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Catatonic Disorder Due to Another Medical Condition

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Catatonic Disorder Due to Another Medical Condition

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https://www.theravive.com/therapedia/catatonia-dsm--5-multiple-diagnostic-codes#:~:text=Causes%20of%20catatonia,who%20have%20experienced%20extreme%20trauma.

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Author: Dr. Kevin Fleming, Ph.D.

Catatonia
Catatonia is aDSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) diagnosis assigned to individuals who display apparent unresponsiveness to external stimuli, despite being awake. Catatonia affects a person's mental functioning and behavior, often occurring in relation to other mental disorders or medical conditions.
Introduction
Catatonia sufferers do not respond to other people or stimuli in the normal way. Commonly characterized by stupor - in which a person cannot move or speak - catatonia may occur in the context of a psychiatric disorder like schizophrenia, with a general medical disorder like encephalitis, or in an unspecified form.

Episodes of catatonia associated with another mental or medical disorder are diagnosed when the individual exhibits at least three of the 12 associated psychomotor features, which - as well as unresponsiveness - can include agitation, mutism or echolalia - repetition of another person's speech.

Catatonia may affect an individual for a few hours in isolation or may recur periodically over weeks, months or even years (Hervey et al 2013). The complex condition occurs in more than ten per cent of people with acute psychiatric illnesses and can cause serious medical complications (Rasmussen et al 2016).
Symptoms
Someone experiencing catatonia will display various signs and symptoms, the most common of which are as follows:

Mutism - the patient is verbally unresponsive

Immobility - an individual displays altered arousal and lack of reaction to stimuli

Negativism - bodily manipulations are resisted during examination

Posturing - the individual maintains bodily or facial postures for long periods of time

Stereotypy - patients display repetitive motor or verbal behavior

Echophenomena - individuals may repeat other people's speech or movements

Other signs that a person is experiencing catatonia include a rigid posture, withdrawal and refusal to eat, as well as staring and excessively repeating random words (verbigeration).

Catatonia is sometimes divided into two subsets: retarded catatonia and excited catatonia. The former is characterized by slow movement and unresponsiveness; the latter is typified by restlessness or agitation, and sufferers may have a fast heartbeat and raised blood pressure.

Although catatonia is most commonly witnessed in its retarded form, excited catatonia - also known as malignant or lethal catatonia - is associated with serious risks of complication, including altered consciousness, hyperthermia and internal body process dysfunctions (Rasmussen et al 2016).
Diagnostic criteria for catatonia
A diagnosis may be made when a person exhibits three or more of the diagnostic criteria for each type of catatonia.
Catatonia associated with another mental disorder (catatonia specifier)

Stupor - no conscious mental activity is witnessed within the person's environment.

Catalepsy - the individual maintains a fixed/frozen posture.

Waxy flexibility - slight, even resistance to bodily manipulation.

Mutism - little to no verbal response; cannot be explained by aphasia.

Negativism - opposition or unresponsiveness to external stimuli or instructions.

Posturing - spontaneous and active maintenance of a posture against gravity.

Mannerism - exaggerated or repetitive gestures or expressions.

Stereotypy - repetitive movements without obvious purpose.

Agitation - emotionally restless; not as a result of external stimuli.

Grimacing - displaying contorted facial expressions.

Echolalia - mimics another's speech.

Echopraxia - mimics another's movements.
Catatonic disorder due to another medical condition
In cases where catatonia is experienced as a result of another disorder, the above measures will again be used in the diagnosis, alongside several other criteria - namely:

B. There is evidence that the disturbance being experienced is a direct result of another medical condition.
C. The disturbance cannot be better explained by another mental disorder.
D. The disturbance does not occur only during episodes of delirium.
E. The disturbance causes distress or impairment in social, occupational or other key areas of functioning.

(American Psychiatric Association 2013)
Unspecified catatonia
If an individual is experiencing symptoms of catatonia that cause significant distress or impairment but that cannot be clearly attributed to another mental or medical condition, or there is not enough information to do so, they may be diagnosed with unspecified catatonia.

Some practitioners use rating scales to aid diagnosis, such as the Bush-Francis Catatonia Rating Scale (BFCRS). The BFCRS scale assesses individuals through 23 indicators on a continuum of zero to three to measure the presence and severity of catatonia (Bush G., Fink. M, Petrides G., et al. 1996).

Another helpful diagnostic aid is the Lorazepam Challenge Test. A fter examination, the patient is given an intravenous dose of the medication lorazepam and examined again five minutes later for a reduction in symptoms. The process may be repeated again; a significant reduction in catatonic symptoms is usually observed within ten minutes in favorable responses, confirming catatonia as the diagnosis (Sienaert, P. et al 2014).
Causes of catatonia
There is no single cause of catatonia, the disorder is usually associated with another mental or medical condition. Catatonia may occur in psychiatric disorders like schizophrenia, bipolar disorder and major depressive disorder, as well as among individuals who have experienced extreme trauma.

A variety of medical conditions may cause - or be associated with - catatonia, such as encephalitis or neurodegenerative disease. Infections, severe vitamin B12 deficiency, autism or exposure to toxins may also be associated with the condition(Psychology Today 2018).

Alternatively, catatonia can occur as a side effect of medication, the result of faulty neurotransmitter activity in the brain or have an altogether unknown cause.
Catatonia differential diagnosis and comorbidity
Catatonia can be difficult to diagnose as the condition's features are characteristic of many other disorders. Physical conditions with similar features include convulsive status epilepticus, metabolic conditions like pellagra and diabetic ketoacidosis, neuroleptic malignant syndrome and a whole host of other neurological disorders (Wilcox & Reid Duffy 2015).

Symptoms of catatonia may be present in a range of mental disorders, too, including schizophrenia, schizophreniform disorder, schizoaffective disorder, brief psychotic disorder, substance/medication-induced psychotic disorder, bipolar and depressive disorders (American Psychiatric Association 2013).
Living with catatonia
Catatonia may come and go over periods of months or years, or may occur as an isolated episode. The condition causes significant distress to sufferers, impacting on areas of functioning such as work and relationships.

Someone experiencing the symptoms of catatonia will be unresponsive, may appear to be in a trance and adopt strange postures or expressions. An individual in a severe catatonic state may be at risk of self-injury, exhaustion, malnutrition and hyperpyrexia (American Psychiatric Association 2013).

Those with affective symptoms may experience long periods of remission from catatonia. Conversely, individuals diagnosed with schizophrenia many experience catatonia as a chronic condition, although symptoms may sometimes present in association with neuroleptic malignant syndrome (Wilcox &Reid Duffy 2018).

Although it is not possible to prevent catatonia because the cause cannot be accurately determined, it is suggested that taking excessive amounts of neuroleptic medications like thorazine should be avoided (Healthline 2018).

Once diagnosed, catatonia can be treated and patients usually respond positively and rapidly to treatment. Different types of treatment may be offered to bring the condition under control, usually taking the form of medication or electroconvulsive therapy.
Treatment for catatonia
Catatonia is a treatable condition, commonly managed with medication or brain stimulation therapy.
Medication
Benzodiazepine medication is often used to treat catatonia, particularly lorazepam, which is sold under the brand name Ativan among others. Acting on the brain and nerves, benzodiazepines have a calming effect and can be used to treat anxiety, symptoms of alcohol withdrawal and insomnia.

Anxiety is a common feature of catatonia in many cases; benzodiazepines work to reduce panic by enhancing the effects of the GABA chemical in the body and regulating nerve abnormalities in the brain.

In patients who cannot actively swallow medication, benzodiazepines can be conveniently administered by placing a tablet under the tongue, or by intramuscular injection. In many cases, signs of recovery may start to show in a matter of hours.

It is recommended that individuals experiencing catatonia continue to take benzodiazepines until any underlying condition is being treated - this is to prevent a relapse into a catatonic state. In some situations, it may be necessary for patients to take the medication indefinitely to keep the condition under control (Rasmussen et al 2016).

Other medications that may be used to treat catatonia include:

Bromocriptine

Amobarbitol

Reserpine

Tricyclic antidepressants

Zolpidem

(Healthline 2018)
Alternative treatments
Electroconvulsive therapy (ECT) is also used to treat catatonia. Individuals who do not respond to benzodiazepines after a number of days generally respond to ECT, which should be used as a secondary treatment option as consent from patients in a catatonic state may be difficult to obtain.

In some cases, however, ECT may be preferable in the earlier stages of treatment - particularly if an individual is suffering from malignant catatonia. This excited form of the condition has a high mortality rate if treatment is not administered rapidly and effectively (Rasmussen et al 2016).

ECT is administered painlessly in a supervised medical setting once the patient is sedated. A machine delivers as electric shock to the brain, causing it to go into seizure for a minute or so. This, in turn, changes the flow of neurotransmitters in the brain and can improve the symptoms of catatonia (Healthline 2018).

In some cases, patients may be treated with anesthetic pain medications or, in co-existing conditions such as vitamin deficiency, supplementary nutrients may be given (Psychology Today 2018).

Catatonia can be severe and potentially life-threatening, however, with rapid and effective treatment, catatonia can be controlled and the prognosis for recovery is good - especially among individuals experiencing catatonia with mood disorders (Sienaert, P. et al 2014).

Dr. Kevin Fleming obtained his PhD from Notre Dame and is the Founder of Grey Matters International (www.greymattersintl.com), a neuroscience-based behavior change consulting firm.
References
Hervey, W., Stewart, J., Catalano, G. (2013) Psychopharmacology for the Clinician. Psychiatry Neurosci DOI: 10.1503/jpn.120249.

Rasmussen, S. A., Mazurek, M. F., & Rosebush, P. I. (2016) Catatonia: Our current understanding of its diagnosis, treatment and pathophysiology. World Journal of Psychiatry, 6(4), 391-398. http://doi.org/10.5498/wjp.v6.i4.391.

American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bush G., Fink. M, Petrides G., et al. (1996) Catatonia I. Rating scale and standardized examination, Acta Psychiatr Scand 93:129-136.

Sienaert, P., Dhossche, D. M., Vancampfort, D., De Hert, M., & Gazdag, G. (2014) A Clinical Review of the Treatment of Catatonia. Frontiers in Psychiatry, 5, 181. http://doi.org/10.3389/fpsyt.2014.00181.

Psychology Today (2018) Catatonia. https://www.psychologytoday.com/gb/conditions/catatonia Date Accessed: 20/09/2018.

Wilcox, J. A., & Reid Duffy, P. (2015) The Syndrome of Catatonia. Behavioral Sciences, 5(4), 576-588. http://doi.org/10.3390/bs5040576.

Healthline Media (2018) What Causes Catatonia? https://www.healthline.com/symptom/catatonia Date accessed: 20/09/2018.

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Catatonia DSM-5 Multiple Diagnostic Codes

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Author: Dr. Kevin Fleming, Ph.D. Catatonia Catatonia is aDSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) diagnosis assigned to individuals who display apparent unresponsiveness to external stimuli, despite being awake. Catatonia affects a person's mental functioning and behavior, often occurring in relation to other mental disorders or medical conditions.

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Catatonia Associated With Another Mental Disorder

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Catatonia Associated With Another Mental Disorder

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4116269/#:~:text=Historically%2C%20catatonia%20is%20related%20to,%2C%20bipolar%20disorder%2C%20and%20psychosis.

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Abstract

Diagnosis and treatment of catatonia in the psychiatry consultation service is not infrequent. Usually, the patient either presents to the Emergency Department or develops catatonia on the medical floor. This condition manifests with significant behavioral changes (from mildly decreased speech output to complete mutism) that interfere with the ability to communicate. After structural brain disorders are excluded, one of the diagnoses that always should be considered is catatonia. However, the causes of catatonia are numerous, ranging from psychiatric causes to a plethora of medical illnesses. Therefore, it is not surprising that there are many proposed underlying mechanisms of catatonia and that controversy persists about the etiology of specific cases.

There are only 6 reports of hyponatremia-induced catatonia and psychosis in the literature. Here, we present the case of a 30-year-old woman with catatonia and psychosis induced by hyponatremia, and we use this report to exemplify the multitude of biologic causes of catatonia and to propose a new way to look at the neuroanatomical basis of processing, particularly the vertical processing systems we believe are involved in catatonia.

Introduction

Catatonia is a frequently diagnosed disorder in psychiatry. The following scenarios are the most common: the patient arrives at the Emergency Department with behavioral changes that interfere with communication, or on the medical floor the patient develops significant behavioral changes that interfere with communication. The main features of catatonia are the same, regardless of the cause, and the clinical picture is dominated by three or more of the following symptoms: stupor, cataplexy, waxy flexibility, negativism, mutism, posturing, mannerism, stereotypy, agitation, grimacing, echolalia, and echopraxia. 1

The differential diagnostic should include illnesses that mimic catatonia, such as akinetic Parkinson disease, malignant hyperthermia, stiff-person syndrome, conversion disorder, selective mutism (selective mutism is a social anxiety disorder in which people who can speak normally in some situations cannot speak in other situations-especially in performance scenarios), locked-in syndrome, and other hypokinetic and hyperkinetic states. 2 Selective mutism, as seen in manifestations of personality disorders, malingering disorder, or factitious disorder, does not share the other features of catatonia and is relatively easily excluded.

