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Bipolar (Manic-Depressive) Disorder.

Introduction

Bipolar disorder, also known as manic-depressive illness, is a brain disorder that causes unusual shifts in a person's mood, energy, and ability to function. Different from the normal ups and downs that everyone goes through, the symptoms of bipolar disorder are severe. They can result in damaged relationships, poor job or school performance, and even suicide. But there is good news: bipolar disorder can be treated, and people with this illness can lead full and productive lives.

More than 2 million American adults,1 or about 1 percent of the population age 18 and older in any given year,2 have bipolar disorder. Bipolar disorder typically develops in late adolescence or early adulthood. However, some people have their first symptoms during childhood, and some develop them late in life. It is often not recognized as an illness, and people may suffer for years before it is properly diagnosed and treated. Like diabetes or heart disease, bipolar disorder is a long-term illness that must be carefully managed throughout a person's life.

"Manic-depression distorts moods and thoughts, incites dreadful behaviors, destroys the basis of rational thought, and too often erodes the desire and will to live. It is an illness that is biological in its origins, yet one that feels psychological in the experience of it; an illness that is unique in conferring advantage and pleasure, yet one that brings in its wake almost unendurable suffering and, not infrequently, suicide."

"I am fortunate that I have not died from my illness, fortunate in having received the best medical care available, and fortunate in having the friends, colleagues, and family that I do."

Kay Redfield Jamison, Ph.D., An Unquiet Mind, 1995, p. 6.
(Reprinted with permission from Alfred A. Knopf, a division of Random House, Inc.)

What Are the Symptoms of Bipolar Disorder?

Bipolar disorder causes dramatic mood swings—from overly "high" and/or irritable to sad and hopeless, and then back again, often with periods of normal mood in between. Severe changes in energy and behavior go along with these changes in mood. The periods of highs and lows are called episodes of mania and depression.

Signs and symptoms of mania (or a manic episode) include:

  • Increased energy, activity, and restlessness
  • Excessively "high," overly good, euphoric mood
  • Extreme irritability
  • Racing thoughts and talking very fast, jumping from one idea to another
  • Distractibility, can't concentrate well
  • Little sleep needed
  • Unrealistic beliefs in one's abilities and powers
  • Poor judgment
  • Spending sprees
  • A lasting period of behavior that is different from usual
  • Increased sexual drive
  • Abuse of drugs, particularly cocaine, alcohol, and sleeping medications
  • Provocative, intrusive, or aggressive behavior
  • Denial that anything is wrong

A manic episode is diagnosed if elevated mood occurs with three or more of the other symptoms most of the day, nearly every day, for 1 week or longer. If the mood is irritable, four additional symptoms must be present.

Signs and symptoms of depression (or a depressive episode) include:

  • Lasting sad, anxious, or empty mood
  • Feelings of hopelessness or pessimism
  • Feelings of guilt, worthlessness, or helplessness
  • Loss of interest or pleasure in activities once enjoyed, including sex
  • Decreased energy, a feeling of fatigue or of being "slowed down"
  • Difficulty concentrating, remembering, making decisions
  • Restlessness or irritability
  • Sleeping too much, or can't sleep
  • Change in appetite and/or unintended weight loss or gain
  • Chronic pain or other persistent bodily symptoms that are not caused by physical illness or injury
  • Thoughts of death or suicide, or suicide attempts

A depressive episode is diagnosed if five or more of these symptoms last most of the day, nearly every day, for a period of 2 weeks or longer.

A mild to moderate level of mania is called hypomania. Hypomania may feel good to the person who experiences it and may even be associated with good functioning and enhanced productivity. Thus even when family and friends learn to recognize the mood swings as possible bipolar disorder, the person may deny that anything is wrong. Without proper treatment, however, hypomania can become severe mania in some people or can switch into depression.

Sometimes, severe episodes of mania or depression include symptoms of psychosis (or psychotic symptoms). Common psychotic symptoms are hallucinations (hearing, seeing, or otherwise sensing the presence of things not actually there) and delusions (false, strongly held beliefs not influenced by logical reasoning or explained by a person's usual cultural concepts). Psychotic symptoms in bipolar disorder tend to reflect the extreme mood state at the time. For example, delusions of grandiosity, such as believing one is the President or has special powers or wealth, may occur during mania; delusions of guilt or worthlessness, such as believing that one is ruined and penniless or has committed some terrible crime, may appear during depression. People with bipolar disorder who have these symptoms are sometimes incorrectly diagnosed as having schizophrenia, another severe mental illness.

It may be helpful to think of the various mood states in bipolar disorder as a spectrum or continuous range. At one end is severe depression, above which is moderate depression and then mild low mood, which many people call "the blues" when it is short-lived but is termed "dysthymia" when it is chronic. Then there is normal or balanced mood, above which comes hypomania (mild to moderate mania), and then severe mania.

double-sided arrow listing range of moods, from severe mania to severe depression

In some people, however, symptoms of mania and depression may occur together in what is called a mixed bipolar state. Symptoms of a mixed state often include agitation, trouble sleeping, significant change in appetite, psychosis, and suicidal thinking. A person may have a very sad, hopeless mood while at the same time feeling extremely energized.

Bipolar disorder may appear to be a problem other than mental illness—for instance, alcohol or drug abuse, poor school or work performance, or strained interpersonal relationships. Such problems in fact may be signs of an underlying mood disorder.

Diagnosis of Bipolar Disorder

Like other mental illnesses, bipolar disorder cannot yet be identified physiologically—for example, through a blood test or a brain scan. Therefore, a diagnosis of bipolar disorder is made on the basis of symptoms, course of illness, and, when available, family history. The diagnostic criteria for bipolar disorder are described in the Diagnostic and Statistical Manual for Mental Disorders, fourth edition (DSM-IV).3

Descriptions offered by people with bipolar disorder give valuable insights into the various mood states associated with the illness:

Depression: I doubt completely my ability to do anything well. It seems as though my mind has slowed down and burned out to the point of being virtually useless…. [I am] haunt[ed]… with the total, the desperate hopelessness of it all…. Others say, "It's only temporary, it will pass, you will get over it," but of course they haven't any idea of how I feel, although they are certain they do. If I can't feel, move, think or care, then what on earth is the point?

Hypomania: At first when I'm high, it's tremendous… ideas are fast… like shooting stars you follow until brighter ones appear…. All shyness disappears, the right words and gestures are suddenly there… uninteresting people, things become intensely interesting. Sensuality is pervasive, the desire to seduce and be seduced is irresistible. Your marrow is infused with unbelievable feelings of ease, power, well-being, omnipotence, euphoria… you can do anything… but, somewhere this changes.

Mania: The fast ideas become too fast and there are far too many… overwhelming confusion replaces clarity… you stop keeping up with it—memory goes. Infectious humor ceases to amuse. Your friends become frightened…. everything is now against the grain… you are irritable, angry, frightened, uncontrollable, and trapped.

Suicide

Some people with bipolar disorder become suicidal. Anyone who is thinking about committing suicide needs immediate attention, preferably from a mental health professional or a physician. Anyone who talks about suicide should be taken seriously. Risk for suicide appears to be higher earlier in the course of the illness. Therefore, recognizing bipolar disorder early and learning how best to manage it may decrease the risk of death by suicide.

Signs and symptoms that may accompany suicidal feelings include:

  • talking about feeling suicidal or wanting to die
  • feeling hopeless, that nothing will ever change or get better
  • feeling helpless, that nothing one does makes any difference
  • feeling like a burden to family and friends
  • abusing alcohol or drugs
  • putting affairs in order (e.g., organizing finances or giving away possessions to prepare for one's death)
  • writing a suicide note
  • putting oneself in harm's way, or in situations where there is a danger of being killed

If you are feeling suicidal or know someone who is:

  • call a doctor, emergency room, or 911 right away to get immediate help
  • make sure you, or the suicidal person, are not left alone
  • make sure that access is prevented to large amounts of medication, weapons, or other items that could be used for self-harm

While some suicide attempts are carefully planned over time, others are impulsive acts that have not been well thought out; thus, the final point in the box above may be a valuable long-term strategy for people with bipolar disorder. Either way, it is important to understand that suicidal feelings and actions are symptoms of an illness that can be treated. With proper treatment, suicidal feelings can be overcome.

What Is the Course of Bipolar Disorder?

Episodes of mania and depression typically recur across the life span. Between episodes, most people with bipolar disorder are free of symptoms, but as many as one-third of people have some residual symptoms. A small percentage of people experience chronic unremitting symptoms despite treatment.4

The classic form of the illness, which involves recurrent episodes of mania and depression, is called bipolar I disorder. Some people, however, never develop severe mania but instead experience milder episodes of hypomania that alternate with depression; this form of the illness is called bipolar II disorder. When four or more episodes of illness occur within a 12-month period, a person is said to have rapid-cycling bipolar disorder. Some people experience multiple episodes within a single week, or even within a single day. Rapid cycling tends to develop later in the course of illness and is more common among women than among men.

People with bipolar disorder can lead healthy and productive lives when the illness is effectively treated (see below—"How Is Bipolar Disorder Treated?"). Without treatment, however, the natural course of bipolar disorder tends to worsen. Over time a person may suffer more frequent (more rapid-cycling) and more severe manic and depressive episodes than those experienced when the illness first appeared.5 But in most cases, proper treatment can help reduce the frequency and severity of episodes and can help people with bipolar disorder maintain good quality of life.

Can Children and Adolescents Have Bipolar Disorder?

Both children and adolescents can develop bipolar disorder. It is more likely to affect the children of parents who have the illness.

Unlike many adults with bipolar disorder, whose episodes tend to be more clearly defined, children and young adolescents with the illness often experience very fast mood swings between depression and mania many times within a day.6 Children with mania are more likely to be irritable and prone to destructive tantrums than to be overly happy and elated. Mixed symptoms also are common in youths with bipolar disorder. Older adolescents who develop the illness may have more classic, adult-type episodes and symptoms.

Bipolar disorder in children and adolescents can be hard to tell apart from other problems that may occur in these age groups. For example, while irritability and aggressiveness can indicate bipolar disorder, they also can be symptoms of attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder, or other types of mental disorders more common among adults such as major depression or schizophrenia. Drug abuse also may lead to such symptoms.

For any illness, however, effective treatment depends on appropriate diagnosis. Children or adolescents with emotional and behavioral symptoms should be carefully evaluated by a mental health professional. Any child or adolescent who has suicidal feelings, talks about suicide, or attempts suicide should be taken seriously and should receive immediate help from a mental health specialist.

What Causes Bipolar Disorder?

Scientists are learning about the possible causes of bipolar disorder through several kinds of studies. Most scientists now agree that there is no single cause for bipolar disorder—rather, many factors act together to produce the illness.

Because bipolar disorder tends to run in families, researchers have been searching for specific genes—the microscopic "building blocks" of DNA inside all cells that influence how the body and mind work and grow—passed down through generations that may increase a person's chance of developing the illness. But genes are not the whole story. Studies of identical twins, who share all the same genes, indicate that both genes and other factors play a role in bipolar disorder. If bipolar disorder were caused entirely by genes, then the identical twin of someone with the illness would always develop the illness, and research has shown that this is not the case. But if one twin has bipolar disorder, the other twin is more likely to develop the illness than is another sibling.7

In addition, findings from gene research suggest that bipolar disorder, like other mental illnesses, does not occur because of a single gene.8 It appears likely that many different genes act together, and in combination with other factors of the person or the person's environment, to cause bipolar disorder. Finding these genes, each of which contributes only a small amount toward the vulnerability to bipolar disorder, has been extremely difficult. But scientists expect that the advanced research tools now being used will lead to these discoveries and to new and better treatments for bipolar disorder.

Brain-imaging studies are helping scientists learn what goes wrong in the brain to produce bipolar disorder and other mental illnesses.9,10 New brain-imaging techniques allow researchers to take pictures of the living brain at work, to examine its structure and activity, without the need for surgery or other invasive procedures. These techniques include magnetic resonance imaging (MRI), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI). There is evidence from imaging studies that the brains of people with bipolar disorder may differ from the brains of healthy individuals. As the differences are more clearly identified and defined through research, scientists will gain a better understanding of the underlying causes of the illness, and eventually may be able to predict which types of treatment will work most effectively.

How Is Bipolar Disorder Treated?

Most people with bipolar disorder—even those with the most severe forms—can achieve substantial stabilization of their mood swings and related symptoms with proper treatment.11,12,13 Because bipolar disorder is a recurrent illness, long-term preventive treatment is strongly recommended and almost always indicated. A strategy that combines medication and psychosocial treatment is optimal for managing the disorder over time.

In most cases, bipolar disorder is much better controlled if treatment is continuous than if it is on and off. But even when there are no breaks in treatment, mood changes can occur and should be reported immediately to your doctor. The doctor may be able to prevent a full-blown episode by making adjustments to the treatment plan. Working closely with the doctor and communicating openly about treatment concerns and options can make a difference in treatment effectiveness.

In addition, keeping a chart of daily mood symptoms, treatments, sleep patterns, and life events may help people with bipolar disorder and their families to better understand the illness. This chart also can help the doctor track and treat the illness most effectively.

Medications

Medications for bipolar disorder are prescribed by psychiatrists—medical doctors (M.D.) with expertise in the diagnosis and treatment of mental disorders. While primary care physicians who do not specialize in psychiatry also may prescribe these medications, it is recommended that people with bipolar disorder see a psychiatrist for treatment.

Medications known as "mood stabilizers" usually are prescribed to help control bipolar disorder.11 Several different types of mood stabilizers are available. In general, people with bipolar disorder continue treatment with mood stabilizers for extended periods of time (years). Other medications are added when necessary, typically for shorter periods, to treat episodes of mania or depression that break through despite the mood stabilizer.

  • Lithium, the first mood-stabilizing medication approved by the U.S. Food and Drug Administration (FDA) for treatment of mania, is often very effective in controlling mania and preventing the recurrence of both manic and depressive episodes.
  • Anticonvulsant medications, such as valproate (Depakote®) or carbamazepine (Tegretol®), also can have mood-stabilizing effects and may be especially useful for difficult-to-treat bipolar episodes. Valproate was FDA-approved in 1995 for treatment of mania.
  • Newer anticonvulsant medications, including lamotrigine (Lamictal®), gabapentin (Neurontin®), and topiramate (Topamax®), are being studied to determine how well they work in stabilizing mood cycles.
  • Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect.
  • Children and adolescents with bipolar disorder generally are treated with lithium, but valproate and carbamazepine also are used. Researchers are evaluating the safety and efficacy of these and other psychotropic medications in children and adolescents. There is some evidence that valproate may lead to adverse hormone changes in teenage girls and polycystic ovary syndrome in women who began taking the medication before age 20.14 Therefore, young female patients taking valproate should be monitored carefully by a physician.
  • Women with bipolar disorder who wish to conceive, or who become pregnant, face special challenges due to the possible harmful effects of existing mood stabilizing medications on the developing fetus and the nursing infant.15 Therefore, the benefits and risks of all available treatment options should be discussed with a clinician skilled in this area. New treatments with reduced risks during pregnancy and lactation are under study.

Treatment of Bipolar Depression

Research has shown that people with bipolar disorder are at risk of switching into mania or hypomania, or of developing rapid cycling, during treatment with antidepressant medication.16 Therefore, "mood-stabilizing" medications generally are required, alone or in combination with antidepressants, to protect people with bipolar disorder from this switch. Lithium and valproate are the most commonly used mood-stabilizing drugs today. However, research studies continue to evaluate the potential mood-stabilizing effects of newer medications.

  • Atypical antipsychotic medications, including clozapine (Clozaril®), olanzapine (Zyprexa®), risperidone (Risperdal®), quetiapine (Seroquel®), and ziprasidone (Geodon®), are being studied as possible treatments for bipolar disorder. Evidence suggests clozapine may be helpful as a mood stabilizer for people who do not respond to lithium or anticonvulsants.17 Other research has supported the efficacy of olanzapine for acute mania, an indication that has recently received FDA approval.18 Olanzapine may also help relieve psychotic depression.19
  • If insomnia is a problem, a high-potency benzodiazepine medication such as clonazepam (Klonopin®) or lorazepam (Ativan®) may be helpful to promote better sleep. However, since these medications may be habit-forming, they are best prescribed on a short-term basis. Other types of sedative medications, such as zolpidem (Ambien®), are sometimes used instead.
  • Changes to the treatment plan may be needed at various times during the course of bipolar disorder to manage the illness most effectively. A psychiatrist should guide any changes in type or dose of medication.
  • Be sure to tell the psychiatrist about all other prescription drugs, over-the-counter medications, or natural supplements you may be taking. This is important because certain medications and supplements taken together may cause adverse reactions.
  • To reduce the chance of relapse or of developing a new episode, it is important to stick to the treatment plan. Talk to your doctor if you have any concerns about the medications.

Thyroid Function

People with bipolar disorder often have abnormal thyroid gland function.5 Because too much or too little thyroid hormone alone can lead to mood and energy changes, it is important that thyroid levels are carefully monitored by a physician.

People with rapid cycling tend to have co-occurring thyroid problems and may need to take thyroid pills in addition to their medications for bipolar disorder. Also, lithium treatment may cause low thyroid levels in some people, resulting in the need for thyroid supplementation.

Medication Side Effects

Before starting a new medication for bipolar disorder, always talk with your psychiatrist and/or pharmacist about possible side effects. Depending on the medication, side effects may include weight gain, nausea, tremor, reduced sexual drive or performance, anxiety, hair loss, movement problems, or dry mouth. Be sure to tell the doctor about all side effects you notice during treatment. He or she may be able to change the dose or offer a different medication to relieve them. Your medication should not be changed or stopped without the psychiatrist's guidance.

Psychosocial Treatments

As an addition to medication, psychosocial treatments—including certain forms of psychotherapy (or "talk" therapy)—are helpful in providing support, education, and guidance to people with bipolar disorder and their families. Studies have shown that psychosocial interventions can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas.13 A licensed psychologist, social worker, or counselor typically provides these therapies and often works together with the psychiatrist to monitor a patient's progress. The number, frequency, and type of sessions should be based on the treatment needs of each person.

