Troubled minds

The 'sympathetic ear' of a hygienist can catch the warning signs of a mental illness.

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by Cathleen Terhune Alty, RDH

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Hygienists are often called upon to lend a sympathetic ear to their patients seeking advice. Most of us have noticed a once energetic elderly patient become sullen and lose interest in his or her appearance. We've seen a beautiful teen become dramatically thinner and develop eroded lingual surfaces on her teeth from purging. We've watched the stressed-out family trying to help a parent with Alzheimer's disease and all the decisions that come with it. All of these situations involve mental disorders and all are a burden, both to the afflicted and the family.

Mental illness is not a particularly comfortable topic. For many people, mental illness brings to mind out-of-control, delirious people behind barred windows in rundown institutions. The media and entertainment industries often portray the mentally ill and their families as damaged, dangerous people. Many people believe that mental illness is rare and happens only to the poor or the elderly. In reality, mental illness is common, cuts across all socioeconomic levels, and can happen at any age. The National Mental Health Association estimates that 54 million Americans suffer from some form of mental disorder, but only about eight million receive treatment.

Mental illness causes disturbances in a person's thought and/or behavior. It may be caused by stress, genetics, biochemical imbalances, infection, or social, psychological, or head trauma. Out of the more than 200 types of mental illness, five are considered common mental disorders. These are depressive and mood disorders, schizophrenic and psychotic disorders, dementias, eating disorders, and anxiety disorders. Each of these has symptoms that vary in severity from person to person and over time.

O Depressive and mood disorders — Mood disorders include depression, bipolar disorder, SAD (seasonal affective disorder), postpartum depression (PPD or "baby blues"), and mania (hyperactive, unrealistic optimism). Experts estimate that 19 million American adults suffer from depression annually. According to the National Institute of Mental Health, about 20 percent of the U.S. population reports at least one depressive symptom in a given month, and 12 percent report two or more in a year. Chronic medical conditions or substance abuse can cause depression. Even those who suffer from moderate depression symptoms are associated with a higher rate of heart attacks and high blood pressure.

Bipolar disorder, formerly known as manic depression, affects about two million Americans and is defined as wild swings between extreme elation and extreme depression. Depression and bipolar disorder are the main underlying disorder in suicide attempts. Suicide is the eighth leading cause of death among dental professionals in the United States.

Mental health experts estimate that 530,000 Americans attempt suicide annually and 30,000 succeed. As many as eight out of 10 suicidal persons give some sign of their intent. If someone tells you they are contemplating suicide, take it seriously and seek professional help.

O Schizophrenic and psychotic disorders — Paranoid or distorted thoughts, delusions, hearing voices, or seeing hallucinations are symptoms of schizophrenia. According to "Rethink," formerly the National Schizophrenia Fellowship, schizophrenia is a serious disorder that affects how a person thinks, feels, and acts. Chemical imbalances in the brain is believed to be the cause. Psychosis is a medical term used to identify symptoms where the individual experiences a loss of their sense of reality.

O Dementias — Dementias include such diseases as Alzheimer's. About four million Americans have Alzheimer's, and experts estimate that by the year 2050, 12 to 15 million Americans will suffer from the disease. Mild Cognitive Impairment is a condition with significant memory loss, but it is not to the level classified as dementia.

O Eating disorders — Anorexia and bulimia are considered mental disorders because symptoms include irrational fear, incorrect self-perception, preoccupation with food or exercise, and wild swings of gorging and/or purging. These are life-threatening illnesses that require treatment. Dental personnel can often identify eating disorders by noticing severe lingual tooth erosion and rampant decay in affected patients.

O Anxiety disorders — The most common type of mental disorder is anxiety disorder. Of course, everyone feels anxious or uneasy at times, such as the first day on a new job, during a difficult confrontation, or while giving a speech. These can leave us with sweaty palms, a pounding heart, or a dry mouth. Some anxiety is good because it helps keep people focused on a task. However, if anxiety begins to interfere with work, leads a person to avoid certain situations, or keeps someone from enjoying life, that person may be suffering from an anxiety disorder.

Anxiety disorders are not just butterflies in the stomach, but a serious medical condition. They can't be wished away or fought with sheer willpower. Trying to ignore the feelings often makes them worse. A person may avoid certain situations that create anxious feelings, or they may feel so intense they may literally be immobilized with fear.

There are several classifications of anxiety disorders. Generalized anxiety disorder (GAD) is defined as six months or more of severe anxiety or tension. Symptoms include insomnia, headaches, irritability, and fatigue. Panic disorder is intense fear accompanied by physical symptoms. Obsessive-compulsive disorders (OCD) are defined as when individuals are haunted by unwanted thoughts or rituals that they feel they cannot control.

Post-traumatic stress disorder (PTSD) can happen after being exposed to terrifying events in which harm occurred or was threatened. These events include violent personal assaults, natural or human caused disasters, accidents, or military combat experience.

Phobias are a common psychiatric disorder and have three main subgroups: specific (simple) phobias, which are the most common and focus on specific objects; social phobia, which causes extreme anxiety in social or public situations; and agoraphobia, which is the fear of being alone in public places from which there are no easy escapes (such as an elevator).

