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What initially begins as social, casual or experimental use of alcohol or other substances (including illegal drugs, medication taken in a way that is not prescribed and/or cigarettes) can escalate into a substance use disorder – people don’t take that first drink, smoke the first joint, or take the first pill thinking about the possibility of a substance use disorder. Over time however, repeated substance use can lead to changes in the brain that affect impulse control and decision making – these changes in the brain end up impairing a person’s ability to make responsible decisions about substance use. What starts out as a way to party or to experiment with feeling the effects of different substances, can lead to abuse and “addiction”– what we currently call a substance use disorder.

In its most serious form, a substance use disorder causes significant impairment at school and in relationships and can have serious, sometimes life-threatening effects on a person’s physical and emotional well-being.

Substance use disorders are difficult to overcome without support and treatment. Substance use disorders (and the consequences of what people used to call addiction) can be a chronic struggle throughout a person’s life but treatment can restore emotional and physical well-being and help a person live life without substances.

Symptoms of substance use disorder include:

• Strong desire for the substance
• An inability to control or reduce use
• Continued use despite negative consequences
• Use of larger amounts over time
• Development of tolerance/dependence (see below)
• Spending a great deal of time to obtain and use substances

Also known as Alcohol Use Disorder (AUD), alcoholism is when a person is unable to control their drinking of alcohol, has continued use of alcohol despite problems resulting from drinking, develops tolerance, drinks even when it leads to risky situations, and/or demonstrates withdrawal symptoms (such as sweating, shaking, vomiting) when they stop drinking.

Cannabis use disorder is a pattern of marijuana use that causes significant impairment and distress in a person’s life. Problems seen in cannabis use disorder include:

• Difficulty in cutting back or stopping the use of marijuana even when a person wants to
• Urges and cravings when not “high”
• Continued use despite family, social, legal, medical or academic consequences

Hallucinogen use disorder is a pattern of use of hallucinogenic drugs that causes significant impairment and distress in a person’s life in a 12 month period. Hallucinogens are illegal substances that are either chemically-synthesized (as with LSD, PCP or ecstasy) or may occur naturally (such as psilocybin mushrooms and peyote). The effects of these drugs include hallucinations (seeing, hearing and feeling things that are not there), feelings of detachment, and distortions in time and perception.

Stimulant use disorder is a pattern of use of amphetamine-type substances (cocaine, methamphetamine, bath salts) leading to significant impairment and distress in a person’s life for a 12-month period. Stimulants include a wide range of drugs – some stimulants have historically been used to treat medical and psychological conditions including obesity and occasionally, depression.

Opioid use disorder is a problematic pattern of opioid use that leads to significant impairment and distress in most parts of a person’s life in a 12-month period. Opioids are drugs that include heroin and prescription pain-relievers: oxycodone, hydrocodone, codeine, morphine, fentanyl, Demerol, Darvon and methadone. Opioid use/addiction has become a serious public health issue.

As with nearly every other substance use disorder, cigarettes are a substance that can lead to a problematic pattern of use associated with tolerance and withdrawal, physical illness (including serious, life-threatening lung, heart and circulation problems, and lung/throat/mouth cancer), and hazardous situations such as smoking in bed or distraction with driving. Nicotine is highly addictive – quitting smoking is very, very difficult.

Treatment options for substance use disorders includes behavioral and family therapy, medication and recovery support services. Since the impact of a substance use disorder reaches into every part of life and affects so many others in a person’s support system, the most effective treatment usually includes more than one approach. Once sobriety (the person has stopped using the drug for some time) has been achieved, the need for support and treatment continues.

Anxiety is a normal part of everyday life. For most people, anxiety is a natural reaction to stress that can help a person stay alert and focused, motivate them to action, and stimulate problem-solving. Typical everyday-anxiety can be uncomfortable, but it is usually brief and resolves itself when the stressor goes away or a problem has been solved.

An anxiety disorder occurs when these feelings of nervousness, worry or fear become long-lasting, out of proportion to the situation and difficult to control. Dealing with this type of anxiety can interfere with daily life, strain relationships, and/or cause significant emotional or physical distress.

