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Depression is an illness that affects many older people. It generally affects their physical as well as their mental well-being. Fortunately, it is a highly treatable illness. Complete, or at least partial improvement, can be obtained in eighty to ninety percent of cases.

Depression can occur "out of the blue," for no obvious reason, or it can occur as a response to adverse life circumstances, such as the loss of a spouse, the loss of a job, the loss of good health, or the loss of any other significant thing or relationship. Regrettably, the nature of depression is such that affected persons, as a result of being depressed, are actually unlikely to realize that they are depressed, and even more unlikely to seek help for themselves. This is related directly to the nature of the symptoms of depression which we will discuss momentarily. The implication of this fact, however, is that healthy relatives and friends of older people should be on the lookout for signs of depression among their older relatives and friends, so they can assist them to obtain treatment.

The Tell Tale Signs of Depression

Not every depressed person experiences all of the signs of depression. But the presence of a whole cluster of these signs should arouse concern, and should lead to having the person evaluated by a physician or mental health professional. The most common signs of depression are:

• a sad, discouraged, mood
• blue, or empty
• persistent pessimism about the present, the future, and the past
• loss of interest in work, hobbies, social life, and sex
• difficulty in making decisions
• lack of energy, and feeling slowed down
• thoughts of suicide
• restlessness, irritability
• loss of appetite and loss of weight
• disturbed sleep, especially early morning awakening
• depressive, gloomy, or desolate dreams

Treatment of Depression

There are three main forms of treatment for depression: (1) counseling and/or psychotherapy; (2) antidepressant medications; and (3) electroconvulsive therapy or ECT.

Psychotherapy can be used when the individual who is depressed is still able to interact with a counselor or therapist, and when a specific loss can be identified about which the depressed person can talk with a therapist.

Antidepressant medication can be used when the depression comes on "out of the blue," or when the individual can no longer respond to verbal support, explanations, or other psychological interactions.

ECT is used only rarely, in the most severe cases, when the patient does not respond to these other forms of therapy, or when medications cannot be used due to specific medical reasons.

A variety of mental health professionals, including physicians, psychologists, or social workers, can provide counseling or psychotherapy. Antidepressant medication can only be prescribed by a physician, who may be a psychiatrist, a family doctor or internist. ECT can generally only be administered in a psychiatric hospital setting.

Response to therapy may take several weeks. Antidepressant medications may have side effects. These can include drowsiness, constipation, blurred vision, dry mouth, and even dizziness. When such side effects occur, they must be reported promptly to the doctor who will determine with the patient whether to continue the medication, reduce the dosage, switch to another medication or stop medication altogether.

As the depressed person begins to feel better, he or she should not stop treatment on their own but do so only on the advice of their doctor. Recent research has shown that people with recurrent depressions should stay on a maintenance dose of antidepressants. Above all, resuming an active life after depression is important in preventing the recurrence of "the mean blues."

Replication of this document is encouraged to provide information on long-term care to older Americans. Source should be noted in all cases.

This ElderAction was developed by the National Eldercare Institute on Long Term Care and Alzheimer's Disease at the Suncoast Gerontology Center, University of South Florida

Source: Administration on Aging

Reviewed by athealth on February 5, 2014.

What is depression?

Everyone occasionally feels blue or sad, but these feelings are usually fleeting and pass within a couple of days. When a woman has a depressive disorder, it interferes with daily life and normal functioning, and causes pain for both the woman with the disorder and those who care about her. Depression is a common but serious illness, and most who have it need treatment to get better.

Depression affects both men and women, but more women than men are likely to be diagnosed with depression in any given year.¹ Efforts to explain this difference are ongoing, as researchers explore certain factors (biological, social, etc.) that are unique to women.

Many women with a depressive illness never seek treatment. But the vast majority, even those with the most severe depression, can get better with treatment.

What are the different forms of depression?

There are several forms of depressive disorders that occur in both women and men. The most common are major depressive disorder and dysthymic disorder. Minor depression is also common.

Major depressive disorder, also called major depression, is characterized by a combination of symptoms that interfere with a person's ability to work, sleep, study, eat, and enjoy once-pleasurable activities. Major depression is disabling and prevents a person from functioning normally. An episode of major depression may occur only once in a person's lifetime, but more often, it recurs throughout a person's life.

Dysthymic disorder, also called dysthymia, is characterized by depressive symptoms that are long-term (e.g., two years or longer) but less severe than those of major depression. Dysthymia may not disable a person, but it prevents one from functioning normally or feeling well. People with dysthymia may also experience one or more episodes of major depression during their lifetimes.

Minor depression may also occur. Symptoms of minor depression are similar to major depression and dysthymia, but they are less severe and/or are usually shorter term.

Some forms of depressive disorder have slightly different characteristics than those described above, or they may develop under unique circumstances. However, not all scientists agree on how to characterize and define these forms of depression. They include the following:

Psychotic depression occurs when a severe depressive illness is accompanied by some form of psychosis, such as a break with reality; seeing, hearing, smelling or feeling things that others can't detect (hallucinations); and having strong beliefs that are false, such as believing you are the president (delusions).

Seasonal affective disorder (SAD) is characterized by a depressive illness during the winter months, when there is less natural sunlight. The depression generally lifts during spring and summer. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not respond to light therapy alone. Antidepressant medication and psychotherapy also can reduce SAD symptoms, either alone or in combination with light therapy.²

Bipolar disorder, also called manic-depressive illness, is not as common as major depression or dysthymia. Bipolar disorder is characterized by cycling mood changes - from extreme highs (e.g., mania) to extreme lows (e.g., depression).

What are the basic signs and symptoms of depression?

Women with depressive illnesses do not all experience the same symptoms. In addition, the severity and frequency of symptoms, and how long they last, will vary depending on the individual and her particular illness. Signs and symptoms of depression include:

• Persistent sad, anxious or "empty" feelings
• Feelings of hopelessness and/or pessimism
• Irritability, restlessness, anxiety
• Feelings of guilt, worthlessness and/or helplessness
• Loss of interest in activities or hobbies once pleasurable, including sex
• Fatigue and decreased energy
• Difficulty concentrating, remembering details and making decisions
• Insomnia, waking up during the night, or excessive sleeping
• Overeating, or appetite loss
• Thoughts of suicide, suicide attempts
• Persistent aches or pains, headaches, cramps or digestive problems that do not ease even with treatment

What causes depression in women?

Scientists are examining many potential causes for and contributing factors to women's increased risk for depression. It is likely that genetic, biological, chemical, hormonal, environmental, psychological, and social factors all intersect to contribute to depression.

Genetics

If a woman has a family history of depression, she may be more at risk of developing the illness. However, this is not a hard and fast rule. Depression can occur in women without family histories of depression, and women from families with a history of depression may not develop depression themselves. Genetics research indicates that the risk for developing depression likely involves the combination of multiple genes with environmental or other factors.³

Chemicals and hormones

Brain chemistry appears to be a significant factor in depressive disorders. Modern brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people suffering from depression look different than those of people without depression. The parts of the brain responsible for regulating mood, thinking, sleep, appetite and behavior don't appear to be functioning normally. In addition, important neurotransmitters-chemicals that brain cells use to communicate-appear to be out of balance. But these images do not reveal WHY the depression has occurred.

Scientists are also studying the influence of female hormones, which change throughout life. Researchers have shown that hormones directly affect the brain chemistry that controls emotions and mood. Specific times during a woman's life are of particular interest, including puberty; the times before menstrual periods; before, during, and just after pregnancy (postpartum); and just prior to and during menopause (perimenopause).

Premenstrual dysphoric disorder

Some women may be susceptible to a severe form of premenstrual syndrome called premenstrual dysphoric disorder (PMDD). Women affected by PMDD typically experience depression, anxiety, irritability and mood swings the week before menstruation, in such a way that interferes with their normal functioning. Women with debilitating PMDD do not necessarily have unusual hormone changes, but they do have different responses to these changes.⁴ They may also have a history of other mood disorders and differences in brain chemistry that cause them to be more sensitive to menstruation-related hormone changes. Scientists are exploring how the cyclical rise and fall of estrogen and other hormones may affect the brain chemistry that is associated with depressive illness.^5,6,7

Postpartum depression

Women are particularly vulnerable to depression after giving birth, when hormonal and physical changes and the new responsibility of caring for a newborn can be overwhelming. Many new mothers experience a brief episode of mild mood changes known as the "baby blues," but some will suffer from postpartum depression, a much more serious condition that requires active treatment and emotional support for the new mother. One study found that postpartum women are at an increased risk for several mental disorders, including depression, for several months after childbirth.⁸

Some studies suggest that women who experience postpartum depression often have had prior depressive episodes. Some experience it during their pregnancies, but it often goes undetected. Research suggests that visits to the doctor may be good opportunities for screening for depression both during pregnancy and in the postpartum period.^9,10

Menopause

Hormonal changes increase during the transition between premenopause to menopause. While some women may transition into menopause without any problems with mood, others experience an increased risk for depression. This seems to occur even among women without a history of depression.^11,12 However, depression becomes less common for women during the post-menopause period.¹³

Stress

Stressful life events such as trauma, loss of a loved one, a difficult relationship or any stressful situation-whether welcome or unwelcome-often occur before a depressive episode. Additional work and home responsibilities, caring for children and aging parents, abuse, and poverty also may trigger a depressive episode. Evidence suggests that women respond differently than men to these events, making them more prone to depression. In fact, research indicates that women respond in such a way that prolongs their feelings of stress more so than men, increasing the risk for depression.¹⁴ However, it is unclear why some women faced with enormous challenges develop depression, and some with similar challenges do not.

What illnesses often coexist with depression in women?

Depression often coexists with other illnesses that may precede the depression, follow it, cause it, be a consequence of it, or a combination of these. It is likely that the interplay between depression and other illnesses differs for every person and situation. Regardless, these other coexisting illnesses need to be diagnosed and treated.

Depression often coexists with eating disorders such as anorexia nervosa, bulimia nervosa and others, especially among women. Anxiety disorders, such as post-traumatic stress disorder (PTSD), obsessive-compulsive disorder, panic disorder, social phobia and generalized anxiety disorder, also sometimes accompany depression.^15,16 Women are more prone than men to having a coexisting anxiety disorder.¹⁷ Women suffering from PTSD, which can result after a person endures a terrifying ordeal or event, are especially prone to having depression.

Although more common among men than women, alcohol and substance abuse or dependence may occur at the same time as depression.17,15 Research has indicated that among both sexes, the coexistence of mood disorders and substance abuse is common among the U.S. population.¹⁸

Depression also often coexists with other serious medical illnesses such as heart disease, stroke, cancer, HIV/AIDS, diabetes, Parkinson's disease, thyroid problems and multiple sclerosis, and may even make symptoms of the illness worse.¹⁹ Studies have shown that both women and men who have depression in addition to a serious medical illness tend to have more severe symptoms of both illnesses. They also have more difficulty adapting to their medical condition, and more medical costs than those who do not have coexisting depression. Research has shown that treating the depression along with the coexisting illness will help ease both conditions.²⁰

How does depression affect adolescent girls?

Before adolescence, girls and boys experience depression at about the same frequency.¹³ By adolescence, however, girls become more likely to experience depression than boys.

Research points to several possible reasons for this imbalance. The biological and hormonal changes that occur during puberty likely contribute to the sharp increase in rates of depression among adolescent girls. In addition, research has suggested that girls are more likely than boys to continue feeling bad after experiencing difficult situations or events, suggesting they are more prone to depression.²¹ Another study found that girls tended to doubt themselves, doubt their problem-solving abilities and view their problems as unsolvable more so than boys. The girls with these views were more likely to have depressive symptoms as well. Girls also tended to need a higher degree of approval and success to feel secure than boys.²²

Finally, girls may undergo more hardships, such as poverty, poor education, childhood sexual abuse, and other traumas than boys. One study found that more than 70 percent of depressed girls experienced a difficult or stressful life event prior to a depressive episode, as compared with only 14 percent of boys.²³

How does depression affect older women?

As with other age groups, more older women than older men experience depression, but rates decrease among women after menopause.¹³ Evidence suggests that depression in post-menopausal women generally occurs in women with prior histories of depression. In any case, depression is NOT a normal part of aging.

The death of a spouse or loved one, moving from work into retirement, or dealing with a chronic illness can leave women and men alike feeling sad or distressed. After a period of adjustment, many older women can regain their emotional balance, but others do not and may develop depression. When older women do suffer from depression, it may be overlooked because older adults may be less willing to discuss feelings of sadness or grief, or they may have less obvious symptoms of depression. As a result, their doctors may be less likely to suspect or spot it.

For older adults who experience depression for the first time later in life, other factors, such as changes in the brain or body, may be at play. For example, older adults may suffer from restricted blood flow, a condition called ischemia. Over time, blood vessels become less flexible. They may harden and prevent blood from flowing normally to the body's organs, including the brain. If this occurs, an older adult with no family or personal history of depression may develop what some doctors call "vascular depression." Those with vascular depression also may be at risk for a coexisting cardiovascular illness, such as heart disease or a stroke.²⁴

How is depression diagnosed and treated?

Depressive illnesses, even the most severe cases, are highly treatable disorders. As with many illnesses, the earlier that treatment can begin, the more effective it is and the greater the likelihood that a recurrence of the depression can be prevented.

The first step to getting appropriate treatment is to visit a doctor. Certain medications, and some medical conditions such as viruses or a thyroid disorder, can cause the same symptoms as depression. In addition, it is important to rule out depression that is associated with another mental illness called bipolar disorder. A doctor can rule out these possibilities by conducting a physical examination, interview, and/or lab tests, depending on the medical condition. If a medical condition and bipolar disorder can be ruled out, the physician should conduct a psychological evaluation or refer the person to a mental health professional.

