Summing up the symptom

Symptoms refer to the subjective experiences individuals report when describing their condition, disorder, or illness. Unlike objective signs that can be directly observed by others (e.g., a rash or a fever), mental health symptoms are felt and communicated by the person experiencing them.

A vague statement like “I’m not feeling good” is generally not considered a symptom. Symptoms need to be much more specific. For instance, instead of “not feeling good,” an individual may report their symptoms as “I feel sad,” “I feel angry,” or “I feel hopeless.” 

Many symptoms may sound like emotional responses so it is important to distinguish between a normal emotional response and a symptom. A normal emotional response typically has a very specific trigger. For example, feeling sad after a bereavement is a natural and culturally accepted response. It wouldn’t be considered pathological.

It is recognized as a symptom when:

• It’s not an emotional response to a specific trigger 
• It represents a pattern of behavior that repeats over time.
• It’s unusual for that particular person’s typical behavior.

Another important aspect to note here is that symptoms do not occur in isolation and a combination of several symptoms should raise concern. For example, sadness solely might not be a cause for alarm. But it may be a cause for concern if it is accompanied by any of the following:

• Feelings of hopelessness
• Reduced appetite
• Sleep disturbances
• Persistent tiredness
• Frequent crying spells

Physical health and mental health are intertwined, and one will usually see some sort of effects of one on the other. Many mental health disorders are accompanied by visible physical effects. These may include headaches, increased heart rate and chronic pain. While these symptoms can also indicate other physical health issues, they can be used as indices for mental health.

It can be challenging for a layperson to definitively recognize mental health issues in someone else, especially if the individual is adept at masking their symptoms. However, if you are close to someone and familiar with their usual patterns of behaviour and emotional responses, you may be more likely to identify subtle changes.

It’s important to remember that some of these symptoms are not inherently abnormal. They become pathological when they are magnified, last longer than usual or frequent, and/or are accompanied by other symptoms that collectively hamper daily functioning. Clinicians can differentiate these from normal age-related changes (e.g. memory decline) by assessing the severity and frequency of the symptoms.

Even for trained clinicians, it takes time and multiple meetings to accurately identify issues. This may be because many mental health challenges are complex and individuals may not always be adept at articulating their symptoms.

Mental health disorders often share symptoms (e.g., anxiety and depression, or certain personality disorders with depression). Clinicians use a process called differential diagnosis to distinguish between these conditions. This involves:

Exploring timing and context: For example, understanding if certain symptoms occur alongside other mood disturbances or independently helps to zero in on the disorder.

Forming a hypothesis: Based on initial diagnostic interviews a clinician might suspect a particular disorder and draw conclusions

Negative interviewing:  By asking specific questions during the negative interview clinicians then aim to disprove the initial hypothesis. This helps to rule out other disorders with similar symptoms.

Comorbidity, the presence of two or more disorders in an individual, significantly affects symptom understanding.

• Mental Health Comorbidities: Having one mental illness increases the likelihood of experiencing another. While some symptoms can overlap some can even appear contradictory (e.g., hyperactivity in ADHD can be masked by low energy in depression). However, clinicians are often aware of the likelihood of such coexistence and will check for both.

Physical Comorbidities: Chronic physical illnesses can significantly impact mental well-being. The strain of managing pain and physical symptoms reduces an individual’s resources to be able to direct them towards dealing with other stress, making them more vulnerable to irritability, anxiety, and depression. Lifestyle changes required for conditions like diabetes can also contribute to psychological distress. For eg. Strict diet restriction may constrain enjoying an evening out with friends.

Syndromes can be culture specific. For example, Dhat syndrome, a belief in males that is characterised by the experiential fear of losing semen through ejaculation and nocturnal emissions, is specific to the Indian subcontinent.

Symptoms may also be expressed differently across cultures. For example, Asians are more likely to report the physical side of symptoms (e.g., fatigue), while the American and Europeans are likely to focus on the feelings (eg., sadness, hopelessness).

As individuals age, they are likely to experience symptoms indicative of a decline in cognitive functioning, such as forgetfulness or loss of orientation. However, these are not exclusive to aging and can occur in other disorders or be related to factors like burnout, stress, or nutritional deficiencies or menopause in case of women.

There are recognized differences in the diagnoses between genders. For instance, women are more frequently diagnosed with depression, anxiety, histrionic personality disorder, and borderline personality disorder, while men are more often diagnosed with ADHD, conduct disorders, substance abuse. 

Social construct can determine the perception around mental health issues. Men are expected to be emotionally stable and self-reliant, hence they may prefer to deal with mental illness on their own rather than seek external help. Women, on the other hand, have less stigma attached to ‘asking for help’. Women are more likely to be diagnosed with depression as they are more expressive when reporting their symptoms.

Diagnosis can not only be influenced by the gender of the patient but also the gender of the clinician.

Certain “red flag” symptoms require immediate attention:

• Suicidal intentions or thoughts: Any hint of suicidal ideation needs immediate attention.
• Psychotic symptoms: Such as hallucinations and delusions, are considered severe and often require medication as the first line of treatment. Psychotherapy can then support medication adherence and coping strategies.

Addressing mental health diagnoses often involves dealing with stigma. Individuals who voluntarily seek care are often more receptive to a diagnosis. However, a person’s level of awareness and understanding of their own issues can impact their acceptance of a diagnosis. For example, individuals with severe delusions may resist the idea of having a mental illness because it contradicts their firmly held beliefs. In such cases, the primary focus of the clinician might be on ensuring adherence to medication.

The process of identifying symptoms of mental health conditions is complex and specific. It varies according to age and culture, but can also carry bias and feed stigma. A conscious effort must be made to arrive at diagnosis bearing in mind personal and systemic biases.