Psychosocial interventions commonly used for bipolar disorder are cognitive behavioral therapy, psychoeducation, family therapy, and a newer technique, interpersonal and social rhythm therapy. NIMH researchers are studying how these interventions compare to one another when added to medication treatment for bipolar disorder.

  • Cognitive behavioral therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness.
  • Psychoeducation involves teaching people with bipolar disorder about the illness and its treatment, and how to recognize signs of relapse so that early intervention can be sought before a full-blown illness episode occurs. Psychoeducation also may be helpful for family members.
  • Family therapy uses strategies to reduce the level of distress within the family that may either contribute to or result from the ill person's symptoms.
  • Interpersonal and social rhythm therapy helps people with bipolar disorder both to improve interpersonal relationships and to regularize their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
  • As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit.

Other Treatments

  • In situations where medication, psychosocial treatment, and the combination of these interventions prove ineffective, or work too slowly to relieve severe symptoms such as psychosis or suicidality, electroconvulsive therapy (ECT) may be considered. ECT may also be considered to treat acute episodes when medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severe depressive, manic, and/or mixed episodes. The possibility of long-lasting memory problems, although a concern in the past, has been significantly reduced with modern ECT techniques. However, the potential benefits and risks of ECT, and of available alternative interventions, should be carefully reviewed and discussed with individuals considering this treatment and, where appropriate, with family or friends.20
  • Herbal or natural supplements, such as St. John's wort (Hypericum perforatum), have not been well studied, and little is known about their effects on bipolar disorder. Because the FDA does not regulate their production, different brands of these supplements can contain different amounts of active ingredient. Before trying herbal or natural supplements, it is important to discuss them with your doctor. There is evidence that St. John's wort can reduce the effectiveness of certain medications.21 In addition, like prescription antidepressants, St. John's wort may cause a switch into mania in some individuals with bipolar disorder, especially if no mood stabilizer is being taken.22
  • Omega-3 fatty acids found in fish oil are being studied to determine their usefulness, alone and when added to conventional medications, for long-term treatment of bipolar disorder.23

A Long-Term Illness That Can Be Effectively Treated

Even though episodes of mania and depression naturally come and go, it is important to understand that bipolar disorder is a long-term illness that currently has no cure. Staying on treatment, even during well times, can help keep the disease under control and reduce the chance of having recurrent, worsening episodes.

Do Other Illnesses Co-occur with Bipolar Disorder?

Alcohol and drug abuse are very common among people with bipolar disorder. Research findings suggest that many factors may contribute to these substance abuse problems, including self-medication of symptoms, mood symptoms either brought on or perpetuated by substance abuse, and risk factors that may influence the occurrence of both bipolar disorder and substance use disorders.24 Treatment for co-occurring substance abuse, when present, is an important part of the overall treatment plan.

Anxiety disorders, such as post-traumatic stress disorder and obsessive-compulsive disorder, also may be common in people with bipolar disorder.25,26 Co-occurring anxiety disorders may respond to the treatments used for bipolar disorder, or they may require separate treatment. For more information on anxiety disorders, contact NIMH (see below).

How Can Individuals and Families Get Help for Bipolar Disorder?

Anyone with bipolar disorder should be under the care of a psychiatrist skilled in the diagnosis and treatment of this disease. Other mental health professionals, such as psychologists, psychiatric social workers, and psychiatric nurses, can assist in providing the person and family with additional approaches to treatment.

Help can be found at:

  • University—or medical school—affiliated programs
  • Hospital departments of psychiatry
  • Private psychiatric offices and clinics
  • Health maintenance organizations (HMOs)
  • Offices of family physicians, internists, and pediatricians
  • Public community mental health centers

People with bipolar disorder may need help to get help.

  • Often people with bipolar disorder do not realize how impaired they are, or they blame their problems on some cause other than mental illness.
  • A person with bipolar disorder may need strong encouragement from family and friends to seek treatment. Family physicians can play an important role in providing referral to a mental health professional.
  • Sometimes a family member or friend may need to take the person with bipolar disorder for proper mental health evaluation and treatment.
  • A person who is in the midst of a severe episode may need to be hospitalized for his or her own protection and for much-needed treatment. There may be times when the person must be hospitalized against his or her wishes.
  • Ongoing encouragement and support are needed after a person obtains treatment, because it may take a while to find the best treatment plan for each individual.
  • In some cases, individuals with bipolar disorder may agree, when the disorder is under good control, to a preferred course of action in the event of a future manic or depressive relapse.
  • Like other serious illnesses, bipolar disorder is also hard on spouses, family members, friends, and employers.
  • Family members of someone with bipolar disorder often have to cope with the person's serious behavioral problems, such as wild spending sprees during mania or extreme withdrawal from others during depression, and the lasting consequences of these behaviors.
  • Many people with bipolar disorder benefit from joining support groups such as those sponsored by the National Depressive and Manic Depressive Association (NDMDA), the National Alliance for the Mentally Ill (NAMI), and the National Mental Health Association (NMHA). Families and friends can also benefit from support groups offered by these organizations. For contact information, see the "For More Information" section at the back of this booklet.

What About Clinical Studies for Bipolar Disorder?

Some people with bipolar disorder receive medication and/or psychosocial therapy by volunteering to participate in clinical studies (clinical trials). Clinical studies involve the scientific investigation of illness and treatment of illness in humans. Clinical studies in mental health can yield information about the efficacy of a medication or a combination of treatments, the usefulness of a behavioral intervention or type of psychotherapy, the reliability of a diagnostic procedure, or the success of a prevention method. Clinical studies also guide scientists in learning how illness develops, progresses, lessens, and affects both mind and body. Millions of Americans diagnosed with mental illness lead healthy, productive lives because of information discovered through clinical studies. These studies are not always right for everyone, however. It is important for each individual to consider carefully the possible risks and benefits of a clinical study before making a decision to participate.

In recent years, NIMH has introduced a new generation of "real-world" clinical studies. They are called "real-world" studies for several reasons. Unlike traditional clinical trials, they offer multiple different treatments and treatment combinations. In addition, they aim to include large numbers of people with mental disorders living in communities throughout the U.S. and receiving treatment across a wide variety of settings. Individuals with more than one mental disorder, as well as those with co-occurring physical illnesses, are encouraged to consider participating in these new studies. The main goal of the real-world studies is to improve treatment strategies and outcomes for all people with these disorders. In addition to measuring improvement in illness symptoms, the studies will evaluate how treatments influence other important, real-world issues such as quality of life, ability to work, and social functioning. They also will assess the cost-effectiveness of different treatments and factors that affect how well people stay on their treatment plans.

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) is seeking participants for the largest-ever, "real-world" study of treatments for bipolar disorder. To learn more about STEP-BD or other clinical studies, see the Clinical Trials page on the NIMH Web site http://www.nimh.nih.gov, visit the National Library of Medicine's clinical trials database http://www.clinicaltrials.gov, or contact NIMH.

 

What Is Attention Deficit Hyperactivity Disorder -
ADD or ADHD?

Symptoms

The principal characteristics of ADHD are inattention, hyperactivity, and impulsivity. These symptoms appear early in a child's life. Because many normal children may have these symptoms, but at a low level, or the symptoms may be caused by another disorder, it is important that the child receive a thorough examination and appropriate diagnosis by a well-qualified professional.

Symptoms of ADHD will appear over the course of many months, often with the symptoms of impulsiveness and hyperactivity preceding those of inattention, which may not emerge for a year or more. Different symptoms may appear in different settings, depending on the demands the situation may pose for the child's self-control. A child who "can't sit still" or is otherwise disruptive will be noticeable in school, but the inattentive daydreamer may be overlooked. The impulsive child who acts before thinking may be considered just a "discipline problem," while the child who is passive or sluggish may be viewed as merely unmotivated. Yet both may have different types of ADHD. All children are sometimes restless, sometimes act without thinking, sometimes daydream the time away. When the child's hyperactivity, distractibility, poor concentration, or impulsivity begin to affect performance in school, social relationships with other children, or behavior at home, ADHD may be suspected. But because the symptoms vary so much across settings, ADHD is not easy to diagnose. This is especially true when inattentiveness is the primary symptom.

According to the most recent version of the Diagnostic and Statistical Manual of Mental Disorders2 (DSM-IV-TR), there are three patterns of behavior that indicate ADHD. People with ADHD may show several signs of being consistently inattentive. They may have a pattern of being hyperactive and impulsive far more than others of their age. Or they may show all three types of behavior. This means that there are three subtypes of ADHD recognized by professionals. These are the predominantly hyperactive-impulsive type (that does not show significant inattention); the predominantly inattentive type (that does not show significant hyperactive-impulsive behavior) sometimes called ADD—an outdated term for this entire disorder; and the combined type (that displays both inattentive and hyperactive-impulsive symptoms).

Hyperactivity-Impulsivity

Hyperactive children always seem to be "on the go" or constantly in motion. They dash around touching or playing with whatever is in sight, or talk incessantly. Sitting still at dinner or during a school lesson or story can be a difficult task. They squirm and fidget in their seats or roam around the room. Or they may wiggle their feet, touch everything, or noisily tap their pencil. Hyperactive teenagers or adults may feel internally restless. They often report needing to stay busy and may try to do several things at once.

Impulsive children seem unable to curb their immediate reactions or think before they act. They will often blurt out inappropriate comments, display their emotions without restraint, and act without regard for the later consequences of their conduct. Their impulsivity may make it hard for them to wait for things they want or to take their turn in games. They may grab a toy from another child or hit when they're upset. Even as teenagers or adults, they may impulsively choose to do things that have an immediate but small payoff rather than engage in activities that may take more effort yet provide much greater but delayed rewards.

Some signs of hyperactivity-impulsivity are:

  • Feeling restless, often fidgeting with hands or feet, or squirming while seated
  • Running, climbing, or leaving a seat in situations where sitting or quiet behavior is expected
  • Blurting out answers before hearing the whole question
  • Having difficulty waiting in line or taking turns.

Inattention

Children who are inattentive have a hard time keeping their minds on any one thing and may get bored with a task after only a few minutes. If they are doing something they really enjoy, they have no trouble paying attention. But focusing deliberate, conscious attention to organizing and completing a task or learning something new is difficult.

Homework is particularly hard for these children. They will forget to write down an assignment, or leave it at school. They will forget to bring a book home, or bring the wrong one. The homework, if finally finished, is full of errors and erasures. Homework is often accompanied by frustration for both parent and child.

The DSM-IV-TR gives these signs of inattention:

  • Often becoming easily distracted by irrelevant sights and sounds
  • Often failing to pay attention to details and making careless mistakes
  • Rarely following instructions carefully and completely losing or forgetting things like toys, or pencils, books, and tools needed for a task
  • Often skipping from one uncompleted activity to another.

Children diagnosed with the Predominantly Inattentive Type of ADHD are seldom impulsive or hyperactive, yet they have significant problems paying attention. They appear to be daydreaming, "spacey," easily confused, slow moving, and lethargic. They may have difficulty processing information as quickly and accurately as other children. When the teacher gives oral or even written instructions, this child has a hard time understanding what he or she is supposed to do and makes frequent mistakes. Yet the child may sit quietly, unobtrusively, and even appear to be working but not fully attending to or understanding the task and the instructions.

These children don't show significant problems with impulsivity and overactivity in the classroom, on the school ground, or at home. They may get along better with other children than the more impulsive and hyperactive types of ADHD, and they may not have the same sorts of social problems so common with the combined type of ADHD. So often their problems with inattention are overlooked. But they need help just as much as children with other types of ADHD, who cause more obvious problems in the classroom.

Is It Really ADHD?

Not everyone who is overly hyperactive, inattentive, or impulsive has ADHD. Since most people sometimes blurt out things they didn't mean to say, or jump from one task to another, or become disorganized and forgetful, how can specialists tell if the problem is ADHD?

Because everyone shows some of these behaviors at times, the diagnosis requires that such behavior be demonstrated to a degree that is inappropriate for the person's age. The diagnostic guidelines also contain specific requirements for determining when the symptoms indicate ADHD. The behaviors must appear early in life, before age 7, and continue for at least 6 months. Above all, the behaviors must create a real handicap in at least two areas of a person's life such as in the schoolroom, on the playground, at home, in the community, or in social settings. So someone who shows some symptoms but whose schoolwork or friendships are not impaired by these behaviors would not be diagnosed with ADHD. Nor would a child who seems overly active on the playground but functions well elsewhere receive an ADHD diagnosis.

To assess whether a child has ADHD, specialists consider several critical questions: Are these behaviors excessive, long-term, and pervasive? That is, do they occur more often than in other children the same age? Are they a continuous problem, not just a response to a temporary situation? Do the behaviors occur in several settings or only in one specific place like the playground or in the schoolroom? The person's pattern of behavior is compared against a set of criteria and characteristics of the disorder as listed in the DSM-IV-TR.

Diagnosis

Some parents see signs of inattention, hyperactivity, and impulsivity in their toddler long before the child enters school. The child may lose interest in playing a game or watching a TV show, or may run around completely out of control. But because children mature at different rates and are very different in personality, temperament, and energy levels, it's useful to get an expert's opinion of whether the behavior is appropriate for the child's age. Parents can ask their child's pediatrician, or a child psychologist or psychiatrist, to assess whether their toddler has an attention deficit hyperactivity disorder or is, more likely at this age, just immature or unusually exuberant.

ADHD may be suspected by a parent or caretaker or may go unnoticed until the child runs into problems at school. Given that ADHD tends to affect functioning most strongly in school, sometimes the teacher is the first to recognize that a child is hyperactive or inattentive and may point it out to the parents and/or consult with the school psychologist. Because teachers work with many children, they come to know how "average" children behave in learning situations that require attention and self-control. However, teachers sometimes fail to notice the needs of children who may be more inattentive and passive yet who are quiet and cooperative, such as those with the predominantly inattentive form of ADHD.

Professionals Who Make the Diagnosis.

If ADHD is suspected, to whom can the family turn? What kinds of specialists do they need?

Ideally, the diagnosis should be made by a professional in your area with training in ADHD or in the diagnosis of mental disorders. Child psychiatrists and psychologists, developmental/behavioral pediatricians, or behavioral neurologists are those most often trained in differential diagnosis. Clinical social workers may also have such training.

The family can start by talking with the child's pediatrician or their family doctor. Some pediatricians may do the assessment themselves, but often they refer the family to an appropriate mental health specialist they know and trust. In addition, state and local agencies that serve families and children, as well as some of the volunteer organizations listed at the end of this document, can help identify appropriate specialists.

Specialty Can Diagnose ADHD Can prescribe medication, if needed Provides counseling or training
Psychiatrists yes yes yes
Psychologists yes no yes
Pediatricians or Family Physicians yes yes no
Neurologists yes yes no
Clinical Social workers yes no yes

Knowing the differences in qualifications and services can help the family choose someone who can best meet their needs. There are several types of specialists qualified to diagnose and treat ADHD. Child psychiatrists are doctors who specialize in diagnosing and treating childhood mental and behavioral disorders. A psychiatrist can provide therapy and prescribe any needed medications. Child psychologists are also qualified to diagnose and treat ADHD. They can provide therapy for the child and help the family develop ways to deal with the disorder. But psychologists are not medical doctors and must rely on the child's physician to do medical exams and prescribe medication. Neurologists, doctors who work with disorders of the brain and nervous system, can also diagnose ADHD and prescribe medicines. But unlike psychiatrists and psychologists, neurologists usually do not provide therapy for the emotional aspects of the disorder.

Within each specialty, individual doctors and mental health professionals differ in their experiences with ADHD. So in selecting a specialist, it's important to find someone with specific training and experience in diagnosing and treating the disorder.

Whatever the specialist's expertise, his or her first task is to gather information that will rule out other possible reasons for the child's behavior. Among possible causes of ADHD-like behavior are the following:

  • A sudden change in the child's life—the death of a parent or grandparent; parents' divorce; a parent's job loss
  • Undetected seizures, such as in petit mal or temporal lobe seizures
  • A middle ear infection that causes intermittent hearing problems
  • Medical disorders that may affect brain functioning
  • Underachievement caused by learning disability
  • Anxiety or depression.

Ideally, in ruling out other causes, the specialist checks the child's school and medical records. There may be a school record of hearing or vision problems, since most schools automatically screen for these. The specialist tries to determine whether the home and classroom environments are unusually stressful or chaotic, and how the child's parents and teachers deal with the child.

Next the specialist gathers information on the child's ongoing behavior in order to compare these behaviors to the symptoms and diagnostic criteria listed in the DSM-IV-TR. This also involves talking with the child and, if possible, observing the child in class and other settings.

The child's teachers, past and present, are asked to rate their observations of the child's behavior on standardized evaluation forms, known as behavior rating scales, to compare the child's behavior to that of other children the same age. While rating scales might seem overly subjective, teachers often get to know so many children that their judgment of how a child compares to others is usually a reliable and valid measure.

The specialist interviews the child's teachers and parents, and may contact other people who know the child well, such as coaches or baby-sitters. Parents are asked to describe their child's behavior in a variety of situations. They may also fill out a rating scale to indicate how severe and frequent the behaviors seem to be.

In most cases, the child will be evaluated for social adjustment and mental health. Tests of intelligence and learning achievement may be given to see if the child has a learning disability and whether the disability is in one or more subjects.

In looking at the results of these various sources of information, the specialist pays special attention to the child's behavior during situations that are the most demanding of self-control, as well as noisy or unstructured situations such as parties, or during tasks that require sustained attention, like reading, working math problems, or playing a board game. Behavior during free play or while getting individual attention is given less importance in the evaluation. In such situations, most children with ADHD are able to control their behavior and perform better than in more restrictive situations.

The specialist then pieces together a profile of the child's behavior. Which ADHD-like behaviors listed in the most recent DSM does the child show? How often? In what situations? How long has the child been doing them? How old was the child when the problem started? Are the behavior problems relatively chronic or enduring or are they periodic in nature? Are the behaviors seriously interfering with the child's friendships, school activities, home life, or participation in community activities? Does the child have any other related problems? The answers to these questions help identify whether the child's hyperactivity, impulsivity, and inattention are significant and long-standing. If so, the child may be diagnosed with ADHD.

