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Your experiences with a new stepfamily are probably difficult, but the changes and transitions are just as difficult for your child. One particular problem you may have encountered is visitation: sharing parents. Your child may be feeling like a visitor in your new home, especially if your new spouse's children live with you and your child does not.

Here is a kid-friendly vignette to illustrate:

Austin and his dad had always been very close. Even after the divorce, Austin saw a lot of his dad. Dad took an apartment very near the house where Austin, his sister and their mom still lived. Not only did Austin, his sister and their dad see each other at least one day each weekend, Dad also saw Austin during the week.

Then Austin 's dad started dating. After a while, he met a woman whom he eventually decided he wanted to marry. Dad moved into her house the day after the wedding. She had two kids, Austin 's new stepbrothers. Austin didn't suppose it made much difference either way, but soon enough, he saw that it did.

For one thing, his dad had less time to spend with him. He still saw a lot of his dad, but not as much as before. Dad was busy with his new family. Austin began to resent his new stepbrothers: it was their fault his dad didn't have as much time for him. They got to be with his dad everyday, and that didn't seem fair at all. He didn't like sharing his dad: they had him to themselves all week!

In a situation like this, several things might help your child to feel more comfortable with visitations, and can help alleviate some of the tensions:

• Encourage your child to talk with you about his feelings. You might be inviting your stepchildren along, thinking it would be more fun for your child, but he might want just the opposite: some alone time with you.
• Remind your child that you are all a family now, and that his new stepsiblings are not competing with him for your time and attention. Let him know that you might be going out of your way with his stepsiblings because you're doing your best to get to know them and make friends with them.
• Validate your child's concerns: yes, it's true that your new stepchildren are with you when he is not, but that isn't their fault. In fact, it's not anyone's fault. Remind your child that his new stepsiblings are not deliberately trying to "hog" your time, or horn in on your relationship.

The sooner your child understands that his new stepsiblings are not out to "steal you away" from him or monopolize your time, the sooner he can get adjusted to the way things are.

Adapted from Jigsaw Puzzle Family: The Stepkids' Guide to Fitting It Together, by Cynthia MacGregor. Available at online and local bookstores or directly from Impact Publishers, Inc., PO Box 6016, Atascadero, CA 93423-6016, 1-800-246-7228.

Reviewed by athealth on February 8, 2014.

Why are traditional therapies used to treat mental illnesses?

Mental health professionals use a variety of approaches to give people tools to deal with ingrained, troublesome patterns of behavior and to help them manage symptoms of mental illness. The best therapists will work with you to design a treatment plan that will be most effective for you. This sometimes involves a single method, or it may involve elements of several different methods, often referred to as an "eclectic approach" to therapy.

Behavioral Therapy:

As the name implies, this approach focuses on behavior-changing unwanted behaviors through rewards, reinforcements, and desensitization. Desensitization, or Exposure Therapy, is a process of confronting something that arouses anxiety, discomfort, or fear and overcoming the unwanted responses. Behavioral therapy often involves the cooperation of others, especially family and close friends, to reinforce a desired behavior.

Biomedical Treatment:

Medication alone, or in combination with psychotherapy, has proven to be an effective treatment for a number of emotional, behavioral, and mental disorders. The kind of medication a psychiatrist prescribes varies with the disorder and the individual being treated.

Cognitive Therapy:

This method aims to identify and correct distorted thinking patterns that can lead to feelings and behaviors that may be troublesome, self-defeating, or even self-destructive. The goal is to replace such thinking with a more balanced view that, in turn, leads to more fulfilling and productive behavior.

Cognitive/Behavioral Therapy:

A combination of cognitive and behavioral therapies, this approach helps people change negative thought patterns, beliefs, and behaviors so they can manage symptoms and enjoy more productive, less stressful lives.

Couples Counseling and Family Therapy:

These two similar approaches to therapy involve discussions and problem-solving sessions facilitated by a therapist-sometimes with the couple or entire family group, sometimes with individuals. Such therapy can help couples and family members improve their understanding of, and the way they respond to, one another. This type of therapy can resolve patterns of behavior that might lead to more severe mental illness. Family therapy can help educate the individuals about the nature of mental disorders and teach them skills to cope better with the effects of having a family member with a mental illness-such as how to deal with feelings of anger or guilt.

Electroconvulsive Therapy:

Also known as ECT, this highly controversial technique uses low voltage electrical stimulation of the brain to treat some forms of major depression, acute mania, and some forms of schizophrenia. This potentially life-saving technique is considered only when other therapies have failed, when a person is seriously medically ill and/or unable to take medication, or when a person is very likely to commit suicide. Substantial improvements in the equipment, dosing guidelines, and anesthesia have significantly reduced the possibility of side effects.

Group Therapy:

This form of therapy involves groups of usually 4 to 12 people who have similar problems and who meet regularly with a therapist. The therapist uses the emotional interactions of the group's members to help them get relief from distress and possibly modify their behavior.

Interpersonal Psychotherapy:

Through one-on-one conversations, this approach focuses on the patient's current life and relationships within the family, social, and work environments. The goal is to identify and resolve problems with insight, as well as build on strengths.

Light Therapy:

Seasonal affective disorder (SAD) is a form of depression that appears related to fluctuations in the exposure to natural light. It usually strikes during autumn and often continues through the winter when natural light is reduced. Researchers have found that people who have SAD can be helped with the symptoms of their illness if they spend blocks of time bathed in light from a special full-spectrum light source, called a "light box."

Play Therapy:

Geared toward young children, this technique uses a variety of activities-such as painting, puppets, and dioramas-to establish communication with the therapist and resolve problems. Play allows the child to express emotions and problems that would be too difficult to discuss with another person.

Psychoanalysis:

This approach focuses on past conflicts as the underpinnings to current emotional and behavioral problems. In this long-term and intensive therapy, an individual meets with a psychoanalyst three to five times a week, using "free association" to explore unconscious motivations and earlier, unproductive patterns of resolving issues.

Psychodynamic Psychotherapy:

Based on the principles of psychoanalysis, this therapy is less intense, tends to occur once or twice a week, and spans a shorter time. It is based on the premise that human behavior is determined by one's past experiences, genetic factors, and current situation. This approach recognizes the significant influence that emotions and unconscious motivation can have on human behavior.

Source: SAMHSA'S National Mental Health Information Center
KEN98-0053

Reviewed by athealth on February 8, 2014.

Child sexual abuse; it is not a topic that makes people comfortable. Discussing child sexual abuse, in fact, remains taboo even in this era of increasing openness about personal or family difficulties. While most Americans can understand, although not condone, how some forms of child abuse occur, it is almost impossible for them to consider the idea of sexual abuse. This is particularly true when the abuser is a parent or family member.

Sexual abuse fuses those areas in which most people still experience discomfort: sexuality, power, gender domination, and the horrific exploitation of an innocent child. Sexual molestation, like so many forms of abuse, wounds not only its victim: it cuts through families and communities, destroying trust and the belief that some things simply do not happen in an enlightened society.

And yet they do. Almost 1 million children were identified as victims of substantiated or indicated abuse or neglect in 1996, according to the Office of Child Abuse and Neglect (formerly the National Center on Child Abuse and Neglect), U.S. Department of Health and Human Services (DHHS). About 12 percent of these children were sexually abused. The figures, of course, include only those incidents of abuse that were reported to, and investigated by, child protection agencies.

Despite these numbers, the Nation lives in denial. The results of this country's refusal to confront the sexual molestation of children are staggering. These include gaps in services to young survivors, little research into the effects of sexual abuse, inadequate technical assistance on effective approaches to supporting youth who have been sexually abused or intervening with their families, and few therapists trained to provide appropriate services. The limited intervention and support typically given to youth survivors is compounded by the fact that they must deal with their trauma in a society that is reluctant to acknowledge that child sexual abuse even occurs.

Denial is a costly tactic:

• The research shows that victims often become victimizers.
• Victims seek comfort in behaviors, such as alcohol or drug abuse, that have consequences for the larger community.
• Severely wounded children sometimes grow up to be violently aggressive adults.

Moreover, a Nation is judged by how it cares for its most vulnerable populations, and to ignore the victimization of children is unacceptable.

Talking About the Unthinkable

Twenty years ago, no one wanted to admit that men beat their wives. Domestic violence was unthinkable, especially in affluent neighborhoods. Today, people know that domestic violence occurs in families across the spectrum of racial groups, and education and income levels. Society's perception of, and response to, domestic violence was changed by battered women's advocates who continued to talk about violence in the home, even when those around them wished they would stop.

Today, that education process must continue. Violence in the home includes sexual violence. And just as with domestic violence, the effects are intergenerational. Clearly, preventing the sexual abuse of future generations by treating the victims of today should be a priority. A key strategy for doing so is to implement a youth development approach that ensures services and opportunities for all youth, that builds on young people's strengths, and that provides support for youth whose developmental process has been delayed by abuse and neglect. Young people who have been sexually abused, especially by a trusted adult, suffer damage to almost every aspect of their personal development: sexual, physical, emotional, and spiritual.

Child Sexual Abuse: The Impact on Adolescent Development

Our culture demands that children mature from an egocentric to a sociocentric focus. They are expected to participate in school, become involved in the community, and develop relationships outside their families. This is a challenging process even for the average young person; living with abuse makes the process incredibly difficult. During adolescence, youth are growing and changing in a range of ways that are affected by sexual abuse:

• Physiological Change: How tall they are or how much they weigh becomes a source of concern to young people during adolescence, particularly as they compare themselves with their peers. That comparison may produce feelings of anxiety or contribute to dampening their self-esteem. For youth who have experienced abuse or criticism by their parents, teasing about their looks may reinforce their perception that they are not valued.
• Emotional Development: Young people in abusive situations must redirect their energy from emotional development to survival. When they are forced to focus on avoiding the violent or sexual advances of an adult caretaker, they do not make the same developmental progress as children who receive unconditional love, support, and guidance.
• Cognitive Change: Young people develop their cognitive thinking ability, which means that they will reexperience and reframe abuse that occurred to them earlier, particularly if it began when they were young.
• Moral and Spiritual Development: During adolescence, youth begin to question the meaning of life and specifically to think about the larger world, the role they play in it, and the options and opportunities available to them.
• Sexual Development: For some young people, it is during adolescence that the real consequences of being sexually abused occur. When a child of 3 or 4 years of age is sexually abused, it is not a sexual event in the way adults may think. It is physically hurtful, confusing, and alarming, but they do not have a context for defining the abuse. When those children turn 12 or 13, they cognitively reassess the abuse as they begin to learn about or experience sexual feelings.

While all young people's development is affected by both internal and external factors, each youth experiences growing up differently. For youth who are abused, however, that process is negatively affected, resulting in certain reactions or behaviors.

The Abused Adolescent

While there is no clear profile of a sexually abused child, the research indicates that there are symptoms that present frequently in young survivors. These include the following:

• Anxiety/Numbing: Young people who have been sexually abused often exhibit the polarity of anxiety/numbing behaviors. These youth are hypervigilant, scanning the environment for threats to their safety; conversely they have learned to shut down their feelings.

  The chronicity of the abuse plays a part in the level of anxiety experienced by child victims. Youth who have been assaulted through most of their developmental phases have learned to maintain a defensive posture to protect themselves. They have learned the most debilitating lesson of child abuse: people who love you hurt you. For these children, the expression of caring is presumed to be followed by harm or danger.

  At the end of 4 months of therapy, 6-year-old "Katie," for example, brought a paddle to her therapist. When the therapist asked about the paddle, Katie said, "It is for you to hit me with." When the therapist asked why Katie thought she wanted to hit her, the child replied, "Well you like me, don't you?"

  The sad reality is that children seek out behaviors with which they are familiar. In some instances, children do so to master or take control of situations, thereby reducing their anxiety about what might happen next.

• Hypersensitivity: Young people growing up in violent or abusive environments tend to be hypersensitive to their surroundings. They flinch at sudden noises and are hyperaroused or overstimulated easily. They may experience acute fear in some situations and typically "stay on alert," which requires energy and takes a tremendous toll on their physical and mental well-being. They tend to carry a lot of tension in their bodies, so they may not move as fluidly as other children. Many of these youth present somatic concerns, such as always having headaches or stomach pains.

  Again, the chronicity of the abuse is an important factor in the degree to which young people develop hypersensitivity. If the abuse is an isolated incident, the child is better able to regroup. When the assault is frequent or long term, the child does not have respite to reorganize or stabilize and must develop highly refined defense mechanisms.

• Depression: Even the youngest children who have been abused exhibit characteristics of depression. They may have a flat affect, not make eye contact, or not laugh. There are many manifestations of depression, including self-mutilation, substance abuse, and eating or sleeping disorders.

  The foster parents of a 9-year-old boy reported that he would cut himself and watch the blood run down his arm. A therapist asked what he said to himself when he watched the blood, and the youth replied, "It's red." She asked what he expected to see, and he replied, "guck." Through further questioning, the therapist learned that the boy expected guck to come out of his arm like the bionic man on television.

  This boy thought of himself as a robot, which is a strong defense mechanism against being hurt. When he saw the blood, he actually felt better because he could say, "I'm a real human being." For the next 3 weeks, he would be more interactive, responsive, and happy because he had verified his own existence.

• Alcohol or Drug Use: While some young people may experiment with drugs or alcohol as a rite of passage, youth who were or are abused use substances to numb their feelings.

  The alcoholism of one 6-year-old child was discovered when her preschool reported unusual behaviors to her foster family. The child was given a medical examination, through which the doctors determined that she had been sexually abused.

  She was referred to a therapist who used play therapy. The child would pick the play therapy rag doll up and roll its head back and forth, put one foot in front of the other, as if the doll were walking, and then make it fall. She repeated the sequence 14 times.

  After watching this behavior, the therapist wondered if the child was acting out the behavior of someone who had been drinking. The therapist brought in a small bottle of liquor, the type you get on an airplane, and waved the open bottle under the child's nose, asking if she had ever smelled the odor before. The child grabbed the bottle and tried to drink its contents. Through further questioning, the therapist learned that the child kept a bottle of vodka she had smuggled from her home to the foster residence inside the zipper pouch of a stuffed animal. It turned out that the child's father had given her alcohol in a bottle so that she would relax and go to sleep while he sexually molested her. The child learned that when she drank, she could go to sleep and have the experience of not being "present" while the abuse occurred.

• Problem Sexual Behaviors: Children who were sexually abused may become involved in sexual acting-out behaviors, particularly when they reach adolescence, a time of increasing biological urges and exposure to sexual education. Under normal conditions, sexual behavior develops gradually over time, with youth showing curiosity and then experimenting with themselves and others. When children are sexually abused, however, they are prematurely exposed to material they do not understand and cannot make sense of.

  Moreover, children become conditioned to respond to certain things. In many instances, adults who interact sexually with children may reward them before or after the event. The children are conditioned to believe that if they engage in certain behaviors they will be rewarded. This is pure learning theory: children repeat acts for which they receive positive reinforcement.

  A judge who was doubting the sexual abuse of a 3-year-old child called everyone into his chambers and hoisted the young girl on his lap so that he could interview her. The moment he placed her on his lap, she reached under his robe and began fondling his genitals. She clearly had been conditioned to believe that when a man sits her on his lap, he expects this type of behavior. The judge quickly reversed his opinion and went forward with the case of sexual abuse.

  Some children who were sexually abused also may become sexually provocative, dressing and talking in a manner that puts them at risk of further sexual exploitation. Others merge sexual behavior and aggression and become the victimizers of other children.

• Aggression: Eventually, most abused children get angry and some begin to act aggressively, typically with smaller children. This is the victim-victimizer dynamic; abused children learn that the bigger, stronger person hurts or takes advantage of the smaller, weaker person. Youth who have been victimized are conditioned to believe that when two people interact, one of them will be hurt. At each interaction with others, they may wonder who will be hurt this time. Some children adopt the victim role; others become the victimizers. In either case, they simply are playing out the roles that they have been conditioned to believe people play during interactions with others.

  The research would indicate that boys tend to adopt the role of aggressor more often than girls. They have a harder time tolerating the role of victim, which is in stark contrast to the cultural definition of masculinity. Girls tend to adopt the role of victim more often, which could be linked to the traditional social view of women as the weaker gender. Yet neither pattern holds true in all cases. Some boys take on the victim role; some girls become aggressive.

Obviously, these behaviors and reactions are learned. Young people who have survived sexual abuse can just as easily learn more positive behaviors if communities choose to provide them with appropriate interventions and support. They need support in both working through the trauma and addressing the developmental stages they may have missed because of the abuse. This includes the critical step of developing an identity separate from their family or caretaker.

Identity Formation in Adolescence

Forming an identity is a major developmental issue during adolescence. This process of individuation, however, is one that begins when children are very young and crystallizes in adolescence. For positive identity formation to occur in any human being, some basic things have to be attained, including the following:

• Expressions of Love: Children have to feel that somebody cares about them.
• Feelings of Significance: Children must feel that they are significant or important to someone.
• A Sense of Virtue: Children must have a belief in their innate, inner goodness.
• A Sense of Belonging: Children must feel connected to a family that provides them with a sense of stable belonging.
• Mastery and Control: Children must experience feelings of mastery and personal power and control.

All of these variables are severely compromised by child abuse and neglect. Abused children's sense of self and their future has been badly damaged. They may have learned that negative attention is better than no attention, and they act accordingly. Unfortunately, their behaviors, which result directly from the abuse, often lead significant people in their lives to react in ways that reinforce this negative self-image. This further damages young people's sense of virtue and feeling of being loved.

To deal with these overwhelmingly negative feelings, some children develop an affect disorder, which results from a person compartmentalizing information about an abusive event separately from their feelings. They will describe an abusive event in great detail without emotion, as if it were happening to someone else. This dissociation is a defense mechanism that helps people block reality, especially when it is painful. Children who are being sexually abused use dissociation to separate from their own experiences. They talk about floating above their bodies or sitting on top of a lamp watching what happened.

