Private Practice Psychology

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.

Definition
Bulimia Nervosa is characterized by recurrent and frequent episodes of binge eating—i.e., unusually large amounts of food consumed in a short time—and a feeling that one lacks control over eating. A bulimic can consume as much as 3,400 calories in little more than an hour, and as much as 20,000 calories in eight hours. People with bulimia often know they have a problem and are afraid of their inability to stop eating. Binging is then followed by purging—namely, self-induced vomiting or the abuse of diuretics or laxatives. Binging and purging are often performed in secret, with feelings of shame alternating with relief.

Unlike anorexia, people with bulimia can maintain a normal weight for their age. But like people with anorexia, they often fear gaining weight, want desperately to lose weight, and are intensely unhappy with their body size and shape, which may explain why bulimic behavior often takes place in secret. The binging and purging cycle usually repeats several times a week. As with anorexia, people with bulimia often have coexisting psychological illnesses, such as depression and anxiety, and substance abuse problems. Many physical dysfunctions result from the purging, including electrolyte imbalances, gastrointestinal troubles, and dental problems.

An estimated 1 to 4 percent of females have bulimia nervosa during their lifetime. Most cases begin in the late teens and early 20s, but can go undetected until the 30s or 40s.

Symptoms

• Recurrent episodes of binge eating, characterized by eating within a discrete period of time—say, two hours—an amount of food substantially larger than most people would eat.
• A feeling that one cannot stop eating or control what or how much one eats.
• Recurrent compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; and excessive exercise.
• Self-evaluation unduly influenced by body shape and weight
• This disturbance doesn’t occur exclusively with anorexia nervosa.

Specific Types:

• Purging type: regularly induced vomiting or misused laxatives, diuretics, or enemas.
• Nonpurging type: other inappropriate compensatory behaviors, such as fasting or excessive exercise, but not self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Other symptoms include:

• chronically inflamed and sore throat
• swollen glands in the neck and below the jaw
• worn tooth enamel and increasingly sensitive and decaying teeth as a result of exposure to stomach acids
• acid reflux disorder (gastroesophageal reflux disorder, or GERD)
• intestinal distress and irritation from laxative abuse
• kidney problems from diuretic abuse
• severe dehydration from purging of fluids.

Causes Bulimia is more than just a problem with food. A binge can be triggered by dieting, stress, or uncomfortable emotions such as anger or sadness. Purging and other actions to prevent weight gain are ways for people with bulimia to feel more in control of their lives and ease stress and anxiety. There is no single known cause of bulimia, but there are some factors that may play a part.

• Culture. Women in the U.S. are under constant pressure to fit a certain ideal of beauty. Images everywhere of flawless, thin females make it hard for women to feel good about their bodies. Increasingly, men are also feeling pressure to have a perfect body.
• Families. If you have a mother or sister with bulimia, you are more likely to have bulimia. Parents who think looks are important, diet themselves, or criticize their children’s bodies are more likely to have a child with bulimia.
• Life changes or stressful events. Traumatic events such as rape, as well as stressors such as starting a new job, can trigger bulimia.
• Personality traits. Someone with bulimia may have low self-esteem and feel hopeless. She or he may be very moody and have difficulty expressing anger or controlling impulsive behaviors.
• Biology. Genes, hormones, and brain chemicals may contribute to developing bulimia.

Treatment As with anorexia, treatment for bulimia often involves a combination of options and depends on individual needs.

To reduce or eliminate binging and purging, a patient may undergo nutritional counseling and psychotherapy, especially cognitive behavioral therapy, and be prescribed medication. Some antidepressants, such as fluoxetine (brand name, Prozac)—the only medication approved by the FDA for treating bulimia—may help patients who also suffer from depression and anxiety. It also appears to help reduce binge-eating and purging as well as the chance of relapse, and it can improve eating attitudes.

Cognitive behavioral therapy tailored to treat bulimia also has shown to be effective in changing binging and purging behavior and improving attitudes towards eating. Therapy may be done one on one or in a group.

Note: Despite the relative safety and popularity of selective serotonin reuptake inhibitors (SSRIs) and other antidepressants, some studies have suggested that they may have unintentional effects, especially on adolescents and young adults. In 2004, after a thorough review of data, the FDA adopted a black box warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking and attempts in children and adolescents. 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.

Current Research

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 neuroscience, such as magnetic resonance imaging (MRI), to better understand eating disorders and how those with a disorder process information, whether they’ve recovered or are still in the throes of their illness.

Behavioral or psychological research on eating disorders is more complex and challenging. New studies are currently underway to remedy the lack of information about treatment. Researchers also are working to define the basic processes of the disorders, which should help identify better treatments.

These and other questions may be answered in the future as scientists and doctors think of eating disorders as medical illnesses with certain biological causes. Researchers are studying behavioral questions, along with genetic and brain systems information, to understand risk factors, identify biological markers and develop medications that can target specific pathways that affect eating behavior. Finally, neuroimaging and genetic studies may provide clues for individual responses to specific treatments.

