Mental Health

Mental Health

Your mental health is just as important as your physical health when it comes to living a vital and fulfilling life. If you’re suffering from a mental health condition, get help understanding the facts, coping with symptoms and finding the right help.

Q:

I recently had a heart attack. The rehab I could handle, but I've been feeling really sad lately. Why is this? I should be happy to be alive!

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What is it?

Overview

What Is It?
Stressors are the external events, including pressures in people's lives, such as divorce, marriage, children, and work and money pressures. The experience of stress, however, is related to how you respond to these stressors.

Stress can be your friend or your foe. When stress fuels the spark of personal achievement, it can work to your benefit by making you more perceptive and productive, acting as a motivator and even making you more creative. But when stress flames out of control—as it often does for many of us—it can take a terrible toll on your physical and emotional health, as well as your relationships.

While stress is not considered an illness, it can cause specific medical symptoms, sometimes serious enough to send you to the emergency room or your health care professional's office. According to the American Psychological Association's 2010 Stress in America survey, the majority of Americans report living with moderate or high levels of stress. And on average, those who report their health as fair or poor have more stress (an average stress rating of 6.2 on a 10-point scale) compared with those who rate their health as excellent or very good (an average stress rating of 4.9 on a 10-point scale).

In today's fast-paced world, women are experiencing more stress at every stage of their lives than ever before. Juggling job pressures, family schedules, money issues, career and educational advancement and child and elder-care concerns are only a few of the common stressors confronting women.

Stressors are the external events, including pressures in people's lives, such as divorce, marriage, children, work and money. The experience of stress, however, is related to how you respond to these stressors. One person's stressor can be another person's motivator.

You can learn to manage how you respond to stressors through relaxation, meditation, some forms of psychotherapy and exercise, among other methods. However, you can also work to reduce the stressors in your life, such as learning to say no to some commitments, simplifying your life or leaving a bad job or relationship. Sometimes techniques that are originally designed to simply reduce your stress response and improve coping (for example, meditation and psychotherapy) can lead you to choose to reduce the stressors in your life because you begin to see more clearly what needs to change.

Working mothers, regardless of whether they are married or single, face higher stress levels—both in the workplace and at home. The National Institute for Occupational Safety and Health (NIOSH), the US agency responsible for conducting research and making recommendations for the prevention of work-related illness and injury, provides these statistics regarding stress in the workplace:

  • 40 percent of workers reported their jobs were very or extremely stressful
  • 25 percent view their jobs as the number one stressor in their lives
  • 75 percent of employees believe that workers have more on-the-job stress than a generation ago
  • 29 percent of workers felt quite a bit or extremely stressed at work
  • 26 percent of workers said they were "often or very often burned out or stressed by their work."

Stress has been linked with a variety of physical ailments from headache to depression to symptoms that mimic a heart attack. The balance between stressors and your ability to cope with them, however, can determine your mental health. When the stressors in your life match your coping abilities, you feel stimulated, engaged and appropriately challenged. Too many stressors in your life that overwhelm your attempts to cope can result in depression or anxiety.

Depression can feel like a pervasive sense of hopelessness, a feeling of wanting to give up, tearfulness or a sadness that does not seem to go away after a couple weeks. Anxiety can feel like a chronic state of feeling "keyed up" or "on edge." Some people who are depressed or anxious have physical symptoms, such as changes in sleep or appetite (too much or too little).

Chronic depression and anxiety have been linked to other physical problems, such as cardiovascular disease, chronic pain, hypertension and diabetes. If you notice symptoms of depression or anxiety, it is important to get them treated. Your health care professional or mental health professional can help.

Regardless of your physical or mental symptoms, talk about the stress in your life with your health care professional. A thorough assessment by your health care team will help determine the cause of these symptoms. You may find that stress has triggered an illness, such as high blood pressure.

Stress and Your Body

Research indicates that women's biological response to stress is to "tend and befriend"; this is, make sure the children are safe and then network with other women in stressful times. Men's biological reaction to stress is to go into the "flight-or-fight" mode. Studies indicate that the hormone oxytocin, which has a calming effect, is released during stressful times in both men and women.

Estrogen may enhance oxytocin release, while testosterone may diminish it; this may be one reason that women seem to seek social support more often then men when under stress. However, women have also been socialized from an early age to look to their social group, particularly their female friends, for support when under stress, whereas men tend to engage in activities, such as exercise or even using substances, when under stress.

During stress, hormones including adrenaline and cortisol flood the body, resulting in:

  • an increased need for oxygen
  • increased heart rate and blood pressure
  • constricted blood vessels in the skin
  • tensed muscles
  • increased blood sugar levels
  • increased clotting ability of blood
  • spilling of stored fat from cells into the bloodstream
  • constriction of bowel and intestinal muscles

All this can strain your heart and artery linings. In fact, if you already have coronary heart disease, stress might lead to chest pain, called angina. Plus, the increased tendency for blood to clot during stress may lead to a clot in your coronary arteries, causing a heart attack.

Other physical dangers of stress include stomach problems as your bowel and intestinal muscles constrict and depression and anxiety. While stress doesn't cause these mental illnesses, it can activate them in people who may already be prone to them.

Other physical dangers of stress include stomach problems, as your bowel and intestinal muscles constrict, as well as depression and anxiety. While stress doesn't cause these mental illnesses, it can activate them in people who may already be prone to them.

Stress can also cause what has been termed "toxic weight gain." Cortisol, a hormone released when you're under stress, is an appetite trigger. That's why so many women eat more—and less-than-healthy food—when under a lot of stress. Those extra calories are converted to fat deposits that gravitate to the waistline. These fat deposits, called visceral fat, are associated with life-threatening illnesses such as heart disease, diabetes, high blood pressure, stroke and cancer. Chronically high levels of cortisol may stimulate the fat cells inside the abdomen to fill with more fat. As you age, this expanding waistline can be life threatening.

Too much stress can also affect your immune system, weakening it and making you more susceptible to colds, coughs and infections.

Other symptoms of stress include muscular tension, headaches, gastrointestinal illnesses and sleeping more or less than normal.

Stress Triggers

It is important to distinguish between the acute stress response—when your heart beats faster and your breath comes faster as you get a rush of adrenalin—and the chronic stress response, in which you are continually under stress.

This chronic stress response is the one that causes the most problems as it literally wears out your body functions, leading to disease. That's because our physical stress response was designed for emergency situations, such as fleeing an attacking animal, not for the everyday stressors we experience in modern society.

You may feel stressed in response to external or internal triggers, such as stressors in your life or your own way of relating to yourself. These include:

  • trauma or crises
  • small daily hassles
  • conflicts or unpleasant people
  • barriers that prevent you from reaching your goals
  • feeling little control over your life
  • excessive or impossible demands from others
  • noise
  • boring or lonely work
  • irrational ideas about how things should or must be; perceiving that life is not unfolding as you think it should
  • believing you are helpless or can't handle a situation
  • drawing faulty conclusions like "they don't like me" or "I'm inferior to them," or having unreasonable fears of dire events such as "I'll be mugged"
  • pushing yourself to excel and/or failing to achieve a desired goal
  • assigning fault for bad events, for example, placing blame on yourself or on others
  • realizing you may have been wrong but wanting to be right
  • overreacting to current stress as a result of intense stress years earlier, especially in childhood

Stress is an individualized experience. What may be stressful to you may not affect someone else. Your past experience, other stressors in your life and even heredity can affect what you experience as stressful.

Diagnosis

Diagnosis

If you are suffering from stress, you may be experiencing a variety of symptoms that feel severe enough to prompt you to see a health care professional. These include:

  • headaches

  • frequent upset stomach, indigestion, gas pain, diarrhea or appetite changes

  • feeling as though you could cry

  • muscular tension

  • tightness in your chest and a feeling as though you can't catch your breath

  • feeling nervous or sad

  • irritability and anger

  • having problems at work or in your normal relationships

  • sleep disturbance: either insomnia or hypersomnia (inability to sleep or sleeping too much)

  • apathy-lack of interest, motivation or energy

  • mental or physical fatigue

  • frequent illness

  • hives or skin rashes

  • tooth grinding

  • feeling faint or dizzy

  • ringing in the ears

  • disruptions in your menstrual cycle or unusually severe PMS or menopausal symptoms

There is no specific test to diagnose stress. Typically, your health care professional conducts a variety of tests (which may include a personal and family health history, blood and urine tests and other assessments) to rule out various medical conditions.

Because your symptoms may be similar to those of depression, your health care professional should also evaluate your mental state to determine if you may be suffering from a depressive or anxiety disorder. Symptoms associated with stress, anxiety and sleeplessness, for example, typically subside when the stress triggering them subsides. When these same symptoms are caused by depression or another mood disorder, however, they may not go away without medication or therapy.

If stress is identified as the culprit for your symptoms, you may want to ask your health care professional for stress management strategies and consider ways to control the stressors in your life-before your health is affected.

Treatment

Treatment

Reducing or eliminating the things that cause stress and changing how you react to it are the safest and most effective ways to treat stress. No single method of stress management is always successful, so you might want to try a variety of approaches. It's also important that you treat any medical symptoms stress exacerbates. However, keep in mind that treating the stress may not cure the medical problem.

Reducing stress can be difficult. Often, people succeed in relieving stress in the short term but return to old stress-producing habits. Plus, personal responsibilities don't alwayslend themselves to stress-reducing tactics. The process of learning to control or redirect stress is lifelong, but working to master it will improve your lifelong health.

Cognitive-behavioral therapy, which helps you substitute desirable responses and behavior patterns for undesirable ones, is one proven way to reduce stress. It is very important that you learn cognitive-behavioral coping skills from a professional. They include:

  • Identifying sources of stress. You may want to keep a stress diary in which you record stressful occasions, incidents that triggered anger or anxiety or that caused a physical response like a sour stomach or headache. Jot down the time of day and the circumstances that led to these feelings, then try to identify the types of events or activities that caused them. See if you can alter or avoid these circumstances.

  • Restructuring priorities. Examine your priorities and goals to determine which stressful activities or situations you can get rid of. For instance, replace time-consuming chores that aren't really necessary (like ironing) with more pleasurable or interesting activities.

  • Find ways to balance the stress inducers you can't eliminate—like unpleasant working conditions, an unhappy family situation or a significant loss—by including stress-reducing activities in your day. Studies have shown that such activities can positively affect your immune system. Making time for recreation and stress reduction is as essential as paying bills or shopping for groceries.

  • Adjusting your responses to stress. Because you can't simply wish some stresses away-you can't just quit your job or walk out on your family, for example-you have to learn how to respond to stress to reduce its effects. These include:

    • Discussing your feelings. If you don't discuss your feelings of anger or frustration, you may feel hopeless and depressed. Becoming aware of your feelings can help you assert yourself when it's important. You can do this in a positive way, by writing a letter or calmly discussing your feelings with the other person. Asserting yourself in a negative way (yelling and behaving aggressively, for example) is only counterproductive. It's also important that you learn to listen, empathize and respond to others with understanding. If you can't talk to a trusted friend, try writing in a journal or composing a letter.

    • Keeping your perspective and looking for the positive. Think of the worst possible outcome to a situation that is stressing you and assess the likelihood of it occurring (usually small). Then, envision a positive outcome and develop a plan to achieve that outcome. It's also helpful to remember past situations that initially seemed negative but ended well.

    • Using humor. Stress management experts often recommend that people keep a sense of humor during difficult situations. Laughing releases the tension of pent-up feelings and helps maintain your perspective on the situation.

In addition to cognitive-behavioral methods to approaching stress, learning a relaxation technique-the natural unwinding of the stress response-can also help. A stress management specialist can teach you some relaxation techniques, including:

  • Deep breathing. When you're under stress, your breathing becomes shallow and rapid. Taking a deep breath is an effective technique for winding down. Inhale through your nose slowly and deeply to the count of 10, making sure your stomach and abdomen expand but your chest does not rise. Exhale through your nose, also to the count of 10. Concentrate fully on the breathing and counting. Repeat five to 10 times. The goal is to take three inhales and three exhales per minute, for a total of three deep breaths.

  • Relax your muscles. Sitting anywhere, even at your desk, relax your shoulders, let your arms drop to your side, rest your hands on top of your thighs, relax your legs, and don't forget your jaw muscles, which often tense with stress. Close your eyes and breathe deeply. You can also do this lying in bed. Beginning with the top of your head and progressing downward, tense and then relax the muscles in your body one by one while maintaining a slow, deep breathing pattern.

  • Passive stretches. Allow gravity to help you relax and stretch your muscles. Relax your neck and let your head fall forward to the right. Then let it drop even more as you breathe slowly. Do the same with your shoulders, arms and back.

  • Visualization. Remember a relaxing time or place like a lakeside picnic or a beautiful beach scene. Close your eyes for a few minutes and picture it in your mind.

  • Meditation. The goal of meditation is to quiet your mind, to relax your thoughts and increase your awareness. Meditation can also reduce your heart rate, blood pressure, adrenaline levels and skin temperature. It involves concentrating on a simple image or sound while sitting in a comfortable position away from distractions. It can involve cultivating an open awareness or a more loving attitude toward yourself and others. Meditation can also help you become more aware of your priorities so you can make more productive choices in your life.

  • Electromyographic Biofeedback (EMG). During this totally painless process conducted in a health care professional's office, you learn to reinforce your relaxation skills using methods such as those described earlier. Electromyograph biofeedback measures the electrical activation that signals muscles to contract. Electromyographic biofeedback training helps you relax overly contracted muscle groups to help reduce tension. As training continues, you learn to use the information from the instruments to discriminate between tension and relaxation. By repeating this process, you learn to associate the sound with the relaxed state and to achieve this state of relaxation by yourself without the machine.

  • Massage therapy. This approach slows the heart and relaxes the body. Rather than causing drowsiness, however, massage actually increases alertness

Your health care professional will probably discuss other issues with you, such as the necessity of:

  • Maintaining healthy habits. People who are coping with chronic stress often resort to unhealthy habits including high-fat and high-salt diets, tobacco use, alcohol abuse and a sedentary lifestyle.

  • Avoiding stimulants like tobacco (which contains nicotine) that make you feel calm in the short run, but actually rev up your nervous system. The addictive characteristics of some stimulants like nicotine can leave you anxious until your next fix.

  • Getting regular aerobic exercise. Even a brisk walk can reduce levels of stress hormones in your blood. At least 30 minutes a day (or two 15-minute sessions) most days of the week is best, but even three times a week offers benefits. In addition, as you get fitter, your body is better able to withstand stress and your mind to cope with stress and stay on an even, happier keel. Start slowly. Strenuous exercise in people who are not used to it can be very dangerous. You should first discuss any exercise program with your health care professional.

  • Strengthening or establishing a support network. Even a pet can help reduce medical problems aggravated by stress. Studies of people who remain happy and healthy despite many life stresses conclude that most have very good social support networks.

  • Reducing stress at work. Try establishing a network of friends there, seeking out a sympathetic manager, or schedule daily pleasant activities and physical exercise during free time. For additional support, schedule an appointment with an Employee Assistance Program clinician, if your company offers that benefit. These programs provide professional counselors who can give you and your family confidential assessment and counseling.

Prevention

Prevention

You can't simply wish away stressful events from your life. The key is to handle the stress appropriately. The following may enhance your ability to manage stressful events in your life:

  • Eat a balanced, nutritious diet. General health and stress resistance can be enhanced by eating well and by avoiding alcohol, caffeine, tobacco and junk food.

  • Exercise regularly. Exercise promotes emotional well-being as well as physical fitness.

  • Schedule your time more effectively using a calendar and to-do lists, prioritizing activities and realizing you can't do everything.

  • Learn how to say no to requests that add extra burdens and can wreak havoc on your day.

  • Insist on help with regular chores.

  • Balance work and play by planning time for hobbies and recreation—activities that relax your mind and temporarily take you away from your stresses. Even diversions like taking a warm shower, going to a movie or taking a walk can help.

  • Practice relaxation exercises every day, including visualization, deep muscle relaxation, meditation and deep breathing.

  • Rehearse for stressful events. Imagine yourself feeling calm and confident in an anticipated stressful situation. You will be able to relax more easily when the situation arises.

  • Let yourself laugh and cry. Laughter makes your muscles go limp and releases tension, so try to keep a sense of humor. Tears can help cleanse the body of substances that accumulate under stress.

  • Talk out troubles. It sometimes helps to talk with a friend, relative or spiritual leader. Another person can help you see a problem from a different point of view.

  • Help others. Because we concentrate on ourselves when we're distressed, sometimes helping others is the perfect remedy for whatever is troubling us.

  • Learn acceptance when a difficult problem is out of your control, which is better than worrying and getting nowhere.

  • Develop and maintain a positive attitude. View changes as positive challenges, opportunities or blessings.

You don't need to do all of these. Some may work for some people and others for other people. The key is to use the ones that work for you. Some of these become more effective with practice. If you are feeling especially overwhelmed, seek help. There is no need to suffer and there are trained people out there to help.

Facts to Know

Facts to Know

  1. According to the American Psychological Association's 2010 Stress in America survey, the majority of Americans report living with moderate or high levels of stress. And on average, those who report their health as fair or poor have more stress in their lives (an average stress rating of 6.2 on a 10-point scale) compared with those who rate their health as excellent or very good (an average stress rating of 4.9 on a 10-point scale).

  2. Working mothers, in particular, are among the people most likely to experience stress, particularly when they do not have a lot of support from others.

  3. Stress takes a toll on your body. Stress can cause stress hormones such as adrenaline and cortisol to flood your system. These hormones cause your heart rate and blood pressure to rise, your muscles to tense, your blood sugar levels to increase and other physical symptoms.

  4. The effects of stress may lead to actual medical illnesses, including heart problems, stomach problems and headaches.

  5. While stress doesn't cause mental illnesses like depressive disorders or anxiety disorders, it can lead to feelings of depression and anxiety. It can precipitate mental illnesses in people predisposed to them, particularly if left untreated.

  6. Symptoms of stress include irritability, sleep disturbances, appetite changes, muscular tension, apathy, fatigue, headache and frequent illness.

  7. Stress can be brought about by external factors such as conflicts in your relationships, job pressures and even traffic. In addition, internal factors-such as a desire for perfection, a feeling of helplessness, blaming yourself for things that are out of your control or intense worry-also cause stress.

  8. The ways you react to stressful situations can be relearned. You can use cognitive-behavioral approaches in which you identify sources of stress and work to minimize them and adjust your responses to the stresses you can't eliminate.

  9. Relaxation techniques help dispel stress and can cause adrenaline and cortisol levels in your blood to decrease. These techniques include deep breathing, muscle relaxation, stretching, visualization, meditation and biofeedback.

  10. A nutritious diet and regular exercise not only prepare your body to withstand the physical effects of stress, but strengthen your mind to cope with stress and stay on an even keel.

  11. According to the National Institute for Occupational Safety and Health, the U.S. agency responsible for conducting research and making recommendations for the prevention of work-related illness and injury, 40 percent of workers reported their job was very or extremely stressful.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about stress so you're prepared to discuss this important health issue with your health care professional.

  1. Could I have an underlying medical condition that could be causing my feelings of stress and anxiety?

  2. Could some medication I'm taking be causing my feelings of stress and anxiety?

  3. Has my stress caused or exacerbated physical or mental illness that needs to be dealt with medically, separately from the stress itself?

  4. If the stress is left untreated, what will happen to my mental and physical health?

  5. Can you refer me to a mental health professional who can teach me how to best manage and control my stress?

  6. Can you teach me relaxation techniques or refer me to someone who can?

  7. Can you refer me to an effective stress management class or workshop?

  8. How can exercise and adequate sleep help me manage my stress?

  9. How can meditation help? Can you teach me this technique or refer me to someone who can?

  10. I have an upset stomach/diarrhea/headaches/stiff neck nearly every day. Could this be stress? And if so, what are some of the other signs of stress?

  11. What substances should I stay away from if I'm having problems with stress? If alcohol relaxes me, why shouldn't I drink when I feel stressed?

  12. What should I do if my stress becomes too overwhelming for me to cope with?

Key Q&A

Key Q&A

  1. I feel so distressed that I have recurrent thoughts of suicide or death. Is this stress? What should I do?

    You should seek care or crisis intervention immediately. These types of thoughts are more indicative of a depressive disorder than stress, but your health care professional can assess your situation, give you a diagnosis and recommend treatment.

  2. What causes stress?

    What causes a person to experience stress is different for different people; what may be one person's stressor can be an exciting motivator to another person. However, this doesn't mean one person is weak and the other is strong. That being said, some common causes of stress are changes in your life like marriage, divorce, a new job or the birth of a child; trauma or crises, like illnesses, death of a loved one, or a traumatic event like a burglary; excessive demands on you and your time; conflicts or unpleasant people; small daily hassles; barriers that prevent you from reaching your goals; feeling little control over your life; and boring or lonely work.

  3. Sometimes when I feel stressed out, I feel a pain or tightness in my chest. What is this and what should I do?

    You need to seek care immediately to rule out heart disease or to begin treatment for any heart-related illness you might have. While you might not have a physical illness, you do need to have this symptom diagnosed. If you don't have a serious illness-rather the stress in your life is causing this symptom-you need to address this issue so your health doesn't deteriorate further.

  4. Is stress an illness?

    While stress is not itself considered an illness, it is a common cause of specific medical symptoms from high blood pressure to muscle aches and stomach ulcers. According to the American Psychological Association (APA), in 2010, 51 percent of people surveyed reported fatigue, 40 percent reported headaches, 49 percent reported lack of motivation or energy, and 56 percent reported irritability or anger as a result of stress.

  5. Who's most likely to suffer from stress?

    According to the APA, women report higher levels of stress than men, and women are less likely to think they are doing enough to manage the stress in their lives. On a 10-point scale, 28 percent of women report an average stress level of eight, nine or 10, versus 20 percent of men. In addition, those most likely to report frequent mental stress include younger adults, working mothers, divorced or widowed individuals, the unemployed and those with low incomes.

  6. What are the effects of stress?

    Stress can cause symptoms of a variety of physical and mental illnesses and make you more susceptible to other illness. Some specific symptoms of stress include feeling anxious, depressed or irritable; stomach upset, diarrhea or appetite changes; muscular tension; headaches; mental or physical fatigue and apathy; sleep disturbances and frequent minor illnesses.

  7. Can I avoid stress?

    You probably can't completely avoid stressful situations, but you can alter your reaction to those situations, resulting in far fewer physical symptoms of stress and negative results. With enough "tools," some stress may actually feel motivating.

  8. Are there treatments for stress?

    While you can't necessarily control the events that cause you stress, you can control how you manage the stress. Cognitive-behavioral methods, a form of psychological treatment that is used to help you substitute desirable responses and behavior patterns for undesirable ones, are the most effective ways to reduce stress. These methods include identifying sources of stress and then altering or avoiding these circumstances; restructuring your priorities and goals; and adjusting your responses to stress by discussing your feelings, keeping your perspective, looking for the positive and using humor. In addition, learning relaxation techniques-the natural unwinding of the stress response-can be helpful. Finally, working with someone to change your life in ways that reduce the external stressors is also helpful. Improving how you cope with stress as well as reducing stressors in your life go hand in hand. Mental health professionals can help you do both of these things.

Lifestyle Tips

Lifestyle Tips

  1. Eat your way to calm

    In general it's a good idea, but particularly during times of stress, to skip the simple sugars and starches, such as potato chips, cakes and ice cream. According to the APA 2010 Stress in America poll, more than half of Americans (51 percent) reported overeating or eating unhealthy foods in response to stress, and one-third (33 percent) said they eat to manage stress. Seek healthier comfort foods as alternatives, such as nonfat or low-fat yogurt instead of ice cream and carrot sticks or nuts instead of potato chips. And avoid coffee and other caffeinated food and drinks. They not only increase levels of certain stress hormones, they also mimic their effects in the body such as increasing heart rate. Load up on vegetables and other high-fiber foods. Not only do they keep your gastrointestinal tract working during high-stress periods (and help you avoid constipation), but the nutrients they provide lend an extra dollop of protection against chronic stress. Choose complex carbohydrates—oatmeal, whole grains, nuts and beans. Their steady release of sugar keeps your blood sugar levels steady and induces the brain to release more of the mood-enhancing chemical serotonin.

