• Depression
• Bipolar Disorder
• Anxiety
• Generalized Anxiety Disorder
• Social Anxiety
• Panic Disorders
• Specific Phobias
• Post Traumatic Stress Disorder
• Women's Issues
• Men's Issues
• Communication Problems
• Life Transition Issues
• Life Dissatisfaction
• Addictions/Co-Dependency Issues
• Eating Disorders
• Sexual Issues
• Attention Deficit Disorder
• Grief Issues
• Relationship Problems
• Marital Difficulty
• Parenting and Childrearing Issues
• Family Issues

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Depression
In any given 1-year period, 9.5 percent of the population, or about 18.8 million American adults, suffer from a depressive illness The economic cost for this disorder is high, but the cost in human suffering cannot be estimated. Depressive illnesses often interfere with normal functioning and cause pain and suffering not only to those who have a disorder, but also to those who care about them. Serious depression can destroy family life as well as the life of the ill person. But much of this suffering is unnecessary. Most people with a depressive illness do not seek treatment, although the great majority—even those whose depression is extremely severe—can be helped. Thanks to years of fruitful research, there are now medications and psychosocial therapies such as cognitive/behavioral, "talk" or interpersonal that can ease the pain of depression. Unfortunately, many people do not recognize that depression is a treatable illness. If you feel that you or someone you care about is one of the many undiagnosed depressed people in this country, the information presented here may help you take the steps that may save your own or someone else's life.

WHAT IS A DEPRESSIVE DISORDER?

A depressive disorder is an illness that involves the body, mood, and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood. It is not a sign of personal weakness or a condition that can be willed or wished away. People with a depressive illness cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people who suffer from depression.

TYPES OF DEPRESSION
Depressive disorders come in different forms, just as is the case with other illnesses such as heart disease. This pamphlet briefly describes three of the most common types of depressive disorders. However, within these types there are variations in the number of symptoms, their severity, and persistence. Major depression is manifested by a combination of symptoms (see symptom list) that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. Such a disabling episode of depression may occur only once but more commonly occurs several times in a lifetime. A less severe type of depression, dysthymia, involves long-term, chronic symptoms that do not disable, but keep one from functioning well or from feeling good. Many people with dysthymia also experience major depressive episodes at some time in their lives. Another type of depression is bipolar disorder, also called manic-depressive illness. Not nearly as prevalent as other forms of depressive disorders, bipolar disorder is characterized by cycling mood changes: severe highs (mania) and lows (depression). Sometimes the mood switches are dramatic and rapid, but most often they are gradual. When in the depressed cycle, an individual can have any or all of the symptoms of a depressive disorder. When in the manic cycle, the individual may be overactive, overtalkative, and have a great deal of energy. Mania often affects thinking, judgment, and social behavior in ways that cause serious problems and embarrassment. For example, the individual in a manic phase may feel elated, full of grand schemes that might range from unwise business decisions to romantic sprees. Mania, left untreated, may worsen to a psychotic state.

SYMPTOMS OF DEPRESSION AND MANIA
Not everyone who is depressed or manic experiences every symptom. Some people experience a few symptoms, some many. Severity of symptoms varies with individuals and also varies over time.

Depression

• Persistent sad, anxious, or "empty" mood
• Feelings of hopelessness, pessimism
• Feelings of guilt, worthlessness, helplessness
• Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex
• Decreased energy, fatigue, being "slowed down"
• Difficulty concentrating, remembering, making decisions
• Insomnia, early-morning awakening, or oversleeping
• Appetite and/or weight loss or overeating and weight gain
• Thoughts of death or suicide; suicide attempts
• Restlessness, irritability
• Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain

Mania

• Abnormal or excessive elation
• Unusual irritability
• Decreased need for sleep
• Grandiose notions
• Increased talking
• Racing thoughts
• Increased sexual desire
• Markedly increased energy
• Poor judgment
• Inappropriate social behavior

CAUSES OF DEPRESSION
Some types of depression run in families, suggesting that a biological vulnerability can be inherited. This seems to be the case with bipolar disorder. Studies of families in which members of each generation develop bipolar disorder found that those with the illness have a somewhat different genetic makeup than those who do not get ill. However, the reverse is not true: Not everybody with the genetic makeup that causes vulnerability to bipolar disorder will have the illness. Apparently additional factors, possibly stresses at home, work, or school, are involved in its onset.
In some families, major depression also seems to occur generation after generation. However, it can also occur in people who have no family history of depression. Whether inherited or not, major depressive disorder is often associated with changes in brain structures or brain function.
People who have low self-esteem, who consistently view themselves and the world with pessimism or who are readily overwhelmed by stress, are prone to depression. Whether this represents a psychological predisposition or an early form of the illness is not clear.
In recent years, researchers have shown that physical changes in the body can be accompanied by mental changes as well. Medical illnesses such as stroke, a heart attack, cancer, Parkinson's disease, and hormonal disorders can cause depressive illness, making the sick person apathetic and unwilling to care for his or her physical needs, thus prolonging the recovery period. Also, a serious loss, difficult relationship, financial problem, or any stressful (unwelcome or even desired) change in life patterns can trigger a depressive episode. Very often, a combination of genetic, psychological, and environmental factors is involved in the onset of a depressive disorder. Later episodes of illness typically are precipitated by only mild stresses, or none at all.

Depression in Women
Women experience depression about twice as often as men. Many hormonal factors may contribute to the increased rate of depression in women—particularly such factors as menstrual cycle changes, pregnancy, miscarriage, postpartum period, pre-menopause, and menopause. Many women also face additional stresses such as responsibilities both at work and home, single parenthood, and caring for children and for aging parents.
A recent NIMH study showed that in the case of severe premenstrual syndrome (PMS), women with a preexisting vulnerability to PMS experienced relief from mood and physical symptoms when their sex hormones were suppressed. Shortly after the hormones were re-introduced, they again developed symptoms of PMS. Women without a history of PMS reported no effects of the hormonal manipulation.
Many women are also particularly vulnerable after the birth of a baby. The hormonal and physical changes, as well as the added responsibility of a new life, can be factors that lead to postpartum depression in some women. While transient "blues" are common in new mothers, a full-blown depressive episode is not a normal occurrence and requires active intervention. Treatment by a sympathetic physician and the family’s emotional support for the new mother is prime considerations in aiding her to recover her physical and mental well-being and her ability to care for and enjoy the infant.

Depression in Men
Although men are less likely to suffer from depression than women, 3 to 4 million men in the United States are affected by the illness. Men are less likely to admit to depression, and doctors are less likely to suspect it. The rate of suicide in men is four times that of women, though more women attempt it. In fact, after age 70, the rate of men's suicide rises, reaching a peak after age 85.
Depression can also affect the physical health in men differently from women. A new study shows that, although depression is associated with an increased risk of coronary heart disease in both men and women, only men suffer a high death rate.
Men's depression is often masked by alcohol or drugs, or by the socially acceptable habit of working excessively long hours. Depression typically shows up in men not as feeling hopeless and helpless, but as being irritable, angry, and discouraged; hence, depression may be difficult to recognize as such in men. Even if a man realizes that he is depressed, he may be less willing than a woman to seek help. Encouragement and support from concerned family members can make a difference. In the workplace, employee assistance professionals or worksite mental health programs can be of assistance in helping men understand and accept depression as a real illness that needs treatment.

Depression in the Elderly
Some people have the mistaken idea that it is normal for the elderly to feel depressed. On the contrary, most older people feel satisfied with their lives. Sometimes, though, when depression develops, it may be dismissed as a normal part of aging. Depression in the elderly, undiagnosed and untreated, causes needless suffering for the family and for the individual who could otherwise live a fruitful life. When he or she does go to the doctor, the symptoms described are usually physical, for the older person is often reluctant to discuss feelings of hopelessness, sadness, loss of interest in normally pleasurable activities, or extremely prolonged grief after a loss.
Recognizing how depressive symptoms in older people are often missed, many health care professionals are learning to identify and treat the underlying depression. They recognize that some symptoms may be side effects of medication the older person is taking for a physical problem, or they may be caused by a co-occurring illness. If a diagnosis of depression is made, treatment with medication and/or psychotherapy will help the depressed person return to a happier, more fulfilling life. Recent research suggests that brief psychotherapy (talk therapies that help a person in day-to-day relationships or in learning to counter the distorted negative thinking that commonly accompanies depression) is effective in reducing symptoms in short-term depression in older persons who are medically ill. Psychotherapy is also useful in older patients who cannot or will not take medication. Efficacy studies show that late-life depression can be treated with psychotherapy.
Improved recognition and treatment of depression in late life will make those years more enjoyable and fulfilling for the depressed elderly person, the family, and caretakers.

Depression in Children
Only in the past two decades has depression in children been taken very seriously. The depressed child may pretend to be sick, refuse to go to school, cling to a parent, or worry that the parent may die. Older children may sulk, get into trouble at school, be negative, grouchy, and feel misunderstood. Because normal behaviors vary from one childhood stage to another, it can be difficult to tell whether a child is just going through a temporary "phase" or is suffering from depression. Sometimes the parents become worried about how the child's behavior has changed, or a teacher mentions that "your child doesn't seem to be himself." In such a case, if a visit to the child's pediatrician rules out physical symptoms, the doctor will probably suggest that the child be evaluated, preferably by a psychiatrist who specializes in the treatment of children. If treatment is needed, the doctor may suggest that another therapist, usually a social worker or a psychologist, provide therapy while the psychiatrist will oversee medication if it is needed. Parents should not be afraid to ask questions: What are the therapist's qualifications? What kind of therapy will the child have? Will the family as a whole participate in therapy? Will my child's therapy include an antidepressant? If so, what might the side effects be?
The National Institute of Mental Health (NIMH) has identified the use of medications for depression in children as an important area for research. The NIMH-supported Research Units on Pediatric Psychopharmacology (RUPPs) form a network of seven research sites where clinical studies on the effects of medications for mental disorders can be conducted in children and adolescents. Among the medications being studied are antidepressants, some of which have been found to be effective in treating children with depression, if properly monitored by the child's physician.

DIAGNOSTIC EVALUATION AND TREATMENT
The first step to getting appropriate treatment for depression is a physical examination by a physician. Certain medications as well as some medical conditions such as a viral infection can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview, and lab tests. If a physical cause for the depression is ruled out, a psychological evaluation should be done, by the physician or by referral to a psychiatrist or psychologist.
A good diagnostic evaluation will include a complete history of symptoms, i.e., when they started, how long they have lasted, how severe they are, whether the patient had them before and, if so, whether the symptoms were treated and what treatment was given. The doctor should ask about alcohol and drug use, and if the patient has thoughts about death or suicide. Further, a history should include questions about whether other family members have had a depressive illness and, if treated, what treatments they may have received and which were effective.
Last, a diagnostic evaluation should include a mental status examination to determine if speech or thought patterns or memory have been affected, as sometimes happens in the case of a depressive or manic-depressive illness.
Treatment choice will depend on the outcome of the evaluation. There are a variety of antidepressant medications and psychotherapies that can be used to treat depressive disorders. Some people with milder forms may do well with psychotherapy alone. People with moderate to severe depression most often benefit from antidepressants. Most do best with combined treatment: medication to gain relatively quick symptom relief and psychotherapy to learn more effective ways to deal with life's problems, including depression. Depending on the patient's diagnosis and severity of symptoms, the therapist may prescribe medication and/or one of the several forms of psychotherapy that have proven effective for depression.
Electroconvulsive therapy (ECT) is useful, particularly for individuals whose depression is severe or life threatening or who cannot take antidepressant medication.3 ECT often is effective in cases where antidepressant medications do not provide sufficient relief of symptoms. In recent years, ECT has been much improved. A muscle relaxant is given before treatment, which is done under brief anesthesia. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a brief (about 30 seconds) seizure within the brain. The person receiving ECT does not consciously experience the electrical stimulus. For full therapeutic benefit, at least several sessions of ECT, typically given at the rate of three per week, are required.

PSYCHOTHERAPIES
Many forms of psychotherapy, including some short-term (10-20 week) therapies, can help depressed individuals. "Talking" therapies help patients gain insight into and resolve their problems through verbal exchange with the therapist, sometimes combined with "homework" assignments between sessions. "Behavioral" therapists help patients learn how to obtain more satisfaction and rewards through their own actions and how to unlearn the behavioral patterns that contribute to or result from their depression.
Two of the short-term psychotherapies that research has shown helpful for some forms of depression are interpersonal and cognitive/behavioral therapies. Interpersonal therapists focus on the patient's disturbed personal relationships that both cause and exacerbate (or increase) the depression. Cognitive/behavioral therapists help patients change the negative styles of thinking and behaving often associated with depression.
Psychodynamic therapies, which are sometimes used to treat depressed persons, focus on resolving the patient's conflicted feelings. These therapies are often reserved until the depressive symptoms are significantly improved. In general, severe depressive illnesses, particularly those that are recurrent, will require medication (or ECT under special conditions) along with, or preceding, psychotherapy for the best outcome.

HOW TO HELP YOURSELF IF YOU ARE DEPRESSED
Depressive disorders make one feel exhausted, worthless, helpless, and hopeless. Such negative thoughts and feelings make some people feel like giving up. It is important to realize that these negative views are part of the depression and typically do not accurately reflect the actual circumstances. Negative thinking fades as treatment begins to take effect. In the meantime:

• Set realistic goals in light of the depression and assume a reasonable amount of responsibility.
• Break large tasks into small ones, set some priorities, and do what you can as you can.
• Try to be with other people and to confide in someone; it is usually better than being alone and secretive.
• Participate in activities that may make you feel better.
• Mild exercise, going to a movie, a ballgame, or participating in religious, social, or other activities may help.
• Expect your mood to improve gradually, not immediately. Feeling better takes time.
• It is advisable to postpone important decisions until the depression has lifted. Before deciding to make a significant transition—change jobs, get married or divorced—discuss it with others who know you well and have a more objective view of your situation.
• People rarely "snap out of" a depression. But they can feel a little better day-by-day.
• Remember, positive thinking will replace the negative thinking that is part of the depression and will disappear as your depression responds to treatment.
• Let your family and friends help you.

How Family and Friends Can Help the Depressed Person
The most important thing anyone can do for the depressed person is to help him or her get an appropriate diagnosis and treatment. This may involve encouraging the individual to stay with treatment until symptoms begin to abate (several weeks), or to seek different treatment if no improvement occurs. On occasion, it may require making an appointment and accompanying the depressed person to the doctor. It may also mean monitoring whether the depressed person is taking medication. The depressed person should be encouraged to obey the doctor's orders about the use of alcoholic products while on medication. The second most important thing is to offer emotional support. This involves understanding, patience, affection, and encouragement. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope. Do not ignore remarks about suicide. Report them to the depressed person's therapist. Invite the depressed person for walks, outings, to the movies, and other activities. Be gently insistent if your invitation is refused. Encourage participation in some activities that once gave pleasure, such as hobbies, sports, religious or cultural activities, but do not push the depressed person to undertake too much too soon. The depressed person needs diversion and company, but too many demands can increase feelings of failure.
Do not accuse the depressed person of faking illness or of laziness, or expect him or her "to snap out of it." Eventually, with treatment, most people do get better. Keep that in mind, and keep reassuring the depressed person that, with time and help, he or she will feel better.

Where to Get Help! Treatment for depression and depressive disorders is available at Olive Branch Counseling Associates, Inc. by calling
(708)-687-3479

**Information found on this website regarding depressive disorders can be found with additional information at www.nimh.nih.gov

REFERENCES
1 Blehar MD, Oren DA. Gender differences in depression. Medscape Women's Health, 1997; 2:3. Revised from: Women's increased vulnerability to mood disorders: Integrating psychobiology and epidemiology. Depression, 1995; 3:3-12.
2 Ferketick AK, Schwartzbaum JA, Frid DJ, Moeschberger ML. Depression as an antecedent to heart disease among women and men in the NHANES I study. National Health and Nutrition Examination Survey. Archives of Internal Medicine, 2000; 160(9): 1261-8.
3 Frank E, Karp JF, Rush AJ (1993). Efficacy of treatments for major depression. Psychopharmacology Bulletin, 1993; 29:457-75.
4 Lebowitz BD, Pearson JL, Schneider LS, Reynolds CF, Alexopoulos GS, Bruce MI, Conwell Y, Katz IR, Meyers BS, Morrison MF, Mossey J, Niederehe G, Parmelee P. Diagnosis and treatment of depression in late life: consensus statement update. Journal of the American Medical Association, 1997; 278:1186-90.
5 Robins LN, Regier DA (Eds). Psychiatric Disorders in America, The Epidemiologic Catchment Area Study, 1990; New York: The Free Press.
6 Rubinow DR, Schmidt PJ, Roca CA. Estrogen-serotonin interactions: Implications for affective regulation. Biological Psychiatry, 1998; 44(9):839-50.
7 Schmidt PJ, Neiman LK, Danaceau MA, Adams LF, Rubinow DR. Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. Journal of the American Medical Association, 1998; 338:209-16.
8 Vitiello B, Jensen P. Medication development and testing in children and adolescents. Archives of General Psychiatry, 1997; 54:871-6.

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Bipolar Disorder Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in a person's mood, energy, and ability to function. Different from the normal ups and downs that everyone goes through, the symptoms of bipolar disorder are severe. They can result in damaged relationships, poor job or school performance, and even suicide. But there is good news: bipolar disorder can be treated, and people with this illness can lead full and productive lives.
More than 2 million American adults, 1 or about 1 percent of the population age 18 and older in any given year, 2 have bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. However, some people have their first symptoms during childhood, and some develop them late in life. It is often not recognized as an illness, and people may suffer for years before it is properly diagnosed and treated. Like diabetes or heart disease, bipolar disorder is a long-term illness that must be carefully managed throughout a person's life.
"Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live. It is an illness that is biological in its origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering and, not infrequently, suicide."
"I am fortunate that I have not died from my illness, fortunate in having received the best medical care available, and fortunate in having the friends, colleagues, and family that I do."
Kay Redfield Jamison, Ph.D., An Unquiet Mind, 1995, p. 6. (Reprinted with permission from Alfred A. Knopf, a division of Random House, Inc.)

What Are the Symptoms of Bipolar Disorder?
Bipolar disorder causes dramatic mood swings—from overly "high" and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. The periods of highs and lows are called episodes of mania and depression. Signs and symptoms of mania (or a manic episode) include:

• Increased energy, activity, and restlessness
• Excessively "high," overly good, euphoric mood
• Extreme irritability
• Racing thoughts and talking very fast, jumping from one idea to another
• Distractibility, can't concentrate well
• Little sleep needed
• Unrealistic beliefs in one's abilities and powers
• Poor judgment
• Spending sprees
• A lasting period of behavior that is different from usual
• Increased sexual drive
• Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
• Provocative, intrusive, or aggressive behavior
• Denial that anything is wrong

A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for 1 week or longer. If the mood is irritable, four additional symptoms must be present. Signs and symptoms of depression (or a depressive episode) include:

• Lasting sad, anxious, or empty mood
• Feelings of hopelessness or pessimism
• Feelings of guilt, worthlessness, or helplessness
• Loss of interest or pleasure in activities once enjoyed, including sex
• Decreased energy, a feeling of fatigue or of being "slowed down"
• Difficulty concentrating, remembering, making decisions
• Restlessness or irritability
• Sleeping too much, or can't sleep
• Change in appetite and/or unintended weight loss or gain
• Chronic pain or other persistent bodily symptoms that are not caused by physical illness or injury
• Thoughts of death or suicide, or suicide attempts

A depressive episode is diagnosed if five or more of these symptoms last most of the day, nearly every day, for a period of 2 weeks or longer.
A mild to moderate level of mania is called hypomania. Hypomania may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. Thus even when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything is wrong. Without proper treatment, however, hypomania can become severe mania in some people or can switch into depression.
Sometimes, severe episodes of mania or depression include symptoms of psychosis (or psychotic symptoms). Common psychotic symptoms are hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person's usual cultural concepts). Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time. For example, delusions of grandiosity, such as believing one is the President or has special powers or wealth, may occur during mania; delusions of guilt or worthlessness, such as believing that one is ruined and penniless or has committed some terrible crime, may appear during depression. People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia, another severe mental illness.
It may be helpful to think of the various mood states in bipolar disorder as a spectrum or continuous range. At one end is severe depression, above which is moderate depression and then mild low mood, which many people call "the blues" when it is short-lived but is termed "dysthymia" when it is chronic. Then there is normal or balanced mood, above which comes hypomania (mild to moderate mania), and then severe mania.
In some people, however, symptoms of mania and depression may occur together in what is called a mixed bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling extremely energized.
Bipolar disorder may appear to be a problem other than mental illness—for instance, alcohol or drug abuse, poor school or work performance, or strained interpersonal relationships. Such problems in fact may be signs of an underlying mood disorder.

