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GENERALIZED ANXIETY DISORDER;
Overview
Definition
A disorder characterized by diffuse feelings of apprehension with physiological symptoms.
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Alternative names
GAD
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Causes, incidences, and risk factors
A generalized anxiety disorder is one of the most common types of anxiety disorder. It is characterized by excessive anxiety and worry about two or more life circumstances for a period of six months or longer. The exact cause of this disorder may be unknown but biological and genetic factors play a role. Stressful life situations or nonadaptive behavior acquired through learning may also contribute to GAD. The disorder may start at any time, including childhood, and a history of excessive worry is common. GAD occurs somewhat more often among women than among men.
No prevention is known.
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Symptoms
typical symptoms of anxiety:
irritability or restlessness
fatigue
trembling or feeling shaky
muscle tension, aches or soreness
sweating, clammy skin
a dry mouth
difficulty swallowing or lump in the throat
sleep disturbances
nightmares
poor concentration
excessive worry
muscle tension
restlessness
fatigue
shortness of breath or breathing difficulty, especially lying down
palpitations
dizziness
nausea, diarrhea
flushing or chills
fainting
an exaggerated startle response
difficulty with concentrating, confusion
feeling keyed up
complaining of urinary frequency or urgency
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Signs and tests
A physical examination and a psychological evaluation should be completed in order to rule out other causes of anxiety. Physical disorders that may mimic an anxiety state are ruled out, as well as drug-induced symptoms. Various diagnostic tests may be done in this process.
Treatment
Medications used to treat anxiety disorders include antidepressants and antianxiety agents. Treatment may also involve sedative (sleep-inducing) drugs, antihistamines, and/or minor tranquilizers. These medications act on the central nervous system to reduce the feelings of anxiety and associated symptoms. A common class of antianxiety medications, the benzodiazepines, are usually used with caution due to potential for dependence. Behavioral therapies, which have been effective with GAD, include relaxation training (a systematic relaxation of the major muscle groups in the body) and cognitive behavioral therapy (treatment that identifies cognitions or thoughts that contribute to anxiety). Caffeine and other stimulants should be reduced or eliminated.
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Prognosis
The disorder may be long-standing and difficult to treat. Although many with this disorder may not be cured with treatment, all can expect substantial improvement with drug or behavioral therapy.
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Complications
Persons with GAD are at risk for development of substance abuse or dependence, sometimes due to self-medication of anxiety symptoms. GAD is frequently complicated by co-existing depression.
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Calling your health care provider
Call your health-care provider if you are experiencing the signs and symptoms of generalized anxiety disorder, especially if this has been going on for a period of six months or longer or interferes with your daily functioning.
OBSESSIVE-COMPULSIVE DISORDER
Overview
Definition
Obsessive-compulsive disorder is an anxiety disorder characterized by the presence of obsessions or compulsions; having one or both is sufficient for the diagnosis. An obsession is a recurrent or persistent thought that is intrusive or inappropriate. A compulsion is a repetitive behavior a person feels driven to perform. This behavior can be a physical action (e.g. handwashing) or a mental act (e.g. praying, repeating words silently, counting.) The behavior is aimed at neutralizing anxiety or distress. One example of this is excessive handwashing intended to ward off infection.
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Alternative names
Obsessive-compulsive neurosis; OCD
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Causes, incidences, and risk factors
OCD was previously believed to be rare. However, recent data show that 2-3% of people, or about 7 million Americans, suffer from this disorder. OCD usually is noticed between the ages of 20 and 30, and 75% of those who will develop it show symptoms by age 30.
There are several psychological theories about its cause the cause of OCD, but none has been confirmed. Some reports associate OCD with head trauma or infections, but no link has been proven. Similarly, although there are several studies showing brain abnormalities in patients with OCD (decreased caudate size, decreased white matter) the results are inconsistent and still under investigation. Interestingly, 20% of OCD sufferers also have motor tics, suggesting it may be related to Tourette Syndrome, but this link has not been proven or explained.
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Prevention
There is no known prevention for this disorder.
Symptoms
The symptoms are obsessions or compulsions that cause significant distress or interference with every day life, and are not due to medical illness or drug use. The person recognizes that the behavior is excessive or unreasonable.
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Signs and tests
The persons own description of the behavior usually leads to diagnosis of the disorder. A physical examination is preformed to rule out physical causes, and a psychological evaluation is given to rule out other psychiatric disorders. Questionnaires such as the Yale-Brown Obsessive Compulsive Scale can help in making the diagnosis
Treatment
OCD is treated using medications and psychotherapy.
The first medication considered is usually an SSRI antidepressant, since these are often effective and do not have severe side effects. SSRIs, or selective serotonin reuptake inhibitors, treat OCD by increasing the serotonin available in the brain. They include fluvoxamine (Luvox), fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil).
