Twenty Questions To Get You Started

Am I Okay?
by Michael B First, M.D., Allen Frances, M.D.

We all have times when we're feeling down, anxious, over the top, or on edge. Or times when we can't sleep, feel spaced out or disconnected from things, can't remember names or faces, can't get over past traumas.

Problems like these are often a common and normal part of the aches and pains of everyday life. However, if these problems last long enough, are severe enough, or interfere with work or relationships, it may mean that you or someone you care about has a diagnosable and treatable disorder.

Written by the same doctors who led the effort to produce the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) — the reference text used by the majority of mental health professionals — Am I Okay? is a thorough, completely authoritative guide designed to help people identify whether or not they have a psychiatric condition as early as possible.

Am I Okay? also includes the following features:

• "Twenty Questions to Get You Started": a diagnostic screening questionnaire that covers most known psychiatric problems

• Detailed chapters on a range of mental health issues, from Depression, Personality Disorders, and Alcohol and Substance Abuse to Anxiety, Dissociative Experiences, and more

• Information about national organizations, support groups, and other sources of help, as well as suggested readings for more information

When you go to a doctor for a routine physical checkup, part of the examination will include what is called a "review of systems." The doctor asks you a comprehensive series of questions covering everything about your health from head to toe in order to ensure that nothing important is missed. The following twenty questions are a "review of systems" for your mental health. A positive answer to a particular question will direct you to one (or more) of the subsequent chapters indicating the range of DSM-IV disorders relevant to understanding your symptoms.

Please remember that a "yes" answer does not necessarily mean that you have a DSM-IV disorder — these questions are written to cast an especially wide net. Almost everyone has had at least some of the problems mentioned below, but most often these are not severe or persistent enough to be considered a mental disorder. The remaining chapters of the book will help you learn more about your problem and decide whether it is "clinically significant." As we've mentioned before, however, a final confirmation must depend on the clinical judgment of an experienced mental health professional.

If your answer is "no" to each and every one of the following twenty questions, then either you have a clean bill of health, or you may be unaware of (or are denying) problems that do exist; or you may have a problem that is not specifically covered in this book.

If you are reading this book on behalf of a family member or friend, substitute the appropriate pronoun ("Is your spouse depressed?").

Question #1: Are you depressed? Do you feel sad and blue much of the time? Are you down in the dumps... as if nothing feels good... as if you don't care about anything?

Do you feel as if you are walking around with a black cloud over your head or falling into a black hole? Does everything seem bleak and gray? Has the fun gone out of your life? Do you find that you just don't care about doing the things that used to matter to you, like hobbies or getting together with friends? Do you just want to crawl into bed and pull the covers over your head? Do you feel as if you no longer have any emotions and don't even care about the people you love? Do you just want to be by yourself and not deal with anyone or anything? Are you a third wheel at work, just occupying space and getting nothing done? Do you find yourself crying frequently, sometimes for apparently no reason? Are you having trouble sleeping or have you found yourself sleeping all the time? Is your appetite not what it used to be and does everything taste like cardboard? Or perhaps you can't keep yourself from eating all day? Do you feel like you are running on half power? Do you feel so agitated and restless that you are jumping out of your skin? Or slowed down as though you are walking in a vat of molasses? Do you feel as if you aren't worth anything to anybody or that you are a burden to everyone around you and that they would be better off if you were dead? Are you unable to concentrate on anything — like watching TV, reading a newspaper, or even following a conversation? Do you feel paralyzed by the prospect of making even a small decision? Are you having thoughts that you should hurt or kill yourself?

We're not talking about just the occasional blues but rather sustained depression that interferes with your life. You feel bad day in and day out for weeks (and sometimes months or years) at a time. Depression has to be distinguished from the aches and pains of everyday life. Everyone has brief periods of unhappiness and disappointment that have little or no impact on daily functioning. A "yes" to these questions means that you have more severe and prolonged periods of depression that really make you miserable, interfere with your functioning, or make everything you do feel like an effort.

If the Answer to This Question Is Yes, Please Refer to Chapter 1.

Question #2: Do you have times when you feel manic? Have you felt so good, "high," hyper, or irritable that you are "not yourself" and have gotten into trouble?

Do you sometimes feel like you are "on top of the world" and "bigger than life"? Do you have times when you suddenly feel especially talented and that you must express your gift — like writing the great American novel or closing the business deal of the century? During these episodes, do you feel as though you have boundless energy, that you can't keep up with your thoughts, that you have more to say than you can fit in, that you need hardly any sleep or any food? Do you become outrageously productive and driven to keep active every minute? Are you on the phone day and night, "catching up" with everyone you have ever known? Do you find yourself going overboard and doing things that are unusual for you (buying expensive clothes you can't afford, traveling all over the place, flooring the accelerator while driving, having sex with people you don't know very well)? Some people who are speeded up have an extremely irritable rather than euphoric mood, especially when they get frustrated.