This process enables a young person not to feel the pain associated with actually being present during the abusive event. Unfortunately, dissociation also creates a problem with a child's sense of identity and interrupts their sense of being anchored in reality.

Children who have an identity problem or no sense of who they are may, for example, develop an insecure attachment disorder. Therapists experience this with young people who ask to see them every day or to come live with them. These young people do not feel real unless they are in another person's presence. Or they fear that the person they are with now will go away and not come back, leading to feelings of abandonment and despair.

When children are not allowed to develop an identity, they may appear as if they are presenting a "false self." These youth simply may not have a good sense of self to present to the world. When with other groups of people, especially other youth with strong personalities, abused children may easily retreat into themselves or mimic those they are around. Helping young people go back through the developmental stages and rebuild a sense of self is critical to their overall emotional well-being.

Treating the Sexually Abused Adolescent

Therapists have identified three stages to working with survivors of childhood abuse:

establishing the young person's safety, both in their home situation and with the therapist;

processing traumatic material; and

fostering social reconnection.

One of a therapist's most important tasks is to ensure that a child is living in a safe environment with a central, supportive, caring adult. Often, young people who have been abused or neglected experience incredible mobility in their lives as they move from one placement to the next. These youth begin to doubt that any adult will be with them for very long. A sense of security and safety in one place, therefore, is very important to the therapeutic process.

Once the child is in a safe environment, the therapist can begin to develop a relationship with the child. Through that relationship, the therapist can begin to help the child understand why it is important to process what happened to them. Most abused adolescents want a sense of control over their lives. Therapists can show youth how, by working through their earlier experience, they can eliminate some of their negative feelings and the resulting behaviors. Through that process, youth can develop a sense of control over their behavior.

When a young person is ready, the therapist can help them begin affiliating with others and developing the ability to trust and have relationships with other people, both adults and peers. Often at this stage, a therapist will place a youth in group therapy.

Time and consistency of care are key factors in all three stages of therapy, but especially in stage 1. By the time an adolescent receives the help they deserve, they may have been sexually or otherwise abused over a period of time. They have built up an array of defenses to protect themselves, and making contact with them may be difficult. To establish the trust of an abused child, a therapist needs to build a relationship with that child, which takes time. Therapists need that time to demonstrate that they are trustworthy, by action as well as words.

In some communities, the new managed care systems are threatening this process by covering the costs of only short-term therapy. The trust of a severely abused child simply cannot be established in six to eight sessions. Under those circumstances, experts caution that therapists should work only on phase 1, or the establishment of the child's safety. It is inappropriate to encourage a child to talk about traumatic abuse if that child is not in a position to receive ongoing therapeutic support.

In such situations, a therapist must simply advocate for children's safe placement and help them to develop coping strategies, teach them about available resources, and suggest behavioral alternatives that may positively affect their interactions with others. A therapist also might help children understand that their behavioral problems may be related to something they learned or experienced a long time ago.

General Principles for Working With Youth Who Have Been Sexually Abused

Helping youth explore past abuse is specialized work, requiring significant education, training, and expertise. The following key principles provide guidance for those working with youth who have been sexually abused:

• Remain Neutral In Your Early Interactions With Abused Children: When some youth sense that a therapist or other professional is paying attention to or trying to help them, they may withdraw because the circumstances feel risky to them. The very nature of counseling or therapy, which involves personal contact with another human being and focused, positive attention, can produce stress and anxiety for children who have been sexually abused. Youth who have been sexually abused also may associate nice behavior with seduction. In the past, people were nice to them when they wanted something. They may wonder what therapists or other adults expect from them in return for their help.
• Assist Youth In Understanding That They Are Not To Blame: Typically, left to their own resources, children make incorrect assumptions about why they were abused or neglected. When 100 youth in San Francisco were asked why they were in the foster care system, 98 of them said, "Because I am bad." And young people's behavior often reflects how they feel about themselves. If they think they are bad, they may act in ways that perpetuate that image.
• Be Nonjudgmental: Youth do not respond well to adults who want to tell them what to do or who are constantly critical.
• Catch Youth Doing Something Good: Focus on telling young people what they are doing that is good. When they make a thoughtful decision and stick to it, for example, congratulate them on following through.
• Help Them View Their Feelings Without Judgment: Feelings are not good or bad, they are just feelings. Help young people understand that it is all right to feel angry, and help them to learn to express their anger in ways that are healthy for themselves and others.
• Think Of Your Interactions With Youth As "Invitations" For Them To Do Or Say As Much Or As Little As They Choose: Youth need to learn to make choices about how they will participate, or not, in different situations. Offering youth options gives them a chance to practice making choices in a safe environment. If a young person does not complete an assignment, for example, consider talking with him or her about what the assignment might have looked like if they had finished it. Or, discuss what might have been the biggest problem in completing the task. Through this process, you might accomplish more than if you focus on the young person's failure to complete the task.
• Avoid Power Struggles With Young People: It generally is nonproductive to spend time arguing a point with an adolescent. Move on to other discussions that might prove more useful. Keep in mind that if a young person is feeling defensive, they are not feeling safe.
• Remember That Abused Adolescents Have A Reason To Be Defensive: If you are hit enough, emotionally or physically, you learn to stand ready to protect yourself or even to ward off attacks by attacking first. Young people who have been abused need time and a trusted relationship to feel safe.
• Understand How Easy It Is For Abused Children To Be Further Victimized: Without question, once abused, children become more vulnerable to further victimization. It is not just the abuse that leaves them exposed to exploitation; it is the concomitant loss of love, nurturing, and feelings of being safe and valued. Often adult predators provide, at least at first, the very things missing from an abused child's history: time, attention, caring, and a sense of belonging.
• Be Aware That Some Behaviors Provide Youth With A Sense Of Control: When children are treated well, nurtured, loved, and accepted, they learn to expect that treatment from others. When children are abused, they similarly expect others will abuse them. These children may engage in aggressive behavior as a defense mechanism; their behavior is a means of taking control of a situation they anticipate will occur anyway. When you work with youth to stop behaviors that place them at risk, it is important to be aware that those behaviors may be the only current means they have for mastery and control.
• Help Educate Others That Young People Are Never Responsible For Their Abuse: Often, people suggest that adolescents should have told someone or fought back. The expectation is that adolescents should be able to protect themselves. It is important to remember that many young people have long histories of abuse, which makes them vulnerable; they are not "normal" (nonabused) adolescents suddenly confronted with dangerous circumstances. Moreover, it is critical to remember that children are relating to their parents, the people they love and need most in the world. When asked, "Who is bad, you or your Mom and Dad?" children will always choose themselves. Children need to protect the idealized image of their parents; those are the people they long for.

Working with youth who have been sexually abused obviously requires special skills and expertise. For that reason, most youth agencies develop strong working relationships with therapists who are experienced in working with youth who have been sexually abused. In selecting a therapist, youth agencies should look for well-trained professionals who understand and apply the above-mentioned principles. They also should look for therapists who do the following:

• Use Therapeutic Approaches Other Than Talk Therapy: Direct talk therapy generally is not the most effective approach with adolescents. Well-trained therapists will use art or play therapy in working with abused youth. They also might discuss news clippings or watch a video and let youth comment on another young person's situation. It may be easier for youth to talk about another person as a means of sharing how they feel. Moreover, helping young people develop empathy for others often can be the first step in developing self-empathy.
• Help Youth Change Behaviors That Cause Negative Reactions In Others: Therapists examine a child's behavior, describe it, and then try to determine why the child is acting in this manner. A 12-year-old girl, for example, who threw temper tantrums explained that she felt quiet inside when the tantrum was over. She said she felt calm because "everything inside had come out." This child had been beaten whenever she showed any emotion, so she had learned to keep her feelings bottled up inside.

  Every now and then, however, she had to let those feelings go. Until she entered therapy, the child had never been taught how to live with and manage real feelings; the result was tension, control, and then loss of control. Her therapist worked with her, using a tea kettle as a metaphor. They jointly developed a plan for the young woman to begin to let her "steam" out in ways that would not cause concern among the people around her or allow the kettle to "blow its lid." Through the process, the young girl learned affect tolerance: the ability to feel, absorb, and express her feelings appropriately.

• Appreciate That Children Sustain Injuries Differently: Some young people are more resilient than others. A therapist needs to assess how well the young person has survived the abuse, what they think about themselves, and how they manage to reach out to others. Through this process, it is important to help the youth build a history of accomplishment by emphasizing the young person's strengths and successes.
• Help Youth Process Traumatic Material: Young people need support to deal with what happened to them, discharge their feelings, and develop a sense of mastery about that process. Unless this happens, images similar to those associated with the abusive event may trigger a posttraumatic stress reaction. A youth may blow up or go into trancelike behavior for no apparent reason. This is an indication that they have unresolved traumatic material and they need help in processing that material in a structured way that creates feelings of empowerment.
• Work With Youth To Assimilate The Information And Feelings Associated With Their Prior Abuse: By processing traumatic material, therapists can help youth talk about the event and feel the associated feelings at the same time.
• Recognize That While Abuse And Neglect Have The Potential To Be Traumatic, Not Every Abused Child Is Traumatized: Traumatized children are a subset of abused children. Factors that distinguish the two groups tend to include the child's relationship to the abuser, age at the onset of abuse, and biology, and the chronicity and severity of the abuse. All abused children are hurt and exploited, but, depending on a broad set of variables, some children continue to live in the climate of the trauma.
• Help Youth Learn How To Manage Their Feelings In Settings In Which It Would Not Be Appropriate To Act Upon Them: Some youth need to learn affect regulation, which is the ability to control feelings in certain situations. Adults, for example, who had a fight with a spouse prior to making a presentation at work are able to refocus themselves. They are able to control the feelings they are experiencing as a result of the fight while they make the presentation.
• Work With Youth To Develop Impulse Control: Children growing up with abusive parents did not have impulse control modeled for them. Many abusive parents think and act at the same time; when they are angry, they strike their children. Nonabusive parents also get angry at their children; they simply have the impulse control not to act on every thought. Children who grew up with abusive parents may need to learn that thoughts and action can be distant on the time spectrum. They need help in determining how to go through a series of steps to make decisions about what they will do in response to their thoughts.
• Accept That All Children Are Different: Some children act out in ways that continue the climate of trauma through behavioral reenactments that keep the victim dynamic present in their life. Others want to talk constantly about the abuse and will do so even with strangers. Still other youth refuse to talk about the abuse; they say it is over and they do not want to deal with it. A good therapist will develop a plan for working with a young person on the basis of that child's behavior, presenting problems, personality
  

If you or someone you care about has been diagnosed with schizophrenia, you may feel like you are the only person facing this illness. But you are not alone-schizophrenia affects almost 3 million Americans. Although widely misunderstood and unfairly stigmatized, schizophrenia is actually a highly treatable brain disease. The treatment for schizophrenia is in many ways similar to that for other medical conditions such as diabetes or epilepsy. The good news is that new discoveries are greatly improving the chances of recovery and making it possible for people with schizophrenia to lead much more independent and productive lives.

What Is Schizophrenia?

This guide is designed to answer the most frequently asked questions about schizophrenia and how it is treated. Many of the recommendations are based on a recent survey of over 100 experts on schizophrenia who were asked about the best ways to treat this illness.

What are the symptoms?

The symptoms of schizophrenia are divided into three categories: positive symptoms, disorganized symptoms, and negative symptoms.

Positive or Psychotic Symptoms

• Delusions, unusual thoughts, and suspiciousness. People with schizophrenia may have ideas that are strange, false, and out of touch with reality. They may believe that people are reading their thoughts or plotting against them, that others are secretly monitoring and threatening them, or that they can control other people's minds or be controlled by them.
• Hallucinations. People with schizophrenia may hear voices talking to them or about them, usually saying negative, critical, or frightening things. Less commonly, the person may see objects that don't exist.
• Distorted perceptions. People with schizophrenia may have a hard time making sense of everyday sights, sounds, smells, tastes, and bodily sensations-so that ordinary things appear frightening. They may be extra-sensitive to background noises, lights, colors, and distractions.

Negative Symptoms

• Flat or blunted emotions. Schizophrenia can make it difficult for people to experience feelings, know what they are feeling, clearly express their emotions, or empathize with other people's feelings. It can be hard for people with such symptoms to relate to others. This can lead to periods of intense withdrawal and profound isolation.
• Lack of motivation or energy. People with schizophrenia usually have trouble starting projects or finishing things they've started. In extreme cases, they may have to be reminded to do simple things like taking a bath or changing clothes.
• Lack of pleasure or interest in things. To people with schizophrenia, the world seems flat, uninteresting, and cardboard. It feels like it is not worth the effort to get out and do things.
• Limited speech. People with schizophrenia often won't say much and may not speak unless spoken to.

Disorganized Symptoms

• Confused thinking and disorganized speech. People with schizophrenia may have trouble thinking clearly and understanding what other people say. It may be difficult for them to carry on a conversation, plan ahead, and solve problems.
• Disorganized behavior. Schizophrenia can cause people to do things that don't make sense, repeat rhythmic gestures, or make ritualistic movements. Sometimes the illness can cause people to completely stop speaking or moving or to hold a fixed position for long periods of time.

When does schizophrenia begin?

Schizophrenia can affect anyone at any age, but it usually starts between adolescence and the age of 40. Children can also be affected by schizophrenia, but this is rare. The person who is having a first episode of schizophrenia may have been ill for a long time before getting help. Usually he or she comes to treatment because delusions or hallucinations have triggered disturbing behavior. At this point, the person often denies having a mental illness and does not want treatment. With treatment, however, delusions and hallucinations are likely to get much better. Most people make a good recovery from a first episode of schizophrenia, although this can take several months.

What is the usual course of schizophrenia?

The severity of the course varies a lot and often depends on whether the person keeps taking medicine. Patients can be divided into three groups based on how severe their symptoms are and how often they relapse.

The patient who has a mild course of illness and is usually stable

• Takes medication as prescribed all the time
• Has had only one or two major relapses by age 45
• Has only a few mild symptoms

The patient who has a moderate course of illness and is often stable

• Takes medication as prescribed most of the time
• Has had several major relapses by age 45, plus periods of increased symptoms during times of stress
• Has some persistent symptoms between relapses

The patient who has a severe and unstable course of illness

• Often doesn't take medication as prescribed and may drop out of treatment
• Relapses frequently and is stable only for short periods of time between relapses
• Has a lot of bothersome symptoms
• Needs help with activities of daily living (e.g., finding a place to live, managing money, cooking, laundry)
• Is likely to have other problems that make it harder to recover (e.g., medical problems, substance abuse, or a mood disorder)

What are the stages of recovery?

Acute episode: this is a period of very intense psychotic symptoms. It may start suddenly or begin slowly over several months.

Stabilization after an acute episode: After the intense psychotic symptoms are controlled by medication, there is usually a period of troublesome, but much less severe, symptoms.

Maintenance phase or between acute episodes: This is the longer term recovery phase of the illness. The most intense symptoms of the illness are controlled by medication, but there may be some milder persistent symptoms. Many people continue to improve during this phase, but at a slower pace.

Why is it important to diagnose and treat schizophrenia as early as possible?

Early diagnosis, proper treatment, and finding the right medications can help people in a number of important ways:

Stabilize acute psychotic symptoms. The first priority is to eliminate or reduce the positive (psychotic) symptoms, especially when they are disruptive. Most people's psychotic symptoms can be stabilized within 6 weeks from the time they start medication. Antipsychotic medications allow patients to be discharged from the hospital much earlier.

Reduce likelihood of relapse and rehospitalization. The more relapses a person has, the harder it is to recover from them. Proper treatment can prevent or delay relapse and break the "revolving door" cycle.

Ensure appropriate treatment. Sometimes a person is misdiagnosed as having another disorder instead of schizophrenia. This can be a serious problem because the person may end up taking the wrong medications.

Decrease alcohol/substance abuse. More than 50% of people with schizophrenia have problems with alcohol or street drugs at some point during their illness, and this makes matters much worse. Prompt recognition and treatment of this "dual diagnosis" problem is essential for recovery.

Decrease risk of suicide. The overall lifetime rate of suicide is over 10%. The risk is highest in the early years of the illness. Fortunately, suicidal behavior is treatable, and the suicide risk eventually decreases over time. Therefore, it is very important to get professional help to avoid this tragic outcome.

Minimize problems in relationships and life disruption. Early diagnosis and treatment decrease the risk that the illness will get in the way of relationships and life goals.

Reduce stress and burden on families. Schizophrenia places a tremendous burden on families and loved ones. Programs that involve families early in the treatment process reduce relapse and decrease stress and disruption in the family.

Begin rehabilitation. Early treatment allows the recovery process to begin before long periods of disability have occurred.

Is schizophrenia inherited?

The answer is yes, but only to a degree. If no one in your family has schizophrenia, the chances are only 1 in 100 that you will have it. If one of your parents or a brother or a sister has it, the chances go up, but only to about 10%. If both your parents have schizophrenia, there is a 40% chance that you will have it. If you have a family member with schizophrenia and you have no signs of the illness by your 30s, it is extremely unlikely that you will get this illness. If you have a parent or brother or sister with schizophrenia, the chances of your children getting schizophrenia are only slightly increased (only to about 3%) and most genetic counselors do not consider this to be a large enough difference to change one's family planning.

Researchers have identified a number of genes that may be linked to the disorder. This suggests that different kinds of biochemical problems may lead to schizophrenia in different people (just as there are different kinds of arthritis). However, many other factors besides genetics are also involved. Research is currently underway to identify these factors and learn how they affect chances of developing the illness. We do know that schizophrenia is not caused by bad parenting, trauma, abuse, or personal weakness.

Medication Treatment

The medications used to treat schizophrenia are called anti-psychotics because they help control the hallucinations, delusions, and thinking problems associated with the illness. Patients may need to try several different antipsychotic medications before they find the medicine, or combination of medicines, that works best for them. When the first antipsychotic medication was introduced 50 years ago, this represented the first effective treatment for schizophrenia. Three categories of antipsychotics are now available, and the wide choice of treatment options has greatly improved patients' chances for recovery.

