Archives: Consumer Topics

What is stress?

Stress is the complex interaction between the events of life and the perception of those events by an individual. Everyone experiences stress and everyone learns either to cope with the stress or not.

Certain events in life are seen as very stressful. Some of the most stressful events include the death of a spouse, divorce, separation, and spending time in jail. Other significant stress factors include serious injury or illness, marriage, being fired from one's job, reconciliation of a relationship, and retirement.

How one deals with stress depends upon one's genetic make-up, background, and sources of emotional and social support. Everyone has ways of defending against excessive stress. Some of those defenses are psychological in nature. Good or healthy psychological responses help people to cope well with stress. Unhealthy responses may lead to physical or emotional problems. It is also possible that even healthy people can be overcome by stress if the stress they are dealing with is too great or if they are in a weakened condition.

What can people do if they need help?

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

Reviewed by athealth on February 8, 2014.

An Interview with Robert Hughes, Jr, PhD

Robert Hughes is an Associate Professor and Extension Specialist in the Department of Human Development and Family Science at Ohio State University. For the past 20 years, he has conducted educational programs in family relations for family life professionals, and for family members themselves, with a primary emphasis on families at risk, family stress, and single parenting. Parent News asked him to discuss his work in the area of divorce and its impact on children. The following article discusses the impact of divorce on children's behavior and academic achievement.

Parent News: What is the current divorce rate? Has the divorce rate changed much over the past 5 to 10 years?

Robert Hughes: The divorce rate in the United States has generally been going up throughout the 20th century until its peak in the late 1970s. The rate of divorce has been slowly declining since that peak. In the most recent data, there were about 20 divorces for every 1,000 women over the age of 15. This number is down from about 23 divorces per 1,000 women in 1978, but it is still significantly greater than the rate of divorce during the 1950s. At that time, the rate of divorce was about 5 per 1,000 women.

The divorce rate has been climbing in every industrialized country in the world. There are two significant factors affecting the rising divorce rate in the United States and elsewhere:

• men and women are less in need of each other for economic survival, and
• gains made in birth control allow men and women to separate sexual activity from having children.

A variety of factors are producing the current leveling off of the divorce rate. We may be at the end of the effects produced by the emergence of reliable birth control in the 1960s, but there are also other factors. Our population is aging, and in general longer marriages are more likely to remain intact. Also, more young people are cohabiting rather than getting married. The breakup of this kind of relationship does not get recorded as a divorce.

Parent News: What are some of the outcomes for children who experience divorce?

Robert Hughes: It is important to note that while divorce increases children's risk for a variety of problems, not all children who experience divorce have problems. Children of divorce are twice as likely as children living in nondivorced families to experience difficulties. Roughly 20% to 25% of these children will have problems. Another way of saying this is that 75% to 80% will not experience these difficulties. In other words, while children of divorce are at greater risk, most will not have major problems.

Sidebar: Divorce may be particularly difficult for children with ADHD, ODD, and other behavioral disorders. These children, who are particularly vulnerable to lack of confidence and low self-esteem, frequently experience school problems, have difficulty making friends, and lag behind their peers in psychosocial development. They are more likely to bully and to be bullied.

Parent News: What are some of the problems children frequently have?

Robert Hughes: Children from divorced families are more likely to have academic problems. They are more likely to be aggressive and get in trouble with school authorities or the police. These children are more likely to have low self-esteem and feel depressed. Children who grow up in divorced families often have more difficulties getting along with siblings, peers, and their parents. Also, in adolescence, they are more likely to engage in delinquent activities, to get involved in early sexual activity, and to experiment with illegal drugs. In adolescence and young adulthood, they are more likely to have some difficulty forming intimate relationships and establishing independence from their families.

Parent News: Can you elaborate on the effects of divorce on children's academic achievement?

Robert Hughes: Whether you use children's grades, standardized test scores, or dropout rates, children whose parents divorce generally have poorer scores. These results have been found quite consistently throughout a variety of research studies over the past three decades. Importantly, children's actual performance on tests consistently shows this difference, but results based on teacher or parent reports are less likely to show this difference. We believe that both parents and teachers often underestimate the difficulties a child may be having in school or may not recognize the problems.

In some cases, it appears that children's difficulties with school may be caused more by their behavior than their intellectual abilities. The pattern may be somewhat different for boys and girls. Boys are more likely to be aggressive and have problems getting along with their peers and teachers. These problems may lead them to spend less time in school or on their schoolwork. Girls, on the other hand, are more likely to experience depression, which may interfere with their ability to concentrate on schoolwork or to put as much effort into their work. School success has long-term implications for children's success in life, and so it is important to find ways to support children from divorced families.

Parent News: Are there other ways that boys and girls differ in their response to divorce?

Robert Hughes: Early research seemed to indicate that boys might experience more difficulties than girls. Today, there are few consistent findings. These changes may be due to more children being reared in joint custody arrangements and more involvement of fathers in general in the lives of their children after divorce. In the school-age years, boys are more likely to be aggressive and get into fights, while girls are more likely to experience depression, as I mentioned earlier. But by adolescence, both boys and girls are more likely to engage in negative conduct and experience bouts of sadness. Adolescent girls are likely to be involved in early sexual behavior, leading to a greater risk of teenage pregnancy and parenting. This set of events can also have dramatic effects on their completion of school and their ability to enter the workforce and earn a good living. Adolescent boys are likely to spend more time with deviant peers and engage in delinquent behavior, including substance abuse. Like the young women, adolescent boys are likely to engage in early sexual behavior and become teen parents.

On the positive side, there are some girls who emerge out of the divorced, mother-headed households as exceptionally resilient young women. It seems that some young women thrive on the increased responsibilities and challenges that they face in these families, and they develop warm and deeply affectionate ties with their mothers. Similar findings do not occur for boys.

Parent News: What kinds of behavior changes can parents, teachers, and caregivers expect to see during the time around a separation or divorce?

Robert Hughes: Parents need to remember that divorce is stressful for their children, just as it is for the parents. In the short-term - perhaps for several months or even a couple of years - children may act in ways that are irritating and sometimes disruptive. This behavior is understandable in view of the changes taking place.

Parent News: How do behavior changes vary with the age of the child?

Robert Hughes: Each child will react somewhat differently to divorce or separation. Let me tell you about some of the more common behavior responses.

Very little is known about the effects of divorce on children younger than 2 years of age. When the bonds between parent and child are severely disrupted, there may be a problem. However, very young children do not necessarily suffer just because a divorce has occurred. Both parents can stay actively involved in child rearing, or one parent can maintain a strong, healthy relationship with the child.

Children from 3 to 5 years of age who go through divorce tend to be fearful and resort to immature or aggressive behavior. They might return to security blankets or old toys. Some may have lapses in toilet training. These types of behavior rarely last for more than a few weeks. Most children are confused about what is happening or about why mom or dad has left. Children often deny that anything has changed.

Preschoolers may also become less imaginative and cooperative in their play. Children may spend more time playing by themselves than with friends. They also may show more anxiety, depression, anger, and apathy in their play and in their interactions with both children and adults. Socially, preschoolers tend to spend more time seeking attention and the nearness of adults. At the same time, they may resist adult suggestions and commands. Some children become much more aggressive.

On the positive side, preschool children also try to understand the situation. They attempt to bring some order to their world by trying to explain to themselves what is happening and by trying to be well behaved. Though it takes some time, most children gradually understand the situation and adjust to it. In the short term, there do not seem to be any effects on the academic achievement of children. They are likely to do just as well in school as they did before the divorce.

Children 6 to 8 years old have some understanding of what the divorce means. With their better sense of what is taking place, these children are able to deal with what is happening. Many young school-age children experience deep grief over the breakup of the family. Some children are fearful and yearn for the absent parent.