A correct diagnosis often resolves confusion about the reasons for the child's problems that lets parents and child move forward in their lives with more accurate information on what is wrong and what can be done to help. Once the disorder is diagnosed, the child and family can begin to receive whatever combination of educational, medical, and emotional help they need. This may include providing recommendations to school staff, seeking out a more appropriate classroom setting, selecting the right medication, and helping parents to manage their child's behavior.

What Causes ADHD?

One of the first questions a parent will have is "Why? What went wrong?" "Did I do something to cause this?" There is little compelling evidence at this time that ADHD can arise purely from social factors or child-rearing methods. Most substantiated causes appear to fall in the realm of neurobiology and genetics. This is not to say that environmental factors may not influence the severity of the disorder, and especially the degree of impairment and suffering the child may experience, but that such factors do not seem to give rise to the condition by themselves.

The parents' focus should be on looking forward and finding the best possible way to help their child. Scientists are studying causes in an effort to identify better ways to treat, and perhaps someday, to prevent ADHD. They are finding more and more evidence that ADHD does not stem from the home environment, but from biological causes. Knowing this can remove a huge burden of guilt from parents who might blame themselves for their child's behavior.

Over the last few decades, scientists have come up with possible theories about what causes ADHD. Some of these theories have led to dead ends, some to exciting new avenues of investigation.

Environmental Agents.

Studies have shown a possible correlation between the use of cigarettes and alcohol during pregnancy and risk for ADHD in the offspring of that pregnancy. As a precaution, it is best during pregnancy to refrain from both cigarette and alcohol use.

Another environmental agent that may be associated with a higher risk of ADHD is high levels of lead in the bodies of young preschool children. Since lead is no longer allowed in paint and is usually found only in older buildings, exposure to toxic levels is not as prevalent as it once was. Children who live in old buildings in which lead still exists in the plumbing or in lead paint that has been painted over may be at risk.

Brain Injury.

One early theory was that attention disorders were caused by brain injury. Some children who have suffered accidents leading to brain injury may show some signs of behavior similar to that of ADHD, but only a small percentage of children with ADHD have been found to have suffered a traumatic brain injury.

Food Additives and Sugar.

It has been suggested that attention disorders are caused by refined sugar or food additives, or that symptoms of ADHD are exacerbated by sugar or food additives. In 1982, the National Institutes of Health held a scientific consensus conference to discuss this issue. It was found that diet restrictions helped about 5 percent of children with ADHD, mostly young children who had food allergies.3 A more recent study on the effect of sugar on children, using sugar one day and a sugar substitute on alternate days, without parents, staff, or children knowing which substance was being used, showed no significant effects of the sugar on behavior or learning.4

In another study, children whose mothers felt they were sugar-sensitive were given aspartame as a substitute for sugar. Half the mothers were told their children were given sugar, half that their children were given aspartame. The mothers who thought their children had received sugar rated them as more hyperactive than the other children and were more critical of their behavior.5

Genetics.

Attention disorders often run in families, so there are likely to be genetic influences. Studies indicate that 25 percent of the close relatives in the families of ADHD children also have ADHD, whereas the rate is about 5 percent in the general population.6 Many studies of twins now show that a strong genetic influence exists in the disorder.7

Researchers continue to study the genetic contribution to ADHD and to identify the genes that cause a person to be susceptible to ADHD. Since its inception in 1999, the Attention-Deficit Hyperactivity Disorder Molecular Genetics Network has served as a way for researchers to share findings regarding possible genetic influences on ADHD.8

Recent Studies on Causes of ADHD.

Some knowledge of the structure of the brain is helpful in understanding the research scientists are doing in searching for a physical basis for attention deficit hyperactivity disorder. One part of the brain that scientists have focused on in their search is the frontal lobes of the cerebrum. The frontal lobes allow us to solve problems, plan ahead, understand the behavior of others, and restrain our impulses. The two frontal lobes, the right and the left, communicate with each other through the corpus callosum, (nerve fibers that connect the right and left frontal lobes).

The basal ganglia are the interconnected gray masses deep in the cerebral hemisphere that serve as the connection between the cerebrum and the cerebellum and, with the cerebellum, are responsible for motor coordination. The cerebellum is divided into three parts. The middle part is called the vermis.

All of these parts of the brain have been studied through the use of various methods for seeing into or imaging the brain. These methods include functional magnetic resonance imaging (fMRI) positron emission tomography (PET), and single photon emission computed tomography (SPECT). The main or central psychological deficits in those with ADHD have been linked through these studies. By 2002 the researchers in the NIMH Child Psychiatry Branch had studied 152 boys and girls with ADHD, matched with 139 age- and gender-matched controls without ADHD. The children were scanned at least twice, some as many as four times over a decade. As a group, the ADHD children showed 3-4 percent smaller brain volumes in all regions—the frontal lobes, temporal gray matter, caudate nucleus, and cerebellum.

This study also showed that the ADHD children who were on medication had a white matter volume that did not differ from that of controls. Those never-medicated patients had an abnormally small volume of white matter. The white matter consists of fibers that establish long-distance connections between brain regions. It normally thickens as a child grows older and the brain matures.9

Although this long-term study used MRI to scan the children's brains, the researchers stressed that MRI remains a research tool and cannot be used to diagnose ADHD in any given child. This is true for other neurological methods of evaluating the brain, such as PET and SPECT.


Disorders that Sometimes Accompany ADHD

Learning Disabilities.

Many children with ADHD—approximately 20 to 30 percent—also have a specific learning disability (LD).10 In preschool years, these disabilities include difficulty in understanding certain sounds or words and/or difficulty in expressing oneself in words. In school age children, reading or spelling disabilities, writing disorders, and arithmetic disorders may appear. A type of reading disorder, dyslexia, is quite widespread. Reading disabilities affect up to 8 percent of elementary school children.

Tourette Syndrome.

A very small proportion of people with ADHD have a neurological disorder called Tourette syndrome. People with Tourette syndrome have various nervous tics and repetitive mannerisms, such as eye blinks, facial twitches, or grimacing. Others may clear their throats frequently, snort, sniff, or bark out words. These behaviors can be controlled with medication. While very few children have this syndrome, many of the cases of Tourette syndrome have associated ADHD. In such cases, both disorders often require treatment that may include medications.

Oppositional Defiant Disorder.

As many as one-third to one-half of all children with ADHD—mostly boys—have another condition, known as oppositional defiant disorder (ODD). These children are often defiant, stubborn, non-compliant, have outbursts of temper, or become belligerent. They argue with adults and refuse to obey.

Conduct Disorder.

About 20 to 40 percent of ADHD children may eventually develop conduct disorder (CD), a more serious pattern of antisocial behavior. These children frequently lie or steal, fight with or bully others, and are at a real risk of getting into trouble at school or with the police. They violate the basic rights of other people, are aggressive toward people and/or animals, destroy property, break into people's homes, commit thefts, carry or use weapons, or engage in vandalism. These children or teens are at greater risk for substance use experimentation, and later dependence and abuse. They need immediate help.

Anxiety and Depression.

Some children with ADHD often have co-occurring anxiety or depression. If the anxiety or depression is recognized and treated, the child will be better able to handle the problems that accompany ADHD. Conversely, effective treatment of ADHD can have a positive impact on anxiety as the child is better able to master academic tasks.

Bipolar Disorder.

There are no accurate statistics on how many children with ADHD also have bipolar disorder. Differentiating between ADHD and bipolar disorder in childhood can be difficult. In its classic form, bipolar disorder is characterized by mood cycling between periods of intense highs and lows. But in children, bipolar disorder often seems to be a rather chronic mood dysregulation with a mixture of elation, depression, and irritability. Furthermore, there are some symptoms that can be present both in ADHD and bipolar disorder, such as a high level of energy and a reduced need for sleep. Of the symptoms differentiating children with ADHD from those with bipolar disorder, elated mood and grandiosity of the bipolar child are distinguishing characteristics.11

The Treatment of ADHD

Every family wants to determine what treatment will be most effective for their child. This question needs to be answered by each family in consultation with their health care professional. To help families make this important decision, the National Institute of Mental Health (NIMH) has funded many studies of treatments for ADHD and has conducted the most intensive study ever undertaken for evaluating the treatment of this disorder. This study is known as the Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder (MTA).12 The NIMH is now conducting a clinical trial for younger children ages 3 to 5.5 years (Treatment of ADHD in Preschool-Age Children).

The Multimodal Treatment Study of Children with Attention Deficit Hyperactivity Disorder.

The MTA study included 579 (95-98 at each of 6 treatment sites) elementary school boys and girls with ADHD, who were randomly assigned to one of four treatment programs: (1) medication management alone; (2) behavioral treatment alone; (3) a combination of both; or (4) routine community care. In each of the study sites, three groups were treated for the first 14 months in a specified protocol and the fourth group was referred for community treatment of the parents' choosing. All of the children were reassessed regularly throughout the study period. An essential part of the program was the cooperation of the schools, including principals and teachers. Both teachers and parents rated the children on hyperactivity, impulsivity, and inattention, and symptoms of anxiety and depression, as well as social skills.

The children in two groups (medication management alone and the combination treatment) were seen monthly for one-half hour at each medication visit. During the treatment visits, the prescribing physician spoke with the parent, met with the child, and sought to determine any concerns that the family might have regarding the medication or the child's ADHD-related difficulties. The physicians, in addition, sought input from the teachers on a monthly basis. The physicians in the medication-only group did not provide behavioral therapy but did advise the parents when necessary concerning any problems the child might have.

In the behavior treatment-only group, families met up to 35 times with a behavior therapist, mostly in group sessions. These therapists also made repeated visits to schools to consult with children's teachers and to supervise a special aide assigned to each child in the group. In addition, children attended a special 8-week summer treatment program where they worked on academic, social, and sports skills, and where intensive behavioral therapy was delivered to assist children in improving their behavior.

Children in the combined therapy group received both treatments, that is, all the same assistance that the medication-only received, as well as all of the behavior therapy treatments.

In routine community care, the children saw the community-treatment doctor of their parents' choice one to two times per year for short periods of time. Also, the community-treatment doctor did not have any interaction with the teachers.

The results of the study indicated that long-term combination treatments and the medication-management alone were superior to intensive behavioral treatment and routine community treatment. And in some areas—anxiety, academic performance, oppositionality, parent-child relations, and social skills—the combined treatment was usually superior. Another advantage of combined treatment was that children could be successfully treated with lower doses of medicine, compared with the medication-only group.

Treatment of Attention Deficit Hyperactivity Disorder in Preschool-Age Children (PATS).

Because many children in the preschool years are diagnosed with ADHD and are given medication, it is important to know the safety and efficacy of such treatment. The NIMH is sponsoring an ongoing multi-site study, "Preschool ADHD Treatment Study" (PATS). It is the first major effort to examine the safety and efficacy of a stimulant, methylphenidate, for ADHD in this age group. The PATS study uses a randomized, placebo-controlled, double-blind design. Children ages 3 to 5 who have severe and persistent symptoms of ADHD that impair their functioning are eligible for this study. To avoid using medications at such an early age, all children who enter the study are first treated with behavioral therapy. Only children who do not show sufficient improvement with behavior therapy are considered for the medication part of the study. The study is being conducted at New York State Psychiatric Institute, Duke University, Johns Hopkins University, New York University, the University of California at Los Angeles, and the University of California at Irvine. Enrollment in the study will total 165 children.

Which Treatment Should My Child Have?

For children with ADHD, no single treatment is the answer for every child. A child may sometimes have undesirable side effects to a medication that would make that particular treatment unacceptable. And if a child with ADHD also has anxiety or depression, a treatment combining medication and behavioral therapy might be best. Each child's needs and personal history must be carefully considered.

Medications.

For decades, medications have been used to treat the symptoms of ADHD.

The medications that seem to be the most effective are a class of drugs known as stimulants. Following is a list of the stimulants, their trade (or brand) names, and their generic names. "Approved age" means that the drug has been tested and found safe and effective in children of that age.

Trade Name Generic Name Approved Age
Adderall amphetamine 3 and older
Concerta methylphenidate
(long acting)
6 and older
Cylert* pemoline 6 and older
Dexedrine dextroamphetamine 3 and older
Dextrostat dextroamphetamine 3 and older
Focalin dexmethylphenidate 6 and older
Metadate ER methylphenidate
(extended release)
6 and older
Metadate CD methylphenidate
(extended release)
6 and older
Ritalin methylphenidate 6 and older
Ritalin SR methylphenidate
(extended release)
6 and older
Ritalin LA methylphenidate
(long acting)
6 and older
*Because of its potential for serious side effects affecting the liver, Cylert should not ordinarily be considered as first-line drug therapy for ADHD.

The U.S. Food and Drug Adminstration (FDA) recently approved a medication for ADHD that is not a stimulant. The medication, Strattera®, or atomoxetine, works on the neurotransmitter norepinephrine, whereas the stimulants primarily work on dopamine. Both of theses neurotransmitters are believed to play a role in ADHD. More studies will need to be done to contrast Strattera with the medications already available, but the evidence to date indicates that over 70 percent of children with ADHD given Strattera manifest significant improvement in their symptoms.

Some people get better results from one medication, some from another. It is important to work with the prescribing physician to find the right medication and the right dosage. For many people, the stimulants dramatically reduce their hyperactivity and impulsivity and improve their ability to focus, work, and learn. The medications may also improve physical coordination, such as that needed in handwriting and in sports.

The stimulant drugs, when used with medical supervision, are usually considered quite safe. Stimulants do not make the child feel "high," although some children say they feel different or funny. Such changes are usually very minor. Although some parents worry that their child may become addicted to the medication, to date there is no convincing evidence that stimulant medications, when used for treatment of ADHD, cause drug abuse or dependence. A review of all long-term studies on stimulant medication and substance abuse, conducted by researchers at Massachusetts General Hospital and Harvard Medical School, found that teenagers with ADHD who remained on their medication during the teen years had a lower likelihood of substance use or abuse than did ADHD adolescents who were not taking medications.13

The stimulant drugs come in long- and short-term forms. The newer sustained-release stimulants can be taken before school and are long-lasting so that the child does not need to go to the school nurse every day for a pill. The doctor can discuss with the parents the child's needs and decide which preparation to use and whether the child needs to take the medicine during school hours only or in the evening and on weekends too.

If the child does not show symptom improvement after taking a medication for a week, the doctor may try adjusting the dosage. If there is still no improvement, the child may be switched to another medication. About one out of ten children is not helped by a stimulant medication. Other types of medication may be used if stimulants don't work or if the ADHD occurs with another disorder. Antidepressants and other medications can help control accompanying depression or anxiety.

Sometimes the doctor may prescribe for a young child a medication that has been approved by the FDA for use in adults or older children. This use of the medication is called "off label." Many of the newer medications that are proving helpful for child mental disorders are prescribed off label because only a few of them have been systematically studied for safety and efficacy in children. Medications that have not undergone such testing are dispensed with the statement that "safety and efficacy have not been established in pediatric patients."

Side Effects of the Medications.

Most side effects of the stimulant medications are minor and are usually related to the dosage of the medication being taken. Higher doses produce more side effects. The most common side effects are decreased appetite, insomnia, increased anxiety, and/or irritability. Some children report mild stomach aches or headaches.

Appetite seems to fluctuate, usually being low during the middle of the day and more normal by suppertime. Adequate amounts of food that is nutritional should be available for the child, especially at peak appetite times.

If the child has difficulty falling asleep, several options may be tried—a lower dosage of the stimulant, giving the stimulant earlier in the day, discontinuing the afternoon or evening dosage, or giving an adjunct medication such as a low-dosage antidepressant or clonidine. A few children develop tics during treatment. These can often be lessened by changing the medication dosage. A very few children cannot tolerate any stimulant, no matter how low the dosage. In such cases, the child is often given an antidepressant instead of the stimulant.

When a child's schoolwork and behavior improve soon after starting medication, the child, parents, and teachers tend to applaud the drug for causing the sudden changes. Unfortunately, when people see such immediate improvement, they often think medication is all that's needed. But medications don't cure ADHD; they only control the symptoms on the day they are taken. Although the medications help the child pay better attention and complete school work, they can't increase knowledge or improve academic skills. The medications help the child to use those skills he or she already possesses.

Behavioral therapy, emotional counseling, and practical support will help ADHD children cope with everyday problems and feel better about themselves.

Facts to Remember About Medication for ADHD.

  • Medications for ADHD help many children focus and be more successful at school, home, and play. Avoiding negative experiences now may actually help prevent addictions and other emotional problems later.
  • About 80 percent of children who need medication for ADHD still need it as teenagers. Over 50 percent need medication as adults.

Medication for the Child with Both ADHD and Bipolar Disorder.

Since a child with bipolar disorder will probably be prescribed a mood stabilizer such as lithium or Depakote®, the doctor will carefully consider whether the child should take one of the medications usually prescribed for ADHD. If a stimulant medication is prescribed, it may be given in a lower dosage than usual.

The Family and the ADHD Child

Medication can help the ADHD child in everyday life. He or she may be better able to control some of the behavior problems that have led to trouble with parents and siblings. But it takes time to undo the frustration, blame, and anger that may have gone on for so long. Both parents and children may need special help to develop techniques for managing the patterns of behavior. In such cases, mental health professionals can counsel the child and the family, helping them to develop new skills, attitudes, and ways of relating to each other. In individual counseling, the therapist helps children with ADHD learn to feel better about themselves. The therapist can also help them to identify and build on their strengths, cope with daily problems, and control their attention and aggression. Sometimes only the child with ADHD needs counseling support. But in many cases, because the problem affects the family as a whole, the entire family may need help. The therapist assists the family in finding better ways to handle the disruptive behaviors and promote change. If the child is young, most of the therapist's work is with the parents, teaching them techniques for coping with and improving their child's behavior.

Several intervention approaches are available. Knowing something about the various types of interventions makes it easier for families to choose a therapist that is right for their needs.

Psychotherapy works to help people with ADHD to like and accept themselves despite their disorder. It does not address the symptoms or underlying causes of the disorder. In psychotherapy, patients talk with the therapist about upsetting thoughts and feelings, explore self-defeating patterns of behavior, and learn alternative ways to handle their emotions. As they talk, the therapist tries to help them understand how they can change or better cope with their disorder.