If an SSRI antidepressant is not effective, clomipramine, a tricyclic antidepressant, may be prescribed. Clomipramine, the oldest medication treatment for OCD, is more effective that SSRI antidepressants but has more numerous and unpleasant side effects, including sedation, urinary retention (difficulty initiating urination), orthostatic hypotension (drop in blood pressure when rising from a seated position), and dry mouth. In more resistant cases, an SSRI and clomipramine may be combined. While other medications, such as benzodiazepines, may offer some relief from anxiety, they are generally used only in conjunction with the more reliable treatments.
Psychotherapy, which may occur on an individual basis or in a group setting, is used to reduce anxiety, resolve inner conflicts, and provide effective ways of reducing stress.
Behavioral therapies are often employed and may include:
exposure/response prevention; the person is repeatedly exposed to a situation that triggers anxiety symptoms, and learns to resist the urge to perform the compulsion.
thought stopping; the person learns to stop unwanted thoughts and focus attention on relieving anxiety.
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Prognosis
OCD is a chronic illness which, like other psychiatric illnesses, has periods of exacerbation followed by periods of relative improvement, though a completely symptom free interval is generally unusual. With treatment, most sufferers have considerable improvement, though total remission is fairly uncommon.
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Complications
The most likely long-term consequences of OCD are related to the nature of the obsessions or compulsions. For example, constant handwashing can cause skin breakdown. However, OCD does not ordinarily "progress" into another disease.
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Calling your health care provider
Call for an appointment with your health care provider if your obsession is interfering with daily life, work, or relationships; or if your compulsion is consuming an inordinate amount of time, energy, or resources
Bulimia
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Overview | Treatment | Images
Definition
Bulimia is an illness characterized by uncontrolled episodes of overeating usually followed by self-induced vomiting or other purging (contrast with anorexia nervosa).
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Alternative names
Bulimia nervosa; Binge-purge behavior; Eating disorders
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Causes, incidences, and risk factors
In bulimia, eating binges may occur as often as several times a day. Induced vomiting known as purging allows the eating to continue without the weight gain; it may continue until interrupted by sleep, abdominal pain, or the presence of another person.
The person is usually aware that their eating pattern is abnormal and may experience fear or guilt associated with the binge-purge episodes. The behavior is usually secretive, although clues to this disorder include overactivity, peculiar eating habits, eating rituals, and frequent weighing. Body weight is usually normal or low, although the person may perceive themselves as overweight.
The exact cause of bulimia is unknown, but factors thought to contribute to its development are family problems, maladaptive behavior, self-identity conflict, and cultural overemphasis on physical appearance. Bulimia may be associated with depression. The disorder is usually not associated with any underlying physical problem although the behavior may be associated with neurological or endocrine diseases. The disorder occurs most often in females of adolescent or young adult age. The incidence is estimated to be 3% in the general population; but 20% of college women suffers from it.
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Prevention
A cultural and family de-emphasis on physical appearance may eventually reduce the incidence of this disorder.
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Symptoms
binge eating followed by purging
self-induced vomiting
inappropriate use of diuretics and laxatives
menstruation, absent or decreased
overachieving behavior
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Signs and tests
Dental exam may show dental cavities or gum infections (such as gingivitis). The enamel of the teeth may be eroded or pitted because of excessive exposure to acid in vomitus.
A chem-20 may show an electrolyte imbalance (such as hypokalemia) or dehydration.
Treatment
Treatment focuses on breaking the binge-purge cycles of behavior since the person is usually aware that the behavior is abnormal. Outpatient treatment may include behavior modification techniques and individual, group, or family counseling.
Antidepressant drugs may be indicated for some whether or not they have coincident depression.
Participation in self-help groups such as Overeaters Anonymous may be of benefit. American Anorexia/Bulimia Association is a source of information about this disorder. See eating disorders - support group.
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Prognosis
With treatment up to one half of those affected continue to experience behavior and psychiatric problems. Death due to bulimia is very rare.
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Complications
pancreatitis
dental cavities
inflammation of the throat
electrolyte abnormalities
dehydration
constipation
hemorrhoids
esophageal tears/rupture
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Calling your health care provider
Call for an appointment with your health care provider if you (or your child) are exhibiting behaviors of any eating disorder, including bulimia.
Dissociative Disorders from DSMIV
300.12 Dissociative Amnesia (formerly Psychogenic Amnesia)
A. The predominant disturbance is one or more episodes of inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness.
B. The disturbance does not occur exclusively during the course of Dissociative Identity Disorder, Dissociative Fugue, Post traumatic Stress Disorder, Acute Stress Disorder, or Somatization Disorder and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a neurological or other general medical condition (e.g., Amnestic Disorder Due to Head Trauma).