If the mother has custody, boys tend to behave aggressively toward her. Many children feel conflicts in loyalty to one parent or the other, even if the parents made no effort to make the child take sides. [This may be particularly problematic if I child has been diagnosed with a disorder such as ADHD or ODD.]

Older school-age children - ages 9 to 12 - try to understand the divorce and keep their behavior and emotions under control. While they may have feelings of loss, embarrassment, and resentment, these children actively involve themselves in play and activities to help manage these feelings. They may make up games and act out make-believe dramas concerning their parents' divorce. These activities seem to help the child cope with the situation. Anger is perhaps the most intense emotion felt by this group of children. This anger may be aimed at one parent or at both parents. These children may also be more easily drawn into choosing one parent over the other. Children who become drawn into struggles between the parents tend to have more difficulties.

While adolescents understand the divorce situation better than younger children do, they too experience some difficulties adjusting. Many teens feel that they are being pushed into adulthood with little time for a transition from childhood. They may feel a loss of support in handling emerging sexual and aggressive feelings. In some cases, adolescents may even feel that they are in competition with their parents when they see them going on dates and becoming romantically involved. Sometimes, teens have grave doubts about their own ability to get married or stay married.

Many adolescents seem to mature more quickly following a divorce. They take on increased responsibilities in the home, show an increased appreciation of money, and gain insight into their own relationships with others. On the other hand, adolescents may be drawn into the role of taking care of the parent and fail to develop relationships with peers.

Parent News: Are there any particular signs that teachers or caregivers should be aware of that signal a child is having difficulty?

Robert Hughes: The signs and symptoms in children when they are going through their parents' divorce are similar to the reactions we see to other stressful events. The most important sign is any significant change in a child's usual pattern of behavior. Some children will react by being easily angered, and others will react by withdrawing from the usual peer activities.

Let me mention some of the common reactions teachers or caregivers may see in children experiencing divorce. Some of these are more likely to occur in younger children, and some are more likely in older children. Young children are more likely to show regressive behaviors such as thumb sucking, increased whining, difficulty making transitions, and increased need to be with a teacher or other caregiver. Older children are more likely to be disobedient, to talk back, and to be destructive. All children are likely to have some new fears about where their parents are or if they will see parents again. Many of these children will have trouble sleeping; be unusually quiet or withdrawn; complain about headaches, stomachaches, and other symptoms of illness; and be distractible and restless. There also may be significant declines in school performance, tardiness, absences, and difficulties getting along with peers. Few children will show all of these signs, but almost all children will show some of these symptoms, especially when there are significant events at home such as a parent moving out, an appearance in court, and general disruptions in the usual home routine.

Parent News: Can we predict which children will have problems?

Robert Hughes: Not very well. We have some good ideas, but we are still unable to accurately predict which children are most vulnerable. Here are some things to consider. Children who are intelligent, socially mature, and responsible are more likely to adapt well to their parents' divorce. Children with a sense of humor and who get along easily with others are likely to get more support from other adults around them. Children who are difficult to manage and who engage in negative interactions with their parents and other caregivers are likely to have more difficulties adjusting at least in part because others are less likely to offer them support.

Parent News: In addition to age and gender, what other factors influence how well a child copes with divorce?

Robert Hughes: There are many influencing factors. Two others include the amount of conflict between parents and the support available from friends and family.

For More Information

Amato, Paul R., & Keith, Bruce. (1991). Parental divorce and the well-being of children: A metaanalysis. Psychological Bulletin, 110(1), 26-46.

Clarke, S. C. (1995, July 14). Advanced report of final marriage statistics: 1989 and 1990. Monthly Vital Statistics Report, 43(12) Supplement. [1999, June 7].

Hetherington, E. Mavis; Bridges, Margaret; & Insabella, Glendessa M. (1998). What matters? What does not? Five perspectives on the association between marital transitions and children's adjustment. American Psychologist, 53(2), 167-184.

Jeynes, William H. (1998). Does divorce or remarriage have the greater negative impact on the academic achievement of children? Journal of Divorce and Remarriage, 29(1-2), 79-100.

Simons, Ronald L. (1996). Understanding differences between divorced and intact families: Stress, interaction, and child outcome. Thousand Oaks, CA: Sage.

Source: Patten, Peggy. (1999). Divorce and Children Part I: An Interview with Robert Hughes, Jr., PhD. ParentNews.

Page last modified or reviewed by athealth.com on February 3, 2014

A Lack of Assertiveness Can Erode Confidence

Panic attacks in and of themselves are powerful agents for eroding confidence. Suddenly, you feel unable to do all sorts of things you used to do, all sorts of things "normal" people do. On top of that, you feel as though you've lost control of your own body, something so basic to your sense of self that you probably never even gave it a second thought before the attacks hit.

Panic sufferers often describe themselves as "people-pleasers" who find it extremely painful to risk others' dislike or disapproval. They may agree to others' requests, suppress their own opinions, and put the needs of others before their own - sometimes to the point that they almost lose touch with their own wishes and feelings. As one woman put it, "I'll turn myself inside out for you if it will get you to say just one nice thing about me."

There are many reasons why people find it difficult to assert themselves. One important reason relates to fears of loss: you may feel you'll put a relationship at risk if you assert yourself too forcefully. Or you may lack the confidence and self-esteem to express your own wishes, perhaps seeing them as unimportant.

Maybe you're so tender-hearted that you can't bear to refuse anyone anything. Or you may have become so accustomed to the role of "giver" in your family of origin that it scarcely occurs to you to refuse.

Many panic sufferers describe themselves as perfectionists who feel it's a sign of "laziness" or "weakness" or "selfishness" to refuse another's request. And still others hold strong religious beliefs about the importance of giving that makes it hard to know where to draw the line. In short, for any number of reasons, you feel obligated to give and give and give some more - even when you feel there's nothing left, even if it leads to resentment inside.

In addition to losing confidence as a result of panic disorder, many panic sufferers say they struggled with feelings of inadequacy before their attacks first began (and sometimes with a need to rely too much on others as a result). If you're someone who's battled with a lack of confidence in the past, it's worth spending a few minutes to consider the sources of those feelings, so you can fight back more effectively.

Adapted from Master Your Panic and Take Back Your Life! Twelve Treatment Sessions to Conquer Panic, Anxiety and Agoraphobia (3rd Ed.), by Denise F. Beckfield, Ph.D. Available at online and local bookstores or directly from Impact Publishers, PO Box 6016 , Atascadero , CA 93423-6016, www.bibliotherapy.com or phone 1-800-246-7228.

Page last modified or reviewed by athealth.com on February 3, 2014

Domestic violence, defined as the use or threat of use of physical, emotional, verbal, or sexual abuse with the intent of instilling fear, intimidating, and controlling behavior, is a prominent public health issue in the United States. It is the most frequent cause of serious injury to women-- more than car accidents, muggings, and stranger rapes combined. Because the majority of victims never report these crimes, it is very difficult to estimate how many individuals are effected. It is estimated that only 20% of all rapes and 24% of all assaults of women in the context of an intimate relationship are reported.

In honor of Domestic Violence Awareness Month, look to an important database of health statistics to find research, facts and figures on domestic violence nationally and locally.

Quick Health Data Online, a free database provided by the U.S. Department of Health and Human Services' Office on Women's Health, includes extensive state-by-state health information. Although comprehensive data are limited due to lack of reporting, Quick Health Data Online maintains a variety of indicators that may be useful in understanding domestic violence. The site includes information on:

• Abuse
• Sexual Violence
• Assault
• Murder
• Homicide
• Rape and Intimate Partner Violence
• Physical Abuse during Pregnancy
• Robbery
• Violent Youth Behavior

The system can generate maps as well as charts and tables to present data, such as the percentage of men and women self-reporting that they have been forced to have non-consensual sex. Additional Chart features in the system can present data in horizontal or vertical bar charts, showing trend lines, or in pie charts.

