Bulimia

What is bulimia?

Bulimia (also called bulimia nervosa) is a condition where you think a lot about your body weight and shape. It affects your ability to have a 'normal' eating pattern. Bulimia nervosa is one of the conditions that form the group of eating disorders that includes anorexia nervosa. There are important differences between these two conditions. For example, in anorexia nervosa you are very underweight, whereas in bulimia, you are most likely to be normal weight or even overweight.

How do you know if you have an eating disorder?

If you answer yes to two or more of these questions then you may have an eating disorder:

• Do you believe you're fat when others think you're thin?
• Do you make yourself sick because you are uncomfortably full?
• Do you worry that you've lost control over how much you eat?
• Have you lost more than 13 pounds in the past three months?
• Would you say that food dominates your life?

Who gets bulimia?

Bulimia nervosa mainly affects women aged 16-40. It most commonly starts around the age of 19 years. It affects around 8 in 100 women in the UK. Bulimia nervosa sometimes develops in men and children. Women are 10 times more likely to develop bulimia nervosa than men. However, bulimia nervosa is becoming more common in boys and men. Bulimia nervosa is more common than anorexia nervosa.

There may be some genetic factor, as the risk of developing bulimia nervosa in close relatives of individuals with bulimia nervosa is four times greater than in the general population.

What are the symptoms of bulimia?

Bingeing and purging are the main symptoms and are usually done in secret.

• Bingeing means that you have repeated episodes of eating large amounts of foods and/or drinks. For example, you may eat a whole large tub of ice cream or two packets of biscuits even if you are not hungry. You feel out of control and unable to stop eating. Binge eating is often done very quickly until you feel physically uncomfortable. This happens not just on one occasion, but regularly. Eating patterns typically become chaotic.

• Purging means that you try and counteract the 'fattening' effects of the food from the bingeing. Self-induced vomiting (making yourself sick) after a bout of bingeing is the most well-known, but not all individuals with bulimia nervosa do this. Other purging methods include taking lots of laxatives, extreme exercise, extreme dieting or even periods of complete starvation, taking diuretics (water tablets) or taking other medicines such as amphetamines.

The reasons why you binge eat and then purge may not be easy to explain. Part of the problem may be due to a fear of getting fat, although it is often not just as simple as that. All sorts of emotions, feelings and attitudes may contribute. The physical act of bingeing and purging may be a way of dealing with your emotions in some way.

What are the physical problems caused by bulimia nervosa?

These are caused by the unusual eating habits and the methods used to purge the body of food (such as vomiting or the excessive use of laxatives). Physical problems do not always develop. They are more likely if you binge and purge often. One or more of the following may develop:

1. Bowel problems— These may occur if you take a lot of laxatives. Laxatives can damage the bowel muscle and nerve endings. This may eventually result in permanent constipation and also sometimes abdominal pains.
2. Chemical imbalances in the body— These are caused by either repeated vomiting or excess use of laxatives. For example, low potassium level which may cause tiredness, weakness, abnormal heart rhythms, kidney damage and convulsions. Low calcium levels can lead to tetany (muscle spasms).
3. Depression— It is fairly common to feel low when you have bulimia nervosa. Some individuals even become depressed, which can respond well to recovery. It is important to talk about any symptoms of depression you may have. Many individuals find they become more moody or irritable.
4. Irregular periods— Many individuals have irregular periods as hormone levels can be affected by poor diet. Periods may even stop all together or you may find that your periods have never started, especially if you started having eating problems when you were younger.
5. Psychological problems— These are very common and include feelings of guilt and disgust after bingeing and purging. Poor self-esteem and mood swings are common.
6. Swelling of hands, feet and face— This is usually due to fluid disturbances in the body. The saliva glands in the face can sometimes swell due to the frequent vomiting.
7. Teeth problems— These can be caused by the acid from the stomach rotting away the enamel as a result of repeated vomiting.

What causes bulimia?

The exact cause is not clear. Some individuals blame the media and the fashion industry which portray the idea that it is fashionable to be slim. This can put pressure on some individuals to try to be slim which can then lead to an eating disorder.

There may be some genetic factor to developing bulimia nervosa, which is triggered by stressful or traumatic life experiences. For example, some individuals with bulimia nervosa have had a childhood where there were frequent family problems with arguments and criticism at home. Some individuals with bulimia nervosa have been abused as a child.

Sometimes bulimia nervosa is also associated with some other psychological problem. (That is, the bulimia nervosa is sometimes just a part of a broader mental health problem.) For example, there is a higher than average rate of bulimia nervosa in individuals with anxiety disorders, obsessive compulsive disorder, depression, post-traumatic stress disorder and some personality disorders.

A chemical called serotonin which is in parts of the brain is thought to have something to do with bulimia nervosa. In some way one or more of the above factors, or even other unknown factors, may lead to a low level of serotonin.

Are there any tests done for bulimia nervosa?

Although there is not an actual test to diagnose bulimia nervosa, your doctor may wish to undertake some blood tests. These are usually done to check your kidney function and potassium levels.

What are the recovery techniques for bulimia?

The aim of recovery is to:

• Encourage healthy eating.
• Help individuals become both physically and mentally stronger.
• Reduce other related symptoms and problems.
• Reduce risk of harm which can be caused by bulimia nervosa.

Many individuals with bulimia nervosa who see their GP will be referred to a specialist mental health team. Members of the team may include psychiatrists, psychologists, nurses, dietitians and other professionals. If you have more severe bulimia nervosa you may be referred to a specialist eating disorder unit.

