Depression can be thought of as the shutting down of the body in the face of overwhelming feelings of sadness and anomie (feeling completely disorientated and lost). Depression can also be the result of great anger which the person cannot accept because it is at odds with their view of themselves. Depression can be caused by life events such as a series of bereavements or can be secondary to an anxiety disorder which has generated feelings of worthlessness because the person has not been able to function and has become isolated. Symptoms of depression include low mood, not experiencing enjoyment or happiness, feelings of hopelessness, lethargy, lack of concentration, difficulty getting to sleep, disturbed sleep, early-morning waking, lack of appetite, low self-esteem and self-confidence and a negative outlook for the future. Depression can lead to thoughts that life is not worth living and self-harm. The first step in the treatment for depression is Behavioural Activation. This pays attention to re-introducing structure into the day, waking and sleeping and also waking up the body with activity.
Anxiety is a physiological reaction to fear. Energy is generated in the body after the senses have detected danger, such as a lion. The heart bets faster in order to move oxygen around the body at a faster rate. Oxygen enters the muscles and the brain at an optimum rate and thus the person is able to fight or run away from the danger. When a person is in an anxious state the fear is generated by thoughts rather than a dangerous object but the physiological reaction is the same and oxygen is pumped around the body. The excess oxygen can lead to the feeling of constriction around the head and headache, gasping and the feeling of not being able to breathe because of excessive carbon dioxide, shaky limbs, excessive sweating, hairs standing on end and cramp in the legs. The experience of anxiety is extremely uncomfortable so the anxious person then begins to avoid situations which will trigger the anxious feeling. This then leads to family and social difficulties such as isolation, the loss of friendships and social standing and difficulty in going to work or study, which results in low self-confidence and self-worth. The domination of the anxiety generates an increasing feeling of powerlessness in the person and the Anxiety States represent the various ways that people try to maintain control in the face of the overwhelming feelings of anxiety.
Panic attacks are experienced as extreme discomfort and fear of dying as the person feels that he/she cannot breathe, hyperventilates, feels faint and shaky with profuse sweating and subsequent headache.
Panic Disorder is the fear of having another panic attack. This fear causes hyper vigilance, which is constantly looking out for danger, and also growing avoidance of going anywhere doing anything or which on another panic attack. Another common feature of having panic disorder is the fear associated with not being in control of thoughts and emotions. This is because the person is unable to identify the triggers causing panic and therefore feels out of control.
Panic Disorder with Agoraphobia can occur when the first panic attack takes place in a public place and the person experiences embarrassment as well as the symptoms of panic. In addition to the symptoms of panic disorder the person also avoids any situation that may cause embarrassment. This results in avoiding social activity including difficulty going to work or study, hobbies and pastimes or enjoying time with friends and family.
The avoidance of social situations caused by Panic Disorder and Panic Disorder with Agoraphobia cause loss of confidence, a negative view of self and lowered mood. CBT treatment includes understanding this and restoring confidence and enjoyment.
Phobia is the name given to a fear of a specific object or experience. Common phobias are fear of dogs, spiders, high places, injections, and vomiting and enclosed spaces. A phobia can arise because of feeling intense fear and loss of control in relation to the object. In children a phobia can be generated by the fear experienced by an adult.
Posttraumatic Stress Disorder (PTSD)
PTSD is the name given to clusters of symptoms – intrusions, hyper-arousal and avoidance - experienced after a person has experienced a traumatic event or bereavement. The symptoms include those of re-experiencing the event as if suddenly transported back to the moment, an intrusive thought or image that causes sudden and extreme fear, sleep disturbance, nightmares, hyper vigilance (constantly looking out for danger) and avoiding any situation which may trigger fear causing difficulties in relationships, work or study.
These symptoms result in loss of confidence, a negative view of self and lowered mood. CBT treatment includes understanding how this has developed over time and restoring confidence and enjoyment.
Complex Posttraumatic Stress Disorder (Complex PTSD)
Complex PTSD describes PTSD that has had a severe impact upon the person’s functioning, self-concept and enjoyment of life. This may be because the trauma was severe and/or impacted upon the person’s core beliefs and sense of self or because the symptoms of PTSD remained untreated over a long period of time.
Obsessional Compulsive Disorder
OCD ranges from mild symptoms to severe. The severity can be caused either due to the length of time the symptoms of OCD have remained untreated and escalated or because of the severity of the stress or distress experienced.
Obsessional, repetitive thoughts such as fear of germs or fear that something terrible is going to happen are experienced as being powerful and outside of the person’s control (intrusive), which cause feelings of anxiety ranging from discomfort to panic. The person neutralises uncomfortable feelings by repetitive actions, for instance the person may think ‘If I do this 3 times then it will be ok’ or they will repeat an action or sequence of actions until it feels ‘Just right’. The actions are called ‘compulsions’ because the person feels compelled by the physiological urge of the anxiety generated by the obsessional thought(s) to carry out the behaviours. Over time the fact that the disaster has not happened is evidence for the person that carrying out the compulsive rituals has averted the pending disaster and so the obsessions and compulsions become more entrenched.
Anorexia Nervosa is an over-evaluation of the importance of shape and weight and keeping control of these. As a result of judging self-worth according to shape and weight, the person actively keeps a low body weight [BMI of 17.5 or below] by eating only small amounts irregularly, exercising and sometimes using laxatives and vomiting.
Bulimia Nervosa is an over-evaluation of the importance of shape and weight and keeping control of these. As a result of judging self-worth according to shape and weight the person finds him/herself having episodes of ‘binge eating’ at which time he/she feels out of control. In order to control weight the person engages in weight control behaviour such as vomiting and laxative misuse. It is unusual for a person suffering from bulimia nervosa to be underweight.
Other eating difficulties have similar symptoms to those above but do not meet the diagnostic criteria for either.
Children sometimes engage in restricted eating which may be due to a developmental disorder or may be because when they were weaned they did not persevere with learning to accept and assimilate a variety of textures and tastes.
Difficulties with Sleeping
May occur for a variety of reasons so a visit to the GP is recommended to rule out physical causes.
Sleep difficulties include persistent nightmares, insomnia, night terrors, sleepwalking and night and/or early morning waking. These can be caused by anxiety and/or low mood generated by thoughts and body feelings such as pain whilst asleep in the same way that anxiety and low mood are generated by thoughts and feelings during the day.
CBT treatment for difficulties with sleeping is based around understanding stressors, introducing a healthy waking/sleeping pattern and encouraging activity and healthy eating.