Over the years, advances in neurology and research have simplified the way psychologists, psychiatrists, and others diagnosis and treat mental health problems. In over one hundred years of mental health treatment, the symptoms and behaviors associated with certain mental health conditions have remained the same. Psychotic disorders, where the individual often can't distinguish between reality and their fantasies, still have auditory hallucinations. Depressed individuals still can't sleep and remain preoccupied with the past. Hyperactive children (Attention-Deficit Hyperactivity Disorder or ADHD) still exhibit uncontrollable restlessness.
When patients first began reclining on the couches of psychoanalytic psychiatrists, the depressed folks talked about their past. This led the founders of psychology and psychiatry to believe that issues that began in childhood caused many mental health problems. But questions were still not answered. Why would a bad relationship with your mother create the appetite loss found in depression, especially when eating problems only started several months prior to the session? By what strange mechanism would a childhood issue create an auditory hallucination, often years after the reported traumatic event? Many people had difficult childhoods, but they didn't hallucinate and have a great appetite. It became clear that many mental health problems also had a physical component that involved changes in concentration, sleep, appetite, speech pattern, energy level, perceptions (hallucinations), and motivation. Studies began to determine the connection, if indeed one was present, between the condition of the patient and the physical signs/symptoms that were also present.
The picture became easier to understand when chemicals in the brain called "neurotransmitters" were discovered. The brain consists of billions of neurons or cells that must communicate with each other. The communication between neurons maintains all body functions, informs us when a fly lands on our hand, or when we have pain. The communication between neurons is controlled by the brain's type and level of neurotransmitters. Neurotransmitters are chemical substances that control and create signals in the brain both between and within neurons. Without neurotransmitters, there would be no communication between neurons. The heart wouldn't get a signal to beat, arms and legs wouldn't know to move, etc.
As we discovered more about neurotransmitters, we began to identify which neurotransmitters controlled certain bodily functions or which were related to certain emotional/psychiatric difficulties. Serotonin, a neurotransmitter, was found to be related to body temperature and the onset of sleep. Research also identified Serotonin as related to depression and later to a variety of mental health conditions such as anorexia and obsessive-compulsive disorder.
As research in neurotransmitters continued, studies between neurotransmitters and mental conditions revealed a strong connection between amounts of certain neurotransmitters in the brain and the presence of specific psychiatric conditions. Using an everyday example, our automobile operates by using a variety of fluids such as engine oil, transmission fluid, brake fluid, and coolant (anti-freeze). Every automobile has a way to measure the levels or amounts of each of these needed liquids such as the dipstick for oil and transmission fluid and marked indicators for anti-freeze and brake-fluid levels. Using our dipstick to measure engine oil, for an example, we can find our engine to be found one, two, or even three quarts low. After a recent oil change, the dipstick may also tell us that we have excessive oil in the engine. To work properly, all fluid levels must be in the "normal range" as indicated by the dipstick. When we receive a blood test, values of certain blood components are given with the "normal range" also provided, indicating if a blood chemical is below or above the average range.
Neurological research has identified over fifty (50) neurotransmitters in the brain. Research also tells us that several neurotransmitters are related to mental health problems – Dopamine, Serotonin, Norepinephrine, and GABA (Gamma Aminobutyric Acid). Too much or too little of these neurotransmitters are now felt to produce psychiatric conditions such as schizophrenia, depression, bipolar disorder, obsessive-compulsive disorder, and ADHD.
Unfortunately, the body doesn't have a built-in dipstick for neurotransmitters, at least one that's inexpensive enough for community mental health practice. There are advanced imaging techniques such as Positron Emission Tomography (PET Scans) that are being utilized in research and in the development of medications that directly influence changes in specific neurotransmitters. Lacking a PET Scanner, most professionals evaluate neurotransmitter levels by looking for indicators in thought, behavior, mood, perception, and/or speech that are considered related to levels of certain neurotransmitters.
This is perhaps best illustrated in individuals with depressed mood. The mental health professional is often required to separate those who would benefit from counseling and those who may require counseling and an antidepressant medication. The key is looking for those symptoms that are known to be related to chemical changes in the brain. For example, situational depression often produces sad expressions, worry, pessimistic attitude and other features but does not create prolonged changes in the physical symptoms such as changes in sexual interest, appetite, or sleep. The continued presence of physical symptoms tells us that the brain's neurotransmitter levels have changed.