The sorts of recovery techniques that may be offered include the following:

1. Psychological ('talking') recovery techniques— Cognitive behavioral therapy (CBT) is the most commonly used psychological treatment for bulimia nervosa. It helps you to look at the reasons why you developed bulimia nervosa, aims to change any false beliefs that you have about your weight and body, and it helps to show you how to deal with emotional issues. Talking recovery techniques take time and usually require regular sessions over several months. Recovery may also involve other members of your family going to meetings to discuss any family issues. However, CBT does not suit everyone. About a third of individuals drop out before finishing the course. Other forms of psychological recovery techniques may also be used. For example, cognitive analytic therapy (CAT), interpersonal psychotherapy (IPT) and focal psychodynamic therapy.

2. Medication— A medicine may be advised by your doctor. The most commonly used medicines are selective serotonin reuptake inhibitor (SSRI) antidepressants. These are used to treat depression but, in higher doses, one called fluoxetine can reduce the urge for bingeing or purging. These are not usually recommended if you are younger than 18 years old. Treatment of any physical or teeth problems that may occur. This may include taking potassium supplements, dental care and not using laxatives.

3. Help with eating— It is best if you have regular meals; even if you only eat small meals. It is beneficial to the body to eat at least three times a day. You should try to be honest (with yourself and other individuals) about the amount of food you are actually eating. You should reduce the number of times you weigh yourself; try only to weigh yourself once a week. It may be useful to keep an eating diary in order to write down all the food that you eat.

Self-help measures—

Self-help methods for the recovery of this disorder are often overlooked by the medical profession because very few professionals are involved in them. Self-help support groups are an especially powerful and effective means of ensuring long-term treatment compliance and decrease the relapse rate. Individuals find they can bounce ideas off of one another, get objective feedback about body image, and just gain increased social support. Many support groups exist within communities throughout the world which are devoted to helping individuals with this disorder share their commons experiences and feelings.

There are a number of self-help books and manuals available. These provide strategies in how to cope with, and overcome, bulimia nervosa. Some individuals find these very helpful and prefer them to 'formal' treatment. It is certainly worth trying a self-help manual if there is a waiting list or difficulty in getting psychological treatment.

Anorexia and bulimia aren’t about food. They’re about using food to cope with painful emotions such as anger, self-loathing, vulnerability, and fear. Disordered eating is a coping mechanism–whether you refuse food to feel in control, binge for comfort, or purge to punish yourself. But you can learn healthier ways to cope with negative emotions.

The first step is figuring out what’s really eating you up inside. Remember, “fat” is not a feeling, so if you feel overweight and unattractive, stop and ask yourself what’s really going on. Are you upset about something? Depressed? Stressed out? Lonely? Once you identify the emotion you’re experiencing, you can choose a positive alternative to starving or stuffing yourself.

Here are a few suggestions to get you started:

• Call a friend
• Listen to music
• Play with a pet
• Read a good book
• Take a walk
• Write in a journal
• Go to the movies
• Get out into nature
• Play a favorite game
• Do something nice for someone else

Emotional Do and Don't Lists—

Do…

• use individuals to comfort you when you feel bad, instead of focusing on food
• let your emotions come and go as they please without fear
• fully experience every emotion
• be open and accepting of all your emotions
• allow yourself to be vulnerable with individuals you trust

Don’t…

• avoid feelings because they make you uncomfortable
• focus on food when you’re experiencing a painful emotion
• let individuals shame or humiliate you for having or expressing feelings
• pretend you don’t feel anything when you do
• worry about your feelings making you fall apart

Improving your self-image—

You are more than what you weigh, a fact you lose sight of when you have an eating disorder. When you base your self-worth on physical appearance alone, you’re ignoring all the other qualities, accomplishments, and abilities that make you beautiful. Think about your friends and family members. Do they love you for the way you look or who you are? Chances are, your appearance ranks low on the list of what they love about you–and you probably feel the same about them. So why does it top your own list?

Placing too much importance on how you look leads to low self-esteem and insecurity. But you can learn to see yourself in a positive, balanced way:

• Challenge negative self-talk. When you catch yourself being self-critical or pessimistic, stop and challenge the negative thought. Ask yourself what evidence you have to support the idea. What is the evidence against it? Just because you believe something, doesn’t mean it’s true. Answering these questions will help you see things in a more realistic light.

• Focus on what you like about your body. Instead of searching for flaws when you look in the mirror, appreciate the things you like about your appearance. If you’re distracted by “imperfections,” remind yourself that nobody’s perfect. Even supermodels get airbrushed.

• Make a list of your positive qualities. Think of all the things you like about yourself. Are you smart? Kind? Creative? Loyal? Funny? What would others say are your good qualities? Include your talents, skills, and achievements. Also think about bad qualities you don’t have.

Learning healthy eating habits—

If you’ve been struggling with an eating disorder, chances are you’ve forgotten what healthy eating looks like. But learning and establishing healthy eating habits is an essential step in recovery from anorexia and bulimia.

• Challenge your strict eating rules. Strict rules about food and eating fuel anorexia and bulimia, so it’s important to replace them with healthier ones. For example, if you have a rule forbidding all desserts, change it into a less rigid guideline such as, “I won’t eat dessert every day.” You won’t gain weight by enjoying an occasional ice cream or cookie.

• Don’t diet. Healthy eating–not dieting–is the key to avoiding weight gain. Instead of focusing on what you shouldn’t eat, focus on nutritious foods that will energize you and make your body strong. Think of food as fuel for your body. Your body knows when the tank is low, so listen to it. Eat when you’re truly hungry, then stop when you’re full. If you follow these simple guidelines -- your body will look and feel its best.