For more information, see: http://www.healthstatus2020.com/owh/

Source: Office of Women's Health
US Department of Health and Human Services (HHS)

Reviewed by athealth on February 6, 2014.

Domestic violence, also called intimate partner violence (IVP), partner abuse, and spousal abuse, is a serious, preventable public health problem that affects millions of Americans. The terms domestic violence or intimate partner violence describe physical, sexual, or psychological harm by a current or former partner or spouse. This type of violence can occur among heterosexual or same-sex couples and does not require sexual intimacy.

Domestic violence can vary in frequency and severity. It often starts with emotional abuse. This behavior can progress to physical or sexual assault, and several types of domestic violence may occur together.

Types of Domestic Violence

There are four main types of intimate partner violence (Saltzman et al. 2002):

• Physical violence is the intentional use of physical force with the potential for causing death, disability, injury, or harm. Physical violence includes, but is not limited to, scratching; pushing; shoving; throwing; grabbing; biting; choking; shaking; slapping; punching; burning; use of a weapon; and use of restraints or one's body, size, or strength against another person.
• Sexual violence is divided into three categories: 1) use of physical force to compel a person to engage in a sexual act against his or her will, whether or not the act is completed; 2) attempted or completed sex act involving a person who is unable to understand the nature or condition of the act, to decline participation, or to communicate unwillingness to engage in the sexual act, e.g., because of illness, disability, or the influence of alcohol or other drugs, or because of intimidation or pressure; and 3) abusive sexual contact.
• Threats of physical or sexual violence use words, gestures, or weapons to communicate the intent to cause death, disability, injury, or physical harm.
• Psychological/emotional violence involves trauma to the victim caused by acts, threats of acts, or coercive tactics. Psychological/emotional abuse can include, but is not limited to, humiliating the victim, controlling what the victim can and cannot do, withholding information from the victim, deliberately doing something to make the victim feel diminished or embarrassed, isolating the victim from friends and family, and denying the victim access to money or other basic resources. It is considered psychological/emotional violence when there has been prior physical or sexual violence or prior threat of physical or sexual violence. In addition, stalking is often included among the types of IPV. Stalking generally refers to "harassing or threatening behavior that an individual engages in repeatedly, 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" (Tjaden & Thoennes 1998).

Domestic Violence Is A Serious Public Health Problem

• Each year, women experience about 4.8 million intimate partner related physical assaults and rapes. Men are the victims of about 2.9 million intimate partner related physical assaults. (Tjaden and Thoennes 2000).
• Intimate partner abuse resulted in 2,340 deaths in 2007. Of these deaths, 70% were females and 30% were males. (Bureau of Justice Statistics 2011).
• The medical care, mental health services, and lost productivity (e.g., time away from work) cost of domestic violence was an estimated $5.8 billion in 1995. Updated to 2003 dollars, that's more than $8.3 billion. (CDC 2003; Max et al. 2004).
• Physical violence by an intimate partner has also been associated with a number of adverse health outcomes (Breiding, Black, and Ryan, 2008). Several health conditions associated with intimate partner violence may be a direct result of the physical violence (for example, bruises, knife wounds, broken bones, back or pelvic pain, headaches). Studies have also demonstrated the impact of intimate partner violence on the endocrine and immune systems through chronic stress or other mechanisms (Crofford, 2007; Leserman and Drossman, 2007) Examples include:
  • Fibromyalgia
  • Irritable bowel syndrome
  • Gynecological disorders
  • Pregnancy difficulties like low birth weight babies and perinatal deaths
  • Sexually transmitted diseases including HIV/AIDS
  • Central nervous system disorders
  • Gastrointestinal disorders
  • Heart or circulatory conditions
• Children may become injured during violent incidents between their parents. A large overlap exists between intimate partner violence and child maltreatment (Appel and Holden 1998).
• Physical violence is typically accompanied by emotional or psychological abuse (Tjaden and Thoennes 2000). IPV-whether sexual, physical, or psychological-can lead to various psychological consequences for victims (Bergen 1996; Coker et al. 2002; Heise and Garcia-Moreno 2002; Roberts, Klein, and Fisher 2003):
  • Depression
  • Antisocial behavior
  • Suicidal behavior in females
  • Anxiety
  • Low self-esteem
  • Inability to trust others, especially in intimate relationships
  • Fear of intimacy
  • Symptoms of post-traumatic stress disorder
  • Emotional detachment
  • Sleep disturbances
  • Flashbacks
  • Replaying assault in the mind
• Women with a history of intimate partner abuse are more likely to display behaviors that present further health risks (e.g., substance abuse, alcoholism, suicide attempts) than women without a history of intimate partner abuse.
• Partner abuse is associated with a variety of negative health behaviors (Heise and Garcia-Moreno 2002; Plichta 2004; Roberts, Auinger, and Klein 2005; Silverman et al. 2001). Studies show that the more severe the violence, the stronger its relationship to negative health behaviors by victims.
  • Engaging in high-risk sexual behavior
  • Unprotected sex
  • Decreased condom use
  • Early sexual initiation
  • Choosing unhealthy sexual partners
  • Multiple sex partners
  • Trading sex for food, money, or other items
  • Using harmful substances
  • Smoking cigarettes
  • Drinking alcohol
  • Drinking alcohol and driving
  • Illicit drug use
  • Unhealthy diet-related behaviors
  • Fasting
  • Vomiting
  • Abusing diet pills
  • Overeating
  • Overuse of health services

Risk Factors for Domestic Violence

Risk factors are associated with a greater likelihood of intimate partner violence victimization or perpetration. They are contributing factors and may or may not be direct causes. Not everyone who is identified as "at risk" becomes involved in violence.

Some risk factors for domestic violence victimization and perpetration are the same. In addition, some risk factors for victimization and perpetration are associated with one another; for example, childhood physical or sexual victimization is a risk factor for future perpetration and victimization.

A combination of individual, relational, community, and societal factors contribute to the risk of becoming a victim or perpetrator of IPV. Understanding these multilevel factors can help identify various opportunities for prevention.

Individual Risk Factors

• Low self-esteem
• Low income
• Low academic achievement
• Young age
• Aggressive or delinquent behavior as a youth
• Heavy alcohol and drug use
• Depression
• Anger and hostility
• Antisocial personality traits
• Borderline personality traits
• Prior history of being physically abusive
• Having few friends and being isolated from other people
• Unemployment
• Emotional dependence and insecurity
• Belief in strict gender roles (e.g., male dominance and aggression in relationships)
• Desire for power and control in relationships
• Perpetrating psychological aggression
• Being a victim of physical or psychological abuse (consistently one of the strongest predictors of perpetration)
• History of experiencing poor parenting as a child
• History of experiencing physical discipline as a child

Relationship Factors

• Marital conflict-fights, tension, and other struggles
• Marital instability-divorces or separations
• Dominance and control of the relationship by one partner over the other
• Economic stress
• Unhealthy family relationships and interactions

Community Factors

• Poverty and associated factors (e.g., overcrowding)
• Low social capital-lack of institutions, relationships, and norms that shape a community's social interactions
• Weak community sanctions against violence (e.g., unwillingness of neighbors to intervene in situations where they witness violence)

Societal Factors

• Traditional gender norms (e.g., women should stay at home, not enter workforce, and be submissive; men support the family and make the decisions)

Domestic Violence Prevention

The goal is to stop domestic violence before it begins. There is a lot to learn about how to prevent abuse between intimate partners. We do know that strategies that promote healthy behaviors in relationships are important. Programs that teach young people skills for dating can prevent violence. These programs can stop violence in dating relationships before it occurs.