The doctor or mental health professional will conduct a complete diagnostic evaluation. He or she should get a complete history of symptoms, including when they started, how long they have lasted, their severity, whether they have occurred before, and if so, how they were treated. He or she should also ask if there is a family history of depression. In addition, he or she should ask if the person is using alcohol or drugs, and whether the person is thinking about death or suicide.

Once diagnosed, a person with depression can be treated with a number of methods. The most common treatment methods are medication and psychotherapy.

Medication

Antidepressants work to normalize naturally occurring brain chemicals called neurotransmitters, notably serotonin and norepinephrine. Other antidepressants work on the neurotransmitter dopamine. Scientists studying depression have found that these particular chemicals are involved in regulating mood, but they are unsure of the exact ways in which they work.

The newest and most popular types of antidepressant medications are called selective serotonin reuptake inhibitors (SSRIs) and include:

• fluoxetine (Prozac)
• citalopram(Celexa)
• sertraline (Zoloft)
• paroxetine (Paxil)
• escitalopram (Lexapro)
• fluvoxamine (Luvox)

Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include:

• venlafaxine (Effexor)
• duloxetine (Cymbalta)

SSRIs and SNRIs tend to have fewer side effects and are more popular than the older classes of antidepressants, such as tricyclics - named for their chemical structure - and monoamine oxidase inhibitors (MAOIs). However, medications affect everyone differently. There is no one-size-fits-all approach to medication. Therefore, for some people, tricyclics or MAOIs may be the best choice.

People taking MAOIs must adhere to significant food and medicinal restrictions to avoid potentially serious interactions. They must avoid certain foods that contain high levels of the chemical tyramine, which is found in many cheeses, wines and pickles, and some medications including decongestants. Most MAOIs interact with tyramine in such a way that may cause a sharp increase in blood pressure, which may lead to a stroke. A doctor should give a person taking an MAOI a complete list of prohibited foods, medicines and substances.

For all classes of antidepressants, people must take regular doses for at least three to four weeks, sometimes longer, before they are likely to experience a full effect. They should continue taking the medication for an amount of time specified by their doctor, even if they are feeling better, to prevent a relapse of the depression. The decision to stop taking medication should be made by the person and her doctor together, and should be done only under the doctor's supervision. Some medications need to be gradually stopped to give the body time to adjust. Although they are not habit-forming or addictive, abruptly ending an antidepressant can cause withdrawal symptoms or lead to a relapse. Some individuals, such as those with chronic or recurrent depression, may need to stay on the medication indefinitely.

In addition, if one medication does not work, people should be open to trying another. Research funded by NIMH has shown that those who did not get well after taking a first medication often fared better after they switched to a different medication or added another medication to their existing one.^25,26

Sometimes other medications, such as stimulants or antianxiety medications, are used in conjunction with an antidepressant, especially if the person has a coexisting illness. However, neither antianxiety medications nor stimulants are effective against depression when taken alone, and both should be taken only under a doctor's close supervision.

Is it safe to take antidepressant medication during pregnancy?

At one time, doctors assumed that pregnancy was accompanied by a natural feeling of well being, and that depression during pregnancy was rare, or never occurred at all. However, recent studies have shown that women can have depression while pregnant, especially if they have a prior history of the illness. In fact, a majority of women with a history of depression will likely relapse during pregnancy if they stop taking their antidepressant medication either prior to conception or early in the pregnancy, putting both mother and baby at risk.^27,12

However, antidepressant medications do pass across the placental barrier, potentially exposing the developing fetus to the medication. Some research suggests the use of SSRIs during pregnancy is associated with miscarriage and/or birth defects, but other studies do not support this.²⁸ Some studies have indicated that fetuses exposed to SSRIs during the third trimester may be born with "withdrawal" symptoms such as breathing problems, jitteriness, irritability, difficulty feeding, or hypoglycemia. In 2004, the U.S. Food and Drug Administration (FDA) issued a warning against the use of SSRIs in the late third trimester, suggesting that clinicians gradually taper expectant mothers off SSRIs in the third trimester to avoid any ill effects on the baby.²⁹

Although some studies suggest that exposure to SSRIs in pregnancy may have adverse effects on the infant, generally they are mild and short-lived, and no deaths have been reported. On the flip side, women who stop taking their antidepressant medication during pregnancy increase their risk for developing depression again and may put both themselves and their infant at risk.^28,12

In light of these mixed results, women and their doctors need to consider the potential risks and benefits to both mother and fetus of taking an antidepressant during pregnancy, and make decisions based on individual needs and circumstances. In some cases, a woman and her doctor may decide to taper her antidepressant dose during the last month of pregnancy to minimize the newborn's withdrawal symptoms, and after delivery, return to a full dose during the vulnerable postpartum period.

Is it safe to take antidepressant medication while breastfeeding?

Antidepressants are excreted in breast milk, usually in very small amounts. The amount an infant receives is usually so small that it does not register in blood tests. Few problems are seen among infants nursing from mothers who are taking antidepressants. However, as with antidepressant use during pregnancy, both the risks and benefits to the mother and infant should be taken into account when deciding whether to take an antidepressant while breastfeeding.³⁰

What are the side effects of antidepressants?

Antidepressants may cause mild and often temporary side effects in some people, but usually they are not long-term. However, any unusual reactions or side effects that interfere with normal functioning or are persistent or troublesome should be reported to a doctor immediately.

The most common side effects associated with SSRIs and SNRIs include:

• Headache-usually temporary and will subside.
• Nausea-temporary and usually short-lived.
• Insomnia and nervousness (trouble falling asleep or waking often during the night)-may occur during the first few weeks but often subside over time or if the dose is reduced.
• Agitation (e.g., feeling jittery).
• Sexual problems-women can experience sexual problems including reduced sex drive and problems having and enjoying sex.

Tricyclic antidepressants also can cause side effects including:

• Dry mouth-it is helpful to drink plenty of water, chew gum, and clean teeth daily.
• Constipation-it is helpful to eat more bran cereals, prunes, fruits, and vegetables.
• Bladder problems-emptying the bladder may be difficult, and the urine stream may not be as strong as usual.
• Sexual problems-sexual functioning may change, and side effects are similar to those from SSRIs and SNRIs.
• Blurred vision-often passes soon and usually will not require a new corrective lenses prescription.
• Drowsiness during the day-usually passes soon, but driving or operating heavy machinery should be avoided while drowsiness occurs. These more sedating antidepressants are generally taken at bedtime to help sleep and minimize daytime drowsiness.

FDA warning 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 percent of those taking antidepressants thought about or attempted suicide (although no suicides occurred), compared to 2 percent 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 is available from the FDA.

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.

Also, the FDA issued a warning that combining an SSRI or SNRI antidepressant with one of the commonly-used "triptan" medications for migraine headache could cause a life-threatening "serotonin syndrome," marked by agitation, hallucinations, elevated body temperature, and rapid changes in blood pressure. Although most dramatic in the case of the MAOIs, newer antidepressants may also be associated with potentially dangerous interactions with other medications.

What about St. John's wort?

The extract from the herb St. John's wort (Hypericum perforatum), a bushy, wild-growing plant with yellow flowers, has been used for centuries in many folk and herbal remedies. Today in Europe, it is used extensively to treat mild to moderate depression. In the United States, it is a top-selling botanical product.

To address increasing American interest in St. John's wort, the National Institutes of Health (NIH) conducted a clinical trial to determine the effectiveness of the herb in treating adults suffering from major depression. Involving 340 patients diagnosed with major depression, the eight-week trial randomly assigned one-third of them to a uniform dose of St. John's wort, one-third to a commonly prescribed SSRI, and one-third to a placebo. The trial found that St. John's wort was no more effective than the placebo in treating major depression.³² Another study is underway to look at the effectiveness of St. John's wort for treating mild or minor depression.

Other research has shown that St. John's wort can interact unfavorably with other drugs, including drugs used to control HIV infection. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain drugs used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. The herb also may interfere with the effectiveness of oral contraceptives. Because of these and other potential interactions, people should always consult their doctors before taking any herbal supplement.

Psychotherapy

Several types of psychotherapy - or "talk therapy" - can help people with depression.

Some regimens are short-term (10 to 20 weeks) and other regimens are longer-term, depending on the needs of the individual. Two main types of psychotherapies-cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT)-have been shown to be effective in treating depression. By teaching new ways of thinking and behaving, CBT helps people change negative styles of thinking and behaving that may contribute to their depression. IPT helps people understand and work through troubled personal relationships that may cause their depression or make it worse.

For mild to moderate depression, psychotherapy may be the best treatment option. However, for major depression or for certain people, psychotherapy may not be enough. Studies have indicated that for adolescents, a combination of medication and psychotherapy may be the most effective approach to treating major depression and reducing the likelihood for recurrence.33 Similarly, a study examining depression treatment among older adults found that patients who responded to initial treatment of medication and IPT were less likely to have recurring depression if they continued their combination treatment for at least two years.³⁴

Electroconvulsive Therapy

For cases in which medication and/or psychotherapy does not help alleviate a person's treatment-resistant depression, electroconvulsive therapy (ECT) may be useful. ECT, formerly known as "shock therapy," used to have a negative reputation. But in recent years, it has greatly improved and can provide relief for people with severe depression who have not been able to feel better with other treatments.

Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. She does not consciously feel the electrical impulse that is administered. A person typically will undergo ECT several times a week, and often will need to take an antidepressant or mood stabilizing medication to supplement the ECT treatments and prevent relapse. Although some people will need only a few courses of ECT, others may need maintenance ECT, usually once a week at first, then gradually decreasing to monthly treatments for up to one year.

ECT may cause some short-term side effects, including confusion, disorientation and memory loss. But these side effects typically clear shortly after treatment. Research has indicated that after one year of ECT treatments, patients showed no adverse cognitive effects.35 A person should weigh the potential risks and benefits of ECT and discuss them with her doctor before deciding to undergo ECT treatment.

How can I help a friend or relative who is depressed?

If you know someone who has depression, the first and most important thing you can do is to help her get an appropriate diagnosis and treatment. You may need to make an appointment on her behalf and go with her to see the doctor. Encourage her to stay in treatment, or to seek different treatment if no improvement occurs after six to eight weeks.

In addition, you can also:

• Offer emotional support, understanding, patience and encouragement.
• Engage her in conversation, and listen carefully.
• Never disparage feelings she expresses, but point out realities and offer hope.
• Never ignore comments about suicide, and report them to your friend's or relative's therapist or doctor.
• Invite your friend or relative out for walks, outings and other activities. Keep trying if she declines, but don't push her to take on too much too soon. Although diversions and company are needed, too many demands may increase feelings of failure.
• Remind her that with time and treatment, the depression will lift.

How can I help myself if I am depressed?

You may feel exhausted, helpless and hopeless. It may be extremely difficult to take any action to help yourself. But it is important to realize that these feelings are part of the depression and do not reflect actual circumstances. As you recognize your depression and begin treatment, negative thinking will fade. In the meantime:

• Engage in mild activity or exercise. Go to a movie, a ballgame, or another event or activity that you once enjoyed.
• Participate in religious, social or other activities.
• Set realistic goals for yourself.
• Break up large tasks into small ones, set some priorities and do what you can as you can.
• Try to spend time with other people and confide in a trusted friend or relative. Try not to isolate yourself, and let others help you.
• Expect your mood to improve gradually, not immediately. Do not expect to suddenly "snap out of" your depression. Often during treatment for depression, sleep and appetite will begin to improve before your depressed mood lifts.
• Postpone important decisions, such as getting married or divorced or changing jobs, until you feel better. Discuss decisions with others who know you well and have a more objective view of your situation.
• Be confident that positive thinking will replace negative thoughts as your depression responds to treatment.

Where can I go for help?

If you are unsure where to go for help, ask your family doctor. Others who can help are:

• Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors.
• Health maintenance organizations (HMOs).
• Community mental health centers.
• Hospital psychiatry departments and outpatient clinics.
• Mental health programs at universities or medical schools.
• State hospital outpatient clinics.
• Family services, social agencies or clergy.
• Peer support groups.
• Private clinics and facilities.
• Employee assistance programs.
• Local medical and/or psychiatric societies.

You can also check the phone book under "mental health," "health," "social services," "hotlines," or "physicians" for phone numbers and addresses. An emergency room doctor also can provide temporary help and can tell you where and how to get further help.

What if I or someone I know is in crisis?

Women are more likely than men to attempt suicide. If you are thinking about harming yourself or attempting suicide, tell someone who can help immediately.

• Call your doctor.
• Call 911 for emergency services.
• Go to the nearest hospital emergency room.
• Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889) to be connected to a trained counselor at a suicide crisis center nearest you.

Citations

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2. Rohan KJ, Lindsey KT, Roecklein KA, Lacy TJ. Cognitive-behavioral therapy, light therapy and their combination in treating seasonal affective disorder. Journal of Affective Disorders. 2004; 80: 273-283.

3. Tsuang MT, Bar JL, Stone WS, Faraone SV. Gene-environment interactions in mental disorders. World Psychiatry. 2004 Jun; 3(2): 73-83.

4. Schmidt PJ, Nieman LK, Danaceau MA, Adams LF, Rubinow DR. Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. New England Journal of Medicine. 1998 Jan 22; 338(4): 209-216.

5. Rubinow DR, Schmidt PJ, Roca CA. Estrogen-serotonin interactions: Implications for affective regulation. Biological Psychiatry. 1998; 44(9): 839-850.

6. Ross LE, Steiner M. A Biopsychosocial approach to premenstrual dysphoric disorder. Psychiatric Clinics of North America. 2003; 26(3): 529-546.

7. Dreher JC, Schmidt PJ, Kohn P, Furman D, Rubinow D, Berman KF. Menstrual cycle phase modulates reward-related neural function in women. Proceedings of the National Academy of Sciences. 2007 Feb 13; 104(7): 2465-2470.