Anxiety disorders are among the most common mental disorders experienced by Americans and one of the most common mental health issues on college campuses.

People who struggle with an anxiety disorder usually experience a combination of emotional and physical symptoms when they are feeling anxious. The extent of these symptoms varies from person to person, however, the common characteristics in all anxiety disorders are:

• A problematic level of fear, worry or fretting about a specific object or situation that is out of proportion to any actual threat;
• along with the excessive fear and worry there is a pattern of emotional and physical responses that are very distressing and difficult to control;
• together, these symptoms cause impairment and distress in many areas of a person’s life.

Here are some potential signs and symptoms of an anxiety disorder in teens and young adults – the duration of at least some of these symptoms would be 6 months or more*:

• Excessive worry that is difficult to control – either about a specific object or situation, or sometimes about nothing specific at all
• Periods of intense fear or panic – constantly feeling nervous and wary; fears of disasters or natural catastrophes
• Sleep disturbances – can’t sleep, restless sleep, sleeping too much
• Recurring nightmares
• Avoidance of social situations – feeling extraordinarily shy and nervous in social settings; excessive worry about social competence or being publically embarrassed
• Wide range of emotions from overly restrained (uptight and quiet) to overly boisterous (clowning around and hyper)
• Difficulty concentrating in schoolwork, more often than not, for at least 6 months
• Repeated, unwanted thoughts or obsessions (an idea that continually preoccupies or intrudes on a person’s mind) that seriously interfere with attention to tasks at hand. For those who experience them, these thoughts typically focus on physical appearance, social acceptance, personal competence and conflicts about independence
• Intrusive memories (frequent, repeated experience of memories that can’t be stopped or controlled) of a traumatic event
• Physical symptoms
  • Nausea or a choking feeling
  • Rapid heart rate, pounding chest
  • Muscle tension and muscle aches, trembling
  • Sweating
  • Face flushing or blotching
  • Dizziness and feeling light-headed
  • Numbness or tingling
  • Difficulty breathing, feeling short of breath without a physical cause
  • Startling easily

There is no single cause for anxiety disorders – it appears that a combination of factors contributes to their development. These disorders tend to run in families and some children are born prone to shyness or nervousness. For some people, an anxiety disorder can be linked to the experience of a stressful or traumatic event such as abuse, the death of a loved one, violence, or prolonged illness. Some anxiety disorders are a consequence of a substance use disorder or a medical condition. For other people, an anxiety disorder develops without a clear precipitating cause.

Fortunately, anxiety disorders are manageable with a combination of interventions. To learn more, call Family & Children’s’ Services at 918.587.9471

Cognitive-behavior therapy:
Cognitive-behavioral therapy (CBT) is an effective treatment for adolescents and young adults who struggle with an anxiety disorder. It involves active exploration of what the person is feeling (anxiety), situations that cause or trigger the feeling, and identification of ways to cope more effectively with similar situations as they come up. CBT provides the opportunity to learn and practice concrete strategies to either avoid trigger thoughts/situations or deal with them in a more positive and productive manner.

Medication:
Prescription medications can be a very effective way to treat anxiety disorders in teens and young adults, especially when they are combined with therapy (CBT). It is very important to get a full psychiatric and medical evaluation before taking these medications and to follow up regularly with a professional once it has been determined that medication may help.

Stress Management and Psychoeducation:

Adults can experience stress in day-to-day life – when that stress becomes a trigger for an anxiety disorder, it can be very helpful to learn to recognize sources of stress and how to manage them. There are many positive ways to manage stress including eating a good diet and getting regular exercise, relaxation and coping strategies, avoiding alcohol and drugs, building a network of support through friends and community, modifying the environment to reduce or eliminate stress.

