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What Is Sleep Apnea?

Sleep apnea is a common disorder that can be very serious. In sleep apnea, your breathing stops or gets very shallow while you are sleeping. Each pause in breathing typically lasts 10 to 20 seconds or more. These pauses can occur 20 to 30 times or more an hour.

The most common type of sleep apnea is obstructive sleep apnea. During sleep, enough air cannot flow into your lungs through your mouth and nose even though you try to breathe. When this happens, the amount of oxygen in your blood may drop. Normal breaths then start again with a loud snort or choking sound.

When your sleep is upset throughout the night, you can be very sleepy during the day. With sleep apnea, your sleep is not restful because:

• These brief episodes of increased airway resistance (and breathing pauses) occur many times.
• You may have many brief drops in the oxygen levels in your blood.
• You move out of deep sleep and into light sleep several times during the night, resulting in poor sleep quality.

People with sleep apnea often have loud snoring. However, not everyone who snores has sleep apnea. Some people with sleep apnea don't know they snore.

• Sleep apnea happens more often in people who are overweight, but even thin people can have it.
• Most people don't know they have sleep apnea. They don't know that they are having problems breathing while they are sleeping.
• A family member and/or bed partner may notice the signs of sleep apnea first.

Untreated sleep apnea can increase the chance of having high blood pressure and even a heart attack or stroke. Untreated sleep apnea can also increase the risk of diabetes and the risk for work-related accidents and driving accidents.

What Causes Sleep Apnea?

Sleep apnea happens when enough air cannot move into your lungs while you are sleeping. When you are awake, and normally during sleep, your throat muscles keep your throat open and air flows into your lungs. In obstructive sleep apnea, however, the throat briefly collapses, causing pauses in your breathing. With pauses in breathing, the oxygen level in your blood may drop. This happens if the following conditions occur:

• Your throat muscles and tongue relax more than is normal.
• Your tonsils and adenoids are large.
• You are overweight. The extra soft tissue in your throat makes it harder to keep the throat area open.
• The shape of your head and neck (bony structure) results in somewhat smaller airway size in the mouth and throat area.

With the throat frequently fully or partly blocked during sleep, enough air cannot flow into your lungs, even though your efforts to breathe continue. Your breathing may become hard and noisy and may even stop for short periods of time (apneas).

Central apnea is a rare type of sleep apnea that happens when the area of your brain that controls your breathing doesn't send the correct signals to the breathing muscles. Then there is no effort to breathe at all for brief periods. Snoring does not typically occur in central apnea.

Who Is At Risk for Obstructive Sleep Apnea?

Anyone can have obstructive sleep apnea.

It is estimated that more than 12 million Americans have obstructive sleep apnea. More than half the people who have sleep apnea are overweight, and most snore heavily.

Sleep apnea is more common in men. One out of 25 middle-aged men and 1 out of 50 middle-aged women have sleep apnea that causes them to be very sleepy during the day. Sleep apnea is more common in African Americans, Hispanics, and Pacific Islanders than in Caucasians. If someone in your family has sleep apnea, you are more likely to develop it than someone without a family history of the condition.

Adults who are most likely to have sleep apnea:

• Snore loudly.
• Are overweight.
• Have high blood pressure.
• Have a decreased size of the airways in their nose, throat, or mouth. This can be caused by the shape of these structures or by medical conditions causing congestion in these areas, such as hay fever or other allergies.
• Have a family history of sleep apnea.

Obstructive sleep apnea can also occur in children who snore. If your child snores, you should discuss it with your child's doctor or health care provider.

What Are the Signs and Symptoms of Sleep Apnea?

• Loud snoring
• Choking or gasping during sleep
• Fighting sleepiness during the day (even at work or while driving)

Your family members may notice the symptoms before you do. Otherwise, you will likely not be aware that you have problems breathing while you are asleep.

Others signs of sleep apnea may include:

• Morning headaches
• Memory or learning problems
• Feeling irritable
• Not being able to concentrate on your work
• Mood swings or personality changes; perhaps feeling depressed
• Dry throat when you wake up
• Frequent urination at night

How Is Sleep Apnea Diagnosed?

Your doctor will do a physical exam and take a medical history that includes asking you and your family questions about how you sleep and how you function during the day. As part of the exam, your doctor will check your mouth, nose, and throat for extra or large tissues; for example, tonsils, uvula (the tissue that hangs from the middle of the back of the mouth), and soft palate (the roof of your mouth in the back of your throat).

Your doctor may order a sleep recording of what happens with your breathing while you sleep. A sleep recording is a test that is often done in a sleep center or sleep laboratory, which may be part of a hospital. You may stay overnight in the sleep center, although sleep studies are sometimes done in the home. The most common sleep recording used to find out if you have sleep apnea is called a polysomnogram (poly-SOM-no-gram), or PSG. This test records:

• Brain activity
• Eye movement
• Muscle activity
• Breathing and heart rate
• How much air moves in and out of your lungs while you are sleeping
• The percentage of oxygen in your blood

A PSG is painless. You will go to sleep as usual. The staff at the sleep center will monitor your sleep throughout the night. The results of your PSG will be analyzed by a sleep medicine specialist to see if you have sleep apnea, how severe it is, and what treatment may be recommended.

In certain circumstances, the PSG can be done at home. A home monitor can be used to record your heart rate, how air moves in and out of your lungs, the amount of oxygen in your blood, and your breathing effort. For this test, a technician will come to your home and help you apply the monitor that you will wear overnight. You will go to sleep as usual, and the technician will come back the next morning to get the monitor and send the results to your doctor.

Once all your tests are completed, the sleep medicine specialist will review the results and work with you and your family to develop a treatment plan. In some cases, you may also need to see another physician for evaluation of:

• Lung problems (treated by a pulmonologist)
• Problems with the brain or nerves (treated by a neurologist)
• Heart or blood pressure problems (treated by a cardiologist)
• Ear, nose, or throat problems (treated by an ENT specialist)
• Mental health, such as anxiety or depression (treated by a psychologist or psychiatrist)

How Is Sleep Apnea Treated?

Treatment is aimed at restoring regular nighttime breathing and relieving symptoms such as very loud snoring and daytime sleepiness. Treatment will also help associated medical problems, such as high blood pressure, and reduce the risk for heart attack and stroke.

Changes in Activities or Habits

If you have mild sleep apnea, some changes in daily activities or habits may be all that are needed:

• Avoid alcohol, smoking, and medicines that make you sleepy. They make it harder for your throat to stay open while you sleep.
• Lose weight if you are overweight. Even a little weight loss can improve your symptoms.
• Sleep on your side instead of your back. Sleeping on your side may help keep your throat open.

People with moderate or severe sleep apnea will need to make these changes as well. They also will need other treatments, such as the following.

Continuous Positive Airway Pressure

Continuous positive airway pressure (CPAP) is the most common treatment for sleep apnea. For this treatment, you wear a mask over your nose during sleep. The mask blows air into your throat at a pressure level that is right for you. The increased airway pressure keeps the throat open while you sleep. The air pressure is adjusted so that it is just enough to stop the airways from briefly getting too small during sleep.

Treating sleep apnea may help you stop snoring. Stopping snoring does not mean that you no longer have sleep apnea or that you can stop using CPAP.

Sleep apnea will return if CPAP is stopped or if it is not used correctly. Usually, a technician comes to your home to bring the CPAP equipment. The technician will set up the CPAP machine and make adjustments based on your doctor's orders.

CPAP treatment may cause side effects in some people. Some side effects are:

• Dry or stuffy nose
• Irritation of the skin on your face
• Bloating of your stomach
• Sore eyes
• Headaches

If you are having trouble with CPAP side effects, work with your sleep medicine specialist and technician. Together you can do things to reduce these side effects, such as:

• Use a nasal spray to relieve a dry, stuffy, or runny nose.
• Adjust the CPAP settings.
• Adjust the size/fit of the mask.
• Add moisture to the air as it flows through the mask.
• Use a CPAP machine that can automatically adjust the amount of air pressure to the level that is required to keep the airway open.
• Use a CPAP machine that will start with a low air pressure and slowly increase the air pressure as you fall asleep.

People with severe sleep apnea symptoms generally feel much better once they begin treatment with CPAP. When using CPAP, it is very important that you follow up with your doctor. If you are having side effects, talk to your doctor.

Mouthpiece

A mouthpiece (oral appliance) may be helpful in some people with mild sleep apnea. Some doctors may also recommend this if you snore loudly but do not have sleep apnea.

A custom-fit plastic mouthpiece will be made by a dentist or orthodontist. An orthodontist is a specialist in correcting teeth or jaw problems. The mouthpiece will adjust your lower jaw and your tongue to help keep the airway in your throat open while you are sleeping. Air can then flow easily into your lungs because there is less resistance to breathing.

Possible side effects of the mouthpiece include damage to your:

• Teeth
• Gums
• Jaw

Follow up with your dentist or orthodontist to check for any side effects and to be sure that your mouthpiece fits.

Surgery

Some people with sleep apnea may benefit from surgery. The type of surgery depends on the cause of the sleep apnea.

Surgery may be done to remove the tonsils and adenoids if they are blocking the airway. This surgery is especially helpful for children.

Uvulopalatopharyngoplasty (U-vu-lo-PAL-a-to-fa-RIN-go-plas-te) (UPPP) is a surgery that removes the tonsils, uvula (the tissue that hangs from the middle of the back of the roof of the mouth), and part of your soft palate (the roof of your mouth in the back of your throat). This surgery is only effective for some people with sleep apnea.

Laser-assisted uvulopalatoplasty (U-vu-lo-PAL-a-to-plas-te) (LAUP) is a surgery that can stop snoring but is probably not helpful in treating sleep apnea. A laser device is used to remove the uvula and part of the soft palate. Because this surgery stops the main symptom of sleep apnea (snoring), it is important to have a sleep study first.

Tracheostomy (TRA-ke-OS-to-me) is a surgery used in severe sleep apnea. A small hole is made in the windpipe and a tube is inserted. Air will flow through the tube and into the lungs. This surgery is very successful but is needed only in patients not responding to all other possible treatments. Other possible surgeries for some people with sleep apnea include:

• Rebuilding the lower jaw
• Surgery on the nose
• Surgery to treat obesity

Currently, there are no medicines for the treatment of sleep apnea.

Living With Sleep Apnea

Getting treatment for sleep apnea and following your doctor's advice can help you and your family members.

• Getting treatment for sleep apnea can help snoring and can improve your sleep.
• Treating sleep apnea helps you feel rested during the day.
• Many people will benefit by making healthy changes, such as stopping smoking and losing weight.
• Some people will need to wear a mask at night to help keep the throat open and improve breathing.
• A few people will need to have surgery to remove tonsils and adenoids, part of the uvula (the tissue that hangs from the middle of the back of the roof of the mouth), and/or the soft palate (the roof of your mouth in the back of your throat) that may block the airway.
• Regular and ongoing followup is needed; your sleep medicine specialist will check whether your treatment is working and whether you are having any side effects.

What Can Family Do To Help?

Often, people with sleep apnea do not know they have it. They are not aware that their breathing stops and starts many times while they are sleeping. Family members or bed partners are usually the first ones to notice that the person snores and stops breathing while sleeping.

There are many things family members can do to help a loved one who has sleep apnea, including:

• Letting the person know if he or she snores loudly during sleep or has breathing stops and starts
• Encouraging the person to get medical help
• Helping the person follow the doctor's treatment plan, including continuous positive airway pressure (CPAP)
• Making sure the person puts on the CPAP mask before falling asleep
• Providing emotional support
• Helping with insurance paperwork

Sleep apnea can be very serious. People with sleep apnea are at higher risk for car crashes, work-related accidents, and other medical problems due to their sleepiness. It is important that people with sleep apnea see their doctor to treat and control this disorder.

Treatment may improve a person's overall health and happiness as well as the quality of sleep for both the person and the entire family.

Key Points

• Sleep apnea is a common breathing disorder that can be very serious.
• In sleep apnea, your breathing stops or becomes very shallow for periods of 10 to 20 seconds or longer many times during the night.
• The most common type of sleep apnea is obstructive sleep apnea.
• It is estimated that more than 12 million Americans have sleep apnea.
• The most common signs of sleep apnea are loud snoring and choking or gasping during sleep and being sleepy during the day.
• Having a physical exam and providing your doctor with information about your sleep will help to diagnose sleep apnea. Your doctor may also want you to have special sleep tests.
• Treatment is aimed at restoring regular nighttime breathing and relieving symptoms such as loud snoring and daytime sleepiness. Treatment will also help associated medical problems, such as high blood pressure, and reduce the risk for heart attack and stroke.
• Continuous positive airway pressure (CPAP) is the most common treatment for sleep apnea. Some people with sleep apnea may benefit from surgery.
• Family members can help a person who snores loudly or stops breathing while sleeping by encouraging him or her to get medical help.
• Treatment for sleep apnea may improve a person's overall health and happiness as well as the quality of sleep for both the person and the entire family.

