To push back on stigma and cut through the confusion, Open Minds is a series that explores your most pressing questions about mental health.
Which mental illnesses can I 'recover' from and which ones will pretty much be with me for life?
One of the ways mental illnesses are less understood by the public than physical ones is that we aren't told much about how the former turn out. People know high cholesterol can be lowered and low blood sugar can be raised; lots of viruses are preventable with vaccines, and that HIV is chronic but treatable. When someone says their cancer is in remission, we understand that that's not the same as saying it's cured. But we tend to lack that grasp of nuance when the disease is psychological.
Most people's experiences with mental illness are actually likely to be short-term. But when we think of ongoing conditions, eating disorders are what we most seem to perceive as disorders we can put in the past. We talk about them with language like "overcame," "survived," and "recovered from." These phrases communicate an ongoing process of vigilance and awareness of one's own triggers—work that's manageable but also never finished, sort of like how alcoholics can stop drinking and still consider themselves alcoholics for life.
"Some do recover," says Lois Choi-Kain, professor of psychiatry at Harvard Medical School. "And when they do, I think it's useful for them to think of themselves as someone 'in recovery,' but it still could be latent."
Of the two eating disorders people are most likely to know—anorexia and bulimia—bulimia is the more treatable. Choi-Kain says this could be because it often manifests as a response to stress—which, conceptually at least, means it does actually resemble substance-abuse disorders like alcoholism. It can be overcome with time; if someone's learned to do something as a response to stress, then the possibility exists that they can learn other responses to replace it.
Like bulimia, borderline personality disorder is often responsive to dialectical behavioral therapy and some antidepressants, even if they weren't designed for it, and it often goes away as the patient gets older. Choi-Kain, who specializes in BPD research and treatment, says the good news regarding BPD is that a significant number of patients who have been carefully followed in longitudinal studies eventually no longer meet the criteria—even without any treatment.
"So you could consider that one [as] something people can quote-unquote 'grow out of,'" Choi-Kain says. "Though we're still not clear on why."
Anorexia can be looked at as a compulsive habit, but borne of a seemingly different mechanism than obsessive-compulsive disorder, though both are notoriously treatment-resistant. Choi-Kain says one of the aspects of OCD researchers find most compelling is that it's thought to be on some level more biological, and not solely psychological. OCD is chronic, but can be mitigated with intensive treatment. The Diagnostic and Statistical Manual of Mental Disorders classified OCD as an anxiety disorder up until 2013, when the DSM V dropped and declared that obsessive/compulsive symptoms merited their own chapter.
When someone's anxiety centers on a specific phobia, doctors can desensitize them through exposure therapy. For example, people whose OCD revolves around germs are frequently treated via safe, structured exposure to icky environments. But conditions like generalized anxiety disorder—the country's most common anxiety disorder, affecting more than 3 million adults— present no such entry point for treatment. Choi-Kain says illnesses like that can actually persist longer than disorders of mood or personality.
"Anxiety disorders are not as responsive to treatment as people seem to think they are," Choi-Kain says. "The escalation in use of the term 'anxiety' has been just explosive…and the popular conception is that it comes and goes and people can overcome it easily. The truth is it can actually be quite chronic."
As an umbrella term, anxiety is the mental illness afflicting the most Americans today. The runner-up category is, of course, depression—all kinds of which Choi-Kain says can be exacerbated by risk factors like having a lot of comorbidities or life adversity.
Regardless of the root cause, she says the majority of depressive patients will show at least some improvement if they just get some kind of treatment, whether it's psychopharmacological, therapeutic, or even through diet and exercise. But there are always those who are prone to being treatment-resistant. We don't know why that is, she explains, but we do know it means their lifetime risk for relapse is higher. The principle is a little like that of bipolar disorder, in which each manic episode increases your risk of future episodes.
"Bipolar is considered one of those where once you have that first episode that qualifies you as needing medication, the standard is you should be on medication from then on, even when you're [not exhibiting symptoms]," Choi-Kain says. "It's not considered something that dissipates eventually the way some other disorders might."
Schizophrenia and other psychotic conditions are in the same vein. People understand how to think about someone's mental illness when they're visibly ill, but they're usually less clear on what it means for them to be "well." You should have all the facts no matter what your diagnosis, but if your illness is primarily characterized by acute, sudden-onset episodes of something— psychosis, mania, depression, and in some cases panic—it's important to know that it's very possible for months, even years, to pass between those episodes; that doesn't mean the illness is gone. It's kind of like herpes—if you have it, you have it forever, with or without flare-ups.
So never bail on your treatment plan just because it feels like you've gotten better. And embrace the fact that you might need treatment, in some form or other, for the rest of your life. But also know that regardless of whether your illness is chronic, there is an ever-expanding arsenal of tools to help you manage it. Choi-Kain says the prognosis for people with chronic disorders isn't nearly as negative as it once was, and that more people are now able to achieve enough symptom reduction that they're not impaired in their daily lives.
"The notion of whether or not something is treatable is really dependent on new discoveries and new research," she says. "We used to just apply a hammer to every nail, and some wouldn't respond. Now, there are more and more treatments coming out that are more specific, that are more tailored to [each] illness. People do get better."
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