Conventional Antipsychotics

The antipsychotics in longest use are called conventional antipsychotics. Although very effective, they often cause serious or troublesome movement side effects. Examples are:

Haldol (haloperidol)
Stelazine (trifluoperazine)
Mellaril (thioridazine)
Thorazine (chlorpromazine)
Navane (thiothixene)
Trilafon (perphenazine)
Prolixin (fluphenazine)

Conventional antipsychotics are becoming obsolete. Because of side effects, experts usually recommend using a newer atypical antipsychotic rather than a conventional.

There are two exceptions. For those individuals who are already doing well on a conventional antipsychotic without troublesome side effects, the experts recommend continuing it. The other exception is when the person has had trouble taking pills regularly. Two of the conventional antipsychotics, Prolixin and Haldol, can be given in long-acting shots (called "depot formulations") at 2- to 4-week intervals. With depot formulations, medication is stored in the body and slowly released. No such depot preparations are yet available for the newer antipsychotics.

Newer Atypical Antipsychotics

The treatment of schizophrenia has been revolutionized in recent years by the introduction of several newer atypical anti-psychotics. These medications are called atypical because they work in a different way than the conventional antipsychotics and are much less likely to cause the distressing movement side effects that can be so troubling with the conventional antipsychotics.

The following newer atypical antipsychotics are currently available:

Risperdal (risperidone)
Seroquel (quetiapine)
Zyprexa (olanzapine)

Other atypical antipsychotics, such as Zeldox (ziprasidone), may be available in the near future.

The experts recommend the newer atypical medications as the treatment of choice for most patients with schizophrenia.

Clozaril (clozapine)

Clozaril, introduced in 1990, was the first atypical antipsychotic. Clozaril can help 25%-50% of patients who have not responded to conventional antipsychotics. Unfortunately, Clozaril has a rare but potentially very serious side effect. In fewer than 1% of those taking it, Clozaril can decrease the number of white blood cells necessary to fight infection. This means that patients receiving Clozaril must have their blood checked regularly. The experts recommend that Clozaril be used only after at least two other safer antipsychotics have not worked.

Selecting Medication For A First Episode

The experts recommend the newer atypical antipsychotics as the treatment of choice for a patient having a first episode of schizophrenia. This reflects their better side effect profile and lower risk of tardive dyskinesia. Clozapine is not recommended for a first episode because of its side effects.

How long does it take antipsychotics to work?

Usually the antipsychotic medications take a while to begin working. Before giving up on a medicine and switching to another one, the experts recommend trying it for about 6 weeks (and perhaps twice as long for Clozaril).

Selecting Medication For Relapses

If a person has a relapse because of not taking the medication as prescribed, it is important to find out why he or she stopped taking it. Sometimes people stop taking medication because of troubling side effects. If this happens, the doctor may lower the dose, add a side effect medication, or switch to a medication with fewer side effects (usually an atypical antipsychotic). If the person was not taking the medication for other reasons, the doctor may suggest switching to a long-acting injection given every 2-4 weeks, which makes it simpler to stay on the medication.

Sometimes a person will relapse despite taking the medication as prescribed. This is generally a good reason to switch to an-other medication-usually one of the newer atypical antipsychotics if the person was taking a conventional antipsychotic, or a different newer atypical antipsychotic if the person had already tried an atypical antipsychotic. Fortunately, even if someone has not responded well to a number of other antipsychotics, clozapine is available as a backup and may work when other things have failed.

Medication During The Recovery Period

We now know that schizophrenia is a highly treatable disease. Like diabetes, a cure has not yet been found, but the symptoms can be controlled with medication in most people. Prospects for the future are constantly brighter through the pioneering explorations in brain research and the development of many new medications. To achieve good results, however, you must stick to your treatment and avoid substance abuse.

It is very important that patients stay in treatment even after recovery. Four out of five patients who stop taking their medications after a first episode of schizophrenia will have a relapse. The experts recommend that first episode patients stay on an antipsychotic medication for 12-24 months before even trying to reduce the dose. Patients who have had more than one episode of schizophrenia or have not recovered fully from a first episode will need treatment for a longer time, maybe even indefinitely. Remember-stopping medication is the most frequent cause of relapse and a more severe and unstable course of illness.

Be sure to take your medicine as directed. Even if you have felt better for a long time, you can still have a relapse if you go off your medication.

What are the possible side effects of antipsychotics?

Because people with schizophrenia have to take their medications for a very long time, it is important to avoid and manage unpleasant side effects.

Perhaps the biggest problem with the conventional antipsychotics is that they often cause muscle movements or rigidity called extrapyramidal side effects (EPS). People may feel slowed down and stiff. Or they may be so restless that they have to walk around all the time and feel like they're jumping out of their skin. The medicine can also cause tremors, especially in the hands and feet. Sometimes the doctor will give a medication called an anticholinergic (usually benztropine [Cogentin]) along with the antipsychotic to prevent or treat EPS. The atypical antipsychotics are much less likely to cause EPS than the conventional antipsychotics.

When people take antipsychotic medications for a long time, they sometimes develop a side effect called tardive dyskinesia- uncontrolled movements of the mouth, a protruding tongue, or facial grimaces. Hands and feet may move in a slow rhythmical pattern without the person wishing this to happen and sometimes even without the person being aware of it. The chances of developing this side effect can be reduced by using the lowest possible effective dose of antipsychotic medication. If someone taking a conventional antipsychotic develops tardive dyskinesia, the experts recommend switching to an atypical antipsychotic.

Medications for schizophrenia can cause problems with sexual functioning that may make patients stop taking them. The doctor will usually treat these problems by lowering the dose of antipsychotic to the smallest effective dose or switching to a newer atypical antipsychotic.

Weight gain can be a problem with all the antipsychotics, but it is more common with the atypical antipsychotics than the conventional antipsychotics. Diet and exercise can help. A rare side effect of antipsychotic medications is neuroleptic malignant syndrome, which involves very severe stiffness and tremor that can lead to fever and other severe complications. Such symptoms require the doctor's immediate attention.

Tell Your Doctor Right Away About Any Side Effects You Have

Different people have different side effects, and some people may have no problems at all with side effects. Also, what is a troublesome side effect for one person (for example, sedation in someone who already feels lethargic because of the illness) may be a helpful effect for someone else (sedation in someone who has trouble sleeping).

It can also be very hard to tell if a problem is part of the illness or is a side effect of the medication. For example, conventional antipsychotics can make you feel slowed down and tired-but so can the lack of energy that is a negative symptom of schizophrenia.

If you develop any new problem while taking an antipsychotic, tell your doctor right away so that he can decide if it is a side effect of your medication. If side effects are a problem for you, you and your doctor can try a number of things to help:

• Waiting a while to see if the side effect goes away on its own
• Reducing the amount of medicine
• Adding another medication to treat the side effect
• Trying a different medicine (especially an atypical antipsychotic) to see if there are fewer or less bothersome side effects

Remember: Changing medicine is a complicated decision. It is dangerous to make changes in your medicine on your own! Changes in medication should also be made slowly.

Psychosocial Treatment and Rehabilitation

Although medication is almost always necessary in the treatment of schizophrenia, it is not usually enough by itself. People with schizophrenia also need services and support to overcome the illness and to deal with the fear, isolation, and stigma often associated with it. In the following sections, we present the experts' recommendations for the kinds of psychosocial treatment, rehabilitation services, and living arrangements that may be helpful at various stages of recovery. These recommendations are intended to be guidelines, not rules. Each patient is unique, and special circumstances may affect the choice of which services are best for a specific patient at a particular time during recovery. Also, some communities have a lot of different services to choose from, while others unfortunately have only a few. It is important for you to find out what services are available to you in your community (and when necessary to advocate for more).

Key Components Of Psychosocial Treatment

Patient and family education. Patient, family, and other key people in the patient's life need to learn as much as possible about what schizophrenia is and how it is treated, and to develop the knowledge and skills needed to avoid relapse and work toward recovery. Patient and family education is an ongoing process that is recommended throughout all phases of the illness.

Collaborative decision making. It is extremely important for patient, family, and clinician to make decisions together about treatments and goals to work toward. Joint decision making is recommended at every stage of the illness. As patients recover, they can take an increasingly active part in making decisions about the management of their own illness.

Medication and symptom monitoring. Careful monitoring can help ensure that patients take medication as prescribed and identify early signs of relapse so that preventive steps can be taken. A checklist of symptoms and side effects can be used to see how well the medication is working, to check for signs of relapse, and to figure out if efforts to decrease side effects are successful. Medication can be monitored by helping the person fill a weekly pill box or by providing supervision at medication times.

Assistance with obtaining medication. Paying for treatment is often difficult. Health insurance coverage for psychiatric illnesses, when available, may have high deductibles and copayments, limited visits, or other restrictions that are not equal to the benefits for other medical disorders. Public programs such as Medicaid and Medicare may be available to finance treatment. The newer medications that can be so helpful for most patients are unfortunately more expensive than the older ones. The treatment team, patient, and family should explore available ways to get access to the best medication by working through public or private insurance, copayment waivers, indigent drug programs, or drug company compassionate need programs.

Assistance with obtaining services and resources. Patients often need help obtaining services (such as psychiatric, medical, and dental care) and help in applying for programs like disability income and food stamps. Such assistance is especially important for people having their first episode and for those who are more severely ill.

Arrange for supervision of financial resources. Some patients may need at least temporary help managing their finances-especially those with a severe and unstable course of illness. If so, a responsible person can be named as the patient's "representative payee." Disability checks are then sent to the representative payee who helps the patient pay bills, gives advice about spending, and helps the patient avoid running out of money before the next check comes.

Training and assistance with activities of daily living. Most people who are recovering from schizophrenia want to become more independent. Some people may need assistance learning how to better manage everyday things like shopping, budgeting, cooking, laundry, personal hygiene, and social/leisure activities.

Supportive Therapy involves providing emotional support and reassurance, reinforcing health-promoting behavior, and helping the person accept and adjust to the illness and make the most of his or her capabilities. Psychotherapy by itself is not effective in treating schizophrenia. However, individual and group therapy can provide important support, skill building, and friendship for patients during the stabilization phase after an acute episode and during the maintenance phase.

Peer support/self-help group. Almost all mutual support groups are run by peers rather than professionals. Many of these groups meet 1-4 times a month, depending on the needs and interest of the members. Guest speakers are sometimes invited to add education to the fellowship, caring, sharing, discussion, peer advice, and mutual support that are vital parts of most consumer support groups. Peer support/self-help groups can play a very important role in the recovery process, especially when patients are stabilizing after an acute episode and during long-term maintenance.

Types Of Services Most Often Needed

Doctor and therapist appointments for medication management and supportive therapy. It is very important to keep appointments with your doctor and therapist during every phase of the illness. These appointments are a necessary part of treatment regardless of where you are in the recovery process-during an acute episode, stabilizing after an acute episode, and during long-term recovery and maintenance. It may be tempting to skip appointments when your symptoms are under control, but continued treatment during all phases of recovery is extremely important in preventing relapse. Many people with schizophrenia also need one or more of the services described below to make the best recovery possible.

Assertive community treatment (ACT). Instead of patients going to a mental health center, the ACT multidisciplinary team works with them at home and in the community. ACT teams are staffed to provide intensive services, so they can visit often-even every day if needed. ACT teams help people with a lot of different things like medication, money management, living arrangements, problem solving, shopping, jobs, and school. ACT is a long-term program that can continue to follow the person through all phases of the illness. The experts strongly recommend ACT programs, especially for patients who have a severe and unstable course of illness.

Rehabilitation. Three types of rehabilitation programs may help patients during the long-term recovery and maintenance phase of the illness. Rehabilitation may be especially important for patients who need to improve their job skills, want to work, have worked in the past, and have few remaining symptoms.

• Psychosocial rehabilitation: a clubhouse program to help people improve work skills with the goal of getting and keeping a job. Fountain House and Thresholds are two well-known examples.
• Psychiatric rehabilitation: a program teaching skills that will allow people to define and achieve personal goals regarding work, education, socialization, and living arrangements.
• Vocational rehabilitation: a work assessment and training program that is usually part of Vocational Rehabilitation Services (VRS). This type of rehabilitation helps people prepare for fulltime competitive employment.

Intensive partial hospitalization. Patients In Partial Hospitalization Programs (PHPs) typically attend structured groups for 4 to 6 hours a day, 3 to 5 days a week. These education, therapy, and skill building groups are designed to help people avoid hospitalization or get out of the hospital sooner, get symptoms under control, and avoid a relapse. A PHP is usually recommended for patients during acute episodes and while stabilizing after an acute episode.

Aftercare day treatment. Day Treatment Programs (DTPs) typically provide a place to go, a sense of belonging and friendship, fun things to do, and a chance to learn and practice skills. They also provide long-term support and an improved quality of life. DTPs can help patients while they are stabilizing after an acute episode and during long-term recovery and maintenance.

Case management. Case managers usually go out to see people in their homes instead of making appointments at an office or clinic. They can help people get the basic things they need such as food, clothes, disability income, a place to live, and medical treatment. They can also check to be sure patients are taking their medication, help them manage money, take them grocery shopping, and teach them skills so they can be more independent. Having a case manager is helpful for many people with schizophrenia.

Types Of Living Arrangements

Treatment won't work well if the person does not have a good and stable place to live. A number of residential options have been developed for patients with schizophrenia-unfortunately, they are not all available in every community.

Brief respite/crisis home: an intensive residential program with on-site nursing/clinical staff who provide 24-hour supervision, structure, and treatment. This level of care can often help prevent hospitalization for patients who are relapsing. Brief respite/crisis homes can be a good choice for patients during acute episodes and sometimes during the stabilization phase after an acute episode.

Transitional group home: an intensive, structured program that often includes in-house daily training in living skills and 24-hour awake coverage by paraprofessionals. Treatment may be pro-vided in-house or the resident may attend a treatment or rehabilitation program during the day. Transitional homes can help patients while they are stabilizing after an acute episode and can often serve as the next step after hospitalization or a brief respite/crisis home. They can also be helpful during an acute relapse if a brief respite/crisis home is not available.

Foster or boarding homes: supportive group living situation owned and operated by lay people. Staff usually provide some supervision and assistance during the day and a staff member typically sleeps in the home at night. Foster homes and boarding homes are recommended for patients during long-term recovery and maintenance, especially if other options (living with family, a supervised/supported apartment, or independent living) are not available or do not fit patient/family needs and preferences.

Supervised or supported apartments: a building with several one- or two-bedroom apartments, with needed support, assistance, and supervision provided by a specially trained residential manager who lives in one of the apartments or by periodic visits from a mental health provider and/or family members. These types of apartments are recommended for patients during long-term recovery and maintenance.

Living with family: For some people, living with family may be the best long-term arrangement. For others, this may be needed only during acute episodes, especially if other types of residence are not available or the patient and family prefer to live together.

Independent living: This type of living arrangement is strongly recommended during long-term recovery and maintenance, but may not be possible during acute episodes of the illness and for patients with a more severe course of illness who may find it hard to live independently.

Other Treatment Issues

Hospitalization

Patients who are acutely ill with schizophrenia may occasionally require hospitalization to treat serious suicidal inclinations, severe delusions, hallucinations, or disorganization and to prevent injury to self or others. Hospitalizations usually last 1 to 2 weeks. However, longer hospitalization may be needed for first episodes or if the person is slow to respond to treatment or has other complications.

It is important for family members to be in touch with the hospital staff so they can tell them what medications the person has received in the past and what worked best. It is useful for the family to be proactive in working with the staff to make living and financial arrangements for the patient after discharge. Family should ask the staff to give them information about the patient's illness and discuss ways to help the patient stick with outpatient treatment.

After Discharge

Patients are usually not fully recovered when they are discharged from inpatient care. This can be a difficult time with increased risks for relapse, substance abuse, and suicide. It is important to be sure that a follow-up outpatient appointment has been scheduled, ideally within a week after discharge, and that the inpatient staff has provided the patient with enough medication to last until that appointment. Ask the staff for an around-the-clock phone number to call if there is a problem. It is a good idea for someone to call the patient shortly before the first appointment as a reminder. If the patient fails to show up, everyone should work to make another appointment and to get the person there for it. Good follow-up care is the best way to avoid a severe course with repeated revolving-door hospitalizations.

Involuntary Outpatient Commitment

Involuntary outpatient commitment and "conditional release" use a court order to require people to take medication and stay in treatment in the community. While not a first line treatment, resorting to legal pressure to require compliance with treatment may sometimes be helpful for patients who deny their illness and relapse frequently.

Postpsychotic Depression

Depression is not uncommon during the maintenance phase of treatment after the active psychotic symptoms have resolved. It is important for patients and family members to alert the treatment team if a patient who has been improving develops depressive symptoms, since this can interfere with the person's recovery and increase the risk of suicide. The doctor may suggest an antidepressant medication, which can help relieve the depression. A psychiatric rehabilitation program may benefit patients experiencing postpsychotic depression who see little hope for the future. Family and patient education can help everyone understand that postpsychotic depression is just a part of the recovery process and can be treated successfully. Peer self-help groups may also provide valuable support for patients who have postpsychotic depression.

Medical Problems Associated With Schizophrenia

Patients with schizophrenia often get very inadequate care for their medical illnesses. This is particularly unfortunate because they are at increased risk for the complications of smoking, obesity, hypertension, substance abuse, diabetes, and cardiovascular problems. The experts therefore recommend regular monitoring for medical illness and close collaboration between the mental health clinicians and the primary care doctor.

What Can I Do To Help My Disorder?

You and your family should learn as much as possible about the disorder and its treatments. There are also a number of other things you can do to help cope with the illness and prevent relapses.

Avoid Alcohol Or Illicit Drugs

The use of these substances provides a short-term lift but they have a devastating effect on the long-term course of the illness. Programs to help control substance problems include dual diagnosis treatment programs, group therapy, education, or counseling. If you can't stop using alcohol or substances, you should still take your antipsychotic medication. Although mixing the two is not a great idea, stopping the antipsychotic medication is a much worse one.