We know less about how to prevent intimate partner abuse in adults. However, some programs that teach healthy relationship skills seem to help stop violence before it ever starts.

References

Appel AE, Holden GW. 1998 The co-occurrence of spouse and physical child abuse: a review and appraisal. J Fam Psychol 12:578-599.

Bergen RK. 1996. Wife rape: understanding the response of survivors and service providers. Thousand Oaks (CA): Sage.

Breiding MJ, Black MC, Ryan GW. 2008. Chronic disease and health risk behaviors associated with intimate partner violence - 18 U.S. states/territories, 2005. Ann Epidemiol 18:538-544.

Centers for Disease Control and Prevention (CDC). Costs of intimate partner violence against women in the United States. Atlanta (GA): CDC, National Center for Injury Prevention and Control; 2003. [cited 2006 May 22]. Available from: URL: www.cdc.gov/ncipc/pub-res/ipv_cost/ipv.htm.

Coker AL, Davis KE, Arias I, Desai S, Sanderson M, Brandt HM, et al. 2002. Physical and mental health effects of intimate partner violence for men and women. Am J Prev Med 23(4):260-268.

Crofford LJ. Violence, stress, and somatic syndromes. 2007. Trauma Violence Abuse 8:299-313.

Department of Justice, Bureau of Justice Statistics. Intimate partner violence [online]. [cited 2011 Jan 07]. Available from URL: http://bjs.ojp.usdoj.gov/index.cfm?ty=tp&tid=971#summary.

Heise L, Garcia-Moreno C. 2002. Violence by intimate partners. In: Krug E, Dahlberg LL, Mercy JA, et al., editors. World report on violence and health. Geneva (Switzerland): World Health Organization. p. 87-121.

Leserman J, Drossman DA. 2007. Relationship of abuse history to functional gastrointestinal disorders and symptoms. Trauma Violence Abuse 8:331-343.

Max W, Rice DP, Finkelstein E, Bardwell RA, Leadbetter S. The economic toll of intimate partner violence against women in the United States. Violence and Victims 2004;19(3):259-72.

Plichta SB. 2004. Intimate partner violence and physical health consequences: policy and practice implications. J Interpers Violence 19(11):1296-1323.

Roberts TA, Auinger P, Klein JD. 2005. Intimate partner abuse and the reproductive health of sexually active female adolescents. J Adolesc Health 36(5):380-385.

Roberts TA, Klein JD, Fisher S. 2003. Longitudinal effect of intimate partner abuse on high-risk behavior among adolescents. Arch Pediatr Adolesc Med 157(9):875-981.

Saltzman LE, Fanslow JL, McMahon PM, Shelley GA. Intimate partner violence surveillance: uniform definitions and recommended data elements, version 1.0. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2002. Available from: http://www.cdc.gov/ncipc/pub-res/ipv_surveillance/intimate.htm

Silverman JG, Raj A, Mucci L, Hathaway J. 2001. Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual risk behavior, pregnancy, and suicidality. JAMA 286(5):572-579

Tjaden P, Thoennes N. Stalking in America: Findings from the National Violence Against Women Survey. Washington (DC): Department of Justice (US); 1998. Publication No. NCJ 169592. Available from: http://www.ncjrs.gov/pdffiles/169592.pdf

Tjaden P, Thoennes N. Extent, nature, and consequences of intimate partner violence: findings from the National Violence Against Women Survey. Washington (DC): Department of Justice (US); 2000. Publication No. NCJ 181867. Available from: URL: www.ojp.usdoj.gov/nij/pubs-sum/181867.htm.

Adapted from
Understanding Intimate Partner Violence
CDC Fact Sheet 2011
http://www.cdc.gov/violenceprevention/pdf/IPV_factsheet-a.pdf

Intimate Partner Violence
Centers for Disease Control and Prevention
http://www.cdc.gov/ViolencePrevention/intimatepartnerviolence/definitions.html

Page last updated: September 20, 2010

Terms You Need to Know

Dementia is a medical condition that interferes with the way the brain works. Symptoms include anxiety, paranoia, personality changes, lack of initiative, and difficulty acquiring new skills. Besides Alzheimer's disease, some other types or causes of dementia include alcoholic dementia, depression, delirium, HIV/AIDS-related dementia, Huntington's disease (a disorder of the nervous system), inflammatory disease (for example, syphilis), vascular dementia (blood vessel disease in the brain), tumors, and Parkinson's disease.

Alzheimer's disease is the most common form of dementia. It proceeds in stages over months or years and gradually destroys memory, reason, judgment, language, and eventually the ability to carry out even simple tasks.

Delirium is a state of temporary but acute mental confusion that comes on suddenly. Symptoms may include anxiety, disorientation, tremors, hallucinations, delusions, and incoherence. Delirium can occur in older persons who have short-term illnesses, heart or lung disease, long-term infections, poor nutrition, or hormone disorders. Alcohol or drugs (including medications) also may cause confusion.

Delirium may be life-threatening and requires immediate medical attention.

Depression can occur in older persons, especially those with physical problems. Symptoms include sadness, inactivity, difficulty thinking and concentrating, and feelings of despair. Depressed persons often have trouble sleeping, changes in appetite, fatigue, and agitation. Depression usually can be treated successfully.

Purpose of this Booklet

This booklet is about Alzheimer's disease and other types of dementia. It presents information for patients, family members, and other caregivers. It talks about the effects Alzheimer's disease can have on you, your family members, and your friends.

The booklet describes the early signs and symptoms of Alzheimer's disease. Sources of medical, social, and financial support are listed in the back of the booklet. This booklet is not about treating Alzheimer's disease.

What Is Alzheimer's Disease?

In Alzheimer's disease and other dementias, problems with memory, judgment, and thought processes make it hard for a person to work and take part in day-to-day family and social life. Changes in mood and personality also may occur. These changes can result in loss of self-control and other problems.

Some 2 to 4 million persons have dementia associated with aging. Of these individuals, as many as two-thirds have Alzheimer's disease.

Although there is no cure for Alzheimer's disease at this time, it may be possible to relieve some of the symptoms, such as wandering and incontinence.

The earlier the diagnosis, the more likely your symptoms will respond to treatment. Talk to your doctor as soon as possible if you think you or a family member may have signs of Alzheimer's disease.

Research is under way to find better ways to treat Alzheimer's disease. Ask your doctor if there are any new developments that might help you.

Who Is Affected?

The chances of getting Alzheimer's disease increase with age. It usually occurs after age 65. Most people are not affected even at advanced ages. There are only two definite factors that increase the risk for Alzheimer's disease: a family history of dementia and Down syndrome.

Family History of Dementia

Some forms of Alzheimer's disease are inherited. If Alzheimer's disease has occurred in your family members, other members are more likely to develop it. Discuss any family history of dementia with your family doctor.

Down Syndrome

Persons with Down syndrome have a higher chance of getting Alzheimer's disease. Close relatives of persons with Down syndrome also may be at risk.

What Are the Signs of Alzheimer's Disease?

The classic sign of early Alzheimer's disease is gradual loss of short-term memory. Other signs include:

• Problems finding or speaking the right word.
• Inability to recognize objects.
• Forgetting how to use simple, ordinary things, such as a pencil.
• Forgetting to turn off the stove, close windows, or lock doors.

Mood and personality changes also may occur. Agitation, problems with memory, and poor judgment may cause unusual behavior. These symptoms vary from one person to the next.

Symptoms appear gradually in persons with Alzheimer's disease but may progress more slowly in some persons than in others. In other forms of dementia, symptoms may appear suddenly or may come and go.

