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What is Tourette syndrome?

Tourette syndrome (TS) is a neurological disorder characterized by repetitive, stereotyped, involuntary movements and vocalizations called tics. The disorder is named for Dr. Georges Gilles de la Tourette, the pioneering French neurologist who in 1885 first described the condition in an 86-year-old French noblewoman.

The early symptoms of TS are almost always noticed first in childhood, with the average onset between the ages of 7 and 10 years. TS occurs in people from all ethnic groups; males are affected about three to four times more often than females. It is estimated that 200,000 Americans have the most severe form of TS, and as many as one in 100 exhibit milder and less complex symptoms such as chronic motor or vocal tics or transient tics of childhood. Although TS can be a chronic condition with symptoms lasting a lifetime, most people with the condition experience their worst symptoms in their early teens, with improvement occurring in the late teens and continuing into adulthood.

What are the symptoms?

Tics are classified as either simple or complex. Simple motor tics are sudden, brief, repetitive movements that involve a limited number of muscle groups. Some of the more common simple tics include eye blinking and other vision irregularities, facial grimacing, shoulder shrugging, and head or shoulder jerking. Simple vocalizations might include repetitive throat-clearing, sniffing, or grunting sounds. Complex tics are distinct, coordinated patterns of movements involving several muscle groups. Complex motor tics might include facial grimacing combined with a head twist and a shoulder shrug. Other complex motor tics may actually appear purposeful, including sniffing or touching objects, hopping, jumping, bending, or twisting. Simple vocal tics may include throat-clearing, sniffing/snorting, grunting, or barking. More complex vocal tics include words or phrases. Perhaps the most dramatic and disabling tics include motor movements that result in self-harm such as punching oneself in the face or vocal tics including coprolalia (uttering swear words) or echolalia (repeating the words or phrases of others). Some tics are preceded by an urge or sensation in the affected muscle group, commonly called a premonitory urge. Some with TS will describe a need to complete a tic in a certain way or a certain number of times in order to relieve the urge or decrease the sensation.

Tics are often worse with excitement or anxiety and better during calm, focused activities. Certain physical experiences can trigger or worsen tics, for example tight collars may trigger neck tics, or hearing another person sniff or throat-clear may trigger similar sounds. Tics do not go away during sleep but are often significantly diminished. even suicide. It is important to learn to identify whether or not a client's reactions to and expressions of anger are a problem.

What is the course of TS?

Tics come and go over time, varying in type, frequency, location, and severity. The first symptoms usually occur in the head and neck area and may progress to include muscles of the trunk and extremities. Motor tics generally precede the development of vocal tics and simple tics often precede complex tics. Most patients experience peak tic severity before the mid-teen years with improvement for the majority of patients in the late teen years and early adulthood. Approximately 10 percent of those affected have a progressive or disabling course that lasts into adulthood.

Can people with TS control their tics?

Although the symptoms of TS are involuntary, some people can sometimes suppress, camouflage, or otherwise manage their tics in an effort to minimize their impact on functioning. However, people with TS often report a substantial buildup in tension when suppressing their tics to the point where they feel that the tic must be expressed. Tics in response to an environmental trigger can appear to be voluntary or purposeful but are not.

What causes TS?

Although the cause of TS is unknown, current research points to abnormalities in certain brain regions (including the basal ganglia, frontal lobes, and cortex), the circuits that interconnect these regions, and the neurotransmitters (dopamine, serotonin, and norepinephrine) responsible for communication among nerve cells. Given the often complex presentation of TS, the cause of the disorder is likely to be equally complex.

What disorders are associated with TS?

Many with TS experience additional neurobehavioral problems including inattention; hyperactivity and impulsivity (attention deficit hyperactivity disorder - ADHD) and related problems with reading, writing, and arithmetic; and obsessive-compulsive symptoms such as intrusive thoughts/worries and repetitive behaviors. For example, worries about dirt and germs may be associated with repetitive hand-washing, and concerns about bad things happening may be associated with ritualistic behaviors such as counting, repeating, or ordering and arranging. People with TS have also reported problems with depression or anxiety disorders, as well as other difficulties with living, that may or may not be directly related to TS. Given the range of potential complications, people with TS are best served by receiving medical care that provides a comprehensive treatment plan.

How is TS diagnosed?

TS is a diagnosis that doctors make after verifying that the patient has had both motor and vocal tics for at least 1 year. The existence of other neurological or psychiatric conditions[1] can also help doctors arrive at a diagnosis. Common tics are not often misdiagnosed by knowledgeable clinicians. But atypical symptoms or atypical presentation (for example, onset of symptoms in adulthood) may require specific specialty expertise for diagnosis. There are no blood or laboratory tests needed for diagnosis, but neuroimaging studies, such as magnetic resonance imaging (MRI), computerized tomography (CT), and electroencephalogram (EEG) scans, or certain blood tests may be used to rule out other conditions that might be confused with TS.

It is not uncommon for patients to obtain a formal diagnosis of TS only after symptoms have been present for some time. The reasons for this are many. For families and physicians unfamiliar with TS, mild and even moderate tic symptoms may be considered inconsequential, part of a developmental phase, or the result of another condition. For example, parents may think that eye blinking is related to vision problems or that sniffing is related to seasonal allergies. Many patients are self-diagnosed after they, their parents, other relatives, or friends read or hear about TS from others.

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[1] These include childhood-onset involuntary movement disorders such as dystonia, or psychiatric disorders characterized by repetitive behaviors/movements (for example, stereotypic behaviors in autism and compulsive behaviors in obsessive-compulsive disorder - OCD).

How is TS treated?

Because tic symptoms do not often cause impairment, the majority of people with TS require no medication for tic suppression. However, effective medications are available for those whose symptoms interfere with functioning. Neuroleptics are the most consistently useful medications for tic suppression; a number are available but some are more effective than others (for example, haloperidol and pimozide). Unfortunately, there is no one medication that is helpful to all people with TS, nor does any medication completely eliminate symptoms. In addition, all medications have side effects. Most neuroleptic side effects can be managed by initiating treatment slowly and reducing the dose when side effects occur. The most common side effects of neuroleptics include sedation, weight gain, and cognitive dulling. Neurological side effects such as tremor, dystonic reactions (twisting movements or postures), parkinsonian-like symptoms, and other dyskinetic (involuntary) movements are less common and are readily managed with dose reduction. Discontinuing neuroleptics after long-term use must be done slowly to avoid rebound increases in tics and withdrawal dyskinesias. One form of withdrawal dyskinesia called tardive dykinesia is a movement disorder distinct from TS that may result from the chronic use of neuroleptics. The risk of this side effect can be reduced by using lower doses of neuroleptics for shorter periods of time.

Other medications may also be useful for reducing tic severity, but most have not been as extensively studied or shown to be as consistently useful as neuroleptics. Additional medications with demonstrated efficacy include alpha-adrenergic agonists such as clonidine and guanfacine. These medications are used primarily for hypertension but are also used in the treatment of tics. The most common side effect from these medications that precludes their use is sedation.

Effective medications are also available to treat some of the associated neurobehavioral disorders that can occur in patients with TS. Recent research shows that stimulant medications such as methylphenidate and dextroamphetamine can lessen ADHD symptoms in people with TS without causing tics to become more severe. However, the product labeling for stimulants currently contraindicates the use of these drugs in children with tics/TS and those with a family history of tics. Scientists hope that future studies will include a thorough discussion of the risks and benefits of stimulants in those with TS or a family history of TS and will clarify this issue. For obsessive-compulsive symptoms that significantly disrupt daily functioning, the serotonin reuptake inhibitors (clomipramine, fluoxetine, fluvoxamine, paroxetine, and sertraline) have been proven effective in some patients.

Psychotherapy may also be helpful. Although psychological problems do not cause TS, such problems may result from TS. Psychotherapy can help the person with TS better cope with the disorder and deal with the secondary social and emotional problems that sometimes occur. More recently, specific behavioral treatments that include awareness training and competing response training, such as voluntarily moving in response to a premonitory urge, have shown effectiveness in small controlled trials. Larger and more definitive NIH-funded studies are underway.

Is TS inherited?

Evidence from twin and family studies suggests that TS is an inherited disorder. Although early family studies suggested an autosomal dominant mode of inheritance (an autosomal dominant disorder is one in which only one copy of the defective gene, inherited from one parent, is necessary to produce the disorder), more recent studies suggest that the pattern of inheritance is much more complex. Although there may be a few genes with substantial effects, it is also possible that many genes with smaller effects and environmental factors may play a role in the development of TS. Genetic studies also suggest that some forms of ADHD and OCD are genetically related to TS, but there is less evidence for a genetic relationship between TS and other neurobehavioral problems that commonly co-occur with TS. It is important for families to understand that genetic predisposition may not necessarily result in full-blown TS; instead, it may express itself as a milder tic disorder or as obsessive-compulsive behaviors. It is also possible that the gene-carrying offspring will not develop any TS symptoms.

The sex of the person also plays an important role in TS gene expression. At-risk males are more likely to have tics and at-risk females are more likely to have obsessive-compulsive symptoms.

People with TS may have genetic risks for other neurobehavioral disorders such as depression or substance abuse. Genetic counseling of individuals with TS should include a full review of all potentially hereditary conditions in the family.

What is the prognosis?

Although there is no cure for TS, the condition in many individuals improves in the late teens and early 20s. As a result, some may actually become symptom-free or no longer need medication for tic suppression. Although the disorder is generally lifelong and chronic, it is not a degenerative condition. Individuals with TS have a normal life expectancy. TS does not impair intelligence. Although tic symptoms tend to decrease with age, it is possible that neurobehavioral disorders such as depression, panic attacks, mood swings, and antisocial behaviors can persist and cause impairment in adult life.

What is the best educational setting for children with TS?

Although students with TS often function well in the regular classroom, ADHD, learning disabilities, obsessive-compulsive symptoms, and frequent tics can greatly interfere with academic performance or social adjustment. After a comprehensive assessment, students should be placed in an educational setting that meets their individual needs. Students may require tutoring, smaller or special classes, and in some cases special schools.

All students with TS need a tolerant and compassionate setting that both encourages them to work to their full potential and is flexible enough to accommodate their special needs. This setting may include a private study area, exams outside the regular classroom, or even oral exams when the child's symptoms interfere with his or her ability to write. Untimed testing reduces stress for students with TS.

What research is being done?

Within the Federal government, the leading supporter of research on TS and other neurological disorders is the National Institute of Neurological Disorders and Stroke (NINDS). The NINDS, a part of the National Institutes of Health (NIH), is responsible for supporting and conducting research on the brain and central nervous system.

NINDS sponsors research on TS both in its laboratories at the NIH and through grants to major medical institutions across the country. The National Institute of Mental Health, the National Center for Research Resources, the National Institute of Child Health and Human Development, the National Institute on Drug Abuse, and the National Institute on Deafness and Other Communication Disorders also support research of relevance to TS. And another component of the Department of Health and Human Services, the Centers for Disease Control and Prevention, funds professional education programs as well as TS research.

Knowledge about TS comes from studies across a number of medical and scientific disciplines, including genetics, neuroimaging, neuropathology, clinical trials (medication and non-medication), epidemiology, neurophysiology, neuroimmunology, and descriptive/diagnostic clinical science.

Genetic studies. Currently, NIH-funded investigators are conducting a variety of large-scale genetic studies. Rapid advances in the technology of gene finding will allow for genome-wide screening approaches in TS, and finding a gene or genes for TS would be a major step toward understanding genetic risk factors. In addition, understanding the genetics of TS genes will strengthen clinical diagnosis, improve genetic counseling, lead to the clarification of pathophysiology, and provide clues for more effective therapies.

Neuroimaging studies. Within the past 5 years, advances in imaging technology and an increase in trained investigators have led to an increasing use of novel and powerful techniques to identify brain regions, circuitry, and neurochemical factors important in TS and related conditions.

Neuropathology. Within the past 5 years, there has been an increase in the number and quality of donated postmortem brains from TS patients available for research purposes. This increase, coupled with advances in neuropathological techniques, has led to initial findings with implications for neuroimaging studies and animal models of TS.

Clinical trials. A number of clinical trials in TS have recently been completed or are currently underway. These include studies of stimulant treatment of ADHD in TS and behavioral treatments for reducing tic severity in children and adults. Smaller trials of novel approaches to treatment such as dopamine agonist and GABAergic medications also show promise.

Epidemiology and clinical science. Careful epidemiological studies now estimate the prevalence of TS to be substantially higher than previously thought with a wider range of clinical severity. Furthermore, clinical studies are providing new findings regarding TS and co-existing conditions. These include subtyping studies of TS and OCD, an examination of the link between ADHD and learning problems in children with TS, a new appreciation of sensory tics, and the role of co-existing disorders in rage attacks. One of the most important and controversial areas of TS science involves the relationship between TS and autoimmune brain injury associated with group A beta-hemolytic streptococcal infections or other infectious processes. There are a number of epidemiological and clinical investigations currently underway in this intriguing area.

Source: National Institute of Neurological Disorders and Stroke
NIH Publication No. 05-2163

Reviewed by athealth on February 8, 2014.

Neurotherapy is a clinically proven, non-drug method of treating ADD/ADHD and other learning disabilities

Neurotherapy is an innovative, non-drug treatment using EEG Neurofeedback to create positive, lasting changes in adults and children.

At the Enhancement Institute, neurotherapy is used to help the individual train his or her brainwaves to produce more of the faster brainwaves associated with concentration and focus.

Someone with ADD/ADHD has an excess of slow brainwaves associated with daydreaming, which makes it difficult to concentrate long enough to accomplish a task quickly or efficiently.

Once a patient learns to produce faster brainwaves, they can access them as needed to better perform everyday tasks such as:

• Reading
• Following directions
• Working analytical problems
• Staying focused

Diminish the symptoms of ADD/ADHD

Most patients are able to diminish the symptoms of ADD/ADHD in a few short months and therefore significantly reduce or eliminate their use of medications.

In addition to ADD/ADHD, other disorders helped by this program include head trauma, addiction, depression, anxiety and other psychobiological disorders. Neurotherapy appears to produce changes in brain chemistry, which may underlie some personality disturbances.

Author: Nancy White, PhD, LMFT, is a recognized leader in the field of Neurotherapy. She is a Diplomate in Quantitative EEG Technology, a member of the Quantitative EEG Certification Board, and a Consulting Editor of the Journal of Neurotherapy. Dr.White has conducted Neurotherapy workshops across the country and abroad teaching health practitioners how to utilize this technology with their own patients.

For more information on this innovative treatment contact The Enhancement Institute.

Reviewed by athealth on February 6, 2014.

What Is Psoriasis?

Psoriasis is a chronic (long-lasting) skin disease of scaling and inflammation that affects 2 to 2.6 percent of the United States population, or between 5.8 and 7.5 million people. Although the disease occurs in all age groups, it primarily affects adults. It appears about equally in males and females. Psoriasis occurs when skin cells quickly rise from their origin below the surface of the skin and pile up on the surface before they have a chance to mature. Usually this movement (also called turnover) takes about a month, but in psoriasis it may occur in only a few days. In its typical form, psoriasis results in patches of thick, red (inflamed) skin covered with silvery scales. These patches, which are sometimes referred to as plaques, usually itch or feel sore. They most often occur on the elbows, knees, other parts of the legs, scalp, lower back, face, palms, and soles of the feet, but they can occur on skin anywhere on the body.

The disease may also affect the fingernails, the toenails, and the soft tissues of the genitals and inside the mouth. While it is not unusual for the skin around affected joints to crack, approximately 1 million people with psoriasis experience joint inflammation that produces symptoms of arthritis. This condition is called psoriatic arthritis.