Sources:

• National Institute of Mental Health
• Diagnostic and Statistical Manual of Mental Disorders, fourth edition, revised;
• American Psychiatric Association Work Group on Eating Disorders
• American Journal of Psychiatry
• U.S. Department of Health and Human Services

Definition
Bereavement means to be deprived of someone by death. The death of someone you love is one of the greatest losses that can occur. However, feelings of bereavement can also accompany other losses, such as the loss of your health or the health of someone you care about—or the end of an important relationship, through divorce, for example. Grief is a normal, healthy response to loss.

Everyone feels grief in their own way, but there are certain stages to the process of mourning. It starts with recognizing a loss and continues until a person eventually accepts that loss. People’s responses to grief will vary depending upon the circumstances of the death.

For example, if the person who died had a chronic illness, the death may have been expected. The end of the person’s suffering might even have come as a relief. If the death was accidental or violent, coming to a stage of acceptance could take longer.

Symptoms A wide and confusing range of emotions may be experienced after a loss. There can be five stages of grief. These reactions might not occur in a specific order, and can (at times) occur together. Not everyone experiences all of these emotions:

• Denial, disbelief, numbness
• Anger, blame
• Bargaining (for instance, “If I am cured of this cancer, I will never smoke again”)
• Depressed mood, sadness, and crying
• Acceptance, coming to terms

People who are grieving will often report crying spells, some trouble sleeping, and lack of productivity at work. At this time, you may find it hard to accept that the loss has actually occurred.

Once the initial shock has worn off, denial of the loss can often be replaced by feelings of anger. The anger may be directed toward doctors and nurses, God, other loved ones, yourself, or even the person who has died. You may experience feelings of guilt with sentiments such as “I should have… “, “I could have… “, or “I wish I had… ” Such thoughts are common. Your emotions may be very intense and you may have mood swings. These are all normal reactions to loss.

Each type of loss means the person has had something taken away. Grief may be experienced as a mental, physical, social, or emotional reaction. Mental reactions can include anger, guilt, anxiety, sadness, and despair. Physical reactions can include sleeping problems, changes in appetite, physical problems, or illness. Social reactions can include feelings about seeing family or friends or returning to work. As with bereavement, grief processes depend on the relationship with the person who died, the situation surrounding the death, and the person’s attachment to the person who died. Grief may be described as the presence of physical problems, constant thoughts of the person who died, guilt, hostility, and a change in the way one normally acts.

Mourning is the process by which people adapt to a loss; mourning is also influenced by cultural customs, rituals, and society’s rules for coping.

Bereavement is the period after a loss during which grief is experienced and mourning occurs. The time spent in a period of bereavement depends on how attached the person was to the person who died, and how much time was spent anticipating the loss.

If you feel that you are not coping with bereavement, it is important to seek help. Although it may seem easier to bury your pain than to face it, unresolved grief can cause long-term physical or emotional illness.

Causes Your reaction to loss will, in part, be influenced by the circumstances surrounding it. The death of a loved one is always difficult, particularly when it is sudden or accidental. Your relationship to the person who has died will greatly influence your reaction to the loss.

A Spouse’s Death

The loss of a husband or wife is particularly hard. The surviving spouse will usually have to deal with a multitude of decisions regarding funeral arrangements, finances, and other legalities at a time when they may feel least able to deal with such matters. The bereaved spouse may also have to explain the death to children and help them through their grief. In addition to the severe emotional trauma, the death may lead to financial problems if the deceased spouse was the family’s main source of income. Returning to the job market (or entering it for the first time) can be one of the most challenging tasks for the recently bereaved spouse. When searching for a job, look for ways to capitalize on the skills you have developed over the years.

A Child’s Death

Regardless of the cause of death, or the age of the child, this is an emotionally devastating event that overwhelms a parent. A child’s death arouses an overwhelming sense of injustice—for lost potential, unfulfilled dreams, and senseless suffering. Parents may feel responsible for the child’s death, no matter how irrational that may seem. Parents may also feel that they have lost a vital part of their own identity.

A Parent’s Death

No matter what age you are—young or old, single or with a family of your own—you will still be deeply affected by the death of your mother or father. When your mom or dad dies, it may be one of the most emotional losses you’ll experience in life. It is only natural to feel consumed by a combination of pain, fear, and deep sadness at the loss of such a significant influence in your life.

The specifics of how you grieve will depend on a number of personal factors, including your relationship with your parent, age, gender, religious beliefs, previous experience with death, and whether or not you believe it was time for your parent to die.

When you lose a parent, you may also lose a lifelong friend, counselor, and adviser. Therefore, you may suddenly feel very much alone, even if you have the support of other family and friends. Even the loss of your parent’s home as a natural place for family gatherings can add to the grief you experience.