Diagnosis of Bipolar Disorder
Like other mental illnesses, bipolar disorder cannot yet be identified physiologically—for example, through a blood test or a brain scan. Therefore, a diagnosis of bipolar disorder is made on the basis of symptoms, course of illness, and, when available, family history. The diagnostic criteria for bipolar disorder are described in the Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DSM-IV).
Descriptions offered by people with bipolar disorder give valuable insights into the various mood states associated with the illness:
Depression: I doubt completely my ability to do anything well. It seems as though my mind has slowed down and burned out to the point of being virtually useless…. [I am] haunt[ed]… with the total, the desperate hopelessness of it all…. Others say, "It's only temporary, it will pass, you will get over it," but of course they haven't any idea of how I feel, although they are certain they do. If I can't feel, move, think or care, then what on earth is the point?
Hypomania: At first when I'm high, it's tremendous… ideas are fast… like shooting stars you follow until brighter ones appear…. All shyness disappears, the right words and gestures are suddenly there… uninteresting people, things become intensely interesting. Sensuality is pervasive, the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria… you can do anything… but, somewhere this changes.
Mania: The fast ideas become too fast and there are far too many… overwhelming confusion replaces clarity… you stop keeping up with it—memory goes. Infectious humor ceases to amuse. Your friends become frightened…. everything is now against the grain… you are irritable, angry, frightened, uncontrollable, and trapped.

Suicide
Some people with bipolar disorder become suicidal. Anyone who is thinking about committing suicide needs immediate attention, preferably from a mental health professional or a physician. Anyone who talks about suicide should be taken seriously. Risk for suicide appears to be higher earlier in the course of the illness. Therefore, recognizing bipolar disorder early and learning how best to manage it may decrease the risk of death by suicide.
Signs and symptoms that may accompany suicidal feelings include:

• talking about feeling suicidal or wanting to die
• feeling hopeless, that nothing will ever change or get better
• feeling helpless, that nothing one does makes any difference
• feeling like a burden to family and friends
• abusing alcohol or drugs
• putting affairs in order (e.g., organizing finances or giving away possessions to prepare for one's death)
• writing a suicide note
• putting oneself in harm's way, or in situations where there is a danger of being killed

If you are feeling suicidal or know someone who is:

• call a doctor, emergency room, or 911 right away to get immediate help
• make sure you, or the suicidal person, are not left alone
• make sure that access is prevented to large amounts of medication, weapons, or other items that could be used for self-harm

While some suicide attempts are carefully planned over time, others are impulsive acts that have not been well thought out; thus, the final point in the box above may be a valuable long-term strategy for people with bipolar disorder. Either way, it is important to understand that suicidal feelings and actions are symptoms of an illness that can be treated. With proper treatment, suicidal feelings can be overcome.

What Is the Course of Bipolar Disorder?
Episodes of mania and depression typically recur across the life span. Between episodes, most people with bipolar disorder are free of symptoms, but as many as one-third of people have some residual symptoms. A small percentage of people experience chronic unremitting symptoms despite treatment.
The classic form of the illness, which involves recurrent episodes of mania and depression, is called bipolar I disorder. Some people, however, never develop severe mania but instead experience milder episodes of hypomania that alternate with depression; this form of the illness is called bipolar II disorder. When four or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycling tends to develop later in the course of illness and is more common among women than among men.
People with bipolar disorder can lead healthy and productive lives when the illness is effectively treated (see below—"How Is Bipolar Disorder Treated?"). Without treatment, however, the natural course of bipolar disorder tends to worsen. Over time a person may suffer more frequent (more rapid-cycling) and more severe manic and depressive episodes than those experienced when the illness first appeared. But in most cases, proper treatment can help reduce the frequency and severity of episodes and can help people with bipolar disorder maintain good quality of life.

Can Children and Adolescents Have Bipolar Disorder?
Both children and adolescents can develop bipolar disorder. It is more likely to affect the children of parents who have the illness.
Unlike many adults with bipolar disorder, whose episodes tend to be more clearly defined, children and young adolescents with the illness often experience very fast mood swings between depression and mania many times within a day. Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated. Mixed symptoms also are common in youths with bipolar disorder. Older adolescents who develop the illness may have more classic, adult-type episodes and symptoms.
Bipolar disorder in children and adolescents can be hard to tell apart from other problems that may occur in these age groups. For example, while irritability and aggressiveness can indicate bipolar disorder, they also can be symptoms of attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, or other types of mental disorders more common among adults such as major depression or schizophrenia. Drug abuse also may lead to such symptoms.
For any illness, however, effective treatment depends on appropriate diagnosis. Children or adolescents with emotional and behavioral symptoms should be carefully evaluated by a mental health professional. Any child or adolescent who has suicidal feelings, talks about suicide, or attempts suicide should be taken seriously and should receive immediate help from a mental health specialist.

What Causes Bipolar Disorder?
Scientists are learning about the possible causes of bipolar disorder through several kinds of studies. Most scientists now agree that there is no single cause for bipolar disorder—rather, many factors act together to produce the illness.
Because bipolar disorder tends to run in families, researchers have been searching for specific genes—the microscopic "building blocks" of DNA inside all cells that influence how the body and mind work and grow—passed down through generations that may increase a person's chance of developing the illness. But genes are not the whole story. Studies of identical twins, who share all the same genes, indicate that both genes and other factors play a role in bipolar disorder. If bipolar disorder were caused entirely by genes, then the identical twin of someone with the illness would always develop the illness, and research has shown that this is not the case. But if one twin has bipolar disorder, the other twin is more likely to develop the illness than is another sibling.
In addition, findings from gene research suggest that bipolar disorder, like other mental illnesses, does not occur because of a single gene.8 It appears likely that many different genes act together, and in combination with other factors of the person or the person's environment, to cause bipolar disorder. Finding these genes, each of which contributes only a small amount toward the vulnerability to bipolar disorder, has been extremely difficult. But scientists expect that the advanced research tools now being used will lead to these discoveries and to new and better treatments for bipolar disorder.
Brain-imaging studies are helping scientists learn what goes wrong in the brain to produce bipolar disorder and other mental illnesses.9, 10 New brain-imaging techniques allow researchers to take pictures of the living brain at work, to examine its structure and activity, without the need for surgery or other invasive procedures. These techniques include magnetic resonance imaging (MRI), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI). There is evidence from imaging studies that the brains of people with bipolar disorder may differ from the brains of healthy individuals. As the differences are more clearly identified and defined through research, scientists will gain a better understanding of the underlying causes of the illness, and eventually may be able to predict which types of treatment will work most effectively.

How Is Bipolar Disorder Treated?
Most people with bipolar disorder—even those with the most severe forms—can achieve substantial stabilization of their mood swings and related symptoms with proper treatment.11,12,13 Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. A strategy that combines medication and psychosocial treatment is optimal for managing the disorder over time.
In most cases, bipolar disorder is much better controlled if treatment is continuous than if it is on and off. But even when there are no breaks in treatment, mood changes can occur and should be reported immediately to your doctor. The doctor may be able to prevent a full-blown episode by making adjustments to the treatment plan. Working closely with the doctor and communicating openly about treatment concerns and options can make a difference in treatment effectiveness.
In addition, keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events may help people with bipolar disorder and their families to better understand the illness. This chart also can help the doctor track and treat the illness most effectively.

Psychosocial Treatments
As an addition to medication, psychosocial treatments—including certain forms of psychotherapy (or "talk" therapy)—are helpful in providing support, education, and guidance to people with bipolar disorder and their families. Studies have shown that psychosocial interventions can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas.13 A licensed psychologist, social worker, or counselor typically provides these therapies and often works together with the psychiatrist to monitor a patient's progress. The number, frequency, and type of sessions should be based on the treatment needs of each person.
Psychosocial interventions commonly used for bipolar disorder are cognitive behavioral therapy, psychoeducation, family therapy, and a newer technique, interpersonal and social rhythm therapy. NIMH researchers are studying how these interventions compare to one another when added to medication treatment for bipolar disorder.

• Cognitive behavioral therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness.
* Psychoeducation involves teaching people with bipolar disorder about the illness and its treatment, and how to recognize signs of relapse so that early intervention can be sought before a full-blown illness episode occurs. Psychoeducation also may be helpful for family members. * Family therapy uses strategies to reduce the level of distress within the family that may either contribute to or result from the ill person's symptoms. * Interpersonal and social rhythm therapy helps people with bipolar disorder both to improve interpersonal relationships and to regularize their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes. * As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit.

A Long-Term Illness That Can Be Effectively Treated
Even though episodes of mania and depression naturally come and go, it is important to understand that bipolar disorder is a long-term illness that currently has no cure. Staying on treatment, even during well times, can help keep the disease under control and reduce the chance of having recurrent, worsening episodes.

Do Other Illnesses Co-occur with Bipolar Disorder? Alcohol and drug abuse are very common among people with bipolar disorder. Research findings suggest that many factors may contribute to these substance abuse problems, including self-medication of symptoms, mood symptoms either brought on or perpetuated by substance abuse, and risk factors that may influence the occurrence of both bipolar disorder and substance use disorders.24 Treatment for co-occurring substance abuse, when present, is an important part of the overall treatment plan.
Anxiety disorders, such as post-traumatic stress disorder and obsessive-compulsive disorder, also may be common in people with bipolar disorder.25, 26 Co-occurring anxiety disorders may respond to the treatments used for bipolar disorder, or they may require separate treatment. For more information on anxiety disorders, contact NIMH (see below).

Where to Get Help:
Treatment for bipolar and other depressive disorders is available at Olive Branch Counseling Associates, Inc. by calling

(708)-687-3479
The voicemail system answers 24 hours each day. Call anytime and leave a message! If you are greeted by the voicemail system during regular business hours, we most likely are in session and do not pick up the phone while seeing clients. Please leave a message and your call will be returned as soon as possible. **Information found on this website regarding bipolar disorder can be found with additional information at www.nimh.nih.gov

References
1Narrow WE. One-year prevalence of depressive disorders among adults 18 and over in the U.S.: NIMH ECA prospective data. Population estimates based on U.S. Census estimated residential population age 18 and over on July 1, 1998. Unpublished.
2Regier DA, Narrow WE, Rae DS, et al. The de facto mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 1993; 50(2): 85-94.
3American Psychiatric Association. Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DSM-IV). Washington, DC: American Psychiatric Press, 1994.
4Hyman SE, Rudorfer MV. Depressive and bipolar mood disorders. In: Dale DC, Federman DD, eds. Scientific American®; Medicine. Vol. 3. New York: Healtheon/WebMD Corp., 2000; Sect. 13, Subsect. II, p. 1.
5Goodwin FK, Jamison KR. Manic-depressive illness. New York: Oxford University Press, 1990.
6Geller B, Luby J. Child and adolescent bipolar disorder: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry, 1997; 36(9): 1168-76.
7NIMH Genetics Workgroup. Genetics and mental disorders. NIH Publication No. 98-4268. Rockville, MD: National Institute of Mental Health, 1998.
8Hyman SE. Introduction to the complex genetics of mental disorders. Biological Psychiatry, 1999; 45(5): 518-21.
9Soares JC, Mann JJ. The anatomy of mood disorders—review of structural neuroimaging studies. Biological Psychiatry, 1997; 41(1): 86-106.
10Soares JC, Mann JJ. The functional neuroanatomy of mood disorders. Journal of Psychiatric Research, 1997; 31(4): 393-432.
11Sachs GS, Printz DJ, Kahn DA, Carpenter D, Docherty JP. The expert consensus guideline series: medication treatment of bipolar disorder 2000. Postgraduate Medicine, 2000; Spec No: 1-104.
12Sachs GS, Thase ME. Bipolar disorder therapeutics: maintenance treatment. Biological Psychiatry, 2000; 48(6): 573-81.
13Huxley NA, Parikh SV, Baldessarini RJ. Effectiveness of psychosocial treatments in bipolar disorder: state of the evidence. Harvard Review of Psychiatry, 2000; 8(3): 126-40.
14Vainionpaa LK, Rattya J, Knip M, Tapanainen JS, Pakarinen AJ, Lanning P, Tekay A, Myllyla VV, Isojarvi JI. Valproate-induced hyperandrogenism during pubertal maturation in girls with epilepsy. Annals of Neurology, 1999; 45(4): 444-50.
15Llewellyn A, Stowe ZN, Strader JR Jr. The use of lithium and management of women with bipolar disorder during pregnancy and lactation. Journal of Clinical Psychiatry, 1998; 59(Suppl 6): 57-64; discussion 65.
16Thase ME, Sachs GS. Bipolar depression: pharmacotherapy and related therapeutic strategies. Biological Psychiatry, 2000; 48(6): 558-72.
17Suppes T, Webb A, Paul B, Carmody T, Kraemer H, Rush AJ. Clinical outcome in a randomized 1-year trial of clozapine versus treatment as usual for patients with treatment-resistant illness and a history of mania. American Journal of Psychiatry, 1999; 156(8): 1164-9.
18Tohen M, Sanger TM, McElroy SL, Tollefson GD, Chengappa KN, Daniel DG, Petty F, Centorrino F, Wang R, Grundy SL, Greaney MG, Jacobs TG, David SR, Toma V. Olanzapine versus placebo in the treatment of acute mania. Olanzapine HGEH Study Group. American Journal of Psychiatry, 1999; 156(5): 702-9.
19Rothschild AJ, Bates KS, Boehringer KL, Syed A. Olanzapine response in psychotic depression. Journal of Clinical Psychiatry, 1999; 60(2): 116-8.
20U.S. Department of Health and Human Services. Mental health: a report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.
21Henney JE. Risk of drug interactions with St. John's wort. From the Food and Drug Administration. Journal of the American Medical Association, 2000; 283(13): 1679.
22Nierenberg AA, Burt T, Matthews J, Weiss AP. Mania associated with St. John's wort. Biological Psychiatry, 1999; 46(12): 1707-8.
23Stoll AL, Severus WE, Freeman MP, Rueter S, Zboyan HA, Diamond E, Cress KK, Marangell LB. Omega 3 fatty acids in bipolar disorder: a preliminary double-blind, placebo-controlled trial. Archives of General Psychiatry, 1999; 56(5): 407-12.
24Strakowski SM, DelBello MP. The co-occurrence of bipolar and substance use disorders. Clinical Psychology Review, 2000; 20(2): 191-206.
25Mueser KT, Goodman LB, Trumbetta SL, Rosenberg SD, Osher FC, Vidaver R, Auciello P, Foy DW. Trauma and posttraumatic stress disorder in severe mental illness. Journal of Consulting and Clinical Psychology, 1998; 66(3): 493-9.
26Strakowski SM, Sax KW, McElroy SL, Keck PE Jr, Hawkins JM, West SA. Course of psychiatric and substance abuse syndromes co-occurring with bipolar disorder after a first psychiatric hospitalization. Journal of Clinical Psychiatry, 1998; 59(9): 465-71.

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Anxiety
Anxiety disorders are serious medical illnesses that affect approximately 19 million American adults.1 These disorders fill people's lives with overwhelming anxiety and fear. Unlike the relatively mild, brief anxiety caused by a stressful event such as a business presentation or a first date, anxiety disorders are chronic, relentless, and can grow progressively worse if not treated. Effective treatments for anxiety disorders are available, and research is yielding new, improved therapies that can help most people with anxiety disorders lead productive, fulfilling lives. If you think you have an anxiety disorder, you should seek information and treatment. The anxiety disorders discussed are

• panic disorder,
• obsessive-compulsive disorder
• post-traumatic stress disorder
• social phobia (or social anxiety disorder)
• specific phobias
• generalized anxiety disorder

Each anxiety disorder has its own distinct features, but they are all bound together by the common theme of excessive, irrational fear and dread.

Depression Depression often accompanies anxiety disorders and, when it does, it needs to be treated as well. Symptoms of depression include feelings of sadness, hopelessness, changes in appetite or sleep, low energy, and difficulty concentrating. Most people with depression can be effectively treated with antidepressant medications, certain types of psychotherapy, or a combination of both.

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Codependency

Co-dependency is a learned behavior that can be passed down from one generation to another. It is an emotional and behavioral condition that affects an individual’s ability to have a healthy, mutually satisfying relationship. It is also known as “relationship addiction” because people with codependency often form or maintain relationships that are one-sided, emotionally destructive and/or abusive. The disorder was first identified about ten years ago as the result of years of studying interpersonal relationships in families of alcoholics. Co-dependent behavior is learned by watching and imitating other family members who display this type of behavior.

Who Does Co-Dependency Affect?

Co-dependency often affects a spouse, a parent, sibling, friend, or co-worker of a person afflicted with alcohol or drug dependence. Originally, co-dependent was a term used to describe partners in chemical dependency, persons living with, or in a relationship with an addicted person. Similar patterns have been seen in people in relationships with chronically or mentally ill individuals. Today, however, the term has broadened to describe any co-dependent person from any dysfunctional family.

What is a Dysfunctional Family and How Does it Lead to Co-Dependency?

A dysfunctional family is one in which members suffer from fear, anger, pain, or shame that is ignored or denied. Underlying problems may include any of the following:

Dysfunctional families do not acknowledge that problems exist. They don’t talk about them or confront them. As a result, family members learn to repress emotions and disregard their own needs. They become “survivors.” They develop behaviors that help them deny, ignore, or avoid difficult emotions. They detach themselves. They don’t talk. They don’t touch. They don’t confront. They don’t feel. They don’t trust. The identity and emotional development of the members of a dysfunctional family are often inhibited.
Attention and energy focus on the family member who is ill or addicted. The co-dependent person typically sacrifices his or her needs to take care of a person who is sick. When co-dependents place other people’s health, welfare and safety before their own, they can lose contact with their own needs, desires, and sense of self.

How Do Co-Dependent People Behave?

Co-dependents have low self-esteem and look for anything outside of themselves to make them feel better. They find it hard to “be themselves.” Some try to feel better through alcohol, drugs or nicotine - and become addicted. Others may develop compulsive behaviors like workaholism, gambling, or indiscriminate sexual activity.
They have good intentions. They try to take care of a person who is experiencing difficulty, but the caretaking becomes compulsive and defeating. Co-dependents often take on a martyr’s role and become “benefactors” to an individual in need. A wife may cover for her alcoholic husband; a mother may make excuses for a truant child; or a father may “pull some strings” to keep his child from suffering the consequences of delinquent behavior.
The problem is that these repeated rescue attempts allow the needy individual to continue on a destructive course and to become even more dependent on the unhealthy caretaking of the “benefactor.” As this reliance increases, the co-dependent develops a sense of reward and satisfaction from “being needed.” When the caretaking becomes compulsive, the co-dependent feels choiceless and helpless in the relationship, but is unable to break away from the cycle of behavior that causes it. Co-dependents view themselves as victims and are attracted to that same weakness in the love and friendship relationships.

Characteristics of Co-Dependent People Are:

Questionnaire To Identify Signs Of Co-Dependency

This condition appears to run in different degrees, whereby the intensity of symptoms are on a spectrum of severity, as opposed to an all or nothing scale. Please note that only a qualified professional can make a diagnosis of co-dependency; not everyone experiencing these symptoms suffers from co-dependency.
1. Do you keep quiet to avoid arguments?
2. Are you always worried about others’ opinions of you?
3. Have you ever lived with someone with an alcohol or drug problem?
4. Have you ever lived with someone who hits or belittles you?
5. Are the opinions of others more important than your own?
6. Do you have difficulty adjusting to changes at work or home?
7. Do you feel rejected when significant others spend time with friends?
8. Do you doubt your ability to be who you want to be?
9. Are you uncomfortable expressing your true feelings to others?
10. Have you ever felt inadequate?
11. Do you feel like a “bad person” when you make a mistake?
12. Do you have difficulty taking compliments or gifts?
13. Do you feel humiliation when your child or spouse makes a mistake?
14. Do you think people in your life would go downhill without your constant efforts?
15. Do you frequently wish someone could help you get things done?
16. Do you have difficulty talking to people in authority, such as the police or your boss?
17. Are you confused about who you are or where you are going with your life?
18. Do you have trouble saying “no” when asked for help?
19. Do you have trouble asking for help?
20. Do you have so many things going at once that you can’t do justice to any of them?
If you identify with several of these symptoms; are dissatisfied with yourself or your relationships; you should consider seeking professional help. Arrange for a diagnostic evaluation with a licensed physician or psychologist experienced in treating co-dependency.

How is Co-Dependency Treated?

Because co-dependency is usually rooted in a person’s childhood, treatment often involves exploration into early childhood issues and their relationship to current destructive behavior patterns. Treatment includes education, experiential groups, and individual and group therapy through which co-dependents rediscover themselves and identify self-defeating behavior patterns. Treatment also focuses on helping patients getting in touch with feelings that have been buried during childhood and on reconstructing family dynamics. The goal is to allow them to experience their full range of feelings again.

When Co-Dependency Hits Home

The first step in changing unhealthy behavior is understanding it. It is important for co-dependents and their family members to educate themselves about the course and cycle of addiction and how it extends into their relationships. Libraries, drug and alcohol abuse treatment centers and mental health centers often offer educational materials and programs to the public.
A lot of change and growth is necessary for the co-dependent and his or her family. Any caretaking behavior that allows or enables abuse to continue in the family needs to be recognized and stopped. The co-dependent must identify and embrace his or her feelings and needs. This may include learning to say “no,” to be loving yet tough, and learning to be self-reliant. People find freedom, love, and serenity in their recovery.
Hope lies in learning more. The more you understand co-dependency the better you can cope with its effects. Reaching out for information and assistance can help someone live a healthier, more fulfilling life.

Where to Get Help!

Treatment for co-dependency is available at Olive Branch Counseling Associates, Inc. by calling (708)-687-3479
**Information found on this website regarding codependency can be found with additional information at http://www.nmha.org/infoctr/factsheets/43.cfm

 

Addictions

When habits or behaviors such as drinking, drug taking or gambling come to dominate daily life and people find themselves powerless to stop the chaos despite many promises to do so, then it is very likely that an addiction is active. Addictions can be formed to any activity or behavior which allows people to escape from life and its problems and includes shopping or spending, sexual activities, gambling, food, prescribed and illegal drugs, alcohol and even other people. There is a growing problem in drug and alcohol abuse amongst young people. Fortunately, it is a highly treatable condition and this web site is set up to help people learn about the illness and sources of help.