Source: National Heart Lung and Blood Institute

February 2006

Reviewed by athealth on February 7, 2014.

What is a sleep disorder?

There are two major kinds of sleep disorders.

• The first kind of sleep disorder is called dyssomnias. Dyssomnias are related to the total amount of time that a person sleeps, the quality of the sleep, or the time of day when the person sleeps. Dyssomnias may be present when a person has difficulty falling asleep, staying asleep, or when a person sleeps too much.

• Parasomnias are sleep disorders which have to do with what happens while a person sleeps. There are five major dyssomnias.
• Primary Insomnia. Insomnia is classified as a problem, if over a period of at least one month, a person has difficulty falling asleep or maintaining his/her sleep. To be diagnosed as primary insomnia, the sleep problem must cause difficulty in the person's social, school, work, or other significant area of life. Most often, people with insomnia complain of problems in falling asleep, or they complain of fitful sleeping or frequent awakening. Some people report that the quality of their sleep is poor, that they are restless during their sleep. This condition may turn into an aggravating cycle in that the more a person focuses on his/her sleep, he/she may be less likely to get good quality sleep. Insomnia can lead to difficulties with a person?s concentration, energy level, or mood.
• Primary Hypersomnia. The major symptoms of this disorder are excessive amounts of sleep and excessive daytime sleepiness. Usually the person with hypersomnia has difficulty getting out of bed even after sleeping more than eight (8) hours. During normal daytime waking hours, the person finds himself/herself taking naps or falling asleep at inappropriate times. People with this disorder often report that no matter how much sleep they get they do not feel rested. Their sleepiness can cause problems in work or social settings. This condition does not include those who are just physically tired or weary.
• Narcolepsy. Narcolepsy is the presence of sleep attacks. Sleep attacks are brief periods of sleep during the person's normal waking. In order for narcolepsy to be diagnosed, a person must have suffered from the sleep attacks for at least three months. The person with narcolepsy will have intermittent periods of feeling very sleepy followed by attacks of sleep that last from only a few seconds to minutes and from which they awaken feeling refreshed. Unfortunately, the sleep attacks are involuntary and can occur during periods of time when a person must be awake, such as when operating machinery or interacting with other people. The sleep episodes can last up to an hour, but more frequently last around fifteen (15) minutes. Many people with narcolepsy have several episodes of sleep during their normal waking period.
• Breathing-Related Sleep Disorder. If a person has difficulty breathing during sleep, he/she may have breathing-related sleep disorder. For instance, some people have sleep apnea which is characterized by the person actually stopping breathing for a period of time. Some sleep apnea is caused by obstruction of the person's airway. Loud snoring or gasping is often noted with this type of sleep problem. However, there are other sleep apnea problems that are not associated with obstruction of the airway. Sleep apnea is potentially very serious and may lead to premature death if not treated.
• Circadian Rhythm Sleep Disorder. Circadian rhythm sleep disorder can occur when there is a mismatch between an individual's sleep-wake schedule and his/her sleep-wake pattern. Sometimes this occurs when an individual's sleep desire or needs are different from the demands of life. For instance, if a person is scheduled to work the midnight shift and has difficulty getting enough sleep during the daylight hours, that person might develop a sleep disorder. Another example is jet lag phenomena where a person travels a great deal and is forced to cross several time zones or endure an erratic sleep-wake schedule. Parasomnias. The following parasomnias are problems that occur during a person?s sleep.
• Nightmare Disorder. Frightening dreams that tend to recur frequently and awaken a person from his/her sleep may lead to nightmare disorder. These dreams usually contain terrorizing or threatening content. Usually, the person can recall the nightmare in detail. When the person awakens, he/she is full of anxiety and usually finds it very difficult to return to sleep. Children frequently complain of nightmares, but they almost always outgrow them.
• Sleep Terror Disorder. When a person awakens from a dream crying or screaming, he/she might be experiencing sleep terror disorder. Usually the person is difficult to wake-up and the episode may last several minutes. Sometimes the person with sleep terror will sit in bed and scream or cry, but cannot be awakened for several minutes. Once awakened, the individual is confused and finds it difficult to relay the detail of his/her dream. Sleep terror usually only occurs once per night. Sometimes the person experiencing a sleep terror will attempt to punch or swing his/her fists at others. Sleep terror occurs in children and adults.
• Sleep Walking Disorder. A person experiencing sleep walking disorder will get out of bed and walk around. Many times, he/she will not communicate and will have a blank stare on his/her face. Once awakened, the person seldom remembers the details of the episode. These individuals become fully awake quite easily. During the sleep walking, some people may negotiate stairs, go out of doors, or eat a snack. Children who experience sleep walking usually outgrow it. However, sleep walking in adults can be chronic and last for many years. What other characteristics can occur with sleep disorder?Other characteristics that can occur with sleep disorders include depression, decreased concentration, fatigue, anxiety, and irritability. People with chronic sleep problems tend to have other illnesses such as stomach problems, muscle aches, and headaches.

Are there genetic factors associated with sleep disorder?

There is some tendency for sleep problems to be found in families.

Do sleep disorders affect males, females, or both?

There is some tendency for females to have more sleep problems than males.

At what age do sleep disorders appear?

Sleep disorders can occur at any age. However, sleep problems increase with increasing age.

How often are sleep disorders seen in our society?

Sleep problems are very common in our culture. More than twenty percent (20%) of adults will complain of sleep problems at some period in their lives.

How are sleep disorders diagnosed?

In order to accurately diagnose a sleep disorder, the person may need to spend the night in a supervised sleep clinic. In the sleep clinic, various recordings are made measuring the quality and duration of sleep. This procedure is called polysomnography.

What happens to someone with sleep disorder?

Sleep problems frequently occur around periods of stress in a person's life. For example, it is not at all uncommon for a person's sleep to be disrupted following the death of a loved one or around the time of a major medical problem. Therefore, many sleep problems resolve once the stress is resolved or the medical condition subsides. However, some sleep disorders can begin with an acute problem and become a chronic sleep problem.

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.

Author: John L. Miller, MD

Reviewed by athealth on February 7, 2014.

Social phobia, also called social anxiety, is a disorder characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations. People with social phobia have a persistent, intense, and chronic fear of being watched and judged by others and of being embarrassed or humiliated by their own actions. Their fear may be so severe that it interferes with work or school - and other ordinary activities. While many people with social phobia recognize that their fear of being around people may be excessive or unreasonable, they are unable to overcome it. They often worry for days or weeks in advance of a dreaded situation.

Social phobia can be limited to only one type of situation - such as a fear of speaking in formal or informal situations, or eating or drinking in front of others - or, in its most severe form, may be so broad that a person experiences symptoms almost anytime they are around other people. Social phobia can be very debilitating - it may even keep people from going to work or school on some days. Many people with this illness have a hard time making and keeping friends.

Physical symptoms often accompany the intense anxiety of social phobia and include blushing, profuse sweating, trembling, and other symptoms of anxiety, including difficulty talking and nausea or other stomach discomfort. These visible symptoms heighten the fear of disapproval and the symptoms themselves can become an additional focus of fear. Fear of symptoms can create a vicious cycle: as people with social phobia worry about experiencing the symptoms, the greater their chances of developing the symptoms.. Social phobia often runs in families and may be accompanied by depression or alcohol dependence.

How Common Is Social Phobia?

• About 3.7% of the U.S. population ages 18 to 54 - approximately 5.3 million Americans - has social phobia in any given year.
• Social phobia occurs in women twice as often as in men, although a higher proportion of men seeks help for this disorder.
• The disorder typically begins in childhood or early adolescence and rarely develops after age 25.

What Causes Social Phobia?

Research to define causes of social phobia is ongoing.

• Some investigations implicate a small structure in the brain called the amygdala in the symptoms of social phobia. The amygdala is believed to be a central site in the brain that controls fear responses.
• Animal studies are adding to the evidence that suggests social phobia can be inherited. In fact, researchers supported by the National Institute of Mental Health (NIMH) recently identified the site of a gene in mice that affects learned fearfulness.
• One line of research is investigating a biochemical basis for the disorder. Scientists are exploring the idea that heightened sensitivity to disapproval may be physiologically or hormonally based.
• Other researchers are investigating the environment's influence on the development of social phobia. People with social phobia may acquire their fear from observing the behavior and consequences of others, a process called observational learning or social modeling.

What Treatments Are Available for Social Phobia?

Research supported by NIMH and by industry has shown that there are two effective forms of treatment available for social phobia: certain medications and a specific form of short-term psychotherapy called cognitive-behavioral therapy. Medications include antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs), as well as drugs known as high-potency benzodiazepenes. Some people with a form of social phobia called performance phobia have been helped by beta-blockers, which are more commonly used to control high blood pressure.

Cognitive-behavior therapy is also very useful in treating social phobia. The central component of this treatment is exposure therapy, which involves helping patients gradually become more comfortable with situations that frighten them. The exposure process often involves three stages. The first involves introducing people to the feared situation. The second level is to increase the risk for disapproval in that situation so people build confidence that they can handle rejection or criticism. The third stage involves teaching people techniques to cope with disapproval. In this stage, people imagine their worst fear and are encouraged to develop constructive responses to their fear and perceived disapproval.

Cognitive-behavior therapy for social phobia also includes anxiety management training - for example, teaching people techniques such as deep breathing to control their levels of anxiety. Another important aspect of treatment is called cognitive restructuring, which involves helping individuals identify their misjudgments and develop more realistic expectations of the likelihood of danger in social situations.

Supportive therapy such as group therapy, or couples or family therapy to educate significant others about the disorder, is also helpful. Sometimes people with social phobia also benefit from social skills training.

What Other Illnesses Co-Occur With Social Phobia?

Social phobia can cause lowered self-esteem and depression. To try to reduce their anxiety and alleviate depression, people with social phobia may use alcohol or other drugs, which can lead to addiction. Some people with social phobia may also have other anxiety disorders, such as panic disorder and obsessive-compulsive disorder.

Source: 
National Institute of Mental Health
Publication No. OM-99 4171 (Revised)
Printed September 1999

Reviewed by athealth on February 7, 2014.

When his self-described "worst episode" of anxiety lay hold of him on stage in 1994, Donny Osmond was no fledgling entertainer. The singer-actor had been in the public spotlight for more than 30 years--four of those, starting when he was just 18, as co-host of a popular variety program with his younger sister, Marie.

"Once the fear of embarrassing myself grabbed me," Osmond writes in his recent autobiography, Life Is Just What You Make It, "I couldn't get loose. It was as if a bizarre and terrifying unreality had replaced everything that was familiar and safe. I felt powerless to think or reason my way out of the panic."

At the time, Osmond was playing the lead character in the Andrew Lloyd Webber musical "Joseph and the Amazing Technicolor Dreamcoat." "… I kept trying to remember the words," he continues, "but they slipped through my fingers like mercury, defying me to try again. The harder I tried, the more elusive they became. The best I could do was to not black out, and I got through the show, barely, by telling myself repeatedly, 'Stay conscious, stay conscious.'"

This was not garden-variety stage fright, Osmond explains. The entertainer who had confidently mixed with such stars as Bob Hope, John Wayne, Andy Griffith, Lucille Ball, Danny Thomas, and Farrah Fawcett, and who had won two celebrity auto races by driving his cars at speeds of up to 150 miles an hour, had become afraid--not just of humiliating himself during his shows, but of being scrutinized off-stage, as well, while doing things as mundane as returning merchandise to the store for a refund. The fear, Osmond says in his book, stemmed from the possibility of not always being in control of what happened to him. His mind would race: "What will I do? What will people think? Will I look stupid?"

As Osmond discovered, the condition that caused his foreboding panics had a name: social phobia. Also called social anxiety disorder, social phobia is an extreme fear of public embarrassment and being judged by others. The condition affects as many as 13 of every 100 Americans at some point in their lives, according to the Anxiety Disorders Association of America, making it the third most common psychiatric condition after substance abuse and depression.

To control his condition, Osmond learned techniques to manage his fears by changing his thought patterns. While many people address their social phobia with such psychological therapy alone, many others find medication helpful, either alone or coupled with psychotherapy. In May, Paxil (paroxetine hydrochloride) became the first drug approved by the Food and Drug Administration specifically for treating social phobia.

Way Beyond Butterflies

Social phobia is far different from the run-of-the-mill nervousness associated with stressful situations. It's the intensity of the fear that distinguishes the condition from the almost inevitable butterflies that most people feel when they are about to give a speech or go to an interview or even a party.

When people with social phobia perceive that others will judge their "performance" in a certain situation, their bodies undergo physical changes, which typically include profuse sweating, rapid heartbeat, shortness of breath, faintness, and blushing.