Behavioral therapy (BT) helps people develop more effective ways to work on immediate issues. Rather than helping the child understand his or her feelings and actions, it helps directly in changing their thinking and coping and thus may lead to changes in behavior. The support might be practical assistance, like help in organizing tasks or schoolwork or dealing with emotionally charged events. Or the support might be in self-monitoring one's own behavior and giving self-praise or rewards for acting in a desired way such as controlling anger or thinking before acting.

Social skills training can also help children learn new behaviors. In social skills training, the therapist discusses and models appropriate behaviors important in developing and maintaining social relationships, like waiting for a turn, sharing toys, asking for help, or responding to teasing, then gives children a chance to practice. For example, a child might learn to "read" other people's facial expression and tone of voice in order to respond appropriately. Social skills training helps the child to develop better ways to play and work with other children.

Support groups help parents connect with other people who have similar problems and concerns with their ADHD children. Members of support groups often meet on a regular basis (such as monthly) to hear lectures from experts on ADHD, share frustrations and successes, and obtain referrals to qualified specialists and information about what works. There is strength in numbers, and sharing experiences with others who have similar problems helps people know that they aren't alone. National organizations are listed at the end of this document.

Parenting skills training, offered by therapists or in special classes, gives parents tools and techniques for managing their child's behavior. One such technique is the use of token or point systems for immediately rewarding good behavior or work. Another is the use of "time-out" or isolation to a chair or bedroom when the child becomes too unruly or out of control. During time-outs, the child is removed from the agitating situation and sits alone quietly for a short time to calm down. Parents may also be taught to give the child "quality time" each day, in which they share a pleasurable or relaxing activity. During this time together, the parent looks for opportunities to notice and point out what the child does well, and praise his or her strengths and abilities.

This system of rewards and penalties can be an effective way to modify a child's behavior. The parents (or teacher) identify a few desirable behaviors that they want to encourage in the child—such as asking for a toy instead of grabbing it, or completing a simple task. The child is told exactly what is expected in order to earn the reward. The child receives the reward when he performs the desired behavior and a mild penalty when he doesn't. A reward can be small, perhaps a token that can be exchanged for special privileges, but it should be something the child wants and is eager to earn. The penalty might be removal of a token or a brief time-out. Make an effort to find your child being good. The goal, over time, is to help children learn to control their own behavior and to choose the more desired behavior. The technique works well with all children, although children with ADHD may need more frequent rewards.

In addition, parents may learn to structure situations in ways that will allow their child to succeed. This may include allowing only one or two playmates at a time, so that their child doesn't get overstimulated. Or if their child has trouble completing tasks, they may learn to help the child divide a large task into small steps, then praise the child as each step is completed. Regardless of the specific technique parents may use to modify their child's behavior, some general principles appear to be useful for most children with ADHD. These include providing more frequent and immediate feedback (including rewards and punishment), setting up more structure in advance of potential problem situations, and providing greater supervision and encouragement to children with ADHD in relatively unrewarding or tedious situations.

Parents may also learn to use stress management methods, such as meditation, relaxation techniques, and exercise, to increase their own tolerance for frustration so that they can respond more calmly to their child's behavior.

Some Simple Behavioral Interventions

Children with ADHD may need help in organizing. Therefore:

  • Schedule. Have the same routine every day, from wake-up time to bedtime. The schedule should include homework time and playtime (including outdoor recreation and indoor activities such as computer games). Have the schedule on the refrigerator or a bulletin board in the kitchen. If a schedule change must be made, make it as far in advance as possible.
  • Organize needed everyday items. Have a place for everything and keep everything in its place. This includes clothing, backpacks, and school supplies.
  • Use homework and notebook organizers. Stress the importance of writing down assignments and bringing home needed books.

Children with ADHD need consistent rules that they can understand and follow. If rules are followed, give small rewards. Children with ADHD often receive, and expect, criticism. Look for good behavior and praise it.

Your ADHD Child and School

You are your child's best advocate. To be a good advocate for your child, learn as much as you can about ADHD and how it affects your child at home, in school, and in social situations.

If your child has shown symptoms of ADHD from an early age and has been evaluated, diagnosed, and treated with either behavior modification or medication or a combination of both, when your child enters the school system, let his or her teachers know. They will be better prepared to help the child come into this new world away from home.

If your child enters school and experiences difficulties that lead you to suspect that he or she has ADHD, you can either seek the services of an outside professional or you can ask the local school district to conduct an evaluation. Some parents prefer to go to a professional of their own choice. But it is the school's obligation to evaluate children that they suspect have ADHD or some other disability that is affecting not only their academic work but their interactions with classmates and teachers.

If you feel that your child has ADHD and isn't learning in school as he or she should, you should find out just who in the school system you should contact. Your child's teacher should be able to help you with this information. Then you can request—in writing—that the school system evaluate your child. The letter should include the date, your and your child's names, and the reason for requesting an evaluation. Keep a copy of the letter in your own files.

Until the last few years, many school systems were reluctant to evaluate a child with ADHD. But recent laws have made clear the school's obligation to the child suspected of having ADHD that is affecting adversely his or her performance in school. If the school persists in refusing to evaluate your child, you can either get a private evaluation or enlist some help in negotiating with the school. Help is often as close as a local parent group. Each state has a Parent Training and Information (PTI) center as well as a Protection and Advocacy (P&A) agency. (For information on the law and on the PTI and P&A, see the section on support groups and organizations at the end of this document.)

Once your child has been diagnosed with ADHD and qualifies for special education services, the school, working with you, must assess the child's strengths and weaknesses and design an Individualized Educational Program (IEP). You should be able periodically to review and approve your child's IEP. Each school year brings a new teacher and new schoolwork, a transition that can be quite difficult for the child with ADHD. Your child needs lots of support and encouragement at this time.

Never forget the cardinal rule—you are your child's best advocate.

Your Teenager with ADHD

Your child with ADHD has successfully navigated the early school years and is beginning his or her journey through middle school and high school. Although your child has been periodically evaluated through the years, this is a good time to have a complete re-evaluation of your child's health.

The teen years are challenging for most children; for the child with ADHD these years are doubly hard. All the adolescent problems—peer pressure, the fear of failure in both school and socially, low self-esteem—are harder for the ADHD child to handle. The desire to be independent, to try new and forbidden things—alcohol, drugs, and sexual activity—can lead to unforeseen consequences. The rules that once were, for the most part, followed, are often now flaunted. Parents may not agree with each other on how the teenager's behavior should be handled.

Now, more than ever, rules should be straightforward and easy to understand. Communication between the adolescent and parents can help the teenager to know the reasons for each rule. When a rule is set, it should be clear why the rule is set. Sometimes it helps to have a chart, posted usually in the kitchen, that lists all household rules and all rules for outside the home (social and school). Another chart could list household chores with space to check off a chore once it is done.

When rules are broken—and they will be—respond to this inappropriate behavior as calmly and matter-of-factly as possible. Use punishment sparingly. Even with teens, a time-out can work. Impulsivity and hot temper often accompany ADHD. A short time alone can help.

As the teenager spends more time away from home, there will be demands for a later curfew and the use of the car. Listen to your child's request, give reasons for your opinion and listen to his or her opinion, and negotiate. Communication, negotiation, and compromise will prove helpful.

Your Teenager and the Car.

Teenagers, especially boys, begin talking about driving by the time they are 15. In some states, a learner's permit is available at 15 and a driver's license at 16. Statistics show that 16-year-old drivers have more accidents per driving mile than any other age. In the year 2000, 18 percent of those who died in speed-related crashes were youth ages 15 to 19. Sixty-six percent of these youth were not wearing safety belts. Youth with ADHD, in their first 2 to 5 years of driving, have nearly four times as many automobile accidents, are more likely to cause bodily injury in accidents, and have three times as many citations for speeding as the young drivers without ADHD.14

Most states, after looking at the statistics for automobile accidents involving teenage drivers, have begun to use a graduated driver licensing system (GDL). This system eases young drivers onto the roads by a slow progression of exposure to more difficult driving experiences. The program, as developed by the National Highway Traffic Safety Administration and the American Association of Motor Vehicle Administrators, consists of three stages: learner's permit, intermediate (provisional) license, and full licensure. Drivers must demonstrate responsible driving behavior at each stage before advancing to the next level. During the learner's permit stage, a licensed adult must be in the car at all times.15 This period of time will give the learner a chance to practice, practice, practice. The more your child drives, the more efficient he or she will become. The sense of accomplishment the teenager with ADHD will feel when the coveted license is finally in his or her hands will make all the time and effort involved worthwhile.

Note: The State Legislative Fact Sheets—Graduated Driver Licensing System can be found at web site http://www.nhtsa.dot.gov/people/outreach/safesobr/21qp/html/fact_sheets/Graduated_Driver.html, or it can be ordered from NHTSA Headquarters, Traffic Safety Programs, ATTN: NTS-32, 400 Seventh Street, S.W., Washington, DC 20590; telephone 202-366-6948.

Attention Deficit Hyperactivity Disorder in Adults

Attention deficit hyperactivity disorder is a highly publicized childhood disorder that affects approximately 3 percent to 5 percent of all children. What is much less well known is the probability that, of children who have ADHD, many will still have it as adults. Several studies done in recent years estimate that between 30 percent and 70 percent of children with ADHD continue to exhibit symptoms in the adult years.16

The first studies on adults who were never diagnosed as children as having ADHD, but showed symptoms as adults, were done in the late 1970s by Drs. Paul Wender, Frederick Reimherr, and David Wood. These symptomatic adults were retrospectively diagnosed with ADHD after the researchers' interviews with their parents. The researchers developed clinical criteria for the diagnosis of adult ADHD (the Utah Criteria), which combined past history of ADHD with current evidence of ADHD behaviors.17 Other diagnostic assessments are now available; among them are the widely used Conners Rating Scale and the Brown Attention Deficit Disorder Scale.

Typically, adults with ADHD are unaware that they have this disorder—they often just feel that it's impossible to get organized, to stick to a job, to keep an appointment. The everyday tasks of getting up, getting dressed and ready for the day's work, getting to work on time, and being productive on the job can be major challenges for the ADHD adult.

Diagnosing ADHD in an Adult.

Diagnosing an adult with ADHD is not easy. Many times, when a child is diagnosed with the disorder, a parent will recognize that he or she has many of the same symptoms the child has and, for the first time, will begin to understand some of the traits that have given him or her trouble for years—distractibility, impulsivity, restlessness. Other adults will seek professional help for depression or anxiety and will find out that the root cause of some of their emotional problems is ADHD. They may have a history of school failures or problems at work. Often they have been involved in frequent automobile accidents.

To be diagnosed with ADHD, an adult must have childhood-onset, persistent, and current symptoms.18 The accuracy of the diagnosis of adult ADHD is of utmost importance and should be made by a clinician with expertise in the area of attention dysfunction. For an accurate diagnosis, a history of the patient's childhood behavior, together with an interview with his life partner, a parent, close friend, or other close associate, will be needed. A physical examination and psychological tests should also be given. Comorbidity with other conditions may exist such as specific learning disabilities, anxiety, or affective disorders.

A correct diagnosis of ADHD can bring a sense of relief. The individual has brought into adulthood many negative perceptions of himself that may have led to low esteem. Now he can begin to understand why he has some of his problems and can begin to face them. This may mean, not only treatment for ADHD but also psychotherapy that can help him cope with the anger he feels about the failure to diagnose the disorder when he was younger.

Treatment of ADHD in an Adult.

Medications. As with children, if adults take a medication for ADHD, they often start with a stimulant medication. The stimulant medications affect the regulation of two neurotransmitters, norepinephrine and dopamine. The newest medication approved for ADHD by the FDA, atomoxetine (Strattera®), has been tested in controlled studies in both children and adults and has been found to be effective.19

Antidepressants are considered a second choice for treatment of adults with ADHD. The older antidepressants, the tricyclics, are sometimes used because they, like the stimulants, affect norepinephrine and dopamine. Venlafaxine (Effexor®), a newer antidepressant, is also used for its effect on norepinephrine. Bupropion (Wellbutrin®), an antidepressant with an indirect effect on the neurotransmitter dopamine, has been useful in clinical trials on the treatment of ADHD in both children and adults. It has the added attraction of being useful in reducing cigarette smoking.

In prescribing for an adult, special considerations are made. The adult may need less of the medication for his weight. A medication may have a longer "half-life" in an adult. The adult may take other medications for physical problems such as diabetes or high blood pressure. Often the adult is also taking a medication for anxiety or depression. All of these variables must be taken into account before a medication is prescribed.

Education and psychotherapy. Although medication gives needed support, the individual must succeed on his own. To help in this struggle, both "psychoeducation" and individual psychotherapy can be helpful. A professional coach can help the ADHD adult learn how to organize his life by using "props"—a large calendar posted where it will be seen in the morning, date books, lists, reminder notes, and have a special place for keys, bills, and the paperwork of everyday life. Tasks can be organized into sections, so that completion of each part can give a sense of accomplishment. Above all, ADHD adults should learn as much as they can about their disorder.

Psychotherapy can be a useful adjunct to medication and education. First, just remembering to keep an appointment with the therapist is a step toward keeping to a routine. Therapy can help change a long-standing poor self-image by examining the experiences that produced it. The therapist can encourage the ADHD patient to adjust to changes brought into his life by treatment—the perceived loss of impulsivity and love of risk-taking, the new sensation of thinking before acting. As the patient begins to have small successes in his new ability to bring organization out of the complexities of his or her life, he or she can begin to appreciate the characteristics of ADHD that are positive—boundless energy, warmth, and enthusiasm.

Understanding Adult ADD

Fidgeting, interrupting conversations, losing things, forgetting the reason for a trip to the grocery store - everyone acts this way once in a while. But a long and persistent history of restless, impulsive, or inattentive behavior may be a sign of Adult ADD. This is especially true if these behaviors have existed since childhood and result in problems at work, home, and/or in social settings.

If you think you might have Adult ADD, here are several questions you might want to ask yourself. These are some of the questions that can help doctors and healthcare professionals screen for Adult ADD.

Ask yourself these questions and think about how long you have experienced these symptoms and how often they occur. If these symptoms are interfering with your success at home, at work, or with friends, and have your whole life, you may want to talk to your doctor or healthcare professional about a clinical evaluation.

Multiple Personality Disorder (Dissociative Identity Disorder) is the existence within a person of two or more distinct personalities. The different personalities are referred to as "alters". Alters may have experienced a distinct personal history, self-image, and identity, including a separate name, as well as age. At least two of these personalities recurrently take control of the person's behavior.

For me multiplicity is life, not a definition, but the purpose here is to help the non-multiple gain insight about the inner world of the multiple, so below is the definition the majority of multiples themselves would give you.

Multiplicity, simply put, is about hiding, pain and survival, no more, no less. It is a desperate, completely creative, and wonderful survival mechanism. For the child who endures repeated and inescapable abuse, it may be their only escape. I consider myself to be blessed with MPD not cursed. It was a gift from God to me, to ensure my survival in a world that was full of insanity and reason not to survive. That is not to say that being a multiple is a picnic, because it is not. It certainly brings it share of difficulties for me in my life, but what I am saying is, at least I can do life and do it with some degree of mental health because I survived an insane childhood with my sanity.

Individuals most likely to develop MPD share several common factors. They have endured repetitive, and often life-threatening abuse during a developmental stage of childhood. The type of abuse can vary or be a combination of physical, extreme emotional, sexual or Satanic Ritual Abuse. The multiple may have a biological predisposition for auto-hypnotic phenomena, or in plain english, a high level of hypnotizablitiy.

To understand MPD, it is helpful to have a basic understanding of dissociation. Dissociation is the state in which, a person becomes separated from reality. Picture dissociation as line with a continuum (see the illustration below) from normal everyday experiences, to disorders that fall in the middle, such as Post Traumatic Stress, to those that go to the far extreme, MPD.


Common examples of normal dissociation are highway hypnosis which at one time or another, most have experienced. For instance, Have you ever been driving and suddenly wondered, "Did I stop for that last stoplight?" (My pyschiatrist says he does this himself) or become so engrossed in a book that you are no longer aware of your surroundings? Have you ever watched a movie and completely lost your sense of the present? Daydreaming is a common form of dissociation, which I think everyone does or has done at sometime.

Dissociation is a common defense mechanism against childhood abuse. There is no adult onset of Multiple Personality. Only children have the flexibility, to fracture off from the "core" personality and escape the traumatic and painful memory. The common belief among most professionals is the personality splintered or fractured before the age of five.

Those with MPD have a dominant personality that determines the individual's behavior. Each personality has a separate and consistent pattern of perceiving their environment, themselves and others. The internal world of an individual who has MPD is structured, although each person's system is as unique as non-multiples are from one another. There are several metaphors that MPD's use to describe how they function and what their internal world looks and acts like. Each multiple has a specific way they see the inside of their mind, where the alters live when they are not in control of the body. Examples include stages, tunnels, houses, and levels. These are their internal homes, where they go when they are not are not out, in control of the body , or when they are hiding. It is helpful for a person with MPD to make a map or diagram of their internal personality system.

The alter's job is to protect the host personality from the memory of the trauma, therefore, it is not necessary for all alters to look and act differently than the host. This task is accomplished for the co-conscious MPD, by means of the dissociative barriers, or for the non-conscious MPD, walls of amnesia. I will elaborate on non conscious versus co-conscious on the next page, but for now either form of MPD would produce typical types of alters. I have listed them below:

A depressed, exhausted host.

A strong, angry protector.

A scared, hurt child.

A helper.

An internal persecutor who blames one or more of the alters for the abuse they have endured. (Sometimes patterened or named after the actual abuser)

Multiples, as well as those who deal with them, come to recognize different alters as completely separate people, rather than just different aspects of the same person. The different personalities usually have different names, ages, gender, likes, dislikes. Certain alters may have physical or mental abilities that the others do not possess. Often there is a difference in body language, speech and mannerisms. Some MPD's (myself included) have an alter that changes the color of the eyes, while others have been known to have one alter with cancer, diabetes, etc., while all the other alters remain healthy or have their own ailments. While most multiples have alters who are very similar to one another, the difference can be so minute, that at times, even the MPD themselves might have a difficult time distinguishing the difference.