C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
300.13 Dissociative Fugue (formerly Psychogenic Fugue)
A. The predominant disturbance is sudden, unexpected travel away from home or one's customary place of work, with inability to recall one's past.
B. Confusion about personal identity or assumption of a new identity (partial or complete).
C. The disturbance does not occur exclusively during the course of Dissociative Identity Disorder and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy).
D. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
300.14 Dissociative Identity Disorder (formerly Multiple Personality Disorder)
A. The presence of two or more distinct identities or personality states (each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self).
B. At least two of these identities or personality states recurrently take control of the person's behavior.
C. Inability to recall important personal information that is too extensive to be explained by ordinary forgetfulness.
D. The disturbance is not due to the direct physiological effects of a substance (e.g., blackouts or chaotic behavior during Alcohol Intoxication) or a general medical condition (e.g., complex partial seizures). In children, the symptoms are not attributable to imaginary playmates or other fantasy play.
300.6 Depersonalization Disorder
A. Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one's mental processes or body (e.g., feeling like one is in a dream).
B. During the depersonalization experience, reality testing remains intact.
C. The depersonalization causes clinically significant distress or impaintient in social, occupational, or other important areas of functioning.
D. The depersonalization experience does not occur exclusively during the course of another mental disorder,such as Schizophrenia, Panic Disorder, Acute Stress Disorder, or another Dissociative Disorder, and is not due to the direct physiological effects of a substance(e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy).
300.15 Dissociative Disorder Not Otherwise Specified
This category is included for disorders in which the predominant feature is a Dissociative symptom (i.e., a disruption in the usually integrated functions of consciousness, memory, identity, or perception of the environment) that does not meet the criteria for any specific Dissociative Disorder. Examples include
1. Clinical presentations similar to Dissociative Identity Disorder that fail to meet full criteria for this disorder.Examples include presentations in which a) there are not two or more distinct personality states, or b) amnesia for important personal information does not occur.
2. Derealization unaccompanied by depersonalization in adults.
3 -States of dissociation that occur in individuals who have been subjected to periods of prolonged and intense coercive persuasion (e.g., brainwashing, thought re- form, or indoctrination while captive).
4. Dissociative trance disorder: single or episodic disturbances in the state of consciousness, identity, or memory that are indigenous to particular locations and cultures. Dissociative trance involves narrowing of awareness of immediate surroundings or stereotyped behaviors or movements that are experienced as being beyond one's control. Possession trance involves re placement of the customary sense of personal identity by a new identity, attributed to the influence of a spirit, power, deity, or other person, and associated with stereotyped "involuntary" movements or amnesia. Examples include amok (Indonesia), bebainan (Indonesia), latab (Malaysia), pibloktoq (Arctic), ataque de nervios (Latin America), and possession (India). The Dissociative or trance disorder is not a normal part of a broadly accepted collective cultural or religious practice.
5. Loss of consciousness, stupor, or coma not attributable to a general medical condition.
6. Ganser syndrome: the giving of approximate answers to questions (e.g., "2 plus 2 equals 5") when not associated with Dissociative Amnesia or Dissociative Fugue
Associated Features and Disorders
Associated descriptive features and mental disorders.
Individuals with Dissociative Identity Disorder frequently report having experienced severe physical and sexual abuse, especially during childhood. Controversy surrounds the accuracy of such report, because childhood memories can be subject to distortion and individuals with this disorder tend to be highly hypnotizable and especially vulnerable to suggestive influences. On the other hand, those responsible for acts of physical and sexual abuse may be prone to deny or distort their behavior. Individuals with Dissociative Identity Disorder may manifest post traumatic symptoms (e.g.,nightmares, flashbacks, and startle responses) or Post traumatic Stress Disorder. Self-mutilation and suicidal and aggressive behavior may occur. Some individuals may have a repetitive pattern of relationships involving physical and sexual abuse. Certain identities may experience conversion symptoms (e.g., pseudoseizures) or have unusual abilities to control pain or other physical symptoms. Individuals with this disorder may also have symptoms that meet criteria for Mood, Substance-Related, Sexual, Eating, or Sleep Disorders. Self-mutilative behavior, impulsivity, and sudden and intense changes in relationships may warrant a concurrent diagnosis of Borderline Personality Disorder.
Associated laboratory findings. Individuals with Dissociative Identity Disorder score toward the upper end of the distribution on measures of hypnotizability and Dissociative capacity. There are reports of variation in physiological function across identity states (e.g., differences in visual acuity, pain tolerance, symptoms of asthma, sensitivity to allergens, and response of blood glucose to insulin).
Associated physical examination findings and general medical conditions. There may be scars from self-inflicted injuries or physical abuse. individuals with this disorder may have migraine and other types of headaches, irritable bowel syndrome, and asthma.
