Private Practice Psychology

Definition
Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, and ability to function. These are not the normal ups and downs; the symptoms of bipolar disorder are severe. They can result in damaged relationships, poor job or school performance, and even suicide.

About 5.7 million American adults or about 2.6 percent of the population age 18 and older in any given year have bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. However, some people have their first symptoms during childhood, and some develop them late in life. Bipolar disorder is often not recognized as an illness, and people may suffer for years before it is properly diagnosed and treated. It is a long-term illness that requires careful management throughout the person’s life.

Bipolar disorder causes dramatic mood swings from overly high and, or, irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes. The periods of highs and lows are called episodes of mania and depression.

Symptoms Signs and symptoms of manic episode:

• Increased energy, activity, and restlessness
• Excessively high, overly good, euphoric mood
• Extreme irritability
• Racing thoughts and talking fast, jumping from one idea to another
• Distractibility or lack of concentration
• Little sleep needed
• Unrealistic beliefs in one’s abilities and powers
• Poor judgment
• Spending sprees
• A lasting period of behavior that is different from usual
• Increased sexual drive
• Abuse of drugs—cocaine, alcohol, and sleep medications
• Provocative, intrusive, or aggressive behavior
• Denial that anything is wrong

A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for one week or longer. If the mood is irritable, four additional symptoms must be present.

Signs and symptoms of depressive episode:

• Lasting sad, anxious, or empty mood
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness, or helplessness
• Loss of interest or pleasure in activities once enjoyed, including sex
• Decreased energy, a feeling of fatigue or of being “slowed down”
• Difficulty concentrating, remembering, making decisions
• Restlessness or irritability
• Sleeping too much, or inability to sleep
• Change in appetite and, or, unintended weight loss or gain
• Chronic pain or other persistent physical symptoms not caused by physical illness or injury
• Thoughts of death or suicide, or suicide attempts

A depressive episode is diagnosed if five or more of these symptoms last most of the day, nearly every day, for a period of two weeks or longer.

A mild to moderate level of mania is called hypomania. Hypomania may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. Thus, even when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything is wrong. Without proper treatment, however, hypomania can become severe mania in some people or can switch to depression.

Sometimes, severe episodes of mania or depression include symptoms of psychosis. Common psychotic symptoms are hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person’s usual cultural concepts). Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time. For example, delusions of grandiosity, such as believing one is the president or has special powers or wealth, may occur during mania; delusions of guilt or worthlessness, such as believing that one is ruined and penniless or has committed some terrible crime, may appear during depression. People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia, another severe mental illness.

It may be helpful to think of the various mood states in bipolar disorder as a spectrum. At the bottom end is severe depression, above which is moderate depression and then mild low mood, which many people call the short-lived blues. It is termed dysthymia when it is chronic. Then there is normal or balanced mood, above which comes hypomania (mild to moderate mania), and then severe mania.

In some people, however, symptoms of mania and depression may occur together in what is called a mixed bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling extremely energized.

Bipolar disorder may appear to be a problem other than mental illness—for instance, alcohol or drug abuse, poor school or work performance, or strained interpersonal relationships. Such problems in fact may be signs of an underlying mood disorder.

Some people with bipolar disorder become suicidal. Anyone who is thinking about committing suicide needs immediate attention, preferably from a mental health professional or a physician. Anyone who talks about suicide should be taken seriously. Risk for suicide appears to be higher earlier in the course of the illness. Therefore, recognizing bipolar disorder early and learning how best to manage it may decrease the risk of death by suicide.

Course of Bipolar Disorder

Episodes of mania and depression typically recur across one’s life span. Between episodes, most people with bipolar disorder are free of symptoms, but as many as one-third of people have some residual symptoms. A small percentage of people experience chronic unremitting symptoms despite treatment.

The classic form of the illness, which involves recurrent episodes of mania and depression, is called bipolar I disorder. Some people, however, never develop severe mania but instead experience milder episodes of hypomania that alternate with depression; this form of the illness is called bipolar II disorder. When four or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycling tends to develop later in the course of illness and is more common among women than men.

People with bipolar disorder can lead healthy and productive lives when the illness is effectively treated. Without treatment, however, the natural course of bipolar disorder tends to worsen. Over time a person may suffer more frequent rapid cycling and more severe manic and depressive episodes than those experienced when the illness first appeared. But in most cases, proper treatment can help reduce the frequency and severity of episodes and can help people with bipolar disorder maintain a good quality of life.

Children and Adolescents with Bipolar Disorder

Both children and adolescents can develop bipolar disorder. It is more likely to affect the children of parents who have the illness.

Unlike many adults with bipolar disorder, whose episodes tend to be more clearly defined, children and young adolescents with the illness often experience very fast mood swings between depression and mania many times within a day. Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated. Mixed symptoms also are common in youths with bipolar disorder. Older adolescents who develop the illness may have more classic, adult-type episodes and symptoms.

Bipolar disorder in children and adolescents can be hard to tell apart from other problems that may occur in these age groups. For example, while irritability and aggressiveness can indicate bipolar disorder, they also can be symptoms of attention-deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, or of other types of mental disorders that are more common among adults, such as major depression or schizophrenia. Drug abuse also may lead to such symptoms.

For any illness, however, effective treatment depends on appropriate diagnosis. Children or adolescents with emotional and behavioral symptoms should be carefully evaluated by a mental-health professional.

Conditions that Can Co-occur with Bipolar Disorder

Alcohol and drug abuse are very common among people with bipolar disorder. Research findings suggest that many factors may contribute to these substance abuse problems, including self-medication of symptoms, mood symptoms either brought on or perpetuated by substance abuse, and risk factors that may influence the occurrence of both bipolar disorder and substance-use disorders. Treatment for co-occurring substance abuse, when present, is an important part of the overall treatment plan.

Anxiety disorders, such as post-traumatic stress disorder and obsessive-compulsive disorder, also may be common in people with bipolar disorder. Co-occurring anxiety disorders may respond to treatments used for bipolar disorder, or they may require separate treatment.

Causes Scientists are learning about the possible causes of bipolar disorder. Most scientists now agree that there is no single cause for bipolar disorder; rather, many factors act together to produce the illness.

Because bipolar disorder tends to run in families, researchers have been seeking specific genes that may increase a person’s chance of developing the illness. But genes are not the whole story. Studies of identical twins, who share all the same genes, indicate that both genes and other factors play a role in bipolar disorder. If bipolar disorder was caused entirely by genetics, then the identical twin of someone with the illness would always develop the illness, and research has shown that this is not the case. But if one twin has bipolar disorder, the other twin is more likely to develop the illness than is another sibling.

In addition, findings suggest that bipolar disorder, like other mental illnesses, does not occur because of a single gene. It is likely that many genes act together, in combination with other factors such as the person’s environment. Finding these genes, each of which contributes only a small amount toward the vulnerability to bipolar disorder, has been extremely difficult. But scientists expect that the advanced research tools now being used will lead to these discoveries and to new and better treatments for bipolar disorder.

Brain-imaging studies are helping scientists learn what goes wrong in the brain to produce bipolar disorder and other mental illnesses. New brain-imaging techniques allow researchers to take pictures of the living brain at work, to examine its structure and activity, without the need for surgery or other invasive procedures. These techniques include magnetic resonance imaging (MRI), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI). There is evidence from imaging studies that the brains of people with bipolar disorder may differ from the brains of healthy individuals. As the differences are more clearly identified and defined through research, scientists will gain a better understanding of the underlying causes of the illness and eventually may be able to predict which types of treatment will work most effectively.

Treatment Most people with bipolar disorder, even those with the most severe forms, can achieve substantial stabilization of their mood swings and related symptoms with proper treatment. Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. A strategy that combines medication and psychosocial treatment is optimal for managing the disorder over time.

In most cases, bipolar disorder is much better controlled if treatment is continuous rather than on and off. But even when there are no breaks in treatment, mood changes can occur and should be reported immediately to your doctor. The doctor may be able to prevent a full-blown episode by making adjustments to the treatment plan. Working closely with the doctor and communicating openly about treatment concerns and options can make a difference in treatment effectiveness.

In addition, keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events may help people with bipolar disorder and their families to better understand the illness. This chart also can help the doctor track and treat the illness most effectively.

Medications

While primary-care physicians who do not specialize in psychiatry also may prescribe these medications, it is recommended that people with bipolar disorder see a psychiatrist for treatment.

Medications known as mood stabilizers are usually prescribed to help control bipolar disorder. Several types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for years. Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression.

Lithium, the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) for treatment of mania, is often very effective in controlling mania and preventing the recurrence of both manic and depressive episodes.

Anticonvulsant medications such as valproate or carbamazepine also can have mood-stabilizing effects and may be especially useful for difficult-to-treat bipolar episodes. Valproate was FDA-approved in 1995 for treatment of mania. Newer anticonvulsant medications, including lamotrigine, gabapentin, and topiramate, are being studied to determine how well they work in stabilizing mood cycles. Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect.

Children and adolescents with bipolar disorder generally are treated with lithium, but valproate and carbamazepine also are used. Researchers are evaluating the safety and efficacy of these and other psychotropic medications in children and adolescents. There is some evidence that valproate may lead to adverse hormone changes in teenage girls and polycystic ovary syndrome in women who begin taking the medication before age 20. Therefore, young female patients taking valproate should be monitored carefully by a physician.

Women with bipolar disorder who wish to conceive or who become pregnant face special challenges due to the possible harmful effects of existing mood stabilizing medications on the developing fetus and the nursing infant. Therefore, the benefits and risks of all available treatment options should be discussed with a clinician skilled in this area. New treatments with reduced risks during pregnancy and lactation are under study.

Research has shown that people with bipolar disorder are at risk of switching into mania or hypomania, or of developing rapid cycling, during treatment with antidepressant medication. Therefore, mood-stabilizing medications generally are required, alone or in combination with antidepressants, to protect people with bipolar disorder from this switch. Lithium and valproate are the most commonly used mood-stabilizing drugs today. However, research studies continue to evaluate the potential mood-stabilizing effects of newer medications.