Become Familiar With Early Warning Signs Of A Relapse

Each individual tends to have some "signature" signs that warn of a coming episode. Some individuals may become increasingly suspicious, worry that other people are talking about them, have altered perceptions, become more irritable or withdrawn, have trouble interacting with others or expressing themselves clearly, or express bizarre ideas. Learn to identify your own warning signals. When these signs appear, speak to your doctor as soon as possible so that your medications can be adjusted. Family members may also be able to help you identify early warning signs of relapse.

Don't Quit Your Treatment

It is normal to have occasional doubts and discomfort with treatment. Be sure to discuss your concerns and discomforts with your doctor, therapist, and family. If you feel a medication is not working or you are having trouble with side effects, tell your doctor-don't stop or adjust your medication on your own. Symptoms that come back after stopping medication are sometimes much harder to treat. Likewise, if you are not satisfied with the program you are in, talk to your therapist about what other services are available. With all the new treatment options, you, your doctor, and your therapist can work together to find the best and most comfortable program for you.

What Can Families and Friends Do To Help?

Once you find out that someone close to you has schizophrenia, expect that it will have a profound impact on your life and that you will need help in dealing with it. Because so many people are afraid and uninformed about the disease, many families try to hide it from friends and deal with it on their own. If someone in your family has schizophrenia, you need under-standing, love, and support from others. No one causes schizophrenia, just as no one causes diabetes, cancer, or heart disease. You are not to blame-and you are not alone.

Help The Person Find Appropriate Treatment And The Means To Pay For It

The most important thing you can do is to help the person find effective treatment and encourage him or her to stick with it. To find a good doctor or clinic, contact your local mental health center, ask your own physician for a referral, or contact the psychiatry department of a university medical school or the American Psychiatric Association. You can contact the National Alliance for the Mentally Ill (NAMI) to consult with others who have a family member with schizophrenia or who have the disorder themselves.

It is also important to help the person find a way to pay for the medications he or she needs. Social workers or case managers may be able to help you through the difficult red tape, but you may also have to contact your local Social Security or social services office directly to find out what benefits are available in your area and how to apply for them. Finding the way through the maze of application processes is difficult even for those who are not ill. A person with schizophrenia will certainly need your help to obtain adequate benefits.

Learn About The Disorder

If you are a family member or friend of someone with schizophrenia, learn all you can about the illness and its treatment. Don't be shy about asking the doctor and therapist questions. Read books and go to National Alliance for the Mentally Ill (NAMI) meetings.

Encourage The Person To Stick With Treatment

The most important factors in keeping patients out of the hospital are for them to take their medications regularly and avoid alcohol and street drugs. Work with your loved one to help him or her remember to take the medicine. Long-acting injectable forms of medication can help patients who find it hard to take a pill every day.

Handling Symptoms

Try your best to understand what your loved one is going through and how the illness causes upsetting or difficult behavior. When people are hallucinating or delusional, it's important to realize that the voices they hear and the images they see are very real to them and difficult to ignore. You should not argue with them, make fun of or criticize them, or act alarmed.

After the acute episode has ended, it is a good time for the patient, the family, and the healthcare provider to review what has been learned about the person's illness in a low-key and non-blaming way. Everyone can work together to develop plans for minimizing the problems and distress that future episodes may cause. For example, the family members can ask the person with schizophrenia to agree that, if they notice warning signs of a relapse, it will be OK for them to contact the doctor so that the medication can be adjusted to try to prevent the relapse.

Learn The Warning Signs Of Suicide

Take any threats the person makes very seriously. Seek help from the patient's doctor and other family members and friends. Call 911 or a hospital emergency room if the situation becomes desperate. Encourage the person to realize that suicidal thinking is a symptom of the illness and will pass in time as the treatment takes effect. Always stress that the person's life is important to you and to others and that his or her suicide would be a tremendous loss and burden to you, not a relief.

Learn To Recognize Warning Signs Of Relapse

Learn the warning signs of a relapse. Stay calm, acknowledge how the person is feeling, indicate that it is a sign of a return of the illness, suggest the importance of getting medical help, and do what you can to help him or her feel safe and more in control.

Don't Expect Too Fast A Recovery

When people are recovering from an acute psychotic episode, they need to approach life at their own pace. Don't push too hard. At the same time, don't be too overprotective. Do thingswith them, rather than for them, so they can regain their sense of self-confidence. Help the person prioritize recovery goals.

People with schizophrenia may have many health problems. They often smoke a lot and may have poor nutrition and excessive weight gain. Although you can encourage the patient to try to control these problems, it is important not to put a lot of pressure on him or her. Focus first on the most important issues: medication adherence and avoiding alcohol and drug use. Your top priority should be to help the patient avoid relapse and maintain stability.

Handling Crises

In some cases, behavior caused by schizophrenia can be bizarre and threatening. If you are confronted with such behavior, do your best to stay calm and nonjudgmental, be concise and direct in whatever you say, clarify the reality of the situation, and be clear about the limits of acceptable behavior. Don't feel that you have to handle the situation alone. Get medical help. Your safety and the safety of the ill person should always come first. When necessary, call the police or 911.

Coping With Schizophrenia

Many people find that joining a family support group is a turning point for them in their struggle to understand the illness and get help for their relative and themselves. More than 1,000 such groups affiliated with the National Alliance for the Mentally Ill (NAMI) are now active in local communities in all 50 states. Members of these groups share information and strategies for everything from coping with symptoms to finding financial, medical, and other resources.

Families who deal most successfully with a relative who has schizophrenia are those who come to accept the illness and its difficult consequences, develop realistic expectations for the ill person and for themselves, accept all the help and support they can get, and also keep a philosophical perspective and a sense of humor. It takes times to develop these attitudes, but the understanding support of others can be a great help.

Schizophrenia poses undeniable hardships for everyone in the family. To deal with it in the best possible way, it's particularly important for you to take care of yourself, do things you enjoy, and not allow the illness to consume your life. Experts on schizophrenia believe that recently introduced new treatments are already a big improvement and that new research discoveries will bring a better understanding of schizophrenia that will result in even more effective treatments. In the meantime, help the patient live the best life he or she can today, and do the same for yourself.

Support Groups

NAMI

The National Alliance for the Mentally Ill (NAMI) is the national umbrella organization for more than 1,140 local support and advocacy groups for families and individuals affected by serious mental illnesses. To learn more about NAMI or locate your state's NAMI affiliate or office, contact:
200 N. Glebe Rd., Suite 1015
Arlington, VA 22203-3754
NAMI Helpline at 800-950-NAMI (800-950-6264)

Several other organizations can also help you locate support groups and information:

National Depressive and Manic-Depressive Association
730 N. Franklin St., Suite 501
Chicago IL, 60610-3526
800-82-NDMDA (800-826-3632)

National Mental Health Association (NMHA)
National Mental Health Information Center
1021 Prince Street
Alexandria, VA 22314-2971
800-969-6642

The National Mental Health Consumer Self Help Clearinghouse
1211 Chestnut St., 11th Floor
Philadelphia, PA 19107
800-688-4226

For More Information

The following materials provide more information on schizophrenia.
Most are available through NAMI.
To order or to obtain a complete publications list, write NAMI or call 703-524-7600.

Books

1. Adamec C. How to Live with a Mentally Ill Person: A Handbook of Day-to-Day Strategies. Wiley & Sons, 1996.
2. Backlar P. The Family Face of Schizophrenia. J P Tarcher, 1994.
3. Bouricius JK. Psychoactive Drugs and Their Effects on Mentally Ill Persons. NAMI, 1996.
4. Carter R, Golant SK. Helping Someone with Mental Illness. Times Books, 1998.
5. Gorman JM. The New Psychiatry: The Essential Guide to State-of-the-Art Therapy, Medication, and Emotional Health. St. Martins, 1996.
6. Hall L, Mark T. The Efficacy of Schizophrenia Treatment. NAMI, 1995.
7. Hatfield A, Lefley HP. Surviving Mental Illness: Stress, Coping, and Adaptation. Guilford, 1993.
8. Lefley HP. Family Caregiving in Mental Illness. Sage, 1996.
9. Mueser KT, Gingerich S. Coping with Schizophrenia: A Guide for Families. Harbinger Press, 1994.
10. Torrey EF. Surviving Schizophrenia: For Families, Consumers, and Providers (Third Edition). Harper & Row, 1995.
11. Weiden PJ. TeamCare Solutions. Eli Lilly, 1997 (to order, call 888-997-7392).
12. Weiden PJ, Diamond RJ, Scheifler PL, Ross R. Breakthroughs in Antipsychotic Medications: A Guide for Consumers, Families, and Clinicians. Norton, 1999.
13. Woolis R. When Someone You Love Has Mental Illness: A Handbook for Family, Friends, and Caregivers. Tarcher/Perigee, 1992.
14. Wyden P. Conquering Schizophrenia. Knopf, 1998.

Videos

The following videos may be ordered from:
Division of Social and Community Psychiatry, Box 3173
Duke University Medical Center
Durham, NC 27710

Burns BJ, Swartz MS, Executive Producers. Harron B, Producer and Director. Hospital without Walls. Department of Psychiatry, Duke University, 1993.

Swartz MS, Executive Producer. Harron B, Producer and Director. Uncertain Journey: Families Coping with Serious Mental Illness. Department of Psychiatry, Duke University, 1996.

To request more copies of this handout, please contact NAMI at 800-950-6264. You can also download the text of this handout on the Internet at www.psychguides.com.

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This Guide was prepared by Peter J. Weiden, MD, Patricia L. Scheifler, MSW, Joseph P. McEvoy, MD, Allen Frances, MD, and Ruth Ross, MA. The guide includes recommendations contained in the 1999 Expert Consensus Treatment Guidelines for Schizophrenia. The Editors gratefully acknowledge Laurie Flynn and the National Alliance for the Mentally Ill for their generous help and permission to adapt their written materials. Eli Lilly, Janssen Pharmaceutica, Novartis Pharmaceuticals, Ortho-McNeil Pharmaceutical, Pfizer Inc, and Zeneca Pharmaceuticals provided unrestricted educational grants in support of this project. Reprinted from J Clin Psychiatry 1999:60 (suppl 11).

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Reviewed by athealth on February 4, 2014.

Bipolar disorder (also known as manic-depressive illness) is a severe biological disorder that affects approximately 1.2% of the adult population (more than 2.2 million people in the United States). Although the symptoms and severity vary, bipolar disorder almost always has a powerful impact on those who have the illness as well as on their family members, partners, and friends. If you or someone you care about has been diagnosed with bipolar disorder, you may have many questions about the nature of the illness, its causes, and the treatments that are available. This guide is intended to answer some of the most commonly asked questions about bipolar disorder.

What Is Bipolar Disorder?

As human beings, we all experience a variety of moods-happiness, sadness, anger, to name a few. Unpleasant moods and changes in mood are normal reactions in everyday life, and we can often identify the events that caused our mood to change. However, when we experience changes in mood-or extremes of mood-that are out of proportion to events or come "out of the blue" and make it hard for us to function, these changes are often the result of a mood disorder.

Mood disorders are biological illnesses that affect our ability to experience normal mood states. There are 2 general groups of mood disorders: unipolar depressive disorders, in which all abnormal mood changes involve a lowering of mood, and bipolar disorders, in which at least some of the mood changes involve abnormal elevation of mood. All mood disorders are caused by changes in brain chemistry. They are not the fault of the person suffering from them. They are not the result of a "weak" or unstable personality. Rather, mood disorders are treatable medical illnesses for which there are specific medications that help most people.

How is the diagnosis made?

Although bipolar disorder is clearly a biological disease, there are no laboratory tests or other procedures that a doctor can use to make a definitive diagnosis. Instead, the doctor diagnoses the illness based on a group of symptoms that occur together. To make an accurate diagnosis, the doctor will need to take a careful history of the symptoms the person is currently experiencing as well as any symptoms he or she has had in the past.

What are the symptoms of bipolar disorder?

Bipolar disorder is a disease in which the person's mood changes in cycles over time. Over the course of the illness, the person experiences periods of elevated mood, periods of depressed mood, and times when mood is normal. There are 4 different kinds of mood episodes that occur in bipolar disorder:

Mania(manic episode). Mania often begins with a pleasurable sense of heightened energy, creativity, and social ease. However, these feelings quickly progress to full-blown euphoria (extremely elevated mood) or severe irritability. People with mania typically lack insight, deny that anything is wrong, and angrily blame anyone who points out a problem. In a manic episode, the following symptoms are present for at least 1 week and make it very difficult for the person to function:.

• Feeling unusually "high," euphoric, or irritable

Plus at least 4 of the following symptoms:

• Needing little sleep yet having great amounts of energy
• Talking so fast that others cannot follow you
• Having racing thoughts
• Being so easily distracted that your attention shifts between many topics in just a few minutes
• Having an inflated feeling of power, greatness, or importance
• Doing reckless things without concern about possible bad consequences (e.g., spending too much money, inappropriate sexual activity, or making foolish business investments)

In severe cases, the person may also experience psychotic symptoms such as hallucinations (hearing or seeing things that are not there) or delusions (firmly believing things that are not true).

Hypomania (hypomanic episode). Hypomania is a milder form of mania that has similar but less severe symptoms and causes less impairment. During a hypomanic episode, the person may have an elevated mood, feel better than usual, and be more productive. These episodes often feel good and the quest for hypomania may even cause some individuals with bipolar disorder to stop their medication. However, hypomania can rarely be maintained indefinitely, and is often followed by an escalation to mania or a crash to depression.

Depression (major depressive episode). In a major depressive episode, the following symptoms are present for at least 2 weeks and make it difficult for the person to function:

• Feeling sad, blue, or down in the dumps or losing interest in the things one normally enjoys

Plus at least 4 of the following symptoms:

• Difficulty sleeping or sleeping too much
• Loss of appetite or eating too much
• Problems concentrating or making decisions
• Feeling slowed down or feeling too agitated to sit still
• Feeling worthless or guilty or having very low self-esteem
• Thoughts of suicide or death

Severe depressions may also include hallucinations or delusions.

Mixed Episode. Perhaps the most disabling episodes are those that involve symptoms of both mania and depression occurring at the same time or alternating frequently during the day. Individuals are excitable or agitated as in mania but also feel irritable and depressed. Owing to the combination of high energy and depression, mixed episodes present the greatest risk of suicide.

What are the different patterns of bipolar disorder?

People with bipolar disorder vary in the types of episodes they usually have and how often they become ill. Some individuals have equal numbers of manic and depressive episodes; others have mostly one type or the other. The average person with bipolar disorder has 4 episodes during the first 10 years of the illness. Men are more likely to start with a manic episode, women with a depressive episode. While a number of years can elapse between the first 2 or 3 episodes of mania or depression, without treatment most people eventually have more frequent episodes. Sometimes these follow a seasonal pattern (for example, becoming hypomanic in the summer and depressed in the winter). A small number of people cycle frequently or even continuously throughout the year (termed "rapid-cycling" bipolar disorder).

Episodes can last days, months, or sometimes even years. On average, without treatment, manic or hypomanic episodes last a few months, while depressions often last well over 6 months. Some individuals recover completely between episodes and may go many years without any symptoms, while others continue to have low-grade but troubling depression or mild swings up and down.

Special terms are used to describe these common patterns:

• In Bipolar I Disorder, a person has manic or mixed episodes and almost always has depressions as well. If someone becomes ill for the first time with a manic episode, the illness is still considered bipolar even though depressions have not yet occurred. It is highly likely that future episodes will involve depression as well as mania unless effective treatment is received.
• In Bipolar II Disorder, a person has only hypomanic and depressive episodes, not full manic or mixed episodes. This type is often hard to recognize because hypomania may seem normal if the person is very productive and avoids getting into serious trouble. Individuals with bipolar II disorder frequently overlook episodes of hypomania and seek treatment only for depression. Unfortunately, if a mood stabilizer is not prescribed with an antidepressant for unrecognized bipolar II disorder, the antidepressant may trigger a "high" or set off more frequent cycles.
• In Rapid-Cycling Bipolar Disorder, a person has at least 4 episodes per year, in any combination of manic, hypomanic, mixed, or depressive episodes. This course pattern is seen in approximately 5% to 15% of patients with bipolar disorder. It is sometimes associated with use of antidepressants without mood stabilizers, which may increase cycling. For unknown reasons, the rapid-cycling subtype of bipolar disorder is more common in women.

Are there other psychiatric conditions that may be confused with, or coexist with, bipolar disorder?

Bipolar disorder can be confused with other disorders, including a variety of anxiety disorders and psychotic disorders (such as schizophrenia and schizoaffective disorder). This is because anxiety and psychotic symptoms often occur during the course of bipolar disorder. Individuals with bipolar disorder also frequently suffer from psychiatric disorders that are "comorbid" with (are present in addition to) the bipolar illness. The most common of these comorbid conditions are substance abuse disorders, obsessive-compulsive disorder, and panic disorder. If you have any concerns about whether your diagnosis is correct, you should feel comfortable asking the doctor to explain how he or she arrived at a diagnosis of bipolar disorder.

When does bipolar disorder begin?

Bipolar disorder usually begins in adolescence or early adulthood, although it can sometimes start in early childhood or as late as the 40s or 50s. When someone over 50 has a manic episode for the first time, the cause is more likely to be a problem imitating bipolar disorder, such as a neurological illness or the effects of drugs, alcohol, or some prescription medications.

Why is it important to diagnose and treat bipolar disorder as early as possible?

On average, people with bipolar disorder see 3 to 4 doctors and spend over 8 years seeking treatment before they receive a correct diagnosis. Earlier diagnosis, proper treatment, and finding the right medications can help people avoid the following:

• Suicide. The risk is highest in the initial years of the illness. Over the course of the illness nearly 1 out of 5 individuals with bipolar disorder will die from suicide, making it one of the most lethal psychiatric illnesses.
• Alcohol/substance abuse. More than 50% of those with bipolar disorder abuse alcohol or drugs during their illness. While some individuals may use substances in an attempt to "self-medicate" symptoms of bipolar illness, individuals with a combination of substance abuse and bipolar illness have a worse outcome.
• Marital and work problems. Prompt treatment improves the prospects for a stable marriage and productive work.
• Treatment difficulties. In some individuals, it appears that episodes become more frequent and harder to treat over time. This is sometimes referred to as "kindling."
• Incorrect, inappropriate, or partial treatment. A person misdiagnosed as having depression alone instead of bipolar disorder may incorrectly receive antidepressants alone without a mood stabilizing medication. This can trigger manic episodes and make the overall course of the illness worse.