If you know someone who is multiple, remember that for them each of the alters are different people. One may do or say something while in control of the body that another would not. Some alters have very specific jobs and you will only see them when they are out to do whatever their job might be. You might like some of the alters better than others but it is a general thought in the psychological community to try not to show partiality between the alters. Also, don't be afraid to ask the MPD questions and learn about them, all of them. Most people who are multiple are more than willing to answer your questions, and even welcome someone who takes the time to ask.

What is schizophrenia?

Schizophrenia is a chronic, severe, and disabling brain disorder. It affects about 1 percent of people all over the world (including 3.2 million Americans) and has been recognized throughout recorded history.

People with schizophrenia may hear voices other people don't hear or believe that others are reading their minds, controlling their thoughts, or plotting to harm them. These experiences are terrifying and can cause fearfulness, withdrawal, or extreme agitation. People with schizophrenia may not make sense when they talk, may sit for hours without moving or talking much, or can seem perfectly fine until they talk about what they are really thinking. Since many people with schizophrenia have difficulty holding a job or caring for themselves, the burden on their families and society is significant as well.

Available treatments can relieve many of the disorder's symptoms, but most people who have schizophrenia must cope with some residual symptoms as long as they live. Nevertheless, this is a time of hope for people with schizophrenia and their families. Many people with the disorder now lead rewarding and meaningful lives in the community. Researchers are developing more effective medications and using new research tools to understand the causes of schizophrenia and find ways to prevent and treat it.

This brochure will present information on the symptoms of schizophrenia, when they appear, how the disease develops, current treatments, new directions in research, and support groups for patients and their loved ones.

When does it start and who gets it?

Psychotic symptoms (such as hallucinations and delusions) usually emerge in men in their late teens and early twenties and in women in their mid-twenties to early thirties. They seldom occur after age 45 and only rarely before puberty, although cases of schizophrenia in children as young as five have been reported. In adolescents, the first signs can include a change of friends, a drop in grades, sleep problems, and irritability. Since many normal adolescents exhibit these behaviors as well, a diagnosis can be difficult to make at this stage. In young people who go on to develop the disease, this is called the "prodromal" period.

Research has shown that schizophrenia affects men and women equally and occurs at similar rates in all ethnic groups around the world.

What are the symptoms of schizophrenia?

The symptoms of schizophrenia fall into three broad categories:

  • Positive symptoms are unusual thoughts or perceptions that include hallucinations, delusions and thought disorder.
  • Negative symptoms represent a loss or a decrease in the ability to initiate plans, speak, express emotion, or find pleasure in everyday life. These symptoms are harder to recognize as part of the disorder and can be mistaken for laziness or depression.
  • Cognitive symptoms (or cognitive deficits) are problems with attention, certain types of memory, and the executive functions that allow us to plan and organize.1 Cognitive deficits can also be difficult to recognize as part of the disorder but are the most disabling in terms of leading a normal life.

Positive symptoms

Positive symptoms are easy-to-spot behaviors not seen in healthy people and usually involve a loss of contact with reality.1 They include hallucinations, delusions, thought disorder, and disorders of movement. Positive symptoms can come and go. Sometimes they are severe and at other times hardly noticeable, depending on whether or not the individual is receiving treatment.

Hallucinations. A hallucination is something a person sees, hears, smells, or feels that no one else can see, hear, smell, or feel. "Voices" are the most common type of hallucination in schizophrenia. Many people with the disorder hear voices that may comment on their behavior, order them to do things, warn them of impending danger, or talk to each other (usually about the patient). They may hear these voices for a long time before family and friends notice that something is wrong.1 Other types of hallucinations include seeing people or objects that are not there, smelling odors that no one else detects (although this can also be a symptom of certain brain tumors), or feeling things like invisible fingers touching their bodies when no one is close by.

Delusions. Delusions are false personal beliefs that are not part of the person's culture and do not change, even when other people present proof that the beliefs are not true or logical. People with schizophrenia can have delusions that are quite bizarre, such as believing that neighbors can control their behavior with magnetic waves, people on television are directing special messages to them, or radio stations are broadcasting their thoughts aloud to others. They may also have delusions of grandeur and think they are a famous historical figure. People with paranoid schizophrenia can believe that others are deliberately cheating, harassing, poisoning, spying upon, or plotting against them or the people they care about. These beliefs are called delusions of persecution.

Thought Disorder. People with schizophrenia often have unusual thought processes. One dramatic form is disorganized thinking where the person may have difficulty organizing his thoughts or connecting them logically. Speech may be garbled or hard to understand. Another form is "thought blocking" where the person stops abruptly in the middle of a thought. When asked sometimes the person says it felt as if the thought had been taken out of his head. Finally, the individual might make up unintelligible words, so-called "neologisms."

Disorders of Movement. People with schizophrenia can be clumsy and uncoordinated. They may also show involuntary movements and may show grimacing or unusual mannerisms. They may repeat certain motions over and over or, in extreme cases, may become catatonic. Catatonia is a state of immobility and unresponsiveness that was more common when treatment for schizophrenia was not available; fortunately, it is now rare.2, 3

Negative symptoms

The term "negative symptoms" refers to reductions in normal emotional and behavioral states. These include:

  • flat affect (immobile facial expression, monotonous voice),
  • lack of pleasure in everyday life,
  • diminished ability to initiate and sustain planned activity, and
  • speaking infrequently, even when forced to interact.

People with schizophrenia often neglect basic hygiene and need help with everyday living activities. Because it is not as obvious that negative symptoms are part of a psychiatric illness, people with schizophrenia are often perceived by others as lazy and not willing to better their lives.

Cognitive symptoms

Cognitive symptoms are subtle and are often detected only when neuropsychological tests are performed. They include:

  • poor executive functioning (the ability to absorb and interpret information and make decisions based on that information),
  • inability to sustain attention, and
  • problems with working memory (the ability to keep recently learned information in mind and use it right away).

Cognitive impairments often interfere with the patient's ability to lead a normal life and earn a living, and can cause great emotional distress.

Are people with schizophrenia violent?

People with schizophrenia are not especially prone to violence and often prefer to be left alone. Studies show that if people have no record of criminal violence before they develop schizophrenia and are not substance abusers, they are unlikely to commit crimes after they become ill. Most violent crimes are not committed by people with schizophrenia, and most people with schizophrenia do not commit violent crimes. Substance abuse always increases violent behavior, whether or not the person has schizophrenia (see sidebar). If someone with paranoid schizophrenia becomes violent, their violence is most often directed at family members and takes place at home.

Substance abuse

Some people who abuse drugs show symptoms similar to those of schizophrenia, and people with schizophrenia may be mistaken for people who are high on drugs. While most researchers do not believe that substance abuse causes schizophrenia, people who have schizophrenia abuse alcohol and/or drugs more often than the general population.

Substance abuse can reduce the effectiveness of treatment for schizophrenia. Stimulants (such as amphetamines or cocaine), PCP, and marijuana may make the symptoms of schizophrenia worse, and substance abuse also makes it more likely that patients will not follow their treatment plan.

Schizophrenia and Nicotine

The most common form of substance abuse in people with schizophrenia is an addiction to nicotine. People with schizophrenia are addicted to nicotine at three times the rate of the general population (75-90 percent vs. 25-30 percent).

Research has revealed that the relationship between smoking and schizophrenia is complex. People with schizophrenia seem to be driven to smoke, and researchers are exploring whether there is a biological basis for this need. In addition to its known health hazards, several studies have found that smoking interferes with the action of antipsychotic drugs. People with schizophrenia who smoke may need higher doses of their medication.

Quitting smoking may be especially difficult for people with schizophrenia since nicotine withdrawal may cause their psychotic symptoms to temporarily get worse. Smoking cessation strategies that include nicotine replacement methods may be better tolerated. Doctors who treat people with schizophrenia should carefully monitor their patient's response to antipsychotic medication if the patient decides to either start or stop smoking.

What about suicide?

People with schizophrenia attempt suicide much more often than people in the general population. About 10 percent (especially younger adult males) succeed. It is hard to predict which people with schizophrenia are prone to suicide, so if someone with schizophrenia talks about or tries to commit suicide, professional help should be sought right away.

What causes schizophrenia?

As is the case for many other illnesses, schizophrenia is believed to result from a combination of environmental and genetic factors. All the tools of modern science are being used to search for the causes of this disorder (see NIMH Research Fact Sheet).

Can schizophrenia be inherited?

Scientists have long known that schizophrenia runs in families. It occurs in 1 percent of the general population, but is seen in 10 percent of people with a first degree relative (a parent, brother, or sister) with the disorder. People who have second degree relatives (aunts, uncles, grandparents, or cousins) with the disease also develop schizophrenia more often than the general population. The identical twin of a person with schizophrenia is most at risk, with a 40-65 percent chance of developing the problem.2,4

Our genes are located on 23 pairs of chromosomes that are found in each cell. We inherit two copies of each gene, one from each parent. Several of these genes are thought to be associated with an increased risk of schizophrenia, but scientists currently believe that each gene has a very small effect and is not responsible for causing the disease by itself. It is still not possible to predict who will develop the disease by looking at their genetic material.

Although there is a genetic risk for schizophrenia, genes alone are not likely to be sufficient to cause the disorder. Interactions between genes and the environment are thought to be necessary for schizophrenia to develop. Many environmental factors have been suggested as risk factors, such as exposure to viruses or malnutrition in the womb, problems during birth, and psychosocial factors, like stressful environmental conditions.

Do people with schizophrenia have faulty brain chemistry?

It is likely that an imbalance in the complex, interrelated chemical reactions of the brain involving the neurotransmitters dopamine and glutamate (and possibly others) plays a role in schizophrenia. Neurotransmitters are substances that allow brain cells to communicate with one another. Basic knowledge about brain chemistry and its link to schizophrenia is expanding rapidly and is a very promising area of research.

Do the brains of people with schizophrenia look different?

The brains of people with schizophrenia look a little different than the brains of healthy people, but the differences are small. Sometimes the fluid-filled cavities at the center of the brain, called ventricles, are larger in people with schizophrenia, overall grey matter volume is lower, and some areas of the brain have less or more metabolic activity.1 Microscopic studies of brain tissue after death have also revealed small changes in the distribution or characteristics of brain cells in people with schizophrenia. It appears that many of these changes were prenatal because they are not accompanied by glial cells, which are always present when a brain injury occurs after birth.1 One theory suggests that problems during brain development lead to faulty connections that lie dormant until puberty. The brain undergoes major changes during puberty, and these changes could trigger psychotic symptoms.

The only way to answer these questions is to conduct more research. Scientists in the U.S. and all over the world are studying schizophrenia and trying to develop new ways to prevent and treat the disorder.

How is schizophrenia treated?

Since the causes of schizophrenia are still unknown, current treatments focus on eliminating the symptoms of the disease.

Antipsychotic medications

Antipsychotic medications have been available since the mid-1950s. They effectively alleviate the positive symptoms of schizophrenia. While these drugs have greatly improved the lives of many patients, they do not cure schizophrenia.

Everyone responds differently to antipsychotic medication. Sometimes several different drugs must be tried before the right one is found. People with schizophrenia should work in partnership with their doctor to find the medications that control their symptoms best with the fewest side effects.

The older antipsychotic medications include chlorpromazine (Thorazine®), haloperidol (Haldol®), perphenazine (Etrafon, Trilafon®), and fluphenzine (Prolixin®). The older medications can cause extrapyramidal side effects, such as rigidity, persistent muscle spasms, tremors, and restlessness.

In the 1990s, new drugs, called atypical antipsychotics, were developed that rarely produced these side effects. The first of these new drugs was clozapine. Clozapine (Clozaril®) was introduced in 1990. It treats psychotic symptoms effectively even in people who do not respond to other medications, but can produce a serious problem called agranulocytosis, a loss of the white blood cells that fight infection. Therefore, patients who take clozapine must have their white blood cell counts monitored every week or two. The inconvenience and cost of both the blood tests and the medication itself has made treatment with clozapine difficult for many people, but it is the drug of choice for those whose symptoms do not respond to the other antipsychotic medications, old or new.

Some of the drugs that were developed after clozapine was introduced — such as risperidone (Risperdal®), olanzapine (Zyprexa®), quietiapine (Seroquel®), sertindole (Serdolect®), and ziprasidone (Geodon®) — are effective and don't produce extrapyramidal symptoms or agranulocytosis; but they can cause weight gain, which increases the risk of diabetes and high cholesterol, together called metabolic syndrome.5,6

People respond very individually to antipsychotic medications, although agitation and hallucinations usually improve within days and delusions in a few weeks. Many people see substantial improvement in both types of symptoms by the sixth week of treatment. No one can tell beforehand exactly how a medication will affect a particular individual, and sometimes several medications must be tried before the right one is found.

When people first start to take atypical antipsychotics, they may become drowsy; experience dizziness when they change positions; have blurred vision; or develop a rapid heartbeat, menstrual problems, a sensitivity to the sun, or skin rashes. Most of these symptoms will go away after the first days of treatment, but people who are taking atypical antipsychotics should not drive until they adjust to their new medication.6,7

If people with schizophrenia become depressed, it may be necessary to add an antidepressant to their drug regimen.

Length of Treatment. Like diabetes or high blood pressure, schizophrenia is a chronic disorder that needs constant management. At the moment, it cannot be cured but the rate or recurrence of psychotic episodes can be decreased significantly by staying on medication. Although responses vary from person to person, most people with schizophrenia need to take some type of medication for the rest of their lives and use other approaches, such as supportive therapy or rehabilitation, as well.

Relapses occur most often when people with schizophrenia stop taking their antipsychotic medication because they feel better, or only take it occasionally because they forget or don't think taking it regularly is important. It is very important for people with schizophrenia to take their medication on a regular basis and for as long as their doctors recommend. If they do so, they will experience fewer psychotic symptoms.

No antipsychotic medication should be discontinued without talking to the doctor who prescribed it, and it should always be tapered off under a doctor's supervision rather than being stopped all at once.

There are a variety of reasons why people with schizophrenia do not adhere to treatment. If they don't believe they are ill, they may not think they need medication at all. If their thinking is too disorganized, they may not remember to take their medication every day. If they don't like the side effects of one medication, they may stop taking it without trying a different medication. Substance abuse can also interfere with treatment effectiveness. Physicians should ask patients how often they take their medication and be sensitive to a patient's request to change dosages or to try new medications in order to eliminate unwelcome side effects.

There are many strategies that can be used to help people with schizophrenia take their drugs regularly. Some medications are available in long-acting, injectable forms that eliminate the need to take a pill every day. Medication calendars or pill boxes labeled with the days of the week can both help patients remember to take their medications and let caregivers know if medication has been taken. Electronic timers on clocks or watches can be programmed to beep when people need to take their pills, and pairing medication with routine daily events, like meals, can help patients adhere to dosing schedules.

Medication Interactions. Antipsychotic medications can produce unpleasant or dangerous side effects when taken with certain other drugs. For this reason, the doctor who prescribes the antipsychotics should be told about all medications (over-the-counter and prescription) and all vitamins, minerals, and herbal supplements the patient takes. Alcohol or other drug use should also be discussed.

Psychosocial treatment

Numerous studies have found that psychosocial treatments can help patients who are already stabilized on antipsychotic medication deal with certain aspects of schizophrenia, such as difficulty with communication, motivation, self-care, work, and establishing and maintaining relationships with others. Learning and using coping mechanisms to address these problems allows people with schizophrenia to attend school, work, and socialize. Patients who receive regular psychosocial treatment also adhere better to their medication schedule and have fewer relapses and hospitalizations. A positive relationship with a therapist or a case manager gives the patient a reliable source of information, sympathy, encouragement, and hope, all of which are essential for recovery.8 By explaining the nature and causes of schizophrenia and the need for medication, the therapist can also help patients acknowledge the reality of their disorder and adjust to the limitations it imposes.9

Illness Management Skills. People with schizophrenia can take an active role in managing their own illness. Once they learn basic facts about schizophrenia and the principles of schizophrenia treatment, they can make informed decisions about their care. If they are taught how to monitor the early warning signs of relapse and make a plan to respond to these signs, they can learn to prevent relapses. Patients can also be taught more effective coping skills to deal with persistent symptoms.

Integrated Treatment for Co-occurring Substance Abuse. Substance abuse is the most common co-occurring disorder in people with schizophrenia, but ordinary substance abuse treatment programs usually do not address this population's special needs. When schizophrenia treatment programs and drug treatment programs are integrated, better outcomes result.

Rehabilitation. Rehabilitation emphasizes social and vocational training to help people with schizophrenia function more effectively in the community. Because people with schizophrenia frequently become ill during the critical career-forming years of life (ages 18-35), and because the disease often interferes with normal cognitive functioning, most patients do not receive the training required for skilled work. Rehabilitation programs can include vocational counseling, job training, money management, learning to use public transportation, and practicing social and workplace communication skills.

Family Education. Patients with schizophrenia are often discharged from the hospital into the care of their families, so it is important that family members know as much as possible about the disease in order to prevent relapses. Family members should be able to use different kinds of treatment adherence programs and have an arsenal of coping strategies and problem-solving skills to manage their ill relative effectively. Knowing where to find outpatient and family services that support people with schizophrenia and their caregivers is also valuable.

Cognitive Behavioral Therapy. Cognitive behavioral therapy is useful for patients with symptoms that persist even when they take medication.9 The cognitive therapist teaches people with schizophrenia how to test the reality of their thoughts and perceptions, how to "not listen" to their voices, and how to shake off the apathy that often immobilizes them. This treatment appears to be effective in reducing the severity of symptoms and decreasing the risk of relapse.

Self-Help Groups. Self-help groups for people with schizophrenia and their families are becoming increasingly common. Although professional therapists are not involved, the group members are a continuing source of mutual support and comfort for each other, which is also therapeutic. People in self-help groups know that others are facing the same problems they face and no longer feel isolated by their illness or the illness of their loved one. The networking that takes place in self-help groups can also generate social action. Families working together can advocate for research and more hospital and community treatment programs, and patients acting as a group may be able to draw public attention to the discriminations many people with mental illnesses still face in today's world.

Support groups and advocacy groups are excellent resources for people with many types of mental disorders.

What is the role of the patient's support system?