"In the more severe cases, people can have a panic-like reaction and become so overwhelmed with anxiety that they feel completely disoriented," says Jerilyn Ross, president of the Anxiety Disorders Association of America and a psychotherapist who has treated thousands of patients with social phobia, including Osmond. "Your fight-or-flight alarm system that warns you when there's danger goes off at the wrong time. You literally feel like you're losing control, you're going to do something stupid to embarrass yourself, you're going to die."

Una McCann, M.D., an associate professor of psychiatry at the Johns Hopkins University School of Medicine and former head of the anxiety disorders unit at the National Institute of Mental Health, admits that when she started at NIMH, even she underestimated the life-altering impact that social phobia could have. "My initial reaction toward social phobia was probably typical of most people's," McCann says. "I thought, 'What's that? That's a disorder?' Because everybody experiences anxiety in some social situations, like public speaking, large crowds, or being the center of attention, it really seemed like a pseudo-disorder to me at first. Until I met some patients. Then, I suddenly realized how unbelievably debilitating social phobia can truly be."

For Marissa Turner, now 27 years old, even visiting her own aunt used to trigger panic-type symptoms. "It was pretty hair-raising," says Turner. "Standing on my aunt's doorstep, I'd be hyperventilating, shaking, and feeling hot when it wasn't hot outside. I'd feel like I wanted to turn around and run a mile. My throat would constrict, and it felt like if I opened my mouth to talk it wouldn't make a sound."

To avoid the frightening, panic-like reactions, people often rearrange their lives to sidestep their personal triggers rather than endure the intense anxiety. "What we're talking about is an anxiety so severe that a person is unable to function, either socially, academically or occupationally," explains Thomas Laughren, M.D., the team leader for FDA's psychiatric drug products group. "You hear of people who would turn down a promotion or quit their job rather than dealing with talking to groups of people. Other people are shut-ins because they fear being judged in almost any social interaction outside of their family."

It's not that these people are shy, necessarily. Turner, for example, craved social interaction. "I could list a million things I wanted to do, which my peers were doing, that I couldn't," Turner says. "I didn't date. I rarely went to parties, and when I did, I was very scared the whole time."

Turner's condition is referred to as "generalized" social phobia because her anxiety extended to a broad variety of settings. Some people with generalized social phobia become very anxious about activities as routine as eating in a restaurant, writing something down while someone is watching, or using a public restroom. As a group, those with generalized social phobia are less likely to graduate from high school and are more likely to rely on government financial assistance or have poverty-level salaries, McCann points out.

Other people have the more limited "specific" social phobia, meaning their fear is associated with just public speaking or another well-defined circumstance.

Combination of Causes

Scientists have not pinpointed the exact causes of social phobia, which tends to run in families and may affect women slightly more often than men. Studies suggest that both biological and psychological factors may contribute to the anxiety disorder.

Some scientists think social phobia is related to an imbalance of the brain chemical serotonin. Perhaps someone who is biologically predisposed to social phobia endures a triggering embarrassing event, Ross says. "I think we can all remember a time when we got up to talk, and the kids giggled because our skirt was up, or we forgot our line in a school play. At the moment it seemed like a traumatic experience, but for people who are biologically predisposed to social phobia, that experience can truly imprint itself on the brain as a traumatic event."

Many unproblematic years can pass between such an event and the phobia rearing its head, Ross says. Social phobia can appear any time in one's life, but typically shows up in the mid- to late-teens and can grow worse for a time after that, according to the Anxiety Disorders Association of America.

Turner has wrestled with her anxiety most of her life, but says that it "shot through the roof" as she neared adulthood. Like many fighting this war of nerves, Turner tried to self-medicate with alcohol. Without medical help, she says, she would have relied increasingly on drinking to get her through social situations. Turner did finally seek medical help, but not, she says, until she felt like she "couldn't cope with another day."

Addressing the Anxiety

Turner's doctor has prescribed the drug Paxil to ease the primary symptoms of her social phobia. This first drug approved by FDA for treating the condition is also approved to treat depression, obsessive compulsive disorder, and an anxiety condition called panic disorder. However, it is not approved for performance anxiety or shyness that does not rise to the level of social phobia.

Paxil is an effective treatment option for doctors to consider, says the agency's Laughren, who adds that many patients will see improvement but not be cured of their anxiety altogether.

Turner says it has made a "really big difference" in her life. "Since I've started taking Paxil, I've been on top of my anxiety."

People taking antidepressant drugs called "monoamine oxidase inhibitors" shouldn't take Paxil. The drug should be used with particular caution in some other patients, such as those who are pregnant or nursing or who have a history of seizures, mania (emotional highs associated with bipolar disorder), or certain other medical conditions.

Besides Paxil, doctors sometimes prescribe certain antidepressants or other drugs--beta blockers and benzodiazepines, for example--to try to control the anxiety symptoms associated with social phobia. While these drugs have not been approved by FDA specifically for treating social phobia, doctors can legally prescribe them if they feel a patient will benefit.

Some patients with social phobia opt for a nondrug treatment approach instead of, or in addition to, medication.

Philip Lawson (not his real name) is one of those who wanted to overcome his social anxiety without drugs. As an agent representing athletes, authors, and other public figures, the 24-year-old Lawson is required not only to meet individually with his clients and others, but also to give speeches. He relished doing presentations in college, but since graduating--during interviews and on his job as a talent representative--has battled an extreme fear of public speaking that's brought on white-knuckle anxiety attacks.

At first, Lawson didn't even want to accept that he had an anxiety disorder. "I'm the antithesis of someone you would expect to have a social problem. I planned my five-year high school reunion." The colleagues in whom he confided about his anxiety reacted with astonishment: "I don't believe it, you? Mister Outgoing Talk-to-Anybody?"

Yes, him, Lawson says. "When I had to give a presentation, I would either pretend to be unprepared or I'd say something really quick," he explains. "The anxiety grew into one-on-one meetings with people, where I would feel like I was completely on the spot. You always assume that all the attention is on you, like a spotlight."

Lawson's low point, he says, was when he called in sick to work because he had to give a speech. "I can either face this," he told himself, "or let it get worse and worse." Rather than allowing his condition to spiral downward, Lawson worked with a psychotherapist, individually and in group sessions, to learn to face down his irrational fears. He participated in a standard, two-pronged approach to treating social phobia called "cognitive-behavioral therapy."

The first part of cognitive-behavioral therapy--the "cognitive" aspect--tries to correct people's catastrophic perceptions of what others are thinking about them and what the real consequences are of a less-than-perfect performance. "Social phobia is a very self-focused illness," explains McCann. "You might think that people see you blushing and trembling, when really, many of them are thinking about what they're going to have for lunch."

To help people put things in perspective, a therapist may ask, "What is going to be the consequence if you do have a panic?" McCann's examples: "If you have a job interview and you blow it, so what? So you don't get that job. But it was good practice. So you do flub a sentence. What is the worst thing that can happen? Somebody might chuckle, maybe they'll rib you about it."

For Osmond, cognitive therapy reinforced what his wife, Debbie, had told him over and over: If he wasn't perfect, on-stage or off, people would like him nonetheless.

The "behavioral" aspect of therapy, typically undertaken at least partially in a group setting, gradually exposes people to the circumstances that can trigger their panic. It teaches them techniques to help them focus on the present reality rather than anticipating the imaginary dangers like "what if I lose control?" For example, people may learn to:

• expect the fear and accept rather than fight it
• focus on manageable things in the present--by paying attention to their breathing, for example, or counting backwards from 100 by threes, repeating an encouraging phrase to themselves ("What doesn't kill me makes me stronger," for instance), picturing themselves at the beach or another place they would like to be, or consciously rubbing their hand on a podium, chair, or other object.

By socializing or giving a speech surrounded by an empathetic group, people can practice using these techniques to cope in the unnerving situation and give their confidence a boost. Speaking groups like Toastmasters might not be a sufficiently nurturing first step for those with social phobia, stresses Ross, who does encourage patients to join such groups once they conquer their paralyzing fear. "Toastmasters teaches you how to give an effective speech and deal with the normal fears and jitters," she says, "but it doesn't teach you how to deal with the more pathological anxiety."

Behavioral therapy homework assignments can include making presentations in a real-life environment. "It's not just going for those 12 or so weeks," McCann says. "You have to go through a little pain and have the failures to get your improvements."

Osmond's "homework" included a trip with Ross to the local shopping center to buy, and the next day return, a shirt. At the mall, he tracked his panics on a scale of 1 to 10 while practicing his coping tricks. "Now, the entire time I was in the mall," he writes, "my panic never went down to 0, but anything under 5 or so, I could cope with."

To this day, Lawson isn't entirely without anxiety, either, but says the quality of his life has improved significantly. "I went from calling in sick to now at least being able to get up in front of a group of people. I'm able to have one-on-one meetings with people without feeling terribly nervous. I try not to take myself so seriously."

Combined with her Paxil treatment, cognitive behavioral therapy contributed to Turner's progress, too. Paxil, she says, "calmed my nerves and elevated my mood enough that I could use all the cognitive behavioral therapy techniques I'd learned."

Taking Control

Up to 80 percent of those treated for social phobia say they've gotten their anxiety under control, according to the Anxiety Disorders Association of America. Yet a recent study reveals that treatment delays of 10 years or more are common among adults with the condition. Some reasons people cited for not being in treatment: a fear of what others might think, a belief that the anxiety could be controlled without professional help, and uncertainty about where to go.

But despite such hesitations, medical experts and individual sufferers alike urge people to seek out help for this real and treatable condition. Turner: "The real me has been hidden for all these years. It's like a big, dark curtain was around me all that time, and I'm just now poking my head out. I want people to know they don't have to suffer. Life can be enjoyable."

As for Osmond, when his mind starts racing, he no longer thinks "what if I lose control?" Now, writes Osmond, he says to himself, "If I lose control, I know what to do."

Source: FDA Consumer Magazine
Date: November-December 1999
Author: Tamar Nordenberg, staff writer for FDA Consumer

Reviewed by athealth on February 7, 2014.

In death, spirituality can deepen meaning of life

By Martha Rutland-Wallis and Hugh Maddry

Gina Pavone knows her time on earth is running short. Without a cure for the ovarian cancer that has spread to her liver, doctors said she has one, two, maybe three years left to live.

She's scared, but she is also ready because of a spiritual belief system that assures her life doesn't end at death.

"It's very hard to face death when you're really not sure what's out there," she said. "And, while I think you have to look at it, you can't dwell on it."

It took every religious lesson she's ever learned and every spiritual occurrence she's ever heard about, read about or experienced to get to this point.

"For the first six months after I was diagnosed, I just laid on the couch with my dog," said Pavone, 54, of Troy, Mich. "When I wasn't sleeping, I was reading spiritual books. I think I was looking for a way to get closer to God. I was looking to believe that (God) was going to take care of me."

Raised Catholic, Pavone said she strayed from the church after childhood, but is still grounded by some of its teachings. She also calls upon all her spiritual senses for strength.

"I really needed to know why I was here," she said. "I think we all ask that question."

That question is answered in many different ways because spirituality has many different faces. It is at the core of all religions, and, in one form or another, it's the comfort most people turn to when they realize they are about to enter an unknown place.

"We are coming to realize that spirituality is of the utmost importance at the end of life," said Rev. Kevin Calloway, who works with St. Paul African Methodist Episcopal Church in Olathe, Kan. "It is that which ultimately concerns us. When someone knows they are dying, life is put in perspective."

Spirituality may be found in the connections, relationships and meanings that give life passion, commitment and hope - a poetry writing group, a 12-step program, love of nature, meditation. It can come through a personal relationship with a higher power, but it can also be tapped via contemplation, art or music.

John Rudd, spiritual care coordinator at Hospice of Bluegrass in Lexington, Ky., oversees a training program that teaches chaplains to better understand how spirituality, as opposed to religion, relate to death and dying. Rudd said it's important for the religious community to respect the differences in people's spirituality.

"It's interesting to see how many people are not associated with any church or group but do have a deep spiritual connection and awareness and strive for a relationship with their higher existence," he said.

Some find deep reservoirs of faith they never even suspected were there. Karen Boland, associate pastor of the Unity Church of Today in Warren, Mich., has seen this happen frequently. An end-of-life diagnosis, she says, can send people into "a mad-dash search" that leads them into a realization that there are deeper truths. And the realization, though sudden, is profound.

"Sometimes it's those people who can jump deeper in an instant than those who have been searching for years," said Boland.

Where they land can be in any direction, including back to a faith they thought they had long ago given up.

"A deep religious faith and being involved in a faith community makes a difference for those with serious or terminal illness," said Dr. Harold G. Koenig, author of "The Healing Power of Faith" and a professor at Duke University. "Research shows that such involvement is related to less depression and anxiety, greater well being and higher quality of life. It may also be linked with stronger immune functioning, lower blood pressures and longer survival."

