ADULTS

DEPRESSION

Not everyone who is depressed experiences every symptom. Some people experience only a few; some people suffer many. The severity of symptoms varies among individuals and also over time.

Symptoms of Depression

• • Persistent sad, anxious, or “empty” mood.
• • Feelings of hopelessness or pessimism.
• • Feelings of guilt, worthlessness, or helplessness.
• • Loss of interest or pleasure in hobbies and activities that were once enjoyable, including sex.
• • Decreased energy, fatigue; feeling “slowed down.”
• • Difficulty concentrating, remembering, or making decisions.
• • Trouble sleeping, early morning awakening, or oversleeping.
• • Changes in appetite and/or weight.
• • Thoughts of death or suicide, or suicide attempts.
• • Restlessness or irritability.
• • Persistent physical symptoms, such as headaches, digestive disorders, and chronic pain that do not respond to routine treatment.

MANIA

Not everyone who is manic experiences every symptom. Some people experience only a few; some people suffer many. The severity of symptoms varies among individuals and also over time.

Symptoms of Mania

• • Abnormal or excessive elation.
• • Unusual irritability.
• • Decreased need for sleep.
• • Grandiose notions.
• • Increased talking.
• • Racing thoughts.
• • Increased sexual desire.
• • Markedly increased energy.

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.

Citations

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.

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

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

4. Regier 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.

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

OBSESSIVE COMPULSIVE DISORDER

“I couldn’t do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good luck number and one wasn’t. It took me longer to read because I’d count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn’t add up to a ’bad’ number.”

“I knew the rituals didn’t make sense, and I was deeply ashamed of them, but I couldn’t seem to overcome them until I had therapy.”

“Getting dressed in the morning was tough, because I had a routine, and if I didn’t follow the routine, I’d get anxious and would have to get dressed again. I always worried that if I didn’t do something, my parents were going to die. I’d have these terrible thoughts of harming my parents. That was completely irrational, but the thoughts triggered more anxiety and more senseless behavior. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me.”

People with obsessive-compulsive disorder (OCD) have persistent, upsetting thoughts (obsessions) and use rituals (compulsions) to control the anxiety these thoughts produce. Most of the time, the rituals end up controlling them.

For example, if people are obsessed with germs or dirt, they may develop a compulsion to wash their hands over and over again. If they develop an obsession with intruders, they may lock and relock their doors many times before going to bed. Being afraid of social embarrassment may prompt people with OCD to comb their hair compulsively in front of a mirror-sometimes they get “caught” in the mirror and can’t move away from it. Performing such rituals is not pleasurable. At best, it produces temporary relief from the anxiety created by obsessive thoughts.

Other common rituals are a need to repeatedly check things, touch things (especially in a particular sequence), or count things. Some common obsessions include having frequent thoughts of violence and harming loved ones, persistently thinking about performing sexual acts the person dislikes, or having thoughts that are prohibited by religious beliefs. People with OCD may also be preoccupied with order and symmetry, have difficulty throwing things out (so they accumulate), or hoard unneeded items.

Healthy people also have rituals, such as checking to see if the stove is off several times before leaving the house. The difference is that people with OCD perform their rituals even though doing so interferes with daily life and they find the repetition distressing. Although most adults with OCD recognize that what they are doing is senseless, some adults and most children may not realize that their behavior is out of the ordinary.

OCD affects about 2.2 million American adults,1 and the problem can be accompanied by eating disorders,6 other anxiety disorders, or depression.2,4 It strikes men and women in roughly equal numbers and usually appears in childhood, adolescence, or early adulthood.2 One-third of adults with OCD develop symptoms as children, and research indicates that OCD might run in families.3

The course of the disease is quite varied. Symptoms may come and go, ease over time, or get worse. If OCD becomes severe, it can keep a person from working or carrying out normal responsibilities at home. People with OCD may try to help themselves by avoiding situations that trigger their obsessions, or they may use alcohol or drugs to calm themselves.4,5 OCD usually responds well to treatment with certain medications and/or exposure-based psychotherapy, in which people face situations that cause fear or anxiety and become less sensitive (desensitized) to them.

SOCIAL PHOBIA

“In any social situation, I felt fear. I would be anxious before I even left the house, and it would escalate as I got closer to a college class, a party, or whatever. I would feel sick in my stomach-it almost felt like I had the flu. My heart would pound, my palms would get sweaty, and I would get this feeling of being removed from myself and from everybody else.”

“When I would walk into a room full of people, I’d turn red and it would feel like everybody’s eyes were on me. I was embarrassed to stand off in a corner by myself, but I couldn’t think of anything to say to anybody. It was humiliating. I felt so clumsy, I couldn’t wait to get out.”

Social phobia, also called social anxiety disorder, is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. People with social phobia have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. They can worry for days or weeks before a dreaded situation. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends.