After the patient is seen by the neurology and the psychiatry service and structural brain damage (such as stroke, tumor, or abscess) in the dominant hemisphere as well as severe dementia or delirium are excluded, the next line of differential diagnosis will include other medical conditions, including metabolic, neurologic, and substance-induced disorders. According to a review of 261 cases of catatonia, mental illness contributed to only up to 25% of those cases. 3

Historically, catatonia is related to schizophrenia and other mental illnesses, such as severe depression, bipolar disorder, and psychosis. 4 However, the causes of catatonia are numerous, ranging from psychiatric to medical illnesses. Therefore, it is not surprising that there are several proposed underlying mechanisms of catatonia-including top-down modulation, cholinergic and serotoninergic rebound hyperactivity, sudden and massive blockade of dopamine, and hyperactivity of glutamate.

One theory suggests that catatonia involves a "top-down modulation" in self-related processing of basal ganglia resulting from a deficiency of gamma aminobutyric acid (GABA). 5 Top-down modulation is described as a bidirectional process that determines our ability to focus on stimuli relevant to our needs and to ignore background information. Therefore, successful interplay between the enhancement and suppression of the neuronal activity generates the contrast necessary for successful representation of relevant information. Benzodiazepines bind to a specific site on a GABA receptor, making it more efficient. As a result there is an increase in chlorine ions that leads to an increase in polarization of postsynaptic neurons, therefore making them less excitable and more able to filter the relevant stimuli. One report states that malignant catatonia can occur in the setting of benzodiazepine withdrawal. 6 Other research suggests that hyperactivity of glutamate can be another underlying chemical dysfunction, 7 especially at the decrease in N-methyl d-aspartate receptor. 8

Catatonia can also happen in clozapine withdrawal. The proposed mechanism for clozapine-withdrawal-induced catatonia very likely happens owing to cholinergic and serotoninergic rebound hyperactivity. 9, 10

Significant dopamine blockade can also cause catatonia. England et al 11 reported that first-generation antipsychotic medications caused worsening catatonia symptoms. However, second-generation antipsychotic medication on several occasions did treat the symptoms of catatonia. 12 In addition, there are many reports that strongly suggest that stimulant medication can treat catatonia symptoms in patients with bipolar disorder 13 or depression. 14

Imaging results are different in various stages of catatonia. For example, in a patient with very-late-onset schizophrenia, hypoperfusion in the thalamus and striatum and hyperperfusion in the left lateral frontal cortex and left temporal cortex during the catatonia was reported. This scan was compared with the scan after the treatment. 15 In another report, 16 the imaging results of a patient with schizoaffective disorder in the acute phase of catatonia showed dramatic decrease in perfusion in the left parietal and motor cortex that reversed to normal after resolution of the episode. In addition, in cases of chronic catatonia, functional imaging identified abnormalities that happen bilaterally in the thalamus and frontal lobes. 17

It is always interesting to look at the evolutionary perspective-is this part of a survival mechanism, when perceived impending doom leads to catatonia? And do the mechanisms presented above overlap with those circuits leading to what we morphonalytically assess as catatonia? 18

Case Presentation

Ms A was a 30-year-old single woman living by herself and working as a factory operator for clean room production. She was born in the Philippines, came to the US as an infant, and was raised in San Diego, CA. She had an intact family and was the second of three children. Her father was in the military and was strict and a disciplinarian. He was occasionally physically abusive with her and her siblings. The patient was very close to her siblings and her mother.

In grammar school, she was a very good student. As a teen, she became more rebellious. She started college but was unable to finish. She dated, and her last relationship ended abruptly six months before she came in to the Emergency Department. Ms A was depressed as a result of that loss and received therapy through church counseling. Her depression improved without medications.

Her medical history was significant for papillary thyroid cancer, which was diagnosed 14 years before this incident and was successfully treated but had resurfaced recently. A few months after her recurrence of cancer, she received iodine-131 therapy for metastatic papillary thyroid cancer, and one day later she became confused and was found to have severe hyponatremia ( Figure 1 ). At the same time she was taking the following medications: levothyroxine 125 mcg every morning, enoxaparin 40 mg subcutaneous every 24 hours, atenolol 50 mg daily, and docusate sodium 100 mg twice a day. On the second day of hospitalization, her confusion worsened, and the next day she developed auditory hallucinations, hearing Britney Spears sing. The patient was dancing: taking small steps, rotating 180 degrees, and repeating this about a dozen times. Then, she would touch the perfusion pole, approximately in the same place, and would repeat the sequence over a period of several hours. She would answer with one or two words to selective questions. When asked to hold a paper, she did and continued to hold it for the next 10 minutes. The psychiatrist ordered clonazepam 0.5 mg orally three times a day and risperidone 0.5 mg orally three times a day.

The following day she was able to sit in a chair, stereotypic activity resolved, and she was able to recognize the psychiatrist. She answered most questions with complete sentences. When asked what happened the day before, she replied, "I had a mild concussion ... which is severe ... because it is a concussion." In the following days she recovered entirely. Medications were stopped 3 months after her full recovery. There have been no similar psychiatric symptoms 18 months after her recovery.

Discussion

There have been some reports of hyponatremia following radio-contrast iodine therapy. 19 The etiology is thought to be caused by a low-iodine diet and withdrawal of thyroxine therapy, which leads to a hypothyroid state. 20, 21 In this case, the iodine-131 protocol was followed, and she had no other changes in her medications or diet shortly before admission. In the absence of other identified confounding factors, we are suggesting that hyponatremia was caused by the radio-contrast iodine therapy.

Hyponatremia is defined as a decrease in serum sodium concentration below 135 mmol/L, and it can occur with high, normal, or low plasma tonicity. 22 In hypervolemic hyponatremia, the body has too much water; this is generally caused by kidney, heart, or liver failure. Euvolemic hyponatremia (normovolemic state) is commonly caused by chronic health conditions including cancer (as in this case) or certain medications; it is often seen in syndrome of inappropriate antidiuretic hormone but also with primary polydipsia and low dietary solute intake. In hypovolemic hyponatremia, there is too little water; this can happen in certain conditions such as strenuous exercise in hot conditions, blood loss, gastrointestinal losses (vomiting or diarrhea), or renal losses (most often thiazide diuretics).

Hypotonicity carries a risk of inducing cerebral edema. The most common causes of hyponatremia are iatrogenic acquisition, cerebral salt wasting, and inappropriate secretion of antidiuretic hormone. 23 The severity of symptoms is proportional to the severity of hyponatremia (usually more pronounced at concentrations less than 120 mmol/L) and the rate of sodium decline in serum. 24 In general, hyponatremia is treated with 3% saline, or more rapidly with 120 mmol/L if the patient is symptomatic, and then the dosage is corrected more slowly, a maximum of 10 mmol to 12 mmol per day and/or 18 mmol/L for any 48 hours, 25 slower if sodium has been chronically low. Each correction would need to be individualized on the basis of specifics of the patient course. 26 Most common initial symptoms of symptomatic hyponatremia are a combination of confusion, anorexia, nausea and vomiting, muscle cramps, and aches. Catatonia symptoms may develop in rare situations, such as in this case. Neurologic examination can reveal cognitive changes and occasionally decreased deep tendon reflexes. Left untreated, patients can develop rapid complications from cerebral edema such as generalized tonic-clonic seizures, coma, and death as a result of brain herniation.

Catatonia has a clinical presentation that is similar regardless of the precipitating or causing factors. When a clinical presentation can be the result of various etiologies, it is also expected to have a variety of neurochemical dysfunctions identified as the underlying mechanisms. Knowing the specific dysfunction involved becomes paramount; we chose the medications to treat on the basis of the particular clinical presentation. In this case, by the time of the psychiatrist's evaluation, the hyponatremia was resolved, but the psychosis and catatonia were getting worse. The prompt response can be explained, in our opinion, as follows: catatonia responded immediately and to a significant though incomplete degree to benzodiazepines; the second-generation antipsychotic medication helped with the residual catatonic symptoms and resolved the emerged psychosis over the next eight days.

There has been much progress in understanding catatonia since it was first described by Kahlbaum 27 as an illness characterized by mood syndromes as primary features and by motor disturbances as characteristic features. Processing seems to be integrally involved in catatonia. A comprehensive discussion of the neuroanatomical basis of processing is beyond the scope of this article and has been addressed elsewhere. 28

The neuroanatomic basis of processing includes vertical and horizontal processing systems and neuroplasticity. Neuroplasticity 29 includes:

1. dendrite rebranching and its participation in formation of new associations

2. hippocampal learning with formation of new neurons in the hippocampus

3. synaptic processes that include a large array of long-term-memory-related mechanisms.

Horizontal processing systems include:

1. interhemispheric processing, which addresses hemispheric synchrony and is essential in processing 30

2. intrahemispheric processing, which assures the basis for ipsilateral coordination between different brain structures. 31

Vertical processing systems include:

1. self-related processing and subcortical and midline structures that assure integrative bodily functions and basic emotional systems 32

2. re-entrance circuits that are essential in bidirectional mirroring between subcortical and cortical neural activity 33- 35

3. prefrontal-subcortical circuitry, which has a major role in mood regulation. 36, 37

We suggest that self-related processing is involved in catatonia. In addition, it is possible that the neurochemical dysfunction potentiates the observed response, such as the observed limited processing of the information from the outside world and behavioral abnormalities.

Self-related processing belongs to the vertical processing systems. It is attributed to a set of midline structures that start in the brain stem, in the reticular activating system, and are interconnected with higher brain structures in the subcortical and cortical areas, referred to as the subcortical-cortical mid-line system. They accomplish the integrative bodily functions and the convergence of basic emotional systems to form the proposed "bodily self or proto-self." 38- 46 These regions are hierarchically organized and functionally connected. Of particular importance is the ascendant reticular activating system, which receives various direct and indirect collaterals with ultimate function of influencing various aspects of consciousness and wakefulness. 47

Conclusion

Catatonia is a condition frequently identified in medical settings and is often induced by organic reasons. Even though the treatment for catatonia is essentially the same, as most of the patients respond well to benzodiazepines and electroconvulsive therapy, identifying the specific organic cause is as important as addressing the underlying condition.

The above-suggested involvement of self-related processing in the development of catatonia provides a unitary explanation for a multitude of described causes, and we believe that further research to elucidate the neuroanatomical pathways of this condition is warranted.

Acknowledgments

Leslie Parker, ELS, provided editorial assistance.

Footnotes

Disclosure Statement
Dr Daniela Bota is on the Advisory Board of Genentec; is on the Advisory Board, the Scholar's Bureau, and is a Consultant for NovoTTF; and is a Senior Scientific Advisor for ERC Belgium. The author(s) have no other potential conflicts of interest to disclose.

References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013. [ Google Scholar]

38. Damasio A. The feeling of what happens: body and emotion in the making of consciousness. New York, NY: Houghton Mifflin Harcourt; 1999. [ Google Scholar]

45. Denton D. The primordial emotions: the dawning of consciousness. New York, NY: Oxford University Press, USA; 2006. [ Google Scholar]

Articles from The Permanente Journal are provided here courtesy of Kaiser Permanente

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Special Medical Conditions Associated with Catatonia in the Internal Medicine Setting: Hyponatremia-Inducing Psychosis and Subsequent Catatonia

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Diagnosis and treatment of catatonia in the psychiatry consultation service is not infrequent. Usually, the patient either presents to the Emergency Department or develops catatonia on the medical floor. This condition manifests with significant behavioral changes (from mildly decreased speech output to complete mutism) that interfere with the ability to communicate.

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Psychotic Disorder Due to Another Medical Condition

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Psychotic Disorder Due to Another Medical Condition

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https://www.psychologytoday.com/us/conditions/psychotic-disorder-due-another-medical-condition#:~:text=A%20diagnosis%20of%20psychotic%20disorder,stroke%20or%20traumatic%20brain%20injury.

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One way in which a person might experience psychosis is through hallucinations. Hallucinations are instances in which a patient will see objects or people that are not in front of them, or sees objects or people that are there, but in a different and distorted way. Hallucinations can be auditory, hearing sounds that do not exist. Psychosis can also include physical feelings on the body that have no explanation and strong feelings or ideas that have no obvious cause.