Alcohol Addictions

As with all addictive behavior problems, it is very difficult for a person to acknowledge the existence of a drinking problem and this means that people suffer for many more years than is necessary. It is often confused with recurring depression and high anxiety levels which are not relieved by conventional treatments, and a failure to identify the role of alcohol in these conditions often means a failure to refer for the correct treatment.

How common is it?

Alcohol Dependency is by far the most common addiction and is responsible for the deaths of many thousands of people every year. Government figures suggest that up to 9.7% of the UK population may be classified as dependent on alcohol.

How do I know if I have it?

People who are concerned should always seek professional assessment. Some symptoms are more easily detected: 1) loss of control once drinking has started; 2) withdrawal symptoms ranging from mild tremors to frightening hallucinations; 3) Noticeable changes in the effects alcohol has on the individual over time.

How do people develop it?

The condition is characterized by the fact that the sufferer, despite many attempts at control, finds that their drinking and the attendant consequences continues to get worse over the period, and the dependent person's guilt, shame and remorse levels become increasingly more burdensome. Attempts to stop can result in withdrawal symptoms which are relieved by taking more alcohol. Attempts at control ('just a couple of drinks won't hurt') almost always end in drunkenness, and things seem to get progressively worse. In extremes, suicide may seem the best option as depression and severe anxiety coupled with feelings of hopelessness and helplessness often accompany addiction to alcohol.

Can it be inherited?

Although an actual gene has not been identified there is considerable evidence of genetic predisposition to the illness, through studies of twins and apocryphal evidence.

Can it be cured?

Alcoholism is almost impossible to overcome alone, but with the help of others, a large number of people find recovery.

Drug Addictions

Everyone will have their own picture of what a drug addict is. It may be the image of the junkie shooting up heroin, and although this may represent one facet of drug addiction the vast majority of addicts do not conform to this stereotype. Addiction can affect anyone and there are many drugs, both legal (for example tranquillizers and sleeping tablets etc.) and illegal (cocaine, cannabis etc.) that people can become addicted to.

How common is it?

Department of Health statistics for a six month period to 30th September 1999 report a 7% increase over the previous period in the number of people seeking help from drug misuse agencies. Heroin was the most commonly used drug (59%) followed by cannabis, methadone, amphetamines and cocaine.

How do I know if I have it?

People who are concerned should always seek professional assessment.

Can it be inherited?

There is growing evidence that there is a genetic predisposition to addiction, but addictions are also common in people with no genetic predisposition, especially in the area of drug addiction.

Gambling Addictions

Like all addictions, Gambling or risk taking involves escaping from reality. It is not just the actual risk, but the whole panoply of events leading up to taking the risk and the fantasy which surrounds it. The process of addiction and the inherent Denial processes prevent the sufferer from seeing the reality of what is happening. The belief that the next risk will be the one which will put everything right, the delusory sense of certainty about the outcome combine to convince the person that just one more risk is essential.

How do I know if I have it?

The consequences of compulsive gambling can be catastrophic. Not only are enormous debts accrued, but these may well have been increased through the use of loan sharks and other unsavory sources which can place the life of the person and their family or friends in jeopardy.

How do people develop it?

As with all addictions, the sufferer seeks escape from the mounting anxiety and depression which accompanies high levels of guilt, shame and remorse, by taking yet more risks. Common sense does not apply in addictions, the person is powerless to find a solution on their own and their lives descend into more and more chaos.

Can it be cured?

Also, in common with all addictions, help is available and treatment is highly effective, restoring people to normal functioning and happiness.

Shopping Addictions

People use what is called retail therapy as a way of enjoying themselves. The normally buy items for which they have a need or have developed a desire for. Compulsive or addictive shopping is not like that, it is a form of behavior designed to avoid unpleasant reality, and is accompanied by a high which causes the sufferer to lose control and buy many items for which they have no need. The adrenaline rush, the fantasy which surrounds the episode and everything which precedes the actual spending spree all add to the sense of unreality which brings a false sense of freedom from life's problems.

How common is it?

It is difficult to ascertain the full extent of this problem as statistics have not been compiled, although it is known that more people are identifying this as a problem and seeking professional help.

How do I know if I have it?

As with all addictions, the resulting overwhelming sense of shame, remorse and guilt accompanied by feelings of hopelessness and helplessness, lead to despair. Often the remedy for the despair is more addictive behavior resulting in more self destructive feelings. The consequences of shopping addiction are obvious: high levels of debt, fear of discovery and retribution leading to more denial and desperate acts to cover up the behavior. For those closely connected to the sufferer life becomes frightening and unpredictable with a growing sense of uselessness and the belief that the sufferer is deliberately causing chaos and a feeling of desperation sets in.

Can it be cured?

Many sufferers are multi addicted, often abusing prescribed drugs or alcohol in addition to the compulsive spending. The despair can be ended through successful treatment and people can be restored to normal life. As with other addictions, success follows an honest admission of the problem and the seeking of help from others.

Sex Addictions

Sex is a powerful driving force, and for some people it becomes an all pervading preoccupation which can lead to dangerous behaviors and life threatening habits. Like any source of pleasure, sex can become addictive, in which case it becomes distorted and is used as a means of escape from the problems of everyday life. Like all addictions it becomes self perpetuating, participation in the act becoming necessary as a way of avoiding the overwhelming sense of shame, remorse and guilt. Rather than deal with the problem, fantasizing about the next or some past sexual activity leads to a feeling of comfort and encourages the sufferer to proceed to turn the fantasy into reality.

How do I know if I have it?

The consequences of this addiction are many, from social rejection to suicide. Many sufferers are arrested and imprisoned without being offered help. They may have hurt others in their pursuit of the addiction and are overcome by remorse and guilt. Those who are closely connected to them suffer grievously either directly or indirectly and share in the growing sense of hopelessness and helplessness which can often lead to suicide. Help is available and many sufferers do manage to find a way forward which can help restore them to normal functioning and heightened self worth. As with other addictions, success follows an honest admission of the problem and the seeking of help from others who understand the nature of the problem and will not seek to judge them. There is a questionnaire on this web site that will help you decide whether you need to seek help.

Can it be cured?

Treatment is available at counseling facilities

Food Addictions

Bulimia nervosa is characterized by cycles of bingeing and purging. Bulimia nervosa usually begins early in adolescence when young women attempt restrictive diets, fail, and react by binge eating. In response to the binges, patients purge by vomiting or by taking laxatives, diet pills, or drugs to reduce fluids. Patients may also revert to severe dieting, which cycles back to bingeing if the patient does not go on to become anorexic. Eating binges prior to purging average about 1,000 calories, but intake during a binge can be as high as 20,000 or as low as 100 calories. Patients diagnosed with bulimia average about 14 episodes of binge-purging per week. People with bulimia that does not progress to anorexia have a normal to high-normal body weight, but it may fluctuate by more than 10 pounds because of the binge-purge cycle. Compulsive Overeating may not involve purging in the same way as bulimia, but is equally damaging in terms of physical and mental health.

How common is it?

It is particularly common in young women, although more men are now being diagnosed with eating disorders of one form or another. Many sufferers also have other forms of addiction.

How do I know if I have it?

One of the most bewildering symptoms of eating disorders is the distorted body image. Although people typically associate distorted body image with severe anorexia, one study indicated that distortion is even more likely in people with bulimia. They were more likely to overestimate their size, and there was a greater disparity between what they wanted to look like and what they believed they looked like than in people with anorexia or with no eating disorders. In another study, people with anorexia tended to have an accurate perception of their upper body, but overestimated the size of their abdominal and pelvic area.

How do people develop it?

There is no single cause for eating disorders. All are rooted in emotions, however, which are triggered by one or more factors or events, including cultural and family pressures, chemical imbalances, and emotional and personality disorders. Genetics may also play a role.

Can it be cured?

The first major difficulty in treating eating disorders is often the resistance of the patient, who believes that the emaciation is normal and even attractive, or the patient who feels that purging is the only way to prevent obesity. Even worse, the anorexic condition may be encouraged by friends who envy thinness or by dance or athletic coaches who encourage low body fat. The family itself may deny the problem and be obstructive or manipulative, adding to the difficulties of treatment. It is very important that the patient and any close friends and relatives be informed about the serious potential of these conditions and the importance of receiving immediate help.
Eating disorders most commonly begin in adolescence, particularly in girls and young women, although boys and young men can be affected. Eating disorders interrupt normal growth and development and at the most severe can be life threatening.

How do I know if I have it?

Having an eating disorder means being controlled by an obsession with food. It could mean being 60kgs overweight, planning diets which are regularly broken and living with feelings of shame, or a distorted body image, thinking that one is fat when, in fact, one is dangerously underweight. Having an eating disorder is being caught in a destructive cycle of compulsive behavior characterized by low self worth, secretiveness, isolation, feelings of loss of control, guilt and great misery. Coping with an eating disorder is a considerable challenge for sufferers and their families. As with other addictions recovery is very possible, and compulsive behavior can be changed.

Can it be cured?

As with other addictions recovery is very possible, and compulsive behavior can be changed. Help is available through various organizations.

Addictions and Young People

Everyone will have their own picture of what an alcoholic, or drug addict is. It may be the image of the old man on the park bench drinking, or the junkie shooting up heroin. The fact is that whilst these images may represent addiction in one form, the vast majority of addicts are not like this. Solvent abuse may be the beginning of an addiction problem which can affect anyone, including people in their teens and early twenties. If recognized and acknowledged early addiction does not have to have the devastating consequences that prolonged drinking or drug taking can cause.

How common is it?

There is growing evidence of an increase in the number of young people that are drinking and using other drugs problematically, especially in Northern Europe.

How do I know if I have it?

The common symptoms of addiction are preoccupation with using addictive substances, finding you need more in order to achieve the desired effect, loss of control once you have started using, withdrawal symptoms such as shaking excessive sweating and vomiting. Some people experience visual or auditory hallucinations. Feelings of paranoia can also be as a result of drug use. Complete a self assessment questionnaire on this site, and/or seek a professional assessment of your problems.

Can it be inherited?

Addiction can be seen as an illness and there is evidence to support a theory of genetic predisposition. This is not always the case however and if you feel that you are using substances problematically you should seek further help.

Can it be cured?

Addiction is almost impossible to overcome alone, but with the help of others, a large number of people find recovery.

Facts about Addictions

Alcohol and drug abuse disorders constitute one of our society's greatest health concerns.

Alcohol and Drug Abuse and Addiction Prevalence

Alcohol and other drug abuse and addiction are major problems for the nation's youth, adults and families. According to the 1999 National Household Survey on Drug Abuse, an estimated 14.8 million Americans are current users (use within past 30 days) of illicit drugs such as sedative-hypnotics or barbiturates, opiates, hallucinogens and stimulants. (SAMHSA 2000)
An estimated 3.6 million people met the diagnostic criteria for dependence on illicit drugs (SAMHSA 2000) Alcoholism, or alcohol addiction, is a progressive disorder and afflicts approximately 8.2 million adults and youth in the U.S. (SAMHSA 2000)
Alcohol and other drug abuse and addiction are major social problems. They affect both men and women, impact all cultures, and are experienced by people of all ages. In the United States, the rates are lower in women than in men, higher in young adults (18-29) than in seniors (65 or more). The incidence of addiction and other substance abuse related problems, as well as the types of substances abused, vary among the major U.S. ethnic groups.
According to the 1999 National Household Survey on Drug Abuse, about 14.8 million Americans had used an illicit drug—a stimulant (upper), a sedative (downer), or a hallucinogen--within the thirty days prior to the survey. Drug addiction could have been diagnosed at that time in about 3.6 million people over the age of 12, including 1.5 million people addicted to both illicit drugs and alcohol.
Alcohol, while legal when used by adults, can be misused, abused and lead to addiction. An estimated 8.2 million adults and 3 million youth in this country suffer from alcoholism (alcohol addiction), which is a chronic, relapsing disorder. Many more use alcohol dangerously. About 45 million people, including 6.8 million under age 21, had “binged” (taken 5 or more drinks) once during the 30 days before the study. More than 12 million individuals, including 2.1 million youth, were “heavy drinkers” who had taken 5 or more drinks for 5 or more days. 

RISK FACTORS FOR SUBSTANCE ABUSE PROBLEMS:

The causes of alcohol or other drug abuse and addiction are complex, with heredity, environment, and social factors all playing a part. However, some specific risk factors are associated with substance abuse by youth.  These risk factors are:
A chaotic home environment (children of alcohol and other drug-dependent parents are at higher risk for developing substance abuse, mental health and related problems)

It is particularly important to address risk factors early. The younger a person starts drinking or using drugs, the more likely that person is to develop an addiction.  In fact, young people who begin to drink or use drugs before the age of 15 are 4 times more likely to become addicted than if they wait until they are 21 to drink, regardless of other hereditary or environmental factors.

SIGNS AND SYMPTOMS OF ABUSE AND ADDICTION:

While a professional assessment is necessary to accurately diagnose a substance abuse or addiction problem, the CAGE instrument provides a self-administered tool for alcohol and other drug abuse screening in educational and primary care settings. The CAGE is comprised of four questions related to behavior surrounding drinking, not directly to clinical diagnostic issues.

C – Have you ever felt the need to Cut down on your drinking/drug use?
A – Do you get Annoyed at criticism by others about your drinking/drug use?
G – Have you ever felt Guilty about your drinking/drug use or something you have done while drinking or using other drugs?
E – Eye-opener: Have you ever felt the need for a drink early in the morning?

One positive answer provides an indication that the person may be at risk for developing a problem with alcohol or other drugs.  Feedback about this potential problem can provide valuable information to an individual, especially if that person has a family history of alcoholism or other drug addiction or has other risk factors for his or her own substance abuse problems.

COSTS: Alcoholism and substance abuse tear at the fabric of the whole community, hurting families, businesses, and neighborhoods, disrupting education, and choking the criminal justice, health, and social service systems.  Drug abuse kills 14,000 Americans every year.  The monetary costs also are astounding. In 1992, additional health care, extra law enforcement, auto accidents, crime, and lost productivity cost taxpayers about $246 billion.  Alcoholism accounted for most of that amount ($148 billion); the remaining $98 billion cost is attributed to the abuse of other drugs. 

PREVENTION: Effective prevention programs teach skills and promote the development of factors that are known to help reduce the risk of drug use. These protective factors include having strong bonds with family, involved parents who communicate rules clearly; success in school; strong bonds with institutions that support society (such as family, school, and religious organizations); and a belief that drug use is unacceptable. 

RECOVERY:  Achieving abstinence from using drugs is the primary goal of recovery. The recovery process is enhanced for some people by involvement in individual and group therapy to increase understanding of the addiction process, behavior and motivations, enhance self-esteem and teach life skills. Self-help groups such as Alcoholics Anonymous and Narcotics Anonymous offer the recovering person a supporting network of peers struggling with similar issues. Al-Anon and Alateen groups assist family members in dealing with the issues resulting from the impact of addiction and the changes that take place during recovery. 

RESEARCH: New instruments and techniques have given scientists a better understanding of the effects of alcohol and drug use on the brain, and clearly established addiction as a disorder with significant changes in the brain function that persist long after drug taking has stopped. Medications have been designed that may improve the treatment of alcoholism and drug addiction and abuse, although there is ongoing debate about the wisdom of treating substance abuse with other substances. Research continues and promises to change the landscape of addiction treatment in years to come.

RELATED MENTAL HEALTH ISSUES: Co-occurring mental health and substance abuse disorders are common. More than half (52 percent) the people surveyed who had ever been diagnosed with alcohol abuse or dependence had also experienced a mental disorder at some time in their lives. An even larger proportion (59 percent) of people with a history of other drug abuse or dependence also had experienced a mental disorder. Mental health problems often predate substance abuse problems by 4-6 years; alcohol or other drugs may be used as a form of self-medication to alleviate the symptoms of the mental disorder. In some cases, substance abuse precedes the development of mental health problems. For instance, anxiety and depression may be brought on as a response to stressors from broken relationships, lost employment, and other situations directly related to a drug-using lifestyle.

            Treatments for Addictions

Detoxification
Detoxification is a process of facilitating safe withdrawal from drugs or alcohol. Withdrawal without medical assistance can be dangerous or life threatening (particularly in the case of alcohol) in some cases and medical advice should always be sought before undertaking it alone. Detoxification centers are provided by public, private and voluntary agencies. Services will vary according to your area. Local telephone directories should list help services.

Inpatient Care
Intensive inpatient treatment programs vary from 4 weeks to 6 months dependent on individual need and program options at the selected facility. Assessment should be sought in order to identify appropriate treatment.

One to One Counseling
This service is provided by some voluntary organizations and private sector providers. As the name suggests it is a less intensive therapy usually involving sessions of about one hour per week. This is also offered as an addition to other programs.

Where to Get Help!
Treatment for addictions is available at Olive Branch Counseling Associates, Inc. by calling (708)-687-3479
**Information found on this website regarding addictions can be found with additional information at http://www.addictions.co.uk/index.asp and http://www.nmha.org/substance/factsheet.cfm

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Attention Deficit Disorder
Have you ever had trouble concentrating, found it hard to sit still, interrupted others during a conversation or acted impulsively without thinking things through? Can you recall times when you daydreamed or had difficulty focusing on the task at hand? Most of us can picture acting this way from time to time. But for some people, these and other exasperating behaviors are uncontrollable, persistently plaguing their day-to-day existence and interfering with their ability to form lasting friendships or succeed in school, at home and in the workforce.
Unlike a broken bone or cancer, ADHD does not show physical signs that can be detected on an X-ray or through a blood test. In addition, many physical and psychological problems can yield symptoms that mimic those that people with ADHD commonly display. Although doctors do not know what causes ADHD, they can diagnose it and provide treatments that can help alleviate the symptoms. There are many resources where families can get the tools they need to better handle problem behaviors when they arise.
Attention deficit disorder, also known as attention deficit hyperactivity disorder (ADD or ADHD), has been around a lot longer than most people realize. Symptoms similar to modern-day ADHD were first reported in the early 20th century. In the late 1970s, attention deficit hyperactivity disorder (ADHD) became the accepted term, although more recently most clinicians have reverted to just attention deficit disorder to describe the disorder characterized by inattention to activities, or impulsivity often accompanied by an increase in energy and activity levels in people who have it. It is diagnosed in both children and adults.
In recent years, major advances have been made in our understanding of ADHD:

ADHD presents many challenges, both for the individuals who grapple with it as well as for society. At its worst, some experts say, ADHD saddles individuals with an increased risk of accidents, drug abuse, failure at school, antisocial behavior and criminal activity. Some people insist that ADHD sparks creativity and is a component of a creative mind. Some issues that often accompany ADHD include:

Exactly what causes ADHD has not been pinpointed, though many practitioners believe neurobiological or genetic elements play a role. In addition, numerous social factors such as family conflict or poor child-rearing practices, while not causing the condition, may complicate the course of ADHD and its treatment.
Symptoms of ADD
The principal characteristics of ADHD are inattention, hyperactivity, and impulsivity. These symptoms appear early in a child's life. Because many normal children may have these symptoms, but at a low level, or the symptoms may be caused by another disorder, it is important that the child receive a thorough examination and appropriate diagnosis by a well-qualified professional.
Symptoms of ADHD will appear over the course of many months, often with the symptoms of impulsiveness and hyperactivity preceding those of inattention, which may not emerge for a year or more. Different symptoms may appear in different settings, depending on the demands the situation may pose for the child's self-control. A child who "can't sit still" or is otherwise disruptive will be noticeable in school, but the inattentive daydreamer may be overlooked. The impulsive child who acts before thinking may be considered just a "discipline problem," while the child who is passive or sluggish may be viewed as merely unmotivated. Yet both may have different types of ADHD. All children are sometimes restless, sometimes act without thinking, sometimes daydream the time away. When the child's hyperactivity, distractibility, poor concentration, or impulsivity begin to affect performance in school, social relationships with other children, or behavior at home, ADHD may be suspected. But because the symptoms vary so much across settings, ADHD is not easy to diagnose. This is especially true when inattentiveness is the primary symptom.
According to the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), there are three patterns of behavior that indicate ADHD. People with ADHD may show several signs of being consistently inattentive. They may have a pattern of being hyperactive and impulsive far more than others of their age. Or they may show all three types of behavior. This means that there are three subtypes of ADHD recognized by professionals. These are the predominantly hyperactive-impulsive type (that does not show significant inattention); the predominantly inattentive type (that does not show significant hyperactive-impulsive behavior) sometimes called ADD—an outdated term for this entire disorder; and the combined type (that displays both inattentive and hyperactive-impulsive symptoms).