  2. Coping with fear and anxiety about war, terrorism and other public threats

    If you're worried about unknown danger, turn it into something known. Educate yourself on the current situation and recommendations from the federal government and public health authorities. Make reasonable plans to take safety precautions, and then think about something else. Leave the television and radio off if they're increasing your anxiety. Get involved in activities that are familiar and rewarding, such as hobbies, yard work, cleaning something, playing a sport or going to the movies. Talk to your friends and family. Plan a weekend getaway. Don't drink or smoke to compensate for anxiety because these activities ultimately do not make stress go away and can damage your health.

  3. Try writing out your stress

    If you are under stress or recovering from a traumatic event, could keeping a daily journal help? Studies of college students suggest that it may. Students were told to write of their experiences at college for 20 minutes a total of three times over a two-week period, but half were instructed to write about their deepest feelings and tie them together at the end of the journal entry. The other half simply wrote of their day and what they could do better. After testing, the students who wrote about their deepest feelings had better memory and higher GPAs, both immediately after the experiment and in the subsequent semester, than those who didn't. In addition, the students in the deep feelings writing group who chose to write about a negative event had fewer problems with intrusive, negative thoughts.

  4. When both partners are stressed

    Learn to recognize the signs of stress in each other. Don't take everything that either of you say or do too seriously if you're both stressed. Use good-natured humor to relieve the tension. Avoid criticism or negativity. Be flexible. Gentle touching, a mutual foot rub, backrubs or baths are all likely to help. Do stretches that involve two people. Take turns with chores. Plan a strategy for the week, with both of you sharing the load. Be realistic about what you can accomplish, and set priorities. Give each other opportunities to talk and for quiet time. Get enough sleep.

  5. Reduce stress at work

    Get enough sleep, exercise regularly and eat nutritional meals to best prepare for coping with work-related stress. Avoid or cut back on alcohol, smoking, caffeine and sugar. Drink water to stay hydrated. Come in a little early and use planning techniques and prioritizing to manage your time. Anticipate that not everything will happen on schedule, and build in buffer time. Delegate if you can. Look for creative ways to solve problems or work around them rather than simply getting angry. Get to know your coworkers a little better. Get up and walk around periodically if you have a desk job. If your job is really not a good match, consider looking for a new one. Sometimes changing the situation is the answer. But consider this as a last resort.

  6. Help your child cope with stress

    Manage your own stress, because your child is sensitive to your anxiety. Make time to spend with your child one-on-one, in a quiet environment without distractions. Ask your child to talk to you, and even if the conversation doesn't focus on your child's worries or concerns, listen carefully. Spend time in outdoor or indoor activities with your child. Encourage a regular schedule with enough time for sleep and balanced meals. Teach your child assertiveness and problem-solving techniques to replace too-passive or too-aggressive behavior. Encourage your child to build a network of friends. Make your home a welcoming place.

Organizations and Support

Organizations and Support

For information and support on coping with Stress, please see the recommended organizations, books and Spanish-language resources listed below.

American Institute of Stress
Website: http://www.stress.org
Address: 124 Park Ave.
Yonkers, NY 10703
Phone: 914-963-1200
Email: stress125@optonline.net

American Psychological Association
Website: http://www.apa.org
Address: 750 First St., NE
Washington, DC 20002
Hotline: 1-800-374-2721
Phone: 202-336-5500

American Self-Help Group Clearinghouse
Website: http://www.mentalhelp.net/selfhelp
Address: 375 E. McFarlan St.
Dover, NJ 07801
Phone: 973-989-1122

Emotions Anonymous
Website: http://www.emotionsanonymous.org
Address: EA International Service Center
P.O. Box 4245
St. Paul, MN 55104
Phone: 651-647-9712
Email: infodf3498fjsd@emotionsanonymous.org

Heal Within, an element of InnerSite, Inc.
Website: http://www.healwithin.com
Address: 208 S. Louise
Glendale, CA 91205
Phone: 818-551-1501
Email: lizab@healwithin.com

Pulmonary Hypertension Association
Website: http://www.phassociation.org
Address: 801 Roeder Road, Suite 400
Silver Spring, MD 20910
Hotline: 1-800-748-7274
Phone: 301-565-3004
Email: adrienne@phassociation.org

Women's Health Initiative (WHI)
Website: http://www.nhlbi.nih.gov/whi
Address: 2 Rockledge Centre
Suite 10018, MS 7936 6701 Rockledge Drive
Bethesda, MD 20892
Phone: 301-402-2900
Email: nihinfo@od31tm1.od.nih.gov

10 Steps to Take Charge of Your Emotional Life: Overcoming Anxiety, Distress, and Depression Through Whole-Person Healing
by Eve A. Wood, M.D.

Calm at Work: Breeze Through Your Day Feeling Calm, Relaxed and in Control
by Paul Wilson

The Food and Feelings Workbook: A Full Course Meal on Emotional Health
by Karen R. Koenig

MindWalks: 100 Easy Ways to Relieve Stress, Stay Motivated, & Nourish Your Soul
by Mary H. Frakes

RealAge Makeover: Take Years Off Your Looks and Add Them to Your Life
by Michael F. Roizen

Relaxation and Stress Reduction Workbook
by Martha Davis, Elizabeth Robbins Eshelman, Matthew McKay and Patrick Fanning

Relax: You May Only Have a Few Minutes Left: Using the Power of Humor to Overcome Stress in Your Life and Work
by Loretta LaRoche

The 6 Stress Points in a Woman's Life
by Kevin Leman

Stress: Living and Working in a Changing World
by George Manning, Kent Curtis, and Steve McMillen

Stress Management Sourcebook: Everything You Need to Know
by J. Barton, Phd Cunningham

Take Back Your Life: Smart Ways to Simplify Daily Living
by Odette Pollar

The Women's Concise Guide to Emotional Well-Being
by Karen J. Carlson M.D., Stephanie A. Eisenstat M.D., and Terra Ziporyn Ph.D.

The Worry Cure: Seven Steps to Stop Worry from Stopping You
by Robert L. Leahy

Your Body Speaks Your Mind: Decoding the Emotional, Psychological, and Spiritual Messages That Underlie Illness
by Deb Shapiro

Medline Plus: Stress
Website: http://www.nlm.nih.gov/medlineplus/spanish/stress.html
Address: US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

American Academy of Family Physicians
Website: http://familydoctor.org/online/famdoces/home/children/teens/prevention/278.html
Email: http://familydoctor.org/online/famdoces/home/about/contact.html

Last date updated: 
Mon, 2011-06-27

What is it?

Overview

What Is It?
Schizophrenia is a brain disorder, with many abnormalities of the brain structure, function and chemistry.

Schizophrenia is a chronic brain disorder that is usually progressively debilitating without medical treatment. According to the National Institute of Mental Health, about 1 percent of the population currently suffers from schizophrenia. While there is no known cure for this severe mental illness, new medications can help alleviate many of the disease's severe symptoms with fewer motor side effects than older medications.

The number of reported cases is split evenly between men and women, although schizophrenia tends to appear earlier for men—usually in the late teens or early 20s—compared to women, who generally begin to display symptoms in their 20s or early 30s. Onset of schizophrenia is rare before puberty and uncommon after age 45.

Early Symptoms

Schizophrenia presents differently in different people. Symptoms tend to appear gradually and can easily go unnoticed by friends and family in the beginning. However, in some cases, symptoms of schizophrenia occur suddenly and can be quite dramatic. As the illness advances, the symptoms can become more bizarre and severe.

People with schizophrenia tend to have psychotic symptoms, such as hearing voices when no one is speaking or insisting that other people are listening to their thoughts or attempting to control them. Many people with schizophrenia have active psychotic episodes, a state where hallucinations and/or delusions occur and they lose touch with reality. Most people with schizophrenia experience at least one relapse after their first such episode.

Other early signs of the disease include increasing social withdrawal and loss of interest in normal pursuits, unusual behavior or a decrease in overall functioning, often before the delusions and hallucinations begin. These are often the first warning signs that alert friends and family to a problem.

As the illness progresses, a person's speech and behavior tend to become progressively disorganized and confused, and their work performance usually deteriorates. Eventually, the symptoms become more extreme, appearing as if the person has undergone a dramatic personality change. If these and other symptoms persist for six months or longer and no external cause such as the effects of illicit drug use or a medical illness is detected, the person is usually diagnosed with schizophrenia.

People who have schizophrenia are more likely to commit suicide than people in the general population, with an estimated 10 percent of all people diagnosed with schizophrenia ending their life this way. Young adult males are most likely to commit suicide.

Role of Genetics

Genetics appear to play a role in schizophrenia. However, genetics alone do not explain the disease. An identical twin of someone with schizophrenia has a 40 percent to 65 percent chance of developing the illness, while children who have a first-degree relative with the disease have about 10 times the risk of developing it than that of someone who does not have a family member with the illness. People with a second-degree relative, such as an aunt, grandparent or cousin with schizophrenia, also have an increased risk.

Researchers believe multiple genes are involved in the risk for schizophrenia but that no single gene causes the disease by itself. Recent research shows certain gene mutations occur among families in which several members have the illness, but that these abnormalities are not found in other families. This suggests that mutations may occur in any of a number of genes that might result in schizophrenia. Affected genes have been linked to various aspects of brain functioning that could account for the symptoms of schizophrenia and could affect a patient's ability to function. Future research may be able to identify who is at risk for developing the disease based on genetic profiles.

Other factors, such as prenatal difficulties (including viral infections and complications around the time of birth), also appear to influence the development of the disease. In addition, some illicit drugs, such as marijuana and stimulants like cocaine and amphetamines, may make schizophrenia symptoms worse. Research has found increasing evidence of a link between marijuana use at a young age and a greater risk of developing schizophrenia.

Role of Brain Abnormalities

Schizophrenia is a brain disorder, with many abnormalities of the brain structure, function and chemistry. For example, several studies find people with schizophrenia have enlarged ventricles, cavities in the brain filled with cerebrospinal fluid. In addition, some studies find that people with schizophrenia tend to have specific areas of the brain that are smaller compared to people without schizophrenia, and that some of these areas have lower metabolic activity. However, scientists are careful to note that these and other abnormalities are subtle, are not found in all cases and could be present in people who never develop schizophrenia.

In addition, studies of brain tissue following death have revealed changes in the distribution or characteristics of brain cells in people with schizophrenia that may have taken place before birth as well as during other times of change in brain development. Considerable brain restructuring occurs during adolescence and may be further altered in schizophrenia, resulting in the characteristic onset of symptoms during this crucial developmental stage in life. Scientists are working to better determine exactly how schizophrenia develops.

Diagnosis

Diagnosis

A challenging part of diagnosing schizophrenia is that there is no way to confirm it with laboratory studies, so clinicians rely on a pattern of psychotic symptoms and functional deterioration. Many of the symptoms can be found in other mental disorders, which can present further challenges. For example, some individuals with schizophrenia have prolonged periods of elation or depression, which can be confused with bipolar disorder (also called manic depression) or major depressive disorder. People with bipolar disorder and major depression can also experience psychotic symptoms. These conditions need to be ruled out before diagnosing schizophrenia.

A mental health professional such as a psychologist or psychiatrist typically diagnoses schizophrenia. The clinician begins with a complete medical history and physical examination followed by blood and urine tests to rule out other medical causes for the symptoms. For instance, commonly abused drugs such as cocaine, methamphetamines or LSD can cause symptoms that mimic schizophrenia (including hallucinations or paranoia).

Interestingly, people who have schizophrenia tend to abuse drugs and alcohol at a higher rate than the general population. So just because someone is abusing drugs doesn't mean the person doesn't also have schizophrenia.

Psychiatrists often diagnose schizophrenia when someone has had at least two active symptoms of the disorder, such as a psychotic episode that includes delusions and hallucinations, for at least a month, with other symptoms, such as a decline in functioning and disturbed thoughts lasting six months or longer.

Schizophrenia appears to improve and worsen over the course of the illness. When it improves, the person suffering from the disease may appear perfectly normal. Unfortunately, this is when many people decide to stop taking their medication and relapse. During an acute psychotic episode, patients often lose their ability to think logically or may lose their perception of who they are or of others around them.

Most people with schizophrenia also have social and occupational problems, including problems in the workplace, with interpersonal relationships and in the way they care for themselves.

Symptoms of schizophrenia are usually split into positive, negative and neurocognitive categories.

Positive symptoms are unusual thoughts, perceptions or distortion of normal functions. They include:

  • Delusions. These are firmly held erroneous beliefs that result from distortions or exaggerations of reasoning or misinterpretations of a person's perceptions or experiences. Common delusions include unrealistic beliefs that the person is being watched or followed (e.g. paranoia).

  • Hallucinations. These are abnormalities of perception that can occur in any of the senses, although auditory hallucinations (hearing voices even though no one is speaking) are most common. These voices often insult the person, comment on his or her behavior or give commands. Visual hallucinations are the second most common type.

  • Thought disorders. These are dysfunctional or unusual ways of thinking. "Disorganized thinking" is when a person can't organize or connect his or her thoughts. Speech may be garbled and hard to understand. "Thought blocking" is when a person stops talking in the middle of a thought. Another form of thought disorders may cause a person to make up meaningless words.

Negative symptoms relate to disruptions of normal emotions, motivation and drive. Symptoms to look for include:

  • "Flat affect," when a person's emotional expressions go "flat," and there is little change in their facial expressions, voice or body language. The person may avoid eye contact.

  • Lack of pleasure in everyday life and/or needing help with everyday activities. May include a neglect of basic personal hygiene.

  • Speaking little, even when spoken to, or giving only disinterested replies.

  • Disinterest in social interaction and retreat into an "inner world."

Neurocognitive symptoms of schizophrenia are symptoms that have to do with the person's ability to think and reason. They include:

  • Problems with attention
  • Trouble with certain types of memory
  • Problems with functions that allow one to plan and organize

Some patients with schizophrenia also experience abnormal movements, such as twitching, repetitive gestures or catatonia (for example, maintaining unusual positions or not moving or responding at all). For reasons that are not understood, more severe forms of catatonia were more common before the availability of antipsychotic medications. On the other hand, certain motor movements, such as tremor, rigidity and restlessness, commonly occur as side effects to antipsychotic medications.

Several subtypes of schizophrenia have been suggested, based on a person's range and intensity of symptoms. There several recognized types of schizophrenia, including the following:

  • Paranoid schizophrenia. A person experiences predominantly positive symptoms (delusions and hallucinations), without a lot of disorganization or negative symptoms. The person may feel suspicious, persecuted and/or grandiose.

  • Disorganized schizophrenia (also called hebephrenic schizophrenia). People with disorganized schizophrenia have difficulty with logical, coherent thinking and speech. They also sometimes lack motivation, emotion and the ability to feel pleasure.

  • Catatonic schizophrenia. People with catatonic schizophrenia exhibit extreme inactivity or activity that's disconnected from his or her environment or encounters with other people. These episodes can last for minutes to hours.

  • Undifferentiated schizophrenia. People with undifferentiated schizophrenia meet diagnostic criteria for schizophrenia, but not the paranoid, disorganized or catatonic subtypes.

  • Residual schizophrenia. People with residual schizophrenia have a history of schizophrenic episodes characterized by negative symptoms or mild positive symptoms. People with this form of schizophrenia differ from those with other forms in that they lack prominent psychotic symptoms.

Although schizophrenia is usually a lifelong illness, some people develop all the symptoms of schizophrenia that resolve spontaneously. When the symptoms last less than one month, a diagnosis of brief psychotic disorder is given. When symptoms last less than six months, the diagnosis schizophreniform disorder is used. Unfortunately, schizophreniform disorder is rare, and most people progress to chronic schizophrenia.

Treatment

Treatment

The best treatment for any individual suffering from schizophrenia blends a combination of antipsychotic medications with psychosocial interventions. Psychosocial interventions include supportive psychotherapy, illness management skills, integrated treatment for any coexisting substance abuse, family participation in therapy and psychosocial and vocational rehabilitation.

People with schizophrenia who need a high degree of social services should receive assistance from an interdisciplinary treatment team.

Antipsychotic medications for schizophrenia can eliminate or reduce the hallucinations and delusions of the disorder. These drugs, which help restore biochemical imbalances, may also help people regain their coherent thinking abilities. The older "conventional" or "typical" antipsychotic drugs were introduced in the 1950s. Over the years, studies have found that these drugs are very effective in treating acute episodes of delusions or hallucinations and can provide long-term maintenance and prevention of future schizophrenic relapses. However, these drugs can cause unpleasant side effects such as dry mouth, constipation, blurred vision and difficulty urinating. These types of side effects are called "anticholinergic."

These medications can also cause extrapyramidal side effects (EPS), which affect how the body moves. For example, restlessness, tremors and slowing of normal gestures and movements can occur after days to weeks of treatment. Some patients report muscle spasms and cramps in the head and neck area, as well as stiff muscles throughout their body.

Tardive dyskinesia (TD) is a type of EPS that can occur after months or years of treatment with antipsychotic medications. The risk of TD increases the longer antipsychotic medications are taken. This condition is more common among older patients. It involves small involuntary movements of the fingers, tongue, lips, face or jaw. The symptoms tend to get worse and turn into thrusting and rolling motions of the tongue, lip smacking, grimacing or uncontrollable sucking motions. Involuntary movements of the hands, feet, neck and shoulders can also occur. Tardive dyskinesia can be a permanent, irreversible side effect.

These medications can also interfere with reproductive hormones, affecting a woman's menstrual cycles and fertility or causing breast enlargement, milk secretion or sexual side effects in both men and women. Sedation and dizziness are also relatively common side effects.

Because of the potential side effects associated with these medications, it is important that any medication regimen is tailored to the individual. You should work closely with your doctor to achieve the most benefit with the fewest problems from the medication. Sometimes adding another drug can help reduce certain antipsychotic-related side effects and possibly improve their effectiveness.

Examples of older "typical" antipsychotic medications include chlorpromazine (Thorazine), haloperidol (Haldol), perphenazine (Trilafon) and fluphenazine (Prolixin).

Over the past 20 years, pharmaceutical manufacturers have introduced a newer generation of antipsychotic drugs known as novel or "atypical" antipsychotics. The major advantage of these medications is a decreased risk of some side effects, such as EPS. These medications include clozapine (Clozaril), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), ziprasidone (Geodon), paliperidone (Invega) and aripiprazole (Abilify).

Clozapine is unique in that it is the most effective antipsychotic medication and is not typically associated with EPS or TD. However, patients taking clozapine must be monitored closely with regular blood tests because the medicine can cause a blood disorder called agranulocytosis, a disorder in which there are an insufficient number of white blood cells. Although it only occurs in a very small percentage of those taking clozapine, it can prove fatal if not caught and treated immediately.

Studies find the atypical antipsychotics are about as effective as the older conventional medications but have fewer extrapyramidal side effects. It has also been suggested that the atypical antipsychotics may improve anxiety, depression and cognitive symptoms. As a result, these newer drugs have replaced older drugs as "first line" therapy in the United States.

However, this new generation of medications has its own potential side effects, including sedation, significant weight gain and sexual dysfunction. Some are associated with a higher incidence of diabetes or high cholesterol, particularly in those who gain weight. While they don't typically interfere with menstruation as much as the typical antipsychotics, there is little information about the safety or impact of antipsychotic treatment during pregnancy and breastfeeding. If you are taking these medications and considering getting pregnant, talk to your health care professional first.

Perhaps the biggest challenge facing people with schizophrenia and their families is the high rate at which many stop taking their medication. Some stop treatment because they don't really believe they are ill. Others have such extreme disorganized thinking they can't remember to take their regular medication doses. Injectable medications that last for several weeks can sometimes help in these situations.

Patients also stop taking their medication because of difficulties with side effects. Substance abuse can also interfere with the efficacy of the medication, influencing patients' compliance. Finally, uninformed family members may suggest patients stop taking their medication because the symptoms seem to have disappeared. That's why it's important for a health care professional to stay involved in the treatment of someone with schizophrenia, even if they seem to be doing fine.

In unusual circumstances, electroconvulsive therapy (ECT) can be used to treat schizophrenia. During ECT, an electrical current passes through the patient's brain inducing a seizure. This treatment may be used if the person hasn't responded to antipsychotic medication or, in some circumstances, for those in catatonic states.

Once the delusions and hallucinations of schizophrenia subside, patients also can benefit from psychosocial therapies that help them improve their social skills and teach them how to live independently. These sessions can be provided in group, family or individual settings. Many therapists use behavioral learning techniques, including coaching, modeling and positive reinforcement, all of which can make a big difference in helping patients cope with other stresses in their lives that could contribute to relapses.

Psychoeducational family therapy is another segment of treatment that many psychiatrists see as necessary to help prevent relapses. These family education training sessions teach family members and close friends how to recognize the early warning signs of a relapse and what to do before the situation worsens. Improving communication and problem-solving skills among family members and the person with schizophrenia can help reduce the potential for relapse.

For individuals suffering from schizophrenia who need community services for support, clinical case managers can coordinate the necessary services and make sure medical and psychiatric treatments are addressed. These case managers can also play a key role in crisis management if the person doesn't have a support network of family and friends.

Facts to Know

Facts to Know

  1. About 1 percent of the population has schizophrenia, according to the National Institute of Mental Health.

  2. The number of reported cases is split between men and women, although schizophrenia tends to appear earlier for men—usually in the late teens or early 20s—compared to women, who generally begin to show signs of trouble in their 20s or early 30s. Onset of schizophrenia is rare before puberty and uncommon after age 45.

  3. People with schizophrenia tend to have psychotic symptoms, such as hearing voices when no one is speaking or insisting that other people are listening to their thoughts or attempting to control them. Many people with schizophrenia have active psychotic episodes, a state where hallucinations and/or delusions occur and they lose touch with reality. Most people with schizophrenia experience at least one relapse after their first such episode. Other early signs of the disease include increasing social withdrawal and loss of interest in normal pursuits, unusual behavior or a decrease in overall functioning, often before the delusions and hallucinations begin. These are often the first warning signs that alert friends and family to a problem.

  4. Genetics appears to play a role in schizophrenia. However, genetics alone does not explain the disease. An identical twin of someone with schizophrenia has a 40 percent to 65 percent chance of developing the illness, while children who have a first-degree relative with the disease have about a 10 percent risk of developing it themselves. People with a second-degree relative, such as an aunt, grandparent or cousin, also have an increased risk.

  5. Researchers find that multiple genes are involved in the risk for schizophrenia, but they are not the only cause. Other factors, such as prenatal difficulties (including viral infections and complications around the time of birth), also appear to influence the development of the disease. Researchers suspect that the disease may be the result of inappropriate connections between neurons in the brain that form during fetal development or puberty, times of significant changes in the brain.

  6. There is no way to definitively diagnose schizophrenia with laboratory studies, so clinicians rely on a pattern of psychotic symptoms and functional deterioration, as well as eliminating other possible causes of symptoms, to make a diagnosis. Psychiatrists often diagnose schizophrenia when someone has had active symptoms of the disorder, such as a psychotic episode that includes delusions and hallucinations, for at least a month, with other symptoms, such as decline in functioning and disturbed thought, lasting six months or longer. Many other conditions can resemble schizophrenia, so diagnosis should be performed by an experienced mental health professional.

  7. Schizophrenia appears to improve and worsen in cycles. When it improves, the person suffering from the disease may appear perfectly normal. Unfortunately, this is when many people decide to stop taking their medication and relapse. However, during the acute or psychotic phase, individuals with schizophrenia think without logical reasoning and may lose perception of who they or others around them are.

  8. In most cases, schizophrenia is a chronic condition requiring lifelong treatment. The best treatment blends a combination of antipsychotic medications with psychosocial interventions such as supportive psychotherapy, family participation in therapy and psychosocial and vocational rehabilitation. During crisis periods or times of severe symptoms, hospitalization may be required. Schizophrenia treatment is usually guided by an experienced psychiatrist, but it may also involve psychologists, social workers, psychiatric nurses and possibly a case manager.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about schizophrenia so you're prepared to discuss this important health issue with your health care professional.

  1. What type of medical professional cares for people with schizophrenia? What specialists should I consider visiting?

  2. What criteria should I use to find a psychiatrist or other specialist who will meet my needs or the needs of my family member?

  3. How many patients with schizophrenia have you provided care for in the last 10 years?

  4. What side effects might occur with the antipsychotic medication you are recommending?

  5. Are there any newer medications that could provide the same outcome—or better—with fewer side effects?

  6. Can antipsychotic medication be taken during pregnancy?

  7. If hallucinations or delusions return while taking antipsychotic medication, what should I (or my family member) do?

  8. Are there injectable (and longer-lasting) versions of this antipsychotic medication to improve the chance that it will be taken as directed? Are they just as effective as medications taken orally on a daily basis?

