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Common Youth Problems

Depression

Definition

Depression may be described as feeling sad, blue, unhappy, miserable, or down in the dumps. Most of us feel this way at one time or another for short periods.

True clinical depression is a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for an extended period of time.

See also:

  • Adolescent depression
  • Depression in the elderly

Alternative Names

Blues; Discouragement; Gloom; Mood changes; Sadness; Melancholy

Considerations

Depression is generally ranked in terms of severity -- mild, moderate, or severe. The degree of your depression, which your doctor can determine, influences how you are treated. Symptoms of depression include:

  • Trouble sleeping or excessive sleeping
  • A dramatic change in appetite, often with weight gain or loss
  • Fatigue and lack of energy
  • Feelings of worthlessness, self-hate, and inappropriate guilt
  • Extreme difficulty concentrating
  • Agitation, restlessness, and irritability
  • Inactivity and withdrawal from usual activities
  • Feelings of hopelessness and helplessness
  • Recurring thoughts of death or suicide

Low self esteem is common with depression. So are sudden bursts of anger and lack of pleasure from activities that normally make you happy, including sex.

Depressed children may not have the classic symptoms of adult depression. Watch especially for changes in school performance, sleep, and behavior. If you wonder whether your child might be depressed, it's worth bringing to a doctor's attention.

The main types of depression include:

  • Major depression -- five or more symptoms listed above must be present for at least 2 weeks, but major depression tends to continue for at least 6 months. (Depression is classified as minor depression if you have fewer than five depression symptoms for at least 2 weeks. In other words, minor depression is similar to major depression except it only has 2 - 4 symptoms.)
  • Atypical depression -- occurs in about a third of patients with depression. Symptoms include overeating and oversleeping. These patients tend to have a feeling of being weighed down and react strongly to rejection.
  • Dysthymia -- a generally milder form of depression that lasts as long as two years.

Other common forms of depression include:

  • Postpartum depression -- many women feel somewhat down after having a baby, but true postpartum depression is rare.
  • Premenstrual dysphoric disorder (PMDD) -- depressive symptoms occur one week prior to menstruation and disappear after you menstruate.
  • Seasonal affective disorder (SAD) -- occurs during the fall-winter season and disappears during the spring-summer season. Likely to be due to lack of sunlight.

Depression may also occur with mania (known as manic-depression or bipolar disorder). In this condition, moods cycle between mania and depression.

Depression is more common in women than men and is especially common during the teen years. Men seem to seek help for feelings of depression less often than women. Therefore, women may only have more documented cases of depression.

Causes

Depression often runs in families. This may due to your genes (inherited), learned behavior, or both. Even if your genes make you more likely to develop depression, a stressful or unhappy life event usually triggers the onset of a depressive episode.

Depression may be brought on by:

  • Alcohol or drug abuse
  • Childhood events like abuse or neglect
  • Chronic stress
  • Death of a friend or relative
  • Disappointment at home, work, or school (in teens, this may be breaking up with a boyfriend or girlfriend, failing a class, or parents divorcing)
  • Drugs such as sedatives and high blood pressure medications
  • Medical conditions such as hypothyroidism (underactive thyroid), cancer, or hepatitis
  • Nutritional deficiencies (such as a lack of folate and omega-3 fatty acids)
  • Overly negative thoughts about one's self and life, self blame, and ineffective social problem solving skills
  • Prolonged pain or having a major illness
  • Sleeping problems
  • Social isolation (common in the elderly)

Home Care

If you are depressed for 2 weeks or longer, you should contact your doctor, who can offer treatment options. Regardless of whether you have mild or major depression, the following self-care steps can help:

  • Get enough sleep.
  • Follow a healthy, nutritious diet.
  • Exercise regularly.
  • Avoid alcohol, marijuana, and other recreational drugs.
  • Get involved in activities that make you happy, even if you don't feel like it.
  • Spend time with family and friends.
  • Try talking to clergy or spiritual advisors who may help give meaning to painful experiences.
  • Consider prayer, meditation, tai chi, or biofeedback as ways to relax or draw on your inner strengths.
  • Add omega-3 fatty acids to your diet, which you can get from cold-water fish like tuna, salmon, or mackerel.
  • Take folate (vitamin B9) in the form of a multivitamin (400 to 800 micrograms).

If your depression occurs in the fall or winter months, try light therapy using a special lamp that mimics the sun.

Many people try a popular over-the-counter herb called St. John's wort. Some studies do suggest that this herbal remedy may be helpful for mild depression, but not moderate or severe. Be aware that St. John's wort has potential drug interactions and should NOT be taken with prescription antidepressants, birth control pills, protease inhibitors for HIV, theophylline, warfarin, digoxin, reserpine, cyclosporine, or loperamide. Talk to your doctor if you are thinking about trying this herb for mild depression.

If you have moderate to severe depression, the most effective treatment plan will likely be a combination of counseling and medication.

When to Contact a Medical Professional

Call 911, a suicide hotline, or get safely to a nearby emergency room if you have thoughts of suicide, a suicidal plan, or thoughts of harming yourself or others.

Call your doctor right away if:

  • You hear voices that are not there
  • You have frequent crying spells with little or no provocation
  • You have had feelings of depression that disrupt work, school, or family life for longer than 2 weeks
  • You have 3 or more depressive symptoms
  • You think that one of your current medications may be making you feel depressed -- DO NOT change or stop any medications without consulting your doctor
  • You believe that you should cut back on drinking, a family member or friend has asked you to cut back, you feel guilty about the amount of alcohol you drink, or you drink alcohol first thing in the morning

What to Expect at Your Office Visit

A complete history, a psychiatric interview, and a physical examination will be performed to try to classify your depression as mild, moderate, or severe and to see if there is an underlying, treatable cause (such as alcohol abuse or an underactive thyroid). Hospitalization is usually recommended if suicide seems possible.

Expect some exploration of the issues and events associated with your feelings of depression. Your doctor will ask you about:

  • Your depressive moods and other symptoms (sleep, appetite, concentration, energy)
  • Possible stressors in your life, and support systems in place
  • Whether thoughts about ending your life have ever crossed your mind
  • Drug and alcohol use, and about the medications you are currently taking, if any

Treatment will vary according to the cause and severity of your depressive symptoms, as well as your personal preference. The most effective therapy for moderate or severe depression is a combination of antidepressant medication and psychotherapy.

For mild depression, counseling and self-care measures without medication may be enough.

If you are taking medications for other purposes that could cause depression as a side effect, these may need to be changed. DO NOT change or stop any of your medications without consulting your doctor.

For people who are so severely depressed as to be unable to function, or who are suicidal and cannot be safely cared for in the community, psychiatric hospitalization may be necessary.

Prevention

Healthy lifestyle habits can help prevent depression, or lessen the chances of it happening again. These habits include eating properly, sleeping adequately, exercising regularly, learning to relax, and not drinking alcohol or using drugs.

Counseling may help you through times of grief, stress, or low mood. Family therapy may be particularly important for teens who feel blue.

If you feel socially isolated or lonely, try volunteering or getting involved in group activities.

References

Moore D, Jefferson J. Major Depressive Disorder. In: Handbook of Medical Psychiatry. 2nd ed. Mosby, Inc., 2004; 134-141.

Screening for Depression Recommendations and Rationale. US Preventive Services Task Force, Guidelines from Guide to Clinical Preventive Services: 3rd ed. Rockville, Md. US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; May 1, 2002.