8. Munk-Olsen T, Laursen TM, Pederson CB, Mores O, Mortensen PB. New parents and mental disorders. Journal of the American Medical Association. 2006 Dec 6; 296(21): 2582-2589.

9. Chaudron LH, Szilagyi PG, Kitzman HJ, Wadkins HI, Conwell Y. Detection of postpartum depressive symptoms by screening at well-child visits. Pediatrics. 2004 Mar; 113(3 Pt 1): 551-558.

10. Freeman MP, Wright R, Watchman M, Wahl RA, Sisk DJ, Fraleigh L, Weibrecht JM. Postpartum depression assessments at well-baby visits: screening feasibility, prevalence and risk factors. Journal of Women's Health. 2005 Nov 10; 14(10): 929-935.

11. Freeman EW, Sammel MD, Lin H, Nelson DB. Associations of hormones and menopausal status with depressed mood in women with no history of depression. Archives of General Psychiatry. 2006 Apr; 63(4): 375-382.

12. Cohen L, Altshuler L, Harlow B, Nonacs R, Newport DJ, Viguera A, Suri R, Burt V, Hendrick AM, Loughead A, Vitonis AF, Stowe Z. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. Journal of the American Medical Association. 2006 Feb 1; 295(5): 499-507.

13. Bebbington PE, Dunn G, Jenkins R, Lewis G, Brugha T, Farrell M, Meltzer H. The influence of age and sex on the prevalence of depressive conditions: report from the National Survey of Psychiatric Morbidity. International Review of Psychiatry. 2003 Feb-May; 15(1-2): 74-83.

14. Nolen-Hoeksema S, Larson J, Grayson C. Explaining the gender difference in depressive symptoms. Journal of Personality and Social Psychology. 1999; 77(5): 1061-1072.

15. Regier DA, Rae DS, Narrow WE, Kaebler CT, Schatzberg AF. Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders. British Journal of Psychiatry. 1998; 173(Suppl. 34): 24-28.

16. Devane CL, Chiao E, Franklin M, Kruep EJ. Anxiety disorders in the 21st century: status, challenges, opportunities, and comorbidity with depression. American Journal of Managed Care. 2005 Oct; 11(Suppl. 12): S344-353.

17. Kessler RC, Barker PR, Colpe LJ, Epstein JF, Gfroerer JC, Hiripi E, Howes MJ, Normand SL, Manderscheid RW, Walters EE, Zaslavsky AM. Screening for serious mental illness in the general population. Archives of General Psychiatry. 2003 Feb; 60(2): 184-189.

18. Conway KP, Compton W, Stinson FS, Grant BF. Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry. 2006 Feb; 67(2): 247-257.

19. Cassano P, Fava M. Depression and public health, an overview. Journal of Psychosomatic Research. 2002 Oct; 53(4): 849-857.

20. Katon W, Ciechanowski P. Impact of major depression on chronic medical illness. Journal of Psychosomatic Research. 2002 Oct; 53(4): 859-863.

21. Hankin BL, Abramson LY. Development of gender differences in depression: an elaborated cognitive vulnerability-transactional stress theory. Psychological Bulletin. 2001 Nov; 127(6): 773-796.

22. Calvete E, Cardenoso O. Gender differences in cognitive vulnerability to depression and behavior problems in adolescents. Journal of Abnormal Child Psychology. 2005 Apr; 33(2): 179-192.

23. Cyranowski J, Frank E, Young E, Shear K. Adolescent onset of the gender difference in lifetime rates of major depression. Archives of General Psychiatry. 2000 Jan; 57(1): 21-27.

24. Krishnan KRR, Taylor WD, McQuoid DR, MacFall JR, Payne ME, Provenzale JM, Steffens DC. Clinical characteristics of magnetic resonance imaging-defined subcortical ischemic depression. Biological Psychiatry. 2004 Feb 15; 55(4): 390-397.

25. Rush JA, Trivedi MH, Wisniewski SR, Stewart JW, Nierenberg AA, Thase ME, Ritz L, Biggs MM, Warden D, Luther JF, Shores-Wilson K, Niederehe G, Fava M. Bupropion-SR, Sertraline, or Venlafaxine-XR after failure of SSRIs for depression. New England Journal of Medicine. 2006 Mar 23; 354(12): 1231-1242.

26. Trivedi MH, Fava M, Wisniewski SR, Thase ME, Quitkin F, Warden D, Ritz L, Nierenberg AA, Lebowitz BD, Biggs MM, Luther JF, Shores-Wilson K, Rush JA. Medication augmentation after the failure of SSRIs for depression.New England Journal of Medicine. 2006 Mar 23; 354(12): 1243-1252.

27. Marcus SM, Flynn HA, Blow F, Barry K. A screening study of antidepressant treatments and mood symptoms in pregnancy. Archives of Women's Mental Health. 2005 May; 8(1): 25-27.

28. Austin M. To treat or not to treat: maternal depression, SSRI use in pregnancy and adverse neonatal effects. Psychological Medicine. 2006 Jul 25; 1-8.

29. U.S. Food and Drug Administration (FDA). FDA Medwatch drug alert on Effexor and SSRIs, 2004 Jun 3. Available at (www.fda.gov/medwatch/safety/2004/safety04.htm#effexor).

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

32. Hypericum Depression Trial Study Group. Effect of Hypericum perforatum (St. John's wort) in major depressive disorder: a randomized controlled trial. Journal of the American Medical Association. 2002 Apr 10; 287(14): 1807-1814.

33. March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J, Treatment for Adolescents with Depression Study (TADS) team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. Journal of the American Medical Association. 2004 Aug 18; 292(7): 807-820.

34. Reynolds CF III, Dew MA, Pollock BG, Mulsant BH, Frank E, Miller MD, Houck PR, Mazumdar S, Butters MA, Stack JA, Schlernitzauer MA, Whyte EM, Gildengers A, Karp J, Lenze E, Szanto K, Bensasi S, Kupfer DJ. Maintenance treatment of major depression in old age. New England Journal of Medicine. 2006 Mar 16; 354(11): 1130-1138.

35. Rami L, Bernardo M, Boget T, Ferrer J, Portella M, Gil-Verona JA, Salamero M. Cognitive status of psychiatric patients under maintenance electroconvulsive therapy: a one-year longitudinal study. The Journal of Neuropsychiatry and Clinical Neurosciences. 2004 Fall; 16(4): 465-471.

NIH Publication No. 09-4779
Revised 2009

Page last reviewed on February 3, 2014

Identifying Your Cognitive Distortions

At the onset of depression there begins a chain reaction of negative cognitives - almost like a single spark that begins a bonfire - triggering an explosion of negative thoughts. When people are depressed, such negative thoughts occur literally hundreds of times a day, each time generating more misery and pessimism. And, like the bonfire, once started, the depressed person may actually throw on additional "logs" to keep it ablaze. The repeated, often almost continuous, negative thoughts keep depression alive and interfere with emotional healing.

The hopeful side, however, is that it is entirely possible to learn some systematic techniques that can effectively stop the destruction. The first step in this process is identifying the types of cognitive distortions:

• Negative Predictions: This is the tendency to make highly negative, pessimistic predictions about the future, for which there is no evidence, and which result in increased despair and hopelessness. Example: A depressed woman thinks, "I've been depressed for months. I'm never going to get over this... nothing will ever get me out of this depression."
• All-or-None Thinking: This is the tendency to jump to broad, over-generalized conclusions about yourself or reality. Example: A recently divorced man spends a Friday night alone at home. He hoped a friend would call, but none did. He concludes, "No one cares about me." The reality may be that he does in fact have friends and family who care a lot about him, but they simply did not call this night.
• Jumping to Conclusions: This is the tendency to conclude the worst in the absence of substantial evidence. Example: A woman applies for a job and is told, "We will call you on Monday if you got the job." By Monday noon she has not heard, and she concludes, "I know I didn?t get the job."
• Tunnel Vision: This is the common tendency when one is depressed to focus selectively on the negative details, to dwell on them and tune out positive aspects of a situation or yourself. Example: A middle-aged man walks by a mirror and notices his pot belly. He thinks, "I'm disgusting. No wonder women aren?t interested in me." The fact that he is somewhat overweight may be accurate, but at that moment in front of the mirror this is what he focuses on exclusively. He sees himself as disgusting. It may very well be that he is a kind and sensitive man.
• Personalizing: This is the tendency to assume that if something is wrong, you are at fault; an assumption that may not be accurate. Example: As a man comes to work, he says "hello" to his boss. The boss nods his head but says nothing. The man concludes, "Boy, he must be mad at me." This may or may not be an accurate conclusion. If he does not check it out with his boss, he may worry needlessly. Many alternative explanations are possible. The point is that we cannot read each other's minds, and there is a strong tendency for people who feel depressed to overreact and personalize - especially when they fear criticism or rejection.
• "Should" Statements: This tendency insists that things should be a certain way, and can be directed toward yourself, toward others, or toward reality. "Should" statements always have the effect of intensifying painful emotions; they never reduce misery or change situations. Example: "He shouldn't have left me. I was so good to him. I gave my whole life to him!"

Each of these cognitive distortions shares two things in common with the others: they distort in some way one's view of reality (resulting in a loss of perspective, and extremely negative and pessimistic views of oneself, current situations and the future), and each cognitive distortion has the effect of intensifying emotional pain. If unrecognized and unchallenged, such distortions in thinking will result in an ongoing destructive depressive process. It is very important to interrupt this process. The first step is to recognize such distortions as they occur. There is realistic hope.

Adapted from You Can Beat Depression:
A Guide to Prevention and Recovery (Fourth Edition), by Dr. John Preston
Available at online and local bookstores or directly from Impact Publishers, Inc.
PO Box 6016, Atascadero, CA 93423-6016
http://www.bibliotherapy.com/
Phone 1-800-246-7228.

Page last modified/reviewed on January 11, 2012

Introduction

Diabetes is one of the most serious health problems facing the world today. In the United States each year, more than 13,000 children are diagnosed with type 1 diabetes. Increasingly, health care providers are finding more and more children and teens with type 2 diabetes, a disease usually seen in people over age 40. Although there are no national data, some clinics report that one-third to one-half of all new cases of childhood diabetes are now type 2. African American, Hispanic/Latino and American Indian children who are obese and have a family history of type 2 diabetes are at especially high risk for this type of diabetes.

What is Diabetes?

Diabetes is a chronic disease in which the body does not make or properly use insulin, a hormone that is needed to convert sugar, starches, and other food into energy. People with diabetes have increased blood glucose (sugar) levels due to a lack of insulin, insufficient insulin, or resistance to insulin's effects. High levels of glucose build up in the blood, and spill into the urine and out of the body. As a result, the body loses its main source of fuel.

Taking care of diabetes is important. If not treated, diabetes can lead to serious problems. Diabetes can affect the eyes, kidneys, nerves, gums, teeth, and blood vessels. Diabetes is the leading cause of adult blindness, lower limb amputations, and kidney failure. It can cause heart disease and stroke, and even death if untreated. Some of these problems can occur in teens and young adults who develop diabetes during childhood. Research in adults shows that these problems can be greatly reduced or delayed by keeping blood glucose levels near normal.

What are Special Concerns for Children and Adolescents with Diabetes?

Diabetes presents unique issues for children and teens with the disease. Simple things - like going to a birthday party, playing sports, or staying overnight with friends - need careful planning. Every day, children with diabetes may need to take insulin or oral medication. They also need to check their blood glucose several times during the day and remember to make correct food choices. For school-age children, these tasks can make them feel "different" from their classmates. These tasks can be particularly bothersome for teens.

For any child or teen with diabetes, learning to cope with the disease is a big job. Dealing with a chronic illness such as diabetes may cause emotional and behavioral challenges. Talking to a social worker or psychologist may help a child or teen and his or her family learn to adjust to lifestyle changes needed to stay healthy.

What Can Families and Others Do?

Managing diabetes in children and adolescents is most effective when the entire family makes a team effort. Families can share concerns with physicians, diabetes educators, dietitians, and other health care providers to get their help in the day-to-day management of diabetes. Extended family members, teachers, school nurses, counselors, coaches, day care providers, or other resources in the community can provide information, support, guidance, and help with coping skills. These individuals also may help with resources for health education, financial services, social services, mental health counseling, transportation, and home visiting.

Diabetes is stressful for both the children and their families. Parents should be alert for signs of depression or eating disorders and seek appropriate treatment. While all parents should talk to their children about avoiding tobacco, alcohol, and other drugs, this is particularly important for children with diabetes. Smoking and diabetes each increase the risk of cardiovascular disease and people with diabetes who smoke have a greatly increased risk of heart disease and circulatory problems. Binge drinking can increase the risk of hypoglycemia (low blood sugar) and symptoms of hypoglycemia can be mistaken for those of intoxication and not properly treated. Local peer groups for children and teens with diabetes can provide positive role models and group activities.

What Are the Types of Diabetes?

There are two main types of diabetes. Type 1 and type 2 diabetes are described below. A third type-gestational diabetes-occurs only during pregnancy and often resolves after pregnancy. Women who have had gestational diabetes are more likely to develop type 2 diabetes later in life. (See "Resources" for information on gestational diabetes.)

Type 1 Diabetes

Type 1 diabetes is a disease of the immune system, which is the body's system for fighting infection. In people with type 1 diabetes, the immune system attacks the beta cells, the insulin-producing cells of the pancreas, and destroys them. The pancreas can no longer produce insulin, so people with type 1 diabetes need to take insulin daily to live. Type 1 diabetes can occur at any age, but the disease occurs most often in children and young adults.