If you have some of these signs, this does not mean you have Alzheimer's disease. Anyone can have a lapse of memory or show poor judgment now and then. When such lapses become frequent or dangerous, however, you should tell your doctor about them immediately.

Possible Signs of Alzheimer's Disease

Do you have problems with any of these activities?

• Learning and remembering new information.

  Do you repeat things that you say or do? Forget conversations or appointments? Forget where you put things?

• Handling complex tasks.

  Do you have trouble performing tasks that require many steps such as balancing a checkbook or cooking a meal?

• Reasoning ability.

  Do you have trouble solving everyday problems at work or home, such as knowing what to do if the bathroom is flooded?

• Spatial ability and orientation.

  Do you have trouble driving or finding your way around familiar places?

• Language.

  Do you have trouble finding the words to express what you want to say?

• Behavior.

  Do you have trouble paying attention? Are you more irritable or less trusting than usual?

Remember, everyone has occasional memory lapses. Just because you can't recall where you put the car keys doesn't mean you have Alzheimer's disease.

Consulting the Doctor

Identifying mild cases of Alzheimer's disease can be very difficult. Your doctor will review your health and mental status, both past and present. Changes from your previous, usual mental and physical functioning are especially important.

Persons with Alzheimer's disease may not realize the severity of their condition. Your doctor will probably want to talk with family members or a close friend about their impressions of your condition.

The doctor's first assessment for Alzheimer's disease should include a focused history, a physical examination, a functional status assessment, and a mental status assessment.

Medical and Family History

Questions the doctor may ask in taking your history include: How and when did problems begin? Have the symptoms progressed in steps or worsened steadily? Do they vary from day to day? How long have they lasted?

Your doctor will ask about past and current medical problems and whether other family members have had Alzheimer's disease or another form of dementia.

Education and other cultural factors can make a difference in how you will do on mental ability tests. Language problems (for example, difficulty speaking English) can cause misunderstanding. Be sure to tell the doctor about any language problems that could affect your test results.

It is important to tell the doctor about all the drugs you take and how long you have been taking them. Drug reactions can cause dementia. Bring all medication bottles and pills to the appointment with your doctor.

Do you take any medications? Even over-the-counter drugs, eye drops, and alcohol can cause a decline in mental ability. Tell your doctor about all the drugs you take. Ask if the drugs are safe when taken together.

Physical Examination

A physical examination can determine whether medical problems may be causing symptoms of dementia. This is important because prompt treatment may relieve some symptoms.

Functional Status Assessment

The doctor may ask you questions about your ability to live alone. Sometimes, a family member or close friend may be asked how well you can do activities like these:

• Write checks, pay bills, or balance a checkbook.
• Shop alone for clothing, food, and household needs.
• Play a game of skill or work on a hobby.
• Heat water, make coffee, and turn off the stove.
• Pay attention to, understand, and discuss a TV show, book, or magazine.
• Remember appointments, family occasions, holidays, and medications.
• Travel out of the neighborhood, drive, or use public transportation.

Sometimes a family member or friend is not available to answer such questions. Then, the doctor may ask you to perform a series of tasks ("performance testing").

Mental Status Assessment

Several other tests may be used to assess your mental status. These tests usually have only a few simple questions. They test mental functioning, including orientation, attention, memory, and language skills. Age, educational level, and cultural influences may affect how you perform on mental status tests. Your doctor will consider these factors in interpreting test results.

Alzheimer's disease affects two major types of abilities:

• The ability to carry out everyday activities such as bathing, dressing, using the toilet, eating, and walking.
• The ability to perform more complex tasks such as using the telephone, managing finances, driving a car, planning meals, and working in a job. When a person has Alzheimer's disease, problems with complex tasks appear first and over time progress to more simple activities.

Treatable Causes of Dementia

Sometimes the physical examination reveals a condition that can be treated. Symptoms may respond to early treatment when they are caused by:

• Medication (including over-the- counter drugs).
• Alcohol.
• Delirium.
• Depression.
• Tumors.
• Problems with the heart, lungs, or blood vessels.
• Metabolic disorders (such as thyroid problems).
• Head injury.
• Infection.
• Vision or hearing problems.

Drug reactions are the most common cause of treatable symptoms. Older persons may have reactions when they take certain medications. Some medications should not be taken together. Sometimes, adjusting the dose can improve symptoms.

Delirium and depression may be mistaken for or occur with Alzheimer's disease. These conditions require prompt treatment. See the inside front cover of this booklet for more information on delirium and depression.

Special Tests

Gathering as much information as possible will help your doctor diagnose early Alzheimer's disease while the condition is mild. You may be referred to other specialists for further testing.

Some special tests can show a person's mental strengths and weaknesses and detect differences between mild, moderate, and severe impairment. Tests also can tell the difference between changes due to normal aging and those caused by Alzheimer's disease.

If you go to a special doctor for these tests, he or she should return all test results to your regular family doctor. The results will help your doctor track the progress of your condition, prescribe treatment, and monitor treatment effects.

Getting the Right Care

When the diagnosis is Alzheimer's disease, you and your family members have serious issues to consider. Talk with your doctor about what to expect in the near future and later on, as your condition progresses. Getting help early will help ensure that you get the care that is best for you.

When tests do not indicate Alzheimer's disease, but your symptoms continue or worsen, check back with your doctor. More tests may be needed. If you still have concerns, even though your doctor says you do not have Alzheimer's disease, you may want to get a second opinion.

Whatever the diagnosis, followup is important.

Report any changes in your symptoms. Ask the doctor what followup is right for you. Your doctor should keep the results of the first round of tests for later use. After treatment of other health problems, new tests may show a change in your condition.

Recognizing Alzheimer's disease in its early stages, when treatment may relieve mild symptoms, gives you time to adjust. During this time, you and your family can make financial, legal, and medical plans for the future.

Coordinating Care

Your health care team may include your family doctor and medical specialists such as psychiatrists or neurologists, psychologists, therapists, nurses, social workers, and counselors. They can work together to help you understand your condition, suggest memory aids, and tell you and your family about ways you can stay independent as long as possible.

Talk with your doctors about activities that could be dangerous for you or others, such as driving or cooking. Explore different ways to do things.

Telling Family and Friends

Ask your doctor for help in telling people who need to know that you have Alzheimer's disease &emdash; members of your family, friends, and coworkers, for example.

Alzheimer's disease is stressful for you and your family. You and your caregiver will need support from others. Working together eases the stress on everyone.

Where To Get Help?

Learning that you have Alzheimer's disease can be very hard to deal with. It is important to share your feelings with family and friends.

Many kinds of help are available for persons with Alzheimer's disease, their families, and caregivers. Turn to the back of this booklet for a list of resources for patients and families. These resources include:

• Support groups.
  Sometimes it helps to talk things over with other people and families who are coping with Alzheimer's disease. Families and friends of people with Alzheimer's disease have formed support groups. The Alzheimer's Association has active groups across the country. Many hospitals also sponsor education programs and support groups to help patients and families.
• Financial and medical planning.
  Time to plan can be a major benefit of identifying Alzheimer's disease early. You and your family will need to decide where you will live and who will provide help and care when you need them.
• Legal matters.
  It is also important to think about certain legal matters. An attorney can give you legal advice and help you and your family make plans for the future. A special document called an advance directive lets others know what you would like them to do if you become unable to think clearly or speak for yourself.