World Health Organization. The World Health Report 2001 - Mental Health: New Understanding, New Hope. Geneva World Health Organization, 2001.

Guide to Clinical Preventive Services: Screening for Depression, Recommendations and Rationale. Rockville, Md. US Preventive Services Task Force, Dept of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. Ann Intern Med. 2002; 136(10): 760–764.

Practice Guideline for the Treatment of Patients With Major Depressive Disorder, 2nd ed. Arlington, VA: American Psychiatric Association; 2000.

Review Date: 1/28/2008
Reviewed By: A.D.A.M. Editorial Team: David Zieve, MD, MHA, Greg Juhn, MTPW, David R. Eltz, Kelli A. Stacy, ELS. Benjamin W. Van Voorhees, MD, MPH, Assistant Professor of Medicine, Pediatrics and Psychiatry, The University of Chicago, Chicago, IL. Review provided by VeriMed Healthcare Network (5/17/2007).
2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
adam.com

Major depression

Definition

Major depression is when five or more symptoms of depression are present for at least 2 weeks. These symptoms include feeling sad, hopeless, worthless, or pessimistic. In addition, people with major depression often have behavior changes, such as new eating and sleeping patterns. Major depression increases a person's risk of suicide.

Alternative Names

Depression - major; Unipolar depression; Major depressive disorder

Causes

The exact cause of depression is not known. Many researchers believe it is caused by chemical imbalances in the brain, which may be hereditary or caused by events in a person's life.

Some types of depression seem to run in families, but depression can also occur in people who have no family history of the illness. Stressful life changes or events can trigger depression in some people. Usually, a combination of factors is involved.

Men and women of all ages, races, and economic levels can have depression. It occurs more often in women.

Women are especially vulnerable to depression after giving birth. This is a result of hormonal and physical changes. Although new mothers commonly experience temporary "blues," depression that lasts longer than 2 - 3 weeks is not normal and requires treatment.

Major depression can occur in children and teenagers, and they can also benefit from treatment.

See also: Adolescent depression

Symptoms

  • Agitation, restlessness, and irritability
  • Dramatic change in appetite, often with weight gain or loss
  • Extreme difficulty concentrating
  • Fatigue and lack of energy
  • Feelings of hopelessness and helplessness
  • Feelings of worthlessness, self-hate, and inappropriate guilt
  • Inactivity and withdrawal from usual activities, a loss of interest or pleasure in activities that were once enjoyed (such as sex)
  • Thoughts of death or suicide
  • Trouble sleeping or excessive sleeping

Depression can appear as anger and discouragement, rather than as feelings of hopelessness and helplessness. If depression is very severe, there may also be psychotic symptoms, such as hallucinations and delusions. These symptoms may focus on themes of guilt, inadequacy, or disease.

Exams and Tests

Major depression is diagnosed if a person reports having five or more depressive symptoms for at least 2 weeks. Beck's Depression Scale Inventory or other screening tests for depression can be helpful in diagnosing depression.

Before diagnosing depression, the health care provider should rule out medical conditions that can cause symptoms of depression.

Treatment

Depression can be treated in a variety of ways, particularly with medications and counseling. Most people benefit from a combination of the two treatments. Some studies have shown that antidepressant drug therapy combined with psychotherapy has better results than either therapy alone.

Medications include tricyclic antidepressants, monoamine oxidase inhibitors, selective serotonin re-uptake inhibitors (SSRIs), and some newer antidepressant drugs. Although antidepressant medications can be very effective, some may not be appropriate for everyone. For example, in 2007, the FDA proposed that all antidepressant medicines should warn of the risk of suicidal behavior in young adults ages 18 - 24 years.

Lithium and thyroid supplements may be needed to enhance the effectiveness of antidepressants. People with psychotic symptoms, such as delusions or hallucinations, may need antipsychotic medications.

Electroconvulsive therapy (ECT) is a treatment that causes a seizure by means of an electrical current. ECT may improve the mood of severely depressed or suicidal people who don't respond to other treatments.

Research is now being conducted on transcranial magnetic stimulation (TMS), which alters brain function in a way similar to ECT, but with fewer side effects. Use of light therapy for depressive symptoms in the winter months and interventions to restore a normal sleep cycle may be effective for relieving depression.

As treatment takes effect, negative thinking diminishes. It takes time to feel better, but there are usually day-to-day improvements.

It is important to maintain a healthy lifestyle:

  • Avoid alcohol and drugs (which make depression worse and may interfere with medications)
  • Eat well-balanced meals
  • Get regular exercise and sleep
  • Seek supportive relationships

Many consumers try herbal products for depression. St. John's wort has a long history of use in Germany and has gained popularity as an herbal antidepressant in the United States. Most of the German studies indicated that St. John's wort was comparable to some antidepressants. However, a large study conducted by the National Center for Complementary and Alternative Medicine found that St. John's wort was NOT effective for treating major depression.

Because herbal products can have side effects, always tell your doctor if you are using them.

Support Groups

For more information and resources, see depression support group.

Outlook (Prognosis)

The outcome is usually good with treatment. Although most depressive episodes can be effectively treated with either medication, psychotherapy, or both, depression is a recurring problem for many people. For people who have experienced repeated episodes of depression, maintenance treatment may be needed to prevent future recurrences.

Possible Complications

  • Suicide (up to 15% of people with major depressive disorder die by suicide)
  • Increased risk of alcohol- and drug-related problems
  • Increased risk of tobacco dependence
  • Increased risk of problems with physical health and premature death due to medical illness

When to Contact a Medical Professional

Call 911, a suicide hotline, or get safely to a nearby emergency room if you have thoughts of suicide, a suicidal plan, or thoughts of harming yourself or others.

Call your doctor right away if:

  • You hear voices that are not there.
  • You have frequent crying spells with little or no provocation.
  • You have had feelings of depression that disrupt work, school, or family life for longer than 2 weeks.
  • You think that one of your current medications may be making you feel depressed. DO NOT change or stop any medications without consulting your doctor.
  • You believe that you should cut back on drinking, a family member or friend has asked you to cut back, you feel guilty about the amount of alcohol you drink, or you drink alcohol first thing in the morning.

Prevention

You may be able to avoid some episodes of depression by:

  • Avoiding alcohol, drugs, and caffeine
  • Exercising regularly
  • Learning how to relax and manage stress
  • Maintaining good sleep habits

Counseling may help you through times of grief, stress, or low mood. Family therapy may be particularly important for teens who feel blue.

The elderly, or others who feel socially isolated or lonely can try volunteering or getting involved in group activities.

Medications and psychiatric counseling may prevent depression from returning. Some episodes of depression are not preventable.

References

Moore DP, Jefferson JW. Mood disorders. In: Moore DP, Jefferson JW, eds. Handbook of Medical Psychiatry. 2nd ed. Philadelphia, Pa: Mosby Elsevier;2004:chap 74.

US Preventive Services Task Force. Guide to clinical preventive services: screening for depression, recommendations and rationale. 2002;136. Accessed October 17, 2008.

Conway MW, Miller MN. Mood disorders. In: Rakel P, Bope ET, eds. Conn's Current Therapy 2008. 60th ed. Philadelphia, Pa:Saunders Elsevier;2008:chap 281.

American Psychiatric Association. Practice guidelines for the treatment of patients with major depressive disorder. 2nd ed. September 2007. Accessed October 27, 2008.

Schiffer RB. Psychiatric disorders in medical practice. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa:Saunders Elsevier;2007:chap 420.