After the initial shock fades, you will experience what is called secondary loss. This is when you may begin to think of all the upcoming experiences that your parent will not be there to share in. Things like career accomplishments, watching your own children grow, and other milestones. If you are older, the death of a parent may even bring up issues of your own mortality.

Allowing yourself to grieve for the loss of your parent will help you to say goodbye and loosen the emotional bonds to a loved one who has been a special part of your life.

A Loss Due To Suicide

For every suicide it is claimed that on average six people suffer intense grief. Those affected include parents, partners, children, siblings, relatives, friends, coworkers, and clinicians. Coping with bereavement through suicide can be more difficult than dealing with other losses because of the feelings of stigmatization, shame, guilt, and rejection that are often experienced. The stigma that still attaches to deaths by suicide in many cultures can increase the bereaved person’s sense of isolation and vulnerability.

A Pet’s Death

The death of a pet will often mean the loss of a cherished family member and can trigger great sorrow. People love their pets and consider them members of their family. Caregivers celebrate their pets’ birthdays, confide in their animals, and carry pictures of them in their wallets. So when your beloved pet dies, it’s not unusual to feel overwhelmed by the intensity of your sorrow. Animals provide companionship, acceptance, emotional support, and unconditional love during the time they share with you. Other people may find it hard to understand such a reaction to what they may see as the loss of “just an animal,” and they may, therefore, be less understanding of your grief. However, your loss is significant and you should give yourself permission to mourn the passing of your beloved pet.

Anticipatory Grief

Anticipatory grief is the normal mourning that occurs when a patient or family is expecting a death. Anticipatory grief has many of the same symptoms as those experienced after a death has occurred.

Anticipatory grief includes depression, extreme concern for the dying person, preparing for the death, and adjusting to changes caused by the death. It can give the family time to get used to the reality of the impending loss. People are able to complete “unfinished business” with the dying person (for example, saying “good-bye,” “I love you,” or “I forgive you”).

Anticipatory grief may not always occur. A person does not necessarily feel the same kind of grief before a death occurs as the grief felt after a death. There is no set amount of grief that a person will feel. Grief experienced before a death does not make the grief after that death easier or shorter in duration.

Some people believe that anticipatory grief is rare. To accept a loved one’s death while he or she is still alive may leave the mourner feeling as if the dying patient has been abandoned. Furthermore, expecting the loss can make the attachment to the dying person stronger. Although anticipatory grief may help the family, witnessing the grief of family and friends can be very hard for the dying person who can become withdrawn as a result.

Some grief reactions are not considered “normal.” For example, persistent and intrusive feelings of guilt in the survivor (or thoughts that he or she should have died along with the deceased) are more characteristic of depression than normal bereavement. Depression in bereavement can be successfully treated.

Other losses occurring in later life may precipitate grief or depression. Retirement, loss of income, deteriorating physical health, and having to give up driving are just some of the more common occurrences that might cause grief reactions in older people.

Treatment Grief is a powerful emotion. It is painful and exhausting. Therefore, it sometimes seems easier to avoid confronting these feelings. However, this approach is not a viable long-term solution. Buried grief can manifest itself later as physical or emotional illness. Working through your sorrow and allowing yourself to express your feelings will help you to heal.

“Grief work” includes the stages a mourner needs to complete before resuming daily life. These processes include separating from the person who died, readjusting to a world without him or her, and forming new relationships. To separate from the person who died, a person must find another way to redirect the emotional energy that was given to the loved one. This does not mean the deceased was not loved or should be forgotten, but that the mourner needs to turn to others for emotional satisfaction. The mourner’s roles, identity, and skills may need to change to readjust to living in a world without the person who died. The bereaved needs to redirect the emotional energy that was once given to the deceased to other people or activities.

It is important not to neglect yourself while grieving. Try to eat regular, healthy meals. If meal preparation is too difficult, try eating several smaller snacks throughout the day.

Grieving is extremely tiring, both physically and emotionally. The grief one is feeling is not just for the person who died, but also for the unfulfilled wishes and plans with the person. Death often reminds people of past losses or separations. Mourning may be described as having the following three phases:

• The urge to bring back the person who died
• Disorganization and sadness
• Reorganization

Depression shares common features with grief, but can completely take over the way you think and feel.

Symptoms of depression include:

• A sad or “empty” mood that will not go away or lighten
• Persistent feelings of hopelessness or worthlessness
• A negative preoccupation with self

Depression in older people has been linked to death from suicide, heart attack, and other causes. Much can be done to ameliorate severe symptoms through formal treatment or through support-group participation. If you feel that you or someone you know is having difficulty in coping with their loss, seek professional help. A family physician can often help, or grief counseling or therapy may be appropriate.

Grief counseling helps mourners with normal grief reactions work through the tasks of grieving. Grief counseling can be provided by professionally trained people or in self-help groups where bereaved people help each other. All of these services may be available in individual or group settings.