• Symptoms. The symptoms of type 1 diabetes usually develop over a short period of time. They include increased thirst and urination, constant hunger, weight loss, and blurred vision. Children may also feel very tired all the time. If not diagnosed and treated with insulin, the child or teen with type 1 diabetes can lapse into a life-threatening diabetic coma, known as diabetic ketoacidosis (KEY-toe-asi-DOE-sis) or DKA.
• Risk Factors. Though scientists have made much progress in predicting who is at risk for developing type 1 diabetes, they do not know exactly what triggers the immune system's attack on beta cells. They believe that type 1 diabetes is due to a combination of genetic and environmental factors. Researchers are working to identify these factors and stop the auto-immune process that leads to type 1 diabetes.

Type 2 Diabetes

The first step in the development of type 2 diabetes is often a problem with the body's response to insulin, called insulin resistance. For reasons scientists do not completely understand, the body cannot use the insulin very well. This means that the body needs increasing amounts of insulin to control blood glucose. The pancreas tries to make more insulin, but after several years, insulin production may drop off.

Type 2 diabetes used to be found mainly in adults who were overweight and age 40 or older. Now, as more children and adolescents in the United States become overweight and inactive, type 2 diabetes occurs more often in young people. Type 2 diabetes is also more common in certain racial and ethnic groups, such as African Americans, American Indians, Hispanic/Latinos, and some Asian and Pacific Islander Americans. To control their diabetes, children with type 2 diabetes may need to take oral medication, insulin, or both.

• Symptoms. Type 2 diabetes develops slowly in some children, but quickly in others. Symptoms may be similar to those of type 1 diabetes. A child or teen can feel very tired, thirsty, or nauseated (sick to the stomach), and have to urinate often. Other symptoms may include weight loss, blurred vision, frequent infections, and slow healing of wounds or sores. Some children or adolescents with type 2 diabetes may show no symptoms at all when they are diagnosed. For that reason, it is important for parents and caregivers to talk to a health care provider about testing children or teens who are at high risk for the disease.
• Risk Factors. Being overweight, being older than 10 years of age, experiencing puberty, and having a family member who has type 2 diabetes are risk factors for the disease. Certain populations, as noted above, are at higher risk. In addition, physical signs of insulin resistance, such as acanthosis nigricans (A-can-tho-sis NIG-reh-cans), may appear: the skin around the neck or in the armpits appears dark, thick, and velvety. High blood pressure also may be a sign of insulin resistance. For children and teens at risk, health care providers can encourage, support, and educate the entire family to make lifestyle changes that may delay - or prevent - the onset of type 2 diabetes. Such lifestyle changes include keeping at a healthy weight and staying active.

What Should a Child or Teen With Diabetes Do Every Day?

To control diabetes and prevent complications, blood glucose levels must be as close to a "normal" range as safely possible. Families should work with a health care provider to help set a child's or teen's targets for blood glucose levels. (See for Resources information on target ranges.) The provider can help develop a personal diabetes plan for the child and discuss ways to manage hypoglycemia (low blood glucose) and hyperglycemia (high blood glucose).

A Personal Diabetes Plan

A personal diabetes plan ensures that a daily schedule is in place to keep a child's diabetes under control. A health care provider develops this plan in partnership with a child or teen and his or her family. The plan shows the child or teen how to follow a healthy meal plan, get regular physical activity, check blood glucose levels, and take insulin or oral medication as prescribed.

• Follow a Healthy Meal Plan. A child or teen needs to follow a meal plan developed by a physician, diabetes educator, or a registered dietitian. A meal plan outlines proper nutrition for growth. A meal plan also helps keep blood glucose levels in the target range. Children or adolescents and their families can learn how different types of food - especially carbohydrates such as breads, pasta, and rice - can affect blood glucose levels. Portion size, the right amount of calories for the child's age, and ideas for healthy food choices at meal and snack time also should be discussed. Family support for following the meal plan and setting up regular meal times is a key to success, especially if the child or teen is taking insulin.
• Get Regular Physical Activity. A child or teen with diabetes needs regular physical activity. Exercise helps to lower blood glucose levels, especially in children and adolescents with type 2 diabetes. Exercise is also a good way to help children control their weight. If possible, a child or teen should check blood glucose levels before beginning a game or sport. A child or teen should not exercise if blood glucose levels are too low.
• Check Blood Glucose Levels Regularly. A child or teen should check blood glucose levels regularly with a blood glucose meter, preferably a meter with a built-in memory. A health care professional can teach a child how to use a blood glucose meter properly and how often to use it. Blood glucose meter results show if blood glucose levels are in the target range, too high, or too low. A child should keep a journal or other records of blood glucose results to discuss with his or her health care provider. This information helps the provider make any needed changes to the child's or teen's personal diabetes plan.
• Take All Diabetes Medication As Prescribed. A child or teen should take all diabetes medication as prescribed. Parents, caregivers, school nurses, and others can help a child or teen learn how to take medications properly. For type 1 diabetes, a child or teen takes insulin shots at regular times each day. Some children and teens use an insulin pump, which delivers insulin. Some children or teens with type 2 diabetes need oral medication or insulin shots or both. In any case, all medication should be balanced with food and activity every day.

Hypoglycemia and Hyperglycemia

Keeping blood glucose levels within the target range is the goal of diabetes control. However, extremes in blood glucose levels can occur for several reasons. The parent or caregiver should talk with a health care provider about how to deal with these potential problems related to a child's or teen's diabetes.

• Blood glucose levels can sometimes drop too low - a condition called hypoglycemia (hi-po-gly-SEE-me-uh). Taking too much diabetes medicine, missing a meal or snack, or exercising too much may cause hypoglycemia. A child or teen can become nervous, shaky, and confused. When blood glucose levels fall very low, the person can lose consciousness or develop seizures. Talk to the child's or teen's health care provider about how to deal with this serious but manageable condition.
• Blood glucose levels can sometimes rise too high - a condition known as hyperglycemia (hi-per-gly-SEE-me-uh). Forgetting to take medicines on time, eating too much, and getting too little exercise may cause hyperglycemia. Being ill also can raise blood glucose levels. Over time, hyperglycemia can lead to serious health problems and cause damage to the eyes, kidneys, nerves, blood vessels, gums, and teeth.

Are There Legal Considerations for Children and Teens with Diabetes?

Several Federal and state laws provide protections to children with disabilities, including children or teens with diabetes. These children must have full access to public programs, including public schools, and to most private schools as well. Students with diabetes are entitled to accommodations and modifications necessary for them to stay healthy at school and have the same access to an education as other students do.

A child's or teen's school should prepare a plan that outlines how the child's special health care needs will be met. The plan should identify school staff responsible for making sure the plan is followed. The parents should be present during development of the plan. Any changes to the plan should be made only with the parents' consent. Ideally, the plan should be updated every year. For information or questions about the Americans With Disabilities Act, call 1-800-514-0301 or 1-800-514-0383 (TDD), or go to http://www.usdoj.gov/crt/ada/ on the World Wide Web.

Are Researchers Studying Diabetes in Children and Adolescents?

Diabetes and Digestive and Kidney Diseases (NIDDK) conducts and supports a wide range of research aimed at finding ways to prevent and treat diabetes and its health complications. The Institute's research on type 1 diabetes focuses on understanding its causes, improving treatment, and developing new therapies that could prevent or cure diabetes. In addition, NIDDK recently created Trialnet, a clinical trials network to test new ways to prevent type 1 diabetes and to preserve beta cell function in people who already have diabetes.

NIDDK is also setting up clinical centers to study the prevention and treatment of type 2 diabetes in children and adolescents. Treatment trials will look at lifestyle changes and drug therapy. Prevention trials will develop programs that can be used in schools and communities to lower risk factors for the disease. Other NIDDK-supported research on type 2 diabetes seeks to understand the causes of the disease, improve diagnosis, and develop new treatments. For more information about NIDDK research on children and adolescents with diabetes, visit http://www.niddk.nih.gov/patient/patient.htm on the Internet.

In 2000, the Centers for Disease Control and Prevention (CDC) began funding a 5-year multi-center study of childhood diabetes. Participating centers are located in California, Colorado, Hawaii, Ohio, South Carolina, and Washington. The goals of the program are to 1) develop population-based registries of childhood diabetes, 2) characterize the types of diabetes, 3) develop case definitions and study the prevalence and incidence of the different types of childhood diabetes, and 4) describe the natural history and the quality of care received during follow-up. For more information, call 1-877-232-3422 or visit http://www.cdc.gov/diabetes/projects/cda2.htm on the Internet.

NIDDK and CDC are joint sponsors of the National Diabetes Education Program (NDEP). The goal of this program is to reduce illness and death associated with diabetes and its complications. The NDEP has developed an initiative to help health care providers identify, diagnose, and treat children and teens with type 2 diabetes. In addition, the NDEP will launch an initiative to increase awareness in the school setting about the importance of helping children and teens with diabetes manage their disease.

Resources

For more information about diabetes, target goals for blood glucose levels, educational materials, and support programs for people with diabetes and their families and friends, contact:

National Diabetes Education Program (NDEP)
1 Diabetes Way
Bethesda, MD 20892-3600
Toll-free: 800-438-5383
Web site: http://www.ndep.nih.gov

For more information about type 1, type 2, and gestational diabetes, as well as diabetes research, statistics, and education, contact:

National Diabetes Information Clearinghouse
1 Information Way
Bethesda, MD 20892-3560
Toll-free: 800-860-8747
Phone: (301) 654-3327
Fax: (301) 907-8906
Email: [email protected]
Web site: http://www.niddk.nih.gov/health/diabetes/diabetes.htm

Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion
1600 Clifton Road
Atlanta, GA 30333
Toll-free: 800-311-3435
Phone: (404) 639-3311
Fax: (770) 448-5195
Web site: http://www.cdc.gov/nccdphp/index.htm

CDC Division of Diabetes Translation
Public Inquiries/Publications
P.O. Box 8728
Silver Spring, MD 20910
Toll-free: 877-CDC-DIAB or 877-232-3422
Fax: (301) 562-1050
Email: [email protected]
Web site: http://www.cdc.gov/diabetes

American Diabetes Association
1701 N. Beauregard Street
Alexandria, VA 22311
Toll-free: 800-DIABETES or 800-342-2383
Phone: (703) 549-1500
Email: [email protected]
Web site: http://www.diabetes.org

Juvenile Diabetes Foundation International
120 Wall Street, 19th Floor
New York, NY 10005
Toll-free: 800-223-1138
Phone: (212) 785-9500
Web site: http://www.jdf.org

Source: National Diabetes Education Program, National Institutes of Health, and the Centers for Disease Control and Prevention

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

ADHD is a chronic health condition, and early identification and treatment of the disorder increase the child's chance for academic, emotional, and social success. -- Harlan Gephart, MD

Athealth.com: We are pleased to welcome Harlan Gephart, MD, Past Chair of the American Board of Pediatrics and an ADHD expert, who talks about the diagnosis and treatment of attention deficit / hyperactivity disorder. Dr. Gephart, former director of the Group Health ADHD Clinic, is the ADHD consultant at Pediatric Associates in Bellevue, Washington, and a Clinical Professor of Pediatrics at the University of Washington Medical School in Seattle. He is a member of the editorial boards of Contemporary Pediatrics and Journal Watch - Pediatric and Adolescent Medicine. Dr. Gephart has also served as the pediatric delegate to the American Board of Medical Specialists and as a member of the Future of Pediatric Education II Project (FOPE II), the national joint task force of pediatric societies studying pediatric practice and education into the 21st century.

Athealth.com: How did you become interested in ADHD?

Dr. Gephart: I completed a pediatric residency at the University of Washington and particularly enjoyed the behavioral side of pediatrics. I considered taking a residency in child psychiatry, but the Viet Nam war intervened, and after I completed a tour of duty with the Air Force, I decided to take additional training in behavioral pediatrics. I returned to the University of Washington as chief resident in pediatrics and spent much of that year at what is now called the Center for Human Development and Disability, working with Dr. Michael Rothenberg, a nationally-known pediatrician / child psychiatrist.

Following my fellowship, I joined Group Health as a general pediatrician. My interest in ADHD and behavioral pediatrics was fueled by my work as physician for one of the local school districts and the significant number of ADHD patients that I was seeing in my practice.

Athealth.com: How did the Center for Attention Deficit Disorders at Group Health come into being?

Dr. Gephart: Another physician, Dr. Connie McDonald, who was a fully trained developmental pediatrician, and I established the clinic in 1989.

It was becoming increasingly difficult for primary care physicians to carve out the block of time necessary to do a complete assessment for ADHD, and we were receiving a large number of these kinds of referrals. We needed a place where we could facilitate the assessment and management of children with the disorder. When Dr. McDonald retired in 1990, I became medical director of the center, and for a number of years I practiced half time in the center and half time in general pediatrics. Today, I limit my practice to half time, but devote 100% of my practice time to assessments, medication management, supervision, teaching, and administration at the center.

Athealth.com: How many patients have been assessed at the center?

Dr. Gephart: We have assessed or managed between 5,000 - 6,000 young people.

Athealth.com: How are patients referred to the center?

Dr. Gephart: We receive around 40 - 50 referrals each month. The majority of our referrals come from within the Group Health system, but about 10% - 15% of the kids are private patients referred to our center from outside of Group Health. About two-thirds to three-quarters of our referrals come from family doctors, and the rest generally come from pediatricians or mental health care providers.

Athealth.com: Why aren't these patients assessed for ADHD by their own health care providers?

Dr. Gephart: The family physician may not have time to conduct a comprehensive evaluation, or his/her clinical expertise may lie elsewhere. Some clinicians do not feel comfortable diagnosing ADHD, but they are able to manage the treatment of the child once the diagnosis is made.

The referrals we receive from pediatricians are often the more complex cases not easily managed in a general pediatric practice. Mental health care providers may refer to the center for an assessment and then rely on us for medication management.

Athealth.com: What is the prevalence of ADHD?

Dr. Gephart: Prevalence estimates vary, but among school-aged children the prevalence is estimated to be between 6% - 10%.