Specific Culture, Age, and Gender Features
It has been suggested that the recent relatively high rates of the disorder reported in the United States might indicate that this is a culture-specific syndrome. In preadolescent children, particular care is needed in making the diagnosis because the manifestations may be less distinctive than in adolescents and adults. Dissociative Identity Disorder is diagnosed three to nine times more frequently in adult females than in adult males; in childhood, the female-to-male ratio may be more even, but data are limited. Females tend to have more identities than do males, averaging 15 or more, whereas males average approximately 8 identities.
Prevalence
The sharp rise in reported cases of Dissociative Identity Disorder in the United States in recent years has been subject to very different interpretations. Some believe that the greater awareness of the diagnosis among mental health professionals has resulted in the identification of cases that were previously undiagnosed. In contrast, others believe that the syndrome has been over diagnosed in individuals who are highly suggestible.
Course
Dissociative Identity Disorder appears to have a fluctuating clinical course that tends to be chronic and recurrent. The average time period from first symptom presentation to diagnosis is 6-7 years. Episodic and continuous courses have been described. The disorder may become less manifest as individuals age beyond their late 40's, but may reemerge during episodes of stress or trauma or with Substance Abuse.
Familial Pattern
Several studies suggest that Dissociative Identity Disorder is more common among the first-degree biological relatives of persons with the disorder than in the general population.
Differential Diagnosis
Dissociative Identity Disorder must be distinguished from symptoms that are caused by the direct physiological effects of a general medical condition (e.g., seizure disorder) (see p. 165). This determination is based on history, laboratory findings, or physical examination. Dissociative Identity Disorder should be distinguished from Dissociative symptoms due to complex partial seizures, although the two disorders may co-occur. Seizure episodes are genrally brief (30 seconds to 5 minutes) and do not involve the complex and enduring structures of identity and behavior typically found in Dissociative Identity Disorder. Also, a history of physical and sexual abuse is less common in individuals with complex partial seizures. EEG studies, especially sleep deprived and with nasopharyngeal leads, may help clarify the differential diagnosis.
Symptoms caused by the direct physiological effects of a substance can be distinguished from Dissociative Identity Disorder by the fact that a substance (e.g., a drug of abuse of a medication) is judged to be etiologically related to the disturbance (see p. 192).
The diagnosis of Dissociative Identity Disorder takes precedence over Dissociative Amnesia, Dissociative Fugue, and Depersonalization Disorder. Individuals with Dissociative Identity Disorder can be distinguished from those with trance and possession trance symptoms that would be diagnosed as Dissociative Disorder Not Otherwise Specified by the fact that those with trance and possession trance symptoms typically describe external spirits or entities that have their bodies and taken control.
Controversy exists concerning the differential diagnosis between Dissociative Identity Disorder and a variety of other mental disorders, including Schizophrenia and other Psychotic Disorders, Bipolar Disorder, With Rapid Cycling, Anxiety Disorders, Somatization Disorders, and Personality Disorders. Some clinicians believe that Dissociative Identity Disorder has been under diagnosised (e.g., the presence of more than one dissociated personality state may be mistaken for a delusion or the communication from one identity to another may be mistaken for an auditory hallucination, leading to confusion with the Psychotic Disorders; shifts between states may be confused with cyclical mood fluctuations leading to confusion with Bipolar Disorder). In contrast, others are concerned that Dissociative Identity Disorder may be overdiagnosed relative to other mental disorders based on the media interest in the disorder and the suggestible nature of the individuals. Factors that may support a diagnosis of Dissociative Identity Disorder are the presence of clear-cut Dissociative symptomatology with sudden shifts in identity states, reversible amnesia, and high scores on measures of dissociation and hypnotizability in individuals who do not have the characteristic presentations of another mental disorder.
Dissociative Identity Disorder must be distinguished from Malingering in situations in which there may be financial or forensic gain and from Factitious Disorder in which there may be a pattern of help-seeking behavior.
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PANIC DISORDER
Overview
Definition
unpredictable attacks of anxiety that are accompanied by physiological manifestations (see also generalized anxiety disorder).
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Alternative names
Panic attacks
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Causes, incidences, and risk factors
The exact cause of panic disorder is unknown. There is a clear influence of heredity. There may be a temporal lobe dysfunction, or the disorder may develop as a persistent pattern of maladaptive behavior acquired by learning. Stimulants, such as caffeine and cocaine, or alcohol may induce or worsen the symptoms.
People with this disorder often undergo medical evaluations for symptoms related to heart attack or other medical conditions before the diagnosis of panic disorder is made. Attacks may last from minutes to hours. An affected person often lives in fear of another attack and may be reluctant to be alone or far from medical assistance.