While many people with social phobia realize that their fears about being with people are excessive or unreasonable, they are unable to overcome them. Even if they manage to confront their fears and be around others, they are usually very anxious beforehand, are intensely uncomfortable throughout the encounter, and worry about how they were judged for hours afterward.

Social phobia can be limited to one situation (such as talking to people, eating or drinking, or writing on a blackboard in front of others) or may be so broad (such as in generalized social phobia) that the person experiences anxiety around almost anyone other than the family.

Physical symptoms that often accompany social phobia include blushing, profuse sweating, trembling, nausea, and difficulty talking. When these symptoms occur, people with social phobia feel as though all eyes are focused on them..

Social phobia affects about 15 million American adults.1 Women and men are equally likely to develop the disorder,10 which usually begins in childhood or early adolescence.2 There is some evidence that genetic factors are involved.11 Social phobia is often accompanied by other anxiety disorders or depression,2,4and substance abuse may develop if people try to self-medicate their anxiety.4,5

Social phobia can be successfully treated with certain kinds of psychotherapy or medications.

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.”

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A specific phobia is an intense, irrational 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.

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.”

“When my problems were at their worst, I’d miss work and feel just terrible about it. Then I worried that I’d lose my job. My life was miserable until I got treatment.”

“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 American adults,1 including twice as many women as men.2 The disorder develops gradually and can begin at any point in the life cycle, although the years of highest risk are between childhood and middle age.2 There is evidence that genes play a modest role in GAD.13

Other anxiety disorders, depression, or substance abuse2,4 often accompany GAD, which rarely occurs alone. GAD is commonly treated with medication or cognitive-behavioral therapy, but co-occurring conditions must also be treated using the appropriate therapies.

ADULT MEN

DEPRESSION

The facts about men and depression

An estimated six million men in the United States have a depressive disorder every year:

• • major depression
• • dysthymia (chronic, less severe depression)
• • bipolar disorder (manic-depressive illness)

Although these illnesses are highly treatable, many men do not recognize, acknowledge, or seek help for their depression.

While both men and women may develop the standard symptoms of depression, they often experience depression differently and may have different ways of coping. Men may be more willing to report fatigue, irritability, loss of interest in work or hobbies, and sleep disturbances rather than feelings of sadness, worthlessness, and excessive guilt, which are commonly associated with depression in women. Also, tragically, four times as many men as women die by suicide, even though women make more suicide attempts during their lives.

“I’d drink and I’d just get numb. I’d get numb to try to numb my head. I mean, we’re talking many, many beers to get to that state where you could shut your head off, but then you wake up the next day and it’s still there. Because you have to deal with it, it doesn’t just go away. It isn’t a two hour movie and then at the end it goes ‘The End’ and you press off. I mean it’s a twenty four hour a day movie and you’re thinking there is no end. It’s horrible.”

-Patrick McCathern, First Sergeant, U.S. Air Force, Retired

Men are more likely than women to report alcohol and drug abuse or dependence in their lifetime.14 Substance use can mask depression, making it harder to recognize depression as a separate illness that needs treatment.

Instead of acknowledging their feelings, asking for help, or seeking appropriate treatment, men may turn to alcohol or drugs when they are depressed, or become frustrated, discouraged, angry, irritable, and, sometimes, violently abusive. Some men deal with depression by throwing themselves compulsively into their work, attempting to hide their depression from themselves, family, and friends. Other men may respond to depression by engaging in reckless behavior, taking risks, and putting themselves in harm’s way.

“When I was feeling depressed I was very reckless with my life. I didn’t care about how I drove. I didn’t care about walking across the street carefully. I didn’t care about dangerous parts of the city. I wouldn’t be affected by any kinds of warnings on travel or places to go. I didn’t care. I didn’t care whether I lived or died and so I was going to do whatever I wanted whenever I wanted. And when you take those kinds of chances, you have a greater likelihood of dying.”

-Bill Maruyama, Lawyer

The truth is, depression is a real and treatable illness. It can strike at any age, from childhood into late life. With proper diagnosis and treatment, the vast majority of men with depression can be helped.

ADULT WOMEN

DEPRESSION

What are the different forms of depression?

More women than men get depression. It is a serious illness, and most women who have it need treatment to get better. The most common types of depression are:

• Major depression — severe symptoms that interfere with a woman's ability to work, sleep, study, eat, and enjoy life. An episode of major depression may occur only once in a person's lifetime. But more often, a person can have several episodes.

• Dysthymic disorder or dysthymia — depressive symptoms that last a long time (2 years or longer), but less severe than those of major depression.

• Minor depression — similar to major depression and dysthymia, but symptoms are less severe and may not last as long.

What are some factors that can cause depression in women?

Brain chemistry and hormones

People with depression have different brain chemistry than those of people without the illness.

During certain times of a woman's life, her hormones (which control emotions and mood) may be changing, which may affect her brain chemistry. For example, after having a baby (postpartum period), hormones and physical changes may be overwhelming. Some women experience postpartum depression, a serious form of depression that needs treatment. Other times of hormonal change, such as transition into menopause, may increase a woman's risk for depression.

