Preventing Relapse

James J. De Santis, Ph.D.
Post Office Box 894, Glendora, CA 91740-0894
(818) 551-1714

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People who are experiencing a mental illness--such as major depression,
bipolar disorder (manic-depression), or schizophrenia--can improve their
condition by learning how to maintain good health, how to avoid a
recurrence of their illness, the importance of compliance with treatments
prescribed by their physician, and to make sure they consult their doctor
and discuss everything about their illness.

Accepting A Mental Illness

Taking the word "relapse" apart helps understand it's meaning. "Re" means
"again" or "backward," and "lapse" means "to slip gradually or depart from, to
fall from an attained and usually higher level to a lower level." Putting the
two parts together, "relapse" means to fall or slip backward from a level of
higher functioning to a previous lower level of functioning. A person who has
recovered or improved and who afterward suffers a return of symptoms is
said to have experienced a "relapse."

There are many ways to avoid relapse. If you have an illness, the first way
is to accept that you have an illness. Unless you accept that you have an
illness, it is difficult to do anything constructive about the problems it may
cause. Accepting an illness means to avoid denial. Denial is an unconscious
psychological process that people sometimes use to try to defend
themselves from something threatening. Denial may temporarily protect the
good feelings we have about ourselves--called our self-esteem; however,
denial blocks from our awareness whatever is threatening to us. Denial can
be seen when a person suffering from an obvious illness seems to be
genuinely unaware of that fact.

Denial can take many forms. "Simple denial" involves arguing that something
which is in fact real is simply not real. "Minimizing" is a form of denial that
involves describing a problem as much less serious than it really is. Blaming
is another form of denial that involves denying responsibility for one's
behavior and arguing that responsibility lies with someone else.
"Rationalizing" involves giving alibis, excuses, or justifications for one's
behavior. "Intellectualizing" involves avoiding a personal emotional
awareness of a problem and, instead, dealing with it in an abstract, general,
or theoretical way. "Diversion" involves changing the subject to avoid the
issue if someone else brings it up. Hostility can function as a form of denial
when it involves becoming angry or irritable when the problem comes up, in
order to make other people drop the subject.

Denial can impair judgement and keep a person locked into an increasingly
destructive pattern that can lead to a relapse. If you have a mental illness,
avoid relapse by avoiding denial, become self-aware, and learn more about
your illness.

Developing a Cooperative Relationship with A Physician or A Therapist

Relapse can be avoided by developing a good, cooperative working
relationship with your doctor and/or therapist. Treat them as a member of
"your team."

Educate your physician about you. Tell your doctor if you have had any
illnesses, including such things as other medical problems. For women, be
sure to tell your doctor if you are pregnant, breast-feeding, or planning a
pregnancy. Tell your doctor if you are taking any other medicines or drugs,
including recreational drugs or alcohol. Tell your doctor if you have taken
medicines in the past that are similar to what your doctor is prescribing and
how effective they were. Tell your doctor if you have any allergies. Let your
doctor know if you are having any unusual or unaccountable experiences or
symptoms.

There is no such thing as a dumb question. Make sure that you consult your
physician if you have questions. In order to eliminate any doubts or
anxieties you may have, ask your physician to explain your illness to you,
how long your illness may last, and what types of symptoms you should
watch for that may signal a relapse.

If you disagree with your doctor's advice, assert yourself by talking about it
with the doctor. Tell your doctor that you disagree and explain why. Find a
way to resolve your differences with your doctor through communicating
rather than simply ignoring your doctor's advice. If symptoms of your illness
recur, contact your doctor immediately.

Be honest with your therapist or counselor. Talk about the frustrations and
worries that are really on your mind. Talk about the stresses in your life and
where you may be having trouble coping. Talk about what you expect from
the counseling process. The more you share, the better your therapist can
understand what's really bothering you and the better your therapist can
help.

Working cooperatively as a team with your physician and therapist can help
prevent relapse.

Becoming Knowledgeable About Your Illness

Becoming knowledgeable about your illness is an important step in
preventing relapse. Unless you understand your mental illness, it is difficult
to accept that there is even a problem. In order to eliminate any doubts or
anxieties you may have, ask your physician to explain (1) your illness to
you, (2) if the illness will last a short time or a long time, and (3) the types
of symptoms you may experience.