• Stick to a regular eating schedule. You may be used to skipping meals or fasting for long stretches. But when you starve yourself, food becomes all you think about. To avoid this preoccupation, make sure to eat every three hours. Plan ahead for meals and snacks, and don’t skip!

Find a specialist—

The first step in eating disorder recovery is finding a doctor or therapist who specializes in anorexia and bulimia. As you search, focus on finding the right fit. Your relationship with your doctor or therapist is important to the recovery process. Look for someone who makes you feel comfortable, accepted, and safe.

To find an eating disorder recovery specialist in your area:

• Ask your primary care doctor for a referral
• Ask your school counselor or nurse
• Call the National Eating Disorders Association’s toll-free hotline at 1-800-931-2237 (Mon–Fri, 8:30 a.m. to 4:30 p.m. PST)
• Check with local hospitals or medical centers
• Search online at the eating disorder websites listed to the right

Address health problems—

Anorexia and bulimia can be deadly–and not just if you’re drastically underweight. Your health may be in danger, even if you only occasionally fast, binge, or purge, so it’s important to get a full medical evaluation. If the evaluation reveals health problems, they should take top recovery priority. Nothing is more important than your physical well-being. If you’re suffering from any other life-threatening problem, you may need to be hospitalized. While the thought of hospitalization may be scary, try to remember that its sole purpose is to keep you safe!

Make a long-term recovery plan—

Once your health problems are under control, you and your doctor or therapist can work on a long-term recovery plan. First, you’ll need to assemble a complete eating disorder recovery team. Your team might include a family doctor, a psychologist, a nutritionist, a social worker, and a psychiatrist. Then you and your team will develop a recovery plan that’s individualized to meet your needs.

Relapse prevention—

The work of eating disorder recovery doesn’t end once you’ve adopted healthy habits. It’s important to take steps to maintain your progress and prevent relapse.

• Avoid pro-ana and pro-mia websites. Don’t visit websites that promote or glorify anorexia and bulimia. These sites are run by individuals who want excuses to continue down their destructive path. The “support” they offer is dangerous and will only get in the way of your recovery.
• Develop a solid support system. Surround yourself with individuals who support you and want to see you healthy and happy. Avoid individuals that drain your energy, encourage your disordered eating behaviors, or make you feel bad about yourself.
• Fill your life with positive activities. Make time for activities that bring you joy and fulfillment. Try something you’ve always wanted to do, develop a new skill, pick up a fun hobby, or volunteer in your community. The more rewarding your life, the less desire you’ll have to focus on food and weight.
• Identify your “triggers”. Are you more likely to revert to your old, destructive behaviors during the holidays, exam week, or swimsuit season? Know what your triggers are, and have a plan for dealing with them, such as going to therapy more often or asking for extra support from family and friends.
• Keep a journal. Writing in a daily journal can help you keep tabs on your thoughts, emotions, and behaviors. If you notice that you’re slipping back into negative patterns, take action immediately.
• Stick with your eating disorder recovery plan. Don’t neglect therapy or other components of your recovery, even if you’re doing better. Listen to the advice of your recovery team and continue to follow their recommendations.

What is the prognosis?

Bulimia nervosa is the sort of condition that is difficult to cure fully 'once and for all'. Many individuals improve with treatment, but bad spells (relapses) may recur from time-to-time in some cases. Many individuals find they still have issues with food, even after recovery, but they are more in control and can lead happier, more fulfilled lives.

Studies suggest that 10 years after a diagnosis of bulimia nervosa about 5 in 10 individuals are well, about 2 in 10 individuals still have bulimia nervosa, and about 3 in 10 individuals are somewhere in the middle. However, the recent study about CBT treatment (cited at the end) suggests that with good quality CBT, the outlook is probably even better than these 'overall' figures. It is very unusual to die from bulimia nervosa.

Acute Stress Disorder

Acute Stress Disorder (ASD) is characterized by the development of severe anxiety, dissociative, and other symptoms that occurs within one month after exposure to an extreme traumatic stress-event (e.g., witnessing a death or serious accident).

As a response to the traumatic event, the person develops dissociative symptoms. Individuals with ASD have a decrease in emotional responsiveness, often finding it difficult or impossible to experience pleasure in previously enjoyable activities, and frequently feel guilty about pursuing usual life tasks.

An individual with ASD may experience difficulty concentrating, feel detached from their bodies, experience the world as unreal or dreamlike, or have increasing difficulty recalling specific details of the traumatic event (dissociative amnesia).

In addition, at least one symptom from each of the symptom clusters required for Posttraumatic Stress Disorder is present:

1. The traumatic event is persistently re-experienced (e.g., recurrent recollections, images, thoughts, dreams, illusions, flashback episodes, a sense of reliving the event, or distress on exposure to reminders of the event).
2. Reminders of the trauma (e.g., places, individuals, activities) are avoided.
3. Hyper-arousal in response to stimuli reminiscent of the trauma is present (e.g., difficulty sleeping, irritability, poor concentration, hyper-vigilance, an exaggerated startle response, and motor restlessness).

Specific Symptoms of ASD:

ASD is most often diagnosed when a person has been exposed to a traumatic event in which both of the following were present:

• The individual's response involved intense fear, helplessness, or horror
• The individual experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others

Either while experiencing or after experiencing the distressing event, the individual has 3 or more of the following dissociative symptoms:

• Dissociative amnesia (i.e., inability to recall an important aspect of the trauma)
• Derealization
• Depersonalization
• A subjective sense of numbing, detachment, or absence of emotional responsiveness
• A reduction in awareness of his or her surroundings (e.g., "being in a daze")

The traumatic event is persistently re-experienced in at least one of the following ways:

• recurrent images, thoughts, dreams, illusions
• flashback episodes
• a sense of reliving the experience
• distress on exposure to reminders of the traumatic event.