How Does Psoriasis Affect Quality of Life?

Individuals with psoriasis may experience significant physical discomfort and some disability. Itching and pain can interfere with basic functions, such as self-care, walking, and sleep. Plaques on hands and feet can prevent individuals from working at certain occupations, playing some sports, and caring for family members or a home. The frequency of medical care is costly and can interfere with an employment or school schedule. People with moderate to severe psoriasis may feel self-conscious about their appearance and have a poor self-image that stems from fear of public rejection and psychosexual concerns. Psychological distress can lead to significant depression and social isolation.

What Causes Psoriasis?

Psoriasis is a skin disorder driven by the immune system, especially involving a type of white blood cell called a T cell. Normally, T cells help protect the body against infection and disease. In the case of psoriasis, T cells are put into action by mistake and become so active that they trigger other immune responses, which lead to inflammation and to rapid turnover of skin cells. In about one-third of the cases, there is a family history of psoriasis. Researchers have studied a large number of families affected by psoriasis and identified genes linked to the disease. (Genes govern every bodily function and determine the inherited traits passed from parent to child.) People with psoriasis may notice that there are times when their skin worsens, then improves. Conditions that may cause flareups include infections, stress, and changes in climate that dry the skin. Also, certain medicines, including lithium and betablockers, which are prescribed for high blood pressure, may trigger an outbreak or worsen the disease.

How Is Psoriasis Diagnosed?

Occasionally, doctors may find it difficult to diagnose psoriasis, because it often looks like other skin diseases. It may be necessary to confirm a diagnosis by examining a small skin sample under a microscope. There are several forms of psoriasis. Some of these include:

• Plaque psoriasis - Skin lesions are red at the base and covered by silvery scales.
• Guttate psoriasis - Small, drop-shaped lesions appear on the trunk, limbs, and scalp. Guttate psoriasis is most often triggered by upper respiratory infections (for example, a sore throat caused by streptococcal bacteria).
• Pustular psoriasis - Blisters of noninfectious pus appear on the skin. Attacks of pustular psoriasis may be triggered by medications, infections, stress, or exposure to certain chemicals.
• Inverse psoriasis - Smooth, red patches occur in the folds of the skin near the genitals, under the breasts, or in the armpits. The symptoms may be worsened by friction and sweating.
• Erythrodermic psoriasis - Widespread reddening and scaling of the skin may be a reaction to severe sunburn or to taking corticosteroids (cortisone) or other medications. It can also be caused by a prolonged period of increased activity of psoriasis that is poorly controlled.
• Psoriatic arthritis - Joint inflammation that produces symptoms of arthritis in patients who have or will develop psoriasis.

How is Psoriasis Treated?

Doctors generally treat psoriasis in steps based on the severity of the disease, size of the areas involved, type of psoriasis, and the patient's response to initial treatments. This is sometimes called the "1-2-3" approach. In step 1, medicines are applied to the skin (topical treatment). Step 2 uses light treatments (phototherapy). Step 3 involves taking medicines by mouth or injection that treat the whole immune system (called systemic therapy).

Over time, affected skin can become resistant to treatment, especially when topical corticosteroids are used. Also, a treatment that works very well in one person may have little effect in another. Thus, doctors often use a trial-and-error approach to find a treatment that works, and they may switch treatments periodically (for example, every 12 to 24 months) if a treatment does not work or if adverse reactions occur.

Topical Treatment

Treatments applied directly to the skin may improve its condition. Doctors find that some patients respond well to ointment or cream forms of corticosteroids, vitamin D3, retinoids, coal tar, or anthralin. Bath solutions and moisturizers may be soothing, but they are seldom strong enough to improve the condition of the skin. Therefore, they usually are combined with stronger remedies.

• Corticosteroids - These drugs reduce inflammation and the turnover of skin cells, and they suppress the immune system. Available in different strengths, topical corticosteroids (cortisone) are usually applied to the skin twice a day. Short-term treatment is often effective in improving, but not completely eliminating, psoriasis. Long-term use or overuse of highly potent (strong) corticosteroids can cause thinning of the skin, internal side effects, and resistance to the treatment's benefits. If less than 10 percent of the skin is involved, some doctors will prescribe a high-potency corticosteroid ointment. High-potency corticosteroids may also be prescribed for plaques that don't improve with other treatment, particularly those on the hands or feet. In situations where the objective of treatment is comfort, medium-potency corticosteroids may be prescribed for the broader skin areas of the torso or limbs. Low-potency preparations are used on delicate skin areas. (Note: Brand names for the different strengths of corticosteroids are too numerous to list in this booklet.)
• Calcipotriene - This drug is a synthetic form of vitamin D3 that can be applied to the skin. Applying calcipotriene ointment (for example, Dovonex*) twice a day controls the speed of turnover of skin cells. Because calcipotriene can irritate the skin, however, it is not recommended for use on the face or genitals. It is sometimes combined with topical corticosteroids to reduce irritation. Use of more than 100 grams of calcipotriene per week may raise the amount of calcium in the body to unhealthy levels.* Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.
• Retinoid - Topical retinoids are synthetic forms of vitamin A. The retinoid tazarotene (Tazorac) is available as a gel or cream that is applied to the skin. If used alone, this preparation does not act as quickly as topical corticosteroids, but it does not cause thinning of the skin or other side effects associated with steroids. However, it can irritate the skin, particularly in skin folds and the normal skin surrounding a patch of psoriasis. It is less irritating and sometimes more effective when combined with a corticosteroid. Because of the risk of birth defects, women of childbearing age must take measures to prevent pregnancy when using tazarotene.
• Coal tar - Preparations containing coal tar (gels and ointments) may be applied directly to the skin, added (as a liquid) to the bath, or used on the scalp as a shampoo. Coal tar products are available in different strengths, and many are sold over the counter (not requiring a prescription). Coal tar is less effective than corticosteroids and many other treatments and, therefore, is sometimes combined with ultraviolet B (UVB) phototherapy for a better result. The most potent form of coal tar may irritate the skin, is messy, has a strong odor, and may stain the skin or clothing. Thus, it is not popular with many patients.
• Anthralin - Anthralin reduces the increase in skin cells and inflammation. Doctors sometimes prescribe a 15- to 30-minute application of anthralin ointment, cream, or paste once each day to treat chronic psoriasis lesions. Afterward, anthralin must be washed off the skin to prevent irritation. This treatment often fails to adequately improve the skin, and it stains skin, bathtub, sink, and clothing brown or purple. In addition, the risk of skin irritation makes anthralin unsuitable for acute or actively inflamed eruptions.
• Salicylic acid - This peeling agent, which is available in many forms such as ointments, creams, gels, and shampoos, can be applied to reduce scaling of the skin or scalp. Often, it is more effective when combined with topical corticosteroids, anthralin, or coal tar.
• Clobetasol propionate - This is a foam topical medication (Olux), which has been approved for the treatment of scalp and body psoriasis. The foam penetrates the skin very well, is easy to use, and is not as messy as many other topical medications.
• Bath solutions - People with psoriasis may find that adding oil when bathing, then applying a moisturizer, soothes their skin. Also, individuals can remove scales and reduce itching by soaking for 15 minutes in water containing a coal tar solution, oiled oatmeal, Epsom salts, or Dead Sea salts.
• Moisturizers - When applied regularly over a long period, moisturizers have a soothing effect. Preparations that are thick and greasy usually work best because they seal water in the skin, reducing scaling and itching.

Light Therapy

Natural ultraviolet light from the sun and controlled delivery of artificial ultraviolet light are used in treating psoriasis.

• Sunlight - Much of sunlight is composed of bands of different wavelengths of ultraviolet (UV) light. When absorbed into the skin, UV light suppresses the process leading to disease, causing activated T cells in the skin to die. This process reduces inflammation and slows the turnover of skin cells that causes scaling. Daily, short, nonburning exposure to sunlight clears or improves psoriasis in many people. Therefore, exposing affected skin to sunlight is one initial treatment for the disease.
• Ultraviolet B (UVB) phototherapy - UVB is light with a short wavelength that is absorbed in the skin's epidermis. An artificial source can be used to treat mild and moderate psoriasis. Some physicians will start treating patients with UVB instead of topical agents. A UVB phototherapy, called broadband UVB, can be used for a few small lesions, to treat widespread psoriasis, or for lesions that resist topical treatment. This type of phototherapy is normally given in a doctor's office by using a light panel or light box. Some patients use UVB light boxes at home under a doctor's guidance.A newer type of UVB, called narrowband UVB, emits the part of the ultraviolet light spectrum band that is most helpful for psoriasis. Narrowband UVB treatment is superior to broadband UVB, but it is less effective than PUVA treatment (see next paragraph). It is gaining in popularity because it does help and is more convenient than PUVA. At first, patients may require several treatments of narrowband UVB spaced close together to improve their skin. Once the skin has shown improvement, a maintenance treatment once each week may be all that is necessary. However, narrowband UVB treatment is not without risk. It can cause more severe and longer lasting burns than broadband treatment.
• Psoralen and ultraviolet A phototherapy (PUVA) - This treatment combines oral or topical administration of a medicine called psoralen with exposure to ultraviolet A (UVA) light. UVA has a long wavelength that penetrates deeper into the skin than UVB. Psoralen makes the skin more sensitive to this light. PUVA is normally used when more than 10 percent of the skin is affected or when the disease interferes with a person's occupation (for example, when a teacher's face or a salesperson's hands are involved). Compared with broadband UVB treatment, PUVA treatment taken two to three times a week clears psoriasis more consistently and in fewer treatments. However, it is associated with more shortterm side effects, including nausea, headache, fatigue, burning, and itching. Care must be taken to avoid sunlight after ingesting psoralen to avoid severe sunburns, and the eyes must be protected for one to two days with UVA-absorbing glasses. Long-term treatment is associated with an increased risk of squamous-cell and, possibly, melanoma skin cancers. Simultaneous use of drugs that suppress the immune system, such as cyclosporine, have little beneficial effect and increase the risk of cancer.
• Light therapy combined with other therapies - Studies have shown that combining ultraviolet light treatment and a retinoid, like acitretin, adds to the effectiveness of UV light for psoriasis. For this reason, if patients are not responding to light therapy, retinoids may be added. UVB phototherapy, for example, may be combined with retinoids and other treatments. One combined therapy program, referred to as the Ingram regime, involves a coal tar bath, UVB phototherapy, and application of an anthralin-salicylic acid paste that is left on the skin for 6 to 24 hours. A similar regime, the Goeckerman treatment, combines coal tar ointment with UVB phototherapy. Also, PUVA can be combined with some oral medications (such as retinoids) to increase its effectiveness.

Systemic Treatment

For more severe forms of psoriasis, doctors sometimes prescribe medicines that are taken internally by pill or injection. This is called systemic treatment. Recently, attention has been given to a group of drugs called biologics (for example, alefacept and etanercept), which are made from proteins produced by living cells instead of chemicals. They interfere with specific immune system processes.

• Methotrexate - Like cyclosporine, methotrexate slows cell turnover by suppressing the immune system. It can be taken by pill or injection. Patients taking methotrexate must be closely monitored because it can cause liver damage and/or decrease the production of oxygen-carrying red blood cells, infection-fighting white blood cells, and clotenhancing platelets. As a precaution, doctors do not prescribe the drug for people who have had liver disease or anemia (an illness characterized by weakness or tiredness due to a reduction in the number or volume of red blood cells that carry oxygen to the tissues). It is sometimes combined with PUVA or UVB treatments. Methotrexate should not be used by pregnant women, or by women who are planning to get pregnant, because it may cause birth defects.
• Retinoids - A retinoid, such as acitretin (Soriatane), is a compound with vitamin A-like properties that may be prescribed for severe cases of psoriasis that do not respond to other therapies. Because this treatment also may cause birth defects, women must protect themselves from pregnancy beginning 1 month before through 3 years after treatment with acitretin. Most patients experience a recurrence of psoriasis after these products are discontinued.
• Cyclosporine - Taken orally, cyclosporine acts by suppressing the immune system to slow the rapid turnover of skin cells. It may provide quick relief of symptoms, but the improvement stops when treatment is discontinued. The best candidates for this therapy are those with severe psoriasis who have not responded to, or cannot tolerate, other systemic therapies. Its rapid onset of action is helpful in avoiding hospitalization of patients whose psoriasis is rapidly progressing. Cyclosporine may impair kidney function or cause high blood pressure (hypertension). Therefore, patients must be carefully monitored by a doctor. Also, cyclosporine is not recommended for patients who have a weak immune system or those who have had skin cancers as a result of PUVA treatments in the past. It should not be given with phototherapy.
• 6-Thioguanine - This drug is nearly as effective as methotrexate and cyclosporine. It has fewer side effects, but there is a greater likelihood of anemia. This drug must also be avoided by pregnant women and by women who are planning to become pregnant, because it may cause birth defects.
• Hydroxyurea (Hydrea) - Compared with methotrexate and cyclosporine, hydroxyurea is somewhat less effective. It is sometimes combined with PUVA or UVB treatments. Possible side effects include anemia and a decrease in white blood cells and platelets. Like methotrexate and retinoids, hydroxyurea must be avoided by pregnant women or those who are planning to become pregnant, because it may cause birth defects.
• Alefacept (Amevive) - This is the first biologic drug approved specifically to treat moderate to severe plaque psoriasis. It is administered by a doctor, who injects the drug once a week for 12 weeks. The drug is then stopped for a period of time while changes in the skin are observed and a decision is made regarding the need or further treatment. Because alefacept suppresses the immune system, the skin often improves, but there is also an increased risk of infection or other problems, possibly including cancer. Monitoring by a doctor is required, and a patient's blood must be tested weekly around the time of each injection to make certain that T cells and other immune system cells are not overly depressed.
• Etanercept (Enbrel) - This drug is an approved treatment for psoriatic arthritis where the joints swell and become inflamed. Like alefacept, it is a biologic response modifier, which after injection blocks interactions between certain cells in the immune system. Etanercept limits the action of a specific protein that is overproduced in the lubricating fluid of the joints and surrounding tissues, causing inflammation. Because this same protein is overproduced in the skin of people with psoriatic arthritis, patients receiving etanercept also may notice an improvement in their skin. Individuals should not receive etanercept treatment if they have an active infection, a history of recurring infections, or an underlying condition, such as diabetes, that increases their risk of infection. Those who have psoriasis and certain neurological conditions, such as multiple sclerosis, cannot be treated with this drug. Added caution is needed for psoriasis patients who have rheumatoid arthritis; these patients should follow the advice of a rheumatologist regarding this treatment.
• Antibiotics - These medications are not indicated in routine treatment of psoriasis. However, antibiotics may be employed when an infection, such as that caused by the bacteria Streptococcus, triggers an outbreak of psoriasis, as in certain cases of guttate psoriasis.

Combination Therapy

There are many approaches for treating psoriasis. Combining various topical, light, and systemic treatments often permits lower doses of each and can result in increased effectiveness. Therefore, doctors are paying more attention to combination therapy.

Psychological Support

Some individuals with moderate to severe psoriasis may benefit from counseling or participation in a support group to reduce self-consciousness about their appearance or relieve psychological distress resulting from fear of social rejection.

What Are Some Promising Areas of Psoriasis Research?

Significant progress has been made in understanding the inheritance of psoriasis. A number of genes involved in psoriasis are already known or suspected. In a multifactor disease (involving genes, environment, and other factors), variations in one or more genes may produce a greater likelihood of getting the disease. Researchers are continuing to study the genetic aspects of psoriasis. Since discovering that inflammation in psoriasis is triggered by T cells, researchers have been studying new treatments that quiet immune system reactions in the skin. Among these are treatments that block the activity of T cells or block cytokines (proteins that promote inflammation). Several of these drugs are awaiting approval by the U.S. Food and Drug Administration (FDA).