Atypical antipsychotic medications, including clozapine and ziprasidone, are being studied as possible treatments for bipolar disorder. Evidence suggests clozapine may be helpful as a mood stabilizer for people who do not respond to lithium or anticonvulsants. Other research has supported the efficacy of olanzapine for acute mania, an indication that has recently received FDA approval. Olanzapine may also help relieve psychotic depression.

If insomnia is a problem, a high-potency benzodiazepine medication such as clonazepam or lorazepam may be helpful. However, because these medications may be habit-forming, they are best prescribed short-term. Other types of sedative medications, such as zolpidem, are sometimes used instead.

Changes to the treatment plan may be needed at various times during the course of bipolar disorder to manage the illness most effectively. A psychiatrist should guide any changes in type or dose of medication. It is important to tell the psychiatrist about all other prescription drugs, over-the-counter medications, or natural supplements you may be taking. This is important because certain medications and supplements taken together may cause adverse reactions.

To reduce the chance of relapse or developing a new episode, it is important to stick to the treatment plan. Talk to your doctor if you have any concerns about the medications.

Thyroid Function

People with bipolar disorder often have abnormal thyroid gland function. Because too much or too little thyroid hormone alone can lead to mood and energy changes, it is important that thyroid levels are carefully monitored by a physician.

People with rapid cycling tend to have co-occurring thyroid problems and may need to take thyroid pills in addition to their medications for bipolar disorder. Lithium treatment may cause low thyroid levels in some people, resulting in the need for thyroid supplementation.

Medication Side Effects

Before starting a new medication for bipolar disorder, always talk with your psychiatrist or pharmacist about possible side effects. Depending on the medication, side effects may include weight gain, nausea, tremors, reduced sexual drive, anxiety, hair loss, movement problems, or dry mouth. Be sure to tell the doctor about all side effects during treatment. She may be able to change the dose or offer a different medication to relieve them. Your medication should not be changed or stopped without the psychiatrist’s guidance.

Psychosocial Treatment

As an addition to medication, psychosocial treatments—including certain forms of psychotherapy (or talk therapy)—are helpful in providing support, education, and guidance to patients and their families. Studies have shown that psychosocial interventions can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas. A licensed psychologist, social worker, or counselor typically provides these therapies and often works together with the psychiatrist to monitor progress. The number, frequency, and type of sessions should be based on the treatment needs of each person.

Psychosocial interventions commonly used for bipolar disorder are cognitive behavioral therapy, psychoeducation, family therapy, and a newer technique—interpersonal and social rhythm therapy. Researchers at the National Institute of Mental Health are studying how these interventions compare to one another when added to medication treatment for bipolar disorder.

Cognitive behavioral therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness.

Psychoeducation involves teaching people with bipolar disorder about the illness and its treatment, and how to recognize signs of relapse so that early intervention can be sought before a full-blown episode occurs. Psychoeducation may also be helpful for family members.

Family therapy uses strategies to reduce the level of family distress that may either contribute to or result from the ill person’s symptoms.

Interpersonal and social rhythm therapy helps people with bipolar disorder both to improve interpersonal relationships and to regulate daily routines. Daily routines and sleep schedules may help protect against manic episodes.

As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit.

Other Treatments

Electroconvulsive Therapy

In situations where medication, psychosocial treatment, and the combination of these interventions prove ineffective or work too slowly to relieve severe symptoms such as psychosis or suicidal thoughts, electroconvulsive therapy (ECT) may be considered. ECT may also be considered to treat acute episodes when medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severe depressive, manic, or mixed episodes. The possibility of long-lasting memory problems has been significantly reduced with modern ECT techniques. However, the potential benefits and risks of ECT and of available alternative interventions, should be carefully reviewed and discussed with individuals considering this treatment and, when appropriate, with family or friends.

Herbal and Natural Supplements

Herbal or natural supplements, such as St. John’s Wort, have not been well studied, and little is known about their effects on bipolar disorder. Because the FDA does not regulate their production, different brands of these supplements can contain different amounts of active ingredient.

Before trying herbal or natural supplements, it is important to discuss them with your doctor. There is evidence that St. John’s Wort can reduce the effectiveness of certain medications. In addition, like prescription antidepressants, St. John’s Wort may cause a switch into mania in some individuals with bipolar disorder, especially if no mood stabilizer is being taken.

Omega-3 fatty acids found in fish oil are being studied to determine their usefulness, alone and when added to conventional medications, for long-term treatment of bipolar disorder.

Even though episodes of mania and depression come and go, it is important to understand that bipolar disorder is a long-term illness that has no cure. Staying on treatment, even during periods without episodes, can help keep the disease under control and reduce the chance of having recurrent, worsening episodes.

People with bipolar disorder may need help to get help:

• Often people with bipolar disorder do not realize how impaired they are, or they blame their problems on some cause other than mental illness.
• A person with bipolar disorder may need strong encouragement from family and friends to seek treatment. Family physicians can play an important role in providing a referral to a mental-health professional.
• Sometimes a family member or friend may need to take the person with bipolar disorder for proper mental health evaluation and treatment.
• A person who is in the midst of a severe episode may need to be hospitalized for his or her own protection and for much-needed treatment. There may be times when the person must be hospitalized against his or her wishes.
• Ongoing encouragement and support are needed after a person obtains treatment, because it may take a while to find the best treatment plan for the individual.
• In some cases, individuals with bipolar disorder may agree, when the disorder is under good control, to a preferred course of action in the event of a future manic or depressive relapse.
• Like other serious illnesses, bipolar disorder is also hard on spouses, family members, friends, and employers.
• Family members of people with bipolar disorder often have to cope with the person’s serious behavioral problems, such as wild spending sprees during mania or extreme withdrawal from others during depression, and the lasting consequences of these behaviors.

Sources:

• National Institute of Mental Health
• Archives of General Psychiatry
• Scientific American
• Medicine
• Goodwin FK & Jamison KR. Manic-depressive illness. New York: Oxford University Press, 1990.
• Journal of the American Academy of Child and Adolescent Psychiatry
• National Institute of Mental Health
• Biological Psychiatry
• Journal of Psychiatric Research
• Postgraduate Medicine, 2000
• Harvard Review of Psychiatry
• Annals of Neurology
• Journal of Clinical Psychiatry
• American Journal of Psychiatry
• U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health
• Journal of the American Medical Association
• Clinical Psychology Review
• Journal of Consulting and Clinical Psychology

Definition
Seasonal affective disorder (also called SAD) is a type of depression that follows the seasons. The most common type of SAD is called winter depression. It usually begins in late fall or early winter and normal mood returns in summer. A less common type of SAD, known as summer depression, usually begins in the late spring or early summer. SAD may be related to changes in the amount of daylight you get.

Seasonal affective disorder is estimated to affect 10 million Americans. Another 10 percent to 20 percent may have mild SAD. SAD is more common in women than in men. Illness typically begins around age 20. Some people experience symptoms severe enough to affect quality of life, and 6 percent require hospitalization. Many people with SAD report at least one close relative with a psychiatric disorder, most frequently a severe depressive disorder (55 percent) or alcohol abuse (34 percent). Although some children and teenagers get SAD, it usually doesn’t start in people younger than age 20. Yet when it does the syndrome is first suspected by parents and teachers. Risk decreases with age. SAD is more common the farther north you live.

Symptoms Not everyone with SAD has the same symptoms, but common symptoms of winter depression include the following:

• Feelings of hopelessness and sadness
• Thoughts of suicide
• Hypersomnia or a tendency to oversleep
• A change in appetite, especially a craving for sweet or starchy foods
• Weight gain
• A heavy feeling in the arms or legs
• A drop in energy level
• Decreased physical activity
• Fatigue
• Difficulty concentrating
• Irritability
• Increased sensitivity to social rejection
• Avoidance of social situations

Symptoms of the summer SAD are:

• Poor appetite
• Weight loss
• Insomnia
• Agitation and anxiety

Either type of SAD may also include some of the symptoms that are present in other kinds of depression, such as feelings of guilt, a loss of interest or pleasure in activities previously enjoyed, ongoing feelings of hopelessness or helplessness, or physical problems such as headaches and stomachaches.

Symptoms of SAD tend to reoccur at about the same time every year. The changes in mood are not necessarily related to obvious seasonal stressors (like being regularly unemployed during the winter). Usually depression is mild or moderate. However, some people experience severe symptoms and 6 percent of SAD patients need hospitalization at some time in their lives.

Seasonal Affective Disorder can be misdiagnosed as hypothyroidyism, hypoglycemia, or a viral infection such as mononucleosis.

Causes The cause for SAD is unknown. One theory is that it is related to the amount of melatonin in the body, a hormone secreted by the pineal gland. The body is exposed to its secretions for a shorter period of time during summer because light suppresses it production. The long nights of winter extends the amount of time melatonin is released into the body, thus increasing symptoms. It is not clear how melatonin produces the symptoms reported. One possible explanation is that melatonin causes a drop in body temperature and lower body temperature is associated with sleep. This could indicate that it is related to the sleep-wake cycle and related to the hypersomnia and fatigue reported.

Treatment Because winter depression is probably caused by a reaction to a lack of sunlight, broad-band light therapy is frequently used. This therapy requires a light box or a light visor worn on the head like a cap. The individual either sits in front of the light box or wears light visor for a certain length of time each day. Generally, light therapy takes between 30 and 60 minutes each day throughout the fall and winter. The amount of time required varies with each individual. When light therapy is sufficient to reduce symptoms and to increase energy level, the individual continues to use it until enough daylight is available, typically in the springtime. Stopping light therapy too soon can result in a return of symptoms.

When used properly, light therapy seems to have very few side effects. Side effects include eyestrain, headache, fatigue, irritability and inability to sleep (when light therapy is used too late in the day). People with manic depressive disorders, skin that is sensitive to light, or medical conditions that make their eyes vulnerable to light damage may not be good candidates for light therapy.

When light therapy does not improve symptoms within a few days, then medication and, or, behavioral therapies should be introduced. In some cases, light therapy can be used in combination with anyone or all of these therapies.