Review Date: 12/15/2008
Reviewed By: Linda Vorvick, MD, Family Physician, Seattle Site Coordinator, Lecturer, Pathophysiology, MEDEX Northwest Division of Physician Assistant Studies, University of Washington School of Medicine; and Timothy A. Rogge, MD, private practice in Psychiatry, Kirkland, Washington. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
adam.com

Bipolar disorder

Definition

Bipolar disorder involves periods of excitability (mania) alternating with periods of depression. The "mood swings" between mania and depression can be very abrupt.

Alternative Names

Manic depression; Bipolar affective disorder

Causes

Bipolar disorder affects men and women equally. It usually appears between ages 15 - 25. The exact cause is unknown, but it occurs more often in relatives of people with bipolar disorder.

Bipolar disorder results from disturbances in the areas of the brain that regulate mood.

There are two primary types of bipolar disorder. People with bipolar disorder I have had at least one fully manic episode with periods of major depression. In the past, bipolar disorder I was called manic depression.

People with bipolar disorder II seldom experience full-fledged mania. Instead they experience periods of hypomania (elevated levels of energy and impulsiveness that are not as extreme as the symptoms of mania). These hypomanic periods alternate with episodes of major depression.

A mild form of bipolar disorder called cyclothymia involves periods of hypomania and mild depression, with less severe mood swings. People with bipolar disorder II or cyclothymia may be misdiagnosed as having depression alone.

Symptoms

The manic phase may last from days to months and can include the following symptoms:

  • Agitation or irritation
  • Elevated mood
    • Hyperactivity
    • Increased energy
    • Lack of self-control
    • Racing thoughts
  • Inflated self-esteem (delusions of grandeur, false beliefs in special abilities)
  • Little need for sleep
  • Over-involvement in activities
  • Poor temper control
  • Reckless behavior
    • Binge eating, drinking, and/or drug use
    • Impaired judgment
    • Sexual promiscuity
    • Spending sprees
  • Tendency to be easily distracted

These symptoms of mania are seen with bipolar disorder I. In people with bipolar disorder II, hypomanic episodes involve similar symptoms that are less intense.

The depressed phase of both types of bipolar disorder involves very serious symptoms of major depression:

  • Difficulty concentrating, remembering, or making decisions
  • Eating disturbances
    • Loss of appetite and weight loss
    • Overeating and weight gain
  • Fatigue or listlessness
  • Feelings of worthlessness, hopelessness and/or guilt
  • Loss of self-esteem
  • Persistent sadness
  • Persistent thoughts of death
  • Sleep disturbances
    • Excessive sleepiness
    • Inability to sleep
  • Suicidal thoughts
  • Withdrawal from activities that were once enjoyed
  • Withdrawal from friends

There is a high risk of suicide with bipolar disorder. While in either phase, patients may abuse alcohol or other substances, which can worsen the symptoms.

Sometimes there is an overlap between the two phases. Manic and depressive symptoms may occur simultaneously or in quick succession in what is called a mixed state.

Exams and Tests

A diagnosis of bipolar disorder involves consideration of many factors. The health care provider may do some or all of the following:

  • Ask about your family medical history, particularly whether anyone has or had bipolar disorder
  • Ask about your recent mood swings and for how long you've experienced them
  • Observe your behavior and mood
  • Perform a thorough examination to identify or rule out physical causes for the symptoms
  • Request laboratory tests to check for thyroid problems or drug levels
  • Speak with your family members to discuss their observations about your behavior
  • Take a medical history, including any medical problems you have and any medications you take

Note: Use of recreational drugs may be responsible for some symptoms, though this does not rule out bipolar affective disorder. Drug abuse may itself be a symptom of bipolar disorder.

Treatment

Bipolar disorder is often treated with mood-stabilizing medications such as valproic acid, lithium, and carbamazepine. These are effective for treating both the manic and depressive phases, as well as preventing future symptoms.

Antidepressant drugs may be useful during the depressive phase if the antidepressants are used with a mood stabilizer. Mood stabilizers are very important in people with bipolar disorder. Without a mood stabilizer, antidepressants may trigger mania in people with bipolar disorder. (Keep in mind that people with bipolar disorder II may be misdiagnosed with depression only because they do not experience full-fledged mania. If these patients take antidepressants without mood stabilizers, it can trigger a manic episode.)

Antipsychotic drugs can help a person who has lost touch with reality. Anti-anxiety drugs, such as benzodiazepines, may also help. The patient may need to stay in a hospital until his or her mood has stabilized and symptoms are under control.

Electroconvulsive therapy (ECT) may be used to treat bipolar disorder. ECT is a psychiatric treatment that uses an electrical current to cause a brief seizure of the central nervous system while the patient is under anesthesia. Studies have repeatedly found that ECT is the most effective treatment for depression that is not relieved with medications.

Getting enough sleep helps keep a stable mood in some patients. Psychotherapy may be a useful option during the depressive phase. Joining a support group may be particularly helpful for bipolar disorder patients and their loved ones.

Outlook (Prognosis)

Mood-stabilizing medication can help control the symptoms of bipolar disorder. However, patients often need help and support to take medicine properly and to ensure that any episodes of mania and depression are treated as early as possible.

Some people stop taking the medication as soon as they feel better or because they want to experience the productivity and creativity associated with mania. Although these early manic states may feel good, discontinuing medication may have very negative consequences.

Suicide is a very real risk during both mania and depression. Suicidal thoughts, ideas, and gestures in people with bipolar affective disorder require immediate emergency attention.

Possible Complications

Stopping or improperly taking medication can cause your symptoms to come back, and lead to the following complications:

  • Alcohol and/or drug abuse as a strategy to "self-medicate"
  • Personal relationships, work, and finances suffer
  • Suicidal thoughts and behaviors

This illness is challenging to treat. Patients and their friends and family must be aware of the risks of neglecting to treat bipolar disorder.

When to Contact a Medical Professional

Call your health provider or an emergency number right way if:

  • You are having thoughts of death or suicide
  • You are experiencing severe symptoms of depression or mania
  • You have been diagnosed with bipolar disorder and your symptoms have returned or you are having any new symptoms

References

Moore DP, Jefferson JW. Bipolar disorder. In: Moore DP, Jefferson JW, eds. Handbook of Medical Psychiatry. 2nd ed. Philadelphia, Pa: Mosby Elsevier;2004:chap 80.

Schiffer RB. Psychiatric disorders in medical practice. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa:Saunders Elsevier;2007:chap 420.

Conway MW, Miller MN. Mood disorders. In: Rakel P, Bope ET, eds. Conn's Current Therapy 2008. 60th ed. Philadelphia, Pa:Saunders Elsevier;2008:chap 281.


Review Date: 12/15/2008
Reviewed By: Linda Vorvick, MD, Family Physician, Seattle Site Coordinator, Lecturer, Pathophysiology, MEDEX Northwest Division of Physician Assistant Studies, University of Washington School of Medicine; and Timothy A. Rogge, MD, private practice in Psychiatry, Kirkland, Washington. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
adam.com

Schizophrenia

Definition

Schizophrenia is a mental disorder that makes it difficult to tell the difference between real and unreal experiences, to think logically, to have normal emotional responses, and to behave normally in social situations.

Causes

Schizophrenia is a complex illness. Even experts in the field are not sure what causes it. Some doctors think that the brain may not be able to process information correctly.