Advances in laser technology are making it possible for doctors to experiment with laser light treatment of localized plaques. A UVB laser was recently tested in a study that was conducted at several medical centers. Although improvements in the skin were noted, this treatment is not without possible side effects. In some patients, the skin became inflamed, blistered, or discolored following treatment.

Where Can People Find More Information About Psoriasis?

National Institute of Arthritis and Musculoskeletal and Skin Diseases

NIAMS/National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 301-495-4484
TTY: 301-565-2966
Fax: 301-718-6366
[email protected]
http://www.niams.nih.gov/

NIAMS provides information about various forms of skin diseases; arthritis and rheumatic diseases; and bone, muscle, and joint diseases. It distributes patient and professional education materials and also refers people to other sources of information. Additional information and updates can be found on the NIAMS Web site.

American Academy of Dermatology
930 N. Meacham Road
PO Box 4014
Shaumburg, IL 60168-4014
Phone: 847-330-0230 or 888-462-DERM (3376) (free of charge)
Fax: 947-330-0050
http://www.aad.org

This national professional association for dermatologists has a Web site (PsoriasisNet) that contains basic information on psoriasis for lay readers. Also included are press releases, answers to frequently asked questions, information updates, and lists of dermatologists.

National Psoriasis Foundation
6600 SW 92nd Avenue, Suite 300
Portland, OR 97223
Phone: 503-244-7404 or 800-723-9166 (free of charge)
Fax: 503-245-0626
[email protected]
http://www.psoriasis.org

The National Psoriasis Foundation provides physician referrals and publishes pamphlets and newsletters that include information on support groups, research, and new drugs and other treatments. The foundation also promotes community awareness of psoriasis.

Acknowledgments

The NIAMS gratefully acknowledges the assistance of Kevin D. Cooper, MD, University Hospitals of Cleveland/Case Western Reserve University, Ohio; Gerald Krueger, MD, University of Utah, Salt Lake City; Mark Lebwohl, MD, The Mount Sinai Medical Center, New York, New York; Laurence H. Miller, MD, PA, Chevy Chase, Maryland; Alan N. Moshell, MD, NIAMS; Robert Stern, MD, Beth Israel Deaconess Medical Center, Boston, Massachusetts; and the National Psoriasis Foundation in the preparation of this and previous versions of this booklet.

Source: National Institutes of Health
National Institute of Arthritis and Musculoskeletal and Skin Diseases
NIH Publication No. 03-5040

Reviewed by athealth on February 6, 2014.

What Are Eating Disorders?

An eating disorder is marked by extremes. It is present when a person experiences severe disturbances in eating behavior, such as extreme reduction of food intake or extreme overeating, or feelings of extreme distress or concern about body weight or shape.

A person with an eating disorder may have started out just eating smaller or larger amounts of food than usual, but at some point, the urge to eat less or more spirals out of control. Eating disorders are very complex, and despite scientific research to understand them, the biological, behavioral and social underpinnings of these illnesses remain elusive.

The two main types of eating disorders are anorexia nervosa and bulimia nervosa. A third category is "eating disorders not otherwise specified (EDNOS)," which includes several variations of eating disorders. Most of these disorders are similar to anorexia or bulimia but with slightly different characteristics. Binge-eating disorder, which has received increasing research and media attention in recent years, is one type of EDNOS.

Eating disorders frequently appear during adolescence or young adulthood, but some reports indicate that they can develop during childhood or later in adulthood. Women and girls are much more likely than males to develop an eating disorder. Men and boys account for an estimated 5 to 15 percent of patients with anorexia or bulimia and an estimated 35 percent of those with binge-eating disorder. Eating disorders are real, treatable medical illnesses with complex underlying psychological and biological causes. They frequently co-exist with other psychiatric disorders such as depression, substance abuse, or anxiety disorders. People with eating disorders also can suffer from numerous other physical health complications, such as heart conditions or kidney failure, which can lead to death.

Eating Disorders Are Treatable Diseases

Psychological and medicinal treatments are effective for many eating disorders. However, in more chronic cases, specific treatments have not yet been identified.

In these cases, treatment plans often are tailored to the patient's individual needs that may include medical care and monitoring; medications; nutritional counseling; and individual, group and/or family psychotherapy. Some patients may also need to be hospitalized to treat malnutrition or to gain weight, or for other reasons.

Anorexia Nervosa

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

Many people with anorexia see themselves as overweight, even when they are starved or are clearly malnourished. Eating, food and weight control become obsessions. A person with anorexia typically weighs herself or himself repeatedly, portions food carefully, and eats only very small quantities of only certain foods. Some who have anorexia recover with treatment after only one episode. Others get well but have relapses. Still others have a more chronic form of anorexia, in which their health deteriorates over many years as they battle the illness.

According to some studies, people with anorexia are up to ten times more likely to die as a result of their illness compared to those without the disorder. The most common complications that lead to death are cardiac arrest, and electrolyte and fluid imbalances. Suicide also can result.

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

Other symptoms may develop over time, including:

• thinning of the bones (osteopenia or osteoporosis)
• brittle hair and nails
• dry and yellowish skin
• growth of fine hair over body (e.g., lanugo)
• mild anemia, and muscle weakness and loss
• severe constipation
• low blood pressure, slowed breathing and pulse
• drop in internal body temperature, causing a person to feel cold all the time
• lethargy

Treating anorexia involves three components:

• Restoring the person to a healthy weight;
• Treating the psychological issues related to the eating disorder; and
• Reducing or eliminating behaviors or thoughts that lead to disordered eating, and preventing relapse.

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

Different forms of psychotherapy, including individual, group and family-based, can help address the psychological reasons for the illness. Some studies suggest that family-based therapies in which parents assume responsibility for feeding their afflicted adolescent are the most effective in helping a person with anorexia gain weight and improve eating habits and moods.

Shown to be effective in case studies and clinical trials, this particular approach is discussed in some guidelines and studies for treating eating disorders in younger, nonchronic patients.

Others have noted that a combined approach of medical attention and supportive psychotherapy designed spe-cifically for anorexia patients is more effective than just psychotherapy. But the effectiveness of a treatment depends on the person involved and his or her situation. Unfortunately, no specific psychotherapy appears to be consistently effective for treating adults with anorexia. However, research into novel treatment and prevention approaches is showing some promise. One study suggests that an online intervention program may prevent some at-risk women from developing an eating disorder.

Bulimia Nervosa

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

Unlike anorexia, people with bulimia can fall within the normal range for their age and weight. But like people with anorexia, they often fear gaining weight, want desperately to lose weight, and are intensely unhappy with their body size and shape. Usually, bulimic behavior is done secretly, because it is often accompanied by feelings of disgust or shame. The binging and purging cycle usually repeats several times a week. Similar to anorexia, people with bulimia often have coexisting psychological illnesses, such as depression, anxiety and/or substance abuse problems. Many physical conditions result from the purging aspect of the illness, including electrolyte imbalances, gastrointestinal problems, and oral and tooth-related problems.

Other symptoms include:

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

Treatment for bulimia often involves a combination of options and depends on the needs of the individual.

To reduce or eliminate binge and purge behavior, a patient may undergo nutritional counseling and psychotherapy, especially cognitive behavioral therapy (CBT), or be prescribed medication. Some antidepressants, such as fluoxetine (Prozac), which is the only medication approved by the U.S. Food and Drug Administration for treating bulimia, may help patients who also have depression and/or anxiety. It also appears to help reduce binge-eating and purging behavior, reduces the chance of relapse, and improves eating attitudes.

CBT that has been tailored to treat bulimia also has shown to be effective in changing binging and purging behavior, and eating attitudes. Therapy may be individually oriented or group-based.

Binge-Eating Disorder

Binge-eating disorder is characterized by recurrent binge-eating episodes during which a person feels a loss of control over his or her eating. Unlike bulimia, binge-eating episodes are not followed by purging, excessive exercise or fasting. As a result, people with binge-eating disorder often are overweight or obese. They also experience guilt, shame and/or distress about the binge-eating, which can lead to more binge-eating.

Obese people with binge-eating disorder often have coexisting psychological illnesses including anxiety, depression, and personality disorders. In addition, links between obesity and cardiovascular disease and hypertension are well documented.

Treatment options for binge-eating disorder are similar to those used to treat bulimia.

Fluoxetine and other antidepressants may reduce binge-eating episodes and help alleviate depression in some patients.

Patients with binge-eating disorder also may be prescribed appetite suppressants. Psychotherapy, especially CBT, is also used to treat the underlying psychological issues associated with binge-eating, in an individual or group environment.

FDA Warnings On Antidepressants

Despite the relative safety and popularity of SSRIs and other antidepressants, some studies have suggested that they may have unintentional effects on some people, especially adolescents and young adults. In 2004, the Food and Drug Administration (FDA) conducted a thorough review of published and unpublished controlled clinical trials of antidepressants that involved nearly 4,400 children and adolescents. The review revealed that 4% of those taking antidepressants thought about or attempted suicide (although no suicides occurred), compared to 2% of those receiving placebos.

This information prompted the FDA, in 2005, to adopt a "black box" warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children and adolescents taking antidepressants. In 2007, the FDA proposed that makers of all antidepressant medications extend the warning to include young adults up through age 24. A "black box" warning is the most serious type of warning on prescription drug labeling.

The warning emphasizes that patients of all ages taking antidepressants should be closely monitored, especially during the initial weeks of treatment. Possible side effects to look for are worsening depression, suicidal thinking or behavior, or any unusual changes in behavior such as sleeplessness, agitation, or withdrawal from normal social situations. The warning adds that families and caregivers should also be told of the need for close monitoring and report any changes to the physician. The latest information from the FDA can be found on their Web site at www.fda.gov.

Results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders.28 The study was funded in part by the National Institute of Mental Health.

How Are Men And Boys Affected?

Although eating disorders primarily affect women and girls, boys and men are also vulnerable. One in four preadolescent cases of anorexia occurs in boys, and binge-eating disorder affects females and males about equally.

Like females who have eating disorders, males with the illness have a warped sense of body image and often have muscle dysmorphia, a type of disorder that is characterized by an extreme concern with becoming more muscular. Some boys with the disorder want to lose weight, while others want to gain weight or "bulk up." Boys who think they are too small are at a greater risk for using steroids or other dangerous drugs to increase muscle mass.

Boys with eating disorders exhibit the same types of emotional, physical and behavioral signs and symptoms as girls, but for a variety of reasons, boys are less likely to be diagnosed with what is often considered a stereotypically "female" disorder.

How Are We Working To Better Understand And Treat Eating Disorders?

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

One approach involves the study of the human genes. With the publication of the human genome sequence in 2003, mental health researchers are studying the various combinations of genes to determine if any DNA variations are associated with the risk of developing a mental disorder. Neuroimaging, such as the use of magnetic resonance imaging (MRI), may also lead to a better understanding of eating disorders.

Neuroimaging already is used to identify abnormal brain activity in patients with schizophrenia, obsessive-compulsive disorder and depression. It may also help researchers better understand how people with eating disorders process information, regardless of whether they have recovered or are still in the throes of their illness.

Conducting behavioral or psychological research on eating disorders is even more complex and challenging. As a result, few studies of treatments for eating disorders have been conducted in the past. New studies currently underway, however, are aiming to remedy the lack of information available about treatment.

Researchers also are working to define the basic processes of the disorders, which should help identify better treatments. For example, is anorexia the result of skewed body image, self esteem problems, obsessive thoughts, compulsive behavior, or a combination of these? Can it be predicted or identified as a risk factor before drastic weight loss occurs, and therefore avoided?

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

References

Agency for Healthcare Research and Quality (AHRQ). Management of Eating Disorders, Evidence Report/Technology Assessment, Number 135, 2006; AHRQ publication number 06-E010, www.ahrq.gov.

American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DSM-IV). Washington, DC: American Psychiatric Press, 1994.

American Psychiatric Association (APA). Let's Talk Facts About Eating Disorders. 2005.

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Anderson AE. Eating disorders in males: Critical questions. In R Lemberg (ed), Controlling Eating Disorders with Facts, Advice and Resources. Phoenix, AZ: Oryx Press, 1992, pp.20-28.

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Becker AE, Grinspoon SK, Klibanski A, Herzog DB. Eating Disorders. New England Journal of Medicine, 1999; 340(14): 1092-1098.

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Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L, Brent DA. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment, a meta-analysis of randomized controlled trials. Journal of the American Medical Association, 2007; 297(15): 1683-1696.

Bryant-Waugh R, Lask B. Childhood-onset eating disorders. In CG Fairburn, KD Brownell (eds.), Eating disorders and obesity: A comprehensive handbook, 2nd ed. New York: Guilford Press, 2002, pp. 210-214.

Bulik CM, Sullivan PF, Kendler KS. Medical and psychiatric comorbidity in obese women with and without binge eating disorder. International Journal of Eating Disorders, 2002; 32: 72-78.

Eisler I, Dare C, Hodes M, Russel G, Dodge, and Le Grange D. Family therapy for adolescent anorexia nervosa: The results of a controlled comparison of two family interventions. Journal of Child Psychology and Psychiatry, 2000; 1: 727-736.

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Lock J, Couturier J, Agras WS. Comparison of long-term outcomes in adolescents with anorexia nervosa treated with family therapy. Journal of the American Academy of Child and Adolescent Psychiatry, 2006; 45: 666-672.

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Pezawas L, Meyer-Lindenberg A, Drabant EM, Verchinski BA, Munoz KE, Kolachana BS, et al. 5-HTTLPR polymorphism impacts human cingulated-amygdala interactions: a genetic susceptibility mechanism for depression. Nature Neuroscience, June 2005; 8 (6): 828-834.

Pope HG, Gruber AJ, Choi P, Olivardi R, Phillips KA. Muscle dysmorphia: an underrecognized form of body dysmorphic disorder. Psychosomatics, 1997; 38: 548-557.

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Spitzer RL, Yanovski S, Wadden T, Wing R, Marcus MD, Stunkard A, Devlin M, Mitchell J, Hasin D, Horne RL. Binge eating disorder: its further validation in a multisite study. International Journal of Eating Disorders, 1993; 13(2): 137-153.

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Walsh et al. Fluoxetine after weight restoration in anorexia nervosa: a randomized controlled trial. Journal of the American Medical Association. 2006 Jun 14; 295(22): 2605-2612.

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NIH Publication No. 07-4901
Page last reviewed by NIH August 24, 2010

Reviewed by athealth on February 8, 2014.

What Is Fibromyalgia?

Fibromyalgia syndrome is a common and chronic disorder characterized by widespread muscle pain, fatigue, and multiple tender points. The word fibromyalgia comes from the Latin term for fibrous tissue (fibro) and the Greek ones for muscle (myo) and pain (algia). Tender points are specific places on the body?on the neck, shoulders, back, hips, and upper and lower extremities?where people with fibromyalgia feel pain in response to slight pressure.

Although fibromyalgia is often considered an arthritisrelated condition, it is not truly a form of arthritis (a disease of the joints) because it does not cause inflammation or damage to the joints, muscles, or other tissues. Like arthritis, however, fibromyalgia can cause significant pain and fatigue, and it can interfere with a person's ability to carry on daily activities. Also like arthritis, fibromyalgia is considered a rheumatic condition.

You may wonder what exactly rheumatic means. Even physicians do not always agree on whether a disease is considered rheumatic. If you look up the word in the dictionary, you'll find it comes from the Greek word rheum, which means flux?not an explanation that gives you a better understanding. In medicine, however, the term rheumatic means a medical condition that impairs the joints and/or soft tissues and causes chronic pain.