What causes bipolar disorder?

There is no single, proven cause of bipolar disorder, but research suggests that it is the result of abnormalities in the way some nerve cells in the brain function or communicate. Whatever the precise nature of the biochemical problem underlying bipolar illness, it clearly makes people with the disorder more vulnerable to emotional and physical stresses. As a result, upsetting life experiences, substance use, lack of sleep, or other stresses can trigger episodes of illness, even though these stresses do not actually cause the disorder.

This theory of an inborn vulnerability interacting with an environmental trigger is similar to theories proposed for many other medical conditions. In heart disease, for example, a person might inherit a tendency to have high cholesterol or high blood pressure, which can cause gradual damage to the heart's supply of oxygen. During stress, such as physical exertion or emotional tension, the person might suddenly develop chest pain or have a heart attack if the oxygen supply becomes too low. The treatment in this case is to take medication to lower the cholesterol or blood pressure (treating the underlying illness) and make changes in lifestyle (e.g., exercise, diet, reducing stresses that can trigger acute episodes). Similarly, in bipolar disorder, we use mood stabilizers to treat the underlying biological disorder while at the same time recommending changes in lifestyle (e.g., reducing stress, good sleep habits, avoiding substances of abuse) to lower the risk of relapse.

Is bipolar disorder inherited?

Bipolar disorder tends to run in families. Researchers have identified a number of genes that may be linked to the disorder, suggesting that several different biochemical problems may occur in bipolar disorder. Like other complex inherited disorders, bipolar disorder only occurs in a fraction of the individuals at genetic risk. For example, if an individual has bipolar disorder and his or her spouse does not, there is only a 1 in 7 chance that their child will develop it. The chance may be greater if you have a greater number of relatives with bipolar disorder or depression.

How Is Bipolar Disorder Treated?

Stages of Treatment

• Acute phase: treatment is aimed at ending the current manic, hypomanic, depressive, or mixed episode
• Preventive or maintenance phase: treatment is continued on a long-term basis to prevent future episodes

Components of Treatment

• Medication is necessary for nearly all patients during acute and preventive phases.
• Education is crucial in helping patients and families learn how best to manage bipolar disorder and prevent its complications.
• Psychotherapy helps patients and families affected by bipolar disorder deal with disturbing thoughts, feelings, and behaviors in a constructive manner.

Types Of Medication

The 3 most important types of medication used to control the symptoms of bipolar disorder are mood stabilizers, antidepressants, and antipsychotics. Your doctor may also prescribe other medications to help with insomnia, anxiety, or restlessness. While we do not understand how some of these medications work, we do know that all of them affect chemicals in the brain called neurotransmitters, which are involved in the functioning of nerve cells.

What are mood stabilizers?

Medications are considered mood stabilizers if they have 2 properties:

• they provide relief from acute episodes of mania or depression, or prevent them from occurring; and
• they do not worsen depression or mania or lead to increased cycling.

Lithium, divalproex and carbamazepine have been shown to meet this definition; the first 2 are the best established and most widely used. Divalproex and carbamazepine were originally developed as anticonvulsants for the control of epilepsy, another brain disorder. Other available medications that are undergoing research as promising mood stabilizers include several new anticonvulsants and the newer "atypical" antipsychotics. Electroconvulsive therapy (ECT), discussed later, is also considered a mood stabilizing treatment.

Lithium (brand names Eskalith, Lithobid, Lithonate)

The first known mood stabilizer, lithium, is actually an element rather than a compound (a substance synthesized by a laboratory). Lithium was first found to have behavioral effects in the 1950s and has been used as a mood stabilizer in the United States for 30 years. Lithium appears to be most effective for individuals with more "pure" or euphoric mania (where there is little depression mixed in with the elevated mood). It is also helpful for depression, especially when added to other medications. Lithium appears to be less effective in mixed manic episodes and in rapid-cycling bipolar disorder. Monitoring blood levels of lithium can reduce side effects and ensure that the patient is receiving an adequate dose to help produce the best response. Common side effects of lithium include weight gain, tremor, nausea, and increased urination. Lithium may affect the thyroid gland and the kidneys, so that periodic blood tests are needed to be sure they are functioning properly.

Divalproex (brand name Depakote)

Divalproex has been used as an anticonvulsant-to treat seizures-for several decades. It has also been extensively researched as a mood stabilizer in bipolar illness. Divalproex is equally effective in both euphoric and mixed manic episodes. It is also effective in rapid cycling bipolar disorder and for individuals whose illness is complicated by substance abuse or anxiety disorders. Unlike other mood stabilizers, divalproex can be given in relatively large initial doses for acute mania, which may produce a more rapid response. Common side effects of divalproex include sedation, weight gain, tremor, and gastrointestinal problems. Blood level monitoring and dose adjustments may help minimize side effects. Divalproex may cause a mild liver inflammation and may affect the production of a type of blood cell called platelets. Although it is quite rare for there to be any serious complications from these potential effects, it is important to monitor liver function tests and platelet counts periodically.

Other Anticonvulsants Used as Mood Stabilizers

• Carbamazepine (Tegretol, Carbatrol). Although fewer clinical studies support the use of carbamazepine, it appears to have a profile similar to divalproex. It, too, has been available for many years, and is effective in a broad range of subtypes of bipolar illness and in both euphoric and mixed manic episodes. Carbamazepine commonly causes sedation and gastrointestinal side effects. Because of a rare risk of bone marrow suppression and liver inflammation, periodic blood testing is also needed during carbamazepine treatment, just as during treatment with divalproex. Because carbamazepine has complicated interactions with many other medications, careful monitoring is needed when it is combined with other medications.
• Lamotrigine (Lamictal). Lamotrigine is a relatively new medication. Recent research suggests that it can act as a mood stabilizer, and may be especially useful for the depressed phase of bipolar disorder. One serious risk of lamotrigine use is that 3 out of every 1,000 individuals (0.3%) taking the medication develop a serious rash. The risk of rash can be lowered by increasing the dosage very slowly. Aside from the risk of rash, lamotrigine tends to have fewer troublesome side effects overall, but can cause dizziness, headaches, and difficulties with vision.
• Gabapentin (Neurontin). Gabapentin has become popular as a mood stabilizer, although there has been relatively little research on its use in bipolar disorder. It appears especially helpful in reducing anxiety. One strength of gabapentin is that it is unlikely to interact with other medications, so that it can be easily added to other mood stabilizers to augment their effect. Side effects of gabapentin can include fatigue, sedation, and dizziness.
• Topiramate (Topomax). Preliminary research suggests that this new anticonvulsant may be helpful in mania. One side effect of topiramate may actually be an advantage. Unlike many of the other mood stabilizers, topiramate does not appear to cause weight gain and may actually help people lose weight. Other side effects may include sedation, dizziness, and cognitive slowing or memory difficulties. It should avoided by people who have had kidney stones.

What are antidepressants?

Antidepressants treat the symptoms of depression. In bipolar disorder, antidepressants must be used together with a mood stabilizing medication. If used without a mood stabilizer, an antidepressant can push a person with bipolar disorder into a manic state. Many types of antidepressants are available with different chemical mechanisms of action and side effect profiles. Most research with antidepressants has been done in people with unipolar depression-people who have never had a manic episode. In unipolar depression, the available medications are about equally effective. There has been little research on the use of antidepressants in bipolar disorder, but most experts consider the following 3 types to be first choices:

• Bupropion (Wellbutrin)
• Selective serotonin reuptake inhibitors: fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft)
• Venlafaxine (Effexor)

If these do not work, or if they cause unpleasant side effects, the other choices are:

• Mirtazapine (Remeron)
• Nefazodone (Serzone)
• Monoamine oxidase inhibitors: phenelzine (Nardil), tranylcypromine (Parnate). These are very effective but also require you to stay on a special diet to avoid dangerous side effects.
• Tricyclic antidepressants: amitriptyline (Elavil), desipramine (Norpramin, Pertofrane), imipramine (Tofranil), nortriptyline (Pamelor). Tricyclics may be more likely to cause side effects or to set off manic episodes or rapid cycling.

What are antipsychotic medications?

Antipsychotic medications are used to control psychotic symptoms, such as hallucinations or delusions, that sometimes occur in very severe depressive or manic episodes. Antipsychotics can be used in 2 additional ways in bipolar disorder, even if no psychotic symptoms are present. They may be used as sedatives, especially during early stages of treatment, for insomnia, anxiety, and agitation. Researchers also believe that the newer antipsychotic medications have mood stabilizing properties, and may help control depression and mania. Antipsychotic medications are therefore often added to mood stabilizers to improve the response in patients who have never had psychotic symptoms. Antipsychotics may also be used alone as mood stabilizers when patients cannot tolerate or do not respond to any of the mood stabilizers.

There are 2 kinds of antipsychotics: older antispychotics (often called "typical" or conventional antipsychotics) and newer antipsychotics (often called atypical antipsychotics). One serious problem with the older antipsychotics is the risk of a permanent movement disorder called tardive dyskinesia (TD). Older antipsychotic medicines may also cause muscle stiffness, restlessness, and tremors. The newer "atypical" antipsychotics have a much lower risk of causing TD (roughly 1% per year) and movement and muscle side effects. Because of this, the newer atypical antipsychotics are usually the first choice in any of the situations when an antipsychotic is needed.

Four atypical antipsychotics, are currently available:

• olanzapine (Zyprexa)
• quetiapine (Seroquel)
• risperidone (Risperdal)
• clozapine (Clozaril)

As mentioned earlier, research is beginning to show that these atypical antipsychotics have mood stabilizing properties. Common side effects of the atypical antipsychotics include drowsiness and weight gain. Although it is very effective, clozapine is not a first choice medication because it can cause a rare and serious blood side effect, requiring weekly or biweekly blood tests.

Examples of conventional antipsychotics include older medications such as haloperidol (Haldol), perphenazine (Trilafon), and chlorpromazine (Thorazine). Although they are not usually a first choice, the older medications can be helpful for patients who do not respond to or have troublesome side effects with the newer atypical antipsychotics.

Acute Phase Of Treatment

Selecting a Mood Stabilizer for an Acute Manic Episode

The first-line drugs for treating a manic episode during the acute phase are lithium and valproate. In choosing between these 2 medications, your doctor will consider your treatment history (whether either of these medicines has worked well for you in the past), the subtype of bipolar disorder you have (e.g., whether you have rapid-cycling bipolar disorder), your current mood state (euphoric or mixed mania), and the particular side effects that you are most concerned about.

Lithium and divalproex are each good choices for "pure" mania (euphoric mood without symptoms of depression), while divalproex is preferred for mixed episodes or for patients who have rapid-cycling bipolar disorder. It is not unusual to combine lithium and divalproex to obtain the best possible response. If this combination is still not fully effective, a third mood stabilizer is sometimes added.

Carbamazepine is a good alternative medication after lithium and divalproex. Like divalproex, carbamazepine may be particularly effective in mixed episodes and in the rapid-cycling subtype. It can be easily combined with lithium, although it is more complicated to combine it with divalproex.

The newer anticonvulsants (lamotrigine, gabapentin, and topiramate) are often best reserved as back-up medications to add to first-line medications for mania, or to use instead of the first-line group if there have been difficult side effects.

How quickly do mood stabilizers work?

It can take a few weeks for a good response to occur with mood stabilizers. However, it is often helpful to combine mood stabilizers with other medications that provide immediate, short-term relief from the insomnia, anxiety, and agitation that often occur during a manic episode. The choices for so-called "adjunctive" medication include:

• antipsychotic medicines, especially if the person is also having psychotic symptoms (see above).
• a sedative called a benzodiazepine. Benzodiazpeines include lorazepam (Ativan), clonazepam (Klonopin), and others. They should be carefully supervised, or avoided, in patients who have a history of drug addiction or alcoholism.

Although both benzodiazepine sedatives and antipsychotic medicines can cause drowsiness, the dosages of these medications can generally be lowered as the person recovers from the acute episode. However, some individuals need to continue taking a sedative for a longer period to control certain symptoms such as insomnia or anxiety. Longer-term treatment with an antipsychotic is sometimes needed to prevent relapse.

Selecting an Antidepressant for an Acute Depression

Although a mood stabilizer alone may treat milder depression, an antidepressant is usually needed for more severe depression. It is dangerous to give antidepressants alone in bipolar disorder, because they can trigger an increase in cycling or cause the person's mood to "overshoot" and switch from depression to hypomania or mania. For this reason, antidepressants are always given in combination with a mood stabilizer in bipolar disorder.

Antidepressants usually take several weeks to show effects. Although the first antidepressant tried will work for the majority of patients, it is common for patients to go through 2 or 3 trials of antidepressants before finding one that is fully effective and doesn't cause troublesome side effects. While waiting for the antidepressant to work, it may be helpful to take a sedating medication to help relieve insomnia, anxiety, or agitation.

If depression persists despite use of an antidepressant with a mood stabilizer, adding lithium (if not already in use) or changing the mood stabilizer might help. Lamotrigine, in particular, may be helpful in depression.

Strategies to Limit Side Effects

All of the medications that are used to treat bipolar disorder can produce bothersome side effects; there are also some serious but rare medical reactions. Just as different people have varying responses to different medications, the type of side effects different people develop can vary widely, and some people may not have any side effects at all. Also, if someone has problems with side effects on 1 medication, this does not mean that that person will develop troublesome side effects on another medication.

Certain strategies can help prevent or minimize side effects. For example, the doctor may want to start at a low dose and adjust the medication to higher doses very slowly. Although this may mean that you need to wait longer to see if the medication will help the symptoms, it does reduce the chances of side effects developing. In the case of lithium or divalproex, blood level monitoring is very important to insure that a patient is receiving enough medication to help, but not more than is necessary. If side effects do occur, the dosage can frequently be adjusted to eliminate the side effects or another medication can be added to help. It is important to discuss your concerns about side effects and any problems you may be experiencing with your doctor, so that he or she can take these into account in planning your treatment.

Electroconvulsive Therapy

Electroconvulsive therapy (ECT) is often life-saving in severe depression and mania, but has received a lot of undeserved negative publicity. ECT is a critically important option if someone is very suicidal, if the person is severely ill and cannot wait for medications to work (e.g., the person is not eating or drinking), if there is a history of many unsuccessful medication trials, if medical conditions or pregnancy make medications unsafe, or if psychosis (delusions or hallucinations) is present. ECT is administered under anesthesia in a carefully monitored medical setting. Patients typically receive 6 to 10 treatments over a few weeks. The most common side effect of ECT is temporary memory problems, but memory returns quickly after a course of treatment.

About Hospitalization

Many patients with bipolar I disorder (i.e., patients who have had at least 1 full manic episode) are hospitalized at some point in the course of their illness. Because acute mania affects insight and judgment, individuals with mania are often hospitalized over their objections, which can be upsetting for both patients and their loved ones. However, most individuals with mania are grateful for the help they received during the acute episode, even if it was given against their will at the time. Hospitalization should be considered under the following circumstances:

• When safety is in question due to suicidal, homicidal, or aggressive impulses or actions
• When severe distress or dysfunction requires round-the-clock care and support (which is difficult, if not impossible, for any family to sustain for a long period of time)
• Where there is ongoing substance abuse, to prevent access to drugs
• When the patient has an unstable medical condition
• When close observation of the patient's reaction to medications is required

Preventive Treatment

Mood stabilizers, especially lithium and divalproex, are the cornerstones of prevention or long-term maintenance treatment. About 1 in 3 people with bipolar disorder will remain completely free of symptoms just by taking mood stabilizing medication for life. Most other people experience a great reduction in the frequency and severity of episodes during maintenance treatment.

It is important not to become overly discouraged when episodes do occur and to recognize that the success of treatment can only be evaluated over the long term, by looking at the frequency and severity of episodes. Be sure to report changes in mood to your doctor immediately, because adjustments in your medicine at the first warning signs can often restore normal mood and head off a full-blown episode. Medication adjustments should be viewed as a routine part of treatment (just as insulin doses are changed from time to time in diabetes). Most patients with bipolar disorder do best on a combination or "cocktail" of medications. Often the best response is achieved with 1 or more mood stabilizers, supplemented from time to time with an antidepressant or possibly an antipsychotic medication.

Continuing to take medication correctly and as prescribed (which is called adherence) on a long-term basis is difficult whether you are being treated for a medical condition (such as high blood pressure or diabetes) or for bipolar disorder. Individuals with bipolar disorder are often tempted to stop taking their medication during maintenance treatment for several reasons. They may feel free of symptoms and think they don't need medication any more. They may find the side effects too hard to deal with. Or they may miss the mild euphoria they experience during hypomanic episodes. However, research clearly indicates that stopping maintenance medication almost always results in relapse, usually in weeks to months after stopping. In the case of lithium discontinuation, the rate of suicide rises precipitously after discontinuation. There is some evidence that stopping lithium in an abrupt fashion (rather than slowly tapering off) carries a much greater risk of relapse. Therefore, if you must discontinue medication, it should be done gradually under the close medical supervision of your doctor.

If someone has had only a single episode of mania, consideration may be given to tapering the medication after about a year. However, if the single episode occurs in someone with a strong family history of bipolar disorder or is particularly severe, longer-term maintenance treatment should be considered. If someone has had 2 or more manic or depressive episodes, experts strongly recommend taking preventive medication indefinitely. The only times to consider stopping a preventive medication that is working well is if a medical condition or severe side effect prevents its safe use, or when a woman is trying to become pregnant. Even these situations may not be absolute reasons to stop, and substitute medications can often be found. You should discuss each of these situations carefully with your doctor.