There is a familial tendency, with age of onset before 25 years old. It occurs more often in women than men. Approximately 2% of the population is affected. Panic disorder can occur in children, but is often not recognized.
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Prevention
Avoid stimulants such as caffeine and cocaine, and avoid alcohol use, if you are prone to panic attacks. Psychiatric intervention may be helpful.
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Symptoms
At least 4 or more of the following symptoms within ten minutes; or 1 or more attacks followed by at least 1 month of persistent fear of having another attack:
Shortness of breath
Dizziness or faintness
Palpitations
Trembling
Sweating
Choking
Nausea
Numbness or tingling
Chest pain or discomfort
Fear of dying
Fear of being out of control
Sleep disturbances
Skin, clammy
Skin blushing or flushing
Heartburn
Facial paralysis
Agitation
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Signs and tests
A physical examination and a psychological evaluation are performed. Underlying medical disorders are ruled out. Cardiovascular, endocrine, respiratory, neurologic, and substance abuse disorders may be suspected and can coexist with panic disorders. Diagnostic tests will vary with symptoms.
Treatment
Anti-anxiety medications and anti-depressants have been successfully used to treat panic disorders. These medications act on the central nervous system to reduce the feelings of anxiety and associated symptoms. A common class of anti-anxiety medications are the benzodiazepines. However, benzodiazepines are associated with dependence.
Behavioral therapies that may be used in conjunction with drug therapy include relaxation techniques, pleasant mental imagery, and cognitive restructuring. Psychological counseling and therapy techniques may be helpful.
Regular exercise may help reduce the frequency of the attacks. Caffeine and other stimulants should be reduced or eliminated.
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Prognosis
The disorder may be long-standing and difficult to treat. Although many with this disorder may not be cured with treatment, many can expect improvement with drug or behavioral therapy.
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Complications
Dependency on anti-anxiety medications
Avoidance of situations or places that might bring on an attack
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Calling your health care provider
Seasonal affective disorder
Overview | Treatment
Definition
A form of depression that recurs with a fall-winter onset and a spring-summer remission (also known as SAD)
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Causes, incidences, and risk factors
The cause of seasonal affective disorder (SAD) is not known, but is thought to be related to the bodys temperature and hormone regulation. The disorder is rare, and most people with the "winter blahs" or cabin fever do not have SAD. The disorder may have its onset in adolescence or early adulthood, and it occurs more frequently in women than in men.
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Prevention
Unknown
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Symptoms
depression with a fall or winter onset
lack of energy
decreased interest in work or significant activities
increased appetite with weight gain
carbohydrate cravings
increased sleep, excessive daytime sleepiness
social withdrawal
afternoon slumps with decreased energy and concentration
slow, sluggish, lethargic movement
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Signs and tests
A psychological evaluation rules out other causes for the symptoms and confirms the diagnosis.
Treatment
Light therapy for varying periods of time under special bright light seems to make the symptoms subside. However, the symptoms usually reappear when the therapy is discontinued. Full-spectrum fluorescent light is being investigated as a treatment.
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Prognosis
The outcome is expected to be good with continuous treatment. Some people may be affected with this disorder throughout their lives.
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Complications
The disorder can sometimes progress to a full major depressive syndrome, but spontaneous remission (especially with the change of seasons) is common.
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Calling your health care provider
Call for an appointment with your health care provider if you experience symptoms of seasonal affective disorder and it is affecting your lifestyle or work.
Eating disorders - resources
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The following organizations are good resources for eating disorders:
National Association of Anorexia Nervosa and Associated Disorders (ANAD)
P.O. Box 7
Highland Park, IL 60035
(847) 831-3438
www.anad.org
Overeaters Anonymous, Inc.
World Service Office(WSO)
6075 Zenith CT. NE
Rio Rancho, NM 87124
(505) 891-2664
www.overeatersanonymous.org
The Academy for Eating Disorders
6728 Old McLean Village Drive
McLean, VA 22101
(703) 556-9222
(703) 556-8729
www.acadeatdis.org
Additional resources can be found through local libraries, your healthcare provider and the yellow pages under "social service organizations".
Anorexia nervosa
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Overview
Definition
An eating disorder associated with a distorted body image that may be caused by a mental disorder. Inadequate calorie intake results in severe weight loss (see also bulimia and intentional weight loss).
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Alternative names
Eating disorder - anorexia nervosa
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Causes, incidences, and risk factors
The exact cause of this disorder is not known, but social attitudes towards body appearance and family factors play a role in its development. The condition affects females more frequently, usually in adolescence or young adulthood. Gorging followed by vomiting (spontaneous or self-induced) and inappropriate use of laxatives or diuretics are behaviors that may accompany this disorder. Risk factors are being Caucasian, having an upper or middle economic background, being female, and having a goal-oriented family or personality. The incidence is 4 out of 100,000 people.