Another aspect of psychosis can be delusions, which are not just sensory but mental. These can include the feeling that external forces are controlling one's brain and body. These external forces can be nearly anything, although a frequent one people in psychotic episodes describe is that of God. Delusions can also manifest as the belief that a patient has superhuman or supernatural powers. Delusions can also present themselves as beliefs that remarks that may be mundane or trivial in nature have a secret meaning, typically with the patient believing they're being persecuted in some manner.

It is possible to be aware of your own hallucinations or delusions to varying degrees. Psychosis has several phases: prodrome, acute, and recovery. During the acute phase of psychosis, it is definitionally the case that the patient believes what they are seeing, feeling, or thinking. That being said, people do not remain in the acute phase forever, and those who have experienced psychosis before may be able to realize they are vulnerable to an oncoming psychotic episode during the prodrome phase. Symptoms of this phase include a depressed mood, a ramping up of anxiety, increased anger, impaired sleeping, and others, all of which can be a warning sign for the patient. In psychiatry, the realization of one's own psychotic experience is called "insight," and while a patient in an acute psychotic episode may believe what they're experiencing, they may also suspect that something has changed and have an awareness that they're experiencing the world differently. More often, insight can be inferred through the willingness of patients to accept treatment and medication.

Psychotic thoughts can manifest differently in each person, so "typical" thoughts should not be conflated as the only thoughts one might experience. Still, there are some themes for those experiencing psychotic delusions, including the belief of being followed by others, being watched by cameras, having supernatural abilities, songs or comments containing hidden messages, and having one's thoughts controlled by outside forces.

The most common individual illnesses that can lead to a psychotic episode include dementia, epilepsy, Huntingdon's Disease, multiple sclerosis, stroke, and many autoimmune conditions, including HIV/AIDs and lupus. Psychosis due to epilepsy has been observed in 2-7.8% of patients. Advanced age is the underlying factor that is most commonly associated with the onset of a psychotic episode associated with another condition.

Epileptic psychosis is one of the most common causes of psychotic disorder due to another medical condition. Psychotic symptoms can arise during seizures (ictal psychosis), following seizures (postictal psychosis), or at a time not related to seizures (interictal psychosis). The prevalence of epileptic psychosis has been reported to be between two and ten percent of those with epilepsy, and is one of the most dangerous outcomes of the disorder. Of the three periods during which psychotic symptoms may occur, postictal psychosis is the most frequent.

Postictal psychosis typically occurs in the days immediately following a seizure but can occur up to a week out. Research has suggested that postictal psychosis is more prevalent in those with seizure foci on both sides of the brain. There are often warning signs before postictal psychosis, with insomnia, restlessness, and irritability being most common. Symptoms of postictal psychosis generally dissipate rapidly when treated with medication such as antipsychotics and benzodiazepines. Postictal psychosis is common enough that some doctors administer low doses of antipsychotic medication prophylactically after a seizure. Postictal psychosis is most commonly seen in people with a long history of drug-resistant seizures. According to research, between 10 and 25 percent of people who experience repeated postictal psychosis will eventually develop interictal psychosis.

Ictal psychosis, a psychotic episode that occurs concurrently with a seizure, is more rare. It typically presents with unresponsiveness and automatic body movements.

Interictal psychosis can occur at any time for people with epilepsy. Data suggests that interictal psychosis is not the result of normal epileptic pathology. The occurrence of interictal psychosis may indicate widespread abnormalities in the brain, or a brain tumor. Typically, interictal psychosis begins only after several years of epileptic seizures. Interictal psychosis is likely to be a chronic condition and should be treated with antipsychotic medication. Some evidence suggests that anti-epileptic drugs may induce psychotic symptoms in patients with interictal psychosis.

In the case of psychotic disorder due to another medical condition, the question of genetics has more to do with the medical condition itself. Epilepsy and Alzheimer's are known to have a genetic component, as are autoimmune disorders, although autoimmune disorders can also arise due to viral infections, diet, and other environmental conditions. Disorders such as schizophrenia and bipolar disorder, which can cause psychotic episodes, are their own separate conditions and so, therefore, are outside the boundaries of diagnosis of psychotic disorder due to another medical condition.

One way in which medical conditions result in psychotic episodes is through damage to the brain or central nervous system, including auditory or visual nerves. Autoimmune disorders can cause damage to the central nervous system. Epilepsy can be a result of and cause damage to the parietal and temporal lobes of the brain. Generally speaking, the method by which psychotic disorder due to another medical condition arises is due to the specific medical conditions themselves: there is no single instance of damage or dysregulation common to all cases.

Whether psychotic disorder due to another medical condition will be temporary or continuous depends on the medical condition. In those conditions that can improve or be resolved through treatment, psychotic episodes are likely to improve along with the resolution of the condition. In recurrent medical conditions, psychotic episodes may cycle through exacerbation and remission along with the condition.

Treatment is dependent largely upon the treatment of the medical condition that caused the psychotic disorder. If the other medical condition is treatable, the concurrent psychosis will likely wane with the treatment of the underlying condition. If the original condition is recurrent and psychotic reactions become frequent, benzodiazepines can be used to calm the patient, anti-depressants, and anti-psychotic medications can also be used to treat the symptoms of psychosis.

Find an expert on psychosis.

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Psychotic Disorder Due to Another Medical Condition

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A diagnosis of psychotic disorder due to another medical condition is given when psychotic symptoms occur alongside a temporary or chronic illness. This may range from a migraine headache to a stroke or traumatic brain injury. People who are genetically disposed or otherwise at high risk of developing a psychotic disorder are more likely to experience a co-occurrence of psychosis and another medical event.

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https://www.verywellmind.com/what-is-substance-medication-induced-psychotic-disorder-21938

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What Is Substance/Medication-Induced Psychotic Disorder?

Substance/medication-induced psychotic disorder, also known as toxic psychosis, alcohol-induced psychosis, and drug-induced psychosis, is the diagnostic name for a specific mental health condition where an individual experiences hallucinations, delusions, or both within a month of using or withdrawing from prescription drugs, illegal drugs, and/or alcohol.

According to the Diagnostic and Statistical Manual (DSM-5), 7% to 25% of patients treated for their first psychotic episode are reported to have substance/medication-induced psychotic disorder.

If you or a loved one are experiencing symptoms of substance/medication-induced psychotic disorder, know that there are many treatment options and resources available to support you.

Symptoms of substance/medication-induced psychotic disorder include experiencing delusions, hallucinations, or both. Individuals experiencing these symptoms may or may not have insight into whether their delusions and/or hallucinations are real.

Delusions are thoughts and beliefs that are not based in reality.

Types of delusions include:

Persecutory: Thoughts that others, including organizations, are out to get you or are surveilling you

Grandiose: Belief that you are exceptional, special, gifted, and better than others

Referential:Belief that individuals and environmental signals have hidden meanings meant to communicate with you

Erotomanic:Belief that someone or multiple people are in love with you despite contrary evidence

Nihilistic: Thoughts that a disaster will take place

Somatic: Belief that something is wrong with your body

For example, a persecutory delusion may be "my former company is monitoring my every move and is out to get me." An example of an erotomanic delusion may be "Tom Hanks is madly in love with me."

Hallucinations

If you have a hallucination, you are experiencing something with one or multiple senses that isn't based in reality.

If an individual has substance/medication-induced psychosis and their hallucinations are due to drugs and/or alcohol, this symptom does not count toward their diagnostic criteria.

Types of hallucinations include:

Auditory: Hearing voices or sounds that aren't really present

Visual: Seeing things that aren't really there

Olfactory: Smelling scents that no one else can

Tactile: Feeling like you're being touched when no one or nothing is on you

Gustatory: Tasting something when there's nothing in your mouth

For example, with an auditory hallucination, an individual may hear a voice telling them to run away or that they are being followed. With a visual hallucination, an individual may see someone following them who isn't really there.

How Long Does It Last?

An individual's medical history, when a particular substance was ingested, and how much was ingested can all impact how long symptoms of substance/medication-induced psychosis may persist.

While symptoms may decrease and stop shortly after a substance has been eliminated from the body, other substances may cause symptoms that last for weeks.

Individuals taking certain pain medications may experience substance/medication-induced psychosis symptoms that may take up to a week to resolve.

Individuals taking amphetamines, such as methamphetamine, may experience symptoms that persist for weeks. It's important to note that amphetamine use in some patients is also linked to schizophrenia (more persistent symptoms of psychosis).

In a study of individuals with cannabis or stimulant use disorder, 46% of individuals who were diagnosed with substance-induced psychosis later developed schizophrenia. Those with cannabis-use disorder were more vulnerable to developing long-term symptoms. About half of the other individuals in the study only experienced symptoms for a brief period.

For the diagnosis of substance/medication-induced psychotic disorder to be made, symptoms must have a significant impact on your quality of life.

While it can be difficult to differentiate substance/medication-induced psychotic disorder from schizophrenia spectrum and other psychotic disorders, there are some key factors to note.

With substance/medication-induced psychosis:

Symptoms begin within a month of using or withdrawing from drugs, alcohol, or both.

There are no psychosis-related symptoms noted prior to the substance use or withdrawal.

Symptoms typically last for under a month.

Symptoms usually diminish after withdrawal.

Individuals typically don't experience disorganized speech or behavior, or reduced emotional expression, which are common symptoms in schizophrenia spectrum and other psychotic disorders.

Onset During Intoxication

Symptoms of substance/medication-induced psychotic disorder can begin almost immediately after ingesting certain substances.

When diagnosing an individual, the treating physician or mental health professional will determine if the symptoms began while the substance was still present in the individual's system. Such a case is known as an onset during intoxication.

Onset During Withdrawal

Symptoms of substance/medication-induced psychotic disorder can also occur during withdrawal.

Your treating clinician will monitor how long your symptoms persist to ensure that other mental health disorders don't need to be ruled out.

If symptoms last longer than a month and the substance has cleared your body, they may collect more information to see if another mental health disorder, such as substance-induced mood disorder, better fits your symptom experience.

There is a high incidence of having a co-occurring mental health disorder alongside a diagnosis of substance use disorder. While substances alone do not directly cause substance/medication-induced psychotic disorder, someone who is at a greater risk for psychosis can be triggered by certain substances.

In a longitudinal study of individuals who presented with substance-induced psychotic disorder due to cannabis, opiates, stimulants, or multiple drugs, risk factors included:

Being male

Being 30 years old or younger

Having an underlying mental health condition

These individuals weren't only at risk for substance-induced psychotic disorder, but were also more prone to developing schizophrenia within the next few years.

Psychoactive Substances

A wide variety of psychoactive substances can trigger substance-induced psychotic disorder including:

Medications

Medications that may trigger substance/medication-induced psychotic disorder include:

Analgesics

Anticholinergics

Antiepileptics

Antidepressants

Antiparkinsonian medication

Steroids

Muscle relaxants

Disulfiram

Treatment for substance/medication-induced psychotic disorder will vary depending on the specific patient and their unique needs. In many cases, stopping the triggering substance and closely monitoring the patient in a safe environment may be enough. However, different substances, such as alcohol, may require more intensive treatment.

Medication

Medications may be used to help reduce symptoms of substance/medication-induced psychosis and stabilize the individual's mood. Medications that may be used include:

Psychotherapy

Long-term, it's important to treat any underlying mental health conditions to reduce the chances of experiencing substance/medication-induced psychosis again.

Treatment options may include:

Alcohol-Induced Psychotic Disorder Considerations

Withdrawing from alcohol may require more monitoring compared to other substances and medications. In serious cases, which can be fatal, the individual may experience delirium tremens (DTs), symptoms of alcohol-induced psychosis, and bodily function failure.

Treatment options and care may include:

Tests and monitoring as you withdraw at the hospital

Stabilizing vitals, replenishing electrolytes and vitamins, and testing for liver disease

Sedation using antipsychotics or benzodiazepines, if needed

Suicide evaluation and monitoring

Once withdrawal is complete and the patient is stabilized, beginning inpatient or outpatient treatment can be incredibly helpful. Support groups may also be beneficial in addition to psychotherapy.

If you or a loved one are experiencing symptoms of substance/medication-induced psychosis, it's important to prioritize self-care.

In addition to seeking professional care, you may also:

Begin practicing mindfulness to help reduce stress

Engage in breathing exercises to ground yourself

Look for signs of caregiver fatigue and take time for yourself to decompress

Connect with trusted loved ones about what you are experiencing

Read helpful literature about substance/medication-induced psychosis

A Word From Verywell

Although it can feel incredibly frightening to experience symptoms of psychosis, keep in mind that they may be directly related to a substance or medication, which can be addressed. Be sure to contact a medical professional if you or a loved one are experiencing any symptoms of psychosis so you can receive appropriate care.

By Elizabeth Hartney, BSc, MSc, MA, PhD
Elizabeth Hartney, BSc, MSc, MA, PhD is a psychologist, professor, and Director of the Centre for Health Leadership and Research at Royal Roads University, Canada.