The technical aspects of neurotransmitter levels, the psychiatric symptoms they produce, and how medications have been developed to raise or lower the brain levels of these neurotransmitters can be very complicated. For this reason, the same procedure of explaining other medical conditions where medication brings symptoms back to the "normal range" is often used. Medical patients with high blood pressure, high blood sugar, or high cholesterol are informed that their body chemistry is too high, or in some cases, too low and must be corrected with medication.
For many years, mental health professionals have used the term "chemical imbalance" to explain the need for medications that are used to treat mental health conditions. This simple and commonly used explanation recognizes that the condition is a medical problem and that it can be treated with medication. The "chemical imbalance" explanation also reflects the overall theme of treatment – identifying what neurotransmitters are involved in the clinical symptom picture and with medication, attempting to return that neurotransmitter level back to the "normal range".
Your emotional health is a combination of attitudes, personality, support systems, and your brain's neurotransmitter levels. Positive attitudes and a healthy personality help us through life's difficulties and a good support system of family and friends is also valuable during times of trouble. Despite having these resources, there are times when coping with our experiences and life events changes our neurotransmitter status. Like an overheated automobile, we begin to have difficulty operating properly.
We are all at-risk for changes in our brain's chemistry. Mostly commonly, we will experience depression, anxiety, or stress reactions. As our neurotransmitters change, they bring with them additional symptoms, behaviors, and sensations that add to our on-going difficulties. Recognizing these changes is an important part of treatment and returning your life to normal and reducing our stress.
This discussion is offered to explain how the neurotransmitter system in the brain can create psychiatric conditions and mental health problems. It is hoped the discussion will provide information that will be of value to those who suspect their neurotransmitter system is creating problems.
The following is a discussion of neurotransmitters and current thoughts about how these neurochemicals are involved in psychiatric illness. Four neurotransmitters, out of over fifty, are well researched and known to be related to psychiatric conditions.
Dopamine is a neurotransmitter linked to motor/movement disorders, ADHD, addictions (including alcohol addiction), paranoia, and schizophrenia. Dopamine strongly influences both motor and thinking areas of the brain.
One type of Dopamine works in the brain movement and motor system. As this level of dopamine decreases below the "normal range" we begin to experience more motor and gross-movement problems. Very low levels of Dopamine in the motor areas of the brain are known to produce Parkinson's Disease with symptoms such as:
Dopamine in the thinking areas of the brain might be considered the neurotransmitter of focus and attending. Low levels impair our ability to focus on our environment or to "lock on" to tasks, activities, or conversations. Low levels of Dopamine make concentration and focus very difficult with low levels also associated with Attention-Deficit Hyperactivity Disorder (ADHD). On the other end of the Dopamine dipstick, as Dopamine levels in the brain begin to raise, we become excited/energized, then suspicious and paranoid, then finally hyperstimulated by our environment. With low levels of Dopamine, we can't focus while with high levels of Dopamine our focus becomes narrowed and intense to the point of focusing on everything in our environment as though it were directly related to our situation.
Mild elevations in Dopamine are associated with addictions. Nicotine, cocaine, and other substances produce a feeling of excited euphoria by increasing Dopamine levels in the brain. Too much of these chemicals/substances and we feel "wired" as moderate levels of Dopamine make us hyperstimulated – paying too much attention to our environment due to being overstimulated and unable to separate what's important and what is not.
In an ADHD child, low levels of Dopamine don't allow the child to focus or attend to anything in the environment, looking very physically hyperactive when running about the room or switching from activity-to-activity due to their lack of focus. As Dopamine levels increase above the normal range, our ability to focus increases to the point of being paranoid. Mild elevations make the environment overly stimulating and excited.
Moderately high Dopamine levels make us on-guard, suspicious, and prone to misinterpret experiences in the environment. Known as an "idea of reference" in psychiatry, we begin thinking unrelated experiences are suddenly directly related to us. People observed talking across the street are now talking about us. As Dopamine increases, it can become so intense that we feel the radio, television, and newspaper contain secret messages directed at us from Hollywood or elsewhere. It's as though we are attempting to incorporate/add everything we witness into our life. Planes flying overhead are snapping pictures of us and motorists talking on cellular phones are calling in a report on us. Our mind speed increases and races in an attempt to add all we see into our life. In an attempt to make sense, we may become extremely religious, paranoid, or feel we are a very important person. Increased Dopamine also increases the perception of our senses, as though turning up the volume in all our senses – hearing, vision, taste, smell, and touch.