Education: Learning To Cope With Bipolar Disorder

Another important part of treatment is education. The more you and your family and loved ones learn about bipolar disorder and its treatment, the better you will be able to cope with it.

Is there anything I can do to help my treatment?

Absolutely, yes. First, you should become an expert on your illness. Since bipolar disorder is a lifetime condition, it is essential that you and your family or others close to you learn all about it and its treatment. Read books, attend lectures, talk to your doctor or therapist, and consider joining a chapter of the National Depressive and Manic-Depressive Association (NDMDA) or the National Alliance for the Mentally Ill (NAMI) near you to stay up to date on medical and other developments, as well as to learn from others about managing the illness. Being an informed patient is the surest path to success.

You can often help reduce the minor mood swings and stresses that sometimes lead to more severe episodes by paying attention to the following:

• Maintain a stable sleep pattern. Go to bed around the same time each night and get up about the same time each morning. Disrupted sleep patterns appear to cause chemical changes in your body that can trigger mood episodes. If you have to take a trip where you will change time zones and might have jet lag, get advice from your doctor.
• Maintain a regular pattern of activity. Don't be frenetic or drive yourself impossibly hard.
• Do not use alcohol or illicit drugs. Drugs and alcohol can trigger mood episodes and interfere with the effectiveness of psychiatric medications. You may sometimes find it tempting to use alcohol or illicit drugs to "treat" your own mood or sleep problems-but this almost always makes matters worse. If you have a problem with substances, ask your doctor for help and consider self-help groups such as Alcoholics Anonymous. Be very careful about "everyday" use of small amounts of alcohol, caffeine, and some over-the-counter medications for colds, allergies, or pain. Even small amounts of these substances can interfere with sleep, mood, or your medicine. It may not seem fair that you have to deprive yourself of a cocktail before dinner or a morning cup of coffee, but for many people this can be the "straw that breaks the camel's back."
• Enlist the support of family and friends. However, remember that it is not always easy to live with someone who has mood swings. If all of you learn as much as possible about bipolar disorder, you will be better able to help reduce the inevitable stress on relationships that the disorder can cause. Even the "calmest" family will sometimes need outside help dealing with the stress of a loved one who has continued symptoms. Ask your doctor or therapist to help educate both you and your family about bipolar disorder. Family therapy or joining a support group can also be very helpful.
• Try to reduce stress at work. Of course, you want to do your very best at work. However, keep in mind that avoiding relapses is more important and will, in the long run, increase your overall productivity. Try to keep predictable hours that allow you to get to sleep at a reasonable time. If mood symptoms interfere with your ability to work, discuss with your doctor whether to "tough it out" or take time off. How much to discuss openly with employers and coworkers is ultimately up to you. If you are unable to work, you might have a family member tell your employer that you are not feeling well and that you are under a doctor's care and will return to work as soon as possible.
• Learn to recognize the "early warning signs" of a new mood episode. Early signs of a mood episode differ from person to person and are different for mood elevations and depressions. The better you are at spotting your own early warning signs, the faster you can get help. Slight changes in mood, sleep, energy, self-esteem, sexual interest, concentration, willingness to take on new projects, thoughts of death (or sudden optimism), and even changes in dress and grooming may be early warnings of an impending high or low. Pay special attention to a change in your sleep pattern, because this is a common clue that trouble is brewing. Since loss of insight may be an early sign of an impending mood episode, don't hesitate to ask your family to watch for early warnings that you may be missing.
• Consider entering a clinical study.

What if you feel like quitting treatment?

It is normal to have occasional doubts and discomfort with treatment. If you feel a treatment is not working or is causing unpleasant side effects, tell your doctor-don't stop or adjust your medication on your own. Symptoms that come back after stopping medication are sometimes much harder to treat. Don't be shy about asking your doctor to arrange for a second opinion if things are not going well. Consultations can be a great help.

How often should I talk with my doctor?

During acute mania or depression, most people talk with their doctor at least once a week, or even every day, to monitor symptoms, medication doses, and side effects. As you recover, contact becomes less frequent; once you are well, you might see your doctor for a quick review every few months.

Regardless of scheduled appointments or blood tests, call your doctor if you have:

• Suicidal or violent feelings
• Changes in mood, sleep, or energy
• Changes in medication side effects
• A need to use over-the-counter medications such as cold medicine or pain medicine
• Acute general medical illnesses or a need for surgery, extensive dental care, or changes in other medicines you take

How can I monitor my own treatment progress?

Keeping a mood chart is a good way to help you, your doctor, and your family manage your disorder. A mood chart is a diary in which you keep track of your daily feelings, activities, sleep patterns, medication and side effects, and important life events. (You can ask your doctor or the NDMDA for a sample chart.) Often just a quick daily entry about your mood is all that is needed. Many people like using a simple, visual scale-from the "most depressed" to the "most manic" you ever felt, with "normal" being in the middle. Noticing changes in sleep, stresses in your life, and so forth may help you identify what are the early warning signs of mania or depression and what types of triggers typically lead to episodes for you. Keeping track of your medicines over many months or years will also help you figure out which ones work best for you.

What can families and friends do to help?

If you are a family member or friend of someone with bipolar disorder, become informed about the patient's illness, its causes, and its treatments. Talk to the patient's doctor if possible. Learn the particular warning signs for that person which indicate that he or she is becoming manic or depressed. Talk with the person, while he or she is well, about how you should respond when you see symptoms emerging.

• Encourage the patient to stick with treatment, to see the doctor, and to avoid alcohol and drugs. If the patient is not doing well or is having severe side effects, encourage the person to get a second opinion, but not to stop medication without advice.
• If your loved one becomes ill with a mood episode and suddenly views your concern as interference, remember that this is not a rejection of you but rather a symptom of the illness.
• Learn the warning signs of suicide and take any threats the person makes very seriously. If the person is "winding up" his or her affairs, talking about suicide, frequently discussing methods of suicide, or exhibiting increased feelings of despair, step in and seek help from the patient's doctor or other family members or friends. Privacy is a secondary concern when the person is at risk of committing suicide. Call 911 or a hospital emergency department if the situation becomes desperate.
• With someone prone to manic episodes, take advantage of periods of stable mood to arrange "advance directives"-plans and agreements you make with the person when he or she is stable to try to avoid problems during future episodes of illness. You should discuss when to institute safeguards, such as withholding credit cards, banking privileges, and car keys, and when to go to the hospital.
• Share the responsibility for taking care of the patient with other loved ones. This will help reduce the stressful effects that the illness has on caregivers and prevent you from "burning out" or feeling resentful.
• When patients are recovering from an episode, let them approach life at their own pace, and avoid the extremes of expecting too much or too little. Try to do things with them, rather than for them, so that they are able to regain their sense of self-confidence. Treat people normally once they have recovered, but be alert for telltale symptoms. If there is a recurrence of the illness, you may notice it before the person does. Indicate the early symptoms in a caring manner and suggest talking with the doctor.
• Both you and the patient need to learn to tell the difference between a good day and hypomania, and between a bad day and depression. Patients with bipolar disorder have good days and bad days just like everyone else. With experience and awareness, you will be able to tell the difference between the two.
• Take advantage of the help available from support groups.

Psychotherapy

Psychotherapy for bipolar disorder helps a person cope with life problems, come to terms with changes in self-image and life goals, and understand the effects of the illness on significant relationships. As a treatment to relieve symptoms during an acute episode, psychotherapy is much more likely to help with depression than with mania-during a manic episode, patients may find it hard to listen to a therapist. Long-term psychotherapy may help prevent both mania and depression by reducing the stresses that trigger episodes and by increasing patients' acceptance of the need for medication.

Types of Psychotherapy

Four specific types of psychotherapy have been studied by researchers. These approaches are particularly useful during acute depression and recovery:

• Behavioral therapy focuses on behaviors that can increase or decrease stress and ways to increase pleasurable experiences that may help improve depressive symptoms.
• Cognitive therapy focuses on identifying and changing the pessimistic thoughts and beliefs that can lead to depression.
• Interpersonal therapy focuses on reducing the strain that a mood disorder may place on relationships.
• Social rhythms therapy focuses on restoring and maintaining personal and social daily routines to stabilize body rhythms, especially the 24-hour sleep-wake cycle.

Psychotherapy can be individual (only you and a therapist), group (with other people with similar problems), or family. The person who provides therapy may be your doctor or another clinician, such as a social worker, psychologist, nurse, or counselor who works in partnership with your doctor.

How To Get the Most Out of Psychotherapy

• Keep your appointments.
• Be honest and open.
• Do the homework assigned to you as part of your therapy.
• Give the therapist feedback on how the treatment is working.

Remember that psychotherapy usually works more gradually than medication and may take 2 months or more to show its full effects. However, the benefits may be long lasting. Remember that people can react differently to psychotherapy, just as they do to medicine.

Information, Advocacy, And Research

Some of the major organizations that help people with bipolar disorder are listed below. The first 3 are advocacy groups- grassroots organizations founded by patients and families to improve care by providing educational material and support groups, helping with referrals, and working to eliminate stigma and to change laws and policies to benefit individuals with mental illness. The support groups they sponsor provide a forum for mutual acceptance and advice from others who have suffered from severe mood disorders-help that can be invaluable for some individuals. The last 3 organizations, headed by medical researchers, provide education and can help with referrals to programs and clinical studies that provide innovative and state-of-the-art treatment.

Depression and Bipolar Support Alliance (DBSA)
800-82-NDMDA (800-826-3632)
http://www.dbsalliance.org/

National Alliance for the Mentally Ill (NAMI)
800-950-NAMI (800-950-6264)
http://www.nami.org

National Mental Health Association (NMHA)
800-969-6642
http://www.nmha.org

National Foundation for Depressive Illness, Inc. (NFDI)
800-248-4344

Madison Institute of Medicine
Home of the Lithium Information Center and the Stanley Center for the
Innovative Treatment of Bipolar Disorder
Distributes very useful consumer guides to mood stabilizers 608-827-2470
http://www.miminc.org/

Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)
Project that is conducting studies involving 5,000 bipolar patients treated
in different centers in the United States. The goal is to improve
effectiveness of treatment for bipolar disorder.
If you are interested in participating, visit:
http://www.edc.gsph.pitt.edu/stepbd

For More Information

The NDMDA distributes free the booklet A Guide to Depressive and Manic-Depressive Illness: Diagnosis, Treatment and Support, along with a NDMDA bookstore catalog and chapter directory. The publications listed below also provide more information on bipolar disorder. Most are available from the NDMDA bookstore. To order these materials, call 800-82-NDMDA.

The recommendations in this article were based on a recent survey of experts on the medication treatment of bipolar disorder (published as A Postgraduate Medicine Special Report, April 2000). You can download an Adobe Acrobat file of this study and this guide for patients and families at our website: http://www.psychguides.com

Authors' Affiliations: Kahn and Printz: Columbia University; Ross: Ross Editorial; Sachs: Massachusetts General Hospital and Harvard Medical School.

Source: A Postgraduate Medicine Special Report
by David Kahn, MD, Ruth Ross, MA, David Printz, MD, Gary Sachs, MD
April 2000

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Reviewed by athealth on February 8, 2014.

Introduction

Research shows that half of all lifetime cases of mental illness begin by age 14.¹ Scientists are discovering that changes in the body leading to mental illness may start much earlier, before any symptoms appear.

Through greater understanding of when and how fast specific areas of children's brains develop, we are learning more about the early stages of a wide range of mental illnesses that appear later in life. Helping young children and their parents manage difficulties early in life may prevent the development of disorders. Once mental illness develops, it becomes a regular part of your child's behavior and more difficult to treat. Even though we know how to treat (though not yet cure) many disorders, many? children with mental illnesses are not getting treatment.

This fact sheet addresses common questions about diagnosis and treatment options for children with mental illnesses. Disorders affecting children may include anxiety disorders, attention deficit hyperactivity disorder (ADHD), autism spectrum disorders, bipolar disorder, depression, eating disorders, and schizophrenia.

Questions and Answers

Q: What should I do if I am concerned about mental, behavioral, or emotional symptoms in my child?

Talk to your child's doctor or health care provider. Ask questions and learn everything you can about the behavior or symptoms that worry you. If your child is in school ask the teacher if your child has been showing worrisome changes in behavior. Share this with your child's doctor or health care provider. Keep in mind that every child is different. Even normal development, such as when children develop language, motor, and social skills, varies from child to child. Ask if your child needs further evaluation by a specialist with experience in child behavioral problems. Specialists may include psychiatrists, psychologists, social workers, psychiatric nurses, and behavioral therapists. Educators may also help evaluate your child.

If you take your child to a specialist, ask, "Do you have experience treating the problems I see in my child?" Don't be afraid to interview more than one specialist to find the right fit. Continue to learn everything you can about the problem or diagnosis. The more you learn, the better you can work with your child's doctor and make decisions that feel right for you, your child, and your family.

Q: Can symptoms be caused by a death in the family, illness in a parent, family financial problems, divorce, or other events?

Yes. Every member of a family is affected by tragedy or extreme stress, even the youngest child. It's normal for stress to cause a child to be upset. Remember this if you see mental, emotional, or behavioral symptoms in your child. If it takes more than one month for your child to get used to a situation, or if your child has severe reactions, talk to your child's doctor.

Check your child's response to stress. Take note if he or she gets better with time or if professional care is needed. Stressful events are challenging, but they give you a chance to teach your child important ways to cope.

Q: How are mental illnesses diagnosed in young children?

Just like adults, children with mental illness are diagnosed after a doctor or mental health specialist carefully observes signs and symptoms. Some primary care physicians can diagnose your child themselves, but many will send you to a specialist who can diagnose and treat children.

Before diagnosing a mental illness, the doctor or specialist tries to rule out other possible causes for your child's behavior. The doctor will:

• Take a history of any important medical problems
• Take a history of the problem - how long you have seen the problem - as well as a history of your child's development
• Take a family history of mental disorders
• Ask if the child has experienced physical or psychological traumas, such as a natural disaster, or situations that may cause stress, such as a death in the family
• Consider reports from parents and other caretakers or teachers.

Very young children often cannot express their thoughts and feelings, so making a diagnosis can be challenging. The signs of a mental illness in a young child may be quite different from those in an older child or adult.

As parents and caregivers know, children are constantly changing and growing. Diagnosis and treatment must be viewed with these changes in mind. While some problems are short-lived and don't need treatment, others are ongoing and may be very serious. In either case, more information will help you understand treatment choices and manage the disorder or problem most effectively.

While diagnosing mental health problems in young children can be challenging, it is important. A diagnosis can be used to guide treatment and link your child's care to research on children with similar problems.

Q: Will my child get better with time?

Some children get better with time. But other children need ongoing professional help. Talk to your child's doctor or specialist about problems that are severe, continuous, and affect daily activities. Also, don't delay seeking help. Treatment may produce better results if started early.

Q: Are there treatment options for children?

Yes. Once a diagnosis is made, your child's specialist will recommend a specific treatment. It is important to understand the various treatment choices, which often include psychotherapy or medication. Talk about the options with a health care professional who has experience treating the illness observed in your child. Some treatment choices have been studied experimentally, and other treatments are a part of health care practice. In addition, not every community has every type of service or program.

Q: What are psychotropic medications?

Psychotropic medications are substances that affect brain chemicals related to mood and behavior. In recent years, research has been conducted to understand the benefits and risks of using psychotropics in children. Still, more needs to be learned about the effects of psychotropics, especially in children under six years of age. While researchers are trying to clarify how early treatment affects a growing body, families and doctors should weigh the benefits and risks of medication. Each child has individual needs, and each child needs to be monitored closely while taking medications.

Q: Are there treatments other than medications?

Yes. Psychosocial therapies can be very effective alone and in combination with medications. Psychosocial therapies are also called "talk therapies" or "behavioral therapy," and they help people with mental illness change behavior. Therapies that teach parents and children coping strategies can also be effective.²

Cognitive behavioral therapy (CBT) is a type of psychotherapy that can be used with children. It has been widely studied and is an effective treatment for a number of conditions, such as depression, obsessive-compulsive disorder, and social anxiety. A person in CBT learns to change distorted thinking patterns and unhealthy behavior. Children can receive CBT with or without their parents, as well as in a group setting. CBT can be adapted to fit the needs of each child. It is especially useful when treating anxiety disorders.³

Additionally, therapies for ADHD are numerous and include behavioral parent training and behavioral classroom management. Visit the NIMH Web site for more information about therapies for ADHD.

Some children benefit from a combination of different psychosocial approaches. An example is behavioral parent management training in combination with CBT for the child. In other cases, a combination of medication and psychosocial therapies may be most effective. Psychosocial therapies often take time, effort, and patience. However, sometimes children learn new skills that may have positive long-term benefits.

More information about treatment choices can be found in the psychotherapies and medications sections of the NIMH Web site.

Q: When is it a good idea to use psychotropic medications in young children?

When the benefits of treatment outweigh the risks, psychotropic medications may be prescribed. Some children need medication to manage severe and difficult problems. Without treatment, these children would suffer serious or dangerous consequences. In addition, psychosocial treatments may not always be effective by themselves. In some instances, however, they can be quite effective when combined with medication.

Ask your doctor questions about the risks of starting and continuing your child on these medications. Learn everything you can about the medications prescribed for your child. Learn about possible side effects, some of which may be harmful. Know what a particular treatment is supposed to do. For example, will it change a specific behavior? If you do not see these changes while your child is taking the medication, talk to his or her doctor. Also, discuss the risks of stopping your child's medication with your doctor.

Q: Does medication affect young children differently than older children or adults?

Yes. Young children handle medications differently than older children and adults. The brains of young children change and develop rapidly. Studies have found that developing brains can be very sensitive to medications. There are also developmental differences in how children metabolize - how their bodies process - medications. Therefore, doctors should carefully consider the dosage or how much medication to give each child. Much more research is needed to determine the effects and benefits of medications in children of all ages. But keep in mind that serious untreated mental disorders themselves can harm brain development.