Symptoms are any kind of event, experience, or noticeable change that
indicates an illness is present. Fever, for example, can be a symptom of
infection. Pain can be a symptom of a sprained ankle. Mental illnesses also
are indicated by the presence of symptoms.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) is a
standard text that describes the symptoms of mental illnesses in detail. Of
the many types of mental illnesses that exist, three types of mental
illnesses are important for us to distinguish: major depression, bipolar
disorder, and schizophrenia.

Characteristic symptoms of major depression can include sad mood, reduced
interest in usual activities, significant weight change, significant sleep
change, either agitation or slowing of behavior, low energy, feelings of
worthlessness or excessive guilt, trouble concentrating, and sometimes
thoughts about death.

Characteristic of bipolar disorder is a fluctuating mood--from very sad mood
on the one hand to unusually happy or irritable mood on the other. These
mood swings can be accompanied by an exaggerated feeling of self-worth,
trouble sleeping, talkativeness, racing thoughts, trouble concentrating,
agitation, and impulsive behavior.

Characteristic symptoms of schizophrenia can include delusions (firm, but
inaccurate beliefs about reality in spite of obvious proof that they are
false), hallucinations (sensations that happen without an external cause,
like visions or voices that seem to be real but are not), disorganized speech
and behavior, and blunted emotions.

Knowing about your illness is important to preventing relapse. The more you
know about the characteristic symptoms of your illness, the more you can
identify a problem early, before it becomes difficult to treat.

Becoming Knowledgeable About Your Medicines

To prevent relapse, it is important to take your medicine only as directed by
your doctor. Do not increase or decrease a dose unless your doctor directs
you to do so first. If you miss a dose, return to the prescribed schedule. It
is important to discuss with your doctor how the medicine is working for
you. When you begin taking a medicine, it may take awhile for your doctor
to find the dose that is most effective.

Your doctor want you to take blood tests in order to closely regulate how
much medicine is in your body. Blood tests are particularly important for
some medicines. If your doctor prescribes a special diet, follow it closely,
especially if you take certain antidepressants.

Some medicines have to be taken for several weeks before you achieve the
maximum benefit. While waiting, don't get discouraged. Don't play doctor by
stopping your medicine just because you start feeling better. If you stop
taking some medicines, they may continue to work for awhile until they
wear off, but they may still have to taken to prevent symptoms from
returning.

Never give your medicine to anyone else, not family, not friends. If their are
children in the house, keep all medicines out of reach.

Avoid street drugs and alcohol. Street drugs and alcohol are "psychoactive"
drugs--this means they affect your mind. If you are currently taking
medications to stabilize your thinking or your mood, street drugs or alcohol
can upset the balance. If you use recreational drugs or alcohol, don't try to
compensate by taking extra doses of your medicine. Discuss with your
doctor any guidelines for the use of alcohol because it may interact
adversely your medicines.

There are five major categories of medicines: neuroleptics (or major
tranquilizers), antidepressants, lithium, minor tranquilizers, and medicines to
control certain side effects produced by some of the other medicines. No
single medicine is right for everyone.

Antidepressants can improve mood, appetite, and sleep. They can increase
physical energy and ability to concentrate. They can relieve feelings of
hopelessness, fear, and anxiety. Lithium can stabilize mood by decreasing
mood swings or extremes of elation, irritability, or sadness. It can help
decrease racing thoughts and physical overactivity. Neuroleptics can
reduce hallucination, which are sensations that happen without an external
cause, like a vision or sounds that seem to be real but are not. Neuroleptics
can reduce delusions, which are firm, but inaccurate beliefs about reality in
spite of obvious proof that the beliefs are false. Neuroleptics can improve
concentration and can reduce unrealistic fears to help you feel calmer.
Minor tranquilizers can help reduce anxiety and help you sleep. Medicines
which control side effects will be discussed later.

If you do not know what medicines you are taking, their dosages or
frequencies, ask your doctor to explain it to you. The more you know about
your medicines, the more you can prevent relapse.

Learning What To Do About Medication Side Effects

Knowing about side effects and how to manage them can help prevent
relapse. Along with the intended, desireable effects of medicines also can
sometimes come side effects. Side effects are the effects a medicine may
have that are unwanted and may be unpleasant. When you are prescribed a
new medicine, talk with your doctor about what side effects to expect. Not
all people experience side effects. Different drugs may have different side
effects. Some side effects are temporary and improve when your body gets
accustomed to your medicine. While some side effects may only be a
nusance, some can be serious. Discuss with your doctor any side effects
that might occur that could be serious and what to do if they occur.

While some side effects may require medical attention, there are some side
effects that usually do not require medical attention. Among them are the
following that can occur with medicines prescribed for mental illnesses.

