Overview of alternative treatments for mental health problems. Includes self-help, diet and nutrition, pastoral counseling, more.

An alternative approach to mental health care that emphasizes the interrelationship between mind, body, and spirit can play an important role in recovery and healing. Although some people with mental health problems recover using alternative methods alone, most people combine them with other, more traditional treatments such as therapy and, perhaps, medication. It is crucial, however, to consult with your health care providers about the approaches you are using to achieve mental wellness.

Although some alternative approaches have a long history, many remain controversial. The National Center for Complementary and Alternative Medicine at the National Institutes of Health was created in 1992 to help evaluate alternative methods of treatment and to integrate those that are effective into mainstream health care practice.

Self-Help

Once considered a fringe approach to managing the symptoms of various illnesses, self-help has become an integral part of treatment for mental health problems. Many people with mental illnesses find that self-help groups are an invaluable resource for recovery and for empowerment. Self-help generally refers to groups or meetings that:

• Involve people who have similar needs
• Are facilitated by a consumer, survivor, or other layperson;
• Assist people to deal with a "life-disrupting" event, such as a death, abuse, serious accident, addiction, or diagnosis of a physical, emotional, or mental disability, for oneself or a relative;
• Are operated on an informal, free-of-charge, and nonprofit basis;
• Provide support and education; and
• Are voluntary, anonymous, and confidential.

Diet and Nutrition

Adjusting both diet and nutrition may help some people with mental illnesses manage their symptoms and promote recovery. For example, research suggests that eliminating milk and wheat products can reduce the severity of symptoms for some people who have schizophrenia and some children with autism. Similarly, some holistic/natural physicians use herbal treatments, B-complex vitamins, riboflavin, magnesium, and thiamine to treat anxiety, autism, depression, drug-induced psychoses, and hyperactivity.

Pastoral Counseling

Some people prefer to seek help for mental health problems from their pastor, rabbi, or priest, rather than from therapists who are not affiliated with a religious community. Counselors working within traditional faith communities increasingly are recognizing the need to incorporate psychotherapy and/or medication, along with prayer and spirituality, to effectively help some people with mental disorders.

Animal Assisted Therapies

Working with an animal (or animals) under the guidance of a health care professional may benefit some people with mental illness by facilitating positive changes, such as increased empathy and enhanced socialization skills. Animals can be used as part of group therapy programs to encourage communication and increase the ability to focus. Developing self-esteem and reducing loneliness and anxiety are just some potential benefits of individual-animal therapy (Delta Society, 2002).

Expressive Therapies

Art Therapy: Drawing, painting, and sculpting help many people to reconcile inner conflicts, release deeply repressed emotions, and foster self-awareness, as well as personal growth. Some mental health providers use art therapy as both a diagnostic tool and as a way to help treat disorders such as depression, abuse-related trauma, and schizophrenia. You may be able to find a therapist in your area who has received special training and certification in art therapy.

Dance/Movement Therapy: Some people find that their spirits soar when they let their feet fly. Others-particularly those who prefer more structure or who feel they have "two left feet"-gain the same sense of release and inner peace from the Eastern martial arts, such as Aikido and Tai Chi. Those who are recovering from physical, sexual, or emotional abuse may find these techniques especially helpful for gaining a sense of ease with their own bodies. The underlying premise to dance/movement therapy is that it can help a person integrate the emotional, physical, and cognitive facets of "self."

Music/Sound Therapy: It is no coincidence that many people turn on soothing music to relax or snazzy tunes to help feel upbeat. Research suggests that music stimulates the body's natural "feel good" chemicals (opiates and endorphins). This stimulation results in improved blood flow, blood pressure, pulse rate, breathing, and posture changes. Music or sound therapy has been used to treat disorders such as stress, grief, depression, schizophrenia, and autism in children, and to diagnose mental health needs.

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Culturally Based Healing Arts

Traditional Oriental medicine (such as acupuncture, shiatsu, and reiki), Indian systems of health care (such as Ayurveda and yoga), and Native American healing practices (such as the Sweat Lodge and Talking Circles) all incorporate the beliefs that:

• Wellness is a state of balance between the spiritual, physical, and mental/emotional "selves."
• An imbalance of forces within the body is the cause of illness.
• Herbal/natural remedies, combined with sound nutrition, exercise, and meditation/prayer, will correct this imbalance. 

Acupuncture: The Chinese practice of inserting needles into the body at specific points manipulates the body's flow of energy to balance the endocrine system. This manipulation regulates functions such as heart rate, body temperature, and respiration, as well as sleep patterns and emotional changes. Acupuncture has been used in clinics to assist people with substance abuse disorders through detoxification; to relieve stress and anxiety; to treat attention deficit and hyperactivity disorder in children; to reduce symptoms of depression; and to help people with physical ailments.

Ayurveda: Ayurvedic medicine is described as "knowledge of how to live." It incorporates an individualized regimen--such as diet, meditation, herbal preparations, or other techniques--to treat a variety of conditions, including depression, to facilitate lifestyle changes, and to teach people how to release stress and tension through yoga or transcendental meditation.

Yoga/meditation: Practitioners of this ancient Indian system of health care use breathing exercises, posture, stretches, and meditation to balance the body's energy centers. Yoga is used in combination with other treatment for depression, anxiety, and stress-related disorders.

Native American traditional practices: Ceremonial dances, chants, and cleansing rituals are part of Indian Health Service programs to heal depression, stress, trauma (including those related to physical and sexual abuse), and substance abuse.

Cuentos: Based on folktales, this form of therapy originated in Puerto Rico. The stories used contain healing themes and models of behavior such as self-transformation and endurance through adversity. Cuentos is used primarily to help Hispanic children recover from depression and other mental health problems related to leaving one's homeland and living in a foreign culture.

Relaxation and Stress Reduction Techniques

Biofeedback: Learning to control muscle tension and "involuntary" body functioning, such as heart rate and skin temperature, can be a path to mastering one's fears. It is used in combination with, or as an alternative to, medication to treat disorders such as anxiety, panic, and phobias. For example, a person can learn to "retrain" his or her breathing habits in stressful situations to induce relaxation and decrease hyperventilation. Some preliminary research indicates it may offer an additional tool for treating schizophrenia and depression.

Guided Imagery or Visualization: This process involves going into a state of deep relaxation and creating a mental image of recovery and wellness. Physicians, nurses, and mental health providers occasionally use this approach to treat alcohol and drug addictions, depression, panic disorders, phobias, and stress

Massage therapy: The underlying principle of this approach is that rubbing, kneading, brushing, and tapping a person's muscles can help release tension and pent emotions. It has been used to treat trauma-related depression and stress. A highly unregulated industry, certification for massage therapy varies widely from State to State. Some States have strict guidelines, while others have none.

Technology-based Applications

The boom in electronic tools at home and in the office makes access to mental health information just a telephone call or a "mouse click" away. Technology is also making treatment more widely available in once-isolated areas.

Telemedicine: Plugging into video and computer technology is a relatively new innovation in health care. It allows both consumers and providers in remote or rural areas to gain access to mental health or specialty expertise. Telemedicine can enable consulting providers to speak to and observe patients directly. It also can be used in education and training programs for generalist clinicians.

Telephone counseling: Active listening skills are a hallmark of telephone counselors. These also provide information and referral to interested callers. For many people telephone counseling often is a first step to receiving in-depth mental health care. Research shows that such counseling from specially trained mental health providers reaches many people who otherwise might not get the help they need. Before calling, be sure to check the telephone number for service fees; a 900 area code means you will be billed for the call, an 800 or 888 area code means the call is toll-free.

Electronic communications: Technologies such as the Internet, bulletin boards, and electronic mail lists provide access directly to consumers and the public on a wide range of information. On-line consumer groups can exchange information, experiences, and views on mental health, treatment systems, alternative medicine, and other related topics.

Radio psychiatry: Another relative newcomer to therapy, radio psychiatry was first introduced in the United States in 1976. Radio psychiatrists and psychologists provide advice, information, and referrals in response to a variety of mental health questions from callers. The American Psychiatric Association and the American Psychological Association have issued ethical guidelines for the role of psychiatrists and psychologists on radio shows.

This fact sheet does not cover every alternative approach to mental health. A range of other alternative approaches-psychodrama, hypnotherapy, recreational, and Outward Bound-type nature programs-offer opportunities to explore mental wellness. Before jumping into any alternative therapy, learn as much as you can about it. In addition to talking with your health care practitioner, you may want to visit your local library, book store, health food store, or holistic health care clinic for more information. Also, before receiving services, check to be sure the provider is properly certified by an appropriate accrediting agency.

