Twenty Questions To Get You Started

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 doesnotnecessarily 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.

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.

Question #10: Is your personality more of a liability than an asset? Do you have patterns of thinking or behavior that keep you from getting what you want or what you need?

All of us have a personality -- a way of viewing the world and ourselves, a style of relating to others, and of pursuing our goals. To a large extent, our personalities determine our fate and create expectations about the world that usually become self-fulfilling prophecies. The way we perceive and act toward others strongly influences the way they perceive and act toward us.

The question here is whether one's personality functioning is so inflexible and maladaptive that it can be considered a personality disorder. Do you find that no matter how hard you try to do things differently, you keep falling into the same patterns -- the same type of unsatisfying relationship, the same battles with authority figures, the same unfulfilling jobs? Do your personality traits lead to the same vicious cycles? For example, if you are unreasonably suspicious and expect to be disliked, you are indeed likely to act in a way that will turn people against you. If you are excessively dependent and terrified of abandonment, your clinging behavior may well provoke the rejection you so greatly fear. If you excessively control others on the assumption that they will never take the initiative, your micromanagement will itself paralyze their ability to act independently. Finally, excessive demands that people praise you are more likely to result in losing rather than gaining their recognition.

Most people have more difficulty answering this question than any of the other nineteen. Unlike symptoms, which are experienced as unwanted and external to the self, most people remain pretty much unaware of their personality traits because they are experienced as so much an essential part of themselves. It is in the nature of things that your personality traits are probably much more evident to the people you live and work with than they are to you. If you have people in your life whose opinion and good will you trust, it may be helpful to ask them how they experience your personality.

If the Answer to This Question Is Yes, Please Refer to Chapter 10.

Question #11: Have you gone from doctor to doctor with concerns about physical symptoms, your physical health or appearance -- without receiving enough help or reassurance?

This question is for people who have recurring physical complaints that cannot be explained by the presence of a medical disorder. This can take several different forms: preoccupation with physical symptoms (e.g., occasional skipped heartbeats, dizziness, pain, or constipation); the belief that one has a serious physical illness; or exaggerated concerns about appearance.

Paying adequate attention to bodily sensations can be an important ingredient in the early identification of illness but some people become hypervigilant about bodily functioning. They spend inordinate and unproductive amounts of time and money in a futile attempt to get to the bottom of every ache or pain. Sometimes visits to multiple doctors may be necessary in the diagnosis of particularly complicated or unusual physical problems. However, if you have been to many doctors, had dozens of tests, and have been frustrated by being told that there is nothing physically wrong, you should consider that these symptoms may be indicative of mental disorder.

Other people become preoccupied with the idea that they are suffering from a serious illness despite being told that there is no cause for concern. A person may interpret a headache as indicating a brain tumor or that fatigue and frequent colds mean a diagnosis of AIDS. No matter how many doctors say that there is nothing to worry about, the person assumes that the medical workup is incomplete and will not end the search until his or her worst fears are confirmed.

Finally, most people are less than thrilled with their physical appearance but more or less manage to come to terms with how they look. In contrast, some people's lives come to revolve around the conviction that something is really terribly wrong with their appearance. They remain unspeakably hideous in their own eyes, despite reassurances from others that these concerns are exaggerated or completely unfounded.

If the Answer to This Question Is Yes, Please Rear to Chapter 11.

Question #12: Do you have trouble controlling your impulses?

From time to time, even the most disciplined person might have a lapse or two in resisting an impulse. The question here is whether you have a pattern of difficulty controlling your impulses that gets you into trouble. Has gambling become the center of your life, interfering with your work and relationships? Do you have a pattern of destructive violent outbursts that are far out of proportion to any provocation? Do you have impulses you can't resist to steal things you don't really need? Do you get a thrill setting fires? Do you have an impulse you can't control to pull out your hair? Are there other impulses that you are having trouble resisting -- drug use, binge eating, sexual desires?

If the Answer to This Question Is Yes, Please Refer to Chapter 12.

Question #13: Do you have the strange experience of feeling disconnected from your memories, from yourself, or from the outside world?

Some people develop amnesia for psychologically traumatic events in their past. Are there particular events or discrete periods of time in your life that you cannot recall anything about? Do you sometimes feel as if you were in a dream or a movie, or as though everything around you is unreal? How about feeling like your body is unreal or that you are like a robot? Have you felt like you don't have a coherent sense of your identity? The most extreme manifestation of this would be your feeling that you have multiple personalities that take control of your behavior.