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Prevention
In some cases, prevention may not be possible. Encouraging healthy, realistic attitudes toward weight and diet may be helpful. Sometimes, counselling can help.
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Symptoms
weight loss of 25% or greater
cold intolerance
constipation
menstruation, absent
skeletal muscle atrophy
loss of fatty tissue
low blood pressure
dental cavities
increased susceptibility to infection
blotchy or yellow skin
dry hair, hair loss
depression (may be present)
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Signs and tests
Diagnosis is based upon ruling out other causes of endocrine, metabolic, and central nervous system abnormalities.
These tests may be used:
chem-20
urinalysis
ECG
This disease may also alter the results of the LH response to GnRH test.
Treatment
The purpose of treatment is to restore normal body weight and eating habits, and resolve any psychological issues. Hospitalization may be indicated in some cases. Supportive care by health care providers, structured behavioral therapy, psychotherapy, and anti-depressive drug therapy are some of the methods that are used for treatment. Severe malnutrition may require intravenous feeding.
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Prognosis
Experienced treatment programs have a two-thirds success rate in restoring normal weight. Half of the people affected with this disorder continue to experience eating and psychological problems. Death may occur from complications of the disorder or from suicide in up to 6% of the cases. Weight management may be difficult and long-term treatment may be necessary to help maintain a healthy body weight.
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Complications
dehydration
cardiac arrhythmias
shock
electrolyte imbalance (such as hypokalemia)
severe malnutrition
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Calling your health care provider
Call for an appointment with your health care provider if symptoms suggestive of anorexia nervosa are present.
Go to the emergency room or call the local emergency number (such as 911) if fainting, irregular pulse, seizures, or other severe symptoms develop in a person with anorexia nervosa.
Alcoholism
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Overview
Definition
A chronic illness marked by consumption of alcoholic beverages at a level that interferes with physical or mental health, and social, family, or occupational responsibilities. Alcohol dependence or alcoholism is the most severe form of alcohol abuse. Alcohol abuse also includes "problem drinking" such as drinking and driving or binge drinking (drinking six or more drinks on one occasion).
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Alternative names
Alcohol dependence; Habitual alcohol use
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Causes, incidences, and risk factors
Alcoholism is a type of drug addiction. There is both physical and psychological dependence with this addiction. Physical dependence reveals itself by withdrawal symptoms when alcohol intake is interrupted, tolerance to the effects of alcohol, and evidence of alcohol-associated illnesses. Alcohol affects the central nervous system as a depressant, resulting in a decrease of activity, anxiety, tension, and inhibitions. Even a low level of alcohol within the body slows reactions. Concentration and judgment become impaired. In excessive amounts, intoxication or poisoning results.
Alcohol also affects other body systems. Irritation of the gastrointestinal tract can occur with erosion of the lining of the stomach causing nausea and vomiting. Vitamins are not absorbed properly, which can lead to nutritional deficiencies with the long-term use of alcohol. Liver disease, called hepatic cirrhosis, may also develop. The cardiovascular system may be affected by cardiomyopathy. Sexual dysfunction can also occur, causing erectile dysfunction in men and cessation of menses in women. Alcohol affects the nervous system and can result in neuropathy and dementia. Chronic alcohol use also increases the risk of cancer of the larynx, esophagus, liver, and colon. Alcohol consumption during pregnancy can cause problems in the developing fetus known as fetal alcohol syndrome, which may result in mental retardation of the child.
The social consequences of problem drinking and alcohol dependence can be as serious as the medical problems. People who abuse alcohol have a higher incidence of unemployment, domestic violence, and difficulty with the law. About half of all traffic fatalities are related to alcohol use.
The development of dependence upon alcohol may occur over a period of years, following a relatively consistent pattern of progression. At first, a tolerance of alcohol develops. This results in a person being able to consume a greater quantity of alcohol before its adverse effects are noticed. Memory lapses relating to drinking episodes may follow tolerance. Then a lack of control over drinking occurs, and the affected person can no longer discontinue drinking whenever desired. The most severe drinking behavior includes prolonged binges of drinking with associated mental or physical complications. Some people are able to gain control over their dependence in earlier phases before a total lack of control occurs.
When a person who is physically dependent on alcohol tries to stop, a withdrawal syndrome develops, with symptoms that may include elevated temperature, increased blood pressure, rapid heart rate, restlessness, anxiety, psychosis, seizures, and rarely even death.
There is no definite cause of alcoholism; however, several factors may play a role in its development. A person who has an alcoholic parent is more likely to become an alcoholic than a person without alcoholism in the immediate family. The reason for this occurrence is not known, but genetic or biochemical abnormalities may be present. Psychological factors may include a need for relief of anxiety, ongoing depression, unresolved conflict within relationships, or low self-esteem. Social factors include availability of alcohol, social acceptance of the use of alcohol, peer pressure, and stressful lifestyles.