Hyperactive children always seem to be "on the go" or constantly in motion. They dash around touching or playing with whatever is in sight, or talk incessantly. Sitting still at dinner or during a school lesson or story can be a difficult task. They squirm and fidget in their seats or roam around the room. Or they may wiggle their feet, touch everything, or noisily tap their pencil. Hyperactive teenagers or adults may feel internally restless. They often report needing to stay busy and may try to do several things at once.
Impulsive children seem unable to curb their immediate reactions or think before they act. They will often blurt out inappropriate comments, display their emotions without restraint, and act without regard for the later consequences of their conduct. Their impulsivity may make it hard for them to wait for things they want or to take their turn in games. They may grab a toy from another child or hit when they're upset. Even as teenagers or adults, they may impulsively choose to do things that have an immediate but small payoff rather than engage in activities that may take more effort yet provide much greater but delayed rewards.
Some signs of hyperactivity-impulsivity are:

Children who are inattentive have a hard time keeping their minds on any one thing and may get bored with a task after only a few minutes. If they are doing something they really enjoy, they have no trouble paying attention. But focusing deliberate, conscious attention to organizing and completing a task or learning something new is difficult.
Homework is particularly hard for these children. They will forget to write down an assignment, or leave it at school. They will forget to bring a book home, or bring the wrong one. The homework, if finally finished, is full of errors and erasures. Homework is often accompanied by frustration for both parent and child.
The DSM-IV-TR gives these signs of inattention:

Children diagnosed with the Predominantly Inattentive Type of ADHD are seldom impulsive or hyperactive, yet they have significant problems paying attention. They appear to be daydreaming, "spacey," easily confused, slow moving, and lethargic. They may have difficulty processing information as quickly and accurately as other children. When the teacher gives oral or even written instructions, this child has a hard time understanding what he or she is supposed to do and makes frequent mistakes. Yet the child may sit quietly, unobtrusively, and even appear to be working but not fully attending to or understanding the task and the instructions.
These children don't show significant problems with impulsivity and overactivity in the classroom, on the school ground, or at home. They may get along better with other children than the more impulsive and hyperactive types of ADHD, and they may not have the same sorts of social problems so common with the combined type of ADHD. So often their problems with inattention are overlooked. But they need help just as much as children with other types of ADHD, who cause more obvious problems in the classroom.
Related Disorders

Learning Disabilities

Many children with ADHD—approximately 20 to 30 percent—also have a specific learning disability (LD). In preschool years, these disabilities include difficulty in understanding certain sounds or words and/or difficulty in expressing oneself in words. In school age children, reading or spelling disabilities, writing disorders, and arithmetic disorders may appear. A type of reading disorder, dyslexia, is quite widespread. Reading disabilities affect up to 8 percent of elementary school children.

Tourette Syndrome

A very small proportion of people with ADHD have a neurological disorder called Tourette syndrome. People with Tourette syndrome have various nervous tics and repetitive mannerisms, such as eye blinks, facial twitches, or grimacing. Others may clear their throats frequently, snort, sniff, or bark out words. These behaviors can be controlled with medication. While very few children have this syndrome, many of the cases of Tourette syndrome have associated ADHD. In such cases, both disorders often require treatment that may include medications.

Oppositional Defiant Disorder

As many as one-third to one-half of all children with ADHD—mostly boys—have another condition, known as oppositional defiant disorder (ODD). These children are often defiant, stubborn, non-compliant, have outbursts of temper, or become belligerent. They argue with adults and refuse to obey.

Conduct Disorder

About 20 to 40 percent of ADHD children may eventually develop conduct disorder (CD), a more serious pattern of antisocial behavior. These children frequently lie or steal, fight with or bully others, and are at a real risk of getting into trouble at school or with the police. They violate the basic rights of other people, are aggressive toward people and/or animals, destroy property, break into people's homes, commit thefts, carry or use weapons, or engage in vandalism. These children or teens are at greater risk for substance use experimentation, and later dependence and abuse. They need immediate help.

Anxiety and Depression

Some children with ADHD often have co-occurring anxiety or depression. If the anxiety or depression is recognized and treated, the child will be better able to handle the problems that accompany ADHD. Conversely, effective treatment of ADHD can have a positive impact on anxiety as the child is better able to master academic tasks.

Bipolar Disorder

There are no accurate statistics on how many children with ADHD also have bipolar disorder. Differentiating between ADHD and bipolar disorder in childhood can be difficult. In its classic form, bipolar disorder is characterized by mood cycling between periods of intense highs and lows. But in children, bipolar disorder often seems to be a rather chronic mood dysregulation with a mixture of elation, depression, and irritability. Furthermore, there are some symptoms that can be present both in ADHD and bipolar disorder, such as a high level of energy and a reduced need for sleep. Of the symptoms differentiating children with ADHD from those with bipolar disorder, elated mood and grandiosity of the bipolar child are distinguishing characteristics.
Causes of ADD/ADHD
Nobody knows the exact cause of ADHD. What we do know is that it's not the parent's fault, and there are a number of factors that are usually involved in the onset of ADHD in most people.
One of the first questions a parent will have is "Why? What went wrong?" "Did I do something to cause this?" There is little compelling evidence at this time that ADHD can arise purely from social factors or child-rearing methods. Most substantiated causes appear to fall in the realm of neurobiology and genetics. This is not to say that environmental factors may not influence the severity of the disorder, and especially the degree of impairment and suffering the child may experience, but that such factors do not seem to give rise to the condition by themselves.
The parents' focus should be on looking forward and finding the best possible way to help their child. Scientists are studying causes in an effort to identify better ways to treat, and perhaps someday, to prevent ADHD. They are finding more and more evidence that ADHD does not stem from the home environment, but from biological causes. Knowing this can remove a huge burden of guilt from parents who might blame themselves for their child's behavior.
Over the last few decades, scientists have come up with possible theories about what causes ADHD. Some of these theories have led to dead ends, some to exciting new avenues of investigation.

ADHD and Environmental Agents

Studies have shown a possible correlation between the use of cigarettes and alcohol during pregnancy and risk for ADHD in the offspring of that pregnancy. As a precaution, it is best during pregnancy to refrain from both cigarette and alcohol use.
Another environmental agent that may be associated with a higher risk of ADHD is high levels of lead in the bodies of young preschool children. Since lead is no longer allowed in paint and is usually found only in older buildings, exposure to toxic levels is not as prevalent as it once was. Children who live in old buildings in which lead still exists in the plumbing or in lead paint that has been painted over may be at risk.

ADHD and Brain Injury

One early theory was that attention disorders were caused by brain injury. Some children who have suffered accidents leading to brain injury may show some signs of behavior similar to that of ADHD, but only a small percentage of children with ADHD have been found to have suffered a traumatic brain injury.

ADHD and Food Additives and Sugar

It has been suggested that attention disorders are caused by refined sugar or food additives, or that symptoms of ADHD are exacerbated by sugar or food additives. In 1982, the National Institutes of Health held a scientific consensus conference to discuss this issue. It was found that diet restrictions helped about 5 percent of children with ADHD, mostly young children who had food allergies. A more recent study on the effect of sugar on children, using sugar one day and a sugar substitute on alternate days, without parents, staff, or children knowing which substance was being used, showed no significant effects of the sugar on behavior or learning.
In another study, children whose mothers felt they were sugar-sensitive were given aspartame as a substitute for sugar. Half the mothers were told their children were given sugar, half that their children were given aspartame. The mothers who thought their children had received sugar rated them as more hyperactive than the other children and were more critical of their behavior.

ADHD and Genetics

Attention disorders often run in families, so there are likely to be genetic influences. Studies indicate that 25 percent of the close relatives in the families of ADHD children also have ADHD, whereas the rate is about 5 percent in the general population. Many studies of twins now show that a strong genetic influence exists in the disorder.
Researchers continue to study the genetic contribution to ADHD and to identify the genes that cause a person to be susceptible to ADHD. Since its inception in 1999, the Attention-Deficit Hyperactivity Disorder Molecular Genetics Network has served as a way for researchers to share findings regarding possible genetic influences on ADHD.

Recent Studies on Causes of ADHD

Some knowledge of the structure of the brain is helpful in understanding the research scientists are doing in searching for a physical basis for attention deficit hyperactivity disorder. One part of the brain that scientists have focused on in their search is the frontal lobes of the cerebrum. The frontal lobes allow us to solve problems, plan ahead, understand the behavior of others, and restrain our impulses. The two frontal lobes, the right and the left, communicate with each other through the corpus callosum, (nerve fibers that connect the right and left frontal lobes).
The basal ganglia are the interconnected gray masses deep in the cerebral hemisphere that serve as the connection between the cerebrum and the cerebellum and, with the cerebellum, are responsible for motor coordination. The cerebellum is divided into three parts. The middle part is called the vermis.
All of these parts of the brain have been studied through the use of various methods for seeing into or imaging the brain. These methods include functional magnetic resonance imaging (fMRI) positron emission tomography (PET), and single photon emission computed tomography (SPECT). The main or central psychological deficits in those with ADHD have been linked through these studies. By 2002 the researchers in the NIMH Child Psychiatry Branch had studied 152 boys and girls with ADHD, matched with 139 age- and gender-matched controls without ADHD. The children were scanned at least twice, some as many as four times over a decade. As a group, the ADHD children showed 3-4 percent smaller brain volumes in all regions—the frontal lobes, temporal gray matter, caudate nucleus, and cerebellum.
This study also showed that the ADHD children who were on medication had a white matter volume that did not differ from that of controls. Those never-medicated patients had an abnormally small volume of white matter. The white matter consists of fibers that establish long-distance connections between brain regions. It normally thickens as a child grows older and the brain matures.
Although this long-term study used MRI to scan the children's brains, the researchers stressed that MRI remains a research tool and cannot be used to diagnose ADHD in any given child. This is true for other neurological methods of evaluating the brain, such as PET and SPECT.
Treatments
Every family wants to determine what treatment will be most effective for their child. This question needs to be answered by each family in consultation with their health care professional. To help families make this important decision, the National Institute of Mental Health (NIMH) has funded many studies of treatments for ADHD and has conducted the most intensive study ever undertaken for evaluating the treatment of this disorder. This study is known as the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (MTA). The NIMH is now conducting a clinical trial for younger children ages 3 to 5.5 years (Treatment of ADHD in Preschool-Age Children).

The Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder.

The MTA study included 579 (95-98 at each of 6 treatment sites) elementary school boys and girls with ADHD, who were randomly assigned to one of four treatment programs: (1) medication management alone; (2) behavioral treatment alone; (3) a combination of both; or (4) routine community care. In each of the study sites, three groups were treated for the first 14 months in a specified protocol and the fourth group was referred for community treatment of the parents' choosing. All of the children were reassessed regularly throughout the study period. An essential part of the program was the cooperation of the schools, including principals and teachers. Both teachers and parents rated the children on hyperactivity, impulsivity, and inattention, and symptoms of anxiety and depression, as well as social skills.
The children in two groups (medication management alone and the combination treatment) were seen monthly for one-half hour at each medication visit. During the treatment visits, the prescribing physician spoke with the parent, met with the child, and sought to determine any concerns that the family might have regarding the medication or the child's ADHD-related difficulties. The physicians, in addition, sought input from the teachers on a monthly basis. The physicians in the medication-only group did not provide behavioral therapy but did advise the parents when necessary concerning any problems the child might have.
In the behavior treatment-only group, families met up to 35 times with a behavior therapist, mostly in group sessions. These therapists also made repeated visits to schools to consult with children's teachers and to supervise a special aide assigned to each child in the group. In addition, children attended a special 8-week summer treatment program where they worked on academic, social, and sports skills, and where intensive behavioral therapy was delivered to assist children in improving their behavior.
Children in the combined therapy group received both treatments, that is, all the same assistance that the medication-only received, as well as all of the behavior therapy treatments.
In routine community care, the children saw the community-treatment doctor of their parents' choice one to two times per year for short periods of time. Also, the community-treatment doctor did not have any interaction with the teachers.
The results of the study indicated that long-term combination treatments and the medication-management alone were superior to intensive behavioral treatment and routine community treatment. And in some areas—anxiety, academic performance, oppositionality, parent-child relations, and social skills—the combined treatment was usually superior. Another advantage of combined treatment was that children could be successfully treated with lower doses of medicine, compared with the medication-only group.

Treatment of Attention Deficit Hyperactivity Disorder in Preschool-Age Children (PATS).

Because many children in the preschool years are diagnosed with ADHD and are given medication, it is important to know the safety and efficacy of such treatment. The NIMH is sponsoring an ongoing multi-site study, "Preschool ADHD Treatment Study" (PATS). It is the first major effort to examine the safety and efficacy of a stimulant, methylphenidate, for ADHD in this age group. The PATS study uses a randomized, placebo-controlled, double-blind design. Children ages 3 to 5 who have severe and persistent symptoms of ADHD that impair their functioning are eligible for this study. To avoid using medications at such an early age, all children who enter the study are first treated with behavioral therapy. Only children who do not show sufficient improvement with behavior therapy are considered for the medication part of the study. The study is being conducted at New York State Psychiatric Institute, Duke University, Johns Hopkins University, New York University, the University of California at Los Angeles, and the University of California at Irvine. Enrollment in the study will total 165 children.

Which Treatment Should My Child Have?

For children with ADHD, no single treatment is the answer for every child. A child may sometimes have undesirable side effects to a medication that would make that particular treatment unacceptable. And if a child with ADHD also has anxiety or depression, a treatment combining medication and behavioral therapy might be best. Each child's needs and personal history must be carefully considered.

Medications.

For decades, medications have been used to treat the symptoms of ADHD.
The medications that seem to be the most effective are a class of drugs known as stimulants. Following is a list of the stimulants, their trade (or brand) names, and their generic names. "Approved age" means that the drug has been tested and found safe and effective in children of that age.

The U.S. Food and Drug Adminstration (FDA) recently approved a medication for ADHD that is not a stimulant. The medication, Strattera®, or atomoxetine, works on the neurotransmitter norepinephrine, whereas the stimulants primarily work on dopamine. Both of theses neurotransmitters are believed to play a role in ADHD. More studies will need to be done to contrast Strattera with the medications already available, but the evidence to date indicates that over 70 percent of children with ADHD given Strattera manifest significant improvement in their symptoms.
Some people get better results from one medication, some from another. It is important to work with the prescribing physician to find the right medication and the right dosage. For many people, the stimulants dramatically reduce their hyperactivity and impulsivity and improve their ability to focus, work, and learn. The medications may also improve physical coordination, such as that needed in handwriting and in sports.
The stimulant drugs, when used with medical supervision, are usually considered quite safe. Stimulants do not make the child feel "high," although some children say they feel different or funny. Such changes are usually very minor. Although some parents worry that their child may become addicted to the medication, to date there is no convincing evidence that stimulant medications, when used for treatment of ADHD, cause drug abuse or dependence. A review of all long-term studies on stimulant medication and substance abuse, conducted by researchers at Massachusetts General Hospital and Harvard Medical School, found that teenagers with ADHD who remained on their medication during the teen years had a lower likelihood of substance use or abuse than did ADHD adolescents who were not taking medications.
The stimulant drugs come in long- and short-term forms. The newer sustained-release stimulants can be taken before school and are long-lasting so that the child does not need to go to the school nurse every day for a pill. The doctor can discuss with the parents the child's needs and decide which preparation to use and whether the child needs to take the medicine during school hours only or in the evening and on weekends too.
If the child does not show symptom improvement after taking a medication for a week, the doctor may try adjusting the dosage. If there is still no improvement, the child may be switched to another medication. About one out of ten children is not helped by a stimulant medication. Other types of medication may be used if stimulants don't work or if the ADHD occurs with another disorder. Antidepressants and other medications can help control accompanying depression or anxiety.
Sometimes the doctor may prescribe for a young child a medication that has been approved by the FDA for use in adults or older children. This use of the medication is called "off label." Many of the newer medications that are proving helpful for child mental disorders are prescribed off label because only a few of them have been systematically studied for safety and efficacy in children. Medications that have not undergone such testing are dispensed with the statement that "safety and efficacy have not been established in pediatric patients."

Side Effects of the Medications.

Most side effects of the stimulant medications are minor and are usually related to the dosage of the medication being taken. Higher doses produce more side effects. The most common side effects are decreased appetite, insomnia, increased anxiety, and/or irritability. Some children report mild stomach aches or headaches.
Appetite seems to fluctuate, usually being low during the middle of the day and more normal by suppertime. Adequate amounts of food that is nutritional should be available for the child, especially at peak appetite times.
If the child has difficulty falling asleep, several options may be tried—a lower dosage of the stimulant, giving the stimulant earlier in the day, discontinuing the afternoon or evening dosage, or giving an adjunct medication such as a low-dosage antidepressant or clonidine. A few children develop tics during treatment. These can often be lessened by changing the medication dosage. A very few children cannot tolerate any stimulant, no matter how low the dosage. In such cases, the child is often given an antidepressant instead of the stimulant.
When a child's schoolwork and behavior improve soon after starting medication, the child, parents, and teachers tend to applaud the drug for causing the sudden changes. Unfortunately, when people see such immediate improvement, they often think medication is all that's needed. But medications don't cure ADHD; they only control the symptoms on the day they are taken. Although the medications help the child pay better attention and complete school work, they can't increase knowledge or improve academic skills. The medications help the child to use those skills he or she already possesses.
Behavioral therapy, emotional counseling, and practical support will help ADHD children cope with everyday problems and feel better about themselves.

Facts to Remember About Medication for ADHD.

Medication for the Child with Both ADHD and Bipolar Disorder.

Since a child with bipolar disorder will probably be prescribed a mood stabilizer such as lithium or Depakote®, the doctor will carefully consider whether the child should take one of the medications usually prescribed for ADHD. If a stimulant medication is prescribed, it may be given in a lower dosage than usual.
Where to Get Help!
Treatment for attention deficit disorder is available at Olive Branch Counseling Associates, Inc. by calling (708)-687-3479
**Information found on this website regarding attention deficit disorder can be found with additional information at http://psychcentral.com/disorders/adhd/

 

 

 

 

 

Inattentive Attention Deficit Disorder: 
Attention Deficit without Hyperactivity.
This form of Attention Deficit Disorder often presents itself on the other end of the energy spectrum from the Classic ADHD type. Where the classic ADHD person is hyperactive, this type can be quite hypoactive.

The Inattentive Attention Deficit Disorder person can be sluggish, slow moving and difficult to motivate. These are the daydreamers who spend much time with their heads in the clouds or in a brain fog. They are disorganized.

This type shuts down when too many demands are made on their ability to listen, focus, concentrate and learn. This type has trouble listening and registering the content when others talk to them. When tasks become to difficult, they simply blank out and the harder this type tries to concentrate, the worse the “shut-down” becomes. This type can miss large gaps in learning.

Since this type quietly goes about their business instead of grating on the nerves of everyone around them, the Inattentive type of Attention Deficit Disorder often goes undiagnosed. People with this “quiet” form of Attention Deficit are often labeled as lazy, defiant or uninterested instead of given the help they need to overcome their Attention Deficit problems. The inattentive type of Attention Deficit Disorder is seen most often in girls.

Inattentive characteristics: (Not all need to be present)
_ Primary ADD symptoms (attentional problems, distractibility, disorganization, and impulsivity).
_ Low energy level/sluggish.
_ Procrastination.
_ Often late.
_ Easily bored.
_ Short attention span, especially for routine matters, tasks that are not interesting or tasks that are difficult.
_ Often does not complete tasks.
_ Excessive daydreaming or “Spacing Out.”
Where to Get Help!
Treatment for attention deficit disorder is available at Olive Branch Counseling Associates, Inc. by calling (708)-687-3479
**Information found on this website regarding attention deficit disorder can be found with additional information at http://www.add-adhd-help-center.com/add_types_inattentive.htm
Attention Deficit Disorder
Attention Deficit Hyperactivity Disorder (ADHD) is a condition that becomes apparent in some children in the preschool and early school years. It is hard for these children to control their behavior and/or pay attention. It is estimated that between 3 and 5 percent of children have ADHD, or approximately 2 million children in the United States. This means that in a classroom of 25 to 30 children, it is likely that at least one will have ADHD.
ADHD was first described by Dr. Heinrich Hoffman in 1845. A physician who wrote books on medicine and psychiatry, Dr. Hoffman was also a poet who became interested in writing for children when he couldn't find suitable materials to read to his 3-year-old son. The result was a book of poems, complete with illustrations, about children and their characteristics. "The Story of Fidgety Philip" was an accurate description of a little boy who had attention deficit hyperactivity disorder. Yet it was not until 1902 that Sir George F. Still published a series of lectures to the Royal College of Physicians in England in which he described a group of impulsive children with significant behavioral problems, caused by a genetic dysfunction and not by poor child rearing—children who today would be easily recognized as having ADHD.1 Since then, several thousand scientific papers on the disorder have been published, providing information on its nature, course, causes, impairments, and treatments.
A child with ADHD faces a difficult but not insurmountable task ahead. In order to achieve his or her full potential, he or she should receive help, guidance, and understanding from parents, guidance counselors, and the public education system. This document offers information on ADHD and its management, including research on medications and behavioral interventions, as well as helpful resources on educational options.
Because ADHD often continues into adulthood, this document contains a section on the diagnosis and treatment of ADHD in adults.