Despite that, confronting death, much less delving into its meaning, is not encouraged in America.

"We live in a death-denying culture," Rudd said. "We know in the back of our minds that it's going to happen but we don't practice it too often. It's a one-time life event and our culture teaches us that it's way down the road."

Truth be known, said Boland, "Everyone of us is standing in the exit line. And we don't know where in the line we are. ... Children die before parents, parents die before grandparents. . . . It's that randomness that adds to the fear."

For some, this is the time of fist-shaking at God, overwhelming fear of physical pain and worry about loved ones who will be left behind. When that initial shock wears off, people really want to talk about what they've accomplished in life and all that has been left undone.

Pavone said during the "crying" period, she had a lot of questions as well, questions such as, "Why me?"

In Rich Lech's case, it was, "Why not me?" according to his wife, Kathy Lech.

For 41-year-old Kathy, strong religious beliefs have provided the most strength during her husband's long-term illness with brain cancer. But her husband is an atheist.

"When people used to say he should thank God that doctors found his cancer early, he said, 'I don't thank God. I thank Aristotle, because he's the one who invented the scientific method that will help save my life.'"

But, said Kathy Lech, "I know the Holy Spirit has come down for us both. Rich is getting special help whether he knows it or not."

Lech said she has been secretly hoping that her husband, who is now receiving hospice care, would change his thinking.

No matter, she said. "Someday, I will go up to him (in heaven) and say, 'I told you so.'"

While some are secure in their one faith, some find searching and blending to be the answer.

That was the case for Rose Thomason. A writer from Palm Coast, Fla., who had followed a diverse spiritual path, she found all of them comforting when, at age 60, she was diagnosed with advanced breast cancer.

She found nourishment in a variety of spiritual traditions, including the Christianity she had grown up with. She was drawn to the contemplative traditions of both East and West. She practiced kum nye, a Buddhist form of body prayer, similar to yoga. She meditated regularly.

Above all, she delved into her own soul through her writing. When she was diagnosed, she kept a journal that was later published as a book, "Shoring Up My Soul: A Year with Cancer." In it, she described the connection between spirituality and dying: "Facing death focuses the viewer," she wrote, "clarifying the soul, and rendering the membranes thin between spirit and matter."

Toward the end of her life, her son, Mark, recalls the family sitting quietly at Rose's bedside. Each was praying silently. A Jamaican woman from Rose's church circle came, bringing her whole family. She asked Mark to offer a prayer for healing. Mark agreed, and was startled when the Jamaican family gathered round the bed, touching Rose and praying loudly. Quickly, he felt the power of this ceremony, a traditional laying on of hands. "I didn't understand it all," he explained, "but it felt good."

While spiritual leaders agree that dying could very well be a profoundly positive experience, they understand human fears about it. The notion of death takes away control, often leaving behind struggles with hopelessness and helplessness.

"We start asking, 'What's the use?'" Boland said, "and that's typically when the search for meaning in their life begins."

While Pavone is convinced that "there is more after the life on earth," she is not ready to leave her body just yet.

Now on her third set of chemotherapy drugs, her tumors are shrinking, offering hope for a longer life. But in the end, she said, "You have to get over the numbers and start concentrating on living."

Pavone is doing just that by moving to New York to be closer to her family. She and her boyfriend just purchased a house on Lake Champlain in Vermont, where they plan to spend time.

"I don't know what God's got in store for me," she said. "And I'm certainly not pushing any buttons. I just go through the routine, get my chemotherapy and all the blood tests."

When her mind wanders to scary places, "I think, I sit and I talk to God. There is nothing in between us."

Copyright © 2005 National Hospice and Palliative Care Organization
All rights reserved. Reprinted with permission.

---

Reviewed by athealth on February 7, 2014.

In recent years, increasing numbers of people of all ages have been heeding their health professionals' advice to get active for all of the health benefits exercise has to offer. But for some people - particularly those who overdo or who don't properly train or warm up - these benefits can come at a price: sports injuries.

Fortunately, most sports injuries can be treated effectively, and most people who suffer injuries can return to a satisfying level of physical activity after an injury. Even better, many sports injuries can be prevented if people take the proper precautions.

This [page] answers frequently asked questions about sports injuries. It discusses some of the most common injuries and their treatment, and injury prevention. The booklet is for anyone who has a sports injury or who is physically active and wants to prevent sports injuries.

It is for casual and more serious athletes as well as the trainers, coaches, and health professionals who deal with sports injuries.

What Are Sports Injuries?

The term sports injury, in the broadest sense, refers to the kinds of injuries that most commonly occur during sports or exercise. Some sports injuries result from accidents; others are due to poor training practices, improper equipment, lack of conditioning, or insufficient warmup and stretching.

Although virtually any part of your body can be injured during sports or exercise, the term is usually reserved for injuries that involve the musculoskeletal system, which includes the muscles, bones, and associated tissues like cartilage. Traumatic brain and spinal cord injuries, (relatively rare during sports or exercise) and bruises are considered briefly in the Appendix. Following are some of the most common sports injuries.

Sprains and Strains

A sprain is a stretch or tear of a ligament, the band of connective tissues that joins the end of one bone with another. Sprains are caused by trauma such as a fall or blow to the body that knocks a joint out of position and, in the worst case, ruptures the supporting ligaments. Sprains can range from first degree (minimally stretched ligament) to third degree (a complete tear). Areas of the body most vulnerable to sprains are ankles, knees, and wrists. Signs of a sprain include varying degrees of tenderness or pain; bruising; inflammation; swelling; inability to move a limb or joint; or joint looseness, laxity, or instability.

A strain is a twist, pull, or tear of a muscle or tendon, a cord of tissue connecting muscle to bone. It is an acute, noncontact injury that results from overstretching or overcontraction. Symptoms of a strain include pain, muscle spasm, and loss of strength. While it's hard to tell the difference between mild and moderate strains, severe strains not treated professionally can cause damage and loss of function.

Knee Injuries

Because of its complex structure and weight-bearing capacity, the knee is the most commonly injured joint. Each year, more than 5.5 million people visit orthopaedic surgeons for knee problems.

Lateral View of the Knee

Knee injuries can range from mild to severe. Some of the less severe, yet still painful and functionally limiting, knee problems are runner's knee (pain or tenderness close to or under the knee cap at the front or side of the knee), iliotibial band syndrome (pain on the outer side of the knee), and tendonitis, also called tendinosis (marked by degeneration within a tendon, usually where it joins the bone).

More severe injuries include bone bruises or damage to the cartilage or ligaments. There are two types of cartilage in the knee. One is the meniscus, a crescent-shaped disc that absorbs shock between the thigh (femur) and lower leg bones (tibia and fibula). The other is a surface-coating (or articular) cartilage. It covers the ends of the bones where they meet, allowing them to glide against one another. The four major ligaments that support the knee are the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the medial collateral ligament (MCL), and the lateral collateral ligament (LCL). (See diagram.)

Knee injuries can result from a blow to or twist of the knee; from improper landing after a jump; or from running too hard, too much, or without proper warmup.

Compartment Syndrome

In many parts of the body, muscles (along with the nerves and blood vessels that run alongside and through them) are enclosed in a "compartment" formed of a tough membrane called fascia. When muscles become swollen, they can fill the compartment to capacity, causing interference with nerves and blood vessels as well as damage to the muscles themselves. The resulting painful condition is referred to as compartment syndrome.

Compartment syndrome may be caused by a one-time traumatic injury (acute compartment syndrome), such as a fractured bone or a hard blow to the thigh, by repeated hard blows (depending upon the sport), or by ongoing overuse (chronic exertional compartment syndrome), which may occur, for example, in long-distance running.

Shin Splints

While the term "shin splints" has been widely used to describe any sort of leg pain associated with exercise, the term actually refers to pain along the tibia or shin bone, the large bone in the front of the lower leg. This pain can occur at the front outside part of the lower leg, including the foot and ankle (anterior shin splints) or at the inner edge of the bone where it meets the calf muscles (medial shin splints).

Shin splints are primarily seen in runners, particularly those just starting a running program. Risk factors for shin splints include overuse or incorrect use of the lower leg; improper stretching, warmup, or exercise technique; overtraining; running or jumping on hard surfaces; and running in shoes that don't have enough support. These injuries are often associated with flat (overpronated) feet.

Achilles Tendon Injuries

A stretch, tear, or irritation to the tendon connecting the calf muscle to the back of the heel, Achilles tendon injuries can be so sudden and agonizing that they have been known to bring down charging professional football players in shocking fashion.

The most common cause of Achilles tendon tears is a problem called tendinitis, a degenerative condition caused by aging or overuse. When a tendon is weakened, trauma can cause it to rupture.

Achilles tendon injuries are common in middle-aged "weekend warriors" who may not exercise regularly or take time to stretch properly before an activity. Among professional athletes, most Achilles injuries seem to occur in quick-acceleration, jumping sports like football and basketball, and almost always end the season's competition for the athlete.

Lateral View of the Ankle

Common Types of Sports Injuries Muscle sprains and strains Tears of the ligaments that hold joints together Tears of the tendons that support joints and allow them to move Dislocated joints Fractured bones, including vertebrae FracturesA fracture is a break in the bone that can occur from either a quick, one-time injury to the bone (acute fracture) or from repeated stress to the bone over time (stress fracture).

Fractures

A fracture is a break in the bone that can occur from either a quick, one-time injury to the bone (acute fracture) or from repeated stress to the bone over time (stress fracture).

Acute fractures: Acute fractures can be simple (a clean break with little damage to the surrounding tissue) or compound (a break in which the bone pierces the skin with little damage to the surrounding tissue). Most acute fractures are emergencies. One that breaks the skin is especially dangerous because there is a high risk of infection.

Stress fractures: Stress fractures occur largely in the feet and legs and are common in sports that require repetitive impact, primarily running/jumping sports such as gymnastics or track and field. Running creates forces two to three times a person's body weight on the lower limbs.

The most common symptom of a stress fracture is pain at the site that worsens with weight-bearing activity. Tenderness and swelling often accompany the pain.

Dislocations

When the two bones that come together to form a joint become separated, the joint is described as being dislocated. Contact sports such as football and basketball, as well as high-impact sports and sports that can result in excessive stretching or falling, cause the majority of dislocations. A dislocated joint is an emergency situation that requires medical treatment.

The Shoulder Joint

The joints most likely to be dislocated are some of the hand joints. Aside from these joints, the joint most frequently dislocated is the shoulder. Dislocations of the knees, hips, and elbows are uncommon.

What's the Difference Between Acute and Chronic Injuries?

Regardless of the specific structure affected, sports injuries can generally be classified in one of two ways: acute or chronic.

Acute Injuries

Acute injuries, such as a sprained ankle, strained back, or fractured hand, occur suddenly during activity. Signs of an acute injury include the following:

• Sudden, severe pain
• Swelling
• Inability to place weight on a lower limb
• Extreme tenderness in an upper limb
• Inability to move a joint through its full range of motion
• Extreme limb weakness
• Visible dislocation or break of a bone

Chronic Injuries

Chronic injuries usually result from overusing one area of the body while playing a sport or exercising over a long period. The following are signs of a chronic injury:

• Pain when performing an activity
• A dull ache when at rest
• Swelling

What Should I Do if I Suffer an Injury?

Whether an injury is acute or chronic, there is never a good reason to try to "work through" the pain of an injury. When you have pain from a particular movement or activity, STOP! Continuing the activity only causes further harm.

Some injuries require prompt medical attention (see "Who Should I See for My Injury?"), while others can be self-treated. Here's what you need to know about both types:

When to Seek Medical Treatment

You should call a health professional if:

• The injury causes severe pain, swelling, or numbness

You can't tolerate any weight on the area

The pain or dull ache of an old injury is accompanied by increased swelling or joint abnormality or instability

To learn about treating sports injuries, see "How Are Sports Injuries Treated?"

When and How to Treat at Home

If you don't have any of the above symptoms, it's probably safe to treat the injury at home?at least at first. If pain or other symptoms worsen, it's best to check with your health care provider. Use the RICE method to relieve pain and inflammation and speed healing. Follow these four steps immediately after injury and continue for at least 48 hours:

• Rest. Reduce regular exercise or activities of daily living as needed. If you cannot put weight on an ankle or knee, crutches may help. If you use a cane or one crutch for an ankle injury, use it on the uninjured side to help you lean away and relieve weight on the injured ankle.
• Ice. Apply an ice pack to the injured area for 20 minutes at a time, four to eight times a day. A cold pack, ice bag, or plastic bag filled with crushed ice and wrapped in a towel can be used. To avoid cold injury and frostbite, do not apply the ice for more than 20 minutes. (Note: Do not use heat immediately after an injury. This tends to increase internal bleeding or swelling. Heat can be used later on to relieve muscle tension and promote relaxation.)
• Compression. Compression of the injured area may help reduce swelling. Compression can be achieved with elastic wraps, special boots, air casts, and splints. Ask your health care provider for advice on which one to use.
• Elevation. If possible, keep the injured ankle, knee, elbow, or wrist elevated on a pillow, above the level of the heart, to help decrease swelling.