Genetic factors appear to play a role. People who have family members with schizophrenia may be more likely to get the disease themselves.

Some researchers believe that events in a person's environment may trigger schizophrenia. For example, problems (infection) during development in the mother's womb and at birth may increase the risk for developing schizophrenia later in life.

Psychological and social factors may also affect its development. However, the level of social and family support appears to affect the course of illness and may protect against the condition returning.

There are 5 types of schizophrenia:

  • Catatonic
  • Disorganized
  • Paranoid
  • Residual
  • Undifferentiated

Schizophrenia usually begins before the age of 45, symptoms last for 6 months or more, and people start to lose their ability to socialize and work.

Schizophrenia is thought to affect about 1% of people worldwide.

Schizophrenia appears to occur in equal rates among men and women, but in women it begins later. For this reason, males tend to account for more than half of patients in services with high numbers of young adults. Although schizophrenia usually begins in young adulthood, there are cases in which the disorder begins later (over 45 years).

Childhood-onset schizophrenia begins after the age of 5 and, in most cases, after normal development. Childhood schizophrenia is rare and can be difficult to tell apart from other developmental disorders of childhood, such as autism.

Symptoms

Schizophrenia may have a variety of symptoms. Usually the illness develops slowly over months or even years.

At first, the symptoms may not be noticeable. For example, you may feel tense, or have trouble sleeping or concentrating. You can become isolated and withdrawn, and have trouble making or keeping friends.

As the illness continues, psychotic symptoms develop:

  • An appearance or mood that shows no emotion (flat affect)
  • Bizarre motor behavior in which there is less reaction to the environment (catatonic behavior)
  • False beliefs or thoughts that have nothing to do with reality (delusions)
  • Hearing, seeing, or feeling things that are not there (hallucinations)
  • Thoughts "jump" between unrelated topics (disordered thinking)

Symptoms can be different depending on the type of schizophrenia.

Catatonic type:

  • Agitation
  • Decreased sensitivity to pain
  • Inability to take care of personal needs
  • Negative feelings
  • Motor disturbances
  • Rigid muscles
  • Stupor

Paranoid type:

  • Anger
  • Anxiety
  • Argumentativeness
  • Delusions of persecution or grandeur
  • Violence

Disorganized type:

  • Child-like (regressive) behavior
  • Delusions
  • Flat affect
  • Hallucinations
  • Inappropriate laughter
  • Not understandable (incoherence)
  • Repetitive behaviors
  • Social withdrawal

Undifferentiated type may include symptoms of more than one type of schizophrenia.

Residual type -- symptoms of the illness have gone away, but some features, such as hallucinations and flat affect, may remain.

Exams and Tests

Because other diseases can cause symptoms of psychosis, psychiatrists should make the final diagnosis. The diagnosis is made based on a thorough interview of the person and family members.

No medical tests for schizophrenia exist. The following factors may suggest a schizophrenia diagnosis, but do not confirm it:

  • Course of illness and how long symptoms have lasted
  • Changes from level of function before illness
  • Developmental background
  • Genetic and family history
  • Response to medication

CT scans of the head and other imaging techniques may find some changes that occur with schizophrenia and may rule out other disorders.

Treatment

During an episode of schizophrenia, you may need to stay in the hospital for safety reasons, and to provide for basic needs such as food, rest, and hygiene.

Antipsychotic or neuroleptic medications change the balance of chemicals in the brain and can help control the symptoms of the illness. These medications are effective, but they can have side effects. However, many of these side effects can be addressed, and should not prevent people from seeking treatment for this serious condition.

Common side effects from antipsychotics may include:

  • Sleepiness (sedation)
  • Weight gain

Other side effects include:

  • Feelings of restlessness or "jitters"
  • Problems of movement and gait
  • Muscle contractions

Long-term risks include a movement disorder called tardive dyskinesia, in which people move without meaning to.

Newer drugs known as atypical antipsychotics appear to have fewer side effects. They also appear to help people who have not improved with the older medications. Treatment with medications is usually needed to prevent symptoms from coming back.

Supportive and problem-focused forms of therapy may be helpful for many people. Behavioral techniques, such as social skills training, can be used during therapy, or at home to improve function socially and at work.

Family treatments that combine support and education about schizophrenia (psychoeducation) appear to help families cope and reduce the odds of symptoms returning. Programs that emphasize outreach and community support services can help people who lack family and social support.

Outlook (Prognosis)

Most people with schizophrenia find that their symptoms improve with medication, and some can get good control of their symptoms over time. However, others have functional disability and are at risk for repeated episodes, especially during the early stages of the illness.

To live in the community, people with schizophrenia may need supported housing, work rehabilitation, and other community support programs. People with the most severe forms of this disorder may be too disabled to live alone, and may need group homes or other long-term, structured places to live.

Possible Complications

  • People with schizophrenia have a high risk of developing a substance abuse problem. Use of alcohol or other drugs increases the risk of relapse.
  • Physical illness is common among people with schizophrenia due to side effects from medication and living conditions. These may not be detected because of poor access to medical care and difficulties talking to health care providers.
  • Not taking medication will often cause symptoms to return.

When to Contact a Medical Professional

Call your health care provider if:

  • Voices are telling you to hurt yourself.
  • You are feeling hopeless and overwhelmed.
  • You are seeing things that aren't really there.
  • You feel like you cannot leave the house.
  • You are unable to care for yourself.

Prevention

The best way to prevent symptoms from coming back is to take the medication your doctor prescribed.

Because side effects are one of the most important reasons why people with schizophrenia stop taking their medication, it is very important to find the medication that controls your symptoms without causing side effects. Always talk to your doctor if you are thinking about changing or stopping your medications.

References

Rakel RE. Textbook of Family Practice. 6th ed. Philadelphia, Pa: WB Saunders; 2005:115-124.

Marx J, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 5th ed. St. Louis, Mo: Mosby; 2002:1541-1548.

Schultz SH, North SW, Shields CG. Schizophrenia: a review. Am Fam Physician. 2007;75:1821-1829.

Lieberman JA. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia: efficacy, safety and cost outcomes of CATIE and other trials. J Clin Psychiatry. 2007;68:e04.

Addington D, Bouchard RH, Goldberg J, Honer B, Malla A, Norman R, Tempier R. Clinical practice guidelines: treatment of schizophrenia. Can J Psychiatry. 2005;50:7s-57s.


Review Date: 2/6/2008
Reviewed By: Christos Ballas, MD, Attending Psychiatrist, Hospital of the University of Pennsylvania, Philadelphia, PA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
adam.com

Stress and anxiety

Definition

Stress can come from any situation or thought that makes you feel frustrated, angry, or anxious. What is stressful to one person is not necessarily stressful to another.

Anxiety is a feeling of apprehension or fear. The source of this uneasiness is not always known or recognized, which can add to the distress you feel.

Alternative Names

Anxiety; Feeling uptight; Stress; Tension; Jitters; Apprehension

Considerations

Stress is a normal part of life. In small quantities, stress is good -- it can motivate you and help you be more productive. However, too much stress, or a strong response to stress, is harmful. It can set you up for general poor health as well as specific physical or psychological illnesses like infection, heart disease, or depression. Persistent and unrelenting stress often leads to anxiety and unhealthy behaviors like overeating and abuse of alcohol or drugs.

Emotional states like grief or depression and health conditions like an overactive thyroid, low blood sugar, or heart attack can also cause stress.