In addition to pain and fatigue, people who have fibromyalgia may experience:

• sleep disturbances,
• morning stiffness,
• headaches,
• irritable bowel syndrome,
• painful menstrual periods,
• numbness or tingling of the extremities,
• restless legs syndrome,
• temperature sensitivity,
• cognitive/memory problems (sometimes referred to as "fibro fog"), or
• a variety of other symptoms.

Fibromyalgia is a syndrome rather than a disease. Unlike a disease, which is a medical condition with a specific cause or causes and recognizable signs and symptoms, a syndrome is a collection of signs, symptoms, and medical problems that tend to occur together but are not related to a specific, identifiable cause.

Who Gets Fibromyalgia?

According to a paper published by the American College of Rheumatology (ACR), fibromyalgia affects 3 to 6 million - or as many as one in 50 - Americans. For unknown reasons, between 80 and 90 percent of those diagnosed with fibromyalgia are women; however, men and children also can be affected. Most people are diagnosed during middle age, although the symptoms often become present earlier in life.

People with certain rheumatic diseases, such as rheumatoid arthritis, systemic lupus erythematosus (commonly called lupus), or ankylosing spondylitis (spinal arthritis) may be more likely to have fibromyalgia, too.

Several studies indicate that women who have a family member with fibromyalgia are more likely to have fibromyalgia themselves, but the exact reason for this - whether it be hereditary or caused by environmental factors or both - is unknown. One study supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) is trying to identify if certain genes predispose some people to fibromyalgia. (See What Are Researchers Learning About Fibromyalgia?)

What Causes Fibromyalgia?

The causes of fibromyalgia are unknown, but there are probably a number of factors involved. Many people associate the development of fibromyalgia with a physically or emotionally stressful or traumatic event, such as an automobile accident. Some connect it to repetitive injuries. Others link it to an illness. People with rheumatoid arthritis and other autoimmune diseases, such as lupus, are particularly likely to develop fibromyalgia. For others, fibromyalgia seems to occur spontaneously.

Many researchers are examining other causes, including problems with how the central nervous system (the brain and spinal cord) processes pain.

Some scientists speculate that a person's genes may regulate the way his or her body processes painful stimuli. According to this theory, people with fibromyalgia may have a gene or genes that cause them to react strongly to stimuli that most people would not perceive as painful. However, those genes?if they, in fact, exist?have not been identified.

How Is Fibromyalgia Diagnosed?

Research shows that people with fibromyalgia typically see many doctors before receiving the diagnosis. One reason for this may be that pain and fatigue, the main symptoms of fibromyalgia, overlap with many other conditions. Therefore, doctors often have to rule out other potential causes of these symptoms before making a diagnosis of fibromyalgia. Another reason is that there are currently no diagnostic laboratory tests for fibromyalgia; standard laboratory tests fail to reveal a physiologic reason for pain. Because there is no generally accepted, objective test for fibromyalgia, some doctors unfortunately may conclude a patient's pain is not real, or they may tell the patient there is little they can do.

A doctor familiar with fibromyalgia, however, can make a diagnosis based on two criteria established by the ACR: a history of widespread pain lasting more than 3 months and the presence of tender points. Pain is considered to be widespread when it affects all four quadrants of the body; that is, you must have pain in both your right and left sides as well as above and below the waist to be diagnosed with fibromyalgia. The ACR also has designated 18 sites on the body as possible tender points. For a fibromyalgia diagnosis, a person must have 11 or more tender points. (See illustration on page 5.) One of these predesignated sites is considered a true tender point only if the person feels pain upon the application of 4 kilograms of pressure to the site. People who have fibromyalgia certainly may feel pain at other sites, too, but those 18 standard possible sites on the body are the criteria used for classification.

How Is Fibromyalgia Treated?

Fibromyalgia can be difficult to treat. Not all doctors are familiar with fibromyalgia and its treatment, so it is important to find a doctor who is. Many family physicians, general internists, or rheumatologists (doctors who specialize in arthritis and other conditions that affect the joints or soft tissues) can treat fibromyalgia.

Fibromyalgia treatment often requires a team approach, with your doctor, a physical therapist, possibly other health professionals, and most importantly, yourself, all playing an active role. It can be hard to assemble this team, and you may struggle to find the right professionals to treat you. When you do, however, the combined expertise of these various professionals can help you improve your quality of life.

You may find several members of the treatment team you need at a clinic. There are pain clinics that specialize in pain and rheumatology clinics that specialize in arthritis and other rheumatic diseases, including fibromyalgia.

At present, there are no medications approved by the U.S. Food and Drug Administration (FDA) for treating fibromyalgia, although a few such drugs are in development. Doctors treat fibromyalgia with a variety of medications developed and approved for other purposes.

Following are some of the most commonly used categories of drugs for fibromyalgia:

Analgesics

Analgesics are painkillers. They range from over-the-counter acetaminophen (Tylenol*) to prescription medicines, such as tramadol (Ultram), and even stronger narcotic preparations. For a subset of people with fibromyalgia, narcotic medications are prescribed for severe muscle pain. However, there is no solid evidence showing that narcotics actually work to treat the chronic pain of fibromyalgia, and most doctors hesitate to prescribe them for long-term use because of the potential that the person taking them will become physically or psychologically dependent on them.

* Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

As their name implies, nonsteroidal anti-inflammatory drugs, including aspirin, ibuprofen (Advil, Motrin), and naproxen sodium (Anaprox, Aleve), are used to treat inflammation. Although inflammation is not a symptom of fibromyalgia, NSAIDs also relieve pain. The drugs work by inhibiting substances in the body called prostaglandins, which play a role in pain and inflammation. These medications, some of which are available without a prescription, may help ease the muscle aches of fibromyalgia. They may also relieve menstrual cramps and the headaches often associated with fibromyalgia.

Antidepressants

Perhaps the most useful medications for fibromyalgia are several in the antidepressant class. Antidepressants elevate the levels of certain chemicals in the brain, including serotonin and norepinephrine (which was formerly called adrenaline). Low levels of these chemicals are associated not only with depression, but also with pain and fatigue. Increasing the levels of these chemicals can reduce pain in people who have fibromyalgia. Doctors prescribe several types of antidepressants for people with fibromyalgia, described below.

• Tricyclic antidepressants - When taken at bedtime in dosages lower than those used to treat depression, tricyclic antidepressants can help promote restorative sleep in people with fibromyalgia. They also can relax painful muscles and heighten the effects of the body's natural pain-killing substances called endorphins.Tricyclic antidepressants have been around for almost half a century. Some examples of tricyclic medications used to treat fibromyalgia include amitriptyline hydrochloride (Elavil, Endep), cyclobenzaprine (Cycloflex, Flexeril, Flexiban), doxepin (Adapin, Sinequan), and nortriptyline (Aventyl, Pamelor). Both amitriptyline and cyclobenzaprine have been proved useful for the treatment of fibromyalgia.
• Selective serotonin reuptake inhibitors - If a tricyclic antidepressant fails to bring relief, doctors sometimes prescribe a newer type of antidepressant called a selective serotonin reuptake inhibitor (SSRI). As with tricyclics, doctors usually prescribe these for people with fibromyalgia in lower dosages than are used to treat depression. By promoting the release of serotonin, these drugs may reduce fatigue and some other symptoms associated with fibromyalgia. The group of SSRIs includes fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft).SSRIs may be prescribed along with a tricyclic antidepressant. Doctors rarely prescribe SSRIs alone. Because they make people feel more energetic, they also interfere with sleep, which often is already a problem for people with fibromyalgia. Studies have shown that a combination therapy of the tricyclic amitriptyline and the SSRI fluoxetine resulted in greater improvements in the study participants' fibromyalgia symptoms than either drug alone.
• Mixed reuptake inhibitors - Some newer antidepressants raise levels of both serotonin and norepinephrine, and are therefore called mixed reuptake inhibitors. Examples of these medications include venlafaxine (Effexor) and nefazadone (Serzone). Researchers are actively studying the efficacy of these newer medications in treating fibromyalgia.

Benzodiazepines

Benzodiazepines help some people with fibromyalgia by relaxing tense, painful muscles and stabilizing the erratic brain waves that can interfere with deep sleep. Benzodiazepines also can relieve the symptoms of restless legs syndrome, which is common among people with fibromyalgia. Restless legs syndrome is characterized by unpleasant sensations in the legs as well as twitching, particularly at night. Because of the potential for addiction, doctors usually prescribe benzodiazepines only for people who have not responded to other therapies. Benzodiazepines include clonazepam (Klonopin) and diazepam (Valium).

Other medications

In addition to the previously described general categories of drugs, doctors may prescribe others, depending on a person's specific symptoms or fibromyalgia-related conditions. For example, in recent years, two medications? tegaserod (Zelnorm) and alosetron (Lotronex) - have been approved by the FDA for the treatment of irritable bowel syndrome. Gabapentin (Neurontin) currently is being studied as a treatment for fibromyalgia. (See What Are Researchers Learning About Fibromyalgia?.) Other symptom-specific medications include sleep medications, muscle relaxants, and headache remedies.

People with fibromyalgia also may benefit from a combination of physical and occupational therapy, from learning pain-management and coping techniques, and from properly balancing rest and activity.

Complementary and alternative therapies

Many people with fibromyalgia also report varying degrees of success with complementary and alternative therapies, including massage, movement therapies (such as Pilates and the Feldenkrais method), chiropractic treatments, acupuncture, and various herbs and dietary supplements for different fibromyalgia symptoms. (For more information on complementary and alternative therapies, contact the National Center for Complementary and Alternative Medicine. See Where Can I Get More Information About Fibromyalgia?.)

Though some of these supplements are being studied for fibromyalgia, there is little, if any, scientific proof yet that they help. The FDA does not regulate the sale of dietary supplements, so information about side effects, the proper 12 dosage, and the amount of a preparation's active ingredient may not be well known. If you are using or would like to try a complementary or alternative therapy, you should first speak with your doctor, who may know more about the therapy's effectiveness, as well as whether it is safe to try in combination with your medications.

Will Fibromyalgia Get Better With Time?

Fibromyalgia is a chronic condition, meaning it lasts a long time - possibly a lifetime. However, it may comfort you to know that fibromyalgia is not a progressive disease. It is never fatal, and it won't cause damage to your joints, muscles, or internal organs. In many people, the condition does improve over time.

What Can I Do To Try To Feel Better?

Besides taking medicine prescribed by your doctor, there are many things you can do to minimize the impact of fibromyalgia on your life. These include:

• Getting enough sleep - Getting enough sleep and the right kind of sleep can help ease the pain and fatigue of fibromyalgia. (See Tips for Good Sleep.) Even so, many people with fibromyalgia have problems such as pain, restless legs syndrome, or brain-wave irregularities that interfere with restful sleep.
• Exercising - Though pain and fatigue may make exercise and daily activities difficult, it's crucial to be as physically active as possible. Research has repeatedly shown that regular exercise is one of the most effective treatments for fibromyalgia. People who have too much pain or fatigue to do vigorous exercise should begin with walking or other gentle exercise and build their endurance and intensity slowly. Although research has focused largely on the benefits of aerobic and flexibility exercises, a new NIAMS-supported study is examining the effects of adding strength training to the traditionally prescribed aerobic and flexibility exercises.
• Making changes at work - Most people with fibromyalgia continue to work, but they may have to make big changes to do so; for example, some people cut down the number of hours they work, switch to a less demanding job, or adapt a current job. If you face obstacles at work, such as an uncomfortable desk chair that leaves your back aching or difficulty lifting heavy boxes or files, your employer may make adaptations that will enable you to keep your job. An occupational therapist can help you design a more comfortable workstation or find more efficient and less painful ways to lift.If you are unable to work at all due to a medical condition, you may qualify for disability benefits through your employer or the Federal Government.Social Security Disability Insurance (SSDI) and Supplemental Security Insurance (SSI) are the largest Federal programs providing financial assistance to people with disabilities. Though the medical requirements for eligibility are the same under the two programs, the way they are funded is different. SSDI is paid by Social Security taxes, and those who qualify for assistance receive benefits based on how much an employee has paid into the system; SSI is funded by general tax revenues, and those who qualify receive payments based on financial need. For information about the SSDI and SSI programs, contact the Social Security Administration. (See Where Can I Get More Information About Fibromyalgia?.)
• Eating well - Although some people with fibromyalgia report feeling better when they eat or avoid certain foods, no specific diet has been proven to influence fibromyalgia. Of course, it is important to have a healthy, balanced diet. Not only will proper nutrition give you more energy and make you generally feel better, it will also help you avoid other health problems.

Tips for Good SleepKeep regular sleep habits. Try to get to bed at the same time and get up at the same time every day?even on weekends and vacations.Avoid caffeine and alcohol in the late afternoon and evening. If consumed too close to bedtime, the caffeine in coffee, soft drinks, chocolate, and some medications can keep you from sleeping or sleeping soundly. Even though it can make you feel sleepy, drinking alcohol around bedtime also can disturb sleep. Time your exercise. Regular daytime exercise can improve nighttime sleep. But avoid exercising within 3 hours of bedtime, which actually can be stimulating, keeping you awake. Avoid daytime naps. Sleeping in the afternoon can interfere with nighttime sleep. If you feel you can't get by without a nap, set an alarm for 1 hour. When it goes off, get up and start moving. Reserve your bed for sleeping. Watching the late news, reading a suspense novel, or working on your laptop in bed can stimulate you, making it hard to sleep. Keep your bedroom dark, quiet, and cool. Avoid liquids and spicy meals before bed. Heartburn and latenight trips to the bathroom are not conducive to good sleep. Wind down before bed. Avoid working right up to bedtime. Do relaxing activities, such as listening to soft music or taking a warm bath, that get you ready to sleep. (An added benefit of the warm bath: It may soothe aching muscles.)

What Are Researchers Learning About Fibromyalgia?

The NIAMS sponsors research that will improve scientists' understanding of the specific problems that cause or 16 accompany fibromyalgia, in turn helping them develop better ways to diagnose, treat, and prevent this syndrome.

The research on fibromyalgia supported by NIAMS covers a broad spectrum, ranging from basic laboratory research to studies of medications and interventions designed to encourage behaviors that reduce pain and change behaviors that worsen or perpetuate pain.