ASD is also characterized by significant avoidance of stimuli that arouse recollections of the trauma (e.g., avoiding thoughts, feelings, conversations, activities, places, individuals). The individual experiencing ASD also has significant symptoms of anxiety or increased arousal (e.g., difficulty sleeping, irritability, poor concentration, hyper-vigilance, exaggerated startle response, motor restlessness).

For ASD to be diagnosed, the problems noted above must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning or impairs the individual's ability to pursue some necessary task, such as obtaining necessary assistance or mobilizing personal resources by telling family members about the traumatic experience.

The disturbance in an ASD must last for a minimum of 2 days and a maximum of 4 weeks, and must occur within 4 weeks of the traumatic event. Symptoms also can not be the result of substance use or abuse (e.g., alcohol, drugs, medications), caused by or an exacerbation of a general or preexisting medical condition, and cannot be better explained by a Brief Psychotic Disorder.

Treatment of ASD

The person with acute stress disorder often will not seek treatment because his ability to mobilize and perform necessary tasks is affected. The severity of the disorder may be reduced if professional intervention is initiated soon after the trauma. Treatment for acute stress disorder usually includes a combination of antidepressant medications and short-term psychotherapy.

Initial Assessment—

The initial step in identifying people with acute stress disorder or post traumatic stress disorder involves screening for recent or remote trauma exposure, although the clinical approach may vary depending on the recency of the traumatic event. If eliciting vivid and detailed recollections of the traumatic event immediately after exposure enhances the patient's distress, the interview may be limited to gathering information that is essential to provide needed medical care. The first interventions in the aftermath of an acute trauma consist of stabilizing and supportive medical care and supportive psychiatric care and assessment. After large-scale catastrophes, initial psychiatric assessment includes differential diagnosis of physical and psychological effects of the traumatic event (e.g., anxiety resulting from hemodynamic compromise, hyperventilation, somatic expressions of psychological distress, fatigue) and identification of persons or groups who are at greatest risk for subsequent psychiatric disorders, including ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER. This identification may be accomplished through individual evaluation, group interviews, consultation, and use of surveillance instruments.

Diagnostic evaluation may be continued after the initial period has passed and a physically and psychologically safe environment has been established, the individual's medical condition has been stabilized, psychological reassurance has been provided, and, in disaster settings, necessary triage has been accomplished. It is important for this diagnostic assessment to include a complete psychiatric evaluation that specifically assesses for the symptoms of ACUTE STRESS DISORDER and POST TRAUMATIC STRESS DISORDER, including dissociative, re-experiencing, avoidance/numbing, and hyper-arousal symptom clusters and their temporal sequence relative to the trauma (i.e., before versus after 1 month from the traumatic event). Other important components of the assessment process include functional assessment, determining the availability of basic care resources (e.g., safe housing, social support network, companion care, food, clothing), and identifying previous traumatic experiences and comorbid physical or psychiatric disorders, including depression and substance use disorders.

Psychiatric Management—

Psychiatric management for all individuals with ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER includes instituting interventions and activities to ensure physical and psychological safety, required medical care, and availability of needed resources for self-care and recovery. The patient's level of functioning and safety, including his or her risk for suicide and potential to harm others, is always important to evaluate during initial assessment and may determine the treatment setting. The goals of psychiatric management for individuals with ACUTE STRESS DISORDER and POST TRAUMATIC STRESS DISORDER also include establishing a therapeutic alliance with the patient; providing ongoing assessment of safety and psychiatric status, including possible comorbid disorders and response to treatment; and increasing the individuals understanding of - and active adaptive coping with - psychosocial effects of exposure to the traumatic event, such as injury, job loss, or loss of loved ones. Additional goals of psychiatric management include providing education regarding ACUTE STRESS DISORDER and POST TRAUMATIC STRESS DISORDER, enhancing treatment adherence, evaluating and managing physical health and functional impairments, and coordinating care to include collaborating with other clinicians.

General Principles of Treatment Selection—

The goals of treatment for people with a diagnosis of ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER include reducing the severity of ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER symptoms, preventing or treating trauma-related comorbid conditions that may be present or emerge, improving adaptive functioning and restoring a psychological sense of safety and trust, limiting the generalization of the danger experienced as a result of the traumatic situation(s), and protecting against relapse.

Individuals assessed within hours or days after an acute trauma may present with overwhelming physiological and emotional symptoms (e.g., insomnia, agitation, emotional pain, dissociation). Limited clinical trial evidence is available in this area, as randomized designs are difficult to implement; however, clinical experience suggests that these acutely traumatized people may benefit from supportive psychotherapeutic and psycho-educational interventions. Pharmacotherapy may be the first-line intervention for acutely traumatized individuals whose degree of distress precludes new verbal learning or non-pharmacological treatment strategies. Research has not consistently identified patient- or trauma-specific factors that predict the development of ACUTE STRESS DISORDER or interventions that will alter the evolution of ACUTE STRESS DISORDER into POST TRAUMATIC STRESS DISORDER. However, early after a trauma, once the patient's safety and medical stabilization have been addressed, supportive psychotherapy, psycho-education, and assistance in obtaining resources such as food and shelter and locating family and friends are useful.

Effective treatments for the symptoms of ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER encompass psychopharmacology, psychotherapy, and psycho-education and other supportive measures. Although studies using a combination of these approaches for ACUTE STRESS DISORDER and POST TRAUMATIC STRESS DISORDER are not presently available, combination treatment is widely used and may offer advantages for some individuals. The psychotropic medications used in clinical practice and research for the treatment of ACUTE STRESS DISORDER and POST TRAUMATIC STRESS DISORDER were not specifically developed for these disorders but have been used in doses similar to those recommended or approved for other psychiatric illnesses.