Anxiety is often accompanied by physical symptoms, including:

  • Twitching or trembling
  • Muscle tension, headaches
  • Sweating
  • Dry mouth, difficulty swallowing
  • Abdominal pain (may be the only symptom of stress, especially in a child)

Sometimes other symptoms accompany anxiety:

  • Dizziness
  • Rapid or irregular heart rate
  • Rapid breathing
  • Diarrhea or frequent need to urinate
  • Fatigue
  • Irritability, including loss of your temper
  • Sleeping difficulties and nightmares
  • Decreased concentration
  • Sexual problems

Anxiety disorders are a group of psychiatric conditions that involve excessive anxiety. They include generalized anxiety disorder, specific phobias, obsessive-compulsive disorder, and social phobia.

Causes

Certain drugs, both recreational and medicinal, can lead to symptoms of anxiety due to either side effects or withdrawal from the drug. Such drugs include:

  • ADHD medications
  • Alcohol
  • Amphetamines
  • Bronchodilators for asthma
  • Caffeine
  • Cocaine
  • Cold remedies
  • Decongestants
  • Diet pills
  • Nicotine
  • Thyroid medications
  • Tricyclic antidepressants

A poor diet -- for example, low levels of vitamin B12 -- can also contribute to stress or anxiety. Performance anxiety is related to specific situations, like taking a test or making a presentation in public. Posttraumatic stress disorder (PTSD) develops after a traumatic event like war, physical or sexual assault, or a natural disaster. People with generalized anxiety disorder experience almost constant worry or anxiety about many things on more than half of all days for 6 months. Panic disorder or panic attacks involve sudden and unexplained fear, rapid breathing, and increased heartbeat.

In very rare cases, a tumor of the adrenal gland (pheochromocytoma) may be the cause of anxiety. The symptoms are caused by an overproduction of hormones responsible for the feelings of anxiety.

Home Care

The most effective solution is to find and address the source of your stress or anxiety. Unfortunately, this is not always possible. A first step is to take an inventory of what you think might be making you "stress out":

  • What do you worry about most?
  • Is something constantly on your mind?
  • Does anything in particular make you sad or depressed?
  • Keep a diary of the experiences and thoughts that seem to be related to your anxiety. Are your thoughts adding to your anxiety in these situations?

Then, find someone you trust (friend, family member, neighbor, clergy) who will listen to you. Often, just talking to a friend or loved one is all that is needed to relieve anxiety. Most communities also have support groups and hotlines that can help. Social workers, psychologists, and other mental health professionals may be needed for therapy and medication.

Also, find healthy ways to cope with stress. For example:

  • Eat a well-balanced, healthy diet. Don't overeat.
  • Get enough sleep.
  • Exercise regularly.
  • Limit caffeine and alcohol.
  • Don't use nicotine, cocaine, or other recreational drugs.
  • Learn and practice relaxation techniques like guided imagery, progressive muscle relaxation, yoga, tai chi, or meditation. Try biofeedback, using a certified professional to get you started.
  • Take breaks from work. Make sure to balance fun activities with your responsibilities. Spend time with people you enjoy.
  • Find self-help books at your local library or bookstore.

When to Contact a Medical Professional

Your doctor can help you determine if your anxiety would be best evaluated and treated by a mental health care professional.

Call 911 if:

  • You have crushing chest pain, especially with shortness of breath, dizziness, or sweating. A heart attack can cause feelings of anxiety.
  • You have thoughts of suicide.
  • You have dizziness, rapid breathing, or racing heartbeat for the first time or it is worse than usual.

Call your health care provider if:

  • You are unable to work or function properly at home because of anxiety.
  • You do not know the source or cause of your anxiety.
  • You have a sudden feeling of panic.
  • You have an uncontrollable fear -- for example, of getting infected and sick if you are out, or a fear of heights.
  • You repeat an action over and over again, like constantly washing your hands.
  • You have an intolerance to heat, weight loss despite a good appetite, lump or swelling in the front of your neck, or protruding eyes. Your thyroid may be overactive.
  • Your anxiety is elicited by the memory of a traumatic event.
  • You have tried self care for several weeks without success or you feel that your anxiety will not resolve without professional help.

Ask your pharmacist or health care provider if any prescription or over-the-counter drugs you are taking can cause anxiety as a side effect. Do not stop taking any prescribed medicines without your provider's instructions.

What to Expect at Your Office Visit

Your doctor will take a medical history and perform a physical examination, paying close attention to your pulse, blood pressure, and respiratory rate.

To help better understand your anxiety, stress, or tension, your doctor may ask the following:

  • When did your feelings of stress, tension, or anxiety begin? Do you attribute the feelings to anything in particular like an event in your life or a circumstance that scares you?
  • Do you have physical symptoms along with your feelings of anxiety? What are they?
  • Does anything make your anxiety better?
  • Does anything make your anxiety worse?
  • What medications are you taking?

Diagnostic tests may include blood tests (CBC, thyroid function tests) as well as an electrocardiogram (ECG).

If the anxiety is not accompanied by any worrisome physical signs and symptoms, a referral to a mental health care professional may be recommended for appropriate treatment.

Psychotherapy such as cognitive-behavioral therapy (CBT) has been shown to significantly decrease anxiety. In some cases, medications such as benzodiazepines or antidepressants may be appropriate.

References

Muller JE, Kohn L, Stein DJ. Anxiety and medical disorders. Curr Psychiatry Rep. 2005 Aug;7(4):245-51.

White KS, Farrell AD. Anxiety and Psychosocial Stress as Predictors of Headache and Abdominal Pain in Urban Early Adolescents. J Pediatr Psychol. 2005.

Lubit R, Rovine D, Defrancisci L, Eth S. Impact of trauma on children. J Psychiatr Pract. 2003; 9(2): 128-138.

Ahmed SM, Lemkau JP. Psychosocial influences on health. In: Rakel RE, ed. Textbook of Family Medicine. 7th ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 4.


Review Date: 12/15/2008
Reviewed By: Linda Vorvick, MD, Family Physician, Seattle Site Coordinator, Lecturer, Pathophysiology, MEDEX Northwest Division of Physician Assistant Studies, University of Washington School of Medicine; and Timothy A. Rogge, MD, private practice in Psychiatry, Kirkland, Washington. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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Attention deficit hyperactivity disorder (ADHD)

Definition

ADHD is a problem with inattentiveness, over-activity, impulsivity, or a combination. For these problems to be diagnosed as ADHD, they must be out of the normal range for the child's age and development.

Alternative Names

ADD; ADHD; Childhood hyperkinesis

Causes

ADHD affects school performance and interpersonal relationships. Parents of children with ADHD are often exhausted and frustrated.

Neuroimaging studies suggest that the brains of children with ADHD are different from those of other children. These children handle neurotransmitters (including dopamine, serotonin, and adrenalin) differently from their peers.

ADHD is often genetic. Whatever the specific cause may be, it seems to be set in motion early in life as the brain is developing.

Depression, sleep deprivation, learning disabilities, tic disorders, and behavior problems may be confused with, or appear along with, ADHD. Every child suspected of having ADHD deserves a careful evaluation to sort out exactly what is contributing to the behaviors causing concern.

Attention Deficit Disorder (ADD) is the most commonly diagnosed behavioral disorder of childhood, affecting an estimated 3 - 5% of school aged children. It is diagnosed much more often in boys than in girls.

Most children with ADHD also have at least one other developmental or behavioral problem.