  9. Are there other treatments to consider to further reduce the potential for relapses? What about family psychotherapy sessions and other types of rehabilitation?

  10. Can you recommend a clinical case manager who can coordinate care and help find appropriate social services that I may need?

Key Q&A

Key Q&A

  1. What is schizophrenia?

    Schizophrenia is a chronic brain disorder that is often progressively debilitating for individuals unless they seek intervention through medications, psychosocial treatments and other types of care.

  2. Are women at greater risk of developing the disorder compared with men?

    The number of reported cases is split rather evenly between men and women, although schizophrenia tends to present itself at different ages for the two sexes. Onset of the disorder tends to occur earlier for men—usually in the late teens or early 20s—compared to women, who generally begin to show signs of trouble in their 20s or early 30s. An identical twin of someone with schizophrenia has about a 40 percent to 65 percent chance of developing the illness. Interestingly, researchers have found there is a further heightened risk for a female identical twin to develop schizophrenia if her twin has the illness. Women tend to have a less severe form of the disorder and respond better to treatment.

  3. Am I at greater risk of developing schizophrenia if I have a close relative who has been diagnosed with the disorder?

    If you have a close relative with the disease, you are more likely to develop it compared with someone who has no close relatives with schizophrenia. Your risk is also slightly elevated if you have a secondary family member with the disease, such as an aunt, uncle, grandparent or cousin.

  4. What are the early warning signs of schizophrenia?

    Most people who develop schizophrenia begin having delusions and hallucinations. Other early signs include increasing social withdrawal, loss of pleasure in everyday life, unusual behavior or decreases in overall functioning before the delusions and hallucinations begin. Speech and behavior tend to become progressively disorganized and confused, and work performance often deteriorates.

  5. What are my treatment options if I am diagnosed with the disorder?

    The primary mode of treatment for schizophrenia is a regimen of antipsychotic medications that make a significant difference in eliminating or significantly reducing the hallucinations and delusions. These drugs, which help restore biochemical imbalances to normal levels, also help the patient regain coherent thinking abilities. However, a major drawback to these medications is a wide array of side effects, some of them quite severe for some patients. In addition to medications, health care professionals strongly recommend patients with schizophrenia supplement their drug regimen with an array of psychosocial interventions.

  6. What are my chances for a relapse once I am taking medications and following a treatment plan?

    When taken as directed, antipsychotic medications can make a huge difference in the long-term potential for minimizing relapses and hospitalizations. Relapses usually happen when people stop taking their medication or take it only occasionally. People often stop their medication because they feel better and don't think they need it anymore. However, you should never stop taking an antipsychotic medication without first checking with your doctor. And even if your doctor gives you the OK, you should taper the dose of your medication gradually and not stop it suddenly.

  7. Is there any way to prevent myself from developing schizophrenia?

    Current research is being done to answer this question, and there are several clinics around the world devoted to identifying and helping "at risk" individuals. It does appear that the onset of schizophrenia can be triggered by stress or by using certain drugs such as marijuana. If a person has a family history of schizophrenia, avoiding illicit drug use is advisable, as well as reducing stress, getting adequate sleep and starting antipsychotic medications as soon as necessary.

Organizations and Support

Organizations and Support

For information and support on Schizophrenia, please see the recommended organizations, books and Spanish-language resources listed below.

American Academy of Child and Adolescent Psychiatry (AACAP)
Website: http://www.aacap.org
Address: 3615 Wisconsin Ave., NW
Washington, DC 20016
Phone: 202-966-7300

American Association for Geriatric Psychiatry (AAGP)
Website: http://www.aagpgpa.org
Address: 7910 Woodmont Ave, Ste 1050
Bethesda, MD 20814
Phone: 301-654-7850
Email: main@aagponline.org

American Association of Suicidology
Website: http://www.suicidology.org
Address: 5221 Wisconsin Avenue, NW
Washington, DC 20015
Hotline: 1-800-273-TALK (1-800-273-8255)
Phone: 202-237-2280
Email: info@suicidology.org

American Psychiatric Association
Website: http://www.psych.org
Address: 1000 Wilson Boulevard, Suite 1825
Arlington, VA 22209
Phone: 703-907-7300
Email: apa@psych.org

American Psychiatric Nurses Association (APNA)
Website: http://www.apna.org
Address: 1555 Wilson Blvd., Suite 530
Arlington, VA 22209
Hotline: 1-866-243-2443
Phone: 703-243-2443

American Psychological Association
Website: http://www.apa.org
Address: 750 First St., NE
Washington, DC 20002
Hotline: 1 -800-374-2721
Phone: 202-336-5500

Bazelon Center
Website: http://www.bazelon.org
Address: The Bazelon Center for Mental Health Law
1101 15th Street NW, Suite 1212
Washington, DC 20005
Phone: 202-467-5730
Email: info@bazelon.org

International Society of Psychiatric-Mental Health Nurses (ISPN)
Website: http://www.ispn-psych.org
Address: 2810 Crossroads Drive, Suite 3800
Madison, WI 53718
Hotline: 1-866-330-7227
Phone: 608-443-2463
Email: info@ispn-psych.org

Mental Health America
Website: http://www.mentalhealthamerica.net
Address: 2000 N. Beauregard Street, 6th Floor
Alexandria, VA 22311
Hotline: 1-800-969-6642
Phone: 703-684-7722

National Alliance on Mental Illness (NAMI)
Website: http://www.nami.org
Address: Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201
Hotline: 1-800-950-NAMI (1-800-950-6264)
Phone: 703-524-7600

National Institute of Mental Health
Website: http://www.nimh.nih.gov
Address: Science Writing, Press and Dissemination Branch
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892
Hotline: 1-866-615-6464
Phone: 301-443-4513
Email: nimhinfo@nih.gov

National Mental Health Consumers' Self-Help Clearinghouse
Website: http://www.mhselfhelp.org
Address: 1211 Chestnut St., Suite 1207
Philadelphia, PA 19107
Hotline: 1-800-553-4539
Phone: 215-751-1810
Email: info@mhselfhelp.org

SAMHSA's National Mental Health Information Center
Website: http://mentalhealth.samhsa.gov
Address: P.O. Box 2345
Rockville, MD 20847
Hotline: 1-800-789-2647
Phone: 240-221-4021

Screening for Mental Health (SMH)
Website: http://www.mentalhealthscreening.org
Address: One Washington Street, Suite 304
Wellesley Hills, MA 02481
Phone: 781-239-0071
Email: smhinfo@mentalhealthscreening.org

Surviving Schizophrenia: A Manual for Families, Patients, and Providers
by E. Fuller Torrey

The Complete Family Guide to Schizophrenia: Helping Your Loved One Get the Most Out of Life
by Kim T. Mueser, Ph.D. and Susan Gingerich, MSW

Getting Your Life Back Together When You Have Schizophrenia
by Roberta Temes

I Am Not Sick, I Don't Need Help!
by Xavier Amador, Ph.D.

The Day the Voices Stopped: A Schizophrenic's Journey from Madness to Hope
by Ken Steele and Claire Berman

American Academy of Family Physicians
Website: http://familydoctor.org/online/famdoces/home/common/mentalhealth/treatment/266.html
Email: http://familydoctor.org/online/famdoces/home/about/contact.html

Medline Plus: Schizophrenia
Website: http://www.nlm.nih.gov/medlineplus/spanish/schizophrenia.html
Address: US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Last date updated: 
Fri, 2012-04-20

What is it?

Overview

What Is It?
Eating disorders are mental illnesses, and although they revolve around eating and body weight, they aren't entirely about food but also about feelings and self-expression.

Eating disorders are devastating mental illnesses that affect an estimated 20 million American women and 10 million American men sometime during their life. Approximately 85 percent to 95 percent of the people who suffer from the eating disorders anorexia nervosa and bulimia nervosa are women.

Although eating disorders revolve around eating and body weight, they are often more about control, feelings and self-expression than they are about food. Women with eating disorders often use food and dieting as ways of coping with life's stresses. For some, food becomes a source of comfort and nurturing, or a way to control or release stress. For others, losing weight may start as a way to gain the approval of friends and family. Eating disorders are not diets, signs of personal weakness or problems that simply will go away without proper treatment.

Eating disorders occur in all socioeconomic and ethnic groups. They usually develop in girls between ages 12 and 25. Because of the shame associated with this complex illness, many women don't seek treatment or get help until years later. Eating disorders also occur in young children, older women and men, but much less frequently.

There are four official eating disorders diagnoses: anorexia nervosa, bulimia nervosa, binge eating disorder and eating disorder not otherwise specified (EDNOS).

Anorexia is a disorder in which preoccupation with dieting and thinness leads to excessive weight loss. If you suffer from this disease, you may not acknowledge that weight loss or restricted eating is a problem, and you may "feel fat" even when you're emaciated. Women with anorexia intentionally starve themselves or exercise excessively in a relentless pursuit to be thin, losing more than 15 percent of their normal body weight. Roughly half of all women suffering from anorexia never return to their pre-anorexic health, and about 20 percent remain chronically ill. The death rate for anorexia is among the highest of any psychiatric illness. The deaths are about evenly divided between suicide and medical complications related to starvation.

Women with bulimia regularly and sometimes secretly binge on large quantities of food—often between 2,000 and 5,000 calories at a time and, on rare occasions, even up to 20,000 calories at a time—then experience intense feelings of guilt or shame and try to compensate by getting rid of the excess calories. Some people purge by inducing vomiting, abusing laxatives and diuretics, or taking enemas. Others fast or exercise to extremes. If you suffer from this disease, you feel out of control and recognize that your behavior is not normal but often deny to others that you have a problem. Women struggling with bulimia can be normal weight or overweight and may experience weight fluctuations.

Women with binge eating disorder (BED) also binge on large quantities of food in short periods, but unlike women with bulimia, they do not use weight control behaviors such as fasting or purging in an attempt to lose weight or compensate for a binging session. When the binge is over, an individual with BED will often feel disgusted, guilty and depressed about overeating.

A fourth type of eating disorder, eating disorder not otherwise specified, refers to symptoms that don't fit into the other three eating disorders diagnoses. Individuals struggling with EDNOS, may have elements of BED, or be close to a diagnosis of anorexia or bulimia, but don't quite meet full diagnostic criteria. EDNOS is simply a catchall term for anyone with significant eating problems who doesn't meet the criteria for the other diagnoses. The majority of those who seek treatment for eating disorders fall into this category.

Although it has become synonymous with eating disorders, anorexia is relatively rare, affecting between 0.5 percent and 1 percent of women in their lifetimes, according to the National Alliance on Mental Illness. Another 2 percent to 3 percent develop bulimia and 3.5 percent develop binge eating disorder.

Yet, statistics don't tell the whole story. Many more women who don't necessarily meet all the criteria for an eating disorder are preoccupied with their bodies and are caught in destructive patterns of dieting and overeating that can seriously affect their health and well being.

There is no single cause of eating disorders. Biological, social and psychological factors all play a role. Evidence suggesting a genetic predisposition reveals that anorexia may be more common between sisters and in identical twins. Therefore, a woman with a mother or sister who has anorexia is 12 times more likely than the general public to develop that disorder and four times more likely to develop bulimia. Furthermore, among identical twins, whose genetic makeup is 100 percent the same, there is a 59 percent chance that if one twin has anorexia, then the other twin will also develop an eating disorder. For fraternal twins sharing only 50 percent of their siblings’ genes, there is an 11 percent chance that the other twin will have an eating disorder.

Other research points to hormonal disturbances and to an imbalance of neurotransmitters, chemicals in the brain that, among other things, regulate mood and appetite.

In some women, an event or series of events triggers the eating disorder and allows it to take root and thrive. Triggers can be as subtle as a degrading comment or as traumatic as rape or incest. Times of transition, such as puberty, divorce, marriage or starting college, can also provoke disordered eating behaviors. Parents who are preoccupied with eating and overly concerned about or critical of a daughter's weight, and coaches who relentlessly insist on weigh-ins or a certain body image from their athletes, especially in weight-conscious sports such as ballet, cheerleading, diving, wrestling and gymnastics, may also unintentionally encourage an eating disorder. Additionally, the pressure of living in a culture where self-worth is equated with unattainable standards of slimness and beauty can also perpetuate body image and/or eating issues.

Furthermore, the discrepancy between our society's concept of the "ideal" body size for women and the size of the average American woman has never been greater—leading many women to unrealistic goals where weight is concerned.

Diagnosis

Diagnosis

Because the consequences of eating disorders can be so severe, early diagnosis is crucial for lasting recovery. Eating disorders in general can disrupt physical and emotional growth in teenagers and can lead to premature osteoporosis, a condition where bones become weak and more susceptible to fracture. Additionally, the triad of osteoporosis, amenorrhea and disordered eating behaviors has the risk of leading to hormonal imbalances, which could also contribute to increased infertility and a higher risk of miscarriages.

Anorexia nervosa

Anorexia nervosa, a serious, potentially life-threatening disease characterized by self-starvation and excessive weight loss, has the highest mortality rate of any mental illness. Its onset is typically in early to mid-adolescence, and it is one of the most common psychiatric diagnoses in young women seeking treatment. Among the physical effects of anorexia are:

  • anemia, often caused by iron deficiency, which reduces the blood's ability to carry oxygen and causes fatigue, difficulty breathing, dizziness, headache, insomnia, pale skin, loss of hunger and irregular heartbeat

  • elevated cholesterol, which occurs because eating disorders affect liver function, reducing bile acid secretions that contain cholesterol and enabling more cholesterol to remain in the body rather than being secreted

  • low body temperature and cold hands and feet

  • constipation and bloating

  • shrunken organs

  • low blood pressure

  • slowed metabolism and reflexes

  • slowed heart rate, which can be mistaken as a sign of physical fitness

  • irregular heartbeat, which can lead to cardiac arrest

  • slowed thinking and cognitive and mood changes secondary to long-term starvation

Women with anorexia have an intense fear of becoming fat and, therefore, are obsessed with food, body shape and size. It is common for women with anorexia, for example, to collect recipes and prepare gourmet meals for family and friends, but not eat any of the food themselves. Instead, they allow their bodies to wither away and "disappear," gauging their hunger as a measure of their self-control. Women struggling with anorexia diet because they want to improve their feelings of self-esteem and love, not to lose a few pounds. Depression and insomnia often occur with eating disorders.

Women struggling with anorexia may tend to keep their feelings to themselves, seldom disobey authority and are often described as perfectionists. These individuals are often good students and excellent athletes. Anorexia is common in dancers and competitive athletes in sports such as gymnastics and figure skating, where success is measured not only on athletic performance, but also on having the "ideal" body.

Symptoms of anorexia nervosa can include:

  • distorted body image and intense persistent fear of gaining weight

  • excessive weight loss

  • menstrual irregularities

  • excessive body/facial hair

  • compulsive exercise

Bulimia nervosa

Bulimia nervosa involves using food and eating for emotional calming or soothing. Bingeing becomes a way to relieve stress, anxiety or depression. Purging the calories, through self-induced vomiting, laxative or diuretic abuse or over-exercising, relieves the guilt of overeating and may also be a way of releasing emotional tension or stress until the binge-purge cycle becomes a habit. Women struggling with bulimia are usually more impulsive, more socially outgoing and exhibit less self-control than those struggling with anorexia. They are also more likely to abuse alcohol and other substances.

Only 6 percent of those struggling with bulimia receive mental health care. Eating disorders are incredibly secretive illnesses, and the symptoms can be hidden or appear subtle, even to friends and loved ones. For example, women struggling with bulimia are not necessarily thin; they can be at an average weight and even a little bit overweight. Even so, they may be starving nutritionally because they are not getting the vitamins, minerals and other nutrients they need.

Symptoms of bulimia include:

  • preoccupation with food, weight and appearance

  • binge eating, usually in secret

  • vomiting and extreme use of laxatives or diuretics after binges

  • menstrual irregularities

  • compulsive exercise

Among the physical effects of bulimia are:

  • dehydration

  • chronic diarrhea

  • extreme weakness

  • damage to bowels, liver and kidneys

  • electrolyte imbalance and low potassium levels, which lead to irregular heartbeat, and in some cases, cardiac arrest

  • tooth erosion from repeated exposure to stomach acid

  • broken blood vessels in the eyes and a puffy face due to swollen glands, which can be indications of self-induced vomiting

  • cuts and calluses across the fingers from self-induced vomiting

  • tears of the esophagus due to forced vomiting

Binge eating disorder

Binge eating disorder (BED) affects approximately 1 percent to 5 percent of people in the United States. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), released in 2013, recognizes BED as an official eating disorder.

Similarly to bulimia, people with BED engage in binge eating, or a rapid consumption of large quantities of food, but they do not use compensatory behaviors such as fasting or purging to "undo" the effects of binge eating and control their weight. People with BED eat large amounts of food even when they aren't hungry. They struggle to differentiate between physical and emotional hunger, feel uncomfortably full after eating and often feel distressed about their binge sessions.

Like the other two official eating disorders diagnoses, BED can occur together with other psychiatric disorders, such as depression, substance abuse or anxiety disorders. Over time, women with BED tend to gain weight due to overeating, so the disorder is often (but not always) associated with obesity.

Symptoms of binge eating disorder include:

  • episodes of binge eating when not physically hungry

  • cycles of frequent dieting

  • feeling unable to stop eating voluntarily

  • awareness that eating patterns are abnormal

  • weight fluctuations

  • depressed mood

  • feelings of shame

  • antisocial behaviors

  • obesity

  • feeling "numb" or "spaced out" during a binge episode

  • feeling out of control while eating

  • losing track of time while eating

If BED is left untreated, it can lead to obesity, which has its own medical consequences such as:

  • high blood pressure

  • high cholesterol

  • gall bladder disease

  • diabetes

  • heart disease

  • certain types of cancer

Tests for Eating Disorders

Eating disorders are complex mental illnesses and there is no medical test that can diagnose an eating disorder. However, when seeking eating disorders treatment, your health care professional may draw some of your blood to determine if you are suffering from any medical consequences related to an eating disorder. Here are some things that may be tested:

  • Electrolyte balance. This primarily checks for dehydration but may also be indicative of malnutrition brought about by self-induced vomiting or laxative and/or diuretic abuse. Electrolytes are a specific combination of minerals your body needs to maintain balance to function properly, such as sodium and potassium. Common symptoms of imbalance are leg cramps, heart palpitations, high or low blood pressure and swelling in the legs and feet. An electrolyte imbalance can lead to kidney failure, heart attack and even death.

  • B12 and folic acid intake assessment. Lack of B12 and folic acid can lead to, or be caused by, problems with the metabolism of protein, carbohydrates and fat, and with the body's ability to absorb nutrients. Low levels of B12 or folic acid can contribute to depression and anxiety.

  • Blood glucose (blood sugar) level. Low levels of blood glucose can be the result of dehydration and malnutrition.

  • Liver function test. The malnourishment associated with eating disorders can lead to liver damage.

  • Cholesterol measurements. Anorexia or binge eating disorder can increase blood cholesterol levels.

  • Thyroid function test. This test rules out any problems with the thyroid, which can affect weight. It is an important test for someone in recovery who may be having a hard time gaining or losing weight. If necessary, medications would be prescribed to regulate the thyroid.

Your health care professional will probably also perform a complete analysis of your urine. This helps evaluate kidney function, urine sugar levels and ketone levels, as well as helps diagnose systemic diseases and urinary tract disorders. Ketones, which can accumulate in the blood rather quickly when the body is starved of food and nutrients, indicate the body is "eating its own fat" for energy. Accumulation of ketones in the blood can lead to ketoacidosis, which can cause coma and death.

Your health care professional may also take a blood pressure reading, provide a referral for a bone density test to evaluate for osteopenia or osteoporosis and perform an electrocardiogram to look for heartbeat irregularities.

Treatment

Treatment

Many women don't realize how damaging eating disorders are to their health. Women struggling with eating disorders may believe that their state of emaciation is normal and sometimes even attractive. Or they think that purging is the only way to avoid gaining weight. Therefore, it is critical that all health care professionals remain educated on the signs and symptoms of eating disorders and intervene if they become concerned.

People fail to realize that a potentially serious eating disorder may underlie their weight loss. Also, it is easy to confuse eating disorders with other emotional problems. Although women with depression may lose or gain weight, for example, that doesn't necessarily make them anorexic or mean they are binge eating. Unlike those with anorexia, bulimia or binge eating disorder, women struggling with depression do not have a distorted body image, a drive to be thin or a compulsion to binge and/or purge.

Eating disorders can be fatal; in fact, they are the deadliest mental illness. If you think you may have an eating disorder, you should seek treatment immediately. The sooner you recognize there is an issue and choose to seek treatment, the greater your chances are for lasting recovery.

Depending on the severity of your disordered eating behaviors, there are various treatment options:

  • Inpatient treatment programs offer 24/7 support and medical monitoring and are designed for those whose eating disordered behaviors have led to extremely low body weight and/or serious medical complications.
  • Residential treatment programs also offer 24-hour observation and support, but individuals in residential eating disorders treatment do not require the same level of medical and psychiatric supervision as is available at the inpatient level of care.
  • Partial hospitalization programs are daytime treatment programs that allow people in treatment to practice recovery skills with guidance during the day and on their own in the evenings and at night.
  • Outpatient programs offer individuals struggling with eating disorders the opportunity to "step down" from a higher level of care while maintaining their daily activities. These types of programs provide additional support for anyone struggling with self-esteem or body image issues.

Insurance coverage for eating disorders treatment varies depending on the individual and their insurance policy. Eating disorders treatment centers work with patients and their families to secure the best possible option to foster lasting recovery.

And treatment is no easy task. When a woman with anorexia starves herself, she feels better. When a woman with bulimia or binge eating disorder binges, she feels less depressed. The eating disorder serves a purpose in the mind of the woman who has it. It becomes a kind of companion that is hard to let go of.

Not surprisingly, relapses are common and lasting eating disorders recovery often comes only after engaging in multiple treatment approaches. You may find it most effective to work with a multidisciplinary treatment team. This team of dietitians, psychotherapists and physicians may use a variety of treatment methods, including:

  • psychological counseling or cognitive-behavioral therapy to help you replace negative attitudes about your body with healthier, more realistic ones
  • medical evaluations to stabilize you physically
  • nutritional counseling to teach you good nutritional habits
  • medications, such as antidepressants, to address coexisting conditions
  • family therapy to establish the support system you need for lasting recovery

Treatment of anorexia is often approached as a three-step process:

  • restoring weight loss due to severe dieting and purging
  • treating psychological conditions such as distorted body image, low self-esteem and interpersonal conflicts
  • long-term remission and rehabilitation or full recovery

A one-year study published in the Journal of the American Medical Association determined that there was no significant difference between those with anorexia who took antidepressants and those who received a placebo—evidence that there is no "magic pill" to make your disorder go away and keep it away.

The only antidepressant approved by the Food and Drug Administration for treatment of bulimia is the selective serotonin reuptake inhibitor (SSRI) fluoxetine (Prozac), but doctors may also prescribe other antidepressants for the condition, including the SSRIs sertraline (Zoloft) and paroxetine (Paxil), and the tricyclic antidepressants amitriptyline (Elavil) and desipramine (Norpramin). The antidepressant bupropion (Zyban) may also be used, although it is not typically recommended as individuals struggling with bulimia because they may experience seizures as a side effect.

While health care professionals may find it beneficial to prescribe various medications to their eating disorders patients, medications are primarily reserved for coexisting conditions.

Some physicians may also prescribe antipsychotic medications to help reduce the rigid and distorted thinking and agitation that can accompany anorexia, but these drugs can frighten patients by dramatically increasing appetite, so they should be used with caution. For people struggling with anorexia who experience extreme anxiety surrounding eating, antianxiety drugs, such as benzodiazepines, may be used.

Cognitive behavioral therapy (CBT) is currently the primary evidence-based treatment approach for bulimia and binge eating disorder. By addressing both structured eating patterns and thoughts that interfere with self-worth and mood management, CBT teaches skills to help you manage triggering situations. Another often utilized treatment philosophy is dialectical behavioral therapy (DBT), which teaches self-regulatory skills and focuses on emotional management.

Another approach to treating eating disorders is family-based treatment. In a family-centered treatment program, the family assumes responsibility for making the patient eat. No one is "blamed" for triggering the illness; rather, the eating disorder is treated as a medical condition, and the family is taught to care for the sick person. The power shifts back to the individual after he or she reaches an acceptable weight. This method works best on people with anorexia, but it also works on some with bulimia. It is typically utilized in adolescents and is being researched for use in young adults.