Self-Care

• Monitor your mood and energy level
• Take advantage of available sunlight
• Plan pleasurable activities for the winter season
• Plan physical activities
• Approach the winter season with a positive attitude
• When symptoms develop seek help sooner rather than later

Sources:

• American Psychiatric Association
• Diagnostic and Statistical Manual of Mental Disorders, 4th Edition
• The Cleveland Clinic: What is seasonal affective disorder?
• National Alliance of Mental Illness
• National Institute of Mental Health
• U.S. Department of Health and Human Services; 2005
• National Mental Health Association
• American Family Physician
• Substance Abuse and Mental Health Services Administration

Definition
A depressive disorder is an illness that involves the body, mood, and thoughts. When a person has a depressive disorder, it interferes with daily life, normal functioning, and causes pain for both the person with the disorder and those who care about him or her. A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Depression is a common but serious illness, and most people who experience it need treatment to get better. Appropriate treatment, however, can help most people who suffer from depression.

Depressive disorders come in different forms, just as is the case with other illnesses such as heart disease. Three of the most common types of depressive disorders are described here. However, within these types there are variations in the number of symptoms as well as their severity and persistence.

Major depression is manifested by a combination of symptoms (see symptom list) that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. Such a disabling episode of depression may occur only once but more commonly occurs several times in a lifetime.

Dysthymic disorder, also called dysthymia, involves long-term (two years or longer) less severe symptoms that do not disable, but keep one from functioning normally or from feeling good. Many people with dysthymia also experience major depressive episodes at some time in their lives.

Some forms of depressive disorder exhibit slightly different characteristics than those described above, or they may develop under unique circumstances. However, not all scientists agree on how to characterize and define these forms of depression. They include:

Psychotic depression, which occurs when a severe depressive illness is accompanied by some form of psychosis, such as a break with reality, hallucinations, and delusions.

Postpartum depression, which is diagnosed if a new mother develops a major depressive episode within one month after delivery. It is estimated that 10 to 15 percent of women experience postpartum depression after giving birth.

Seasonal affective disorder (SAD), which is characterized by the onset of a depressive illness during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not respond to light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.

Bipolar disorder, also called manic-depressive illness is not as prevalent as major depression or dysthymia, and characterized by cycling mood changes: severe highs (mania) and lows (depression).

Symptoms Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms, some many. Severity of symptoms varies with individuals and also varies over time.

• Persistent sad, anxious, or empty mood
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness, or helplessness
• Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
• Decreased energy, fatigue, being “slowed down”
• Difficulty concentrating, remembering, or making decisions
• Insomnia, early morning awakening or oversleeping
• Appetite and/or weight loss, or overeating and weight gain
• Thoughts of death or suicide, suicide attempts
• Restlessness, irritability
• Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders and chronic pain

Causes There is no single known cause of depression. Rather, it likely results from a combination of genetic, biochemical, environmental, and psychological factors.

Research indicates that depressive illnesses are disorders of the brain. Brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different than those of people without depression. The parts of the brain responsible for regulating mood, thinking, sleep, appetite, and behavior appear to function abnormally. In addition, important neurotransmitters—chemicals that brain cells use to communicate—appear to be out of balance. But these images do not reveal why the depression has occurred.

Some types of depression tend to run in families, suggesting a genetic link. However, depression can occur in people without family histories of it as well. Genetics research indicates that risk for depression results from the influence of multiple genes acting together with environmental or other factors.

In addition, trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger a depressive episode. Subsequent depressive episodes may occur with or without an obvious trigger.

Depression in Women

Women experience depression about twice as often as men. Biological, life cycle, hormonal, and other factors unique to women may be linked to their higher depression rate. Researchers have shown that hormones directly affect brain chemistry that controls emotions and mood. Some women may be susceptible to a severe form of premenstrual syndrome called premenstrual dysphoric disorder (PMDD). Women affected by PMDD typically experience depression, anxiety, irritability, and mood swings the week before menstruation, in such a way that interferes with their normal functioning. Women with debilitating PMDD do not necessarily have unusual hormone changes, but they do have different responses to these changes. They may also have a history of other mood disorders and differences in brain chemistry that cause them to be more sensitive to menstruation-related hormone changes. Scientists are exploring how the cyclical rise and fall of estrogen and other hormones may affect the brain chemistry that is associated with depressive illness.

For example, women are particularly vulnerable to depression after giving birth, when hormonal and physical changes, along with the new responsibility of caring for a newborn, can be overwhelming. Many new mothers experience a brief episode of the “baby blues,” but some will develop postpartum depression, a much more serious condition that requires active treatment and emotional support for the new mother. Some studies suggest that women who experience postpartum depression have had prior depressive episodes. Treatment by a sympathetic physician and the family’s emotional support for the new mother are prime considerations in aiding her to recover her physical and mental well-being as well as her ability to care for and enjoy the infant.

Many women also face additional stresses of work and home responsibilities, single parenthood and caring for children and aging parents, abuse, poverty, and relationship strains. It remains unclear why some women faced with enormous challenges develop depression, while others with similar challenges do not.

Depression in Men

Researchers estimate that at least 6 million men in the United States suffer from a depressive disorder every year. Research and clinical evidence reveal that while both women and men can develop the standard symptoms of depression, they often experience depression differently and may have different ways of coping with the symptoms. Men may be more willing to acknowledge fatigue, irritability, loss of interest in work or hobbies, and sleep disturbances rather than feelings of sadness, worthlessness, and excessive guilt. Some researchers question whether the standard definition of depression and the diagnostic tests based upon it adequately capture the condition as it occurs in men.

Depression can also affect the physical health in men differently from women. One study shows that, although depression is associated with an increased risk of coronary heart disease in both men and women, only men suffer a high death rate.

Instead of acknowledging their feelings, asking for help, or seeking appropriate treatment, men may turn to alcohol or drugs when they are depressed, or become frustrated, discouraged, angry, irritable, and, sometimes, violently abusive. Some men deal with depression by throwing themselves compulsively into their work, attempting to hide their depression from themselves, family, and friends. Other men may respond to depression by engaging in reckless behavior, taking risks, and putting themselves in harm’s way.

More than four times as many men as women die by suicide in the United States, even though women make more suicide attempts during their lives. In light of the research indicating that suicide is often associated with depression, the alarming suicide rate among men may reflect the fact that many men with depression do not obtain adequate diagnosis and treatment that may be life saving.

Even if a man realizes that he is depressed, he may be less willing than a woman to seek help. Encouragement and support from concerned family members can make a difference. In the workplace, employee assistance professionals or work-site mental health programs can be of assistance in helping men understand and accept depression as a real illness that needs treatment.

Depression in the Elderly

Some people have the mistaken idea that it is normal for the elderly to feel depressed. On the contrary, older people feel satisfied with their lives. Sometimes, though, when depression develops, it may be dismissed as a normal part of aging. However, when older adults do have depression, it may be overlooked because seniors may show different, less obvious symptoms, and may be less inclined to experience or acknowledge feelings of sadness or grief.

In addition, older adults may have more medical conditions such as heart disease, stroke or cancer, which may cause depressive symptoms, or they may be taking medications with side effects that contribute to depression. Some older adults may experience what doctors call vascular depression, also called arteriosclerotic depression or subcortical ischemic depression. Vascular depression may result when blood vessels become less flexible and harden over time, becoming constricted. Such hardening of vessels prevents normal blood flow to the body’s organs, including the brain. Those with vascular depression may have, or be at risk for, a co-existing cardiovascular illness or stroke.

The majority of older adults with depression improve when they receive treatment with an antidepressant, psychotherapy, or a combination of both. Research has shown that medication alone and combination treatment are both effective in reducing the rate of depressive recurrences in older adults. Psychotherapy alone also can be effective in prolonging periods free of depression, especially for older adults with minor depression, and it is particularly useful for those who are unable or unwilling to take antidepressant medication.

Improved recognition and treatment of depression in late life will make those years more enjoyable and fulfilling for the depressed elderly person, the family, and caretakers.

Treatment Depression, even the most severe cases, is a highly treatable disorder. As with many illnesses, the earlier that treatment can begin, the more effective it is and the greater the likelihood that recurrence can be prevented. Appropriate treatment for depression starts with a physical examination by a physician. Certain medications, as well as some medical conditions such as viral infections or a thyroid disorder, can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview and lab tests. If a physical cause for the depression is ruled out, a psychological evaluation that includes a mental status exam should be done either by the physician or by referral to a mental health professional.

He or she should discuss any family history of depression including their treatment, and get a complete history of symptoms, such as when they started, how long they have lasted, how severe they are, whether the patient had them before. And if so, whether the symptoms were treated and what treatment was given. The doctor should ask about alcohol and drug use, and if the patient has thoughts about death or suicide.

Once diagnosed, a person with depression can be treated with a number of methods. The most common treatments are medication and psychotherapy.

Medications

Antidepressants work to normalize naturally occurring brain chemicals called neurotransmitters, notably serotonin and norepinephrine. Other antidepressants work on the neurotransmitter dopamine.

The newest and most popular medications are called selective serotonin reuptake inhibitors (SSRIs). SSRIs include fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft) and several others. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). SSRIs and SNRIs are more popular than the older classes of antidepressants, such as tricyclics—named for their chemical structure—and monoamine oxidase inhibitors (MAOIs) because they tend to have fewer side effects. However, medications affect everyone differently so “no one-size-fits-all” approach to medication exists. Therefore, for some people, tricyclics or MAOIs may be the best choice.

People taking MAOIs must adhere to significant food and medicinal restrictions to avoid potentially serious interactions. They must avoid certain foods that contain high levels of the chemical tyramine, which is found in many cheeses, wines and pickles, and some medications including decongestants. MAOIs interact with tyramine in such a way that may cause a sharp increase in blood pressure, which could lead to a stroke. A doctor should give a patient taking an MAOI a complete list of prohibited foods, medicines and substances.