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What You Need to Know About Substance-Induced Psychotic Disorder

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Substance/medication-induced psychotic disorder, also known as toxic psychosis, alcohol-induced psychosis, and drug-induced psychosis, is the diagnostic name for a specific mental health condition where an individual experiences hallucinations, delusions, or both within a month of using or withdrawing from prescription drugs, illegal drugs, and/or alcohol.

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https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Schizoaffective-Disorder

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Schizoaffective disorder is a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression.

Many people with schizoaffective disorder are often incorrectly diagnosed at first with bipolar disorder or schizophrenia. Because schizoaffective disorder is less well-studied than the other two conditions, many interventions are borrowed from their treatment approaches.

Schizoaffective is relatively rare, with a lifetime prevalence of only 0.3%. Men and women experience schizoaffective disorder at the same rate, but men often develop the illness at an earlier age. Schizoaffective disorder can be managed effectively with medication and therapy. Co-occurring substance use disorders are a serious risk and require integrated treatment.

Symptoms

The symptoms of schizoaffective disorder can be severe and need to be monitored closely. Depending on the type of mood disorder diagnosed, depression or bipolar disorder, people will experience different symptoms:

Hallucinations, which are seeing or hearing things that aren't there.

Delusions, which are false, fixed beliefs that are held regardless of contradictory evidence.

Disorganized thinking. A person may switch very quickly from one topic to another or provide answers that are completely unrelated.

Depressed mood. If a person has been diagnosed with schizoaffective disorder depressive type they will experience feelings of sadness, emptiness, feelings of worthlessness or other symptoms of depression.

Manic behavior. If a person has been diagnosed with schizoaffective disorder: bipolar type they will experience feelings of euphoria, racing thoughts, increased risky behavior and other symptoms of mania.

Causes

The exact cause of schizoaffective disorder is unknown. A combination of causes may contribute to the development of schizoaffective disorder.

Genetics. Schizoaffective disorder tends to run in families. This does not mean that if a relative has an illness, you will absolutely get it. But it does mean that there is a greater chance of you developing the illness.

Brain chemistry and structure. Brain function and structure may be different in ways that science is only beginning to understand. Brain scans are helping to advance research in this area.

Stress. Stressful events such as a death in the family, end of a marriage or loss of a job can trigger symptoms or an onset of the illness.

Drug use. Psychoactive drugs such as LSD have been linked to the development of schizoaffective disorder.

Diagnosis

Schizoaffective disorder can be difficult to diagnose because it has symptoms of both schizophrenia and either depression or bipolar disorder. There are two major types of schizoaffective disorder: bipolar type and depressive type. To be diagnosed with schizoaffective disorder a person must have the following symptoms.

A period during which there is a major mood disorder, either depression or mania, that occurs at the same time that symptoms of schizophrenia are present.

Delusions or hallucinations for two or more weeks in the absence of a major mood episode.

Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the illness.

The abuse of drugs or a medication are not responsible for the symptoms.

Treatment

Schizoaffective disorder is treated and managed in several ways:

Medications, including mood stabilizers, antipsychotic medications and antidepressants

Psychotherapy, such as cognitive behavioral therapy or family-focused therapy

Self-management strategies and education

Related Conditions

A person with schizoaffective disorder may have additional mental health conditions:

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Schizoaffective disorder is a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression. Many people with schizoaffective disorder are often incorrectly diagnosed at first with bipolar disorder or schizophrenia.

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https://www.nimh.nih.gov/health/topics/schizophrenia

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National Institute of Mental Health (NIMH)

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Learn about schizophrenia, including onset & symptoms, risk factors, treatments and therapies, how to help a loved one, & resources for more information.

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https://www.webmd.com/schizophrenia/mental-health-schizophreniform-disorder

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Schizophreniform disorder is a type of psychotic illness with symptoms similar to those of schizophrenia, but lasting for less than 6 months.

Like schizophrenia, schizophreniform disorder is a type of "psychosis" in which a person cannot tell what is real from what is imagined. It also affects how people think, act, express emotions, and relate to others.

If symptoms last longer than 6 months, doctors consider the person to have schizophrenia rather than schizophreniform disorder.

Symptoms

Like schizophrenia, symptoms may include:

Delusions (false beliefs that the person refuses to give up, even after they get the facts)

Hallucinations (seeing, hearing, or feeling things that aren't real)

Disorganized speech, such as not making sense, using nonsense words, and skipping from one topic to another

Odd or strange behavior, such as pacing, walking in circles, or writing constantly

Lack of energy

Poor hygiene and grooming habits

Loss of interest or pleasure in life

Withdrawal from family, friends, and social activities

Causes

Doctors don't know what causes schizophreniform disorder. A mix of factors may be involved, including:

Genetics: A tendency to develop schizophrenia and schizophreniform disorder may pass from parents to their children.

Brain structure and function: People with schizophrenia and schizophreniform disorder may have a disturbance in brain circuits that manage thinking and perception.

Environment: Poor relationships or very stressful events may trigger schizophreniform disorder in people who have inherited a tendency to develop the illness.

How Common Is It?

About one person in 1,000 develops schizophreniform disorder during their lifetime. The disorder happens equally in men and women, although it often strikes men at a younger age, between ages 18 and 24. In women, it most often happens between ages 24 and 35.

Diagnosis

If someone has symptoms, a doctor may use various tests -- such as brain imaging (like MRI scans) or blood tests -- to rule out a nonpsychiatric medical problem.

If the doctor finds no physical reason for the symptoms, they may refer the person to a psychiatrist or psychologist, mental health professionals who are trained to diagnose and treat mental illnesses. They use specially designed interview and assessment tools to see if someone has a psychotic disorder. For a diagnosis of schizophreniform disorder, the symptoms can only have lasted for less than 6 months.

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Schizophreniform disorder is a type of psychotic illness with symptoms similar to those of schizophrenia, but lasting for less than 6 months. Like schizophrenia, schizophreniform disorder is a type of "psychosis" in which a person cannot tell what is real from what is imagined.

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https://www.ncbi.nlm.nih.gov/books/NBK539912/

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Continuing Education Activity

Brief psychotic disorder (BPD) according to DSM-5 is the sudden onset of psychotic behavior that lasts less than 1 month followed by complete remission with possible future relapses. It is differentiated from schizophreniform disorder and schizophrenia by the duration of the psychosis. The diagnosis is often anticipatory or retrospective due to the diagnostic requirement of complete remission within 1 month. This activity describes the presentation and pathophysiology of brief psychotic disorder and highlights the role of the interprofessional team in its management.

Objectives:

Review the presentation of a patient with brief psychotic disorder.

Summarize the treatment of brief psychotic disorder.

Describe the DSM 5 criteria for brief psychotic disorder.

Explain the importance of improving care coordination among the interprofessional team to enhance the delivery of care for patients with a brief psychotic disorder.

Access free multiple choice questions on this topic.
Introduction

Brief psychotic disorder (BPD) according to DSM-5 is the sudden onset of psychotic behavior that lasts less than 1 month followed by complete remission with possible future relapses.[1] It is differentiated from schizophreniform disorder and schizophrenia by the duration of the psychosis. The diagnosis is often anticipatory or retrospective due to the diagnostic requirement of complete remission within 1 month. Brief psychotic disorder is an acute but transient disorder with the onset of one or more of the following psychotic symptoms:

At least one of these symptoms must be delusions, hallucinations, or disorganized speech. The symptoms in BPD last between one day to one month, with a complete return to premorbid level of functioning after the disease course in response to antipsychotic medications. The disturbance in behavior cannot be better accounted for by schizophrenia, schizoaffective disorder, mood disorder with psychotic features, or be a direct result of a drug, medication, or medical condition like thyrotoxicosis, sarcoidosis, or syphilis.

Etiology

Although unclear, the underlying etiology of brief psychotic disorder can be a stressful event or trauma. There may be a genetic, neurological, or environmental component to BPD as well. The specific trigger of BPD, if present, must be specified as follows[2][3]:

Brief psychotic disorder with marked stressor(s) is also referred to as brief reactive psychosis. It is the onset of psychotic symptoms that occur in response to a traumatic event that would be stressful for anyone in similar circumstances in the same culture

Brief psychotic disorder without marked stressor(s) is the onset of psychotic symptoms that occur in the absence of a traumatic event that would be stressful for anyone in similar circumstances in the same culture

Brief psychotic disorder with postpartum onset is defined as the onset of psychotic symptoms that occur within four weeks postpartum

Epidemiology

Reliable data on the frequency of brief psychotic disorder are not available, mostly because of its low incidence and variation based on the population under study. However, increased frequency of the disorder generally occurs in populations known to be under high stress such as immigrants, refugees, earthquake victims, etc.[4][5] A study researching the Finnish population found the prevalence of brief psychotic disorder to be 0.05%.[6] Another study in rural Ireland found 10 cases of BPD among 196 first-admission psychosis cases.[7]

Compared to developed countries, reports show a higher incidence of brief psychotic disorder in developing countries. Data drawn from the World Health Organization Determinants of Outcome Study also found that the incidence of BPD in developing countries was ten times as much as that in industrialized countries.[8] BPD is also thought to be more common in women and those with a personality disorder.[6][7][9][10]

Pathophysiology

The pathophysiology of BPD is not known, especially given the extremely low incidence of the disorder. Its higher prevalence among patients with personality or mood disorders may suggest underlying biological or psychological susceptibility which may some genetic influence.

History and Physical

Three essential elements of the history and physical in an individual with suspected brief psychotic disorder are:

1. The presence of at least one positive psychotic symptom such as delusions, hallucinations, disorganized speech, or disorganized or catatonic behavior

2. Establishing that the symptoms have not been present for less than one day or more than one month

3. Investigating if the disturbance in behavior is otherwise explainable by another mood disorder, medical condition, or substance/medication use

In order to further classify individual cases of brief psychotic disorder, it becomes essential to recognize if the triggering of psychotic symptoms were from a stressful event or if it is postpartum. Common stressors are death, environmental disaster, military activity, recent immigration.[11] Acknowledging patient characteristics such presence of a personality disorder that can limit coping skills will also be crucial to identifying individuals at a greater risk of developing disorders like BPD. It is also important to keep in mind that the presenting symptoms of BPD may occasionally be highly severe and mimic the presentation of delirium as a result.

Evaluation

There are no particular lab studies or psychological testing that are performable to make the diagnosis of a brief psychotic disorder.

The most appropriate tests and imaging to be done would rule out other potential diagnoses or causes for the behavioral disturbances. Hence, it would be apt to do a serum pregnancy test in women to evaluate any underlying triggers for the patient's behavioral disturbances. Other potential tests to consider ordering would be ECG, electrolytes, glucose level, liver function tests, thyroid function tests, and urinalysis. Urine toxicology tests can help exclude any potential drug or medication intoxication or withdrawal. CT and MRI of the brain may also be performed to evaluate for any underlying structural causes for the symptoms.

Treatment / Management

It is important to first and foremost decide the appropriate level of care and whether the patient should be hospitalized or treated on an outpatient basis. The basis for decisions regarding treatment should be on multiple factors such as the patient's presenting symptoms, socioeconomic stability, the presence of supporting individuals or family, and the presence of homicidal or suicidal ideation. Because of the limited number of clinical trials evaluating the efficacy of specific treatment modalities in patients with brief psychotic disorder, current recommendations for treatment of BPD rely on pharmacological and psychotherapeutic interventions known to be effective in patients with other psychotic disorders.[12][13]

Pharmacotherapy

Antipsychotics, especially second-generation, are the first-line treatment for brief psychotic disorder. Although BPD characteristically shows complete resolution of symptoms within one month of symptom onset, it is suggested to continue treatment with antipsychotics for one to three months after symptom remission. Although oral formulations are preferable as first-line treatment for BPD, intramuscular formulations may have to be used in patients during immediate assessments and treatment, especially in emergency settings.

1. Second-generation or atypical antipsychotics: Quetiapine, paliperidone, olanzapine, risperidone, aripiprazole, ziprasidone, and clozapine are the medications that are classified as second-generation and preferred because of their better side effect profile in terms of extrapyramidal symptoms. Olanzapine may be more favorable in lactating mothers as compared to the other drugs from the same class.[14] Metabolic symptoms such as weight gain, dyslipidemia, and hyperglycemia are the most common side effects seen with this drug class that would necessitate obtaining a baseline and periodic waist circumference, BMI, HbA1c, fasting lipid panel, and fasting blood glucose. Clozapine, in particular, is used in treatment-resistant individuals and requires weekly full blood count monitoring for any blood dyscrasias because of its possibility of inducing neutropenia and agranulocytosis.