Premenstrual dysphoric disorder

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

Postpartum depression

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

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

Menopause

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

Stress

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

Genes

Women with a family history of depression may be more likely to develop it than those whose families do not have the illness.

EATING DISORDERS

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

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

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

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

ANOREXIA AND BULIMIA – SEE “ADOLESCENTS AND GIRLS”

CHILDREN AND ADOLESCENTS

What is attention deficit hyperactivity disorder?

Attention deficit hyperactivity disorder (ADHD) is one of the most common childhood disorders and can continue through adolescence and adulthood. Symptoms include difficulty staying focused and paying attention, difficulty controlling behavior, and hyperactivity (over-activity).

ADHD has three subtypes:1

• Predominantly hyperactive-impulsive

o Most symptoms (six or more) are in the hyperactivity-impulsivity categories.

o Fewer than six symptoms of inattention are present, although inattention may still be present to some degree.

• Predominantly inattentive

o The majority of symptoms (six or more) are in the inattention category and fewer than six symptoms of hyperactivity-impulsivity are present, although hyperactivity-impulsivity may still be present to some degree.

o Children with this subtype are less likely to act out or have difficulties getting along with other children. They may sit quietly, but they are not paying attention to what they are doing. Therefore, the child may be overlooked, and parents and teachers may not notice that he or she has ADHD.

• Combined hyperactive-impulsive and inattentive

o Six or more symptoms of inattention and six or more symptoms of hyperactivity-impulsivity are present.

o Most children have the combined type of ADHD.

Treatments can relieve many of the disorder's symptoms, but there is no cure. With treatment, most people with ADHD can be successful in school and lead productive lives. Researchers are developing more effective treatments and interventions, and using new tools such as brain imaging, to better understand ADHD and to find more effective ways to treat and prevent it.

What are the symptoms of ADHD in children?

Inattention, hyperactivity, and impulsivity are the key behaviors of ADHD. It is normal for all children to be inattentive, hyperactive, or impulsive sometimes, but for children with ADHD, these behaviors are more severe and occur more often. To be diagnosed with the disorder, a child must have symptoms for 6 or more months and to a degree that is greater than other children of the same age.

Children who have symptoms of inattention may:

• • Be easily distracted, miss details, forget things, and frequently switch from one activity to another
• • Have difficulty focusing on one thing
• • Become bored with a task after only a few minutes, unless they are doing something enjoyable
• • Have difficulty focusing attention on organizing and completing a task or learning something new
• • Have trouble completing or turning in homework assignments, often losing things (e.g., pencils, toys, assignments) needed to complete tasks or activities
• • Not seem to listen when spoken to
• • Daydream, become easily confused, and move slowly
• • Have difficulty processing information as quickly and accurately as others
• • Struggle to follow instructions

Children who have symptoms of hyperactivity may:

• • Fidget and squirm in their seats
• • Talk nonstop
• • Dash around, touching or playing with anything and everything in sight
• • Have trouble sitting still during dinner, school, and story time
• • Be constantly in motion
• • Have difficulty doing quiet tasks or activities.

Children who have symptoms of impulsivity may:

• • Be very impatient
• • Blurt out inappropriate comments, show their emotions without restraint, and act without regard for consequences
• • Have difficulty waiting for things they want or waiting their turns in games
• • Often interrupt conversations or others' activities.

Does my child have ADHD? Watch this video about the signs, symptoms, and research. See here

ADHD Today

• Using brain imaging technology like magnetic resonance imaging (MRI), scientists have observed that in some children, ADHD may be related to how the brain is wired or how it is structured. For other children with ADHD, brain development follows a normal but delayed pattern. In some regions, development is delayed by an average of three years compared to children without the disorder.

• The delay appears to be in the frontal cortex, a part of the brain that supports the ability to suppress inappropriate actions and thoughts, focus attention, remember things moment to moment, work for reward, and plan ahead. In contrast, the motor cortex—the area that controls movement—tends to mature faster than normal in children with ADHD, an exception to the pattern of delay. This mismatch in brain development may account for the restlessness and fidgety symptoms commonly associated with ADHD.

• Different types of psychotherapy are effective in treating ADHD. Behavioral therapy helps teach practical skills such as how to organize tasks and manage time to complete homework assignments. It also helps children work through difficult emotions. Therapists also teach children social skills such as how to wait their turn, share toys, ask for help, or respond to teasing.

• Studies show that interventions that include intensive parent education programs can help decrease ADHD problem behavior because parents are better educated about the disorder and better prepared to manage their child’s symptoms. They are taught organizational skills and how to develop and keep a schedule for their child. They are also taught how to give immediate and positive feedback for behaviors they want to encourage, and how to ignore or immediately redirect behaviors they want to discourage.