Everyone experiences changes in mood and most people can probably think of a time when their mood went from happy or “up” to sad and “down.” It is common to have a range of moods that last for a brief time and usually pass on their own without impairing a person’s ability to maintain the activities of everyday life or cause symptoms that put a significant strain on relationships. Some people tend not to exhibit their emotions – others seem to be more emotionally expressive, exhibiting more of their ups and downs. A person with more obvious ups and downs, but otherwise no other impairments in life, probably does not have bipolar disorder – this is more likely to be a normal variation of typical mood swings.

Bipolar disorder (also known as manic-depressive illness) is an illness characterized by distinct mood changes that are extremely distressing, can be very disruptive and are usually a marked change from the normal variations in mood that most people experience. A person with bipolar disorder has distinct episodes of mania (feeling excessively “up”) and episodes of major depression (feeling very “down”) that last longer and are clearly a change from their typical range of emotions. Mania and major depression are much more disruptive and distressing than the typical “ups” and “downs” of daily life. Bipolar disorder is a serious illness that causes extreme and enduring changes in mood, behavior, thoughts, energy level, activity and judgment.

The following are many of the signs and symptoms that will be present during a manic episode:

• A constantly elevated, “up,” extremely hyper, irritable mood
• Extremely talkative, much more than normal – not to be confused with being chatty – a manic person appears to be talking as though their words are under pressure, they switch topics quickly and they can’t be interrupted
• Very distracted, poor concentration
• Self-esteem/self-confidence is unrealistically high (inflated) – they can think they can achieve or have achieved much more than is actually true; feel like they have superhuman abilities and achievements
• Increased goal-directed activity (such as coming up with big plans that they can’t stop thinking about) or physically agitated and moving around without purpose
• Increased energy, restlessness, being “revved up”
• Decreased need for sleep – getting only 3-4 hours (or less) sleep per night for days and days without feeling tired
• Increase in risk-taking behavior – reckless driving, sexual promiscuity, spending money they don’t have (spending spree), abusing drugs
• Thoughts are poorly organized or they feel like their thoughts are “racing” in their head
• Poor judgment – for example, unprotected sexual intercourse, gambling or spending much more money than they actually have
• Psychosis – thoughts or perceptions that are not based in reality such as seeing things that are not there or hearing voices

When a person has bipolar depression, most of the following signs and symptoms will be present most of the day, nearly every day:

• Low, sad mood
• Low self-esteem
• Poor concentration and inability to make decisions
• Fatigue and loss of energy
• Weight loss, loss of appetite or overeating
• Loss of interest in most or all activities of daily living
• Difficulty sleeping or sleeping too much
• Thoughts of death or suicide

The specific biological causes of bipolar disorder are not well understood – though there is clear evidence that the illness tends to run in families. Environmental factors such as stress, sleep disruption (for example, travel involving changing time zones can precipitate manic episodes in some people with bipolar disorder), some medications and drug or alcohol use may trigger the onset or cycling of mood episodes. A stressful event such as a death in the family, an illness, a romantic break-up or other major life events can trigger the first bipolar episode.

What else could it be?
Several other conditions can look like Bipolar Disorder:

• Medical conditions (e.g., epilepsy or thyroid dysfunction)
• Psychiatric illnesses may account for the symptoms (e.g., major depressive disorder, schizophrenia or a severe personality disorder).
• Additionally, there are a number of conditions that often co-occur with bipolar disorder, including:
  • Anxiety disorders
  • Post-traumatic stress disorder (PTSD)
  • Attention-deficit hyperactivity disorder (ADHD)
  • Substance abuse
  • Migraines

Bipolar disorder is treated and managed in several ways – most often and most effectively with a combination of medication and therapy. Contact F&CS to learn more (918.587.9471).

It is normal and part of being human to feel low or sad at times – it is normal to feel sad or down in response to an upsetting experience, a break-up, illness, problems with family or friends or for no reason at all. Usually, when this happens, a person can go on with their day and keep up with activities of daily living. This type of sadness and down mood doesn’t last long and usually resolves itself when the situation improves or time passes.