Other Booklets Are Available

The information in this booklet is based on Recognition and Initial Assessment of Alzheimer's Disease and Related Dementias: Clinical Practice Guideline No. 19. A multidisciplinary panel of physicians, psychiatrists, psychologists, neurologists, nurses, a geriatrician, a social worker, and two consumer representatives developed the guideline. The Agency for Health Care Policy and Research (AHCPR), an agency of the U.S. Department of Health and Human Services, supported its development. Other AHCPR guidelines may be helpful to families affected by Alzheimer's disease. They include the following:

• Depression Is a Treatable Illness: Patient Guide discusses major depressive disorder, which usually can be treated successfully with the help of a health professional. (AHCPR Publication No. 93-0053)
• Recovering After a Stroke: Patient and Family Guide tells how to help a person who has had a stroke achieve the best possible recovery. (AHCPR Publication No. 95-0664)
• Understanding Urinary Incontinence in Adults: Patient Guide describes why people lose urine when they don't want to and what can be done about it. (AHCPR Publication No. 96-0684)
• Preventing Pressure Ulcers: Patient Guide discusses symptoms and causes of bed sores and ways to prevent them. (AHCPR Publication No. 92-0048)
• Treating Pressure Sores: Consumer Guide describes basic steps of care for bed sores. (AHCPR Publication No. 95-0654)

For more information on these or other guidelines, or to receive more copies of this booklet, call toll-free: 800-358-9295. Or write to:Agency for Health Care Policy and Research, Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907

Source: Agency for Healthcare Research and Quality

AHCPR Publication No. 96-0704

Page last modified or reviewed by athealth.com on February 4, 2014

If you have a job and other responsibilities (like taking care of a family), you might feel like:

• There is too much to be done.
• You don't ever have enough time.
• Your life is stressful.

Ways to avoid these feelings that are covered in this fact sheet include:

• Organizing your time,
• Budgeting your money, and
• Getting along with family and friends.

Organize Your Time

Completing tasks

• Decide what is really important in your life. List the five most important parts of your life.

For example, you might list: children, home, work, friends, and self.

• Make taking care of yourself a priority. You will be better able to take care of your other responsibilities if you first take care of your needs, such as: eating well, getting enough rest, and taking time for yourself.
• Decide what really needs to be done each day. Say "No" to activities that don't fit in with the most important parts of your life.
  

  For example, if "children" are on your list, but "shopping" is not, then you might choose to help your child with homework instead of going shopping one night.

• Make "to do" lists every day. Put the most important things at the top of the list. Start with the "musts" (things that have to be done), then list your "wants" (things you'd like to do, but that aren't necessary).
• Accept that you can't do everything. Try to do the most important things, and don't worry or feel guilty about not doing everything on your list. Be sure to tell people who expect you to do something if you decide not to do it.
• Pick the best times to do chores. Everyone has natural times of the day when they feel most energetic. It could be morning, evening, or any other time. Do really hard tasks during the times when you have the most energy, and do easier tasks at other times.
• Find a calm time to do chores. This might be early in the morning, before your children wake up.
• Break down big jobs into smaller parts. Instead of doing everything all at once, do one small piece at a time.
  

  For example, instead of cleaning your whole house at once, you could do one room each evening or early morning.

• Try to think about just one thing at a time.
• Do what you can, a little at a time. In order to get more important things done, you might have to let other things be less than perfect. That's okay!
• Even though some chores need to be done, they could be done less often - maybe once a month rather than once a week.
• Let others do some tasks. Most school-aged children can be taught to make their own lunches and snacks, get their clothes and backpacks ready the night before school, wash dishes, pick up or put things away, and make their beds. If you take the time to teach them these things, it will save you much more time later!
• Divide chores among family members. Think about what your children are able to do and what they are good at before deciding on their chores. Remember, it's okay if the chore is not done perfectly; the important thing is that it gets done! It's a learning process!
• Ask for help from - or trade chores with - neighbors, relatives, or friends.
  

  For example, you could help your neighbor with something you are good at (such as sewing), and your neighbor could do you a favor in return (like getting your children off the school bus).

  Planning and Scheduling

  • Put up a family calendar and message board in your home. Each family member can write down activities or things that need to be done on the family calendar, as soon as they know about it. You can plan around these activities.
  • Put notes, reminders, and messages for family members in one central place, like on your message board. Help everyone get in the habit of checking it often. Put the family calendar and message board in a place where everyone will see it, such as in the kitchen or near the telephone.
  • List emergency phone numbers and other numbers that are used often on the message board.
  • Make a plan for emergency situations.
    

    For example, create a plan for who will take care of your child while you work if your child is sick, so you won't have to arrange child care at the last minute. Consider who can take the child to the place for sick-child care as well.

  • Avoid rushing to get ready for work. Set your alarm clock early enough so that you won't have to rush. Decide on work clothes ahead of time, make sure they are clean, and lay them out.
  • Keep the things you need for work in one place.
  • Plan on having a happy morning with your children. Some children are more active in the morning and some are still half asleep! A smooth morning can set the pace for your day and theirs.
  • Try to do several errands in the same trip, to save time and money. You may want to buy more groceries during a trip to the grocery store, if you can, so you won't have to make as many trips. Big packages of food (in bulk) sometimes cost less per serving, last longer, and save you time.
  • Plan the errands you will run and make a shopping list of what you will buy before you leave the house.

  Budgeting
  
  You may earn more money when you start a new job, but you may also have to pay for new things.

  For example, you might need to spend money on: Transportation to get to work, (such as gas for a car or bus fare) Child care, and New clothes to wear for work.

  These new expenses may be very hard to deal with at first. But if you are ready for them, you can keep yourself from feeling too stressed about how to pay your bills.

  • Be prepared (before you start work). Make a list of all the new things you will have to pay for when you start working. Think about whether they really have to be "new" and where you can get the best buy.
  • Think about what you spend money on now. What you could cut back on in order to handle new work expenses?
  • Create a budget (a plan for how to spend your money). If you need it, get help in learning how to budget. Many community agencies can help, such as the Cooperative Extension Service.

Basic Steps to Budgeting

• Figure out about how much income you expect to have in the next month. Ask your employer what your take home pay will be.
• Create a spending plan, based on everything you think you will need to pay for in a month. Decide how much you expect to spend on different areas, such as food, clothing, rent or housing, electric or gas bills, transportation, child care, medical care, and savings. Make sure the total spending isn't more than your total income.
• Try to follow your spending plan for a month, and keep track of how much you really spend in the different areas. You can do this by writing down everything you spend in a notebook, or by keeping all your receipts in a special place (a box, envelope or drawer).
• After a month, compare your actual income and expenses to your spending plan.
  • Did you follow your spending plan?
  • Did you spend more money than the income you received?
  • Do you need to change your spending plan, the way you shop, or both?

  After a few months of working and trying out different spending plans, you will probably be able to make a spending plan that helps you spend less and save more.

  Relationships with Family and Friends

  Having positive relationships with your family and friends can help make your transition into work much easier. Here are a few things to keep in mind.

  • Think about who can give you personal support. Expand this support group. Get to know your neighbors, and keep strong ties with friends and relatives. It's important to have at least one person you can talk to about your concerns, decisions, or when you are just having a bad day.

  If there is no one available for you to talk to, look in your community for people who give counseling (in places like churches or mental health agencies) and take advantage of it. You'd be surprised how much easier it is to handle a problem when you tell someone about it.

  • Expect an adjustment period for your family and friends. Starting work not only changes your life, it affects the people around you, too! Because you may have a different schedule, new responsibilities, and less time to be with the people close to you, be prepared for them to have a difficult time at first - especially your children!

  It may take a little time for your family and friends to adjust, so try to be patient. Soon they should become used to your new lifestyle.

  • Work on getting along with family members. Be open and honest when talking to other family members. Tell each other exactly how you feel.

  Listen carefully when others are talking to you; give them your full attention. Make sure you know what they mean by asking them questions or repeating what they said. For example: "Are you saying that...?" or "Do you mean....?"

  If a family member does something that upsets you, tell him or her how that behavior made you feel, instead of insulting the person.