As Dopamine levels increase, the noises we heard loudly suddenly become auditory hallucinations. Our inner thoughts are now being heard outside our body. These "voices" begin talking to us, known to take different forms such as derogatory (putting you down), religious topics, command (telling you to do something), or sexual content. Hallucinations (experiencing something that is not truly there in reality) will soon develop in all our senses. We may begin seeing faces in clouds, carpets, or patterns. We may sense the touch of spirits or movements inside our body. We may experience unusual smells or tastes.
High levels of Dopamine in the brain often cause us to lose our contact with reality. As though living in a science-fiction movie, we begin to develop unusual if not bizarre ideas about what is happening to us. With our paranoia, we may experience delusions (false beliefs) of persecution or may think we have super powers (delusions of grandiosity) and can predict the future or read minds. High levels of Dopamine are found in Schizophrenia, drug intoxication, and other psychotic conditions where the ability to distinguish the inner world from the real world is impaired.
Treatment for psychiatric/medical conditions associated with Dopamine imbalance, as you might expect, involves increasing or decreasing Dopamine levels in the brain. Low-Dopamine disorders are treated with medications that increase Dopamine in the brain. For Parkinson's Disease – L Dopa is prescribed and for ADHD, medications that are psychostimulants. Amphetamines and medications with similar action actually slow down the hyperactive (ADHD) children by increasing Dopamine – boasting their level into the normal range, allowing them to now focus and attend.
Mildly elevations in Dopamine are associated with addictions such as narcotics, speed, and nicotine/smoking. Thus, medications used in the treatment of addictions actually block or lower Dopamine production. If a medication blocks dopamine, it also blocks the effects of the addicted substance as well as blocking the craving sensation. The medication to help smokers, Zyban, is actually the antidepressant Wellbutrin that is known to block Dopamine.
Moderate to high levels of Dopamine, associated with severe psychiatric conditions such as Paranoia and Schizophrenia, are treated with medications that block or lower Dopamine in the brain. These medications, called antipsychotics, have been available for many years. Early antipsychotic medications however, lowered Dopamine throughout the brain, including the Dopamine located in the motor/movement areas. For that reason, older antipsychotic medications produced motor/movement problems that looked like Parkinson's Disease – short-step gait, fixed facial expression, tremors, poor balance, etc. Newer medications have fewer side effects in motor areas, as they are able to specifically target one type of Dopamine.
Dopamine levels typically change very slowly. Patients who develop Paranoia and/or Schizophrenia often experience a gradual increase in Dopamine levels over several years – also experiencing an increase in the severity of symptoms over those years. A typical high school or college student may develop a sense of being on-edge or unusual feelings, gradually becoming suspicious and feeling alienated, moving into auditory hallucinations, and finally developing bizarre false beliefs (delusions) of persecution or exaggerated self-importance over the next several years. Stress can often rapidly increase Dopamine, but it still rarely happens overnight.
When an individual becomes psychotic, paranoid, and hallucinates in only a few days, we must strongly suspect medication/drug intoxication or neurological events – something that could increase Dopamine levels dramatically and almost instantly. The prolonged use of amphetamines (speed) or steroids can produce a loss of reality and sudden paranoia. As it might happen, a construction worker taking "street" speed to increase his work productivity finds his hand or foot talking to him (auditory hallucinations) and decides to cut it off. The sudden presence of psychosis (hallucinations, delusions, paranoia, etc.) in an individual with a history of prior normal adjustment would suggest the need for intensive medical and neurological workup.
Serotonin, first isolated in 1933, is the neurotransmitter that has been identified in multiple psychiatric disorders including depression, obsessive-compulsive disorder, anorexia, bulimia, body dysmorphic disorder (nose doesn't look perfect after ten surgeries), social anxiety, phobias, etc. Serotonin is a major regulator and is involved in bodily processes such as sleep, libido (sexual interest), body temperature, and other areas.