Major Depressive Disorder (MDD) and other mood disorders are very different from the type of sadness and down mood that people feel from time to time.  MDD is a significant change in mood from their usual mood that lasts at least two weeks and causes a person to feel depressed nearly all day, every day or to lose interest/pleasure in all activities. With a major depressive disorder, the episode of depressed mood or loss of interest in activities is always associated with a significant level of distress and impairment in school/work, relationships and self-care.

Impact
The impact of depression extends beyond the person struggling with the illness. Depression can have a marked impact on relationships with family members, friends and on a person’s ability to connect with the community around them.

People with a depressive illness do not all experience the same symptoms. Problems vary in intensity and consistency but are present for at least two weeks.

Change in Mood and Thoughts

• Persistently low, down, depressed mood – feeling sad, empty and hopeless
• Low self-esteem – feeling worthless
• Feeling guilty and unworthy
• Thoughts about death and suicide
• Irritability – teens tend to exhibit irritability more than sadness
• Psychosis –hallucinations (hearing or seeing things that are not there) or delusions (believing things that are not based in reality). Of people with major depression, 5-15% will experience psychotic symptoms as part of their illness

Change in Behaviors

• Restlessness
• Persistent loss of interest in activities that used to be pleasurable or interesting, including sex
• Loss of interest in how they look, poor hygiene
• Difficulty concentrating, remembering details and making decisions
• Insomnia, early-morning wakefulness or excessive sleeping
• No appetite or overeating

Physical symptoms

• They may look very sad or empty or appear distracted
• Loss of weight
• They may complain about multiple physical symptoms that are not due to other medical issues – such as headaches, digestive problems, muscle aches and pains.

The American Journal of Psychiatry

When it is appropriate, treatment for a mild major depressive disorder (first episode, without suicidal thoughts or psychosis) would start out with psychotherapy. For more serious episodes or recurrent depression, a combination of psychotherapy and medication is an effective approach.

Psychosis is a symptom that can be present in a number of disorders and is always a serious and distressing sign of emotional disturbance. Psychosis can be seen in illnesses such as depression (rarely), bipolar disorder, alcohol and drug use disorders and in a psychotic disorder such as schizophrenia.

A primary psychotic disorder is diagnosed when symptoms of psychosis are present over an extended time and cause extreme impairment in a person’s thinking, behavior, emotional responses, ability to communicate and ability to remain in touch with reality.

Often there are warning signs months or years before the full-blown onset of a full-blown psychotic disorder. It is really important to pay attention to the earliest warning signs of changes in a person’s thoughts, behaviors, moods and perceptions that may indicate a developing psychotic disorder. Early recognition provides the best opportunity for early intervention and prevention of psychosis. This is particularly important due to the increased risk for suicidality in the early course of psychotic illness.

Psychosis affects 3 in 100 people and occurs in equal numbers in males and females. Most commonly, a first psychotic episode occurs between the ages of 15 and 30.

Psychotic disorders are usually quite disruptive and interfere with relationships, the ability to work, attend school or gain independence and self-care. There is variability in the course of these illnesses (and associated impact). In some cases, a person has a single psychotic episode that is followed by complete recovery, others have periods of psychotic illness that last for weeks to months with full remission of their symptoms between each episode. Others experience ongoing symptoms that fluctuate but do not ever fully disappear. Because this is a serious, debilitating and usually chronic illness that begins to emerge in teens and young adults, it can have a deep impact on school success, establishing a career, developing long term relationships and achieving independence.

In general, psychotic illnesses involve a constellation of symptoms that are manifested by changes in thinking, perceptions, behavior, and mood. Significant features include:

Delusions
Fixed and false beliefs that are not based in reality. A person who has delusions can’t be convinced that their thoughts are not true; confronting a person with delusions about the absence of reality in their thinking can provoke mistrust and anger.

• Delusions are fixed beliefs because attempts by others to reason with or debate the validity or truth of the delusional belief are usually unsuccessful.
• False beliefs are not based in reality and can be bizarre in nature. Examples could include feeling like they are being watched or followed, believing they have special powers or abilities, feeling like they are being controlled by others or outside forces, believing that other people can read their thoughts or inject thoughts in their head, or believing that other people can tell what they are thinking. It is also common for a person with delusions to have intense feelings of distrust or suspicion about other people and their actions (paranoid feelings).