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RESOURCES

American Art Therapy Association, Inc.
1202 Allanson Road
Mundelein, IL 60060-3808
Telephone: 847-949-6064/888-290-0878
Fax: 847-566-4580
E-mail: arttherapy@ntr.net
www.arttherapy.org

American Association of Pastoral Counselors
9504-A Lee Highway
Fairfax, VA 22031-2303
Telephone: 703-385-6967
Fax: 703-352-7725
E-mail: info@aapc.org
www.aapc.org

American Chiropractic Association
1701 Clarendon Boulevard
Arlington, VA 22209
Telephone: 800-986-4636
Fax: 703-243-2593
www.amerchiro.org

American Dance Therapy Association
2000 Century Plaza, Suite 108
10632 Little Patuxent Parkway
Columbia, MD 21044
Telephone: 410-997-4040
Fax: 410-997-4048
E-mail: info@adta.org
www.adta.org

American Music Therapy Association
8455 Colesville Rd, Suite 1000
Silver Spring, MD 20910
Telephone: 301-589-3300
Fax: 301-589-5175
E-mail: info@musictherapy.org
www.musictherapy.org

American Association of Oriental Medicine
5530 Wisconsin Avenue, Suite 1210
Chevy Chase, MD 20815
Telephone: 888-500-7999
Fax: 301-986-9313
E-mail: hq@aaom.org
www.aaom.org

The Delta Society
580 Naches Avenue SW, Suite 101
Renton, WA 98055-2297
Telephone: 425-226-7357
Fax: 425-235-1076
E-mail: info@deltasociety.org
www.deltasociety.org

National Empowerment Center
599 Canal Street
Lawrence, MA 01840
Telephone: 800-769-3728
Fax: 508-681-6426
www.power2u.org

National Mental Health Consumers'
Self-Help Clearinghouse
1211 Chestnut Street, Suite 1207
Philadelphia, PA 19107
Telephone: 800-553-4539
Fax: 215-636-6312
E-mail: info@mhselfhelp.org
www.mhselfhelp.org

Note: Inclusion of an alternative approach or resource in this fact sheet does not imply endorsement by the Center for Mental Health Services, the Substance Abuse and Mental Health Services Administration, or the U.S. Department of Health and Human Services.

Source: United States Department of Health and Human Services Substance Abuse and Mental Health Services Administration. Current as of September 2002.

next: Mind / Body Medicine for Treating Depression
~ depression library articles
~ all articles on depression

Minorities Have Trouble Getting Mental Health Help

Although minorities are just a likely as non-minorities to experience severe mental disorders such as anxiety, depression, bipolar disorder and schizophrenia, they are far less likely to receive treatment. For instance, the percentage of African Americans receiving needed care is only half that of whites, and 24% of Hispanics with depression and anxiety receive appropriate care compared to 34% of whites with the same diagnosis. Reasons include a lack of access to services, cultural and language barriers, and limited research concerning mental health and minorities.

Many studies have found that lack of access to services is strongly associated with one's level of income and access to medical insurance. Racial and ethnic minorities have higher rates of poverty and a much greater likelihood of being uninsured. For instance, 8% of whites live below the poverty level compared to 22% of African Americans and 27% of Mexican and Native Americans. The percentage of uninsured minorities is over half that of whites.

Individuals experiencing symptoms of a mental disorder are most likely to seek help from their primary care physician, but close to 30% of Hispanics and 20% of African Americans do not have a usual source of healthcare. Even when minorities seek care from a primary care physician, they are less likely to receive appropriate treatment. Also, many minorities live in rural, isolated areas where access to mental health services is limited.

Language is a significant barrier to receiving appropriate mental healthcare. Diagnosis and treatment of mental disorders greatly depends on the ability of the patient to explain their symptoms to their physician and understand steps for treatment. The language barrier often deters individuals from seeking treatment. Thirty-five percent of Asian Americans and Pacific Islanders (AA/PIs) live in households where the primary language is not English and 40% of Hispanics living in the U.S. do not speak English.

Culture, a system of shared meanings, is defined as a common heritage or set of beliefs, expectations for behavior, and values. Culture significantly influences the definition and treatment of mental illness, affecting the way individuals describe their symptoms and the symptoms they exhibit. For instance, African Americans experience symptoms uncommon among other groups such as isolated sleep paralysis, or the inability to move while falling asleep or waking up. Some Hispanics experience symptoms of anxiety that include uncontrollable screaming, crying, trembling, and seizure-like fainting. Cultural beliefs about mental health strongly affect whether or not some people seek treatment, a person's coping styles and social supports, and the stigma they attach to mental illness.

Many people from different cultures see mental illness as shameful and delay treatment until symptoms reach crisis proportions. The culture of physicians and mental health professionals influences how they interpret symptoms and interact with patients.

Research to evaluate different minority groups' response to treatment is limited. Very few studies exist that investigate the appropriateness of certain types of treatment. For example, some research suggests that African Americans metabolize psychiatric medications more slowly than whites, but often receive higher dosages than do whites, leading to more severe side effects. More extensive research is needed to insure minorities receive appropriate treatment.

Finally, while all groups experience mental disorders, minorities are over represented in populations at high risk for experiencing mental illness, including people who are exposed to violence, homeless, in prison or jail, foster care, or the child welfare system. At risk populations are far less likely to receive services than the general population. For more information on this topic, read the Surgeon General's special report on culture, race and ethnicity.

next: Suicide Among Blacks
~ depression library articles
~ all articles on depression

female sexual problems

Frigidity is an inappropriate word used to describe an absence of sexual desire and is often used as a put-down.

This can send confusing messages. Unresponsiveness is a more appropriate word to use to describe this temporary or ongoing lack of sexual desire.

Another definition of sexual unresponsiveness is an unwillingness or lack of enthusiasm to begin or enjoy sex. It can manifest as vaginismus - the inability of the vagina to be penetrated by the penis. The woman's inability to reach orgasm is another indication of unresponsiveness.

For men, a lack of sexual desire is difficult to conceal - the absence of an erection or the inability to ejaculate are obvious; but female unresponsiveness can be hidden - sexual desire and orgasm can be '"faked."

A woman who is sexually unresponsive may still be able to satisfy her partner, but often her unresponsiveness can be evident to him, even if she is fulfilling, or attempting to fulfill, his desires. In any case, the problem needs to be confronted and dealt with.

Why Are Women Sometimes Unresponsive to Sex?

There are some physical causes of sexual unresponsiveness.

Physical causes of sexual unresponsiveness can include illness, disease, being overweight or underweight, some medications such as some contraceptive pills, or the recent birth of a child, and in such cases a medical practitioner should be consulted.

More commonly, the cause lies elsewhere. Male and female sexual responses are different - although most men occasionally lack a desire for sex, their sexual responsiveness can be more instantly 'triggered' than a woman's. Men's sexual fulfillment can also be less complex to achieve, sometimes requiring less stimulation than a woman's.

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A woman's sexual responsiveness can be keyed to many variables - her background and childhood experiences; her casual or formal regard for sex; her satisfaction or otherwise with her own self and self-image; her compatibility with her partner and, very particularly, her partner's capacity and willingness to arouse and stimulate her sexually.

Fatigue is a common cause of female sexual unresponsiveness - particularly so if a woman has the primary responsibility for raising young children. It is very difficult today to find time to be spontaneous about anything, particularly sex. Sex within relationships may be fairly frequent when the relationship is just starting and the thrill can be pursued sometimes at the expense of other things such as work, study, other friendships, playing sport or simply going out together.

Gradually though, other demands take their toll, particularly work and study, family matters, household chores. In most relationships, over time, sex can be relegated to the last thing before bed, something to do on weekends or on holiday - it can become a routine. Often, one partner feels the other partner expects sex at a particular time and the sex can become one-sided or half-hearted, the spontaneity and romance have disappeared. Worries about whether we're satisfying our partner, whether our partner is satisfying us, or about work and finances can inhibit our desire for sex. Feeling anxious about your own sexual performance can be a major factor in turning you away from sex. Some partners feel pressured into having sex because they feel the other partner always wants it.

Women compare themselves and are compared with the 'superwoman' depicted in the media - ever ready to 'satisfy' their man, capable of multiple orgasms 24 hours a day, with the ability to be a mother and dynamic professional at the same time. These images are mythical. Because of media stereotyping and some people's false expectations, a lot of women are genuinely anxious about how they 'rate' in bed compared with their partner's previous partners - the mythical superwoman depicted in the media.

This anxiety compounds sexual problems, with each successive sexual encounter becoming more difficult or less desirable than the last. Sexual unresponsiveness can occur when the woman is anxious about sex - it can cause her to have sex less often with her partner or not actively seek sexual partners at all. When a woman is unresponsive to sex her partner will often register their disappointment and this can make the woman even more anxious so that the woman anticipates her own unresponsiveness each time she is about to have sex.

Some women, who are not happy in a particular relationship, may be disinclined to have or enjoy sex with their partner but will masturbate or have sex with other partners. Their lack of sexual desire is not general, it is specifically related to their main partner. It may be that the woman is suppressing her true sexual self - she may be lesbian or bi-sexual and have no desire to continue having sex with her present partner.

A few women, even in long term relationships, may fear becoming pregnant - this can happen even if both partners have agreed, at least on the surface, to have children. The woman may suppress her true desires about starting or extending a family and the prospect of intercourse may stifle desire and arousal.

Sexual desire can decrease gradually - and naturally - as we age. Sex is not the same at 60 as it was at 25 but it can be just as fulfilling and important.

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Sexual Unresponsiveness - What Can Be Done?

In just about every case, it is possible to overcome an occasional, more frequent or even long-term lack of desire for sex.

It is important to rule out any physical cause. If you suspect that an illness, disease, the physical after-affects of childbirth or a medication (including a contraceptive) may be repressing your desire for sex you should consult a medical practitioner. Alternatively, you may feel you have been suppressing sexual feelings for most of your life; perhaps because of a particular cultural, environmental or religious background or a traumatic incident in your childhood - if so, you should seek the assistance of a counselor.

Depression and similar disorders, and grief after the death of a relative or close friend, can temporarily suppress many feelings of desire - the desire to eat or control eating, the desire to work, the desire to be involved and the desire to have sex.

Some women find the idea of masturbation a turn-off, this is sometimes caused by influences from childhood where masturbation may have been regarded as 'dirty', or by the woman's lack of regard for and pleasure in her own body. Masturbation is a healthy and normal part of sexuality - it is important to learn to turn yourself on, develop erotic and sensual fantasies and feelings and prepare your body and mind for other desires, such as sex with a partner.

