Take our Internet addiction test and find out if you're spending too much time online.

"One more minute," a typical Internet user often says to a spouse or parent who yearns for their attention during a long on-line session. But before they know how or why it happened, that minute invariably turns into one or more hours - at the cost of the people and activities that more and more often are ignored. But there is a difference between the Internet as a distraction and becoming addicted to the Internet. If you aren't sure, we invite you to take our Internet Addiction Test.

If you want to learn more, please review Caught in the NET which illustrates what makes specific Internet applications so time consuming, and outlines time management techniques that will help users regain control of their time.

Click here to order Caught in the Net

If you think you have a problem with controlling your Internet use, please contact our Virtual Clinic.

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next:  How Do You Treat Internet Addiction? or find out about The Risk Factors for Internet Addiction
~ all center for online addiction articles
~ all articles on addictions

1. What is Internet Addiction?

Internet addiction is defined as any online-related, compulsive behavior which interferes with normal living and causes severe stress on family, friends, loved ones, and one's work environment. Internet addiction has been called Internet dependency and Internet compulsivity. By any name, it is a compulsive behavior that completely dominates the addict's life. Internet addicts make the Internet a priority more important than family, friends, and work. The Internet becomes the organizing principle of addicts' lives. They are willing to sacrifice what they cherish most in order to preserve and continue their unhealthy behavior.

2. How do you know if you have Internet addiction (IA)?

No single behavior pattern defines Internet addiction. These behaviors, when they have taken control of addicts' lives and become unmanageable, include: compulsive use of the Internet, a preoccupation with being online, lying or hiding the extent or nature of your online behavior, and an inability to control or curb your online behavior. If your Internet use pattern interferes with your life in any way shape or form, (e.g. does it impact your work, family life, relationships, school, etc.) you may have a problem. In addition, if you find that you are using the Internet as a means to regularly alter your mood you may be developing a problem. It is important to note that it is not the actual time spent online that determines if you have a problem, but rather how that time you spend impacts your life. To learn more, you can take our Internet Addiction Test.

3. What causes Internet addiction?

Internet addiction can be understood by comparing it to other types of addictions. Individuals addicted to alcohol or other drugs, for example, develop a relationship with their "chemical(s) of choice" -- a relationship that takes precedence over any and all other aspects of their lives. Addicts find they need drugs merely to feel normal. In Internet addiction, a parallel situation exists. The Internet -- like food or drugs in other addictions -- provides the "high" and addicts become dependent on this cyberspace high to feel normal. They substitute unhealthy relationships for healthy ones. They opt for temporary pleasure rather than the deeper qualities of "normal" intimate relationships. Internet addiction follows the same progressive nature of other addictions. Internet addicts struggle to control their behaviors, and experience despair over their constant failure to do so. Their loss of self-esteem grows, fueling the need to escape even further into their addictive behaviors. A sense of powerlessness pervades the lives of addicts.

How many people suffer from Internet addiction?

Estimates suggest that five to ten percent of the population.

5. What are the types of Internet Addiction?

Cybersex and cyberporn addiction is the most common form of Internet addiction. The widespread availability of sexual content online has given rise to a new form of sexual addiction as almost 60% of the cases of online sexual compulsivity seen result exclusively from Internet use. New problems related to online affairs have also emerged as a sub-type of Internet abuse given the widespread popularity of interactive online applications such as chat rooms and instant messaging leading to surprising new trends in divorce and marital separation. Finally addictions to eBay, online gambling, and multi-user role-playing online games are growing new forms of Internet abuse. For more information, you can also read our article on Compulsive Surfing.

6. Do men and women differ in what they become addicted to?

Gender influences the types of applications and underlying reasons for Internet addiction. Men tend to seek out dominance and sexual fantasy online, while women seek out close friendships, romantic partners, and prefer anonymous communication in which to hide their appearance. Men are more likely to become addicted to online games, cyberporn, and online gambling, while women are more likely to become addicted to chatting, instant messaging, eBay, and online shopping. It seems to be a natural conclusion that attributes of gender played out in cyberspace parallel the stereotypes men and women have in our society.

7. Who is most at risk for developing Internet addiction?

National surveys revealed that over 50% of Internet addicts also suffered from other addictions, mainly to drugs, alcohol, smoking, and sex. Trends also showed that Internet addicts suffer from emotional problems such as depression and anxiety-related disorders and often use the fantasy world of the Internet to psychologically escape unpleasant feelings or stressful situations. Internet addicts also suffer from relationship problems in almost 75% of the cases and use interactive online applications such as chat rooms, instant messaging, or online gaming as a safe way of establishing new relationships and more confidently relating to others through the Internet.

8. What can you do about Internet addiction if you feel you have it?

Treatment options for Internet addicts include inpatient, outpatient, and aftercare support, and self-help groups. Treatment options may also include family counseling, support groups, and educational workshops for addicts and their families to help them understand the facets of belief and family life that are part of the addiction. Unlike recovering alcoholics who must abstain from drinking for life, treatment for Internet addiction focuses on moderation and controlled use of the Internet, much in the way those suffering from eating disorders must relearn healthy eating patterns. Dr. Young's program is based on cognitive-behavioral techniques to achieve moderation and controlled use along with a comprehensive psychosocial approach to address the underlying problems in a person's life creating the need to use the Internet as a way of escape. Dr. Young also focuses on the spiritual principals of the Twelve Steps and incorporates the expertise of the most knowledgeable health care professionals in the field of Internet addiction.

9. Is Internet addiction recognized by the professional healthcare community?

Internet addiction was first brought to the forefront in Dr. Kimberly Young's 1998 book, Caught in the Net: How to Recognize the Signs of Internet Addiction and a Winning Strategy for Recovery (Wiley). Since then, thousands of people have come forward seeking help, and more and more professionals are being trained to identify and treat Internet addiction.

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next:  Do You Spend Too Much Time Online?
~ all center for online addiction articles
~ all articles on addictions

Self-Therapy For People Who ENJOY Learning About Themselves

I want to tell you about the least successful therapy I've ever done.

A few years ago a woman was referred to me by her doctor.

When I met her at the door she mentioned caustically that there was a lot of snow out by the curb and that it was difficult for her to climb over it to get to the sidewalk.

While she took off her boots she said: "You ought to have a bigger mat for these boots, they'll make a mess all over the floor!"

And when I offered to make her some coffee she proceeded to give me step-by-step instructions - first of all on how to measure the coffee as I made it, and then on the process I should use when I cleaned the pot, how often I should do it, and which brand of vinegar I should use. (At this point we had spent less than five minutes together.)

Needless to say, when our meeting started I asked her rather quickly if she was angry. She said "absolutely not!" and then proceeded to blast me for the implied supposition. When that had its desired effect of shutting me up, she proceeded to blast her doctor, her husband, her children, her coworkers, and as far as I could tell everyone else in her life for also believing she was angry all the time!

I breathed a sigh of relief when she told me at the end of the meeting that she wasn't coming back and that she thought therapy was a bunch of bull anyway.

I was in a unique situation that day. As a therapist I know that the only way to start a new relationship with a client is to let them tell their story without unnecessary interruption. I was, at least for that one meeting, duty bound to let her have her say.

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But when she left my heart was pounding in rage. I thought: "How dare she tell me how to live my life! I didn't ask for her opinions!"

I know she was in great pain, but I only offer to help people with their pain, not to absorb it for them.

ABOUT ASKING FOR CRITICISM

Asking someone for their opinion of your work is one of the most mature things you can do.

Caring about the opinions of others, allowing yourself to benefit from their wisdom, and being willing to learn and change are all hallmarks of competence, autonomy, and maturity.

But accepting the unsolicited criticisms of others can be a sign of gross immaturity, acceptance of humiliation and abuse, and a life filled with internalized rage.

Some people criticize you, instead of what you do.

Employers, parents, teachers and many others have a responsibility to offer criticism of our actions,
but they have a much more important responsibility to avoid criticizing who we are.

CRITICISM IS UNAVOIDABLE

There is no behavior everyone accepts, and critical people will criticize anything!