Perhaps the best way to think of Serotonin is again with an automobile example. Most automobiles in the United States are made to cruise at 70 miles per hour, perfect for interstate highways and that summer vacation. If we place that same automobile on a racetrack and drive day-after-day at 130 mph, two things would happen. Parts would fail and we would run the engine so hot as to evaporate or burnout the oil. Serotonin is the brain's "oil".
Like a normal automobile on a race track, when we find ourselves living in a high stress situation for a prolonged period of time, we use more Serotonin than is normally replaced. Imagine a list of your pressures, responsibilities, difficulties and environmental issues (difficult job, bad marriage, poor housing, rough neighborhood, etc.). Prolonged exposure to such a high level of stress gradually lowers our Serotonin level. As we continue to "hang on" we develop symptoms of a severe stress-produced depression.
An automobile can be one, two or three quarts low in oil. Using the automobile as an example, imagine that brain Serotonin can have similar stages, being low (one quart low), moderately low (two quarts low), and severely low (three quarts low). The less Serotonin available in the brain, the more severe our depression and related symptoms.
When Serotonin is low, we experience problems with concentration and attention. We become scatterbrained and poorly organized. Routine responsibilities now seem overwhelming. It takes longer to do things because of poor planning. We lose our car keys and put odd things in the refrigerator. We call people and forget why we called or go to the grocery and forget what we needed. We tell people the same thing two or three times.
As stress continues and our Serotonin level continues to drop, we become more depressed. At this point, moderately low or "two quarts" low, major changes occur in those bodily functions regulated by Serotonin. When Serotonin is moderately low, we have the following symptoms and behaviors:
Individuals can live many years moderately depressed. They develop compensations for the sleep and other symptoms, using sleeping medication or alcohol to get some sleep. While chronically unhappy and pessimistic, they explain their situation with "It's just my life!" They may not fully recognize the depressive component.
Very low levels of Serotonin typically bring people to the attention of their family physician, their employer, or other sources of help. Severe Serotonin loss produces symptoms that are difficult to ignore. Not only are severe symptoms present, but also the brain's ideation/thinking becomes very uncomfortable and even torturing. When Serotonin is severely low, you will experience some if not all of the following:
Clinical Depression is perhaps the most common mental health problem encountered in practice. One in four adults will experience clinical depression within their lifetime. Depression is the "common cold" of mental health practice – very common and much easier to treat today than in the past.
Treatment for depression, as might be expected, involves increasing levels of Serotonin in the brain. Since the mid-eighties, medications have been available that attempt to specifically target and increase Serotonin. Known as Selective Serotonin Reuptake Inhibitors (SSRI's), these medications such as Prozac, Zoloft, and Paxil are felt to work by making more Serotonin available in the brain.
Like all neurotransmitters, we can have too much Serotonin. While elevated levels of Serotonin produce a sense of well-being, bliss, and "oneness with the universe" – too much Serotonin can produce a life-threatening condition known as Serotonin Syndrome (SS).
Likely to occur by accident by combining two Serotonin-increasing medications or substances, Serotonin Syndrome (SS) produces violent trembling, profuse sweating, insomnia, nausea, teeth chattering, chilling, shivering, aggressiveness, over-confidence, agitation, and malignant hyperthermia. Emergency medical treatment is required, utilizing medications that neutralize or block the action of Serotonin as the treatment for Serotonin Syndrome (SS).
Like Dopamine, Serotonin can be accidentally increased or decreased by substances. One method of birth control is known to produce severe depression as it lowers Serotonin levels. A specific medication for acne has also been linked with depression and suicidal ideation. For this reason, always inform your physicians if you are taking any medication for depression. Also avoid combining antidepressants with any herbal substances reported to be of help in Depression such as St. John's Wort.
Norepinephrine (NE) is the neurotransmitter often associated with the "fight or flight" response to stress. Strongly linked to physical responses and reactions, it can increase heart rate and blood pressure as well as create a sense of panic and overwhelming fear/dread. This neurotransmitter is similar to adrenaline and is felt to set threshold levels to stimulation and arousal. Emotionally, anxiety and depression are related to norepinephrine levels in the brain, as this neurotransmitter seems to maintain the balance between agitation and depression.
Low levels of norepinephrine are associated with a loss of alertness, poor memory, and depression. Norepinephrine appears to be the neurotransmitter of "arousal" and for that reason, lower-than-normal levels of this neurotransmitter produce below-average levels of arousal and interest, a symptom found in several psychiatric conditions including depression and ADHD. It is for this reason that medications for depression and ADHD often target both dopamine and norepinephrine in an attempt to restore both to normal level.