2. First-generation or typical antipsychotics: Trifluoperazine, fluphenazine, haloperidol, chlorpromazine, and thioridazine are the medications that are classified as first-generation. Extrapyramidal symptoms (EPS) such as acute dystonia, akathisia, cogwheel rigidity, and tardive dyskinesia are some of the more prominent side effects to keep in mind within this drug class. Anticholinergic medications such as benztropine and biperiden may be added to the treatment regimen to treat the EPS.

3. Benzodiazepines: Medications within the benzodiazepine class may prove helpful to ameliorate symptom manifestation in acutely combative or agitated individuals.[15]

Psychotherapy

As expected, a brief yet major psychotic episode can be highly disruptive to the livelihood and functioning of an individual and his/her family and friends. Psychotherapeutic management of BPD would involve medically informing the patient and his/her family about the condition and treatment modalities employed for the particular patient. Along with emphasizing reintegration into the societal milieu, it is essential to focus on managing comorbid disorders or stressors and improving overall coping skills.

During the treatment process, the patient should be monitored on a long-term basis to assess for relapse or the presence of residual symptoms that may necessitate referral to a specialist. It is essential to support the patient to maintain medication adherence as a lack of adherence may facilitate symptom relapse. The overall treatment plan for BPD should ideally include both pharmacological and psychosocial interventions. The biological, psychological, and social dimensions of the patient's life should in unison dictate the eventual treatment decisions made.

Differential Diagnosis

It is essential to consider other possible etiologies before determining a final diagnosis of the brief psychotic disorder. A diagnosis of brief psychotic disorder can only be made retrospectively after the symptoms have remitted within one month of presentation, as the symptoms of psychosis may otherwise be an early manifestation of another disorder with a psychotic component. Prior to symptomatic remission, a diagnosis of "psychotic disorder, not otherwise specified" may be given. Primary differential diagnoses to consider are psychotic affective disorder, schizophrenia-spectrum disorders, personality disorders, delusional disorder, substance use disorder (including withdrawal), substance-induced psychosis, and psychosis secondary to medical conditions.

Psychotic affective disorder is diagnosed in the presence of a major mood component with symptoms of depression or mania. Even with treatment, a patient with affective disorder with psychosis is not expected to return to baseline in 30 days, unlike patients with BPD. Schizophrenia-spectrum disorders such as schizophreniform disorder and schizophrenia are distinguished from BPD based mainly on the presence of symptoms for longer than 30 days. Schizoaffective disorder is diagnosed in a patient who meets the criteria for major depressive disorder or manic disorder who also has psychotic symptoms consistent with schizophrenia concurrently with the mood symptoms and for at least 2 weeks in the absence of mood symptoms. Patients with personality disorder, especially borderline personality disorder, may also have transient episodes of psychosis mostly induced by stress that may only last for 1 day or less. Substance intoxication, substance withdrawal, or medical conditions such as syphilis, neurosarcoidosis, metastasis likely secondary to lung cancer, thyrotoxicosis, and head trauma may occasionally present with symptoms that mimic that of BPD, however, a comprehensive history and physical examination in addition to necessary laboratory testing and imaging will help elucidate the underlying condition.

Prognosis

Given the nature of this condition, the prognosis is considerably well with complete remission of symptoms within a month per definition based on DSM-5 criteria. However, the symptoms may recur especially in the setting of a stressful psychosocial milieu. Some positive prognostic indicators for the brief psychotic disorder are the absence of genetically related individuals with schizophrenia or brief psychotic disorder, sudden symptom onset, the presence of stressful triggers, and a short duration of symptoms.

Prognosis is notably worse for individuals diagnosed with BPD who have then been able to meet criteria for other disorders characterized by psychosis. A study conducted in Suffolk County, New York in 2000 found that only 2% of the first-admission psychosis patients met the criteria for BPD at the six-month mark. Per the Suffolk County study consisting of 11 patients initially given the diagnosis of brief psychotic disorder, three retained the diagnosis of BPD while the remaining nine received diagnoses of mood disorder, schizophrenia, schizophreniform disorder, and other disorders involving psychosis.[16]

Complications

The most significant complication associated with brief psychotic disorder is the sudden onset of symptoms and accompanying loss in functioning. It is crucial to make special note of predisposing stressors and comorbid disorders and manage them appropriately as that may have precipitated this episode and may result in similar manifestations in the future. Although pharmacotherapy may help curb the presenting symptoms of BPD, it is psychotherapy that will empower the patient with the skills and techniques to cope with this disorder during and after the symptoms have remitted.

Deterrence and Patient Education

Patient and family education is an imperative aspect of the psychotherapeutic interventions used to manage brief psychotic disorder. Experiencing one or more psychotic symptoms including delusions, hallucinations, disorganized speech, or grossly disorganized/catatonic behavior can be extremely unsettling to the individual and family likewise. As a result, adequate education about treatment options and psychotherapy are necessary, in addition to facilitating a strong support system for the patient.

Enhancing Healthcare Team Outcomes

As with most other psychiatric pathologies, the diagnosis, treatment, and management of brief psychotic disorder require the coordinated efforts of a strong interprofessional team that includes the primary care provider, mental health nurse, psychologist, and psychiatrist. It is paramount to develop and follow a patient-centered approach with a particular focus on psychotherapy and pharmacotherapy, given how disruptive such a disease process can be to the patient and his/her family. Working on the biopsychosocial aspect of well-being will ensure that the patient is well supported all-around and help curtail the overall negative impact of this disorder on the life and functioning of the individual.

References

Disclosure: Anu Stephen declares no relevant financial relationships with ineligible companies.

Disclosure: Forshing Lui declares no relevant financial relationships with ineligible companies.

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Brief psychotic disorder (BPD) according to DSM-5 is the sudden onset of psychotic behavior that lasts less than 1 month followed by complete remission with possible future relapses.[1] It is differentiated from schizophreniform disorder and schizophrenia by the duration of the psychosis.

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https://my.clevelandclinic.org/health/diseases/9599-delusional-disorder#:~:text=Delusional%20disorder%20is%20a%20type,treatable%20with%20psychotherapy%20and%20medication.

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Overview

What is delusional disorder?

Delusional disorder is a type of psychotic disorder. Its main symptom is the presence of one or more delusions.

A delusion is an unshakable belief in something that's untrue. The belief isn't a part of the person's culture or subculture, and almost everyone else knows this belief to be false.

People with delusional disorder often experience non-bizarre delusions. Non-bizarre delusions involve situations that could possibly occur in real life, such as being followed, deceived or loved from a distance. These delusions usually involve the misinterpretation of perceptions or experiences. In reality, these situations are either untrue or are highly exaggerated.

Non-bizarre delusions are different from bizarre delusions, which include beliefs that are impossible in our reality, such as believing someone has removed an organ from your body without any physical evidence of the procedure.

People with delusional disorder often continue to socialize and function well, apart from the subject of their delusion. Generally, they don't behave in an odd or unusual manner. This is unlike people with other psychotic disorders, who might also have delusions as a symptom. In some cases, however, people with delusional disorder might become so preoccupied with their delusions that their lives are disrupted.

What are the types of delusional disorder?

There are different types of delusional disorder, which are determined based on the main theme of the delusions the person experiences. The types of delusional disorder include:

Erotomanic: People with this type of delusional disorder believe that another person, often someone important or famous, is in love with them. They may attempt to contact the person of the delusion and engage in stalking behavior.

Grandiose: People with this type of delusional disorder have an overinflated sense of self-worth, power, knowledge or identity. They may believe they have a great talent or have made an important discovery.

Jealous: People with this type of delusional disorder believe that their spouse or sexual partner is unfaithful without any concrete evidence.

Persecutory: People with this type of delusional disorder believe someone or something is mistreating, spying on or attempting to harm them (or someone close to them). People with this type of delusional disorder may make repeated complaints to legal authorities.

Somatic: People with this type of delusional disorder believe that they have a physical issue or medical problem, such as a parasite or a bad odor.

Mixed: People with this type of delusional disorder have two or more of the types of delusions listed above.

What is the difference between delusional disorder and schizophrenia?

Schizophrenia is a spectrum (or range) of conditions that involve psychotic symptoms, which include:

Disorganized speech or behavior.

Negative symptoms (a decrease in emotion in a person's facial expressions and motivation).

Delusional disorder is different from schizophrenia because there aren't any other psychotic symptoms other than delusions.

In addition, in contrast to schizophrenia, delusional disorder is relatively rare, and daily functioning isn't as impaired as it is in schizophrenia.

Who does delusional disorder affect?

Delusional disorder most often occurs in middle to late life, with the average age of onset being 40 years.

The persecutory and jealous types of delusional disorder are more common in people assigned male at birth (AMAB), and the erotomanic type is more common in people assigned female at birth (AFAB).

People who tend to be socially isolated are more likely to develop delusional disorder. These populations include:

Immigrants who have language barriers.

People who are deaf.

People who are visually impaired.

Elderly people.

How common is delusional disorder?

Although delusions might be a symptom of more common disorders, such as schizophrenia, delusional disorder itself is rather rare. Approximately 0.05% to 0.1% of the adult population has delusional disorder.

What is the most common type of delusional disorder?

The most common type of delusional disorder is the persecutory type - when someone believes others are out to harm them despite evidence to the contrary.

Symptoms and Causes

What are the signs and symptoms of delusional disorder?

The presence of delusions is the most obvious sign of delusional disorder, which vary based on the type.

Another characteristic of this condition is that the person often lacks self-awareness that their delusions are problematic. They're unable to accept that their delusions are irrational or inaccurate, even if they recognize that other people would describe their delusions this way.

Anger and violent behavior may be present if someone is experiencing persecutory, jealous or erotomanic delusions.

People with delusional disorder may also develop anxiety and/or depression as a result of the delusions.

Early symptoms of delusional disorder may include:

Feelings of being exploited.

Preoccupation with the loyalty or trustworthiness of friends.

A tendency to read threatening meanings into benign remarks or events.

Persistently holding grudges.

A readiness to respond and react to perceived slights.

What causes delusional disorder?

As with many other psychotic disorders, researchers don't yet know the exact cause of delusional disorder. Researchers are, however, looking at the role of various factors that may contribute to the development of the condition, including:

Genetic factors: The fact that delusional disorder is more common in people who have family members with delusional disorder or schizophrenia suggests there might be a genetic factor involved. Researchers believe that, as with other mental disorders, a tendency to develop delusional disorder might be passed on from parents to their biological children.

Biological factors: Researchers are studying how abnormalities of certain areas of your brain might be involved in the development of delusional disorder. An imbalance of certain chemicals in your brain, called neurotransmitters, has been linked to the formation of delusional symptoms.

Environmental and psychological factors: Evidence suggests that delusional disorder can be triggered by stress. Alcohol use disorder and substance use disorder might contribute to the condition. Hypersensitivity and ego defense mechanisms like reaction formation, projection and denial are some psychodynamic theories for the development of delusional disorder. Social isolation, envy, distrust, suspicion and low self-esteem are also some psychological factors that may lead to a person seeking an explanation for these feelings and, thus, forming a delusion as a solution.

Diagnosis and Tests

How is delusional disorder diagnosed?

Healthcare providers - mainly mental health professionals - diagnose delusional disorder when a person has one or more delusions for one month or more that can't be explained by any other condition. The person must also not have the characteristic symptoms of other psychotic disorders, such as schizophrenia.

If someone is experiencing signs and symptoms of delusional disorder, a healthcare provider will perform a complete medical history and physical examination. Although there aren't any laboratory tests to diagnose delusional disorder, their healthcare provider might use various diagnostic tests - such as imaging tests, a urine drug screen and blood tests - to rule out any physical conditions, medications or substances that could be causing the symptoms.

If their healthcare provider finds no physical reason for the symptoms, a consultation with a psychiatrist or psychologist will likely be made. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a person for a psychotic disorder. They'll ask questions about the delusions and assess the person's mental status.

The psychiatrist or psychologist may also interview family members and friends so they can provide further details about the person's delusions and a timeline of the symptoms.

As other mental health conditions can cause delusions, mental health professionals carefully assess the person for other symptoms. Delusional disorder can be misdiagnosed as any of the following conditions:

Management and Treatment

How is delusional disorder treated?

Treatment for delusional disorder most often includes psychotherapy (talk therapy) and medication, but delusional disorder is highly resistant to treatment with medication alone.

People with delusional disorder often don't seek treatment for the condition on their own because most people with delusional disorder don't realize their delusions are problematic or incorrect. It's more likely they'll seek help due to other mental health conditions such as depression or anxiety.

People with severe symptoms or who are at risk of hurting themselves or others might need to be admitted to the hospital until the condition is stabilized.

Psychotherapy for delusional disorder

Psychotherapy is a term for a variety of treatment techniques that aim to help people identify and change troubling emotions, thoughts and behaviors. Working with a mental health professional, such as a psychologist or psychiatrist, can provide support, education and guidance to the person and their family.

