following day to review the blood work and plan a strategy.
The visit on the following day changed Paul's life in several ways; first, there was no heart concern, and second, his thyroid levels of TSH, (Thyroid Stimulating Hormone) were sky-high! The cardiologist recognized Paul's problem as Graves Disease, or hyperactive thyroid. There was no anxiety or panic disorder, but a biologically based problem. High levels of TSH show all of the symptoms that Paul had been suffering with for years. A referral to an endocrinologist confirmed the thyroid problem and Paul had the thyroid surgically removed. He is now on a synthetic thyroid replacement medication and the panic has subsided. But, you would infer from this procedure  that if the symptoms were from a hyperactive thyroid, and if  the removal and subsequent correct levels of TSH were consistent, the problem with anxiety would be resolved. Not quite so!
The brain is a very flexible and pliable organ and can be programmed and re-wired with learning. Over the years that Paul's "anxiety" had been diagnosed, he learned to fear many of the environmental parts of life. Being in public places, waiting in line at stores, being in stopped traffic, and several other common occurrences continued to be anxiety producing events. It may take years to "unlearn" these destructive behaviors.
We tend to believe that medical doctors and professional psychiatrists have the ability to diagnose and separate biological and psychological problems. But, in Paul's case, at least four doctors and two psychiatrists failed to identify the underlying physical problem causing the anxiety. And, I continue to see the same mistake being made all of the time. For me, the take away here is that we have to be strong advocates for ourselves, and not accept the diagnosis that doctors make at face value. Ask questions, seek alternative opinions, and consider all of the options available. Doctors are human and make mistakes, but that alone should prepare us for being proactive. And it is important to remember that some anxiety is perfectly normal and comes with life. But, when it becomes an interference in daily life, then, seek some assistance and correction.
Next time we will investigate obsessive-compulsive disorder and the remaing topics associated with aniety...

We are going to begin the discussion concerning anxiety disorders with an illness that affects about 10 million adults, with almost twice as many women patients as men. This is a disorder that I believe is under reported and the number may be much higher. It is panic disorder, and has several aspects that are sometimes difficult to describe and understand. The primary symptoms are basically physical in nature, but are complicated by an individuals assessment of the bodily responses. The patient has the sense that they have lost control over the situation they find themselves in and may suffer rapid heartbeat, sweaty hands, shakiness, and a feeling of great dread. Often, the patient believes that they are having a heart attack, losing their mind, or, will at least certainly pass out. The origins are not completely understood but make life almost unbearable for those suffering with the disorder. This will be the first of several stories or vignettes that illustrate how the disorder starts, and how it can become can become unmanageable. My assessment on these events will be italicized to offer some insight.
Paul was a 22 year old freshman in college and was just beginning his second semester. The first semester went well and he had confidence in his ability to continue to do well in school. But, one day in a class, his life changed, and now, some 20 years later, he is still dealing with that first attack of panic. It began with a strange sensation washing over him that he was unfamiliar with. His heart began to beat fast, his hands became sweaty, and he felt almost like he would faint. Feeling very insecure, he left the class and returned to his dorm room to lie down and try and recover. After an hour or so, he felt better and decided to go to another class later in the day. But, the same feelings occurred again and he left the second class. He now began to worry that something was wrong and went to the college health clinic. There, a doctor advised him that it was an anxiety attack and prescribed a tranquilizer. During the next week, despite the use of a tranquilizer, the attacks continued, and he followed the earlier strategy of leaving class and returning to the safety of his dorm room. Two things are very important at this point and need to be considered. First, Paul reacted to the "attacks" by escaping to the safety of his dorm room. Second, the attacks were "officially diagnosed" as anxiety. What he was learning was that he had some condition that caused anxiety, and that the best course of action was to get away from the situation. Both of these factors set Paul up for the continuation of his reactions to panic attacks.
In order to keep these post entries short enough to read easily, I will continue Paul's story with the next post. As always, comments are welcome and encouraged.