For all classes of antidepressants, patients must take regular doses for at least three to four weeks before they are likely to experience a full therapeutic effect. They should continue taking the medication for the time specified by their doctor, even if they are feeling better, in order to prevent a relapse of the depression. Medication should be stopped only under a doctor’s supervision. Some medications need to be gradually stopped to give the body time to adjust. Although antidepressants are not habit-forming or addictive, abruptly ending an antidepressant can cause withdrawal symptoms or lead to a relapse. Some individuals, such as those with chronic or recurrent depression, may need to stay on the medication indefinitely.

In addition, if one medication does not work, the doctor may switch to another medication and patients should be open to trying another. NIMH-funded research has shown that patients who did not improve after taking a first medication increased their chances of becoming symptom-free after they switched to a different medication or added another medication to their existing one.

Sometimes stimulants, anti-anxiety medications, or other medications are used in conjunction with an antidepressant, especially if the patient has a co-existing mental or physical disorder. However, neither anti-anxiety medications nor stimulants are effective against depression when taken alone, and both should be taken only under a doctor’s close supervision.

Medications of any kind—prescribed, over-the-counter or borrowed—should never be mixed without consulting the doctor. All health professionals who are working with the patient should be told of all the medications that are being taken. Some drugs, though safe when taken alone, can cause severe and dangerous side effects if taken with others. Some drugs, like alcohol or street drugs, may reduce the effectiveness of antidepressants and should be avoided.

Despite the relative safety and popularity of SSRIs and other antidepressants, some studies have suggested that they may have unintentional effects on some people, especially adolescents and young adults. Based on the FDA’s thorough review of published and unpublished controlled clinical trials of antidepressants of nearly 4,400 children and adolescents, the FDA was prompted, in 2005, to adopt a “black box” warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24. A “black box” warning is the most serious type of warning on prescription drug labeling.

Questions about any antidepressant prescribed, or problems that may be related to the medication, should be discussed with the doctor.

Side Effects

Antidepressants may cause mild and, usually, temporary side effects (sometimes referred to as adverse effects) in some people. Typically these are annoying, but not serious. However, any unusual reactions or side effects or those that interfere with functioning should be reported to the doctor immediately. The most common side effects of tricyclic antidepressants, and ways to deal with them, are:

• Dry mouth—it is helpful to drink sips of water, chew sugarless gum and clean teeth daily.
• Constipation—eat bran cereals, prunes, fruit and vegetables.
• Bladder problems—emptying the bladder may be troublesome, and the urine stream may not be as strong as usual; the doctor should be notified if there is marked difficulty or pain.
• Sexual problems—sexual functioning may change; if worrisome, discuss with the doctor.
• Blurred vision—this will pass soon and will not usually necessitate new glasses.
• Dizziness—rising from the bed or chair slowly is helpful.
• Drowsiness as a daytime problem—this usually passes soon. A person feeling drowsy or sedated should not drive or operate heavy equipment. The more sedating antidepressants are generally taken at bedtime to help sleep and minimize daytime drowsiness.

The most common side effects associated with SSRIs and SNRIs include:

• Headache—this usually goes away.
• Nausea—this is also temporary, but even when it occurs, it is transient after each dose.
• Nervousness and insomnia (trouble falling asleep or waking often during the night)—these may occur during the first few weeks; dosage reductions or time will usually resolve them.
• Agitation (feeling jittery)—if this happens for the first time after the drug is taken and is more than transient, the doctor should be notified.
• Sexual problems—the doctor should be consulted if the problem is persistent or worrisome.

Herbal Therapy

In the past few years, there has been much interest in the use of herbs in the treatment of both depression and anxiety. St. John’s Wort (Hypericum perforatum), an herb used extensively in the treatment of mild to moderate depression in Europe, has aroused interest in the United States. St. John’s Wort, an attractive bushy, low-growing plant covered with yellow flowers in summer, has been used for centuries in many folk and herbal remedies.

Because of the widespread interest in St. John’s Wort, the National Institutes of Health (NIH) conducted a three-year study, sponsored by three NIH components—the National Institute of Mental Health, the National Center for Complementary and Alternative Medicine, and the Office of Dietary Supplements. The study was designed to include 336 patients with major depression of moderate severity, randomly assigned to an eight-week trial. One third of patients received a uniform dose of St. John’s Wort; another third, sertraline, a selective serotonin reuptake inhibitor (SSRI) commonly prescribed for depression; and the final third, a placebo (a pill that looks exactly like the SSRI and St. John’s Wort, but has no active ingredients). The trial found that St. John’s wort was no more effective than the placebo in treating major depression.

A late 2008 German study reviewed and analyzed previous studies on St. John’s Wort in the treatment of mild or minor depression. Their results indicated that the herbal remedy was effective and study participants experienced fewer side effects. Yet the researchers issued some caveats regarding their findings. First, the St. John’s Wort that is available on the market varies widely so their results are only applicable to the preparations tested. Secondly, they cautioned against using the remedy without medical advice because St. John’s Wort can affect the effectiveness of other drugs.

In February 2000, the Food and Drug Administration had issued a Public Health Advisory, stating that St. John’s Wort appears to interfere with certain drugs prescribed to treat conditions such as AIDS, heart disease, depression, seizures, certain cancers and organ transplant rejection. The herb also may interfere with the effectiveness of oral contraceptives. Because of these potential interactions, patients should always consult with their doctors before taking any herbal supplement.

Psychotherapies

Many forms of psychotherapy, including some short-term (10- to 20-week) and other regimens are longer-term, depending on the needs of the individual. Two main types of psychotherapies—cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT)—have been shown to be effective in treating depression. By teaching new ways of thinking and behaving, CBT helps people change negative styles of thinking and behaving that may contribute to their depression. IPT helps people understand and work through troubled personal relationships that may cause their depression or make it worse.

For mild to moderate depression, psychotherapy may be the best treatment option. However, for major depression or for certain people, psychotherapy may not be enough. Studies have indicated that for adolescents, a combination of medication and psychotherapy may be the most effective approach to treating major depression and reducing the likelihood for recurrence. Similarly, a study examining depression treatment among older adults found that patients who responded to initial treatment of medication and IPT were less likely to have recurring depression if they continued their combination treatment for at least two years.

Electroconvulsive therapy (ECT) is useful, particularly for individuals whose depression is severe or life threatening, or for those who cannot take antidepressant medication. ECT often is effective in cases where antidepressant medications do not provide sufficient relief of symptoms. In recent years, ECT has been much improved. A muscle relaxant is given before treatment, which is done under brief anesthesia. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a brief (about 30 seconds) seizure within the brain. The person receiving ECT does not consciously experience the electrical stimulus. For full therapeutic benefit, at least several sessions of ECT, typically given at the rate of three per week, are required.

How to Help Yourself If You Are Depressed

Depressive disorders can make a person feel exhausted, worthless, helpless and hopeless. Such negative thoughts and feelings make some people feel like giving up. It is important to realize that these negative views are part of the depression and typically do not reflect actual circumstances. Negative thinking fades as treatment begins to take effect. In the meantime:

• Set realistic goals in light of the depression and assume a reasonable amount of responsibility.
• Break large tasks into small ones, set some priorities and do what you can, as you can.
• Try to be with other people and to confide in someone; it is usually better than being alone and secretive.
• Participate in activities that may make you feel better.
• Mild exercise, going to a movie or a ball game, or participating in religious, social or other activities may also help.
• Expect your mood to improve gradually, not immediately; feeling better takes time.
• It is advisable to postpone important decisions until the depression has lifted. Before deciding to make a significant transition—change jobs, get married or divorce—discuss it with others who know you well and have a more objective view of your situation.
• People rarely “snap out of” a depression. But they can feel a little better day by day.
• Remember, positive thinking will replace the negative thinking that is part of the depression, and this negative thinking will disappear as your depression responds to treatment.
• Let your family and friends help you.

How Family and Friends Can Help the Depressed Person

If you know someone who is depressed, it affects you too. The most important thing anyone can do for the depressed person is to help him or her get an appropriate diagnosis and treatment. You may need to make an appointment on behalf of your friend or relative and go with her to see the doctor. Encourage him to stay in treatment, or to seek different treatment if no improvement occurs after six to eight weeks.

The second most important thing is to offer emotional support. This involves understanding, patience, affection and encouragement. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope. Do not ignore remarks about suicide. Report them to the depressed person’s therapist. Invite the depressed person for walks, outings, to the movies and other activities. Keep trying if he declines, but don’t push her to take on too much too soon. Although diversions and company are needed, too many demands may increase feelings of failure. Remind your friend or relative that with time and treatment, the depression will lift.

Sources:

• Medscape Women’s Health Depression
• National Health and Nutrition Examination Survey
• Archives of Internal Medicine
• Psychopharmacology Bulletin
• Journal of the American Medical Association
• National Institute of Mental Health
• U.S. Department of Health and Human Services
• Biological Psychiatry
• Altshuler LL, Hendrich V, Cohen LS. Course of mood and anxiety disorders during pregnancy and the postpartum period. Journal of Clinical Psychiatry, 1998; 59: 29.
• Rohan KJ, Lindsey KT, Roecklein KA, Lacy TJ. Cognitive-behavioral therapy, light therapy and their combination in treating seasonal affective disorder. Journal of Affective Disorders, 2004; 80: 273-283.
• Tsuang MT, Faraone SV. The genetics of mood disorders. Baltimore, MD: Johns Hopkins University Press, 1990.
• Tsuang MT, Bar JL, Stone WS, Faraone SV. Gene-environment interactions in mental disorders. World Psychiatry, 2004 June; 3(2): 73-83.
• Schmidt PJ, Nieman LK, Danaceau MA, Adams LF, Rubinow DR. Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. New England Journal of Medicine. 1998 Jan 22; 338(4): 209-216
• Dreher JC, Schmidt PJ, Kohn P, Furman D, Rubinow D, Berman KF. Menstrual cycle phase modulates reward-related neural function in women. Proceedings of the National Academy of Sciences. 2007 Feb 13; 104(7): 2465-2470.
• Pollack W. Mourning, melancholia, and masculinity: recognizing and treating depression in men. In: Pollack W, Levant R, eds. New Psychotherapy for Men. New York: Wiley, 1998; 147 66.
• Cochran SV, Rabinowitz FE. Men and depression: clinical and empirical perspectives. San Diego: Academic Press, 2000.
• Gallo JJ, Rabins PV. Depression without sadness: alternative presentations of depression in late life. American Family Physician, 1999; 60(3): 820-826.
• Reynolds CF III, Dew MA, Pollock BG, Mulsant BH, Frank E, Miller MD, Houck PR, Mazumdar S, Butters MA, Stack JA, Schlernitzauer MA, Whyte EM, Gildengers A, Karp J, Lenze E, Szanto K, Bensasi S, Kupfer DJ. Maintenance treatment of major depression in old age. New England Journal of Medicine, 2006 Mar 16; 354(11): 1130-1138.
• Rush JA, Trivedi MH, Wisniewski SR, Stewart JW, Nierenberg AA, Thase ME, Ritz L, Biggs MM, Warden D, Luther JF, Shores-Wilson K, Niederehe G, Fava M. Bupropion-SR, Sertraline, or Venlafaxine-XR after failure of SSRIs for depression. New England Journal of Medicine, 2006 Mar 23; 354(12): 1231-1242.
• Trivedi MH, Fava M, Wisniewski SR, Thase ME, Quitkin F, Warden D, Ritz L, Nierenberg AA, Lebowitz BD, Biggs MM, Luther JF, Shores-Wilson K, Rush JA. Medication augmentation after the failure of SSRIs for depression. New England Journal of Medicine, 2006 Mar 23; 354(12): 1243-1252.