ANXIETY DISORDER Today

• A large, national survey of adolescent mental health reported that about 8 percent of teens ages 13-18 have an anxiety disorder, with symptoms commonly emerging around age 6. However, of these teens, only 18 percent received mental health care.

• Imaging studies show that children with anxiety disorders have atypical activity in specific brain areas, compared with other people. For example:

        o In one, very small study, anxious adolescents exposed to an anxiety-provoking situation showed heightened activity in brain structures associated with fear processing and emotion regulation, when compared with normal controls.

        o Another small study found that youth with generalized anxiety disorder had unchecked activity in the brain’s fear center, when looking at angry faces so quickly that they are hardly aware of seeing them.

• Brain scans of teens sizing each other up reveal an emotion circuit activating more in girls as they grow older, but not in boys. This finding highlights how emotion circuitry diverges in the male and female brain during a developmental stage in which girls are at increased risk for developing mood and anxiety disorders.

• The Child/Adolescent Anxiety Multimodal Study (CAMS), in addition to other studies on treating childhood anxiety disorders, found that high-quality cognitive behavioral therapy (CBT), given with or without medication, can effectively treat anxiety disorders in children.

What Are the Autism Spectrum Disorders?

The autism spectrum disorders are more common in the pediatric population than are some better known disorders such as diabetes, spinal bifida, or Down syndrome.2 A recent study of a U.S. metropolitan area estimated that 3.4 of every 1,000 children 3-10 years old had autism.3 The earlier the disorder is diagnosed, the sooner the child can be helped through treatment interventions. Pediatricians, family physicians, daycare providers, teachers, and parents may initially dismiss signs of ASD, optimistically thinking the child is just a little slow and will “catch up.”

All children with ASD demonstrate deficits in 1) social interaction, 2) verbal and nonverbal communication, and 3) repetitive behaviors or interests. In addition, they will often have unusual responses to sensory experiences, such as certain sounds or the way objects look. Each of these symptoms runs the gamut from mild to severe. They will present in each individual child differently. For instance, a child may have little trouble learning to read but exhibit extremely poor social interaction. Each child will display communication, social, and behavioral patterns that are individual but fit into the overall diagnosis of ASD.

Children with ASD do not follow the typical patterns of child development. In some children, hints of future problems may be apparent from birth. In most cases, the problems in communication and social skills become more noticeable as the child lags further behind other children the same age. Some other children start off well enough. Oftentimes between 12 and 36 months old, the differences in the way they react to people and other unusual behaviors become apparent. Some parents report the change as being sudden, and that their children start to reject people, act strangely, and lose language and social skills they had previously acquired. In other cases, there is a plateau, or leveling, of progress so that the difference between the child with autism and other children the same age becomes more noticeable.

ASD is defined by a certain set of behaviors that can range from the very mild to the severe. The following possible indicators of ASD were identified on the Public Health Training Network Webcast, Autism Among Us.4

Possible Indicators of Autism Spectrum Disorders

• • Does not babble, point, or make meaningful gestures by 1 year of age
• • Does not speak one word by 16 months
• • Does not combine two words by 2 years
• • Does not respond to name
• • Loses language or social skills

Some Other Indicators

• • Poor eye contact
• • Doesn't seem to know how to play with toys
• • Excessively lines up toys or other objects
• • Is attached to one particular toy or object
• • Doesn't smile
• • At times seems to be hearing impaired

Social Symptoms

From the start, typically developing infants are social beings. Early in life, they gaze at people, turn toward voices, grasp a finger, and even smile.

In contrast, most children with ASD seem to have tremendous difficulty learning to engage in the give-and-take of everyday human interaction. Even in the first few months of life, many do not interact and they avoid eye contact. They seem indifferent to other people, and often seem to prefer being alone. They may resist attention or passively accept hugs and cuddling. Later, they seldom seek comfort or respond to parents' displays of anger or affection in a typical way. Research has suggested that although children with ASD are attached to their parents, their expression of this attachment is unusual and difficult to “read.” To parents, it may seem as if their child is not attached at all. Parents who looked forward to the joys of cuddling, teaching, and playing with their child may feel crushed by this lack of the expected and typical attachment behavior.

Children with ASD also are slower in learning to interpret what others are thinking and feeling. Subtle social cues—whether a smile, a wink, or a grimace—may have little meaning. To a child who misses these cues, “Come here” always means the same thing, whether the speaker is smiling and extending her arms for a hug or frowning and planting her fists on her hips. Without the ability to interpret gestures and facial expressions, the social world may seem bewildering. To compound the problem, people with ASD have difficulty seeing things from another person's perspective. Most 5-year-olds understand that other people have different information, feelings, and goals than they have. A person with ASD may lack such understanding. This inability leaves them unable to predict or understand other people's actions.

Although not universal, it is common for people with ASD also to have difficulty regulating their emotions. This can take the form of “immature” behavior such as crying in class or verbal outbursts that seem inappropriate to those around them. The individual with ASD might also be disruptive and physically aggressive at times, making social relationships still more difficult. They have a tendency to “lose control,” particularly when they're in a strange or overwhelming environment, or when angry and frustrated. They may at times break things, attack others, or hurt themselves. In their frustration, some bang their heads, pull their hair, or bite their arms.