Some medicines can cause dry mouth. Remedies include (1) frequent, small
sips of water, (2) chewing sugarless gum or sucking on sugarless candy, or
(3) sucking on ice. Sometimes medicines can cause blurred vision. Blurred
vision is a temporary side effect; your eyes are not damaged. There is no
specific treatment for blurred vision, but some remedies may help. Adjust
your reading distance--adjust your viewing distance from your magazine,
newspaper, or television. Avoid driving a car or operating machinery if your
vision is blurred. Another possible side effect is constipation. Remedies
include (1) drinking fruit juices, (2) adding more fruit and vegetables or bran
cereal to your diet, (3) getting regular exercise, and (4) developing a
regular bowel habit at the same time each day.

Another possible side effect is sleepiness. (One caution is that sleepiness
may not be a side effect of the medicine you are taking, but may be a
symptom of the illness itself. Your doctor will know more about this.)
Remedies can include (1) avoiding naps during the day that would cause
you to be less drowsy at bedtime, (2) avoiding alcohol, caffeine, and
cigarettes, (3) eating a light snack before bedtime, (4) relaxing with a book
or soft music before bedtime, or (5) taking a shower before bedtime. If you
are drowsy, avoid driving, operating machinery, or performing tasks where
alertness is required.

Dizziness or light-headedness can sometimes occur with medicines. When
getting up from a sleeping position, do so gradually by sitting up and
pausing for a few moments before standing up.

For these side effects, your physician may recommend taking most of the
medicine at night to reduce the effects when you are awake during the
day. Or the doctor may change you to a different medicine--not all
medicines have the same side effects. Once symptoms of your illness are
under control, the doctor may reduce the dose of medicine to reduce the
side effect. But don't make any changes on your own.

One group of side effects, collectively called "EPS" for "extrapyramidal side
effects," includes such things as muscle spasms, shakes, stiffness, and
restlessness. Activity, such as exercise, can be useful to channel
restlessness into something useful. Your doctor may prescribe an additional
medicine that will help control EPS. Once symptoms of your illness are
controlled, the doctor may reduce the dose of medicine to help. The doctor
may prescribe that you take your medicine at night.

If you do not know what medicines you are taking or what side effects may
occur, ask your doctor. The more you know about side effects, the more
you can prevent relapse.

Getting Involved In Life

Preventing relapse involves being active, getting involved, and enjoying life.
Enjoying life means avoiding loneliness and isolation. Avoid loneliness by
building friendships. It's great to have casual acquaintances, people you
can engage in "small talk," but it's also important to have a support system
of friends. Develop at least one close friend in whom you can really talk to
about your thoughts and feelings. Friends can help you; they can
sometimes recognize changes in your behavior that may signal that you
need to see your doctor. Changes in behavior can include poor grooming,
withdrawing socially from other people, or not sleeping.

Avoid accumulating stress in your life. Stress is a physical, social, or
emotional demand or pressure that causes bodily or mental strain. Stress
can be a factor in the development or recurrence of diseases including
mental illnesses. It is important to recognize stresses in life. Stress can
develop from either positive or negative sources. Work and finances can be
a source of stress, including a challenging new job, a change in work hours,
or money worries. Family, social life, and friends can be a source of stress,
including arguments, the loss of a loved one, or even a fun but stressful
vacation. Physical illnesses can be a source of stress, too.

Coping with stress is better than simply avoiding it. Ways of coping with
stress include learning to be more assertive, learning to communicate better
with other people, and resolving conflicts with others when then occur.
Learn some relaxation techniques like progressive muscle relaxation, guided
imagery, autogenic training, or deep breathing to help manage stress.

Make good use of your leisure time. Make time for fun. Plan enjoyable
activities each week. Fun is a good way of relieving stress. Develop a
hobby. Set aside time each week for fun activities. If you find you do not
naturally set time aside for fun, then write out specific plans on your
calendar.

Don't hesitate to seek help when you need it. Get involved with community
mental health programs and resources. Find out what kinds of programs are
available at your local clinic that might be suitable for your needs and
enjoyable too. Keep all scheduled appointments with community mental
health clinics and with your doctor and therapist. Get involved in athletic
organizations like the "Y" or community recreation centers. Get involved
with self-help groups such as Alliance for the Mentally Ill, Emotional Health
Anonymous, or Ups-And-Downs.

Getting involved in community life, coping with stress, making friends, and
having fun are all ways of helping prevent relapse.