Support for someone with a mental disorder can come from family, a professional residential or day program caregiver, shelter operators, friends or roommates, professional case managers, or anyone else in their community or place of worship that is concerned for their welfare. There are many situations in which people with schizophrenia will need help from other people.

Getting Treatment. People with schizophrenia often resist treatment, believing that their delusions or hallucinations are real and psychiatric help is not required. If a crisis occurs, family and friends may need to take action to keep their loved one safe.

The issue of civil rights enters into any attempt to provide treatment. Laws protecting patients from involuntary commitment have become very strict, and trying to get help for someone who is mentally ill can be frustrating. These laws vary from state to state, but generally, if a person is dangerous to himself or others because of mental illness and refuses to seek treatment, family members or friends may have to call the police to transport the person to the hospital if he/she will not go of his own accord. In the emergency room, a mental health professional will assess the patient and determine whether a voluntary or involuntary admission is needed.

People with mental illnesses who do not want treatment may hide their strange behavior or ideas from a professional, so family members and friends should ask to speak privately with the person conducting the patient's examination and explain what has been happening at home. The professional will then be able to question the patient and hear the patient's distorted thinking for themselves. Professionals must personally witness bizarre behavior and hear delusional thoughts before they can legally recommend commitment, and family and friends can give them the information they need to do so.

Caregiving. Ensuring that people with schizophrenia continue to get treatment and take their medication after they leave the hospital is also important. If patients stop taking their medication or stop going for follow-up appointments, their psychotic symptoms will return. If these symptoms become severe enough, they can become unable to care for their own basic needs for food, clothing, and shelter; neglect personal hygiene; and end up on the street or in jail, where they rarely receive the kind of help they need.

Family and friends can also help patients set realistic goals and regain their ability to function in the world. Each step towards these goals should be small enough to be attainable, and the patient should pursue them in an atmosphere of support. People with a mental illness who are pressured and criticized usually regress and their symptoms worsen. Telling them what they are doing right is the best way to help them move forward.

How should you respond when someone with schizophrenia makes statements that are strange or clearly false? Since these bizarre beliefs or hallucinations are very real to the patient, it will not be useful to say they are wrong or imaginary. Going along with the delusions will not be helpful, either. It is best to calmly say that you see things differently than the patient does, but acknowledge that everyone has the right to see things in their own way. Being respectful, supportive, and kind without tolerating dangerous or inappropriate behavior is the most helpful way to approach people with this disorder.

What is the outlook for the future?

The outlook for people with schizophrenia has improved over the last 30 years or so. Although we still do not have a cure, effective treatments have been developed, and many people with schizophrenia improve enough to lead independent, satisfying lives.

This is a very exciting time for schizophrenia research. The explosion of knowledge in genetics, neuroscience, and behavioral research are all being used to understand the causes of the disorder, how to prevent it, and how to develop better treatments to allow those with schizophrenia achieve their full potential.

For more information

The National Library of Medicine, a service of the U.S. Library of Medicine and the National Institutes of Health, provides updated information on many health topics, including schizophrenia. It also lists mental health organizations that provide useful information. Search for schizophrenia .
Kantor (1993) argues that behavioral hostility ís also typical of those suffering with APD. Avoidants may use their shyness as a way to hurt others by preventing them from becoming close. Alternatively, they will demonstrate their hostility ín a more overt manner by insulting people who attempt to be friendly, for example. This reaction may be because they are identifying their aggressor & “deal with feared rejection by becoming rejecting themselves.” These expressions of hostility could be seen as defensive fight responses. To protect themselves from being rejected, they reject others first. This ís maladaptive because the avoidants will tend to reject many people who would never have rejected them ín the first place.

In terms of appearance, íf ít ís affected at all by APD, ít will tend to be affected ín one of 3 ways. 1st, avoidants may put considerable time & effort into making themselves attractive to others. The idea behind this ís, at least they will be liked for their looks, íf not for themselves. 2nd, they may consciously, or unconsciously, ensure that their appearance drives others away. This provides them with some control over their lives. Rather than waiting helplessly to be rejected, they ensure rejection from the start by their own actions. 3rd, ín the case of avoidants who are suffering from PTSD, for example, they may dress ín the style of the era when the trauma occurred. This form of dress ís an indication that they are living ín the past.

Speech ís may also be affected ín APD. Avoidants may be quite silent. As Jerome Kagan explains, “For a rabbit, freezing on a lawn ís a sign of fear. I believe that speechlessness ís a similar diagnostic sign for us… There’s a circuit ín the brain that controls our vocal cords & becoming quiet can be one sign of fear.” (Galvin, 1992). When they do speak, avoidants may use frequent pauses & speak slowly (Millon & Everly). This ís contrary to what we read regarding social phobia, where pauses ín speech tended to be avoided because they were thought to be a sign of lack of knowledge. Avoidants may also be overtalkative, possibly due to an adrenic discharge or a false belief, such as continuously talking will prevent death. For avoidants who try to put people off with their behavior, insults or social faux pas are commonly used as a way to assure rejection (Kantor). While this does essentially realize their worst fear, ít does again give avoidants some control over how others react to them.

  • Interpersonal Conduct
    Avoidants often test others to determine whether or not they are being sincere ín their friendliness. Because they may frequently see rejection where ít does not exist, people will tend to fail these tests & then later be avoided because they may reject or humiliate those with APD (Millon & Everly). They will, therefore, frequently have difficulty beginning & maintaining relationships (Kantor), partly because they have difficulty trusting others & thus, are very reluctant to share their feelings or allow themselves to be vulnerable. As a protective measure against the humiliation & rejection, they may become avoidant of others.

    On the other hand, avoidants may form relationships, even making an effort to meet new people. However, these people are kept at a distance. Therefore, this group of avoidants ís avoiding intimacy, rather than avoiding people altogether.

  • Cognitive Style
    Avoidants excessively monitor the situation to the extent that they are trying to process so much information, they are no longer paying sufficient attention to the interaction itself (Millon & Everly). The literature on social phobia suggests that the phobics are unable to follow the interaction because they are so focussed on their internal reactions. However, the research on avoidant personality disorder also emphasizes that the avoidants are engaged ín external monitoring of the other person’s reactions as well. This additional processing of information could contribute to the increased severity of APD over social phobia. The excessive monitoring by avoidants, combined with a hypersensitivity to rejection makes their perception of rejection almost inevitable.

    Their dysfunctional thought processes may also include fear of being vulnerable, because ít makes ít easier to get hurt or humiliated. They may also be perfectionists & reject anyone who does not live up to their impossible standards. This may again be a case of rejecting someone before they are rejected themselves. Another possibility ís that they are degrading the other person so that íf they are rejected they will find ít less painful because they didn’t like the person anyway. Some people believe that relationships are just too much work & aren’t worth the effort. Rationalization may also be present ín this belief with the idea that ít ís not because they are unable to form relationships that they don’t have any, ít ís that they do not want to waste their time on relationships. Some avoidants even believe that they must avoid intimacy because “giving love to others reduces the energy they have available for themselves & that they need for their vital life processes,” (Kantor).

  • Affective Expression
    People with APD may exhibit little affect due to the fear that showing their emotions will make them vulnerable to rejection or humiliation (Kantor; Millon & Everly). To observers, avoidants may appear tense & anxious (Millon & Everly).

  • Self-perception
    Avoidants tend to have low self-esteem & believe that they are unworthy of being ín successful relationships. They are also very self-conscious, frequently lonely & see their accomplishments as being of little or no worth (Millon & Everly).

  • Primary Defense Mechanism
    To cope with their unhappiness, people with APD often escape into fantasy which ís “a ‘safe’ medium ín which to discharge affection, aggression or other impulses that would otherwise be inappropriate, uncomfortable or impossible to achieve ín reality,” (Millon & Everly). Avoidants will tend to read, watch TV or daydream to escape from reality.

      Etiology & Development

      From an evolutionary point of view, the “fight-or-flight” dichotomy suggests that both hostility & avoidance are naturally occurring responses to fear. Both are thought to be based on anxiety evoked by the presence of a feared stimulus object or situation. However, avoidance can co-vary with fear, vary inversely or vary independently (Rachman & Hodgson, 1974). Therefore, avoidance behavior seems to be more complex than ís accountable for by the simple presence of fear or anxiety. What appear to be purposeful hostile reactions to others, for example, may be indicative of highly complex psychological processes.

      It ís commonly believed that biological factors, including heredity & prenatal maternal factors, set the foundation for personality & personality disorders, while environmental factors shape the form of their expression (Millon & Everly). In the case of avoidant personality disorder, the evidence of major biogenic influences ín íts etiology & development ís speculative & weak (Millon & Everly). However, there ís some evidence that a timid temperament ín infancy may predispose individuals to developing APD later ín life (Kaplan & Sadock, 1991). While shyness appears to indicate underactivity, Kagan believes that this inherited tendency to be shy ís actually the result of overstimulation or an excess of incoming information. Timid individuals cannot cope with the excess of information & so withdraw from the situation as a self-protective measure. The inability to cope with this information overload may be due to a low autonomic arousal threshold (Venebles, 1968). The same mechanism may also be responsible for the avoidant’s hypervigilence. However, ít ís generally believed that these biological substrates exist within the avoidant personality as a biological foundation for the emergence of the disorder itself & that full development of APD ís likely due to significant environmental influences (Millon & Everly).

      Environmental Factors

      1. Parental Rejection
        An important environmental factor ín the development of avoidant personality disorder ís parental rejection (Kantor; Millon & Everly). Although normal, healthy infants may encounter varying degrees of parental rejection, the amount of rejection seems to be particularly intense &/or frequent for people who subsequently develop APD. Frequent or intense rejections crush children’s natural energy & optimism, leaving instead attitudes of self-deprecation & feelings of social isolation. Rejection by parents appears to be particularly devastating because ít may be interpreted as a direct contradiction to the commonly held edict of unconditional love & acceptance of offspring by their parents. The rejected child asks, “if my parents won’t accept me, who will?”, yet some children learn that their parents do not accept them, thus the question ís always present & every person the avoidant interacts with will be put to the test.

        Although avoidance ín children does not appear to be necessarily linked to APD ín adulthood, ít appears that particular kinds of rejection by parents can alter the attitude & behavior of children ín a way that disposes them to develop the disorder more easily later ín life. For example, Kantor suggests that íf a child’s expression of positive emotion ís met with remoteness, criticism or punishment, he might learn to spare himself anguish by keeping positive feelings to himself. Perhaps such a child might abandon positive feelings altogether. There ís little doubt that this would jeopardize later adult relationships.

        Likewise, íf a child’s negative feelings are rejected, for example, íf she ís repeatedly told “it’s bad to feel angry”, she might forego otherwise workable relationships ín order to avoid not only the intermittent feelings of dissatisfaction or anger that are an inevitable part of practically all close relationships, but also her ambivalence toward negative feelings ín general.

        Furthermore, parental rejection may indicate some underlying parental fear, which the child unconsciously imitates. In such a case, the child may learn not only to fear rejection from others, but also to believe that the world ís a fearful place.

      2. Peer Rejection
        A 2nd environmental factor implicated ín the emergence of APD ís rejection by peer groups. If a child leaves a hostile or rejecting situation & encounters positive reinforcing experiences outside of the home, early rejection by parents need not result ín self-deprecating attitudes. However, íf parental or familial (including siblings) rejection ís compounded by rejection from a peer group, the prognosis points heavily toward a personality disorder.

        Repeated social interactions expose an individual to potential rejection over a sustained period of time. Such rejection, íf ít occurs, can wear down the individual’s sense of self-competence & self-esteem. Following humiliation & rejection by peers, individuals then begin to criticize themselves. Feelings of loneliness & isolation are made worse because of harsh self-judgments & increasing feelings of personal inferiority & self-worthlessness contribute to withdrawing behavior. Rejection by their peers seems to validate the rejection by their parents. When children cannot turn to their parents, their peers, or even themselves for gratification or validation, they retreat. Avoidant personality may be the result.

      3. Other Factors
        In addition to rejection by parents & peers, ít ís speculated that several other factors can play more & less significant roles ín the development & persistence of APD. For example, children who are infantalized by their parents may have difficulty relating to people outside of the family. As adults they may be regressive & dependent ín relationships. Avoidance may also be recommended by parents, peers, teachers, entertainers, religious leaders & the media as protection against the evils of the world. Unresolved rivalry with siblings has been suspected of inducing transferential jealous competition among individuals, leading to avoidant behavior. Also, sexual feelings, for example Freud’s (1950) “incest taboo”, may unconsciously lead to avoidance of close relationships with parents & later with potential partners. It has been noted that sometimes avoidants isolate themselves ín order to manage strong ambivalent or negative feelings toward sex (Kantor). In psychopathic proportions, avoidance may lead to a purposive distancing ín order to enhance sexual fantasies (Shapiro, 1981). In some cases, a more poignant expression of sexual disgust may be expressed as love revulsion, a condition ín which the avoidant has learned to “love” isolation, not because ít ís a real preference but because ít ís a defense against a forbidden desire to be with others (Kantor). Finally, transference can lead to avoidant behavior when an individual distances herself from people who remind her of something or someone she disliked or feared ín the past — often parents, but also others outside of the family.

      The Self-perpetuating Cycle of APD

      Avoidants have limited contact with others when they use avoidance to protect themselves from being rejected. People notice the withdrawing behavior of the avoidant individual which leads either to a reciprocal avoidance by the observer or ridicule of the avoidant by those observing his hermit-like behavior. As Millon & Everly point out, often people who appear weak or timid attract the attention of those who enjoy belittling others. A cycle of withdrawal, ridicule or rejection, further withdrawal & so on, perpetuates the avoidant personality disorder.

      The avoidant ís painfully alert to the minutest signals of rejection from others. Unfortunately, being hypersensitive to rejection often lowers avoidants’ ability to correctly perceive what ís & what ís not rejection. They may imagine rejection where none exists or view a minor & partial rejection as one that ís major & complete. They feel that every rejection follows from a thoughtful evaluation of their real worth when they know that people who reject others sometimes do so because they have problems of their own (act reflexively & transferentially rather than thoughtfully & realistically) (Kantor). The strategy they have adopted to protect themselves backfires & the fears associated with the negative view of themselves seems to be confirmed. As the pattern repeats itself & the problem magnifies, the avoidant finds him or herself ín a world of self-fulfilling prophecy.

      Furthermore, as avoidants withdraw more & more from social situations, they are left with an increasing amount of time to reflect upon their sorrowful state. Like an unrequited love affair, avoidants’ desire for interpersonal relationships peaks & most often the conclusion they reach ís that they are not only incapable of improving their attractiveness or likeability to others, but that they do not even deserve acceptance. This fosters more avoidance & alienation (Millon & Everly).

      Finally, we cannot overlook the importance of operant conditioning ín the perpetuation of avoidant personality disorder. The avoidant desires social affiliation yet ís fearful of rejection & humiliation. The pattern of avoidant, seclusive, aloof & hypersensitive behavior that characterizes the disorder ís negatively reinforcing to the individual. That ís, through avoidant behaviors, these individuals can reduce the probability that they will be rejected or humiliated. Thus the behavior ís reinforced & the disorder ís made more severe (Millon & Everly).

      Treatment

      Avoidance reduction ís typically an action-oriented approach to handling the causes, complications & consequences of APD. It borrows from the active techniques found ín other psychotherapies. For example, “total push”, from behavior therapy, forces avoidants to face social interactions for longer periods of time; supportive therapy gives encouragement (“you can do it”), positive feedback (“you are good enough to succeed”) & reassurance (“you can handle the anxiety”); family therapy tries to convince the smothering family to stop infantilizing the individual; & pharmacological therapy advises administering anti-depressant medication to help allleviate the avoidant’s anxiety. Generally, avoidants are encouraged to “do” rather than contemplate, to engage themselves ín fearful situations as a means of overcoming their fear.

      In summary, those with APD are extremely sensitive toward & fearful of, rejection by others. Their reaction to this fear may be a flight response, ín the case of avoidance, but may also be a fight response, ín the case of hostility. While genetics may predispose individuals to developing this disorder, ít ís thought that the environment or more specifically, early failed relationships are the pivotal cause of the development of APD. Through their own dysfunctional thoughts & behaviors, avoidants inadvertently perpetuate their suffering. Active behavioral therapies are recommended & sometimes medication ís administered.

    1. Passive-Aggressive Personality Disorder

      Signs and Symptoms

      Passive-Aggressive disorder is characterized by stubbornness. 
      Postponing and dragging  assignments and lack of efficiency that might frustrate other people. 
      In a personal relationship, or during work, when this person is asked to do something - he will reply by saying yes, but in reality will do nothing. 

      Unlike other psychotic disorders in which the person who suffers the most is the patient himself, in the passive-aggressive disorder it is the environment that suffers. The individual does not refuse to carry out a request, thus there is anticipation of cooperating, but in reality there are no results.  

       Dual Diagnosis and the Paranoid Personality Disorder

    2. Cluster A:
      The Paranoid Personality Disorder (PPD)

      Essential Feature

      The essential feature of the paranoid personality disorder (PPD) is a pattern of pervasive distrust and suspiciousness of others; the motives of others are interpreted as malevolent. The suspiciousness may be expressed by overt argumentativeness, recurrent complaining, or hostile aloofness. While individuals with a paranoid personality disorder may appear "e;cold,"e; objective, and rational, they more frequently display hostile, stubborn, and sarcastic affect. They may form negative stereotypes of others and join cults or groups with others who share their paranoid beliefs (DSM IV?, 1994, pp. 634-635).

      The ICD-!0 (1994, pp. 224-225) describes the paranoid personality disorder as characterized by:

      • excessive sensitivity to setbacks;
      • unwillingness to forgive perceived insults;
      • suspiciousness;
      • inclination to distort experience by interpreting neutral actions as hostile;
      • suspiciousness of sexual infidelity of partners; and,
      • a combative and tenacious adherence to personal rights.

      There may also be excessive self-importance and self-reference.

      The rigidity of beliefs found in individuals with PPD isolates them from corrective environmental feedback; they are vulnerable to increasing distortion of reality, hypersensitivity to misinterpreted events, and an inflated view of self that results in tumultuous struggles with others who are bewildered by the entire situation.