For individuals with ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER, choice of treatment includes consideration of age and gender, presence of comorbid medical and psychiatric illnesses, and propensity for aggression or self-injurious behavior. Other factors that may influence treatment choice include the recency of the precipitating traumatic event; the severity and pattern of symptoms; the presence of particularly distressing target symptoms or symptom clusters; the development of interpersonal or family issues or occupational or work-related problems; preexisting developmental or psychological vulnerabilities, including prior trauma exposure; and the patient's preferences.

When the patient's symptoms do not respond to a plan of treatment, selection of subsequent interventions will depend on clinical judgment, as there are limited data to guide the clinician. It is important to systematically review factors that may contribute to treatment non-response, including the specifics of the initial treatment plan and its goals and rationale, the patient's perceptions of the effects of treatment, the patient's understanding of and adherence to the treatment plan, and the patient's reasons for non-adherence if non-adherence is a factor. Other factors that may need to be addressed in individuals who are not responding to treatment include problems in the therapeutic alliance; the presence of psychosocial or environmental difficulties; the effect of earlier life experiences such as childhood abuse or previous trauma exposures; and comorbid psychiatric disorders, including substance-related disorders and personality disorders.

Specific Treatment Strategies—

Psychopharmacology:

Although it has been hypothesized that pharmacological treatment soon after trauma exposure may prevent the development of ACUTE STRESS DISORDER and POST TRAUMATIC STRESS DISORDER, existing evidence is limited and preliminary. Thus, no specific pharmacological interventions can be recommended as efficacious in preventing the development of ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER in at-risk people.

For individuals with ACUTE STRESS DISORDER, there are few studies of pharmacological interventions. However, selective serotonin reuptake inhibitors (SSRIs) and other antidepressants represent reasonable clinical interventions that are supported by limited findings in ACUTE STRESS DISORDER as well as by findings of therapeutic benefits in individuals with POST TRAUMATIC STRESS DISORDER.

SSRIs are recommended as first-line medication treatment for POST TRAUMATIC STRESS DISORDER. In both male and female individuals, treatment with SSRIs has been associated with relief of core POST TRAUMATIC STRESS DISORDER symptoms in all three symptom clusters (re-experiencing, avoidance/numbing, hyper-arousal). Other antidepressants, including tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs), may also be beneficial in the treatment of POST TRAUMATIC STRESS DISORDER.

Benzodiazepines may be useful in reducing anxiety and improving sleep. Although their efficacy in treating the core symptoms of POST TRAUMATIC STRESS DISORDER has not been established, benzodiazepines are often used in trauma-exposed people and individuals with POST TRAUMATIC STRESS DISORDER. However, clinical observations include the possibility of dependence, increased incidence of POST TRAUMATIC STRESS DISORDER after early treatment with these medications, or worsening of POST TRAUMATIC STRESS DISORDER symptoms after withdrawal of these medications. Thus, benzodiazepines cannot be recommended as mono-therapy in POST TRAUMATIC STRESS DISORDER.

In addition to being indicated in individuals with comorbid psychotic disorders, second generation antipsychotic medications (e.g., olanzapine, quetiapine, risperidone) may be helpful in individual individuals with POST TRAUMATIC STRESS DISORDER. Anticonvulsant medications (e.g., divalproex, carbamazepine, topiramate, lamotrigine), alpha-2-adrenergic agonists, and beta-adrenergic blockers may also be helpful in treating specific symptom clusters in individual individuals.

Psychotherapeutic Interventions:

Some evidence is available about the effectiveness of psychotherapeutic intervention immediately after trauma in preventing development of ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER. Studies of cognitive behavior therapy in motor vehicle and industrial accident survivors as well as in victims of rape and interpersonal violence suggest that cognitive behavior therapies may speed recovery and prevent POST TRAUMATIC STRESS DISORDER when therapy is given over a few sessions beginning 2-3 weeks after trauma exposure.

Early supportive interventions, psycho-education, and case management appear to be helpful in acutely traumatized people, because these approaches promote engagement in ongoing care and may facilitate entry into evidence-based psychotherapeutic and psychopharmacological treatments. Encouraging acutely traumatized persons to first rely on their inherent strengths, their existing support networks, and their own judgment may also reduce the need for further intervention. In populations of individuals who have experienced multiple recurrent traumas, there is little evidence to suggest that early supportive care delivered as a stand-alone treatment will result in lasting reductions in POST TRAUMATIC STRESS DISORDER symptoms. However, no evidence suggests that early supportive care is harmful. In contrast, psychological debriefings or single-session techniques are not recommended, as they may increase symptoms in some settings and appear to be ineffective in treating people with ACUTE STRESS DISORDER and in preventing POST TRAUMATIC STRESS DISORDER.

No controlled studies of psychodynamic psychotherapy, eye movement desensitization and reprocessing (EMDR), or hypnosis have been conducted that would establish data-based evidence of their efficacy as an early or preventive intervention for ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER.

For individuals with a diagnosis of ACUTE STRESS DISORDER or POST TRAUMATIC STRESS DISORDER, available evidence and clinical experience suggest that a number of psychotherapeutic interventions may be useful. Individuals with ACUTE STRESS DISORDER may be helped by cognitive behavior therapy and other exposure-based therapies. In addition, cognitive behavior therapy is an effective treatment for core symptoms of acute and chronic POST TRAUMATIC STRESS DISORDER. EMDR also appears to be effective; however, therapeutic benefit for the rapid eye movement component of this therapy has not been consistently demonstrated. Stress inoculation, imagery rehearsal, and prolonged exposure techniques may also be indicated for treatment of POST TRAUMATIC STRESS DISORDER and POST TRAUMATIC STRESS DISORDER-associated symptoms such as anxiety and avoidance. The shared element of controlled exposure of some kind may be the critical intervention.