The goals of grief counseling include:

• Describing normal grieving and encouraging the bereaved to accept the loss by talking about it
• Helping the bereaved to identify and express feelings related to the loss (for example, anger, guilt, anxiety, helplessness, and sadness)
• Helping the bereaved to separate emotionally from the deceased, as well as to make decisions and live alone
• Helping the bereaved to understand his or her methods of coping
• Describing normal grieving and the differences in grieving among individuals
• Providing continuous support
• Providing support at important times, such as birthdays and anniversaries
• Identifying coping problems the bereaved may have, and making recommendations for professional grief therapy, if necessary

Grief therapy is used with people who have more serious grief reactions. The goal of grief therapy is to identify and solve problems the mourner may have in separating from the person who died. When separation difficulties occur, they may appear as physical or behavioral problems, delayed or extreme mourning, conflicted or extended grief, or unexpected mourning.

In grief therapy, the mourner talks about the deceased and tries to recognize whether he or she is experiencing an expected amount of emotion about the death. Grief therapy may allow the mourner to see that anger, guilt, or other negative or uncomfortable feelings can exist at the same time as more positive feelings about the person who died.

Humans tend to make strong bonds of affection or attachment with others. When these bonds are broken, as in death, a strong emotional reaction occurs. After a loss, a person must accomplish certain tasks to complete the process of grief. These basic tasks of mourning include accepting that the loss happened, living with and feeling the physical and emotional pain of grief, adjusting to life without the loved one, and emotionally separating from the loved one and going on without him. It is important that these tasks are completed before mourning can end.

In grief therapy six tasks can be used to help a mourner work through her grief:

1. Develop the ability to experience, express, and adjust to painful grief-related changes
2. Find effective ways to cope
3. Establish a continuing relationship with the person who died
4. Stay healthy and keep functioning
5. Reestablish relationships, and understand that others may have difficulty empathizing with the grief he is experiencing
6. Develop a healthy image of herself and the world

Complications in grief may come about due to unresolved grief from earlier losses. The grief for these earlier losses must be managed to handle the current grief. Grief therapy includes dealing with blockages to the mourning process, identifying any unfinished business with the deceased and identifying other losses that result from the death. The bereaved must see that the loss is final and to picture life after the mourning period.

Grief therapy may be available as individual or group therapy. A contract is set up with the individual that establishes the time limit of the therapy, the fees, the goals, and the focus of the therapy.

Complicated Grief

Complicated grief reactions require more complex therapies than uncomplicated grief reactions. Adjustment disorders (especially depressed and anxious mood or disturbed emotions and behavior), major depression, substance abuse, and even post-traumatic stress disorder are some of the common problems of complicated bereavement. Complicated grief is identified by the extended duration of the symptoms, the disruption to daily life caused by the symptoms or by the intensity of the symptoms (for example, intense suicidal thoughts or acts).

Complicated or unresolved grief may appear as a complete absence of grief and mourning, an ongoing inability to experience normal grief reactions, delayed grief, conflicted grief, or chronic grief. Factors that contribute to the chance that one may experience complicated grief include the suddenness of the death, the gender of the person in mourning, and the relationship to the deceased (for example, an intense, extremely close or very contradictory relationship).

Grief reactions that turn into major depression require treatment. Someone who avoids any reminders of the person who died, who constantly thinks or dreams about the person who died, or who gets scared and panics easily at any reminders of the deceased may be suffering from post-traumatic stress disorder. Substance abuse may occur, frequently in an attempt to avoid painful feelings about the loss and consequent symptoms (such as sleeplessness), and this should also be treated.

Children and Grief

In the past, children were thought to be miniature adults and were expected to behave as adults. It is now understood that there are differences in the ways in which children and adults mourn.

Unlike adults, bereaved children do not experience continual and intense emotional and behavioral grief reactions. Children may seem to show grief only occasionally and briefly, but in reality a child’s grief usually lasts longer than that of an adult. This may be explained by the fact that a child’s ability to experience intense emotions is limited. Mourning in children may need to be addressed again and again as the child gets older. Since bereavement is a process that continues over time, children will think about the loss repeatedly, especially during important times in their life, such as going to camp, graduating from school, getting married, or giving birth to their own children.

A child’s grief may be influenced by her age, personality, developmental stage, earlier experiences with death, and her relationship with the deceased. The surroundings, cause of death, family members’ ability to communicate with one another and to continue as a family after the death can also affect grief. Factors that may influence grief include the child’s ongoing need for care, the child’s opportunity to share his feelings and memories, the parent’s ability to cope with stress, and the child’s steady relationships with other adults.

Children do not react to loss in the same ways as adults. Grieving children may not show their feelings as openly as adults. Grieving children may not withdraw and dwell on the person who died, but instead may throw themselves into activities (for example, they may be sad one minute and playful the next). Often families think the child doesn’t really understand or has gotten over the death. Neither is true; children’s minds protect them from what is too powerful for them to handle. Children’s grieving periods are shortened because they cannot think through their thoughts and feelings like adults. Also, children have trouble putting their feelings about grief into words. Instead, his behavior speaks for the child. Strong feelings of anger and fears of abandonment or death may show up in the behavior of grieving children. Children often play death games as a way of working out their feelings and anxieties. These games are familiar to the children and provide safe opportunities to express their feelings.