Following are descriptions of some of the promising research now being conducted:

• Understanding pain - Because research suggests that fibromyalgia is caused by a problem in how the body processes pain - or more precisely, a hypersensitivity to stimuli that normally are not painful - several NIAMS-supported researchers are focusing on ways the body processes pain to better understand why people with fibromyalgia have increased pain sensitivity.Previous research has shown that people with fibromyalgia have reduced blood flow to parts of the brain that normally help the body deal with pain. In one new NIAMS-funded study, researchers will be using imaging technology called positron emission tomography (PET) to compare blood flow in the brains of women who have have fibromyalgia with those who do not. In both groups, researchers will study changes in blood flow that occur in response to painful stimuli.Researchers speculate that female reproductive hormones may be involved in the increased sensitivity to pain characteristic of fibromyalgia. New research will examine the role of sex hormones in pain sensitivity, in reaction to stress, and in symptom perception at various points in the menstrual cycles of women with fibromyalgia and of women without it. The results from studying these groups of women will be compared with results from studies of the same factors in men without fibromyalgia over an equivalent period of time.Another line of NIAMS-funded research involves developing a rodent model of fibromyalgia pain. Rodent models, which use mice or rats that researchers cause to develop symptoms similar to fibromyalgia in humans, could provide the basis for future research into this complex condition.
• Understanding stress - Medical evidence suggests that a problem or problems in the way the body responds to physical and/or emotional stress may trigger or worsen the symptoms of any illness, including fibromyalgia. Researchers funded by NIAMS are trying to uncover and understand these problems by examining chemical interactions between the nervous system and the endocrine (hormonal) system. Scientists know that people whose bodies make inadequate amounts of the hormone cortisol experience many of the same symptoms as people with fibromyalgia, so they also are exploring if there is a link between the regulation of the adrenal glands, which produce cortisol, and fibromyalgia.Another NIAMS-funded study suggests that exercise improves the body's response to stress by enhancing the function of the pituitary and adrenal glands. The hormones produced by these two endocrine glands are essential to regulating sleep and emotions, as well as processing pain.
• Improving sleep - Researchers supported by NIAMS are investigating ways to improve sleep for people with fibromyalgia whose sleep problems persist despite treatment with medications. One team has observed that fibromyalgia patients with persistent sleep problems share characteristics with people who have insomnia, such as having erratic sleep and wake schedules and spending too much time in bed. This team is testing whether strategies developed to help insomnia patients will also help people with fibromyalgia achieve deep sleep, which eases pain and fatigue. Preliminary results show that sleep education, which teaches good sleep habits, and cognitive behavioral therapy, which includes sleep education and a regimen to correct poor habits and improper sleep schedules, both reduce insomnia.
• Looking for the family connection - Because fibromyalgia appears to run in families, one group of NIAMS-supported researchers is working to identify whether a gene or genes predispose people to the condition.Another team is trying to determine if fibromyalgia is more common in people with other conditions, such as serious mood disorders, that tend to run in families. Specifically, the group is studying the prevalence of psychiatric disorders and arthritis and related disorders in people with fibromyalgia and their first-degree relatives (parents, children, sisters, brothers) as compared to people with rheumatoid arthritis and their relatives. The group is exploring whether clusters of conditions exist in families, which might shed light on shared common risk factors or disease processes.
• Studying and targeting treatments - NIAMS recently funded its first study of a drug treatment for fibromyalgia. The study will measure the effectiveness of gabapentin, an anticonvulsant medication, in reducing symptoms of fibromyalgia. Gabapentin has been found to relieve chronic pain caused by nervous system disorders, and it was recently approved by the FDA for the treatment of persistent, severe pain that can follow an episode of shingles.Scientists recognize that people with fibromyalgia often fall into distinct subgroups that adapt to and cope with their symptoms differently. They also realize that these subgroups may respond to treatments differently. One NIAMS-funded team of researchers has divided people with fibromyalgia into three groups based on how they cope with the condition. Relative to other chronic pain patients, those in the first group have higher levels of pain and report more interference in their life due to pain. They also have higher levels of emotional distress, and feel less control over their lives and are less active. The second group reports receiving less support from others, higher levels of negative responses from significant others, and lower levels of supportive responses from significant others. Those in the third group are considered adaptive copers; they have less pain, report less interference in their lives due to pain, and have less emotional distress. Members of this last group feel more control over their lives and are more active. On the premise that the better you understand the subgroups, the better you can tailor treatments to fit them, the researchers now are trying to design and test different programs for each group, combining physical therapy, interpersonal skills training, and supportive counseling.

Where Can I Get More Information About Fibromyalgia?

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 877-22-NIAMS (226-4267) (free of charge)
TTY: 301-565-2966
Fax: 301-718-6366
[email protected]
http://www.niams.nih.gov

National Center for Complementary and Alternative Medicine
National Institutes of Health
PO Box 7923
Gaithersburg, MD 20898-7923
Phone: 888-644-6226 (free of charge)
TTY: 866-464-3615 (free of charge)
Fax: 866-464-3616 (free of charge)
[email protected]
http://www.nccam.nih.gov

Social Security Administration
Office of Public Inquiries
Windsor Park Building
6401 Security Boulevard
Baltimore, MD 21235
Phone: 800-772-1213 (free of charge)
TTY: 800-325-0778 (free of charge)
http://www.ssa.gov/disability

American College of Rheumatology/Association of Rheumatology Health Professionals
1800 Century Place, Suite 250
Atlanta, GA 30345-4300
Phone: 404-633-3777
Fax: 404-633-1870
http://www.rheumatology.org

Advocates for Fibromyalgia Funding, Treatment, Education, and Research
PO Box 768
Libertyville, IL 60048-0766
Phone: 847-362-7807
Fax: 847-680-3922
[email protected]
http://www.affter.org

Fibromyalgia Network
PO Box 31750
Tucson, AZ 85751-1750
Phone: 800-853-2929 (free of charge)

Home

National Fibromyalgia Association
2200 N. Glassell Street, Suite "A"
Orange, CA 92865
Phone: 714-921-0150

Home New

National Fibromyalgia Partnership
PO Box 160
Linden, VA 22642-0160
Phone: 866-725-4404 (free of charge)
Fax: 866-666-2727 (free of charge)
[email protected]
http://www.fmpartnership.org

Arthritis Foundation
1330 West Peachtree Street
Atlanta, GA 30309
Phone: 404-872-7100 or
800-283-7800 (free of charge) or call your local chapter
(To find your local chapter, check your phone directory or visit the foundation's Web site.)
http://www.arthritis.org

Key Words

Adrenal glands - A pair of endocrine glands located on the surface of the kidneys. The adrenal glands produce corticosteroid hormones such as cortisol, aldosterone, and the reproductive hormones.

Arthritis - Literally means joint inflammation, but is often used to indicate a group of more than 100 rheumatic diseases. These diseases affect not only the joints but also other connective tissues of the body, including important supporting structures, such as muscles, tendons, and ligaments, as well as the protective covering of internal organs.

Analgesic - A medication or treatment that relieves pain.

Connective tissue - The supporting framework of the body and its internal organs.

Chronic disease - An illness that lasts for a long time, often a lifetime.

Cortisol - A hormone produced by the adrenal cortex, important for normal carbohydrate metabolism and for a healthy response to stress.

Fibrous capsule - A tough wrapping of tendons and ligaments that surrounds the joint.

Fibromyalgia - A chronic syndrome that causes pain and stiffness throughout the connective tissues that support and move the bones and joints. Pain and localized tender points occur in the muscles, particularly those that support the neck, spine, shoulders, and hip. The disorder includes widespread pain, fatigue, and sleep disturbances.

Inflammation - A characteristic reaction of tissues to injury or disease. It is marked by four signs: swelling, redness, heat, and pain. Inflammation is not a symptom of fibromyalgia.

Joint - A junction where two bones meet. Most joints are composed of cartilage, joint space, fibrous capsule, synovium, and ligaments.

Ligaments - Bands of cordlike tissue that connect bone to bone.

Muscle - A structure composed of bundles of specialized cells that, when stimulated by nerve impulses, contract and produce movement.

Nonsteroidal anti-inflammatory drugs (NSAIDs) - A group of drugs, such as aspirin and aspirin-like drugs, used to reduce inflammation that causes joint pain, stiffness, and swelling.

Pituitary gland - A pea-sized gland attached beneath the hypothalamus at the base of the skull that secretes many hormones essential to bodily functioning. The secretion of pituitary hormones is regulated by chemicals produced in the hypothalamus.

Sleep disorder - A disorder in which a person has difficulty achieving restful, restorative sleep. In addition to other symptoms, people with fibromyalgia usually have a sleep disorder.

Tender points - Specific places on the body where a person with fibromyalgia feels pain in response to slight pressure.

Tendons - Fibrous cords that connect muscle to bone.

Acknowledgments

The NIAMS gratefully acknowledges the assistance of Deborah Ader, PhD, NIAMS, NIH; Karen Amour and Lynne Matallana, National Fibromyalgia Association, Orange, CA; Michele L. Boutaugh, MPH, Arthritis Foundation, Atlanta, GA; Daniel Clauw, MD, and Leslie Crofford, MD, University of Michigan, Ann Arbor; and Tamara Liller, National Fibromyalgia Partnership, Linden, VA, in the preparation of this booklet.

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Source: National Institutes of Health
National Institute of Arthritis and Musculoskeletal and Skin Diseases
NIH Publication No. 04-5326
2004

Reviewed by athealth on February 4, 2014.

by Jill Fletcher

As a parent, there are moments when warning bells go off-times when you notice that your child might be having trouble grasping certain skills that their peers seem to have mastered. Over the course of my career as a teacher and child case worker, time and time again I've heard parents make statements like the following :

"I have been reading with my child, but he doesn't seem to understand what he has read."

"I notice while we're practicing spelling words, my daughter mixes up the letters, or writes them in reverse order."

"My child just seems to drift away; she's not really overly active, but she doesn't seem to be paying attention."

Do any of these scenarios sound familiar? If so, you may want to start the process of getting some help with your child's education. When your child is diagnosed with a disability, the rule of thumb for parents is: the earlier you can document the problem, the better.

Where to start?

Start by gathering information to support your concerns. Contact daycare providers, the child's doctor, or anyone else who might be interacting with your child or knows them and may have observations to share. Are they seeing what you have noticed? Have them put something into writing. Then it's time to contact your child's school for help.

Put your concerns in a letter to your child's school and be sure to include the date. Keep a copy of this letter in your files. This letter will start the "timeline" that documents the disability and need for extra support. Clearly state that the letter serves as a request for a multi-factored evaluation and that you are giving consent for this to take place, and be sure to clearly outline your observations and concerns. Include copies of any documentation, evaluations or assessments that support those concerns. Also, describe any special or extra supports that the school may already be providing for your child.

Be sure to provide your contact information with your address, both day and night phone numbers, email and cell phone. Remember that a reasonable time frame for response would be (1-2 weeks), and address your letter to the principal and Special Education Coordinator of your school or district. By doing this, you have started the process for your child to get the help they need. There are timelines that each state must go by, but the final determination of what type of help they will provide should be made within 100 days.

The process may vary from state to state. You do have the right and responsibility to participate in any meetings with your school during the evaluation process. There should be several meetings: one to plan what evaluations will take place, which could include screenings, classroom observations, monitoring, consultations, assisted technology, and materials to support student achievement. Your child must be assessed in all areas associated with the suspected disability including an appropriate evaluation in the areas of: health, vision, hearing, social and emotional status, general intelligence, academic performance, communicative skills, and motor abilities.

The members of the team from the school will come together to review the results and determine if your child meets the criteria for services. The right to receive those services has been mandated under Federal Law-The Individuals with Disabilities Education Act (IDEA) provides that if school-aged children fall under one or more qualifying conditions or under Section 504 of the Rehabilitation Act of 1973, they should be eligible for support.

If your child is determined to be eligible, your child's team will develop an "Appropriate" (which means equal to an education that is provided for those students who are not disabled) program that will be designed to provide an "educational benefit for a person with disabilities." This covers all school age children who meet specific criteria who may fall under on or more qualifying conditions, i.e. autism, specific learning disabilities, speech /language impairments, emotional disturbance, traumatic brain injury, visual or hearing impairment, and other health impairment. Under IDEA, an Individual Educational Plan will be made. The name of this plan will vary from state to state, but it must be developed within 30 days. This plan will be reviewed on a yearly basis, to establish goals for your child's education and the supports that will be provided. Your child will be re-evaluated every three years to determine eligibility for continuation of services.

A child may also receive services under Section 504, which has less specific procedural criteria under which school personnel and services are provided. Under Section 504, a child who meets the definition for qualified "handicapped person" may receive services,, such as a physical or mental handicap that substantially limits a major life activity. This would include a child who has a disability that impairs walking, seeing, hearing, speaking, learning, working, or caring for him or herself. 504 services cover a lifespan, and safeguard a person with disabilities in areas of school, employment, transportation and public access to buildings, among other things. If a 504 plan is developed, it will be reviewed periodically, usually annually, and the guidelines are more flexible.

What are my rights and responsibilities?

If your child is denied services, you have the right to request that an independent evaluation be done to assess your child's needs. Under IDEA the school will be responsible for the expenses, while under 504 the parents would cover the costs. You may also appeal the decision under due process with the state education department. Each state may have a slightly different process-you can find out more about the process in your particular area by accessing the websites for the Department of Education for you state/province. Also check the yellow pages and web sites for advocacy groups for various disabilities in your area. They can be a strong support for parents during this process, and have materials that can help you on this journey.

Remember: You are your child's advocate. You know your child better than anyone else at the table and it is your role to help develop the best educational supports to meet your child's needs. You should be notified of any planning meetings scheduled for your child. Prepare for these meetings by making notes and doing research. Be ready to give your views: you are an important part of the planning process.

Build a file or binder about your child. Keep copies of all correspondence, (send important concerns by registered mail), evaluations, minutes of the meetings and your copy of the educational plan. This can become one of the most valuable documents in your child's life. Most schools make sincere efforts to provide the education and services your child needs. But there may be times where you will need to push for things that you feel will make a difference for your son or daughter's education.

Accommodations and supports may range from very minor changes to more restrictive or creative educational settings. Some supports may be as simple as alternative means of testing for your child, (oral testing, extended time to test, etc.) to employing a one-on-one aide who will support your child on the bus or in each class. The beauty of the team approach is the problem-solving and creative solutions that can be developed to meet the needs of your child. This is why it is called the individual education plan.

Remember that we must "parent the child we have." It is our job to advocate for the best education that can be provided for your child. You know your child, and you are their cheerleader and supporter. Your involvement in their education will make all the difference.

For more in-depth information about special education, see the National Information Center for Children and Youth with Disabilities (NICHY)

How to Navigate the School System When Your Child Has a Disability reprinted with permission from Empowering Parents. For more information, visit www.EmpoweringParents.com

Author: Jill Fletcher has a Master's in Education and is a certified Assistant Principal. Jill also taught for five years in a special program for "Youth at Risk of Dropping Out of School" in New Brunswick, Canada.

Reviewed by athealth on February 5, 2014.

Page last modified or reviewed on March 28, 2011

Marital infidelity often makes front page news, especially when it involves such notable public figures as former New York Governor Elliot Spitzer, South Carolina Governor Mark Sanford, and former Senator and Presidential candidate John Edwards.

Infidelity happens in the lives of ordinary people, too. According to a 2006 report on American Sexual Behavior by the National Opinion Research Center, 25% of married men and 13% of married women have had affairs. Affairs can be devastating to a marriage and can cause tremendous emotional distress to the offended spouse and children in the marriage.

An affair is based on deception and betrayal, and it is often, but not always, a symptom of marital issues that have not been faced. It can also involve intra psychic problems on the part of the offending spouse. Affairs can be emotional as well as sexual and can be long-lasting or one night stands. The emergence of Internet affairs is a recent phenomenon made possible by the development of technology.

Generally, emotional affairs with sexual relationships are the most devastating to the marital relationship.

Affairs may start with inappropriate self-disclosure to another person, as self-disclosure of highly personal issues can lead to intimacy. This often indicates that the married couple cannot effectively communicate feelings or needs. Psychiatric implications of affairs include depression, severe anxiety, and trauma on the part of the betrayed spouse. The offending souse can also become depressed and anxious if threatened with the loss of a valued relationship.

Warning signs are sometimes present and can include disinterest, lying, lack of transparency with financial matters, inappropriate travel or e-mails and cell phone calls. Treatment requires determining commitment to work on the marriage, rebuilding trust, complete transparency, recognizing that anger is often a reaction to being hurt, and taking responsibility for the affair. When the offending spouse is genuinely sorry for the affair, the hurt partner needs to verbalize the acceptance of the apology and a willingness to start the forgiveness process. Forgiveness and rebuilding trust can be a long, arduous process. The couple will need to identify and implement behavioral changes that enhance their relationship and provide self soothing techniques for the hurt spouse .Therapy often involves conjoint treatment with individual sessions for each spouse. Therapy can be difficult, and at times medication may be recommended to treat the severe distress that is experienced. In treatment, the couple will need to address the needs of their children, too.