Talking with your partner is one of the most important things you can do to overcome your lack of sexual desire - don't suppress the problem, bring it out into the open. Your partner needs to be told what you expect from them - in the home, within the relationship and in bed. If there are things you desire your partner to do with you in bed, tell or show them - partners need to respond to each other in such a way that they both know what they both like and dislike during sex. Don't lie there, 'take it' and let your partner fumble in the dark.

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There will be periods in your life, for example when you are very tired, over stressed by work, family and other commitments or have been ill, when you may experience a lack of sexual desire - this is a normal response. It is important to put these feelings into perspective, to understand the reasons behind them, and understand they need only be temporary - worrying about why you don't feel like sex can turn temporary feelings into a pattern of sexual anxiety.

Be positive about your sexual 'self'. Don't put off sex because you think you're going to 'flunk' or not come up to your partner's expectations or your perceptions of those expectations - tell yourself you can, and will, have terrific sex with your partner. If you don't feel like 'full-on' sex, tell your partner. Don't leave them guessing. And don't let your relationship become penetration-centered, explore other aspects of your relationship - physical affection like cuddling, necking, massage, sensual touch. Feel good about discovering other kinds of sex - tickling and caressing, oral sex, mutual masturbation.

'Variety is the spice of life' - to make it fresh and more exciting, it's important not to get too routine about it - the same positions, limited foreplay, no seduction, penetration only, no 'adventure'. Try to recover some sexual spontaneity- take time to have a 'quickie' occasionally, if you both feel like it, don't lock in to the same time every other night, especially when you're tired or stressed. Be true to yourself and your partner - if you are unwilling to have children, but your partner is and you are worried about getting pregnant, be honest and discuss your differing expectations.

Think about how often you would like to have sex - with your partner, or with someone else. If you would like to have and enjoy sex more often with your current partner, think about the reasons why you don't - are you put off by your partner's criticism (verbal or otherwise) of your performance.

Are you turned-off by what your partner does during sex? Are there positions and techniques you would like to try with your partner? Is there something about yourself that you believe turns your partner off? Is your partner more sexually 'driven' than you? If you would like to have less sex with your partner or more sex, but with someone else, think about the reasons why - are you no longer aroused or turned-on by your partner, are you with the 'right' partner, do you believe your partner has certain expectations of you that you feel you cannot fulfill?

If you are troubled by work hassles, by finances or by family, try to resolve these problems or discuss them with your partner or at least put them at the back of your mind before taking them to bed with you. If you believe you are lesbian, unhappy with your present relationship and would prefer a lesbian lifestyle, don't suppress it, seek counseling from lesbian support agencies.

next: Vaginal Dryness Not Enough Vaginal Lubrication

A woman with bipolar disorder provides her experience of being on a locked psychiatric ward.

Personal Stories on Living with Bipolar Disorder

The Hospital

Please note: The information presented here was obtained from one of my hospitalizations at the Johns Hopkins Hospital in Baltimore Maryland. The hand outs are written by the doctors and staff of the hospital. They reflect the programs offered at Hopkins. Please keep in mind that other psychiatric wards are different. This was just my experience.

What's It Like Being In The Hospital? ~ Patient Information ~ ECT ~ Affective Disorders Program Information

I have been hospitalized more times then I want to remember. Each hospitalization is different. It varies because most of the time there are different doctors and other staff members and very different approaches. Each facility is different as well. Sometimes the programs change. I can tell you that the best place I have ever been hospitalized is Johns Hopkins Hospital in Baltimore, Maryland. It's located about 3 hours from my home. They have an excellent medical team and approach. I have been a "guest" there more times then I'd like to remember. Prior to going to Hopkins, I have been in and out of my small local area hospitals on numerous occasions. It wasn't until I went to Johns Hopkins that I started on my journey to some stability.

In my experience, it's a strange occurrence to be on a locked psychiatric ward. They tell you that the locked aspect of the ward is for safety purposes. It's odd not to be able to come and go but when one is in a critical state, I suppose it is safe to be "locked in." Each hospital has its own set of rules and expectations of the patient. They are some what similar in my experience. When you arrive you are evaluated by a nurse and then the doctor. They ask a series of questions regarding your affect. At Johns Hopkins, they give you what's called a "mini mental" exam. It's a series of questions designed to see how you function and what your memory capacity is at the time. The psychiatrist will evaluate you and then give you a physical examination. When I was at Johns Hopkins last July, the exam with the doctors was about 90 minutes. They have a "team" approach at the hospital.

The team is made up of an attending doc who is the primary on the case, and an resident doc who does most of the work and sometimes a medical student. They do rounds in the morning to assess how you are doing. The rooms are comfortable and the baths are shared by two rooms. They have private and semi-private rooms. Fortunately, I was able to get a private room. I was glad of that. The daily routine consists of educational groups, support groups, occupational therapy, relaxation therapy and gym. Not all hospitals offer these programs. Twice a day you meet with your assigned nurse to discuss how you're feeling. This gives the staff an opportunity to write down your progress so that the team can review your status each day. The majority of the nurses at Johns Hopkins were excellent and very comforting. Meals are served three times a day. One is allowed to select meals from a provided menu. The food was pretty decent and the selections were adequate.

I usually end up in the hospital because I am suffering from very severe depression or mixed states. I had an excellent and very skilled set of doctors thankfully. After my assessment, the team put together a proposal for me that I was not comfortable with however. They suggested ECT for me which threw me completely. Because of the nature and duration of my depression, they felt that ECT would help break the cycle. I had been in bed for months on end with no hope in site and finally I developed a plan to take my life. I was a wreck when I went into Johns Hopkins. After four days of careful consideration, I decided to ask what plan "B" was. My doctors had examined my lengthy records and decided that I had not had a long enough trial of Lithium. Thus they decided to put my back on that drug. They felt I needed two mood stabilizers and I was already taking Depakote. I went through days getting my blood drawn to check my levels and suffered some side effects to boot. However, I decided I wanted to give this a fair chance. So I went through the daily routine each day in the hopes I would start to feel better soon. Just a note about ECT. I did see some improvements in some of the patients who were undergoing ECT. It just wasn't for me at the time. (Update: I no longer take Depakote (Divalproex). I'm on Lamictal (Lamotrigine) and Lithium Carbonate (Eskalith) now).

The first and second days being hospitalized are the hardest. I cried and cried after my husband had to leave. It was very difficult on me. I felt totally isolated and all alone. My depression seemed to get a bit worse because of these intense feelings. You feel like you're under a microscope with all the docs and nurses watching you, not to mention the other patients. Eventually, you make friends on a very deep level. It's easy to relate to someone who shares a similar illness. At first you're very quiet at the groups and don't want to talk or look at anyone. Then in due time you warm up a bit. It becomes easier to look people in the eye instead of away. It also becomes easier to speak if you choose to. The main thing to remember is that your there to get stabilized. That should be your main goal. It takes a lot of work to get there, however.

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Each day I awoke around 7 AM and literally forced myself to shower at least every other day. That was really hard because I was not showering properly at home. I would try eat breakfast like a good camper even though I didn't have much of an appetite. I went to most of the groups as it was expected of me. I tried my best to do what was asked of me, but sometimes I skipped going to the gym and relaxation group because I just wasn't up to it. I would take naps on occasion even though they request that you stay out of your room for the day. Occupational therapy allows you to work on arts and crafts and other things. That group seemed the most enjoyable. They requested that I do an extra task and cook a meal because I was not going to the grocery store or cooking at home. They took me to the grocery store, well actually we walked, and I purchased what was needed for me to cook lunch. Making the lunch seemed rather foreign to me since I hadn't cooked anything in such a long time. It took me a while to get going, but once I did everything turned out fine. I worked the program as best as I could even though it was tremendously difficult. When your so depressed you can't see straight, it's really hard to participate. I fought my feelings to surrender to my gloom on a daily basis.

While I was in the hospital, my mood was not stable. My doctors gave me a scale to measure my moods on from 1-10, 1 being the lowest, 10 being the highest. My moods would fluctuate several times a day. I was never hypo manic, however. For example, my mood would climb in very small increments usually between a 1 and 3. I was very hopeful when my mood would get to a 3 thinking the drugs were working. Then I get slammed back down again. It was very upsetting to say the least. I was in tears a lot of the time. The whole experience was very difficult. I also suffered agitated depression which is very uncomfortable.

Being hospitalized is not glamorous. They expect a lot out of you in an attempt to help you I suppose. You are exposed to all walks of people with varying degrees of illnesses. You are expected to follow the schedule, eat, and participate even if you don't feel like it. On Meyer 4 where I was, there are two groups of illnesses which are affective disorders and eating disorders. The unit has 22 beds and it's very difficult to get on this unit. They always have a waiting list. I had to wait a day or two before they would take me. This was really hard on my family because of the degree of my suicidal state. They watched over me very carefully until I was able to be admitted. Once there, I felt extremely sad, especially when my husband had to leave. He was facing a 3 hour drive home. He visited me during visiting hours as much as possible. The staff was very nice and allowed him to come a bit early and stay a bit late sometimes as long as it didn't interfere with the groups. They do this for people who live far away.

Gradually after almost a month, they discharged me. The Lithium was not an instant success. My doctors explained that it could take several months for the lithium to reach optimum benefits. When I left the hospital, I was still depressed however it wasn't as seriously pronounced and my death wish had gone. I look back on this experience and am thankful for the excellent and knowledgeable doctors that I had. The staff treated me very well for the most part. I fired my old psychiatrist and went with another Hopkins trained doctor. He's excellent and has written four books to boot. I feel very fortunate to have him. Today, I'm doing much better and I feel the Lithium and other drugs I'm taking are starting to improve my state. It was very hard to be hospitalized for that long of a period of time, but I managed and got through it!