Children’s Grief and Developmental Stages

Children at different stages of development have different understandings of death and the events near death.

Infants

Infants do not recognize death, but feelings of loss and separation are part of developing an awareness of death. Children who have been separated from their mother may be sluggish, quiet, unresponsive to smiling or cooing, undergo physical changes (for example, weight loss), be less active, and sleep less.

Age 2-3 years

Children at this age often confuse death with sleep and may experience anxiety as early as age 3. They may stop talking and appear to feel overall distress.

Age 3-6 years

At this age children see death as a kind of sleep; the person is alive, but only in a limited way. The child cannot fully separate death from life. Children may think that the person is still living, even though she might have been buried, and ask questions about the deceased (for example, how does the deceased eat, go to the toilet, breathe, or play?). Young children know that death occurs physically, but think it is temporary, reversible, and not final. The child’s concept of death may involve magical thinking. For example, the child may think that his or her thoughts can cause another person to become sick or die. Grieving children under 5 may have trouble eating, sleeping, and controlling bladder and bowel functions.

Age 6-9 years

Children at this age are commonly curious about death, and may ask questions about what happens to one’s body when it dies. Death is thought of as a person or spirit separate from the person who was alive, such as a skeleton, ghost, angel of death, or bogeyman. They may see death as final and frightening but as something that happens mostly to old people (and not to themselves). Grieving children can become afraid of school, have learning problems, develop antisocial or aggressive behaviors, become overly concerned about their own health (for example, developing symptoms of imaginary illness), or withdraw from others. Or, children this age can become too attached and clinging. Boys usually become more aggressive and destructive (for example, acting out in school), instead of openly showing their sadness. When a parent dies, children may feel abandoned by both their deceased parent and their surviving parent because the surviving parent is grieving and is unable to emotionally support the child.

Ages 9 and older

By the time a child is 9 years old, death is known to be unavoidable and is not seen as a punishment. By the time a child is 12 years old, death is seen as final and something that happens to everyone.

Treatment—Child Specific

A child’s grieving process may be made easier by being open and honest with the child about death. Not talking about death indicates that the subject is taboo and does not help a child to cope with loss. Use clear, direct language. Explanations should be simple and straightforward. Euphemisms such as “She passed away” or “We lost him” are best avoided, as they can confuse and alarm children. Each child should be told the truth, using as much detail as he or she is able to understand. Listen to any questions the child may have and try to answer them as fully as possible. Children often need to be reassured about their own security (they often worry that they, or a surviving parent, will also die).

If you are planning a memorial ceremony, try to include the child in the arrangements and in the ceremony itself. These events help children (and adults) remember loved ones. Children should not be forced to be involved in funerals or memorials, but they should be encouraged to take part in those portions of the events with which they feel most comfortable. If the child wants to attend the funeral, wake or memorial service, she should be given a full explanation of what to expect in advance. Try to encourage them to express their feelings. The surviving parent may be too incapacitated by his own grief to give the child full attention. Therefore, support from a familiar adult or family member can be extremely helpful.

Sources:

• AARP
• National Cancer Institute
• National Institutes of Health-Bethesda
• National Institutes of Health-National Library of Medicine
• Canadian Mental Health Association
• Mental Health Association
• Worden JW: Grief Counseling and Grief Therapy. New York: Springer Publishing Company
• Shuchter SR and Zisook S. Treatment of spousal bereavement: a multidimensional approach. Psychiatric Annals 16 (5): 295-305.
• Corr CA, Nabe CM, Corr DM: Death and Dying, Life and Living. 2nd ed. Pacific Grove, Calif: Brooks/Cole Publishing Company
• Humane Society of the United States
• National Funeral Directors Association

Definition
Attention-deficit/hyperactivity disorder is a neurobehavioral disorder characterized by a combination of inattentiveness, distractibility, hyperactivity, and impulsive behavior. AD/HD appears early in life. It is estimated that 3 percent to 7 percent of school-age children are diagnosed with AD/HD; boys are diagnosed more often than girls. Untreated AD/HD has been shown to have long-term adverse affects on academic performance, vocational success, and social-emotional development. AD/HD children have difficulty sitting still and paying attention in class and do not do well at school, even when they have normal or above-normal intelligence. They engage in a broad array of disruptive behaviors and experience peer rejection. As they grow older, children with untreated AD/HD are more prone to drug abuse, antisocial behavior, and injuries of all sorts. More than half the children diagnosed with AD/HD continue to have symptoms during their adolescent years and into adulthood.