Symptoms

The principal characteristics of ADHD are inattention, hyperactivity, and impulsivity. These symptoms appear early in a child's life. Because many normal children may have these symptoms, but at a low level, or the symptoms may be caused by another disorder, it is important that the child receive a thorough examination and appropriate diagnosis by a well-qualified professional.
Symptoms of ADHD will appear over the course of many months, often with the symptoms of impulsiveness and hyperactivity preceding those of inattention, which may not emerge for a year or more. Different symptoms may appear in different settings, depending on the demands the situation may pose for the child's self-control. A child who "can't sit still" or is otherwise disruptive will be noticeable in school, but the inattentive daydreamer may be overlooked. The impulsive child who acts before thinking may be considered just a "discipline problem," while the child who is passive or sluggish may be viewed as merely unmotivated. Yet both may have different types of ADHD. All children are sometimes restless, sometimes act without thinking, sometimes daydream the time away. When the child's hyperactivity, distractibility, poor concentration, or impulsivity begin to affect performance in school, social relationships with other children, or behavior at home, ADHD may be suspected. But because the symptoms vary so much across settings, ADHD is not easy to diagnose. This is especially true when inattentiveness is the primary symptom.
According to the most recent version of the Diagnostic and Statistical Manual of Mental Disorders2 (DSM-IV-TR), there are three patterns of behavior that indicate ADHD. People with ADHD may show several signs of being consistently inattentive. They may have a pattern of being hyperactive and impulsive far more than others of their age. Or they may show all three types of behavior. This means that there are three subtypes of ADHD recognized by professionals. These are the predominantly hyperactive-impulsive type (that does not show significant inattention); the predominantly inattentive type (that does not show significant hyperactive-impulsive behavior) sometimes called ADD—an outdated term for this entire disorder; and the combined type (that displays both inattentive and hyperactive-impulsive symptoms).

Hyperactivity-Impulsivity

Hyperactive children always seem to be "on the go" or constantly in motion. They dash around touching or playing with whatever is in sight, or talk incessantly. Sitting still at dinner or during a school lesson or story can be a difficult task. They squirm and fidget in their seats or roam around the room. Or they may wiggle their feet, touch everything, or noisily tap their pencil. Hyperactive teenagers or adults may feel internally restless. They often report needing to stay busy and may try to do several things at once.
Impulsive children seem unable to curb their immediate reactions or think before they act. They will often blurt out inappropriate comments, display their emotions without restraint, and act without regard for the later consequences of their conduct. Their impulsivity may make it hard for them to wait for things they want or to take their turn in games. They may grab a toy from another child or hit when they're upset. Even as teenagers or adults, they may impulsively choose to do things that have an immediate but small payoff rather than engage in activities that may take more effort yet provide much greater but delayed rewards.
Some signs of hyperactivity-impulsivity are:

Inattention

Children who are inattentive have a hard time keeping their minds on any one thing and may get bored with a task after only a few minutes. If they are doing something they really enjoy, they have no trouble paying attention. But focusing deliberate, conscious attention to organizing and completing a task or learning something new is difficult.
Homework is particularly hard for these children. They will forget to write down an assignment, or leave it at school. They will forget to bring a book home, or bring the wrong one. The homework, if finally finished, is full of errors and erasures. Homework is often accompanied by frustration for both parent and child.
The DSM-IV-TR gives these signs of inattention:

Children diagnosed with the Predominantly Inattentive Type of ADHD are seldom impulsive or hyperactive, yet they have significant problems paying attention. They appear to be daydreaming, "spacey," easily confused, slow moving, and lethargic. They may have difficulty processing information as quickly and accurately as other children. When the teacher gives oral or even written instructions, this child has a hard time understanding what he or she is supposed to do and makes frequent mistakes. Yet the child may sit quietly, unobtrusively, and even appear to be working but not fully attending to or understanding the task and the instructions.
These children don't show significant problems with impulsivity and overactivity in the classroom, on the school ground, or at home. They may get along better with other children than the more impulsive and hyperactive types of ADHD, and they may not have the same sorts of social problems so common with the combined type of ADHD. So often their problems with inattention are overlooked. But they need help just as much as children with other types of ADHD, who cause more obvious problems in the classroom.

Is It Really ADHD?

Not everyone who is overly hyperactive, inattentive, or impulsive has ADHD. Since most people sometimes blurt out things they didn't mean to say, or jump from one task to another, or become disorganized and forgetful, how can specialists tell if the problem is ADHD?
Because everyone shows some of these behaviors at times, the diagnosis requires that such behavior be demonstrated to a degree that is inappropriate for the person's age. The diagnostic guidelines also contain specific requirements for determining when the symptoms indicate ADHD. The behaviors must appear early in life, before age 7, and continue for at least 6 months. Above all, the behaviors must create a real handicap in at least two areas of a person's life such as in the schoolroom, on the playground, at home, in the community, or in social settings. So someone who shows some symptoms but whose schoolwork or friendships are not impaired by these behaviors would not be diagnosed with ADHD. Nor would a child who seems overly active on the playground but functions well elsewhere receive an ADHD diagnosis.
To assess whether a child has ADHD, specialists consider several critical questions: Are these behaviors excessive, long-term, and pervasive? That is, do they occur more often than in other children the same age? Are they a continuous problem, not just a response to a temporary situation? Do the behaviors occur in several settings or only in one specific place like the playground or in the schoolroom? The person's pattern of behavior is compared against a set of criteria and characteristics of the disorder as listed in the DSM-IV-TR.

Diagnosis

Some parents see signs of inattention, hyperactivity, and impulsivity in their toddler long before the child enters school. The child may lose interest in playing a game or watching a TV show, or may run around completely out of control. But because children mature at different rates and are very different in personality, temperament, and energy levels, it's useful to get an expert's opinion of whether the behavior is appropriate for the child's age. Parents can ask their child's pediatrician, or a child psychologist or psychiatrist, to assess whether their toddler has an attention deficit hyperactivity disorder or is, more likely at this age, just immature or unusually exuberant.
ADHD may be suspected by a parent or caretaker or may go unnoticed until the child runs into problems at school. Given that ADHD tends to affect functioning most strongly in school, sometimes the teacher is the first to recognize that a child is hyperactive or inattentive and may point it out to the parents and/or consult with the school psychologist. Because teachers work with many children, they come to know how "average" children behave in learning situations that require attention and self-control. However, teachers sometimes fail to notice the needs of children who may be more inattentive and passive yet who are quiet and cooperative, such as those with the predominantly inattentive form of ADHD.

Professionals Who Make the Diagnosis.

If ADHD is suspected, to whom can the family turn? What kinds of specialists do they need?
Ideally, the diagnosis should be made by a professional in your area with training in ADHD or in the diagnosis of mental disorders. Child psychiatrists and psychologists, developmental/behavioral pediatricians, or behavioral neurologists are those most often trained in differential diagnosis. Clinical social workers may also have such training.
The family can start by talking with the child's pediatrician or their family doctor. Some pediatricians may do the assessment themselves, but often they refer the family to an appropriate mental health specialist they know and trust. In addition, state and local agencies that serve families and children, as well as some of the volunteer organizations listed at the end of this document, can help identify appropriate specialists.

Knowing the differences in qualifications and services can help the family choose someone who can best meet their needs. There are several types of specialists qualified to diagnose and treat ADHD. Child psychiatrists are doctors who specialize in diagnosing and treating childhood mental and behavioral disorders. A psychiatrist can provide therapy and prescribe any needed medications. Child psychologists are also qualified to diagnose and treat ADHD. They can provide therapy for the child and help the family develop ways to deal with the disorder. But psychologists are not medical doctors and must rely on the child's physician to do medical exams and prescribe medication. Neurologists, doctors who work with disorders of the brain and nervous system, can also diagnose ADHD and prescribe medicines. But unlike psychiatrists and psychologists, neurologists usually do not provide therapy for the emotional aspects of the disorder.
Within each specialty, individual doctors and mental health professionals differ in their experiences with ADHD. So in selecting a specialist, it's important to find someone with specific training and experience in diagnosing and treating the disorder.
Whatever the specialist's expertise, his or her first task is to gather information that will rule out other possible reasons for the child's behavior. Among possible causes of ADHD-like behavior are the following:

Ideally, in ruling out other causes, the specialist checks the child's school and medical records. There may be a school record of hearing or vision problems, since most schools automatically screen for these. The specialist tries to determine whether the home and classroom environments are unusually stressful or chaotic, and how the child's parents and teachers deal with the child.
Next the specialist gathers information on the child's ongoing behavior in order to compare these behaviors to the symptoms and diagnostic criteria listed in the DSM-IV-TR. This also involves talking with the child and, if possible, observing the child in class and other settings.
The child's teachers, past and present, are asked to rate their observations of the child's behavior on standardized evaluation forms, known as behavior rating scales, to compare the child's behavior to that of other children the same age. While rating scales might seem overly subjective, teachers often get to know so many children that their judgment of how a child compares to others is usually a reliable and valid measure.
The specialist interviews the child's teachers and parents, and may contact other people who know the child well, such as coaches or baby-sitters. Parents are asked to describe their child's behavior in a variety of situations. They may also fill out a rating scale to indicate how severe and frequent the behaviors seem to be.
In most cases, the child will be evaluated for social adjustment and mental health. Tests of intelligence and learning achievement may be given to see if the child has a learning disability and whether the disability is in one or more subjects.
In looking at the results of these various sources of information, the specialist pays special attention to the child's behavior during situations that are the most demanding of self-control, as well as noisy or unstructured situations such as parties, or during tasks that require sustained attention, like reading, working math problems, or playing a board game. Behavior during free play or while getting individual attention is given less importance in the evaluation. In such situations, most children with ADHD are able to control their behavior and perform better than in more restrictive situations.
The specialist then pieces together a profile of the child's behavior. Which ADHD-like behaviors listed in the most recent DSM does the child show? How often? In what situations? How long has the child been doing them? How old was the child when the problem started? Are the behavior problems relatively chronic or enduring or are they periodic in nature? Are the behaviors seriously interfering with the child's friendships, school activities, home life, or participation in community activities? Does the child have any other related problems? The answers to these questions help identify whether the child's hyperactivity, impulsivity, and inattention are significant and long-standing. If so, the child may be diagnosed with ADHD.
A correct diagnosis often resolves confusion about the reasons for the child's problems that lets parents and child move forward in their lives with more accurate information on what is wrong and what can be done to help. Once the disorder is diagnosed, the child and family can begin to receive whatever combination of educational, medical, and emotional help they need. This may include providing recommendations to school staff, seeking out a more appropriate classroom setting, selecting the right medication, and helping parents to manage their child's behavior.

What Causes ADHD?

One of the first questions a parent will have is "Why? What went wrong?" "Did I do something to cause this?" There is little compelling evidence at this time that ADHD can arise purely from social factors or child-rearing methods. Most substantiated causes appear to fall in the realm of neurobiology and genetics. This is not to say that environmental factors may not influence the severity of the disorder, and especially the degree of impairment and suffering the child may experience, but that such factors do not seem to give rise to the condition by themselves.
The parents' focus should be on looking forward and finding the best possible way to help their child. Scientists are studying causes in an effort to identify better ways to treat, and perhaps someday, to prevent ADHD. They are finding more and more evidence that ADHD does not stem from the home environment, but from biological causes. Knowing this can remove a huge burden of guilt from parents who might blame themselves for their child's behavior.
Over the last few decades, scientists have come up with possible theories about what causes ADHD. Some of these theories have led to dead ends, some to exciting new avenues of investigation.

Environmental Agents

Studies have shown a possible correlation between the use of cigarettes and alcohol during pregnancy and risk for ADHD in the offspring of that pregnancy. As a precaution, it is best during pregnancy to refrain from both cigarette and alcohol use.
Another environmental agent that may be associated with a higher risk of ADHD is high levels of lead in the bodies of young preschool children. Since lead is no longer allowed in paint and is usually found only in older buildings, exposure to toxic levels is not as prevalent as it once was. Children who live in old buildings in which lead still exists in the plumbing or in lead paint that has been painted over may be at risk.

Brain Injury

One early theory was that attention disorders were caused by brain injury. Some children who have suffered accidents leading to brain injury may show some signs of behavior similar to that of ADHD, but only a small percentage of children with ADHD have been found to have suffered a traumatic brain injury.

Food Additives and Sugar

It has been suggested that attention disorders are caused by refined sugar or food additives, or that symptoms of ADHD are exacerbated by sugar or food additives. In 1982, the National Institutes of Health held a scientific consensus conference to discuss this issue. It was found that diet restrictions helped about 5 percent of children with ADHD, mostly young children who had food allergies.3 A more recent study on the effect of sugar on children, using sugar one day and a sugar substitute on alternate days, without parents, staff, or children knowing which substance was being used, showed no significant effects of the sugar on behavior or learning.4
In another study, children whose mothers felt they were sugar-sensitive were given aspartame as a substitute for sugar. Half the mothers were told their children were given sugar, half that their children were given aspartame. The mothers who thought their children had received sugar rated them as more hyperactive than the other children and were more critical of their behavior.5

Genetics

Attention disorders often run in families, so there are likely to be genetic influences. Studies indicate that 25 percent of the close relatives in the families of ADHD children also have ADHD, whereas the rate is about 5 percent in the general population.6 Many studies of twins now show that a strong genetic influence exists in the disorder.7
Researchers continue to study the genetic contribution to ADHD and to identify the genes that cause a person to be susceptible to ADHD. Since its inception in 1999, the Attention-Deficit Hyperactivity Disorder Molecular Genetics Network has served as a way for researchers to share findings regarding possible genetic influences on ADHD.8

Disorders that Sometimes Accompany ADHD

Learning Disabilities

Many children with ADHD—approximately 20 to 30 percent—also have a specific learning disability (LD).10 In preschool years, these disabilities include difficulty in understanding certain sounds or words and/or difficulty in expressing oneself in words. In school age children, reading or spelling disabilities, writing disorders, and arithmetic disorders may appear. A type of reading disorder, dyslexia, is quite widespread. Reading disabilities affect up to 8 percent of elementary school children.

Tourette Syndrome

A very small proportion of people with ADHD have a neurological disorder called Tourette syndrome. People with Tourette syndrome have various nervous tics and repetitive mannerisms, such as eye blinks, facial twitches, or grimacing. Others may clear their throats frequently, snort, sniff, or bark out words. These behaviors can be controlled with medication. While very few children have this syndrome, many of the cases of Tourette syndrome have associated ADHD. In such cases, both disorders often require treatment that may include medications.

Oppositional Defiant Disorder

As many as one-third to one-half of all children with ADHD—mostly boys—have another condition, known as oppositional defiant disorder (ODD). These children are often defiant, stubborn, non-compliant, have outbursts of temper, or become belligerent. They argue with adults and refuse to obey.

Conduct Disorder

About 20 to 40 percent of ADHD children may eventually develop conduct disorder (CD), a more serious pattern of antisocial behavior. These children frequently lie or steal, fight with or bully others, and are at a real risk of getting into trouble at school or with the police. They violate the basic rights of other people, are aggressive toward people and/or animals, destroy property, break into people's homes, commit thefts, carry or use weapons, or engage in vandalism. These children or teens are at greater risk for substance use experimentation, and later dependence and abuse. They need immediate help.

Anxiety and Depression

Some children with ADHD often have co-occurring anxiety or depression. If the anxiety or depression is recognized and treated, the child will be better able to handle the problems that accompany ADHD. Conversely, effective treatment of ADHD can have a positive impact on anxiety as the child is better able to master academic tasks.

Bipolar Disorder

There are no accurate statistics on how many children with ADHD also have bipolar disorder. Differentiating between ADHD and bipolar disorder in childhood can be difficult. In its classic form, bipolar disorder is characterized by mood cycling between periods of intense highs and lows. But in children, bipolar disorder often seems to be a rather chronic mood dysregulation with a mixture of elation, depression, and irritability. Furthermore, there are some symptoms that can be present both in ADHD and bipolar disorder, such as a high level of energy and a reduced need for sleep. Of the symptoms differentiating children with ADHD from those with bipolar disorder, elated mood and grandiosity of the bipolar child are distinguishing characteristics.11

The Treatment of ADHD

Every family wants to determine what treatment will be most effective for their child. This question needs to be answered by each family in consultation with their health care professional. To help families make this important decision, the National Institute of Mental Health (NIMH) has funded many studies of treatments for ADHD and has conducted the most intensive study ever undertaken for evaluating the treatment of this disorder. This study is known as the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (MTA).12 The NIMH is now conducting a clinical trial for younger children ages 3 to 5.5 years (Treatment of ADHD in Preschool-Age Children).

The Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder.

The MTA study included 579 (95-98 at each of 6 treatment sites) elementary school boys and girls with ADHD, who were randomly assigned to one of four treatment programs: (1) medication management alone; (2) behavioral treatment alone; (3) a combination of both; or (4) routine community care. In each of the study sites, three groups were treated for the first 14 months in a specified protocol and the fourth group was referred for community treatment of the parents' choosing. All of the children were reassessed regularly throughout the study period. An essential part of the program was the cooperation of the schools, including principals and teachers. Both teachers and parents rated the children on hyperactivity, impulsivity, and inattention, and symptoms of anxiety and depression, as well as social skills.
The children in two groups (medication management alone and the combination treatment) were seen monthly for one-half hour at each medication visit. During the treatment visits, the prescribing physician spoke with the parent, met with the child, and sought to determine any concerns that the family might have regarding the medication or the child's ADHD-related difficulties. The physicians, in addition, sought input from the teachers on a monthly basis. The physicians in the medication-only group did not provide behavioral therapy but did advise the parents when necessary concerning any problems the child might have.
In the behavior treatment-only group, families met up to 35 times with a behavior therapist, mostly in group sessions. These therapists also made repeated visits to schools to consult with children's teachers and to supervise a special aide assigned to each child in the group. In addition, children attended a special 8-week summer treatment program where they worked on academic, social, and sports skills, and where intensive behavioral therapy was delivered to assist children in improving their behavior.
Children in the combined therapy group received both treatments, that is, all the same assistance that the medication-only received, as well as all of the behavior therapy treatments.
In routine community care, the children saw the community-treatment doctor of their parents' choice one to two times per year for short periods of time. Also, the community-treatment doctor did not have any interaction with the teachers.
The results of the study indicated that long-term combination treatments and the medication-management alone were superior to intensive behavioral treatment and routine community treatment. And in some areas—anxiety, academic performance, oppositionality, parent-child relations, and social skills—the combined treatment was usually superior. Another advantage of combined treatment was that children could be successfully treated with lower doses of medicine, compared with the medication-only group.

Treatment of Attention Deficit Hyperactivity Disorder in Preschool-Age Children (PATS).

Because many children in the preschool years are diagnosed with ADHD and are given medication, it is important to know the safety and efficacy of such treatment. The NIMH is sponsoring an ongoing multi-site study, "Preschool ADHD Treatment Study" (PATS). It is the first major effort to examine the safety and efficacy of a stimulant, methylphenidate, for ADHD in this age group. The PATS study uses a randomized, placebo-controlled, double-blind design. Children ages 3 to 5 who have severe and persistent symptoms of ADHD that impair their functioning are eligible for this study. To avoid using medications at such an early age, all children who enter the study are first treated with behavioral therapy. Only children who do not show sufficient improvement with behavior therapy are considered for the medication part of the study. The study is being conducted at New York State Psychiatric Institute, Duke University, Johns Hopkins University, New York University, the University of California at Los Angeles, and the University of California at Irvine. Enrollment in the study will total 165 children.

Which Treatment Should My Child Have?

For children with ADHD, no single treatment is the answer for every child. A child may sometimes have undesirable side effects to a medication that would make that particular treatment unacceptable. And if a child with ADHD also has anxiety or depression, a treatment combining medication and behavioral therapy might be best. Each child's needs and personal history must be carefully considered.

The Family and the ADHD Child

Medication can help the ADHD child in everyday life. He or she may be better able to control some of the behavior problems that have led to trouble with parents and siblings. But it takes time to undo the frustration, blame, and anger that may have gone on for so long. Both parents and children may need special help to develop techniques for managing the patterns of behavior. In such cases, mental health professionals can counsel the child and the family, helping them to develop new skills, attitudes, and ways of relating to each other. In individual counseling, the therapist helps children with ADHD learn to feel better about themselves. The therapist can also help them to identify and build on their strengths, cope with daily problems, and control their attention and aggression. Sometimes only the child with ADHD needs counseling support. But in many cases, because the problem affects the family as a whole, the entire family may need help. The therapist assists the family in finding better ways to handle the disruptive behaviors and promote change. If the child is young, most of the therapist's work is with the parents, teaching them techniques for coping with and improving their child's behavior.
Several intervention approaches are available. Knowing something about the various types of interventions makes it easier for families to choose a therapist that is right for their needs.
Psychotherapy works to help people with ADHD to like and accept themselves despite their disorder. It does not address the symptoms or underlying causes of the disorder. In psychotherapy, patients talk with the therapist about upsetting thoughts and feelings, explore self-defeating patterns of behavior, and learn alternative ways to handle their emotions. As they talk, the therapist tries to help them understand how they can change or better cope with their disorder.
Behavioral therapy (BT) helps people develop more effective ways to work on immediate issues. Rather than helping the child understand his or her feelings and actions, it helps directly in changing their thinking and coping and thus may lead to changes in behavior. The support might be practical assistance, like help in organizing tasks or schoolwork or dealing with emotionally charged events. Or the support might be in self-monitoring one's own behavior and giving self-praise or rewards for acting in a desired way such as controlling anger or thinking before acting.
Social skills training can also help children learn new behaviors. In social skills training, the therapist discusses and models appropriate behaviors important in developing and maintaining social relationships, like waiting for a turn, sharing toys, asking for help, or responding to teasing, then gives children a chance to practice. For example, a child might learn to "read" other people's facial expression and tone of voice in order to respond appropriately. Social skills training helps the child to develop better ways to play and work with other children.
Support groups help parents connect with other people who have similar problems and concerns with their ADHD children. Members of support groups often meet on a regular basis (such as monthly) to hear lectures from experts on ADHD, share frustrations and successes, and obtain referrals to qualified specialists and information about what works. There is strength in numbers, and sharing experiences with others who have similar problems helps people know that they aren't alone. National organizations are listed at the end of this document.
Parenting skills training, offered by therapists or in special classes, gives parents tools and techniques for managing their child's behavior. One such technique is the use of token or point systems for immediately rewarding good behavior or work. Another is the use of "time-out" or isolation to a chair or bedroom when the child becomes too unruly or out of control. During time-outs, the child is removed from the agitating situation and sits alone quietly for a short time to calm down. Parents may also be taught to give the child "quality time" each day, in which they share a pleasurable or relaxing activity. During this time together, the parent looks for opportunities to notice and point out what the child does well, and praise his or her strengths and abilities.
This system of rewards and penalties can be an effective way to modify a child's behavior. The parents (or teacher) identify a few desirable behaviors that they want to encourage in the child—such as asking for a toy instead of grabbing it, or completing a simple task. The child is told exactly what is expected in order to earn the reward. The child receives the reward when he performs the desired behavior and a mild penalty when he doesn't. A reward can be small, perhaps a token that can be exchanged for special privileges, but it should be something the child wants and is eager to earn. The penalty might be removal of a token or a brief time-out. Make an effort to find your child being good. The goal, over time, is to help children learn to control their own behavior and to choose the more desired behavior. The technique works well with all children, although children with ADHD may need more frequent rewards.
In addition, parents may learn to structure situations in ways that will allow their child to succeed. This may include allowing only one or two playmates at a time, so that their child doesn't get overstimulated. Or if their child has trouble completing tasks, they may learn to help the child divide a large task into small steps, then praise the child as each step is completed. Regardless of the specific technique parents may use to modify their child's behavior, some general principles appear to be useful for most children with ADHD. These include providing more frequent and immediate feedback (including rewards and punishment), setting up more structure in advance of potential problem situations, and providing greater supervision and encouragement to children with ADHD in relatively unrewarding or tedious situations.
Parents may also learn to use stress management methods, such as meditation, relaxation techniques, and exercise, to increase their own tolerance for frustration so that they can respond more calmly to their child's behavior.