Cheating does not have to end a relationship. It can lead to rebuilding the marriage, but there has to be commitment, a willingness to take full responsibility for offending behavior, and a readiness to learn and change on the part of both partners. Once the couple is back on track, they will need to be acutely aware of warning signs of future marital distress.

Author: Phillip L. Elbaum, LCSW, CADC
Phillip L. Elbaum, MSW, LCSW, CADC, is a licensed clinical social worker who has a clinical practice in Deerfield, Illinois.

Reviewed by athealth on February 5, 2014.

A brown paper bag may hold the key to safer use of medications, according to health experts.

"A 'brown bag checkup' is the single best thing that patients can do to avoid medication mistakes and cut down on unnecessary medications," says Douglas Paauw, M.D., professor of medicine at the University of Washington in Seattle. "But I would estimate that only about 10 percent of people actually do it."

The checkup involves putting all of your medications and over-the-counter products in a brown paper bag and bringing them into your doctor's office. The bag should include any over-the-counter or prescription drugs, herbs, vitamins, dietary supplements, and topical treatments such as ointments and creams. "This kind of checkup is a good idea for anyone who takes medication, but particularly for older people who are the most likely to be taking several medications," Paauw says. The average 75-year-old has three chronic conditions and uses five prescription drugs, according to a report from the Merck Institute of Aging & Health.

Researchers at Pennsylvania State University found that when adults ages 65 to 91 were asked to bring in the brown paper bag containing their medicines, the list of medications in the bag was more complete than their official pharmacy records. And people with worse health consistently had poorer matches between the brown bags and the paperwork.

"If not a paper bag, then write out a list and bring that in," Paauw says. You could also share the information with your pharmacist, who can check for drug duplications, interaction problems, inappropriate dosing, and whether each drug is being given for the right indication.

The idea is to have at least one health care professional informed about everything that you take. "This should be done at least every year and preferably more often," Paauw says. "Some of my patients do it at every visit."

When the bottles and tubes are spread out on the table, the picture becomes clear. "When someone pulls out 10 bottles, then something might not be right and we can make adjustments," Paauw says. The doctor can also see that your multivitamin with iron is the reason your thyroid treatment isn't working. "Both iron and calcium supplements can interfere with the absorption of thyroid medicine," says Paauw, who gave a talk on common drug errors at the annual meeting of the American College of Physicians in April 2006.

Stephen Setter, Pharm.D., associate professor of pharmacotherapy at Washington State University in Spokane, says doubling up on therapy is another common problem. "Someone may be taking two products containing acetaminophen," which raises the risk of liver damage. Other common problems include expired medications and medications that are no longer needed, but were never reevaluated.

After you and your doctor settle on what you should be taking, then the next thing is for you to know the name of your medication and what it's for, says Karen Gunning, Pharm.D., associate professor of pharmacy practice at the University of Utah in Salt Lake City. "If an older person has memory problems or difficulty with comprehension, a family member or caregiver could help," Gunning says.

Setter cites an example in which one of his older patients mistakenly thought her glaucoma medication was for treating headaches. "So she was taking her eye medication only when she had a headache, but she should have been taking it every day to treat her eye disease," Setter says. Experts say that it's important to understand your medications because you are more likely to take the medicine correctly, more likely to know what to expect from the medication, and better able to report what you are taking to your doctors and pharmacist.

"Keep the list of medications in your wallet and let a family member know that you have it," Gunning suggests. "Patients should be able to take that list out at the dentist's office, an appointment with a specialist, or in an emergency," she says. "But it's not uncommon for an older patient to come to the hospital and say that their doctor gave them a white pill and that's all they know."

John Lowery, 87, Delphi, Ind., carries his medication list in his wallet, keeps it on his computer at home, and gives a copy of it to his primary care doctor every time he sees her. His oldest son, 65, lives nearby and also knows about the list.

Sticking With the Plan Setter, a pharmacist who helps older people manage their lives at home, says he often discovers that patients stray from their medication plan and that their doctor isn't aware of it. "I've seen a person's blood pressure go up because the patient hasn't been taking the medication, but the doctor thinks the drug isn't working," Setter says. "So a second medication is added or the dose is increased when the problem is really a compliance issue." Setter says that when this happens, he contacts the doctor and talks with the patient to reinforce the importance of two-way communication.

Robert Ferguson, M.D., chief of internal medicine at Union Memorial Hospital in Baltimore, says that intentional noncompliance with the regimen typically occurs because the patient can't afford the medicine or is worried about side effects. "When noncompliance is unintentional," Ferguson says, "it's usually because complying with the regimen became too difficult. It's so complex that it's too hard to keep it up."

Ferguson says he teaches medical residents that the regimen should be as simple as possible and effective, and should result in minimal side effects. "Sometimes, we can reduce the number of medications by treating two problems with one medication," Ferguson says. There also are ways to make the schedule simpler such as switching from a medicine that's given three times a day to another medicine that can be given once a day.

You can make sticking to a schedule easier by attaching the medications to meals or other daily activities. Lowery says this works for him. "The three medications that I need to take in the morning go on top of the refrigerator and I have them with breakfast," he says. "I take the others at night before bedtime."

For more complicated regimens, pill boxes with compartments can help. Pill boxes are also useful for people who have trouble opening pill bottles. Setter says, "You can ask for pre-filled pill boxes or request bottles without child-proof caps if no children live in or visit the home." Pharmacies usually charge a nominal fee for pre-filled pill boxes.

Everything from gadgets that beep to simple medication charts posted on the refrigerator can serve as reminders. "For some people, we color code the medication bottles or use a big picture of the sun to signal morning medications," Setter says.

Setter says he talks with many older people who are confused about the purpose of the drug and the instructions. "The typical scenario is that a patient has three new prescriptions and had to wait in the pharmacy for 30 minutes, so they just want to get the prescriptions filled and go," he says. "Health providers need to speak more slowly and take the time to explain, which can be a challenge," Setter says. "And patients should ask questions. But people get intimidated and don't want to ask or they feel like they don't have time to ask questions." Writing questions down is always a good idea, Setter says. "Family members and caregivers can help with this."

Examples of questions to ask about a new medication: What should I do if I forget a dose? Should I take the medicine before, during, or after meals? What should the timing be between each dose?

With some diseases, people may stop taking medication because they don't understand why they are taking it or don't feel that it helps. "But we don't want people to stop taking an osteoporosis drug and then have a fracture a year later," Setter says. "And with a diabetes drug, we are hoping to prevent blindness, amputation, and kidney disease."

Lowery, who has survived a heart attack and kidney failure, says he is diligent about managing his medications because he feels they improve his quality of life. From the pills that ease his joint pain to the drops that soothe his dry eyes, medications help him stay active. "I keep up a garden and go to bluegrass music festivals," Lowery says. He also visits Helen, his wife of 66 years, every day at the nursing home.

Managing Side Effects Most medication side effects are mild and may lessen over time. But if they are bothersome, you should discuss them with your doctor. The doctor may switch to a different drug or change the dose. "Neither patients nor physicians should shrug off side effects by chalking them up to old age," Setter says. "And side effects shouldn't be treated with more drugs."

Compared with younger people, older people can be more likely to experience some side effects, Ferguson says. Side effects may also be more troublesome than they would be for someone younger. There are no absolutes here. Some robust 85-year-olds can handle a medication better than a 50-year-old who has a lot of health problems. But generally, older people have a decline in liver and kidney function, which affects the way a drug is broken down and removed from the body. "The kidneys decline about 1 percent each year starting at age 40," Ferguson says. "Medication stays in the body longer and side effects can have bigger consequences in older people."

Examples of side effects that may affect older people more than younger people are dizziness, dry mouth, drowsiness, falls, depression, insomnia, nausea, and diarrhea. David Greeley, M.D., a neurologist at Northwest Neurological Institute in Spokane, says the effects of sedating antihistamines such as diphenhydramine can be disastrous in older people.

Diphenhydramine is commonly found in over-the-counter sleep aids such as Unisom Sleep Gels, Tylenol PM, and cold and allergy medicines such as Benadryl. Greeley says, "Whereas a younger person can take it at night and feel back to normal by morning, the medication can linger in the system of someone older, which may result in falls and confusion."

Paauw says diphenhydramine can also affect a man's prostate gland. "An older person who already has trouble urinating can end up in the emergency room with urinary retention," he says.

Another example is the drug Mirapex (pramipexole), a treatment for Parkinson's disease, for which there is an increased risk of hallucinations in people older than 65 compared with people younger than 65. "Quinolone antibiotics may also cause hallucinations," Paauw says. Examples of quinolone antibiotics include Cipro (ciprofloxacin), Levaquin (levofloxacin), and Floxin (ofloxacin).

In 2005, the Food and Drug Administration warned the public about the use of certain drugs called atypical antipsychotic drugs. The drugs are approved to treat schizophrenia and mania, but clinical studies of the drugs to treat behavioral disorders in older patients with dementia showed a higher death rate associated with their use when compared with patients receiving an inactive pill (placebo). The advisory applies to these antipsychotic drugs: Abilify (aripiprazole), Risperdal (risperidone), Zyprexa (olanzapine), Geodon (ziprasidone), Seroquel (quetiapine), and Clozaril (clozapine). Symbyax (olanzapine and fluoxetine), which is approved to treat depressive episodes associated with bipolar disorders, was also part of the advisory. The causes of death in older patients were varied, but most appeared to be related to the heart or pneumonia.

Reducing Errors Setter says that older adults sometimes inadvertently receive an initial dose of medication that's too high. "The dose may be totally appropriate for a younger adult," Setter says, "but with the aging process, an older adult is less able to tolerate the typical starting dose."

Health care providers try to find a balance that gives older people appropriate medications and appropriate doses. Experts say the philosophy has always been "start low and go slow" with dosing for older people because there are not enough clinical trial data in this age group for many drugs, especially in people ages 75 and older.

And because of the use of multiple medications, drug interactions are of concern. "Some interactions aren't necessarily harmful and can be easily managed," Setter says. "We want to prevent drug interactions that are dangerous."

Improving the knowledge base about how drugs work together is helpful, Setter says. "We have clinical guidelines that address individual diseases like Alzheimer's disease, Parkinson's, or diabetes. But there is a need for clinical guidelines with a geriatric slant--guidelines that can apply to a person who may have five co-existing diseases."

Drug-drug interactions occur when a drug may increase the effect of another drug or render it ineffective. Paauw says interactions involving warfarin (Coumadin) are the most common ones that result in hospitalization. Warfarin, a medication that thins the blood and helps prevent clots, is commonly prescribed to older people with an irregular heartbeat (atrial fibrillation) who are at risk of blood clots that can cause strokes.

Warfarin should not be taken with aspirin, ibuprofen, or other nonsteroidal anti-inflammatory drugs because of the increased risk of gastrointestinal bleeding. Warfarin also interacts with the antibiotic Bactrim (sulfamethoxazole), which is commonly used in older people. This combination can result in severe increased bleeding. The supplements Ginkgo biloba, garlic, ginger, and ginseng can also interact with warfarin.

Many interactions can be prevented with more communication between doctors and patients, as well as better coordination between all the health care professionals who see a particular patient, says Nicole Brandt, Pharm.D., director of clinical and educational programs at the Peter Lamy Center for Drug Therapy and Aging in Baltimore. She and her colleagues are partnering with a managed care system to study medication management in older patients who have been discharged from five hospitals. As part of the study, a pharmacist visits newly discharged patients to conduct a medication evaluation.

"The goal is to create a more integrated social and health care support system to improve adherence and reduce errors," Brandt says. "Ultimately, we want to decrease readmissions to the hospital."

Sarah Ray, Pharm.D., ambulatory clinical coordinator of pharmaceutical services at Aurora Health Care in Milwaukee, says that technology is increasingly playing a role in improving patient safety. "We'll notice if patients are discharged from the hospital on a different dose than what they were on when they were in the hospital or before entering the hospital," Ray says. "I then have to clarify with the doctor, and the prescription may have been written incorrectly." Ray says she's able to catch that kind of error because she works in an integrated health care system and has access to computerized information about what the patient was taking in the hospital. But that kind of error might not be caught at an independent pharmacy that does not have access to hospital records.

Ray says she thinks electronic prescribing will make a big difference in reducing medication errors. Electronic prescribing allows doctors to transmit prescriptions to pharmacies electronically. This method decreases errors caused by hard-to-read handwriting and automates the process of checking for drug interactions and allergies. The Medicare Prescription Drug Improvement and Modernization Act of 2003 established standards for electronic prescribing. Final standards will be set by the U.S. Department of Health and Human Services no later than April 2008.

By Michelle Meadows
FDA Consumer Magazine
July-August 2006

Reviewed by athealth on February 5, 2014.

How can I help my child to become more confident?

Young teens often feel inadequate. They have new bodies and developing minds and their relationships with friends and family members are in flux. They understand for the first time that they aren't good at everything. The changes in their lives may take place more rapidly than their ability to adjust to them.

Children with ADHD, ODD, and other behavioral disorders are particularly vulnerable to lack of confidence and low self-esteem. They frequently experience school problems, have difficulty making friends, and lag behind their peers in psychosocial development.

Poor self-esteem often peaks in early adolescence, then improves during the middle and late teen years as identities gain strength and focus. At any age, however, a lack of confidence can be a serious problem. Young teens with poor self-esteem can be lonely, awkward with others and sensitive to criticism and with what they see as their shortcomings. Young teens with low confidence are less likely to join in activities and form friendships. This isolates them further and slows their ability to develop a better self-image. When they do make friends, they are more vulnerable to negative peer pressure.

Some young adolescents who lack confidence hold back in class. Others act out to gain attention. At its worst, a lack of confidence is often linked with self-destructive behavior and habits?smoking or drug or alcohol use, for example.