Symptoms Diagnosing an adult with AD/HD is not easy. Many times, when a child is diagnosed with the disorder, a parent will recognize that he or she has many of the same symptoms the child has and, for the first time, will begin to understand some of the traits that have given him or her trouble for years—distractibility, impulsivity, restlessness. Other adults will seek professional help for depression or anxiety and will find out that the root cause of some of their emotional problems is AD/HD. They may have a history of school failures, problems at work, or frequent automobile accidents.

To be diagnosed with AD/HD, an adult must have childhood-onset, persistent, and current symptoms. The accuracy of the diagnosis of adult AD/HD is of utmost importance and should be made by a clinician with expertise in the area of attention dysfunction. For an accurate diagnosis, a history of the patient’s childhood behavior, together with an interview with his life partner, a parent, close friend, or other close associate, will be needed. A physical examination and psychological tests should also be given. Comorbidity with other conditions may exist such as specific learning disabilities, anxiety, or affective disorders.

A correct diagnosis of AD/HD can bring a sense of relief. The individual has brought into adulthood many negative perceptions of himself that may have led to low esteem. Now he can begin to understand why he has some of his problems and can begin to face them. This may mean, not only treatment for AD/HD but also psychotherapy that can help him cope with the anger he feels about the failure to diagnose the disorder when he was younger.

Causes Health professionals are still unsure about what causes AD/HD. It may be a genetically determined disorder, as attention disorders often run in families. Studies indicate that 25 percent of close relatives in the families of AD/HD children also have AD/HD, whereas the rate is about 5 percent in the general population. Many studies of twins now show that a strong genetic influence exists in the disorder.

Recent studies show that AD/HD is caused by neurobiological dysfunction. Scientists using neuroimaging and brain scanning tools for studying the brain have demonstrated a link between a person’s ability to maintain attention and the level of activity in the brain. For example, scientists have found differences between the frontal lobes of individuals who have AD/HD and those who do not.

Current research is exploring the structure of the brain to determine if there are differences that might indicate a physical basis for attention-deficit/hyperactivity disorder.

There is correlating evidence between the use of cigarettes and alcohol during pregnancy and the risk for developing AD/HD in the unborn child. These substances may endanger the fetus’ developing brain. It is best to refrain from smoking, alcohol use, and use of other drugs during pregnancy, as they may distort developing nerve cells and lead to AD/HD.

Toxins in the environment may also disrupt brain development or brain processes, which may lead to AD/HD. Lead is one such possible toxin. It is found in dust, soil, and flaking paint in areas where leaded gasoline or paint were once used. It is also present in some older water pipes.

There is, however, little compelling evidence that AD/HD stems from the home environment. Researchers report that not all children from unstable or dysfunctional homes have AD/HD, and not all children with AD/HD come from dysfunctional families. Scientists have also found no real evidence that head injury, undetectable damage to the brain, early infection, or complications at birth cause AD/HD.

Typically, adults with AD/HD are unaware that they have this disorder—they often just feel that it’s impossible to get organized, to stick to a job, to keep an appointment. The everyday tasks of getting up, getting dressed and ready for the day’s work, getting to work on time, and being productive on the job can be major challenges for the AD/HD adult.

Treatment When adults take a medication for AD/HD, they often start with a stimulant medication. The stimulant medications affect the regulation of two neurotransmitters, norepinephrine and dopamine. The newest medication approved for AD/HD by the FDA, atomoxetine (Strattera®), has been tested in controlled studies in both children and adults and has been found to be effective.

Antidepressants are considered a second choice for treatment of adults with AD/HD. The older antidepressants, the tricyclics, are sometimes used because they, like the stimulants, affect norepinephrine and dopamine. Venlafaxine (Effexor®), a newer antidepressant, is also used for its effect on norepinephrine. Bupropion (Wellbutrin®), an antidepressant with an indirect effect on the neurotransmitter dopamine, has been useful in clinical trials on the treatment of AD/HD in both children and adults. It has the added attraction of being useful in reducing cigarette smoking.

In prescribing for an adult, special considerations are made. The adult may need less of the medication for his weight, or at its regular dosage its effect may last longer in an adult. The adult may take other medications for physical problems, such as diabetes or high blood pressure; often the adult is also taking a medication for anxiety or depression. All of these variables must be taken into account before a medication is prescribed.

Although medication gives needed support, the individual must succeed on his own. To help in this struggle, both AD/HD education and individual psychotherapy can be helpful. The therapist can encourage the AD/HD patient to adjust to changes brought into his life by treatment—the perceived loss of impulsivity and love of risk-taking, the new sensation of thinking before acting. As the patient begins to have small successes in his new ability to bring organization out of the complexities of his or her life, he or she can begin to appreciate the characteristics of AD/HD that are positive—boundless energy, warmth, and enthusiasm.