Separation anxiety refers to a developmental stage in which a child experiences anxiety due to separation from the primary care giver (usually the mother). This phase is fairly standard at around 8 months of age and can last until the child is 14 months old. In young children, unwillingness to leave a parent or a caregiver is a sign that attachments have developed between the caregiver and child. The child is beginning to understand that each object (including people) in the environment is different and permanent. Young children do not yet understand time, therefore they do not know when or even if a parent will ever come back. Children at this stage struggle between the desire to strike out on their own and the need to stay safe by a parent or caregiver’s side.

While separation anxieties are normal among infants and toddlers, they are inappropriate for older children and may indicate separation anxiety disorder. To be diagnosed as such, the symptoms must cause distress or affect social, academic, or job functioning and must last at least 1 month.

Infants experience various emotions as they develop, usually in a relatively predictable sequence. Before 8 months, they are so new to the world that they cannot easily gauge what is ordinary and what may be dangerous, so new situations or experiences seem usual, not frightening.

In normal development, this early period involves establishing familiarity with the home environment, and feeling safe when parents or other known caretakers are present. After this time, lack of familiarity often produces fear as the infant recognizes that something unusual is going on.

Children recognize their parents as familiar and safe. When separated from parents, particularly when away from home, they feel threatened and unsafe. This is particularly strong when the child is between 8 and 14 months.

Separation anxiety is a normal stage in an infant’s development. It helped keep our ancestors alive and helps children learn how to master their environment. It usually ends at around age 2, when toddlers begin to understand that a parent may be out of sight right now, but they will return later. At this age, a child also tends to want to test their autonomy.

Symptoms

• Excessive distress when separated from the primary caregiver
• Worry about losing or harm coming to the primary caregiver
• Recurrent reluctance to go anywhere because of fear of separation
• Reluctance to go to sleep without the significant adult nearby
• Nightmares
• Repeated physical complaints
• Symptoms last four weeks or longer
• Symptoms begin before 18 years of age
• Impairment of school, social, or personal functioning as a result of anxiety

Causes Though the cause of separation anxiety disorder is unknown, some risk factors have been identified. Affected children tend to come from families that are very close-knit. The disorder might develop after a stress such as moving or a death in the family, or in certain, cases, a trauma (such as physical or sexual assault) might bring on the disorder. It sometimes runs in families, but the precise role of genetic and environmental factors has not been established.

To resolve the feelings of separation anxiety, a child must develop an adequate sense of safety in the environment, as well as trust in people other than their parents, and trust in the parent’s return.

Even after children have successfully mastered this developmental stage, separation anxiety may return during periods of stress. Most children will experience some degree of separation anxiety when in unfamiliar situations, for example if the child is in a hospital without parents, these symptoms are likely to return.

Treatment It is helpful for a parent to accompany the child during medical examinations or treatments whenever possible. When a parent is not available, prior exposure to the situation, such as visiting the doctor’s office before a test, will be helpful for the child. In these situations, many physicians will recommend the child taking a sedating medication. Otherwise, the child may display severe anxiety by begging, crying, screaming, and resisting treatment.

Some hospitals provide Child Life specialists who explain procedures and medical conditions to children of all ages. If your child is particularly anxious and needs significant medical care, you may consider asking your health care provider about such services.

Explain the situation and experience to the child and assure him or her that a parent is waiting, and specifically, explain WHERE the parent is waiting.

For older children, effective treatments may include counseling for the parents and child, changes in parenting techniques, and anti-anxiety medications.

Treatment for certain cases may involve individual psychotherapy, family education, and family therapy.

For younger children, there are courses of action a parent or caregiver can take:

• Try to schedule departures after naps and mealtimes since your child will be more susceptible to separation anxiety when tired, hungry, or sick.
• Prepare your child before the separation occurs by reassuring him that you will return. Treat the anxiety seriously and react with understanding, patience, and confidence: “I know you don’t want me to go away right now, but I will be back after school.” Do not tease: “You’re so silly to cry about it.” Or sound annoyed: “You make me feel so mad when you cry like that!”
• Stay calm, matter-of-fact and, sympathetic: “I know you are upset that I have to go into the kitchen, but I need to cook the chicken for dinner.” Go into the kitchen with the child on your leg if necessary.
• Create feelings of security for your toddler by giving lots of love and attention. Young children learn faster when they receive necessary attention and affection than by the parent’s taking a “learn the hard way” attitude.
• Practice short-term separations around the house. As you go into the next room out of sight, talk to your child: “Where did mommy go?” When you return, let her know: “Here I am!” These repeated separations might help your child learn that your disappearance is only temporary.
• Do not sneak away from your child. While tempting, this approach will only lead to more difficulty the next time you leave.
• Maintain control over your own anxieties. If your child senses or sees your distress at leaving, that will tell him that there must be something wrong.

Sources:

• American Academy of Pediatrics
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised
• Brazelton, T. Berry. Touchpoints: Your Child’s Emotional and Behavioral Development
• Eisenberg, Arlene, Murkoff, Heidi, & Hathaway, Sandee. What to Expect the Toddler Years
• Goenjian, A. K., Pynoos, R. S., Steinberg, A. M., et al. Psychiatric comorbidity in children after the 1988 earthquake in Armenia
• Morrison, James, DSM-IV Made Easy: The Clinician’s Guide to Diagnosis
• National Institutes of Health - National Library of Medicine

Definition
A person with panic disorder experiences sudden and repeated episodes of intense fear accompanied by physical symptoms such as chest pain, heart palpitations, breathlessness, vertigo or abdominal distress. Because these symptoms are so similar to those of a heart attack or other life-threatening medical conditions, panic disorder may not be diagnosed until extensive and expensive medical tests have ruled out other serious illnesses.

Even between panic attacks, it is common for sufferers to be extremely anxious. These people often develop phobias about places such as shopping malls—where previous episodes have occurred. They also develop fears about experiences that have set off an attack, such as an airplane flight. As panic attacks become more frequent, the person may begin to shun situations that might trigger another episode. This avoidance may lead to agoraphobia, the inability to leave familiar, safe surroundings because of intense fear and anxiety.

Approximately 2.4 million Americans, or 1.7 percent of the population between the ages of 18 and 54, suffer from panic disorder each year. Women are twice as likely as men to develop the disorder and in about half of all cases, it strikes before age 25.

Symptoms To be formally diagnosed with panic disorder, a patient must have experienced either four panic attacks in four weeks, or one or more attacks followed by at least a month of continual anxiety about having another episode. During one of these attacks, at least four of these symptoms must peak within 10 minutes.

• Palpitations, pounding heart, or accelerated heart rate
• Sweating
• Trembling or shaking
• Shortness of breath or a sensation of smothering
• A choking feeling
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, lightheaded, or faint
• Feeling detached from oneself
• Fear of losing control or of going crazy
• Fear of dying
• Numbness or tingling sensation
• Chills or hot flashes

Causes Heredity, other biological factors, stressful events, and thinking that magnifies normal reactions play a role in the onset of panic disorder. Although the precise causes are still unknown, they are the subject of many scientific studies.

Researchers have conducted both animal and human studies to pinpoint the particular parts of the brain that are involved in anxiety and fear. Because fear evolved to deal with danger, it sets off an immediate protective response without conscious thought. This fear response is believed to be coordinated by the amygdala, a structure deep inside the brain. Although relatively small, the amygdala is quite complex, and recent studies suggest that anxiety disorders may be associated with abnormal activity in the amygdala.

Treatment Panic disorder is treated with medications and cognitive-behavioral therapy, psychotherapy that teaches patients to view their attacks in a different way and demonstrates how to reduce anxiety. Appropriate treatment by an experienced professional can reduce or prevent panic attacks in 70 to 90 percent of people with the disorder. Most patients show significant progress after just a few weeks of therapy. Relapses may occur, but they can be treated effectively.

Antidepressants

Several medications initially approved to treat depression have been found to be effective for relieving panic disorder. These antidepressants must be taken for several weeks before symptoms begin to disappear. Patients must not get discouraged or stop taking their medications, which need time to work.

Among the latest antidepressants are the selective serotonin reuptake inhibitors, or SSRIs. These work in the brain on a chemical messenger called serotonin. SSRIs tend to have fewer side effects than the earlier generation of antidepressants. Patients may be slightly nauseated or jittery when they first take SSRIs, but in time that feeling goes away. Sexual dysfunction may be a side effect of these antidepressants, but an adjustment in dosage or a switch to another SSRI may correct the problem. Patients should discuss all side effects with their doctor so that any needed changes in medication can be made.