Also, it is important to avoid drug interactions. If your child takes medicine for asthma or cold symptoms, talk to your doctor or pharmacist. Drug interactions could cause medications to not work as intended or lead to serious side effects.

Q: How should medication be included in an overall treatment plan?

Medication should be used with other treatments. It should not be the only treatment. Consider other services, such as family therapy, family support services, educational classes, and behavior management techniques. If your child's doctor prescribes medication, he or she should evaluate your child regularly to make sure the medication is working. Children need treatment plans tailored to their individual problems and needs.

Q: What medications are used for which kinds of childhood mental disorders?

Psychotropic medications include stimulants, antidepressants, anti-anxiety medications, antipsychotics, and mood stabilizers. Dosages approved by the U.S. Food and Drug Administration (FDA) for use in children depend on body weight and age. NIMH's medications booklet describes the types of psychotropic medications and includes a chart that lists the ages for which each medication is FDA-approved. See the FDA Web site for the latest information on medication approvals, warnings, and patient information guides.

Q: What does it mean if a medication is specifically approved for use in children?

When the FDA approves a medication, it means the drug manufacturer provided the agency with information showing the medication is safe and effective in a particular group of people. Based on this information, the drug's label lists proper dosage, potential side effects, and approved age. Medications approved for children follow these guidelines.

Many psychotropic medications have not been studied in children, which means they have not been approved by the FDA for use in children. But doctors may prescribe medications as they feel appropriate, even if those uses are not included on the label. This is called "off-label" use. Research shows that off-label use of some medications works well in some children. Other medications need more study in children. In particular, the use of most psychotropic medications has not been adequately studied in preschoolers.

More studies in children are needed before we can fully know the appropriate dosages, how a medication works in children, and what effects a medication might have on learning and development.

Q: Why haven't many medications been tested in children?

In the past, medications were seldom studied in children because mental illness was not recognized in childhood. Also, there were ethical concerns about involving children in research. This led to a lack of knowledge about the best treatments for children. In clinical settings today, children with mental or behavioral disorders are being prescribed medications at increasingly early ages. The FDA has been urging that medications be appropriately studied in children, and Congress passed legislation in 1997 offering incentives to drug manufacturers to carry out such testing. These activities have helped increase research on the effects of medications in children.

There still are ethical concerns about testing medications in children. However, strict rules protect participants in research studies. Each study must go through many types of review before, and after it begins.

Q: How do I work with my child's school?

If your child is having problems in school, or if a teacher raises concerns, you can work with the school to find a solution. You may ask the school to conduct an evaluation to determine whether your child qualifies for special education services. However, not all children diagnosed with a mental illness qualify for these services.

Start by speaking with your child's teacher, school counselor, school nurse, or the school's parent organization. These professionals can help you get an evaluation started. Also, each state has a Parent Training and Information Center and a Protection and Advocacy Agency that can help you request the evaluation. The evaluation must be conducted by a team of professionals who assess all areas related to the suspected disability using a variety of tools and measures.

Q: What resources are available from the school?

Once your child has been evaluated, there are several options for him or her, depending on the specific needs. If special education services are needed, and if your child is eligible under the Individuals with Disabilities Education Act (IDEA), the school district must develop an "individualized education program" specifically for your child within 30 days.

If your child is not eligible for special education services, he or she is still entitled to "free appropriate public education," available to all public school children with disabilities under Section 504 of the Rehabilitation Act of 1973. Your child is entitled to this regardless of the nature or severity of his or her disability.

The U.S. Department of Education's Office for Civil Rights enforces Section 504 in programs and activities that receive Federal education funds. Visit programs for children with disabilities for more information.

Q: What special challenges can school present?

Each school year brings a new teacher and new schoolwork. This change can be difficult for some children. Inform the teachers that your child has a mental illness when he or she starts school or moves to a new class. Additional support will help your child adjust to the change.

Q: What else can I do to help my child?

Children with mental illness need guidance and understanding from their parents and teachers. This support can help your child achieve his or her full potential and succeed in school. Before a child is diagnosed, frustration, blame, and anger may have built up within a family. Parents and children may need special help to undo these unhealthy interaction patterns. Mental health professionals can counsel the child and family to help everyone develop new skills, attitudes, and ways of relating to each other.

Parents can also help by taking part in parenting skills training. This helps parents learn how to handle difficult situations and behaviors. Training encourages parents to share a pleasant or relaxing activity with their child, to notice and point out what their child does well, and to praise their child's strengths and abilities. Parents may also learn to arrange family situations in more positive ways. Also, parents may benefit from learning stress-management techniques to help them deal with frustration and respond calmly to their child's behavior.

Sometimes, the whole family may need counseling. Therapists can help family members find better ways to handle disruptive behaviors and encourage behavior changes. Finally, support groups help parents and families connect with others who have similar problems and concerns. Groups often meet regularly to share frustrations and successes, to exchange information about recommended specialists and strategies, and to talk with experts.

Q: How can families of children with mental illness get support?

Like other serious illnesses, taking care of a child with mental illness is hard on the parents, family, and other caregivers. Caregivers often must tend to the medical needs of their loved ones, and also deal with how it affects their own health. The stress that caregivers are under may lead to missed work or lost free time. It can strain relationships with people who may not understand the situation and lead to physical and mental exhaustion.

Stress from caregiving can make it hard to cope with your child's symptoms. One study shows that if a caregiver is under enormous stress, his or her loved one has more difficulty sticking to the treatment plan.⁴ It is important to look after your own physical and mental health. You may also find it helpful to join a local support group.

Q: Where can I go for help?

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

• Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
• Health maintenance organizations
• 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 can also provide temporary help and can tell you where and how to get further help.

More information on mental health is at the NIMH Web site. For the latest information on medications, see the U.S. Food and Drug Administration website.

Citations

1. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun;62(6):617-27.
2. Silverman WK, Hinshaw SP. The Second Special Issue on Evidence-Based Psychosocial Treatments for Children and Adolescents: A Ten-Year Update. J Clin Child Adolesc Psychol. 2008 Jan-Mar;37(1).
3. Silverman WK, Hinshaw SP. The Second Special Issue on Evidence-Based Psychosocial Treatments for Children and Adolescents: A Ten-Year Update. J Clin Child Adolesc Psychol. 2008 Jan-Mar;37(1).
4. Perlick DA, Rosenheck RA, Clarkin JF, Maciejewski PK, Sirey J, Struening E, Link BG. Impact of family burden and affective response on clinical outcome among patients with bipolar disorder. Psychiatr Serv. 2004 Sep;55(9):1029-35.

Source: National Institute of Mental Health (NIMH)
NIH No. 09-4702
Revised 2009

Reviewed by athealth on February 8, 2014.

by Dr. Robert Myers, Child Psychologist

"I never suspected my nine-year-old daughter's inability to concentrate was due to ADHD," said Diane, the mother of three girls. "She isn't 'hyper' or noisy-in fact, just the opposite. Kayla is the middle child-she's quiet and tends to daydream a lot. We were frustrated because she couldn't ever seem to concentrate or get her schoolwork done...But we were still really surprised when our pediatrician finally diagnosed her with ADHD last year."

When many people hear the term ADHD, the first thing that usually comes to mind is a young, out-of-control boy running all over the place or having a major meltdown at the mall while his frantic parents try to calm him down. Unless you personally know a girl struggling with this disorder, the "wound-up boy" is the image most associated with ADHD. Of course, one reason for this is the fact that boys with the diagnosis outnumber girls by a whopping 3 to 1. Another reason is that ADHD in girls is more often associated with impaired attention and concentration-girls who are labeled as either "dreamy" or "spacey," rather than hyperactive and impulsive.

Unfortunately, research has shown that this stereotype often leads parents, teachers, and health professionals to misdiagnose girls with depression or anxiety. Sometimes the significant difficulties they're experiencing are dismissed altogether. Whether boy or girl, a child who has trouble learning and maintaining healthy peer relationships is more likely to be ignored, while the child exhibiting disruptive behavior is not only more likely to be noticed, but also more likely to be referred for evaluation and treatment. The sad result is that girls are often under-treated, which results in years of suffering in silence, and subsequently leads to self-doubt and low self-esteem. Recent studies have even shown that women with ADHD suffer from depression much more frequently than men with the same disorder.

Slipping Through the Cracks

Here are some signs to look for that may indicate ADHD:

• Gradual or sudden decline in academic achievement
• Forgetting to turn in homework assignments
• Easily frustrated when learning something new
• Always losing personal possessions or leaving things all over the house
• Trouble making friends
• Easily upset over minor incidents
• Overly anxious about trying new things or minor changes in routing or surroundings

What else could be causing these symptoms?

• Sometimes normal child development or a child's temperament
• Undiagnosed learning disabilities
• Adjustment disorder
• Anxiety disorder
• Depression

As ADHD children get older, boys are more likely to receive additional diagnoses of disruptive or conduct disorders. Boys and girls appear to have an equal opportunity to have co-occurring anxiety and depression. However, ADHD girls seem to be more likely to smoke or drink than ADHD boys during the teen years. Another recent study has shown that they are more likely to have eating disorders.

One answer to the problem of misdiagnosing ADHD is for educational professionals to get additional training to be better able to spot the disorder sooner, as early intervention can prevent more serious symptoms down the road. Mental health professionals also need to develop instruments that may be more sensitive to detecting ADHD in girls. This will require shifting some resources to more in-depth research on the diagnosis and treatment of the disorder in girls.

What You Can Do for Your ADHD Girl Right Now

If you are the parent of a girl with ADHD, you need to work closely with teachers. Don't put off addressing problems related to poor academic achievement or your daughter's difficulty getting along with other kids. Whether the school is concerned or not, you should be an advocate for your child and insist on an evaluation to determine the cause of her difficulties. Whether they are related to ADHD, learning disabilities, anxiety, delayed maturation--or a combination of one or more of these--the sooner the cause is identified and appropriate interventions are initiated, the better for your child.

Another good reason to have ADHD diagnosed early in both girls and boys: Once everything is out in the open, the "blame game" can stop and help can begin. An early diagnosis ensures parents and children that no individual is the cause of the problems. Rather, the child has a brain difference that can be addressed and improved.

You should not be afraid to seek help, thinking that your child will immediately be placed on medication. Depending on the findings of the evaluation, special education and/or psychological treatment may be sufficient to turn things around and keep your child moving in a positive direction.

School is often a source of anxiety for kids with ADHD and for their parents. Perhaps your child's lack of concentration skills and difficulty following through on projects makes it hard for her to feel good about school. The good news is, when a student meets the eligibility criteria for special education services set forth in federal and state guidelines, an Individual Educational Plan (IEP) will be developed and implemented. Even when a student may not meet criteria for special education, they may be eligible for counseling and classroom modifications to help them improve their academic achievement, as well as develop a more positive self-concept and get along better with other kids and adults.

Early Intervention Helps.

Does Your Child Need to be Medicated? Maybe Not... While there is no doubt that there is a group of ADHD kids with moderate to severe symptoms who definitely need to be on medication, there is also a group with only mild to moderate symptoms that will be fine with only psychological treatment. The unanswered question is how to accurately determine to which group your child belongs.

Girls in particular will benefit from interventions that develop improved attention, concentration and memory functions. They also thrive on the techniques that reduce anxiety and increase self-esteem and confidence. Learning to use problem-solving to cope with difficult situations and relaxation to help with frustration is also very helpful. Girls are usually quick learners when it comes to learning and applying specialized training in social skills.

When considering psychological treatment, the key to success is intensive and comprehensive treatment. Parents are often drawn to products that promise a quick and easy fix. Your best bet is to choose a program that provides a psychological treatment that is based on not one, but a combination of research-supported modalities that are sufficiently intense and comprehensive to provide the desired results. The sooner you can get your child the help she needs, the better off she will be in the long run.

Under the Radar: How Girls with ADHD Go Undetected reprinted with permission from Empowering Parents. For more information, visit www.EmpoweringParents.com

Author: Dr Robert Myers is a child psychologist with over 25 years of experience working with children and adolescents with Attention Deficit Hyperactivity Disorder and learning disabilities and is the creator of the Total Focus Program www.trytotalfocus.com. Dr Myers is Associate Clinical Professor of Psychiatry and Human Behavior at UC Irvine School of Medicine. "Dr Bob" has provided practical information for parents as a radio talk show host and as editor of Child Development Institute's website, 4parenting.com which reaches 3 million parents each year. Dr. Myers earned his PhD from the University of Southern California.

Reviewed by athealth on February 8, 2014.

Today, 66 percent of adults in the United States are considered overweight or obese. Obesity puts people at increased risk for chronic diseases such as heart disease, type 2 diabetes, high blood pressure, stroke, and some forms of cancer.

The large number of people considered to be obese and the serious health risks that come with it make understanding its causes and treatment crucial. This fact sheet provides basic information about obesity: What is it? How is it measured? What causes it? What are the health risks? What can you do about it?

What is obesity?

"Obesity" specifically refers to an excessive amount of body fat. "Overweight" refers to an excessive amount of body weight that includes muscle, bone, fat, and water. There are few studies in humans that link direct measurements of total body fat to morbidity and mortality. There are also no official standards identified by the National Institutes of Health (NIH) that define obesity based on the amount or percentage of a person's total body fat.

How is obesity measured?

Measuring the exact amount of a person's body fat is not easy. The most accurate measures are to weigh a person underwater or in a chamber that uses air displacement to measure body volume, or to use an X-ray test called Dual Energy X-ray Absorptiometry, also known as DEXA. These methods are not practical for the average person, and are done only in research centers with special equipment.

There are simpler methods to estimate body fat. One is to measure the thickness of the layer of fat just under the skin in several parts of the body. Another involves sending a harmless amount of electricity through a person's body. Results from these methods, however, can be inaccurate if done by an inexperienced person or on someone with extreme obesity.

Because measuring a person's body fat is difficult, health care professionals often rely on other means to diagnose obesity. Weight-for-height tables, used for decades, have a range of acceptable weights for a person of a given height. One problem with these tables is that there are many versions, all with different weight ranges. Another problem is that they do not distinguish between excess fat and muscle. According to the tables, a very muscular person may be classified obese when he or she is not. The Body Mass Index (BMI) is less likely to misidentify a person's appropriate weight-for-height range.

Body Mass Index

The BMI is a tool used to assess overweight and obesity and monitor changes in body weight. Like the weight-for-height tables, BMI has its limitations because it does not measure body fat or muscle directly. It is calculated by dividing a person's weight in pounds by height in inches squared and multiplied by 703.

Men and women can have the same BMI but different body fat percentages. As a rule, women usually have more body fat than men. A bodybuilder with a large muscle mass and low percentage of body fat may have the same BMI as a person who has more body fat. However, a BMI of 30 or higher usually indicates excess body fat.

Find your weight on the bottom of the graph. Go straight up from that point until you come to the line that matches your height. Then look to find your weight group.

Body Fat Distribution

Health care professionals are concerned not only with how much fat a person has, but also where the fat is located on the body. Women typically collect fat in their hips and buttocks, giving them a "pear" shape. Men usually build up fat around their bellies, giving them more of an "apple" shape. Of course, some men are pear-shaped and some women become apple-shaped, especially after menopause.

Excess abdominal fat is an important, independent risk factor for disease. Research has shown that waist circumference is directly associated with abdominal fat and can be used in the assessment of the risks associated with obesity or overweight. If you carry fat mainly around your waist, you are more likely to develop obesity-related health problems.

Women with a waist measurement of more than 35 inches and men with a waist measurement of more than 40 inches may have more health risks than people with lower waist measurements because of their body fat distribution.

Causes of Obesity

Obesity occurs when a person consumes more calories from food than he or she burns. Our bodies need calories to sustain life and be physically active, but to maintain weight we need to balance the energy we eat with the energy we use. When a person eats more calories than he or she burns, the energy balance is tipped toward weight gain and obesity. This imbalance between calories-in and calories-out may differ from one person to another. Genetic, environmental, and other factors may all play a part.

Genetic Factors

Obesity tends to run in families, suggesting a genetic cause. However, families also share diet and lifestyle habits that may contribute to obesity. Separating genetic from other influences on obesity is often difficult. Even so, science does show a link between obesity and heredity.

Environmental and Social Factors

Environment strongly influences obesity. Consider that most people in the United States alive today were also alive in 1980, when obesity rates were lower. Since this time, our genetic make-up has not changed, but our environment has.

Environment includes lifestyle behaviors such as what a person eats and his or her level of physical activity. Too often Americans eat out, consume large meals and high-fat foods, and put taste and convenience ahead of nutrition. Also, most people in the United States do not get enough physical activity.

Environment also includes the world around us - our access to places to walk and healthy foods, for example. Today, more people drive long distances to work instead of walking, live in neighborhoods without sidewalks, tend to eat out or get "take out" instead of cooking, or have vending machines with high-calorie, high-fat snacks at their workplace. Our environment often does not support healthy habits.

In addition, social factors including poverty and a lower level of education have been linked to obesity. One reason for this may be that high-calorie processed foods cost less and are easier to find and prepare than healthier foods, such as fresh vegetables and fruits. Other reasons may include inadequate access to safe recreation places or the cost of gym memberships, limiting opportunities for physical activity. However, the link between low socioeconomic status and obesity has not been conclusively established, and recent research shows that obesity is also increasing among high-income groups.

Cultural Factors

An individual's cultural background may also play a role in his or her weight. For instance, foods specific to certain cultures that are prepared with a lot of fat or salt may hamper one's weight-loss efforts. Similarly, family gatherings offering large amounts of food may make it difficult to pay attention to proper portion control and serving sizes. Lastly, research has shown that individuals originally from countries other than the United States have difficulty adjusting to the calorie-rich foods offered here. These individuals may not be able to prepare food with the ingredients they would use in their native countries.