Over the years I've challenged hundreds of students with this question: "Name any behavior that cannot be criticized." Every answer ever given was immediately criticized by the other students in the class.

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FOR SOME PEOPLE, CRITICIZING IS A LIFESTYLE

Critical people almost always operate under the guise of "helping" us.

They can always find some "better way" we could have behaved, some higher goal we could have achieved, or some opportunity we shouldn't have missed.

I could tell you a lot about how painful a critic's life is, but I don't want to help you to be understanding about them. Your responsibility is to protect yourself from their attacks on your self-worth!

Never be so caring or understanding that you lose sight of your responsibility to yourself.

Critical people are universally loathed. But they carry a lot of clout in any office or in any family
because we give them power. We do this by believing there must be something wrong with us if we aren't perfect.

The only way to protect ourselves from chronic critics is to demand that they stop criticizing us
and to stay away from them if they don't.

Say: "I didn't ask for your opinion, and I don't care what it is. If you keep treating me this way, I will stay away from you."

Usually this threat will be enough, because chronic critics are lonely people. But for those who refuse to change, leaving them is long overdue anyway.

GETTING READJUSTED

When someone criticizes us repeatedly, it's as if they take little bites out of our self-esteem.
After you are around such people for a long while, you need an antidote.

The best antidote is the touch of someone who loves the imperfect you.

Enjoy Your Changes!

Everything here is designed to help you do just that!

 

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next: How To Play

Agoraphobia: What is agoraphobia? Definition, signs, symptoms of agoraphobia plus examples of agoraphobia.

Agoraphobia is the fear of going out into public places. Agoraphobia can occur with or without panic attacks. (more on panic disorder with agoraphobia)

Mary's problems started one day when she was pumping gas. Some rough young men came over and made rude remarks. She was frightened and began avoiding gas stations. The fear increased, and she became unable to do the grocery shopping without her husband. She spent much of her day worrying about anticipated trips out of the house. Within two years, she was housebound.

Her husband consulted a psychiatrist who gave him advice on how to persuade Mary to come in for a consultation. The psychiatrist saw them together, educated them about agoraphobia, and prescribed medication. At Mary's next session, she was calm enough to begin the therapeutic work of enlarging her "perimeter of safety." Her husband attended all of the sessions. Between sessions, he helped her with her homework. He would accompany her as she gradually went further from home. When she began to go places on her own, he was coach and cheerleader. She was eventually able to deal with her fears on her own. Mary elected to remain on her medications for a year after her symptoms had gone away. *

Criteria for Agoraphobia:

• Anxiety about being in places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having an unexpected or situationally predisposed panic attack or panic-like symptoms. Agoraphobic fears typically involve characteristic clusters of situations that include being outside the home alone; being in a crowd or standing in a line; being on a bridge; and traveling in a bus, train, or automobile. Note: Consider the diagnosis of Specific Phobia if the avoidance is limited to one or only a few specific situations, or social phobia if the avoidance is limited to social situations.
• The situations are avoided (e.g., travel is restricted) or else are endured with marked distress or with anxiety about having a panic attack or panic-like symptoms, or require the presence of a companion.
• The anxiety or phobic avoidance is not better accounted for by another mental disorder, such as social phobia (e.g., avoidance limited to social situations because of fear of embarrassment), specific phobia (e.g., avoidance limited to a single situation like elevators), obsessive-compulsive disorder (e.g., avoidance of dirt in someone with an obsession about contamination), posttraumatic stress disorder (e.g., avoidance of stimuli associated with a severe stressor), or separation anxiety disorder (e.g., avoidance of leaving home or relatives).

Treatment for Agoraphobia

In milder forms, agoraphobia may cause an individual to avoid certain situations and jobs. However, in some cases, the fear increases until the individual becomes depressed and housebound. Occasionally one may be too fearful to come in for treatment. This may be a reason for resurrecting the old concept of the physician's house call.

Individuals with severe agoraphobia should usually start both medication and therapy as soon as possible. Without the medication, such an individual might not be able to make full use of the therapeutic process. People with mild to moderate symptoms might choose a combination approach or therapy alone. Homework between situations and coaching from family members or therapists help one gradually face feared situations.

*vignettes are fictional examples

For information on agoraphobia and other anxiety disorders, visit comprehensive anxiety articles.

Source: American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association.

Thorough overview of Posttraumatic Stress Disorder (PTSD). Description of PTSD- PTSD symptoms and causes, treatment for PTSD.

What is Posttraumatic Stress Disorder (PTSD)

It's been called shell shock, battle fatigue, accident neurosis, and post-rape syndrome. It has often been misunderstood or misdiagnosed, even though the disorder has very specific symptoms that form a definite psychological syndrome.

The disorder is posttraumatic stress disorder (PTSD) and it affects hundreds of thousands of people who have been exposed to violent events such as rape, domestic violence, child abuse, war, accidents, natural disasters, and political torture. Psychiatrists estimate that up to one to three percent of the population have clinically diagnosable PTSD. Still more show some symptoms of the disorder. While it was once thought to be a disorder of war veterans who had been involved in heavy combat, researchers now know that PTSD can result from many types of trauma, particularly those that include a threat to life. It afflicts both females and males.

In some cases the symptoms of PTSD disappear with time, while in others they persist for many years. PTSD often occurs with other psychiatric illnesses, such as depression.

Not all people who experience trauma require treatment; some recover with the help of family, friends, a pastor or rabbi. But many do need professional help to successfully recover from the psychological damage that can result from experiencing, witnessing or participating in an overwhelmingly traumatic event.

Although the understanding of posttraumatic stress disorder is based primarily on studies of trauma in adults, PTSD also occurs in children as well. It is known that traumatic occurrences--sexual or physical abuse,loss of parents, the disaster of war--often have a profound impact on the lives of children. In addition to PTSD symptoms, children may develop learning disabilities and problems with attention and memory. They may become anxious or clinging, and may also abuse themselves or others.

PTSD Symptoms

The symptoms of PTSD may initially seem to be part of a normal response to an overwhelming experience. Only if those symptoms persist beyond three months do we speak of them being part of a disorder. Sometimes the disorder surfaces months or even years later. Psychiatrists categorize PTSD's symptoms in three categories: intrusive symptoms, avoidant symptoms, and symptoms of hyperarousal.

Intrusive Symptoms

Often people suffering from PTSD have an episode where the traumatic event "intrudes" into their current life. This can happen in sudden, vivid memories that are accompanied by painful emotions. Sometimes the trauma is "re-experienced." This is called a flashback--a recollection that is so strong that the individual thinks he or she is actually experiencing the trauma again or seeing it unfold before his or her eyes. In traumatized children, this reliving of the trauma often occurs in the form of repetitive play.

At times, the re-experiencing occurs in nightmares. In young children, distressing dreams of the traumatic event may evolve into generalized nightmares of monsters, of rescuing others or of threats to self or others.

At times, the re-experience comes as a sudden, painful onslaught of emotions that seem to have no cause. These emotions are often of grief that brings tears, fear or anger. Individuals say these emotional experiences occur repeatedly, much like memories or dreams about the traumatic event.

Symptoms of Avoidance

Another set of symptoms involves what is called avoidance phenomena. This affects the person's relationships with others, because he or she often avoids close emotional ties with family, colleagues and friends. The person feels numb, has diminished emotions and can complete only routine, mechanical activities. When the symptoms of "re-experiencing" occur, people seem to spend their energies on suppressing the flood of emotions. Often, they are incapable of mustering the necessary energy to respond appropriately to their environment: people who suffer posttraumatic stress disorder frequently say they can't feel emotions, especially toward those to whom they are closest. As the avoidance continues, the person seems to be bored, cold or preoccupied. Family members often feel rebuffed by the person because he or she lacks affection and acts mechanically.

Emotional numbness and diminished interest in significant activities may be difficult concepts to explain to a therapist. This is especially true for children. For this reason, the reports of family members, friends, parents,teachers and other observers are particularly important.

The person with PTSD also avoids situations that are reminders of the traumatic event because the symptoms may worsen when a situation or activity occurs that reminds them of the original trauma. For example, aperson who survived a prisoner-of-war camp might overreact to seeing people wearing uniforms. Over time, people can become so fearful of particular situations that their daily lives are ruled by their attempts to avoid them.