  For example: If your teenager comes home very late, you can say, "It scares me when you come home so late, because I get worried that something happened to you," instead of saying, "You have no sense of time; what's wrong with you?" (When things are calm, talk to them about what you expect next time!)

• Have family meetings. Schedule a regular time for the family to sit down and talk about everyone's concerns and feelings about how things are going at home. You might want to have a meeting every week. Allow each person to share his or her problems and ideas for solutions.

• A scheduled time to talk together helps you deal with any problems before they cause a lot of stress for the family. Family members will also be happier when they feel like their concerns are being listened to and considered.
  • Give children a few minutes of attention after work. Even though you will probably feel exhausted when you get home from work, try to spend a short time with your children right when you get home. For older children, it may only need to be a quick hug and a few minutes of talking or playing games. This will help your children to feel more safe and content, and it may keep them from getting irritable and upset that evening. (It may save you more time later!)

  Summary

  Although these actions will not solve all your work and family balance issues, they may help some in your transition. By organizing your time, developing a budget, and planning family time, you are on your way to great success!

  References

  Prather, C. G. (1996). Time Effectiveness: Prioritizing Your Time, GH-6653. University of Missouri-Columbia Extension.

  Wessel, J. A. (1994). Ways to Improve Time Use, HYG-5009-94. Ohio State University Extension.

  Lloyd, J. H. (1996). Money Matters, HE-348-4. Single Parenting Series, North Carolina Cooperative Extension Service.

  Managing Your Money -- Learning for Better Living Series (1993), 91-ESPN-1-5169. Cooperative Extension System.

  Matthews, D. W. (1994). Family Communication During Times of Stress, HE-424. North Carolina Cooperative Extension Service.

  This is part of a Workfront-Homefront series that were developed based on telephone interviews with Work First participants in North Carolina.

  Reprinted with permission from the National Network for Child Care - NNCC. DeBord, K.& R. F. Canu (1997). *Easing transitions: Balancing work & family* in Workfront-Homefront: A series for people making the transition from welfare to work. FCS-479-1. Raleigh, NC: North Carolina State University Cooperative Extension Service.

  National Network for Child Care
  Karen DeBord, PhD, Child Development Specialist, NC State Univ. Ext.
  and Rebekah F. Canu, Graduate Student, Univ. of NC at Greensboro
  March 1998

  Page last modified or reviewed by athealth.com on February 4, 2014

What Are Eating Disorders?

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

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

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

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

Eating Disorders Are Treatable Diseases

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

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

Anorexia Nervosa

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

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

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

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

Other symptoms may develop over time, including:

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

Treating anorexia involves three components:

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

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

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

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

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

Bulimia Nervosa

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

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

Other symptoms include:

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

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

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

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

Binge-Eating Disorder

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

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

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

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

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

FDA Warnings On Antidepressants

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

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

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

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

How Are Men And Boys Affected?

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

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

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

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

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

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

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

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

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

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

References

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

Reviewed by athealth on February 8, 2014.

What are eating disorders?

Eating disorders are abnormal eating behaviors, which include anorexia and bulimia. Anorexia is defined as the refusal to reach or to keep a weight that is considered to be the minimum required for a person's height and age. Bulimia is an eating pattern of repeated occurrences of binge eating followed by attempts to keep from gaining weight.

See Anorexia or Bulimia

What characteristics occur with eating disorders?

The characteristics associated with eating disorders include the following:

• Unhealthy restriction of food
• Weight loss amounting to more than fifteen percent (15%) of a person's usual weight
• Heightened fear associated with weight gain
• Misperception about body thinness, shape, or weight
• Absence of menstrual cycles in females
• Binge eating
• Self-induced vomiting
• Overuse of laxatives
• Inappropriate use of diuretics
• Inappropriate use of enemas
• Prolonged fasting
• Excessive exercise
• Low self-esteem
• Fear of loss of control

Are there genetic factors associated with eating disorders?

Yes, if a person has an eating disorder, it is more likely that a close relative has had an eating disorder, mood disorder, or substance abuse disorder.

Do eating disorders affect males, females, or both?

Females are much more likely to have eating disorders than males. In the United States young women may have a greater tendency to develop eating disorders because American culture encourages females to be thin.

At what age do eating disorders appear?

Eating disorders are usually diagnosed in adolescence or early adulthood. However, it is not unusual for someone who is twenty to thirty (20 - 30) years of age to suffer from an eating disorder.

What is the prevalence of eating disorders seen in our society?

It is estimated that three percent (3%) of the young female population has some form of eating disorder.

How are eating disorders diagnosed?

Individuals with eating problems often attempt to keep this information secret from parents or friends. Therefore, other family members or friends must sometimes bring a young person's abnormal eating behavior to their parents' attention, or they must talk directly with the individual about these issues. The individual can then be encouraged to seek proper professional help.

A mental health professional makes a diagnosis of an eating disorder by taking a careful personal history from the client/patient and other available family members. It is important that the therapist learn the details of that person's life. No laboratory tests are required to make a diagnosis of an eating disorder. However, in addition to the personal history, anorexia is diagnosed by obtaining body weight. A person must lose at least fifteen percent (15%) of her ideal weight in order to be diagnosed with anorexia. A growing child can be anorexic if he/she fails to attain eighty-five percent (85%) of the ideal body weight.

Bulimia is also diagnosed by personal history. There must be a history of binge eating which takes place inside of a two hour period. Following the episode of binge eating, the individual must attempt to prevent weight gain. Behaviors associated with the prevention of weight gain include vomiting, the overuse of laxatives, diuretics or enemas, excessive exercise, and prolonged fasting.

It is very important not to overlook a physical illness that might mimic or contribute to an eating disorder. If there is any question that the individual might have a physical problem, the mental health professional should recommend a complete physical examination by a medical doctor. Laboratory tests might be necessary as a part of the physical workup.

How are eating disorders treated?

The treatment for eating disorders includes individual and/or group psychotherapy. Therapy focuses on education about the harmful effects of starvation, purging behaviors, and excessive exercise. Therapy also aims to improve the individual's self-esteem and acceptance of a healthy body image. The use of medication may be helpful to control symptoms of obsessions, compulsions, anxiety, and depression which are often associated with the eating disorders.

What happens to someone with an eating disorder?

The course of eating disorders varies widely. Some people have only one brief episode of anorexia. Others may struggle with the illness for decades. Many people have mild forms of anorexia or bulimia that never come to the attention of treatment providers. At the other extreme, some individuals with anorexia starve themselves to the point where their lives become threatened, and they need to be hospitalized for acute care. About five percent (5%) of those with anorexia die of complications associated with this illness.

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.
Page last modified or reviewed by athealth.com on May 20, 2012

How Are They Related?

Eating disorders and obesity are usually seen as very different problems but actually share many similarities. In fact, eating disorders, obesity, and other weight-related disorders may overlap as girls move from one problem, such as unhealthy dieting, to another, such as obesity. This information sheet is designed to help parents, other adult caregivers, and school personnel better understand the links between eating disorders and obesity so they can promote healthy attitudes and behaviors related to weight and eating.

How are eating disorders and obesity related?

Eating disorders and obesity are part of a range of weight-related problems.

These problems include anorexia nervosa, bulimia nervosa, anorexic and bulimic behaviors, unhealthy dieting practices, binge eating disorder, and obesity. Adolescent girls may suffer from more than one disorder or may progress from one problem to another at varying degrees of severity. It is important to understand this range of weightrelated problems in order to avoid causing one disorder, such as bulimia, while trying to prevent another, such as obesity.¹

Body dissatisfaction and unhealthy dieting practices are linked to the development of eating disorders, obesity, and other problems.