Although you cannot change your genetic makeup, you can work on changing your eating habits, levels of physical activity, and other environmental factors. Try these ideas:

• Learn to choose sensible portions of nutritious meals that are lower in fat.
• Learn healthier ways to make your favorite foods.
• Learn to recognize and control environmental cues (like inviting smells or a package of cookies on the counter) that make you want to eat when you are not hungry.
• Have a healthy snack an hour or two before a social gathering to prevent overeating. Mingle and talk between bites to prevent eating too much too quickly.
• Engage in at least 30 minutes of moderate-intensity physical activity (like brisk walking) on most, preferably all, days of the week.
• Take a walk instead of watching television.
• Eat meals and snacks at a table, not in front of the TV.
• Pay attention to why you are eating. Determine if you are eating because you are actually hungry or because you are bored, depressed, or lonely.
• Keep records of your food intake and physical activity.

Other Causes of Obesity

Some illnesses may lead to or are associated with weight gain or obesity. These include:

• Hypothyroidism, a condition in which the thyroid gland fails to produce enough thyroid hormone. It often results in lowered metabolic rate and loss of vigor.
• Cushing's syndrome, a hormonal disorder caused by prolonged exposure of the body's tissues to high levels of the hormone cortisol. Symptoms vary, but most people have upper body obesity, rounded face, increased fat around the neck, and thinning arms and legs.
• Polycystic ovary syndrome, a condition characterized by high levels of androgens (male hormone), irregular or missed menstrual cycles, and in some cases, multiple small cysts in the ovaries. Cysts are fluid-filled sacs.

A doctor can tell whether there are underlying medical conditions that are causing weight gain or making weight loss difficult.

Lack of sleep may also contribute to obesity. Recent studies suggest that people with sleep problems may gain weight over time. On the other hand, obesity may contribute to sleep problems due to medical conditions such as sleep apnea, where a person briefly stops breathing at multiple times during the night. (Visit http://www.win.niddk.nih.gov/publications/health_risks.htm#sleep for more information on the relationship between sleep apnea and obesity.) You may wish to talk with your health care provider if you have difficulty sleeping.

Certain drugs such as steroids, some antidepressants, and some medications for psychiatric conditions or seizure disorders may cause weight gain. These drugs may slow the rate at which the body burns calories, stimulate appetite, or cause the body to hold on to extra water. Be sure your doctor knows all the medications you are taking (including over-the-counter medications and dietary supplements). He or she may recommend a different medication that has less effect on weight gain.

Consequences of Obesity

Health Risks

Obesity is more than a cosmetic problem. Many serious medical conditions have been linked to obesity, including type 2 diabetes, heart disease, high blood pressure, and stroke. Obesity is also linked to higher rates of certain types of cancer. Men who are considered obese are more likely than nonobese men to develop cancer of the colon, rectum, or prostate. Women who are considered obese are more likely than nonobese women to develop cancer of the gallbladder, uterus, cervix, or ovaries. Esophageal cancer has also been associated with obesity.

Other diseases and health problems linked to obesity include:

• Gallbladder disease and gallstones.
• Fatty liver disease (also called nonalcoholic steatohepatitis or NASH).
• Gastroesophageal reflux, or what is sometimes called GERD. This problem occurs when the lower esophageal sphincter does not close properly and stomach contents leak back - or reflux - into the esophagus.
• Osteoarthritis, a disease in which the joints deteriorate. This is possibly the result of excess weight on the joints.
• Gout, another disease affecting the joints.
• Pulmonary (breathing) problems, including sleep apnea, which causes a person to stop breathing for a short time during sleep.
• Reproductive problems in women, including menstrual irregularities and infertility.

Health care professionals generally agree that the more obese a person is, the more likely he or she is to develop health problems.

Psychological and Social Effects

Emotional suffering may be one of the most painful parts of obesity. American society emphasizes physical appearance and often equates attractiveness with slimness, especially for women. Such messages may make people considered overweight feel unattractive.

Many people think that individuals who are considered obese are gluttonous, lazy, or both. This is not true. As a result, people who are considered obese often face prejudice or discrimination in the job market, at school, and in social situations. Feelings of rejection, shame, or depression may occur.

Who should lose weight?

Health care professionals generally agree that people who have a BMI of 30 or greater can improve their health through weight loss. This is especially true for people with a BMI of 40 or greater, who are considered extremely obese.

Preventing additional weight gain is recommended if you have a BMI between 25 and 29.9, unless you have other risk factors for obesity-related diseases. Obesity experts recommend you try to lose weight if you have two or more of the following:

• Family history of certain chronic diseases. If you have close relatives who have had heart disease or diabetes, you are more likely to develop these problems if you are obese.
• Preexisting medical conditions. High blood pressure, high LDL cholesterol levels, low HDL cholesterol levels, high triglycerides, and high blood glucose are all warning signs of some obesity-associated diseases.
• Large waist circumference. Men who have waist circumferences greater than 40 inches, and women who have waist circumferences greater than 35 inches, are at higher risk of diabetes, dyslipidemia (abnormal amounts of fat in the blood), high blood pressure, and heart disease.

Fortunately, a weight loss of 5 to 10 percent of your initial body weight can do much to improve health by lowering blood pressure and other risk factors for obesity-related diseases. In addition, research shows that a 5- to 7-percent weight loss brought about by moderate diet and exercise can delay or possibly prevent type 2 diabetes in people at high risk for the disease. In a recent study, participants who were considered overweight and had pre-diabetes - a condition in which a person's blood glucose level is higher than normal, but not high enough to be classified as diabetes - were able to delay or prevent the onset of type 2 diabetes by adopting a low-fat, low-calorie diet and exercising for 30 minutes a day, 5 days a week.

How is obesity treated?

The method of treatment depends on your level of obesity, overall health condition, and readiness to lose weight. Treatment may include a combination of diet, exercise, behavior modification, and sometimes weight-loss drugs. In some cases of extreme obesity, bariatric surgery may be recommended. (Visit http://www.win.niddk.nih.gov/publications/gastric.htm for more information on bariatric surgery.)

Remember, weight control is a life-long effort, and having realistic expectations about weight loss is an important consideration. Eating healthier foods and getting at least 30 minutes of moderate-intensity physical activity on most, preferably all, days of the week have important health benefits. Sixty minutes of physical activity a day may be required to prevent gradual weight gain in adulthood. Individuals who were previously considered overweight and obese individuals are encouraged to get 60 to 90 minutes of exercise a day to sustain weight loss.

Although most adults do not need to see their health care professional before starting a moderate-intensity physical activity program, men older than 40 years and women older than 50 years who plan a vigorous program, or who have either chronic disease or risk factors for chronic illnesses, should speak with their health care provider before starting a physical activity program.

Source

Weight-control Information Network
1 Win Way
Bethesda, MD 20892-3665
Phone: (202) 828-1025
FAX: (202) 828-1028
E-mail: [email protected]
Internet: http://www.win.niddk.nih.gov
Toll-free number: 1-877-946-4627

The Weight-control Information Network (WIN) is a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health, which is the Federal Government's lead agency responsible for biomedical research on nutrition and obesity. Authorized by Congress (Public Law 103-43), WIN provides the general public, health professionals, the media, and Congress with up-to-date, science-based health information on weight control, obesity, physical activity, and related nutritional issues.

Publications produced by WIN are carefully reviewed by both NIDDK scientists and outside experts. This fact sheet was also reviewed by Steven N. Blair, Professor, Department of Exercise Science, Arnold School of Public Health, University of South Carolina.

This publication is not copyrighted. WIN encourages users of this brochure to duplicate and distribute as many copies as desired.

Adapted from NIH Publication No. 06-3680
November 2008

Reviewed by athealth on February 8, 2014.

The Problem of Anger

In the most general sense, anger is a feeling or emotion that ranges from mild irritation to intense fury and rage. Anger is a natural response to those situations where we feel threatened, we believe harm will come to us, or we believe that another person has unnecessarily wronged us. We may also become angry when we feel another person, like a child or someone close to us, is being threatened or harmed. In addition, anger may result from frustration when our needs, desires, and goals are not being met. When we become angry, we may lose our patience and act impulsively, aggressively, or violently.

People often confuse anger with aggression. Aggression is behavior that is intended to cause harm to another person or damage property. This behavior can include verbal abuse, threats, or violent acts. Anger, on the other hand, is an emotion and does not necessarily lead to aggression. Therefore, a person can become angry without acting aggressively.

A term related to anger and aggression is hostility. Hostility refers to a complex set of attitudes and judgments that motivate aggressive behaviors. Whereas anger is an emotion and aggression is a behavior, hostility is an attitude that involves disliking others and evaluating them negatively.

When Does Anger Become a Problem?

Anger becomes a problem when it is felt too intensely, is felt too frequently, or is expressed inappropriately. Feeling anger too intensely or frequently places extreme physical strain on the body. During prolonged and frequent episodes of anger, certain divisions of the nervous system become highly activated. Consequently, blood pressure and heart rate increase and stay elevated for long periods. This stress on the body may produce many different health problems, such as hypertension, heart disease, and diminished immune system efficiency. Thus, from a health standpoint, avoiding physical illness is a motivation for controlling anger.

Another compelling reason to control anger concerns the negative consequences that result from expressing anger inappropriately. In the extreme, anger may lead to violence or physical aggression, which can result in numerous negative consequences, such as being arrested or jailed, being physically injured, being retaliated against, losing loved ones, being terminated from a substance abuse treatment or social service program, or feeling guilt, shame, or regret.

Even when anger does not lead to violence, the inappropriate expression of anger, such as verbal abuse or intimidating or threatening behavior, often results in negative consequences. For example, it is likely that others will develop fear, resentment, and lack of trust toward those who subject them to angry outbursts, which may cause alienation from individuals, such as family members, friends, and coworkers.

The inappropriate expression of anger initially has many apparent payoffs. One payoff is being able to manipulate and control others through aggressive and intimidating behavior; others may comply with a person's demands because they fear verbal threats or violence. Another payoff is the release of tension that occurs when one loses his or her temper and acts aggressively.

Although the individual may feel better after an angry outburst, everyone else may feel worse. In the long term, these initial payoffs lead to negative consequences. For this reason they are called "apparent" payoffs because the long-term negative consequences far outweigh the short-term gains. For example, consider a father who persuades his children to comply with his demands by using an angry tone of voice and threatening gestures. These behaviors imply to the children that they will receive physical harm if they are not obedient. The immediate payoff for the father is that the children obey his commands. The long-term consequence, however, may be that the children learn to fear or dislike him and become emotionally detached from him. As they grow older, they may avoid contact with him or refuse to see him altogether.

Myths About Anger

• Myth #1: Anger Is Inherited. One misconception or myth about anger is that the way we express anger is inherited and cannot be changed. Sometimes, we may hear someone say, "I inherited my anger from my father; that's just the way I am." This statement implies that the expression of anger is a fixed and unalterable set of behaviors. Evidence from research studies, however, indicates that people are not born with set, specific ways of expressing anger. These studies show, rather, that because the expression of anger is learned behavior, more appropriate ways of expressing anger also can be learned.It is well established that much of people's behavior is learned by observing others, particularly influential people. These people include parents, family members, and friends. If children observe parents expressing anger through aggressive acts, such as verbal abuse and violence, it is very likely that they will learn to express anger in similar ways. Fortunately, this behavior can be changed by learning new and appropriate ways of anger expression. It is not necessary to continue to express anger by aggressive and violent means.
• Myth #2: Anger Automatically Leads to Aggression. A related myth involves the misconception that the only effective way to express anger is through aggression. It is commonly thought that anger is something that builds and escalates to the point of an aggressive outburst. As has been said, however, anger does not necessarily lead to aggression. In fact, effective anger management involves controlling the escalation of anger by learning assertiveness skills, changing negative and hostile "self-talk," challenging irrational beliefs, and employing a variety of behavioral strategies.
• Myth #3: People Must Be Aggressive To Get What They Want. Many people confuse assertiveness with aggression. The goal of aggression is to dominate, intimidate, harm, or injure another person-to win at any cost. Conversely, the goal of assertiveness is to express feelings of anger in a way that is respectful of other people. For example, if you were upset because a friend was repeatedly late for meetings, you could respond by shouting obscenities and name-calling. This approach is an attack on the other person rather than an attempt to address the behavior that you find frustrating or anger provoking.An assertive way of handling this situation might be to say, "When you are late for a meeting with me, I get pretty frustrated. I wish that you would be on time more often." This statement expresses your feelings of frustration and dissatisfaction and communicates how you would like the situation changed. This expression does not blame or threaten the other person and minimizes the chance of causing emotional harm.
• Myth #4: Venting Anger Is Always Desirable. For many years, the popular belief among numerous mental health professionals and laymen was that the aggressive expression of anger, such as screaming or beating on pillows, was healthy and therapeutic. Research studies have found, however, that people who vent their anger aggressively simply get better at being angry (Berkowitz, 1970; Murray, 1985; Straus, Gelles, & Steinmetz, 1980). In other words, venting anger in an aggressive manner reinforces aggressive behavior.

Anger as a Habitual Response

Not only is the expression of anger learned, but it can become a routine, familiar, and predictable response to a variety of situations. When anger is displayed frequently and aggressively, it can become a maladaptive habit because it results in negative consequences. Habits, by definition, are performed over and over again, without thinking. People with anger management problems often resort to aggressive displays of anger to solve their problems, without thinking about the negative consequences they may suffer or the debilitating effects it may have on the people around them.

Breaking the Anger Habit

Becoming Aware of Anger. To break the anger habit, you must develop an awareness of the events, circumstances, and behaviors of others that "trigger" your anger. This awareness also involves understanding the negative consequences that result from anger. For example, you may be in line at the supermarket and become impatient because the lines are too long. You could become angry, then boisterously demand that the checkout clerk call for more help. As your anger escalates, you may become involved in a heated exchange with the clerk or another customer. The store manager may respond by having a security officer remove you from the store. The negative consequences that result from this event are not getting the groceries that you wanted and the embarrassment and humiliation you suffer from being removed from the store.

Strategies for Controlling Anger. In addition to becoming aware of anger, you need to develop strategies to effectively manage it. These strategies can be used to stop the escalation of anger before you lose control and experience negative consequences. An effective set of strategies for controlling anger should include both immediate and preventive strategies.

Immediate strategies include taking a timeout, deep-breathing exercises, and thought stopping. Preventive strategies include developing an exercise program and changing your irrational beliefs. One example of an immediate anger management strategy worth exploring at this point is the timeout. The timeout can be used formally or informally. For now, we will only describe the informal use of a timeout. This use involves leaving a situation if you feel your anger is escalating out of control. For example, you may be a passenger on a crowded bus and become angry because you perceive that people are deliberately bumping into you. In this situation, you can simply get off the bus and wait for a less crowded bus.

The informal use of a timeout may also involve stopping yourself from engaging in a discussion or argument if you feel that you are becoming too angry. In these situations, it may be helpful to actually call a timeout or to give the timeout sign with your hands. This lets the other person know that you wish to immediately stop talking about the topic and are becoming frustrated, upset, or angry.

Adapted from: Reilly PM and Shopshire MS. Anger Management for Substance Abuse and Mental Health Clients: A Cognitive Behavioral Therapy Manual. DHHS Pub. No. (SMA) 02-3661. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration

Reviewed by athealth on February 8, 2014.

Bipolar disorder, formerly termed "manic-depressive illness," is meant to characterize the fluctuations in mood from one end or "pole" to the other-severe depression to mania. Unlike schizophrenia, bipolar illness might have little effect on the client's ability to think; that is, it does not necessarily include the symptoms of a "thought disorder," whereas schizophrenia at some point always shows disturbances of thought (such as delusions, bizarre beliefs, or loose associations).

The lifetime prevalence of bipolar disorder also is roughly 1 percent of the general U.S. population (APA 2000), so both schizophrenia and bipolar disorder are relatively rare compared to major depressive illness, which has lifetime incidences in the general population of 10 to 25 percent for women and 5 to 12 percent for men (APA 2000). People with bipolar disorder also are subject to high rates of co-occurring substance abuse and dependence, with even higher rates in specific populations. In the ECA study, nearly 90 percent of those with bipolar disorder in a prison population had a co-occurring substance use disorder (Regier et al. 1990).

Depressive phases in bipolar clients are similar to those in clients who are severely depressed -- that is, the person feels sad; might feel life is not worthwhile; gets little or no enjoyment from anything, even from involvement with children or family/friends; and has altered appetite and sleep needs, for example, waking up early in the morning almost 2 hours before normal or oversleeping. Similarly, the client may overeat or have little or no appetite. The person might experience lethargy; fatigue easily; have feelings of guilt or worthlessness (sometimes for seemingly trivial things) or show strong feelings disproportional to the acts or thoughts involved; and experience recurrent thoughts of death, illness, or manifest suicidal thoughts, plans, or attempts.

Manic episodes for someone with bipolar disorder also vary in intensity. Full-blown, intense mania (during which a client might, for example, take off all his or her clothes and run to a church to declare that the secrets of the universe have been revealed) is relatively rare and, especially with medication, usually short-lived. An evolving manic episode might be hard to detect, especially in someone who is drinking and/or using drugs; some people with mania can get by on a day-to-day basis, partying and barely sleeping, telling tall tales others might ignore, and even being intact enough to persuade others that their delusion of vast wealth is true. People in a manic state have been known to get yachts to take to sea for a trial run or to run up thousands in bills at expensive hotels before anyone recognizes that the individual has not changed clothes in 6 days and cannot carry on a conversation without stating outlandish impossibilities (such as owning Nebraska or being married to the queen of England).

In between the extremes of elation and depression, some clients with bipolar disorder are likely to struggle almost all the time with mild-to-moderate depression and, on occasion, with "hypomanic" (mildly elevated) states that can carry deterioration in judgment, leading to legal trouble, financial loss, or relapse to abusing substances. For the 20 to 30 percent of people with bipolar illness who are not fully functional between episodes of mania and/or depression, the residual phase is usually characterized by mood instability, interpersonal problems, and/or occupational difficulties (APA 2000). However, clients with bipolar disorder who are successfully treated frequently return to positive and productive lives without any future disruption.

Adapted from Substance Abuse Treatment for Persons with Co-Occurring Disorders
Treatment Improvement Protocol 42
US Department of Health and Human Services
DHHS Publication No. (SMA) 2005-3992

Reviewed by athealth on February 8, 2014.