If you wish, you can click the links below to see what patient hand-outs and things they give you when you arrive. It will give you good insight as to what it's like to be in the hospital. Thank you.

This is a patient information hand-out I received upon my arrival at Johns Hopkins.

WELCOME TO MEYER 4

Meyer 4 is one of the four separate Inpatient Units of the Henry Phipps Psychiatric Service. It is a specialty unit for affective disorders and eating disorders. The unit functions on the basis of an interdisciplinary team approach working together with you and your family in implementing your individual treatment plan. The members of your treatment team working under the direction of an attending physician are:

Attending physician:	_____________________________
Nurse Manager:	_____________________________
Resident Physician:	_____________________________
Social Worker	_____________________________
Primary Nurse:	_____________________________
Associate Nurse:	_____________________________
Occupational Therapist:	_____________________________
Nutritionist:	_____________________________

Telephones: Nurses Station:

Patient Pay Phones:	_____________________________
Front DayArea:	_____________________________
Patients Hallway:	_____________________________

Patient phones are limited in use to the hours of 8AM-11PM. Please limit calls to 15 minutes at a time in consideration of others.

VISITING HOURS:

Monday/Wednesday/Friday - 6PM-7PM
Tuesday/Thursday: - 6PM-8PM
SaturdaylSunday/Holidays: - 12PM-8PM

Children and infants must be under the supervision of parents or guardians. Parents or guardians of patients under the age of 18 years must provide the staff with a written list of approved visitors.

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MEDICATIONS: On admission, medications will be ordered by your Meyer 4 physicians. Please arrange to send home any medications (prescribed or over-the-counter medications) brought with you. All medications will be administered to you on a daily basis by nursing staff. No medications are allowed to be kept in your room, (unless an exceptional doctor's order is given. Please take note of the times they are ordered. It is important to keep them on schedule. We encourage you to learn all you can from your physicians and nurses about your medications.

VALUABLES: Please send all valuables home. If not possible, hospital security will place your valuables in the Admitting Office safe and give you a receipt for retrieval. We advise keeping a small amount of case to use for laundry, magazines, sundries, etc. You can purchase items in the gift shop located on the first floor of the hospital.

ROOMS: On admission, you will be assigned a single or a double room. There are times when we must change patient rooms because of your treatment requirements or those of another patient
NOTE: Male and female patients are not allowed to visit in the same room.

TEAM ROUNDS AND INDIVIDUAL THERAPY:Your physicians will make walking rounds on the unit every morning. Therefore, you should not leave the unit until after your physicians have seen you. This is an essential time to discuss your problems and treatment plan on a daily basis.

For individual therapy, your assigned resident physician will arrange set times with you.

Your primary and associate nurses will individually plan your care with you and take a special interest in assisting you with your treatment goals. When they are not on duty, another nurse will be assigned. You and your nurse arrange an appropriate time to meet for an individual session.

The social worker is concerned with understanding you in relation to your family and your environment. Sessions can be arranged for guidance in utilizing community resources, discharge planning and family counseling.

The nutritionist is concerned with your dietary needs. Sessions can be arranged to guide you individually, especially if you have an Eating Disorder.

GROUP THERAPY: Much of your psychotherapy is conducted in the group setting. The occupational therapist will discuss with you which groups you are assigned, and you will receive a schedule to follow. The nursing staff also conducts teaching and support groups. Attendance and participation are expected at the daily groups (Monday-Friday), and in community meetings (Monday and Friday evenings). We encourage you to learn all you can, ask questions and appropriately discuss problems. Educational material about your illness will be provided in the form of videos, slides, books, articles and other printed handouts.

RESEARCH: The Johns Hopkins Hospital is proud of its contributions to the discovery of causes and treatments of disease. The advances in psychiatry are the results of research projects involving clinicians and their patients.

We hope you will consider taking part in research projects presented to you. However, you have no obligation to take part in them.

GETTING UP IN THE MORNING AND BEDTIME:All patients are expected to be up no later than 9:00 a.m., and dressed in appropriate street clothes. Patients are expected to retire to their rooms at the latest by 12 midnight (during the week), and by 1:00 a.m. (on weekends). The night staff checks each patient's room every half hour during the night for your safety. Please alert the staff if you have difficulty sleeping.

MEALS: Three meals a day (and a snack if appropriate) will be brought to the unit Patients are expected to eat int the front day area of the unit. Your name will be on your menu on your tray. Blank menus will be brought each evening to the unit for your selection. Note that newly admitted patients who have Eating Disorders do not receive menus but will receive special instructions and be provided with an Eating Disorder
Protocol booklet.

MealTimes: Breakfast 8 am-9 am
Lunchl2 pm-l pm
Supper5 pm -6 pm

SAFETY FOR ALL PATIENTS: All packages brought to the unit must be checked at the nurses station. Sharps such as, (razors, scissors, knives, etc.) will be taken from you and secured at the nurses station. Potentially harmful chemicals (such as, nail polish remover), will be removed and secured Visitors may not give any type of medication to patients. Visitors may notprovide food (including candy and gum) to patients who have Eating Disorders because their diet is strictly and therapeutically supervised. Alcoholic beverages and illicit drugs are strictly prohibited on the unit Please note: For reasons of patient safety, the treatment team will decide to keep wilt doors locked.

T.L.O.A.'s: or Therapeutic Leave of Absence. A physician's order, with the approval of the treatment team, as required. First fill out a request form; talk it over with your primary or associate nurse; and obtain comments and signatures from either of them. The request will then be discussed and a decision will be made by your treatment team.

T.L.O.A's are generally granted toward the end of hospital stay. The main purpose of a T.L.O.A. is to assess how patients function and communicate with their families and loved ones, (in the home setting usually). This is preparatory to discharge. It is vital that patients, families, and significant others inform the staff about the activities, and interactions involved on T.L.O.A

T. L.O.A's are usually granted for Saturday and Sunday in time spans of 4-8 hours (never overnight). Overnight and too frequent day passes are not usually approved by health insurance. T. L.O.A.'s should not interfere with groups.

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ON CAMPUS WALKS:Means that you may walk inside the hospital and the sidewalk encircling the building; not woss streets. These are usually permitted with staff, or family (if considered therapeutic); and are time-limited. They are not to interfere with scheduled groups. Sometimes patients are allowed time-limited on campus walks alone (if therapeutic).
NOTE: This is an inner city area wherein you should exercise caution, more so than in a rural or suburban area. Patients under the age of 18 years are required to have written permission from parents or guardians stating approval for on campus walks alone. All patients leaving the unit must sign out at the nurses station.

UNIT FACULTIES: The laundry room is located in the patient's hallway. Itis equipped with a washer and dryer.

The day area, in the front of the unit, contains a kitchen as well as a dining area, a lounge area with a television, VCR, books, games, and plants.

The back activity room has a lounge with a television, books, games, and a ping-pang table.

We hope you'll be able to use and enjoy these facilities, and please remember that they are shared with as many as 22 patients at a time. Noise level should be kept down. Each person should be considerate of others. We encourage self responsibility for keeping rooms and unit facilities in order.

We encourage you to ask questions. We will do our best to keep you informed and to assist you in getting adapted to the community of Meyer 4.

I was given this hand out explaining ECT while hospitalized at Johns Hopkins.

ECT Procedure

ECT involves a series of treatments. For each treatment, you will be brought to a specially equipped room in this hospital. The treatments are usually given in the morning, before breakfast. Because the treatments involve general anesthesia, you will have had nothing to drink or eat for at least 6 hours before each treatment, unless special orders have been written by the doctor to receive medicines with a sip of water. An intravenous line (IV) is placed in your arm so that medicines that are part of the procedure can be given. One of these is an anesthetic drug that will quickly put you to sleep. When you are asleep, you are given a second drug that relaxes your muscles. Because you are asleep, you do not experience pain or discomfort during the procedure. You do not feel the electrical current and when you wake up you have no memory of the treatment.

To prepare for the treatments, monitoring sensors are placed on your head and chest. Blood pressure cuffs are placed on one arm and one ankle. This enables the physician to monitor your brain waves, heart, and blood pressure. These recordings involve no pain or discomfort.

After you are asleep, a small, carefully controlled amount of electricity is passed between two electrodes that have been placed on your head. Depending on where the electrodes are placed, you may receive either bilateral ECT or unilateral ECT. In bilateral ECT, one electrode is placed on the left side of the head, the other on the right side. When the current is passed, a generalized seizure is produced in the brain. Because you will be given a medication to relax your muscles, muscular contractions in your body that would ordinarily accompany a seizure will be considerably softened. You will be given oxygen to breathe. The seizure will last for approximately one minute.

Within a few minutes, the anesthetic drug will wear off an you will awaken.

You will be brought to a recovery room, where you will be observed unfit you are ready to leave the ECT area and return to the unit.

Frequently asked questions about ECT...

1.Will the procedure hurt?

No. Prior to getting ECT you will receive a muscle relaxant to prevent muscle strain from the seizure and general anesthesia so no pain is felt.

2.Why has my doctor recommended ECT for me?

ECT is recommended for patients will drug resistant affective disorders and patients who are acutely suicidal and at high risk of harming themselves.

3.How effective is ECT?

ECT is proven to be effective in about 80% of people receiving it. This is more promising than most anti-depressants.