Athealth.com: Why is it important to treat ADHD?

Dr. Gephart: Attention deficit/hyperactivity disorder is the most common behavioral disorder of childhood. Children with ADHD exhibit symptoms of inattention, hyperactivity, and impulsivity, and as a result, they frequently experience school problems, have difficulty with peers and family members, and show poor psychosocial development. They are at higher risk for teen pregnancy, substance abuse, and other comorbid conditions, and they are more likely to drop out of school at an early age. Virtually all children with ADHD suffer from low self-esteem.

ADHD is a chronic health condition, and early identification and treatment of the disorder increase the child's chance for academic, emotional, and social success. If we let an ADHD child go untreated, we may well be handing that child a life sentence of academic and social failure.

Athealth.com: What is being done to improve the diagnosis and treatment of ADHD?

Dr. Gephart: In recent years a significant effort has been made to develop evidence-based guidelines that standardize the diagnosis and treatment of the disorder. For example, the American Academy of Pediatrics (AAP) recently published guidelines for the diagnosis and treatment of ADHD in children 6 to 12 years of age. The American Academy of Child and Adolescent Psychiatry has published similar guidelines.

The next important step is developing effective programs that teach physicians, nurses, mental health providers, school staff, and other members of the treatment team how to apply the guidelines.

Athealth.com: How do you conduct an ADHD assessment?

Dr. Gephart: ADHD assessments require a considerable amount of time and effort. At the center we plan about four hours for an initial assessment.

The diagnosis of ADHD requires that a child meet the criteria set forth in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). A complete assessment includes the following:

A complete history from the child's parent or caretaker, including information about the child's inattention, hyperactivity, and impulsivity, the age of onset of the symptoms, and the extent of the child's academic and social impairment;

Behavior and academic reports, including report cards and samples of school work, from the child's school. It is also helpful to gather information from other collateral resources such as counselors, day care providers, or coaches if they have significant contact with the child.

Use of ADHD-specific behavior rating scales and questionnaires. Scales are used in an attempt to quantify the level of the child's impairment. All kids have some characteristics of ADHD. However, if a child has ADHD, the symptoms will be clinically significant for longer than 6 months and will manifest themselves in at least two environments, typically at home and at school. The scales also assist us in establishing a baseline so that once the condition is treated, we have something against which we can measure improvement.

The AAP guidelines recommend several parent and teacher rating scales, including:

• CPRS-R:L-ADHD Index (Conners Parent Rating Scale-1997 Revised Version: Long Form, ADHD Index Scale);
• CTRS-R:L-ADHD Index (Conners Teacher Rating Scale-1997 Revised Version: Long Form, ADHD Index Scale);
• CPRS-R:L-DSM-IV Symptoms (Conners Parent Rating Scale-1997 Revised Version: Long Form, DSM-IV Symptoms Scale); and
• CTRS-R:L-DSM-IV Symptoms (Conners Teacher Rating Scale-1997 Revised Version: Long Form, DSM-IV Symptoms Scale).

A complete physical examination, including a neurological examination if indicated, to determine if there is a physical reason for the problem, such as a visual or hearing impairment or a genetic disorder;

An interview with the child separate from the physical examination;

An assessment for co-existing conditions. There are a number of look alike and/or co-occurring disorders associated with ADHD - depression, anxiety, substance abuse, learning disorders, conduct disorder, oppositional defiant disorder (ODD), and Tourette syndrome to name a few.

It is not uncommon for an ADHD child to have a co-existing condition. In patients with ADHD about fifty percent (50%) fulfill the criteria for ODD and about twenty-five percent (25%) fulfill the criteria for conduct disorder.

Learning disorders are two times more common in children with ADHD. If an ADHD child is performing below grade level in school, the clinician should recommend that the school conduct a psychoeducational evaluation.

Athealth.com: What causes ADHD and can it be cured?

Dr. Gephart: We don't have a complete answer for what causes ADHD, but we certainly understand a great deal more than we did. We now know that:

• ADHD doesn't occur because the parent is a bad parent or because the child is a bad kid;
• ADHD runs in families;
• ADHD may, at least in part, be caused by neurotransmitter deficits;
• Although chronic, ADHD is a highly treatable medical condition.

We used to say that ADHD kids would eventually outgrow the disorder. Today, we know that inattention and lack of organization can persist into adulthood - although hyperactivity and impulsivity tend to diminish with age.

School is a burden for kids with ADHD. In adults, it isn't that the disorder goes away, it's that school goes away, and therefore, the focus on the symptoms and the resultant impairment is often reduced.

Athealth.com: What about girls with ADHD?

Dr. Gephart: I would say that ADHD is under-diagnosed in girls. This may be, in part, because girls with ADHD tend to be more inattentive than hyperactive, and therefore, draw less attention to themselves. In recent years we have come to recognize that this disorder has a significant impact on girls, too.

For example, it was previously thought that ADHD was ten times more common in boys than in girls. However, recent studies indicate that the ratio is much lower than that, i.e., ADHD is four times more common in boys than in girls. As patients get older, the ratios are reduced. In adults, the ratio between males and females with ADHD is 1:1.

In our clinic we see two definite referral spikes related to age and gender:

The first referral spike occurs around the first grade where we see a large influx of hyperactive boys, ages 5 - 7.

The second referral spike occurs around the sixth grade, and girls are predominate in this referral group. Often, these are previously well-liked girls who, once they reach middle school, are overwhelmed by classroom changes, increased assignments, and large class sizes. They begin to fall further behind academically, and they start to struggle socially.

The DSM-IV criteria are somewhat limited with regard to diagnosing ADHD in girls. Prior to reaching middle school, the inattentive girl may not exhibit all of the symptoms required by the DSM-IV, and as a result, the diagnosis may be missed.

Athealth.com: Is the evaluation and treatment for boys different than for girls?

Dr. Gephart: The assessment and the treatment are the same. However, if the patient is a hyperactive, impulsive child, that child will require more intervention. And, since boys tend to be more hyperactive than girls, boys will often require more intense intervention than girls.

Athealth.com: Do you treat children differently than you treat teenagers?

Dr. Gephart: No. Teenagers respond to stimulant medication and behavioral treatment approaches in the same ways that younger children do. However, teenagers have more control over how they participate in treatment, and therefore, adolescents present a different set of compliance issues than children do.

Athealth.com: How is ADHD treated?

Dr. Gephart: There are two proven treatments:

Stimulant medication such as Ritalin, Dexedrine, and Adderall, and

Behavioral therapy such as parent training, social skills programs, and the daily report card.

The best treatment involves the use of both approaches.

In parent training classes parents learn how to work with their kids on a daily basis. These programs focus on teaching parents how to deal with the child's social and academic problems - when to use time-outs, how to give clear, concise instructions to the child, how to set up a system of rewards and consequences. It is important to keep in mind that many ADHD kids have ADHD parents. The parents, therefore, may forget to give the child his/her medication or be disorganized in their approach to the child. These programs teach parents how to be more successful in dealing with the child.

Many ADHD children exhibit socially inappropriate behavior and have problems getting along with siblings and peers. Social skills programs, particularly camping programs that provide intense intervention, group work, and a lot of one-on-one assistance, can help these kids learn skills in problem solving, working with others, and anger management. ADHD kids need to experience success, and when a child learns how to interact appropriately with others, this can be an important self-esteem builder.

The daily report card is a tool used by the school to give more immediate feedback to the parent (and the clinician) about the child's progress. The report card focuses both on behavior and academics, and a system of rewards and consequences can be designed to reinforce the performance goals.

Athealth.com: We hear a lot in the media that ADHD is over-diagnosed and that kids are over-medicated. Can you comment on this?

Dr. Gephart: People are certainly more aware of the disorder. Although there may be evidence of over-prescribing in some communities, one recent study concluded that, in fact, ADHD is actually under-diagnosed in the U.S., that only 50% of children with ADHD are actually being treated with stimulant medication (despite its proven effectiveness), and that for a significant number of children who are taking stimulant medication, the treatment is inadequate.

In addition, it is possible that prescribing variations could be attributed to such wide-ranging factors as inconsistent care, affluent neighborhoods where families have more resources to cover the costs of diagnosis and treatment, or a greater number of child psychiatrists and other clinicians in a community who are trained to make the diagnosis.

Athealth.com: What do you do if parents are resistant to giving their child medication?

Dr. Gephart: I think the key is to spend a lot of time conducting a careful assessment before ever talking to parents about medication and other treatment options. Most parents are eager for help, but they want to be certain that their child has been properly evaluated, and they may be resistant to certain treatments if they feel their child has not received a complete evaluation. Also, practitioners need to spend time giving parents information about the pluses and minuses of each intervention and educating families about how to manage the disorder.

In our clinic we schedule a separate appointment to discuss treatment options. For parents who don't want to use medication, we recommend parent groups, skills training, and other educational interventions.

With regard to medication, a more common problem is the ADHD teen that refuses to take his/her medication. In such situations adherence to the treatment plan is disrupted, and we have to develop strategies that encourage the teen to participate in the treatment.

Athealth.com: Is there any concern about the risk of increased substance abuse for kids taking ADHD medication?

Dr. Gephart: ADHD kids are at increased risk for substance abuse, but research indicates that ADHD kids who are on stimulant medication are not more prone to substance abuse. In fact, early treatment reduces the risk of substance abuse.

We do talk to kids about the possibility of adverse drug reactions if they use alcohol or other substances while taking their medications. Unfortunately, this doesn't necessarily mean that they refrain from the use of alcohol or drugs. The more likely result is that they may not take their medication when they are drinking.

Athealth.com: Do you find that kids share their medications with other students?

Dr. Gephart: Generally, this has not been a problem in my practice. Kids know that the medication helps them, and even though they may not like to take it, they recognize that there are benefits when they do take it.

Athealth.com: How important is it to work with the school and others who have significant contact with the child?

Dr. Gephart: It is very important. Treating an ADHD child is a team effort. Parents, teachers, nursing staff, mental health professionals, case managers, and others are essential members of the team and are critical to the success of the treatment. We also need to remember that building a therapeutic alliance with the child is an important component.

In treating ADHD we use a chronic illness treatment model as opposed to an acute illness treatment model. Consequently, treatment is usually a long-term proposition that requires the implementation of a medication schedule as well as education and behavioral interventions at home, in day care, at school, and wherever else the child spends time.

Athealth.com: Earlier you mentioned the importance of obtaining a learning assessment. Can you comment further on that?

Dr. Gephart: It is essential to determine if the child has a comorbid learning disorder. ADHD kids slowly fall behind in school. They may have normal IQs, but they frequently perform below grade level.

These kids daydream and are easily distracted. They find it hard to process language, organize their materials, and pay attention to details - tasks that are required in all educational settings. If a child is not paying attention for one-third of the day, that child is essentially missing every third day of school.

The parent or the clinician can initiate a request for a learning assessment. There are at least two federal statues that apply to children with disabilities:

The Individuals with Disabilities Education Act (IDEA) and

Section 504 of the Rehabilitation Act of 1973.

IDEA governs special education, and Section 504 provides for reasonable accommodations for children with disabilities. It is difficult to get kids into special education, but ADHD kids can receive certain accommodations such as extra time for tests, preferential seating, taking tests in a quiet room, and so on. Parents can be a great deal of help in advocating for the child on these kinds of issues.

Athealth.com: In 1999 you wrote an article entitled, The ADHD History: 42 Questions to Ask Parents (Contemporary Pediatrics 1999;10:127-128, 130-136), in which you described a list of questions that you use when evaluating a child for ADHD. Describe some of those questions.

Dr. Gephart: In my initial interview with the parents I try to ask such questions as: Does your child have a history of accidents or injuries? How does your child react to schedule changes? Does your child sit quietly when watching TV? Does anyone in the family have ADHD or learning problems? Does your child have friends? Does your child interrupt others when they are talking? What are your child's strengths? Does your child obey you? How would you describe your child's self-esteem?

These questions are not all inclusive nor are they meant to be used as a checklist for diagnosing ADHD. Rather, they are designed to flesh-out the DSM-IV criteria. For example, if I ask a parent if the child is fidgety, the parent may say, "No." However, if I ask if the child is able to sit through dinner in a restaurant, the parent may give a very different response. These more specific responses often provide information that is pertinent to the diagnosis.

Athealth.com: Do you consider one or two of the questions to be more important than the others?

Dr. Gephart: No. All of the questions used in the parent interview are important to learning about the child. However, if you really pressed me to choose a question that seems to describe a significant percentage of ADHD kids, it would be: Does your child do his/her homework and forget to turn it in?

Athealth.com: Describe how you treat a child with ADHD.

Dr. Gephart: Once the diagnosis is made, we develop a child-specific treatment plan that includes goals, methods of treatment, patient education, a system for monitoring progress, and plans for follow-up.

Athealth.com: What do you do if the child does not respond to treatment?

Dr. Gephart: If the target outcomes are not met and the child is not responsive to treatment, we re-group and try to find out why. This means reassessing the original diagnosis, evaluating the selection of medications, looking to see if all appropriate treatments have been tried, examining compliance issues, and determining if there is a co-occurring condition that we may have missed.

Athealth.com: Does the presence of ADHD in a child pose particular problems for other members of the family?

Dr. Gephart: Parents of ADHD children have a higher incidence of depression and alcohol-related disorders and are at greater risk for marital problems. Dealing with an ADHD child can place a considerable amount of stress on a family, particularly if the child's symptoms are severe. If sibling relationships are poor (and they often are), the strain on the family is increased. It is not uncommon for more than one child in a family to have the disorder.

Because ADHD is a chronic condition, families who have an ADHD child may be in for a long haul, and they have to develop long-term coping skills. Single parents are particularly hard hit since they are alone on the front line.