Others--many war veterans, for example--avoid accepting responsibility for others because they think they failed in ensuring the safety of people who did not survive the trauma. Some people also feel guilty because they survived a disaster while others--particularly friends or family--did not. In combat veterans or with survivors of civilian disasters, this guilt may be worse if they witnessed or participated in behavior that was necessary to survival but unacceptable to society. Such guilt can deepen depression as the person begins to look on him or herself as unworthy, a failure, a person who violated his or her pre-disaster values. Children suffering from PTSD may show a marked change in orientation toward the future. A child may, for example, not expect to marry or have a career. Or he or she may exhibit "omen formation," the belief in an ability to predict future untoward events.

PTSD sufferers' inability to work out grief and anger over injury or loss during the traumatic event mean the trauma will continue to control their behavior without their being aware of it. Depression is a common product of this inability to resolve painful feelings.

Symptoms of Hyperarousal

PTSD can cause those who suffer with it to act as if they are threatened by the trauma that caused their illness. People with PTSD may become irritable. They may have trouble concentrating or remembering current information, and may develop insomnia. Because of their chronic hyperarousal, many people with PTSD have poor work records, trouble with their bosses and poor relationships with their family and friends.

The persistence of a biological alarm reaction is expressed in exaggerated startle reactions. War veterans may revert to their war behavior, diving for cover when they hear a car backfire or a string of firecrackers exploding.At times, those with PTSD suffer panic attacks, whose symptoms include extreme fear resembling that which they felt during the trauma. They may feel sweaty, have trouble breathing and may notice their heart rate increasing. They may feel dizzy or nauseated. Many traumatized children and adults may have physical symptoms, such as stomachaches and headaches, in addition to symptoms of increased arousal.

Other Associated Features

Many people with PTSD also develop depression and may at times abuse alcohol or other drugs as a "self-medication" to blunt their emotions and forget the trauma. A person with PTSD may also show poor control over his or her impulses and may be at risk for suicide.

Treatment for PTSD

Psychiatrists and other mental health professionals today have effective psychological and pharmacological treatments available for PTSD. These treatments can restore a sense of control and diminish the power of past events over current experience. The sooner people are treated, the more likely they are to recover from a traumatizing experience. Appropriate therapy can help with other chronic trauma-related disorders, too.

Psychiatrists help people with PTSD by helping them to accept that the trauma happened to them, without being overwhelmed by memories of the trauma and without arranging their lives to avoid being reminded of it.

It is important to re-establish a sense of safety and control in the PTSD sufferer's life. This helps him or her to feel strong and secure enough to confront the reality of what has happened. In people who have been badlytraumatized, the support and safety provided by loved ones is critical. Friends and family should resist the urge to tell the traumatized person to "snap out of it," instead allowing time and space for intense grief and mourning. Being able to talk about what happened and getting help with feelings of guilt, self-blame, and rage about the trauma usually is very effective in helping people put the event behind them. Psychiatrists know that loved ones can make a significant difference in the long-term outcome of the traumatized person by being active participants in creating a treatment plan--helping him or her to communicate and anticipating what he or she needs to restore a sense of equilibrium to his or her life. If treatment is to be effective it is important, too, that the traumatized person feel that he or she is a part of this planning process.

Sleeplessness and other symptoms of hyperarousal may interfere with recovery and increase preoccupation with the traumatizing experience. Psychiatrists have several medications--including benzodiazepines and the new class of serotonin re-uptake blockers--that can help people to sleep and to cope with their hyperarousal symptoms. These medications, as part of an integrated treatment plan, can help the traumatized person to avoid the development of long-term psychological problems.

In people whose trauma occurred years or even decades before, the professionals who treat them must pay close attention to the behaviors--often deeply entrenched--which the PTSD sufferer has evolved to cope with his or her symptoms. Many people whose trauma happened long ago have suffered in silence with PTSD's symptoms without ever having been able to talk about the trauma or their nightmares, hyperarousal, numbing, or irritability. During treatment, being able to talk about what has happened and making the connection between past trauma and current symptoms provides people with the increased sense of control they need to manage their current lives and have meaningful relationships.

Relationships are often a trouble spot for people with PTSD. They often resolve conflicts by withdrawing emotionally or even by becoming physically violent. Therapy can help PTSD sufferers to identify and avoid unhealthy relationships. This is vital to the healing process; only after the feeling of stability and safety is established can the process of uncovering the roots of the trauma begin.

To make progress in easing flashbacks and other painful thoughts and feelings, most PTSD sufferers need to confront what has happened to them, and by repeating this confrontation, learn to accept the trauma as part of their past. Psychiatrists and other therapists use several techniques to help with this process.

One important form of therapy for those who struggle with posttraumatic stress disorder is cognitive behavioral therapy. This is a form of treatment that focuses on correcting the PTSD sufferer's painful and intrusive patterns of behavior and thought by teaching him or her relaxation techniques, and examining (and challenging) his or her mental processes. A therapist using behavior therapy to treat a person with PTSD might, for example, help a patient who is provoked into panic attacks by loud street noises by setting a schedule that gradually exposes the patient to such noises in a controlled setting until he or she becomes "desensitized" and thus is no longer so prone to terror. Using other such techniques, patient and therapist explore the patient's environment to determine what might aggravate the PTSD symptoms and work to reduce sensitivity or to learn new coping skills.

Psychiatrists and other mental health professionals also treat cases of PTSD by using psychodynamic psychotherapy. Posttraumatic stress disorder results, in part, from the difference between the individual's personal values or view of the world and the reality that he or she witnessed or lived during the traumatic event. Psychodynamic psychotherapy, then, focuses on helping the individual examine personal values and how behavior and experience during the traumatic event violated them. The goal is resolution of the conscious and unconscious conflicts that were thus created. In addition, the individual works to build self-esteem and self-control, develops a good and reasonable sense of personal accountability and renews a sense of integrity and personal pride.

Whether PTSD sufferers are treated by therapists who use cognitive/behavioral treatment or psychodynamic treatment, traumatized people need to identify the triggers for their memories of trauma, as well as identifying those situations in their lives in which they feel out of control and the conditions that need to exist for them to feel safe. Therapists can help people with PTSD to construct ways of coping with the hyperarousal and painful flashbacks that come over them when they are around reminders of the trauma. The trusting relationship between patient and therapist is crucial in establishing this necessary feeling of safety. Medications can help in this process also.

Group therapy can be an important part of treatment for PTSD. Trauma often affects people's ability to form relationships--especially such traumas as rape or domestic violence. It can profoundly affect their basic assumption that the world is a safe and predictable place, leaving them feeling alienated and distrustful, or else anxiously clinging to those closest to them. Group therapy helps people with PTSD to regain trust and a sense of community, andto regain their ability to relate in healthy ways to other people in a controlled setting.

Most PTSD treatment is done on an outpatient basis. However, for people whose symptoms are making it impossible to function or for people who have developed additional symptoms as a result of their PTSD, inpatient treatment is sometimes necessary to create the vital atmosphere of safety in which they can examine their flashbacks, re-enactments of the trauma, and self-destructive behavior. Inpatient treatment is also important for PTSD sufferers who have developed alcohol or other drug problems as a result oftheir attempts to "self medicate." Occasionally too, inpatient treatment can be very useful in helping a PTSD patient to get past a particularly painful period of their therapy.

The recognition of PTSD as a major health problem in this country is quite recent. Over the past 15 years, research has produced a major explosion of knowledge about the ways people deal with trauma--what places them at risk for development of long-term problems, and what helps them to cope. Psychiatrists and other mental health professionals are working hard to disseminate this understanding, and an increasing number of mental health professionals are receiving specialized training to help them reach out to people with Posttraumatic Stress Disorder in their communities.

For comprehensive information on posttraumatic stress disorder (PTSD) and other anxiety disorders, visit the HealthyPlace.com Anxiety-Panic Community.

(c) Copyright 1988 American Psychiatric Association

Produced by the APA Joint Commission on Public Affairs and the Division of Public Affairs. This document contains the text of a pamphlet developed for educational purposes and does not necessarily reflect opinion or policy of the American Psychiatric Association.