4.Is it dangerous? And how do you know if it is safe for me?

The risks of ECT are about equal to that of minor surgery with general anesthesia. About I death occurs in 10,000 patients receiving ECT. The procedure itself is administered by an experienced team of clinicians and is carefully monitored. Many
pre-ECT tests will be done to make sure ECT is safe for you. This includes blood tests, general physical, mental status exam, and an anesthesia consult. Chest x-rays and an ECG are done for older patients.

5.Doesn't ECT make you lose your memory?

ECT causes short term memory disturbances. Long term memory is generally not affected. You may forget events surrounding the procedure and even things that happen a few days before and in between treatments. It will be difficult to remember things. This clears up in a few weeks after treatments with a return to pre-treatment functioning in 3-6 months.

6.Does it cause brain damage?

No. Research shows that ECT does not cause any cellular or neurological changes in your brain.

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7.What other side effects might I experience?

Along with memory disturbances, you may experience confusion, muscle soreness, headache, and nausea. Inform your doctor or nurse if you experience any of these.

8.How many ECT treatments will I need?

A series of 6-12 treatments is recommended for the greatest effect. Your doctor will decide how many are best for you.

9.Why can't I eat or drink before the treatment?

As with a surgical procedure you should have nothing in your stomach so as to prevent anything from coming up and choking you.

10.How long does the procedure take?

The procedure takes about one hour from the time you leave the unit to the time you return. The seizure itself will only last 20-90 seconds. The rest of the time is for preparation for and recovery from the procedure.

11.When will I notice improvements from ECT?

Most people will notice improvements in their symptoms in about one to two weeks

Information Obtained From The Johns Hopkins Hospital, Baltimore, Maryland.

This was given to me while I was hospitalized at Johns Hopkins in July 2000.

AFFECTIVE DISORDERS PROGRAM

Affective disorders are illnesses that affect the way people feel, think and act. They may cause patients to develop unhealthy behaviors that may easily become habits. One of the goals of the Phipps Clinic is to encourage the return of healthy behaviors that will support that patient after returning home. Our structured program supports the medical treatment that patients receive and enhances treatment outcomes. We encourage patients to participate fully in the Affective Disorder Program and to share the responsibility for their treatment by following these guidelines:

Communication:

Be informed about your illness and about your treatment. We encourage full participation in treatment and discharge planning. Discuss your concerns and your treatment plan on a daily basis with the treatment team. If your family has specific concerns they should contact the social worker.

Making everyone feel comfortable is important. Be polite and respectful in interactions with other patients, staff and visitors.

Groups:

Groups are an essential part of the program. We offer several types of groups - education, support and occupational therapy groups. These groups are designed to help you learn more about your illness and develop skills to help you cope with your illness. They also give us important information that help us assess your progress; so it is important to attend all your scheduled groups. We ask that you use on campus privileges only during non-group times and ask visitors, including any out-of-town visitors, to come during non-group times.

You may also be given assignments designed to address your treatment goals. It is important to complete your assignments.

Medications:

You will receive education about your medications. Try to learn as much as possible about your medications and to get into the habit of taking medications at the regularly scheduled times. You are encouraged to approach your nurse for your medications on time. This will help establish the health habit of taking responsibility for taking medication at specific times while you are still in the supportive surroundings of the hospital.

Activities of Daily Living:

The symptoms of the illness may lead patients with affective disorder to neglect activities of daily living, e.g., getting out of bed, maintaining personal hygiene, eating meals, etc., which can lead to worsening of the depressions and other complications. We encourage patients to maintain appropriate activities of daily living by maintaining proper hygiene, grooming and appropriate dress. Please ask your nurse if you will need assistance.

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Physical Activity:

It is also important to keep active by getting some physical activity each day, in the gym or on walks. We encourage you to stay out of your room at least 6 hours a day and not isolate yourself from others.

Sleep Habits:

We encourage you to be up and out of bed by 8:30 AM. To promote proper sleep hygiene, we recommend that patients retire to their rooms by 12:00 midnight during the week, and by 1:00 AM on weekends. Adolescents are to be in bed by 11:00 PM on weekdays and 12:00 midnight on weekends.

Nutrition:

We will be assessing your food and fluid intake to see if you are maintaining proper nutrition. Meals should be eaten in the dining area. To facilitate getting the meal that you ordered, please complete your menus for the next day by 1:00 PM.

Privileges:

Patient safety is our highest priority. For this reason, if we think a patient is at risk for harming himself or herself, we have the patient stay on the inpatient unit on observation until he/she is safe. Once a patient is safe to go off the unit the first privilege is to go on campus with staff for tests and groups.

The next privilege level is to go on campus with family, then later in the hospitalization, on campus alone for periods of time.

Towards the end of the hospitalization, the patient may be given a therapeutic leave of absence (TLOA) to assess one's mood and level of functioning off the unit.

You are strongly encouraged to follow these guidelines which we have found to be helpful in our treatment of many patients with affective disorders. Participation in the entire Affective Disorder Program is considered when the Treatment Team determines what privilege level is appropriate for you.

next: Juliet: Family and Bipolar Disorder
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Examine closely your dreams and goals for your children and other loved ones. Are you over-emphasizing beauty and body shape?

1. Consider your thoughts, attitudes, and behaviors toward your own body and the way that these beliefs have been shaped by the forces of weightism and sexism. Then educate your children about. 
   1. the genetic basis for the natural diversity of human body shapes and sizes, and
   2. the nature and ugliness of prejudice.
   Make an effort to maintain positive, healthy attitudes & behaviors. Children learn from the things you say and do!
2. Examine closely your dreams and goals for your children and other loved ones. Are you over-emphasizing beauty and body shape?
   • Avoid conveying an attitude which says in effect, "I will like you more if you lose weight, don't eat so much, look more like the slender models in ads, fit into smaller clothes, etc."
   • Decide what you can do and what you can stop doing to reduce the teasing, criticism, blaming, staring, etc. that reinforce the idea that larger or fatter is "bad" and smaller or thinner is "good."
3. Learn about and discuss with your sons and daughters (a) the dangers of trying to alter one's body shape through dieting, (b) the value of moderate exercise for health, and (c) the importance of eating a variety of foods in well-balanced meals consumed at least three times a day.
   • Avoid categorizing foods into "good/safe/no-fat or low-fat" vs. "bad/dangerous/ fattening."
   • Be a good role model in regard to sensible eating, exercise, and self-acceptance.
4. Make a commitment not to avoid activities (such as swimming, sunbathing, dancing, etc.) simply because they call attention to your weight and shape. Refuse to wear clothes that are uncomfortable or that you don't like but wear simply because they divert attention from your weight or shape.
5. Make a commitment to exercise for the joy of feeling your body move and grow stronger, not to purge fat from your body or to compensate for calories eaten.
6. Practice taking people seriously for what they say, feel, and do, not for how slender or "well put together" they appear.
7. Help children appreciate and resist the ways in which television, magazines, and other media distort the true diversity of human body types and imply that a slender body means power, excitement, popularity, or perfection.
8. Educate boys and girls about various forms of prejudice, including weightism, and help them understand their responsibilities for preventing them.
9. Encourage your children to be active and to enjoy what their bodies can do and feel like. Do not limit their caloric intake unless a physician requests that you do this because of a medical problem.
10. Do whatever you can to promote the self-esteem and self-respect of all of your children in intellectual, athletic, and social endeavors. Give boys and girls the same opportunities and encouragement. Be careful not to suggest that females are less important than males, e.g., by exempting males from housework or childcare. A well-rounded sense of self and solid self-esteem are perhaps the best antidotes to dieting and disordered eating.

next: What Parents Can Do To Promote Self-Esteem in Girls
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~ all articles on eating disorders

A comparison between entrepreneurs and characteristics of people with ADHD and the impact undiagnosed ADHD has had on some entrepreneurs.

The majority of business owners exhibit ADHD characteristics.

The United States is in the midst of an entrepreneurial renaissance. People are literally waking up to the idea that they can work for themselves and make a lot of money doing it. And, while there are as many types of entrepreneurs as there are businesses, most entrepreneurs share some common traits. They tend to be visionaries. People who go into business for themselves tend to be risk takers. After almost a decade of coaching entrepreneurs, it has also been my observation that a majority of all entrepreneurs have Attention Deficit Hyperactivity Disorder, or AD/HD.
They may not be taking medication and many of them haven't even been diagnosed, but anyone who knows AD/HD would recognize the signs. The chart below compares AD/HD with Entrepreneurship. As they use to say on those old TV shows, only the names have been changed.

ADHD Distracted-Seems to always have something new to think about.
Entrepreneur - Constantly has new ideas for how to improve the business

ADHD - Starts several projects at the same time, may not complete any of them.
Entrepreneur - Flexible. Approaches problems from several different angles, always ready to change direction if that is what is needed

ADHD - Distorted sense of time. For example, will spend hours playing a video game without realizing how much time has passed.
Entrepreneur - Immerses him or herself in the job and often does not realize how much time has passed

ADHD - Visual thinkers
Entrepreneur - Visionaries who paint a picture for others

ADHD - Hands-on learners
Entrepreneur - Hands-on managers

ADHD - Hyperactive
Entrepreneur - Always on the go

Once you understand what AD/HD looks like, you could easily conclude that virtually all successful entrepreneurs have AD/HD. Experts on AD/HD believe that Benjamin Franklin had AD/HD. Coincidentally, Franklin is also thought to be the first American entrepreneur. There is evidence that Thomas Edison had AD/HD, as did Henry Ford, Walt Disney and both of the Wright Brothers. You don't have to go as far back as Edison and Ford to find examples of successful AD/HD entrepreneurs. David Neeleman, CEO of JetBlue, has publicly acknowledged his AD/HD. Neeleman has chosen not to take medication for AD/HD and has instead learned how to use his "unique brain wiring" to his advantage, now that he better understands it.