Psychodynamic psychotherapy may be useful in addressing developmental, interpersonal, or intrapersonal issues that relate to the nature, severity, symptoms, or treatment of ACUTE STRESS DISORDER and POST TRAUMATIC STRESS DISORDER and that may be of particular importance to social, occupational, and interpersonal functioning.

Case management, psycho-education, and other supportive interventions may be useful in facilitating entry into ongoing treatment, appear not to exacerbate POST TRAUMATIC STRESS DISORDER symptoms, and in some pilot investigations have been associated with POST TRAUMATIC STRESS DISORDER symptom reduction. Present-centered and trauma-focused group therapies may also reduce POST TRAUMATIC STRESS DISORDER symptom severity.

Facts and Tips about Acute Stress Disorder—

• ASD begins with contact with an extremely traumatic, horrifying, or terrifying event.
• ASD is a kind of diagnostic category which was started in 1994 to differ the reactions for trauma which are time dependent and reactions from post-traumatic stress disorder (PTSD).
• ASD is the immediate reaction to trauma and if not treated, it could develop into Post traumatic stress disorder (PTSD).
• Clonidine, propanolol, clonazepam and fluoxetine are some medications used to treat the individual symptoms.
• Cognitive behavioral therapy is the most successful treatment to combat ASD.
• Some dissociative symptoms of ASD include derealization, reduction in awareness of vicinity, psychic numbing, depersonalization and sometimes dissociative amnesia.

Useful Terms:

• Trauma- In the context of ASD, a disastrous or life-threatening event.
• Dissociation- A reaction to trauma in which the mind splits off certain aspects of the trauma from conscious awareness. Dissociation can affect the patient's memory, sense of reality, and sense of identity.
• Derealization- A dissociative symptom in which the external environment is perceived as unreal.
• Depersonalization- A dissociative symptom in which the patient feels that his or her body is unreal, is changing, or is dissolving.

Adjustment Disorder

Work problems, getting married, going away to school, an illness — any number of life changes can cause stress. Most of the time, individuals adjust to such changes within a few months. But if you continue to feel down or self-destructive, you may have an Adjustment Disorder (AD).

An AD is a type of stress-related mental illness. You may feel anxious or depressed, or even have thoughts of suicide. You may not be able to go about some of your daily routines, such as work or seeing friends. Or you may make reckless decisions. In essence, you have a hard time adjusting to change in your life, and it has serious consequences.

You don't have to tough it out on your own, though. Treatment of an AD may help you regain your emotional footing. Most adults get better within just a few months, although teens may struggle longer. Treatment may also help prevent an AD from becoming a more serious problem.

Symptoms—

The signs and symptoms of ADs vary from person to person. The symptoms you have may be very different from those of someone else with an AD. But for everyone, symptoms of an AD begin within three months of a stressful event in your life.

Emotional symptoms of ADs-

Signs and symptoms of AD may affect how you feel and think about yourself or life, including:

• Anxiety
• Crying spells
• Desperation
• Difficulty concentrating
• Feeling overwhelmed
• Hopelessness
• Lack of enjoyment
• Nervousness
• Sadness
• Thoughts of suicide
• Trouble sleeping
• Worry

Behavioral symptoms of ADs-

Signs and symptoms of AD may affect your actions or behavior, such as:

• Avoiding family or friends
• Fighting
• Ignoring bills
• Poor school or work performance
• Reckless driving
• Skipping school
• Vandalism

Length of symptoms-

How long you have symptoms of an AD also can vary:

• Longer than six months (chronic). In these cases, symptoms continue to bother you and disrupt your life. Professional treatment can help symptoms improve and prevent the condition from continuing to get worse.
• Six months or less (acute). In these cases, symptoms may go away on their own, especially if you actively follow self-care measures.

When to see a doctor:

Sometimes the stressful change in your life goes away, and your symptoms of AD get better on their own. But often, the stressful event remains a part of your life. Or a new stressful situation comes up, and you face the same emotional struggles all over again.

You may think that an AD is less serious than other mental health problems because it involves stress, but that's not necessarily true. ADs can affect your whole life. You may feel so overwhelmed, stressed and hopeless that you can't go about your normal daily activities. You may skip work or school, for instance, or not pay your bills. You may drive dangerously or pick fights.

Individuals with ADs also may abuse alcohol or drugs, engage in violence, and have thoughts of suicide. If you or a loved one has suicidal thoughts or is seriously considering hurting someone, seek help immediately.

Talk to your doctor if you're having trouble getting through each day. You can get treatment to help cope better with stressful events and feel better about life again.

Causes—

Individuals of all ages are affected by ADs. Among kids and teens, both boys and girls have about the same chance of having AD. Among adults, women are twice as likely as men to have AD. But researchers are still trying to figure out what causes ADs. As with other mental disorders, the cause is likely complex and may involve genetics, your life experiences, your temperament and even changes in the natural chemicals in the brain.

Risk factors—

Although researchers don't know exactly what causes ADs, they do know some of the risk factors involved, or the things that make you more likely to have an AD.

Stressful events:

One or more stressful life events may put you at risk of developing AD. It may involve almost any type of stressful event in your life. Both positive and negative events can cause extreme stress. Some common examples include:

• Being diagnosed with a serious illness
• Death of a loved one
• Divorce or relationship breakup
• Financial problems
• Going away to school
• Having a baby
• Job loss
• Physical assault
• Problems in school
• Retirement
• Surviving a disaster

In some cases, individuals who face an ongoing stressful situation — such as living in a crime-ridden neighborhood — can reach a breaking point and develop an AD.