Prevention

Prevention

Eating disorders screening and prevention programs on college campuses across the country aim to educate young women and men about the signs, symptoms and dangers of eating disorders and teach them how to develop a healthy body image and self-worth and positive coping skills.

Screening is important because it is so difficult to change body image attitudes and unhealthy eating patterns once they form. Primary prevention needs to take place early, before young people learn to feel bad about their bodies. Therefore, eating disorder prevention efforts are beginning to occur in high schools, middle schools and even as early as elementary schools.

How a person perceives his or her body is only one component of a complete self-image, but too often it becomes the sole factor in determining self-esteem. When "how I look" becomes more important than "who I am," the groundwork is laid for crippling and life-threatening eating disorders.

Parents, loved ones and other role models can help prevent poor self-images from occurring by examining their own attitudes about their bodies and by fostering a healthy, positive body image in their children. Take these steps, even with young girls, to discourage unhealthy behaviors:

  • Accept that puberty will influence girls' perception of their bodies, but be prepared to step in if certain behaviors become unhealthy.
  • Don't reinforce the message that women have to look a certain way.
  • Teach girls how their bodies change during adolescence and that it is normal and healthy to gain weight during puberty.
  • Talk about images of women portrayed in the media and invite discussion on whether or not the images are realistic or create an unattainable "ideal" body shape and size.
  • Take women and girls seriously for what they say, feel and do, not for how slim they are or how they look. It is about what the body does, not what it looks like.
  • Encourage children to be active as a way to have fun and to enjoy what their bodies can do.
  • Exercise with your children to promote a healthy family lifestyle.
  • Model healthy attitudes about your own body. Girls need to see women who are satisfied with their bodies and appearance or who take positive and healthy steps toward making changes. Girls who see their mothers worrying about their own appearance and weight are more likely to believe that being thin will make them happy.
  • Don't nag about eating or focus on eating habits, which could make a child more self-conscious and secretive about her or his relationship with food.
  • Don't compare young children and teenagers to others and don't be judgmental about other people's weight.
  • Be on the lookout for the use of diet pills, which has been documented in children as young as 10 years old.

Most important, do not ignore disordered eating behaviors. Eating disorders are devastating and potentially fatal diseases. But people can and do recover from these illnesses, once they are accurately diagnosed and properly treated.

Facts to Know

Facts to Know

  1. Eating disorders affect an estimated 20 million American women and 10 million American men sometime during their life. Eighty-five to 95 percent of those suffering from anorexia and bulimia are women.

  2. Eating disorders most often begin early, usually between the ages of 12 and 25, but are not limited to people within these ages.

  3. Between 0.5 percent and 1 percent of women suffer from anorexia, between 2 percent and 3 percent of women suffer from bulimia and 3.5 percent suffer from binge eating disorder.

  4. Women struggling with anorexia, though often well-liked and admired for their competence, often strive to seek approval and may have very low self-esteem and feel inadequate. They may use food and dieting as ways of coping with life's stresses.

  5. An eating disorder usually does not go away without treatment. Eating disorders are mental illnesses that can be deadly if not treated and are difficult to recover from; however, recovery is possible. Many women have recovered successfully and gone on to live full and satisfying lives.

  6. Treatment for eating disorders encompasses a mixture of strategies, including psychological counseling, nutritional counseling and individual, group and family therapy.

  7. Thereis a high incidence of depression among women suffering from bulimia, thus the utilization of antidepressants for some people. But antidepressants are most effective when combined with cognitive-behavioral therapy.

  8. The self-starvation of anorexia can cause severe medical complications, such as: anemia; shrunken organs; low blood pressure; slowed metabolism and reflexes; bone mineral loss, which can lead to osteoporosis; and irregular heartbeat, which can lead to cardiac arrest.

  9. The bingeing and purging of bulimia can lead to liver, kidney and bowel damage; tooth erosion; tears of the esophagus and stomach lining; and electrolyte imbalance, which can lead to irregular heartbeat and, eventually, cardiac arrest.

  10. If obesity results from bingeing, medical consequences include high blood pressure, high cholesterol, gall bladder disease, diabetes, heart disease and risk factors for certain types of cancer.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about eating disorders so you're prepared to discuss this important health issue with your health care professional.

  1. What are my options for treatment?

  2. How would you describe your approach to eating disorders treatment?

  3. How do you address depression and/or anxiety? What if I do not feel like I am depressed (or anxious)?

  4. Will you involve my family?

  5. What role, if any, will medication play? What percentage of people who see you take medication? Which medications?

  6. What can I expect from the medications?

  7. What can I expect during a counseling session?

  8. When, if ever, do you hospitalize patients?

  9. What goals would we set for my treatment?

  10. What does the recovery process look like?

Key Q&A

Key Q&A

  1. How can I tell if I have an eating disorder?

    If you have lost a fair amount of weight in a short amount of time, you may have eating disorders symptoms. If you binge by consuming large amounts of food at a time, often in secret, and perhaps follow it by purging and feelings of guilt and shame, you may be struggling with an eating disorder. If you are preoccupied with your body and caught up in destructive patterns of dieting and overeating, these are signs of disordered eating behaviors. All of these behaviors can affect your health and overall well-being. Talk to a health care professional about your feelings and constant need to diet, control your food intake and/or your fixation on food. Have him or her assess the diets you are trying; if they do not offer enough nutrients or calories, they will be almost impossible to stick to.

    If you are concerned about your behaviors or those of a friend or loved one, it is important to seek an eating disorders assessment and talk with an eating disorders professional to determine an official diagnosis and proper course of treatment.

  2. My daughter is neither overweight nor underweight, but I have found evidence of secretive eating, like dozens of candy wrappers under her bed. What's going on?

    Bulimia is often hard to recognize because individuals struggling with the disease do not tend to be at an extreme weight-high or low. However, if a person takes in a significant amount of calories at a time, as in a dozen candy bars at one time, for instance, then purges by making himself or herself vomit, taking laxatives or enemas, fasting or exercising to the extreme, he or she may have bulimia. If asked, there is a good chance that he or she will deny that fact. Parents and loved ones concerned for their children and their children's health should speak to a health care professional, such as their children's pediatrician, about the child's eating behaviors.

  3. Is a compulsion to exercise to the extreme, such as several hours a day, part of an eating disorder?

    If the compulsion is driven by a desire to lose weight, despite being within a healthy weight range, or if the compulsion is driven by guilt due to bingeing, then, yes, this compulsion to exercise is a dimension of an eating disorder. There are also individuals who compulsively exercise because that has become their sole way of coping with stress or emotions. These individuals may not be as motivated by body image distortions or desires to lose weight, but rather by an inability to tolerate emotions and daily stressors. This is also a dimension of an eating disorder.

  4. How is anorexia treated? Does it require hospitalization?

    Your health care professional may hospitalize you if your anorexia has resulted in life-threatening complications that are best treated in a hospital, or if continued starvation will soon lead to such complications. In any case, you will likely be treated with a combination of psychological counseling, nutritional education, and individual, group and family therapy.

  5. How is binge eating treated?

    Frequent binge eating is a symptom of bulimia and binge eating disorder. Psychological counseling, nutritional education, medications and individual, group and family therapy can all play a role in recovery from these eating disorders.

  6. Who gets eating disorders?

    Eating disorders are mental illnesses that cut across the socioeconomic and ethnic spectrum; they know no gender, age or lifestyle. However, 85 percent to 95 percent of those suffering from eating disorders are women.

  7. What causes eating disorders?

    There is no single cause of eating disorders. Biological, social and psychological factors all play a role. A person may even have a genetic predisposition to eating disorders. In many people, an event or series of events-a degrading comment, traumatic event, a transition such as divorce or starting college-may trigger eating disordered behaviors and allow the eating disorder to take root and thrive. Parents or coaches who are preoccupied with eating and overly concerned or critical of a young child or teenager's weight or body image may also unintentionally "encourage" an eating disorder, as can societal and cultural pressures.

  8. How do I prevent my young daughter from developing an eating disorder?

    The best thing you can do is start young. First, instill in her a healthy body image and good eating patterns by modeling these yourself and having open conversations with her. Teach her about how her body will change as she enters puberty so she will expect the changes in body shape and size. Show her that women of all body types and sizes can be successful and independent. Talk to her about the unrealistic expectations formed by constant exposure to models and actresses who starve themselves to look emaciated. Don't nag her or focus on her eating habits, but, rather, set a healthy example and emphasize that it is what our bodies do for us that is important, not how they look.

Organizations and Support

Organizations and Support

For information and support on coping with Eating Disorders, please see the recommended organizations, books and Spanish-language resources listed below.

Academy for Eating Disorders
Website: http://www.aedweb.org
Address: 111 Deer Lake Road, Suite 100
Deerfield, IL 60015
Phone: 847-498-4274
Email: info@aedweb.org

American Psychological Association
Website: http://www.apa.org
Address: 750 First St., NE
Washington, DC 20002
Hotline: 1 -800-374-2721
Phone: 202-336-5500

Harris Center for Education and Advocacy in Eating Disorders
Website: http://www.harriscentermgh.org
Address: 2 Longfellow Place, Suite 200
Boston, MA 02114
Phone: 617-726-8470
Email: dherzog@partners.org

Multi-service Eating Disorder Association (MEDA)
Website: http://www.medainc.org
Address: 92 Pearl St.
Newton, MA 02458
Hotline: 1-866-343-MEDA (1-866-343-6332)
Phone: 617-558-1881
Email: info@medainc.org

National Association of Anorexia Nervosa and Associated Disorders (ANAD)
Website: http://www.anad.org
Address: P.O. Box 640
Naperville, IL 60566
Hotline: 630-577-1330
Phone: 630-577-1333
Email: anadhelp@anad.org

National Eating Disorders Association (NEDA)
Website: http://www.nationaleatingdisorders.org
Address: 603 Stewart St., Suite 803
Seattle, WA 98101
Hotline: 1-800-931-2237
Phone: 206-382-3587
Email: info@nationaleatingdisorders.org

Overeaters Anonymous
Website: http://www.oa.org
Address: P.O. Box 44020
Rio Rancho, NM 87174
Phone: 505-891-2664

Renfrew Center
Website: http://www.renfrew.org
Address: 475 Spring Lane
Philadelphia, PA 19128
Hotline: 877-367-3383
Email: foundation@renfrew.org

Shape Up America!
Website: http://www.shapeup.org
Address: 15009 Native Dancer Road
North Potomac, MD 20878

Anorexia Nervosa: A Guide to Recovery
by Lindsey Hall, Monika Ostroff

Anorexia Nervosa: When Food is the Enemy
by Erica Smith

A Starving Madness: Tales of Hunger, Hope and Healing in Psychotherapy
by Ph.D. Judith Ruskay Rabinor, Judith Ruskay Rabinor

Body Wars: Making Peace with Women's Bodies
by Margo Maine

Bulimia: A Guide to Recovery
by Lindsey Hall, Leigh Cohn M.A.T.

Como entender y superar la anorexia nervosa
by Lindsey Hall, Monika Ostroff

Como entender y superar la bulimia
by Lindsey Hall, Leigh Cohn M.A.T., Leigh Cohn

Cure Your Cravings - The Revolutionary Program Used by Thousands to Conquer Compulsions
by Yefim Shubentsov, Barbara Gordon

Eating Disorder Sourcebook: A Comprehensive Guide to the Causes, Treatments and Prevention of Eating Disorders
by Carolyn Costin

Eating in the Light of the Moon: How Women Can Transform Their Relationship with Food Through Myths, Metaphors, and Storytelling
by Anita A. Johnston PhD.

Hunger Within: A Twelve-Week Self-Guided Journey from Compulsive Eating to Recovery
by Marilyn Migliore

If You Think You Have an Eating Disorder
by John Barnhill, Nadine Taylor

Inner Hunger - A Young Woman's Struggle Through Anorexia and Bulimia
by Apostolides Marianne

Making Weight: Healing Men's Conflicts with Food, Weight, Shape and Appearance
by M.D. Arnold Andersen, Leigh Cohn M.A.T., M.D. Tom Holbrook, Leigh Cohn, et al.

Self-Esteem Comes in all Sizes: How to Be Happy and Healthy at Your Natural Weight
by Carol A. Johnson M.A., Gary Foster Ph.D., M.A., Carol A. Johnson, Gary Foster

Women Afraid to Eat: Breaking Free in Today's Weight-Obsessed World
by Frances M. Berg

Medline Plus: Eating Disorders
Website: http://www.nlm.nih.gov/medlineplus/spanish/eatingdisorders.html
Address: Customer Service
US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20984
Email: custserv@nlm.nih.gov

National Easting Disorders Associations
Website: http://www.nationaleatingdisorders.org/information-resources/general-information.php#NEDA_Espa_ol
Address: Information and Referral Helpline
603 Stewart Street, Suite 803
Seattle, WA 98101
Hotline: 1-800-931-2237
Phone: 206-382-3587
Email: info@NationalEatingDisorders.org

Last date updated: 
Mon, 2013-08-26

What is it?

Overview

What Is It?
If you are depressed, you feel a sense of helplessness, hopelessness or despair. You lose interest in your favorite activities, may experience changes in appetite, weight and sleep patterns, have difficulty concentrating and may be preoccupied with death or suicide.

Feelings of sadness can be normal, appropriate and even necessary during life's setbacks or losses. Or you may feel blue or unhappy for short periods without reason or warning, which also is normal and ordinary. But if such feelings persist or impair your daily life, you may have a depressive disorder. Severity, duration and the presence of other symptoms are factors that distinguish ordinary sadness from a depressive disorder.

Depression can happen to anyone of any age, race, class or gender. According to Mental Health America, depression afflicts more than 21 million Americans each year, 12 million of whom are women. Women are twice as likely as men to suffer from depression. Many women first experience symptoms of depression during their 20s and 30s. Once you experience depression, there's a 50 percent chance you'll be depressed again. Once you've experienced two episodes, you have a 70 percent chance of being depressed again. And once you’ve experienced three episodes, you have a 90 percent chance of being depressed again.

A complex combination of physiological, social, environmental, cultural, hormonal, biological and psychological factors may contribute to the reasons why women experience depression at a higher rate than men.

Depression affects both mind and body. If you are depressed, you feel a sense of helplessness, hopelessness or despair. You lose interest in your favorite activities; may experience changes in appetite, weight and sleep patterns; have difficulty concentrating; and may be preoccupied with death or suicide.

Additionally, depression often occurs in conjunction with certain chronic illnesses, like diabetes, and after a heart attack or stroke. Research suggests that depression is a risk factor for the development of coronary artery disease and may even be a major risk factor for osteoporosis. It also can develop as a result of conditions that cause unrelieved pain. Left untreated, depression contributes to increased complications, prolonged recovery time and a greater chance of death.

The good news is that depression is a treatable illness. Yet, 10 to 30 percent of people treated for a major depressive episode will have an incomplete recovery, with persistent symptoms of depression or dysthymia.

One reason that treatment for depression is inadequate is that many people do not know or are confused about where to seek mental health treatment. Another reason is that many individuals do not perceive depression as a real medical condition that should or could be treated. Also, there is still a social stigma attached to mental illnesses like depression. These perceptions are wrong. Depression is a potentially life-threatening disorder, and anyone suffering from its debilitating symptoms deserves to have it treated.

Types of Depression

Depression is classified as a mood disorder. The primary types of depression are:

Major depression: Major depression is marked by a combination of symptoms that interfere with life activities, such as work, sleep and eating, as well as a loss of interest in previously pleasurable activities. The depressed mood represents a change from previous behavior or mood and has lasted for at least two consecutive weeks.

Dysthymia: This is a form of chronic but low-grade depression marked by low energy, a general negativity and a sense of dissatisfaction and hopelessness. A person suffering from dysthymia may experience many of the same symptoms that occur in major depression, but they are less intense and last much longer—at least two years. If you suffer from dysthymia, you may not feel good, but you aren't as disabled as during an episode of major depression. However, sometimes women with dysthymia also suffer from episodes of major depression, a condition known as double depression.

Postpartum depression (PPD): While the "baby blues" are common in many women within the first few days or weeks following pregnancy and childbirth, they are temporary. However, for some women these symptoms become more severe and long-lasting. This is known as postpartum depression. The condition typically occurs within a month after the baby is born. About 10 to 15 percent of women report diagnosable postpartum depression after giving birth. If you've had prior depressive episodes, you have a much higher risk of developing postpartum depression. Postpartum depression can seriously interfere with your ability to care for yourself and your child. You should report any symptoms immediately to your health care professional for further evaluation.

Premenstrual dysphoric disorder (PMDD): The syndrome of more severe depression, irritability and tension occurring seven to 14 days prior to the start of the menstrual period is known as premenstrual dysphoric disorder (PMDD), also called late-luteal phase dysphoric disorder. It affects 3 to 8 percent of women of childbearing age. Though PMDD shares many of the characteristics of premenstrual syndrome (PMS), particularly the timing of the symptoms, there are differences between the two. When diagnosing PMDD, the focus is more on the mood-related symptoms than physical symptoms because the mood-related symptoms are significantly more severe in PMDD than in PMS. Experts say the difference between PMDD and PMS is similar to the difference between a mild tension headache and a migraine.

Seasonal affective disorder (SAD): Also called winter depression, SAD is a form of depression that affects an estimated 10 to 20 percent of Americans when both its mild and severe forms are considered. Women are more likely than men to suffer from SAD. The key feature of SAD is your response to less light during the winter months. Experts believe that brain chemistry in some people is affected by diminished daylight, triggering depression at this time of the year. However, it is episodic—it comes and goes—and many people who experience SAD recover in the spring. These people, however, have an increased risk of developing bipolar disorder, another form of depression.

Bipolar disorder: This form of depression is sometimes called manic-depressive illness. Not nearly as prevalent as other forms of depressive disorders, bipolar disorder is characterized by intense episodes of elation and despair, with any combination of mood experiences in between, including periods of normal moods. When in the depressed phase, an individual can have any or all of the symptoms of a depressive disorder. Symptoms during the manic phase include a decreased need for sleep, increased talkativeness, racing thoughts and increased activity, including sexual activity, excessive spending or having a great deal of energy. Sometimes manic episodes may include extreme irritability. Women who are bipolar may have more episodes of depression than mania.

Diagnosis

Diagnosis

Researchers are unclear about the specific causes of depression. An imbalance of certain chemicals in the brain called neurotransmitters, including serotonin, dopamine and norepinephrine, may be partly responsible. Low levels of folate may also contribute. Also, some people may have a genetic predisposition to depression; that means your family history puts you at risk.

If you have a history of substance abuse, or physical or sexual abuse, you are particularly at risk for depression. Also, women who are separated or divorced, living in poverty or married with young children at home are more vulnerable to depression than other women.

Because depression is so common, your primary health care professional should ask you about any symptoms of depression you may be experiencing during any comprehensive physical examination. Keep in mind that although primary care physicians are qualified to treat depression, they may not be the best choice of provider in all cases, particularly if the depression is severe. And women themselves may be unable to sense or admit to their own depression.

If your primary health care professional suspects a depressive disorder, he or she may request a consultation with a mental health specialist such as a psychiatrist, clinical social worker or clinical psychologist. To assess your mental health, a health care professional may ask you questions like:

  • Have you been sad a lot lately?

  • Have you had crying spells?

  • Is there a change in your productivity or your ability to concentrate?

  • How does your future look?

  • Do you have difficulty making decisions?

  • Have you lost interest in aspects of life that used to be important to you?

  • Are you tired?

  • Do you feel guilty or like a failure?

  • Do you ever wish you were dead?

Untreated episodes of major or acute depression last an average of about six months. At least five of the symptoms below must occur for a period of at least two consecutive weeks, and they must represent a change from previous behavior or mood, to receive a diagnosis of major or acute depression.

  • depressed mood on most days for most of each day

  • total or very noticeable loss of pleasure most of the time

  • significant increase or decrease in appetite, weight or both

  • sleep disorders, either insomnia or excessive sleepiness, nearly every day

  • loss of energy and a daily sense of tiredness

  • sense of guilt and worthlessness nearly all the time

  • change in psychomotor activity

  • inability to concentrate occurring nearly every day

  • recurrent thoughts of death or suicide

How to Tell the Difference Between Depression and Other Mood-Related Conditions

The symptoms of grief or bereavement mimic those of depression in many ways, but if you are grieving, you experience a succession of emotions over a period of three to six months that lead to a recovery period. Severe grief lasting longer than six months affects your health and increases your risk for ongoing depression, however. Some experts suggest that this severe persistent grieving state be categorized as a separate psychological diagnosis termed complicated grief disorder, which would be related to post-traumatic stress syndrome and require special treatment.

Dysthymia (chronic, low-grade depression) is marked by the same symptoms as major depression but is not usually accompanied by changes in appetite or sexual drive, and severe agitation, sedentary behavior and suicidal thoughts are not usually present. Possibly because of the duration of the symptoms, you may not exhibit marked changes in mood or daily functioning. However, treatment for dysthymia is important because it is effective and prevents a lifetime of sadness.

As the days get shorter, people with seasonal affective disorder (SAD) get increasingly tired and lethargic and have difficulty concentrating. You may also experience a craving for carbohydrates and sweets. Your appetite increases, often resulting in weight gain, and as the winter darkens you may become socially withdrawn and despondent. The exact causes of SAD are unclear. One theory is that serotonin, a chemical in the brain widely believed to play a major role in depression, is triggered by sunlight and falls to its lowest level during the winter months. If you are affected by SAD, you may have less serotonin available or be less able to handle the decrease than those unaffected by the disorder.

Like other forms of depression, the causes of postpartum depression have not been pinpointed, but both psychologic and neurochemical influences are suspected. Women who experience postpartum depression very often have had problems with depression prior to pregnancy. Also, if you experience premenstrual syndrome (PMS), you may be more susceptible to varying degrees of postpartum depression. Another significant risk factor is lack of social support for the mother and baby. The stress involved with adjustment to a new baby; being unprepared and subsequently overwhelmed by the baby's birth; a difficult birthing experience; a sick or colicky infant; and exhaustion may also contribute. Symptoms of postpartum depression include:

  • uncontrollable crying

  • feelings of inadequacy or negative feelings toward the baby

  • irritability

  • anxiety or panic

  • feeling numb

  • excessive sleep or inability to sleep

  • over- or under-eating

  • other symptoms common to depression

The most severe form of postpartum depression can include intense, suicidal and homicidal thoughts and/or postpartum psychosis. Only about one woman in 1,000 experiences this serious form of postpartum depression following childbirth.

The symptoms of premenstrual dysphoric disorder (PMDD) are similar to those of major depressive disorder but subside with the onset of menstruation. They include: a markedly depressed mood, decreased interest in usual activities, lethargy, fatigue or lack of energy, insomnia and hypersomnia (sleeping too much). A diagnosis of PMDD requires that these symptoms occur during most menstrual cycles, get worse seven to 14 days before the menstrual period begins and improve once it starts or soon afterward.

Treatment

Treatment

If you aren't sure whether to seek help for a mood disorder or emotional problem, ask yourself, "Could I use some help right now?" The questions below may help you decide:

  • Is the problem interfering with your work, relationships, health or medical conditions or other aspects of your personal life?

  • Have you been feeling less happy, less confident and less in control than usual for a period of several weeks or longer?

  • Have close, trusted friends or family members commented on changes in your behavior and personality?

  • Have your own efforts to deal with a problem failed to change your behavior or improve the situation?

  • Is dealing with everyday problems more of a struggle than before?

  • Are you having suicidal thoughts?

If you answered yes to any of these questions, talk to your health care professional about how you are feeling.

Left untreated, depression can be devastating—an estimated 1 percent of women and 7 percent of men with a lifetime history of depression will eventually commit suicide. What's more, depression is known to play a major role in exacerbating existing medical conditions and may even predispose people to develop other illnesses. Depression may have adverse effects on the immune system, blood clotting, blood pressure, blood vessels and heart rhythms.

Unfortunately, many people who suffer from depression do not seek help. They believe that nothing can help, or that they can simply cure themselves. Many women and their families don't understand that depression is a medical illness. Many mothers struggling with postpartum depression don't seek help because they feel guilty, believing that they shouldn't be sad now that they have a baby. Furthermore, because some symptoms of depression are common to other medical illnesses, depression is often misdiagnosed. The tragedy of this is that in the last few decades, treatments have emerged that can lead to recovery for most sufferers.

With accurate diagnosis and proper treatment, you can learn how depression affects your life and get the help you need to be productive again. In fact, 80 percent of individuals who are depressed recover with appropriate treatment.