Some Simple Behavioral Interventions

Children with ADHD may need help in organizing. Therefore:

Children with ADHD need consistent rules that they can understand and follow. If rules are followed, give small rewards. Children with ADHD often receive, and expect, criticism. Look for good behavior and praise it.

Your ADHD Child and School

You are your child's best advocate. To be a good advocate for your child, learn as much as you can about ADHD and how it affects your child at home, in school, and in social situations.
If your child has shown symptoms of ADHD from an early age and has been evaluated, diagnosed, and treated with either behavior modification or medication or a combination of both, when your child enters the school system, let his or her teachers know. They will be better prepared to help the child come into this new world away from home.
If your child enters school and experiences difficulties that lead you to suspect that he or she has ADHD, you can either seek the services of an outside professional or you can ask the local school district to conduct an evaluation. Some parents prefer to go to a professional of their own choice. But it is the school's obligation to evaluate children that they suspect have ADHD or some other disability that is affecting not only their academic work but their interactions with classmates and teachers.
If you feel that your child has ADHD and isn't learning in school as he or she should, you should find out just who in the school system you should contact. Your child's teacher should be able to help you with this information. Then you can request—in writing—that the school system evaluate your child. The letter should include the date, your and your child's names, and the reason for requesting an evaluation. Keep a copy of the letter in your own files.
Until the last few years, many school systems were reluctant to evaluate a child with ADHD. But recent laws have made clear the school's obligation to the child suspected of having ADHD that is affecting adversely his or her performance in school. If the school persists in refusing to evaluate your child, you can either get a private evaluation or enlist some help in negotiating with the school. Help is often as close as a local parent group. Each state has a Parent Training and Information (PTI) center as well as a Protection and Advocacy (P&A) agency. (For information on the law and on the PTI and P&A, see the section on support groups and organizations at the end of this document.)
Once your child has been diagnosed with ADHD and qualifies for special education services, the school, working with you, must assess the child's strengths and weaknesses and design an Individualized Educational Program (IEP). You should be able periodically to review and approve your child's IEP. Each school year brings a new teacher and new schoolwork, a transition that can be quite difficult for the child with ADHD. Your child needs lots of support and encouragement at this time.
Never forget the cardinal rule—you are your child's best advocate.

Your Teenager with ADHD

Your child with ADHD has successfully navigated the early school years and is beginning his or her journey through middle school and high school. Although your child has been periodically evaluated through the years, this is a good time to have a complete re-evaluation of your child's health.
The teen years are challenging for most children; for the child with ADHD these years are doubly hard. All the adolescent problems—peer pressure, the fear of failure in both school and socially, low self-esteem—are harder for the ADHD child to handle. The desire to be independent, to try new and forbidden things—alcohol, drugs, and sexual activity—can lead to unforeseen consequences. The rules that once were, for the most part, followed, are often now flaunted. Parents may not agree with each other on how the teenager's behavior should be handled.
Now, more than ever, rules should be straightforward and easy to understand. Communication between the adolescent and parents can help the teenager to know the reasons for each rule. When a rule is set, it should be clear why the rule is set. Sometimes it helps to have a chart, posted usually in the kitchen, that lists all household rules and all rules for outside the home (social and school). Another chart could list household chores with space to check off a chore once it is done.
When rules are broken—and they will be—respond to this inappropriate behavior as calmly and matter-of-factly as possible. Use punishment sparingly. Even with teens, a time-out can work. Impulsivity and hot temper often accompany ADHD. A short time alone can help.
As the teenager spends more time away from home, there will be demands for a later curfew and the use of the car. Listen to your child's request, give reasons for your opinion and listen to his or her opinion, and negotiate. Communication, negotiation, and compromise will prove helpful.

Your Teenager and the Car

Teenagers, especially boys, begin talking about driving by the time they are 15. In some states, a learner's permit is available at 15 and a driver's license at 16. Statistics show that 16-year-old drivers have more accidents per driving mile than any other age. In the year 2000, 18 percent of those who died in speed-related crashes were youth ages 15 to 19. Sixty-six percent of these youth were not wearing safety belts. Youth with ADHD, in their first 2 to 5 years of driving, have nearly four times as many automobile accidents, are more likely to cause bodily injury in accidents, and have three times as many citations for speeding as the young drivers without ADHD.14
Most states, after looking at the statistics for automobile accidents involving teenage drivers, have begun to use a graduated driver licensing system (GDL). This system eases young drivers onto the roads by a slow progression of exposure to more difficult driving experiences. The program, as developed by the National Highway Traffic Safety Administration and the American Association of Motor Vehicle Administrators, consists of three stages: learner's permit, intermediate (provisional) license, and full licensure. Drivers must demonstrate responsible driving behavior at each stage before advancing to the next level. During the learner's permit stage, a licensed adult must be in the car at all times.15 This period of time will give the learner a chance to practice, practice, practice. The more your child drives, the more efficient he or she will become. The sense of accomplishment the teenager with ADHD will feel when the coveted license is finally in his or her hands will make all the time and effort involved worthwhile.
Note: The State Legislative Fact Sheets—Graduated Driver Licensing System can be found at web site http://www.nhtsa.dot.gov/people/outreach/safesobr/21qp/html/fact_sheets/Graduated_Driver.html, or it can be ordered from NHTSA Headquarters, Traffic Safety Programs, ATTN: NTS-32, 400 Seventh Street, S.W., Washington, DC 20590; telephone 202-366-6948.

Attention Deficit Hyperactivity Disorder in Adults

Attention deficit hyperactivity disorder is a highly publicized childhood disorder that affects approximately 3 percent to 5 percent of all children. What is much less well known is the probability that, of children who have ADHD, many will still have it as adults. Several studies done in recent years estimate that between 30 percent and 70 percent of children with ADHD continue to exhibit symptoms in the adult years.16
The first studies on adults who were never diagnosed as children as having ADHD, but showed symptoms as adults, were done in the late 1970s by Drs. Paul Wender, Frederick Reimherr, and David Wood. These symptomatic adults were retrospectively diagnosed with ADHD after the researchers' interviews with their parents. The researchers developed clinical criteria for the diagnosis of adult ADHD (the Utah Criteria), which combined past history of ADHD with current evidence of ADHD behaviors.17 Other diagnostic assessments are now available; among them are the widely used Conners Rating Scale and the Brown Attention Deficit Disorder Scale.
Typically, adults with ADHD are unaware that they have this disorder—they often just feel that it's impossible to get organized, to stick to a job, to keep an appointment. The everyday tasks of getting up, getting dressed and ready for the day's work, getting to work on time, and being productive on the job can be major challenges for the ADHD adult.

Diagnosing ADHD in an Adult

Diagnosing an adult with ADHD is not easy. Many times, when a child is diagnosed with the disorder, a parent will recognize that he or she has many of the same symptoms the child has and, for the first time, will begin to understand some of the traits that have given him or her trouble for years—distractibility, impulsivity, restlessness. Other adults will seek professional help for depression or anxiety and will find out that the root cause of some of their emotional problems is ADHD. They may have a history of school failures or problems at work. Often they have been involved in frequent automobile accidents.
To be diagnosed with ADHD, an adult must have childhood-onset, persistent, and current symptoms.18 The accuracy of the diagnosis of adult ADHD is of utmost importance and should be made by a clinician with expertise in the area of attention dysfunction. For an accurate diagnosis, a history of the patient's childhood behavior, together with an interview with his life partner, a parent, close friend, or other close associate, will be needed. A physical examination and psychological tests should also be given. Comorbidity with other conditions may exist such as specific learning disabilities, anxiety, or affective disorders.
A correct diagnosis of ADHD can bring a sense of relief. The individual has brought into adulthood many negative perceptions of himself that may have led to low esteem. Now he can begin to understand why he has some of his problems and can begin to face them. This may mean, not only treatment for ADHD but also psychotherapy that can help him cope with the anger he feels about the failure to diagnose the disorder when he was younger.

Treatment of ADHD in an Adult

Education and psychotherapy
Although medication gives needed support, the individual must succeed on his own. To help in this struggle, both "psychoeducation" and individual psychotherapy can be helpful. A professional coach can help the ADHD adult learn how to organize his life by using "props"—a large calendar posted where it will be seen in the morning, date books, lists, reminder notes, and have a special place for keys, bills, and the paperwork of everyday life. Tasks can be organized into sections, so that completion of each part can give a sense of accomplishment. Above all, ADHD adults should learn as much as they can about their disorder.
Psychotherapy can be a useful adjunct to medication and education. First, just remembering to keep an appointment with the therapist is a step toward keeping to a routine. Therapy can help change a long-standing poor self-image by examining the experiences that produced it. The therapist can encourage the ADHD patient to adjust to changes brought into his life by treatment—the perceived loss of impulsivity and love of risk-taking, the new sensation of thinking before acting. As the patient begins to have small successes in his new ability to bring organization out of the complexities of his or her life, he or she can begin to appreciate the characteristics of ADHD that are positive—boundless energy, warmth, and enthusiasm.
Where to Get Help!
Treatment for attention deficit disorder is available at Olive Branch Counseling Associates, Inc. by calling (708)-687-3479
**Information found on this website regarding attention deficit disorder can be found with additional information at http://www.nimh.nih.gov

References

1Still GF. Some abnormal psychical conditions in children: the Goulstonian lectures. Lancet, 1902;1:1008-1012.
2DSM-IV-TR workgroup. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association.
3Consensus Development Panel. Defined Diets and Childhood Hyperactivity. National Institutes of Health Consensus Development Conference Summary, Volume 4, Number 3, 1982.
4Wolraich M, Milich R, Stumbo P, Schultz F. The effects of sucrose ingestion on the behavior of hyperactive boys. Pediatrics, 1985; 106; 657-682.
5Hoover DW, Milich R. Effects of sugar ingestion expectancies on mother-child interaction. Journal of Abnormal Child Psychology, 1994; 22; 501-515.
6Biederman J, Faraone SV, Keenan K, Knee D, Tsuang MF. Family-genetic and psychosocial risk factors in DSM-III attention deficit disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 1990; 29(4): 526-533.
7Faraone SV, Biederman J. Neurobiology of attention-deficit hyperactivity disorder. Biological Psychiatry, 1998; 44; 951-958.
8The ADHD Molecular Genetics Network. Report from the third international meeting of the attention-deficit hyperactivity disorder molecular genetics network. American Journal of Medical Genetics, 2002, 114:272-277.
9Castellanos FX, Lee PP, Sharp W, Jeffries NO, Greenstein DK, Clasen LS, Blumenthal JD, James RS, Ebens CI, Walter JM, Zijdenbos A, Evans AC, Giedd JN, Rapoport JL. Developmental trajectories of brain volume abnormalities in children and adolescents with attention-deficit/hyperactivity disorder. Journal of the American Medical Association, 2002, 288:14:1740-1748.
10Wender PH. ADHD: Attention-Deficit Hyperactivity Disorder in Children and Adults. Oxford University Press, 2002, p. 9.
11Geller B, Williams M, Zimerman B, Frazier J, Beringer L, Warner KL. Prepubertal and early adolescent bipolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling. Journal of Affective Disorders, 1998, 51:81-91.
12The MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit hyperactivity disorder (ADHD). Archives of General Psychiatry, 1999;56:1073-1086.
13Wilens TC, Faraone, SV, Biederman J, Gunawardene S. Does stimulant therapy of attention-deficit/hyperactivity disorder beget later substance abuse? A meta-analytic review of the literature. Pediatrics, 2003, 111:1:179-185.
14Barkley RA. Taking Charge of ADHD. New York: The Guilford Press, 2000, p. 21.
15U.S. Department of Transportation, National Highway Traffic Safety Administration. State Legislative Fact Sheet, April 2002.
16Silver LB. Attention-deficit hyperactivity disorder in adult life. Child and Adolescent Psychiatric Clinics of North America, 2000:9:3: 411-523.
17Wender PH. Pharmacotherapy of attention-deficit/hyperactivity in adults. Journal of Clinical Psychiatry, 1998; 59 (supplement 7):76-79.
18Wilens TE, Biederman J, Spencer TJ. Attention deficit/hyperactivity disorder across the lifespan. Annual Review of Medicine, 2002:53:113-131.
19Attention Deficit Disorder in Adults. Harvard Mental Health Letter, 2002:19;5:3-6.

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Panic Disorder

"For me, a panic attack is almost a violent experience. I feel disconnected from reality. I feel like I'm losing control in a very extreme way. My heart pounds really hard, I feel like I can't get my breath, and there's an overwhelming feeling that things are crashing in on me."

"It started 10 years ago, when I had just graduated from college and started a new job. I was sitting in a business seminar in a hotel and this thing came out of the blue. I felt like I was dying."

"In between attacks there is this dread and anxiety that it's going to happen again. I'm afraid to go back to places where I've had an attack. Unless I get help, there soon won't be anyplace where I can go and feel safe from panic."

Panic disorder is a real illness that can be successfully treated. It is characterized by sudden attacks of terror, usually accompanied by a pounding heart, sweatiness, weakness, faintness, or dizziness. During these attacks, people with panic disorder may flush or feel chilled; their hands may tingle or feel numb; and they may experience nausea, chest pain, or smothering sensations. Panic attacks usually produce a sense of unreality, a fear of impending doom, or a fear of losing control.

A fear of one's own unexplained physical symptoms is also a symptom of panic disorder. People having panic attacks sometimes believe they are having heart attacks, losing their minds, or on the verge of death. They can't predict when or where an attack will occur, and between episodes many worry intensely and dread the next attack.

Panic attacks can occur at any time, even during sleep. An attack usually peaks within 10 minutes, but some symptoms may last much longer. Panic disorder affects about 6 million American adults¹ and is twice as common in women as men.² Panic attacks often begin in late adolescence or early adulthood,² but not everyone who experiences panic attacks will develop panic disorder. Many people have just one attack and never have another. The tendency to develop panic attacks appears to be inherited.³

People who have full-blown, repeated panic attacks can become very disabled by their condition and should seek treatment before they start to avoid places or situations where panic attacks have occurred. For example, if a panic attack happened in an elevator, someone with panic disorder may develop a fear of elevators that could affect the choice of a job or an apartment, and restrict where that person can seek medical attention or enjoy entertainment.

Some people's lives become so restricted that they avoid normal activities, such as grocery shopping or driving. About one-third become housebound or are able to confront a feared situation only when accompanied by a spouse or other trusted person. ² When the condition progresses this far, it is called agoraphobia, or fear of open spaces.

Early treatment can often prevent agoraphobia, but people with panic disorder may sometimes go from doctor to doctor for years and visit the emergency room repeatedly before someone correctly diagnoses their condition. This is unfortunate, because panic disorder is one of the most treatable of all the anxiety disorders, responding in most cases to certain kinds of medication or certain kinds of cognitive psychotherapy, which help change thinking patterns that lead to fear and anxiety.

Panic disorder is often accompanied by other serious problems, such as depression, drug abuse, or alcoholism.^4,5 These conditions need to be treated separately. Symptoms of depression include feelings of sadness or hopelessness, changes in appetite or sleep patterns, low energy, and difficulty concentrating. Most people with depression can be effectively treated with antidepressant medications, certain types of psychotherapy, or a combination of the two.

Treatment of Anxiety Disorders

In general, anxiety disorders are treated with medication, specific types of psychotherapy, or both.¹⁴ Treatment choices depend on the problem and the person's preference. Before treatment begins, a doctor must conduct a careful diagnostic evaluation to determine whether a person's symptoms are caused by an anxiety disorder or a physical problem. If an anxiety disorder is diagnosed, the type of disorder or the combination of disorders that are present must be identified, as well as any coexisting conditions, such as depression or substance abuse. Sometimes alcoholism, depression, or other coexisting conditions have such a strong effect on the individual that treating the anxiety disorder must wait until the coexisting conditions are brought under control.

People with anxiety disorders who have already received treatment should tell their current doctor about that treatment in detail. If they received medication, they should tell their doctor what medication was used, what the dosage was at the beginning of treatment, whether the dosage was increased or decreased while they were under treatment, what side effects occurred, and whether the treatment helped them become less anxious. If they received psychotherapy, they should describe the type of therapy, how often they attended sessions, and whether the therapy was useful.

Often people believe that they have "failed" at treatment or that the treatment didn't work for them when, in fact, it was not given for an adequate length of time or was administered incorrectly. Sometimes people must try several different treatments or combinations of treatment before they find the one that works for them.

Medications

Medication will not cure anxiety disorders, but it can keep them under control while the person receives psychotherapy. Medication must be prescribed by physicians, usually psychiatrists, who can either offer psychotherapy themselves or work as a team with psychologists, social workers, or counselors who provide psychotherapy. The principal medications used for anxiety disorders are antidepressants, anti-anxiety drugs, and beta-blockers to control some of the physical symptoms. With proper treatment, many people with anxiety disorders can lead normal, fulfilling lives.

Antidepressants

Antidepressants were developed to treat depression but are also effective for anxiety disorders. Although these medications begin to alter brain chemistry after the very first dose, their full effect requires a series of changes to occur; it is usually about 4 to 6 weeks before symptoms start to fade. It is important to continue taking these medications long enough to let them work.

SSRIs

Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other neurotransmitters, helps brain cells communicate with one another.

Fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and citalopram (Celexa®) are some of the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. Venlafaxine (Effexor®), a drug closely related to the SSRIs, is used to treat GAD. These medications are started at low doses and gradually increased until they have a beneficial effect.

SSRIs have fewer side effects than older antidepressants, but they sometimes produce slight nausea or jitters when people first start to take them. These symptoms fade with time. Some people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the dosage or switching to another SSRI.

Tricyclics

Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD. They are also started at low doses that are gradually increased. They sometimes cause dizziness, drowsiness, dry mouth, and weight gain, which can usually be corrected by changing the dosage or switching to another tricyclic medication.

Tricyclics include imipramine (Tofranil®), which is prescribed for panic disorder and GAD, and clomipramine (Anafranil®), which is the only tricyclic antidepressant useful for treating OCD.

MAOIs

Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. The MAOIs most commonly prescribed for anxiety disorders are phenelzine (Nardil®), followed by tranylcypromine (Parnate®), and isocarboxazid (Marplan®), which are useful in treating panic disorder and social phobia. People who take MAOIs cannot eat a variety of foods and beverages (including cheese and red wine) that contain tyramine or take certain medications, including some types of birth control pills, pain relievers (such as Advil®, Motrin®, or Tylenol®), cold and allergy medications, and herbal supplements; these substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help lessen these risks. MAOIs can also react with SSRIs to produce a serious condition called "serotonin syndrome," which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions.

Anti-Anxiety Drugs

High-potency benzodiazepines combat anxiety and have few side effects other than drowsiness. Because people can get used to them and may need higher and higher doses to get the same effect, benzodiazepines are generally prescribed for short periods of time, especially for people who have abused drugs or alcohol and who become dependent on medication easily. One exception to this rule is people with panic disorder, who can take benzodiazepines for up to a year without harm.

Clonazepam (Klonopin®) is used for social phobia and GAD, lorazepam (Ativan®) is helpful for panic disorder, and alprazolam (Xanax®) is useful for both panic disorder and GAD.

Some people experience withdrawal symptoms if they stop taking benzodiazepines abruptly instead of tapering off, and anxiety can return once the medication is stopped. These potential problems have led some physicians to shy away from using these drugs or to use them in inadequate doses.

Buspirone (Buspar®), an azapirone, is a newer anti-anxiety medication used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an anti-anxiety effect.