The Body's Healing Process

From the moment a bone breaks or a ligament tears, your body goes to work to repair the damage. Here's what happens at each stage of the healing process:

At the moment of injury: Chemicals are released from damaged cells, triggering a process called inflammation. Blood vessels at the injury site become dilated; blood flow increases to carry nutrients to the site of tissue damage.

Within hours of injury: White blood cells (leukocytes) travel down the bloodstream to the injury site where they begin to tear down and remove damaged tissue, allowing other specialized cells to start developing scar tissue.

Within days of injury: Scar tissue is formed on the skin or inside the body. The amount of scarring may be proportional to the amount of swelling, inflammation, or bleeding within. In the next few weeks, the damaged area will regain a great deal of strength as scar tissue continues to form.

Within a month of injury: Scar tissue may start to shrink, bringing damaged, torn, or separated tissues back together. However, it may be several months or more before the injury is completely healed.

Who Should I See for My Injury?

While severe injuries will need to be seen immediately in an emergency room, particularly if they occur on the weekend or after office hours, most sports injuries can be evaluated and, in many cases, treated by your primary health care provider.

Depending on your preference and the severity of your injury or the likelihood that your injury may cause ongoing, long-term problems, you may want to see, or have your primary health care professional refer you to, one of the following:

• Orthopaedic surgeon: A doctor specializing in the diagnosis and treatment of the musculoskeletal system, which includes bones, joints, ligaments, tendons, muscles, and nerves.
• Physical therapist/physiotherapist: A health care professional who can develop a rehabilitation program. Your primary care physician may refer you to a physical therapist after you begin to recover from your injury to help strengthen muscles and joints and prevent further injury.

How Are Sports Injuries Treated?

Although using the RICE technique described previously can be helpful for any sports injury, RICE is often just a starting point. Here are some other treatments your doctor or other health care provider may administer, recommend, or prescribe to help your injury heal.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

The moment you are injured, chemicals are released from damaged tissue cells. This triggers the first stage of healing: inflammation (see "The Body's Healing Process" box). Inflammation causes tissues to become swollen, tender, and painful. Although inflammation is needed for healing, it can actually slow the healing process if left unchecked.

To reduce inflammation and pain, doctors and other health care providers often recommend taking an over-the-counter (OTC) nonsteroidal anti-inflammatory drug (NSAID) such as aspirin, ibuprofen (Advil1, Motrin IB, Nuprin), ketoprofen (Actron, Orudis KT), or naproxen sodium (Aleve). For more severe pain and inflammation, doctors may prescribe one of several dozen NSAIDs available in prescription strength.2

1 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.

2 Like all medications, NSAIDs can have side effects. The list of possible adverse effects is long, but major problems are few. The intestinal tract heads the list with nausea, abdominal pain, vomiting, and diarrhea. Changes in liver function frequently occur in children (but not in adults) who use aspirin. Changes in liver function are rare in children using the other NSAIDs. Questions about the appropriate use of NSAIDs should be directed toward your health care provider or pharmacist.

Though not an NSAID, another commonly used OTC medication, acetaminophen (Tylenol), may relieve pain. It has no effect on inflammation, however.

Immobilization

Immobilization is a common treatment for sports injuries that may be done immediately by a trainer or paramedic. Immobilization involves reducing movement in the area to prevent further damage. By enabling the blood supply to flow more directly to the injury (or the site of surgery to repair damage from an injury), immobilization reduces pain, swelling, and muscle spasm and helps the healing process begin. Following are some devices used for immobilization:

• Slings, to immobilize the upper body, including the arms and shoulders.
• Splints and casts, to support and protect injured bones and soft tissue. Casts can be made from plaster or fiberglass. Splints can be custom made or ready made. Standard splints come in a variety of shapes and sizes and have Velcro straps that make them easy to put on and take off or adjust. Splints generally offer less support and protection than a cast, and therefore may not always be a treatment option.
• Leg immobilizers, to keep the knee from bending after injury or surgery. Made from foam rubber covered with fabric, leg immobilizers enclose the entire leg, fastening with Velcro straps.

Surgery

In some cases, surgery is needed to repair torn connective tissues or to realign bones with compound fractures. The vast majority of sports injuries, however, do not require surgery.

Rehabilitation (Exercise)

A key part of rehabilitation from sports injuries is a graduated exercise program designed to return the injured body part to a normal level of function.

With most injuries, early mobilization - getting the part moving as soon as possible - will speed healing. Generally, early mobilization starts with gentle range-of-motion exercises and then moves on to stretching and strengthening exercise when you can without increasing pain. For example, if you have a sprained ankle, you may be able to work on range of motion for the first day or two after the sprain by gently tracing letters with your big toe. Once your range of motion is fairly good, you can start doing gentle stretching and strengthening exercises. When you are ready, weights may be added to your exercise routine to further strengthen the injured area. The key is to avoid movement that causes pain.

As damaged tissue heals, scar tissue forms, which shrinks and brings torn or separated tissues back together. As a result, the injury site becomes tight or stiff, and damaged tissues are at risk of reinjury. That's why stretching and strengthening exercises are so important. You should continue to stretch the muscles daily and as the first part of your warmup before exercising.

When planning your rehabilitation program with a health care professional, remember that progression is the key principle. Start with just a few exercises, do them often, and then gradually increase how much you do. A complete rehabilitation program should include exercises for flexibility, endurance, and strength; instruction in balance and proper body mechanics related to the sport; and a planned return to full participation.

Throughout the rehabilitation process, avoid painful activities and concentrate on those exercises that will improve function in the injured part. Don't resume your sport until you are sure you can stretch the injured tissues without any pain, swelling, or restricted movement, and monitor any other symptoms. When you do return to your sport, start slowly and gradually build up to full participation. For more advice on how to prevent injuries as you return to active exercise, see the "Tips for Preventing Injury" box.

Rest

Although it is important to get moving as soon as possible, you must also take time to rest following an injury. All injuries need time to heal; proper rest will help the process. Your health care professional can guide you regarding the proper balance between rest and rehabilitation.

Other Therapies

Other therapies commonly used in rehabilitating sports injuries include:

• Electrostimulation: Mild electrical current provides pain relief by preventing nerve cells from sending pain impulses to the brain. Electrostimulation may also be used to decrease swelling, and to make muscles in immobilized limbs contract, thus preventing muscle atrophy and maintaining or increasing muscle strength.
• Cold/cryotherapy: Ice packs reduce inflammation by constricting blood vessels and limiting blood flow to the injured tissues. Cryotherapy eases pain by numbing the injured area. It is generally used for only the first 48 hours after injury.
• Heat/thermotherapy: Heat, in the form of hot compresses, heat lamps, or heating pads, causes the blood vessels to dilate and increase blood flow to the injury site. Increased blood flow aids the healing process by removing cell debris from damaged tissues and carrying healing nutrients to the injury site. Heat also helps to reduce pain. It should not be applied within the first 48 hours after an injury.
• Ultrasound: High-frequency sound waves produce deep heat that is applied directly to an injured area. Ultrasound stimulates blood flow to promote healing.
• Massage: Manual pressing, rubbing, and manipulation soothe tense muscles and increase blood flow to the injury site.

Most of these therapies are administered or supervised by a licensed health care professional.Who Is at Greatest Risk for Sports Injuries?

If a professional athlete dislocates a joint or tears a ligament, it makes the news. But anyone who plays sports can be injured. Three groups?children and adolescents, middle-aged athletes, and women?are particularly vulnerable.

Children and Adolescents

While playing sports can improve children's fitness, self-esteem, coordination, and self-discipline, it can also put them at risk for sports injuries: some minor, some serious, and still others that may result in lifelong medical problems.

Young athletes are not small adults. Their bones, muscles, tendons, and ligaments are still growing and that makes them more prone to injury. Growth plates?the areas of developing cartilage where bone growth occurs in growing children?are weaker than the nearby ligaments and tendons. As a result, what is often a bruise or sprain in an adult can be a potentially serious growth-plate injury in a child. Also, a trauma that would tear a muscle or ligament in an adult would be far more likely to break a child's bone.

Because young athletes of the same age can differ greatly in size and physical maturity, some may try to perform at levels beyond their ability in order to keep up with their peers.

Injuries in Kids by Sport Children aged 5 through 14 sustained an estimated 2.38 million sports and recreational injuries annually from 1997 through 1999. By sport, this number includes the following: Pedal cycling                      332,000 injuries Basketball                          261,000 injuries Football                             243,000 injuries Playground equipment       219,000 injuries Baseball/softball               185,000 injuries Source: National Health Interview Survey

Contact sports have inherent dangers that put young athletes at special risk for severe injuries. Even with rigorous training and proper safety equipment, youngsters are still at risk for severe injuries to the neck, spinal cord, and growth plates. Evaluating potential sports injuries on the field in very young children can involve its own special issues for concerned parents and coaches. Some helpful hints are presented in the Appendix.

Adult Athletes Injuries by Sports Recreational sports*                      332,000 injuries Basketball                          370,000 injuries Exercising                           331,000 injuries Basketball                           276,000 injuries Pedal cycling                       231,000 injuries Baseball/softball                   205,000 injuries Source: National Health Interview Survey *Includes racquet sports, golf, bowling, hiking, and other leisure sports.

More adults than ever are participating in sports. Many factors contribute to sports injuries as the body grows older. The main one is that adults may not be as agile and resilient as they were when they were younger. It is also possible that some injuries occur when a person tries to move from inactive to a more active lifestyle too quickly.

Women

More women of all ages are participating in sports than ever before. In women's sports, the action is now faster and more aggressive and powerful than in the past. As a result, women are sustaining many more injuries, and the injuries tend to be sport specific.

Female athletes have higher injury rates than men in many sports, particularly basketball, soccer, alpine skiing, volleyball, and gymnastics. Female college basketball players are about six times more likely to suffer a tear of the knee's anterior cruciate ligament (ACL) than men are, according to a study of 11,780 high school and college players. Information on injuries collected since 1982 by the National Collegiate Athletic Association shows that female basketball and soccer players have a much higher incidence of ACL injuries than their male counterparts.

Previous assumptions that methods of training, risks of participation, and effects of exercise are the same for men and women are being challenged. Scientists are working to understand the gender differences in sports injuries.

While poor conditioning has not been related to an increased incidence of ACL injuries specifically, it has been associated with an increase in injuries in general. For most American women, the basic level of conditioning is much lower than that of men. Studies at the U.S. Naval Academy revealed that overuse injuries were more frequent in women; however, as women became used to the rigors of training, the injury rates for men and women became similar.

Aside from conditioning level, other possible factors in women's sports injuries include structural difference of the knee and thigh muscles, fluctuating estrogen levels caused by menstruation, the fit of athletic shoes, and the way players jump, land, and twist. Also, "the female triad," a combination of disordered eating, curtailed menstruation (amenorrhea), and loss of bone mass (osteoporosis), is increasingly more common in female athletes in some sports. Its true prevalence is unknown, but it appears to be greater in athletes, adolescents, and young adults, especially in people who are perfectionists and overachievers.

Scientists trying to better understand sports injuries in women met in June 1999 for a workshop sponsored jointly by the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the American Academy of Orthopaedic Surgeons. The workshop proceedings were published in a book titled Women's Health in Sports & Exercise, edited by William Garrett, M.D., Ph.D., and Gayle Lester, Ph.D. The book may be purchased from the American Academy of Orthopaedic Surgeons (www.aaos.org).

What Can Groups at High Risk Do to Prevent Sports Injuries?

Anyone who exercises is potentially at risk for a sports injury and should follow the injury prevention tips. But additional measures can be taken by groups at higher risk of injury.

Children

Preventing injuries in children is a team effort, requiring the support of parents, coaches, and the kids themselves. Here's what each should do to reduce injury risk.

What parents and coaches can do:

• Try to group youngsters according to skill level and size, not by chronological age, particularly during contact sports. If this is not practical, modify the sport to accommodate the needs of children with varying skill levels.
• Match the child to the sport, and don't push the child too hard into an activity that she or he may not like or be physically capable of doing.
• Try to find sports programs where certified athletic trainers are present. These people, in addition to health care professionals, are trained to prevent, recognize, and give immediate care to sports injuries.
• See that all children get a preseason physical exam.
• Don't let (or insist that) a child play when injured. No child (or adult) should ever be allowed to work through the pain.
• Get the child medical attention if needed. A child who develops any symptom that persists or that affects athletic performance should be examined by a health care professional. Other clues that a child needs to see a health professional include inability to play following a sudden injury, visible abnormality of the arms and legs, and severe pain that prevents the use of an arm or leg.
• Provide a safe environment for sports. A poor playing field, unsafe gym sets, unsecured soccer goals, etc., can cause serious injury to children.

