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6. How doctors classify mental illness

ICD10 is the International Classification of Disease. It is a way of classifying mental illnesses and is internationally understood and accepted. This makes the diagnosis of mental illness as clear in Lagos as it is in London. Information and research can be applied widely if a classification system is used, and it is clear that we are discussing the same illness. The classification system aims to be practical and versatile. Each mental illness is given a code, which you may have seen used on insurance claims forms as a form of shorthand. The DSM4 is the Fourth Diagnostic and Statistical Manual for Mental Disorders, which was evolved by the Americans. It is the second important diagnostic manual that we have in use.

Both classifications are widely used and respected, and they complement each other.

6.1 Symptoms of depressive illness

These are some of the symptoms you may have had:

• Sleep disturbance. Classically someone wakes up at 3-4 am with their mind working overtime. ‘It’s as if I’ve got some unfinished business.’ It is difficult to get back to sleep.

• Sleep quality is poor. Whether broken or heavy, people wake in the morning unrefreshed.

• Appetite change. Usually this is loss of appetite, but can appear as overeating.

• Loss of sex drive.

• Constipation.

• Weight changes. This could be weight gain or loss.

• Lethargy, or restlessness and agitation.

6.2 How depression affects how you feel

• Mood low, loss of pleasure, loss of interest in usual activities.

• Mood may vary through the day, tending to be worse in the mornings.

• Tears over little things.

• Poor self-esteem and self-image.

• Poor concentration (people can perform unexpectedly poorly at work).

• Indecisiveness, dithering.

• Feeling awfully guilty, or hostile and angry.

• Feeling useless and helpless.

• Lack of drive.

• Irritability and behaviour out of character.

• Disengaging, withdrawing from life.

6.3  Insomnia

I get insomnia, but my doctor won’t give me sleeping pills; she seems to think I’m depressed but there’s no earthly reason why I should be.

You don’t have to have a reason to become depressed. Sometimes there is an obvious stress or life-event, but sometimes it just seems to overtake someone for no reason. Insight can be subtly affected so that you are the last person to realise how low you have become. It is understandable to feel that having depression means that you have failed in some way, that somehow you haven’t made the grade, and that it’s your fault. Once you have managed to get past these thoughts, you can get on with dealing with it – and making it better. Depression is an illness not a failing. Insomnia means difficulty with sleeping. Difficulty getting off to sleep is usually a sign of stress and worry. If you are persistently waking up very early in the morning, perhaps at 4 am, that sort of sleep disturbance is likely to be associated with depression. It is important to make the connection because the right medication will then help. Like your GP, most doctors are rather reluctant to give out sleeping tablets in this sort of situation for two reasons: first it is often best to try self-help methods, and secondly it may well be that a course of antidepressants (rather than sleeping pills) would be much more helpful in getting your sleep pattern re-established. A few nights of good sleep makes a lot of difference to how we function; severe sleep deprivation is torture.

Question: Why can’t I get to sleep?

 Answer: There are two patterns of sleep disturbance. If you are anxious and unsettled, worried about things happening in your life, then you may not get off to sleep easily. This is a common sign of anxiety and stress. A warm milky drink, a breath of fresh air, a quiet evening without too much excitement on the TV, a comfortable bed, will all help you settle down and get off to sleep naturally. Sleep is a habit and some people sleep more than others. It is said that we need less as we get older. Shift workers and aircrew have to put up with disturbed sleep patterns and may need an occasional sleeping tablet to correct their sleep pattern. If you get off to sleep without difficulties, but then wake in the early hours, perhaps at 3-4 am, that is much more suggestive of depression. Persistent early morning wakening is one of the cast iron signs of a depressive illness. It is caused by a shift in the body’s chemistry as a result of the illness, and is often associated with anxiety and, particularly, low mood on awakening. Some people sleep more than usual when depressed. They may feel tired all the time, and awake unrefreshed after a night’s sleep.

6.4 Loss of drive

Question: I’m a marathon runner, and I developed depression a few years ago. One of the first ways it affected me was that I lost the drive to train, it became harder and harder to keep fit and I couldn’t understand why. Is this common?

Answer: It’s not common, but this is certainly one of the ‘atypical’ ways in which depression can manifest itself. Competitive athletes have to focus on their fitness to the exclusion of much else on a daily basis, and they may have to overlook many of their own feelings to keep in training at a high level.

Athletes in serious training, who get an injury or who have to reduce their activity for some other reason, do miss their exercise dreadfully. They are probably missing their own ‘endorphins’, nervous system chemicals produced during exercise. These naturally occurring opiates make you feel well; you can get feelings of withdrawal from them when you stop exercise, as well as feeling flatter in mood.

When athletic patients cannot train for some reason, they may be helped by burning up the same amount of energy in other ways; so runners with foot injuries may use the pool or the gym instead to keep fit, thus avoiding loss of their natural endorphins. You don’t have to be a marathon runner, but taking up some exercise can be a really good way of improving your mood.

Get off that sofa!

 Loss of drive is often one of the subtler signs of depression.

Those of us who are not athletes might experience it as a general lack of energy, and difficulty in getting started on anything, whether work projects or doing the laundry. Sex drive is often affected, and perhaps writer’s block can be a form of this too.

6.5  Loss of weight

Question: My aunt feels generally unwell and has lost weight. I was worried it might be cancer because my mum (her sister) had that, but she’s had all sorts of scans and tests and they can’t find anything wrong. Now they want to put her on antidepressants, even though she doesn’t really feel depressed. Is this the right thing to do?