Understanding your AD/HD, if you have AD/HD, could be the first step towards realizing your full potential in business and in your personal life.

Thomas Apple, the inventor/designer of the NASDAQ video billboard in New York's Times Square and a successful businessman, told ADDitude magazine how his undiagnosed AD/HD had affected his life: "I was 40 years old when I realized I really was a smart person," he says. Like many entrepreneurs and others who don't color in the lines, Apple had trouble as a child. "I was well on the way to delinquent behavior by third-grade," Apple recalls. "I thought, 'if I'm going to be treated this way, I might as well act this way." After his son and daughter were diagnosed with AD/HD, Apple took a hard look at his pattern of career difficulties and two failed marriages and realized that he probably had it too. A doctor confirmed the diagnosis. Apple now takes medication to treat his AD/HD, but he realizes that there's more to it than taking medication. ADD isn't a 'take two pills and call me in the morning' type of diagnosis," he says. "It is something that you have to do 24/7."

Apple's story about realizing he had AD/HD after first seeing it in his children is very common among adults who have been diagnosed. AD/HD is a genetic disorder. If a child has it, there is up to a 70% chance that at least one of the parents has it too.

David Giwerc MCC,(Master Certified Coach, ICF) is the Founder/President of the ADD Coach Academy (ADDCA), http://www.addca.com,/ a comprehensive training program designed to teach the essential skills necessary to powerfully coach individuals with Attention Deficit Hyperactivity Disorder. He has been featured in the New York Times, London Times, Fortune and other well-known publications. He has a busy coaching practice dedicated to ADHD entrepreneurs and the mentoring of ADD coaches. He helped develop ADDA's Guiding Principals For Coaching Individuals with Attention Deficit Hyperactivity Disorder. He has been a featured speaker at ADDA, CHADD, International Coach Federation and other conferences. David is the current President of ADDA.

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next: Business Solutions for the ADHD Entrepreneur
~ adhd library articles
~ all add/adhd articles

And the Finger of the Day

The hand of the past pushes a depressive toward depression. But it is usually the jab of a present event that triggers the pain - say, loss of your job, or being jilted by your lover. It is that contemporary happening that darkly dominates your thoughts when you are depressed. To get undepressed you must reconstitute your current mode of thinking so you can get rid of the black thoughts. Again - yes, the past causes you to be what you are now. But the main avenue out of your present predicament is by reconstructing the present rather than dealing with the past.

A crucial issue is whether you interpret contemporary events accurately, or instead distort them in such manner as to make them seem more negative than they "really" are. We are here talking only of negatively-perceived current events. Positively- perceived current events which are persistently misperceived as even more positive than they "really" are constitute part of the manic phase of a manic depressive cycle. (By the way, most depressives do not have extended manic periods after their depression becomes chronic.)

Usually there is little question about whether a current event has a negative or positive valence for a person. Almost all of us, almost all the time, agree about whether such events as loss of a job, death of a loved one, damage to health, financial distress, success in sports or education, are positive or negative. Sometimes, of course, a person's reaction is unexpected: You may conclude that loss of wealth or a job or a competition really is beneficial, by relieving you of a hidden burden or opening up new perspectives or changing your view of life. But such unusual cases are not our topic.

In many cases the knowledge of your fate reaches you along with knowledge of how others have done. And in fact, such outcomes as an examination score or a competitive sports outcome only have meaning relative to the performance of other people.

What Should Be Your Standards For Self-Comparisons?

The choice of whom to compare yourself with is one of the important ways that you structure your view of your life. Some choices lead to frequent negative comparisons and consequent unhappiness. A psychologically "normal" seven-year-old boy will compare his performance in shooting a basketball to other seven- year-olds, or to his own performance yesterday. If he is psychologically normal but physically not talented, he will compare his performance today only to his performance of yesterday, or to other boys who are not good at basketball. But some seven-year-olds like Billy H., insist on comparing their performances to their eleven-year-old brothers; inevitably they compare poorly. Such children will bring unnecessary sadness and despondency upon themselves unless they change their standards of comparison.

Whose performance should you compare yourself to? People of the same age? Those with similar training? People with similar physical attributes? With similar skills? There is no general answer, obviously. We can say, however, that the "normal" person chooses a standard for comparison in such manner that the standard does not cause very much sadness. A sensible fifty- year-old jogger learns to compare his time for the mile to others' times in his age and skill class, not to the world record or even to the best fifty-year-old runner in the club. (If the standard is so low that it provides no challenge, the normal person will move to a higher standard that offers some uncertainty and excitement and pleasure in achievement.) The normal person lowers too-high standards in the same manner that a baby learns to hold on when starting to walk; the pain of doing otherwise is an effective teacher. But some people do not adjust their standards in a sensible flexible fashion, and hence they open themselves to depression. To understand why this is so for a particular person, we must refer to his psychological history.

I am an example of a person with an unwise set of standards. I treat myself the way an engineer treats a factory: the goal is perfect deployment and allocation of resources, and the criterion is whether the maximum output is achieved. For example, when I wake at 8:30 a.m. on weekdays, I feel like a time thief until I have hit my desk and started work. On a weekend day I may wake at nine--and then I think "Am I cheating the children by sleeping too much?" Maximum productivity may be a reasonable goal for a factory. But one's life cannot be satisfactorily reduced to a striving to meet a single criterion. A person is more complex than is a factory, and a person is also an end in himself or herself, whereas a factory is only a means to an end.

How We Distort Reality and Cause Negative Self-Comparisons

One may manipulate current reality in still other ways that produce frequent negative self-comparisons. For example, one may convince oneself that other people perform better than they really do, or are better off than they are. A young girl may believe that other girls really are prettier than she is, or that others have many more dates than she has, when this is not true. An employee may be wrongly convinced that other employees are being paid more than she is. A child may refuse to believe that other children share her difficulty in making friends. A person may think that all others have argument-free marriages, and never fail to cope with the demands of their children.

Another way that you may generate more negative self- comparisons than a "normal" person is by inaccurately interpreting a single event as something other than what it really is. If you receive a reprimand from the boss, you may immediately leap to the conclusion that you will be fired, and if you are warned that you may be fired you may conclude that the boss surely intends to fire you, even when these conclusions are not warranted. A person who suffers a temporary physical disability may conclude that he is disabled for life when that is medically most improbable.

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Still another way a person can produce many negative self- comparisons is by putting disproportionate weight on single negative instances. A non-depressive girl will react to the information that she has failed an exam or received a reprimand from the boss by combining this instance with her entire past record. And if this is the first failed test in her school history, or the first reprimand on this job, the non-depressive girl will see this instance as being somewhat exceptional and therefore not deserving of great attention. But some people (all of us do it sometimes) will, on the basis of this one instance, make a faulty generalization about their present conditions with respect to this dimension of the person's life. Or, one may make an inaccurate generalization about one's whole life on this dimension based on this one instance. The depressive carpenter who loses a job once may generalize, "I can't hold onto a job," and the depressive basketball player may generalize, "I'm a lousy athlete" after one poor game on the basketball court.

A person's judgment may also be inaccurate because he or she puts too little emphasis on a present event. A woman who has learned athletics late in life may continue to think of herself as unathletic, though her present achievements make the past irrelevant in this respect.

The Causes of Distortion

Why should some people's interpretations of their present conditions and life experiences be inaccurate or distorted in such manner that depression is brought on? There are several possible factors acting singly or together, including early training in thinking, extent of education, fears caused by present and past experience, and physical condition. These will now be discussed in turn.

Albert Ellis and Aaron Beck explain most depression as due to poor thinking and distorted interpretations of present reality. And they analyze the present operation of the mechanism without delving into the past causes of such bad thinking. They believe that just as a student can be taught to do valid social-science research in a university, and just as a child in school can improve his or her information-gathering and reasoning with guided practice, so can depressives be taught better information- gathering and processing, by education in the course of psychotherapy.

Indeed, it is reasonable that if you judge your situation in the light of a biased sample of experience, an incorrect "statistical" analysis of your life's data, and an unsound definition of the situation, you are likely to misinterpret your reality. For example, anthropologist Molly H. was often depressed for long periods of time whenever one of her professional papers was rejected by a professional journal. She ignored all her acceptances and successes, and focused only on the present rejection. Ellis' and Beck's sort of "cognitive therapy" trained Molly to consider a wider sample of her life experience after such a rejection, and hence reduced her sadness and shortened her depressed periods.

Burns prepared an excellent list of the main ways that depressed patients distort their thinking. They are included as an after note to the chapter.

Poor childhood training in thinking, and subsequent lack of schooling, may be responsible for an adult's misinterpretation of reality in some cases. But the lack of strong relationship between, on the one hand, amount of schooling, and on the other hand, propensity to depression, casts doubt on poor mental training as a complete explanation in many cases. More plausible is that a person's fears cooperate with poor training. Few of us reason well in the midst of panic; when fire breaks out few of us think as clearly about the situation as if we were sitting quietly, and coolly considering such a situation. Similarly, if a person greatly fears failure in school or profession or in an interpersonal relationship because the person was severely punished for such failure when young, then the fear may panic the person into poor thinking about such an occurrence when it happens. The genesis and cure of such poor thinking will be discussed in following sections.