Through therapy, people with delusional disorder can learn to manage their symptoms, identify early warning signs of relapse and develop relapse prevention plans. Types of psychotherapy include:

Individual psychotherapy: This type of therapy can help a person recognize and correct the underlying thinking that has become distorted.

Cognitive behavioral therapy (CBT): This is a structured, goal-oriented type of therapy. A mental health professional helps people take a close look at their thoughts and emotions. They'll come to understand how their thoughts affect their actions. Through CBT, they can unlearn negative thoughts and behaviors and learn to adopt healthier thinking patterns and habits.

Family-focused therapy: This therapy can help people with delusional disorder and their families. This treatment involves psychoeducation regarding delusional disorder, communication improvement training and problem-solving skills training.

Medications for delusional disorder

The primary medications used to help treat delusional disorder are called antipsychotics (neuroleptics). Medications include the following:

First-generation ("typical") antipsychotics: Healthcare providers have used these medications to treat mental health conditions since the mid-1950s. These medicines work by blocking dopamine receptors in your brain. Dopamine is a neurotransmitter believed to be involved in the development of delusions. First-generation antipsychotics include chlorpromazine (Thorazine®), fluphenazine (Prolixin®), haloperidol (Haldol®), thiothixene (Navane®), trifluoperazine (Stelazine®), perphenazine (Trilafon®) and thioridazine (Mellaril®).

Second-generation ("atypical") antipsychotics: These newer antipsychotics are also effective in treating the symptoms of delusional disorder. They work by blocking dopamine and serotonin receptors in your brain. These drugs include risperidone (Risperdal®), clozapine (Clozaril®), quetiapine (Seroquel®), ziprasidone (Geodon®) and olanzapine (Zyprexa®). These medications are usually better tolerated than first-generation antipsychotics.

Other medications that healthcare providers might prescribe to treat delusional disorder include anxiolytics and antidepressants. Anxiolytics might help if the person has a very high level of anxiety and/or problems sleeping. Antidepressants can help treat depression, which often occurs in people with delusional disorder.

Prevention

Can delusional disorder be prevented?

There's no known way to prevent delusional disorder. However, early diagnosis and treatment can help decrease the disruption to the person's life, family and friendships.

Outlook / Prognosis

What is the prognosis (outlook) for delusional disorder?

The prognosis (outlook) for people with delusional disorder varies depending on a few factors, including:

The type of delusional disorder.

The severity of the delusions.

The person's life circumstances, including the availability of support and a willingness to stick with treatment.

Delusional disorder doesn't usually significantly affect a person's daily functioning, but the severity of the delusion may gradually get worse. Most people with delusional disorder can remain employed as long as their work doesn't involve things related to their delusions.

The prognosis of delusional disorder is better if the person sticks to their treatment plan. Almost 50% of people have a full recovery, more than 20% of people report a decrease in symptoms and less than 20% of people report minimal to no change in symptoms.

Unfortunately, many people with this condition don't seek help. It's often difficult for people with mental health conditions to recognize they're not well. They also might be too embarrassed or afraid to seek treatment. Without treatment, delusional disorder can be a life-long condition.

What are the possible complications of delusional disorder?

If left untreated, delusional disorder might lead to:

Depression, often as a consequence of difficulties associated with the delusions.

Social isolation.

Legal issues - for example, stalking or harassing the person involved with the delusion could lead to arrest.

Self-harm or harm to others. This is more common in the jealous and persecutory types.

Living With

How can I help someone with delusional disorder?

If you know someone with delusional disorder, you can help by providing support and encouragement for them to seek help and treatment.

People with delusional disorder who feel pressured or repeatedly criticized by others will likely experience stress, which may worsen their symptoms. Because of this, a positive approach may be more helpful and effective.

The friends and family members of people with delusional disorder often experience stress, depression, grief and isolation. It's important to take care of your mental health and seek help if you're experiencing these symptoms.
A note from Cleveland Clinic
It's important to remember that delusional disorder is a mental health condition. As with all mental health conditions, seeking help as soon as symptoms appear can help decrease the disruptions to life. Mental health professionals can offer treatment plans that can help manage thoughts and behaviors.

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Delusional Disorder: Causes, Symptoms, Types & Treatment

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Delusional disorder is a type of psychotic disorder. Its main symptom is the presence of one or more delusions. A delusion is an unshakable belief in something that's untrue. The belief isn't a part of the person's culture or subculture, and almost everyone else knows this belief to be false.

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https://my.clevelandclinic.org/health/diseases/23061-schizotypal-personality-disorder#:~:text=schizotypal%20personality%20disorder%3F-,Schizotypal%20personality%20disorder%20(STPD)%20is%20a%20mental%20health%20condition%20marked,usually%20hindered%20by%20their%20symptoms.

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Overview

What is schizotypal personality disorder?

Schizotypal personality disorder (STPD) is a mental health condition marked by a consistent pattern of intense discomfort with close relationships and social interactions. People with STPD have distorted views of reality, superstitions and unusual behaviors. Their relationships are usually hindered by their symptoms.

Schizotypal personality disorder is one of a group of conditions called "Cluster A" personality disorders, which involve unusual and eccentric thinking or behaviors. Personality disorders are chronic (long-term) dysfunctional behavior patterns that are inflexible, prevalent and lead to social issues and distress.

People with schizotypal personality disorder typically display unusual behavior, odd speech and magical beliefs. They often don't realize their behavior is unusual or problematic.

Some people with schizotypal personality disorder later develop schizophrenia.

What is the difference among schizoid and schizotypal personality disorders and schizophrenia?

Schizoid personality disorder (ScPD) is a mental health condition marked by a consistent pattern of detachment from and general disinterest in social relationships. This is distinct from schizotypal personality disorder (STPD) because people with STPD have an intense discomfort with personal relationships, not a lack of interest in them.

People with STPD also have peculiar thoughts and behaviors, such as magical thinking, whereas people with ScPD generally don't.

Many researchers consider schizotypal personality disorder to be one of the schizophrenia spectrum disorders, which also includes brief psychotic disorder, schizophreniform disorder, schizoaffective disorder and delusional disorder.

However, schizotypal personality disorder is distinct from schizophrenia because people with STPD don't have psychotic symptoms, such as hallucinations and delusions, which are hallmarks of schizophrenia.

Schizophrenia negatively impacts someone's day-to-day function much more than schizotypal personality disorder.

Who does schizotypal personality disorder affect?

Most personality disorders, including schizotypal personality disorder (STPD), begin in the teen years when personality further develops and matures.

STPD affects people assigned male at birth (AMAB) slightly more than people assigned female at birth (AFAB).

How common is schizotypal personality disorder?

Schizotypal personality disorder is relatively rare. It affects approximately 3% to 5% of people in the United States.

Symptoms and Causes

What are the signs and symptoms of schizotypal personality disorder?

People with schizotypal personality disorder experience intense discomfort and distress in social situations. They have a lot of difficulties forming close relationships and maintaining them, partially due to a distorted interpretation of social interactions, as well as odd social behavior.

A person with schizotypal personality disorder may:

Have intense social anxiety and poor social relationships.

Not have close friends or confidants, except for first-degree relatives.

Have peculiar behaviors and mannerisms.

Have odd thoughts and speech, such as using excessively abstract or concrete phrases or using phrases or words in unusual ways.

Have unusual perceptive experiences and magical beliefs, such as thinking they have special paranormal powers.

Incorrectly interpret ordinary situations or happenings as having special meaning for them (idea of reference).

Be paranoid and suspicious of others' intentions.

Have difficulty with responding appropriately to social cues, such as maintaining eye contact.

Have a lack of motivation and underachieve in educational and work settings.

A person with STPD generally lacks awareness about how their thoughts and behaviors impact others.

What causes schizotypal personality disorder?

Personality disorders, including schizotypal personality disorder, are among the least understood mental health conditions. Researchers are still trying to figure out the exact cause of them, but believe they develop due to several factors.

Researchers think the cause of schizotypal personality disorder (STPD) is mainly biological and genetic because it shares many of the brain changes characteristic of schizophrenia. STPD is also more common among biological relatives of people with schizophrenia or Cluster A personality disorders, which suggests a genetic link.

Diagnosis and Tests

How is schizotypal personality disorder diagnosed?

Personality continues to evolve throughout childhood, adolescence and early adulthood. Because of this, healthcare providers don't typically diagnose someone with schizotypal personality disorder until after the age of 18.

Personality disorders, including schizotypal personality disorder, can be difficult to diagnose since most people with a personality disorder don't think there's a problem with their behavior or way of thinking and don't think they need to change their behavior.

When they do seek help, it's often due to co-existing conditions, such as anxiety or depression, not the disorder itself. Rates of these two mental health conditions are particularly high among people with schizotypal personality disorder.

When a mental health professional, such as a psychologist or psychiatrist, suspects someone might have schizotypal personality disorder, they often ask questions that'll shed light on:

Childhood history.

Relationships.

Work history.

Reality testing.

Because a person suspected of having schizotypal personality disorder may lack insight into their behaviors, mental health professionals often work with the person's family and friends to collect more details about their behaviors and history.

Mental health providers base a diagnosis of schizotypal personality disorder on the criteria for the condition in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.

Management and Treatment

How is schizotypal personality disorder treated?

Psychotherapy (talk therapy) and low-dose antipsychotic (neuroleptic) medication are the main treatment options for schizotypal personality disorder.

Antipsychotic medication for schizotypal personality disorder

Healthcare providers sometimes prescribe low-dose antipsychotic (neuroleptic) medications for people with schizotypal personality disorder to treat the following symptoms:

Antipsychotic medications are particularly useful for people with moderately severe schizotypal symptoms and those experiencing mild, transient psychotic symptoms.

Psychotherapy for schizotypal personality disorder

Psychotherapy (talk therapy) is a term for a variety of treatment techniques that aim to help people identify and change troubling emotions, thoughts and behaviors. Working with a mental health professional, such as a psychologist or psychiatrist, can provide support, education and guidance to the person and their loved ones.

Types of psychotherapy that may benefit people with schizotypal personality disorder include:

Group therapy: This is a type of psychotherapy in which a group of people meets to describe and discuss their problems together under the supervision of a therapist or psychologist. Group therapy may help someone with schizotypal personality disorder develop social skills because it addresses social anxiety and awkwardness. However, people with more severe symptoms may be disruptive in group therapy, especially if they have prominent paranoid thinking and behaviors.

Cognitive behavioral therapy (CBT): This is a structured, goal-oriented type of therapy. A therapist or psychologist helps someone take a closer look at their thoughts and emotions to understand how their thoughts affect their actions. For someone with schizotypal personality disorder, a therapist may focus on reality testing and attention to interpersonal boundaries. They may also help the person recognize distorted thinking patterns, such as referential, paranoid or magical thinking.

Prevention

Can schizotypal personality disorder be prevented?

While schizotypal personality disorder generally can't be prevented, treatment can allow a person who's prone to this condition to learn more productive ways of altering unhelpful behaviors and thoughts.

Outlook / Prognosis

What is the prognosis (outlook) for schizotypal personality disorder?

Schizotypal personality disorder is a chronic condition that requires lifelong treatment.

If left untreated, the prognosis (outlook) for schizotypal personality disorder (STPD) is generally poor. It's very common for people with STPD to have other mental health conditions, including:

About 30% to 50% of people have major depressive disorder when they're diagnosed with STPD.

It's essential that people with STPD receive treatment for these conditions.
A note from Cleveland Clinic
It's important to remember that schizotypal personality disorder (STPD) is a mental health condition. As with all mental health conditions, seeking help as soon as symptoms appear can help decrease the disruptions in a person's life. Mental health professionals can offer treatment plans that can help manage thoughts and behaviors.

The family members of people with STPD often experience stress, depression and isolation. It's important to take care of your mental health and seek help if you're experiencing these symptoms.

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Schizotypal Personality Disorder: Symptoms & Treatment

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Schizotypal personality disorder (STPD) is a mental health condition marked by a consistent pattern of intense discomfort with close relationships and social interactions. People with STPD have distorted views of reality, superstitions and unusual behaviors.

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https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596

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Diagnostic and Statistical Manual of Mental Disorders

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https://childmind.org/guide/quick-guide-to-conduct-disorder/

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Quick Guide to Conduct Disorder - Child Mind Institute

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Download our free guide to conduct disorder. Children who have conduct disorder are unkind and often violent, and they don’t care about other people’s feelings. Conduct disorder can also involve crimes like theft and vandalism.

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Centers for Disease Control and Prevention

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Children sometimes argue, are aggressive, or act angry or defiant around adults. A behavior disorder may be diagnosed when these disruptive behaviors are uncommon for the child's age at the time, persist over time, or are severe. Because disruptive behavior disorders involve acting out and showing unwanted behavior towards others they are sometimes called externalizing disorders.