Communication Difficulties

By age 3, most children have passed predictable milestones on the path to learning language; one of the earliest is babbling. By the first birthday, a typical toddler says words, turns when he hears his name, points when he wants a toy, and when offered something distasteful, makes it clear that the answer is “no.”

Some children diagnosed with ASD remain mute throughout their lives. Some infants who later show signs of ASD coo and babble during the first few months of life, but they soon stop. Others may be delayed, developing language as late as age 5 to 9. Some children may learn to use communication systems such as pictures or sign language.

Those who do speak often use language in unusual ways. They seem unable to combine words into meaningful sentences. Some speak only single words, while others repeat the same phrase over and over. Some ASD children parrot what they hear, a condition called echolalia. Although many children with no ASD go through a stage where they repeat what they hear, it normally passes by the time they are 3.

Some children only mildly affected may exhibit slight delays in language, or even seem to have precocious language and unusually large vocabularies, but have great difficulty in sustaining a conversation. The “give and take” of normal conversation is hard for them, although they often carry on a monologue on a favorite subject, giving no one else an opportunity to comment. Another difficulty is often the inability to understand body language, tone of voice, or “phrases of speech.” They might interpret a sarcastic expression such as “Oh, that's just great” as meaning it really IS great.

While it can be hard to understand what ASD children are saying, their body language is also difficult to understand. Facial expressions, movements, and gestures rarely match what they are saying. Also, their tone of voice fails to reflect their feelings. A high-pitched, sing-song, or flat, robot-like voice is common. Some children with relatively good language skills speak like little adults, failing to pick up on the “kid-speak” that is common in their peers.

Without meaningful gestures or the language to ask for things, people with ASD are at a loss to let others know what they need. As a result, they may simply scream or grab what they want. Until they are taught better ways to express their needs, ASD children do whatever they can to get through to others. As people with ASD grow up, they can become increasingly aware of their difficulties in understanding others and in being understood. As a result they may become anxious or depressed.

Screening

A “well child” check-up should include a developmental screening test. If your child's pediatrician does not routinely check your child with such a test, ask that it be done. Your own observations and concerns about your child's development will be essential in helping to screen your child.9 Reviewing family videotapes, photos, and baby albums can help parents remember when each behavior was first noticed and when the child reached certain developmental milestones.

What is Bipolar Disorder?

Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in mood and energy. It can also make it hard for someone to carry out day-to-day tasks, such as going to school or hanging out with friends. Symptoms of bipolar disorder are severe. They are different from the normal ups and downs that everyone goes through from time to time. They can result in damaged relationships, poor school performance, and even suicide. But bipolar disorder can be treated, and people with this illness can lead full and productive lives.

Bipolar disorder often develops in a person's late teens or early adult years, but some people have their first symptoms during childhood. At least half of all cases start before age 25.

What are common symptoms of bipolar disorder in children and teens?

Youth with bipolar disorder experience unusually intense emotional states that occur in distinct periods called "mood episodes." An overly joyful or overexcited state is called a manic episode, and an extremely sad or hopeless state is called a depressive episode. Sometimes, a mood episode includes symptoms of both mania and depression. This is called a mixed state. People with bipolar disorder also may be explosive and irritable during a mood episode.

Extreme changes in energy, activity, sleep, and behavior go along with these changes in mood. Symptoms of bipolar disorder are described below.

Symptoms of mania include:

• Mood Changes
• • Being in an overly silly or joyful mood that's unusual for your child.
It is different from times when he or she might usually get silly and have fun.
• • Having an extremely short temper. This is an irritable mood that is unusual.
• Behavioral Changes
• • Sleeping little but not feeling tired.
• • Talking a lot and having racing thoughts.
• • Having trouble concentrating, attention jumping from one thing to the next in an unusual way.
• • Talking and thinking about sex more often.
• • Behaving in risky ways more often, seeking pleasure a lot, and doing more activities than usual.

Symptoms of depression include:

• Mood Changes
• • Being in a sad mood that lasts a long time
• • Losing interest in activities they once enjoyed
• • Feeling worthless or guilty.
• Behavioral Changes
• • Complaining about pain more often, such as headaches, stomach aches, and muscle pains
• • Eating a lot more or less and gaining or losing a lot of weight
• • Sleeping or oversleeping when these were not problems before
• • Losing energy
• • Recurring thoughts of death or suicide.




It's normal for almost every child or teen to have some of these symptoms sometimes. These passing changes should not be confused with bipolar disorder.

Symptoms of bipolar disorder are not like the normal changes in mood and energy that everyone has now and then. Bipolar symptoms are more extreme and tend to last for most of the day, nearly every day, for at least one week. Also, depressive or manic episodes include moods very different from a child's normal mood, and the behaviors described in the chart above may start at the same time. Sometimes the symptoms of bipolar disorder are so severe that the child needs to be treated in a hospital.