Incidence of alcohol dependence is increasing. Statistics vary, but approximately 7% of adults in the United States are affected.
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Prevention
Educational programs and medical advice about alcohol abuse has been successful in decreasing problem drinking and its associated problems. Alcohol dependency requires more intensive management.
The National Institute on Alcohol Abuse and Alcoholism recommends that women have no more than one drink per day and men no more than two drinks per day. One drink is defined as a 12-ounce bottle of beer; a 5-ounce glass of wine; or a 1 1/2-ounce shot of liquor.
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Symptoms
At-risk drinkers are men who consumes 15 or more drinks a week, women who consume 12 or more drinks a week, or anyone who consumes 5 or more drinks per occasion at least once a week. (One drink is defined as a 12-ounce bottle of beer; a 5-ounce glass of wine; or a 1 1/2-ounce shot of liquor).
The following questions are used by the National Institute on Alcohol Abuse and Alcoholism to screen for alcohol abuse:
Have you ever thought you had an alcohol problem?
Do you ever drive when drinking?
Is someone in your family concerned about your drinking?
Have you ever had any blackouts after drinking?
Have you ever been absent from work or lost a job because of drinking?
Does it take more drinks than it used to achieve the desired effect (tolerance)?
Other symptoms associated with alcoholism include
solitary drinking
making excuses to drink
need for daily or frequent use of alcohol for adequate function
lack of control over drinking, with inability to discontinue or reduce alcohol intake
episodes of violence associated with drinking
secretive behavior to hide alcohol related behavior
hostility when confronted about drinking
neglect of food intake
neglect of physical appearance
nausea and vomiting
shaking in the morning
abdominal pain
numbness and tingling
confusion
Note: Symptoms may vary.
Alcohol withdrawal symptoms may vary from mild to severe:
rapid heart rate and sweating
restlessness, agitation, or confusion
loss of appetite, nausea, or vomiting
confusion of hallucinations
tremors and seizures
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Signs and tests
There is a history of chronic and excessive alcohol use. A history may be obtained from family if the affected person is unwilling or unable to answer questions. A physical examination is performed to identify physical problems related to alcohol use.
A toxicology screen or blood alcohol level confirms recent alcohol ingestion (which does not necessarily confirm alcoholism).
Liver function tests can be elevated - GGPT (glutaryl transaminase) is often elevated more than other liver function tests.
CBC (complete blood count) - MCV can be elevated (mean corpuscular volume or size of the red blood cells).
Sometimes serum magnesium, uric acid, total protein, and folate tests are abnormal.
Treatment
Alcohol dependency usually requires treatment programs that include medical supervision and counseling. The person with alcohol dependence often has little recognition of the problem. Alcoholism is associated with denial, allowing the person to believe there is no need for treatment. The person should be confronted when sober, not while drinking or recovering from a drinking episode. Often people enter treatment only after their family, doctor, or the legal system pressures them. Once the problem has been recognized, total abstinence from alcohol is required. Programs are available to offer detoxification, rehabilitation, and aftercare or follow-up. Because alcoholism creates victims of people associated closely with the alcoholic, treatment for family members through counseling is often necessary.
Detoxification is the first phase of treatment. Alcohol is withdrawn under a controlled, supervised setting. Tranquilizers and sedatives are often prescribed to control alcohol withdrawal symptoms. Detoxification usually takes 4 to 7 days. Examination for other medical problems is necessary. Liver disease and blood clotting problems are common. A balanced diet with vitamin supplements is important. Complications associated with the acute withdrawal of alcohol may occur, such as delirium tremens (DTs). Depression or other underlying mood disorders should be treated. Often, alcohol abuse develops from efforts to self-treat an illness.
Alcohol recovery or rehabilitation programs support the affected person after detoxification to maintain abstinence from alcohol. Counseling, psychological support, nursing, and medical care are usually available within these programs. Education about the disease of alcoholism and its effects is part of the therapy. Many of the professional staff involved in rehabilitation centers is recovered alcoholics who serve as role models. Programs can be either inpatient, with the patient residing in the facility during the treatment, or outpatient, with the patient attending the program while they reside at home.
Medications are sometimes prescribed to prevent relapses. Naltrexone (an opioid antagonist) decreases alcohol cravings. Disulfiram (Antabuse) works by producing very unpleasant side effects if even a small amount of alcohol is ingested within 2 weeks after taking the drug. These medications are not given during pregnancy or with certain medical conditions. Long-term treatment with counseling or support groups is often necessary. The effectiveness of medication and counseling varies.