Beta-Blockers

Beta-blockers, such as propranolol (Inderal®), which is used to treat heart conditions, can prevent the physical symptoms that accompany certain anxiety disorders, particularly social phobia. When a feared situation can be predicted (such as giving a speech), a doctor may prescribe a beta-blocker to keep physical symptoms of anxiety under control.

Psychotherapy

Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor, to discover what caused an anxiety disorder and how to deal with its symptoms.

Cognitive-Behavioral Therapy

Cognitive-Behavioral Therapy Cognitive-behavioral therapy (CBT) is very useful in treating anxiety disorders. The cognitive part helps people change the thinking patterns that support their fears, and the behavioral part helps people change the way they react to anxiety-provoking situations.

For example, CBT can help people with panic disorder learn that their panic attacks are not really heart attacks and help people with social phobia learn how to overcome the belief that others are always watching and judging them. When people are ready to confront their fears, they are shown how to use exposure techniques to desensitize themselves to situations that trigger their anxieties.

People with OCD who fear dirt and germs are encouraged to get their hands dirty and wait increasing amounts of time before washing them. The therapist helps the person cope with the anxiety that waiting produces; after the exercise has been repeated a number of times, the anxiety diminishes. People with social phobia may be encouraged to spend time in feared social situations without giving in to the temptation to flee and to make small social blunders and observe how people respond to them. Since the response is usually far less harsh than the person fears, these anxieties are lessened. People with PTSD may be supported through recalling their traumatic event in a safe situation, which helps reduce the fear it produces. CBT therapists also teach deep breathing and other types of exercises to relieve anxiety and encourage relaxation.

Exposure-based behavioral therapy has been used for many years to treat specific phobias. The person gradually encounters the object or situation that is feared, perhaps at first only through pictures or tapes, then later face-to-face. Often the therapist will accompany the person to a feared situation to provide support and guidance.

CBT is undertaken when people decide they are ready for it and with their permission and cooperation. To be effective, the therapy must be directed at the person's specific anxieties and must be tailored to his or her needs. There are no side effects other than the discomfort of temporarily increased anxiety.

CBT or behavioral therapy often lasts about 12 weeks. It may be conducted individually or with a group of people who have similar problems. Group therapy is particularly effective for social phobia. Often "homework" is assigned for participants to complete between sessions. There is some evidence that the benefits of CBT last longer than those of medication for people with panic disorder, and the same may be true for OCD, PTSD, and social phobia. If a disorder recurs at a later date, the same therapy can be used to treat it successfully a second time.

Medication can be combined with psychotherapy for specific anxiety disorders, and this is the best treatment approach for many people.

TAKING MEDICATIONS

Before taking medication for an anxiety disorder:

• Ask your doctor to tell you about the effects and side effects of the drug.
• Tell your doctor about any alternative therapies or over-the-counter medications you are using.
• Ask your doctor when and how the medication should be stopped. Some drugs can't be stopped abruptly but must be tapered off slowly under a doctor's supervision.
• Work with your doctor to determine which medication is right for you and what dosage is best.
• Be aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.

How to Get Help for Anxiety Disorders

If you think you have an anxiety disorder, the first person you should see is your family doctor. A physician can determine whether the symptoms that alarm you are due to an anxiety disorder, another medical condition, or both.

If an anxiety disorder is diagnosed, the next step is usually seeing a mental health professional. The practitioners who are most helpful with anxiety disorders are those who have training in cognitive-behavioral therapy and/or behavioral therapy, and who are open to using medication if it is needed.

You should feel comfortable talking with the mental health professional you choose. If you do not, you should seek help elsewhere. Once you find a mental health professional with whom you are comfortable, the two of you should work as a team and make a plan to treat your anxiety disorder together.

Remember that once you start on medication, it is important not to stop taking it abruptly. Certain drugs must be tapered off under the supervision of a doctor or bad reactions can occur. Make sure you talk to the doctor who prescribed your medication before you stop taking it. If you are having trouble with side effects, it's possible that they can be eliminated by adjusting how much medication you take and when you take it.

Most insurance plans, including health maintenance organizations (HMOs), will cover treatment for anxiety disorders. Check with your insurance company and find out. If you don't have insurance, the Health and Human Services division of your county government may offer mental health care at a public mental health center that charges people according to how much they are able to pay. If you are on public assistance, you may be able to get care through your state Medicaid plan.

 

Help is available by calling

Olive Branch Counseling Associates, Inc. 

at (708) 687-3479.

Ways to Make Treatment More Effective

Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common. Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a mental health professional.

Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided. Check with your physician or pharmacist before taking any additional medications.

The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one's symptoms. Family members should not trivialize the disorder or demand improvement without treatment. If your family is doing either of these things, you may want to show them this booklet so they can become educated allies and help you succeed in therapy.

References

1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.

²Robins LN, Regier DA, eds. Psychiatric disorders in America: the Epidemiologic Catchment Area Study. New York: The Free Press, 1991.

³The NIMH Genetics Workgroup. Genetics and mental disorders. NIH Publication No. 98-4268. Rockville, MD: National Institute of Mental Health, 1998.

⁴Regier DA, Rae DS, Narrow WE, et al. Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders. British Journal of Psychiatry Supplement, 1998; (34): 24-8.

The above information and other information on mental health is available through the National Institute of Mental Health website: www.nimh.gov.

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Generalized Anxiety Disorder (GAD)

"I always thought I was just a worrier. I'd feel keyed up and unable to relax. At times it would come and go, and at times it would be constant. It could go on for days. I'd worry about what I was going to fix for a dinner party, or what would be a great present for somebody. I just couldn't let something go."

"I'd have terrible sleeping problems. There were times I'd wake up wired in the middle of the night. I had trouble concentrating, even reading the newspaper or a novel. Sometimes I'd feel a little lightheaded. My heart would race or pound. And that would make me worry more. I was always imagining things were worse than they really were: when I got a stomachache, I'd think it was an ulcer."

People with generalized anxiety disorder (GAD) go through the day filled with exaggerated worry and tension, even though there is little or nothing to provoke it. They anticipate disaster and are overly concerned about health issues, money, family problems, or difficulties at work. Sometimes just the thought of getting through the day produces anxiety.

GAD is diagnosed when a person worries excessively about a variety of everyday problems for at least 6 months.¹³ People with GAD can't seem to get rid of their concerns, even though they usually realize that their anxiety is more intense than the situation warrants. They can't relax, startle easily, and have difficulty concentrating. Often they have trouble falling asleep or staying asleep. Physical symptoms that often accompany the anxiety include fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, nausea, lightheadedness, having to go to the bathroom frequently, feeling out of breath, and hot flashes.

When their anxiety level is mild, people with GAD can function socially and hold down a job. Although they don't avoid certain situations as a result of their disorder, people with GAD can have difficulty carrying out the simplest daily activities if their anxiety is severe.

GAD affects about 6.8 million adult Americans¹ and about twice as many women as men.² The disorder comes on gradually and can begin across the life cycle, though the risk is highest between childhood and middle age.² It is diagnosed when someone spends at least 6 months worrying excessively about a number of everyday problems. There is evidence that genes play a modest role in GAD.¹³

 

Treatment for Generalized Anxiety Disorder is available in Oak Forest, Illinois by calling

Olive Branch Counseling Associates, Inc.

(708) 687-3479.

 

Treatment of Anxiety Disorders

In general, anxiety disorders are treated with medication, specific types of psychotherapy, or both.¹⁴ Treatment choices depend on the problem and the person's preference. Before treatment begins, a doctor must conduct a careful diagnostic evaluation to determine whether a person's symptoms are caused by an anxiety disorder or a physical problem. If an anxiety disorder is diagnosed, the type of disorder or the combination of disorders that are present must be identified, as well as any coexisting conditions, such as depression or substance abuse. Sometimes alcoholism, depression, or other coexisting conditions have such a strong effect on the individual that treating the anxiety disorder must wait until the coexisting conditions are brought under control.

People with anxiety disorders who have already received treatment should tell their current doctor about that treatment in detail. If they received medication, they should tell their doctor what medication was used, what the dosage was at the beginning of treatment, whether the dosage was increased or decreased while they were under treatment, what side effects occurred, and whether the treatment helped them become less anxious. If they received psychotherapy, they should describe the type of therapy, how often they attended sessions, and whether the therapy was useful.

Often people believe that they have "failed" at treatment or that the treatment didn't work for them when, in fact, it was not given for an adequate length of time or was administered incorrectly. Sometimes people must try several different treatments or combinations of treatment before they find the one that works for them.

Medications

Medication will not cure anxiety disorders, but it can keep them under control while the person receives psychotherapy. Medication must be prescribed by physicians, usually psychiatrists, who can either offer psychotherapy themselves or work as a team with psychologists, social workers, or counselors who provide psychotherapy. The principal medications used for anxiety disorders are antidepressants, anti-anxiety drugs, and beta-blockers to control some of the physical symptoms. With proper treatment, many people with anxiety disorders can lead normal, fulfilling lives.

Antidepressants

Antidepressants were developed to treat depression but are also effective for anxiety disorders. Although these medications begin to alter brain chemistry after the very first dose, their full effect requires a series of changes to occur; it is usually about 4 to 6 weeks before symptoms start to fade. It is important to continue taking these medications long enough to let them work.

SSRIs

Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other neurotransmitters, helps brain cells communicate with one another.

Fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and citalopram (Celexa®) are some of the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. Venlafaxine (Effexor®), a drug closely related to the SSRIs, is used to treat GAD. These medications are started at low doses and gradually increased until they have a beneficial effect.

SSRIs have fewer side effects than older antidepressants, but they sometimes produce slight nausea or jitters when people first start to take them. These symptoms fade with time. Some people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the dosage or switching to another SSRI.

Tricyclics

Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD. They are also started at low doses that are gradually increased. They sometimes cause dizziness, drowsiness, dry mouth, and weight gain, which can usually be corrected by changing the dosage or switching to another tricyclic medication.

Tricyclics include imipramine (Tofranil®), which is prescribed for panic disorder and GAD, and clomipramine (Anafranil®), which is the only tricyclic antidepressant useful for treating OCD.

MAOIs

Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. The MAOIs most commonly prescribed for anxiety disorders are phenelzine (Nardil®), followed by tranylcypromine (Parnate®), and isocarboxazid (Marplan®), which are useful in treating panic disorder and social phobia. People who take MAOIs cannot eat a variety of foods and beverages (including cheese and red wine) that contain tyramine or take certain medications, including some types of birth control pills, pain relievers (such as Advil®, Motrin®, or Tylenol®), cold and allergy medications, and herbal supplements; these substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help lessen these risks. MAOIs can also react with SSRIs to produce a serious condition called "serotonin syndrome," which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions.

Anti-Anxiety Drugs

High-potency benzodiazepines combat anxiety and have few side effects other than drowsiness. Because people can get used to them and may need higher and higher doses to get the same effect, benzodiazepines are generally prescribed for short periods of time, especially for people who have abused drugs or alcohol and who become dependent on medication easily. One exception to this rule is people with panic disorder, who can take benzodiazepines for up to a year without harm.

Clonazepam (Klonopin®) is used for social phobia and GAD, lorazepam (Ativan®) is helpful for panic disorder, and alprazolam (Xanax®) is useful for both panic disorder and GAD.

Some people experience withdrawal symptoms if they stop taking benzodiazepines abruptly instead of tapering off, and anxiety can return once the medication is stopped. These potential problems have led some physicians to shy away from using these drugs or to use them in inadequate doses.

Buspirone (Buspar®), an azapirone, is a newer anti-anxiety medication used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an anti-anxiety effect.

Beta-Blockers

Beta-blockers, such as propranolol (Inderal®), which is used to treat heart conditions, can prevent the physical symptoms that accompany certain anxiety disorders, particularly social phobia. When a feared situation can be predicted (such as giving a speech), a doctor may prescribe a beta-blocker to keep physical symptoms of anxiety under control.

Psychotherapy

Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor, to discover what caused an anxiety disorder and how to deal with its symptoms.

Cognitive-Behavioral Therapy

Cognitive-Behavioral Therapy Cognitive-behavioral therapy (CBT) is very useful in treating anxiety disorders. The cognitive part helps people change the thinking patterns that support their fears, and the behavioral part helps people change the way they react to anxiety-provoking situations.

For example, CBT can help people with panic disorder learn that their panic attacks are not really heart attacks and help people with social phobia learn how to overcome the belief that others are always watching and judging them. When people are ready to confront their fears, they are shown how to use exposure techniques to desensitize themselves to situations that trigger their anxieties.

People with OCD who fear dirt and germs are encouraged to get their hands dirty and wait increasing amounts of time before washing them. The therapist helps the person cope with the anxiety that waiting produces; after the exercise has been repeated a number of times, the anxiety diminishes. People with social phobia may be encouraged to spend time in feared social situations without giving in to the temptation to flee and to make small social blunders and observe how people respond to them. Since the response is usually far less harsh than the person fears, these anxieties are lessened. People with PTSD may be supported through recalling their traumatic event in a safe situation, which helps reduce the fear it produces. CBT therapists also teach deep breathing and other types of exercises to relieve anxiety and encourage relaxation.

Exposure-based behavioral therapy has been used for many years to treat specific phobias. The person gradually encounters the object or situation that is feared, perhaps at first only through pictures or tapes, then later face-to-face. Often the therapist will accompany the person to a feared situation to provide support and guidance.

CBT is undertaken when people decide they are ready for it and with their permission and cooperation. To be effective, the therapy must be directed at the person's specific anxieties and must be tailored to his or her needs. There are no side effects other than the discomfort of temporarily increased anxiety.

CBT or behavioral therapy often lasts about 12 weeks. It may be conducted individually or with a group of people who have similar problems. Group therapy is particularly effective for social phobia. Often "homework" is assigned for participants to complete between sessions. There is some evidence that the benefits of CBT last longer than those of medication for people with panic disorder, and the same may be true for OCD, PTSD, and social phobia. If a disorder recurs at a later date, the same therapy can be used to treat it successfully a second time.

Medication can be combined with psychotherapy for specific anxiety disorders, and this is the best treatment approach for many people.

TAKING MEDICATIONS

Before taking medication for an anxiety disorder:

• Ask your doctor to tell you about the effects and side effects of the drug.
• Tell your doctor about any alternative therapies or over-the-counter medications you are using.
• Ask your doctor when and how the medication should be stopped. Some drugs can't be stopped abruptly but must be tapered off slowly under a doctor's supervision.
• Work with your doctor to determine which medication is right for you and what dosage is best.
• Be aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.

How to Get Help for Anxiety Disorders

If you think you have an anxiety disorder, the first person you should see is your family doctor. A physician can determine whether the symptoms that alarm you are due to an anxiety disorder, another medical condition, or both.

If an anxiety disorder is diagnosed, the next step is usually seeing a mental health professional. The practitioners who are most helpful with anxiety disorders are those who have training in cognitive-behavioral therapy and/or behavioral therapy, and who are open to using medication if it is needed.

You should feel comfortable talking with the mental health professional you choose. If you do not, you should seek help elsewhere. Once you find a mental health professional with whom you are comfortable, the two of you should work as a team and make a plan to treat your anxiety disorder together.

Remember that once you start on medication, it is important not to stop taking it abruptly. Certain drugs must be tapered off under the supervision of a doctor or bad reactions can occur. Make sure you talk to the doctor who prescribed your medication before you stop taking it. If you are having trouble with side effects, it's possible that they can be eliminated by adjusting how much medication you take and when you take it.

Most insurance plans, including health maintenance organizations (HMOs), will cover treatment for anxiety disorders. Check with your insurance company and find out. If you don't have insurance, the Health and Human Services division of your county government may offer mental health care at a public mental health center that charges people according to how much they are able to pay. If you are on public assistance, you may be able to get care through your state Medicaid plan.

Ways to Make Treatment More Effective

Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common. Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a mental health professional.

Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided. Check with your physician or pharmacist before taking any additional medications.

The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one's symptoms. Family members should not trivialize the disorder or demand improvement without treatment. If your family is doing either of these things, you may want to show them this booklet so they can become educated allies and help you succeed in therapy.

Help is available by calling:

Olive Branch Counseling Associates, Inc.

(708) 687-3479.

 

The above information and other information about mental health is available at the webpage for the National Institute of Mental Health: www.nimh.gov.

References

1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.

²Robins LN, Regier DA, eds. Psychiatric disorders in America: the Epidemiologic Catchment Area Study. New York: The Free Press, 1991.

³The NIMH Genetics Workgroup. Genetics and mental disorders. NIH Publication No. 98-4268. Rockville, MD: National Institute of Mental Health, 1998.

⁴Regier DA, Rae DS, Narrow WE, et al. Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders. British Journal of Psychiatry Supplement, 1998; (34): 24-8.

• X Close Window

Specific Phobias

"I'm scared to death of flying, and I never do it anymore. I used to start dreading a plane trip a month before I was due to leave. It was an awful feeling when that airplane door closed and I felt trapped. My heart would pound, and I would sweat bullets. When the airplane would start to ascend, it just reinforced the feeling that I couldn't get out. When I think about flying, I picture myself losing control, freaking out, and climbing the walls, but of course I never did that. I'm not afraid of crashing or hitting turbulence. It's just that feeling of being trapped. Whenever I've thought about changing jobs, I've had to think, "Would I be under pressure to fly?" These days I only go places where I can drive or take a train. My friends always point out that I couldn't get off a train traveling at high speeds either, so why don't trains bother me? I just tell them it isn't a rational fear."

A specific phobia is an intense fear of something that poses little or no actual danger. Some of the more common specific phobias are centered around closed-in places, heights, escalators, tunnels, highway driving, water, flying, dogs, and injuries involving blood. Such phobias aren't just extreme fear; they are irrational fear of a particular thing. You may be able to ski the world's tallest mountains with ease but be unable to go above the 5th floor of an office building. While adults with phobias realize that these fears are irrational, they often find that facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety.

Specific phobias affect an estimated 19.2 million adult Americans¹ and are twice as common in women as men.¹⁰ They usually appear in childhood or adolescence and tend to persist into adulthood.¹² The causes of specific phobias are not well understood, but there is some evidence that the tendency to develop them may run in families.¹¹

If the feared situation or feared object is easy to avoid, people with specific phobias may not seek help; but if avoidance interferes with their careers or their personal lives, it can become disabling and treatment is usually pursued.

Specific phobias respond very well to carefully targeted psychotherapy.

Treatment of Anxiety Disorders

In general, anxiety disorders are treated with medication, specific types of psychotherapy, or both.¹⁴ Treatment choices depend on the problem and the person's preference. Before treatment begins, a doctor must conduct a careful diagnostic evaluation to determine whether a person's symptoms are caused by an anxiety disorder or a physical problem. If an anxiety disorder is diagnosed, the type of disorder or the combination of disorders that are present must be identified, as well as any coexisting conditions, such as depression or substance abuse. Sometimes alcoholism, depression, or other coexisting conditions have such a strong effect on the individual that treating the anxiety disorder must wait until the coexisting conditions are brought under control.

People with anxiety disorders who have already received treatment should tell their current doctor about that treatment in detail. If they received medication, they should tell their doctor what medication was used, what the dosage was at the beginning of treatment, whether the dosage was increased or decreased while they were under treatment, what side effects occurred, and whether the treatment helped them become less anxious. If they received psychotherapy, they should describe the type of therapy, how often they attended sessions, and whether the therapy was useful.

Often people believe that they have "failed" at treatment or that the treatment didn't work for them when, in fact, it was not given for an adequate length of time or was administered incorrectly. Sometimes people must try several different treatments or combinations of treatment before they find the one that works for them.

Medications

Medication will not cure anxiety disorders, but it can keep them under control while the person receives psychotherapy. Medication must be prescribed by physicians, usually psychiatrists, who can either offer psychotherapy themselves or work as a team with psychologists, social workers, or counselors who provide psychotherapy. The principal medications used for anxiety disorders are antidepressants, anti-anxiety drugs, and beta-blockers to control some of the physical symptoms. With proper treatment, many people with anxiety disorders can lead normal, fulfilling lives.

Antidepressants

Antidepressants were developed to treat depression but are also effective for anxiety disorders. Although these medications begin to alter brain chemistry after the very first dose, their full effect requires a series of changes to occur; it is usually about 4 to 6 weeks before symptoms start to fade. It is important to continue taking these medications long enough to let them work.

SSRIs

Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other neurotransmitters, helps brain cells communicate with one another.

Fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and citalopram (Celexa®) are some of the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. Venlafaxine (Effexor®), a drug closely related to the SSRIs, is used to treat GAD. These medications are started at low doses and gradually increased until they have a beneficial effect.

SSRIs have fewer side effects than older antidepressants, but they sometimes produce slight nausea or jitters when people first start to take them. These symptoms fade with time. Some people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the dosage or switching to another SSRI.

Tricyclics

Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD. They are also started at low doses that are gradually increased. They sometimes cause dizziness, drowsiness, dry mouth, and weight gain, which can usually be corrected by changing the dosage or switching to another tricyclic medication.

Tricyclics include imipramine (Tofranil®), which is prescribed for panic disorder and GAD, and clomipramine (Anafranil®), which is the only tricyclic antidepressant useful for treating OCD.

MAOIs

Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. The MAOIs most commonly prescribed for anxiety disorders are phenelzine (Nardil®), followed by tranylcypromine (Parnate®), and isocarboxazid (Marplan®), which are useful in treating panic disorder and social phobia. People who take MAOIs cannot eat a variety of foods and beverages (including cheese and red wine) that contain tyramine or take certain medications, including some types of birth control pills, pain relievers (such as Advil®, Motrin®, or Tylenol®), cold and allergy medications, and herbal supplements; these substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help lessen these risks. MAOIs can also react with SSRIs to produce a serious condition called "serotonin syndrome," which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions.