Treatment options for persons with mental disorders may include medications, psychotherapy and counseling, hospitalization, exercise, even dietary changes. Most people with mental disorders can recover and live a normal life.

In the course of our work, hygienists are often asked for information about medical or family problems. When faced with a patient who needs help, get involved by asking some important questions. Ask them if they've seen a professional about their situation, if they're getting help, of if they have someone they can talk to who can help. Having resources available, both locally and nationally, can help a person seek the treatment they need.

Unfortunately, those who are diagnosed with mental illnesses may find good treatment difficult to find. The public mental health system in the United States appears to be in dire need of revamping. President Bush formed the "New Freedom Commission on Mental Health" in April 2002 to recommend how to improve America's mental health delivery systems, and to recommend policies to improve services.

In the report released in July 2003, the commission stated, "America's mental health system is in shambles, resulting in people with mental illnesses not receiving the care they need."

The report calls for "transforming public mental health services into a system focused on early intervention and recovery." The report calls for better access, earlier interventions, more support, and appropriate consumer- and family-centered treatment options. While mental health experts applaud the findings, the question remains whether any changes in the system will be forthcoming.

In closing, here are some Web sites for more information about mental illness:

• National Institute of Mental Health, www.nimh.gov
• Rethink (formerly the National Schizophrenia Fellowship), www.rethink.org
• National Mental Health Association, www.nmha.org
• Depression and Bipolar Support Alliance, www.ndmda.org
• Anxiety Disorders Association of America, www.adaa.org
• National Mental Health Consumer Self Help Clearinghouse, www.mhselfhelp.org


The following information is part of the National Mental Health Association's Campaign for America's Mental Health:

A suicide attempt is a clear indication that something is gravely wrong in a person's life. No matter the race or age of the person, or how rich or poor they are, it's true that most people who commit suicide have a mental or emotional disorder.

Warning signs of someone considering suicide

Any one of these symptoms does not necessarily mean the person is suicidal, but several of these symptoms may signal a need for help:

• Verbal suicide threats such as, "You'd be better off without me," or "Maybe I won't be around."
• Expressions of hopelessness and helplessness.
• Previous suicide attempts.
• Daring or risk-taking behavior.
• Personality changes.
• Depression.
• Giving away prized possessions.
• Lack of interest in future plans.

Remember, eight out of 10 suicidal individuals give some sign of their intentions. People who talk about suicide, threaten to commit suicide, or call suicide crisis centers are 30 times more likely than average to kill themselves.

What to do if you think someone is suicidal

• Trust your instincts that the person may be in trouble.

• Talk with the person about your concerns. Communication should include listening.
• Ask direct questions without being judgmental. Determine if the person has a specific plan to carry out the suicide. The more detailed the plan, the greater the risk.
• Get professional help, even if the person resists.
• Do not leave the person alone.
• Do not swear to secrecy.
• Do not act shocked or judgmental.
• Do not counsel the person yourself.

If you or someone you know is contemplating suicide, call 1-800-SUICIDE.


The following information about symptoms of Depression is part of the National Mental Health Association's "Campaign for America's Mental Health."

Some people experience periods of normal mood and behavior following a manic phase; however, the depressive phase will eventually appear. Symptoms of depression include:

• Persistent sad, anxious, or empty mood
• Sleeping too much or too little, middle-of-the-night or early morning waking
• Reduced appetite and weight loss or increased appetite and weight gain
• Loss of interest or pleasure in activities, including sex
• Irritability or restlessness
• Difficulty concentrating, remembering, or making decisions
• Fatigue or loss of energy
• Persistent physical symptoms that don't respond to treatment (such as chronic pain or digestive disorders)
• Thoughts of death or suicide, including suicide attempts
• Feeling guilty, hopeless, or worthless


The following information from the National Mental Health Association's "Campaign for America's Mental Health" project indicate "signs" that a person may want to speak to a medical or mental health professional.

In adults:

• Confused thinking
• Prolonged depression (sadness or irritability)
• Feelings of extreme highs and lows
• Excessive fears, worries and anxieties
• Social withdrawal
• Dramatic changes in eating or sleeping habits
• Strong feelings of anger
• Delusions or hallucinations
• Growing inability to cope with daily problems and activities
• Suicidal thoughts
• Denial of obvious problems
• Numerous unexplained physical ailments
• Substance abuse

In older children and pre-adolescents:

• Substance abuse
• Inability to cope with problems and daily activities
• Change in sleeping and/or eating habits
• Excessive complaints of physical ailments
• Defiance of authority, truancy, theft, and/or vandalism
• Intense fear of weight gain
• Prolonged negative mood, often accompanied by poor appetite or thoughts of death
• Frequent outbursts of anger

In younger children:

• Changes in school performance
• Poor grades despite strong efforts
• Excessive worry or anxiety (i.e. refusing to go to bed or school)
• Hyperactivity
• Persistent nightmares
• Persistent disobedience or aggression
• Frequent temper tantrums


Cathleen Terhune Alty, RDH, is a frequent contributor. She is based in Clarkston, Mich.

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