How to recognise the early signs of mental distress

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What is mental distress?
What are the signs?
What happens when someone hears voices?
Am I going mad?
How should friends or relatives respond?
Is there any risk involved?
What causes mental distress?
What can be done to help?
How can I help myself?
How easy is it to do without medication?
Useful organisations
Further reading

This booklet is designed for anyone who wants to know more about mental distress – those who experience it, their friends, families, carers and mental health professionals. It's not intended to be a means of do-it-yourself diagnosis, but should help identify the warning signs. It aims to help people to understand the causes and effects, and to cope better when it strikes. We use the term mental distress in preference to medical labels such as schizophrenia or manic depression (bipolar disorder).

What is mental distress?

Mental distress covers a range of experiences that seriously limit an individual's ability to cope with day-to-day living. One person in four will have some form of mental health problem, according to some estimates, and for as many as one in fifty, it will be serious. Although figures and definitions vary, what is clear is that millions of people in the UK will encounter problems themselves, or know someone else who does.

The kinds of problems include:

• Hearing and seeing things that others don't. This is a common feature of mental distress (although many people see or hear things without it causing them any distress).
• Other differences in perception, for example, mistakenly believing that someone is tying to harm you, is laughing at you, or trying to take over your body.
• Mood swings that are very extreme or fast. Deep or prolonged depression can be very disabling, and very difficult to escape from. Extreme highs are often more difficult for those around the person concerned. But they can cause serious problems, particularly when they are associated with sleep deprivation.
• Self-harming behaviour, such as cutting yourself.
• Changes in eating habits; eating distress.

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What are the signs?

The first signs of mental distress will be different for the onlooker than it is for the person in distress. When someone's mood starts changing, for instance, it may take some time for them to become aware of it; people around them may be much more conscious of the difference.

Changes in sleep patterns are a common sign, and appetite may also be affected. Lethargy, low energy levels, feeling antisocial and spending too much time in bed may indicate the onset of depression. Wanting to go out more, needing very little sleep, and feeling highly energetic, creative and sociable, may signal that a person is becoming 'high'.

The first time it happens, the effects of hearing or seeing things that other people don't are likely to be especially dramatic. Hearing voices can be a very confusing experience for the person concerned. It's often (but not always) clear to him or her that nobody else can hear the same thing, and this can be very frustrating. When someone is seeing an image that others can't, the experience may cause immense distress simply because we're all accustomed to believing what we see.

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What happens when someone hears voices?

It's almost impossible not to react to something we hear or see, and this is one of the most frightening aspects of mental distress. Exactly what someone does will depend on what it is they are experiencing. Some images are so frightening that people freeze, scream, try to hide, or literally try to run away from them.

Some voice-hearers react by confronting their voices. The behaviour of a person who is hearing and seeing things can be unsettling to an onlooker: he or she may be talking to or even shouting or swearing at someone who isn’t there. Strange and disturbing as this might seem, it begins to make sense if we consider what he or she is experiencing. If someone talks to us, we answer; if they bother us, we tell them to leave us alone. This is what someone who hears voices is doing. What appears to be a person ranting, hurling random abuse or holding a one-sided conversation can be seen as a person responding to threats or insults from their voices.

Hearing voices is remarkably widespread. Many people hear voices all their lives, without it causing them any difficulties or distress at all. Some say they would be lost without them. Attitudes vary in different cultures, and at different times. Some cultures see voice-hearing very positively and treat people accordingly. Generally, hearing voices only comes to the attention of other people when it becomes a problem.

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Am I going mad?

If you are in mental distress, you may begin to doubt yourself and become desperately afraid you are going mad. All the stereotypes of insanity, from Dr Jekyll and Mr Hyde to Psycho , may come flooding to mind. You may question your ability to think and reason properly, and be afraid of becoming a danger to others or of being locked up in an institution.

These fears are often reinforced by the negative way that mental illness is portrayed on screen and in the newspapers. This may stop you from talking about your problems. The risk of being branded 'mad', of losing friends, family and freedom may deter you from being open about your experiences. This, in turn, is likely to increase your distress and sense of isolation, and adds to the frustration of those around you.

There are many problems that follow the onset of mental distress, but putting up shutters only makes things worse. Talking about what you’re going through, with someone you trust, is a good way to ease your distress.

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How should friends or relatives respond?

Friends may want to be supportive, but may not be sure how best to respond. When someone starts behaving in a way that suggests they may be suffering from mental distress, it's vital to be sensitive to their situation. They may have many of the fears outlined earlier, and need reassurance. Some people may benefit from talking to other people, or they may need time to themselves.

It's important for them to have someone they can trust and talk to openly, when they are ready. Sometimes, opening up to relatives is simply impossible. If this is the case, trying to force someone to express their distress will only make it worse. They may find it easier to communicate with someone who's had a similar experience (see Useful organisations) or to a counsellor or therapist.