Reaching out for help is a wise step when you can't spring back from sad or depressed moods or when emotional difficulties begin to interfere with work, relationships or other aspects of your life. But it's often difficult to seek help because depression typically robs your motivation and energy.

The single most important function your health care professional can perform is to distinguish between mild and severe depression. If your depression is mild, you may need an antidepressant and/or a referral to a clinical psychologist or social worker for counseling. If your depression is severe, however, you may need to see a specialist such as a psychiatrist, who can determine the treatment. Although primary care physicians are qualified to treat depression, they may not be the best choice of provider in severe cases. No matter what type of health care professional you are seeing for your depression, it's important that you communicate honestly about your illness, your current treatment and other treatment options. Though it can be challenging, you can find another medical professional if you are not satisfied with the care you're receiving.

Psychotherapy

Most cases of major depression can be successfully treated with psychotherapy, medication (known as antidepressants) or both. Depression often improves within a few months of starting psychotherapy.

Psychotherapy focuses on changing negative thinking and behaviors and/or unhealthy relationships that can contribute to depression. Talking to a psychological counselor can provide relief, lead to new insights and help replace unhealthy behaviors with more effective ways of coping with problems. Most mental health professionals tailor their approach to the needs, problems and personality of the person seeking help, and they may combine different techniques. The various types of psychotherapy include:

  • Cognitive-behavioral therapy, which focuses on identifying distorted perceptions you may have of the world and yourself, changing these perceptions and discovering new patterns of actions and behavior.

  • Behavior therapy, which is based on the premise that if you are depressed, you behave in ways that reduce positive outcomes and increase negative consequences. Behavioral activation therapists help you change what you do so you can change how you feel. You create a list of enjoyable or rewarding activities and begin with the easiest and continue in an organized fashion. For instance, you might be encouraged to become more active or add pleasurable activities to your life, learn to assert yourself, or create relaxation techniques.

  • Interpersonal therapy (IPT) acknowledges the childhood roots of depression but focuses on symptoms and current issues that may be causing problems. IPT does not delve into the psychological origins of symptoms; rather, it concentrates on relationships as the key to understanding and overcoming emotional difficulties. The therapist seeks to redirect the patient's attention, which has been distorted by depression, outward toward the daily details of social and family interaction. The goals of this treatment method are improved communication skills and increased self-esteem within a short period (three to four months of weekly appointments). Among the forms of depression best served by IPT are those caused by distorted or delayed mourning, unexpressed conflicts with people in close relationships, major life changes and isolation. People with major depression, chronic difficulties developing relationships, dysthymia or the eating disorder bulimia are most likely to benefit.

Cognitive-behavioral therapy and interpersonal therapy have been shown in clinical trials to work as well as antidepressant drugs for treating mild cases of depression, although they take longer than medication to achieve results.

Other therapies are available, but most haven't been proven effective in treating depression. These include:

  • Psychodynamic psychotherapy, which concentrates on working through unresolved conflicts from childhood. Some psychiatric specialists view depression as a grieving process for the loss of a parent or other significant person, or for the loss of their love. Others theorize that depressed individuals can only express rage at this loss by turning it against themselves and transforming it into depression. Psychodynamic therapists discuss their patients' early experiences and repressed feelings to provide insight into current problems and bring about behavioral change. Therapy may be brief or may continue for several years.

  • Supportive psychotherapy is meant to provide the patient with a nonjudgmental environment by offering advice, attention and sympathy. The goal of supportive psychotherapy, which can be brief or long-term, is to help patients who may temporarily feel unable to cope during times of great stress, such as after learning that they have a serious physical illness. Although many people think of supportive psychotherapy as simply giving comfort and advice, the process is far more complex and may include therapeutic techniques such as education, reassurance, reinforcement, setting limits, social skills training and medication. Supportive therapy appears to be particularly helpful for improving compliance with medications by giving reassurance, especially when setbacks and frustration occur.

Medications

If you have major or chronic depression, you may be prescribed an antidepressant.

Antidepressants are thought to alter the action and distribution of brain chemicals and can be effective in bringing mood, appetite, energy level, outlook and sleep patterns back to normal. About 80 percent of people with major depression will improve with good compliance and adequate doses of the right antidepressant drug.

To reduce or avoid side effects, you may be started on low doses that increase over time. You and your health care professional should first thoroughly discuss your medical history, including the presence of any emotional disorders in family members, and assess your overall health to rule out any illnesses that might be causing your psychiatric symptoms. You should also weigh the benefits and risks of the medication with input from your health care professional. While current antidepressants are not addictive, virtually all have side effects and sometimes serious interactions with other drugs. You should inform your health care professional of any drugs you take, including over-the-counter medications and herbal remedies.

If you have never been treated for depression, your medications will probably be maintained for six months or longer after your depression improves. Some women, however, may require a longer time or even indefinite maintenance therapy. Note: According to the U.S. Food and Drug Administration (FDA), there is an increased suicide risk associated with antidepressants. If you begin to feel like hurting yourself or killing yourself, or someone close to you notices a drastic change in your behavior, be sure to get in touch with your health care provider or call a suicide hotline for help and guidance right away.

Medications used to treat depression include:

Selective serotonin reuptake inhibitors (SSRIs) are now usually the first-line treatment of major depression. They are thought to work by blocking a pump mechanism in the brain that normally moves serotonin back into brain cells. Blocking this action temporarily increases the level of serotonin outside brain cells, especially in the specialized connection zones (synapses) between the brain cells. Because they act on serotonin specifically, SSRIs have fewer side effects than tricyclic antidepressants, which affect a number of chemicals in the body. Commonly prescribed SSRIs include fluoxetine (Prozac, Sarafem), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa) and escitalopram oxalate (Lexapro).

People taking SSRIs report not only relief of depressive symptoms, but also a higher level of efficiency, energy and better relationships.

Some people may notice an improvement of their symptoms within two weeks of taking an SSRI; in others, it can take up to eight weeks. If you don't respond to your medication after eight weeks, tell your health care professional. He or she may adjust the dosage or try another SSRI. Escitalopram oxalate (Lexapro), the newest antidepressant in its class, appears to offer some advantages over some other SSRIs in the treatment of depression: higher potency and lower incidence of side effects. Additionally, the drug is approved for the treatment of generalized anxiety disorder.

The most common side effects of SSRIs are nausea and gastrointestinal problems. Other possible side effects include anxiety, drowsiness, sweating, headache, difficulty sleeping and mild tremor. All usually wear off over time. During the first few weeks of treatment, some people lose a small amount of weight but, in general, they regain it. Sexual dysfunction, including delay or loss of orgasm and low sexual drive, occurs in up to 50 percent or more of people and is a major reason people quit taking their medicine. However, these side effects can usually be managed or reduced with a different medication or by prescribing an additional medication.

More rarely, SSRIs may cause bruising or bleeding in those who are predisposed to bleeding, such as the elderly. SSRIs can also cause dry mouth, which increases the risk of oral health problems. You can increase salivation by chewing sugarless gum, using saliva substitutes and frequently rinsing your mouth.

Some people taking SSRIs report a group of side effects known as extrapyramidal symptoms, which are similar to those in Parkinson's disease and affect the nerves and muscles controlling movement and coordination. They are very uncommon, however. If they develop, it tends to be in the first month of treatment.

Contact your health care professional if you experience any bothersome side effects. Don't discontinue your medication without guidance from a health care professional who is familiar with your health history.

Also, if you are taking an SSRI and are pregnant or plan to become pregnant, discuss potential risks with your health care professional as soon as possible. To date, studies on the risks of SSRIs during pregnancy have had mixed results, in part depending on the specific medication.

  • Serotonin-norepinephrine reuptake inhibitors (SNRIs). This class of antidepressants works on two neurotransmitters in the brain important in mood—norepinephrine and serotonin. The drugs in this class approved for the treatment of depression are venlafaxine (Effexor) and duloxetine (Cymbalta). These drugs tend to have fewer adverse effects on sexual function than SSRIs, and some people even report enhanced sexuality. Common side effects include drowsiness, nausea, dizziness and dry mouth.

  • Tricyclic antidepressants had been the standard treatment for depression before the introduction of SSRIs. Some of the most frequently prescribed tricyclics are amitriptyline (Elavil), desipramine (Norpramin), clomipramine (Anafranil), doxepin (Sinequan), imipramine, (Tofranil), nortriptyline (Pamelor, Aventyl), protriptyline (Vivactil) and trimipramine (Surmontil). Tricyclics are as effective as SSRIs and may offer benefits for many people with chronic depression who do not respond to SSRIs or other antidepressants. They are much less expensive than SSRIs and SNRIs but cause more potentially severe side effects than those newer antidepressants.

    Tricyclic antidepressants may also be used to treat chronic pain-related symptoms, even when a person is not depressed. These medications help restore the body's normal perception of pain.

    Side effects are fairly common with these medications and include dry mouth, blurred vision, sexual dysfunction, weight gain, difficulty urinating, constipation, disturbances in heart rhythm, drowsiness and dizziness. Blood pressure may drop suddenly when sitting up or standing. Tricyclics can also have serious, although rare, side effects and can cause fatal overdose.

  • Monoamine oxidase inhibitors (MAOIs) are usually indicated when other antidepressants don't work. They include phenelzine (Nardil), isocarboxazid (Marplan) and tranylcypromine (Parnate).

    There is also an antidepressant patch, selegiline (Emsam), that delivers the MAO inhibitor selegiline into the bloodstream through the skin. In its lowest strength, Emsam can be used without the dietary restrictions (described below) that are needed for all oral MAOIs approved for treating major depression.

    MAOIs take up to six weeks to become effective. They commonly cause a sudden drop in blood pressure upon standing that can make you dizzy, drowsiness, sexual dysfunction and insomnia. An extremely serious adverse effect is severe hypertension that could lead to stroke brought on by eating certain foods that have high levels of the amino acid tyramine, such as aged cheese, red wine, sauerkraut, vermouth, chicken livers, dried meats and fish, canned figs, fava beans and concentrated yeast products. This class of drugs also can cause birth defects and should not be taken by pregnant women. They may also interact with other drugs, including common over-the-counter cough medications, stimulants such as Ritalin and decongestants. Very dangerous side effects can occur from interactions with other antidepressants, including SSRIs. You should take at least a two- to five-week break between taking an MAOI and any other form of antidepressant.

  • Aminoketone antidepressants: bupropion (Wellbutrin, Wellbutrin SR, Zyban) appears to work by blocking dopamine uptake. The side effects of are similar to those of other antidepressants. Bupropion does not, however, have the degree of sexual side effects common with other antidepressants. People with a seizure disorder or at risk of a seizure disorder should not use bupropion.

Some people experience withdrawal symptoms when stopping an antidepressant. Therefore, when discontinuing an antidepressant, you should gradually withdraw under your health care professional's supervision.

Other treatment options

Other treatments for depression include:

  • Estrogen therapy. This menopausal hormone therapy is sometimes used with other treatments to relieve mood-related symptoms such as irritability, mood swings and depression, particularly during the transition to menopause. Some women become depressed because of sleep deprivation caused by night sweats. In this situation, estrogen may be prescribed to reduce night sweats and improve sleep which may, in turn, improve depression. Estrogen therapy also has some benefits when used to relieve depression in elderly women who don't respond to standard antidepressants and to relieve symptoms of postpartum depression.

    However, the U.S. Food and Drug Administration now recommends that health care professionals prescribe the lowest dose and the shortest treatment duration for all hormone therapies that contain estrogen. Studies generally find that estrogen's antidepressant affect is relatively mild, and that it primarily works on mild depression mood-related symptoms or in combination with an antidepressant.

  • St. John's wort (Hypericum perforatum) is an herbal remedy that may help relieve mild to moderate acute depression in some people. It is widely prescribed in Germany, and European studies show that St. John's wort is more effective than a placebo and as effective as some anti-depressants in the short-term treatment of depression. However, studies find little to no effect in treating major depression.

    Hypericin, the active substance in St. John's wort, is manufactured in tablet and liquid form. However, this herbal substance is not regulated and there is no guarantee of quality or purity in any brands currently available. Effective dose levels have not been established.

    Common side effects of St. John's wort include gastrointestinal problems, dry mouth, allergic reactions and fatigue. It may also increase sensitivity to the sun, and some people have reported temporary nerve damage after sun exposure. People with severe depression, pregnant or nursing women and children should not take St. John's wort. It should never be combined with other antidepressants. Because this herbal substance may be similar to MAOI inhibitors, some experts suggest avoiding foods and substances that have high amounts of tyramine, such as red wine, dried meat and aged cheese.

  • Augmentation strategies generally involve drugs not typically thought of as antidepressants in combination with an antidepressant. Such strategies are being used for people who do not respond to standard therapies or to speed up the response to the antidepressant. Augmentation therapies include lithium, stimulants such as Ritalin, thyroid hormones and anti-anxiety drugs. Additionally, estrogen is sometimes used to augment antidepressant therapy in postmenopausal women. Bupropion and buspirone have also been used. Anti-anxiety drugs, stimulants or sedatives are not antidepressants, however, and they are not effective when taken alone for a depressive disorder.

You should start feeling better within about four to 10 weeks of starting drug therapy. If you do not experience any relief within that time, talk to your health care professional or therapist or seek a second opinion. A change in your therapy approach, medication or dosage may make a significant difference. Psychiatrists with an expertise in drug therapy can usually find a medication that works even if it means switching drugs several times.

Sometimes a physician may write a prescription but not follow up to see if it's working or if the dosage is correct. You should continue to communicate with your health care professional so that an effective, tolerable dosage can be established.

While your health care professional will most likely begin treatment with psychotherapy and/or antidepressants or other medications, there are other treatments for depression, including:

  • Electroconvulsive therapy (ECT). Commonly called shock treatment, ECT has been used for more than 70 years and has been refined since its early introduction as a treatment for depression. According to Mental Health America, ECT is administered to an estimated 100,000 people a year, primarily in general hospital psychiatric units and in psychiatric hospitals.

    Once considered a controversial procedure, ECT has been refined over the years and now successfully works in the majority of mood-disorder people who undergo this treatment. (However, some studies show that the relapse rate is high.) It is recommended for people with severe depression who do not respond to medication. ECT may also be considered when certain medical conditions, such as pregnancy, make the use of medication too risky.

    Before receiving ECT, you get a muscle relaxant and short-acting anesthetic. Then a small amount of current is sent to your brain, causing a generalized seizure that lasts for about 30 to 90 seconds. You won't remember the treatments and will probably awake slightly confused. You will most likely recover in five to 15 minutes and be able to go home the same day. Acute treatments usually occur three times per week for about a month.

    Although ECT has been performed for decades, researchers still don't know precisely how it works to combat depression, but they know it does work. Most people receive treatments three times a week for a total of six to 12 treatments. Others may require maintenance ECT, which usually involves treatments once a week, gradually decreasing to monthly treatments.

    Side effects of ECT may include temporary confusion, memory lapses, headache, nausea, muscle soreness and heart disturbances. ECT may be beneficial for people who cannot take antidepressant drugs, for suicidal people and for elderly people who are psychotic and depressed. Some health care professionals feel it is safer to use ECT than many antidepressants for pregnant women or for people who have certain heart problems. Some psychiatrists believe that it may also be helpful for adolescents who fit the adult criteria for ECT.

    Although myths and negative perceptions continue to be perpetuated about ECT, it is a very effective treatment for many people with severe depression who don't respond to other treatments. Researchers are developing better ways to provide this treatment with fewer side effects.

  • Exercise may reduce mild to moderate depression. Either brief periods of intense training or prolonged aerobic workouts can raise feel-good chemicals in the brain like endorphins, adrenaline, serotonin and dopamine, which produce the so-called runner's high. It also appears to elevate the body's levels of phenylethylamine, a natural chemical linked to energy, mood and attention. Meanwhile, physical activity, particularly rhythmic aerobic and yoga exercises, helps combat stress and anxiety. And, of course, weight loss and increased muscle tone can boost self-esteem.

  • Phototherapy is recommended as the first-line treatment for seasonal affective disorder (SAD). You sit a few feet away from a box-like device that emits very bright fluorescent light (10,000 lux) 10 to 20 times brighter than ordinary indoor light for 30 minutes or more every morning. Studies show that phototherapy leads to a reduction in depressive symptoms in most people; however, phototherapy has not been proven to be effective in the prevention of SAD or the treatment of the disorder long-term. Some people report mood improvement as early as two days after treatment; in others, depression may not lift for two to four weeks. If no improvement is experienced after that, then the depression is probably caused by factors other than lack of sunlight. Side effects include headache, eye strain and irritability, although these symptoms are usually minimal and tend to disappear within a week. Severe SAD may require both phototherapy and antidepressant medications. Stress management and exercise can also help relieve symptoms of seasonal affective disorder.

  • Support. Support is particularly important for anyone seeking treatment and relief from depression. Typically, support comes from family members but can also be provided by friends, relatives, coworkers or members of a faith-based community. If you know someone who is struggling with depression, ask how you might be able to provide support. In addition, while treatment for women who experience postpartum depression includes medication as well as therapy, support and early intervention are also important. Mothers' support groups, or groups specifically designed for women with postpartum depression, may be worth exploring to give the woman with postpartum depression a place to share her feelings. Other critical interventions include approaches that any mother with a newborn needs: nutritious, regular meals; light exercise; a few hours without childcare responsibilities; and extra sleep to combat exhaustion. Support is an important component in the road to recovery for all forms of depression.

Prevention

Prevention

Self-help strategies play an important role in maintaining mental health. Among the most useful are:

  • Exercise. Aerobic workouts such as walking or jogging can keep your mood elevated and help prevent bouts of depression. Even non-aerobic exercise, such as weight-lifting, can keep your spirits high, improve sleep and appetite, reduce irritability and anger and produce feelings of mastery and accomplishment. Be sure to check with your health care professional before you start an exercise program.

  • Tune into your problems. Analyze recent events to identify possible sources of stress, either alone or with a close friend or loved one, to help you regain a better perspective. However, if you find yourself focusing too much on a problem, try another technique because thinking about the problem excessively can lead to depression.

  • Self-talk. If your inner voice is constantly critical, try to make note of unrealistically negative or critical remarks and focus more on the things you like about yourself.

  • Journaling. Write about problems and concerns in a journal to ease your anxiety and help you work through painful feelings. To get started, reflect upon each day or week and identify the most meaningful moments. If you experience an intense emotion, positive or negative, write down the circumstances and the effects of the experience. Analyze any encounter that makes you feel bad.

  • Meditation. Meditation involves daily contemplation in a quiet place. There are many forms of mediation, both religious and secular. All of them involve a focal point and repeated practice. This can lead to a state of relaxation as well as a distraction from everyday worries and concerns.

  • Self-help or support groups. Talk with people with similar problems through hospital- or community health-sponsored support groups. Such groups can help prevent depression recurrences.

The Holiday Blues

The holidays are a stressful time of year for many people. The "holiday blues" are a common response to the additional responsibilities the holiday season can impose. Additionally, you may feel loss more acutely during the holidays as you remember loved ones who have died.

Symptoms of the holiday blues can include feeling overwhelmed, anxious or angry; crying spells; withdrawal; or self-medicating with food or alcohol. While these symptoms can be similar to those experienced by someone who is clinically depressed, they are temporary. Depression is not. If holiday blues become incapacitating and/or persist for two or more weeks, professional help is advised. Some simple interventions can help you prepare for the holiday hustle, minimize stress and keep the holidays healthy:

  • Talk about the person you're missing.

  • Plan ahead and prioritize activities.

  • Be realistic about what can be accomplished in the upcoming weeks.

  • Alter a tradition that is particularly uncomfortable or overwhelming.

  • Be honest about feelings.

  • Focus on something positive and not a memory of a negative experience.

  • Take time off for yourself.

  • Recognize that alcohol, cigarettes and caffeine increase stress; limit use of these substances.

  • Exercise, eat nutritiously and get enough sleep to prevent exhaustion.

  • If you don't have a support network during the holidays, try to join others in a community center, book club or religious service or activity.

Facts to Know

Facts to Know

  1. Depression afflicts more than 12 million American women each year and strikes women twice as often as men. Biological differences in women, such as hormonal changes and genetic factors, may contribute to higher rates of depression. Stress experienced by women from work- and family-related responsibilities, poverty or abuse may also play a role. After one episode of depression, a woman has a 50 percent chance of experiencing another episode. After she has experienced two bouts of major depression, a woman has a 70 percent chance of experiencing a third. And after three episodes of depression, a woman has a 90 percent chance of experiencing a fourth.

  2. Depression is not something you can just "get over." It is a complex medical condition. Depression is thought to be triggered by low levels of certain brain chemicals called neurotransmitters. Serotonin, one example of a neurotransmitter, has been identified as a major player in depression and other mental illnesses.

  3. Prolonged stress, loss, substance abuse, some medications and certain illnesses can trigger depression in people who are susceptible to it. Depression also can occur spontaneously, without any apparent trigger.

  4. Antidepressant medications can greatly relieve symptoms for most people who suffer from depression. Newer medications with fewer side effects have been developed in the last decade, offering more options for people with this illness.

  5. Depression is likely to show up in more than one family member or generation.

  6. Depression often strikes between the ages of 25 and 44; teenagers may also develop depression. It can last for weeks, months, years or a lifetime, if not diagnosed and treated. Anyone—regardless of income, education or status—can suffer from this disease.

  7. Depression often gets translated into physical complaints. It can be mistaken for other illnesses by both a health care professional and the patient herself, instead of being properly recognized and diagnosed.

  8. About 7 percent of men and 1 percent of women with a lifetime history of depression will commit suicide. If not treated, depression can spiral into feelings of worthlessness, despair and suicide. Early intervention and treatment can reverse these feelings and make life seem livable again.

  9. Within six months of giving birth, about 10 to 15 percent of women report diagnosable postpartum depression, which is more severe and long-lasting than the "baby blues." If you've had prior depressive episodes, you have a much higher risk.

  10. Chronic but mild depression, or dysthymia, is marked by low energy, a general negativity and a sense of dissatisfaction and hopelessness. A person suffering from dysthymia may experience many of the same symptoms that occur in major depression, but they are less intense and last much longer—at least two years.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about depression so you're prepared to discuss this important health issue with your health care professional.

  1. Do I have depression? What kind of depression do I have?

  2. Could my depression be caused by an underlying medical condition or by medications I'm taking?

  3. Should I see a psychiatrist to determine if medication might help me?

  4. If medication is prescribed, how long before the drug begins to help me? How will I know if it is helping?

  5. Is this medication safe for me to take given my current situation? Is it safe with other medications I'm taking? Does it have any side effects I should be aware of?

  6. How long will I need to take this medication?

  7. Should I avoid other medications, alcohol or certain foods while I take this medication?

  8. What if this medication doesn't work? Should I call you and come in for another visit before stopping the medication?

  9. What if I can't tolerate the side effects of this medication? Should I call you and come in for another visit before stopping it?

  10. Will you be counseling me or referring to me to counseling, as well as prescribing medication? What should I do if I believe I need counseling or other types of support?

  11. Is the medication you're prescribing for me in any way addictive? Are there any substances, like alcohol, that I should stay away from while taking my medication?

  12. What should I do if I find myself thinking of suicide?

Key Q&A

Key Q&A

  1. What is depression? How is it different from just having a couple of "bad days?"

    Depression, also known as depressive disorder, is caused by an imbalance of certain chemicals normally present in the brain that help control or initiate certain behaviors. Depression is distinctly different from feeling sad about an event or feeling "blue" for a short period. These feelings pass. Depression is an illness and needs treatment. It's not a weakness or something to feel ashamed about. Symptoms can be long lasting and debilitating and represent a change for most people from their normal experiences. One of the most significant changes is a loss of joy or pleasure from situations that once were fulfilling.

  2. Who develops depression?

    Anyone can suffer from depression at any time, but certain people are more susceptible to this illness. Women are twice as likely as men to suffer from depression. After one bout of depression, a woman's chance of having another episode increases by 50 percent, after two depressive episodes, she has a 70 percent chance of experiencing a third, and after three episodes, she has a 90 percent chance of experiencing a fourth. Depression seems to run in families. Prolonged stress, abuse, illness, drug and alcohol use, certain medications and significant losses can trigger depression, especially in those individuals at higher risk for developing it.