Mild elevations in our norepinephrine levels produce heightened arousal, something known to be produced by stimulants. This arousal is considered pleasurable and several "street drugs" such as cocaine and amphetamines work by increasing the brains level of norepinephrine. This increased sense of arousal is pleasurable, linking these substances to their potential for addiction. Research tells us that some individuals using antidepressants develop a state of "hypomania" or emotional elation and physical arousal in this same manner. For that reason, individuals using modern antidepressants are often cautioned to notify their treating physician/psychiatrist if they become "too happy".
Moderately high levels of norepinephrine create a sense of arousal that becomes uncomfortable. Remembering that this neurotransmitter is strongly involved in creating physical reactions, moderate increases create worry, anxiety, increased startle reflex, jumpiness, fears of crowds & tight places, impaired concentration, restless sleep, and physical changes. The physical symptoms may include rapid fatigue, muscle tension/cramps, irritability, and a sense of being on edge. Almost all anxiety disorders involve norepinephrine elevations.
Severe and sudden increases in norepinephrine are associated with panic attacks. Perhaps the best way to visualize a panic attack is to remember the association with the "flight or fight" response. The "flight or fight" response is a chemical reaction to a dramatic and threatening situation in which the brain produces excessive amounts of norepinephrine and adrenaline – giving us extra strength, increased energy/arousal, muscle tightness (for fighting or running), and a desperate sense that we must do something immediately. This animal response was activated in early man when a bear showed up at his cave or when faced with a tiger in the woods. In modern times, imagine your reaction if while calmly watching television, someone or something started trying to knock your front door in to attack you. In the "flight or fight" reaction, your brain and body chemistry prepare you to either run from the situation or fight to the death!
A panic attack is the activation of the "flight or fight" chemical reaction without a bear at the door. It's as though the self-protection animal response is kicking-off accidentally, when no real life-threatening situation is present. Known now as panic attacks, they can surface at the grocery, at church, or when you least expect it. As norepinephrine is a fast-acting neurotransmitter, the panic attack may last less than ten minutes (feels like hours however!) but you'll be rattled/shaken for several hours. Panic attacks are strong physical and chemical events and include the following symptoms:
If we think about the automobile example, a panic attack is the equivalent of your dashboard warning lights coming on – your stress level is too high. Panic attacks, or surges of norepinephrine, can also occur by accident as when created by the use of certain medications. The medications for certain medical conditions can cause a panic attack or increase our level of anxiety. Medications often used for asthma, for example, can create anxiety or panic attacks.
Treating low or elevated levels of norepinephrine in the brain involve different approaches. Low levels of norepinephrine are often treated using newer antidepressants. Many new antidepressants, known as Serotonin-Norepinephrine Reuptake Inhibitors (SNRI's) with brand names like Effexor and Serzone, treat depression by increasing levels of both serotonin and norepinephrine neurotransmitters.
Treatment for high levels of norepinephrine, as found in anxiety and panic disorders, involves decreasing neurotransmitter levels directly or using medications which increase another neurotransmitter that inhibits or decreases the action of norepinephrine. One of those inhibiting neurotransmitters is GABA, also known as Gamma-Aminobutyric Acid.
Gamma-Aminobutyric Acid (GABA) is a neurotransmitter that is inhibitory, that is, it decreases the ability of other neurotransmitters to work. GABA is involved in our level of excitability. Rather than encouraging communication between cells such as Dopamine, Serotonin or Norepinephrine - GABA reduces, discourages, and blocks communication. This neurotransmitter is important in brain areas involving emotion and anxiety.
When GABA is in the normal range in the brain, we are not overly aroused or anxious. At the same time, we have appropriate reactions to situations in our environment. GABA is the communication speed controller, making sure all brain communications are operating at the right speed and with the correct intensity. Too little GABA in the brain, the communication becomes out of control, overstimulated, and chemically unstable. Too much GABA and we are overly relaxed and sedated, often to the point that normal reactions are impaired.