Until you can understand why a person is cutting him- or herself, for example, it's almost impossible to provide constructive support. Some people perceive changes to their own body. They may feel, for instance, that an external force is in control of it. Or they may see a snake wrapped around their arm, attacking them, and may retaliate by cutting at their arm with a knife. Dealing with any wounds is obviously a high priority; dealing with mistaken perceptions takes longer. This is true of all the different kinds of response to a faulty perception.

Over time, you will learn how best to help and you will be well placed to help break down some of the stigma and prejudice that surrounds mental distress. Don't be quick to judge. The more thoughtful and measured your response, the more effective your help will be. Trust and respect are important. They help to rebuild and maintain a sense of self-esteem, which mental distress can so easily crush.

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Is there any risk involved?

There is a strong, but misplaced belief that there's a link between mental illness and violent behaviour. This is reinforced by excessive and inaccurate reporting of the dangers posed by people with psychiatric diagnoses, especially schizophrenia. But there are relatively few serious acts of violence by people in mental distress.

There are ways of reducing any risk. If someone is highly distressed, it's important to try and understand why he or she is behaving as they are. If they seem to want to escape from something, it's not a good idea to block their way, in case it increases their desperation. Similarly, if someone is hiding, trying to prise him or her out may add to the danger. A calm and measured response is always likely to be far more effective.

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What causes mental distress?

There are as many possible causes as there are experiences. People’s personal circumstances and experiences are important. There are many reasons why people may get depressed or elated because of what's happened in their lives, and certain events may act as triggers to mental distress.

For instance, a person who loses a loved one will find it hard to bear, and it's not unusual for people to see or hear the person who has died. A degree of depression is likely to follow, but for some it goes far beyond bearable limits. If they then go through the break up of a relationship, this will be a further loss. The drop in self-esteem that follows will add to the loss of self-esteem that already accompanies mental distress. Any criticism from other people will reinforce their own self-criticism and this, in turn, feeds the criticism from the voice.

For a significant number of people who experience mental distress, problems can be linked back to physical or sexual abuse, sometimes many years prior to the distress.

No one really knows why some people react to life events far more than others. But there are various medical, psychological, social, spiritual and religious explanations that have been suggested. It's possible that some people may be more prone to developing problems; some problems seem to run in families, and experts are researching whether there is a genetic reason, with no clear results. There is evidence that mood problems are linked to changes in brain chemistry, but it isn't possible to say which comes first, the mood or the chemical change.

Similarly, it's difficult to say, sometimes, whether problems are the cause of certain difficulties, or the effect. For example, depression may be the original source of mental distress, or it may be a response – and a perfectly reasonable one – to hearing voices inside your head criticising you the whole time, or seeing frightening things. Similarly, getting little sleep could be an effect of being emotionally high, or it may be because sleep is impossible for other reasons. The same holds true for changes in appetite or eating habits.

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There is a strong temptation, especially perhaps among people’s relatives or carers, to accept a simple explanation or diagnosis for a state of mental distress. The idea being that giving something a medical name (for example, schizophrenia) is halfway to solving the problem. Sadly, that’s not the case.

There is no one single, guaranteed approach to mental distress, whether spiritual, social or medical. If people only see mental distress as an illness, it can limit them to trying only medical treatments. Instead, it’s possible to use a range of approaches that identify and meet each person’s individual needs. Ideally, you should be offered a range of support, so that you can identify for yourself which treatments, therapies or lifestyle suit you best and reduce your distress.

Mental health professionals
There are a number of professionals who may be able to offer a variety of types of support: informal advice from a family doctor; talking therapies from a counsellor or psychotherapist; or medication from a psychiatrist.

Many people experiencing a crisis for the first time contact their GP. In some cases, the GP may refer him or her on to specialist services for further assessment, treatment and care. Sometimes, people go straight to the Accident and Emergency department of their local hospital. These tend to be busy and unsettling places, and you may have to wait a long time. There should be a psychiatrist on call and sometimes other members of staff who link people into mental health services. If you are seriously distressed, you may be admitted to hospital. Hospitals tend to rely heavily on medication, but may also be able to offer additional therapy and talking treatments. In some areas, there are crisis services available to help people avoid having to go to hospital (see below).

The Government's priority is for people to receive care in the community via outpatient psychiatric services and Community Mental Health Teams (CMHT). CMHTs are multidisciplinary teams, including social workers and mental health care professionals.

Some CMHTs can provide 24-hour crisis support, either in a person’s home or in another community setting (such as a staffed house). They are often geared to specific sections of the community, such as women, members of minority ethnic communities or young people with a first episode of mental distress. They are not yet widely available.

Talking treatments
Talking treatments, sometimes in combination with medication, can be very successful in helping people deal with mental distress. Counsellors and psychotherapists are trained to listen, to help people understand themselves and find ways of overcoming their difficulties. It’s only available in a limited way on the NHS, although the Government are trying to drive forward more treatments such as cognitive behaviour therapy (CBT) that produce fast results. Note, this is not appropriate for everyone. (See Mind’s booklet Making sense of cognitive behaviour therapy.) There are also private organisations that can help (see Useful organisations).

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How can I help myself?