Additional Resources

Burgess, Ann Wolbert. Rape: Victims of Crisis. Bowie, Maryland: Robert J. Brady, Co., 1984.

Cole, PM, Putnam, FW. "Effect of Incest on Self and Social Functioning: A Developmental Psychopathology Perspective." Journal of Consulting and Clinical Psychology, 60:174-184, 1992.

Eitinger, Leo, Krell, R, Rieck, M. The Psychological and Medical Effects of Concentration Camps and Related Persecutions on Survivors of the Holocaust. Vancouver: University of British Columbia Press, 1985.

Eth, S. and R.S. Pynoos. Posttraumatic Stress Disorder in Children. Washington, DC: American Psychiatric Press, Inc., 1985.

Herman, Judith L. Trauma and Recovery. New York: Basic Books, 1992.

Janoff, Bulman R. Shattered Assumptions. New York: Free Press, 1992.

Lindy, Jacob D. Vietnam: A Casebook. New York: Brunner/Mazel, 1987.

Kulka, RA, Schlenger, WE, Fairbank J, et al. Trauma and the Vietnam War Generation. New York: Brunner/Mazel, 1990.

Ochberg F., Ed. Posttraumatic Therapies. New York: Brunner/Mazel, 1989.

Raphael, B. When Disaster Strikes: How Individuals and Communities Cope with Catastrophe. New York: Basic Books, 1986.

Ursano, RJ, McCaughey, B, Fullerton, CS. Individual and Community Responses to Trauma and Disaster: the Structure of Human Chaos. Cambridge, England: The Cambridge University Press, 1993.

van der Kolk, B.A. Psychological Trauma. Washington, DC: American Psychiatric Press, Inc., 1987.

van der Kolk, B.A. "Group Therapy with Traumatic Stress Disorder," in Comprehensive Textbook of Group Psychotherapy, Kaplan, HI and Sadock, BJ, Eds. New York: Williams & Wilkins, 1993.

Other Resources

Anxiety Disorders Association of America, Inc.
(301) 831-8350

International Society for Traumatic Stress Studies
(708) 480-9080

National Center for Child Abuse and Neglect
(205) 534-6868

National Center for Posttraumatic Stress Disorder
(802) 296-5132

National Institute of Mental Health
(301) 443-2403

National Organization for Victim Assistance
(202) 232-6682

U.S. Veterans Administration-Readjustment Counseling Service
(202) 233-3317

Teen suicide is becoming more common. Discover what causes a teen to consider taking their own life, the risk for teen suicide or self-harm, suicide warning signs and how to help a suicidal person.

Teen Suicide Statistics

For any parent, thinking about the possibility that your teen might commit suicide is almost too much to bear. The book, "Your Child" by the American Academy of Child and Adolescent Psychiatry, states that 10% of all teens think about suicide at one point or another and a half million teens commit suicide every year.

Teen suicide is becoming more common every year in the United States. In fact, only car accidents and homicides (murders) kill more people between the ages of 15 and 24, making suicide the third leading cause of death in teens and overall in youths ages 10 to 19 years old.

Read on to learn more about this serious issue - including what causes a teenager to consider taking their own life, what puts a teen at risk for suicide or self-harm, and warning signs that someone might be considering suicide and how they can get help to find other solutions.

Pressures of Growing Up

It's not easy growing up in today's world. There's a lot of pressure to succeed both educationally and financially. There's divorce, blended families, working parents, relocation; all of which can be very unsettling and can intensify self-doubts in a teen. And then there's just the process of growing up and trying to figure things out.

Thinking About Suicide

It's common for teens to think about death to some degree. Teens' thinking capabilities have matured in a way that allows them to think more deeply - about their existence in the world, the meaning of life, and other profound questions and ideas. Unlike kids, teens realize that death is permanent. They may begin to consider spiritual or philosophical questions such as what happens after people die. To some, death, and even suicide, may seem poetic (consider Romeo and Juliet, for example). To others, death may seem frightening or be a source of worry. For many, death is mysterious and beyond our human experience and understanding.

Thinking about suicide goes beyond normal ideas teens may have about death and life. Wishing to be dead, thinking about suicide, or feeling helpless and hopeless about how to solve life's problems are signs that a teen may be at risk - and in need of help and support. Beyond thoughts of suicide, actually making a plan or carrying out a suicide attempt is even more serious.

Warning Signs of Teen Suicide

Parents should be aware of the following signs of adolescents who may try to kill themselves:

• change in eating and sleeping habits
• withdrawal from friends, family, and regular activities
• violent actions, rebellious behavior, or running away
• drug and alcohol use
• unusual neglect of personal appearance
• marked personality change
• persistent boredom, difficulty concentrating, or a decline in the quality of schoolwork
• frequent complaints about physical symptoms, often related to emotions, such as stomachaches, headaches, fatigue, etc.
• loss of interest in pleasurable activities
• not tolerating praise or rewards

A teenager who is planning to commit suicide may also:

• complain of being a bad person or feeling rotten inside
• give verbal hints with statements such as I won't be a problem for you much longer, Nothing matters, It's no use, and I won't see you again
• put his or her affairs in order, for example, give away favorite possessions, clean his or her room, throw away important belongings, etc.
• become suddenly cheerful after a period of depression
• have signs of psychosis (hallucinations or bizarre thoughts)

If your child says: "I want to kill myself" or "I'm going to commit suicide," it's extremely important to take that seriously and take immediate action by calling your doctor, a mental health professional such as a child psychiatrist or psychologist, and keeping a very watchful eye on your child.

Sometimes people feel uncomfortable asking or discussing suicide with their child. Maybe you think that just bringing up the subject will result in your child committing suicide. In general, mental health professionals agree that isn't true. In fact, the opposite may be true. Asking your child whether he or she is depressed or thinking about suicide can be helpful. Rather than putting thoughts in the child's head, such a question will provide assurance that somebody cares and will give the young person the chance to talk about problems.

Causes of Teen Suicide

What makes some teens begin to think about suicide - and even worse, to plan or do something with the intention of ending their own lives? One of the biggest factors is depression. Suicide attempts are usually made when a person is seriously depressed or upset. A teen who is feeling suicidal may see no other way out of problems, no other escape from emotional pain, or no other way to communicate their desperate unhappiness.

Getting Help for Suicidal Thoughts and Depression

There are many different reasons for feeling depressed and suicidal. As a parent, it's important to keep in mind that there are different depression treatments that work for depression in children and adolescents. But you must take action by talking to your teenager and have him or her evaluated by a doctor or trained mental health professional.

The National Hopeline Network 1-800-SUICIDE provides access to trained telephone counselors, 24 hours a day, 7 days a week. 

For comprehensive information on teen and adult suicide, visit our HealthyPlace.com Suicide Center.

Sources: 1. American Psychiatric Association, Teen Suicide Fact Sheet. 2. American Academy of Child and Adolescent Psychiatry, Teen Suicide Fact Sheet, Updated May 2008.

An in-depth overview of schizophrenia including symptoms, causes, treatments of schizophrenia. Also resources for schizophrenia patients and family members.

What is Schizophrenia

One of the most stigmatized and debilitating mental illnesses is Schizophrenia. Though it has a specific set of symptoms, Schizophrenia varies in its severity from individual to individual, and even within any one afflicted individual from one time period to another.

The symptoms of schizophrenia generally can be controlled with treatment and, in more than 50 percent of individuals given access to continuous schizophrenia treatment and rehabilitation over many years, recovery is often possible. Though researchers and mental health professionals don't know what causes schizophrenia, they have developed treatments that allow most persons with schizophrenia to work, live with their families and enjoy friends. But like those with diabetes, people with schizophrenia probably will be under medical care for the rest of their lives.

Symptoms of Schizophrenia

Generally, schizophrenia begins during adolescence or young adulthood. The symptoms of schizophrenia appear gradually and family and friends may not notice them as the illness takes initial hold. Often, the young man or woman feels tense, can't concentrate or sleep, and withdraws socially. But at some point, loved ones realize the patient's personality has changed. Work performance, appearance and social relationships may begin to deteriorate.