As mentioned in the previous post, anxiety is one of the most prevalent and persistent conditions in the mental health field. The National Institute of Mental Health reports the number of US citizens at between 40 and 50 million persons. There is further evidence that more women suffer from anxiety than men. It is evenly spread over ethnic and religious backgrounds and is indiscriminate in its selection of patient sexual orientation. I believe that this number is very much an underestimation, and there are many people who I consider "silent sufferers". There are also conditions where anxiety is a part of another illness and remains under reported. For example, although alcohol is a central nervous system depressant, many of those with alcohol addiction also have anxiety issues that are simply not considered reportable. So, the issue of anxiety becomes a central part of our exploration of mental illness and it will take more than one post to fully cover the significance of this problem.
Anxiety occurs along a continuum from daily worries to being completely debilitating. We are all familiar with the stress associated with starting a new job, speaking in public, or any other number of life events that cause temporary anxiety. Generally, we accommodate the short-term distress, and move on with our lives. This type of anxiety is more like a reasonable fear in that it is focused, and has potential for being very short-term. But, the following anxiety conditions with a brief description have a more significant and long-lasting impact:
Panic Disorder: Patients with this disorder experience terror and a loss of control. It is anxiety that has no apparent trigger stimuli, causes sensations of rapid heartbeat, sweating, and sometimes chest pain, a desire to seek safety, and a sense that either a heart attack or death is occurring, and has no rational explanation.
Obsessive-Compulsive Disorder (OCD): Patients with OCD have ongoing thoughts and fears that cause them to perform rituals and routines that they believe will protect them from something dreadful happening. The thoughts themselves are considered the obsession, and the rituals are the compulsions. The classic example is that of the person concerned with germs who washes their hands continually despite the risk of any real infection.
Post -Traumatic Stress Disorder (PTSD): The issue of PTSD can follow any event involving trauma, such as the death of a loved one, sexual assault, military combat, or natural disasters. PTSD patients suffer frightening memories, and develop a numbness to the world around them.
Social Anxiety Disorder: This disorder causes patients to be overly concerned and worried when in a social setting, fearing to be judged and being embarrassed or ridiculed.
Specific Phobias: This condition involves an intense fear of particular and specific objects or situations. For example, fear of snakes, flying, heights, elevators, with the fear being disproportionate to the actual object or situation.
Generalized Anxiety Disorder: This is a condition where the patient has an excessive and unrealistic worry about almost anything in life. It is a pervasive condition where anything can be a threat.
As a case manager, I have been involved with all of these anxiety conditions and can attest to the fact that these are really just the tip of the anxiety iceberg. With the next post we will begin to look at each of these illnesses and I will share composite vignettes to illustrate these examples of anxiety.

In the previous post I suggested that a workable system exists for the diagnosis of mental illness. And, that remains true, but, there are several concerns about how the complete system really functions. To begin this post we have to consider how mental illness is first discovered, and what happens when there is evidence of an emerging problem.
Consider for a moment that as the early stages of a mental illness are observed, it will probably not be with a qualified mental health professional. It may be a parent, teacher, guidance counselor, friend, or family doctor who are the first to see some behavior that draws attention to the "potential" patient. Or, in fact, it may be the person with the problem who self-identifies and seeks assistance. So, it becomes very important when a problem emerges, that it is managed correctly. Unfortunately, this is not always the case.
Let us for the moment consider little Johnny sitting in the classroom. He is fidgeting, talking with other children, and not "behaving" as he should. The teacher makes an observation of the behavior and if it is occurring more than the teacher believes that it should, the guidance person is consulted. If it continues, the parents are asked to come in and discuss the inappropriate actions. And, at some point, the term ADHD (Attention Deficit Hyperactivity Disorder) may be applied as a consideration for the behavior. And, while it could simply be boredom, lack of interest, or an excess of sugar in the bloodstream, ADHD, the most over- diagnosed and over-medicated adolescent problem in the US will now be attached to this child. And, once the seed is planted, the label will stick.
Or, what will happen if an adult goes to the family doctor with symptoms of lethargy, reduced libido, and a general lack of interest in everyday life? (Recall that symptoms are what the patients describes, and signs are what the doctor observes). In this case the doctor can not see the symptoms, and can react to the report in several possible ways. The doctor can refer the patient to a mental health professional, suggest a "wait and see" scenario, or prescribe an anti-depressant. In many situations the medication approach is the easier of the alternatives and is frequently followed. Although the doctor is a trained professional, the most recent exposure to psychiatry was during  a clinical rotation in medical school. So, like many doctors, the biochemistry of the patient is not considered, but, may in fact be the cause. Unfortunately, after any discussion of depression with a doctor, the seed of depression is planted in the patient's mind.
In our stress filled lives with fast cures and medication, our culture fosters many incorrect and misleading conclusions about underlying reasons for mental health problems. And although what I have presented is a simplistic and quick view of system failure, it really is a cautionary vision.
So, despite the fact that we have good diagnostic guidelines in place, we are frequently victims of the structure and the culture of our society. We need a better way of communicating the recent advances in brain chemistry to those we trust with our mental health.
The next post will begin with anxiety, one of the most perplexing and prevalent mental disorders. It can be a stand-alone condition, but anxiety also accompanies many other illnesses.