Sometimes a current major catastrophe such as loss of a loved one, a physical disability, or a tragedy in the community, triggers depression. Normal people recover from grief, and find satisfying lives again, and in a "reasonable" length of time. But a depressive may not recover. Why the difference? It is reasonable to think that experiences in the past predispose some people to remain in depression after a tragedy whereas others recover, as discussed in Chapter 5.

Grief deserves attention because, as Freud put it, the person's sad feelings in ordinary depression are like those in grief. And indeed, his observation is consistent with the view of this book that sadness results from a negative comparison of actual and benchmark states. The benchmark event in the grief after the loss of a loved one is the wish that the loved one is still alive. Grief in the normal person also resembles depression in that the sadness is more prolonged than the normal person suffers after less catastrophic events. But the depressive may not recover from his grief at all, in which case we properly call it depression. Freud's analogy of depression with grief is otherwise not helpful, however, because it is the difference between depression and grief--as between depression and all other sadness from which people recover quickly--that is important, rather than any special similarity between depression and grief.

Physical condition can affect one's interpretation of present circumstances. We have all had the experience of suffering a setback when tired, but after a rest later realizing that we had overestimated the damage and the seriousness. And this is logical, because a tired person is less able to deal with a problem, and hence the setback is more serious and more negative relative to a desired or accustomed state of affairs than when one is fresh. Too much mental stimulation may have a similar effect by overloading and tiring the nervous system. (The role of too little stimulation in depression might be interesting, too.)

Summary

A crucial issue in depression is whether you interpret contemporary events accurately, or instead distort them in such manner as to make them seem more negative than they "really" are. We are here talking only of negatively-perceived current events.

The choice of whom to compare yourself with is one of the important ways that you structure your view of your life. Some choices lead to frequent negative comparisons and consequent unhappiness. This chapter discusses various mechanisms that can operate to cause one to view one's situation in a fashion that produces negative self-comparisons.

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"I think about food constantly. I am always trying to control the calories and fat I eat, but so often I end up overeating. Then I feel guilty and vomit or take laxatives so I won't gain weight. Each time this happens I promise myself that the next day I will eat normally and stop the vomiting and laxatives. However, the next day the same thing happens. I know this is bad for my body, but I am so afraid of gaining weight."

The stereotypic image of those suffering from eating disorders is not as valid as once thought.

This vignette describes the daily existence of one person seeking treatment for an eating disorder in our clinic. A second person reported, "I don't eat all day and then I come home from work and binge. I always tell myself I'm going to eat a normal dinner, but it usually turns into a binge. I have to re-buy food so no one notices all the food is gone."

Stop for a moment and try to envision these two individuals. For most people, the image of a young, middle-class, white female comes to mind. In fact, the first quote came from "Patricia," a 26-year-old African-American female, and the second from "Gabriella," a 22-year-old Latina* woman.

Recently, it has become apparent that the stereotypic image of those suffering from eating disorders may not be as valid as once thought. A primary reason why eating disorders appeared to be restricted to white women seems to be that white women were the only people with these problems who underwent study. Specialists conducted most of the early research in this area on college campuses or in hospital clinics. For reasons related to economics, access to care, and cultural attitudes toward psychological treatment, middle-class white females were the ones seeking treatment and thus the ones who became the subjects of research.

Defining Eating Disorders

Experts have identified three major categories of eating disorder:

• Anorexia nervosa is characterized by the incessant pursuit of thinness, an intense fear of gaining weight, a distorted body image, and a refusal to maintain a normal body weight. Two types of anorexia nervosa exist. Those suffering from the so-called restricting type severely restrict their caloric intake by extreme dieting, fasting, and/or excessive exercise. Those of the so-called binge-eating purging type exhibit the same restricting behavior but also fall victim to bouts of gorging, which they follow with vomiting or abusing laxatives or diuretics in an attempt to counteract the overeating.
• Bulimia nervosa consists of episodes of binge eating and purging that occur an average of twice a week for at least three months. Binge eaters devour an excessive amount of food in a brief period of time, during which they feel a general loss of control. A characteristic binge might include a pint of ice cream, a bag of chips, cookies, and large quantities of water or soda, all consumed in a short time. Again, purging behavior such as vomiting, abusing laxatives or diuretics, and/or excessive exercise occurs after the binge in an effort to get rid of the calories taken in.
• Binge-eating disorder (BED) is a more recently described disorder that comprises bingeing similar to bulimia but without the purging behavior used to avoid gaining weight. As among bulimics, those experiencing BED feel a lack of control and undergo bingeing an average of twice a week.

Bulimia and binge-eating disorder are more common than anorexia.

It may come as a surprise to some that both bulimia and BED are more common than anorexia. Interestingly, prior to the 1970's, eating-disorder specialists rarely encountered bulimia, yet today it is the most commonly treated eating disorder. Many experts believe the rise in rates of bulimia has to do in part with western society's obsession with thinness and the shifting role of women in a culture that glorifies youth, physical appearance, and high achievement. Eating-disorder therapists are also treating more individuals with BED. Although doctors identified binge eating without purging as early as the 1950's, BED was not systematically studied until the 1980's. As such, the apparent increase in BED incidence may merely reflect an increase in BED identification. Among females, typical rates for bulimia are 1 to 3 percent and for anorexia 0.5 percent. The prevalence of significant binge eating among obese persons in community populations is higher, ranging from 5 to 8 percent.

Next to white women, African-American women have been studied the most when it comes to eating disorders. Yet apparent contradictions exist in the data.

As the field of eating disorders has evolved, researchers and therapists have begun seeing a number of changes. These include an increase in eating disorders among men. While the vast majority of anorexics and bulimics are female, for example, a higher percentage of men are now struggling with BED. And despite the common wisdom that minority women have a kind of cultural immunity to developing eating disorders, studies indicate that minority females may be just as likely as white females to develop such debilitating problems.

"Patricia" and other African-Americans

Of all minority groups in the U.S., African-Americans have undergone the most study, yet results bear apparent contradictions.

On the one hand, much of the research suggests that even though African-American women are heavier than white women -- 49 percent of black females are overweight as opposed to 33 percent of white females -- they are less likely to have disordered eating than white women are. In addition, African-American women are generally more satisfied with their bodies, basing their definition of attractiveness on more than simply body size. Instead, they tend to include other factors such as how a woman dresses, carries, and grooms herself. Some have considered this broader definition of beauty and greater body satisfaction at heavier weights a potential protection against eating disorders. In fact, some studies conducted in the early 1990's indicate that African-American women exhibit less restrictive eating patterns, and that, at least among those who are college students, are less likely than white women to engage in bulimic behaviors.

Younger, more educated, and perfection-seeking African-American women are most at risk of succumbing to eating disorders.

The overall picture is not so clear, however. Take, for example, Patricia's story. Patricia's struggle with daily bingeing followed by vomiting and laxative abuse is not unique. Nearly 8 percent of the women we see in our clinic are African-American, and our clinical observations parallel research studies reporting that African-American women are just as likely to abuse laxatives as white women are. Data from a recent large, community-based study give more reason for concern. The results indicate that more African-American women than white women report using laxatives, diuretics, and fasting to avoid weight gain.

Much research is now focused on identifying factors that affect the onset of eating disorders among African-American women. It seems that eating disorders may relate to the degree to which African-American women have assimilated into the dominant American social milieu -- that is, how much they have adopted the values and behaviors of the prevailing culture. Not surprisingly, African-American women who are the most assimilated equate thinness with beauty and place great importance on physical attractiveness. It is these typically younger, more educated, and perfection-seeking women who are most at risk of succumbing to eating disorders.

Patricia fits this profile. Recently graduated from law school, she moved to Chicago to take a position with a large law firm. Each day she strives to do her job perfectly, eat three low-calorie, low-fat meals, avoid all sweets, exercise for at least an hour, and lose weight. Some days she is successful, but many days she cannot maintain the rigid standards she has set for herself and ends up bingeing and then purging. She feels quite alone with her eating disorder, believing that her eating troubles are not the kind of problems that her friends or family could possibly understand.

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"Gabriella" and other Latinas

As the fastest-growing minority population in the U.S., Latinas have been increasingly included in studies of disordered eating. Like African-American women, Latina women were thought to bear cultural immunities to eating disorders because they have a preference for a larger body size, place less emphasis on physical appearance, and generally pride themselves on a stable family structure.

Studies are now challenging this belief. Research suggests that white and Latina women have similar attitudes about dieting and weight control. Further, prevalence studies of eating disorders indicate similar rates for white and Latina girls and women, particularly when considering bulimia and BED. As with African-Americans, it appears that eating disorders among Latinas may be related to acculturation. Thus, as Latina women attempt to conform to the majority culture, their values change to incorporate an emphasis on thinness, which places them at higher risk for bingeing, purging, and overly restrictive dieting.

Life African-American women, Latina women were thought to posses a kind of cultural immunity to eating disorders, but current trends disprove that.

Consider Gabriella. She is a young Mexican woman whose parents moved to the U.S. when she was just a child. While her mother and father continue to speak Spanish at home and place a high value on maintaining their Mexican traditions, Gabriella wants nothing more than to fit in with her friends at school. She chooses to speak only English, looks to mainstream fashion magazines to guide her clothing and make-up choices, and wants desperately to have a fashion-model figure. In an attempt to lose weight, Gabriella has made a vow to herself to eat only one meal a day -- dinner -- but on her return home from school, she is rarely able to endure her hunger until dinnertime. She often loses control and ends up "eating whatever I can get my hands on." Frantic to keep her problem hidden from her family, she races to the store to replace all the food she has eaten.