As the illness progresses, the symptoms often become more bizarre. The patient develops peculiar behavior, begins talking in nonsense, and has unusual perceptions. This is the beginning of psychosis. Psychiatrists diagnose schizophrenia when a patient has had active symptoms of the illness (such as a psychotic episode) for at least two weeks, with other symptoms lasting six months. In many cases, patients experience psychotic symptoms for many months before seeking help. Schizophrenia seems to worsen and become better in cycles known as relapse and remission, respectively. At times, people suffering from schizophrenia appear relatively normal. However, during the acute or psychotic phase, people with schizophrenia cannot think logically and may lose all sense of who they and others are. They suffer from delusions, hallucinations or disordered thinking and speech.

Positive and Negative Symptoms of Schizophrenia

Delusions and hallucinations are referred to as "positive symptoms" of schizophrenia

Delusions are thoughts that are fragmented, bizarre and have no basis in reality. For example, people suffering from schizophrenia might believe that someone is spying on or planning to harm them or that someone can "hear" their thoughts, insert thoughts into their minds, or control their feelings, actions or impulses. Patients might believe they are Jesus, or that they have unusual powers and abilities.

People suffering from schizophrenia also have hallucinations. The most common hallucination in schizophrenia is hearing voices that comment on the patient's behavior, insult the patient or give commands. Visual hallucinations, such as seeing nonexistent things and tactile hallucinations, such as a burning or itching sensation, also can occur.

Patients also suffer disordered thinking in which the associations among their thoughts are very loose. They may shift from one topic to another completely unrelated topic without realizing they are making no logical sense. They may substitute sounds or rhymes for words or make up their own words, which have no meaning to others.

These symptoms don't mean people with schizophrenia are completely out of touch with reality. They know, for example, that people eat three times a day, sleep at night and use the streets for driving vehicles. For that reason, their behavior may appear quite normal much of the time.

However, their illness does severely distort their ability to know whether an event or situation they perceive is real. A person with schizophrenia waiting for a green light at a crosswalk doesn't know how to react when he hears a voice say, "You really smell bad." Is that a real voice, spoken by the jogger standing next to him, or is it only in his head? Is it real or a hallucination when he sees blood pouring from the side of the person next to him in a college classroom? This uncertainty adds to the terror already created by distorted perceptions.

Psychotic symptoms of schizophrenia may lessen--a period during which doctors say the patient is in the residual stage or remission. Other symptoms, such as social withdrawal, inappropriate or blunted emotions, and extreme apathy, may continue during both these periods of remission and periods when psychosis returns--a period called relapse and may persist for years. People with schizophrenia who are in remission still may not be mentally able to bathe or dress appropriately. They may speak in a monotone and report that they have no emotions at all. They appear to others as strange, disconcerting people who have odd speech habits and who live socially marginal lives.

Cognitive deficits include impairment in attention, processing speed, working memory, abstract thinking, problem-solving, and understanding social interactions. The patient's thinking may be inflexible, and the ability to problem solve, understand the viewpoints of other people, and learn from experience may be diminished.

There are many types of schizophrenia. For example, a person whose symptoms are most often colored by feelings of persecution is said to have "paranoid schizophrenia;" a person who is often incoherent but has no delusions is said to have "disorganized schizophrenia." Even more disabling than the delusions and hallucinations are the symptoms of "negative" or "deficit" schizophrenia. Negative or deficit schizophrenia refers to the lack or absence of initiative, motivation, social interest, enjoyment and emotional responsiveness. Because schizophrenia can vary from person to person in intensity, severity and frequency of both psychotic and residual symptoms, many scientists use the word "schizophrenia" to describe a spectrum of illnesses that range from relatively mild to severe. Others think of schizophrenia as a group of related disorders, much as "cancer" describes many different but related illnesses.

Schizophrenia and Violence

Schizophrenia is a relatively modest risk factor for violent behavior. Threats of violence and minor aggressive outbursts are far more common than seriously dangerous behavior. Patients more likely to engage in significant violence include those with substance abuse, persecutory delusions, or command hallucinations and those who do not take their prescribed drugs. Very rarely, a severely depressed, isolated, paranoid person attacks or murders someone whom he perceives as the single source of his difficulties (eg, an authority, a celebrity, his spouse). Patients with schizophrenia may present in an emergency setting with threats of violence to obtain food, shelter, or needed care.

Some Numbers

Approximately 2.2 million American adults have schizophrenia. About 24 million people worldwide suffer from schizophrenia; meaning about 150 of every 100,000 persons will develop schizophrenia. Schizophrenia affects men and women equally, however, its onset in women is typically five years later than with men. Though it is a relatively rare illness, its early age of onset and the lifelong disability, emotional and financial devastation it brings to its victims and their families make schizophrenia one of the most catastrophic mental illnesses. Schizophrenia fills more hospital beds than almost any other illness, and Federal figures reflect the cost of schizophrenia to be from $30 billion to $48 billion in direct medical costs, lost productivity and Social Security pensions. According to the World Health Organization, more than 50% of persons worldwide with schizophrenia are not receiving appropriate care.

Theories About the Causes of Schizophrenia

Theories about the causes of schizophrenia abound, but research hasn't pinpointed the origins.

In years past, psychiatric researchers theorized that schizophrenia arose from bad parenting. A cold, distant and unfeeling mother was called "schizophrenigenic" because it was believed that such a mother could, through inadequate care, cause the symptoms of schizophrenia. This theory has been discredited today.

Most scientists now suspect that people inherit a susceptibility to the illness, which can be triggered by environmental events such as a viral infection that changes the body's chemistry, a highly stressful situation in adult life, or a combination of these.

While scientists have long known that the illness runs in families, much of the recent research evidence supports the linking of schizophrenia to heredity. For example, studies show that children with one parent suffering from schizophrenia have an 8 to 18 percent chance of developing the illness, even if they were adopted by mentally healthy parents. If both parents suffer from schizophrenia, the risk rises to between 15 and 50 percent. Children whose biological parents are mentally healthy but whose adoptive parents suffer from schizophrenia have a one percent chance of developing the disease, the same rate as the general population.

Moreover, if one identical twin suffers from schizophrenia, there is a 50 to 60 percent chance that the sibling--who has identical genetic make-up also has schizophrenia.

But people don't inherit schizophrenia directly, as they inherit the color of their eyes or hair. Like many genetically related illnesses, schizophrenia appears when the body is undergoing the hormonal and physical changes of adolescence. Genes govern the brain's structure and biochemistry. Because structure and biochemistry change dramatically in teen and young adult years, some researchers suggest that schizophrenia lies "dormant" during childhood. It emerges as the body and brain undergo changes during puberty.

Certain genetic combinations could mean a person doesn't produce a certain enzyme or other biochemical, and that deficiency produces illnesses ranging from cystic fibrosis to, possibly, diabetes. Other genetic combinations could mean that specific nerves don't develop correctly or completely, giving rise to genetic deafness. Similarly, a genetically determined sensitivity could mean the brain of a person with schizophrenia is more prone to be affected by certain biochemicals, or that it produces inadequate or excessive amounts of biochemicals needed to maintain mental health. Genetically determined triggers could also the development of part of the brain of a person with schizophrenia, or could cause problems with the way the person's brain screens stimuli, so that the person with schizophrenia is overwhelmed by sensory information which normal people can easily handle.

These theories arise from the ability of researchers to see the structure and activity of the brain through very sophisticated medical technology. For example:

• Using computer images of brain activity, scientists have learned that a part of the brain called the prefrontal cortex--which governs thought and higher mental functions--"lights up" when healthy people are given an analytical task. This area of the brain remains quiet in those with schizophrenia who are given the same task. Magnetic resonance imaging (MRI) and other techniques have suggested that the neural connections and circuits between the temporal lobe structures and the prefrontal cortex may be have an abnormal structure or may function abnormally.
• The prefrontal cortex in the brains of some schizophrenia sufferers appears to have either atrophied or developed abnormally.
• Computed axial tomography or CAT scans have shown subtle abnormalities in the brains of some people suffering from schizophrenia. The ventricles--the fluid-filled spaces within the brain--are larger in the brains of some people with schizophrenia.
• Successful use of medications that interfere with the brain's production of a biochemical called dopamine indicates that the brains of those with schizophrenia are either extraordinarily sensitive to dopamine or produce too much dopamine. This theory is strengthened by observing treatment for Parkinson's disease, caused by too little dopamine. Parkinson's patients, who are treated with medication that helps increase the amount of dopamine, may also develop psychotic symptoms.