Of course, memory is fallible and not everyone feels totally integrated in identity every minute of every day. Do not answer "yes" simply because you cannot remember all of the details of your childhood -- nobody can. Moreover, it is perfectly normal to have occasional periods of feeling "spaced out" or feeling so conflicted that you are not sure who the "real you" is.

If the Answer to This Question Is Yes, Please Refer to Chapter 13.

Question #14: Are you unable to handle the stresses you have to face in your life?

Is there something stressful in your life that is really throwing you for a loop? Stress is an unavoidable part of our lives and will inevitably lead to an occasional bad day. This is not what we are talking about in this question. Instead, the issue is whether you are having symptoms in response to a stressful event that are more intense and prolonged than most other people would have in similar circumstances. Is this reaction maladaptive -- that is, does it hurt more than help you in dealing with the stressful event? Do you find that you can't just pick yourself up and dust yourself off? The most common problems caused by stress are feeling down and/or anxious, performing poorly at work or at school, developing physical symptoms, and, particularly in children, displaying bad behavior.

If the Answer to This Question Is Yes, Please Refer to Chapter 14.

Question #15: Do you sometimes lose touch with reality?

Have you had any particularly unusual experiences or upsetting beliefs that seem to puzzle other people or make them think you are strange? For example...Are you convinced that strangers are talking about you, that you are being followed, that you are being spied on, that there is a plot against you, that you have special supernatural powers, that your spouse is unfaithful, that something is terribly wrong with your body or that it is being poisoned or tampered with, that other people can hear your thoughts, or that someone is controlling your thoughts or actions against your will? Have you ever heard voices of people talking when there was no one around, had visions of things that are not really there, or smelled a foul odor coming from your body that no one else can smell?

A "yes" answer to any of these questions suggests the possibility that the person has lost the ability to distinguish what is real from what is a product of imagination. However, before assuming that there is a severe mental disorder, it is important to determine what is really happening in that person's life. Some people seem to act in a paranoid way because there really is someone out there trying to get them. A "no" answer must also be taken with a grain of salt since it may reflect the denial of illness frequently encountered in those who have lost touch with reality.

If the Answer to This Question Is Yes, Please Refer to Chapter 15.

Question #16: Does your mind seem to be failing you?

This question addresses problems with a number of different mental functions. Do you have trouble with your memory -- learning new things and recalling past events? Do you have times in which you lose touch with what's going on around you and have difficulty focusing your attention? Do you sometimes get disoriented -- not knowing where you are, what day it is, and who are the people around you? Do you have trouble understanding others when they talk to you or in making sense when you speak? Do you have trouble carrying out the activities of everyday life -- washing yourself, dressing, cooking, planning your day?

Most people are more or less dissatisfied with their mental functioning, especially as it begins to decline with age. The question here is whether you are having problems with your mental functioning that are severe enough to interfere with your work or day-to-day activities.

If the Answer to This Question Is Yes, Please Refer to Chapter 16.

The remaining four questions are for those disorders that always have their onset during childhood or adolescence. In some cases, the child will outgrow the problem or have successful treatment for it. In other cases the symptoms persist into adulthood. You may, therefore, be answering these questions either for yourself or for your child. You should be aware that children and adolescents can be afflicted with virtually any of the problems covered in this book.

If you are going through this chapter with your child's problems in mind, be sure to review the first sixteen questions in this chapter as well.

Question #17: Has your child had delays in development of intellectual, academic, motor, communication, or social skills?

Children vary tremendously in the rate at which they develop intellectual, motor, language, and social skills. This question refers to functioning that is significantly below what is normal for your child's age and which causes marked impairment in school or home. Has your child's IQ been measured to be below 70 and, if so, is he having trouble functioning as a result? Has your child been diagnosed with a specific learning disability in reading, writing, or mathematics? Does your child have a severe problem with coordination, speech, or language? Is your child strange in the way he relates to other people -- showing no emotion, not maintaining eye contact, treating other people as if they are pieces of furniture? Is your child's behavior rigid, repetitive, or unusual and are his interests and activities quite restricted?

If the Answer to This Question Is Yes, Please Refer to Chapter 17.

Question #18: Has your child had behavior problems?

We cannot expect, and probably would not want, our children to always be perfect little angels. However, some children display patterns of bad conduct or disruptive behavior that are sufficiently severe and

Excerpted from Am I Okay?: A Layman's Guide to the Psychiatrist's Bible by Allen J. Frances, Michael B. First
All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.