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Question #5: Are you haunted by an extremely traumatic event from your past?

When people are exposed to a terribly stressful event, they often cannot get the haunting images of it out of their daytime thoughts or nighttime dreams and may become unhinged by anything that even remotely resembles what happened. The shock of the event also causes a wide range of other symptoms, including being easily startled, having trouble sleeping or concentrating, feeling irritable or angry, or withdrawing from activities and from other people.

Long-lasting psychological effects often occur when someone experiences the threat of serious physical injury or death — as in military combat; severe automobile accidents; violent crime (rape, physical assault, robbery, mugging, torture); natural or man-made disasters (earthquake, tornado, fire, industrial accident); or life-threatening illness. Severe reactions to stress can also be caused by witnessing certain terrible things — seeing people die as a result of violence, accident, war, or disaster; or unexpectedly seeing a dead body or body part. Sometimes learning about a terrible event that has happened to someone you care about causes severe reactions — the sudden, unexpected death or serious injury of a family member or a close friend; or learning that your child has a life-threatening disease.

Of course, even the hardiest soul is shaken up at least to some degree by exposure to an extremely stressful situation. Don't expect to come through a terrible life event completely unscathed. Answer "yes" to this question only if your reaction to the stressor is particularly distressing, severe, prolonged, and interferes with your ability to function.

If the Answer to This Question Is Yes, Please Refer to Chapter 5.

Question #6: Do you have a problem with drinking or substance use? Has your drinking or substance use been excessive; out of control; hazardous to your health; causing problems at home, at work, or with other people; gotten you into trouble with the law; or put you in dangerous situations?

In DSM-IV, the term "substance" is defined broadly to include alcohol and other mind-altering or mood-altering drugs or medicines whether prescribed or obtained illegally. Can you identify with Mark Twain's comment about what it is like to try to let go of an addictive substance (in his case tobacco) — "it's easy to stop smoking... I've done it hundreds of times!" Do you crave the substance, think about it all the time? Do you feel as if you can't live without it? Has your husband, wife, or partner told you that they are really worried about your substance use or are becoming so fed up that they are thinking of leaving you? Are your children disappointed in you and embarrassed about the effect the substance is having on you? Does it feel as though your substance use is taking over your life rather than your being in charge of it? You may find that you are spending virtually all of your time thinking about the substance, taking it, experiencing its effects (both good and bad), or making sure you have it regularly available.

Substance use can lead to physical health problems like cancer, stomach ulcers, liver damage, and breathing problems; psychological problems like paranoia, depression, and anxiety; legal problems like arrests for disorderly conduct, and social problems like marital conflicts and physical fights; and occupational problems like missed work, and poor work or school performance. Have you been using a substance in situations where it may be dangerous, like driving while intoxicated, even though so far you may have been lucky enough not to have had an accident? Of course, not everyone who uses substances has a problem with them. Some people are especially vulnerable to substance use problems and some substances are especially likely to cause problems. If you do use substances at all, you should really search your soul before concluding that you do not have a problem since so many people with substance use problems are "in denial." Before saying "no" to this question, be sure that you have no evidence of physical or psychological dependence on a substance, or adverse consequences from using it.

If the Answer to This Question Is Yes, Please Refer to Chapter 6.

Question #7: Do you have an eating disorder? Do you have a problem with binge eating or purging, weigh much less than you should, or are you excessively worried about being or becoming fat?

Do you frequently engage in binge eating behavior? These are distinct episodes of extreme overeating in which you lose control and eat an abnormally large amount of food in a short period of time. A "large amount" is not just two cups of ice cream in one sitting but more in the neighborhood of a half-gallon. After the bingeing, do you frantically do things to get rid of the calories — vomiting, laxatives, fasting, or exercise? Do you feel really bad about yourself after you binge or purge? Depending on how much you compensate for your episodes of binge eating, you might be overweight, normal weight, or underweight.

Are you so terrified of getting fat that you will go to any lengths of starvation, exercise, or purging to remain thin? Has your weight gotten down so low that it is much less than people say it should be? Are you satisfied with the way your body looks (or still feel too fat) even though everyone else says you look emaciated? Are you preoccupied by food, the exact number of calories in everything you eat, and what effect each morsel will have on your weight? Do you find yourself not going to restaurants with other people because you are embarrassed by your strange eating habits? Do you feel you can control your eating only by following strict rules about what you can and cannot have?

We are a society of people obsessed with weight and body image, but most people do not have an eating disorder. You should answer "yes" to this question only if your eating behavior goes well beyond normal dieting to unhealthy weight loss or you are stuck in a disturbing cycle of bingeing and purging.

If the Answer to This Question Is Yes, Please Refer to Chapter 7.

Question #8: Do you have a problem related to sexual functioning or gender identity?

The sexual response cycle has several steps: desire, arousal, orgasm, and resolution. Do you have problems with sexual functioning related to one or more of these steps — lack of sexual fantasies or desire for sex; problems with getting an erection or becoming lubricated; or delayed orgasm or premature ejaculation; or do you have pain or spasms during intercourse? Remember that when it comes to sexual functioning, nobody is perfect and there are no clear-cut standards for what constitutes normal. At a minimum, the problem should be relatively persistent and cause marked distress for you or your partner.

Are your preferred sexual fantasies or situations way out of the ordinary or illegal? For example, are you turned on only by children, by hurting someone else, by being hurt, by exposing yourself, by peeping, or by cross-dressing?

Finally, do you feel that nature made a mistake in the assignment of your gender and that you are a woman in a man's body (or vice versa)? Do you find your own sexual characteristics upsetting or even repulsive? Do you wish you could switch genders?

If the Answer to This Question Is Yes, Please Refer to Chapter 8.

Question #9: Do you have trouble sleeping, sleep too much, or do unusual things happen while you sleep?

There are many different ways in which people have trouble sleeping. Does it take you a long time to fall asleep, tossing and turning while you think about the day's events? Do you wake up many times in the middle of the night? Do you awaken hours earlier than you want to in the morning and feel miserable because you cannot fall back to sleep?

Some people need too much sleep. Do you still feel tired during the day despite getting a full night's sleep? Do you find yourself falling asleep whenever things slow down, like while watching a movie or listening to a lecture?

Is your natural bedtime consistently out of sync with what your schedule requires? Are you a "night owl" who feels like going to sleep at just about the time you are supposed to be getting up for work? Or are you a starling who falls asleep right after dinner and wakes up hours before dawn? Do you work night shifts or have a constantly changing schedule so that you always feel alert or exhausted at the wrong times?

Finally, some people, especially children, have unusual things happen during sleep. Are you (or is your child) a sleepwalker? Do you (or your child) wake up in the middle of the night confused and screaming in terror?

Everyone has an occasional sleepless night and some people are simply restless sleepers. Moreover, the ability to sleep soundly through the night is likely to diminish as you age. You don't have clinically significant insomnia unless your problem with sleeping is severe, persistent, and regularly causes difficulties the following day. Before you diagnose yourself as having hypersomnia, check to see whether you are getting enough sleep. Sleep deprivation has become an ubiquitous feature in our overscheduled lives. Like it or not there are only twenty-four hours in the day. We all require a sufficient amount of sleep and this cannot be dispensed with simply because we are too busy to fit it in.

If the Answer to This Question Is Yes, Please Refer to Chapter 9.

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

Tags: Counseling and Therapy, Pathology

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.

About the Author

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.