SSRIs commonly prescribed for panic disorder in combination with obsessive-compulsive disorder, social phobia, or depression include fluoxetine, sertraline, fluvoxamine, paroxetine and citalopram. An initial low dose of these medications is gradually increased until it reaches a therapeutic level.

The antidepressants known as tricyclics are also taken at low doses, and are slowly increased. Tricyclics have been around longer than SSRIs and have been more widely studied for treating panic disorders. They are as effective as the SSRIs, but many physicians and patients prefer the newer drugs because the tricyclics can have side effects such as dizziness, drowsiness, dry mouth, and weight gain. If these problems persist, the patient may request a change in dosage or a switch in medications.

The oldest generation of antidepressant medications is the monoamine oxidase inhibitors, or MAOIs. Phenelzine, the most commonly prescribed MAOI, is helpful for patients with panic disorder. People who take MAOIs must watch their diet because these antidepressants can interact with some foods and beverages, including cheese and red wine, which contain a chemical called tyramine. MAOIs also interact with certain other medications, including SSRIs. These different interactions can cause a dangerous rise in blood pressure and other life-threatening reactions.

Anti-Anxiety Medications

The group of anti-anxiety medications known as benzodiazepines, including alprazolam and lorazepam, may be prescribed for patients with panic disorder. These drugs alleviate symptoms quickly and have few side effects other than drowsiness, but because people can develop a tolerance to them—and would have to increase the dosage to keep getting the same effect—they are generally prescribed only for short time periods. Because of dependency issues, they are not recommended for patients who have abused drugs or alcohol. Reducing the dosage gradually should prevent possible withdrawal symptoms in patients going off benzodiazepines, but their anxiety may return once they stop taking the medication.

Cognitive-Behavioral and Behavioral Therapy

One form of psychotherapy that has been shown to be effective in treating several anxiety disorders, including panic, is cognitive-behavioral therapy (CBT). A major goal of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that trigger panic. It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. For example, a person with panic disorder might be helped to see that his or her attacks are not really heart problems as previously feared; the tendency to put the worst possible interpretation on physical symptoms can be overcome.

The behavioral component of CBT seeks to change people’s reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear. The therapist helps the patient to cope with the resultant anxiety. Eventually, after this exercise has been repeated a number of times, anxiety will diminish. If you undergo CBT or behavioral therapy, exposure will be carried out only when you are ready; it will be done gradually and only with your permission. You will work with the therapist to determine how much you can handle and at what pace you can proceed.

To be effective, CBT or behavioral therapy must be directed at the person’s specific anxieties and it is necessary to tailor it to the person’s particular concerns. CBT and behavioral therapy have no adverse side effects other than the temporary discomfort of increased anxiety, but the therapist must be well trained in the techniques of the treatment in order for it to work as desired. During treatment, the therapist probably will assign “homework”—specific problems that the patient will need to work on between sessions.

CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. There is some evidence that, after treatment is terminated, the beneficial effects of CBT last longer than those of medications for people with panic disorder.

Medication may be combined with psychotherapy, and for many people this is the best approach to treatment. As stated earlier, it is important to give any treatment a fair trial. And if one approach doesn’t work, the odds are that another one will, so don’t give up.

If you have recovered from an anxiety disorder, and at a later date it recurs, don’t consider yourself a “treatment failure.” Recurrences can be treated effectively, just like an initial episode. In fact, the skills you learned in dealing with the initial episode can be helpful in coping with a setback.

Sources:

• National Institutes of Health - National Library of Medicine
• National Institute of Mental Health
• US Department of Health and Human Services

Definition
Generalized anxiety disorder (GAD) is much more than the normal anxiety people experience day to day. Without provoking, it is chronic and exaggerated worry and tension. This disorder involves anticipating disaster, often worrying excessively about health, money, family or work. Sometimes, though, just the thought of getting through the day brings on anxiety.

People with GAD can’t shake their concerns, even though they usually realize that much of their anxiety is unwarranted. People with GAD also seem unable to relax and often have trouble falling or staying asleep. Their worries are accompanied by physical symptoms, especially trembling, twitching, muscle tension, headaches, irritability, sweating, hot flashes and feeling lightheaded or out of breath.

Many individuals with GAD startle more easily than other people. They tend to feel tired, have trouble concentrating and may suffer from depression. GAD may involve nausea, frequent trips to the bathroom or feeling like there is a lump in the throat.

GAD affects about 4 million adult Americans and about twice as many women as men. The disorder comes on gradually and can begin at any time, though the risk is highest between childhood and middle age. It is diagnosed when someone spends at least six months worrying excessively about a number of everyday problems, and it is commonly treated with medications. Evidence shows that genes play a modest role in GAD.

GAD rarely occurs alone; it is usually accompanied by another anxiety disorder, depression or substance abuse. These other conditions must be treated along with GAD.

Symptoms Generalized anxiety disorder (GAD) is characterized by six months or more of chronic, exaggerated worry and tension that is unfounded or much more severe than the normal anxiety most people experience. People with this disorder usually:

• Expect the worst
• Worry excessively about money, health, family or work, when there are no signs of trouble
• Are unable to relax
• Are irritable
• Suffer from insomnia
• Have physical symptoms, such as fatigue, trembling, muscle tension, headaches, irritability or hot flashes

Causes Like heart disease and diabetes, anxiety disorders are complex and probably result from a combination of genetic, behavioral, developmental and other factors.

Using brain imaging technologies and neurochemical techniques, scientists are finding that a network of interacting structures is responsible for these emotions. Much research centers on the amygdala, an almond-shaped structure deep within the brain. The amygdala is believed to serve as a communications hub between the parts of the brain that process incoming sensory signals and the parts that interpret them. It can signal that a threat is present, thus triggering a fear response (anxiety). It appears that emotional memories stored in the central part of the amygdala may play a role in disorders involving very distinct fears, like phobias, while different parts may be involved in other forms of anxiety.

By learning more about brain circuitry involved in fear and anxiety, scientists may be able to devise more specific treatments for anxiety disorders. It someday may be possible to increase the influence of the thinking parts of the brain on the amygdala, thus placing the fear and anxiety response under conscious control. In addition, with new findings about neurogenesis (birth of new brain cells) throughout life, perhaps a method will be found to stimulate growth of new neurons in the hippocampus in people with severe anxiety.

Studies of twins and families suggest that genes play a role in the origin of anxiety disorders. However, experience also plays a part. In PTSD, for example, while trauma triggers the anxiety disorder, genetic factors may explain why only certain individuals exposed to similar traumatic events develop full-blown PTSD. Researchers are attempting to learn how genetics and experience interact in each of the anxiety disorders — information they hope will yield clues to prevention and treatment.

Treatment Medication and specific types of psychotherapy are the recommended treatments for this disorder. The choice of one or the other, or both, depends on the patient’s and the doctor’s preference, and also on the particular anxiety disorder.

Before treatment can begin, the doctor must conduct a careful diagnostic evaluation to determine whether your symptoms are due to an anxiety disorder, which anxiety disorder(s) you may have, and what coexisting conditions may be present. Anxiety disorders are not all treated the same, and it is important to determine the specific problem before embarking on a course of treatment. Sometimes alcoholism or some other coexisting condition will have such an impact that it is necessary to treat it at the same time or before treating the anxiety disorder.

If you have been treated previously for an anxiety disorder, be prepared to tell the doctor what treatment you tried. If it was a medication, what was the dosage, was it gradually increased and how long did you take it? If you had psychotherapy, what kind was it, and how often did you attend sessions? Oftentimes people believe they have “failed” at treatment, or that the treatment has failed them, when in fact it was never given an adequate trial.

When you undergo treatment for an anxiety disorder, you and your doctor or therapist will be working together as a team. Together, you will attempt to find the approach that is best for you. If one treatment doesn’t work, the odds are good that another one will. And new treatments are continually being developed through research.

Antidepressants

A number of medications that were originally approved for treating depression have been found to be effective for anxiety disorders. These must be taken for several weeks before symptoms start to fade, so it is important not to get discouraged and stop taking these medications before they’ve had a chance to work.

Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. These medications act on a chemical messenger in the brain called serotonin. SSRIs tend to have fewer side effects than older antidepressants. People do sometimes report feeling slightly nauseated or jittery when they first start taking SSRIs, but that usually disappears with time. Some people also experience sexual dysfunction when taking some of these medications. An adjustment in dosage or a switch to another SSRI will usually correct bothersome problems. It is important to discuss side effects with your doctor so that he or she will know when there is a need for a change in medication. Venlafaxine, a drug closely related to the SSRIs, is useful for treating GAD.

Similarly, antidepressant medications called tricyclics are started at low doses and gradually increased. Tricyclics have been around longer than SSRIs and have been more widely studied for treating anxiety disorders. For anxiety disorders other than OCD, they are as effective as the SSRIs, but many physicians and patients prefer the newer drugs because the tricyclics sometimes cause dizziness, drowsiness, dry mouth, and weight gain. When these problems persist or are bothersome, a change in dosage or a switch in medications may be needed. Tricyclics are useful in treating people with co-occurring anxiety disorders and depression. Imipramine, prescribed for panic disorder and GAD, is an example of such a tricyclic.

Antianxiety Medications

High-potency benzodiazepines relieve symptoms quickly and have few side effects, although drowsiness can be a problem. Because people can develop a tolerance to them — and would have to continue increasing the dosage to get the same effect — benzodiazepines are generally prescribed for short periods of time. People who have had problems with drug or alcohol abuse are not usually good candidates for these medications because they may become dependent.

Some people experience withdrawal symptoms when they stop taking benzodiazepines, although reducing the dosage gradually can diminish those symptoms. In certain instances, the symptoms of anxiety can rebound after stopping medication. Potential problems with benzodiazepines have led some physicians to shy away from using them, or to use them in inadequate doses, even when they are of potential benefit to the patient. Alprazolam is a benzodiazepine that is helpful for panic disorder and GAD.

Buspirone, a member of a class of drugs called azipirones, is a newer antianxiety medication that is used to treat GAD. Possible side effects include dizziness, headaches and nausea. Unlike the benzodiazepines, buspirone must be taken consistently for at least two weeks to achieve an antianxiety effect.