Schizophrenia is similar in several respects to "autoimmune" illnesses -disorders like multiple sclerosis (MS) and amyotrophic lateral sclerosis (ALS or Lou Gherig's disease), caused when the body's immune system attacks itself. Like the autoimmune diseases, schizophrenia is not present at birth but develops during adolescence or young adulthood. It comes and goes in cycles of remission and relapse, and it runs in families. Because of these similarities, scientists suspect schizophrenia could fall into the autoimmune category.

Some scientists think genetics, autoimmune illness and viral infections combine to cause schizophrenia. Genes determine the body's immune reaction to viral infection. Instead of stopping when the infection is over, the genes tell the body's immune system to continue its attack on a specific part of the body. This is similar to the theories about arthritis, in which the immune system is thought to attack the joints.

The genes of people with schizophrenia may tell the immune system to attack the brain after a viral infection. This theory is supported by the discovery that the blood of people with schizophrenia contains antibodies--immune system cells--specific to the brain. Moreover, researchers in a National Institute of Mental Health study found abnormal proteins in the fluid that surrounds the brain and spinal cord in 30 percent of people with schizophrenia but in none of the mentally healthy people they studied. These same proteins are found in 90 percent of the people who have suffered herpes simplex encephalitis, an inflammation of the brain caused by the family of viruses that causes warts and other illnesses.

Finally, some scientists suspect a viral infection during pregnancy. Many people suffering from schizophrenia were born in late winter or early spring. That timing means their mothers may have suffered from a slow virus during the winter months of their pregnancy. The virus could have infected the baby to produce pathological changes over many years after birth. Coupled with a genetic vulnerability, a virus could trigger schizophrenia.

Most psychiatrists today believe that the above--genetic predisposition, environmental factors such as viral infection, stressors from the environment such as poverty and emotional or physical abuse--form a constellation of "stress factors" that should be taken into account in understanding schizophrenia. An unsupportive home or social environment and inadequate social skills can bring on schizophrenia in those with genetic vulnerability or cause relapse in those already suffering with the disease. Psychiatrists also believe these stress factors can often be offset with "protective factors" when the person with schizophrenia receives proper maintenance doses of antipsychotic medication, and help in creating a secure network of supportive family and friends, in finding a steady and understanding place of employment, and in learning necessary social and coping skills.

Treatment of Schizophrenia

Antipsychotics, rehabilitation with community support services, and psychotherapy are the major components of treatment.

When treated early, schizophrenia patients tend to respond more quickly and fully. Without ongoing use of antipsychotics after an initial episode, 70 to 80% of patients have a subsequent episode within 12 months. Continuous use of antipsychotics can reduce the 1-year relapse rate to about 30%. Because schizophrenia is a long-term and recurrent illness, teaching patients self-management skills is a significant overall goal.

Antipsychotic Medication for Treating Schizophrenia

Psychiatrists have found a number of antipsychotic medications that help bring biochemical imbalances closer to normal. The medications significantly reduce the hallucinations and delusions and help the patient maintain coherent thoughts. Like all medications, however, antipsychotic drugs should be taken only under the close supervision of a psychiatrist or other physician.

Antipsychotics are broken down into two categories: Typical or conventional antipsychotics are the older antipsychotic medications. These include Chlorpromazine, Thioridazine, Trifluoperazine, Fluphenazine, Haloperidol and others. About 30% of patients with schizophrenia do not respond to conventional antipsychotics, but they may respond to Atypical or second-generation antipsychotics. These include Abilify, Clozaril, Geodon, Risperdal, Seroquel, and Zyprexa.

The reported advantages of atypical antipsychotics is that they tend to alleviate positive symptoms; may lessen negative symptoms to a greater extent than do conventional antipsychotics (although such differences have been questioned); may cause less cognitive blunting; are less likely to cause extrapyramidal (motor) adverse effects; have a lower risk of causing tardive dyskinesia; and for some atypicals produce little or no elevation of prolactin.

Side Effects of Antipsychotic Medications

Like virtually all other medications, antipsychotic agents have side effects. While the patient's body adjusts to the medication during the first few weeks, he or she may have to contend with dry mouth, blurred vision, constipation and drowsiness. One may also experience dizziness when standing up due to a drop in blood pressure. These side effects usually disappear after a few weeks.

Other side effects include restlessness (which can resemble anxiety), stiffness, tremor, and a dampening of accustomed gestures and movements. Patients may feel muscle spasms or cramps in the head or neck, restlessness, or a slowing and stiffening of muscle activity in the face, body, arms and legs. Though discomforting, these are not medically serious and are reversible.

Weight gain, hyperlipidemia, and development of type 2 diabetes are among the more serious side effects of atypical antipsychotics such as Zyprexa, Risperdal, Abilify and Seroquel. Clozaril's most serious adverse effect is agranulocytosis, which can occur in about 1% of patients. Clozaril is generally reserved for patients who have responded inadequately to other drugs. Patients should be routinely monitored for all these conditions.

Because some other side effects may be more serious and not fully reversible, anyone taking these medications should be closely monitored by a psychiatrist. One such side effect is called tardive dyskinesia (TD), a condition that affects 20 to 30 percent of people taking antipsychotic drugs. TD is more common among older patients.

It begins with small tongue tremors, facial tics and abnormal jaw movements. These symptoms may progress into thrusting and rolling of the tongue, lip licking and smacking, pouting, grimacing, and chewing or sucking motions. Later, the patient may develop spasmodic movements of the hands, feet, arms, legs, neck and shoulders.

Most of these symptoms reach a plateau and do not become progressively worse. TD is severe in less than 5 percent of its victims. If medication is stopped, TD also fades away among 30 percent of all patients and in 90 percent of those younger than 40. There is also evidence that TD subsides eventually, even in patients who continue with medication. Despite the risk of TD, many suffering with schizophrenia accept medication because it so effectively ends the horrifying and painful psychoses brought on by their illness. However, the unpleasant side effects of antipsychotic medication also leads many patients to stop using medication against the advice of their psychiatrist. The refusal of patients with schizophrenia to comply with psychiatrists' treatment recommendations is a serious challenge to those specializing in the treatment of chronically mentally ill people. Psychiatrists treating people with schizophrenia must often practice with tolerance and flexibility to overcome this resistance.

Rehabilitation and Counseling for Schizophrenia Patients

By ending or reducing the painful hallucinations, delusions and thought disorders, antipsychotic medications allow a patient to gain benefit from rehabilitation and counseling aimed at promoting the individual's functioning in society. Social skills training, which can be provided in group, family or individual sessions, is a structured and educational approach to learning social relationship and independent living skills. By using behavioral learning techniques, such as coaching, modeling and positive reinforcement, skills trainers have been successful in overcoming the cognitive deficits that interfere with rehabilitation. Research studies show that social skills training improves social adjustment and equips patients with means of coping with stressors, thereby reducing relapse rates by up to 50 percent.

Another type of learning-based treatment that has been documented to reduce relapse rates is behaviorally oriented, psychoeducational family therapy. Mental health professionals recognize the important role families play in treatment and should maintain open lines of communication with the families as treatment evolves over time. Providing family members, including the patient, with a better understanding of schizophrenia and its treatment, while helping them to improve their communication and problem-solving skills, is becoming a standard practice in many psychiatric clinics and mental health centers. In one study, when psychoeducational family therapy and social skills training were combined, the relapse rate during the first year of treatment was zero.

Psychiatric management and supervision of regular medication use, social skills training, behavioral and psychoeducational family therapy, and vocational rehabilitation must be delivered within the context of a community support program. The key personnel in community support programs are clinical case managers who are experienced in linking the patient to needed services, assuring that social services as well as medical and psychiatric treatment is delivered, forming solid and supportive long-term helping relationships with the patient, and advocating for patients' needs when there is a crisis or problem.