  3. Are there different types of depression?

    Yes. Two of the most common types of depression are major depression (also known as clinical depression) and dysthymia. Each type of depression shares similar symptoms, but these vary in intensity and duration. Symptoms of major depression include a disruption of normal sleeping and eating patterns and an increase in negative feelings or thoughts. Dysthymia is a chronic but less severe type of depression. However, its symptoms can be equally disabling. A person with dysthymia may feel that she never quite functions at her full potential or never quite feels "good." Dysthymia can also occur with major depression, which is a condition sometimes referred to as "double depression."

  4. How can I tell if I'm depressed?

    Depression, like other medical illnesses, has a specific set of criteria that medical professionals use to make a diagnosis. Here are a few of the symptoms of depression:

    • loss of interest in activities and relationships

    • feeling empty, sad and frequently tearful

    • feeling excessively tired or "slowed down"

    • eating and/or sleeping more or less than usual

    • feeling restless, irritable, worthless, pessimistic, or anxious

    • having difficulty remembering, concentrating and making decisions

    • chronic aches and pains that don't respond to treatment

    • feeling suicidal or that life is not worth living

  5. How is depression treated?

    Most health experts agree that the best way to treat depression is with a combination of psychotherapy and medication called antidepressants. Psychotherapy consists of discussing possible causes for certain feelings and behaviors with a trained professional, such as a psychiatrist, clinical psychologist, psychiatric nurse specialist, clergy with specialized training, social worker or counselor, and developing strategies for resolving the feelings. Antidepressants work by correcting the imbalance of certain brain chemicals.

  6. Do antidepressants have side effects? How long will I have to take medication?

    The newer antidepressants, called selective serotonin reuptake inhibitors (SSRIs) cause fewer side effects than the older types of drugs used to treat depression. Antidepressant medication can cause side effects such as nausea, drowsiness, gastrointestinal upset, anxiety and insomnia, which may subside after your body adjusts to the medication after about a month. Sexual dysfunction (impotence, loss of desire, inability to reach orgasm) is a possible side effect from SSRIs. In some cases, other medication may be prescribed to lessen these symptoms or another type of SSRI may be suggested.

    Some people make the mistake of stopping the medication when they first start to experience side effects or without speaking to their health care professional about the side effects. Because many types of antidepressants are available, it is likely that one can be identified that produces fewest side effects with best results.

    Most people don't have to take antidepressants forever. Once your depression subsides, you can determine with your health care team what the best course is for you. Short-term treatment, from six months to one year, is common. But, longer treatment may be necessary to prevent a recurrence. People who have recurrent depression may need to take antidepressants for the rest of their lives.

  7. What are the "baby blues?" Is this depression?

    The "baby blues" refers to the short period of time after a woman delivers a baby when she may feel tearful, fatigued and overwhelmed. These feelings can last for a week or two and typically subside once the woman is more rested and hormones related to pregnancy and delivery become more balanced. The "baby blues" are not considered clinical depression; however, postpartum depression is a form of depression that affects some women after they deliver. It is different from the "baby blues" because it lasts longer than six weeks and significantly disables the mother, greatly interfering with her relationship with her baby and other members of her family. The symptoms of postpartum depression are the same as symptoms of other forms of depression.

  8. Can antidepressants be taken during pregnancy and while breastfeeding?

    Antidepressants do cross the placenta, potentially exposing fetuses to their effects. There is not a lot of research about how antidepressants may affect a developing fetus, and of the research out there, the results are mixed. Women and their doctors need to weigh the potential risks and benefits to both the mother and fetus of taking or avoiding antidepressants in pregnancy and make a decision based on individual circumstances.

    Research is equally unclear about how antidepressants may affect a nursing baby. Antidepressants are excreted in breast milk, but in very small amounts. As a result, few problems are found in breastfed infants of mothers who take antidepressants. However, similar to the use of antidepressants in pregnancy, a woman and her health care professional should weigh the risks and benefits to both the mother and her infant before deciding whether to use antidepressants while breastfeeding.

Lifestyle Tips

Lifestyle Tips

  1. Coping with holiday depression

    Feelings of depression can strike not only during the winter holidays, but also on any occasion with high social and emotional expectations. Begin by understanding that you are not obligated to feel cheerful or any particular way; accept your feelings so you can deal with them. Understand that one reason for your sadness may have to do with missing people who have died, either recently or even years ago. Avoid alcohol or other substances if they serve as "quick fixes"—they do more harm than good. Don't spend extra money either. Share responsibility for preparing for a social event rather than taking it all on yourself. Make time for yourself to "recharge" and relieve stress. If you're lonely, volunteer to help others.

  2. What to do when depression starts

    Think of specific triggers that might be causing or aggravating your depression. Some examples are sleep deprivation, diet deficiencies, seasonal light deprivation, stress, grief due to loss, alcohol abuse, problems in relationships and medications. Change the factors that you can, and bring others to the attention of your health care professional. Take care of yourself with a healthy diet, adequate sleep and moderate exercise. Don't withdraw, but maintain only a reasonable amount of responsibilities. See your health care professional, go to a walk-in center or call a hotline for the help you need. Let your family and friends help you.

  3. What to do while waiting for your medication to start working

    Break large tasks into small ones and set priorities to make your day less frustrating. You may also find that it's easier to do physical tasks (like cleaning) than analytical tasks, and these still accomplish something useful. Choose non-stressful activities that normally make you feel good, like going to a movie, a religious service or a ballgame. Moderate exercise may help. Consciously turn to more positive thoughts when you find yourself concentrating on the negative. Ask friends and family for support. Take your medication as prescribed and expect your mood to lift gradually, not suddenly. Call your health care provider if you have questions or concerns.

  4. Put the light back in your life

    If you have seasonal affective disorder (SAD) or "winter depression," don't use tanning beds as light therapy. The ultraviolet rays they give off may be harmful to your eyes and skin. Instead, try light boxes, wearable visors and even masks specially made as SAD therapy. These light sources are much brighter than ordinary indoor light. Sit about two feet away and read or do whatever you wish for about 30 minutes per day. Mornings are best. Don't use the treatment too late in the evening, or you may have trouble sticking to your normal sleeping hours.

  5. What to do if you think your child may have depression

    Talk to your child. Pay attention to behavioral changes like crying more often, irritability, complaining of feeling sad and empty, discouragement and hopelessness, disrupted sleep, loss of interest in favorite activities, a change in school performance, isolation from friends and family. Remember that even a child with good grades can be depressed, if he or she is trying to compensate for low self-esteem by being anxious to please. School-age children may complain of headache or stomachache or may act irritable or misbehave. Teens may behave recklessly. Consult with your pediatrician, school guidance counselor or mental health professional and know the warning signs of suicide so you can act swiftly if you see them.

Organizations and Support

Organizations and Support

For information and support on coping with Depression, please see the recommended organizations, books and Spanish-language resources listed below.

American Academy of Child and Adolescent Psychiatry (AACAP)
Website: http://www.aacap.org
Address: 3615 Wisconsin Ave., NW
Washington, DC 20016-3007
Phone: 202-966-7300

American Association for Marriage and Family Therapy
Website: http://www.aamft.org
Address: 112 South Alfred Street, Suite 3000
Alexandria, VA 22314-3061
Phone: 703-838-9808
Email: central@aamft.org

American Association of Pastoral Counselors (AAPC)
Website: http://www.aapc.org
Address: 9504A Lee Hwy.
Fairfax, VA 22031
Phone: 703-385-6967
Email: info@aapc.org

American Association of Suicidology
Website: http://www.suicidology.org
Address: 5221 Wisconsin Avenue, NW
Washington, DC 20015
Hotline: 1-800-273-TALK (1-800-273-8255)
Phone: 202-237-2280
Email: info@suicidology.org

American Psychological Association
Website: http://www.apa.org
Address: 750 First St., NE
Washington, DC 20002
Hotline: 1 -800-374-2721
Phone: 202-336-5500

Association for Behavioral and Cognitive Therapies (ABCT)
Website: http://www.abct.org
Address: 305 7th Avenue, 16th Floor
New York, NY 10001
Phone: 212 647-1890

Depression and Bipolar Support Alliance (DBSA)
Website: http://www.dbsalliance.org
Address: 730 N. Franklin Street, Suite 501
Chicago, IL 60610
Hotline: 1-800-826-3632
Email: info@dbsalliance.org

Federation of Families for Children's Mental Health
Website: http://www.ffcmh.org
Address: 9605 Medical Center Drive, Suite 280
Rockville, MD 20850
Phone: 240-403-1901
Email: ffcmh@ffcmh.org

Freedom From Fear
Website: http://www.freedomfromfear.org
Address: 308 Seaview Avenue
Staten Island, NY 10305
Phone: 718-351-1717
Email: help@freedomfromfear.org

Geriatric Mental Health Foundation
Website: http://www.gmhfonline.org
Address: 7910 Woodmont Ave, Suite 1050
Bethesda, MD 20814
Phone: 301-654-7850
Email: web@GMHFonline.org

Mental Health America
Website: http://www.mentalhealthamerica.net
Address: 2000 N. Beauregard Street, 6th Floor
Alexandria, VA 22311
Hotline: 1-800-969-6642
Phone: 703-684-7722

National Alliance on Mental Illness (NAMI)
Website: http://www.nami.org
Address: Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201
Hotline: 1-800-950-NAMI (1-800-950-6264)
Phone: 703-524-7600

National Institute of Mental Health
Website: http://www.nimh.nih.gov
Address: Science Writing, Press and Dissemination Branch
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892
Hotline: 1-866-615-6464
Phone: 301-443-4513
Email: nimhinfo@nih.gov

National Mental Health Consumers' Self-Help Clearinghouse
Website: http://www.mhselfhelp.org
Address: 1211 Chestnut St., Suite 1207
Philadelphia, PA 19107
Hotline: 1-800-553-4539
Phone: 215-751-1810
Email: info@mhselfhelp.org

Postpartum Support International
Website: http://www.postpartum.net
Address: P.O. Box 60931
Santa Barbara, CA 93160
Hotline: 1-800-944-4PPD (1-800-944-4773)
Phone: 805-967-7636
Email: psioffice@postpartum.net

SAMHSA's National Mental Health Information Center
Website: http://mentalhealth.samhsa.gov
Address: P.O. Box 2345
Rockville, MD 20847
Hotline: 1-800-789-2647
Phone: 240-221-4021

Screening for Mental Health (SMH)
Website: http://www.mentalhealthscreening.org
Address: One Washington Street, Suite 304
Wellesley Hills, MA 02481
Phone: 781-239-0071
Email: smhinfo@mentalhealthscreening.org

Suicide Prevention Advocacy Network USA (SPAN USA)
Website: http://www.spanusa.org
Address: 1010 Vermont Avenue, NW, Suite 408
Washington, DC 20005
Phone: 202-449-3600
Email: info@spanusa.org

10 Steps to Take Charge of Your Emotional Life: Overcoming Anxiety, Distress, and Depression Through Whole-Person Healing
by Dr. Eve A. Wood M.D.

50 Signs of Mental Illness: A Guide to Understanding Mental Health
by Dr. James Whitney Hicks M.D.

The American Medical Association Essential Guide to Depression
by AMA

Healing Depression: A Holistic Guide
by Catherine Carrigan , M.D. William G. Crook M.D. M.D., William G. Crook

How You Can Survive When They're Depressed - Living and Coping with Depression Fallout
by Anne Sheffield, Mike Wallace, Donald F. Klein

Living Well with a Hidden Disability: Transcending Doubt and Shame and Reclaiming Your Life
by Stacy Taylor, Robert Epstein

My Feelings Are Like Wild Animals! How Do I Tame Them?: A Practical Guide to Help Teens (& Former Teens) Feel & Deal with Painful Emotions
by Gary Egeberg

Postpartum Survival Guide
by Ann Dunnewold, Diane G. Sanford

Stop Depression Now: SAM-e, the Breakthrough Supplement That Works Better Than Prescription Antidepressants in Half the Time...With No Side Effects
by Richard Brown, Teodoro Bottiglieri, and Carol Colman

What the Blues Is All About - Black Women Overcoming Stress & Depression
by Angela Mitchell, Kennise Herring

Win the Battle: The 3-Step Lifesaving Formula to Conquer Depression and Bipolar Disorder
by Bob Olson

Women & Anxiety: A Step-by-Step Program for Managing Anxiety and Depression
by Helen DeRosis

National Institute of Mental Health
Website: http://www.nimh.nih.gov/health/publications/espanol/depresion/index.shtml
Address: NIMH
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892
Hotline: 1-866-615-6464
Phone: 301-443-4513

Medline Plus: Depression
Website: http://www.nlm.nih.gov/medlineplus/spanish/depression.html
Address: Customer Service
US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Womenshealth.gov
Website: http://www.womenshealth.gov/espanol/preguntas/postpartum.htm
Address: National Women's Health Information Center
8270 Willow Oaks Corporate Drive
Fairfax, VA 22031
Hotline: 1-800-994-9662

Last date updated: 
Fri, 2012-07-20

What is it?

Overview

What Is It?
Bipolar disorder is characterized by intense episodes of elation or irritability and despair, with any combination of mood experiences in between, including periods of normal moods.

Bipolar disorder can be one of the most distinct and dramatic of mental illnesses. It is characterized by intense episodes of elation or irritability and despair, with any combination of mood experiences in between, including periods of normal moods. Mood changes are accompanied by changes in behavior, such as altered patterns of sleep and activity.

Traditionally, one percent of the population has been affected by bipolar disorder, but as the condition has expanded to include a spectrum of proposed bipolar conditions, this number has risen to an estimated 2.6 to 6.5 percent. According to the World Health Organization, bipolar disorder is the sixth leading cause of disability among people aged 15 to 44. It is less common than major depression, also called "unipolar" depression, or simply, "depression."

The classic form of bipolar disorder, 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, called hypomania, that alternate with depression; this form of the illness is called bipolar II disorder. In addition, there are two other forms of bipolar disorder: bipolar disorder not otherwise specified (BP-NOS) and cyclothymic disorder, or cyclothymia. BP-NOS is reserved for cases where people have symptoms of bipolar disorder that do not meet all the diagnostic criteria for bipolar I or II. Cyclothymia is a mild form of bipolar disorder where people have episodes of hypomania that shift back and forth with mild depression for at least two years. The symptoms of cyclothymia also do not fit into the diagnostic criteria for bipolar I or II.

Studies show that men and women are equally likely to develop bipolar disorder; however, there is some evidence that women may have more depressive and fewer manic episodes than men with the illness. Women seem to have "mixed states" (mania or hypomania occurring at the same time as depression) more often than men. Also, women are more likely to have the rapid cycling form of the disease, which is characterized by four or more episodes of depression, mania or hypomania a year, and may be more resistant to standard treatments. Women are also more likely to have bipolar II disorder.

The symptoms of bipolar disorder can be severe and debilitating. Bipolar disease is not curable. However, medication can help many people achieve remission of symptoms. Treatment and maintenance of this disorder is necessary throughout a person's life once bipolar disorder is diagnosed.

Like some other illnesses that require lifelong treatment, bipolar disorder poses unique medical challenges for women with the disorder who are pregnant or considering pregnancy. The notion that pregnancy itself is protective for women with bipolar disorder is not true. The risk of recurrence of either depression or mania during pregnancy and postpartum is high. A recurrence during the postpartum period often develops as postpartum psychosis. These risks are high for women who stop their mood-stabilizing medications and even higher for women who stop these medications abruptly.

So a woman with bipolar disorder who wants to become pregnant should discuss her treatment options with her health care team before conception, if possible, or as early in her pregnancy as possible. Concerns exist about the potential harmful effects mood-stabilizing medications used to treat bipolar disorder may have on the developing fetus and the nursing infant. However, these concerns need to be weighed against the potential serious risks that an episode of mania or depression may pose to the developing fetus, infant or mother.

Diagnosis

Diagnosis

Bipolar disorder, also known as manic depression, generally strikes in late adolescence or early adulthood, most often between the ages of 15 and 30, and usually continues throughout a person's life. However, some people develop their first symptoms in childhood and others don't develop them until later in life.

Researchers theorize that there are a number of contributing factors for why and how someone develops bipolar disorder, including a genetic predisposition, environmental influences and brain chemistry.

According to the National Institute of Mental Health (NIMH), close relatives of people suffering from bipolar illness are four to six times more likely to develop bipolar disorder than the general population. It is important to note, however, that not everybody with a family history develops the illness. No one gene has been identified for the disorder, but it appears likely that many genes act together and in combination with other factors in the person or the person's environment to cause bipolar disorder.

Studies of identical twins who share the same genes show that a person who has an identical twin with bipolar disorder is more likely to develop the disorder than someone who has a sibling with the illness, indicating that genes are definitely involved. However, an individual who has a twin with bipolar disorder will not always develop the illness, indicating that genes and other factors both play a role.

Studies suggest that stress, difficulty at work or interpersonal relationships may trigger episodes in those with bipolar disorder, particularly if the stress causes loss of sleep. The theory is that stress and/or loss of sleep precipitates changes in brain chemistry in susceptible people.

Behaviors and moods common to bipolar disorder may initially be attributed to other medical problems, or other mental illnesses, which can delay an accurate diagnosis and appropriate treatment. For example, many people with bipolar disorder are misdiagnosed with major depression. In addition, alcohol and drug abuse and/or difficulties with work and school performance may be identified, but their underlying cause—bipolar disorder—may not be diagnosed. However, the disorder is not difficult to diagnose by a well-trained clinician.

Bipolar disorder is diagnosed based on an evaluation of symptoms, the course of the illness and family history. To be diagnosed with bipolar disorder, a person must meet the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), published by the American Psychological Association. In addition to a psychiatric evaluation, a complete medical exam should be completed. A physical exam and blood tests can rule out medical conditions that can mimic or worsen bipolar disorder.

Physical tests, such as a blood test or brain scan, cannot conclusively identify the illness, although progress is being made in these areas. For example, brain-imaging studies using magnetic resonance imaging (MRI), positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) procedures allow researchers to take pictures of the brain to examine its structure and activity. These noninvasive techniques are beginning to help scientists learn what goes wrong in the brain to produce bipolar disorder as well as other mental illnesses.

Symptoms

The symptoms of bipolar disorder fall into several categories: depression, mania and mixed state type of episodes (in mixed episodes, symptoms of both depression and mania are present at the same time). In addition, people experiencing any of these types of mood episodes may experience psychosis, which is a serious inability to think and perceive clearly, or losing touch with reality. If you or a family member experiences any of these symptoms, you should discuss them with a health care professional and request a thorough evaluation, which should include a physical checkup and a family health history.

The symptoms of depression include:

  • constant or persistent sadness

  • loss of pleasure and interest in activities that were once fun, including sex

  • significant change in appetite or weight (either increase or decrease)

  • restlessness or agitation

  • irritability or excessive crying

  • change in sleep patterns, either oversleeping or insomnia

  • lack of energy, feeling slowed down mentally and physically

  • feelings of guilt, worthlessness, helplessness, hopelessness

  • persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders and chronic pain

  • difficulty thinking or concentrating

  • recurring thoughts of death or suicide

The symptoms of mania include:

  • persistent and abnormally elevated mood (euphoria)

  • irritability

  • overly inflated self-esteem or feelings of importance

  • a decreased need for sleep

  • increased talkativeness

  • racing thoughts

  • increased activity, including sexual activity

  • distractibility

  • increased energy and/or physical agitation

  • excessive involvement in risky behaviors, such as spending money irresponsibly

  • poor judgment

  • inappropriate social behavior

Significant disruption in your sleep-wake cycle is an early warning sign of an impending episode. Controlling your sleep-wake cycle and maintaining a regular pattern is critical to avoid making the illness worse. Decreased and disrupted sleep occurs frequently for new mothers. It is important for women with bipolar disorder who are pregnant or considering pregnancy to talk with their health care providers about ways to reduce their sleep disruptions after giving birth.

Other symptoms of manic depression include psychosis, which involves hallucinations and delusions (falsely believing in something with conviction, despite proof or evidence to the contrary).

Mixed state episodes include symptoms of both depression and mania, often including agitation, trouble sleeping, change in appetite, psychosis and thoughts of suicide.

Symptoms of mania, depression or mixed state are episodic and typically recur. Episodes may become more frequent with age if the condition isn't properly treated. These episodes, especially early in the course of the illness, are separated by periods of wellness, when someone suffers few or no symptoms.

Women with bipolar syndrome are more likely to experience psychosis and manic episodes during pregnancy and after giving birth. This risk is higher for women who stop their mood-stabilizing medications and even higher for women who stop these medications abruptly.

The combinations and severity of symptoms vary from person to person. Some people have severe manic episodes in which they feel out of control, have tremendous difficulty functioning and severe psychosis. Other people have milder "hypomanic" episodes that include increased energy, euphoria and irritability. Some suffer completely incapacitating periods of depression and are unable to function within their normal daily routine. Hospitalization is necessary to treat severe episodes of mania or depression.

If you have bipolar disorder, you may have difficulty acknowledging your mood swings even if family and friends tell you about these behaviors.

During a manic episode, you might abuse alcohol, schedule too many events or meetings for one day, drive recklessly, go on a spending spree, make unwise or risky business decisions or be unusually promiscuous sexually. Untreated, the manic phase can last from days to months. As it fades, a period of normal mood and behavior may occur. Sometimes the depressive phase of the illness then sets in, but another manic episode could also follow.

When you're experiencing a depressed episode, you might lose complete interest in everything you used to enjoy, not be able to stop crying, feel completely hopeless and contemplate suicide. In some people, depression occurs immediately after a manic episode or within the next few months. But with others, there is a long interval before the next manic or depressive episode. The depressive phase has the same symptoms as major depression (also called "unipolar" depression).

People with bipolar disorder may 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 your health care professional closely monitor your thyroid levels. Additionally, if you're treated with lithium, that may cause low thyroid levels.

Treatment

Treatment

If you have bipolar disorder, you will need lifelong treatment. Regular monitoring and consultation with a health care professional is necessary to establish which medication or combination of drugs works best.

Medications called "mood stabilizers" are most often prescribed to help control bipolar disorder, and several types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for an extended time to manage their illness, usually for years. Other medications are sometimes combined with mood stabilizers when necessary to treat powerful episodes of mania or depression that may break through despite the mood stabilizer. These additional medications may include: an antipsychotic for psychosis or mania; an antidepressant for depression; and/or a benzodiazepine for agitation.

For nearly 40 years, the mood stabilizer lithium has been one of the main treatments for people with bipolar disorder.

Lithium evens out moods so you don't feel as high or as low, but it's unclear exactly how the medication works in the brain. Lithium is not used just for manic attacks, but rather as an ongoing treatment to prevent all types of episodes. It can take up to three weeks to start reducing severe manic symptoms. It might take a few months of medication before the illness is under control.

When taken regularly, lithium can effectively control depression and mania and reduce the chances of recurrence. However, while it is effective treatment for many people, it doesn't work for everybody.

Regular blood tests are a must if you're taking lithium. The level of lithium in your blood can be measured with a blood test. This level is used by your doctor, along with your symptoms, to determine the appropriate dose of lithium for you. Too small a dose might not be effective and too large might produce unwanted side effects, including weight gain, tremors, excessive thirst and urination, drowsiness, weakness, nausea, vomiting and fatigue.

Salt intake also affects the amount of lithium in your body. A dramatic reduction in salt intake, excessive exercise and sweating, fever, vomiting or diarrhea may cause lithium to build up in your body to toxic levels. An overdose of lithium can cause confusion, delirium, seizures, coma and may result, although rarely, in death.

In addition to lithium, other mood stabilizers used in the treatment of bipolar disorder include anticonvulsants. They may be combined with lithium or with each other for maximum effect. Specific ones used for bipolar syndrome include:

  • Anticonvulsants. Antiseizure medications (also called anticonvulsants) such as valproic acid (Depakene) and divalproex (Depakote) can have a mood-stabilizing effect in people with bipolar disorder. There is some evidence that valproic acid may result in hormonal changes in teenage girls and polycystic ovarian syndrome (PCOS) in women who began taking the medication before age 20. Young women should discuss this risk with their health care professionals, and those taking valproic acid should be monitored carefully for possible hormonal problems.

    The anticonvulsants carbamazepine (Tegretol) and oxcarbazepine (Trileptal) also have some effects as mood stabilizers, although they are not yet approved for bipolar disorder by the U.S. Food and Drug Administration (FDA). At this point, there is more evidence on the effectiveness of Tegretol than Trileptal.

    And the anticonvulsant lamotrigine (Lamictal) is FDA-approved for the long-term treatment of adults with bipolar disorder. It is specifically used to treat the depressive episodes involved with bipolar disorder.