Treatment plans for adult AD/HD may include:

1. Consultation with appropriate medical professionals
2. Education about AD/HD
3. Medication
4. Support groups
5. Psychotherapy for help change a longstanding poor self-image
6. Coaching in organizational skills
7. Vocational/educational counseling
8. Appropriate accommodations for work and school (NIMH, 2006)

Sources:

• American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
• Barkley R.A. (2000). Taking Charge of AD/HD. New York: The Guilford Press, p. 21.
• Biederman J, Faraone SV, Keenan K, Knee D, Tsuang MF. (1990) Family-genetic and psychosocial risk factors in DSM-III attention deficit disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 29(4): 526-533.
• Consensus Development Panel (CDP) (1982). Defined Diets and Childhood Hyperactivity. National Institutes of Health Consensus Development Conference Summary, Volume 4(3).
• Faraone SV, Biederman J. (1998) Neurobiology of attention-deficit hyperactivity disorder. Biological Psychiatry, 44, 951-958.
• Harvard Mental Health Letter (2002). Attention Deficit Disorder in Adults. Vol. 19:5, 3-6.
• The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit hyperactivity disorder (AD/HD) (1999). Archives of General Psychiatry, 56:1073-1086.
• National Institute of Mental Health (2006). Attention-Deficit/Hyperactivity Disorder. Bethesda (MD): National Institute of Mental Health, National Institutes of Health, US Department of Health and Human Services. http://www.nimh.nih.gov/publicat/AD/HD.cfm#teen
• National Institutes of Health - National Library of Medicine - MedlinePlus, 2007. Attention deficit hyperactivity disorder (AD/HD). http://www.nlm.nih.gov/medlineplus/ency/article/001551.htm
• US Department of Justice (USDOJ) (2006). A Guide to Disability Rights Laws. Civil Rights Division: Disability Rights Section http://www.usdoj.gov/crt/ada/cguide.htm#anchor62335
• U.S. Department of Transportation, National Highway Traffic Safety Administration. State Legislative Fact Sheet, April 2002.
• Wilens TC, Faraone, SV, Biederman J, Gunawardene S. (2003). Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics, 111:1:179-185.
• Wilens TE, Biederman J, Spencer TJ. Attention (2002). deficit/hyperactivity disorder across the lifespan. Annual Review of Medicine, 53:113-131.

We all feel sad sometimes. Sadness is a normal emotion that can make life more interesting. Much art and poetry is inspired by sadness and melancholy. Sadness almost always accompanies loss. When we say goodbye to a loved one we usually feel sad. The sadness is even deeper if a close relationship has ended or a loved one has died.

Sadness also helps us appreciate happiness. When our mood eventually changes from sadness toward happiness the sense of contrast adds to the enjoyment of the mood.

Here are some ways to experience normal sadness in a healthy way and to allow this emotion to enrich your life:

• Allow yourself to be sad. Denying such feelings may force them underground, where they can do more damage with time. Cry if you feel like it. Notice if you feel relief after the tears stop.

• If you are feeling sad, plan a sadness day. Plan a day or evening just to be alone, listen to melancholy music, and to observe your thoughts and feelings.
  Planning time to be unhappy can be actually feel good. It can help you ultimately move into a more happy mood.

• Think about the context of the sad feelings. Are they related to a loss or an unhappy event? It is usually not as simple as discovering the “cause” of the sadness, but it may be possible to understand factors involved.

• Sadness can result from a change that you did not expect, or it can signal the need for a change in your life. Change is usually stressful, but it is necessary for growth.

• Know when sadness turns into depression. Get help if this happens rather than getting stuck in it.

Get help if you experience more than a couple of the following symptoms of depression:

• Persistent sad, anxious, or “empty” mood
• Feelings of hopelessness, pessimism
• Feelings of guilt, worthlessness, 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, 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.

Recent research has linked lack of sleep to a wide range of ailments, including memory problems and obesity. Learn more about some of the top reasons why you should get a good night’s sleep.

 

Sleep May Help You Learn More Effectively

Researchers have long believed that sleep plays an important role in memory, but recent evidence suggests that getting a good night’s sleep can improve learning. In one study, researchers found that depriving students of sleep after learning a new skill significantly decreased memory of that skill up to three days later (Winerman, 2006). Known as the memory consolidation theory of sleep, this notion proposes that sleep serves to process and retain information learned earlier while awake. While there is research both for and against the theory, many studies have shown that sleep can play an important role in certain types of memory.

 

 

Research Suggests Sleep Deprivation May Contribute to Obesity

In addition to affecting memory and learning, lack of sleep has been linked to body weight. In one 2005 study published in the Archives of Internal Medicine, overweight participants were found to sleep less than participants of a normal weight (Vorona et al., 2005). Brandon Peters, About.com’s Guide to Sleep Disorders, reports that poor sleep at age 30 months can predict obesity at age seven. While researchers do not yet understand exactly how sleep disruption impacts appetite and metabolism, getting a good night’s sleep certainly can’t hurt your weight loss or weight maintenance efforts.