Gabriella says that although she has heard her "Anglo" friends talk about eating problems, she has never heard of anything like this in the Latina community. Like Patricia, she feels isolated. "Yeah, sure, I want to fit in with mainstream America," she says, "but I hate what this bingeing is doing to my life."

Despite an apparent rise in such problems among Latina women, it is difficult to assess the status of eating disorders among them for three reasons. First, little research has been conducted on this group. Second, the few studies that have been done are somewhat flawed. Many studies, for example, have based their conclusions on very small groups of women or on groups comprised only of clinic patients. Finally, most studies have neglected to consider the role that factors like acculturation or country of origin (e.g., Mexico, Puerto Rico, Cuba) might have on the prevalence or type of eating disorders.

Other minorities

Information on Asian-Americans, Native Americans, and other minorities with eating disorders remains scant, and more research is urgently needed

As with all minority groups, not enough is known about eating disorders among Asian-American women. Available research, which has focused on adolescents or college students, appears to indicate that eating disorders are less prevalent in Asian-American females than in white females. Asian-American women report less binge eating, weight concerns, dieting, and body dissatisfaction. But to come to any firm conclusions about eating disorders within this ethnic group, researchers need to gather more information across different ages, levels of acculturation, and Asian subgroups (e.g., Japanese, Chinese, Indian).

Stemming the trend

The study of eating disorders in minority populations in the U.S. remains in its infancy. Yet as the stories of Patricia and Gabriella reveal, minority women with eating disorders experience the same feelings of shame, isolation, pain, and struggle as their white counterparts. Sadly, clinical anecdotes suggest that disordered eating behavior among minority women often goes unnoticed until it reaches dangerous levels. Only stepped-up research and efforts to increase awareness of the dangers can begin to stem this disturbing trend.

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Relapses - they can and will happen during recovery from an eating disorder. I want to say right now that if you are suffering from an eating disorder and making a hard attempt at getting better, that sooner or later you will encounter a relapse (if you haven't already). The relapse could last a day, a week, a month, but a relapse is not an uncommon thing to have happen during recovery from an eating disorder. This does not mean that you shouldn't try at all to recover because you think, "Well, I'm just going to relapse anyway, so what's the point?"

Relapses are a common part of recovery from an eating disorder because during the time at which we are trying to break free from the chains of a anorexia or bulimia, we are learning to be ourselves again. Many times, someone doesn't even know who they actually are when in the world of an eating disorder, so recovery means breaking free from everything they have thought they were in life. This makes recovery from an eating disorder a big learning experience for not just finding out who we are in life, but also how to deal with the pain in our lives that we tried to starve into control or purge away. Relapses will happen, but that doesn't mean you should give up right away or not try. Relapses are here to teach us where the areas are that we still need to work on.

Just like with an eating disorder, recovery from an eating disorder is not about perfection. No one recovery is perfect and never will be. Don't beat yourself up for any relapses that you have. Instead, look at your progress and the good days, and congratulate yourself for those.=)

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For reasons that are unclear, some people--mainly young women--develop potentially life-threatening eating disorders called bulimia nervosa and anorexia nervosa. People with bulimia, known as bulimics, indulge in bingeing (episodes of eating large amounts of food) and purging (getting rid of the food by vomiting or using laxatives). People with anorexia, whom doctors sometimes call anorectics, severely limit their food intake. About half of them also have bulimia symptoms.

The National Center for Health Statistics estimates that about 9,000 people admitted to hospitals were diagnosed with bulimia in 1994, the latest year for which statistics are available, and about 8,000 were diagnosed with anorexia. Studies indicate that by their first year of college, 4.5 to 18 percent of women and 0.4 percent of men have a history of bulimia and that as many as 1 in 100 females between the ages of 12 and 18 have anorexia.

Males account for only 5 to 10 percent of bulimia and anorexia cases. While people of all races develop the disorders, the vast majority of those diagnosed are white.

Most people find it difficult to stop their bulimic or anorectic behavior without professional help. If untreated, the disorders may become chronic and lead to severe health problems, even death. Antidepressants are sometimes prescribed for people with these eating disorders, and, in November 1996, FDA added the treatment of bulimia to the indications for the antidepressant Prozac (Fluoxetine).

About 1,000 women die of anorexia each year, according to the American Anorexia/Bulimia Association. More specific statistics from the National Center for Health Statistics show that "anorexia" or "anorexia nervosa" was the underlying cause of death noted on 101 death certificates in 1994, and was mentioned as one of multiple causes of death on another 2,657 death certificates. In the same year, bulimia was the underlying cause of death on two death certificates and mentioned as one of several causes on 64 others.

As to the causes of bulimia and the causes of anorexia, there are many theories. One is that some young women feel abnormally pressured to be as thin as the "ideal" portrayed by magazines, movies and television. Another is that defects in key chemical messengers in the brain may contribute to the disorders' development or persistence.

The Bulimia Secret

Once people begin binge eating and purging, usually in conjunction with a diet, the cycle easily gets out of control. While cases tend to develop during the teens or early 20s, many bulimics successfully hide their symptoms, thereby delaying help until they reach their 30s or 40s. Several years ago, actress Jane Fonda revealed she had been a secret bulimic from age 12 until her recovery at 35. She told of bingeing and purging up to 20 times a day.

Many people with bulimia maintain a nearly normal weight. Though they appear healthy and successful--"perfectionists" at whatever they do--in reality, they have low self-esteem and are often depressed. They may exhibit other compulsive behaviors. For example, one physician reports that a third of his bulimia patients regularly engage in shoplifting and that a quarter of the patients have suffered from alcohol abuse or addiction at some point in their lives.

While normal food intake for women and teenagers is 2,000 to 3,000 calories in a day, bulimic binges average about 3,400 calories in 1 1/4 hours, according to one study. Some bulimics consume up to 20,000 calories in binges lasting as long as eight hours. Some spend $50 or more a day on food and may resort to stealing food or money to support their obsession.

To lose the weight gained during a binge, bulimics begin purging by vomiting (by self-induced gagging or with an emetic, a substance that causes vomiting) or by using laxatives (50 to 100 tablets at a time), diuretics (drugs that increase urination), or enemas. Between binges, they may fast or exercise excessively.

Extreme purging rapidly upsets the body's balance of sodium, potassium, and other chemicals. This can cause fatigue, seizures, irregular heartbeat, and thinner bones. Repeated vomiting can damage the stomach and esophagus (the tube that carries food to the stomach), make the gums recede, and erode tooth enamel. (Some patients need all their teeth pulled prematurely). Other effects include various skin rashes, broken blood vessels in the face, and irregular menstrual cycles.

Complexities of Anorexia

While anorexia most commonly begins in the teens, it can start at any age and has been reported from age 5 to 60. Incidence among 8- to 11-year-olds is said to be increasing.

Anorexia may be a single, limited episode with large weight loss within a few months followed by recovery. Or it may develop gradually and persist for years. The illness may go back and forth between getting better and getting worse. Or it may steadily get more severe.

Anorectics may exercise excessively. Their preoccupation with food usually prompts habits such as moving food about on the plate and cutting it into tiny pieces to prolong eating, and not eating with the family.

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Obsessed with weight loss and fear of becoming fat, anorectics see normal folds of flesh as "fat" that must be eliminated. When the normal fat padding is lost, sitting or lying down brings discomfort not rest, making sleep difficult. As the disorder continues, victims may become isolated and withdraw from friends and family.

The body responds to starvation by slowing or stopping certain bodily processes. Blood pressure falls, breathing rate slows, menstruation ceases (or, in girls in their early teens, never begins), and activity of the thyroid gland (which regulates growth) diminishes. Skin becomes dry, and hair and nails become brittle. Lightheadedness, cold intolerance, constipation, and joint swelling are other symptoms. Reduced fat causes the body temperature to fall. Soft hair called lanugo forms on the skin for warmth. Body chemicals may get so imbalanced that heart failure occurs.

Anorectics who additionally binge and purge impair their health even further. The late recording artist Karen Carpenter, an anorectic who used syrup of ipecac to induce vomiting, died after buildup of the drug irreversibly damaged her heart.

Getting Help

Early treatment is vital. As either disorder becomes more entrenched, its damage becomes less reversible.

Usually, the family is asked to help in the treatment, which may include psychotherapy, nutrition counseling, behavior modification, and self-help groups. Therapy often lasts a year or more--on an outpatient basis unless life-threatening physical symptoms or severe psychological problems require hospitalization. If there is deterioration or no response to therapy, the patient (or parent or other advocate) may want to talk to the health professional about the plan of treatment.

There are no drugs approved specifically for bulimia or anorexia, but several, including some antidepressants, are being investigated for this use.

If you think a friend or family member has bulimia or anorexia, point out in a caring, nonjudgmental way the behavior you have observed and encourage the person to get medical help. If you think you have bulimia or anorexia, remember that you are not alone and that this is a health problem that requires professional help. As a first step, talk to your parents, family doctor, religious counselor, or school counselor or nurse.

Disorders' Definitions

According to the American Psychiatric Association, a person diagnosed as bulimic or anorectic must have all of that disorder's specific symptoms:

Bulimia Nervosa

• recurrent episodes of binge eating (minimum average of two binge-eating episodes a week for at least three months)
• a feeling of lack of control over eating during the binges
• regular use of one or more of the following to prevent weight gain: self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise
• persistent over-concern with body shape and weight.

Anorexia Nervosa

• refusal to maintain weight that's over the lowest weight considered normal for age and height
• intense fear of gaining weight or becoming fat, even though underweight
• distorted body image
• in women, three consecutive missed menstrual periods without pregnancy.

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