What children can do:

• Be in proper condition to play the sport. Get a preseason physical exam.
• Follow the rules of the game.
• Wear appropriate protective gear.
• Know how to use athletic equipment.
• Avoid playing when very tired or in pain.
• Make warmups and cooldowns part of your routine. Warmup exercises, such as stretching or light jogging, can help minimize the chances of muscle strain or other soft tissue injury. They also make the body's tissues warmer and more flexible. Cooldown exercises loosen the muscles that have tightened during exercise.

Tips for Preventing InjuryWhether you've never had a sports injury and you're trying to keep it that way or you've had an injury and don't want another, the following tips can help.

• Avoid bending knees past 90 degrees when doing half knee bends.
• Avoid twisting knees by keeping feet as flat as possible during stretches.
• When jumping, land with your knees bent.
• Do warmup exercises not just before vigorous activities like running, but also before less vigorous ones such as golf.
• Don't overdo.
• Do warmup stretches before activity. Stretch the Achilles tendon, hamstring, and quadriceps areas and hold the positions. Don't bounce.
• Cool down following vigorous sports. For example, after a race, walk or walk/jog for five minutes so your pulse comes down gradually.
• Wear properly fitting shoes that provide shock absorption and stability.
• Use the softest exercise surface available, and avoid running on hard surfaces like asphalt and concrete. Run on flat surfaces. Running uphill may increase the stress on the Achilles tendon and the leg itself.

Adult Athletes

To prevent injuries, adult athletes should take the following precautions:

• Don't be a "weekend warrior," packing a week's worth of activity into a day or two. Try to maintain a moderate level of activity throughout the week.
• Learn to do your sport right. Using proper form can reduce your risk of "overuse" injuries such as tendinitis and stress fractures.
• Remember safety gear. Depending on the sport, this may mean knee or wrist pads or a helmet.
• Accept your body's limits. You may not be able to perform at the same level you did 10 or 20 years ago. Modify activities as necessary.
• Increase your exercise level gradually.
• Strive for a total body workout of cardiovascular, strength training, and flexibility exercises. Cross-training reduces injury while promoting total fitness.

Women

Increased emphasis on muscle strength and conditioning should be a priority for all women. Women should also be encouraged to maintain a normal body weight and avoid excessive exercise that affects the menstrual cycle. In addition, women should follow precautions listed above for other groups.

What Are Some Recent Advances in Treating Sports Injuries?

Today, the outlook for an injured athlete is far more optimistic than in the past. Sports medicine has developed some near-miraculous ways to help athletes heal and, in most cases, return to sports. Following are some procedures that have greatly advanced the treatment of sports injuries:

Arthroscopy

Most doctors agree that the single most important advance in sports medicine has been the development of arthroscopic surgery, or arthroscopy. Arthroscopy uses a small fiberoptic scope inserted through a small incision in the skin to see inside a joint. It is primarily a diagnostic tool, allowing surgeons to view joint problems without major surgery. Depending on the problem found, surgeons may use small tools inserted through additional incisions to repair the damage, such as a torn meniscus or a torn ligament that fails to heal naturally. Using arthroscopy, for example, a surgeon may reattach the torn ends of a ligament or reconstruct the ligament by using a piece (graft) of healthy ligament from the patient or from a cadaver.

Because arthroscopy uses tiny incisions, it results in less trauma, swelling, and scar tissue than conventional surgery, which in turn decreases hospitalization and rehabilitation times. Problems can be diagnosed earlier and treated without serious health risks or more invasive procedures. Furthermore, because injuries are often addressed at an earlier stage, operations are more likely to be successful.

Tissue Engineering

When joint cartilage is damaged by an injury, it doesn't heal on its own the way other tissues do. In recent years, however, the field of sports medicine and orthopaedic surgery has begun to develop techniques such as transplantation of one's own healthy cartilage or cells to improve healing. At present, this technique is used for small cartilage defects. Questions remain about its usefulness and cost.

Targeted Pain Relief

For people with painful sports injuries, new pain-killing medicated patches can be applied directly to the injury site. The patch is an effective method of delivering pain relief, especially for many people who prefer to put their pain medication exactly where it's needed rather than throughout their entire system.

What Advances Might We Expect in the Future?

Recent advances in treating sports injuries are likely to be just the beginning. Watch for developments in these areas in the not-too-distant future:

• The need for surgery may decline as improved rehabilitation techniques lead to a more "natural" progression to recovery for more musculoskeletal injuries.
• Technical advances and new imaging methods will lead to better ways to diagnose and treat injuries.
• Scientists will gain a better understanding of the role of nutrition in inflammation and healing. Such knowledge could lead to improvements in treatment.
• Tissue engineering will become more commonplace. Early studies of cartilage tissue engineering are now underway.
• Using gene therapy, doctors may be able to modify particular cells to induce repair of injured tissues.

Where Can People Find More Information About Sports Injuries?

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
(301) 495-4484 or (877) 22-NIAMS (free of charge)
TTY: (301) 565-2966
Fax: (301) 718-6366
[email protected]
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.

American Academy of Orthopaedic Surgeons (AAOS)
PO Box 2058
Des Plaines, IL 60017
(800) 824-BONE (2663) (free of charge)
http://www.aaos.org

The academy provides education and practice management services for orthopaedic surgeons and allied health professionals. It also serves as an advocate for improved patient care and informs the public about the science of orthopaedics. The orthopaedist's scope of practice includes disorders of the body's bones, joints, ligaments, muscles, and tendons. For a single copy of an AAOS brochure, send a self-addressed stamped envelope to the address above or visit the AAOS Web site.

American Academy of Pediatrics
141 Northwest Point Boulevard
Elk Grove Village, IL 60007-1098
(847) 434-4000
Fax: (847) 434-8000
http://www.aap.org

The American Academy of Pediatrics (AAP) and its member pediatricians dedicate their efforts and resources to the health, safety, and well-being of infants, children, adolescents, and young adults. Activities of the AAP include advocacy for children and youth, public education, research, professional education, and membership service and advocacy for pediatricians.

American College of Sports Medicine
PO Box 1440
Indianapolis, IN 46206-1440
(317) 637-9200
Fax: (317) 634-7817
http://www.acsm.org

The American College of Sports Medicine is the largest sports medicine and exercise science organization in the world. Nearly 18,500 members throughout the U.S. and the world are dedicated to promoting and integrating scientific research, education, and practical applications of sports medicine and exercise science to maintain and enhance physical performance, fitness, health, and quality of life.

American Medical Society for Sports Medicine (AMSSM)
11639 Earnshaw
Overland Park, KS 66210
(913) 327-1415
Fax: (913) 327-1491
http://www.amssm.org

The society fosters a collegial relationship among dedicated, competent sports medicine specialists and provides a quality educational resource for members, other sports medicine professionals, and the public.

American Orthopaedic Society for Sports Medicine
6300 N. River Road, Suite 500
Rosemont, IL 60018
(847) 292-4900
Fax: (847) 292-4905
http://www.sportsmed.org

The society is an organization of orthopaedic surgeons and allied health professionals dedicated to educating health care professionals and the general public about sports medicine. It promotes and supports educational and research programs in sports medicine, including those concerned with fitness, as well as programs designed to advance our knowledge of the recognition, treatment, rehabilitation, and prevention of athletic injuries.

American Physical Therapy Association
1111 North Fairfax Street
Alexandria, VA 22314-1488
(703) 684-2782 or (800) 999-2782 (free of charge)
Fax: (703) 684-7343
http://www.apta.org

The association is a national professional organization of physical therapists, physical therapist assistants, and physical therapy students. Its objectives are to improve physical therapy practice, research, and education to promote, restore, and maintain optimal physical function, wellness, fitness, and quality of life, especially as it relates to movement and health.

National Athletic Trainers Association
2952 Stemmons Freeway
Dallas, TX 75247-6916
(800) TRY-NATA (800-879-6282) (free of charge)
Fax: (214) 637-2206
http://www.nata.org

The association enhances the quality of health care for athletes and those engaged in physical activity. It also advances the profession of athletic training through education and research in the prevention, evaluation, management, and rehabilitation of injuries.

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Appendix

Traumatic Brain and Spinal Cord Injuries

Traumatic brain injury (TBI) occurs when a sudden physical assault on the head causes damage to the brain. A closed injury occurs when the head suddenly and violently hits an object, but the object does not break through the skull. A penetrating injury occurs when an object pierces the skull and enters the brain tissue.

Several types of traumatic injuries can affect the head and brain. A skull fracture occurs when the bone of the skull cracks or breaks. A depressed skull fracture occurs when pieces of the broken skull press into the tissue of the brain. This can cause bruising of the brain tissue, called a contusion. A contusion can also occur in response to shaking of the brain within the confines of the skull. Damage to a major blood vessel within the head can cause a hematoma, or heavy bleeding into or around the brain. The severity of a TBI can range from a mild concussion to the extremes of coma or even death.

What to do: For anything more than the most super-ficial injury, call for emergency medical assistance immediately. Observe symptoms so that you can report when help arrives. Do not allow the person to continue the activity. In more serious cases, do not move the person unless there is danger.

Spinal cord injury (SCI) occurs when a traumatic event results in damage to cells in the spinal cord or severs the nerve tracts that relay signals up and down the spinal cord. The most common types of SCI include contusion (bruising of the spinal cord) and compression (caused by pressure on the spinal cord). Other types include lacerations (severing or tearing of nerve fibers) and central cord syndrome (specific damage to the cervical region of the spinal cord).

What to do: In some cases, drugs called corticosteroids can minimize cell damage from a spinal cord injury. To be effective, they must be given within 8 hours of the injury. For this reason, it is important to call for emergency medical assistance immediately. Any person suspected of sustaining such a spinal cord injury should not be moved unless it is absolutely essential to keep the airway open so the person can breathe or to maintain circulation.

For more information, visit the Web site of the National Institute of Neurological Disorders and Stroke at http://www.ninds.nih.gov/ or call (800) 352-9424.

Bruises

A bruise, or muscle contusion, can result from a fall or from contact with a hard surface, a piece of equipment, or another player while participating in sports. A bruise results when muscle fiber and connective tissue are crushed; torn blood vessels may cause a bluish appearance. Most bruises are minor, but some can cause more extensive damage and complications.

What to do: Put the muscle in a gentle stretch position and begin using the RICE method to start the healing process. For more severe bruises, consult a doctor.

Sports Injuries in Young Children: Tips for Caregivers

Here are some "on-the-field" tips for helping a young child who has been injured:

• Minor injuries are fairly common in young children; severe injuries are not.
• A young child's self-esteem and enjoyment of a sport can be influenced by an adult's reaction when the child is injured.
• Judging the intensity and finding the site of the pain in a preschool child may not be easy. The child's perception of severity, influenced by his/her temperament and developmental level, may not match reality. The child's response to an injury may also reflect his/her prior experiences or the experiences of a friend or family member who has had an injury.
• Don't judge a child's reaction to an injury based on the child's age, sex, or size. Young children may vary greatly in their physical and mental development, temperaments, and reactions to and tolerance of pain and stress.
• Acknowledge the child's feelings (pain, fright, and/or anxiety), provide emotional support, and convey a sense of protection and caring.
• Treat children with respect. Never ridicule or belittle them in front of their peers, as this may be harmful to their developing self-esteem. Reassure the child that he/she will be cared for and the injury will be evaluated.
• Inappropriate overconcern can have negative effects and may lead to a more frightened child or eventually to a more vulnerable child. Parents may have difficulty remaining objective regarding their child's injury. On the other hand, parental knowledge of their child's temperament and typical reaction to pain can be immensely helpful to others trying to evaluate the severity of the injury.
• Question the child simply and directly. An authoritative approach, gentle but firm, will be reassuring for some youngsters.
• Listen to the injured youngster and get his/her reaction to reentering a sport or activity. Sometimes hidden fears will be expressed that can be addressed by a caregiver who listens. A child's mental health and development are as important as his/her physical health.
• Time, ice, and a caring attitude will help to minimize many simple traumatic injuries.

Acknowledgments

The NIAMS gratefully acknowledges the assistance of the American Academy of Orthopaedic Surgeons, Des Plaines, IL; the American Physical Therapy Association, Alexandria, VA; William E. Garrett, Jr., MD, PhD, University of North Carolina; Jo A. Hannafin, MD, PhD, Hospital for Special Surgery, New York, NY; Lynn Haverkof, MD, the National Institute of Child Health and Human Development, NIH; Cato T. Laurencin, MD, PhD, University of Virginia, Charlottesville, VA; Gayle Lester, PhD, NIAMS, NIH; the National Institute of Neurological Disorders and Stroke, NIH; and James S. Panagis, MD, MPH, NIAMS, NIH, in the preparation and review of this booklet. Special thanks also go to the individuals who reviewed this publication and provided valuable assistance. Mary Anne Dunkin was the author of this booklet.