 

Sleep is Important for Managing Stress

According to many experts, most people need between seven and eight hours of sleep each night. What happens when you don’t get enough sleep? Symptoms such as moodiness, anxiety, aggression and increased stress levels can result. About.com’s Guide to Stress Management, Elizabeth Scott, suggests taking “power naps” to combat drowsiness, reduce stress and increase productivity. While sleeping more certainly won’t eliminate all stress, it can help increase your readiness to cope with the stress of day-to-day life.

 

Sleep Can Help You Make Better Decisions

Have you ever found yourself struggling to make relatively simple decisions after a night of poor sleep? In addition to reducing such things as response time and accuracy, lack of sleep has also been linked to difficulty making good decisions. In one study published in the journal Sleep, researchers found that sleepiness has a serious impact on the ability to make effective decisions (Roehrs, 2004). Another study suggested that sleep impairs decision-making when gambling by increasing expectations of potential gains while minimizing losses. If you’re facing a challenging decision, make sure that you are well rested so that you will be at your best.

 

References

_{American Academy of Sleep Medicine (2007, May 5). Sleep Deprivation Can Threaten Competent Decision-making. ScienceDaily. National Sleep Foundation. (2008). Longer Work Days Leave Americans Nodding Off On the Job.}

_{Peters, B. (2008). Why so fat and tired?}

_{Roehrs, T., Greenwald, M., Roth T. (2004). Risk-taking behavior: effects of ethanol, caffeine, and basal sleepiness. Sleep, 27(5), 887-93.}

_{Vorona, R. et al. (2005, Jan. 10). Overweight and Obese Patients in a Primary Care Population Report Less Sleep Than Patients With a Normal Body Mass Index. Archives of Internal Medicine, 165, 25-30.}

_{Winerman, L. (2006). Let’s sleep on it: A good night’s sleep may be the key to effective learning, says recent research. Monitor on Psychology.}

Someone says to you, “But the chances of your getting killed in an airplane crash are millions to one? What are you worried about?” And you reply, “But what if I’m the one?” Or you go to your doctor and she says, “It looks like you don’t have cancer”. You go home and you think, “Can she be absolutely sure?” And then you get a second and third opinion. You can’t tolerate not knowing for sure.

Researchers Michel Dugas and Robert Ladouceur have found that a core feature of worry is the inability to tolerate uncertainty. In fact, some worriers say that they would rather know for sure that the outcome will be bad than left in suspense not knowing for sure. In fact, you may worry in order to “gain certainty”. You look for all kinds of information and possible solutions to every problem you come up with—and then you ask yourself, “Will this solution tell me the answer?” But the only answer that you will accept is absolute certainty. So you reject almost all the answers because they are not perfect and they can’t tell you for sure.

Are you intolerant of uncertainty? Do you reject the evidence that the chances are very, very low? Do you continually demand perfect solutions that will have to work for sure? Do you seek out reassurance and , then, say, “Well, you can’t tell me for sure”? Do you think that if you simply think about a problem— “It’s possible I could have cancer”—that this means that you absolutely must find out for sure that you don’t?

Chronic worriers often equate uncertainty with a bad outcome. They think that if they don’t know for sure that they would be irresponsible allowing this uncertainty to persist.

What can you do?

First, ask yourself what the advantages would be in accepting some reasonable uncertainty. Would you be less anxious, less worried, and more able to enjoy the present moment?

Second, what are the disadvantages in accepting uncertainty? Does it mean that you are now irresponsible, in danger, letting your guard down? Are these really rational evaluations? Or are you exaggerating?

Third, what uncertainty do you already accept? For example, when you drive, take a plane, eat in a restaurant, interact with someone new, go to a new city, start a new project at work—aren’t you already accepting uncertainty?

Fourth, do you know anyone who has absolute certainty? Anyone? How do they live with themselves? Are they irresponsible or in danger?

Fifth, your thought, “I could always be the one”, is something you fear. Try repeating this thought for thirty minutes every day—as slowly as you can. As you repeat the thought, imagine yourself standing back and observing the words floating by on a stream. Stay with the words. Do this very very slowly. Imagine yourself as a zombie repeating the feared thought. Do you notice that your anxiety goes up and then eventually goes down? Are you becoming less afraid of the thought?

Sixth, what is the advantage of uncertainty? Does uncertainty create novelty, pleasant surprises, new and exciting challenges? How would your life be a dreadful bore if you had absolute certainty?

Seventh, rather than thinking of uncertainty, think about how you can actually solve real problems that really exist. People who fear uncertainty underestimate their ability to solve real problems in the real world. What are some real problems that you have solved? Have some of these problems been events that you didn’t anticipate? Perhaps you are good at solving problems—if they really exist.

Eighth, practice mindful breathing. Spend twenty minutes each day, mindfully watching your breath as you sit in a quiet room. Don’t try to control your breathing, watch to see if your mind wanders. Stay in the moment with your breath. If you stay in the current moment, your worries will temporarily disappear.