Low levels of GABA are associated with Bipolar Disorder, Mania. With GABA levels below average, the brain is too stimulated. We begin talking rapidly, staying up for days at a time, and develop wild and grandiose ideas. In a Manic state, we are so "high" and out of control that social problems are quick to develop, often due to hypersexuality, excessive spending, reckless decisions, risk-taking behavior, and grandiose ideas. We may feel so good that we think we are a heavenly spirit, an intellectual genius, or possessing extraordinary powers. I personally had one patient who locked himself in his mobile home and spent one week rewriting the New Testament in "hillbilly". Another, with limited education, began purchasing books on the Theory of Relativity by Albert Einstein, sensing he may be able to use the information to invent "warp drive".
Low levels of GABA are also associated with problems of poor impulse control, including clinical conditions such as gambling, temper tantrums, and stealing. When GABA is low in the brain, impulsive behaviors are not inhibited (stopped) by logical or reasonable thinking.
Low levels of GABA are also associated with epilepsy or seizure disorders. If we imagine a seizure as a type of electrical storm, the seizure begins at one location in the brain then rushes across and through the brain like a sudden storm. Low levels of GABA make it easy for the brain to develop seizures which is why seizures are part of the withdrawal syndrome for many substances that work with GABA such as alcohol and tranquilizers (benzodiazepines – Xanax, Ativan, Librium, Valium, etc.). Substances that artificially maintain a high level of GABA, when stopped, create a dramatic drop in GABA levels, thus creating the risk for withdrawal seizures due to the chemical instability that is created.
High levels of GABA produce more control, relaxation, and even sedation. Alcohol works by increasing GABA levels, which is why all body systems are relaxed at first – then sedated to the point of slurred speech, unsteady gait, and foggy thinking. Alcohol withdrawal, or the sudden severe drop of high GABA levels, produce a low GABA level and the possibility of seizures. Withdrawal from benzodiazepines is known to follow the same pattern. Taking forty milligrams of Valium for two years, suddenly stopping all medication, will likely produce a seizure.
Medications for anxiety create relaxation and a decrease in anxiety by increasing GABA levels in the brain. Alcoholic beverages work in the same manner; the alcohol increasing GABA levels to produce mild euphoria, loss of social anxiety, and other symptoms of intoxication. Excessive intake of benzodiazepines and/or alcohol is extremely dangerous as the high GABA level actually smothers the communication between brain neurons – sometimes to the point of a total lack of communication between neurons – also known as death.
Medications for seizures, impulse control problems, and Bipolar Disorder, Mania all work by increasing the GABA levels without accompanying euphoria. Lithium and anti-seizure medications all increase GABA into the normal range, thus lowering the possibility of seizures and producing brain chemical stability. As GABA is the neurotransmitter policeman, changes in GABA can influence all neurotransmitters but especially norepinephrine.
Understanding these four neurotransmitters provides a window to understanding the majority of psychiatric conditions, ranging from depression to schizophrenia. Mental health professionals use psychological testing, interviews, questionnaires, and patient history to determine first, if a change in the neurotransmitter system is present, then second, what neurotransmitters are involved. A proper clinical diagnosis then leads to proper medication treatment.
Medications are prescribed in an effort to return the brain's neurotransmitter status to normal. Much like a physician may prescribe a medication to lower your cholesterol or increase another body chemical, mental health professionals are concerned with returning your neurotransmitter levels to normal.
Medications for mental health conditions work in several ways:
Based on the neurotransmitter theory of psychiatric illness, we can plot clinical conditions and see how mental health professionals determine medication treatment by recognizing which neurotransmitters are involved:
A variety of conditions and circumstances encountered in life can produce changes in our brain chemistry. These changes can then create mental health problems. We have known for years that chemical and substances in the body can become unregulated as in high blood pressure, high cholesterol, low/high blood sugar, etc. There is no stigma associated with using medications to return these body chemicals/substances back to their normal levels.
It is the hope of mental health professionals that the public can understand the medical and neurochemical nature of various emotional and psychiatric conditions, thus eliminating the stigma often associated with treatment. Modern treatment is very effective and can eliminate years of emotional suffering with very little in the way of intervention or treatment. Mental health treatment is available in every county in the United States.
Credit: This handout was written by Joseph M. Carver, Ph.D., a psychologist in private practice at Joseph M. Carver, Ph.D., Inc. in Portsmouth, Ohio. The handout is provided as a public service to the community.
This article is presented as a public service by Joseph M. Carver, Ph.D., a Clinical Psychologist.
Revised: January 2002
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