Source: National Institutes of Health
National Institute of Arthritis and Musculoskeletal and Skin Diseases
NIH Publication No. 04-5278

Reviewed by athealth on February 7, 2014.

Children do not adjust to divorce in one short time. It is a long process. Divorce does not happen all at once, either. It is a series of events and changes. At different points, children deal with different issues. Also, different children react to the same changes and situations in different ways. Researchers believe that children react to divorce in three stages:

1. Initial stage: The first stage is when parents are making the decision to separate. This might be a very difficult time for children. Parents may be fighting more. The stress at home may be very upsetting for a child. Children can react very strongly in this time. It is also possible that the children do not know about the decisions their parents are making. They may not know there is any problem. Parents themselves may be in a crisis now, and they may be unable to pay attention to the child's needs, or they may hide the problems from the child. If the child knows there are problems, she might be worried about other issues like changing houses, moving, not seeing one parent at home, and so on. If there had been physical violence or bad fights between parents, the separation can be a relief to the child and the parent. Even then, the divorce will cause stress. Only a very small number of children are happy that a divorce is coming.

At this stage, it is very important for childcare providers to be steady and supportive of children. Providers also need to be aware of what is happening with the parent. They need to know if the children know about the problems. Situations can change very quickly, and parents may be very emotional. Many providers may want to make sure that other sources of help are available to the parent. They may want to help parents get some advice.

2. Transition stage: The second stage occurs when the family separates. One parent moves out, or both parents move to new homes. For some children this will be the first time they knew there were problems. For other children, this could be a relief, because the fighting and arguing will stop or slow down. All families start working out different arrangements for childcare, housing, money, custody, and visitation at this point. The child slowly begins to get used to a different family life. She gets used to one parent not being at home and to visiting that parent. She may make new friends, adjust to a different financial situation, and so on. This stage can last for as long as two to three years.

Providers may notice that many things change during this stage, too. This might be a good time to sit down with parents and make some decisions about the child's care. Parents might be more willing to talk now. Again, providers can help parents find other resources.

3. Restabilization stage: This stage is when the new life becomes normal. Some families can take up to five years to reach this final stage. They reach this stage when the family is used to all the changes that divorce created in their lives. The fears and anger are not as strong in this stage. The family can now become a single-parent family or a stepfamily. Many families do become stepfamilies - often in the first three years after divorce. That change also brings about new stresses!

If parents first come to the childcare setting at this final stage, providers might not know there was a divorce, so it is important for providers to talk to parents. Providers need to know about visitation plans. They need to know who is allowed to take the child. Providers also need to realize that parents may not stay in a stable stage. They may sometimes get upset or angry. This might happen when there is a change in custody arrangements. It might happen when one parent stops paying child support. It also may happen when one parent remarries. Again, providers can help if they know how to connect parents with other resources.

Source:

Provider-Parent Partnerships
http://www.ces.purdue.edu/providerparent/index.htm
Purdue University, School of Consumer and Family Sciences
Department of Child Development and Family Studies
by Nithyakala Karuppaswamy and Judith Myers-Walls, PhD, CFLE

Reviewed by athealth on February 8, 2014.

What is stalking?

Stalking statutes vary from state to state. In general, stalking refers to repeated harassing or threatening behavior by an individual, such as following a person, appearing at a person's home or place of business, making harassing phone calls, leaving written messages or objects, or vandalizing a person's property. Virtually any unwanted contact between two people that directly or indirectly communicates a threat or places the victim in fear can be considered stalking.

Anyone can be a stalker, just as anyone can be a stalking victim.

Stalking is a crime that can touch anyone, regardless of gender, race, sexual orientation, socioeconomic status, geographic location, or personal associations. Most stalkers are young to middle-aged men with above-average intelligence.

Unfortunately, there is no single psychological or behavioral profile for stalkers. Every stalker is different. This makes it virtually impossible to devise a single effective strategy that can be applied to every situation. It is vital that stalking victims immediately seek the advice of local victim specialists who can work with them to devise a safety plan for their unique situation and circumstances.

Some stalkers develop an obsession for another person with whom they have no personal relationship. When the victim does not respond as the stalker hopes, the stalker may attempt to force the victim to comply by use of threats and intimidation. When threats and intimidation fail, some stalkers turn to violence.

The most prevalent type of stalking case involves some previous personal or romantic relationship between the stalker and the victim. This includes domestic violence cases and relationships in which there is no history of violence. In these cases, stalkers try to control every aspect of their victims' lives. The victim becomes the stalker's source of self-esteem, and the loss of the relationship becomes the stalker's greatest fear. This dynamic makes a stalker dangerous. Stalking cases that emerge from domestic violence situations, however, are the most lethal type of stalking.

The stalker may attempt to renew the relationship by sending flowers, gifts, and love letters. When the victim spurns these unwelcome advances, the stalker often turns to intimidation. Attempts at intimidation typically begin in the form of an unjustified and inappropriate intrusion into the victim's life. The intrusions become more frequent over time. This harassing behavior often escalates to direct or indirect threats. Unfortunately, cases that reach this level of seriousness often end in violence.

If You Are Being Stalked

Any person who suspects that he or she is being stalked should report all contacts and incidents to local law enforcement. To make arrest and prosecution more likely, stalking victims should document every incident as thoroughly as possible, including collecting/keeping videotapes, audiotapes, phone answering machine messages, photos of property damage, letters received, objects left, affidavits from eyewitnesses, and notes. Experts also recommend that victims keep a journal to document all incidents, including the time, date, and other relevant information for each. Regardless of how much evidence they have gathered, victims should file a complaint with law enforcement as soon as possible.

As a result of the stalking, you may experience a variety of physical, emotional, and financial consequences. The emotional trauma of constantly being on alert for the stalker, or the next harassment, may seem to use up all the energy you have. You may feel vulnerable and out of control of your life. You may have nightmares. Your eating and sleeping habits may change. You may feel depressed or hopeless and lack interest in things you once enjoyed. This is not unusual. The constant stress in stalking situations is very real and harmful. Realize that what is happening to you is not normal, not your fault, and not caused by anything you have done.

Where can you get help?

Remember, as a stalking victim, you are not alone. Do not lose hope. The support network in your community may include hotlines, counseling services, and support groups. Trained victim advocates can provide vital information and a full range of support services, such as assistance through the criminal justice process and help finding out about your rights as a stalking victim.

You may be able to obtain a restraining order or a "no-contact" order through the clerk of court. These are court orders signed by a judge telling the stalker to stay away from you and not to have contact with you in person or by phone. It is not necessary for a civil or criminal domestic violence case to be filed for these orders to be issued. Most states authorize law enforcement to make an arrest for violation of such an order. Each jurisdiction and community may differ in the type of restraining order available and the process for application and issuance of orders. Local victim advocates can tell you how the process works in your community.

All states now have crime victim compensation programs that reimburse victims for certain out-of-pocket expenses, including medical expenses, lost wages, and other financial needs considered reasonable. To be eligible, you must report the crime to the police and cooperate with the criminal justice system. Victim assistance programs in your community can provide you with compensation applications and additional information.

What are the facts about stalking?

The results of the April 1998 National Violence Against Women Survey (for discussion, see Stalking in America: Findings From the National Violence Against Women Survey. Washington, DC: National Institute of Justice, 1998), jointly sponsored by the National Institute of Justice and the Centers for Disease Control and Prevention, found that--

• One out of every 12 women (8,200,000) and one out of every 45 men (2,000,000) in the United States have been stalked at some time in their lives.
• It is estimated that every year in the United States, 1,006,970 women and 370,990 men are stalked.
• Ninety percent of stalking victims were stalked by just one person each during their lives. Nine percent of female victims and 8 percent of male victims were stalked by two different people, and 1 percent of female victims and 2 percent of male victims were stalked by three different people.
• The majority of stalking victims (74 percent) are between 18 and 39 years old.
• In a 1-year period, women are three times more likely to be stalked than raped, but they are two times more likely to be physically assaulted than stalked.
• Eighty-seven percent of the stalkers identified by their victims were male.
• Only 23 percent of female stalking victims and 36 percent of male stalking victims were stalked by strangers.
• Thirty-eight percent of female stalking victims were stalked by current or former husbands, 10 percent by current or former cohabiting partners, and 14 percent by current or former dates or boyfriends.

Resources for Information and Assistance

National Center for Victims of Crime
http://www.ncvc.org

National Domestic Violence Hotline
http://www.www.ndvh.org

National Organization for Victim Assistance
http://www.try-nova.org

Office for Victims of Crime Resource Center
http://www.ojp.usdoj.gov/ovc/ovcres/welcome.html

Violence Against Women Office
http://www.ovw.usdoj.gov/

This brochure was developed by the National Center for Victims of Crime under a project supported by Grant No. 97-VF-GX-K007 awarded by the Office for Victims of Crime, Office of Justice Programs, U.S. Department of Justice. Points of view in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice.

Title: Stalking Victimization
Series: Help Series Brochure
Author: Office for Victims of Crime (OVC)
Published: February 2002

Reviewed by athealth on February 8, 2014.

Why Step Relationships Aren't Easy

When two people remarry with one or both having children, they must double up their adjustment. They do not have the luxury of simply marrying as partners. They must commit to the complexity of learning to marry as parents, too. This parental dimension to their union requires additional communication as they not only work out how to function as a couple, but as a family, as well.

If they want to keep their marriage together, they must keep their parenting together. They must never allow the child to become divisive of the marriage - to cause them to feel they are on opposing sides in the parental relationship. They must always stay on the same side with both of them wanting to support dialogue and decisions that preserve the union they have created. "We really see this situation differently, and that's okay. Let's talk until we understand each other's point of view and work out a position we can both support."

The Entry Adjustment

Before remarriage, honeymoon harmony may have reigned among them all, with everyone on his/her best behavior, playing together but not living together. However, once they actually form a blended family unit, the easy-going shine quickly wears off, and hard reality sets in. Now, differences between stepparent and stepchildren over household conduct, between parent and stepparent over child raising, between parent and children over respect for the new marriage, begin to irritate family relationships, causing conflicts as incompatibilities become hard to deny and harder to accept.

• "Your kids never pick anything up!"
• "Our stepparent is a neat freak!"
• "You care more about your new marriage than you do for us!"
• "Who comes first, your kids or me?"
• "Why can't you both just get along for my sake?"

Complaints, complaints! Unhappily, the couple may wonder: "Why can't everyone just enjoy each other's company?" That's a good question. Knowing some of the answers allows the couple to develop realistic expectations and make effective choices that can help remarriage with children work.

Adjustment to Parental Remarriage

It can frustrate a remarried mother or father to have a child whose discontent threatens to spoil the happiness that parent seeks. "Why must you make things so difficult at a time when I want everything to go well?" At this point it is worth remembering that remarriage is an adult decision, selfishly made, at least for one of the parents, for his or her personal happiness. Like divorce, it is not a decision either made by the child or for the child's sake. And, it is not a decision that necessarily pleases the child who may feel jerked around by family changes over which he or she had no control. "I liked things better living with my parent alone, and I still miss having Mom and Dad and us all together." Divorce and remarriage both create a powerful conflict of interest between parent and child. These family changes are chosen to advance happiness of the parent, to some degree at the child's felt expense.

Being Taken Through One's Parents' Changes

The transition from parental marriage to parental divorce to parental remarriage creates a host of changes for the child to accept.

• Divorce ends living all together in the original family and creates separate households, while remarriage means learning to live on daily intimacy with a step parent whose ways are unfamiliar and who is in many ways a stranger. "It feels awkward living with some adult I hardly know."
• Divorce and remarriage also alters caring. In the original family caring felt unconditional; then divorce questioned the constancy of caring (as parents lost love for each other); and, now, in remarriage caring from and for the step parent can feel conditional. "We like each other when we get along, and we don't like each other when we don't."
• In the original family, both parents were fully there; divorce meant one parent was always gone; and with remarriage the resident parent is only partly there. "I get less time with my parent now that my stepparent is here."
• In the original family, the child assumed the parents would always be together; divorce meant accepting they would never be together again; remarriage means parent and stepparent will be together for the foreseeable future. "First they tear up the old family, then they expect me to get used to a new one!"
• In the original family, parents were the same as the child had always known them; with freedom from divorce each parent starts making personal changes; and with remarriage the influence of the stepparent changes how the mother or father has always parented. "What I hate most about your remarriage is the way you've changed!"

And these are just some of the adjustments a child must make.