Hallucinations
Hearing, seeing or feeling things that other people do not hear, see or feel. A person who has hallucinations can’t be convinced that their experiences are not real. Confronting a person with hallucinations about the absence of reality in their perceptions can provoke mistrust and anger.

• Hearing, seeing, tasting, smelling or feeling things that are not there, but seem very real to the person experiencing them
• Hearing voices (auditory hallucinations): sometimes a person who has this type of hallucination believes that the voices are threatening them or directing their actions (such as commanding them to harm themselves).

Disorganized thoughts and speech (thought disorder)
Thoughts may be confused and disorganized, and speech may not make sense.

• A person with a thought disorder will either jump from topic to topic when they speak or will answer questions with responses that have nothing to do with the question.
• Sometimes the thoughts are so disorganized, speech cannot be followed.

Grossly disorganized and abnormal physical behavior
This can range from agitated body movements to nearly complete absence of reaction to what is happening in the environment (catatonia).

• This can be any problem with performing the activities of daily living
• Sometimes seen as rigid, bizarre postures
• Sometimes expressed as repeated stereotyped movements, staring, grimacing, repeating everything a person hears
• In rare cases, this can be a complete lack of and speech or movement

Decreased emotional expression and lack of motivation
These are called “negative symptoms” and include:

• Flat or blunted emotional expression – include poor eye contact, rigid or little show of emotion in face or eyes, speech that has no expression and very little movement in the body as a person interacts in conversation
• Lack of desire to act (avolition) – this can be observed when a person shows no interest in participating in social, school or family activities
• Decreased ability to enjoy or take pleasure in activities or social interactions

The challenge is that early signs of psychosis are somewhat non-specific, and may look similar to common behaviors of adolescents and young adults.

Early warning signs of possible psychotic illness include:

• Social withdrawal
• Reduced concentration, attention; inability to make decisions, listen carefully or make plans
• Change in personal appearance and poor hygiene
• Feeling strange or cut off from the world
• Depression/anxiety; flat affect (no expression on a person’s face or in their eyes)
• Sleep disturbance
• Unusual sensitivity to stimuli such as light, noise, colors or textures
• Suspiciousness
• Skipping school or work
• Showing emotions that don’t match the situation – for example, laughing about a sad situation
• Substance use, especially a change in their behavior around drugs and alcohol.
• Thoughts that seem to be “off” – confusing TV and dreams with reality and speech that is hard to follow or does not make clear sense

Some indications that a person may be experiencing psychosis, include:

• Talking in a way that doesn’t make sense: for example, they may say they feel like a stranger, even in familiar places.
• Being totally absorbed in their own thoughts and may seem confused about what is happening around them.
• Acting oddly or disconnected from others around them: for example, they may not make good eye contact, or eye contact may be too intense; their emotions may be flat or inconsistent with the situation.
• Showing signs of paranoia: paranoia is excessive or irrational suspiciousness and distrustfulness that seems odd or doesn’t make logical sense in a particular setting or context. An individual who is paranoid may share that “people are after them” or seem overly sensitive in social situations. They may believe that their cell phone is being tapped or that they are getting special messages from TV shows.
• Making people around them feel uneasy: peers and others may respond to the person in an odd fashion because they feel uncomfortable, don’t understand or aren’t sure what to do.
• Showing poor self-care: not showering, grooming themselves or changing clothes. This is an observable sign that the problem in thinking may be impacting day-to-day functioning.

We know that these kinds of signs may be seen in someone who is drunk or has taken drugs. In fact, for some people with a predisposition to problems with reality, these difficulties can follow a period of heavy alcohol or drug use. The thing to notice here is that unusual behavior and thinking continues even when the person is no longer intoxicated.