Symptoms

The Diagnostic and Statistical Manual (DSM-IV) divides the symptoms of ADHD into those of inattentiveness and those of hyperactivity and impulsivity.

To be diagnosed with ADHD, children should have at least 6 attention symptoms or 6 activity and impulsivity symptoms -- to a degree beyond what would be expected for children their age.

The symptoms must be present for at least 6 months, observable in 2 or more settings, and not caused by another problem. The symptoms must be severe enough to cause significant difficulties. Some symptoms must be present before age 7.

Older children have ADHD in partial remission when they still have symptoms but no longer meet the full definition of the disorder.

Some children with ADHD primarily have the Inattentive Type, some the Hyperactive-Impulsive Type, and some the Combined Type. Those with the Inattentive type are less disruptive and are easier to miss being diagnosed with ADHD.

Inattention symptoms:

  1. Fails to give close attention to details or makes careless mistakes in schoolwork
  2. Difficulty sustaining attention in tasks or play
  3. Does not seem to listen when spoken to directly
  4. Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace
  5. Difficulty organizing tasks and activities
  6. Avoids or dislikes tasks that require sustained mental effort (such as schoolwork)
  7. Often loses toys, assignments, pencils, books, or tools needed for tasks or activities
  8. Easily distracted
  9. Often forgetful in daily activities

Hyperactivity symptoms:

  1. Fidgets with hands or feet or squirms in seat
  2. Leaves seat when remaining seated is expected
  3. Runs about or climbs in inappropriate situations
  4. Difficulty playing quietly
  5. Often "on the go," acts as if "driven by a motor," talks excessively

Impulsivity symptoms:

  1. Blurts out answers before questions have been completed
  2. Difficulty awaiting turn
  3. Interrupts or intrudes on others (butts into conversations or games)

Exams and Tests

Too often, difficult children are incorrectly labeled with ADHD. On the other hand, many children who do have ADHD remain undiagnosed. In either case, related learning disabilities or mood problems are often missed. The American Academy of Pediatrics (AAP) has issued guidelines to bring more clarity to this issue.

The diagnosis is based on very specific symptoms, which must be present in more than one setting. The child should have a clinical evaluation if ADHD is suspected.

Evaluation may include:

  • Parent and teacher questionnaires (Connors, Burks)
  • Psychological evaluation of the child AND family including IQ testing and psychological testing
  • Complete developmental, mental, nutritional, physical, and psychosocial examination

Treatment

The American Academy of Pediatrics has guidelines for treating ADHD:

  • Set specific, appropriate target goals to guide therapy.
  • Medication and behavior therapy should be started.
  • When treatment has not met the target goals, evaluate the original diagnosis, the possible presence of other conditions, and how well the treatment plan has been implemented.
  • Systematic follow-up is important to regularly reassess target goals, results, and any side effects of medications. Information should be gathered from parents, teachers, and the child.

ADHD is a frustrating problem. Alternative remedies have become quite popular, including herbs, supplements, and chiropractic manipulation. However, there is little or no solid evidence for many remedies marketed to parents.

Children who receive both behavioral treatment and medication often do the best. Medications should not be used just to make life easier for the parents or the school. There are now several different classes of ADHD medications that may be used alone or in combination. Psychostimulants are the primary drugs used to treat ADHD. Although these drugs stimulate the central nervous system, they have a calming effect on people with ADHD.

These drugs include:

  • Methylphenidate (Ritalin, Concerta, Metadate, Daytrana)
  • Dexmethylphenidate (Focalin)
  • Amphetamine-dextroamphetamine (Adderall)
  • Dextroamphetamine (Dexedrine, Dextrostat)
  • Lisdexamfetamine (Vyvanse)

The FDA has approved the nonstimulant drug atomoxetine (Strattera) for use in ADHD. Effectiveness appears to be similar to that of stimulants. Strattera is not addicting.

Some ADHD medicines have been linked to sudden death in children with heart problems. Talk to your doctor about which drug is best for your child.

The following may also help:

  • Limit distractions in the child's environment.
  • Provide one-on-one instruction with teacher.
  • Make sure the child gets enough sleep.
  • Make sure the child gets a healthy, varied diet, with plenty of fiber and basic nutrients.

Outlook (Prognosis)

ADHD is a long-term, chronic condition. About half of the children with ADHD will continue to have troublesome symptoms of inattention or impulsivity as adults. However, adults are often more capable of controlling behavior and masking difficulties.

Statistics show that there is an increased incidence in juvenile delinquency and adult encounters with the law among individuals who had ADHD as a child.

Every effort should be made to manage symptoms and direct the child's energy to constructive and educational paths.

Possible Complications

Many adults with ADHD are in successful jobs. Possible complications, if ADHD is not adequately treated, could include failure in school or other similar problems.

When to Contact a Medical Professional

Call your health care provider if you or your child's school personnel suspect the possibility of attention deficit disorder.

Prevention

While there is no proven way to prevent ADHD itself, early identification and treatment can prevent many of the problems associated with ADHD.

References

Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007 Jul;46(7):894-921.

This article uses information by permission from Alan Greene, M.D., © Greene Ink, Inc.


Review Date: 6/27/2008
Reviewed By: Timothy A. Rogge, MD, private practice in Psychiatry, Kirkland, Washington. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.
2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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Suicide and suicidal behavior

Definition

Suicide is the act of deliberately taking one's own life. Suicidal behavior is any deliberate action with potentially life-threatening consequences, such as taking a drug overdose or deliberately crashing a car.

Causes

Suicidal behaviors can accompany many emotional disturbances, including depression, bipolar disorder, and schizophrenia. More than 90% of all suicides are related to a mood disorder or other psychiatric illness.

Suicidal behaviors often occur in response to a situation that the person views as overwhelming, such as social isolation, death of a loved one, emotional trauma, serious physical illness, aging, unemployment or financial problems, guilty feelings, or dependence on alcohol or other drug.

In the U.S., suicide accounts for about 1% of all deaths each year. The elderly have the highest rate of suicide, but there has been a steady increase among adolescents. Suicide is now the third leading cause of death for 15- to 19-year-olds, after accidents and homicide.

Suicide attempts that do not result in death far outnumber completed suicides. Many unsuccessful suicide attempts are carried out in a manner that makes rescue possible. These attempts often represent a desperate cry for help

The method of suicide can be relatively nonviolent (such as poisoning or overdose) or violent (such as shooting oneself). Males are more likely to choose violent methods, which probably accounts for the fact that suicide attempts by males are more likely to be completed. Many suicides involve a firearm. This is especially true in elderly men, in which 80% of suicides are performed with a gun.

Relatives of people who seriously attempt or complete suicide often blame themselves or become extremely angry, seeing the attempt or act as selfish. However, when people are suicidal, they often mistakenly believe that they are doing their friends and relatives a favor by taking themselves out of the world. These irrational beliefs often drive their behavior.

Symptoms

Early signs:

  • Depression
  • Statements or expressions of guilt feelings
  • Tension or anxiety
  • Nervousness
  • Impulsiveness

Critical signs:

  • Sudden change in behavior, especially calmness after a period of anxiety
  • Giving away belongings, attempts to "get one's affairs in order"
  • Direct or indirect threats to commit suicide
  • Direct attempts to commit suicide

Treatment

Emergency measures may be necessary after a person has attempted suicide. First aid, CPR, or mouth-to-mouth resuscitation may be required.

Hospitalization is often needed to treat the recent actions and to prevent future attempts. Psychiatric intervention is one of the most important aspects of treatment.