There is one more vital area to cover before we begin to look at the specific illnesses that are the subject of this series and in fairness, will require two parts. We have to ask how is mental illness  diagnosed and who is qualified to make this critical evaluation? The answers to these questions are a bit complicated based on my experience and close examination of the mental health system. And, while it may seem fairly straightforward, there are aspects of the diagnostic protocol that need reform.
First, let's consider the fact that all structured investigations have guidelines for determination of whatever facts are needed. Metal illness is no exception, and this structure comes from the American Psychiatric Association. They publish the DSM, (Diagnostic and Statistical Manual of Mental Disorders). The current edition is the DSM-IV-TR, which is a text revision. There is a new version due in 2013 from my understanding. This is the guideline manual that covers all recognized mental illnesses and the criteria needed for evaluation. All mental health professionals use this manual in the US, and it is the basis for all diagnostics in mental illness.
The DSM uses a mufti-axis model to allow the health professional  to qualify and semi-quantify a particular illness. It is a five axis system and although it seems complicated, it is a workable system. I will cover the axis's briefly here, but there will be more as we look at mental illness more deeply.  Axis I is the clinical syndromes or what we might call the primary diagnosis. Example might be depression, schizophrenia, bipolar, etc. Axis II are the developmental and personality disorders. The developmental disorders are those typically discovered in childhood as autism and mental retardation. The personality disorders may be collective syndromes as paranoid, antisocial, or borderline personality. Axis III looks at the physical condition of the patient and might consider brain injury or other physical condition that may impact symptoms of mental illness. Axis IV in the severity of psychosocial stressors such as death of a loved one, divorce, or job loss. Axis V is a global assessment of functioning and that considers at what level the patient is now functioning, and the highest level in the previous year.
Hopefully, in this post entry, there is some understanding of how mental illness is diagnosed and the strategies that have been useful in designing treatment and general prognosis protocols. In part 5, we will consider how this system really works and what can go wrong with the use of the guidelines discussed.

Before we can begin the exploration into the world of mental illness we have to consider two significant aspects of the development of the science of the mind and cultural expectations and popular understanding.
The first important factor to look at is the historical view that we have had about the condition of mental illness, and how we perceive it currently.
For most of our past history until the middle of the 20th century, mental illness has been poorly understood and very poorly managed. The fact that anyone who exhibited behavior that was atypical or significantly out of the norm, suggested that they should be isolated from the "normal" population and secured lest they hurt themselves, or others. From early medieval times, it was the church that determined whether or not an individual was either just blasphemous, or was truly insane. (Insane by the way is a legal term and not a clinical definition). But, the only way to isolate anyone was to create an ersatz "treatment facility" but in reality, a prison, where treatment was essentially non-existent. Even into the early 20th century, treatment consisted of submerging a patient in ice cold water, deprivation of food, and water, and not allowing interaction with other patients. But, simultaneously, the science of psychiatry was being developed  and non-typical behavior was being reconsidered as a disease or illness. And, with both WWI and WWII, the reality of "shell shock" the precursor to PTSD, post traumatic stress disorder, was recognized and the effort to treat rather than isolate became more common.
But, in the 1960's and 1970's, many changes began to redefine mental behavior and to look at hospitalization as a sentence and not a cure. Medications had been developed that could significantly reduce symptoms of many mental illnesses, and psychiatry had become a mainstream treatment modality. A bold new idea was becoming a real plan to treat mental illness. The concept was simple; set up treatment centers that were staffed with a psychiatrist, therapists, and mental health professionals, and begin to have patients in hospitals return to their homes and community to be re-integrated into a more normal setting to recover. Please notice that I have not used the word "cure" as many mental illnesses are not curable but rather can be managed to provide some level of consistency for the patient. The treatment center concept was a means for supporting recovery and providing a significantly better quality of life. And, to a large degree, the concept has been successful. There are now treatment centers across the US and these are funded by State and Federal dollars, as well as by private money. But, that is not the end of the story.
We still have the stigma of mental illness as a problem no matter how it is treated. We have a patchwork of cultural understanding and tolerance. For family members dealing with mental illness or developmental disability there is an understanding of the difficulty and challenges facing chronic illness patients. For mental health professionals, the challenge is to find new ways to educate the public and increase the opportunity to assist those with marginal capabilities. But, there is always the persistent misconception that mental illness equals danger. There are many crime dramas and news stories about serial killers, sociopaths, psychopaths, and the threat to personal safety. I would be remiss to say that these threats do not exist, but the reality is that the threat is much less than the perception would suggest. I will not shy away from this reality but it is more important to look at the successes rather than the failures. It is the same as believing that because there are traffic fatalities, we will all be a statistic.
In the next post    we will consider how a mental illness is diagnosed, and how treatment is determined. But, I would like to offer a link to NAMI, The Alliance on Mental Illness, a national organization for the dissemination of information and resources for the public. Here. Thanks for following these posts, Ken...