Everyone (hopefully) has at least occasional outstanding days in which the sun is in the heavens and all is right with the world. Answer "yes" to this question only if your periods of elevated mood cross the line from being wonderful into causing serious problems. We're not talking about normal self-confidence but rather unwarranted grandiosity, impulsivity, and poor judgment that can be of disastrous proportions.

If the Answer to This Question Is Yes, Please Refer to Chapter 2.

Question #3: Are you especially anxious, fearful, or panicky? Do you always feel nervous, on edge, and worry too much? Are you excessively fearful of things you know you shouldn't be that afraid of, so that you have to go out of your way to avoid them?

Do you get an inexplicable terror that seems to come out of nowhere, the sudden feeling that something dreadful is going to happen, that you're about to faint, you don't have enough air, and your heart is beating irregularly or is about to break out of your chest because it is pounding so hard? These panic attacks are usually brief but intense and can come on "out of the blue" or in response to specific triggers that are frightening to you.

Are there situations that you avoid because they make you anxious? Many people react to their anxiety and fears by avoiding the offending situation. Other brave souls stick it out and plow ahead, putting up with the intense anxiety with white knuckles and sweaty palms. Typical situations that people avoid include airplanes, public transportation, bridges, tunnels, heights, elevators, department stores, animals, closed spaces, thunderstorms, and medical procedures. Some people are unreasonably fearful of social situations like taking a class or a job that requires speaking in public, playing a musical instrument or singing in front of others, eating in a restaurant, or using a public bathroom. Do you feel embarrassed to be seen blushing or trembling?

For some, anxiety is a constant companion that is present almost all the time. Are you a worrywart, uptight about everything? Do you find it difficult to concentrate at work because you can't stop worrying about things at home and then can't concentrate at home because you can't stop worrying about things at work? Do you experience a lot of physical symptoms of anxiety such as muscle tension, difficulty sleeping, restlessness, irritability, fatigue, or being keyed up or "on edge"?

It is indeed fortunate that nature has programmed us to experience some degree of fear and avoidance as a way of motivating us to perform and of keeping us out of trouble. People who are completely fearless may be stars on the battlefield (or the football field) but generally get injured in life one way or another. On the other hand, some people have a hair-trigger tendency to experience intense and impairing anxiety that is out of all proportion to the real expectations or dangers of the situation — they are like a smoke detector that goes off in response to burnt toast. Answer "yes" to this question only if your fear and avoidance are excessive, unreasonable, and impairing.

If the Answer to This Question Is Yes, Please Refer to Chapter 3.

Question #4: Do you have obsessions or compulsions?

Obsessions are upsetting or intrusive thoughts or images that don't make any sense to you but keep coming back no matter how hard you try to banish them. People with obsessive thoughts may become preoccupied with the idea that they are contaminated with germs, have run over someone with their car, or have left the stove on even after having already checked it fifteen times. Alternatively, someone might be haunted by the obsessive image of strangling a loved one or doing something obscene or sacrilegious.

Compulsions are thoughts or behaviors that you cannot stop yourself from doing and that lessen the intense anxiety resulting from your obsessions. For example, a person feels driven to repeatedly wash his hands until the skin is raw as a way of counteracting anxiety about being contaminated. Ritualistic praying or counting (for example, from one to eighteen exactly eighteen times forward and then backward) may be performed to atone for having blasphemous or violent preoccupations. Compulsively checking every few minutes that the coffeemaker is turned off or that the front door is locked temporarily allays obsessive doubts concerning safety. And there are people who are compelled to spend hours ensuring that everything in their bedroom is in its own exact "spot" before sleep becomes possible.

Don't answer "yes" to this question if your upsetting thoughts are about realistic concerns (like not having enough money to pay your taxes, getting fired from work, or that your elderly parents may become ill) or if your "compulsions" truly serve you well and are part of your being a careful person.

If the Answer to This Question Is Yes, Please Refer to Chapter 4.

Copyright © 1998 by Allen Frances, M.D. and Michael B. First, M.D.

About the Author

Michael B. First, M.D., is Associate Professor of Clinical Psychiatry at Columbia University College of Physicians and Surgeons and is a research psychiatrist in the Biometrics Research Department at New York State Psychiatric Institute. He was the editor of the DSM-IV text and criteria, and now maintains a private practice in Manhattan.

Allen Frances, M.D., is Professor of Psychiatry and former chairman of the Department of Psychiatry and Behavioral Science at Duke University. Dr. Frances was chairman of the DSM-IV Task Force and is currently leading an effort to develop expert consensus practice guidelines for the different psychiatric disorders.