Attachment Expectations

One particular area of adjustment about which there can be unrealistic parental expectations is concerning the child's attachment to the parent's new partner. Central to the dream of a happy remarriage may be the dream of a loving bond between child and stepparent. Chances for this to occur are largely dependent on how old the child is at the time of parental remarriage. The watershed age when acceptance tends to become harder is the onset of early adolescence, around years nine or ten, when the developmental separation from childhood commonly begins. Below that age, significant attachment is more likely to occur; but above that age, adolescence makes bonding much more difficult.

Divorce and remarriage tend to intensify the natural grievance and rebellion of adolescence. Sense of injury and being treated unfairly by disruptive family change can fuel the young person's anger. The stepparent is an easy target for this resentment since in this relationship there is no history of love so there's no love to lose. Now the stepparent/stepchild relationship is easily inflamed by mutual blame, each one scapegoating and stereotyping the other for what is wrong in the family, pitting the "evil" stepparent who is always "mean and moody" against the "no good kid" who is " bad mannered and uncooperative."

To prevent these stereotypes from taking hold, rather than stepparent and stepchild having less to do with each other (which is what they want), they actually need more time alone together to allow contact to inform their judgments with knowledge, and not allow separation to reinforce their prejudices with ignorance.

Realistic Expectations for the Step Relationship

A parent's realistic expectations for attachment between stepparent and stepchild when that child is in adolescence are these. It is realistic for the parent to expect, and insist, that the teenager treat the stepparent with respect, even when that young person wishes this outside adult could just go away. It is realistic for the parent to expect the stepparent to care about what happen to the stepchild even when the stepparent does not at the moment much care for the stepchild's attitude or behavior.

It is also realistic to expect that many of the differences the stepparent brings into the family -- of sex role definition, of personality, of skills, of knowledge, of interests -- can all be turned to positive value for the stepchild when they create an opportunity to learn and grow and profit from this association. This is not to recommend divorce and remarriage, but increased diversity of family life is not simply a cause for divisiveness, it is a source of additional richness as well. To encourage taking advantage of this positive side, it helps if the stepparent clarifies that he or she is not in any way competing with, or trying to supplant, the absent biological parent. "I'm not your real parent and have no desire to be. But I am your real stepparent, and exactly what that means is something you and I will have to work out together. Hopefully, we can make it into a relationship we can both enjoy."

Dealing With Step Family Differences

Step relationships mix people up by increasing the mix of individual differences in a family. These differences are often incompatible and make accommodating and fitting in hard to do. When two cultures come together for the first time, some clashes are bound to occur. "Whose way is the right way?" is the common denominator for many conflicts as stepparent and parent (plus children) work out on whose terms they will live, which way of family life will prevail. The outcome is always some mix of the two, each side in the partnership giving up more traditional practices and tolerating more change than was originally anticipated. "I never thought I'd learn to live this way!" From "my way" and from "your way" the couple comes to define "our way," and the stepfamily starts creating a cultural identity of its own.

From the outset of remarried life, there will be stepchild behavior and parenting practices that seem acceptable to the parent, but are offensive to the stepparent. "How can you let them act like that? Why haven't you taught them any better?" And immediately the parent feels put on the spot. "There's nothing wrong with their behavior, you're just not used to normal kids!"

In remarriage, stepchildren come to represent the cultural divide between parent and stepparent. To attack child raising differences by attacking each other, arguing over who is right and who is wrong, will not serve the new marriage partners well. It will only polarize and antagonize their relationship. Parent and stepparent will never see the children through the same perceptual lens. Typically, the parent sees the child more affirmatively ("He is really trying!"), and the stepparent sees the child more critically ("He is not trying hard enough!"). The parent (attached and approving) tends to see the glass (the child) as half-full, and the stepparent (fatigued and frustrated) tends to see the glass as half empty. Parent and stepparent need to turn their contrasting perspectives to advantage.

What the parent has to offer is constancy and acceptance. "Loving who they are is always more important to me than always liking how they act." What the stepparent has to offer is distance and perspective. "Sometimes I can see what your kids need more objectively than you can." It is this mix of parental acceptance and stepparent perspective that can be combined to great advantage, depth of caring and breadth of vision both contributing the children's well being. Love can blind the parent to problems the stepparent is willing to see. Frustration can cause the stepparent to give up on the child to whom the parent remains loyally committed.

The Discussion Contract

In their discussions over the children, it helps enormously if parent and stepparent agree to the following contractual exchange. When an issue over the stepchild's behavior arises, the stepparent will express that concern to the parent with utmost tact, not putting the parent on the defensive by voicing complaints, comparisons, or criticism. Instead, communication is kept as objective and non-evaluative as possible. "I don't agree with how your child is choosing to act, and I would like to talk with you about trying to change that behavior." In return, the parent will be continually mindful of the stepparent's efforts to help create a family for the stepchild, expressing this partner's appreciation to the stepparent for hanging in there with a child not his or her own. The stepparent needs appreciation because the stepchild is not likely to give it. And the parent needs tact because it is so easy to feel defensive on one's child's behalf.

Role Pressures

In addition, it helps for each partner to be sensitive to stepfamily pressures that complicate each other's role. To be the parent in the remarried family often means feeling torn apart by conflicting loyalties and sympathies, caught in the middle between two loved ones who sometimes can't stand each other, each coming to the parent/partner to confide complaints. Of course, the good part of being in the middle is getting twice as much love as either of the two occasional antagonists. How much of the conflict between spouse and child to mediate and how much to let them just work out is an ongoing dilemma. In general, the more stepparent and stepchild are allowed to work out their differences directly, the less often the parent will intervene and feel caught in the painful middle. One approach that usually helps is for stepparent and stepchild to have some times with just the two of them together without the parent present. In this situation there is no parent time and attention to vie for, so each is usually more open to finding ways to get along.

To be the stepparent is to feel continually affronted by parenting values and stepchild behavior that seem unacceptable, to wonder whether to speak up or not, or to make an invisible effort to get along by shutting up about a lot. "Swallowing offenses" is how one stepfather described it. Since these efforts at tolerance and restraint are not seen by anyone else, they are not credited as effort, hence the problem of invisibility. In addition, there is often the frustration of being discounted by the stepchild who ignores the stepparent's presence and opinions, treating the parent as the only adult in the family who matters, the only adult worth talking to or seeking out for companionship. If this dismissive conduct is going on, the parent can insist on more respectful treatment. "I expect you to treat your stepparent with the same courtesy and respect that we give you."

These are the pains that come with the two roles. The parent often feels caught in the middle, unable to do right by one loved one without doing wrong in the eyes of the other. The stepparent often feels like an invisible and discounted family member whose efforts at adjustment, tolerance, and restraint are unseen and unappreciated. For the sake of the marriage, the parent can recognize the stepparent's efforts, thereby reducing discomfort from invisibility, and the stepparent can work out differences with the stepchild without pulling the parent into the middle.

Time for the Marriage

Finally, there is the abiding importance of parent and stepparent making and taking sufficient time alone and apart to shed parental roles and concerns and just enjoy being together as partners. Becoming life partners is the primary reason why they got together in the first place.

And, when they are back into parental role, the parent can explain how there is not one but two ways he or she experiences the stepparent's love. "When you treat me as your loving partner, and when you treat my children with love, in both ways do I experience your love for me." To which the stepparent can reply: "When you love me as your partner and as co-parent of your children, in both ways do I experience your love for me." Remarriage with stepchildren is at least twice as hard as marriage with mutual children or with none, but well done, it can be twice as rewarding, too.

About the Author

Carl E. Pickhardt, PhD, is the author of numerous articles and books on parenting, including The Connected Father: Understanding Your Unique Role and Responsibilities During Your Child Adolescence; Keys To Developing Your Child's Self-Esteem; and The Future of Your Only Child: How to Guide Your Child to a Happy and Successful Life to be published in 2008. His books are available at amazon.com.

© Carl Pickhardt, PhD, 2003 Used with permission.
Page last modified or reviewed on January 24, 2014

How Can I Tell If a Friend or a Loved One Has a Problem With Alcohol, Marijuana, or Other Illicit Drugs?

Sometimes it is tough to tell. Most people won't walk up to someone they're close to and ask for help. In fact, they will probably do everything possible to deny or hide the problem. But, there are certain warning signs that may indicate that a family member or friend is using drugs and drinking too much alcohol.

If your friend or loved one has one or more of the following signs, he or she may have a problem with drugs or alcohol:

• Getting high on drugs or getting drunk on a regular basis
• Lying about things, or the amount of drugs or alcohol they are using
• Avoiding you and others in order to get high or drunk
• Giving up activities they used to do such as sports, homework, or hanging out with friends who don't use drugs or drink
• Having to use more marijuana or other illicit drugs to get the same effects
• Constantly talking about using drugs or drinking
• Believing that in order to have fun they need to drink or use marijuana or other drugs
• Pressuring others to use drugs or drink
• Getting into trouble with the law
• Taking risks, including sexual risks and driving under the influence of alcohol and/or drugs
• Feeling run-down, hopeless, depressed, or even suicidal
• Suspension from school for an alcohol- or drug-related incident
• Missing work or poor work performance because of drinking or drug use

Many of the signs, such as sudden changes in mood, difficulty in getting along with others, poor job or school performance, irritability, and depression, might be explained by other causes. Unless you observe drug use or excessive drinking, it can be hard to determine the cause of these problems. Your first step is to contact a qualified alcohol and drug professional in your area who can give you further advice.

How Can I Tell if I Have a Problem with Drugs or Alcohol?

Drug and alcohol problems can affect every one of us regardless of age, sex, race, marital status, place of residence, income level, or lifestyle.

You may have a problem with drugs or alcohol, if

• You can't predict whether or not you will use drugs or get drunk.
• You believe that in order to have fun you need to drink and/or use drugs.
• You turn to alcohol and/or drugs after a confrontation or argument, or to relieve uncomfortable feelings.
• You drink more or use more drugs to get the same effect that you got with smaller amounts.
• You drink and/or use drugs alone.
• You remember how last night began, but not how it ended, so you're worried you may have a problem.
• You have trouble at work or in school because of your drinking or drug use.
• You make promises to yourself or others that you'll stop getting drunk or using drugs.
• You feel alone, scared, miserable, and depressed.

If you have experienced any of the above problems, take heart, help is available. More than a million Americans like you have taken charge of their lives and are living healthy and drug-free.

Messages for Teenagers

• Know the law. Methamphetamines, marijuana, hallucinogens, crack, cocaine, and many other substances are illegal. Depending on where you are caught, you could face high fines and jail time. Alcohol is illegal to buy or possess if you are under 21.
• Be aware of the risks. Drinking or using drugs increases the risk of injury. Car crashes, falls, burns, drowning, and suicide are all linked to drug use.
• Keep your edge. Drug use can ruin your looks, make you depressed, and contribute to slipping grades.
• Play it safe. One incident of drug use could make you do something that you will regret for a lifetime.
• Do the smart thing. Using drugs puts your health, education, family ties, and social life at risk.
• Think twice about what you're advertising when you buy and wear T-shirts, hats, pins, or jewelry with a pot leaf, joint, blunt, beer can, or other drug paraphernalia on them. Do you want to promote something that can cause cancer? make you forget things? or make it difficult to drive a car?
• Face your problems. Using drugs won't help you escape your problems, it will only create more.
• Be a real friend. If you know someone with a drug problem, be part of the solution. Urge your friend to get help.
• Remember, you DON'T NEED drugs or alcohol. If you think "everybody's doing it," you're wrong! Doing drugs won't make you happy or popular or help you to learn the skills you need as you grow up. In fact, doing drugs can cause you to fail at all of these things.

How Can I Get Help?

You can get help for yourself or for a friend or loved one from numerous national, State, and local organizations, treatment centers, referral centers, and hotlines throughout the country. There are various kinds of treatment services and centers. For example, some may involve outpatient counseling, while others may be 3- to 5-week-long inpatient programs.

While you or your friend or loved one may be hesitant to seek help, know that treatment programs offer organized and structured services with individual, group, and family therapy for people with alcohol and drug abuse problems. Research shows that when appropriate treatment is given, and when clients follow their prescribed program, treatment can work. By reducing alcohol and/or drug abuse, treatment reduces costs to society in terms of medical care, law enforcement, and crime. More importantly, treatment can help keep you and your loved ones together.

Remember, some people may go through treatment a number of times before they are in full recovery. Do not give up hope.

Each community has its own resources. Some common referral sources that are often listed in the phone book are:

• Community Drug Hotlines
• Local Emergency Health Clinics, or Community Treatment Services
• City/Local Health Departments
• Alcoholics Anonymous, Narcotics Anonymous, or Al-Anon/Alateen
• Hospitals

Source: National Clearinghouse for Alcohol and Drug Information

Reviewed by athealth on February 8, 2014.