In addition, the disorder places a financial burden on families. Evaluation and treatment can be costly, and work schedules and careers sometimes have to be adjusted to meet the child's needs.

Athealth.com: What are some of the most significant developments in the treatment of ADHD in recent years?

Dr. Gephart:

• Despite it's limitations, the development of the DSM-IV criteria for diagnosing ADHD;
• The development of practice guidelines that help us do a better job of assessing and treating ADHD; and
• The introduction of longer-acting medications. For example, once-a-day medications help reduce the social stigma associated with ADHD because they eliminate the need to interrupt after-school activities or single out the child for a trip to the nurse's office to receive his/her medication.

Athealth.com: Are there areas that still need improvement?

Dr. Gephart: Always. We need to develop a better understanding of ADHD in girls. Additional research needs to be done with regard to the diagnosis and treatment of ADHD in adolescents. Also, there is very little information in the literature on ADHD and multicultural issues, and I hope to see some research generated in this area.

Athealth.com: Thank you for taking time to share your expertise with us.

Copyright © At Health, Inc.

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

Diagnosis of Depression in Parkinson's Disease

Bernard Ravina, MD, Emmeline Edwards, Ph.D., & Paul Sheehy, Ph.D. NINDS
Hotel Sofitel, Washington DC, December 4-5, 2003

A conference to address diagnostic issues related to depression in PD was held on December 4 and 5, 2003 in Washington DC. The conference, was sponsored by the National Institute of Neurological Diseases and Stroke (NINDS) with participation from the National Institute of Mental Health (NIMH), and was organized and moderated by Dr. Bernard Ravina of NINDS. One of the goals of the conference was to determine whether or not current diagnostic criteria for depression, as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth addition (DSM-IV), are adequate to effectively diagnose depression in PD. Another goal was to determine if currently available depression rating scales are adequate for use in PD. A fundamental question that was debated is whether or not depression in PD is different than depression in non-PD patients. The conference did not yield definitive answers, but resolved some issues and framed the approach necessary to advance our knowledge of depression in PD and, ultimately, to alleviate suffering in affected patients and their loved ones. The participants in the meeting included psychiatrists, psychologists, neurologists and a statistician, who all brought vast and diverse experience to the table. There were formal presentations and lively discussions. The presentations included overviews of the clinical characteristics, causes and classification/measurement of depression in PD. Several participants reviewed research studies in which currently available diagnostic criteria and depression rating scales were used in PD populations.

An Overview of Depression in Parkinson's Disease

Studies indicate that almost half of all PD patients will experience depression at some point in their illness. Depression is different from normal sadness that everyone experiences on occasion. Depression is an illness characterized by sad mood and/or diminished ability to enjoy things accompanied by other symptoms such as changes in appetite, problems sleeping or excessive sleepiness, decreased energy level, slowed movements and poor concentration. At times, patients can have recurrent thoughts of death or that life is not worth living. Depression is generally diagnosed when these symptoms have been present every day for at least two weeks. It has been shown that depression in PD is a leading factor contributing to reduced quality of life (more so than the motor features). Most research suggests that depression in PD is caused by biological changes related to the underlying brain disease, rather than solely a reaction to disability.

Difficulties Associated with Diagnosing Depression in PD

It can sometimes be difficult to make a diagnosis of depression in the setting of PD. This is, in part, because many symptoms of depression (e.g. slowed movements, sleep disturbances) may also be seen in non-depressed PD patients. It is also not clear how closely depression in PD resembles depression seen in non-PD patients. Furthermore, there are some aspects of PD that must be kept in mind when attempting to evaluate depression in PD. For example, many patients with PD who have fluctuations in their motor function also have fluctuations in their mood. These individuals may look and act very differently depending on their motor and mood state.

The reasons for ensuring diagnostic accuracy include the following:

• To make sure that we are capturing all depressed PD patients with our current criteria so that they be diagnosed and treated.

• PD patients may have "atypical" features to their depression (such as more anxiety or less guilt than depressed people without PD)

• Many PD patients have less severe (but none-the-less distressing) symptoms and they would not meet current criteria for the diagnosis of a depressive syndrome These patients are sometimes referred to as having "subsyndromal" depression.
• To make sure that we are not diagnosing depression based on symptoms that, while part of the current depression criteria are not due to depression in those particular patients. Symptoms that can be seen in both depressed and non-depressed PD patients include sleep disturbance, apathy, diminished concentration and slowed thinking and movements.

Some participants suggested excluding these symptoms from the current diagnostic criteria but others argued that modifying the criteria would be premature because we lack evidence on which to base any change in existing criteria. For example, we really don't know for sure that PD patients with depression are any more anxious than other patients who are the same age, nor do we know if (and to what extent) symptoms such as sleep disturbance and diminished concentration are part of the depressive syndrome in PD.

Depression Rating Scales

Another goal of the meeting was determine whether or not current depression rating scales are adequate in this population. Rating scales can either be self-administered (e.g. Beck Depression Inventory) or administered by an examiner in the form of an interview (Hamilton Depression Rating Scale). Rating scales are not used to diagnose depression. Their uses include the following:

• to screen people for the presence of depression (patients obtaining a certain score or higher are then interviewed to determine whether or not they have depression), 

• to measure the severity of depression in patients who have already been diagnosed, 

• to measure what effects treatments for depression are having on the symptoms of the illness. 

Several participants reviewed the use of various depressions rating scales in PD and provided some fairly compelling evidence that, the existing scales are both valid (are measuring what they are supposed to measure) and reliable (measure the same thing each time they are used). It was the consensus of the group that the examiner should count every symptom, rather than try to determine whether or not a symptom is due to depression or due to some other aspect of PD. For example, patients with problems sleeping would get points on the rating scales for sleep disturbances, regardless of whether their insomnia was perceived to be due to worrying or tremor.

Treatment of Depression in PD

The meeting did not address treatment of depression in PD but the group agreed that we need to 1) increase awareness of depression in PD and 2) determine the best way to treat PD patients with depression. Despite the large number of PD patients suffering from depression, there have been no rigorous studies of antidepressant medications in this disease. Fortunately, one clinical trial is underway and another multicenter clinical trial is planned to start in April 2004.

Source: National Institute of Neurological Disorders and Stroke

Last updated November 05, 2004

Last reviewed by athealth.com on February 3, 2014

What are dissociative disorders?

A dissociative disorder is the breakdown of one's perception of his/her surroundings, memory, identity, or consciousness.

There are four main kinds of dissociative disorders:

• Dissociative amnesia
• Dissociative fugue
• Dissociative identity disorder (previously called multiple personality disorder)
• Depersonalization disorder

What are the main characteristics of each dissociative disorder?

Dissociative amnesia:

A dissociative amnesia may be present when a person is unable to remember important personal information, which is usually associated with a traumatic event in his/her life. The loss of memory creates gaps in this individual's personal history.

Dissociative fugue:

A dissociative fugue may be present when a person impulsively wanders or travels away from home and upon arrival in the new location is unable to remember his/her past. The individual's personal identity is lost because that person is confused about who he/she is. The travel from home generally occurs following a stressful event. The person in the fugue appears to be functioning normally to other people. However, after the fugue experience, the individual may not be able to recall what happened during the fugue state. The condition is usually diagnosed when relatives find their lost family member living in another community with a new identity.

Dissociative identity disorder:

Dissociative identity disorder was formerly called "multiple personality disorder." When a person intermittently experiences two or more identities, he/she may have a dissociative identity disorder. While experiencing a new identity, a separate personality takes control, and the person is unable to remember important and personal information about himself/herself. Each personality has its own personal history and identity and takes on a totally separate name.

Depersonalization disorder:

Feelings of detachment or estrangement from one's self are signs of depersonalization. Although these feelings are difficult to describe, individuals with this disorder will report feeling as if they are living in a dream or watching themselves on a movie screen. They feel separated from themselves or outside their own bodies. People with this disorder feel like they are "going crazy" and they frequently become anxious and depressed.

Are there genetic factors associated with dissociative disorders?

Yes, people with dissociative identity disorder usually have close relatives who have also had similar experiences.

Do dissociative disorders affect males, females, or both?

Females are more frequently affected. More than five times as many women than men have problems with dissociative identity disorder.

At what age do dissociative disorders appear?

Dissociative amnesia is generally a problem in adulthood, but it can be found in children and adolescents.

Dissociative fugue happens mostly during adulthood

Dissociative identity disorder occurs most frequently in adulthood.

Depersonalization disorder usually occurs during late adolescence or adulthood.

How often is a dissociative disorder seen in our society?

Dissociative disorders are uncommon. However, there has been significant interest in dissociative amnesia in the past few years. Much of the interest has been related to forgotten childhood traumas and repressed memories. There is considerable debate regarding the authenticity of repressed memories.

How are dissociative disorders diagnosed?

A mental health professional makes a diagnosis of a dissociative disorder by taking a careful personal history from the client/patient and family members. It is important that the therapist learn the details of the person's life. No laboratory tests are required to make a diagnosis of dissociative disorder nor are there any physical conditions that must be met. However, it is very important not to overlook a physical illness that might mimic or contribute to a psychological 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 the various dissociative disorders treated?

The treatment for dissociative amnesia is therapy aimed at helping the client/patient restore lost memories as soon as possible. If a person is not able to recall the memories, hypnosis or a medication called Pentothal (thiopental) can sometimes help to restore the memories. Psychotherapy can help an individual deal with the trauma associated with the recalled memories.

Hypnosis is often used in the treatment of dissociative fugue. Hypnosis can help the client/patient recall his/her true identity and remember the events of the past. Psychotherapy is helpful for the person who has traumatic, past events to resolve.

Treatment for dissociative identity disorder involves long-term psychotherapy that helps the person merge his/her multiple personalities into one. The trauma of the past has to be explored and resolved with proper emotional expression. Hospitalization may be required if behavior becomes bizarre or destructive.

Treatment for depersonalization disorder is very difficult. However, the condition can improve with a thorough therapeutic exploration of the trauma in the individual's past and the expression of the emotions associated with that trauma.

What happens to people with dissociative disorders?

Dissociative amnesia: The length of an event of dissociative amnesia may be as short as a few minutes or as long as several years. If the episode is associated with a traumatic event, the amnesia may clear when the individual is removed from the traumatic situation.

Dissociative fugue: Once dissociative fugue is discovered and treated, many people recover quickly. The problem may never occur again.

Dissociative identity disorder: The course of dissociative identity disorder tends to recur over several years. It may become less of a problem, however, after mid-life.

Depersonalization disorder: An episode of depersonalization disorder can be as brief as a few seconds or continue for several years.

What can people do if they need help?

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

Author: John L. Miller, MD

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

Self-Esteem - Definition

Even though a vast quantity of theory, research, and commentary on the construct of self-concept has been produced since William James first introduced the notion more than one hundred years ago, the construct and its manifestations remain elusive. As Harter (1983) points out, constructs that are related to the construct of self-concept are also usually described by hyphenated terms such as self-worth, self-esteem, self-assurance, and self-regard.

Bednar, Wells, and Peterson (1989) define self-esteem "as a subjective and realistic self-approval" (p. 4). They point out that "self-esteem reflects how the individual views and values the self at the most fundamental levels of psychological experiencing" (p. 4) and that different aspects of the self create a "profile of emotions associated with the various roles in which the person operates...and [that self-esteem] is an enduring and affective sense of personal value based on accurate self-perceptions." According to this definition, low self-esteem would be characterized by negative emotions associated with the various roles in which a person operates and by either low personal value or inaccurate self-perceptions.

Furthermore, Bednar et al. describe paradoxical examples of individuals of substantial achievement who report deep feelings of low self-esteem. The authors suggest that a theory of self-esteem must take into account the important role of an individual's "self-talk and self-thoughts" as well as the perceived appraisal of others (p. 11). They conclude that "high or low levels of self-esteem...are the result and the reflection of the internal, affective feedback the organism most commonly experiences" (p. 14). They point out that all individuals must experience some negative feedback from their social environment, some of which is bound to be valid. Thus a significant aspect of the development and maintenance of self-esteem must address how individuals cope with negative feedback.

Bednar et al. suggest that, if individuals avoid rather than cope with negative feedback, they have to devote substantial effort to "gain the approval of others by impression management, that is, pretending to be what we believe is most acceptable to others" (p. 13; italics theirs). If individuals respond to negative feedback by striving to manage the impressions they make on others to gain their approval, they also have to "render most of the favorable feedback they receive [as] untrustworthy, unbelievable, and psychologically impotent because of their internal awareness of their own facade" (p. 13). This preoccupation with managing the impression one makes on others is a behavior characteristic usually included in definitions of narcissism.

Developmental Considerations

For very young children, self-esteem is probably best thought to consist of deep feelings of being loved, accepted, and valued by significant others rather than of feelings derived from evaluating oneself against some external criteria, as in the case of older children. Indeed, the only criterion appropriate for accepting and loving a newborn or infant is that he or she has been born. The unconditional love and acceptance experienced in the first year or two of life lay the foundation for later self-esteem, and probably make it possible for the preschooler and older child to withstand occasional criticism and negative evaluations that usually accompany socialization into the larger community.

As children grow beyond the preschool years, the larger society imposes criteria and conditions upon love and acceptance. If the very early feelings of love and acceptance are deep enough, the child can most likely weather the rebuffs and scoldings of the later years without undue debilitation. With increasing age, however, children begin to internalize criteria of self-worth and a sense of the standards to be attained on the criteria from the larger community they observe and in which they are beginning to participate. The issue of criteria of self-esteem is examined more closely below.