Taking positive action to help yourself is an important step. It's worth exploring all the options available to you, including those provided by voluntary organisations, such as local Mind associations, and registered bodies focusing on particular problems or therapies. (See Useful organisations.)

Joining a self-help group can be very helpful in rebuilding confidence. There are many local support groups for a range of different types of mental distress. Through them, people with the same kind of problem (including relatives and friends) can meet up and share their experiences, learn to identify triggers and develop different strategies for coping. People often find that certain events or circumstances can trigger mental distress for them. Recognising these triggers can minimise both the likelihood of mental distress and its effects when it strikes. There are a number of publications with suggested strategies.

Many of the problems that accompany mental distress can have a negative effect on your general health, and this can make coping with distress even more difficult. Good physical health care, regular exercise and a healthy diet can reduce the depth and duration of mental distress, and may even help to prevent problems returning. (See Further reading.)

Many people have found it worthwhile exploring alternative and complementary medicines and therapies which have proved very useful to people who want to have more control over their own treatment, health and wellbeing.

How easy is it to do without medication?

Medication can play an important role for some people, but for others it doesn’t help at all. Most drugs prescribed by psychiatrists have potential withdrawal and side effects, which need to be considered before consenting to any treatment. Once someone has started to use medication it can be difficult to change treatments: if the person decides to reduce the amount they are taking, or if they decide to stop altogether, withdrawal symptoms can sometimes be mistaken for a relapse in the condition and so the drug begins to be used again.

It’s therefore very important for anyone who decides to come off prescribed medication to make sure that friends, family or carers are aware of what they are doing. Many people have successfully reduced their medication or come off it altogether. The best way to succeed is by doing it slowly, with as much support as possible from those around you. Changes in mood and perception are common effects of withdrawal. They are less likely if withdrawal is paced (over 12 months, or longer, is not unusual), and they are much easier to cope with in a supportive environment. (See Mind’s booklet Making sense of coming off psychiatric drugs.)

For people who have experienced mental distress, there’s always a risk that perfectly normal behaviour, such as being angry or upset, will subsequently be seen as signs of relapse. It’s important that friends, relatives and professionals looking for signs of mental distress realise that because someone has or has had some form of mental distress not everything they do or say is because of their mental distress. Everyone has a right to react to situations and express emotions.

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Useful organisations

British Association for Counselling and Psychotherapy
tel. 0870 443 5252
web: www.bacp.co.uk
For details of local practitioners

Carers UK
32-36 Loman Street, London SE1 0EE
helpline: 0808 808 7777
web: www.carersonline.org.uk
Information and advice on all aspects of caring

Depression Alliance
tel. 0845 123 2320
web: www.depressionalliance.org
For anyone affected by depression

Hearing Voices Network
79 Lever Street, Manchester M1 1FL
tel. 0845 122 8641
web: www.hearing-voices.org
User network and local support groups for people who hear voices

The Manic Depression Fellowship (MDF)
tel. 0845 340 540
web: www.mdf.org.uk
For people affected by manic depression. Runs local self-help groups and an online community

Papyrus (Prevention of Young Suicide)
Rossendale GH, Union Road, Rawtenstall, Lancashire BB4 6NE
tel. 01282 432777
web: www.papyrus-uk.org
For the prevention of young suicide

Rethink Severe Mental Illness (formerly NSF)
28 Castle Street, Kingston upon Thames KT1 1SS
advice line: 020 8974 6814
web: www.rethink.org
For everyone affected by severe mental illness

Samaritans
Chris, PO Box 9090, Stirling FK8 2SA
helpline: 08457 90 90 90 minicom: 08457 90 91 92
email: jo@samaritans.org  
web: www.samaritans.org
24-hour telephone helpline offering emotional support

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Further reading
Accepting voices eds. M. Romme, S. Escher (Mind 1993)
Coping with depression in young people; a guide for parents (John Wiley and sons 2004)
Going mad? Understanding Mental illness M. Corry, A. Tubridy (Newleaf 2001)
How to look after yourself (Mind 2006)
Living with mental illness: a book for relatives and friends (3rd ed.) (Souvenir Press 1997)
Making sense of antipsychotics (major tranquillisers) (Mind 2007)
Making sense of antidepressants (Mind 2006)
Mind guide to food and mood (Mind 2006)
Mind guide to physical activity (Mind 2006)
Understanding bipolar disorder (manic depression) (Mind 2006)
Understanding depression (Mind 2007)
Understanding eating distress (Mind 2007)
Understanding mental illness (Mind 2007)
Understanding paranoia (Mind 2007)
Understanding personality disorders (Mind 2007)
Understanding postnatal depression (Mind 2007)
Understanding schizophrenia (Mind 2005)
Understanding self-harm (Mind 2007)
Understanding talking treatments (Mind 2005)
Your drug may be your problem P. Breggin, D. Cohen (Perseus 2007)

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This booklet was written by David Crepaz-Keay. Revised by Mind
First published by Mind 1996. Revised edition © Mind 2008
ISBN 9781874690566
No reproduction without permission