Outlook (Prognosis)

Suicide attempts and threats should always be taken seriously. About one-third of people who attempt suicide will repeat the attempt within 1 year, and about 10% of those who threaten or attempt suicide eventually do kill themselves.

Mental health care should be sought immediately. Dismissing the person's behavior as attention-seeking can have devastating consequences.

Possible Complications

Complications vary depending on the type of suicide attempt.

When to Contact a Medical Professional

A person who threatens or attempts suicide MUST be evaluated immediately by a mental health professional. NEVER IGNORE A SUICIDE THREAT OR ATTEMPT!

Prevention

Many people who attempt suicide talk about it before making the attempt. Sometimes, simply talking to a sympathetic, nonjudgmental listener is enough to prevent the person from attempting suicide. For this reason suicide prevention centers have telephone "hotline" services. Again, do not ignore a suicide threat or attempted suicide.

As with any other type of emergency, it is best to immediately call the local emergency number (such as 911). Do not leave the person alone even after phone contact with an appropriate professional has been made.


Review Date: 12/24/2008
Reviewed By: Christos Ballas, M.D., Attending Psychiatrist, Hospital of the University of Pennsylvania, Philadelphia, PA. Review provided by VeriMed Healthcare Network.
2009 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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Grief

Definition

Grief is a reaction to a major loss. It is most often an unhappy and painful emotion triggered by the death of a loved one.

People also can experience grief if they have an illness for which there is no cure, or a chronic condition that affects their quality of life. The end of a significant relationship often results in a grieving process, as well.

Alternative Names

Mourning; Grieving; Bereavement

Causes

Everyone feels grief in their own way, but there are certain stages to the process of mourning. It starts with recognizing a loss and continues until a person eventually accepts that loss. People's responses to grief will vary depending upon the circumstances of the death.

For example, if the person who died had a chronic illness, the death may have been expected. The end of the person's suffering might even have come as a relief. If the death was accidental or violent, coming to a stage of acceptance could take longer.

Symptoms

There can be five stages of grief. These reactions might not occur in a specific order, and can (at times) occur together. Not everyone experiences all of these emotions:

  • Denial, disbelief, numbness
  • Anger, blaming others
  • Bargaining (for instance "If I am cured of this cancer, I will never smoke again.")
  • Depressed mood, sadness, and crying
  • Acceptance, coming to terms

People who are grieving will often report crying spells, some trouble sleeping, and lack of productivity at work.

Exams and Tests

The doctor will perform a physical exam and ask questions about your symptoms, including sleep and appetite disturbances. Symptoms that last for a while may lead to clinical depression.

Treatment

Family and friends can offer emotional support during the grieving process. Sometimes outside factors can affect the normal grieving process, and people might need help from clergy, social workers, mental health specialists, or self-help groups.

The acute phase of grief can usually last up to 2 months, but some milder symptoms may last for a year or longer. Psychological counseling may help a person who is unable to face the loss (absent grief reaction), or who has depression associated with grieving.

Support Groups

You can help the stress of grieving by joining a support group where members share common experiences and problems.

See also:

  • Loss of a child - support group
  • Loss of a spouse - support group

Outlook (Prognosis)

It may take a year or longer to overcome strong feelings of grief, and to accept the loss.

Possible Complications

Grief and loss can affect your overall health. It can lead to depression or excessive alcohol or drug use. Major depression is also a problem with grief. Grief that lasts for more than two months and is severe enough to interfere with daily life may be a sign of more serious illness.

When to Contact a Medical Professional

Call your health care provider if you can't deal with grief, are using excessive amounts of drugs or alcohol, become very depressed, or have prolonged depression that interferes with your daily life.

Prevention

Grief should not be prevented because it is a healthy response to loss. Instead, it should be respected, and those who are grieving should have support to help them through the process.

Review Date: 7/27/2007
Reviewed By: Benjamin W. Van Voorhees, MD, MPH, Assistant Professor of Medicine, Pediatrics and Psychiatry, The University of Chicago, Chicago, IL. Review provided by VeriMed Healthcare Network.
2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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Hyperactivity

Definition

Hyperactivity is a state of too much muscle activity. This term is also used to describe a situation when a particular portion of the body is too active, such as when a gland produces too much of its particular hormone. See also attention deficit hyperactivity disorder (ADHD).

Alternative Names

Activity - increased; Hyperkinetic behavior

Considerations

Hyperactive behavior usually refers to a group of characteristics. These can include constant activity, being easily distracted, impulsiveness, inability to concentrate, aggressiveness, and similar behaviors.

Typical behaviors may include fidgeting or constant moving, wandering, too much talking, and difficulty participating in quiet activities (such as reading).

Hyperactivity is not easily defined, because it often depends on the tolerance of the observer. Behavior that seems excessive to one observer may not seem excessive to another. However, certain children -- when compared to others -- are clearly far more active, which can become a problem if it interferes with school work or making friends.

Hyperactivity is often considered more of a problem for schools and parents than it is for the affected child. However, many hyperactive children are unhappy or even depressed. Hyperactive behavior may make a child a target for bullying, or make it harder to connect with other children. Schoolwork may be more difficult, and hyperactive kids are frequently punished for their behavior.

Hyperkinetic (excessive movement) behavior often decreases as the child grows older, and may disappear entirely by adolescence.

Causes

  • Attention deficit disorder
  • Emotional disorders
  • Brain or central nervous system disorders
  • Hyperthyroidism

Home Care

A child who is normally very active often responds well to specific directions and a program of regular physical activity. A child with a hyperactivity disorder, on the other hand, has a hard time following directions and controlling impulses.

When to Contact a Medical Professional

  • Your child seems persistently hyperactive
  • Your child is very active, aggressive, impulsive, and has difficulty concentrating
  • Your child's activity level is causing social difficulties, or difficulty with schoolwork

What to Expect at Your Office Visit

The medical history will be obtained and a physical examination performed. There may also be a review of the home and school environments.

Medical history questions documenting hyperactivity in detail may include:

  • Is this a new behavior for the child or has the child always been very active?
  • Is the behavior getting worse?
  • Exactly what behavior have you noticed?
  • Is the child physically active?
  • Is the child easily distracted?
  • Does the child have trouble following directions?
  • Have you noticed anything that makes the child more or less active?
  • Is the child more active at school than at home?
  • What other symptoms are present?

The provider may recommend a thorough psychological evaluation.

Review Date: 5/12/2006
Reviewed By: Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor of Pediatrics, NYU School of Medicine, New York, NY. Review provided by VeriMed Healthcare Network.
2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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Child Abuse

Alternative Names

Sexual abuse - children

Definition

Child sexual abuse is the deliberate exposure of minor children to sexual activity. This means a child is forced or talked into sex or sexual activities by another person. Such abuse includes touching (fondling), sexual intercourse, oral sex, pornography, and other sexual activity.

With the exception of sexual abuse among family members (incestuous relationships), child sexual abuse was not clearly described until the late 1970s. The problem is far more common than had been thought. Indeed, the medical literature up through the mid-1970s contained articles about children and sexually transmitted diseases, such as gonorrhea. However, there was no discussion of how the children caught such disease. There was great reluctance in society to deal with this issue, but after 30 years of examination worldwide, child sexual abuse is now considered a serious issue.

Causes

It is difficult to determine how common child sexual abuse is. It is often more secret than physical abuse. Children are often scared to tell someone about the event. According to the American Academy of Child and Adolescent Psychiatry, it is reported up to 80,000 times a year, but the actual number of unreported events is probably much higher.