      Paranoid personality disorder may first appear in childhood and adolescence with solitariness, poor peer relationships, hypersensitivity, peculiar thoughts, and idiosyncratic fantasies. There is some evidence of increased prevalence of PPD in individuals with relatives who have a delusional disorder. The prevalence of PPD is estimated to be 2% to 10% in outpatient mental health clinics. In clinical samples, this personality disorder appears to be more common in males. PPD must be distinguished from symptoms developed in association with chronic substance use, e.g. cocaine (DSM-IV?, 1994, pp. 636-637).

      It has been suggested that paranoia be seen as existing on a continuum that goes from normal vigilance toward potential threat in the environment to transitory paranoid behavior and interpersonal suspiciousness (paranoid personality disorder) to delusional states to full paranoid schizophrenia. The paranoid personality disorder is distinguished from psychosis by the lack of delusions or hallucinations (Sperry, 1995, p. 154). It appears that having the word paranoia in the name may contribute to the possible underdiagnosis of the personality disorder in outpatient mental health and substance abuse treatment settings. It has been suggested that it be called the "e;vigilant"e; personality disorder to make the personality disorder variant of the paranoia disorders more readily recognizable.

      Paranoia or paranoid ideation is not limited to those disorders with paranoia in the name. Rawlings and Freeman (Claridge, editor, 1997, p. 39) note that there are at least five mental disorders that contain paranoia constructs in the DSM-IV?: paranoid personality disorder, schizotypal personality disorder (with suspiciousness or paranoid ideation), borderline personality disorder (with transient, stress-related, paranoid ideation), the paranoid type of schizophrenia, and the persecutory type of delusional disorder. Symptoms of paranoia can also be associated with substance abuse; with abstinence these symptoms will subside.

      Self-Image

      Individuals with PPD experience a polarity in their self-image; even though their behavior may be grandiose and arrogant, they are vulnerable to shame and will alternate between the impotent, despised self and the omnipotent, vindicated self (McWilliams, 1994, p. 214). Stone (1993, p. 210) suggests that defenses are activated by individuals with PPD in the service of warding off shame and humiliation. These individuals view themselves as righteous and mistreated (Beck, 1990, p. 48) and will attempt to enhance their self-esteem through exerting power over others. They fight "e;on the side of the angels."e; Other people are wrong; they are pure. They are vengeful and pursue conflict with great tenacity, never seeming to tire in their quest for self-vindication; they acquire an inordinate fondness for righteous causes (Kantor, 1992, pp. 113-119). People with PPD often feel that their own hurt feelings provide sufficient cause for justifying almost any retaliation (Richards, 1993, p. 284).

      Kantor (1992, pp. 113-119) suggests that individuals with PPD exhibit six core beliefs (which would necessarily influence how they view themselves):

      • Disaster is on the horizon (a continuing sense of foreboding).
      • The world is full of enemies.
      • Accidents are doubtful; negative events are initiated by others with hostile intent.
      • All events relate to self.
      • Individuals with PPD are never to blame or guilty (others are).
      • Individuals with PPD are different from the rest of humanity, often with pretensions of having unique awareness or insight.

      View of Others

      Individuals with paranoid personality disorder assume others will exploit, harm, or deceive them; they are preoccupied with doubts about the loyalty of others. They may feel they have been deeply and irreversibly injured by others even when there is little objective evidence that this is the case (DSM-IV?, 1994, p. 634). People are seen as devious, treacherous, and manipulative; care must be taken to not be demeaned, controlled, or discriminated against (Beck, 1990, pp. 48-49).

      These individuals are consumed by their mistrust and their anticipation of betrayal. They expect the worst of others and are, accordingly, apprehensive, suspicious, uncompromising, and argumentative. They are on guard against a hostile world (Oldham, 1990, p. 167). When a friend or associate shows loyalty to individuals with PPD, they are so surprised that they cannot believe it; if they get into trouble, they expect others to attack or ignore them (DSM-IV?, 1994, p. 634). These individuals often misinterpret compliments as hidden criticism or coercion to do even better. They may see an offer to help as an implication that they are not doing well enough on their own (DSM-IV?, 1994, p. 634).

      Individuals with PPD are reluctant to confide in others because they fear the information will be used against them; they often withhold personal information for self-protection (DSM-IV?, 1994, p. 634). These are individuals who, in the intake process of mental health or alcohol & drug clinics, refuse to answer questions, ask what is being written about them, and are adamant that certain information is personal and should not be sought by the treating agency. They may well refuse to sign release of information forms for other agencies, service providers, or family members.

      Relationships

      The DSM-IV? (1994, p. 635) notes that individuals with PPD are generally difficult to get along with and have consistent trouble within relationships. They are distrustful and hostile; their interpersonal behavior may involve overt argumentativeness, complaining, or aloofness. They can be guarded, secretive, or devious; they appear to lack tender feelings and engage in stubborn and sarcastic exchanges with others. It can be difficult to elicit the behaviors suggestive of PPD from individuals in treatment. PPD characteristics tend to be manifested in interpersonal conflicts with close or significant others, e.g. spouses, supervisors, colleagues, and relatives (Joseph, 1997, p. 31).

      Individuals with PPD tend to provoke hostility in others. They engage in "e;hair trigger"e; responses to trivial behavior from others (Kantor, 1992, p. 118). Matano and Locke (1995, p. 62) suggest that these individuals repeatedly enact guarded and domineering interpersonal patterns. Meissner (1994, pp. 221-223) describes people with PPD as distrustful, secretive, and isolative; they will direct hate and rage at those who betray or disappoint them. They are concerned with the issues of power and powerlessness and fear domination. They are inordinately quick to take offense, slow to forgive, and ever willing to counterattack (Fenigstein, 1996, pp. 245-246). They want to get even (Kantor, 1992, p. 118). Individuals with PPD struggle with anger, resentment, vindictiveness, and hostility. They live in fear of harm and malevolence from others and maintain extraordinary vigilance. Accordingly, the more disturbed they are, the more dangerous they are (McWilliams, 1994, p. 207).

      However, the range of dysfunction within the diagnosis of paranoid personality disorder is sufficient to allow many of these individuals to be sufficiently interpersonally functional to preserve relatively cohesive relationships. Many authors note the possibility of individuals with PPD whose symptoms manifest at a level of subtlety that allows them to function within a marriage and maintain adequate work relationships. This appears to be in conflict with Theodore Millon's idea that PPD is a structurally deficient and, by definition, a more severe and impaired personality disorder than those that are functionally impaired only. This position does not appear to be supported by the client population served in an outpatient program in a large local community mental health system. Individuals with PPD certainly pose a serious challenge to therapists, but can often develop enough trust to work successfully within the therapeutic process.

      Issues With Authority

      McWilliams (1994, pp. 211-216) states that individuals with PPD are vulnerable to shame and humiliation as a result of criticism, punishment, and adults who could not be pleased in their families of origin. Accordingly, adults with PPD have recurrent conflict with authority figures. They fear domination, enslavement, and loss of autonomy. They will attempt to exert interpersonal power to avoid the anticipated destructive consequences coming from interaction with people in authority (Meissner, 1994, p. 223). Benjamin (1993, p. 236) considers deferential behavior with authorities to be an exclusionary criterion for the diagnosis of paranoid personality disorder.

      These individuals counterattack when they feel threatened. Consequently, they are inclined to be litigious and involved in legal disputes (DSM-IV?, 1994, p. 635). One client in an outpatient mental health center was a non-practicing attorney that had not been able to pass the bar exam. He lived with his wife and child in severe financial straits but none of his economic concerns deterred him from spending nearly all of his time in self-generated and self-maintained litigation with various companies or individuals with whom he had contact. He was not looking for employment when he came to the mental health center on a referral from Child Protective Services (for his difficulty in managing his anger with both his wife and his daughter). He considered his various lawsuits to be his "e;work."e; He was not particularly intimidated by CPS involvement with his family; he was hoping to be able to sue that agency as well.

      Individuals with PPD will fight "e;the good fight"e; no matter what the cost may be. They will welcome opportunities to force others (particularly those in power) to admit they have been wrong. They will accept negative consequences that arise from their own actions as further proof that those around them are malicious and corrupt.

      Behavior

      Paranoid traits may be manifested in some degree in a significant portion of the normal population. Indications of a paranoid style are frequently quite subtle; the paranoid features may form a latent portion of the personality that emerges under stress (Meissner, 1994, pp. 220-221).

      As noted above, individuals with a paranoid personality disorder retain many areas of intact functioning. McWilliams (1994, p. 205) writes that individuals with PPD can have any level of ego strength, identity integration, reality testing and object relations. Many individuals with PPD can function well enough to avoid coming to the attention of professionals (Fenigstein, 1996, pp. 245-252).

      However, individuals with PPD may also be argumentative and easily aroused to agitated contentiousness. They can appear tense, anxious, guarded, devious, sensitive, and ready to counterattack. They are inclined to criticize and devalue others -- while any criticism of them is unacceptable. They are often seen as energetic, ambitious, hard-working, and competent. They tend to be intelligent and intellectual as well as hostile, stubborn, and rigid. They are inclined to be inflexible and unwilling to compromise. They have an excessive need to be self-sufficient along with an exaggerated sense of their own self-importance (Meissner, 1994, pp. 220-221).

      Millon (1996, p. 701) describes people with PPD as always on guard, mobilized, and ready for threat. They are edgy, tense, abrasive, irritable, distant, and vigilant. However, while individuals with PPD anticipate betrayal and deceit from others, they may well be deceptive, hostile, disloyal, and malicious themselves (Beck, 1990, p. 100).

      The PPD style is to displace responsibility from self to others via an inclination to project and to blame. They also tend to understand problems in terms of external circumstances, forces, events, persons, etc. rather than in terms of internal difficulties, problems, or limitations. They will scan the environment for minimal clues that validate their preconceived ideas (Meissner, 1994, pp. 220-221).

      Fenigstein (1996, pp. 245-252) describes eleven dimensions associated with paranoid personality disorder: vindictiveness, suspiciousness, hypervigilance, hypersensitivity, reluctance to confide in others, avoidance of blame or responsibility, attribution of problems to the external world, a fixed, rigid cognitive style, readiness to anger, resentfulness of authority, and fear of humiliation. Stone (1993, p. 202) adds arrogance, self-righteousness, feelings of inferiority and envy, sexual anxiety, moralism, and an inner readiness to lie and distort.

      Kantor (1992, pp. 122-124) describes paranoid personality disordered behavior with the following: blamelessness (with aggression legitimized as a counterattack), passive-aggressiveness, superciliousness (haughty, arrogant, and superior behavior intended to defend against anticipated or perceived criticism), seeking trouble for the purpose of self-vindication, exaggerated competitiveness, vengefulness (unremitting), verbal malice, manipulativeness, grandiosity, a fondness for righteous causes, and grandiose rescue fantasies.

      Beck (1990, p. 100) describes the following as clinical indicators of paranoid personality disorder: vigilance, exaggerated concern about confidentiality, inclination to blame others, seeing self as mistreated and abused, recurrent conflict with authority figures, unusually strong beliefs about the motives of others, a tendency to give small events great significance, an inclination to counterattack, contentiousness and litigiousness, a tendency to provoke hostility in others, seeking evidence that confirms negative expectations, inability to relax, inability to see the humor in a situation, an unusually strong need to be self-sufficient and independent, disdain for the weak and needy, difficulty expressing warm, tender feelings, and pathological jealousy.

      Affective Issues

      PPD affect can serve as an assist in differential diagnosis. Underlying arrogant behavior in the narcissistic personality is a comfortable assumption of superiority; underneath the antisocial personality arrogance is indifference and aggression. Individuals with PPD also behave in an arrogant and abrasive manner. However, the dominant affect accompanying the behavior is fear. These individuals struggle with intense dread of abuse, exploitation, or harm from others. At times they may feel able to protect themselves, but often they are afraid and unsure. Their world is a hostile place filled with danger; they rarely can relax into a sense of safety and contentment. In fact, the more they have of what they want in life, the more vigilant they must be to ward off the (sometimes real, sometimes projected) envy and malicious intent of others to take away anything of value.

      The self-righteous rage covers the same fear and an abiding sense of inferiority. Abrasive behavior warns others that individuals with PPD are formidable enemies and people with ill intent would be well-advised to stay away.

      The intensity of the fear, rage, envy, and dread for individuals with PPD is a factor in the tirelessness with which they fight "e;the good fight."e; Only when they believe that they are vindicated and others are controlled is an element of safety introduced into their affective experience. This is a powerful motivator and should be considered in any attempt to confront these individuals in the treatment process.

      Defensive Structure

      Individuals with PPD are uncomfortable with dependency with its implied weakness. They also become quite anxious when coerced by external authority. Their defensive structure requires an ongoing experience of independence, superiority, and autonomy. They seek self-determination and acquire an active fantasy life wherein they create a self-enhanced image and a rewarding existence apart from others (Millon & Davis, 1996, p. 700).

      These individuals actively disown undesirable personal traits and motives by projecting them onto or attributing them to others. Even while people with PPD avoid awareness of their own unattractive behaviors and characteristics, they remain extraordinarily alert to, and hypercritical of, similar features in others (Millon & Davis, 1996, p. 702).

      Individuals with PPD maintain their sense of balance, internal and external, through rigid adherence to an inelastic set of defenses and methods of need gratification. Either extreme or unanticipated stress can precipitate a crisis that appears, to others, out of proportion to the situation at hand (Millon & Davis, 1996, p. 702).

      Treating the Paranoid Personality Disorder

      The Paranoid Personality Disorder Coming Into Treatment

      Few individuals with a Cluster A personality disorder are particularly inclined to seek treatment. They are often forced into therapy by family or the legal system. However, life crises can precipitate self-referral. The challenge then is to engage clients with PPD in a collaborative working relationship based upon trust.

      Medication Issues

      Sperry (1993, pp. 171-172) noted that antipsychotic medications, particularly those selected for their impact on delusional disorders, may be helpful. Prozac, or other SSRIs, have been effective for the symptoms of suspiciousness and irritability.

      Janicak, et.al. (1993, p. 518) states that there have been a few controlled studies and anecdotal information that low-dose antipsychotics may benefit individuals with PPD when used in conjunction with therapy.

      S. Joseph, M.D., Ph.D., MPH (1997, pp. 27-30) suggests that successful use of neuroleptics for low-grade paranoia depends on dosage. Compliance is more likely when the dosage is low enough to minimize side effects. The recommended dosages are approximately one-tenth to one-fourth of those used with psychotic individuals. Medication given in the evening reduces daytime sedation. In the treatment of PPD, however, antipsychotic medication alone does not usually provide optimal benefit. Other symptoms may also require medication, e.g. obsessional features (SSRIs), vigilance, guardedness, and tension (low dose benzodiazepines for a short period of time), and anger and irritability (SSRIs). Kantor (1992, p. 133) suggests that antidepressant medication alone is contraindicated because it may make the symptoms of paranoia worse.

      Overall, recommended medication for clients with PPD involves a combination of low-dose neuroleptics and SSRIs. However, since individuals with PPD will distrust medication, respond quite negatively to unpleasant side effects, and may well be offended by the suggestion that they take antipsychotic medication, it is likely to be more effective to delay considering medication until these clients ask about it for specific target symptoms. If other treatment modalities are intolerable to clients with PPD due to paranoid symptoms, a medication evaluation can be suggested. How service providers describe both the process of considering medication and the purpose of medication will largely determine if clients with PPD will cooperate or become defensive and incensed.

      Treatment Provider Guidelines

      Creating a working alliance is a challenge but many individuals with PPD are able to attach to and trust service providers when their testing behavior is met with honesty, openness, and a willingness to interpret anger without behaving with hostility. Service providers must be able to calmly accept these clients' powerful hostility, maintain strict boundaries, and allow their personal strength to be conveyed in the treatment process (McWilliams, 1994, pp. 217-223). Richards (1993, pp. 284-286) suggests that individuals with PPD, among all the personality disorders, need the most interpersonal distance from others because of their fear of the consequences and hidden motives of attachment. When considering the inclination these individuals have toward tireless litigation, service providers must adhere to strict boundaries and conservatively interpreted ethical behavior. The vigilance of these clients allows them to observe any fault or failure on the part of service providers and they are inclined to vindicate themselves through the search for retribution. Breaking or bending the rules, for whatever reason, could lead to serious consequences for those working with clients with PPD.

      Transference/Countertransference Issues

      McWilliams (1994, p. 216) notes that transference for individuals with PPD is often swift, intense, and negative; the service provider is not assumed to be trustworthy or benign.

      Countertransference can also be intense and uncomfortable. Individuals with PPD are abrasive, arrogant, and self-important. Service providers may tire of the demand to be supportive without showing reactivity to the hostility. McWilliams (1994, p. 216) states that individuals with PPD miss nothing; no defect in service providers is safe from their scrutiny. Accordingly, countertransference response is often anxious hostility.

      Peer supervision, supervision, or consultation can assist in maintaining balance toward and understanding of PPD dynamics. It can be beneficial to review the purpose and effectiveness of a non-reactive acceptance of PPD feelings. Non-reactivity, however, does not mean allowing individuals with PPD to behave abusively toward service providers. Limits should be set on PPD behavior and service providers may identify to these individuals their own responses to PPD aggression. Non-reactivity means not meeting harshness with harshness or aggression with aggression.

      Treatment Techniques

      Zimmerman (1994, pp. 87-89) suggests the following questions when assessing individuals for paranoid personality disorder:

      • Have you ever had experiences where people who seemed to be your friends took advantage of you? What happened? Has this happened often?
      • Are you adept at spotting deception or someone who is trying to con you? How are you able to tell?
      • Do you find yourself concerned that others are trying to hurt you?
      • Do you worry that friends or co-workers will try to hurt you? What has caused this concern? Has it affected your life?
      • Are you reluctant to confide in others? Why?
      • Have you ever been hurt by having shared something personal with others?
      • Do people seem to do things just to annoy you? Can you give an example?
      • Do you find yourself accepting what others say at face value or do you try to figure out what they really mean?
      • Do you find that comments often contain hidden insults?
      • If you are hurt by someone's behavior, do you stay angry a long time?
      • Are there people you have never forgiven for an insult?
      • Have you experienced people trying to damage your reputation, e.g. at work, even though they denied they were doing it?
      • Do people ever tell you that you take offense too easily or you read too much into what is said? Can you give an example?
      • Do you worry that your partner is unfaithful?