Other Medications

Beta-blockers, such as propanolol, are often used to treat heart conditions but have also been found to be helpful in certain anxiety disorders, particularly in social phobia. When a feared situation, such as giving an oral presentation, can be predicted in advance, your doctor may prescribe a beta-blocker to keep your heart from pounding, your hands from shaking and other physical symptoms from developing.

Psychotherapy

Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker or counselor to learn how to deal with problems like anxiety disorders.

Cognitive-Behavioral and Behavioral Therapy

Research has shown that cognitive-behavioral therapy (CBT), a form of psychotherapy, is effective for several anxiety disorders, particularly panic disorder and social phobia. It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. For example, a person with panic disorder might be helped to see that his or her panic attacks are not really heart attacks; the tendency to put the worst possible interpretation on physical symptoms can be overcome. Similarly, a person with social phobia might be helped to overcome the belief that others are continually watching and harshly judging him or her.

The behavioral component of CBT seeks to change people’s reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear. Another behavioral technique is to teach the patient deep breathing as a relaxation aid.

Behavioral therapy alone, without a strong cognitive component, has long been used effectively to treat specific phobias. Here also, therapy involves exposure. The person is gradually exposed to the object or situation that is feared. At first, the exposure may be only through pictures or audiotapes. Later, if possible, the person actually confronts the feared object or situation. Often the therapist will accompany him or her to provide support and guidance.

If you undergo CBT or behavioral therapy, exposure will be carried out only when you are ready; it will be done gradually and only with your permission, and you will work with the therapist to determine how much you can handle and at what pace you can proceed.

A major aim of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that help to maintain the disorder. For example, avoidance of a feared object or situation prevents a person from learning that it is harmless. Similarly, performance of compulsive rituals in OCD gives some relief from anxiety and prevents the person from testing rational thoughts about danger, contamination, and so forth.

To be effective, CBT or behavioral therapy must be directed at the person’s specific anxieties. An approach that is effective for a person with a specific phobia about dogs is not going to help a person with OCD who has intrusive thoughts of harming loved ones. CBT and behavioral therapy have no adverse side effects other than the temporary discomfort of increased anxiety, but the therapist must be well trained in the techniques of the treatment in order for it to work as desired. During treatment, the therapist probably will assign homework — specific problems that the patient will need to work on between sessions.

CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. Group therapy is particularly effective for people with social phobia. There is some evidence that, after treatment is terminated, the beneficial effects of CBT last longer than those of medications for people with panic disorder; the same may be true for OCD, PTSD and social phobia.

For many people, the best approach to treatment is medication combined with therapy. As stated earlier, it is important to give any treatment a fair trial. And if one approach doesn’t work, the odds are that another one will.

If you have recovered from an anxiety disorder, and at a later date it recurs, don’t consider yourself a treatment failure. Recurrences can be treated effectively, just like an initial episode. The skills you learned in dealing with the initial episode can be helpful in coping with a setback.

Sources:

• Archives of General Psychiatry
• National Institute of Mental Health Anxiety Disorders
• British Journal of Psychiatry Supplement
• Psychiatric disorders in America: the Epidemiologic Catchment Area Study

Rumination is a style of thinking in which, like a hamster in a cage, you run in tight circles on a treadmill in your brain. It means obsessing about problems, about a loss, about any kind of a setback or ambiguity without moving past thought into the realm of action.

The trouble with rumination is at least twofold. As you ruminate, you deepen the grooves in the brain, intensifying levels of anxiety and depression. And your problems remain unsolved, and are perhaps even exacerbated by the failure to move on them.

As Dr. Susan Nolen-Hoeksema has shown, the tendency to engage in rumination exposes a huge gender difference in the handling of emotional experience. Simply put, women are predisposed to rumination, largely because they value relationships and thus devote a great deal of time and mental energy to processing the often-ambiguous content of them.

And there they get lost, obsessing about issues without taking action. Men, in general, take the opposite tack. They are given to launching themselves into action without thinking their problems through well enough. As a result, the solutions they attempt are not always directly or efficiently focused on their problems.

When it comes to thinking styles, men and women need to learn from each other.

The following strategies can help you improve the way you handle your thoughts in difficult situations.

• Assess your own tendency to obsess about problems. Think of it as a maintenance check for your brain. Ask not only your friends but also your enemies how much of an obsessor you are, on a scale of mild to moderate to severe.
• Time yourself in thinking about a problem, whether it concerns one of your children, your work or whether to purchase a new vacuum cleaner. By the end of five minutes, you should have some sense of a next step, of the action required to solve the problem.

If you are thinking about the problem for more than five minutes, there is a good chance that you are a ruminator.

• Men can especially benefit by looking at whether they are repressing their thoughts. How much time are you not spending in looking at emotion-related problems? Do days and weeks go by when you haven’t given a thought to the most pressing problems of life? Again, rely on others—family, friends, even enemies—to give you accurate feedback on how good you are at repression.
• If you are a repressor, allocate five-minute chunks of time to thinking through a particular problem. It’s actually best if you can talk the problem through with another person. That will give you feedback that helps you open up your thinking, and the feedback will lead you to action that is then more likely to be on target—and thus more likely to be effective.
• A key element in gaining control over thinking that errs on the side of obsession is the use of techniques of distraction through action. When thoughts begin to run away with themselves, it is necessary to break their hold by engaging in action-distraction maneuvers. Go for a walk. Go out and garden. Go into the kitchen and cook. Or open a book and read.
• Understand that problem-solving always requires both processing your thoughts in a constructive manner and taking action on them; both are needed. But in difficult situations you need to know when to process whatever issue you are struggling with, and when not to, and how much. And that depends on how much energy you have.

You can switch between processing and activity modes as often as it takes to make headway on the issues that otherwise bog you down in rumination. If you are moving forward, you’re going in the right direction.

It can come out of nowhere. You’re shopping for groceries or buckling your seat belt when suddenly your muscles contract and your heart begins to pound.

Panic attacks can be both bewildering and terrifying, but they’re not unusual. An estimated 2.4 million people experience one every year. It may begin as tightness in the chest, shortness of breath or a galloping heartbeat. Many sufferers believe they are having a heart attack and rush to the emergency room.

The cause of an attack can be unclear, but they often arise in the face of major life changes, such as childbirth or a new job. Attacks may also follow trauma.

Prevalence rates have been on the upswing since the 1950s, although many experts believe what seems like a trend is simply better diagnosis.

What is a panic attack?

More than a feeling of anxiety, a panic attack produces distinctive physical symptoms. Each person experiences panic differently, but most people report intense fear accompanied by bodily sensations that can range from a racing heart to nausea and dizziness. Panic can come on suddenly or slowly and usually lasts no more than 20 minutes at its peak.

What causes a panic attack?

Scientists believe panic attacks stem from the brain’s “fight or flight” system gone awry, often ignited by stress or a traumatic event. In our high-octane society, that response can kick in with no real threat in sight or after the source of stress is long gone.

Research suggests that chronic panic sufferers may be easily flummoxed by their bodily sensations. Someone vulnerable to panic might interpret a rapid heartbeat as a heart attack. If fear overwhelms her, the symptoms intensify in a vicious cycle.

Does it run in families?

Vulnerability to anxiety may have a biological basis. If a parent or sibling has panic attacks, a person’s risk increases by about sixfold. A Yale study found that panic attack sufferers had fewer serotonin receptors in their brains, while other studies suggest those with anxiety may have overly sensitive “suffocation alarm systems,” which detect a shortage of oxygen even under normal conditions.

What is panic disorder?

Panic attacks are so frightening that sufferers will do just about anything to avoid another. That may mean staying away from situations associated with anxiety. Someone who once panicked on an airplane might decide not to fly. But the fear often extends to other settings; the plane phobic might start to dread cars and buses as well.

People with full-blown panic disorder, in which attacks are a frequent problem, feel constantly vulnerable, which forces them to be vigilant.

Only about a third of people who get occasional panic attacks will go on to develop panic disorder. Even though men and women report the attacks with equal frequency, women are twice as likely to get the disorder.

Some scientists think Irritable Bowel Syndrome (IBS) may be linked to panic disorder. Because IBS can be uncomfortable and embarrassing, sufferers dread their next IBS attack and become highly sensitive to their digestive system. When something feels awry, their agitation mounts, causing real stomach upset and pain. Since both panic and IBS symptoms are highly stress-sensitive, sufferers of either condition might find themselves trapped in a feedback loop.

How can I cope?

Antidepressant medication may help alleviate panic. However, cognitive-behavioral therapy may work even better; researchers estimate that up to 80 percent of panic sufferers can be helped by psychotherapy alone.

Therapists often treat panic by exposing the patient to feared settings of increasing intensity. Exposure therapy can also include exposure to the physical sensations of panic—spinning clients in circles to make them dizzy, having them inhale carbon dioxide or breathe through a straw or jog to raise their heart rates. Once clients learn that those feelings do not signal impending doom, they can better withstand panic—and eventually prevent it altogether.

Eating disorders happen as a result of severe disturbances in eating behavior, such as unhealthy reduction of food intake or extreme overeating. These patterns can be caused by feelings of distress or concern about body shape or weight and they harm normal body composition and function. A person with an eating disorder may have started out just eating smaller or larger amounts of food than usual, but at some point, the urge to eat less or more spirals out of control. Eating disorders are very complex, and despite scientific research to understand them, the biological, behavioral and social underpinnings of these illnesses remain elusive. Eating disorders frequently develop during adolescence or early adulthood, but some reports indicate their onset can occur during childhood or later in adulthood. Many adolescents are able to hide these behaviors from their family for months or years.