Cassidy's (1988) study of the relationship between self-esteem at age five and six years and the quality of early mother-child attachment supports Bowlby's theory that construction of the self is derived from early daily experience with attachment figures. The results of the study support Bowlby's conception of the process through which continuity in development occurs, and of the way early child-mother attachment continues to influence the child's conception and estimation of the self across many years. The working models of the self derived from early mother-child inter-action organize and help mold the child's environment "by seeking particular kinds of people and by eliciting particular behavior from them" (Cassidy, 1988, p. 133). Cassidy points out that very young children have few means of learning about themselves other than through experience with attachment figures. She suggests that if infants are valued and given comfort when required, they come to feel valuable; conversely, if they are neglected or rejected, they come to feel worthless and of little value.

In an examination of developmental considerations, Bednar, Wells, and Peterson (1989) suggest that feelings of competence and the self-esteem associated with them are enhanced in children when their parents provide an optimum mixture of acceptance, affection, rational limits and controls, and high expectations. In a similar way, teachers are likely to engender positive feelings when they provide such a combination of acceptance, limits, and meaningful and realistic expectations concerning behavior and effort (Lamborn et al., 1991). Similarly, teachers can provide contexts for such an optimum mixture of acceptance, limits, and meaningful effort in the course of project work as described by Katz and Chard (1989).

Many teachers feel compelled to employ the questionable practices described above as strategies to help children who seem to them not to have had the kind of strong and healthy attachment experiences in their early years that support the development of self-esteem. While such children may not be harmed by exercises that tell them they are special or by constant praise and flattery, the argument here is that they are more likely to achieve real self-esteem from experiences that provide meaningful challenge and opportunities for real effort.

The Cyclic Nature of Self-Esteem

The relationships between self-evaluation, effort, and reevaluation of the self suggest a cyclic aspect to the dynamics of self-esteem. Harter (1983) asserts that the term self-worth is frequently used to refer to aspects of motivation and moods. High self-esteem is associated with a mood of cheerfulness, feelings of optimism, and relatively high energy. Low self-esteem is accompanied by feelings of doubt about one's worth and acceptability, and with feeling forlorn, morose, or even sad. Such feelings may be accompanied by relatively low energy and weak motivation, invariably resulting in low effort. In contrast, high self-esteem is associated with high energy, which increases effectiveness and competence, which in turn strengthen feelings of self-esteem and self-worth. In this way, feelings about oneself constitute a recursive cycle such that the feelings arising from self-appraisal tend to produce behavior that strengthens those feelings-both positive and negative.

The cyclic formulation of self-esteem is similar to Bandura's (1989) conception of self-efficacy, namely, processes by which perceptions of one's own capacities and effective action "affect each other bidirectionally" (p. 1176). In other words, effective action makes it possible to see oneself as competent, which in turn leads to effective action, and so forth. The same cycle applies to self-perceptions of incompetence. However, Bandura (1989) warns that a sense of personal efficacy [does] not arise simply from the incantation of capability. Saying something should not be confused with believing it to be so. Simply saying that one is capable is not necessarily self-convincing, especially when it contradicts preexisting firm beliefs. No amount of reiteration that I can fly will persuade me that I have the efficacy to get myself airborne and to propel myself through the air. (p. 1179)

This formulation of the dynamics of feelings about the self confirms the view that self-esteem merits the concern of educators and parents. Nevertheless, it also casts some doubt on the frequent assertion that, if children are somehow made to "feel good about themselves," success in school will follow. In other words, just because young children need to "feel good about themselves," telling them that they are special (e.g., because they can color) or that they are unique, and providing them with other similar flattery may not cause them to believe they are so or engender in them good feelings about themselves.

Dunn's (1988) view of the nature of self-esteem is that it is related to the extent to which one sees oneself as the cause of effects. She asserts that "the sense of cause [is] a crucial feature of the sense of self" and the essence of self-confidence is the feeling of having an effect on things and being able to cause or at least affect events and others. On the other hand, feeling loved by the significant others in one's environment involves feeling and knowing that one's behavior and status really matter to them-matter enough to cause them to have real emotion and to provoke action and reaction from them, including anger and stress as well as pride and joy.

Criteria of Self-Esteem

It is reasonable to assume that self-esteem does not exist in a vacuum, but is the product of evaluating oneself against one or more criteria and reaching expected standards on these criteria. These evaluations are unlikely to be made consciously or deliberately, but by means of preconscious or intuitive thought processes. It is likely that these criteria vary not only between cultures and subcultures, but also within them. The criteria may also vary by gender. Furthermore, the standards within a family, subculture, or culture that have to be met on these criteria may also vary by gender. For example, higher standards on a criterion of assertive-ness may be required for self-esteem in males than in females. In addition, the criteria against which the worth and acceptability of an individual are estimated may carry different weights across cultures, subcultures, and families, and for the sexes. Criteria may have different weighting for different families, some giving more weight in their total self-esteem to physical appearance, and others to personal traits or teacher acceptance, for example.

Criteria for self-esteem frequently employed in American self-concept research include physical appearance, physical ability, achievement, peer acceptance, and a variety of personal traits (Harter, 1983). As is indicated in the discussion below, Western and Eastern cultures vary in how the self is defined and the criteria against which the self is estimated. These sources of variation imply that some children are likely to have acquired criteria of self-esteem at home and in their immediate community that differ from those assumed valuable in the classroom and in the school.

One of the many challenges teachers face in working with young children of diverse backgrounds is to help them understand and come to terms with the criteria of self-esteem applicable in the class and school without belittling the criteria advocated and applied at home. While it is not appropriate for schools to challenge the criteria or standards of self-esteem of children's families, careful consideration of those self-esteem criteria advocated within the school is warranted.

To the extent that one's self-esteem is based on competitive achievement, it can be enhanced by identifying other individuals or groups who can be perceived as lower or inferior to oneself in achievement. If, for example, schools convey to children that their self-esteem is related to their academic achievement as indicated by the results of competitive grading practices, then a significant proportion of children, ipso facto, must have low self-esteem-at least on that criterion. In such a school culture the development of cooperation and intergroup solidarity becomes very problematic. Also, if competitive academic achievement is highly weighted among not only the school's criteria of self-esteem but also the criteria of the culture as a whole, a substantial proportion of school children may be condemned to feel inadequate. An adaptive response of children at the low end of the distribution of academic achievement might be to distance themselves from that culture and to identify and strive to meet other criteria of self-esteem, such as the criteria of various peer groups, that may or may not enhance participation in the larger society. To avoid these potentially divisive effects of such competitive and comparative self-evaluations, the school should provide contexts in which all participants can contribute to group efforts, albeit in individual ways. A substantial body of research indicates that cooperative learning strategies and cooperative goals are effective ways to address these issues (see Ames, 1992).

The matter of what constitute appropriate criteria of self-esteem cannot be settled empirically by research or even theory. These criteria are deeply imbedded within a culture, promoted and safeguarded by the culture's religious, moral, and philosophical institutions.

Although, as stated earlier, it is important to value an infant simply for the fact that he or she has been born, if criteria for self-esteem that are applied later in the child's life include characteristics that are present at birth-such as one's nationality, race, or gender-then the ability of all citizens to achieve self-esteem in a society of diverse groups, especially when one group is culturally or otherwise dominant, is problematic. Furthermore, as suggested above, if children are taught to base their self-appraisals on favorable comparisons of themselves with others, then the identification of inferior others, whether individuals or groups, may become endemic in a society. When the two tendencies-to base self-esteem on characteristics that are present at birth and to elevate one's self-appraisal by identifying others who are inferior on any given criterion-occur together in a society, conditions develop which are likely to support prejudice and oppression.

If, on the other hand, the criteria address personal attributes that are susceptible to individual effort and intention, such as contributing to one's community, then all citizens have the potential to achieve feelings of self-worth, self-respect, and dignity. Thus, while a person's nationality might not be an appropriate basis of self-esteem, accepting responsibility for the conduct of one's nation in the world and contributing to the welfare of one's nation might be appropriate bases for positive self-appraisal. In any case, the designation of appropriate criteria is not primarily the responsibility of educators, but of the moral institutions of the community and culture at large that educators are duty-bound to support.

This view that nationality in and of itself may be a faulty basis for self-esteem is not to deny the value and desirability of love of country or patriotism, both of which contribute to involvement in the country's welfare. Nor should this view be interpreted as belittling civic and national pride, which can motivate and mobilize efforts to work on behalf of one's community and country.

A related issue is the role of reflected glory in self-esteem, which has both apparently inappropriate and potentially beneficial effects. Should individuals' self-esteem be influenced by the performance of their hometown football team or their country's Olympic teams? According to research on "basking in reflected glory" (BIRGing) reported by Cialdini (1974, 1976), Lee (1985), and Kowalski (1991), the tendency to strengthen one's association with those who are visibly successful and to distance oneself from those who have experienced obvious failures as means of self-enhancement is a common phenomenon. Inasmuch as a sports fan makes no real contribution to the team's performance, that performance would seem to be an inappropriate source of either pride or shame and of fluctuations in the fan's self-esteem. On the other hand, the capacity to experience reflected glory and reflected shame might provide powerful motivation for community action. Action on behalf of one's community would seem to be a legitimate basis for self-esteem.

While the issues are complex, the main argument here is that if personal attributes that are present by virtue of birth alone, without individual effort and contribution, are a source of self-esteem beyond the first few years of life, individuals born without these attributes must see themselves as lacking or low in self-worth; therefore, such attributes seem to be inappropriate criteria for self-esteem.

Situational Determinants of Self-Esteem

Bednar, Wells, and Peterson (1989) state that there may be a "situated" as well as a "general" self-identity (p. 39), suggesting that self-esteem may vary from one interpersonal situation to another. In other words, although the overall context of experience may remain constant, changes in interpersonal situations can cause reassessments of the self. For example, a teacher might have a fairly high estimation of herself in the context of teaching her own class, but when the interpersonal situation changes by the entrance of a colleague or the principal or a parent, she may shift her estimation or self-rating-probably downward! Although the teacher is exactly the same person five minutes before the intrusion as she is five minutes afterwards, the change in self-esteem is created by the teacher herself when she attributes greater significance to the other's assessment of herself than to her own assessment. On the other hand, if the other person's assessment is based on greater knowledge, experience, and expertise, the teacher could consider herself informed or instructed by that assessment rather than simply accorded lower esteem.

Shifts in self-estimation based on the assessments of significant others may be developmentally appropriate for young children. In an adult, however, revision of self-estimation based on the perceived or imagined assessments of another adult that are at variance with one's own requires placing oneself in the role of child with respect to the other adult. The essence of self-esteem for mature adults is to take seriously the assessments of others, but not to take them more seriously than they take their own self-assessments.

While adults can seek contexts and interpersonal situations that maximize their self-esteem and can strive to avoid those that minimize it, children are at the mercy of the situations in which adults place them. Inasmuch as young children vary in background, abilities, culture, and so forth, a wide rather than narrow range of interpersonal situations should be provided for them. In other words, an early childhood program is most likely to enhance children's self-esteem and their capacities to deal with inevitable fluctuations in self-esteem when a variety of types of interpersonal situations is available to them.

Rosenholtz and Simpson (1984) addressed this issue in terms of the variety of dimensions of children's behavior to which teachers assign importance in a classroom. They define classes in which a limited range of child behavior is accepted, acknowledged, and rewarded as unidimensional. Multidimensional classes are those in which teachers provide a wide range of ways for children to contribute to and participate in the classroom life and in which a range of behavior is accepted, rewarded, and acknowledged. Rosenholtz and Simpson suggest that the unidimensional classroom limits opportunity for self-enhancement, and the multidimensional classroom makes it possible for many if not all pupils to find ways to enhance their feelings of self-esteem and self-worth. Multidimensionality in the classroom can be fostered when teachers include as part of the curriculum the kinds of projects described by Katz and Chard (1989) in which a wide range of activities of intellectual, social, aesthetic, and artistic value is included.

Cultural Variations

Markus and Kitayama (1991) point out that the construal of the self varies among cultures and that Americans and other Westerners typically construe the self as an independent, bounded, unitary, stable entity that is internal and private. On the other hand, they assert that in non-Western cultures such as those in Asia and Africa the self is construed as interdependent, connected with the social context, flexible, variable, external, and public. Westerners view the self as an autonomous entity consisting of a unique configuration of traits, motives, values, and behaviors. The Asian view is that the self exists primarily in relation to others, and to specific social contexts, and is esteemed to the extent that it can adjust to others, maintain harmony, and exercise the kind of restraint that will minimize social disruption.

According to Markus and Kitayama (1991), these contrasting culture-bound construals of the self have significant consequences for cognition, affect, and motivation. Asian children must learn that positive feelings about the self should derive from fulfilling tasks associated with the well-being of relevant others. On the other hand, Western children have to learn that the self consists of stable dispositions or traits and that "they must try to enhance themselves whenever possible...taking credit for success...explaining away their failures, and in various ways try to aggrandize themselves" (p. 242). Eventually American children must learn that "maintaining self-esteem requires separating oneself from others and seeing oneself as different from and better than others" (p. 242). According to this formulation, Americans cannot perceive themselves as better than others without describing the others as worse than themselves. When one's own self-esteem is the result of comparison processes, its maintenance may contribute to constant wariness of the risk of coming out poorly in such comparative assessments of self-worth. At worst, such sources of self-esteem may contribute to a need to identify lesser or inferior others-either individuals or groups. At best, they may contribute to excessive competitiveness and may distract individuals from giving their full attention to the tasks at hand, thereby depressing their learning and effectiveness. Developmental studies reviewed by Markus and Kitayama (1991) indicate that self-enhancement and self-promotion are perceived negatively in Japan and that, although not apparent in the early years, by fifth grade Japanese children have learned that it is unwise to gloat over their accomplishments or to express confidence in their own ability. Research indicates that as children are socialized in an interdependent cultural context, they begin to appreciate the cultural value of self-restraint and, furthermore, to believe in a positive association between self-restraint and other favorable attributes of the person not only in the social, emotional domains but also in the domains of ability and competence. (p. 242)

The distinctions between the Western independent and the non-Western interdependent construal of the self indicate that the sources of self-esteem are also distinctive. For Westerners, independent self-esteem is achieved by actualizing one's own attributes, having one's accomplishments validated by others, and being able to compare oneself to others favorably. In Asian and other non-Western cultures, self-esteem is related to self-restraint, modesty, and connectedness with others. Stevenson and his colleagues (Stevenson, Lee, Chen, Lummis, Stigler, Fan, & Ge, 1990; Stevenson, Lee, Chen, Stigler, Hsu, & Kitamura, 1990) have noted that American children appear to have more positive conceptions of their mathematical abilities than Asian children do, even though the latter actually perform much better than the former. Such findings must be interpreted in light of the cultural differences of the two groups. Asian children apparently learn early that pride in one's strengths is interpreted as gloating and is unacceptable; American children are encouraged to be proud of their accomplishments. Frequent exhortations to "feel good about oneself" and to see oneself as "special" may contribute to the unrealistic self-appraisals reported by Stevenson and his colleagues.