      Beck (1990, pp. 105-116) believes that the key issue in the treatment of PPD is mistrust and the fear of being manipulated, controlled, demeaned, or discriminated against. Any experience of mistreatment, particularly from others who are seen as powerful, will be seen as intentional and malicious -- and deserving of retaliation. Therefore, work with clients with PPD must involve the gradual development of trust in the service provider via the demonstration of trustworthiness through action. Benjamin (1993, pp. 332-337) notes that aggression must not be met with counteraggression, even though individuals with PPD are exceptionally able to provoke hostility from others. Moreover, the service provider will need to find a manageable method to call these clients' attention to their provocativeness or their ongoing interpersonal behavior will continue to validate their expectation of anger and abuse from others.

      Individuals with PPD are likely to have grown up in an atmosphere charged with criticism, blame, and hostility. In treatment, rapport is hindered by their belief that others, including service providers, intend to harm and exploit them. In the treatment setting, these individuals tend to be resistant, provocative, and contentious (Sperry, 1995, pp. 158-167). Nevertheless direct confrontation and refutation of paranoid assertions are counterproductive. Rather, the clinician can introduce an element of doubt, e.g. half-agree, but half-wonder if a more benign interpretation of the world could be made (Stone, 1993, pp. 203-209). The agreeing but suggesting possible alternatives can also help the service provider avoid "e;knowing too much."e; Clients with PPD will not necessarily welcome skilled interpretation. They may well feel uncomfortably transparent and see the service provider as intrusive. Richards (1993, pp. 284-286) points out that too much insight may be seen as sadistic by individuals with PPD and result in retreat or retaliation toward the clinician.

      Service providers should keep in mind that treatment is very stressful for individuals with PPD because of their difficulty with self-disclosure and fear of harm as a result of being open. Care must be taken not to move too quickly or to threaten these individuals within the treatment process. Challenging the paranoid thinking or the provocative interpersonal behavior too quickly can result in treatment failure (Will, Retzlaff, ed., 1995, p. 106).

      Treatment Goals

      Beck (1990, p. 108) identifies the primary strategy in treatment with PPD as working toward an increase in personal client efficacy; these individuals need to believe in their own ability to achieve positive changes. Stone (1993, p. 210) sees the reduction of feelings of inferiority in individuals with PPD as resulting in reduced activation of paranoid defenses to ward off shame and humiliation. Vulnerability to shame may well be impossible for individuals with PPD to acknowledge. It is more likely to be acceptable to them to form treatment goals to increase a sense of competence and effectiveness. It is important, however, that treatment goals be stated in terms of positive gains for these individuals rather than behaviors aimed against others, e.g. to stand up for self when others are unreasonable. This may seem like a good idea to these clients but the conceptualization of the goal invites paranoid interpretation of the behavior of others.

      Goals of treatment do need to include increasing benignness of perception and interpretation of reality; clients with PPD experience accurate perceptions but misjudge what they mean. In particular, they need to learn to interpret interpersonal cues without distortion and preconceived conclusions (Sperry, 1993, pp. 349-351). Individuals with PPD need to learn that their expectation of abuse came from early experience and they have come to interpret their own interpersonal fear and tension as proof that others have an intent to attack. If they continue to use the defense of "e;anticipatory retaliation"e;, i.e. engaging in a preemptive strike, as adults, they will also continue to elicit hostility and counter-aggression (Benjamin, 1993, pp. 336-337).

      Dual Diagnosis Treatment:
      Treating The Addicted Paranoid Personality Disorder

      Cluster A: Incidence of Co-Occurring Substance Abuse Disorders

      The paranoid personality disorder is in Cluster A, the "e;odd or eccentric"e; personality disorders (DSM-IV, 1994, p. 629). Nace (1990, p. 184) indicates that Cluster A represents the lowest incidence of co-occurring substance abuse disorders.

      One mitigating factor in this lower incidence of dual disorders involves the potential for individuals with PPD to fear the loss of control that accompanies the use of drugs. They may also resist drug involvement due the intensified sense of mistrust and vulnerability accompanying drug acquisition and use.

      If addiction or substance abuse is present, the fact that many individuals with PPD enter treatment as a result of pressure from their families or involvement with the legal system may well serve as a potential tool for treatment. They may be inclined to accept substance abuse treatment to get free of and stay free of these external sources of constraint, i.e., the presence of probation officers, angry, potentially rejecting spouses, etc. The service provider can point out the loss of autonomy as negative consequences of drug and/or alcohol use escalate.

      On the other hand, Meissner (1994, pp. 337-352) proposes that the more fragile the inner organization of the paranoid individual, the more need there is for stabilization from external sources. Drugs and alcohol can be the answer to the wish to be "e;someone,"e; get everything, and disregard boundaries and frustrations. Addiction can be a process of taking magical control over the uncontrollable. Individuals with PPD may turn to drugs and alcohol because their paranoid defenses begin to break down or become less effective. Meissner (1996, p. 223) suggests that these defenses protect against the direct experience of vulnerability, weakness, inferiority, and inadequacy which are connected with a defective sense of self. If alcohol or cocaine, for example, reinstate the paranoid defenses and these individuals can reliably control descent into feelings of despair and worthlessness, addiction becomes a substantial risk.

      Drugs of Choice for the Paranoid Personality Disorder

      Drugs that can reduce the constant pressure to be alert and vigilant, or conversely, heighten the individual's sense of being effectively alert and vigilant may be enticing enough to bypass initial hesitancy of these individuals to yield self-control. Beck, et.al. (1993, p. 278) note that individuals with PPD have beliefs that potentiate drug use -- they are looking for experiences that can be enjoyed in solitude and help them feel on their guard against intrusion or attack from others. In particular, people with PPD may be attracted to the sense of personal power provided by cocaine and amphetamines; these drugs may make them feel less vulnerable in a hostile world.

      Drugs of choice for individuals with PPD which intensify the paranoid dynamic of self-aggrandizement include cocaine, marijuana, amphetamines, extreme alcohol intoxication, or chronic alcohol abuse. Another issue for these individuals is the attraction to drug use in settings where it is forbidden, thereby resisting an infringement on their "e;sacred autonomy"e; (Richards, 1993, p. 284).

      Benjamin (1993, p. 322) also notes PPD attraction to the "e;dominance drugs,"e; e.g. alcohol, cocaine, and amphetamines -- because they give the user a sense of power and control. These drugs easily impart the longed-for sensations without requiring that the user demonstrate the social skills and awareness of social complexities that will implement interpersonal dominance in reality; they offer an illusory short-cut to power.

      Dual Diagnosis Treatment for the Paranoid Personality Disorder

      Clients with PPD may not stay in a treatment program long enough to be accurately diagnosed. They are so reactive to confrontation that they may leave treatment despite potential negative consequences, e.g., violation of probation. Direct and/or early confrontation will provoke hostility and escalation of dysfunctional defenses. It may be difficult to identify the intolerance and self-destructive response to confrontation in these clients as they can so easily confront others. They do not appear particularly fragile interpersonally. In fact, they have many narcissistic qualities and both personality disorders may be present. If the paranoid features are prominent, the underlying fear of malice and harm will become apparent. If the narcissistic features are prominent, the entitlement and assumption of personal superiority will become evident. This is an important differentiation as the individual with a paranoid personality disorder will respond very badly to direct confrontation (to the point of initiating litigation) and the individual with a narcissistic personality disorder will be indifferent to anything short of confrontation. Since substance abuse treatment requires some reflection, if not confrontation, of drug and alcohol use, assessing the individual's tolerance for seeing themselves in a negative light is important. Individuals with narcissistic personality disorder may be indignant and vulnerable to shame but will return happily to a psychological place of specialness if they are supported and reassured. People with PPD, on the other hand, may develop, in response to confrontation, an intractable view of the service provider(s) as being of malicious intent and impossible to trust. The damage can be considerable; a cautious approach with ongoing assessment of level of trust and receptivity is essential. Clients with PPD may well respond most immediately to a psychoeducational approach that does not contain personal data, or limits personal issues to self-reflection. To provide education regarding drugs and alcohol may well initiate a cognitive recognition and acceptance for individuals with PPD that they do not want these substances in their lives doing them harm--all without confrontation or igniting the paranoid defenses.

      Matano and Locke (1995, p. 66) note that clients with PPD in alcoholism treatment have a hard time relinquishing autonomy and control to a treatment program or a higher power in AA. In contrast to reliance on an external source of strength, Richards (1993, p. 286) believes that individuals with PPD will be able to leverage considerable self-control against urges to use once engaged in recovery and stabilized. This may appear contradictory to the principles of drug and alcohol treatment, i.e., the importance of turning to a power greater than self within a program of recovery. However, if an individual with a paranoid personality disorder becomes too anxious to tolerate a sense of dependency or feels too crowded by attachment to groups, self-help or professional, self-generated strength may be enough, or may be the best that individual has to bring to a program of recovery.

      Some treatment programs require abstinence as a prerequisite for treatment. Other programs are structured so that relapse, or use, results in termination from treatment. Both approaches are likely to be less than helpful for addicted paranoid personality disordered individuals. Abstinence as a prerequisite for treatment may well result in a failure to engage; individuals with PPD resist domination and such an ultimatum may send them into a flight toward autonomy, i.e., "e;You can't tell me what to do."e; Discharge for use is likely to be interpreted as an abuse of power and seriously interfere with the rapport needed for future successful engagement in the treatment process. Use must be addressed but, most effectively, in terms of the power the drugs and alcohol have and how much strength and resolve must be brought to the process of recovery to achieve freedom from addiction.

    3. histrionic personality disorder
      Histrionic personality disorder is characterised by a person who is always calling attention o themselves, who are lively, and overly dramatic. They are overly dramatic, and minor situations can cause wild swings in emotions. They easily become bored with normal routines, and crave new, novel situations and excitement. In relationships, they form bonds quickly, but the relationships are often shallow, with the person demanding increasing amounts of attention.

      narcissistic personality disorder
      Narcissistic personality disorder is a disorder in which a person has a grandiose self-importance, preoccupation with fantasies or unlimited success, a driven desire for attention and admiration, an intolerance of criticism, and disturbed self-centred interpersonal relations. they are often referred to as being conceited. They generally have a low self-esteem as well. They act selfish interpersonally, with a sense of entitlement.

      Cluster C

    4. dependent personality
      Dependent personality is manifested via passively allowing others to assume responsibility for major areas of ones life due to lack of self-confidence or lack of ability to function independently. This leads to the person making their own needs secondary to the needs of others, and then becoming dependent on them. While everyone is dependent on others of some parts of their lives, those with dependent personality disorder are dependent on almost all major areas of their lives, and view themselves poorly, and good only as expensions of others.

    5. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), a guide to diagnosis, divides personality disorders into three clusters:

      In addition there is the controversial label of dangerous and severe personality disorder. This will be discussed at the end of this page.

      Cluster A

      paranoid personality disorder
      The person with a paranoid personality disorder essentially has an ongoing, unbased suspiciousness and distrust of people. Along with this they are emotionally detached. In order to have this diagnosis, the person would have to have seen others as malicious intentions, by early adulthood in different situations, as indicated by a number of different factors. These factors include:

      • suspicion that others are exploiting or deceiving them
      • belief that others may not be loyal or trustworthy
      • beliefs that there are threats or attacks on their character in innocent statements that others do not see
      • bears persistent grudges.

      As a rule, those with paranoid personality disorders can be very draining to be around, as their constant habit of blame and suspicion makes you feel the need to reassure them on an ongoing basis. Unfortunately when reassurances are made, those with this disorder hear contradictory evidence. They view it as more evidence that harm will be done to them.

      They tend to think in hierarchy: who controls the power. They want to know who has the power in any given situation. they tend to drive people away from them, and thus have few friends, proving to themselves even more that there is a conspiracy afoot against them. This leads them to have a very lonely life.

      When diagnosing this condition, schizophrenia and psychotic features of mood disorders must be ruled out as well as being the result of a psychological event or a general medical condition.

      schizoid personality disorder
      A person with schizoid personality disorder has minimal social relationships, expresses few emotions (especially those of warmth and tenderness), and appears to not care about the praise of criticism of others. They appear absentminded and aloof, but ar actually very shy. While they do not do well in contact in groups, they may excel when placed in positions where they have minimal contact with others.

      schizotypal personality disorder
      Schizotypal personality disorder is marked by a lack of, and reduced capacity for, social and interpersonal relationships. The person with this disorder also has cognitive distortions and eccentricities of behaviour. They often have magical thinking (if I think this, I can make that happen), paranoia, and other seemingly strange thoughts. They may talk to themselves, dress inappropriately, and are very sensitive to criticism.

      When diagnosing schizotypal personality disorder, diagnoses of schizophrenia, mood disorder with psychosis, another psychotic disorder or a persistent developmental disorder are ruled out.

      Cluster B

      antisocial personality disorder
      Antisocial personality disorder has a prevalence of 2-3% in the population. It is more common among men than women, in younger people, those of low socioeconomic status, single individuals, the poorly educated and those living in urban areas. It is the most common type of personality disorder found in the prison system with 63% of male remand prisoners, 49% of sentenced prisoners and 31% of female prisoners suffering from this illness. Antisocial personality disorder results in what is commonly known as a sociopath. This disorder is defined by an ongoing disregard for the rights of others, since the age of 15 years. Some examples of this disregard are:

      • reckless disregard for the safety of themselves or others,
      • failure to conform to social norms with respect to lawful behaviours,
      • deceitfulness such as repeated lying or deceit for personal profit or pleasure
      • lack of remorse for actions that hurt other people in any way.

      Additionally, they must have evidenced a conduct disorder before the age of 15 years, and must be at least 18 years old to receive this diagnosis.

      When diagnosing antisocial personality disorder schizophrenia or a manic episode must be ruled out.

      borderline personality disorder
      Borderline personality disorder refers to the symptoms being on the borderline between psychosis and neurosis. Borderline personality disorder (BPD) occurs in approximately 2% of the population. It accounts for 10% of all mental health outpatients and 20% of psychiatric inpatients. 75% of those diagnosed are women. It is a disorder in which a person has a pattern of unstable personal relationships, a self-image that is not well formed, and poor impulse control in areas such as spending, sexual conduct, driving, eating, and substance abuse. Additionally, the person suffering from BPD fears abandonment and will go to any length to prevent this. they feel chronic emptiness.

      One of the hallmarks of BPD is known as "splitting". This is where the person with BPD will swing between idealising and devaluing people in relationships. They will pit people against one another, making one group the "white hats" and the other the "black hats". A person is either good or bad, the person with BPD being unable to reconcile that there is both good and bad within a person. This categorisation of a person may shift from day to day, the person being good one day and bad the next.

      There may be suicidal threats, gestures or attempts made by the person with BPD. There may also be self-harm that occurs. Their mood may be prone to outside stress with feelings of depression and anger readily provoked, with anxiety also a common occurrence. With extreme stress, the person with BPD may experience paranoid ideation, or may have dissociative symptoms such as "running on automatic" and disconnecting from reality.

      histrionic personality disorder
      Histrionic personality disorder is characterised by a person who is always calling attention o themselves, who are lively, and overly dramatic. They are overly dramatic, and minor situations can cause wild swings in emotions. They easily become bored with normal routines, and crave new, novel situations and excitement. In relationships, they form bonds quickly, but the relationships are often shallow, with the person demanding increasing amounts of attention.

      narcissistic personality disorder
      Narcissistic personality disorder is a disorder in which a person has a grandiose self-importance, preoccupation with fantasies or unlimited success, a driven desire for attention and admiration, an intolerance of criticism, and disturbed self-centred interpersonal relations. they are often referred to as being conceited. They generally have a low self-esteem as well. They act selfish interpersonally, with a sense of entitlement.

      dependent personality
      Dependent personality is manifested via passively allowing others to assume responsibility for major areas of ones life due to lack of self-confidence or lack of ability to function independently. This leads to the person making their own needs secondary to the needs of others, and then becoming dependent on them. While everyone is dependent on others of some parts of their lives, those with dependent personality disorder are dependent on almost all major areas of their lives, and view themselves poorly, and good only as expensions of others.

      avoidant personality disorder
      Avoidant personality disorder is where a person has an extreme fear of being judged negatively by other people, and suffers from a high level of social discomfort as a result. They tend to only enter into relationships where uncritical acceptance is almost guaranteed, undergo social withdrawal, suffer low self-esteem, but have a great desire for affection and acceptance. However, they do not want the affection as much as they fear the rejection.

      obsessive-compulsive personality disorder
      Obsessive-compulsive personality disorder is characterised by a person who has a decreased ability to show warm and tender emotions, a perfectionism that decreases with the ability to see the larger picture, difficulty in doing things any way but their own, and an excessive devotion to work, as well as indecisiveness. Essentially, everything must be just right, and nothing can be left to chance. Obsesive-compulsive personality disorder is different from obsessive-compulsive disorder and the latter must be ruled out.

      dangerous and severe personality disorder

      The government first introduced the term dangerous and severe personality disorder in a consultation paper 'Managing Dangerous People with Severe Personality Disorder' in 1999, which proposed how to detain and treat a small minority of mentally disordered offenders who pose a significant risk of harm to others and themselves. Specialist services to deal with these people, most of whom are thought to be serious violent and sex offenders, were proposed in the white paper 'Reforming the Mental Health Act ' in December 2000.

      The term DSPD has no legal or medical basis and many doctors regard it as a political intervention. DSPD is thought to be an extreme form of antisocial personality disorder - the diagnosis most commonly associated with psychopathy. Head of Whitemoor DSPD unit said that people would need a long history of sex or violent offenses to meet the criteria of DSPD.

      It is thought that there are 200-2,400 people in England and Wales that are thought to have DSPD. The home office estimate that, 1,400 are already in prison, a further 400 are patients in high security psychiatric hospitals, with between 300 and 600 in the community. about 98% of those with DSPD are believed to be men. Since the new disorder's definition in unclear, these figures may be speculation.

      Currently people in DSPD units receive a psychological therapy called dialectical behavioural therapy (DBT), rehabilitation programmes and reoffending reduction courses. The effectiveness of these is not yet proven.

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