Eating disorders are not due to a failure of will or behavior; rather, they are real, treatable medical illnesses in which certain maladaptive patterns of eating take on a life of their own. The main types of eating disorders are anorexia nervosa and bulimia nervosa. A person with anorexia nervosa starves himself or herself to be thin, experiencing extreme weight-loss. An estimated .5 to 3.7 percent of females suffer from anorexia nervosa in their lifetime. Bulimia nervosa is binge eating followed by purging (vomiting). An estimated 1.1 percent to 4.2 percent of females have bulimia nervosa in their lifetime. A third disorder, binge-eating disorder, is characterized by frequent episodes of out-of-control eating. A cycle develops due to feelings of shame and disgust caused by obesity brought on by the overeating and leading to bingeing again. Community surveys have estimated that between 2 percent and 5 percent of Americans experience binge-eating disorder in a six-month period. This illness has only been suggested but has not yet been approved as a formal psychiatric diagnosis.

Eating disorders frequently occur together with other psychiatric illness such as depression, substance abuse, or anxiety disorders. In addition, people who suffer from eating disorders can experience a wide range of physical health complications, including serious heart conditions and kidney failure, which may lead to death. Recognition of eating disorders as real and treatable diseases, therefore, is critically important.

Females are much more likely than males to develop an eating disorder. Only an estimated 5 to 15 percent of people with anorexia or bulimia and an estimated 35 percent of those with binge-eating disorders are male.

Symptoms Anorexia nervosa is characterized by emaciation, a relentless pursuit of thinness and unwillingness to maintain a normal or healthy weight, a distortion of body image and intense fear of gaining weight, a lack of menstruation among girls and women, and extremely disturbed eating behavior. Some people with anorexia lose weight by dieting and exercising excessively; others lose weight by self-induced vomiting, or misusing laxatives, diuretics or enemas. More characteristics of anorexia nervosa include:

• Significant weight loss
• Continual dieting
• Intense fear of gaining weight or becoming fat, even if underweight
• Undue influence of body weight or shape on self-evaluation
• Preoccupation with food calories or nutrition
• Preference to eat alone
• Compulsive exercise
• Bingeing and purging
• Brittle hair or nails
• Depression
• Infrequent or absent menstrual periods (in females who have reached puberty)
• Growth of fine hair over body
• Mild anemia, and muscle weakness and loss
• Severe constipation
• Low blood pressure, slowed breathing and pulse
• Drop in internal body temperature, causing a person to feel cold all the time
• Lethargy

Many people with anorexia also have coexisting psychiatric and physical illnesses, including depression, anxiety, obsessive behavior, substance abuse, cardiovascular and neurological complications, and impaired physical development.

Bulimia Nervosa

Bulimia nervosa is characterized by recurrent and frequent episodes of eating unusually large amounts of food (binge-eating), and feeling a lack of control over the eating. This is followed by some type of behavior that compensates for the binge, such as purging (vomiting, excessive use of laxatives or diuretics), fasting and/or excessive exercise. Usually, bulimic behavior is done secretly. Additional symptoms include:

• Recurrent episodes of binge eating
• Purging by strict dieting, fasting, vigorous exercise or vomiting
• Abuse of laxatives or diuretics to lose weight
• Frequent use of bathroom after meals
• Reddened fingers
• Swollen cheeks
• Self-evaluation is unduly influenced by body shape and weight
• Depression or mood swings
• Irregular menstrual periods
• Dental problems, like tooth decay
• Heartburn or bloating
• Intestinal distress and irritation from laxative abuse
• Kidney problems from diuretic abuse
• Severe dehydration from purging of fluids

Binge-Eating Disorder

Binge-eating disorder is characterized by recurrent binge-eating episodes during which a person feels a loss of control over her eating. Unlike bulimia, binge-eating episodes are not followed by purging, excessive exercise or fasting. As a result, people with binge-eating disorder often are overweight or obese. Characteristics include:

• Eating much more rapidly than normal
• Eating until feeling uncomfortably full
• Eating large amounts of food when not hungry
• Eating alone because of embarrassment caused by how much is eaten
• Marked distress about the binge-eating behavior
• Binge-eating occurs, on average, at least 2 days a week for 6 months
• Binge-eating not associated with regular use of compensatory behaviors (purging, fasting, excessive exercise)

Causes Researchers are unsure of the underlying causes and nature of eating disorders. Unlike a neurological disorder, which generally can be pinpointed to a specific lesion on the brain, an eating disorder likely involves abnormal activity distributed across brain systems. With increased recognition that mental disorders are brain disorders, more researchers are using tools from both modern neuroscience and modern psychology to better understand eating disorders. Additionally, eating disorders appear to run in families so research on genetic factors continues.

Other factors—psychological, interpersonal and social—can play roles in eating disorders. Psychological factors that can contribute to eating disorders include low self-esteem, feelings of inadequacy or lack of control in life, depression, anxiety, anger, or loneliness.

Interpersonal Factors include troubled family and personal relationships, difficulty expressing emotions and feelings, a history of being teased or ridiculed based on size or weight or a history of physical or sexual abuse. Social factors that can contribute include cultural pressures that glorify “thinness” and place value on obtaining the “perfect body”, narrow societal definitions of beauty that include only women and men of specific body weights and shapes or cultural norms that value people on the basis of physical appearance and not inner qualities and strengths.

People with anorexia nervosa see themselves as overweight even though they are dangerously thin. In bulimia nervosa, despite sufferers usually weighing within the normal range for their age and height, like individuals with anorexia, they may fear gaining weight, desire to lose weight, and feel intensely dissatisfied with their bodies. Many with binge-eating disorders are overweight for their age and height. Feelings of self-disgust and shame associated with this illness can lead to bingeing again, creating a cycle of binge-eating.

Treatment Eating disorders can be treated and a healthy weight can be restored. The sooner these disorders are diagnosed and treated, the better the outcomes are likely to be. Because of their complexity, eating disorders require a comprehensive treatment plan involving medical care and monitoring, professional interventions, nutritional counseling and, when appropriate, medication management.

Treatment of anorexia calls for a specific program that involves three main phases: restoring the person to a healthy weight lost to severe dieting and purging; treating psychological disturbances such as distortion of body image, low self-esteem, and interpersonal conflicts; and reducing or eliminating behaviors or thoughts that lead to disordered eating, and preventing relapse.

Some research suggests that the use of medications, such as antidepressants, antipsychotics or mood stabilizers, may be modestly effective in treating patients with anorexia by helping to resolve mood and anxiety symptoms that often co-exist with anorexia. Recent studies, however, have suggested that antidepressants may not be effective in preventing some patients with anorexia from relapsing. In addition, no medication has shown to be effective during the critical first phase of restoring a patient to healthy weight. Overall, it is unclear if and how medications can help patients conquer anorexia, but research is ongoing.

Different forms of psychotherapy, including individual, group and family-based, can help address the psychological reasons for anorexia nervosa. Some studies suggest that family-based therapies in which parents assume responsibility for feeding their afflicted adolescent are the most effective in helping a person with anorexia gain weight and improve eating habits and moods. Others have noted that a combined approach of medical attention and supportive psychotherapy designed specifically for anorexia patients is more effective than just psychotherapy. But the effectiveness of a treatment depends on the person involved and her situation.

Hospital based care (including inpatient, partial hospitalization, intensive outpatient and/or residential care in an eating disorders specialty unit or facility) is necessary when an eating disorder has led to physical problems that may be life-threatening, or when it is associated with severe psychological or behavioral problems.

The course and outcome of anorexia nervosa vary across individuals: some fully recover after a single episode; some fluctuate between weight gain and relapse; and others chronically deteriorate over many years. The mortality rate among people with anorexia has been estimated at .56 percent per year which is about 12 times higher than the annual death rate due to all causes of death among females ages 15-24 in the general population. The most common causes of death are complications of the disorder, such as cardiac arrest or electrolyte imbalance, and suicide.

The primary goal of treatment for bulimia is to reduce or eliminate binge-eating and purging behavior. Nutritional rehabilitation, professional intervention and medication management are often employed. As with anorexia, treatment for bulimia often involves a combination of options and depends on the needs of the individual.

To reduce or eliminate binge and purge behavior, a patient may undergo nutritional counseling and psychotherapy, especially cognitive behavioral therapy (CBT), or be prescribed medication. Some antidepressants, such as fluoxetine (Prozac), which is the only medication approved by the FDA for treating bulimia, may help patients who also have depression and/or anxiety. It also appears to help reduce binge-eating and purging behavior, reduces the chance of relapse, and improves eating attitudes. CBT that has been tailored to treat bulimia also has shown to be effective in changing binging and purging behavior, and eating attitudes. Therapy may be individually oriented or group-based.

The treatment goals and strategies for binge-eating disorder are similar to those for bulimia. Fluoxetine and other antidepressants may reduce binge-eating episodes and help alleviate depression in some patients. Patients with binge-eating disorder also may be prescribed appetite suppressants. Psychotherapy, especially CBT, is also used to treat the underlying psychological issues associated with binge-eating, in an individual or group environment.

People with eating disorders often do not recognize or admit that they are ill. As a result, they may strongly resist getting and staying in treatment. Family members or other trusted individuals can be helpful in ensuring that the person with an eating disorder receives needed care and rehabilitation.

Sources:

• American Psychiatric Association
• National Institutes of Health
• National Eating Disorders Association (2006)

Imagine how you might feel in each of the following situations:

• You are stuck in a traffic jam and are about to be late for an important meeting
• You are about to stand up and give a public address to 200 people
• You or your loved one have to go to the hospital for a major and risky surgical procedure
• You are working towards an important deadline and suddenly collapse from fatigue

In this century, stress affects people of all ages. Today, being stuck in traffic could be classified as “stress”. In fact, if you are the kind of person who always expects the worst to happen or you tend to push yourself very hard and have high expectations of yourself, you may be suffering from stress with very little external provocation.

Herein lies one of the major challenges with the concept of stress. It can be caused by almost any event as well as chronic circumstances such as poor work conditions. Stress sometimes seems to be an almost inevitable spin-off of just about all aspects of modern life, yet at the same time there are huge and largely unexplained differences in people’s susceptibility.

Why Manage Stress?

People don’t die from stress. They die from stress related diseases. The wide range of techniques and expertise known and practice today guarantees that our professionals consider all areas of your personality and external factors to customised a stress management programme that works best for you and not against you, leading you to a more stress - free life, better productivity at work and greater relationships.