Answer: ‘Medically unexplained symptoms’ are surprisingly common among people coming to see their family doctor. People often complain of dizziness, tiredness, headaches, poor sleep, chronic aches and pains in chest, back or abdomen.

Research has shown that in only 10–15% of people with these symptoms is there any physical cause to be found. In the remainder, physical, social and psychological factors are probably combining in some complex way to produce the feeling that someone is ill.

For example, unrecognized tensions at work or in the family may cause someone unconsciously to clench their muscles. This muscle tension may cause headaches, back strains, or unexplained exhaustion; it’s as if someone has had to run 5 miles even though they’ve been only sitting at their desk.

Our autonomic nervous system runs automatic bodily functions, such as blood pressure, breathing and heart rate, pain responses and gut activity. When this system responds to stress we may experience palpitations, or stomach aches and cramps (‘irritable bowel syndrome’). Some people may breathe faster when under stress, without realizing it.

This ‘hyperventilation’ causes dizziness, giddiness and, perhaps, unexplained tingling and numbness, especially in fingers and toes: this tingling also affects the area around your mouth.

Over breathing causes us to ‘wash out’ carbon dioxide from our bodies; this causes a subtle and temporary change in the acidity of the blood. This in turn causes the tingling by effecting a transient lowering of the chemical calcium in our blood.

Sometimes we are the last people to recognize our own pressures and stresses; yet they may be so obvious to a bystander.

Explaining why someone feels inexplicably ill is not always easy.

Some people may clearly be worried about a particular major illness, such as cancer or AIDS, and once that is out in the open, and we both realize that is what they are worried about, we can start to deal with their concerns with appropriate tests. In other cases we may have to carry out extensive investigations to exclude any other illness.

We have to be careful that these do not add to someone’s anxiety about themselves, as the stress of waiting for investigations and results is, in itself, considerable.

A referral to a specialist for a consultant overview can be most helpful in reassuring people that everything has been done, although it is also important not to chase around the Health Service for cures for the inexplicable.

Question: What can be done to help her?

Answer: She still feels awful, even though all the tests are normal. I don’t think she’s making it up. Feeling awful is not imaginary. When a doctor comes across this type of problem, it is important that all medications are kept to a bare minimum, to reduce any chance of side-effects or odd drug reactions.

Over investigation should be avoided – more and more X-rays, scans and other tests, unless new symptoms appear, will only add to further worry.

We will look for sources of stress and strain, past or present, in people’s lives. These symptoms do seem commoner in those who have had an unhappy childhood. Doctors look for obvious signs of depressive illness.

A good night’s sleep can make all the difference to one’s well-being, and poor sleep can insidiously lower mood. Continuing worry about illness lowers mood too, as do continuing symptoms. Finally, in large trials there is strong evidence of benefits from using antidepressant medication, whether or not people with these ‘unexplained medical symptoms’ were obviously depressed.

Many people with this sort of picture are helped by long courses of low-dose antidepressants. There is also evidence that cognitive behavioural therapy, individually or in a group setting, is helpful.

6.6 Tiredness

Question: I feel tired all the time. Is this likely to be a physical illness, or is it depression?

Answer: Fatigue is a very common complaint.

At any one time about 20% of men and about 30% of women will say that they feel tired all the time.

The majority of younger women in European Union have a job and a family, and the working day is long. Sleep may be disrupted by young children. Efforts to remain physically fit may be thwarted because of time constraints.

The situation is no less difficult for most working men.

Stresses of work, plus taking much more responsibility for child care and running the house, often make the ‘new man’ a stressed and tired man.

If the tiredness is sufficiently troublesome to warrant seeing the doctor, the commonest reason for feeling ‘tired all the time’ is mild depression and anxiety. Antidepressants may be of help in this situation. Other common causes are continuing stress and difficulties.

There are also some common and easily treatable physical causes for tiredness, which include iron deficiency anaemia (common in women of child-bearing age), thyroid gland disorders and, occasionally, the bowel disorder, coeliac disease, which might cause few signs except fatigue. The physical causes are much less common that the ‘social’ causes.

Question: What cause it? What can I do about it?

Answer: Stress, worry, and anxiety can all cause exhaustion. Having your muscles unconsciously tense from stress and strain leaves you feeling as though you’ve run a marathon at the end of the day – even if you’ve not been out of doors. Doing too much is obviously tiring, but more insidious is the sort of tiredness people get when they become out of condition, get run down, and stop taking any exercise. Little things like an uncomfortable bed, a noisy bedroom, too many late nights can all contribute. You can get too tired to relax.

Some people may have a particular worry, and getting this out into the open can be a great relief. Others need to make some life change to improve how they feel: a job that’s not right for you, a relationship that you’re not happy in, housing that isn’t satisfactory.

We all know that holidays are good for you. If you can’t take a break soon, try to wind down and reduce all your responsibilities for a couple of weeks. Then start an exercise programme, to get back into condition. Gradually build up your level of physical activity; you don’t have to run marathons, but aim to make yourself feel out of breath for 20 minutes, 3 times weekly. Look after yourself: good nutrition, healthy sleep, and social recreation are important. Make sure that you have something enjoyable to look forward to in your week. Relaxation techniques such as yoga, breathing exercises or meditation will all help keep tension – and hence tiredness – under control.

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