Alcoholics Anonymous is a self-help group of recovering alcoholics that offers emotional support and an effective model of abstinence for people recovering from alcohol dependence. There are more than 1 million members worldwide, and local chapters are found throughout the United States.
Al-Anon is a support group for spouses and others who are affected by someone elses alcoholism. Alateen provides support for teenage children of alcoholics. See alcoholism - support group.
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Prognosis
Alcoholism is a major social, economic, and public health problem. Alcohol is involved in more than half of all accidental deaths and almost half of all traffic fatalities. A high percentage of suicides involve the use of alcohol in combination with other substances. Additional deaths are related to the long-term medical complications associated with the disease. Only 15% of those with alcohol dependence seek treatment for this disease. Treatment programs have varying success rates, but many people with alcohol dependency have a full recovery.
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Complications
acute pancreatitis and chronic pancreatitis
alcoholic cardiomyopathy
alcoholic neuropathy
bleeding esophageal varices
cerebellar degeneration
cirrhosis of the liver
complicated alcohol abstinence (delirium tremens)
depression
erectile dysfunction
fetal alcohol syndrome in the offspring of alcoholic women
high blood pressure
increased incidence of cancer
insomnia
nutritional deficiencies
suicide
Wernicke-Korsakoff syndrome
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Calling your health care provider
Go to the emergency room or call the local emergency number (such as 911) if severe confusion, seizures, bleeding, or other health problems develop in a person known or suspected to have alcohol dependence.
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ALSO ON CHOOSING COUNSELORS:
Solving The Puzzle, Finding Help:
Finding the help you need is similar to putting the pieces of a jigsaw puzzle together. One of the most devastating aspects of mental and emotional difficulties is when people begin to feel hopeless.
Whether your need is for yourself, your children, spouse, or entire family, your task is to find the therapist who can best help you. While there is excellent therapy available, there is also poor and abusive therapy. Sometimes, people simply go to the wrong therapist for their personality and needs. In these cases, the puzzle pieces never fit together.
You can get the help you need!
What happens to many people is that they develop a lot of psychological pain and begin to feel different from other people. Sometimes they have had unsuccessful
counseling experiences, and even believe that mental health is something they cannot have. Most seriously, you might have lost your vision of yourself as a
functioning and contented human being. Don't give up!
Continue to search for the therapist who matches your needs and personality.
One major factor in successful therapy is the relationship that develops between you and your psychotherapist. What you can expect from effective therapy continues our comparison to a puzzle with many pieces. These puzzle pieces are described below.
Improvement
Your therapy is supposed to increase your coping ability in our day-to-day life.
Open Communication
Look for encouragement to learn to communicate your full range of emotions.
Listening Actively
Expect to be heard and understood.
Believe in You
Your therapist must believe you can improve to be able to help you.
Psychological Safety
You must be able reveal your true self without being criticized.
Encouraging You
Therapy offers support and encouragement for you to try new behaviors.
Sharing The Power
Seek out a therapist who respects your right to have control over what you say and do in therapy.
Limits
Therapy is only effective if you know that your boundaries will not be violated.
Boundaries
Make certain that you know who is deciding what help you receive and why.
There are some actions you can take to increase the success of your therapy and continue filling in the pieces of the puzzle.
Choose someone you like, admire, and feel comfortable with.
Ask your friends or relatives for the name of a therapist they trust.
Call and interview the therapist on the telephone.
Take your time to develop trust.
Set goals for yourself.
Check to see if you are meeting your goals in therapy.
Let your counselor know when you are not getting what you need.
Trust your gut instincts more than the counselor's authority.
Get a second opinion if you think you need it.
Be open to change.
Terminate therapy when you are ready.
Ask any questions you need to ask.
You can tell a lot about the counselor by how they respond to your questions, comments, feelings and requests. A checklist of questions you may want to ask
is listed below. You are entitled to ask any of these questions. If you don't understand the answers, ask again.
Qualifications :
What is your educational background?
Are you licensed?
Are you board certified?
What experiences have you had with my type of problem?
Therapy Approaches :
What is your specialty?
How does it work?
Are there any possible risks involved?
About how long will it take?
What should I do if I feel therapy isn't working?
Support Groups :
Do you work with people who go to support groups?
Do you refer people to support groups?
How does this work with your type of therapy?
Appointments:
How are appointments scheduled?
How long are sessions?
How can I reach you in an emergency?
If you are not available, who is there I can talk to?
Confidentiality :
What kind of record do you keep?
Who gets to see your records?
Do you tell people what we talk about?
How do you handle information when you work with children?
How do you handle information when you work with couples or families?
Boundaries :
Who decides the kind of therapy I will receive from you?
How co you decide what kind of therapy to use?
FINANCES:
What is your fee?
How do I need to pay?
Do you bill clients?
How do you handle cancellations?
Do I need to pay for telephone calls or letters?
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