Abusers are usually men. They usually know the person they are abusing. This is the case in 80 to 90% of cases. Because the abuser violates the trust of the younger person, it makes the sexual abuse even more psychologically devastating.

Child sexual abuse occurs in all social and economic classes of people, but it has the same type of risk factors as physical child abuse, including poverty, disordered families, and abuse of alcohol and street drugs. Abusers often have a history of physical or sexual abuse themselves.

A small group of repeated abusers suffer from the psychiatric disorder pedophilia, in which the preferred sexual contact is with children.

Symptoms

Symptoms of child abuse are similar to those seen in depression or severe anxiety and nervousness. They can include:

  • Repeated headaches
  • Stomach aches (vague complaints)
  • Bowel disorders, such as soiling oneself (encopresis)
  • Eating disorders, such as anorexia nervosa
  • Sleep problems
  • Genital or rectal symptoms, such as pain during a bowel movement or urination, or vaginal itch or discharge

Children may withdrawal from normal activities, have excessive fears, do poorly in school, and display disruptive behaviors such as using alcohol and street drugs or engaging in high-risk sexual behaviors.

Exams and Tests

If you suspect a child has been sexually abused, the child should be examined as soon as possible by a trained healthcare professional.

A doctor's exam should not be delayed for any reason. Many signs of injury related to sexual abuse are temporary. Ideally, the exam should occur within 72 hours of the event or discovery. A complete physical exam must always be performed, so that the examiner can look for any signs of physical and sexual abuse. The two forms of abuse may co-exist.

Affected areas may include the mouth, throat, penis, anus, and vagina, including the hymen. The hymen is a thin piece of tissue covering the opening of the vagina. There are some normal variations to this structure, but it can be affected by abuse.

Your doctor may also order blood tests to check for sexually transmitted diseases, such as syphilis and HIV, and pregnancy in females. These tests can help determine treatment.

Photographs of injuries may help establish what happened.

Most pediatricians, many family medicine doctors, and most emergency room (ER) doctors have training in examining cases involving sexual abuse. It is extremely important to write down physical findings related to any form of child abuse. A second exam with an expert abuse examiner should be scheduled after the first exam. A doctor or nurse specialist can be found through child protective services program anywhere in the United States.

An exam will automatically be scheduled when suspected child sexual abuse is reported to police or child protection agencies.

Treatment

Treatment for any physical signs of sexual abuse is the same as for any form of cuts, bruises, or scrapes. The patient may need medicines to prevent or treat sexually transmitted diseases. Older females may receive medicines to prevent pregnancy.

All children who have been sexually abused or traumatized in any way should receive mental health counseling.

Suspicion of child sexual abuse must be reported to child protective services and the police. Medical professionals, teachers, and child care professionals are required by law to make a report.

Once a case is reported, child protection agencies and the police must investigate. If the allegation is considered true, the child must be protected from further abuse. Placement with a non-abusing parent, another relative, or a foster home may result.

In physical abuse cases, the goal of child protection agencies is to educate an abusing caretaker and attempt to re-join the family together, if safe. .

Support Groups

Support groups for abused children, their parents, and caretakers are available and strongly recommended. The following organizations may provide more information:

Child Help USA - https://www.childhelpusa.org/

Prevent Child Abuse America - https://www.childabuse.org/

Outlook (Prognosis)

Mental health is the major issue. Outcome depends on psychotherapy, family and social support, the nature and length of time the child was abused, and the individual characteristics of the child.

Possible Complications

  • Post-traumatic stress disorder (PTSD)
  • Depression
  • Eating disorders
  • Sleep disorders
  • Anxiety disorders
  • Participation in unsafe sexual activities. Those who have been abused as children have an increased risk of becoming abusers themselves when they reach adulthood.

When to Contact a Medical Professional

If you suspect child abuse in any form, immediately call your health care provider, child protective services, or police.

Prevention

Prevention involves teaching children never to keep secrets and the difference between "good" and "bad" touches. Parents need to begin this work at home. Most schools now have programs to teach young school-aged children about sexual abuse and its prevention.

Teenagers also need education about how to avoid rape and date rape.

Constant supervision and vigilance by adults is essential to preventing all forms of child abuse.

Review Date: 1/22/2007
Reviewed By: Leisha M. Andersen, M.D., Private Practice specializing in Pediatrics, Denver, CO. Review provided by VeriMed Healthcare Network.
2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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Conduct Disorder

Definition

Conduct disorder, a disorder of childhood and adolescence, involves chronic behavior problems, such as defiant, impulsive, or antisocial behavior; drug use; or criminal activity.

Causes

Conduct disorder has been associated with family conflicts, child abuse, poverty, genetic defects, and parental drug addiction or alcoholism. The diagnosis is more common among boys and is estimated to be as high as 10%.

However, because many of the qualities necessary to make the diagnosis (such as "defiance" and "rule breaking") can be subjective, it is hard to know how common the disorder really is. For accurate diagnosis, the behavior must be far more extreme than simple adolescent rebellion or boyish exuberance.

Conduct disorder is often associated with attention-deficit disorder, and the two together carry a major risk for alcohol and/or other drug dependence.

Children with conduct disorder tend to be impulsive, difficult to control, and unconcerned about the feelings of others.

Symptoms

  • Cruel or aggressive behavior toward people and animals
  • Destruction of property, including fire setting
  • Lying, truancy, running away
  • Vandalism, theft
  • Heavy drinking and/or heavy illicit drug use
  • Breaking rules without apparent reason
  • Antisocial behaviors, such as bullying and fighting

Exams and Tests

Some of the common signs of conduct disorder are bullying, fighting and staying out at night without concern for curfew or other limits. These children often make no effort to hide their aggressive behaviors and have difficulty making close friends. The diagnosis is made on the basis of a history of these kinds of behaviors.

Treatment

Successful treatment requires close involvement of the child's family. Parents can learn techniques to help manage their child's problem behavior. In cases of abuse, the child may need to be removed from the family and placed in a less chaotic environment. Treatment with medications or talk therapy may be used for depression and attention-deficit disorder, which commonly accompany conduct disorder.

Many "behavioral modification" schools, "wilderness programs," and "boot camps" are sold to parents as solutions for conduct disorder. These may use a form of "attack therapy" or "confrontation," which can actually be harmful. There is no research support for such techniques. Research suggests that treating children at home, along with their families, is more effective.

If you are considering an inpatient program, be sure to check it out thoroughly. Serious injuries and deaths have been associated with some programs, which are not regulated in many states.

Outlook (Prognosis)

Children who have severe or frequent symptoms tend to have the poorest prognosis. Expectations are also worse for those who have other illnesses such as mood and drug abuse disorders.

Possible Complications

Children with conduct disorder may go on to develop personality disorders as adults, particularly antisocial personality disorder. As their behaviors worsen, these individuals may also develop significant drug and legal problems.

When to Contact a Medical Professional

See your health care provider if your child seems to be overly aggressive, is bullying others, is being victimized, or continually gets in trouble. Early treatment may help.

Prevention

The sooner the treatment for conduct disorder is started, the more likely the child will learn adaptive behaviors and prevent some of the potential complications.

Review Date: 11/15/2006
Reviewed By: Paul Ballas, D.O., Department of Psychiatry, Thomas Jefferson University Hospital, Philadelphia, PA. Review provided by VeriMed Healthcare Network.
2008 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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