Oppositional Defiant Disorder

When children act out persistently so that it causes serious problems at home, in school, or with peers, they may be diagnosed with Oppositional Defiant Disorder (ODD). ODD usually starts before 8 years of age, but no later than by about 12 years of age. Children with ODD are more likely to act oppositional or defiant around people they know well, such as family members, a regular care provider, or a teacher. Children with ODD show these behaviors more often than other children their age.

Examples of ODD behaviors include

Often being angry or losing one's temper

Often arguing with adults or refusing to comply with adults' rules or requests

Often resentful or spiteful

Deliberately annoying others or becoming annoyed with others

Often blaming other people for one's own mistakes or misbehavior

Learn more about ODD
Conduct Disorder

Conduct Disorder (CD) is diagnosed when children show an ongoing pattern of aggression toward others, and serious violations of rules and social norms at home, in school, and with peers. These rule violations may involve breaking the law and result in arrest. Children with CD are more likely to get injured and may have difficulties getting along with peers.

Examples of CD behaviors include

Breaking serious rules, such as running away, staying out at night when told not to, or skipping school

Being aggressive in a way that causes harm, such as bullying, fighting, or being cruel to animals

Lying, stealing, or damaging other people's property on purpose

Learn more about CD
Treatment for disruptive behavior disorders

Starting treatment early is important. Treatment is most effective if it fits the needs of the specific child and family. The first step to treatment is to talk with a healthcare provider. A comprehensive evaluation by a mental health professional may be needed to get the right diagnosis. Some of the signs of behavior problems, such as not following rules in school, could be related to learning problems which may need additional intervention. For younger children, the treatment with the strongest evidence is behavior therapy training for parents, where a therapist helps the parent learn effective ways to strengthen the parent-child relationship and respond to the child's behavior. For school-age children and teens, an often-used effective treatment is a combination of training and therapy that includes the child, the family, and the school.

Get help finding treatment

Here are tools to find a healthcare provider familiar with treatment options:

Managing Symptoms: Staying Healthy

Being healthy is important for all children and can be especially important for children with behavior or conduct problems. In addition to behavioral therapy and medication, practicing certain healthy lifestyle behaviors may reduce challenging and disruptive behaviors your child might experience. Here are some healthy behaviors that may help:

Engaging in regular physical activity, including aerobic and vigorous exercise

Eating a healthful diet centered on fruits, vegetables, whole grains, legumes (for example, beans, peas, and lentils), lean protein sources, and nuts and seeds

Getting the recommended amount of sleep each night based on age

Strengthening relationships with family members

Prevention of disruptive behavior disorders

It is not known exactly why some children develop disruptive behavior disorders. Many factors may play a role, including biological and social factors. It is known that children are at greater risk when they are exposed to other types of violence and criminal behavior, when they experience maltreatment or harsh or inconsistent parenting, or when their parents have mental health conditions like substance use disorders, depression, or attention-deficit/hyperactivity disorder (ADHD). The quality of early childhood care also can impact whether a child develops behavior problems.

Although these factors appear to increase the risk for disruptive behavior disorders, there are ways to decrease the chance that children experience them. Learn about public health approaches to prevent these risks:

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Behavior or Conduct Problems in Children | CDC

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Children sometimes argue, are aggressive, or act angry or defiant around adults. A behavior disorder may be diagnosed when these disruptive behaviors are uncommon for the child's age at the time, persist over time, or are severe. Learn about behavior or conduct problems in children.

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https://www.texaschildrens.org/health/pediatric-obsessive-compulsive-disorder-ocd

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Obsessive-compulsive disorder (OCD) is a common disorder that often begins in childhood and is frequently unrecognized, underdiagnosed, and undertreated.

OCD is characterized by recurrent obsessions (unwanted ideas, thoughts, images, or urges) and compulsions (repetitive behaviors or mental acts) designed to ward off risk and/or to ease distress.

Pediatric OCD is distinct from developmentally typical rituals of childhood such as rule-bound bedtime routines and superstitious behaviors. OCD is distinct from occasional uncomfortable thoughts and common childhood worries. It is more intense and persistent and the experience of OCD is more disturbing and senseless than everyday worries.

Pediatric OCD has many different manifestations - concerns about germs, worrying about being responsible for harm, seeing disturbing violent images, preoccupation with luck rules, and having to have things be "just right."

What is consistent across the many faces of OCD is the persistent effort made to reduce uncertainty and distress. Unfortunately, these efforts actually maintain and strengthen OCD symptoms. When left untreated, pediatric OCD has the potential to become a chronic and debilitating condition that interferes with development and persists into adulthood.

At any point in time, about 1 in every 100 adults (or between 2 to 3 million adults in the United States) has OCD. It is estimated that at least 1 in 200 children and adolescents in the United States has pediatric OCD. This is about the same number of kids who have diabetes.

Both boys and girls are affected by pediatric OCD. Boys are more likely to have prepubescent onset (and a family history of OCD or Tourette syndrome). Girls are more likely to develop OCD in adolescence or in their twenties.

Causes and Risk Factors

As with many behavioral or mental health conditions, the causes of OCD are not fully understood. Most experts agree that OCD is a neurobehavioral disorder, involving both brain and behavior. The brain areas most frequently implicated are the front part of the brain and deeper brain structures (called the cortical-striatal brain circuits). Serotonin is the neurotransmitter (chemical messenger) involved in these circuits. Some evidence exists that a small subset of prepubescent children with OCD have onsets and symptom exacerbations that are associated with their immune response to certain infections (such as strep throat).

Additionally, evidence suggests that OCD runs in families, and genes likely play a role in the biologic vulnerability for this disorder for many individuals. Interestingly, some experts view the type of OCD that emerges in childhood as having a stronger genetic component relative to OCD that emerges in adulthood.

While differences in the brain and genes of those affected likely play a role in OCD's development, OCD is also a learned disorder. OCD typically begins with seemingly harmless and well-intentioned behaviors designed to make uncomfortable feelings go away. However, these ways of thinking and behavioral patterns become overlearned and strengthen over time the more they are practiced. Developing new learning about feared outcomes and one's own abilities is a key component of effective treatment.

Symptoms and Types

Obsessions are intrusive thoughts, images, or urges that occur over and over again. These thoughts get stuck in the affected child's mind, like industrial strength velcro. Children and adolescents experience these thoughts as highly disturbing and unwanted. Understandably so, because obsessions come with uncomfortable feelings including fear, anxiety, disgust, doubt, and/or "not right" sensations.

The following are examples of common obsessions experienced by those with OCD:

Preoccupation with body fluids or waste, dirt, germs/disease, chemicals, or sticky substances. Fear of becoming contaminated by and/or spreading perceived contaminants.

Preoccupation with getting sick or having an illness (e.g., vomiting, developing a disease, having cancer).

Fear about being responsible for terrible harm if not sufficiently cautious (e.g., burning down a house, running over someone, irreparably hurting someone's feelings).

Unwanted thoughts (e.g., violent images, forbidden thoughts or images about sex or taboo behaviors, worries about being gay).

Fear of losing control and doing something that is horrible or inconsistent with one's sense of self (e.g., stealing, harming others, harming self).

Over concern about right and wrong, having pure intentions, fear of offending God, or concerns about blasphemy.

Superstitious ideas about luck (lucky/unlucky numbers, colors, etc.).

Concerns about evenness, symmetry, completeness, or doing something "just right" (e.g., reading or writing, arranging).

Need to know, remember, understand, or say, or do something perfectly.

Compulsions (also called rituals) are repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. While children might not always be able to explain their purpose, compulsions are aimed at preventing or reducing distress, and/or preventing a dreaded outcome. These compulsive behaviors are clearly excessive, however, and are not connected in a realistic way to the outcomes they intended to neutralize or prevent.

The following are examples of common compulsions experienced by those with OCD:

Excessive hand washing, showering, grooming, cleaning or other efforts to decontaminate.

Following rigid rules or ritualized behaviors to ensure safety.

Checking to be sure that harm was not caused or no mistakes were made.

Reassurance seeking, confessing, repeatedly asking questions.

Information seeking, body checking/inspecting.

Mental rituals such as special sayings, prayers, mentally reviewing situations.

Doing certain tasks perfectly and/or making things "just right."

Repeating, counting, touching, ordering/arranging, do-overs, or undoing.

Avoidance of situations that trigger obsessions and compulsions is a very frequent response (e.g., avoid touching items, going places, thinking things). Indeed, avoidance is often the go-to response because it frequently circumvents anxiety and the perceived need to engage in time-consuming compulsive rituals.

OCD compulsions and avoidance are sometimes called " safety behaviors " because they are used to avoid risk and discomfort. OCD does not follow the rules of common sense, however, and over time these safety behaviors actually strengthen the severity of and interference from OCD.

Diagnosis and Tests

Child psychologists, child psychiatrists and other qualified behavioral health professionals usually diagnose pediatric OCD following a comprehensive diagnostic evaluation based on observation and an assessment of symptoms. A comprehensive evaluation differentiates OCD symptoms from other conditions that also involve recurrent thoughts or repetitive behaviors (e.g., other anxiety disorders, tic disorders, habits, hair pulling, skin picking, preoccupation with body or weight, autism spectrum disorder or psychosis). Additionally, a comprehensive evaluation includes assessment of frequently co-occurring conditions as well as the family's understanding of, and participation in, the management of the child's OCD.

OCD is diagnosed when a child or adolescent has obsessions or compulsions that are time consuming, distressing, and/or are interfering with important areas of functioning (such as at school, with friends, or at home). If the child has a tic disorder (or a history of a tic disorder), a "tic-related" specifier is applied to the OCD diagnosis.

Treatment and Care

Pediatric OCD is very treatable. The first level treatment for mild to moderate pediatric OCD is a type of cognitive behavior therapy (CBT) that emphasizes an approach called exposure and response prevention or E/RP. When OCD symptoms are moderate to severe, or in circumstances that might impede successful CBT, a combined treatment approach (CBT plus medication management via serotonin reuptake inhibitors [SSRIs]) should be considered.

In CBT, children and parents are educated about the cycle of OCD and strategies to break free of OCD's dead-end traps. Early CBT involves building the child and family's readiness for engagement in the treatment. E/RP uses well-planned exposures to OCD situations combined with the child refraining from unproductive safety behaviors. Using E/RP, children and teens learn to demote the power of their OCD thoughts, learn to increase their tolerance for discomfort, and learn to develop the "mental muscles" needed to stop engaging in all the safety behaviors that keep OCD in charge.

Parents play a very important role in supporting successful CBT. They serve as cheerleaders who support and reinforce bravery, tolerance, and learning to live with doubt. Parents are taught how to change their engagement with their child's OCD, including how to fade family accommodation behaviors that enable OCD symptoms.

Since OCD often co-occurs with other disorders (e.g., Tourette syndrome, AD/HD, other anxiety disorders, eating disorders), the overall treatment plan frequently needs to take these into account. Such co-occurrences might shift treatment priorities and/or result in a refinement of the recommended treatment approach. In the small subset of children whose OCD is linked to infection, the treatment for OCD is the same (CBT and/or SSRI). Antibiotics are recommended only when a child has a current active infection.

More Information and related links

International OCD Foundation - www.ocfoundation.org Anxiety and Depression Association of America - www.adaa.org

References and Sources

American Academy of Child and Adolescent Psychiatry (2012) Practice parameters for the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 51(1), 98-113.

National Institute of Mental Health, Pediatrics and Developmental Neurosciences Branch - Information about PANDAS - www.nimh.nih.gov

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Obsessive-compulsive disorder (OCD) is a common disorder that often begins in childhood and is frequently unrecognized, underdiagnosed, and undertreated. OCD is characterized by recurrent obsessions (unwanted ideas, thoughts, images, or urges) and compulsions (repetitive behaviors or mental acts) designed to ward off risk and/or to ease distress.

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https://childmind.org/guide/quick-guide-to-obsessive-compulsive-disorder-ocd/

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What is obsessive-compulsive disorder?

Obsessive-compulsive disorder (OCD) is an anxiety disorder that can affect children and teenagers. Kids with OCD experience unwanted thoughts, worries or impulses called obsessions. Obsessions are very upsetting and hard to control. Children with OCD develop repetitive actions - called compulsions- to calm the anxiety caused by their obsessions.

Often, compulsions are not connected to obsessions in a realistic way. For example, a child might have an obsessive fear that their parents will be in a car accident. To deal with that fear, they might turn a light on and off five times. Even if they know it doesn't make sense, they feel that the ritual will keep their parents from getting hurt. Professionals call that feeling "magical thinking."