In addition to mania and depression, bipolar disorder can cause a range of moods, as shown on the scale below. One side of the scale includes severe depression, moderate depression, and mild low mood. Moderate depression may cause less extreme symptoms, and mild low mood is called dysthymia when it is chronic or long-term. In the middle of the scale is normal or balanced mood.



Sometimes, a child may have more energy and be more active than normal, but not show the severe signs of a full-blown manic episode. When this happens, it is called hypomania, and it generally lasts for at least four days in a row. Hypomania causes noticeable changes in behavior, but does not harm a child's ability to function in the way mania does.





BIPOLAR DISORDER Today

• A large, nationally representative survey shows that at least half of all cases of bipolar disorder start before age 25.

• Some medications have been approved for treating bipolar disorder in children and teens, and psychotherapies, such as family focused therapy, also appear to be effective in helping children to manage their symptoms.

• Children with bipolar disorder can have co-occurring disorders, such as attention deficit hyperactivity disorder, anxiety disorders, or other mental disorders, in addition to bipolar disorder. Scientists and doctors now know that, while having co-occurring disorders can hinder treatment response, treating bipolar disorder can have positive effects on treatment outcomes and recovery from co-occurring disorders as well.

• Imaging studies are beginning to reveal brain activity patterns and connections associated with specific traits associated with children who have bipolar disorder, such as mood instability and difficulty interpreting social or emotional cues.

• Genetic research reveals genetic similarities among bipolar disorder, depression, and schizophrenia. Such studies point to possible common pathways that give rise to these disorders.





BRAIN DEVELOPMENT Today

• Scientists are continually refining imaging techniques to provide more detailed information on brain development, even in very young children. Researchers are tracing how changes in the developing brain underlie milestones in a child’s mental and physical abilities, and behavior.

• Scientists are conducting studies to determine what individual genes do in the brain and how changes in genes disrupt brain function.

• Research on early childhood stress is showing how early trauma can alter the brain’s stress response system and contribute to future risk of anxiety and mood disorders.

• Scientists are also studying how genes that convey vulnerability to stress may increase risk.

• Studies of how the environment can turn genes on and off—a field called epigenetics—are providing clues to how early experience can have lasting effects on behavior, even across generations. Epigenetic changes are likely to be involved in the effects of the environment on development of the nervous system. Knowledge of epigenetic processes may offer targets for the development of new medications.






DEPRESSION Today

• We now know that youth who have depression may show signs that are slightly different from the typical adult symptoms of depression. Children who are depressed may complain of feeling sick, refuse to go to school, cling to a parent or caregiver, or worry excessively that a parent may die. Older children and teens may sulk, get into trouble at school, be negative or grouchy, or feel misunderstood.

• The Treatment for Adolescents with Depression Study (TADS) found that combination treatment of medication and psychotherapy works best for most teens with depression.

• The Treatment of SSRI-resistant Depression in Adolescents (TORDIA) study found that teens who did not respond to a first antidepressant medication are more likely to get better if they switch to a treatment that includes both medication and psychotherapy.

• The Treatment of Adolescent Suicide Attempters (TASA) study found that a new treatment approach that includes medication plus a specialized psychotherapy designed specifically to reduce suicidal thinking and behavior may reduce suicide attempts in severely depressed teens.

• Depressed teens with coexisting disorders such as substance abuse problems are less likely to respond to treatment for depression. Studies focusing on conditions that frequently co-occur and how they affect one another may lead to more targeted screening tools and interventions.

• With medication, psychotherapy, or combined treatment, most youth with depression can be effectively treated. Youth are more likely to respond to treatment if they receive it early in the course of their illness.

• Although antidepressants are generally safe, the U.S. Food and Drug Administration has placed a “black box” warning label—the most serious type of warning—on all antidepressant medications. The warning says there is an increased risk of suicidal thinking or attempts in youth taking antidepressants. Youth and young adults should be closely monitored especially during initial weeks of treatment.

• Multi-generational studies have revealed a link between depression that runs in families and changes in brain structure and function, some of which may precede the onset of depression. This research is helping to identify biomarkers and other early indicators that may lead to better treatment or prevention.

• Advanced brain imaging techniques are helping scientists identify specific brain circuits that are involved in depression and yielding new ways to study the effectiveness of treatments.






SUICIDE: A major, preventable mental health problem

Some common questions and answers about suicide and suicide prevention among teens and young adults:

Q: How common is suicide in children and teens?

A: In 2007, suicide was the third leading cause of death for young people ages 15-24. Suicide accounted for 4,140 deaths (12%) of the total 34,598 suicide deaths in 2007. While these numbers may make suicide seem common, it is important to realize that suicide and suicidal behavior are not healthy or typical responses to stress.

Q: What are some of the risk factors for suicide?