Your life experiences:

If you generally don't cope well with change or you don't have a strong support system, you may be more likely to have an extreme reaction to a stressful event.

Some studies also suggest that your risk of an AD is higher if you experienced stress in early childhood. Overprotective or abusive parenting, family disruptions and frequent moves early in life may make you feel like you're unable to control events in your life. When difficulties then arise, you may have trouble coping.

Other risk factors may include:

• Difficult life circumstances
• Exposure to wars or violence
• Other mental health problems

Complications—

Most individuals with AD get better within six months and don't have long-term complications. However, individuals who also have another mental health disorder, a substance abuse problem or a chronic AD are more likely to have long-term mental health problems, which may include:

• Alcohol and drug addiction
• Depression
• Suicidal thoughts and behavior

Compared with adults, teens with AD — especially chronic AD marked by behavior problems — are at significantly increased risk of long-term problems. In addition to depression, substance abuse and suicidal behavior, teens with AD are at risk of developing psychiatric illnesses such as:

• Antisocial personality disorder
• Bipolar disorder
• Schizophrenia

Preparing for an appointment—

If you or your youngster has thoughts of suicide, go to an emergency room or call 911 or your local emergency number immediately.

If you or your youngster has less urgent symptoms of an AD, make an appointment with your family doctor or your youngster's pediatrician. While ADs resolve on their own in most cases, your doctor may be able to recommend coping strategies or treatments that may help you or your youngster feel better sooner.

Here's some information to help you prepare for your appointment, and what to expect from your doctor.

What you can do:

• Make a list of your medical information, including other physical or mental health conditions with which you've been diagnosed. Also write down the names of any medications you're taking.
• Take a trusted family member or friend along, if you are the one with symptoms of AD. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down any symptoms you've been experiencing, and for how long.
• Write down questions to ask your doctor in advance so that you can make the most of your appointment.
• Write down your key personal information, including any major stresses or recent life changes, both positive and negative. Even happy events such as getting married or adding a new youngster to your family can cause AD.

For AD, some basic questions to ask your doctor include:

• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?
• Are there any other possible causes?
• Do you recommend any temporary changes at home, work or school to encourage recovery?
• Do you recommend treatment? If yes, with what types of therapy?
• Does AD increase the risk of other mental health problems?
• How soon do you expect symptoms to improve?
• How will you determine the diagnosis?
• Is this condition likely temporary or chronic?
• Should a mental health specialist be consulted?
• Should school staff or work colleagues be made aware of this diagnosis?
• What do you believe is causing these symptoms?
• What will you recommend next if symptoms don't improve within a few months?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor:

Being ready to answer your doctor's questions may save some time to go over any points you want to talk about in-depth.

You or your youngster should be prepared to answer the following questions from your doctor:

• Are you avoiding social or family events?
• Are you having trouble sleeping?
• Are you talking with friends or family about these changes?
• Do you drink alcohol or use illicit drugs? How often?
• Do you have difficulty finishing tasks at home, work or school that previously felt manageable to you?
• Have been having any problems at school or work?
• Have you been treated for other psychiatric symptoms or mental illness in the past? If yes, what type of therapy was most beneficial?
• Have you ever thought about harming yourself or others?
• Have you made any impulsive decisions or engaged in reckless behavior that doesn't seem like you?
• How often do you feel anxious or worried?
• How often do you feel sad or depressed?
• What are your symptoms?
• What major changes have recently occurred in your life, both positive and negative?
• What other symptoms or behaviors are causing you or your loved ones distress?
• When did you or your loved ones first notice your symptoms?

What you can do in the meantime:

While you're waiting for your doctor appointment, try reaching out to your friends or family. Talking about your feelings and asking for help is the most important thing you can do to aid your recovery from AD.

If your youngster has symptoms of an AD, try gently encouraging him or her to talk about feelings. Many parents assume that talking about a difficult change, such as divorce, will only make a youngster feel worse. But the opposite is true. Your youngster needs the opportunity to express feelings of grief, and to hear your reassurance that you'll remain a constant source of love and support.

Tests and diagnosis—

ADs are diagnosed based on signs and symptoms and a thorough psychological evaluation. To be diagnosed with AD, someone must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health professionals to diagnose mental conditions and by insurance companies to reimburse for treatment.

For an AD to be diagnosed, several criteria must be met, including:

• An improvement of symptoms within six months of the stressful event coming to an end
• Experiencing distress that is in excess of what would normally be expected in response to the stressor or that causes significant problems in your relationships, at work or at school
• Having emotional or behavioral symptoms within three months of a specific stressor occurring in your life

Types of ADs:

Your health care provider may ask detailed questions about how you feel and how you spend your time. This will help him or her pinpoint which specific type of AD you have. There are six main types of ADs. Although they're all related, each type of AD has certain signs and symptoms.

The six types of AD are:

• AD unspecified. Symptoms don't fit the other types of ADs but often include physical problems, problems with family or friends, or work or school problems.
• AD with anxiety. Symptoms mainly include nervousness, worry, difficulty concentrating or remembering things, and feeling overwhelmed. Kids who have AD with anxiety may strongly fear being separated from their parents and loved ones.
• AD with depressed mood. Symptoms mainly include feeling sad, tearful and hopeless, and a lack of pleasure in the things you used to enjoy.
• AD with disturbance of conduct. Symptoms mainly involve behavioral problems, such as fighting, reckless driving or ignoring your bills. Youngsters may skip school or vandalize property.
• AD with mixed anxiety and depressed mood. Symptoms include a mix of depression and anxiety.
• AD with mixed disturbance of emotions and conduct. Symptoms include a mix of depression and anxiety as well as behavioral problems.