Girls often experience deeper self-doubts than do boys (although there are many exceptions). This can be for many reasons:

• Society sends girls the message that it is important for them to get along with others and to be very, very thin and pretty. Life can be just as hard, however, for a boy who thinks he has to meet society's expectations that boys have to be good at sports and other physical activities.
• Girls mature physically about two years earlier than do boys, which requires girls to deal with issues of how they look, popularity and sexuality before they are emotionally mature enough to do so.
• Girls may receive confusing messages about the importance of achievement. Although girls are told that achievement is important, some also fear that they won't be liked, especially by boys, if they come across as too smart or too capable, especially in the areas of math, science and technology.If your young adolescent suffers from a severe lack of confidence over long period, she may benefit from seeing a counselor or other professional. This is especially true if she also has a drug or alcohol problem, a learning disability, an eating disorder or severe depression. (See the Problems section, for information that can help you to decide whether your child fits into one of these categories.) Most young adolescents will get through the rough spots with adequate time and support.
  Most psychologists now believe that self-esteem and self-confidence represent a range of feelings that a child has about himself in many different situations. Psychologist Susan Harter has developed a theory of self-esteem that considers both a child's sense of confidence in an area of activity and how important that area is to the child. For example, adolescents may think about a number of situations: competing on the track team, studying math, dating, taking care of younger brothers or sisters and so on. An adolescent is likely to feel more confident doing some of these things than others. She may feel very good about her athletic ability and skill at math, but feel bad about her dating life. She may also have mixed feelings about how good a sister she is to her baby brother. How good this teenager feels about herself ties to how important each of these area is to her. If having a very active dating life is the most important area of her life, this girl will feel bad about herself. If being a scholar-athlete is most important area, then she will feel very good about herself. Based on this theory, the best ways to help your child to develop confidence include the following:
  • Provide opportunities for your child to succeed. As teacher Diane Crim points out, "The best way to instill confidence in someone is to give them successful experiences. You need to set them up to succeed?give them experiences where they can see how powerful they are. Kids can engineer those experiences. Part of confidence is knowing what to do when you don't know what to do."Help your child to build confidence in his abilities by encouraging him to take an art class, act in a play, join a soccer or baseball team, participate in science fairs or computer clubs or play a musical instrument?whatever he likes to do that brings out the best in him. Don't push a particular activity on your child. Most children, whether they are 3 or 13 years old, resist efforts to get them to do things that they don't enjoy. Pushing children to participate in activities they haven't chosen for themselves can lead to frustration. Try to balance your child's experiences between activities that he is already good at doing with new activities or with activities that he is not so good at doing.You can also help your child to build confidence by assigning him family responsibilities at which he can succeed?unloading the dishwasher, cleaning his room or mowing the lawn.
  • Help young teens feel safe and trust in themselves. The ability of adolescents to trust in themselves comes from receiving unconditional love that helps them to feel safe and to develop the ability to solve their own problems. Your child, like all children, will encounter situations that require her to lean on you and others. But always relying on you to bail her out of tough situations can stunt her emotional growth. "We have to teach our children how to cope with the things they encounter, instead of easing the path," says teacher Anne Jolly.
  • Talk about anxieties that are related to school violence and to global terrorism. Many children have seen terrifying images of death and destruction on television and on the Internet. You can help your child to understand that although the country has suffered awful acts of terror, we are strong people who can come together and support each other through difficult times. In addition, you can:
    • Create a calm environment in your home through your own behavior. This may not be possible if your family has been affected directly by an act of terror or violence. If you are anxious, you need to explain to your child what you are feeling and why. Children take emotional cues from those they love.
    • Listen to what your child has to say. Assure him that adults are working to make homes and schools safe.
    • Help your child to separate fact from fiction. Discuss facts with your child and avoid guessing, exaggerating or overreacting.
    • Monitor your child's television, radio and Internet activity. Help her to avoid overexposure to violent images, which can heighten her anxiety.
    • Use historical examples (for example, Pearl Harbor or the Challenger space shuttle explosion) to explain to your child that bad things happen to innocent people, but that people go on with their lives and resolve even terrible situations.
    • Continue your normal family routines.
  • Praise and encourage. Praise is meaningful to adolescents when it comes from those they love and count on most?their parents and other important adults in their lives. Praising your child will help her to gain confidence. However, the compliments that you give her must be genuine. She will recognize when they are not.
  • Have patience. As adults, most people have confidence. This confidence comes about through years of experiencing success, but also through years of exploring strengths and weakness and choosing to stress different parts of our lives. Most of us would be unhappy if we had to do only those things that we are not good at. As adults, we tend to find our areas of strength and - to the extent we can ? to pursue these areas more than others. For an adolescent, however, it is difficult to downplay the areas in which they are less confident. For example, it is very hard for an adolescent with academic skills to focus on school rather than on dating, when all of her friends are dating and telling her how important dating is. For a parent this can lead to feelings of helplessness. You know that whether that cute new boy asked out your daughter will have little consequence on her life for the long run, but you also know that she cannot yet see this!

  US Department of Education
  10/15/2007
  Page last modified or reviewed by AH on March 28, 2011

What is bipolar disorder?

Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks. Symptoms of bipolar disorder are severe. They are different from the normal ups and downs that everyone goes through from time to time. Bipolar disorder symptoms can result in damaged relationships, poor job or school performance, and even suicide. But bipolar disorder can be treated, and people with this illness can lead full and productive lives.

Bipolar disorder often develops in a person's late teens or early adult years. At least half of all cases start before age 25.¹ Some people have their first symptoms during childhood, while others may develop symptoms late in life.

Bipolar disorder is not easy to spot when it starts. The symptoms may seem like separate problems, not recognized as parts of a larger problem. Some people suffer for years before they are properly diagnosed and treated. Like diabetes or heart disease, bipolar disorder is a long-term illness that must be carefully managed throughout a person's life.

What are the symptoms of bipolar disorder?

People with bipolar disorder experience unusually intense emotional states that occur in distinct periods called "mood episodes." An overly joyful or overexcited state is called a manic episode, and an extremely sad or hopeless state is called a depressive episode. Sometimes, a mood episode includes symptoms of both mania and depression. This is called a mixed state. People with bipolar disorder also may be explosive and irritable during a mood episode.

Extreme changes in energy, activity, sleep, and behavior go along with these changes in mood. It is possible for someone with bipolar disorder to experience a long-lasting period of unstable moods rather than discrete episodes of depression or mania.

A person may be having an episode of bipolar disorder if he or she has a number of manic or depressive symptoms for most of the day, nearly every day, for at least one or two weeks. Sometimes symptoms are so severe that the person cannot function normally at work, school, or home.

Symptoms of mania or a manic episode include:

Mood Changes

• A long period of feeling "high," or an overly happy or outgoing mood
• Extremely irritable mood, agitation, feeling "jumpy" or "wired."

Behavioral Changes

• Talking very fast, jumping from one idea to another, having racing thoughts
• Being easily distracted
• Increasing goal-directed activities, such as taking on new projects
• Being restless
• Sleeping little
• Having an unrealistic belief in one's abilities
• Behaving impulsively and taking part in a lot of pleasurable, high-risk behaviors, such as spending sprees, impulsive sex, and impulsive business investments.

Symptoms of depression or a depressive episode include;

Mood Changes

• A long period of feeling worried or empty
• Loss of interest in activities once enjoyed, including sex.

Behavioral Changes

• Feeling tired or "slowed down"
• Having problems concentrating, remembering, and making decisions
• Being restless or irritable
• Changing eating, sleeping, or other habits
• Thinking of death or suicide, or attempting suicide.

In addition to mania and depression, bipolar disorder can cause a range of moods, as shown on the scale.

One side of the scale includes severe depression, moderate depression, and mild low mood. Moderate depression may cause less extreme symptoms, and mild low mood is called dysthymia when it is chronic or long-term. In the middle of the scale is normal or balanced mood.

At the other end of the scale are hypomania and severe mania. Some people with bipolar disorder experience hypomania. During hypomanic episodes, a person may have increased energy and activity levels that are not as severe as typical mania, or he or she may have episodes that last less than a week and do not require emergency care. A person having a hypomanic episode may feel very good, be highly productive, and function well. This person may not feel that anything is wrong even as family and friends recognize the mood swings as possible bipolar disorder. Without proper treatment, however, people with hypomania may develop severe mania or depression.

During a mixed state, symptoms often include agitation, trouble sleeping, major changes in appetite, and suicidal thinking. People in a mixed state may feel very sad or hopeless while feeling extremely energized.

Sometimes, a person with severe episodes of mania or depression has psychotic symptoms too, such as hallucinations or delusions. The psychotic symptoms tend to reflect the person's extreme mood. For example, psychotic symptoms for a person having a manic episode may include believing he or she is famous, has a lot of money, or has special powers. In the same way, a person having a depressive episode may believe he or she is ruined and penniless, or has committed a crime. As a result, people with bipolar disorder who have psychotic symptoms are sometimes wrongly diagnosed as having schizophrenia, another severe mental illness that is linked with hallucinations and delusions.

People with bipolar disorder may also have behavioral problems. They may abuse alcohol or substances, have relationship problems, or perform poorly in school or at work. At first, it's not easy to recognize these problems as signs of a major mental illness.

How does bipolar disorder affect someone over time?

Bipolar disorder usually lasts a lifetime. Episodes of mania and depression typically come back over time. Between episodes, many people with bipolar disorder are free of symptoms, but some people may have lingering symptoms.

Doctors usually diagnose mental disorders using guidelines from the Diagnostic and Statistical Manual of Mental Disorders, or DSM. According to the DSM, there are four basic types of bipolar disorder:

• Bipolar I Disorder is mainly defined by manic or mixed episodes that last at least seven days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, the person also has depressive episodes, typically lasting at least two weeks. The symptoms of mania or depression must be a major change from the person's normal behavior.
• Bipolar II Disorder is defined by a pattern of depressive episodes shifting back and forth with hypomanic episodes, but no full-blown manic or mixed episodes.
• Bipolar Disorder Not Otherwise Specified (BP-NOS) is diagnosed when a person has symptoms of the illness that do not meet diagnostic criteria for either bipolar I or II. The symptoms may not last long enough, or the person may have too few symptoms, to be diagnosed with bipolar I or II. However, the symptoms are clearly out of the person's normal range of behavior.
• Cyclothymic Disorder, or Cyclothymia, is a mild form of bipolar disorder. People who have cyclothymia have episodes of hypomania that shift back and forth with mild depression for at least two years. However, the symptoms do not meet the diagnostic requirements for any other type of bipolar disorder.

Some people may be diagnosed with rapid-cycling bipolar disorder. This is when a person has four or more episodes of major depression, mania, hypomania, or mixed symptoms within a year.² Some people experience more than one episode in a week, or even within one day. Rapid cycling seems to be more common in people who have severe bipolar disorder and may be more common in people who have their first episode at a younger age. One study found that people with rapid cycling had their first episode about four years earlier, during mid to late teen years, than people without rapid cycling bipolar disorder.³ Rapid cycling affects more women than men.⁴

Bipolar disorder tends to worsen if it is not treated. Over time, a person may suffer more frequent and more severe episodes than when the illness first appeared.⁵ Also, delays in getting the correct diagnosis and treatment make a person more likely to experience personal, social, and work-related problems.⁶

Proper diagnosis and treatment helps people with bipolar disorder lead healthy and productive lives. In most cases, treatment can help reduce the frequency and severity of episodes.

What illnesses often co-exist with bipolar disorder? Substance abuse is very common among people with bipolar disorder, but the reasons for this link are unclear.⁷ Some people with bipolar disorder may try to treat their symptoms with alcohol or drugs. However, substance abuse may trigger or prolong bipolar symptoms, and the behavioral control problems associated with mania can result in a person drinking too much.

Anxiety disorders, such as post-traumatic stress disorder (PTSD) and social phobia, also co-occur often among people with bipolar disorder.^8-10 Bipolar disorder also co-occurs with attention deficit hyperactivity disorder (ADHD), which has some symptoms that overlap with bipolar disorder, such as restlessness and being easily distracted.

People with bipolar disorder are also at higher risk for thyroid disease, migraine headaches, heart disease, diabetes, obesity, and other physical illnesses.^10,11 These illnesses may cause symptoms of mania or depression. They may also result from treatment for bipolar disorder.

Other illnesses can make it hard to diagnose and treat bipolar disorder. People with bipolar disorder should monitor their physical and mental health. If a symptom does not get better with treatment, they should tell their doctor.

What are the risk factors for bipolar disorder? Scientists are learning about the possible causes of bipolar disorder. Most scientists agree that there is no single cause. Rather, many factors likely act together to produce the illness or increase risk.

Genetics

Bipolar disorder tends to run in families, so researchers are looking for genes that may increase a person's chance of developing the illness. Genes are the "building blocks" of heredity. They help control how the body and brain work and grow. Genes are contained inside a person's cells that are passed down from parents to children.

Children with a parent or sibling who has bipolar disorder are four to six times more likely to develop the illness, compared with children who do not have a family history of bipolar disorder.¹² However, most children with a family history of bipolar disorder will not develop the illness.

Genetic research on bipolar disorder is being helped by advances in technology. This type of research is now much quicker and more far-reaching than in the past. One example is the launch of the Bipolar Disorder Phenome Database, funded in part by NIMH. Using the database, scientists will be able to link visible signs of the disorder with the genes that may influence them. So far, researchers using this database found that most people with bipolar disorder had:¹³

• Missed work because of their illness
• Other illnesses at the same time, especially alcohol and/or substance abuse and panic disorders
• Been treated or hospitalized for bipolar disorder.

The researchers also identified certain traits that appeared to run in families, including:

• History of psychiatric hospitalization
• Co-occurring obsessive-compulsive disorder (OCD)
• Age at first manic episode
• Number and frequency of manic episodes.

Scientists continue to study these traits, which may help them find the genes that cause bipolar disorder some day.

But genes are not the only risk factor for bipolar disorder. Studies of identical twins have shown that the twin of a person with bipolar illness does not always develop the disorder. This is important because identical twins share all of the same genes. The study results suggest factors besides genes are also at work. Rather, it is likely that many different genes and a person's environment are involved. However, scientists do not yet fully understand how these factors interact to cause bipolar disorder.

Brain structure and functioning

Brain-imaging studies are helping scientists learn what happens in the brain of a person with bipolar disorder.^14,15 Newer brain-imaging tools, such as functional magnetic resonance imaging (fMRI) and positron emission tomography (PET), allow researchers to take pictures of the living brain at work. These tools help scientists study the brain's structure and activity.

Some imaging studies show how the brains of people with bipolar disorder may differ from the brains of healthy people or people with other mental disorders. For example, one study using MRI found that the pattern of brain development in children with bipolar disorder was similar to that in children with "multi-dimensional impairment," a disorder that causes symptoms that overlap somewhat with bipolar disorder and schizophrenia.¹⁶ This suggests that the common pattern of brain development may be linked to general risk for unstable moods.

Learning more about these differences, along with information gained from genetic studies, helps scientists better understand bipolar disorder. Someday scientists may be able to predict which types of treatment will work most effectively. They may even find ways to prevent bipolar disorder.

How is bipolar disorder diagnosed? The first step in getting a proper diagnosis is to talk to a doctor, who may conduct a physical examination, an interview, and lab tests. Bipolar disorder cannot currently be identified through a blood test or a brain scan, but these tests can help rule out other contributing factors, such as a stroke or brain tumor. If the problems are not caused by other illnesses, the doctor may conduct a mental health evaluation. The doctor may also provide a referral to a trained mental health professional, such as a psychiatrist, who is experienced in diagnosing and treating bipolar disorder.

The doctor or mental health professional should conduct a complete diagnostic evaluation. He or she should discuss any family history of bipolar disorder or other mental illnesses and get a complete history of symptoms. The doctor or mental health professionals should also talk to the person's close relatives or spouse and note how they describe the person's symptoms and family medical history.

People with bipolar disorder are more likely to seek help when they are depressed than when experiencing mania or hypomania.¹⁷ Therefore, a careful medical history is needed to assure that bipolar disorder is not mistakenly diagnosed as major depressive disorder, which is also called unipolar depression. Unlike people with bipolar disorder, people who have unipolar depression do not experience mania. Whenever possible, previous records and input from family and friends should also be included in the medical history.

How is bipolar disorder treated? To date, there is no cure for bipolar disorder. But proper treatment helps most people with bipolar disorder gain better control of their mood swings and related symptoms.^18-20 This is also true for people with the most severe forms of the illness.

Because bipolar disorder is a lifelong and recurrent illness, people with the disorder need long-term treatment to maintain control of bipolar symptoms. An effective maintenance treatment plan includes medication and psychotherapy for preventing relapse and reducing symptom severity.²¹

Medications

Bipolar disorder can be diagnosed and medications prescribed by people with an M.D. (doctor of medicine). Usually, bipolar medications are prescribed by a psychiatrist. In some states, clinical psychologists, psychiatric nurse practitioners, and advanced psychiatric nurse specialists can also prescribe medications. Check with your state's licensing agency to find out more.

Not everyone responds to medications in the same way. Several different medications may need to be tried before the best course of treatment is found.

Keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events can help the doctor track and treat the illness most effectively. Sometimes this is called a daily life chart. If a person's symptoms change or if side effects become serious, the doctor may switch or add medications.

Some of the types of medications generally used to treat bipolar disorder are listed on the next page. Information on medications can change. For the most up to date information on use and side effects contact the U.S. Food and Drug Administration (FDA).