As we continue our journey into the world of mental illness we have to ask, what is mental health? Is there a "normal", "typical", or "average", measure that we can use to suggest exactly what is "good mental health"? I hesitate to use these terms but I use them to provide context, and not to  mislead anyone to believe that there is a standard  which we can use to understand such a complex issue.
As I mentioned in the first post, mental health and mental illness rest on a continuum, and can be sometimes difficult to define. But, let's look at physical health as a way of understanding mental balance. There are times in each day that have ups and downs with regard to how we feel physically. Some people are wide awake early and feel good and ready to face the day. Others are a bit slower to adapt to the day and face a more difficult start. And, during the day, we often have a good outlook, and at other times, the day seems to drag on forever. And what happens if we have a cold, started the day with a backache or stiff neck from sleeping? At any time of the day we have may have some minor malady that colors the way we feel physically. And, if we had taken a snapshot at any time of day, the result would be only a brief look at how we felt, and only at that time. It is only when we evaluate the entire day that we have a feeling of good or poor physical health. It is important to recognize that most of our reflection of a day in our life is based on perception! So, for example, what if you have a backache that is causing a problem? It can be acute, and only troubling periodically, or chronic, and  a constant discomfort in your life. But, the manner and methods of dealing with the problem determines your perception of how good or bad you feel.
So now, let's translate this analogy into the world of mental health and wellness. At any time of the day you may encounter traffic problems, road rage, a situation at work or home that can be considered a disturbance from the norm. And, worse, it could be the dissolution of a relationship, personal trauma with a death, or other unbalancing of what would be considered typical. And, the manner in which you deal with these occurrences and perceive the impact on your life, defines mental health for you. and only you.
So, is there a way that we can measure our personal or individual mental wellness? The answer really becomes a question of how we perceive our life, how we react to the ever changing world around us, and how we manage to integrate the bad with the good. By definition, the normal, typical, or average, is different for each of us and sometimes extremely difficult to quantify. We live in a complicated world with ever.changing stimuli, and life changing events, but we can control the way we see, hear, and react to those changes. But, what happens when the situation cannot be controlled due to brain chemistry, and an inability to have any insight of perception? We will begin to explore the world of mental illness in the next post. Thanks for following this journey...

This is the first entry in an in-depth investigation of mental health and wellness. This is a complex issue and I hope to make it interesting and relevant to life in the 21st century. Mental health and mental illness follows a continuum and it is very much a personal subject. So, before I begin, I think that it might be helpful to see how I arrived at this idea to begin a long running dialog on mental health, my qualifications, and the strategy to provide a unique view of a sometimes bewildering subject. In the past year I have maintained the four blog pages currently part of observationsblog.com and have tried to educate, entertain, and inform readers in a variety of areas. According to comments received so far, the site has been well received and I have had good, sound constructive criticism and encouragement to continue my efforts to provide an ad free, open site. But, in the back of my mind I have always wanted to tackle the issue of mental illness, but in a new and innovative way. And now, I am ready to take the plunge with our readers.
Despite the fact that I have been employed in the fields of chemistry and electronics as my primary careers, I have always been involved in the humanities and the helping professions. I started a drop-in center for troubled youth, am a founding member of a volunteer ambulance service, and a family mediator. So, in 1990 I went back to college to obtain a degree in mental health services. I then changed my full-time career to mental health as a therapeutic case manager and worked in two community-based mental health centers.
In the intervening years I have had the opportunity to work with well over three hundred patients with both severe mental illness (SMI) and severe and persistent mental illness (SPMI). Both of these terms will become evident over time as we look at what mental illness is, and how it can manifest itself, and affect the quality of life.
It seemed to me that I could present information about mental illness by doing the research and re-writing it as a post entry. But, anyone can read, comprehend, and rewrite information, and perhaps adequately cover the subject. The better alternative, in my opinion, is to present the information in the form of case histories. These will be composites of patients that I have been involved with as a community-based case manager. I am with patients in their homes, hospitals, their community, and  their families.I have had the opportunity to learn and understand mental illness in a very intimate manner. There are cases with remarkable recovery, and those with tragic endings. It is all part of a complex and yet vital part of life for those with a mental illness. I look forward to sharing these vignettes with our readers. To end this post, I have included a chart that captures the extent and demographic impact of mental illness in the US. It is copied from the National Institute of Mental Health from 2008, the most recent accurate data: