Psoriasis

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
niamsinfo@mail.nih.gov
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
getinfo@npfusa.org
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.

Psychotic Disorders

What is a psychotic disorder?

Psychotic disorders are mental disorders in which the personality is seriously disorganized and a person's contact with reality is impaired. During a psychotic episode a person is confused about reality and often experiences delusions and/or hallucinations.

The following is a brief description of some of the types of psychotic disorders:

  • Schizophrenia - psychotic symptoms which continue for at least six months coupled with the deterioration of occupational and social functioning
  • Schizoaffective Disorder - psychotic and mood disturbances.
  • Schizophreniform Disorder - same criteria as Schizophrenia but the episode lasts from 1 - 6 months and there is no deterioration of social status.
  • Brief Psychotic Disorder - psychotic symptoms that last between 1 and 30 days.

What characteristics are associated with psychotic disorder?

Some of the characteristics associated with psychotic disorders include delusions, hallucinations, bizarre behavior, incoherent or disorganized speech, and/or disorganized behavior.

Delusions are described as false, inaccurate beliefs the person holds onto even when he/she is presented with accurate information.

Examples of delusions include:

  • Grandiose delusion: This occurs when a person's belief about his/her own importance or station in life is grossly out of proportion to what is really true. For instance, a person might believe that he/she is Jesus Christ.
  • Persecutory delusion: This occurs when a person believes that there is a conspiracy to harass, punish, or attack him/her. The person also might believe that the group to which he/she belongs is being harassed or punished.

Hallucinations are internal sensory perceptions, such as sights or sounds, that are not actually present.

Common hallucinations include:

  • Visual hallucinations: People who have visual hallucinations see the image of something that is not real, such as another person.
  • Auditory hallucinations: People who have auditory hallucinations hear something that is not really present, such as someone's voice. Are there genetic factors associated with psychotic disorder?Some psychotic disorders, like schizophrenia, tend to run in families. If someone has a psychotic disorder, it is quite likely that another member of his/her immediate or extended family also has had a psychotic disorder.

Do psychotic disorders affect males, females, or both?

Most psychotic disorders tend to affect males and females in equal numbers.

At what age do psychotic disorders appear?

Generally, the first signs of most psychotic disorders appear when a person is in his/her late teens, twenties, or thirties.

How common are psychotic disorders in society?

Psychotic disorders are actually quite common worldwide. About one percent (1%) of the population is thought to have some form of psychotic disorder.

How is a psychotic disorder diagnosed?

A mental health professional arrives at the diagnosis of a psychotic disorder by conducting a mental status examination and by taking a very careful personal history from the patient/client. It is very important not to overlook a physical illness that might mimic or contribute to a psychological disorder. If there is any doubt about a medical problem, the mental health professional should refer to a physician, who will perform a complete physical examination and request any necessary laboratory tests.

Frequently, people with psychotic disorders are brought involuntarily for evaluation and treatment.

How is a psychotic disorder treated?

In the acute stage, a person with a psychotic disorder is treated with medication. The medications are called antipsychotics, and they are used to help organize the person's thinking and, therefore, his/her behavior. Examples of such medications are Clozaril (clozapine), Haldol (haloperidol), Risperdal (risperidone), and Zyprexa (olanzapine). Many types of psychotherapy, including individual, group, and family therapy, may be used at some point in the illness to help support the person suffering from a psychotic disorder. Although some patients with psychotic disorders can be treated as outpatients, acutely disorganized people with psychoses frequently need hospitalization in order to be stabilized.

What happens to someone with a psychotic disorder?

The course of psychotic disorders varies greatly from a few days to many years.

What can people do if they need help?

If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.

Reviewed by athealth on February 6, 2014.

PTSD Fact Sheet

What is Posttraumatic Stress Disorder (PTSD)?

Posttraumatic stress disorder (PTSD) is an anxiety disorder that can occur after you have been through a traumatic event. A traumatic event is something horrible and scary that you see, hear about, or that happens to you. During a traumatic event, you think that your life or others' lives are in danger. You may feel afraid or feel that you have no control over what is happening.

Anyone who has gone through a life-threatening event can develop PTSD. These events can include:

  • Combat or military exposure
  • Child sexual or physical abuse
  • Terrorist attacks
  • Sexual or physical assault
  • Serious accidents, such as a car wreck
  • Natural disasters, such as a fire, tornado, hurricane, flood, or earthquake.

After the event, you may feel scared, confused, or angry. Most people have some stress-related reactions after a traumatic event; but, not everyone gets PTSD. If these feelings don't go away or they get worse, you may have PTSD. These symptoms may disrupt your life, making it hard to continue with your daily activities.

How does PTSD develop?

Most people who go through a trauma have some symptoms at the beginning. Only some will develop PTSD over time. It isn't clear why some people develop PTSD and others don't.

Whether or not you get PTSD depends on many things:

  • How intense the trauma was or how long it lasted
  • If you lost someone you were close to or were injured
  • How close you were to the event
  • How strong your reaction was
  • How much you felt in control of events
  • How much help and support you got after the event

What are the symptoms of PTSD?

PTSD symptoms usually start soon after the traumatic event, but they may not appear until months or years later. They also may come and go over many years. If the symptoms last longer than 4 weeks, cause you great distress, or interfere with your work or home life, you might have PTSD.

There are four types of PTSD symptoms:

  • Reliving the event (also called re-experiencing symptoms):

You may have bad memories or nightmares. You even may feel like you're going through the event again. This is called a flashback.

  • Avoiding situations that remind you of the event:

You may try to avoid situations or people that trigger memories of the traumatic event. You may even avoid talking or thinking about the event.

  • Feeling numb:

You may find it hard to express your feelings. Or, you may not be interested in activities you used to enjoy. This is another way to avoid memories.

  • Feeling keyed up (also called hyperarousal):

You may be jittery, or always alert and on the lookout for danger. This is known as hyperarousal.

What are other common problems?

People with PTSD may also have other problems. These include:

  • Drinking or drug problems.
  • Feelings of hopelessness, shame, or despair
  • Depression or anxiety
  • Employment problems
  • Relationships problems including divorce
  • Physical symptoms or chronic pain

Can children have PTSD?

Children can have PTSD too. They may have symptoms described above or other symptoms depending on how old they are. As children get older, their symptoms are more like those of adults. Here are some examples of PTSD symptoms in children:

  • Children age birth to 5 may get upset if their parents are not close by, have trouble sleeping, or suddenly have trouble with toilet training or going to the bathroom.
  • Children age 6 to 11 may act out the trauma through play, drawings, or stories. Some have nightmares or become more irritable or aggressive. They may also want to avoid school or have trouble with schoolwork or friends.
  • Children age 12 to 18 have symptoms more similar to adults: depression, anxiety, withdrawal, or reckless behavior like substance abuse or running away.

Will I get better?

"Getting better" means different things for different people, and not everyone who gets treatment will be "cured." Even if you continue to have symptoms, however, treatment can help you cope. Your symptoms don't have to interfere with your everyday activities, work, and relationships.

What treatments are available?

When you have PTSD, dealing with the past can be hard. Instead of telling others how you feel, you may keep your feelings bottled up. But treatment can help you get better. There are two main types of treatment, psychotherapy (sometimes called counseling) and medication. Sometimes people combine psychotherapy and medication.

Psychotherapy for PTSD:

Psychotherapy, or counseling, involves meeting with a therapist. There are different types of psychotherapy:

  • Cognitive behavioral therapy (CBT) is the most effective treatment for PTSD. There are different types of CBT. such as cognitive therapy and exposure therapy.
    • One type is Cognitive Processing Therapy (CPT) where you learn skills to understand how trauma changed your thoughts and feelings.
    • Another type is Prolonged Exposure (PE) therapy where you talk about your trauma repeatedly until memories are no longer upsetting. You also go to places that are safe, but that you have been staying away from because they are related to the trauma.
  • A similar kind of therapy is called eye movement desensitization and reprocessing (EMDR). This therapy involves focusing on sounds or hand movements while you talk about the trauma.

Medications for PTSD:

Medications can be effective too. A type of drug known as a selective serotonin reuptake inhibitor (SSRI), which is also used for depression, is effective for PTSD. Another medication called Prazosin has been found to be helpful in decreasing nightmares related to the trauma.

IMPORTANT: Benzodiazepines and atypical antipsychotics should generally be avoided for PTSD treatment because they do not treat the core PTSD symptoms.

National Center for PTSD
Date Created: January 1, 2007
Reviewed/Updated Date: May 29, 2012

Reviewed by athealth on February 7, 2014.

Listening Well

Introduction

One of the most important steps to having good relationships at work, at home, and with friends is to listen well. What's surprising is that for most people, listening well is very difficult. For most of us, talking is much easier than listening. Misunderstandings are very common in interactions between people as a result of poor listening. Plus, listening may be especially challenging for people with PTSD because it is easy to get distracted or hyper aroused. In this section, you'll read about what it means to really listen to what someone is saying and how you can improve your listening skills to build more satisfying relationships.

What does it mean to really listen?

It means listening with understanding.

What makes listening difficult?

Listening well takes attentiveness. Attention is often difficult when you are tired, distracted, under stress, or experiencing some of the symptoms associated with PTSD. Listening well means having the patience to hear someone out. It means being able to restate someone else's words, thoughts, and opinions, even if you may not agree with them.

If you find yourself doing any of the following, it may be a sign that you are not listening well in your communications with others. These are habits that can keep you from developing and maintaining good friendships and relationships.

  • You find yourself cutting people off and finishing their sentences.
  • You find yourself distracted, tuned out, or thinking about other things while someone is talking to you.
  • You interrupt people to give them advice or tell them what to do before they are done speaking.
  • You listen just enough to decide what you will say in response. You are constructing your response before the other person is done talking.
  • Others may find you arrogant, impatient, or uninterested.
  • You hear from other people that you don't understand them.

Listening well

True listening is listening for understanding. When you listen for understanding, you hear the entire message someone is sending. That means hearing more than just the words, but also understanding body language and mood. It means asking questions and clarifying what you think you are hearing to make sure you understand completely. It is at this level of listening that meaningful relationships are built and maintained. This includes work relationships, relationships with friends, family, and loved ones.

Here are the keys to listening for understanding...or listening well!

Clarify what is being said. Clarifying means getting additional information about what has been said and why. It also means asking questions in a non-defensive fashion, as if you were just trying to understand without being critical. To clarify, you ask questions such as

  • "Tell me more. Why do you think...?"
  • "Why do you say that?"
  • "What do you mean by..."

By clarifying, you are making certain you really understand what the person is saying.

Confirming what has been said and why. You confirm what has been said by stating your understanding of their thoughts. Remember, confirming does not necessarily mean you agree with what has been said - it only means that you understand what was said. When you use the skill of confirming, you keep channels of communication open and avoid discouraging other people from talking with you. Confirming is especially valuable before responding to a statement with which you disagree. Confirming demonstrates that you understand the other person's position. This tends to encourage the other person to keep an open mind when you respond with your own thoughts.

Some ways to confirm are:

  • "So, my understanding of your idea is..."
  • "In other words what you're saying is..."
  • "In other words..."

Reading body language. Listening for understanding means paying attention not only to what someone is saying, but how they are saying it. For example, body language will tell you if someone is happy or angry, tense or relaxed. You can ask about body language to help make things clearer for yourself. For instance, you might say, "You look upset. Is that correct?" Here are some body language signs to watch for:

  • Facial expression. Is the person smiling? Frowning? Looking perplexed? Is the person's face red?
  • Body posture. Are the person's shoulders tense or relaxed? Are they breathing slowly and regularly (a sign they are relaxed) or in short tight breaths (a sign they may be tense)?

Your own body language. Your own body language sends out a message to others about whether you are listening to them. Here are some ways to send out body language to show that you are listening.

  • Keep eye contact with other person to show you are interested in what is being said.
  • Nod to show you hear what is being said.
  • Keep your arms relaxed instead of crossed to show you are open to what is being said

Learning to listen for understanding is hard work and will take practice, but you can do it! Remember, the rewards will be having closer and more satisfying relationships.

Source: Adapted from Positive Coping Skills Toolbox
VA Mental Illness Research, Education, and Clinical Centers (MIRECC)

Reviewed by athealth on February 5, 2014.

Questions and Answers About Acne

What Is Acne?

Acne is a disorder resulting from the action of hormones and other substances on the skin's oil glands (sebaceous glands) and hair follicles. These factors lead to plugged pores and outbreaks of lesions commonly called pimples or zits. Acne lesions usually occur on the face, neck, back, chest, and shoulders. Although acne is usually not a serious health threat, it can be a source of significant emotional distress. Severe acne can lead to permanent scarring.

How Does Acne Develop?

Doctors describe acne as a disease of the pilosebaceous units (PSUs). Found over most of the body, PSUs consist of a sebaceous gland connected to a canal, called a follicle, that contains a fine hair (see "Normal Pilosebaceous Unit" diagram). These units are most numerous on the face, upper back, and chest. The sebaceous glands make an oily substance called sebum that normally empties onto the skin surface through the opening of the follicle, commonly called a pore. Cells called keratinocytes line the follicle.

Normal Pilosebaceous Unit

The hair, sebum, and keratinocytes that fill the narrow follicle may produce a plug, which is an early sign of acne. The plug prevents sebum from reaching the surface of the skin through a pore. The mixture of oil and cells allows bacteria Propionibacterium acnes (P. acnes) that normally live on the skin to grow in the plugged follicles. These bacteria produce chemicals and enzymes and attract white blood cells that cause inflammation. (Inflammation is a characteristic reaction of tissues to disease or injury and is marked by four signs: swelling, redness, heat, and pain.) When the wall of the plugged follicle breaks down, it spills everything into the nearby skin - sebum, shed skin cells, and bacteria - leading to lesions or pimples.

People with acne frequently have a variety of lesions, some of which are shown in the diagrams below. The basic acne lesion, called the comedo (KOM-e-do), is simply an enlarged and plugged hair follicle. If the plugged follicle, or comedo, stays beneath the skin, it is called a closed comedo and produces a white bump called a whitehead. A comedo that reaches the surface of the skin and opens up is called an open comedo or blackhead because it looks black on the skin's surface. This black discoloration is due to changes in sebum as it is exposed to air. It is not due to dirt. Both whiteheads and blackheads may stay in the skin for a long time.

Types of Lesions

Other troublesome acne lesions can develop, including the following:

  • Papules - Inflamed lesions that usually appear as small, pink bumps on the skin and can be tender to the touch
  • Pustules (pimples) - topped by white or yellow pus-filled lesions that may be red at the base
  • Nodules - large, painful, solid lesions that are lodged deep within the skin
  • Cysts - deep, painful, pus-filled lesions that can cause scarring

What Causes Acne?

The exact cause of acne is unknown, but doctors believe it results from several related factors. One important factor is an increase in hormones called androgens (male sex hormones). These increase in both boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum. Hormonal changes related to pregnancy or starting or stopping birth control pills can also cause acne.

Another factor is heredity or genetics. Researchers believe that the tendency to develop acne can be inherited from parents. For example, studies have shown that many school-age boys with acne have a family history of the disorder. Certain drugs, including androgens and lithium, are known to cause acne. Greasy cosmetics may alter the cells of the follicles and make them stick together, producing a plug.

Factors That Can Make Acne Worse

Factors that can cause an acne flare include:

  • Changing hormone levels in adolescent girls and adult women 2 to 7 days before their menstrual period starts
  • Oil from skin products (lubricants or cosmetics) or grease encountered in the work environment (for example, a kitchen with fry vats)
  • Pressure from sports helmets or equipment, backpacks, tight collars, or tight sports uniforms
  • Environmental irritants, such as pollution and high humidity
  • Squeezing or picking at blemishes
  • Hard scrubbing of the skin
  • Stress

Myths About the Causes of Acne

There are many myths about what causes acne. Chocolate and greasy foods are often blamed, but there is little evidence that foods have much effect on the development and course of acne in most people. Another common myth is that dirty skin causes acne; however, blackheads and other acne lesions are not caused by dirt. Stress doesn't cause acne, but research suggests that for people who have acne, stress can make it worse.

Who Gets Acne?

People of all races and ages get acne. It is most common in adolescents and young adults. An estimated 80 percent of all people between the ages of 11 and 30 have acne outbreaks at some point. For most people, acne tends to go away by the time they reach their thirties; however, some people in their forties and fifties continue to have this skin problem.

How Is Acne Treated?

Acne is often treated by dermatologists (doctors who specialize in skin problems). These doctors treat all kinds of acne, particularly severe cases. Doctors who are general or family practitioners, pediatricians, or internists may treat patients with milder cases of acne.

The goals of treatment are to heal existing lesions, stop new lesions from forming, prevent scarring, and minimize the psychological stress and embarrassment caused by this disease. Drug treatment1 is aimed at reducing several problems that play a part in causing acne:

  • abnormal clumping of cells in the follicles
  • increased oil production
  • bacteria
  • inflammation

1 All medicines can have side effects. Some medicines and side effects are mentioned in this booklet. Some side effects may be more severe than others. You should review the package insert that comes with your medicine and ask your health care provider or pharmacist if you have any questions about the possible side effects.

Depending on the extent of the problem, the doctor may recommend one of several over-the-counter (OTC) medicines and/or prescription medicines. Some of these medicines may be topical (applied to the skin), and others may be oral (taken by mouth). The doctor may suggest using more than one topical medicine or combining oral and topical medicines.

Treatment for Blackheads, Whiteheads, and Mild Inflammatory Acne

Doctors usually recommend an OTC or prescription topical medicine for people with mild signs of acne. Topical medicine is applied directly to the acne lesions or to the entire area of affected skin.

There are several OTC topical medicines used for mild acne. Each works a little differently. Following are the most common ones:

  • Benzoyl peroxide - destroys P. acnes, and may also reduce oil production
  • Resorcinol - can help break down blackheads and whiteheads
  • Salicylic acid - helps break down blackheads and whiteheads. Also helps cut down the shedding of cells lining the hair follicles
  • Sulfur - helps break down blackheads and whiteheads.

Topical OTC medicines are available in many forms, such as gels, lotions, creams, soaps, or pads. In some people, OTC acne medicines may cause side effects such as skin irritation, burning, or redness, which often get better or go away with continued use of the medicine. If you experience severe or prolonged side effects, you should report them to your doctor.

OTC topical medicines are somewhat effective in treating acne when used regularly; however, it may take up to 8 weeks before you see noticeable improvement.

Treatment for Moderate to Severe Inflammatory Acne

Patients with moderate to severe inflammatory acne may be treated with prescription topical or oral medicines, alone or in combination.

Prescription Topical Medicines

Several types of prescription topical medicines are used to treat acne. They include:

  • Antibiotics - help stop or slow the growth of bacteria and reduce inflammation
  • Vitamin A derivatives (retinoids) - unplug existing comedones (plural of comedo), allowing other topical medicines, such as antibiotics, to enter the follicles. Some may also help decrease the formation of comedones. These drugs contain an altered form of vitamin A. Some examples are tretinoin, adapalene, and tazarotene
  • Others - may destroy P. acnes and reduce oil production or help stop or slow the growth of bacteria and reduce inflammation. Some examples are prescription strength benzoyl peroxide, sodium sulfacetamide/sulfur-containing products, or azelaic acid.

Like OTC topical medicines, prescription topical medicines come as creams, lotions, solutions, gels, or pads. Your doctor will consider your skin type when prescribing a product. Creams and lotions provide moisture and tend to be good choices for people with sensitive skin. If you have very oily skin or live in a hot, humid climate, you may prefer an alcohol-based gel or solution, which tends to dry the skin. Your doctor will tell you how to apply the medicine and how often to use it.

For some people, prescription topical medicines cause minor side effects, including stinging, burning, redness, peeling, scaling, or discoloration of the skin. With some medicines, such as tretinoin, these side effects usually decrease or go away after the medicine is used for a period of time. If side effects are severe or don't go away, notify your doctor.

As with OTC medicines, the benefits of prescription topical medicines are not immediate. Your skin may seem worse before it gets better. It may take from 4 to 8 weeks to notice improvement.

Prescription Oral Medicines

For patients with moderate-to-severe acne, doctors often prescribe oral antibiotics. Oral antibiotics are thought to help control acne by curbing the growth of bacteria and reducing inflammation. Prescription oral and topical medicines may be combined. Common antibiotics used to treat acne are tetracycline, minocycline, and doxycycline.

Other oral medicines less commonly used are clindamycin, erythromycin, or sulfonamides. Some people taking these antibiotics have side effects, such as an upset stomach, dizziness or lightheadedness, changes in skin color, and increased tendency to sunburn. Because tetracyclines may affect tooth and bone formation in fetuses and young children, these drugs are not given to pregnant women or children under age 14. There is some concern, although it has not been proven, that tetracycline and minocycline may decrease the effectiveness of birth control pills. Therefore, a backup or another form of birth control may be needed. Prolonged treatment with oral antibiotics may be necessary to achieve the desired results.

Treatment for Severe Nodular or Cystic Acne

People with nodules or cysts should be treated by a dermatologist. For patients with severe inflammatory acne that does not improve with medicines such as those described above, a doctor may prescribe isotretinoin, a retinoid (vitamin A derivative). Isotretinoin is an oral drug that is usually taken once or twice a day with food for 15 to 20 weeks. It markedly reduces the size of the oil glands so that much less oil is produced. As a result, the growth of bacteria is decreased.

Advantages of Isotretinoin (Accutane)

Isotretinoin is a very effective medicine that can help prevent scarring. After 15 to 20 weeks of treatment with isotretinoin, acne completely or almost completely goes away in most patients. In those patients where acne recurs after a course of isotretinoin, the doctor may institute another course of the same treatment or prescribe other medicines.

Disadvantages of Isotretinoin (Accutane)

Isotretinoin can cause birth defects in the developing fetus of a pregnant woman. It is important that women of childbearing age are not pregnant and do not get pregnant while taking this medicine. Women must use two separate effective forms of birth control at the same time for 1 month before treatment begins, during the entire course of treatment, and for 1 full month after stopping the drug. You should ask your doctor when it is safe to get pregnant after you have stopped taking isotretinoin.

Some people with acne become depressed by the changes in the appearance of their skin. Changes in mood may be intensified during treatment or soon after completing a course of medicines like isotretinoin. There have been a number of reported suicides and suicide attempts in people taking isotretinoin; however, the connection between isotretinoin and suicide or depression is not known. Nevertheless, if you or someone you know feels unusually sad or has other symptoms of depression, such as loss of appetite, loss of interest in once-loved activities, or trouble concentrating, it's important to consult your doctor.

Other possible side effects of isotretinoin include:

  • dry eyes, mouth, lips, nose, or skin (very common)
  • itching
  • nosebleeds
  • muscle aches
  • sensitivity to the sun
  • poor night vision
  • changes in the blood, such as an increase in fats in the blood (triglycerides and cholesterol)
  • change in liver function.

To be able to determine if isotretinoin should be stopped if side effects occur, your doctor may test your blood before you start treatment and periodically during treatment. Side effects usually go away after the medicine is stopped.

Treatments for Hormonally Influenced Acne in Women

In some women, acne is caused by an excess of androgen (male) hormones. Clues that this may be the case include hirsutism (excessive growth of hair on the face or body), premenstrual acne flares, irregular menstrual cycles, and elevated blood levels of certain androgens.

The doctor may prescribe one of several drugs to treat women with this type of acne:

  • Birth control pills - to help suppress the androgen produced by the ovaries
  • Low-dose corticosteroid drugs, such as prednisone or dexamethasone - to help suppress the androgen produced by the adrenal glands
  • Antiandrogen drugs such as spironolactone - to reduce the excessive oil production.

Side effects of antiandrogen drugs may include irregular menstruation, tender breasts, headaches, and fatigue.

Other Treatments for Acne

Doctors may use other types of procedures in addition to drug therapy to treat patients with acne. For example, the doctor may remove the patient's comedones during office visits. Sometimes the doctor will inject corticosteroids directly into lesions to help reduce the size and pain of inflamed cysts and nodules.

Early treatment is the best way to prevent acne scars. Once scarring has occurred, the doctor may suggest a medical or surgical procedure to help reduce the scars. A superficial laser may be used to treat irregular scars. Dermabrasion (or microdermabrasion), which is a form of "sanding down" scars, is sometimes used. Another treatment option for deep scars caused by cystic acne is the transfer of fat from another part of the body to the scar. A doctor may also inject a synthetic filling material under the scar to improve its appearance.

How Should People With Acne Care for Their Skin?

Clean Skin Gently

If you have acne, you should gently wash your face with a mild cleanser, once in the morning and once in the evening, as well as after heavy exercise. Wash your face from under the jaw to the hairline and be sure to thoroughly rinse your skin.

Ask your doctor or another health professional for advice on the best type of cleanser to use.

Using strong soaps or rough scrub pads is not helpful and can actually make the problem worse. Astringents are not recommended unless the skin is very oily, and then they should be used only on oily spots.

It is also important to shampoo your hair regularly. If you have oily hair, you may want to wash it every day.

Avoid Frequent Handling of the Skin

Avoid rubbing and touching skin lesions. Squeezing, pinching or picking blemishes can lead to the development of scars or dark blotches.

Shave Carefully

Men who shave and who have acne should test both electric and safety razors to see which is more comfortable. When using a safety razor, make sure the blade is sharp and soften your beard thoroughly with soap and water before applying shaving cream. Shave gently and only when necessary to reduce the risk of nicking blemishes.

Avoid a Sunburn or Suntan

Many of the medicines used to treat acne can make you more prone to sunburn. A sunburn that reddens the skin or suntan that darkens the skin may make blemishes less visible and make the skin feel drier. However, these benefits are only temporary, and there are known risks of excessive sun exposure, such as more rapid skin aging and a risk of developing skin cancer.

Choose Cosmetics Carefully

While undergoing acne treatment, you may need to change some of the cosmetics you use. All cosmetics, such as foundation, blush, eye shadow, lubricants, and hair-care products should be oil free. Choose products labeled noncomedogenic (meaning they don't promote the formation of closed pores). In some people, however, even these products may make acne worse.

For the first few weeks of treatment, applying foundation evenly may be difficult because the skin may be red or scaly, particularly with the use of topical tretinoin or benzoyl peroxide.

Where Can People Find More Information on Acne?

National Institute of Arthritis and Musculoskeletal and Skin Diseases
National Institutes of Health
Web Site: http://www.niams.nih.gov

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

Acknowledgments

1. NIAMS gratefully acknowledges the assistance of the preparation and review of current and previous versions of this booklet: Laurence H. Miller, M.D., Chevy Chase, MD; Kenneth A. Katz, M.D., M.Sc., University of Pennsylvania School of Medicine, Philadelphia; Edward W. Cowen, M.D., National Cancer Institute, NIH; and Alan Moshell, M.D., NIAMS, NIH.

Source: National Institutes of Health
National Institute of Arthritis and Musculoskeletal and Skin Diseases
NIH Publication No. 06-4998

Reviewed by athealth on February 7, 2014.

Rates of Depression Among Full-Time Workers

According to a study released by the Substance Abuse and Mental Health Services Administration (SAMHSA), data indicates that an annual average of 7.0 percent of full-time workers aged 18 to 64 experienced a major depressive episode in the past year.

According to the National Survey on Drug Use and Health Report, released by the Substance Abuse and Mental Health Services Administration (SAMHSA) on October 11, 2007, combined data from 2004 to 2006 indicate that an annual average of 7.0 percent of full-time workers aged 18 to 64 experienced a major depressive episode (MDE) in the past year.

A major depressive episode (MDE) is defined in the report as a period of two weeks or longer during which there is depressed mood or loss of interest or pleasure and at least four other symptoms that reflect a change in functioning, such as problems with sleep, eating, energy, concentration and self-image.

Among the 21 major occupational categories, the highest rates of past year depression among full-time workers aged 18 to 64 were found in the personal care and service occupations (10.8 percent) and the food preparation and serving related occupations (10.3 percent). The occupational categories with the lowest rates of past year MDE were engineering, architecture, and surveying (4.3 percent); life, physical, and social science (4.4 percent); and installation, maintenance, and repair (4.4 percent).

Depression Among Workers by Occupation

Workers who reported a major depressive episode in the past year among occupational categories are as follows:

  • Personal Care and Service - 10.8%
  • Food Preparation and Serving Related - 10.3%
  • Community and Social Services - 9.6%
  • Healthcare Practitioners and Technical - 9.6%
  • Arts, Design, Entertainment, Sports, and Media - 9.1%
  • Education, Training, and Library - 8.7%
  • Office and Administrative Support - 8.1%
  • Building and Grounds Cleaning and Maintenance - 7.3%
  • Financial - 6.7%
  • Sales and Related - 6.7%
  • Legal - 6.4%
  • Transportation and Material Moving - 6.4%
  • Mathematical and Computer Scientists - 6.2%
  • Production - 5.9%
  • Management - 5.8%
  • Farming, Fishing, and Forestry - 5.6%
  • Protective Service - 5.5%
  • Construction and Extraction - 4.8%
  • Installation, Maintenance, and Repair - 4.4%
  • Life, Physical, and Social Science - 4.4%
  • Engineering, Architecture, and Surveyors - 4.3%

Depression is a treatable illness. Because it often goes unrecognized, depression continues to cause unnecessary suffering.

According to a study funded by the National Institute of Mental Health (NIHM), and published September 26, 2007, in the Journal of the American Medical Association, workplace depression screening and treatment improves employee health and productivity and can lead to lower overall costs for the employer.

Previous studies have shown that employees who are depressed are less productive and are absent more often. NIMH Director Thomas R. Insel, MD, said, "This study provides compelling evidence of the importance of workplace depression screening, outreach, and enhanced treatment. It is in the interest of workers' health and the company's bottom line to ensure depressed employees are effectively treated."

Sources:

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. (October 11, 2007).

The NSDUH Report: Depression among Adults Employed Full-Time, by Occupational Category. Rockville, MD.

Reviewed by athealth on February 7, 2014.

Reading Disorder

What is a reading disorder?

Students with this learning disorder have a problem with their reading skills. Their reading skills are significantly below what is normal considering the student's age, intelligence, and education. The poor reading skills cause problems with the student's academic success and/or other important areas in life.

What signs are associated with a reading disorder?

Signs associated with reading disorder include:

  • poor recognition of the written word
  • very slow oral reading
  • many mistakes in oral reading
  • very poor comprehension of what has been read

Students who suffer from this kind of learning disorder frequently have:

  • low self-esteem
  • social problems
  • increased dropout rate at school

Reading disorders may also be associated with:

  • conduct disorder
  • ADHD and ADD
  • depression
  • other learning disorders

Are there genetic factors associated with a reading disorder?

Reading disorders tend to show up more in certain families.

At what age does a reading disorder appear?

Reading disorder is usually brought to the attention of the child's parents in kindergarten or first grade when reading instruction becomes a very important part of the classroom teaching.

How often is a reading disorder seen in our society?

Although it is difficult to determine exactly, at least five percent (5%) of children in the United States suffer from a reading disorder.

How is a reading disorder diagnosed?

The person with normal intelligence demonstrates poor reading skills and no other neurological, visual, or hearing problems. Some children with very high intelligence may not have a reading disorder discovered until later in elementary school.

Because standardized group testing is not accurate enough to diagnose this disorder, it is very important that the individual be given special psychoeducational tests to determine if a learning disorder is present. Special attention must be given to the child's ethnic and cultural background by the student's examiner.

How is a reading disorder treated?

The treatment for reading disorder mainly involves putting the student into a program with an emphasis on remedial or corrective reading instruction. Usually the extra help in reading is supplied to the student through reading resource classrooms in school, small class size, or individual tutoring.

What happens to someone with a reading disorder?

With or without treatment, the reading disorder will gradually improve. However, even when good help is available to the student, the person may have chronic problems with reading. Students with high intelligence tend to improve the most.

What can people do if they need help?

If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.

Developed by John L. Miller, MD

Reviewed by athealth on February 7, 2014.

Recovering from Rejection

We all get rejected at different times in our lives. Our lovers unexpectedly break up with us. Friends terminate relationships sometimes without rhyme or reason. The job that seemed a shoe-in was not to be had. The college you banked on accepting you with open arms sends a terse rejection letter.

Rejection hurts whether you are prepared for it or not. There is a whole series of emotions you go through when you are snubbed. These emotions are similar to what one goes through while grieving. At first it is extremely difficult to take in the rejection experience. It often feels like being totally abandoned and left to fend for yourself. Denial is the state that occurs here. The rejection does not feel like it actually happened. It feels surrealistic, a trauma someone else is facing, not you.

The next emotion experienced is rage. You are angry with the person who rejected you. You may feel this anger intently or it may be experienced as more distant. Often the rage becomes self-directed. You express anger at yourself for not being "good enough" for the rejecter. You dwell on second guessing and wondering what could have been. You blame yourself for his leaving and at that point you are indeed broken hearted.

The next stage, as grief expert Elizabeth Kubler Ross explains, is bargaining. You say to yourself, "If I keep living the clean life, she will come back to me." If I stop smoking, I will be reunited with my boyfriend." The next stage is depression when you begin to realize that the person who rejected you is not coming back. This stage is filled with sadness where the tears fall and the longing ache for the rejecter is realized. Bitterness is also part of depression. It is at this point that you feel extremely resentful that you gave so much of yourself to your lover and now he is gone. You also realize that your vision of your former lover is tainted and he is not the virtuous person that you believed him to be. it feels like he bought the heaviest boots he could find and stomped all over your heart.

The final stage is acceptance where you understand that the time to dwell on this loss is over and it is time to move on.

Theses stages don't have any set sequence and you can experience more than one simultaneously. It also takes time to work through rejection. It is not a matter of snapping your fingers in order to instantly remove the pain.

Some folks are so devastated by rejection that they avoid social situations or other settings that may lead to rejection. They learn to not take any risks that even hint at the possibility of becoming emotionally wounded. There lives become safe, but lacking passion and fulfillment.

Other folks attempt to escape the pain of rejection through drugs, alcohol, overwork or other nonproductive means of escape.

Often times the most recent rejection triggers intense memories of earlier rebuffs. Most likely the earlier rejections have not been worked through and resolved. These rejections are experienced as abrupt, horrifying abandonment.

We are not taught by our parents or society at large how to effectively deal with rejection. First of all, we need to be aware that rejection is an essential facet of life. If we take chances and risks like trying out for a play, writing a book, applying to college or asking out the attractive man, there is the distinct possibility that none of these pursuits will work out. Will your feelings be hurt? Of course they will, but if you don't follow your dreams, your life will be restrictive and perhaps most of all, boring.

The second truth about facing rejection is that you can recover from it. However, you will never resolve this loss if you push it away through denial or other self-destructive behavior. You can take the following steps to recover from rejection:

  • Be aware of the different stages of grief you are experiencing. You may be experiencing denial, anger, bargaining, depression, bitterness or acceptance. Knowing what stage you are going through help put your loss in perspective and provide a road map for recovery.
  • Keep repeating to yourself that rejection is part of life and if you continue to pursue your dreams, they will eventually come true. I vividly remember getting stacks of rejection letters from literary agents and publishers. I did feel hopeless at times, but I knew that rejection was as natural as the sun rising and if I kept pursuing my dream of being a published author, it would happen and sure enough it did.
  • Make plans to actively face the pain of rejection by writing about it in a journal, talking to your friends and family. Don't isolate yourself. Talking and writing about your pain are proactive means for reaching resolution, while isolation and silence prevents the pain from being felt and released.
  • Begin a regular exercise program and feel the pain of the rejection eventually move through your body until you feel the weight of it lift and float away. When you are exercising, the endorphins are kicking in and you are able to face rejection in a calm, confident manner that does not occur when you are sedentary.

Author: Bob Livingstone, LCSW, has been a psychotherapist in private practice for almost twenty years. He works with adults, teenagers and children who have experienced traumas such as family violence, neglect and divorce. He works with men around anger issues and adults in recovery from child abuse. He is the author of the critically acclaimed Redemption of the Shattered: A Teenager's Healing Journey through Sandtray Therapy and The Body-Mind-Soul Solution: Healing Emotional Pain through Exercise. For more information visit http://www.boblivingstone.com/.

Reviewed by athealth on February 7, 2014.

Restless Legs Syndrome

Restless legs syndrome (RLS) causes an unpleasant prickling or tingling in the legs, especially in the calves, that is relieved by moving or massaging them. This sensation creates a need to stretch or move the legs to get rid of these uncomfortable or painful feelings. As a result, a person may have difficulty falling asleep and staying asleep. One or both legs may be affected. In some people, the sensations are also felt in the arms. These sensations can also occur with lying down or sitting for prolonged periods of time, such as while at a desk, riding in a car, or watching a movie.

Many people who have RLS also have brief limb movements during sleep, often with abrupt onset, occurring every 5-90 seconds. This condition, known as periodic limb movements in sleep (PLMS), can repeatedly awaken people who have RLS and reduce their total sleep time. Some people have PLMS but have no abnormal sensations in their legs while awake.

RLS affects 5-15 percent of Americans, and its prevalence increases with age. RLS occurs more often in women than men. One study found that RLS accounted for one-third of the insomnia seen in patients older than age 60. Children also can have RLS. This condition can be difficult to diagnose in children, and it often is confused with hyperactivity or "growing pains."

RLS is often inherited. Pregnancy, kidney failure, and anemia related to iron or vitamin deficiency can trigger or worsen RLS symptoms. Researchers suspect that these conditions cause insufficient iron that results in a lack of dopamine. The brain uses dopamine to control limb movements. Doctors usually can diagnose RLS by patients' symptoms and a telltale worsening of symptoms at night or while at rest. Some doctors may order a blood test for iron, although many people who have RLS have normal levels of iron in their blood but abnormal levels in the fluid that bathes their brain. Doctors may also ask people who have RLS to spend a night in a sleep lab where they are monitored to rule out other sleep disorders and to document the excessive limb movements.

RLS is a treatable but not curable condition. Dramatic improvements are seen quickly when patients are given dopamine-like drugs. Alternatively, people who have milder cases may be treated successfully with sedatives or by behavioral strategies. These strategies include stretching, taking a hot bath, or massaging the legs before bedtime. Avoiding caffeinated beverages can also help reduce symptoms. If iron or vitamin deficiency underlies RLS, symptoms may improve with prescribed iron, vitamin B12, or folate supplements. Some people may require anticonvulsant medications to stem the creeping and crawling sensations in their limbs. Others who have severe symptoms may need to be treated with pain relievers, such as codeine or morphine, or a combination of drug treatments.

Adapted from Your Guide to Healthy Sleep

National Heart, Lung, and Blood Institute
NIH Publication No. 06-5271

Reviewed by athealth on February 7, 2014.

Schizophrenia

What is schizophrenia?

Schizophrenia is a chronic, severe, and disabling brain disorder that has affected people throughout history. About 1 percent of Americans have this illness.[1]

People with the disorder may hear voices other people don't hear. They may believe other people are reading their minds, controlling their thoughts, or plotting to harm them. This can terrify people with the illness and make them withdrawn or extremely agitated.

People with schizophrenia may not make sense when they talk. They may sit for hours without moving or talking. Sometimes people with schizophrenia seem perfectly fine until they talk about what they are really thinking.

Families and society are affected by schizophrenia too. Many people with schizophrenia have difficulty holding a job or caring for themselves, so they rely on others for help.

Treatment helps relieve many symptoms of schizophrenia, but most people who have the disorder cope with symptoms throughout their lives. However, many people with schizophrenia can lead rewarding and meaningful lives in their communities. Researchers are developing more effective medications and using new research tools to understand the causes of schizophrenia. In the years to come, this work may help prevent and better treat the illness.

What are the symptoms of schizophrenia?

The symptoms of schizophrenia fall into three broad categories: positive symptoms, negative symptoms, and cognitive symptoms.

Positive symptoms

Positive symptoms are psychotic behaviors not seen in healthy people. People with positive symptoms often "lose touch" with reality. These symptoms can come and go. Sometimes they are severe and at other times hardly noticeable, depending on whether the individual is receiving treatment. They include the following:

    • Hallucinations are things a person sees, hears, smells, or feels that no one else can see, hear, smell, or feel. "Voices" are the most common type of hallucination in schizophrenia. Many people with the disorder hear voices. The voices may talk to the person about his or her behavior, order the person to do things, or warn the person of danger. Sometimes the voices talk to each other. People with schizophrenia may hear voices for a long time before family and friends notice the problem.

Other types of hallucinations include seeing people or objects that are not there, smelling odors that no one else detects, and feeling things like invisible fingers touching their bodies when no one is near.

    • Delusions are false beliefs that are not part of the person's culture and do not change. The person believes delusions even after other people prove that the beliefs are not true or logical. People with schizophrenia can have delusions that seem bizarre, such as believing that neighbors can control their behavior with magnetic waves. They may also believe that people on television are directing special messages to them, or that radio stations are broadcasting their thoughts aloud to others. Sometimes they believe they are someone else, such as a famous historical figure. They may have paranoid delusions and believe that others are trying to harm them, such as by cheating, harassing, poisoning, spying on, or plotting against them or the people they care about. These beliefs are called "delusions of persecution."
    • Thought disorders are unusual or dysfunctional ways of thinking. One form of thought disorder is called "disorganized thinking." This is when a person has trouble organizing his or her thoughts or connecting them logically. They may talk in a garbled way that is hard to understand. Another form is called "thought blocking." This is when a person stops speaking abruptly in the middle of a thought. When asked why he or she stopped talking, the person may say that it felt as if the thought had been taken out of his or her head. Finally, a person with a thought disorder might make up meaningless words, or "neologisms."
    • Movement disorders may appear as agitated body movements. A person with a movement disorder may repeat certain motions over and over. In the other extreme, a person may become catatonic. Catatonia is a state in which a person does not move and does not respond to others. Catatonia is rare today, but it was more common when treatment for schizophrenia was not available.[2]

"Voices" are the most common type of hallucination in schizophrenia.

Negative symptoms

Negative symptoms are associated with disruptions to normal emotions and behaviors. These symptoms are harder to recognize as part of the disorder and can be mistaken for depression or other conditions. These symptoms include the following:

  • "Flat affect" (a person's face does not move or he or she talks in a dull or monotonous voice)
  • Lack of pleasure in everyday life
  • Lack of ability to begin and sustain planned activities
  • Speaking little, even when forced to interact.

People with negative symptoms need help with everyday tasks. They often neglect basic personal hygiene. This may make them seem lazy or unwilling to help themselves, but the problems are symptoms caused by the schizophrenia.

Cognitive symptoms

Cognitive symptoms are subtle. Like negative symptoms, cognitive symptoms may be difficult to recognize as part of the disorder. Often, they are detected only when other tests are performed. Cognitive symptoms include the following:

  • Poor "executive functioning" (the ability to understand information and use it to make decisions)
  • Trouble focusing or paying attention
  • Problems with "working memory" (the ability to use information immediately after learning it).

Cognitive symptoms often make it hard to lead a normal life and earn a living. They can cause great emotional distress.

When does schizophrenia start and who gets it?

Schizophrenia affects men and women equally. It occurs at similar rates in all ethnic groups around the world. Symptoms such as hallucinations and delusions usually start between ages 16 and 30. Men tend to experience symptoms a little earlier than women. Most of the time, people do not get schizophrenia after age 45.3 Schizophrenia rarely occurs in children, but awareness of childhood-onset schizophrenia is increasing.[4,5]

It can be difficult to diagnose schizophrenia in teens. This is because the first signs can include a change of friends, a drop in grades, sleep problems, and irritability - behaviors that are common among teens. A combination of factors can predict schizophrenia in up to 80 percent of youth who are at high risk of developing the illness. These factors include isolating oneself and withdrawing from others, an increase in unusual thoughts and suspicions, and a family history of psychosis.[6] In young people who develop the disease, this stage of the disorder is called the "prodromal" period.

Are people with schizophrenia violent?

People with schizophrenia are not usually violent. In fact, most violent crimes are not committed by people with schizophrenia.[7] However, some symptoms are associated with violence, such as delusions of persecution. Substance abuse may also increase the chance a person will become violent.[8] If a person with schizophrenia becomes violent, the violence is usually directed at family members and tends to take place at home.

The risk of violence among people with schizophrenia is small. But people with the illness attempt suicide much more often than others. About 10 percent (especially young adult males) die by suicide.[9,10] It is hard to predict which people with schizophrenia are prone to suicide. If you know someone who talks about or attempts suicide, help him or her find professional help right away.

What about substance abuse?

Some people who abuse drugs show symptoms similar to those of schizophrenia. Therefore, people with schizophrenia may be mistaken for people who are affected by drugs. Most researchers do not believe that substance abuse causes schizophrenia. However, people who have schizophrenia are much more likely to have a substance or alcohol abuse problem than the general population.[11]

Substance abuse can make treatment for schizophrenia less effective. Some drugs, like marijuana and stimulants such as amphetamines or cocaine, may make symptoms worse. In fact, research has found increasing evidence of a link between marijuana and schizophrenia symptoms.[12,13] In addition, people who abuse drugs are less likely to follow their treatment plan.

Schizophrenia and smoking

Addiction to nicotine is the most common form of substance abuse in people with schizophrenia. They are addicted to nicotine at three times the rate of the general population (75 to 90 percent vs. 25 to 30 percent).[14]

The relationship between smoking and schizophrenia is complex. People with schizophrenia seem to be driven to smoke, and researchers are exploring whether there is a biological basis for this need. In addition to its known health hazards, several studies have found that smoking may make antipsychotic drugs less effective.

Quitting smoking may be very difficult for people with schizophrenia because nicotine withdrawal may cause their psychotic symptoms to get worse for a while. Quitting strategies that include nicotine replacement methods may be easier for patients to handle. Doctors who treat people with schizophrenia should watch their patients' response to antipsychotic medication carefully if the patient decides to start or stop smoking.

What causes schizophrenia?

Experts think schizophrenia is caused by several factors.

Genes and environment. Scientists have long known that schizophrenia runs in families. The illness occurs in 1 percent of the general population, but it occurs in 10 percent of people who have a first-degree relative with the disorder, such as a parent, brother, or sister. People who have second-degree relatives (aunts, uncles, grandparents, or cousins) with the disease also develop schizophrenia more often than the general population. The risk is highest for an identical twin of a person with schizophrenia. He or she has a 40 to 65 percent chance of developing the disorder.[15]

We inherit our genes from both parents. Scientists believe several genes are associated with an increased risk of schizophrenia, but that no gene causes the disease by itself.[16] In fact, recent research has found that people with schizophrenia tend to have higher rates of rare genetic mutations. These genetic differences involve hundreds of different genes and probably disrupt brain development.[17]

Other recent studies suggest that schizophrenia may result in part when a certain gene that is key to making important brain chemicals malfunctions. This problem may affect the part of the brain involved in developing higher functioning skills.[18] Research into this gene is ongoing, so it is not yet possible to use the genetic information to predict who will develop the disease.

Despite this, tests that scan a person's genes can be bought without a prescription or a health professional's advice. Ads for the tests suggest that with a saliva sample, a company can determine if a client is at risk for developing specific diseases, including schizophrenia. However, scientists don't yet know all of the gene variations that contribute to schizophrenia. Those that are known raise the risk only by very small amounts. Therefore, these "genome scans" are unlikely to provide a complete picture of a person's risk for developing a mental disorder like schizophrenia.

In addition, it probably takes more than genes to cause the disorder. Scientists think interactions between genes and the environment are necessary for schizophrenia to develop. Many environmental factors may be involved, such as exposure to viruses or malnutrition before birth, problems during birth, and other not yet known psychosocial factors.

Scientists are learning more about brain chemistry and its link to schizophrenia.

Different brain chemistry and structure. Scientists think that an imbalance in the complex, interrelated chemical reactions of the brain involving the neurotransmitters dopamine and glutamate, and possibly others, plays a role in schizophrenia. Neurotransmitters are substances that allow brain cells to communicate with each other. Scientists are learning more about brain chemistry and its link to schizophrenia.

Also, in small ways the brains of people with schizophrenia look different than those of healthy people. For example, fluid-filled cavities at the center of the brain, called ventricles, are larger in some people with schizophrenia. The brains of people with the illness also tend to have less gray matter, and some areas of the brain may have less or more activity.

Studies of brain tissue after death also have revealed differences in the brains of people with schizophrenia. Scientists found small changes in the distribution or characteristics of brain cells that likely occurred before birth.[3] Some experts think problems during brain development before birth may lead to faulty connections. The problem may not show up in a person until puberty. The brain undergoes major changes during puberty, and these changes could trigger psychotic symptoms. Scientists have learned a lot about schizophrenia, but more research is needed to help explain how it develops.

Scientists have learned a lot about schizophrenia, but more research is needed to help explain how it develops.

How is schizophrenia treated?

Because the causes of schizophrenia are still unknown, treatments focus on eliminating the symptoms of the disease. Treatments include antipsychotic medications and various psychosocial treatments.

Antipsychotic medications

Antipsychotic medications have been available since the mid-1950's. The older types are called conventional or "typical" antipsychotics. Some of the more commonly used typical medications include:

  • Chlorpromazine (Thorazine)
  • Haloperidol (Haldol)
  • Perphenazine (Etrafon, Trilafon)
  • Fluphenazine (Prolixin).

In the 1990's, new antipsychotic medications were developed. These new medications are called second generation, or "atypical" antipsychotics.

One of these medications, clozapine (Clozaril) is an effective medication that treats psychotic symptoms, hallucinations, and breaks with reality. But clozapine can sometimes cause a serious problem called agranulocytosis, which is a loss of the white blood cells that help a person fight infection. People who take clozapine must get their white blood cell counts checked every week or two. This problem and the cost of blood tests make treatment with clozapine difficult for many people. But clozapine is potentially helpful for people who do not respond to other antipsychotic medications.[19]

Other atypical antipsychotics were also developed. None cause agranulocytosis. Examples include:

  • Risperidone (Risperdal)
  • Olanzapine (Zyprexa)
  • Quetiapine (Seroquel)
  • Ziprasidone (Geodon)
  • Aripiprazole (Abilify)
  • Paliperidone (Invega).

When a doctor says it is okay to stop taking a medication, it should be gradually tapered off, never stopped suddenly.

What are the side effects?

Some people have side effects when they start taking these medications. 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.[20] A person's weight, glucose levels, and lipid levels should be monitored regularly by a doctor while taking an atypical antipsychotic medication.

Typical antipsychotic medications can cause side effects related to physical movement, such as:

  • Rigidity
  • Persistent muscle spasms
  • Tremors
  • Restlessness.

Long-term use of typical antipsychotic medications may lead to a condition called tardive dyskinesia (TD). TD causes muscle movements a person can't control. The movements commonly happen around the mouth. TD can range from mild to severe, and in some people the problem cannot be cured. Sometimes people with TD recover partially or fully after they stop taking the medication.

TD happens to fewer people who take the atypical antipsychotics, but some people may still get TD. People who think that they might have TD should check with their doctor before stopping their medication.

How are antipsychotics taken and how do people respond to them?

Antipsychotics are usually in pill or liquid form. Some anti-psychotics are shots that are given once or twice a month.

Symptoms of schizophrenia, such as feeling agitated and having hallucinations, usually go away within days. Symptoms like delusions usually go away within a few weeks. After about six weeks, many people will see a lot of improvement.

However, people respond in different ways to antipsychotic medications, and no one can tell beforehand how a person will respond. Sometimes a person needs to try several medications before finding the right one. Doctors and patients can work together to find the best medication or medication combination, as well as the right dose.

Some people may have a relapse-their symptoms come back or get worse. Usually, relapses happen when people stop taking their medication, or when they only take it sometimes. Some people stop taking the medication because they feel better or they may feel they don't need it anymore. But no one should stop taking an antipsychotic medication without talking to his or her doctor. When a doctor says it is okay to stop taking a medication, it should be gradually tapered off, never stopped suddenly.

How do antipsychotics interact with other medications?

Antipsychotics can produce unpleasant or dangerous side effects when taken with certain medications. For this reason, all doctors treating a patient need to be aware of all the medications that person is taking. Doctors need to know about prescription and over-the-counter medicine, vitamins, minerals, and herbal supplements. People also need to discuss any alcohol or other drug use with their doctor.

To find out more about how antipsychotics work, the National Institute of Mental Health (NIMH) funded a study called CATIE (Clinical Antipsychotic Trials of Intervention Effectiveness). This study compared the effectiveness and side effects of five antipsychotics used to treat people with schizophrenia. In general, the study found that the older typical antipsychotic perphenazine (Trilafon) worked as well as the newer, atypical medications. But because people respond differently to different medications, it is important that treatments be designed carefully for each person. More information about CATIE is on the NIMH website.

Psychosocial treatments

Psychosocial treatments can help people with schizophrenia who are already stabilized on antipsychotic medication. Psychosocial treatments help these patients deal with the everyday challenges of the illness, such as difficulty with communication, self-care, work, and forming and keeping relationships. Learning and using coping mechanisms to address these problems allow people with schizophrenia to socialize and attend school and work.

Patients who receive regular psychosocial treatment also are more likely to keep taking their medication, and they are less likely to have relapses or be hospitalized. A therapist can help patients better understand and adjust to living with schizophrenia. The therapist can provide education about the disorder, common symptoms or problems patients may experience, and the importance of staying on medications. For more information on psychosocial treatments, see the psychotherapies section on the NIMH website.

Illness management skills. People with schizophrenia can take an active role in managing their own illness. Once patients learn basic facts about schizophrenia and its treatment, they can make informed decisions about their care. If they know how to watch for the early warning signs of relapse and make a plan to respond, patients can learn to prevent relapses. Patients can also use coping skills to deal with persistent symptoms.

Integrated treatment for co-occurring substance abuse. Substance abuse is the most common co-occurring disorder in people with schizophrenia. But ordinary substance abuse treatment programs usually do not address this population's special needs. When schizophrenia treatment programs and drug treatment programs are used together, patients get better results.

Rehabilitation. Rehabilitation emphasizes social and vocational training to help people with schizophrenia function better in their communities. Because schizophrenia usually develops in people during the critical career-forming years of life (ages 18 to 35), and because the disease makes normal thinking and functioning difficult, most patients do not receive training in the skills needed for a job.

Rehabilitation programs can include job counseling and training, money management counseling, help in learning to use public transportation, and opportunities to practice communication skills. Rehabilitation programs work well when they include both job training and specific therapy designed to improve cognitive or thinking skills. Programs like this help patients hold jobs, remember important details, and improve their functioning.[21,22,23]

Family education. People with schizophrenia are often discharged from the hospital into the care of their families. So it is important that family members know as much as possible about the disease. With the help of a therapist, family members can learn coping strategies and problem-solving skills. In this way the family can help make sure their loved one sticks with treatment and stays on his or her medication. Families should learn where to find outpatient and family services.

Cognitive behavioral therapy. Cognitive behavioral therapy (CBT) is a type of psychotherapy that focuses on thinking and behavior. CBT helps patients with symptoms that do not go away even when they take medication. The therapist teaches people with schizophrenia how to test the reality of their thoughts and perceptions, how to "not listen" to their voices, and how to manage their symptoms overall. CBT can help reduce the severity of symptoms and reduce the risk of relapse.

Self-help groups. Self-help groups for people with schizophrenia and their families are becoming more common. Professional therapists usually are not involved, but group members support and comfort each other. People in self-help groups know that others are facing the same problems, which can help everyone feel less isolated. The networking that takes place in self-help groups can also prompt families to work together to advocate for research and more hospital and community treatment programs. Also, groups may be able to draw public attention to the discrimination many people with mental illnesses face.

Once patients learn basic facts about schizophrenia and its treatment, they can make informed decisions about their care.

How can you help a person with schizophrenia?

People with schizophrenia can get help from professional case managers and caregivers at residential or day programs. However, family members usually are a patient's primary caregivers.

People with schizophrenia often resist treatment. They may not think they need help because they believe their delusions or hallucinations are real. In these cases, family and friends may need to take action to keep their loved one safe. Laws vary from state to state, and it can be difficult to force a person with a mental disorder into treatment or hospitalization. But when a person becomes dangerous to himself or herself, or to others, family members or friends may have to call the police to take their loved one to the hospital.

Treatment at the hospital. In the emergency room, a mental health professional will assess the patient and determine whether a voluntary or involuntary admission is needed. For a person to be admitted involuntarily, the law states that the professional must witness psychotic behavior and hear the person voice delusional thoughts. Family and friends can provide needed information to help a mental health professional make a decision.

After a loved one leaves the hospital. Family and friends can help their loved ones get treatment and take their medication once they go home. If patients stop taking their medication or stop going to follow-up appointments, their symptoms likely will return. Sometimes symptoms become severe for people who stop their medication and treatment. This is dangerous, since they may become unable to care for themselves. Some people end up on the street or in jail, where they rarely receive the kind of help they need.

Family and friends can also help patients set realistic goals and learn to function in the world. Each step toward these goals should be small and taken one at a time. The patient will need support during this time. When people with a mental illness are pressured and criticized, they usually do not get well. Often, their symptoms may get worse. Telling them when they are doing something right is the best way to help them move forward.

It can be difficult to know how to respond to someone with schizophrenia who makes strange or clearly false statements. Remember that these beliefs or hallucinations seem very real to the person. It is not helpful to say they are wrong or imaginary. But going along with the delusions is not helpful, either. Instead, calmly say that you see things differently. Tell them that you acknowledge that everyone has the right to see things his or her own way. In addition, it is important to understand that schizophrenia is a biological illness. Being respectful, supportive, and kind without tolerating dangerous or inappropriate behavior is the best way to approach people with this disorder.

People with schizophrenia can get help from professional case managers and caregivers at residential or day programs.

What is the outlook for the future?

The outlook for people with schizophrenia continues to improve. Although there is no cure, treatments that work well are available. Many people with schizophrenia improve enough to lead independent, satisfying lives.

Continued research and understanding in genetics, neuroscience, and behavioral science will help scientists and health professionals understand the causes of the disorder and how it may be predicted and prevented. This work will help experts develop better treatments to help people with schizophrenia achieve their full potential. Families and individuals who are living with schizophrenia are encouraged to participate in clinical research. For up-to-date information about the latest NIMH-funded research in schizophrenia, see the NIMH Web site.

Citations

  1. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry. 1993 Feb;50(2):85-94.
  2. World Health Organization (WHO). Catatonic Schizophrenia. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines.1992.Geneva, Switzerland: World Health Organization.
  3. Mueser KT and McGurk SR. Schizophrenia. Lancet. 2004 Jun 19;363(9426):2063-2072.
  4. Nicolson R, Lenane M, Hamburger SD, Fernandez T, Bedwell J, Rapoport JL. Lessons from childhood-onset schizophrenia. Brain Research Review. 2000;31(2-3):147-156.
  5. Masi G, Mucci M, Pari C. Children with schizophrenia: clinical picture and pharmacological treatment. CNS Drugs. 2006;20(10):841-866.
  6. Cannon TD, Cadenhead K, Cornblatt B, Woods SW, Addington J, Walker E, Seidman LJ, Perkins D, Tsuang M, McGlashan T, Heinssen R. Prediction of psychosis in high-risk youth: A Multi-site longitudinal study in North America. Archives of General Psychiatry. 2008 Jan;65(1):28-37.
  7. Walsh E, Buchanan A, Fahy T. Violence and schizophrenia: examining the evidence. British Journal of Psychiatry. 2002 Jun;180:490-495.
  8. Swanson JW, Swartz MS, Van Dorn RA, Elbogen E, Wager HR, Rosenheck RA, Stroup S, McEvoy JP, Lieberman JA. A national study of violent behavior in persons with schizophrenia. Archives of General Psychiatry. 2006 May;63(5):490-499.
  9. Meltzer HY, Alphs L, Green AI, Altamura AC, Anand R, Bertoldi A, Bourgeois M, Chouinard G, Islam MZ, Kane J, Krishnan R, Lindenmayer JP, Potkin S, International Suicide Prevention Trial Study Group. Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention Trial (InterSePT). Archives of General Psychiatry. 2003 Jan;60(1):82-91.
  10. Meltzer HY and Baldessarini RJ. Reducing the risk for suicide in schizophrenia and affective disorders. Journal of Clinical Psychiatry. 2003 Sep;64(9):1122-1129.
  11. Blanchard JJ, Brown SA, Horan WP, Sherwood AR. Substance use disorders in schizophrenia: Reviews, integration and a proposed model. Clinical Psychological Review. 2000;20:207-234.
  12. Zullino DF, Waber L, Khazaal Y. Cannabis and the course of schizophrenia. American Journal of Psychiatry. 2008;165(10):1357-1358.
  13. Muller-Vahl KR and Emrich HM. Cannabis and schizophrenia: towards a cannabinoid hypothesis of schizophrenia. Expert Review of Neurotherapeutics. 2008;8(7):1037-1048.
  14. Jones RT and Benowitz NL. Therapeutics for Nicotine Addiction. In Davis KL, Charney D, Coyle JT & Nemeroff C (Eds.), Neuropsychopharmacology: The Fifth Generation of Progress (pp1533-1544). 2002. Nashville, TN:American College of Neuropsychopharmacology.
  15. Cardno AG and Gottesman II. Twin studies of schizophrenia: from bow-and-arrow concordances to star wars Mx and functional genomics. American Journal of Medical Genetics. 2000 Spring;97(1):12-17.
  16. Harrison PJ and Weinberger DR. Schizophrenia genes, gene expression, and neuropathology: on the matter of their convergence. Molecular Psychiatry. 2005;10(1):40-68.
  17. Walsh T, McClellan JM, McCarthy SE, Addington AM, Pierce SB, Cooper GM, Nord AS, Kusenda M, Malhotra D, Bhandari A, Stray SM, Rippey CF, Roccanova P, Makarov V, Lakshmi B, Findling RL, Sikich L, Stromberg T, Merriman B, Gogtay N, Butler P, Eckstrand K, Noory L, Gochman P, Long R, Chen Z, Davis S, Baker C, Eichler EE, Meltzer PS, Nelson SF, Singleton AB, Lee MK, Rapoport JL, King MC, Sebat J. Rare structural variants disrupt multiple genes in neurodevelopmental pathways in schizophrenia. Science. 2008 Apr 25;320(5875):539-543.
  18. Huang HS, Matevossian A, Whittle C, Kim SY, Schumacher A, Baker SP, Akbarian S. Prefrontal dysfunction in schizophrenia involves missed-lineage leukemia 1-regulated histone methylation at GABAergic gene promoters.Journal of Neuroscience. 2007 Oct 17;27(42):11254-11262.
  19. Gogtay N and Rapoport J. Clozapine use in children and adolescents. Expert Opinion on Pharmacotherapy. 2008;9(3):459-465.
  20. Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, Perkins DO, Keefe RS, Davis SM, Davis CE, Lebowitz BD, Severe J, Hsiao JK, Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. New England Journal of Medicine. 2005 Sep 22;353(12):1209-1223.
  21. Greig TC, Zito W, Wexler BE, Fiszdon J, Bell MD. Improved cognitive function in schizophrenia after one year of cognitive training and vocational services. Schizophrenia Research. 2007 Nov;96(1-3):156-161.
  22. Bell M, Fiszon J, Greig T, Wexler B, Bryson G. Neurocognitive enhancement therapy with work therapy in schizophrenia: 6-month follow-up of neuropsychological performance. Journal of Rehabilitation Research and Development. 2007;44(5):761-770.
  23. Hogarty GE, Flesher S, Ulrich R, Carter M, Greenwald D, Poque-Geile M, Kechavan M, Cooley S, DiBarry AL, Garrett A, Parepally H, Zoretich R. Cognitive enhancement therapy for schizophrenia: effects of a 2-year randomized trial on cognition and behavior. Archives of General Psychiatry. 2004 Sep;61(9):866-876.

National Institute of Mental Health
NIH Publication 09-3517
Revised 2009


Reviewed by athealth on February 7, 2014.