• Mood stabilizing medications are usually the first choice to treat bipolar disorder. In general, people with bipolar disorder continue treatment with mood stabilizers for years. Except for lithium, many of these medications are anticonvulsants. Anticonvulsant medications are usually used to treat seizures, but they also help control moods. These medications are commonly used as mood stabilizers in bipolar disorder:
• Lithium (sometimes known as Eskalith or Lithobid) was the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) in the 1970s for treatment of mania. It is often very effective in controlling symptoms of mania and preventing the recurrence of manic and depressive episodes.
• Valproic acid or divalproex sodium (Depakote), approved by the FDA in 1995 for treating mania, is a popular alternative to lithium for bipolar disorder. It is generally as effective as lithium for treating bipolar disorder.^23,24 Also see the section in this booklet, "Should young women take valproic acid?"
• More recently, the anticonvulsant lamotrigine (Lamictal) received FDA approval for maintenance treatment of bipolar disorder.
• Other anticonvulsant medications, including gabapentin (Neurontin), topiramate (Topamax), and oxcarbazepine (Trileptal) are sometimes prescribed. No large studies have shown that these medications are more effective than mood stabilizers.

Valproic acid, lamotrigine, and other anticonvulsant medications have an FDA warning. The warning states that their use may increase the risk of suicidal thoughts and behaviors. People taking anticonvulsant medications for bipolar or other illnesses should be closely monitored for new or worsening symptoms of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior. People taking these medications should not make any changes without talking to their health care professional.

Lithium and Thyroid Function

People with bipolar disorder often have thyroid gland problems. Lithium treatment may also cause low thyroid levels in some people.²² Low thyroid function, called hypothyroidism, has been associated with rapid cycling in some people with bipolar disorder, especially women.

Because too much or too little thyroid hormone can lead to mood and energy changes, it is important to have a doctor check thyroid levels carefully. A person with bipolar disorder may need to take thyroid medication, in addition to medications for bipolar disorder, to keep thyroid levels balanced.

Should young women take valproic acid?

Valproic acid may increase levels of testosterone (a male hormone) in teenage girls and lead to polycystic ovary syndrome (PCOS) in women who begin taking the medication before age 20.^25,26 PCOS causes a woman's eggs to develop into cysts, or fluid filled sacs that collect in the ovaries instead of being released by monthly periods. This condition can cause obesity, excess body hair, disruptions in the menstrual cycle, and other serious symptoms. Most of these symptoms will improve after stopping treatment with valproic acid.²⁷ Young girls and women taking valproic acid should be monitored carefully by a doctor.

• Atypical antipsychotic medications are sometimes used to treat symptoms of bipolar disorder. Often, these medications are taken with other medications. Atypical antipsychotic medications are called "atypical" to set them apart from earlier medications, which are called "conventional" or "first-generation" antipsychotics.
• Olanzapine (Zyprexa), when given with an antidepressant medication, may help relieve symptoms of severe mania or psychosis.²⁸ Olanzapine is also available in an injectable form, which quickly treats agitation associated with a manic or mixed episode. Olanzapine can be used for maintenance treatment of bipolar disorder as well, even when a person does not have psychotic symptoms. However, some studies show that people taking olanzapine may gain weight and have other side effects that can increase their risk for diabetes and heart disease. These side effects are more likely in people taking olanzapine when compared with people prescribed other atypical antipsychotics.
• Aripiprazole (Abilify), like olanzapine, is approved for treatment of a manic or mixed episode. Aripiprazole is also used for maintenance treatment after a severe or sudden episode. As with olanzapine, aripiprazole also can be injected for urgent treatment of symptoms of manic or mixed episodes of bipolar disorder.
• Quetiapine (Seroquel) relieves the symptoms of severe and sudden manic episodes. In that way, quetiapine is like almost all antipsychotics. In 2006, it became the first atypical antipsychotic to also receive FDA approval for the treatment of bipolar depressive episodes.
• Risperidone (Risperdal) and ziprasidone (Geodon) are other atypical antipsychotics that may also be prescribed for controlling manic or mixed episodes.

• Antidepressant medications are sometimes used to treat symptoms of depression in bipolar disorder. People with bipolar disorder who take antidepressants often take a mood stabilizer too. Doctors usually require this because taking only an antidepressant can increase a person's risk of switching to mania or hypomania, or of developing rapid cycling symptoms.29 To prevent this switch, doctors who prescribe antidepressants for treating bipolar disorder also usually require the person to take a mood-stabilizing medication at the same time.

Recently, a large-scale, NIMH-funded study showed that for many people, adding an antidepressant to a mood stabilizer is no more effective in treating the depression than using only a mood stabilizer.³⁰

• Fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), and bupropion (Wellbutrin) are examples of antidepressants that may be prescribed to treat symptoms of bipolar depression.

Some medications are better at treating one type of bipolar symptoms than another. For example, lamotrigine (Lamictal) seems to be helpful in controlling depressive symptoms of bipolar disorder.

What are the side effects of these medications?

Before starting a new medication, people with bipolar disorder should talk to their doctor about the possible risks and benefits.

The psychiatrist prescribing the medication or pharmacist can also answer questions about side effects. Over the last decade, treatments have improved, and some medications now have fewer or more tolerable side effects than earlier treatments. However, everyone responds differently to medications. In some cases, side effects may not appear until a person has taken a medication for some time.

If the person with bipolar disorder develops any severe side effects from a medication, he or she should talk to the doctor who prescribed it as soon as possible. The doctor may change the dose or prescribe a different medication. People being treated for bipolar disorder should not stop taking a medication without talking to a doctor first. Suddenly stopping a medication may lead to "rebound," or worsening of bipolar disorder symptoms. Other uncomfortable or potentially dangerous withdrawal effects are also possible.

FDA Warning on Antidepressants

Antidepressants are safe and popular, but some studies have suggested that they may have unintentional effects on some people, especially in adolescents and young adults. The FDA warning says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation, or withdrawal from normal social situations. Families and caregivers should report any changes to the doctor. For the latest information visit the FDA website.

The following sections describe some common side effects of the different types of medications used to treat bipolar disorder.

1. Mood Stabilizers

In some cases, lithium can cause side effects such as:

• Restlessness
• Dry mouth
• Bloating or indigestion
• Acne
• Unusual discomfort to cold temperatures
• Joint or muscle pain
• Brittle nails or hair.³¹

Lithium also causes side effects not listed here. If extremely bothersome or unusual side effects occur, tell your doctor as soon as possible.

If a person with bipolar disorder is being treated with lithium, it is important to make regular visits to the treating doctor. The doctor needs to check the levels of lithium in the person's blood, as well as kidney and thyroid function.

These medications may also be linked with rare but serious side effects. Talk with the treating doctor or a pharmacist to make sure you understand signs of serious side effects for the medications you're taking.

Common side effects of other mood stabilizing medications include:

• Drowsiness
• Dizziness
• Headache
• Diarrhea
• Constipation
• Heartburn
• Mood swings
• Stuffed or runny nose, or other cold-like symptoms.^32-37

2. Atypical Antipsychotics

Some people have side effects when they start taking atypical antipsychotics. Most side effects go away after a few days and often can be managed successfully. People who are taking antipsychotics should not drive until they adjust to their new medication. Side effects of many antipsychotics include:

• Drowsiness
• Dizziness when changing positions
• Blurred vision
• Rapid heartbeat
• Sensitivity to the sun
• Skin rashes
• Menstrual problems for women.

Atypical antipsychotic medications can cause major weight gain and changes in a person's metabolism. This may increase a person's risk of getting diabetes and high cholesterol.³⁸ A person's weight, glucose levels, and lipid levels should be monitored regularly by a doctor while taking these medications.

In rare cases, long-term use of atypical antipsychotic drugs may lead to a condition called tardive dyskinesia (TD). The condition causes muscle movements that commonly occur around the mouth. A person with TD cannot control these moments. TD can range from mild to severe, and it cannot always be cured. Some people with TD recover partially or fully after they stop taking the drug.

3. Antidepressants

The antidepressants most commonly prescribed for treating symptoms of bipolar disorder can also cause mild side effects that usually do not last long. These can include:

• Headache, which usually goes away within a few days
• Nausea (feeling sick to your stomach), which usually goes away within a few days
• Sleep problems, such as sleeplessness or drowsiness. This may happen during the first few weeks but then go away. To help lessen these effects, sometimes the medication dose can be reduced, or the time of day it is taken can be changed.
• Agitation (feeling jittery)
• Sexual problems, which can affect both men and women. These include reduced sex drive and problems having and enjoying sex.

Some antidepressants are more likely to cause certain side effects than other types. Your doctor or pharmacist can answer questions about these medications. Any unusual reactions or side effects should be reported to a doctor immediately.

For the most up-to-date information on medications for treating bipolar disorder and their side effects, please see the online NIMH Medications booklet.

Should women who are pregnant or may become pregnant take medication for bipolar disorder?

Women with bipolar disorder who are pregnant or may become pregnant face special challenges. The mood stabilizing medications in use today can harm a developing fetus or nursing infant.³⁹ But stopping medications, either suddenly or gradually, greatly increases the risk that bipolar symptoms will recur during pregnancy.⁴⁰Scientists are not sure yet, but lithium is likely the preferred mood-stabilizing medication for pregnant women with bipolar disorder.^40,41 However, lithium can lead to heart problems in the fetus. Women need to know that most bipolar medications are passed on through breast milk.⁴¹ Pregnant women and nursing mothers should talk to their doctors about the benefits and risks of all available treatments.

Psychotherapy

In addition to medication, psychotherapy, or "talk" therapy, can be an effective treatment for bipolar disorder. It can provide support, education, and guidance to people with bipolar disorder and their families. Some psychotherapy treatments used to treat bipolar disorder include:

Cognitive behavioral therapy (CBT) helps people with bipolar disorder learn to change harmful or negative thought patterns and behaviors.
Family-focused therapy includes family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their loved one. This therapy also improves communication and problem-solving.

Interpersonal and social rhythm therapy helps people with bipolar disorder improve their relationships with others and manage their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.

Psychoeducation teaches people with bipolar disorder about the illness and its treatment. This treatment helps people recognize signs of relapse so they can seek treatment early, before a full-blown episode occurs. Usually done in a group, psychoeducation may also be helpful for family members and caregivers.

A licensed psychologist, social worker, or counselor typically provides these therapies. This mental health professional often works with the psychiatrist to track progress. The number, frequency, and type of sessions should be based on the treatment needs of each person. As with medication, following the doctor's instructions for any psychotherapy will provide the greatest benefit.

Other treatments

Electroconvulsive Therapy (ECT)—For cases in which medication and/or psychotherapy does not work, electroconvulsive therapy (ECT) may be useful. ECT, formerly known as "shock therapy," once had a bad reputation. But in recent years, it has greatly improved and can provide relief for people with severe bipolar disorder who have not been able to feel better with other treatments.

Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. He or she does not consciously feel the electrical impulse administered in ECT. On average, ECT treatments last from 30–90 seconds. People who have ECT usually recover after 5–15 minutes and are able to go home the same day.⁴³

Sometimes ECT is used for bipolar symptoms when other medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severely depressive, manic, or mixed episodes, but is generally not a first-line treatment.

ECT may cause some short-term side effects, including confusion, disorientation, and memory loss. But these side effects typically clear soon after treatment. People with bipolar disorder should discuss possible benefits and risks of ECT with an experienced doctor.[44]

Sleep Medications—People with bipolar disorder who have trouble sleeping usually sleep better after getting treatment for bipolar disorder. However, if sleeplessness does not improve, the doctor may suggest a change in medications. If the problems still continue, the doctor may prescribe sedatives or other sleep medications. People with bipolar disorder should tell their doctor about all prescription drugs, over-the-counter medications, or supplements they are taking. Certain medications and supplements taken together may cause unwanted or dangerous effects.

Herbal Supplements

In general, there is not much research about herbal or natural supplements. Little is known about their effects on bipolar disorder. An herb called St. John's wort (Hypericum perforatum), often marketed as a natural antidepressant, may cause a switch to mania in some people with bipolar disorder.⁴⁵ St. John's wort can also make other medications less effective, including some antidepressant and anticonvulsant medications.⁴⁶ Scientists are also researching omega-3 fatty acids (most commonly found in fish oil) to measure their usefulness for long-term treatment of bipolar disorder.⁴⁷ Study results have been mixed.⁴⁸ It is important to talk with a doctor before taking any herbal or natural supplements because of the serious risk of interactions with other medications.

What can people with bipolar disorder expect from treatment?

Bipolar disorder has no cure, but can be effectively treated over the long-term. It is best controlled when treatment is continuous, rather than on and off. In the STEP-BD study, a little more than half of the people treated for bipolar disorder recovered over one year's time. For this study, recovery meant having two or fewer symptoms of the disorder for at least eight weeks.

However, even with proper treatment, mood changes can occur. In the STEP-BD study, almost half of those who recovered still had lingering symptoms. These people experienced a relapse or recurrence that was usually a return to a depressive state.⁴⁹ If a person had a mental illness in addition to bipolar disorder, he or she was more likely to experience a relapse.⁴⁹ Scientists are unsure, however, how these other illnesses or lingering symptoms increase the chance of relapse. For some people, combining psychotherapy with medication may help to prevent or delay relapse.⁴²

Treatment may be more effective when people work closely with a doctor and talk openly about their concerns and choices. Keeping track of mood changes and symptoms with a daily life chart can help a doctor assess a person's response to treatments. Sometimes the doctor needs to change a treatment plan to make sure symptoms are controlled most effectively. A psychiatrist should guide any changes in type or dose of medication.

How can I help a friend or relative who has bipolar disorder?

If you know someone who has bipolar disorder, it affects you too. The first and most important thing you can do is help him or her get the right diagnosis and treatment. You may need to make the appointment and go with him or her to see the doctor. Encourage your loved one to stay in treatment.

To help a friend or relative, you can:

• Offer emotional support, understanding, patience, and encouragement
• Learn about bipolar disorder so you can understand what your friend or relative is experiencing
• Talk to your friend or relative and listen carefully
• Listen to feelings your friend or relative expresses-be understanding about situations that may trigger bipolar symptoms
• Invite your friend or relative out for positive distractions, such as walks, outings, and other activities
• Remind your friend or relative that, with time and treatment, he or she can get better.
• Never ignore comments about your friend or relative harming himself or herself. Always report such comments to his or her therapist or doctor.

Support for caregivers

Like other serious illnesses, bipolar disorder can be difficult for spouses, family members, friends, and other caregivers. Relatives and friends often have to cope with the person's serious behavioral problems, such as wild spending sprees during mania, extreme withdrawal during depression, poor work or school performance. These behaviors can have lasting consequences.

Caregivers usually take care of the medical needs of their loved ones. The caregivers have to deal with how this affects their own health. The stress that caregivers are under may lead to missed work or lost free time, strained relationships with people who may not understand the situation, and physical and mental exhaustion.

Stress from caregiving can make it hard to cope with a loved one's bipolar symptoms. One study shows that if a caregiver is under a lot of stress, his or her loved one has more trouble following the treatment plan, which increases the chance for a major bipolar episode.[50] It is important that people caring for those with bipolar disorder also take care of themselves.

How can I help myself if I have bipolar disorder?

It may be very hard to take that first step to help yourself. It may take time, but you can get better with treatment.

To help yourself:

• Talk to your doctor about treatment options and progress
• Keep a regular routine, such as eating meals at the same time every day and going to sleep at the same time every night
• Try to get enough sleep
• Stay on your medication
• Learn about warning signs signaling a shift into depression or mania
• Expect your symptoms to improve gradually, not immediately.

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National Institutes of Health
NIH Publication 08-3679
Revised 2008

Reviewed by athealth on January 29, 2014