A: Risk factors vary with age, gender, or ethnic group. They may occur in combination or change over time. Some important risk factors are:

• • Depression and other mental disorders, substance-abuse disorder (often in combination with other mental disorders)
• • Prior suicide attempt
• • Family history of suicide
• • Family violence including physical or sexual abuse
• • Firearms in the home
• • Incarceration
• • Exposure to suicidal behavior of others, such as family members or peers.

However, it is important to note that many people who have these risk factors, are not suicidal.

Q: What are signs to look for?

A: The following are some of the signs you might notice in yourself or a friend that may be reason for concern.

• • Feelings of hopelessness or worthlessness, depressed mood, poor self esteem or guilt
• • Not wanting to participate in family or social activities
• • Changes in sleeping and eating patterns: too much or too little
• • Feelings of anger, rage, need for revenge
• • Feeling exhausted most of the time
• • Trouble with concentration, problems academically or socially in school
• • Feeling listless, irritable
• • Regular and frequent crying
• • Not taking care of yourself
• • Reckless, impulsive behaviors
• • Frequent physical symptoms such as headaches or stomach aches

Seeking help is a sign of strength, if you are concerned, go with your instincts, get help!

Q: What can I do for myself or someone else?

A: If you are concerned, immediate action is very important. Suicide can be prevented and most people who feel suicidal demonstrate warning signs. Recognizing some of these warning signs is the first step in helping yourself or someone you care about.







BOYS AND MALE TEENS





DEPRESSION

Only in the past two decades has depression in children been taken very seriously. Research has revealed that depression is occurring earlier in life today than in past decades.24 In addition, research has shown that early onset depression often persists, recurs, and continues into adulthood, and that depression in youth may also predict more severe illness in adult life.25 An NIMH sponsored study of 9 to 17 year olds estimates that the prevalence of any depressive disorder is more than 6 percent in a six month period, with 4.9 percent having major depression.26 Before puberty, boys and girls are equally likely to develop depressive disorders. After age 14, however, females are twice as likely as males to have major depression or dysthymia.27 The risk of developing bipolar disorder remains approximately equal for males and females throughout adolescence and adulthood.

The depressed younger child may say he is sick, refuse to go to school, cling to a parent, or worry that the parent may die. The depressed older child may sulk, get into trouble at school, be negative and grouchy, and feel misunderstood. Signs of depressive disorders in young people are often viewed as normal mood swings typical of a particular developmental stage. In addition, health care professionals may be reluctant to prematurely “label” a young person with a mental illness diagnosis. However, early diagnosis and treatment of depressive disorders are critical to healthy emotional, social, and behavioral development. Depression in young people frequently co occurs with other mental disorders, most commonly anxiety, disruptive behavior, or substance abuse disorders, as well as with other serious illnesses such as diabetes.28,29

Among both children and adolescents, depressive disorders confer an increased risk for illness and interpersonal and psychosocial difficulties that persist long after the depressive episode is resolved; in adolescents, there is also an increased risk for substance abuse and suicidal behavior.25,30,31 Unfortunately, these disorders often go unrecognized by families and physicians alike.

Although the scientific literature on treatment of children and adolescents with depression is far less extensive than that for adults, a number of recent studies have confirmed the short term efficacy and safety of treatments for depression in youth. An NIMH funded clinical trial of 439 adolescents with major depression found that a combination of medication and psychotherapy is the most effective treatment.32 Additional research is needed on how best to incorporate these treatments into primary care practice.

Bipolar disorder, although rare in young children, can appear in both children and adolescents.33 The unusual shifts in mood, energy, and functioning that are characteristic of bipolar disorder may begin with manic, depressive, or mixed manic and depressive symptoms. It is more likely to affect the children of parents who have the illness. Twenty to 40 percent of adolescents with major depression go on to reveal bipolar disorder within five years after the onset of depression.

Depression in children and adolescents is associated with an increased risk of suicidal behaviors.25,34 This risk may rise, particularly among adolescent males, if the depression is accompanied by conduct disorder and alcohol or other substance abuse.35 In 2002, suicide was the third leading cause of death among young males, age 15 to 24.36 NIMH supported researchers found that among adolescents who develop major depressive disorder, as many as 7 percent may die by suicide in the young adult years.25 Therefore, it is important for doctors and parents to take seriously any remarks about suicide.

NIMH researchers are developing and testing various interventions to prevent suicide in children and adolescents. Early diagnosis and treatment, accurate evaluation of suicidal thinking, and limitations on young people’s access to lethal agents ¬including firearms and medications¬ may hold the greatest suicide prevention value.

Citations

24 Klerman GL, Weissman M. Increasing rates of depression. Journal of the American Medical Association, 1989; 261: 2229 35.

25 Weissman MM, Wolk S, Goldstein RB, Moreau D, Adams P, Greenwald S, Klier CM, Ryan ND, Dahl RE, Wickramaratne P. Depressed adolescents grown up. Journal of the American Medical Association, 1999; 281(18): 1701 13.