Treatments and drugs—

Most individuals find treatment of AD helpful, and they're in treatment only for several months. Others may benefit from longer treatment, though. There are two main types of treatment for AD — psychotherapy and medications.

• Medications- In some cases, medications may help, too. Medications can help with such symptoms as depression, anxiety and suicidal thoughts. Antidepressants and anti-anxiety medications are the medications most often used to treat ADs. As with therapy, you may need medications only for a few months.

• Psychotherapy- The main treatment for ADs is psychotherapy, also called counseling or talk therapy. You may attend individual therapy, group therapy or family therapy. Therapy can provide emotional support and help you get back to your normal routine. It can also help you learn why the stressful event affected you so much. As you understand more about this connection, you can also learn healthy coping skills. These skills can help you weather other stressful events that may arise in your life.

Lifestyle and home remedies—

When you face a stressful event or major life change, you can take some steps to care for your emotional well-being. Do what works for you. Some examples include:

• Engaging in a hobby you enjoy
• Finding a support group geared toward your situation
• Finding support from a faith community
• Getting regular physical activity
• Sticking to a regular sleep routine
• Talking things over with caring family and friends
• Trying to keep eating a healthy diet

If it's your youngster who's having difficulty adjusting, you can help by:

• Letting your youngster make simple decisions, such as what to eat for dinner or which movie to watch
• Offering encouragement to talk about his or her feelings
• Offering support and understanding
• Reassuring your youngster that such reactions are common
• Touching base with your youngster's teacher to check on progress or problems at school

If you use these kinds of self-care steps but they don't seem to be helping, be sure to talk to your health care provider.

Prevention—

There are no guaranteed ways to prevent AD. But developing healthy coping skills and learning to be resilient may help you during times of high stress. Resilience is the ability to adapt well to stress, adversity, trauma or tragedy. Some of the ways you can improve your resilience are:

• Having a good support network
• Living a healthy lifestyle
• Seeking out humor or laughter
• Thinking positively about yourself

If you know that a stressful situation is coming up — such as a move or retirement — call on your inner strength in advance. Remind yourself that you can get through it. Use stress management and coping skills, such as exercise, yoga, meditation or even a night at the movies with friends. In addition, consider checking in with your health care or mental health care provider to review healthy ways to manage your stress.

Q and A—

What is an adjustment disorder (AD) and how does it occur?

There are six major adjustment disorders:

• Adjustment disorder unspecified
• Adjustment disorder with anxiety
• Adjustment disorder with depressed mood
• Adjustment disorder with disturbance of conduct
• Adjustment disorder with mixed anxiety and depressed mood
• Adjustment disorder with mixed disturbance of emotions and conduct

What are the characteristics associated with an AD?

A person with AD often experiences feelings of depression or anxiety or combined depression and anxiety. As a result, that person may act out behaviorally against the "rules and regulations" of family, work, or society. In some individuals, an AD may manifest itself in such behaviors as skipping school, unexpected fighting, recklessness, or legal problems. Other individuals, however, instead of acting out, may tend to withdraw socially and isolate themselves during their adjustment problems. Still others may not experience behavioral disturbances, but will begin to suffer from physical illness. If someone is already suffering from a medical illness, that condition may worsen during the time of the AD. Individuals in the midst of ADs often do poorly in school or at work. Very commonly they begin to have more difficulty in their close, personal relationships.

Listed below are some of the characteristics associated with ADs:

1. A person with an AD with anxiety would experience anxious feelings, nervousness, and worry.
2. A person with an AD with depressed mood may have mostly a depressed mood, hopeless feelings, and crying spells.
3. A person with an AD with mixed disturbance of emotions and conduct would have a mixture of emotional and conduct problems.
4. An individual with an AD with disturbance of conduct may act out inappropriately. This person may act out against society, skip school, or begin to have trouble with the police.
5. Someone with an AD with mixed anxiety and depressed mood would, obviously, have a mixture of anxious and depressed feelings.

At what age can an AD appear?

ADs can occur at any age. Individuals are particularly vulnerable during normal transitional periods such as adolescence, mid-life, and late life.

Do ADs affect males, females, or both?

In the United States the same number of males and females experience the various ADs.

How is an AD diagnosed?

A mental health professional makes a diagnosis of an AD by taking a careful personal history from the client/patient. It is important to the therapist to learn the details that surround the stressful event or events in that person's life. No laboratory tests are required to make a diagnosis of AD nor are there any physical conditions that must be met. However, it is very important for the therapist not to overlook a physical illness that might mimic or contribute to a psychological disorder. If there is any question whether the individual might have a physical problem, the mental health professional should recommend a complete physical examination by a medical doctor. Laboratory tests might be necessary as a part of the physical workup.

How is an AD treated?

Therapy can be very helpful to lessen or alleviate ongoing symptoms of AD before they become disabling. Group therapy can be useful to individuals who are enduring similar stress. In some situations the use of prescription medications can be very useful to ease the depression or the anxiety associated with AD.

How often does AD appear in the community?

AD is very common in the United States. More than five percent (5%) of all persons seen in clinical, outpatient mental health settings have some type of AD.

What can individuals do if they need help?

If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.

What happens to a person with an AD?

The conditions associated with AD develop within three months of the beginning of the stressful problem. An AD usually lasts no longer than three to six months. The condition may persist, however, if an individual is suffering from chronic stress such as that caused by an illness, a difficult relationship, or worsening financial problems.