High numbers of adolescent girls are reporting that they are dissatisfied with their bodies and are trying to lose weight in unhealthy ways, including skipping meals, fasting, and using tobacco. A smaller number of girls are even resorting to more extreme methods such as self-induced vomiting, diet pills, and laxative use.²

These attitudes and behaviors place girls at a greater risk for eating disorders, obesity, poor nutrition, growth impairments, and emotional problems such as depression.³ Research shows, for example, that overweight girls are more concerned about their weight, more dissatisfied with their bodies, and more likely to diet than their normal-weight peers.⁴

Binge eating is common among people with eating disorders and people who are obese.

People with bulimia binge eat and then purge by vomiting, using laxatives, or other means. Binge eating that is not followed by purging may also be considered an eating disorder and can lead to weight gain. More than one-third of obese individuals in weight-loss treatment programs report difficulties with binge eating.⁵ This type of eating behavior contributes to feelings of shame, loneliness, poor self-esteem, and depression.⁶ Conversely, these kinds of feelings can cause binge eating problems.⁷ A person may binge or overeat for emotional reasons, including stress, depression, and anxiety.⁸

Depression, anxiety, and other mood disorders are associated with both eating disorders and obesity.

Adolescents who are depressed may be at an increased risk of becoming obese. One recent study found that depressed adolescents were two times more likely to become obese at the one year follow up than teens who did not suffer from depression.⁹ In addition, many people with eating disorders suffer from clinical depression, anxiety, personality or substance abuse disorders, or in some cases obsessive compulsive disorder.¹⁰ Therefore, a mental health professional may need to be involved in treating an adolescent who is obese or suffers from an eating disorder or other weight-related problem.

The environment may contribute to both eating disorders and obesity.

The mass media, family, and peers may be sending children and adolescents mixed messages about food and weight that encourage disordered eating.¹¹ Today's society idealizes thinness and stigmatizes fatness, yet high-calorie foods are widely available and heavily advertised.¹² At the same time, levels of physical activity are at record lows as television and computers replace more active leisure activities, travel by automobile has replaced walking, and many communities lack space for walking and recreation.¹³

Most teens don't suffer from either anorexia or obesity. They are more likely to engage in disordered eating behaviors such as bingeing, purging, and dieting. These behaviors are associated with serious physical and emotional health problems. We've got to get back to three square meals a day, healthy meal planning, nutritious snacks, and regular physical activity.¹⁴
- Richard Kreipe, MD, Chief, Division of Adolescent Medicine, University of Rochester Medical Center

Health Risks

Eating disorders may lead to

• Stunted growth
• Delayed menstruation
• Damage to vital organs such as the heart and brain
• Nutritional deficiencies, including starvation
• Cardiac arrest
• Emotional problems such as depression and anxiety

Obesity increases the risk for

• High blood pressure
• Stroke
• Cardiovascular disease
• Gallbladder disease
• Diabetes
• Respiratory problems
• Arthritis
• Cancer
• Emotional problems such as depression and anxiety

Definitions

Body image is how you see yourself when you look in the mirror or picture yourself in your mind.

Obesity means having an abnormally high proportion of body fat. A person is considered obese if he or she has a body mass index (BMI) of 30 or greater. BMI is calculated by dividing a person's weight in kilograms by height in meters squared. You can also calculate your BMI by going to an online BMI calculator at www.fns.usda.gov/tnrockyrun/diff.htm.

Overweight refers to an excess of body weight compared to set standards. The excess weight may come from muscle, bone, fat, and/or body water. A person can be overweight without being obese (for example, athletes who have a lot of muscle). However, many people who are overweight are considered obese due to excess fat on their bodies. A person may be considered overweight if he or she has a BMI of 25-29.9.

Anorexia nervosa is self-starvation. People with this disorder eat very little even though they are thin. They have an intense and overpowering fear of body fat and weight gain.

Bulimia nervosa is characterized by cycles of binge eating and purging, either by vomiting or taking laxatives or diuretics (water pills). People with bulimia have a fear of body fat even though their size and weight may be normal.

Binge eating disorder means eating large amounts of food in a short period of time, usually alone, without being able to stop when full. The overeating and bingeing are often accompanied by feeling out of control and followed by feelings of depression, guilt, or disgust.

Disordered eating refers to troublesome eating behaviors, such as restrictive dieting, bingeing, or purging, which occur less frequently or are less severe than those required to meet the full criteria for the diagnosis of an eating disorder.

End Notes

1 Neumark-Sztainer, D. Obesity and Eating Disorder Prevention: An Integrated Approach. Adolescent Medicine, Feb;14(1):159-73 (Review), 2003.

2 Neumark-Sztainer, D., Story, M., Hannan, P.J., et al. Weight-Related Concerns and Behaviors Among Overweight and Non-Overweight Adolescents: Implications for Preventing Weight-Related Disorders. Archives of Pediatrics and Adolescent Medicine, Feb;156(2):171-8, 2002.

3 Neumark-Sztainer, D. Obesity and Eating Disorder Prevention: An Integrated Approach. 2003.

4 Burrows, A., Cooper, M. Possible Risk Factors in the Development of Eating Disorders in Overweight Pre-Adolescent Girls. International Journal of Obesity and Related Metabolic Disorders, Sept;26(9):1268-1273, 2002; Davison, K.K., Markey, C.N., Birch, L.L. Etiology of Body Dissatisfaction and Weight Concerns Among 5-year-old Girls. Appetite, Oct;35(2):143-151, 2000; Vander Wal, J.S., Thelen, M.H. Eating and Body Image Concerns Among Obese and Average-Weight Children. Addictive Behavior, Sep-Oct;25(5):775-778, 2000.

5 Yanovski, S.Z. Binge Eating in Obese Persons. In Fairburn, C.G., Brownell, K.D. (eds), Eating Disorders and Obesity, 2nd ed. New York: Guilford Press, 403-407, 2002.

6 Waller, G. The Psychology of Binge Eating. In Fairburn, C.G., Brownell, K.D. (eds) Eating Disorders and Obesity, 2nd ed. New York: Guilford Press, 98-102, 2002.

7 Fairburn, C., Overcoming Binge Eating. New York: The Guilford Press, 1995, pp. 80-99.

8 Goodman, E, Whitaker, R. A Prospective Study of the Role of Depression in the Development and Persistence of Adolescent Obesity. Pediatrics. 2002 Sep;110(3):497-504. Lumeng JC, Gannon K, Cabral HJ, Frank DA, Zuckerman B. Association between clinically meaningful behavior problems and overweight in children. Pediatrics. 2003 Nov;112(5):1138-45.

9 Goodman, E., Whitaker, R.C. A Prospective Study of the Role of Depression in the Development and Persistence of Adolescent Obesity. Pediatrics. Sep;110(3):497-504, 2002.

10 National Mental Health Association. Teen Eating Disorders. 1997.

11 Irving, L.M., Neumark-Sztainer, D. Integrating the Prevention of Eating Disorders and Obesity: Feasible or Futile. Preventive Medicine, 34:299-309, 2002. Stice, E. Sociocultural Influences on Body Image and Eating Disturbance. In Fairburn, C.G., Brownell, K.D. (eds) Eating Disorders and Obesity, 2nd ed. New York: Guilford Press, 103-107, 2002.

12 Battle, E.K., Brownell, K.D. Confronting a Rising Tide of Eating Disorders and Obesity: Treatment vs. Prevention and Policy. Addictive Behavior, 21:755-65 (Review), 1996.

13 French, S.A, Story, M., Jeffery, R. Environmental Influences on Eating and Physical Activity. Annual Review of Public Health, 22:309-35 (Review), 2001.

14 Kreipe, R. Personal communication. November 9, 2003.

Adapted from Eating Disorders and Obesity Companion Piece
U.S. Department of Health and Human Services Office on Women's Health.

Page last modified or reviewed by athealth.com on February 4, 2014