26 Shaffer D, Fisher P, Dulcan MK, Davies M, Piacentini J, Schwab Stone ME, Lahey BB, Bourdon K, Jensen PS, Bird HR, Canino G, Regier DA. The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC 2.3): description, acceptability, prevalence rates, and performance in the MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study. Journal of the American Academy of Child and Adolescent Psychiatry, 1996; 35(7): 865 77.

27 Angold A, Worthman CW. Puberty onset of gender differences in rates of depression: a developmental, epidemiologic and neuroendocrine perspective. Journal of Affective Disorders, 1993; 29: 145 58.

28 Angold A, Costello EJ. Depressive comorbidity in children and adolescents: empirical, theoretical, and methodological issues. American Journal of Psychiatry, 1993; 150(12): 1779 91.

29 Kovacs M. Psychiatric disorders in youths with IDDM: rates and risk factors. Diabetes Care, 1997; 20(1): 36 44.

30 Birmaher B, Brent DA, Benson RS. Summary of the practice parameters for the assessment and treatment of children and adolescents with depressive disorders. American Academy of Child and Adolescent Psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry, 1998; 37(11): 1234 8.

31 Ryan ND, Puig Antich J, Ambrosini P, Rabinovich H, Robinson D, Nelson B, Iyengar S, Twomey J. The clinical picture of major depression in children and adolescents. Archives of General Psychiatry, 1987; 44(10): 854 61.

32 March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J; Treatment for Adolescents With Depression Study (TADS) Team. Fluoxetine, cognitive behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. Journal of the American Medical Association, 2004; 292(7): 807 20.

33 McClellan J, Werry J. Practice parameters for the assessment and treatment of children and adolescents with bipolar disorder. American Academy of Child and Adolescent Psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry, 1997; 36(Suppl 10): 157S 76S.

34 Shaffer D, Gould MS, Fisher P, Trautman P, Moreau D, Kleinman M, Flory M. Psychiatric diagnosis in child and adolescent suicide. Archives of General Psychiatry, 1996; 53(4): 339 48.

35 Shaffer D, Craft L. Methods of adolescent suicide prevention. Journal of Clinical Psychiatry, 1999; 60(Suppl 2): 70 4; discussion 75 6, 113 6.

36 Kochanek KD, Murphy SL, Anderson, RN, Scott, C. Deaths: final data for 2002. National Vital Statistics Reports; 53(5). Hyattsville, MD: National Center for Health Statistics, 2004.







GIRLS AND TEENS





EATING DISORDERS – SEE “WOMEN”





Anorexia Nervosa

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

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

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

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

Other symptoms may develop over time, including:

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





Bulimia Nervosa

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

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

Other symptoms include:

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






ELDERLY





DEPRESSION

Men must cope with several kinds of stress as they age. If they have been the primary wage earners for their families and have identified heavily with their jobs, they may feel stress upon retirement¬loss of an important role, loss of self esteem¬that can lead to depression. Similarly, the loss of friends and family and the onset of other health problems can trigger depression.

Depression is not a normal part of aging.18 Depression is an illness that can be effectively treated, thereby decreasing unnecessary suffering, improving the chances for recovery from other illnesses, and prolonging productive life. However, health care professionals may miss depressive symptoms in older patients. Older adults may be reluctant to discuss feelings of sadness or grief, or loss of interest in pleasurable activities.19 They may complain primarily of physical symptoms. It may be difficult to discern a co occurring depressive disorder in patients who present with other illnesses, such as heart disease, stroke, or cancer, which may cause depressive symptoms or may be treated with medications that have side effects that cause depression. If a depressive illness is diagnosed, treatment with appropriate medication and/or brief psychotherapy can help older adults manage both diseases, thus enhancing survival and quality of life.

“As you get sick, as you become drawn in more and more by depression, you lose that perspective. Events become more irritating, you get more frustrated about getting things done. You feel angrier, you feel sadder. Everything’s magnified in an abnormal way.”

-Paul Gottlieb, Publisher

Identifying and treating depression in older adults is critical. There is a common misperception that suicide rates are highest among the young, but it is older white males who suffer the highest rate. Over 70 percent of older suicide victims visit their primary care physician within the month of their death; many have a depressive illness that goes undetected during these visits.20 This fact has led to research efforts to determine how to best improve physicians’ abilities to detect and treat depression in older adults.21

Approximately 80 percent of older adults with depression improve when they receive treatment with antidepressant medication, psychotherapy, or a combination of both.22 In addition, research has shown that a combination of psychotherapy and antidepressant medication is highly effective for reducing recurrences of depression among older adults.23 Psychotherapy alone has been shown to prolong periods of good health free from depression, and is particularly useful for older patients who cannot or will not take medication.18 Improved recognition and treatment of depression in later life will make those years more enjoyable and fulfilling for the depressed elderly person, and his family and caregivers.

See video: Depression