    Some anticonvulsants can decrease the effectiveness of hormonal contraceptives, such as birth control pills. It is important to discuss your method of contraception with your health care provider to determine if there is an interaction.

Severely ill patients may require a combination treatment with mood stabilizers and other drugs, including:

  • Antidepressant medications. Several classes of antidepressant medications are sometimes used to treat the depressive symptoms of bipolar disorder, including fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft) and bupropion (Wellbutrin). However, the use of antidepressants in people with bipolar disorder is controversial, since antidepressants may not be any more effective than mood stabilizers at treating depressive episodes in people with bipolar disorder and can trigger manic episodes. Make sure you tell your health care professional about any prior symptoms of hypomania or mania (episodes that include increased energy, euphoria and irritability) before beginning antidepressants.

    Side effects and effectiveness differ for each class of antidepressant, as well as for the individual brands.

  • Antipsychotics. If you're experiencing psychotic or manic symptoms during an episode of bipolar disorder, health care practitioners will sometimes prescribe antipsychotic medicine alone or in combination with a traditional mood stabilizer to control symptoms.

    Olanzapine can also be used alone for the treatment of bipolar disorder.

    Examples of antipsychotics used include: olanzapine (Zyprexa), ziprasidone (Geodon), quetiapine (Seroquel), aripiprazole (Abilify) and risperidone (Risperdal), all FDA-approved for the treatment of bipolar disorder.

    In addition, antianxiety medications such as benzodiazepines may be used in some people with bipolar disorder with acute mania to help with sleep. There is a potential for abuse of or physical dependence on benzodiazepines. Therefore, these medications are often prescribed only for a limited time, such as during an acute episode.

Be patient. It may take up to three weeks of regular use of a new drug before your symptoms improve or subside. Stay in close communication with your health care professional and let him or her know if you don't feel like you are responding to treatment. In some cases, treatment plans need to be changed to effectively control symptoms.

Electroconvulsive therapy (ECT) is another treatment option for bipolar disorder and other types of major depression. It is usually only used to treat bipolar disorder when medication, psychosocial treatment or the combination of these treatments are ineffective or work too slowly to relieve severe symptoms such as psychosis or thoughts of suicide. ECT may also be considered when certain medical conditions, such as pregnancy, make the use of medication too risky.

Just prior to ECT treatment, you're given a muscle relaxant and sometimes general anesthesia. Electrodes are then attached to your scalp. An electric current causes a brief convulsion. Treatments usually last for 30 to 90 seconds. You won't remember the treatments and will probably awake slightly confused. You will most likely recover in five to 15 minutes and be able to go home the same day. Acute treatments usually occur three times per week for about a month. Maintenance treatments may be given after that at a reduced frequency.

ECT has been used for more than 70 years and has been refined since its early introduction as a treatment for depression. According to Mental Health America , ECT is administered to an estimated 100,000 people a year, primarily in general hospital psychiatric units and in psychiatric hospitals. Researchers don't understand exactly how it works to improve symptoms of depression and/or mania in some individuals, but the evidence is clear that it does work.

Although myths and negative perceptions continue to be perpetuated about ECT, it is a very effective treatment for many people with severe depressive, manic or mixed episodes who don't respond to or have bad effects from other treatments or can't take other treatments for some reason. Research has shown that patients who receive ECT followed by maintenance lithium therapy have better outcomes than patients who receive lithium alone. As with all other treatments, you should undergo a complete physical evaluation before beginning ECT therapy.

Side effects can include permanent memory loss and confusion. These side effects were more of a concern in the past, and modern ECT techniques have reduced them significantly. However, the benefits and risks of ECT should still be carefully weighed before an individual or his or her family and friends decide to go with the treatment.

Psychotherapy. As with all mental illnesses and other serious conditions, bipolar disorder can devastate a person's self-esteem and relationships, especially with spouses and family. Without treatment, people with the illness may jeopardize their finances, their careers, their families and their lives. Thus, in addition to treatment with medications, psychotherapy ("talk therapy") is also recommended for individuals with the disorder, as well as for their family members.

Bipolar Disorder and Pregnancy

Women with bipolar disorder who want to become pregnant need to consider several issues. Careful planning for pregnancy can help women with bipolar disease best manage their illness while avoiding risks to their babies. The goal is to maintain a stable mood during pregnancy and postpartum. It is extremely important to consider both the risks of the medications to the unborn baby, as well as the risks of untreated bipolar disorder to both the mother and unborn baby. These should be weighed carefully in a thorough discussion with your health care provider.

After discussing risks and benefits with your health care professional, if you prefer not to use medication during pregnancy, a trial off medications (following a gradual taper) prior to pregnancy, possibly only stopping medications after conception, might be an option. Most health care professionals suggest avoiding sudden changes in medication during pregnancy, which can increase the risk of relapse.

Overall, studies show that taking only one mood stabilizer during pregnancy poses less of a risk to the developing fetus than does taking multiple medications. Some anticonvulsants have been shown to be harmful to fetuses, possibly leading to birth defects. However, rates of problems vary widely based on the medication. Discuss possible medications and their risks with your health care professional and always weigh this against the risk of untreated bipolar disorder.

Some of these medications can be used while breastfeeding but all options should be discussed with your health care professional. Overall, if you are pregnant or planning to become pregnant and you have bipolar disorder, be sure to discuss safety of various treatment options during and after pregnancy with your health care professional.

ECT has also been used for decades (with appropriate adjustments) in pregnancy to treat severe mania or depression.

Prevention

Prevention

Patients and their families need to understand that bipolar disorder will not go away, and there is no way to prevent the disorder from developing. The only way to keep the disorder under control is through continued compliance with treatment.

Facts to Know

Facts to Know

  1. Bipolar disorder involves episodes of mania and depression.

  2. Traditionally, one percent of the population has been affected by bipolar disorder, but as the condition has expanded to include a spectrum of proposed bipolar conditions, this number has risen to an estimated 2.6 to 6.5 percent. According to the World Health Organization, bipolar disorder is the sixth leading cause of disability among people aged 15 to 44.

  3. Most people with bipolar disorder can expect that even their most severe mood swings will be relieved with treatment.

  4. Like other serious illnesses, bipolar disorder is not only difficult for the person who has it but also hard on family members, friends and employers. Family members of people with bipolar disorder often have to cope with serious behavioral problems (such as wild spending sprees) and the lasting consequences of these behaviors.

  5. Bipolar disorder generally strikes between the ages of 15 and 30.

  6. Bipolar disorder tends to run in families, and many researchers believe it is genetic. Researchers, however, have not associated a specific genetic defect with the disease.

  7. Not everybody with a family history of manic depression develops the illness.

  8. Studies suggest that stress, difficulty at work or with interpersonal relationships may trigger episodes in people with bipolar disorder, particularly if the stress causes loss of sleep.

  9. Lithium has been the treatment of choice for people with bipolar disorder but doesn't work for everyone with the disorder. Other effective treatment options are available.

  10. Bipolar disorder can get worse during and after pregnancy. Because of potential risk to the developing fetus due to both untreated illness as well as some medications, the disease must be carefully treated by a health care professional during this time.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about bipolar disorder so you're prepared to discuss this important health issue with your health care professional.

  1. Why did you diagnose me with bipolar disorder?

  2. What are the names and types of my medications and what are they supposed to do?

  3. How and when do I take these medications? Are there any side effects?

  4. Will they react with one another?

  5. What should I do if I notice side effects?

  6. How long do I have to take these medications?

  7. What if I want to become pregnant? How will my medications or my condition affect my pregnancy, my baby and the safety of my nursing my baby?

  8. Would I benefit from counseling?

  9. How can I keep my sleeping patterns regular?

  10. How can I keep my sleep patterns as regular as possible with a new baby?

  11. What should I do if I begin to have trouble sleeping or waking up?

  12. Other than medication, counseling, and attention to my sleep-wake cycle, what other things could I do to increase my chances of staying well?

Key Q&A

Key Q&A

  1. What is bipolar disorder?

    Also called manic depressive illness or manic depression, this mental illness is characterized by episodic mood swings that range from overly "high" and/or irritable to sadness and hopelessness, and then back again, with periods of normal mood in between.

  2. Who usually is affected by bipolar disorder?

    Men and women are equally likely to develop the condition, usually between the ages of 15 and 30. However, research has shown that women are more likely than men to develop the rapid cycling form of the condition—with episodes occurring four or more times within a 12-month period. Most often, symptoms begin between age 15 and 30. Research has shown that there is a genetic component to the disorder and that people with a close relative with bipolar disorder are four to six times more likely to develop it than people with no family history.

  3. Can the disorder be effectively treated?

    Yes. For nearly 40 years, lithium has been the treatment of choice for people with bipolar disorder. It levels out mood swings so that patients don't feel as high or as low and is used as an ongoing treatment. Symptoms may diminish after one to three weeks of treatment, but it might take a few months of medication to control the illness. Newer drugs developed for the disorder, used alone or in combination with lithium, are also prescribed.

  4. Can bipolar disorder be cured?

    No. Treatment for the illness in considered lifelong. Ongoing maintenance and periodic consultation with a knowledgeable health care professional is typical.

  5. What if I can't tolerate lithium?

    There are a number of other effective treatments. Your health care professional might prescribe several medications including both antidepressants and anticonvulsant medications. However, it may take several months to determine the proper medication, dosage and frequency.

Organizations and Support

Organizations and Support

For information and support on coping with Bipolar Disorder, please see the recommended organizations, books and Spanish-language resources listed below.

American Academy of Child and Adolescent Psychiatry (AACAP)
Website: http://www.aacap.org
Address: 3615 Wisconsin Ave., NW
Washington, DC 20016
Phone: 202-966-7300

American Psychological Association
Website: http://www.apa.org
Address: 750 First St., NE
Washington, DC 20002
Hotline: 1-800-374-2721
Phone: 202-336-5500

Association for Behavioral and Cognitive Therapies (ABCT)
Website: http://www.abct.org
Address: 305 7th Avenue, 16th Floor
New York, NY 10001
Phone: 212 647-1890

Bazelon Center
Website: http://www.bazelon.org
Address: The Bazelon Center for Mental Health Law
1101 15th Street NW Suite 1212
Washington, DC 20005
Phone: 202-467-5730
Email: info@bazelon.org

Child & Adolescent Bipolar Foundation
Website: http://www.bpkids.org
Address: 820 Davis St, Suite 520
Evanston, IL 60201-4448
Phone: 847-492-8519
Email: cabf@bpkids.org

Depression and Bipolar Support Alliance (DBSA)
Website: http://www.dbsalliance.org
Address: 730 N. Franklin Street, Suite 501
Chicago, IL 60610-7224
Hotline: 1-800-826-3632
Email: info@dbsalliance.org

Federation of Families for Children's Mental Health
Website: http://www.ffcmh.org
Address: 9605 Medical Center Drive, Suite 280
Rockville, MD 20850
Phone: 240-403-1901
Email: ffcmh@ffcmh.org

Geriatric Mental Health Foundation
Website: http://www.gmhfonline.org
Address: 7910 Woodmont Ave, Suite 1050
Bethesda, MD 20814
Phone: 301-654-7850
Email: web@GMHFonline.org

Mental Health America
Website: http://www.mentalhealthamerica.net
Address: 2000 N. Beauregard Street, 6th Floor
Alexandria, VA 22311
Hotline: 1-800-969-6642
Phone: 703-684-7722

National Alliance on Mental Illness (NAMI)
Website: http://www.nami.org
Address: Colonial Place Three
2107 Wilson Blvd., Suite 300
Arlington, VA 22201
Hotline: 1-800-950-NAMI (1-800-950-6264)
Phone: 703-524-7600

National Institute of Mental Health
Website: http://www.nimh.nih.gov
Address: Science Writing, Press and Dissemination Branch
6001 Executive Boulevard, Room 8184, MSC 9663
Bethesda, MD 20892
Hotline: 1-866-615-6464
Phone: 301-443-4513
Email: nimhinfo@nih.gov

National Mental Health Consumers' Self-Help Clearinghouse
Website: http://www.mhselfhelp.org
Address: 1211 Chestnut St., Suite 1207
Philadelphia, PA 19107
Hotline: 1-800-553-4539
Phone: 215-751-1810
Email: info@mhselfhelp.org

SAMHSA's National Mental Health Information Center
Website: http://mentalhealth.samhsa.gov
Address: P.O. Box 2345
Rockville, MD 20847
Hotline: 1-800-789-2647
Phone: 240-221-4021

Screening for Mental Health (SMH)
Website: http://www.mentalhealthscreening.org
Address: One Washington Street, Suite 304
Wellesley Hills, MA 02481
Phone: 781-239-0071
Email: smhinfo@mentalhealthscreening.org

Why Am I Up, Why Am I Down? Understanding Bipolar Disorder
by Roger Granet, Elizabeth Ferber

50 Signs of Mental Illness: A Guide to Understanding Mental Health
by Dr. James Whitney Hicks

Bipolar II: Enhance Your Highs, Boost Your Creativity, and Escape the Cycles of Recurrent Depression--The Essential Guide to Recognize and Treat the Mood Swings of This Increasingly Common Disorder
by Ronald R. Fieve

Bipolar Disorder
Website: http://www.nlm.nih.gov/medlineplus/spanish/bipolardisorder.html
Address: U.S. National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov

Factsheet: Bipoloar Disorder in Children
Website: http://www.mentalhealthamerica.net/go/en-espanol
Address: Mental Health America
2000 N. Beauregard Street, 6th Floor
Alexandria, VA 22311
Hotline: 1-800-969-6642
Phone: 703-684-7722
Email: sjones@mentalhealthamerica.net

Last date updated: 
Fri, 2009-12-11

What is it?

Overview

What Is It?
ADHD interferes with your ability to regulate activity (hyperactivity), control some behaviors (impulsivity) and focus on tasks (inattention).

Experts suggest that attention deficit hyperactivity disorder (ADHD) affects an estimated 8 percent of school-aged children, and about two-thirds of children diagnosed with ADHD continue to show signs of the disorder into adulthood.

ADHD interferes with your ability to regulate motor activity (hyperactivity), control key behaviors (impulsivity) and focus on tasks (inattention). When the hyperactivity is not present, the condition is sometimes called attention deficit disorder (ADD), although the more accurate term is ADHD-inattentive type.

By current estimates, more than two times as many boys as girls are affected by ADHD, but the ratio appears to become more even by adulthood.

Overall, women and girls may exhibit fewer of the typical symptoms associated with ADHD in boys. For example, girls with ADHD are more likely to be reserved than hyperactive. They tend to be less defiant and more compliant than boys and men with the condition. Like boys and men with ADHD, however, women with the condition may have difficulty completing tasks and remaining organized. Instead of being tested for ADHD, they're often dismissed as flighty or spacey.

Thus, because girls are less likely to disrupt class—the kind of behavior that often brings boys with the condition to medical professionals' attention—girls are less likely to get diagnosed with ADHD. Consequently, many girls and women do not get the help they need. Often, girls' self-esteem suffers as they encounter academic problems in school. They may have difficulty with interpersonal relationships as well as social challenges.

These secondary difficulties may result in depression, anxiety disorders, problems sleeping, self-harmful (cutting) behaviors and/or abuse of alcohol or other substances. Furthermore, girls with ADHD are at greater risk for early pregnancy, promiscuity and sexually transmitted diseases. A recent study following girls for 10 years showed significantly higher risk for suicide attempts and self-injury compared to a comparison group.

Once diagnosed, many women recall painful or difficult childhood experiences in school that were likely to have been linked to ADHD but attributed at the time to other causes, such as laziness or lack of ability. This misattribution can itself lead to significant damage to self-esteem and self-confidence, resulting in demoralization.

Causes of ADHD

Although no one knows for sure what causes ADHD, the condition does run in families, suggesting a strong genetic component. Children who have a parent with ADHD are at an increased risk for ADHD themselves. And twin and adoption studies confirm a high degree of genetic connection with this condition. For identical twins, there is a strong chance the other twin has it. Again, this "family resemblance" appears strongly related to genes rather than social factors. Many researchers around the world are now investigating various genes that may contribute to the development of ADHD in families. It is unlikely a single gene is responsible, but undoubtedly many genes, operating interactively with one another and with environmental risks.

A smaller percentage of cases of ADHD are due to environmental or nongenetic biological risk factors, including premature birth, low birth weight; prenatal use of alcohol, tobacco and/or cocaine; and exposure to lead, which can alter brain development in the fetus. Infections and complications during pregnancy can also increase the chances that a baby will eventually develop ADHD in childhood. Additionally, some postnatal problems, such as chronic low levels of lead, recurrent ear infections or severe head trauma, can result in ADHD.

For years, ADHD was thought to be a disruptive behavior disorder that most experts intuitively believed involved some brain abnormality. With the development of more sophisticated brain scanning techniques, it is now known that people with ADHD do have anatomical differences in their brains, as well as differences in the biochemical balance that controls everything from mood to impulses.

Brain imaging studies show differences in ADHD brains in several areas:

  • differences in dopamine receptors in specific areas of the brain
  • differences in total brain volume and brain volume of specific areas of the brain
  • differences in the brain networks that are used to solve specific tasks
  • differences in the rate of maturation of frontal/prefrontal areas of the brain

Children with ADHD show a pattern of delayed maturation of certain regions of the brain compared to their peers without the disorder. These regions of delayed development are involved with controlling motor behavior, impulse control and attention levels. The conclusion is that slower brain development is a characteristic of ADHD brains and may explain the delay in development of emotion/impulse control and organizational skills.

Another biological component of ADHD has to do with levels of certain neurotransmitters in the brain. Adults with ADHD who have never received any medication have lower amounts of receptors for the neurotransmitter dopamine in key subcortical regions linked to motivation and reward than do adults without the disorder. In fact, stimulant medications used in the treatment of ADHD help balance levels of dopamine, improving symptoms of inattention, hyperactivity and impulsivity.

ADHD is not caused by many environmental triggers commonly believed to be associated with the disorder, such as too much TV, food allergies, eating too much sugar, problematic home life, poor teaching or schools or permissive parenting. Still, it is essential to realize that the home environment and the school setting are extremely important in managing ADHD—and that ineffective parenting and educational settings can exacerbate the symptoms and lead to additional impairments.

Diagnosis

Diagnosis

Attention deficit hyperactivity disorder (ADHD) is the most prevalent chronic neurobiological disorder in children. Once thought to affect only children, it is now recognized as a disorder that most often continues into adulthood and presents unique issues for girls and women.

Common symptoms of ADHD can include:

  • failing to give close attention to details or making careless mistakes
  • difficulty sustaining attention to tasks
  • appearing not to listen when spoken to directly
  • failing to follow instructions carefully and completely
  • losing or forgetting important things
  • feeling restless or fidgeting
  • talking excessively or blurting out answers before hearing the whole question

ADHD is a serious diagnosis that can have a tremendous negative impact on your life, work and family. It may require long-term treatment with counseling and medication, so it's important that a health care professional carefully evaluate all symptoms to rule out other conditions that could cause similar symptoms or behaviors.

For instance, stress can cause symptoms similar to those seen in ADHD, such as forgetfulness or feeling overwhelmed and disorganized. However, reactions to stress are usually temporary, subside when the stressful events pass, and are not present in a chronic fashion since childhood. Symptoms caused by ADHD are persistent, chronic and unchanging since childhood or early adolescence.

The diagnosis itself, however, must be approached very carefully and shouldn't be done during a time-limited office visit with a pediatrician or other medical doctor. Improper treatment from misdiagnosis or failure to obtain treatment because of a missed ADHD diagnosis can both have significant, long-term consequences.

To reach an ADHD diagnosis in children, health care professionals use diagnostic criteria published by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV-TR) and consider information from other sources. For example, interviews with the patient, the patient's family and, in the case of children, information provided by caregivers and teachers who see the child regularly can provide a picture of the patient's behavior and learning styles.

Diagnosing and treating adults is challenging. The diagnostic criteria, with their emphasis on school behavior and performance, are designed to make the diagnosis in children, not adults. Hyperactivity, for instance, tends to diminish by adulthood, although other symptoms, such as inattention, may appear worse because of mounting adult responsibilities.

The following informal checklist further describes behaviors in adults that may be the result of ADHD. An individual having chronic problems since childhood with many of these symptoms may require further evaluation:

  • I am constantly trying to get organized, but can never seem to get or stay there.

  • I often feel that I talk too much or impulsively blurt things out.

  • I often feel overwhelmed.

  • I make impulsive purchases and decisions.

  • I frequently misplace personal items.

  • I start one thing but never finish it because I am distracted by something else.

  • I am frequently late.

  • I am a procrastinator.

  • I often make careless errors and oversights during the day.

  • I often pay bills late and have difficulty managing my money.

There are three primary subtypes of ADHD: predominantly hyperactive-impulsive, predominantly inattentive and combined hyperactive-impulsive and inattentive. The DSM-IV lists these other signs of ADHD, many of which apply to children in the classroom:

Inattention

Those who are inattentive find it difficult to keep their minds on any one thing and may get bored with a task after only a few minutes. They may, however, give effortless, automatic attention to activities and things that are highly engaging, like video games. But they may have difficulty with deliberate focus, conscious attention on organizing and completing tasks, responses to repetitive materials or mastery of challenging information.

Hyperactivity-impulsivity

  • Hyperactivity: Those who are hyperactive always seem to be in motion and have trouble sitting still. They squirm in their seats or roam around the room. Or they might wiggle their feet, touch everything or noisily tap their pencils. They may be fidgety or try to do several things at once, bouncing around from one activity to the next. They report an internal sense of restlessness and the need to continually move around.

  • Impulsivity: Those who are overly impulsive seem unable to curb or weigh their immediate reactions, thoughts and behaviors before acting. As a result, they may blurt out inappropriate comments or physically attempt something without thinking it through. This could apply to taking tests in school as well as participating in potentially dangerous behaviors. Their impulsivity also makes it hard for them to wait for things they want. This leads to poor frustration tolerance and temper outbursts.

Not everyone who is overly hyperactive, inattentive or impulsive has an attention disorder. Nor does everyone with ADHD exhibit all behaviors associated with the disorder. It's important to realize that during certain stages of development, it may be normal for children to be inattentive, hyperactive or impulsive, and that these behaviors at these stages don't fit an ADHD profile.

For example, preschoolers typically have lots of energy and run everywhere they go, but that doesn't mean they are hyperactive. And many teenagers go through a phase when they are messy, disorganized and reject authority. This phase doesn't necessarily persist as a lifelong problem with attention, organization and/or impulse control.

Because everyone exhibits some of these behaviors at times, the DSM-IV contains very specific guidelines for determining when the behaviors indicate ADHD. Specific symptoms must appear early in life, before age seven, and continue for at least six months. In children, they must be much more frequent or severe than in others the same age. Above all, the behaviors must create a real handicap in at least two areas of a person's life, such as school, home, work or social settings. However, it's important to know that the inattentive type of ADHD may not be diagnosed until age nine or 10, the age when symptoms of inattention become noticeable and problematic because school demands have increased.

So if your behavior or your child's doesn't impair work, friendships or other relationships, you probably won't be diagnosed with ADHD. Nor would a child who seems overly active at school but who functions well elsewhere.

Health care professionals also consider the following questions during an assessment for ADHD:

  • Are these behaviors excessive, long-term and pervasive? That is, do they occur more often in you or your child than in others the same age?

  • Are they a continuous problem rather than a response to a temporary situation?

  • Do the behaviors occur in several settings or only in one specific place?

The health care professional pieces together a profile of behaviors, based on all available information, and then considers:

  • Which ADHD-like behavior patterns listed in the DSM-IV are apparent?

  • How often and in what situations?

  • How long have they been going on?

  • How old was the child/adult when the problem(s) started?

  • Are the behaviors seriously interfering with school, friendships, activities or home life?

  • Are there any other related problems?

  • Is there a parent with ADHD symptoms?

The answers to these questions help identify whether the hyperactivity, impulsivity and inattention are significant and long-standing. If so, a diagnosis of ADHD may be made.

Other conditions may occur with ADHD, making it more difficult to arrive at a clear diagnosis. Women and girls with ADHD, for example, are more prone to depression than men and boys with ADHD. A serious but treatable mental disorder, depression can disrupt all areas of your life, including mood, sleep, appetite, relationships, and the ability to think clearly. If you think you're suffering from depression, it's critical that you get a diagnosis and proper treatment. Left untreated, depression can be life-threatening, given the risk of suicide that accompanies the disorder.