It is believed that people develop psychotic disorders – and specifically schizophrenia – as a result of a combination of biological makeup and environmental stresses. Genetics play a significant role in the development of chronic psychotic illnesses like schizophrenia. In some people, a traumatic event such as the death of a loved one, war or sexual assault can trigger a psychotic episode. Additionally, the use of marijuana, LSD, amphetamines and other substances can increase the risk of psychosis in people who are already vulnerable. Although some individuals first develop psychotic symptoms in response to a marked stress, others slowly develop their symptoms over months and years and there is not a clearly identifiable precipitant.

What else could it be?
Psychotic symptoms can arise during a mental or physical illness, substance use, or following trauma or extreme stress. There are many medical disorders that could account for psychotic symptoms, including delirium caused by medication interactions, thyroid dysfunction, head trauma or brain tumor, strokes, HIV, and some brain diseases such as Parkinson’s, Alzheimer’s and dementia. Psychotic symptoms can occur with a mood disorder such as depression or bipolar disorder, and as a result of using drugs or alcohol.

A comprehensive medical evaluation and psycho-social history is important to make an accurate diagnosis. Regardless of the cause, psychotic symptoms should always trigger immediate professional attention.

F&CS’s NAVIGATE is a team-based approach, including the following members:

• Program director, who educates the community, recruits individuals who have begun to experience psychosis and leads the team.
• Prescriber, trained in using low doses of medications and addressing special issues of clients with first-episode psychosis
• Individual Resiliency Trainer (IRT), who helps individuals identify and work towards their goals, teaching them strategies and skills to build their resiliency in coping with psychosis while staying on track with their lives
• Family Education (FE) Clinician, who helps the whole family learn about psychosis and how to manage it, and also how to support each other and build family resiliency
• Supported Employment and Education (SEE) Specialist, who helps people identify and achieve their educational and/or employment goals
• Case Management, provided either by a separate case manager or by a specified NAVIGATE team member

PTSD is an anxiety disorder that can develop after a person experiences or witnesses a traumatic or catastrophic event.  The traumatic event can be a natural disaster, serious accident, the sudden death of a loved one, war, violent assault, diagnosis of a serious or life-threatening illness, or abuse.

After the trauma, people with PTSD can show a significant change in behavior, mood and thoughts that can have a negative impact on daily life and last for at least one month.  The greater the magnitude of the trauma, the greater the risk for PTSD.

People who struggle with PTSD “re-live” the traumatic experience in several ways:

• Recurring, upsetting memories of the traumatic event
• Recurring, distressing dreams that have to do with the experienced trauma
• Flashbacks – feeling like the event is happening again
• Intense and prolonged anxiety and distress in response to things that remind the person of the trauma they experienced
• Physical reactions such as easily startling or jumpiness when exposed to something that seems to re-enact the trauma

PTSD is associated with suicidal ideation and suicide attempts, substance abuse disorders and other mood disorders such as depression and anxiety.  When a person struggles with PTSD they may have difficulties in school and impaired relationships with peers and family, poor functioning in social situations and problems with physical health (e.g., pain syndromes, hypertension).

The signs and symptoms of PTSD usually emerge in the first three months after experiencing trauma – the symptoms can last months to years.

Emotional symptoms

• Intense anxiety, irritability, angry outbursts
• Feeling guilty, ashamed
• Sudden and extreme emotional reactions
• Depression and worry
• Feeling flat and empty – “dissociated”-as though in a different place or time

Behavioral symptoms

• Hypervigilance – nervously aware of a person’s surroundings
• Decreased interest in activities of daily living and in activities that used to be fun or bring pleasure
• Socially withdrawn
• Aggression – quick-tempered
• Easily startled
• Poor concentration
• Sleep disturbances

Treatment for PTSD includes psychotherapy (cognitive behavioral therapy, group, family and individual therapy, exposure therapy, and Eye Movement Desensitization and Reprocessing and medication treatment.  As with every other mental health issue, it is important to have a comprehensive medical and mental health evaluation to determine the most appropriate treatment plan and to be closely followed by a professional.