When continuing treatment and supportive care is available in the community, with a partnership of family, patient and professional caregivers, patients can learn to control their symptoms, identify early warning signs of relapse, develop a relapse prevention plan, and succeed in vocational and social rehabilitation programs. For the vast majority of persons with schizophrenia, the future is bright with optimism--new and more effective medications are on the horizon, neuroscientists are learning more and more about the function of the brain and how it goes awry in schizophrenia, and psychosocial rehabilitation programs are increasingly successful in restoring functioning and quality of life.

For comprehensive information on schizophrenia, visit the HealthyPlace.com Thought Disorders Community.

Sources: 1. American Psychiatric Association, Schizophrenia pamphlet, last revised 1994. 2. NIMH, Schizophrenia Fact Sheet, last revised April 2008. 3. Merck Manual, Schizophrenia, Nov. 2005.

Additional Resources

Ascher-Svanum, Haya and Krause, Audrey, Psychoeducational Groups for Patients with Schizophrenia: A Guide for Practitioners. Gaithersburg, MD: Aspen Publishers, 1991.

Deveson, Anne., The Me I'm Here: One Family's Experience of Schizophrenia. Penguin Books, 1991.

Howells, John G., The Concept of Schizophrenia: Historical Perspectives. Washington, DC: American Psychiatric Press, Inc., 1991.

Kuehnel TG, Liberman, RP, Storzbach D and Rose, G, Resource Book for Psychiatric Rehabilitation. Baltimore, MD: Williams & Wilkins, 1990.

Kuipers, Liz., Family Work for Schizophrenia: A Practical Guide. Washington, D.C.: American Psychiatric Press, Inc., 1992

Liberman, Robert Paul, Psychiatric Rehabilitation of Chronic Mental Patients. Washington, DC: American Psychiatric Press, 1988.

Matson, Johnny L., Ed., Chronic Schizophrenia and Adult Autism: Issues in Diagnosis, Assessment, and Psychological Treatment. New York: Springer, 1989.

Mendel, Werner, Treating Schizophrenia. San Francisco: Jossey-Bass, 1989.

Menninger, W. Walter and Hannah, Gerald, The Chronic Mental Patient. American Psychiatric Press, Inc., Washington, D.C., 1987. 224 pages.

Schizophrenia: Questions and Answers. Public Inquiries Branch, National Institute of Mental Health, Room 7C-02, 5600 Fishers Lane, Rockville, MD 20857. 1986. Free single copies. (Available in Spanish_"Esquizofrenia: Preguntas y Respuestas")

Seeman, Stanley and Greben, Mary, Eds., Office Treatment of Schizophrenia. Washington, DC: American Psychiatric Press, Inc., 1990.

Torrey, E. Fuller., Surviving Schizophrenia: A Family Manual. New York, NY: Harper and Row, 1988.

Other Resources

American Academy of Child and Adolescent Psychiatry
(202) 966-7300

National Alliance for the Mentally Ill
(703) 524-7600

National Alliance for Research on Schizophrenia and Depression
(516) 829-0091

National Mental Health Association
(703) 684-7722

National Institute of Mental Health Information Resources and Inquiries Branch
(301) 443-4513

National Self-Help Clearinghouse
(212) 354-8525

Tardive Dyskinesia/Tardive Dystonia
(206) 522-3166

College life and eating disorder

The college years can be an exciting time of new opportunities and increased freedom. However, the transition to college can also present challenges as students adjust to living away from family, negotiating new relationships and coping with academic pressures. Another challenge of college life is assuming more responsibility for eating habits, including making choices in the dining hall and dorm and deciding when to eat in the middle of a busy schedule. The transitions of college and the increased autonomy in all of these areas can be very demanding. For those individuals predisposed to developing an eating disorder, the stresses of the college environment can contribute to a troubling sense of a lack of control. Individuals who develop eating disorders often substitute internal control of eating and body weight as a way to deal with feelings of powerlessness over the external environment. In addition, preoccupation with food and body image may serve as a distraction from problems and a way of numbing difficult feelings.

Who is vulnerable to developing an eating disorder?

According to the National Institute of Mental Health (1993), over 5 million Americans suffer from eating disorders. Over ninety percent of these individuals are women, with 1% of adolescent girls developing anorexia and 2-3% of young women developing bulimia. The mortality rate for anorexia is higher than for any other psychological disorder; 1 in 10 anorexics will die from the effects of starvation, including cardiac arrest, or from suicide. Up to ten percent of individuals with eating disorders are male, and many of these men suffer from problems with binge eating. The mean age of onset of an eating disorder is most common in the college-aged years (age 17 for anorexia; 18-20 for bulimia).

Many college-aged women don't meet criteria for an eating disorder but are preoccupied with losing weight and dissatisfied with their bodies. Up to a third of college women have "disordered eating" habits, such as using diet pills or laxatives, not eating at all to try to lose weight, or binge-eating .

An important contributing factor to college-aged women's increased risk of developing eating disorders is young women's sensitivity to sociocultural messages of the importance of being thin as essential to attractiveness. In reality, the figure of the average college-aged woman is much larger than the cultural ideal as depicted in the media. Yet young women are prone to internalizing societal expectations of the female body and may experience shame and feelings of failure in not "measuring up" to the images seen on television, film, billboards and magazines. In addition, women often struggle with assertiveness and speaking up about feelings and needs. Without a voice to express important aspects of the self, an eating disorder may serve as a form of communication to oneself and to others that something is very wrong. An eating disorder may be a way of expressing frustration and pain without directly talking about underlying feelings and emotional conflicts. Many women with eating disorders may be deeply troubled by the preoccupation with eating and body image, but lack awareness of the emotional struggles that also contribute to the relentless pursuit of thinness.

Athletes represent another subgroup of the population at increased risk of developing eating disorders. Athletic competition and demands for performance may lead to perfectionism in many areas, including the body. Athletes who engage in sports that emphasize slenderness or in which lean body weight is a factor in performance (e.g. track, rowing, gymnastics, diving, wrestling, figure-skating, dance, cheerleading) are particularly vulnerable to developing an eating disorder. Often, moderate weight loss in these sports may improve performance which further reinforces unhealthy eating practices. However, eventually athletic performance becomes compromised by the factors of emotional exhaustion, physical fatigue, poor nutrition and medical problems that are part of an eating disorder.

What are the symptoms of an eating disorder?

Although many individuals worry about food and body image, there are specific criteria used by mental health professionals to diagnose an eating disorder:

Anorexia

• refusal to maintain body weight at or above a minimally normal weight for age and height
• intense fear of gaining weight or becoming fat
• distorted body image, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of low body weight
• amenorrhea in women (absence of at least three consecutive menstrual cycles)

Bulimia

• recurrent episodes of binge eating
• recurrent use of laxatives, diuretics, enemas, fasting or excessive exercise to prevent weight gain
• self-evaluation unduly influenced by body shape and weight

When to seek help

Sometimes, a specific event may trigger the initial onset of eating disorder symptoms (e.g. a diet that gets "out of control," leaving home, a negative comment about one's weight, death of a loved one, quitting a sport or other activity, relationship breakup, family problems). Warning signs of a problem with eating may include the following: obsessive preoccupation with food or body image; compulsive exercising; binge eating, purging and/or strict dieting; inability to stop eating; secretiveness or shame about eating; feeling out of control; depression; low self-esteem; social isolation. It is important to seek professional help if you suspect you have a problem with food or weight. Eating disorders can often be prevented if an individual seeks help in the early stages.

next: Eating Disorders: The Female Athlete Triad
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sexual problems

"Although I love my partner as much as ever, I seem to have lost interest in sex"

• "All this fuss about sleeping together. For physical pleasure I'd sooner go to the dentist any day." (Evelyn Waugh, British writer)
• "I know it does make people happy, but to me it's just like having a cup of tea." (Cynthia Payne, after her acquittal of a charge of controlling prostitutes in a famous case in 1987)
• 37% of men have sex less than once a fortnight (MORI/Esquire poll of 800 men aged 18-45, 1992)

Sexual appetite (libido) tends to wax and wane - there are periods in our lives when we have little desire for sex, and other periods when sex assumes an over-riding importance. Most of the time we are somewhere in between. So losing interest in sex is probably a temporary phase, and not a disaster. In fact it is only a problem if it means there is an imbalance between our desires and those of our partner, if it makes our partner feel unloved and frustrated, or if we ourselves feel unhappy because of it. It is also important to remember that most people are having much less sex than everyone else thinks, as has been shown by many surveys. All the same, there may be a reason for lack of sexual desire which can be remedied.