Anxiety is another common condition seen in those with ADHD. Some children with ADHD, for example, feel tremendous worry, tension or uneasiness, even when there's nothing to fear. Because the feelings are scarier, stronger and more frequent than normal fears, they can affect the child's thinking and behavior.

Children with ADHD are also more likely to have achievement problems than children without the disorder, even if they don't have a full-blown learning disability. ADHD is not in itself a learning disability but learning disabilities commonly occur with ADHD. But because it can interfere with concentration and attention, it can make it doubly hard for a child to do well in school, creating lifelong frustrations.

A very small number of people with ADHD have a rare disorder called Tourette syndrome. People with Tourette syndrome have tics and other involuntary movements like eye blinks or facial twitches they can't control. Some may grimace, shrug, sniff or bark out words. Fortunately, these behaviors can be controlled with medication.

The effects of ADHD extend far beyond the classroom, often wreaking havoc on everything from educational budgets to sibling relationships. In 2005, the CDC reported that the educational cost of ADHD was about $36 billion to $52 billion annually. Children with ADHD use more mental health services, have more frequent emergency department visits and have higher rates of pedestrian, bicycle and driving accidents than children without ADHD. All of which places extreme stress on their parents.

It doesn't matter if the child with ADHD is male or female; parenting either is equally stressful. Overall, mothers of children with ADHD report significantly higher levels of parenting stress than mothers of children with other chronic disorders, and they're more likely to become depressed.

Parents of children with ADHD are also more likely to experience increased absenteeism and decline in productivity in the workforce than parents of children without the disorder. The annual cost to the economy in terms of lack of productivity, unemployment and related issues linked to ADHD is measurable in many billions of dollars. Of course, ADHD also places tremendous strain on relationships and places marriages at higher risk for divorce. Learning how to manage children with ADHD effectively and consistently is a major component of most treatment plans.

Some research looks at the concept of executive function (EF). This involves the ability to organize, sequence a task, shift from task to task, prioritize, plan and anticipate, and hold information in your memory as you consider multiple factors when making a decision. Some researchers consider executive dysfunction inherent to ADHD, while others consider it a separate category as defined by neuropsychological test results. Children and adults with ADHD plus EF deficits show more academic and life impairments that those with ADHD without EF dysfunction. ADHD medication, although helpful for ADHD symptoms, has much less beneficial effect on EF symptoms. Skills-based therapies are more useful in these cases.

Getting a Diagnosis

Several types of health care professionals are qualified to diagnose and treat ADHD.

For children:

  • Child psychiatrists are physicians who specialize in diagnosing and treating childhood mental and behavioral disorders. A psychiatrist can provide therapy and prescribe any necessary medications.

  • Child psychologists are also qualified to diagnose and treat ADHD. They can provide therapy for the child and help the family develop ways to deal with the disorder. But psychologists are not medical doctors and must rely on physicians for medical exams and prescriptions.

  • Neurologists, physicians who work with disorders of the brain and nervous system, can also diagnose ADHD and prescribe medicines. They will likely be involved with any brain imaging tests. But unlike psychiatrists and psychologists, neurologists usually do not provide therapy for the emotional/organizational aspects of the disorder.

  • Family physicians receive training to provide continuing and comprehensive medical care, health maintenance and preventive services to patients of all ages. When it comes to ADHD, they can diagnose the condition, prescribe medications and, in some cases, provide counseling.

  • Pediatricians are physicians who have specialized training in treating children's illnesses. Like family practitioners, pediatricians may or may not have specialty training in or experience with ADHD. Because ADHD is most prevalent in children, it is likely that a pediatrician will have experience in the ADHD screening process and can help rule out (or identify) medical conditions similar to behavior or learning patterns of ADHD. Pediatricians can also provide referrals to local ADHD specialists.

  • Developmental and behavioral pediatricians specialize in behavior and development in children. Serving as a liaison with primary care physicians and other medical specialists, developmental and behavioral pediatricians serve as key members of a multidisciplinary team. They provide comprehensive developmental, medical and behavioral assessments; education for parents and professionals regarding various medical/developmental diagnoses; and medical management of ADHD and other neurobehavioral disorders.

For adults:

  • Psychologists, psychiatrists, neurologists and primary care physicians may also diagnose and treat ADHD in adults. But not all health care professionals are trained and skilled in identifying or treating ADHD in adults.

Within each specialty, individual health care professionals and mental health professionals differ in their knowledge of and experience with ADHD. So when selecting a health care professional, it's important to find someone with specific training and experience in diagnosing and treating the disorder and distinguishing coexisting psychiatric disorders.

Treatment

Treatment

An effective treatment plan will help you cope with ADHD, whether you or your child is the one with the diagnosis. For adults, the treatment plan may include medication along with practical and emotional support. For children and adolescents, it may include providing an appropriate classroom setting and accommodations, as well as medication and helping parents understand and manage the child's behavior.

Treatment for ADHD may involve medication, behavioral/psychological counseling, educational/workplace interventions or a combination.

Three medications in the class of medications known as psychostimulants, or stimulants, seem to be the most effective in treating ADHD in both children and adults. These are:

  • Methylphenidate (e.g., Ritalin, Concerta, Metadate, Methylin, Daytrana). Methylphenidate is available in brand name and generic tablets,capsules and liquid. Daytrana is a methylphenidate transdermal patch approved for treating ADHD in children aged six to 12.

  • Dexmethylphenidate (Focalin, Focalin XR)

  • Dextroamphetamine-amphetamine mix (Adderall, Adderall XR).

  • Dextroamphetamine(Dexedrine, Dextrostat, Concentra).

  • Lisdexamfetamine (Vyvanse)

Stimulant medications, when used with medical supervision, are usually considered safe. Stimulants seldom make children with ADHD "high" when taken as prescribed. Because these medications are stimulants, there is no sedating effect. However, restlessness and fidgetiness may decline leaving the person feeling "calmer." Ultimately, the stimulants help children control their hyperactivity, inattention and other ADHD-related behaviors.

Stimulant drugs are available in both short-, medium- and long-acting forms. The short-acting forms last for about four hours, medium-acting forms for about 6 hours and long-acting forms last 8 to 14 hours.

Stimulants do carry the risk of abuse and addiction. However, abuse and dependence with ADHD stimulant medication are more likely with short-acting forms. To reduce chances of substance abuse, make sure you or your child is getting the right dose of stimulant medication at the needed time of the day. Do not put your child or adolescent in charge of his or her own medication. Keep medication locked in a childproof container at home. If a school time dose is needed, don't send supplies of medication to school with your child; instead, deliver medication to the school nurse or health office yourself.

Although sudden deaths have occurred in children on stimulant medications, a recent extensive review of sudden death in children and adolescents on stimulant medication concluded that stimulant medication poses no increased risk for sudden death, cardiac arrest or stroke compared to children and adolescents not on these medication. Always review medication packaging information, and talk to your health care professional about this potential risk. Heart screening questions to assess any risk should be asked before starting any ADHD medication.

Additionally, stimulant medications have been associated with a slightly reduced growth rate in some children, although the extent of this appears to be a half inch on average.

Other potential side effects, such as weight loss, problems sleeping and tics, should be carefully weighed against the benefits before prescribing the medications. Preexisting tics may or may not worsen with stimulant medication. Most side effects can often be handled by reducing the dosage.

Atomoxetine (Strattera). The first non-stimulant medication approved to treat ADHD, Strattera is classified as a selective norepinephrine reuptake inhibitor. It works by blocking norepinephrine in the brain, thus leading to greater amounts in the synapse when the medication is used. Overall, Strattera has been shown to lead to significant improvements in individuals with ADHD, but the benefit may be less substantial than stimulants.

Strattera has been linked to rare side effects that include liver problems as well as the increased risk of suicide, according to the FDA. Call your health care professional right away if you or your child experiences yellowing of the skin or eyes (jaundice), unexplained flu-like symptoms or dark-colored urine, or if you or your child has thoughts of suicide or a sudden change in mood or behavior, especially at the beginning of treatment or after a change in dose.

Strattera is not classified as a controlled substance like the other ADHD medications (i.e., the stimulants), although it is a prescription drug. Unlike stimulants, refills can be provided on prescriptions. Side effects include: decreased appetite, upset stomach, nausea or vomiting, and fatigue. In addition, some of the most common side effects in adults are problems sleeping, dry mouth, dizziness, problems urinating (more so in males) and sexual side effects.

Other additional medications are sometimes used to treat the condition if stimulants don't work completely or if the ADHD occurs with another disorder. These medications are not approved for the treatment of ADHD, yet many have been shown effective in at least some studies.

For example, clonidine (Catapres) and guanfacine (Tenex), medications normally used to treat hypertension, may be helpful in people with ADHD who have tics and/or insomnia as a result of ADHD medications or who experience aggression as part of their condition. Clonidine can be administered either by pill or skin patch and has different side effects than stimulants, including rash (from the patch), constipation,nervousness and sedation.

Other medications not FDA-approved for ADHD but that may be prescribed include the antidepressants nortriptyline (Pamelor, Aventyl) and bupropion (Wellbutrin).

Antidepressants may temporarily increase risk of suicidal thoughts and behavior in people up to age 24, according to the FDA. Short-term studies in children and adolescents with major depressive disorder and other psychiatric disorders showed an increased risk of suicidal thoughts in those taking antidepressants, during the initial weeks of treatment. Although this effect is rare, anyone considering the use of an antidepressant in a child or adolescent must balance this risk with the need for the drug.

Also, health care professionals should observe their patients closely for any increased risk of suicide or unusual changes in behavior. Families and caregivers should also closely watch patients.

Medication won't cure ADHD; it will just control the symptoms while you're taking the medication. For instance, stimulants have only immediate benefits, so once a dose wears off that day, the symptoms return.

Also, although the medications may help you pay better attention to and complete your work, they can't increase your knowledge or improve your (or your child's) academic skills. As the expression goes, "Pills don't teach skills." The medications alone can't make you feel better about yourself or cope with problems. These issues require other kinds of treatment and support.

Psychosocial Treatment

Although ADHD primarily affects a person's behavior and cognition, the disorder has broad emotional repercussions. Scolding is the only attention some people with ADHD ever get while growing up. They may have few positive experiences to build their sense of worth and competence. Facing the daily frustrations that can come with having ADHD can make people fear that they are strange, abnormal, lazy or stupid.

Often the cycle of frustration, blame and anger has gone on so long it becomes incorporated into one's self-concept. In such cases, mental health professionals can help adolescents and adults with ADHD develop new skills, attitudes and ways of relating to other people. Often successful treatment will help a person separate the disorder (ADHD) and its symptoms/impairments from the individual and their innate strengths and potential.

In group counseling, people learn that they are not alone; other people with ADHD have similar experiences, and there are people who want to help. Support from group therapy can be complimented with individual therapy to address specific life issues. Very often, ADHD symptoms and inconsistent performance adversely affects personal relationships. Family and marital therapy with a professional aware of ADHD can be helpful in changing the communication pattern.

Several types of therapy are available, with different therapists preferring different approaches. Knowing something about the various types of interventions makes it easier to choose a therapist.

  • Psychotherapy works to help people with ADHD like and accept themselves despite their disorder. In psychotherapy, patients talk with the therapist about upsetting thoughts and feelings, explore self-defeating patterns of behavior and learn alternative ways to handle their emotions. As they talk, the therapist tries to help them understand how they can change. However, people dealing with ADHD usually want to gain control of their symptomatic behaviors more directly. The following interventions can provide that kind of help.
  • Behavior therapy, used with children and adolescents, involves providing parents with education about ADHD, teaching them to use regular and consistent rewards and punishments with their children and coordinating efforts with teachers at school. Indeed, for children and adolescents, behavior therapy and medication are the only two evidence-based interventions that consistently lead to improvement in symptoms and impairments.
  • Cognitive-behavioral therapy helps you work on immediate issues. Rather than helping you understand your feelings and actions, it supports you directly in changing your thoughts and behavior. The support might be practical assistance, like learning to think through tasks and organize work or changing a repetitive negative thought pattern. Cognitive therapies have not been found to be very helpful for children and adolescents, but for adults, results are promising.
  • Social skills training helps children and adults learn new behaviors, specifically social behaviors. Impulsive behavior can be intrusive and abrasive in interactions. In social skills training, the therapist discusses and models appropriate behaviors and helps the patient practice the new behavior. It is essential that clear limits are set in the social skills groups; otherwise, children may model maladaptive behaviors from one another.
  • Support groups connect people who have common concerns. Many adults with ADHD and parents of children with ADHD find it useful to join a local or national support group. Many groups deal with issues of children's disorders, and even ADHD specifically.

Ineffective or unproven alternative treatments

The following treatments have NOT been scientifically shown to be effective in treating people with ADHD:

  • restricted diets (although recent studies from the United Kingdom do show small effects of certain food additives on hyperactive behavior)

  • allergy treatments

  • medicines to correct problems in the inner ear

  • megavitamins

  • chiropractic adjustment and bone realignment

  • treatment for yeast infection

  • eye training

  • special colored glasses

  • herbal supplements

  • essential fatty acids

  • yoga and meditation

Neurofeedback, also known as biofeedback, is a promising intervention, not completely supported by definitive studies but with some recent investigations yielding support for improvements in attention and behavior.

Be cautious about pursuing complementary and alternative treatments that are not supported by scientific research and/or the U.S. Food and Drug Administration. Although single positive studies often receive media attention, it is important that such findings be replicated. Until sound, scientific testing shows a treatment to be effective, families risk spending time, money and hope on fads and false promises.

Managing Your Life as an Adult with ADHD

Here are some practical steps you can take to manage your life with ADHD from ADHD expert Kathleen Nadeau, PhD.

  1. Give yourself a break. High expectations are deeply ingrained in many women. Identify your strengths and perform those tasks. Identify your weakness and either find a compensatory skill or ask someone else to perform these tasks. Psychotherapy can help capitalize on strengths while limiting the impairments in areas of weakness.

  2. Educate your partner about ADHD and how it affects you. Your partner may be angry or resentful about a less-than-organized lifestyle. If your partner understands this as a disorder, he or she may be more understanding and accommodating. Reassign household responsibilities based on skill strength. Strategize how to make your life at home and work more accommodating.

  3. Try to create an "ADHD-friendly" environment in your home and work. If you can approach your ADHD with acceptance and good humor, tensions will decrease and you'll save more energy for the positive side of things.

  4. Simplify your life. Look for ways to reduce commitments so you're not always pressed for time. Learn how to better prioritize tasks to avoid overcommitment.

  5. Choose supportive friends. Many women describe friends or neighbors whose houses are immaculate, whose children are always clean, neat and well-behaved and who make them feel terrible by comparison. Try to avoid situations that lead you to impossible expectations and negative comparisons.

  6. Build a support group for yourself. For example, ask a friend who understands your condition to keep you company while completing a task that is always difficult for you.

  7. Build in daily breaks. This is essential when you have ADHD, especially if you're raising children. Make them routine so that you don't have to keep planning and juggling. For example, arrange for a regular babysitter several times a week.

  8. Eliminate and delegate. Look at things that you require of yourself at home or on the job. Can you eliminate some of these things? Can you hire someone to do some of them?

  9. Get help for premenstrual or menopausal symptoms. They may be severe in women with ADHD. Managing the destabilizing effects of your hormonal fluctuations is a critical part of managing your ADHD.

  10. Make lists and encourage other family members to list and record activities, responsibilities and events. Try to create a central family calendar with all activities for everyone to check. Online calendars may facilitate this. Avoid scattering information on multiple pieces of paper that can get lost.

  11. Create filing systems or organizational systems that work for you. Color coding folders is a fast visual way to identify what's in them. Set up autopay for bills, provided you have money and won't overdraw accounts. Don't let yourself be overwhelmed at home or at the office by mountains of paperwork: sort, file or discard.

Prevention

Prevention

According to current medical research, there is no known way to prevent most ADHD. There are some pre and post-natal risk factors that can be addressed: avoid alcohol and tobacco when pregnant, avoid a premature birth if possible and avoid lead exposure to the child.

Facts to Know

Facts to Know

  1. It is estimated that attention deficit hyperactivity disorder (ADHD), also known as attention deficit disorder (ADD) when present without hyperactivity, affects 8 percent of U.S. school-aged children, according to the Centers for Disease Control.

  2. Follow-up studies of children with ADHD find that the vast majority will continue to suffer impairments through adolescence, and 60 percent through adulthood. Many girls and women suffer the effects of ADHD and do not get the help they need.

  3. Once diagnosed, many women recall painful or difficult childhood experiences in school that were likely caused by ADHD, but at the time were attributed to laziness or lack of ability. Low self-esteem is the outcome of chronic criticism and is common among women with ADHD.

  4. ADHD, once called hyperkinesis or minimal brain dysfunction, is the most common psychiatric condition among children. More than two times as many boys as girls are affected in childhood; however, in adults it's almost equal proportions.

  5. ADHD can be mild, moderate or severe. An ADHD diagnosis is more difficult to identify in women and girls because they tend to be less hyperactive, less defiant and more compliant than boys (though this is not always the case). The absence of disruptive behavior can delay identification.

  6. ADHD has a very strong genetic component. Children who have a parent with ADHD or another mood or behavioral disorder are at an increased risk. Still, as with other conditions with a strong genetic liability, the quality of life and the provision of strong parenting and quality schooling can greatly influence any long-term outcomes.

  7. Like all chronic medical conditions, there are no cures for ADHD. Treatment for ADHD may involve medication, behavioral/psychological counseling, educational interventions or a combination.

  8. Medication can help to control the core symptoms: hyperactivity, impulsivity and inattention. But more often, there are other aspects of the problem that medication won't alleviate. Even though ADHD primarily affects a person's behavior and cognition, having the disorder has broad emotional repercussions.

  9. Currently, ADHD is a diagnosis made in people who demonstrate chronic and persistent symptoms across a number of settings. Although people identify with some of these symptoms at different times in their lives, ADHD is a disorder starting in childhood that usually persists into adulthood. Childhood onset (or early adolescence, in the case of the inattentive type) is the cornerstone of the diagnosis. There is no such disorder as "adult-onset ADHD," although some adults with this condition may not have been diagnosed as children.

Questions to Ask

Questions to Ask

Review the following Questions to Ask about attention deficit hyperactivity disorder (ADHD) so you're prepared to discuss this important health issue with your health care professional.

  1. Do you have experience in diagnosing/treating ADHD? How long have you been treating patients with ADHD?

  2. Do you have experience treating girls with ADHD?

  3. Do I or does my child have ADHD? How can you tell? Could something else be causing this behavior?

  4. What can I do about my child's behavior at home and school? How can I help my child?

  5. What can I do to function better at home and work? What tools can I use to organize my responsibilities and activities?

  6. Should I or my child be medicated for ADHD? What are the risks of medication for ADHD? What can I expect the benefits will be with medication?

  7. Do you offer counseling or behavior therapy as well as medication? Do you know of others in the community who can offer such treatment?

  8. When should I or my child be medicated, and when is it not necessary to take the medication?

  9. How should I approach the subject of ADHD with the people in my life, such as relatives, colleagues, other parents or teachers?

  10. Are there support groups for people with ADHD and their families?

  11. Can I expect my child to grow out of ADHD?

  12. Do you have experience working with adults and/or women with ADHD?

  13. As an adult with ADHD, should I tell my employer, boyfriend, husband, partner?

  14. What accommodations can I get at school or work in regards to my ADHD?

  15. As an adult on other medications, what concerns should I have when adding ADHD medication?

Key Q&A

Key Q&A

  1. I have trouble focusing on tasks and often feel overwhelmed during times of extreme stress. Does this mean I have attention deficit hyperactivity disorder (ADHD)?

    Not necessarily. Stress can cause symptoms similar to ADHD, such as forgetfulness or feeling overwhelmed and disorganized. Reactions to stress are usually temporary and subside when stress subsides. These symptoms should not be confused with ADHD symptoms or behaviors, which are long lasting and persistent.

  2. Are bad parenting skills to blame for ADHD?

    No. ADHD is a complex neurobiological disorder that affects learning and behavior. Too much TV, poor home life, poor schools or teachers, food allergies or excess sugar do not cause ADHD. International research demonstrates the presence of ADHD in children regardless of culture and parenting. Still, how a family responds to their child's ADHD may go a long way in shaping the child's ultimate outcome. Biology is not destiny.

  3. Does ADHD only affect children? I think I recognize some symptoms in myself.

    No. Until recent years, adults were not thought to have ADHD, so many adults with ongoing symptoms have never been diagnosed. There has been a recent increased awareness of adult ADHD, however. About half of children with ADHD continue to have impairments through adulthood. The recent awareness of adult ADHD means that many people can finally be correctly diagnosed and treated.

  4. What causes ADHD?

    Scientists are not sure what causes ADHD, although genetic and neurobiological factors are clearly involved. Health care professionals stress that because there is no known cause, it is far more important for a woman and her family to move forward with treatment and identify ways to manage her lifestyle in areas affected by ADHD than to search for a cause.

  5. Can stimulant medications be abused?

    Although stimulant medications are recognized as a safe and effective treatment for ADHD when taken as prescribed, these medications, like many others, nonetheless do have the potential for abuse. Stimulant medication has been misused by people without ADHD. They take these medications to increase alertness and focus but also to gain a "high." Substance abuse and dependence does not develop in people who take their medications as prescribed. You should discuss the risks and benefits of stimulant medication with your health care professional. If you have a history of substance or alcohol abuse, this should be discussed with your physician to choose the right course of treatment and medication.

  6. My relationship with my husband has suffered because of my ADHD. Is there anything I can do?

    Yes. Because adult women often suffer for many years without help for their ADHD, their personal relationships can become strained. Health care professionals usually recommend counseling for women and their families, along with medication treatments. A therapist can assist you and your family in finding better ways to deal with your ADHD and reduce the frustration of the non-ADHD spouse/family member.

  7. Is ADHD a learning disorder?

    No. ADHD is a specific psychiatric disorder that can occur with a coexisting learning disorder. Learning disorders do not, in general, improve with medication. Intelligence and ADHD are separate entities. People with ADHD can have a broad range of IQs. Regardless of IQ, most ADHD individuals feel frustrated at not living up to their potential because of the impairments.

Organizations and Support

Organizations and Support

For information and support on coping with Attention Deficit Hyperactivity Disorder, please see the recommended organizations, books and Spanish-language resources listed below.

Attention Deficit Disorder Association
Web Site: http://www.add.org
Address: 15000 Commerce Parkway, Suite C
Mount Laurel, NJ 08054
Phone: 856-439-9099
Email: adda@add.org

Attention Deficit Information Network (ADIN)
Address: 475 Hillside Avenue
Needham, MA 02194
Phone: 617-455-9895

CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder)
Web Site: http://www.chadd.org
Address: 8181 Professional Place, Suite 150
Landover, MD 20785
Hotline: 1-800-233-4050
Phone: 301-306-7070

Learning Disabilities Association of America
Web Site: http://www.ldaamerica.org
Address: 4156 Library Road
Pittsburgh, PA 15234
Phone: 412-341-1515

National Center for Girls and Women with AD/HD
Web Site: http://www.ncgiadd.org
Address: 3268 Arcadia Place NW
Washington, DC 20015
Hotline: 1-888-238-8588
Email: contact@ncgiadd.org

National Institute of Neurological Disorders and Stroke
Web Site: http://www.ninds.nih.gov
Address: NIH Neurological Institute
P.O. Box 5801
Bethesda, MD 20824
Hotline: 1-800-352-9424
Phone: 301-496-5751

A.D.D. & Romance: Finding Fulfillment in Love, Sex, & Relationships
by Jonathan Halverstadt

ADHD: A Path to Success: A Revolutionary Theory and New Innovation in Drug-Free Therapy
by Lawrence Weathers

ADHD Handbook for Families: A Guide to Communicating with Professionals
by Paul Weingartner

The Attention Deficit Answer Book: The Best Medications and Parenting Strategies for Your Child
by Michael Boyett

Put Yourself in Their Shoes: Understanding Teenagers with Attention Deficit Disorder
by Harvey C. Parker

Kids Health from Nemours Foundation
Website: http://kidshealth.org/parent/emotions/behavior/adhd.html
Email: PR@KidsHealth.org

Centers for Disease Control and Prevention
Website: http://www.cdc.gov/ncbddd/Spanish/adhd/whatisADHD.htm
Address: Centros para el Control y la Prevención de Enfermedades,
1600 Clifton Road
Atlanta, GA 30333
Hotline: 1-800-232-4636
Phone: 404-639-3311
Email: cdcinfo@cdc.gov

Last date updated: 
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