Anti-Anxiety Drugs

High-potency benzodiazepines combat anxiety and have few side effects other than drowsiness. Because people can get used to them and may need higher and higher doses to get the same effect, benzodiazepines are generally prescribed for short periods of time, especially for people who have abused drugs or alcohol and who become dependent on medication easily. One exception to this rule is people with panic disorder, who can take benzodiazepines for up to a year without harm.

Clonazepam (Klonopin®) is used for social phobia and GAD, lorazepam (Ativan®) is helpful for panic disorder, and alprazolam (Xanax®) is useful for both panic disorder and GAD.

Some people experience withdrawal symptoms if they stop taking benzodiazepines abruptly instead of tapering off, and anxiety can return once the medication is stopped. These potential problems have led some physicians to shy away from using these drugs or to use them in inadequate doses.

Buspirone (Buspar®), an azapirone, is a newer anti-anxiety medication used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an anti-anxiety effect.

Beta-Blockers

Beta-blockers, such as propranolol (Inderal®), which is used to treat heart conditions, can prevent the physical symptoms that accompany certain anxiety disorders, particularly social phobia. When a feared situation can be predicted (such as giving a speech), a doctor may prescribe a beta-blocker to keep physical symptoms of anxiety under control.

Psychotherapy

Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor, to discover what caused an anxiety disorder and how to deal with its symptoms.

Cognitive-Behavioral Therapy

Cognitive-Behavioral Therapy Cognitive-behavioral therapy (CBT) is very useful in treating anxiety disorders. The cognitive part helps people change the thinking patterns that support their fears, and the behavioral part helps people change the way they react to anxiety-provoking situations.

For example, CBT can help people with panic disorder learn that their panic attacks are not really heart attacks and help people with social phobia learn how to overcome the belief that others are always watching and judging them. When people are ready to confront their fears, they are shown how to use exposure techniques to desensitize themselves to situations that trigger their anxieties.

People with OCD who fear dirt and germs are encouraged to get their hands dirty and wait increasing amounts of time before washing them. The therapist helps the person cope with the anxiety that waiting produces; after the exercise has been repeated a number of times, the anxiety diminishes. People with social phobia may be encouraged to spend time in feared social situations without giving in to the temptation to flee and to make small social blunders and observe how people respond to them. Since the response is usually far less harsh than the person fears, these anxieties are lessened. People with PTSD may be supported through recalling their traumatic event in a safe situation, which helps reduce the fear it produces. CBT therapists also teach deep breathing and other types of exercises to relieve anxiety and encourage relaxation.

Exposure-based behavioral therapy has been used for many years to treat specific phobias. The person gradually encounters the object or situation that is feared, perhaps at first only through pictures or tapes, then later face-to-face. Often the therapist will accompany the person to a feared situation to provide support and guidance.

CBT is undertaken when people decide they are ready for it and with their permission and cooperation. To be effective, the therapy must be directed at the person's specific anxieties and must be tailored to his or her needs. There are no side effects other than the discomfort of temporarily increased anxiety.

CBT or behavioral therapy often lasts about 12 weeks. It may be conducted individually or with a group of people who have similar problems. Group therapy is particularly effective for social phobia. Often "homework" is assigned for participants to complete between sessions. There is some evidence that the benefits of CBT last longer than those of medication for people with panic disorder, and the same may be true for OCD, PTSD, and social phobia. If a disorder recurs at a later date, the same therapy can be used to treat it successfully a second time.

Medication can be combined with psychotherapy for specific anxiety disorders, and this is the best treatment approach for many people.

TAKING MEDICATIONS

Before taking medication for an anxiety disorder:

• Ask your doctor to tell you about the effects and side effects of the drug.
• Tell your doctor about any alternative therapies or over-the-counter medications you are using.
• Ask your doctor when and how the medication should be stopped. Some drugs can't be stopped abruptly but must be tapered off slowly under a doctor's supervision.
• Work with your doctor to determine which medication is right for you and what dosage is best.
• Be aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.

How to Get Help for Anxiety Disorders

If you think you have an anxiety disorder, the first person you should see is your family doctor. A physician can determine whether the symptoms that alarm you are due to an anxiety disorder, another medical condition, or both.

If an anxiety disorder is diagnosed, the next step is usually seeing a mental health professional. The practitioners who are most helpful with anxiety disorders are those who have training in cognitive-behavioral therapy and/or behavioral therapy, and who are open to using medication if it is needed.

You should feel comfortable talking with the mental health professional you choose. If you do not, you should seek help elsewhere. Once you find a mental health professional with whom you are comfortable, the two of you should work as a team and make a plan to treat your anxiety disorder together.

Remember that once you start on medication, it is important not to stop taking it abruptly. Certain drugs must be tapered off under the supervision of a doctor or bad reactions can occur. Make sure you talk to the doctor who prescribed your medication before you stop taking it. If you are having trouble with side effects, it's possible that they can be eliminated by adjusting how much medication you take and when you take it.

Most insurance plans, including health maintenance organizations (HMOs), will cover treatment for anxiety disorders. Check with your insurance company and find out. If you don't have insurance, the Health and Human Services division of your county government may offer mental health care at a public mental health center that charges people according to how much they are able to pay. If you are on public assistance, you may be able to get care through your state Medicaid plan.

Ways to Make Treatment More Effective

Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common. Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a mental health professional.

Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided. Check with your physician or pharmacist before taking any additional medications.

The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one's symptoms. Family members should not trivialize the disorder or demand improvement without treatment. If your family is doing either of these things, you may want to show them this booklet so they can become educated allies and help you succeed in therapy.

Help is available by calling:

Olive Branch Counseling Associates, Inc.

(708) 687-3479.

The above information and other information on mental health is available at the website of the National Institute of Mental Health: www.nihm.gov.

References

1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.

²Robins LN, Regier DA, eds. Psychiatric disorders in America: the Epidemiologic Catchment Area Study. New York: The Free Press, 1991.

³The NIMH Genetics Workgroup. Genetics and mental disorders. NIH Publication No. 98-4268. Rockville, MD: National Institute of Mental Health, 1998.

⁴Regier DA, Rae DS, Narrow WE, et al. Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders. British Journal of Psychiatry Supplement, 1998; (34): 24-8.

⁵Kushner MG, Sher KJ, Beitman BD. The relation between alcohol problems and the anxiety disorders. American Journal of Psychiatry, 1990; 147(6): 685-95.

⁶Wonderlich SA, Mitchell JE. Eating disorders and comorbidity: empirical, conceptual, and clinical implications. Psychopharmacology Bulletin, 1997; 33(3): 381-90.

⁷Davidson JR. Trauma: the impact of post-traumatic stress disorder. Journal of Psychopharmacology, 2000; 14(2 Suppl 1): S5-S12.

⁸Margolin G, Gordis EB. The effects of family and community violence on children. Annual Review of Psychology, 2000; 51: 445-79.

⁹Yehuda R. Biological factors associated with susceptibility to posttraumatic stress disorder. Canadian Journal of Psychiatry, 1999; 44(1): 34-9.

¹⁰Bourdon KH, Boyd JH, Rae DS, et al. Gender differences in phobias: results of the ECA community survey. Journal of Anxiety Disorders, 1988; 2: 227-41.

¹¹Kendler KS, Walters EE, Truett KR, et al. A twin-family study of self-report symptoms of panic-phobia and somatization. Behavior Genetics, 1995; 25(6): 499-515.

¹²Boyd JH, Rae DS, Thompson JW, et al. Phobia: prevalence and risk factors. Social Psychiatry and Psychiatric Epidemiology, 1990; 25(6): 314-23.

¹³Kendler KS, Neale MC, Kessler RC, et al. Generalized anxiety disorder in women. A population-based twin study. Archives of General Psychiatry, 1992; 49(4): 267-72.

¹⁴Hyman SE, Rudorfer MV. Anxiety disorders. In: Dale DC, Federman DD, eds. Scientific American>® Medicine. Volume 3. New York: Healtheon/WebMD Corp., 2000, Sect. 13, Subsect. VIII.

¹⁵LeDoux J. Fear and the brain: where have we been, and where are we going? Biological Psychiatry, 1998; 44(12): 1229-38.

¹⁶Rauch SL, Savage CR. Neuroimaging and neuropsychology of the striatum. Bridging basic science and clinical practice. Psychiatric Clinics of North America, 1997; 20(4): 741-68.

¹⁷Bremner JD, Randall P, Scott TM, et al. MRI-based measurement of hippocampal volume in combat-related posttraumatic stress disorder. American Journal of Psychiatry, 1995; 152: 973-81.

¹⁸Stein MB, Hanna C, Koverola C, et al. Structural brain changes in PTSD: does trauma alter neuroanatomy? In: Yehuda R, McFarlane AC, eds. Psychobiology of posttraumatic stress disorder. Annals of the New York Academy of Sciences, 821. New York: The New York Academy of Sciences, 1997.

¹⁹Molavi DW. The Washington University School of Medicine Neuroscience Tutorial for First-Year Medical Students. (1997) Washington University Program in Neuroscience. Retrieved November 16, 2005, from http://thalamus.wustl.edu/course.

²⁰Understanding Obsessive-Compulsive and Related Disorders. Stanford University School of Medicine. Retrieved November 16, 2005, from http://ocd.stanford.edu/about/understanding.html.

²¹Rolls ET. The functions of the orbitofrontal cortex. Neurocase. 1999;5:301-312.

²²Saxena S, Brody AL, Schwartz JM, et al. Neuroimaging and frontal-subcortical circuitry in obsessive-compulsive disorder. British Journal of Psychiatry Supplement. 1998;35:26-37.

²³Gould E, Reeves AJ, Fallah M, et al. Hippocampal neurogenesis in adult Old World primates. Proceedings of the National Academy of Sciences USA, 1999, 96(9): 5263-7.

• X Close Window

Post-Traumatic Stress Disorder (PTSD)

"I was raped when I was 25 years old. For a long time, I spoke about the rape as though it was something that happened to someone else. I was very aware that it had happened to me, but there was just no feeling."

"Then I started having flashbacks. They kind of came over me like a splash of water. I would be terrified. Suddenly I was reliving the rape. Every instant was startling. I wasn't aware of anything around me, I was in a bubble, just kind of floating. And it was scary. Having a flashback can wring you out."

"The rape happened the week before Thanksgiving, and I can't believe the anxiety and fear I feel every year around the anniversary date. It's as though I've seen a werewolf. I can't relax, can't sleep, don't want to be with anyone. I wonder whether I'll ever be free of this terrible problem."

Post-traumatic stress disorder (PTSD) develops after a terrifying ordeal that involved physical harm or the threat of physical harm. The person who develops PTSD may have been the one who was harmed, the harm may have happened to a loved one, or the person may have witnessed a harmful event that happened to loved ones or strangers.

PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes.

People with PTSD may startle easily, become emotionally numb (especially in relation to people with whom they used to be close), lose interest in things they used to enjoy, have trouble feeling affectionate, be irritable, become more aggressive, or even become violent. They avoid situations that remind them of the original incident, and anniversaries of the incident are often very difficult. PTSD symptoms seem to be worse if the event that triggered them was deliberately initiated by another person, as in a mugging or a kidnapping. Most people with PTSD repeatedly relive the trauma in their thoughts during the day and in nightmares when they sleep. These are called flashbacks. Flashbacks may consist of images, sounds, smells, or feelings, and are often triggered by ordinary occurrences, such as a door slamming or a car backfiring on the street. A person having a flashback may lose touch with reality and believe that the traumatic incident is happening all over again.

Not every traumatized person develops full-blown or even minor PTSD. Symptoms usually begin within 3 months of the incident but occasionally emerge years afterward. They must last more than a month to be considered PTSD. The course of the illness varies. Some people recover within 6 months, while others have symptoms that last much longer. In some people, the condition becomes chronic.

PTSD affects about 7.7 million American adults,¹but it can occur at any age, including childhood.⁷ Women are more likely to develop PTSD than men,⁸ and there is some evidence that susceptibility to the disorder may run in families.⁹ PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders.⁴

Certain kinds of medication and certain kinds of psychotherapy usually treat the symptoms of PTSD very effectively.

Treatment of Anxiety Disorders

In general, anxiety disorders are treated with medication, specific types of psychotherapy, or both.¹⁴ Treatment choices depend on the problem and the person's preference. Before treatment begins, a doctor must conduct a careful diagnostic evaluation to determine whether a person's symptoms are caused by an anxiety disorder or a physical problem. If an anxiety disorder is diagnosed, the type of disorder or the combination of disorders that are present must be identified, as well as any coexisting conditions, such as depression or substance abuse. Sometimes alcoholism, depression, or other coexisting conditions have such a strong effect on the individual that treating the anxiety disorder must wait until the coexisting conditions are brought under control.

People with anxiety disorders who have already received treatment should tell their current doctor about that treatment in detail. If they received medication, they should tell their doctor what medication was used, what the dosage was at the beginning of treatment, whether the dosage was increased or decreased while they were under treatment, what side effects occurred, and whether the treatment helped them become less anxious. If they received psychotherapy, they should describe the type of therapy, how often they attended sessions, and whether the therapy was useful.

Often people believe that they have "failed" at treatment or that the treatment didn't work for them when, in fact, it was not given for an adequate length of time or was administered incorrectly. Sometimes people must try several different treatments or combinations of treatment before they find the one that works for them.

Medications

Medication will not cure anxiety disorders, but it can keep them under control while the person receives psychotherapy. Medication must be prescribed by physicians, usually psychiatrists, who can either offer psychotherapy themselves or work as a team with psychologists, social workers, or counselors who provide psychotherapy. The principal medications used for anxiety disorders are antidepressants, anti-anxiety drugs, and beta-blockers to control some of the physical symptoms. With proper treatment, many people with anxiety disorders can lead normal, fulfilling lives.

Antidepressants

Antidepressants were developed to treat depression but are also effective for anxiety disorders. Although these medications begin to alter brain chemistry after the very first dose, their full effect requires a series of changes to occur; it is usually about 4 to 6 weeks before symptoms start to fade. It is important to continue taking these medications long enough to let them work.

SSRIs

Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other neurotransmitters, helps brain cells communicate with one another.

Fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and citalopram (Celexa®) are some of the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. Venlafaxine (Effexor®), a drug closely related to the SSRIs, is used to treat GAD. These medications are started at low doses and gradually increased until they have a beneficial effect.

SSRIs have fewer side effects than older antidepressants, but they sometimes produce slight nausea or jitters when people first start to take them. These symptoms fade with time. Some people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the dosage or switching to another SSRI.

Tricyclics

Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD. They are also started at low doses that are gradually increased. They sometimes cause dizziness, drowsiness, dry mouth, and weight gain, which can usually be corrected by changing the dosage or switching to another tricyclic medication.

Tricyclics include imipramine (Tofranil®), which is prescribed for panic disorder and GAD, and clomipramine (Anafranil®), which is the only tricyclic antidepressant useful for treating OCD.

MAOIs

Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. The MAOIs most commonly prescribed for anxiety disorders are phenelzine (Nardil®), followed by tranylcypromine (Parnate®), and isocarboxazid (Marplan®), which are useful in treating panic disorder and social phobia. People who take MAOIs cannot eat a variety of foods and beverages (including cheese and red wine) that contain tyramine or take certain medications, including some types of birth control pills, pain relievers (such as Advil®, Motrin®, or Tylenol®), cold and allergy medications, and herbal supplements; these substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help lessen these risks. MAOIs can also react with SSRIs to produce a serious condition called "serotonin syndrome," which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions.

Anti-Anxiety Drugs

High-potency benzodiazepines combat anxiety and have few side effects other than drowsiness. Because people can get used to them and may need higher and higher doses to get the same effect, benzodiazepines are generally prescribed for short periods of time, especially for people who have abused drugs or alcohol and who become dependent on medication easily. One exception to this rule is people with panic disorder, who can take benzodiazepines for up to a year without harm.

Clonazepam (Klonopin®) is used for social phobia and GAD, lorazepam (Ativan®) is helpful for panic disorder, and alprazolam (Xanax®) is useful for both panic disorder and GAD.

Some people experience withdrawal symptoms if they stop taking benzodiazepines abruptly instead of tapering off, and anxiety can return once the medication is stopped. These potential problems have led some physicians to shy away from using these drugs or to use them in inadequate doses.

Buspirone (Buspar®), an azapirone, is a newer anti-anxiety medication used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an anti-anxiety effect.

Beta-Blockers

Beta-blockers, such as propranolol (Inderal®), which is used to treat heart conditions, can prevent the physical symptoms that accompany certain anxiety disorders, particularly social phobia. When a feared situation can be predicted (such as giving a speech), a doctor may prescribe a beta-blocker to keep physical symptoms of anxiety under control.

Psychotherapy

Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor, to discover what caused an anxiety disorder and how to deal with its symptoms.

Cognitive-Behavioral Therapy

Cognitive-Behavioral Therapy Cognitive-behavioral therapy (CBT) is very useful in treating anxiety disorders. The cognitive part helps people change the thinking patterns that support their fears, and the behavioral part helps people change the way they react to anxiety-provoking situations.

For example, CBT can help people with panic disorder learn that their panic attacks are not really heart attacks and help people with social phobia learn how to overcome the belief that others are always watching and judging them. When people are ready to confront their fears, they are shown how to use exposure techniques to desensitize themselves to situations that trigger their anxieties.

People with OCD who fear dirt and germs are encouraged to get their hands dirty and wait increasing amounts of time before washing them. The therapist helps the person cope with the anxiety that waiting produces; after the exercise has been repeated a number of times, the anxiety diminishes. People with social phobia may be encouraged to spend time in feared social situations without giving in to the temptation to flee and to make small social blunders and observe how people respond to them. Since the response is usually far less harsh than the person fears, these anxieties are lessened. People with PTSD may be supported through recalling their traumatic event in a safe situation, which helps reduce the fear it produces. CBT therapists also teach deep breathing and other types of exercises to relieve anxiety and encourage relaxation.

Exposure-based behavioral therapy has been used for many years to treat specific phobias. The person gradually encounters the object or situation that is feared, perhaps at first only through pictures or tapes, then later face-to-face. Often the therapist will accompany the person to a feared situation to provide support and guidance.

CBT is undertaken when people decide they are ready for it and with their permission and cooperation. To be effective, the therapy must be directed at the person's specific anxieties and must be tailored to his or her needs. There are no side effects other than the discomfort of temporarily increased anxiety.

CBT or behavioral therapy often lasts about 12 weeks. It may be conducted individually or with a group of people who have similar problems. Group therapy is particularly effective for social phobia. Often "homework" is assigned for participants to complete between sessions. There is some evidence that the benefits of CBT last longer than those of medication for people with panic disorder, and the same may be true for OCD, PTSD, and social phobia. If a disorder recurs at a later date, the same therapy can be used to treat it successfully a second time.

Medication can be combined with psychotherapy for specific anxiety disorders, and this is the best treatment approach for many people.

TAKING MEDICATIONS

Before taking medication for an anxiety disorder:

• Ask your doctor to tell you about the effects and side effects of the drug.
• Tell your doctor about any alternative therapies or over-the-counter medications you are using.
• Ask your doctor when and how the medication should be stopped. Some drugs can't be stopped abruptly but must be tapered off slowly under a doctor's supervision.
• Work with your doctor to determine which medication is right for you and what dosage is best.
• Be aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.

How to Get Help for Anxiety Disorders

If you think you have an anxiety disorder, the first person you should see is your family doctor. A physician can determine whether the symptoms that alarm you are due to an anxiety disorder, another medical condition, or both.

If an anxiety disorder is diagnosed, the next step is usually seeing a mental health professional. The practitioners who are most helpful with anxiety disorders are those who have training in cognitive-behavioral therapy and/or behavioral therapy, and who are open to using medication if it is needed.

You should feel comfortable talking with the mental health professional you choose. If you do not, you should seek help elsewhere. Once you find a mental health professional with whom you are comfortable, the two of you should work as a team and make a plan to treat your anxiety disorder together.

Remember that once you start on medication, it is important not to stop taking it abruptly. Certain drugs must be tapered off under the supervision of a doctor or bad reactions can occur. Make sure you talk to the doctor who prescribed your medication before you stop taking it. If you are having trouble with side effects, it's possible that they can be eliminated by adjusting how much medication you take and when you take it.

Most insurance plans, including health maintenance organizations (HMOs), will cover treatment for anxiety disorders. Check with your insurance company and find out. If you don't have insurance, the Health and Human Services division of your county government may offer mental health care at a public mental health center that charges people according to how much they are able to pay. If you are on public assistance, you may be able to get care through your state Medicaid plan.

Ways to Make Treatment More Effective

Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common. Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a mental health professional.

Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided. Check with your physician or pharmacist before taking any additional medications.

The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one's symptoms. Family members should not trivialize the disorder or demand improvement without treatment. If your family is doing either of these things, you may want to show them this booklet so they can become educated allies and help you succeed in therapy.

Current research at NIMH on anxiety disorders includes studies that address how well medication and behavioral therapies work in the treatment of OCD, and the safety and effectiveness of medications for children and adolescents who have a combination of anxiety disorders and attention deficit hyperactivity disorder.

Help is available by calling:

 

Olive Branch Counseling Associates, Inc.

(708) 687-3479.

 

The above information and other information about Mental Health is available at the website of the National Institute of Mental Health www.nimh.gov.

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