Along similar lines, Trafimow, Triandis, and Goto (1991) distinguish between private and collective aspects of the self, arguing that the private self is emphasized more in individualistic cultures such as in North America and parts of Europe and that the collective aspects of the self are emphasized more in collectivistic cultures such as those of East Asia. These contrasts suggest that, while self-esteem seems to be important in all cultures, it is achieved in diverse ways in different cultures.

The practices described earlier in this discussion that are intended to help children achieve and maintain high self-esteem (e.g., "All About Me" books and "I am Special" celebrations) may inadvertently cultivate narcissism-not in its pathological form as the term is used in psychiatric diagnoses, but as a general disposition. These school practices may be symptomatic of our larger culture, described by several observers as having many of the attributes of a narcissistic society (Lasch, 1979; Wallach & Wallach, 1985). Lowen (1985) claims that when success is more important than self-respect, the culture itself overvalues image and is narcissistic, and further that narcissism denotes a degree of unreality in individuals and the culture.

Our culture seems almost obsessed with the image one projects to others. Many of our political leaders use expressions like not wanting their actions "to appear to be improper" rather than not wanting them to be improper. At the beginning of the Gulf War crisis, President Bush said, "We have to appear to be strong" rather than that we have to be strong, suggesting that momentous decisions are based as much or more upon appearances than upon actualities. The term impression management has indeed entered into the national vocabulary!

A related manifestation of confusing images with reality is explored thoughtfully by Kakutani under the heading "Virtual Confusion: Time for a Reality Check." Kakutani (1992) points out that "ardent soap opera viewers routinely confuse their favorite characters with the actors who play them...and send 'CARE' packages to actors who play impoverished characters" (p. B2).

Narcissism - Definition

According to Lowen (1985), narcissism refers to a syndrome characterized by exaggerated investment in one's own image versus one's true self and in how one appears versus how one actually feels. Dispositions often mentioned in definitions of narcissism as being characteristic of narcissism include dispositions to behave in seductive and manipulative ways, to strive for power, and to sacrifice personal integrity for ego needs. Adults diagnosed as suffering from the narcissism syndrome often complain that their lives are empty or meaningless, and they often show insensitivity to the needs of others. Their behavior patterns suggest that notoriety and attention are more important to them than their own dignity.

According to Emmons (1987), narcissism is characterized by being self-absorbed, self-centered, or selfish, even to the extent that it "may lessen individuals' willingness to pursue common social objectives...[and] increase potential for social conflict...on a group level" such as occurs with "excessive ethnocentrism" (p. 11). As part of the definition of narcissism in adults, Emmons refers to the tendency to "accept responsibility for successful outcomes and deny blame for failed outcomes" (p. 11). According to some specialists, narcissism includes a preoccupation with fantasies about unlimited success, power, and beauty, plus a grandiose sense of self-importance. Raskin, Novacek, and Hogan (1991) interpret their experimental findings to mean that narcissistic behaviors are defenses against, or defensive expression of, threatening emotions such as anger, anxiety, and fear. Anger, hostility, and rage seem central to the emotional life of the narcissist; consequently, narcissistic behaviors may allow the expression of these emotions in a way that protects a sense of positive self-regard. (p. 917)

Narcissists are also sometimes described as exhibitionistic, requiring constant attention and admiration, often believing that they are entitled to special favors without the need to reciprocate. They tend to exploit others, to be seekers of sensations, experiences, and thrills, and to be highly susceptible to boredom. Many of these characteristics of narcissism seem to apply to our culture in general and to many of our youth in particular.

Wink (1991) suggests that narcissism takes at least two major forms. The classical form is indicated by excessive need for admiration, frequent exhibitionism, conceit, and a tendency toward open expression of grandiosity-commonly referred to as "being a bit too full of oneself." Wink calls the second form "covert narcissism," in which individuals "appear to be hypersensitive, anxious, timid, and insecure; but on close contact surprise others with their grandiose fantasies" (p. 591). They tend to be exploitative and to over-interpret others' behavior as caused by or directed to themselves rather than to others.

In sum, healthy self-esteem refers to realistic and accurate positive appraisals of the self on significant criteria across a variety of interpersonal situations. It also includes the ability to cope with the inevitability of some negative feedback. By contrast, unhealthy self-esteem, as in narcissism, refers to insensitivity to others, with excessive preoccupation with the self and one's own image and appearance in the eyes of others.

Adapted from: Distinctions between Self-Esteem and Narcissism: Implications for Practice
Author: Lilian G. Katz
October 1993
Accessed: http://ceep.crc.uiuc.edu/eecearchive/books/selfe.html [2009, January 8].

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

Have you ever thought of yourself as one of the meek who will inherit the earth? Or maybe you're the type of person who notices that people cower when you come near. Well, imagine a mad scientist combining these two individuals together to create a happy medium. This happy medium can be thought of as assertiveness.

Assertiveness is a manner of behaving that communicates respect for others as well as commands respect for yourself.

When you are assertive, you are able to:

• Express and communicate your feelings accurately.
• Ask for things you want.
• Say no to things you do not want.
• Have the opportunity to have your needs and wants met.
• Attain the respect of others.

People often fall into one of three primary modes of behavior: Passive, Assertive, and Aggressive.

Passive people:

• Tend to give in to other people's wishes while forgetting their own needs and wants.
• Have a difficult time saying no to people.
• Often have a hard time making decisions.
• Have a hard time maintaining eye contact.
• Avoid confrontation at all costs (e.g. not speaking up when the waiter brings you fish instead of chicken).

Aggressive people:

• Tend to be concerned only for their needs at the expense of others' needs.
• Have a tendency to lose their temper.
• May make decisions for other people.
• May shout or use bully techniques to get their way.
• May continue to argue long after someone has had enough.
• May call others names or even use obscenities when angry.
• May openly criticize or find fault with others ideas, opinions, or behaviors.
• Often use confrontation to get what they want.

Assertive people:

• Are concerned with both their needs as well as other people's needs.
• Are openly able to express themselves with other people.
• Are able to respond in a respectful manner when there is a disagreement.
• Are able to ask for help.
• Are confident and able to make decisions.
• Are able to say no to people/places/things they do not want.
• Are responsible for their own feelings/behaviors/thoughts.

Not everyone is assertive in all situations.

Try to identify the situations in which you behave in a non-assertive manner.

• When are you non-assertive? (not asking for help, not stating an opposing opinion, not expressing a negative feeling).
• Who are you non-assertive with? (boss, salespeople, girlfriend/boyfriend, etc)
• What have you been unable to achieve as a result of your non-assertiveness? (missed out on meeting new relationships, lost job opportunities. etc.)

How can I develop more assertiveness?

In order to respond assertively try phrasing your request using what is called a DESC script. The DESC script was developed by Sharon and Gordon Bower and is discussed more fully in their book, Asserting Yourself. DESC stands for Describe, Express, Specify, and Consequences.

Try practicing the script for several situations that you just identified. You should try writing the script out and practicing it before you talk to the person.

• Describe. Describe the behavior/situation as completely and objectively as possible. Just the facts! "The last time, my brother George came to visit, I cleaned the entire house all by myself."
• Express. Express your feelings and thoughts about the situation/behavior. Try to phrase your statements using "I", and not "You". Beginning sentences with "You" often puts people on the defensive, which means they won't listen to you. "As a result, I felt exhausted and angry."
• Specify. Specify what behavior/outcome you would prefer to happen. "I would like the two of us to work on cleaning the house."
• Consequences. Specify the consequences (both positive and negative). "If we both work together, the house will be cleaned up faster and we can all enjoy his visit together." Or "If we work together, I will be less tired and irritable."

How to Say NO and mean it.

Saying no is an important component of learning to be assertive. It helps to develop boundaries, which can safeguard your time and energy. In some cases, saying no effectively may even help keep you safe from harm.

Edmund Bourne, PhD, in his book, The Anxiety and Phobia Workbook, has developed a way to effectively say no to both people who are close to you, and to those with whom you do not wish to have further contact.

Saying no to family/friend

• Repeat their request. "I would love to go to the game with you."
• Explain your reason for stating no. "I have a deadline on Monday, so I have lots of work to do."
• Say no. "So I'll have to say no."
• If necessary, suggest an alternative that is acceptable to the two of you. "I would love to go another time, how about next Friday."

Saying no, to a person that you do not want to be friends with, or who seems "unsafe"

• Simply saying "No" or "No thank you" is all that is needed. You may need to repeat "No" again. With these individuals you may not want to engage in any further conversation where you feel pressured to concede to their wishes.
• Pay attention to your nonverbal behavior. Use good eye contact, stand tall, shoulders back, etc. If you're slumped over you can't adequately assess the situation.

Remember: If you have been behaving passively for a long time, you might be tempted to move over into the aggressive mode of operating. This often happens after you've buried situations for so long that you turn into a powder keg. Just realize that learning to be assertive takes practice, and it's O.K. to make a few mistakes along the way. Despite what people tell you, you are human, so keep on trying these new skills.

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

Page last modified/reviewed by athealth on January 29, 2014

Ben and Jerry did it with Pillsbury. Engineer Allan MacDonald did it with NASA. Dan Rather did it with Richard Nixon. Columnist Ellen Goodman, however, admits it didn't work with the carpet cleaner.

How about you? Can you hold your own when confronted with difficult people and situations? Are you "too polite" to hang up on obnoxious telemarketers? Are you stuck at the bottom of the "pecking order" at work? Can you stand up to the office bully when he tries to intimidate you to get his way?

"We all need 'survival tactics' - ways to respond when others are trying to push us around," say California psychologists Robert Alberti and Michael Emmons. "Nobody likes that one-down feeling that comes when you can't quite express what you really want. But when problems come up in social situations, too many people assume their only choices are to be pushy or be pushed. Manipulating others is not the answer to personal powerlessness."

"There's a huge difference between appropriate self-expression -- assertion -- and pushing others around -- destructive aggression," Alberti explains. "Assertiveness is, first and foremost, a matter of personal choice. If you know how to act assertively, you are free to choose whether or not you will."

"You'll need to learn new attitudes and skills for handling social situations that have been problems for you," adds Emmons. "The key is to focus on equal-relationship assertiveness." Bottom line: Don't put others down to put yourself up.

So how do you learn to be effectively assertive? "The same way you get to Carnegie Hall: Practice, practice, practice," quips Alberti, an amateur trombonist.

• Start by recognizing that it's okay to speak up for yourself.
• Learn the basic skills (it's not what you say, it's how you say it).
• Work to overcome obstacles, including your own inhibitions.
• Practice your new skills in non-threatening situations first, with a coach, if possible.

Dealing with others when you're not face-to-face is a little different, of course. "The new media of communication - online, cell phones, social networking, and more - demand more than ever that individuals have the skills to express themselves - and defend themselves when necessary - even in situations when you're not in direct contact," Alberti points out.

Recognized as experts in the field of self-expression, the pair have advocated, taught and written about assertiveness as a tool for promoting equality in human relationships for nearly four decades. Their work has been widely acclaimed for its contribution to such varied fields as civil rights, corporate management, and individual self-development.

Alberti and Emmons are authors of the international best-seller, Your Perfect Right: Assertiveness and Equality in Your Life and Relationships. Their guide to "standing up for yourself" without stomping on the rights of others was published in May 2008 in a completely revised and updated ninth edition (Impact Publishers).

The book, with over 1.3 million copies sold since the first edition in 1970, is the assertiveness training guide most widely recommended by psychologists and other professional therapists, and includes detailed procedures, examples, stories and exercises. Your Perfect Right was ranked fifth among all self-help books in a national survey of psychologists reported in American Journal of Psychotherapy, Psychology Today, and The New York Times.

The new edition has been thoroughly updated and expanded with extensive discussions of email and social networks, social intelligence, personal boundaries, persistence, recent brain research, anger expression, dealing with social anxiety, giving and receiving criticism, facial expression research, and what to do when assertiveness doesn't work.

And the authors don't limit their approach solely to individual behavior. "Ultimately," Drs. Alberti and Emmons point out, "those acts which are in the best interest of our fellow humans are in our own best interests as well. Effective assertive communication can build positive, equal relationships between people - the most valuable assets any human being can have."

Robert E. Alberti, PhD, is a psychologist, editor, consultant, Fellow of the American Psychological Association, and Clinical Member of the American Association for Marriage and Family Therapy. Michael L. Emmons, PhD, is a psychologist in private practice and consultant to educational, government and business organizations.

Adapted from Your Perfect Right: Assertiveness and Equality in Your Life and Relationships (Ninth Edition) , by Robert E. Alberti, PhD, and Michael L. Emmons, PhD. Available at online and local bookstores or directly from Impact Publishers, Inc., PO Box 6016, Atascadero, CA 93423-6016, http://www.bibliotherapy.com/ or phone 1-800-246-7228.

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