Reasons in both men and women

Depression is one of the most common reasons. Surveys show that about two out of three people with depression lose interest in sex, as a result of imbalances in brain biochemistry. So it is not something that you should blame yourself for.

Medications, such as antidepressants, tranquillizers and beta-blockers, can damp down sex drive.

Sexual side-effects of antidepressant drugs

Women

• Loss of desire
• Vaginal dryness (so intercourse is uncomfortable)
• Difficulty having an orgasm

Men

• Loss of desire
• Erection problems
• Delayed ejaculation

Stress and physical illnesses take their toll on every aspect of life, including sexuality. It is difficult to be enthusiastic about sex if you are worried, tired, in pain or generally under par.

Relationship problems of any kind can depress libido (although some couples find their sex life improves when other aspects of their relationship are rocky).

Something in the past can affect the present, such as memories of sexual abuse, or a demoralizing sexual relationship.

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Reasons in women

A contraceptive method you aren't comfortable with, or worries about infection can trigger a loss of interest in sex. For example, you may have noticed some vaginal discharge, or something about your partner's genitals, and are worrying that you or your partner could have a sexually transmitted disease. Some contraceptive pills, particularly those with a high progesterone content, can reduce sexual desire.

A new baby is very demanding of time and energy, hormone balances are changing and there may be soreness from stitches. So it is not surprising that 50% of women do not have much interest in sex for many months after childbirth (although 1 in 5 women feels more sexual than before). The American sexologists Masters and Johnson found that 47% of women had little desire for sex for at least 3 months after having a baby. Another survey asked women about their sex life 30 weeks after having a baby: only 25% were as sexually active as before, most said their sexual desire was much reduced, and 22% had almost stopped having any sex at all.

Breast-feeding causes temporary vaginal dryness and discomfort (because of the high levels of the breast-feeding hormone, prolactin), making sex seem even less attractive.

Painful intercourse is obviously a turn-off. This can happen because the vagina is dry or for various other. In some women the pelvic and nearby muscles clamp up so strongly when intercourse is attempted that it is uncomfortable, painful or even downright impossible; this is called vaginismus.

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Reasons in men

Pressure to perform well in bed seems to be increasing - fuelled by media images of the ever-potent, ever-ready male. A man is expected always to be able to perform sexually. At the same time, modern society expects him to deal with increasing stresses in the workplace, to do his share of household tasks, to be an intellectual companion and emotional support to his partner, and to be a perfect father. It is no wonder that he finds he cannot perform sexually. Over the past decade, the number of couples coming to Relate (the relationship counselling organization) with difficulties blamed on lack of sexual desire in the male partner has doubled.

Heavy drinking is a common cause of loss of interest in sex (and problems with erections). This is because alcohol eventually reduces the production of testosterone by the testes, interferes with processing of testosterone (male hormone) by the cells of the body, and affects the parts of the brain that control hormone balance.

A low testosterone level is seldom the reason for a loss of sex drive, but your doctor can check this quite easily.

Questions to ask yourself

• Is this really a problem, are my expectations unrealistic, what do I really want, is it affecting my relationship? You and your partner may feel the situation is quite acceptable. On the other hand, it may be affecting your self-esteem and your relationship.
• Am I depressed? Feelings of sadness, hopelessness and helplessness, with lack of energy and disturbed sleep, and an inability to find anything enjoyable are symptoms of depression. Modern antidepressants are very effective at treating depression, and are not addictive. As your depression gradually lifts, your sex life will improve. If this doesn't happen, it may be that the tablets are curing the depression, but their side-effect is making the sex problem worse. Don't stop taking the medication; mention the problem to your doctor, who will be able to change the dose or use a different antidepressant.
• Am I drinking too much? If so, try to cut down.
• Have I started taking any new medications? A drug is unlikely to be the cause if you had already gone off sex before starting it, but otherwise it is worth checking with your doctor to see if any medication could be responsible.

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• Is there any other physical reason? If you are tired or physically unwell it is quite reasonable to wish to put your sex life on hold for a while.
• Is there any specific aspect of our sex life that is putting me off? A relatively simple problem, such as the type of contraception or pain on intercourse, can be dealt with by a visit to your doctor or family planning clinic. However, there may be a problem which is easy to put your finger on but less easy to deal with. This could be anything - your partner's standards of cleanliness, the type of sexual activities your partner wants, lack of privacy, a suspicion that your partner has a sexually transmitted disease, a triggering of unpleasant memories of sexual abuse. Unfortunately, this type of problem doesn't usually go away on its own, but a counsellor (see Useful Contacts) will be able to help you find the best way of dealing with it.
• Is my loss of interest in sex really because I am unhappy about other aspects of the relationship? If so, tackle these issues, perhaps with the help of a counsellor.

Here are some exercises to rekindle sexual desire.

next: Addictive Sexual Behaviors

Over the past several weeks, I've experienced some major life changes; living conditions, work conditions, relationships, leisure time—all have been affected or will be affected in one way or another. I guess it's basically a time of testing for me, a time of transition, a time of growth, a time to take my recovery "on the road" so to speak.

First of all, the condo I am renting is up for sale. About mid-October a realtor called me one night out of the blue and said, "I'm coming by with a client tomorrow to show your unit. The landlord has put it on the market, so I'll need to take a key as well." First I had heard of all this. Naturally, I began to wonder whether I'd have to move, find a new place—all the attendant worries of being suddenly uprooted. I still don't have an answer, but the realtor has shown the condo at least once per week since the call.

Then, during the same week (at work this time), one of my best employees suddenly resigned. I was caught off-guard, then was immediately too busy for a couple of weeks, scrambling around, re-assigning assignments, filling out new employee requisition forms—all the attendant worries of being suddenly short-handed. I still don't have a new employee, but do I have a couple of folks to interview later this week.

Then, there have been problems with the car (a "lifter" in the engine is rattling), communicating with my ex-wife trying to work out holiday visitation times with the kids (Thanksgiving, Christmas, New Year's), making some travel arrangements to attend my niece's wedding on New Year's day in Arkansas, planning Christmas gift purchases—all the attendant worries of being a one-man show during the holiday season.

But so far, I've survived. Yes, everything—literally—about my life is up in the air right now. I have no idea where it is all going to land. And you know what? I really am fine with the idea.

Of course, I'm worried—but it's not a sick kind of worrying, not an obsessive worrying. Maybe it's not even worrying per se—but I do have more on my mind these days concerning the future and its uncertainty than I have had in many months previous to October.

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Maybe it is time for me to be jarred out of my routine. Maybe it is time for me to grow some more. Maybe it is time for me to re-evaluate my priorities and my recovery goals. Maybe it is time for me to sit up and pay closer attention to my needs and take better care of myself.

There is one thing I am certain about—I trust God that all this change will be for my good and the end result will be for my ultimate benefit.

Recovery has taught me that no matter how bad things get, there is good stuff that comes my way out of every life situation. Therefore, I can anticipate the changes rather than dreading them. I can look for the ways my life is going to get better, rather than getting letting myself get bitter.

These are the times when recovery pays off. These are the times when I reap the rewards of all the work I've put into meditating, reading, going to meetings, praying, and focusing. These are the times when I trust God, let go, and let my faith grow even stronger. Above all, these are the times when I know, without doubt, that external circumstances may change, but I am still me. I will be OK, no matter what happens.

Thank You God, for giving me more opportunities to trust You. Thank You for all the changes I am going through, because You have taught me that change brings new growth and good things into my life.

next: Single-Minded Focus