Children as young as five can develop OCD. At that age, they may not even realize that their thoughts and fears are exaggerated or unrealistic.

A child with OCD may hide their rituals until they get to be too overwhelming. They may be able to suppress their rituals at school and then act out when they get home.

Some children suddenly develop OCD symptoms, along with other disturbing symptoms, after they have had an infection, such as a staph infection. This is a disorder called PANDAS or PANS.

What are the symptoms of obsessive-compulsive disorder?

Kids with OCD usually experience both obsessions and compulsions. They use compulsions to control the anxiety that obsessions cause.

Common obsessions that kids experience include:

Fear of contamination (germs, waste, vomit, chemicals, etc.)

Needing everything to be even or symmetrical

Extreme worry about safety, like thinking that the house will burn down or a parent will get hurt

Fear that they might do something violent or terrible

Common compulsions include:

Washing their hands repeatedly

Locking and relocking doors a certain number of times

Lining up objects or touching parts of their bodies symmetrically, like scratching both ears

Counting a certain number of times or repeating something mentally

Repeatedly asking parents for reassurance that something bad isn't going to happen

Compulsions can be thoughts instead of behaviors, so they can be hard to spot. For example, a child's compulsion might be counting to 20 in their head.

How is obsessive-compulsive disorder diagnosed?

To be diagnosed with OCD a child has to have obsessions, compulsions or both. They must get in the way of the child's normal life.

The severity of the symptoms can be measured using a rating scale called Y-BOCS, or the Yale-Brown Obsessive-Compulsive Scale.

How is obsessive-compulsive disorder treated?

The most effective treatment for OCD is a form of cognitive behavior therapy (CBT) called exposure and response prevention.

In this therapy, the therapist exposes the child to small amounts of the thing that usually triggers their obsession. That way, the child gets practice dealing with their anxiety in a safe environment. The therapist helps the child avoid using their compulsion. Over time, the child feels less anxious, and they don't need the compulsion anymore. The therapist can also train the child's family to practice at home.

More severe cases of OCD are often treated with a combination of CBT and medication. The most effective medication for anxiety is SSRIs, or selective serotonin reuptake inhibitors. The medication can reduce anxiety and help the child get more out of therapy. Once kids learn skills in therapy, they can take less medication or stop altogether.

Kids with OCD will often return to their clinician in the years after their treatment for "booster sessions" to freshen up the skills they learned to control their anxiety.

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Quick Guide to Obsessive-Compulsive Disorder (OCD) - Child Mind Institute

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Lo sentimos, la página que usted busca no se ha podido encontrar. Puede intentar su búsqueda de nuevo o visitar la lista de temas populares. Obsessive-compulsive disorder (OCD) is an anxiety disorder that can affect children and teenagers. Kids with OCD experience unwanted thoughts, worries or impulses called obsessions.

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https://kidshealth.org/en/parents/ocd.html

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What Is OCD?

Obsessive-compulsive disorder (OCD) causes upsetting thoughts called obsessions. It also causes the urge to do behaviors called compulsions (also called rituals). Kids and teens with OCD get stuck in a stressful cycle of these thoughts, anxiety, and rituals.

If you think your child has OCD, start with a visit to your child's doctor or mental health provider. They can check for OCD or for other problems that could be the cause of your child's symptoms.

How Is OCD Treated?

Treatment for OCD is a type of cognitive behavioral therapy (CBT). In therapy, kids learn coping and calming skills for anxiety. They learn how to safely face fears without doing rituals.

Along with therapy, doctors may give medicines for OCD to some kids. For kids who need medicines, doctors give SSRIs (selective serotonin reuptake inhibitors). These include Zoloft®, Prozac®, and Luvox®.

Treatment works best when a parent or caregiver goes to therapy with their child. That way, they can learn how to coach their child through OCD symptoms, help their child practice skills they learn in therapy, and offer daily support.

What Signs Might Parents Notice?

Obsessions

These are stressful thoughts that come to mind over and over. A child with OCD doesn't want to think about these things. But they feel they can't stop.

Parents may notice obsessions as intense fears or worries. Kids with OCD may feel unusually upset about:

germs, dirt, illness, injury, or harm

whether someone could get sick, hurt, or die

things that seem wrong, or out of place

whether bad thoughts might come true

things that are not straight, even, or arranged "just right"

Compulsions (Rituals)

These are behaviors a child will do, trying to feel better. To the child, rituals seem like the way to stop thoughts and relieve fears. They seem like a way to keep bad things from happening.

Parents may notice that kids:

touch, tap, or step in unusual ways

arrange things over and over

repeat words, phrases, or questions

have many doubts, and trouble making choices

wash or clean more than needed

take a long time to do things - like get dressed, shower, eat, do homework

Kids may involve parents in rituals. And at first, parents may not realize that something is a ritual. For example, a child with OCD might ask for reassurance over and over. Or a child may insist a parent say or do something a set number of times, or in a set way.

Kids and teens with OCD can have obsessions, compulsions, or both.

Feelings

OCD symptoms are hard on kids. Rituals may seem to give them some relief at first. But rituals multiply. They start to take more time and energy. Kids have little left for things they enjoy. OCD thoughts, feelings, and rituals become a stressful cycle. This can make it hard to focus in school, have fun with friends, get to sleep, or relax.

Kids may seem:

anxious, worried

frustrated, irritable

sad, tired

upset when they can't do a ritual

to need constant reassurance from a parent that things are OK

Some kids may not let parents know about the thoughts, fears, and behaviors OCD causes. They may feel confused or ashamed about their fear and keep it to themselves. They may try to hide rituals they do. Some kids may have OCD symptoms for a while before their parents realize it.

How Can I Help My Child?

If you think your child may have OCD:

Talk with your child about what you've noticed. Talk in a supportive way, listen, and show love. Say something that works for your child's situation like, "I notice you fixing your socks a lot, trying to get them even. Getting them to feel right causes you a lot of stress."

Say that something called OCD might be causing the worry and the fixing. Tell your child that a checkup with a doctor can find out if this is what's going on. Let your child know that this can get better, and that you want to help.

Make an appointment with a child psychiatrist or psychologist. Your child's doctor can help you find the right person. To diagnose OCD, they will spend time talking with you and your child. They will ask questions about your child's symptoms that help point them to signs of OCD. If they diagnose OCD, they can explain the treatment.

Take part in your child's therapy. Part of treatment is coaching parents on how to respond to their child's OCD symptoms. Learn all you can about ways you can help. Learn how to support your child's progress without giving in to rituals.

Be patient. Overcoming OCD is a process. There will be many therapy visits. Be sure to go to them all. Help your child practice the things the therapist shows you. Praise your child's effort. Show how proud you feel. Remind them that OCD is not their fault.

Get support, and give it. There are lots of resources and support for families dealing with OCD. The International OCD Foundation is a good place to start. Knowing that you're not alone can help you cope. Sharing success stories with other parents can give you hope and confidence.

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OCD causes upsetting thoughts (obsessions) and the urge to do "ritual" behaviors (compulsions). Kids and teens get stuck in a stressful cycle of these thoughts, anxiety, and rituals. OCD can get better with the right attention and care.

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https://www.cdc.gov/childrensmentalhealth/ocd.html

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Centers for Disease Control and Prevention

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Many children occasionally have thoughts that bother them, and they might feel like they have to do something about those thoughts, even if their actions don't actually make sense. For example, they might worry about having bad luck if they don't wear a favorite piece of clothing. For some children, the thoughts and the urges to perform certain actions persist, even if they try to ignore them or make them go away. Children may have an obsessive-compulsive disorder (OCD) when unwanted thoughts, and the behaviors they feel they must do because of the thoughts, happen frequently, take up a lot of time (more than an hour a day), interfere with their activities, or make them very upset. The thoughts are called obsessions. The behaviors are called compulsions.

Symptoms

Having OCD means having obsessions, compulsions, or both.

Examples of obsessive or compulsive behaviors include:

Having unwanted thoughts, impulses, or images that occur over and over and which cause anxiety or distress.

Having to think about or say something over and over (for example, counting, or repeating words over and over silently or out loud)

Having to do something over and over (for example, handwashing, placing things in a specific order, or checking the same things over and over, like whether a door is locked)

Having to do something over and over according to certain rules that must be followed exactly in order to make an obsession go away.

Children do these behaviors because they have the feeling that the behaviors will prevent bad things from happening or will make them feel better. However, the behavior is not typically connected to actual danger of something bad happening, or the behavior is extreme, such as washing hands multiple times per hour.

A common myth is that OCD means being really neat and orderly. Sometimes, OCD behaviors may involve cleaning, but many times someone with OCD is too focused on one thing that must be done over and over, rather than on being organized. Obsessions and compulsions can also change over time.
Learn more about OCD
Treatment for OCD

The first step to treatment is to talk with a healthcare provider to arrange an evaluation. A comprehensive evaluation by a mental health professional will determine if the anxiety or distress involves memories of a traumatic event that actually happened, or if the fears are based on other thoughts or beliefs. The mental health professional should also determine whether someone with OCD has a current or past tic disorder. Anxiety or depression and disruptive behaviors may also occur with OCD.

Treatments can include behavior therapy and medication. Behavior therapy, specifically cognitive-behavioral therapy, helps the child change negative thoughts into more positive, effective ways of thinking, leading to more effective behavior. Behavior therapy for OCD can involve gradually exposing children to their fears in a safe setting; this helps them learn that bad things do not really occur when they don't do the behavior, which eventually decreases their anxiety. Behavior therapy alone can be effective, but some children are treated with a combination of behavior therapy and medication. Families and schools can help children manage stress by being part of the therapy process and learning how to respond supportively without accidentally making obsessions or compulsions more likely to happen again.

Get help finding treatment

Here are tools to find a healthcare provider familiar with treatment options:

Prevention of OCD

It is not known exactly why some children develop OCD. There is likely to be a biological and neurological component, and some children with OCD also have Tourette syndrome or other tic disorders. There are some studies that suggest that health problems during pregnancy and birth may make OCD more likely, which is one of many important reasons to support the health of women during pregnancy.
Learn about preventing problems during pregnancy

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Obsessive-Compulsive Disorder in Children | CDC

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Many children occasionally have thoughts that bother them, and they might feel like they have to do something about those thoughts, even if their actions don't actually make sense. Learn about Obsessive-Compulsive Disorder (OCD) in children.

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https://www.nationwidechildrens.org/conditions/conduct-disorders#:~:text=Conduct%20disorder%20refers%20to%20a,hostile%20and%20sometimes%20physically%20violent.

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What Symptoms Should Parents Look for?

There are four basic types of behavior that characterize conduct disorder:

Physical aggression (such as cruelty toward animals, assault or rape).

Violating others' rights (such as theft or vandalism).

Lying or manipulation.

Delinquent behaviors (such as truancy or running away from home).

Conduct disorder is characterized by aggression toward others and a callous disregard for their rights and needs. Adolescents and teens with conduct disorder can find acts of aggression, deceit and coercion to be gratifying. Your child may meet the criteria for conduct disorder if you find them engaging in several of the below behaviors:

Many young people with conduct disorder will have trouble:

Feeling and expressing empathy or remorse.

Showing emotion toward others.

Performing well in the school or community and blaming others for poor performance.

They often misinterpret the actions of others as being hostile or aggressive. They respond by escalating the situation into verbal or physical conflict.

In adolescents and teens, conduct disorder may be associated with other difficulties, including:

In younger children, it can be more of a challenge to distinguish signs of conduct disorder from more typical "acting out".

At times, these same symptoms can be seen in children without the disorder. The difference is frequency, intensity, and duration, as well as to what extent it impacts their functioning. In children with conduct disorder, these behaviors happen much more frequently.

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There are four basic types of behavior that characterize conduct disorder: Physical aggression (such as cruelty toward animals, assault or rape). Violating others' rights (such as theft or vandalism). Lying or manipulation. Delinquent behaviors (such as truancy or running away from home).

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https://www.verywellmind.com/what-is-cognitive-behavior-therapy-2795747

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Cognitive behavior therapy (CBT) is a type of mental health treatment that helps identify and change thought patterns that contribute to psychological distress.

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https://www.additudemag.com/what-is-adhd-symptoms-causes-treatments/

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What Is ADHD? Symptoms & Meaning

ADHD stands for attention deficit hyperactivity disorder, a complex brain disorder that impacts approximately 11% of children and almost 5% of adults in the U.S. ADHD is a developmental impairment of the brain's executive functions. People with ADHD have trouble with impulse-control, focusing, and organization.

Neuroscience, brain imaging, and clinical research tell us a few important things: ADHD is not a behavior disorder. ADHD is not a mental illness. ADHD is not a specific learning disability. ADHD is, instead, a developmental impairment of the brain's self-management system. Both adults and children can be diagnosed with ADHD.

ADHD Symptoms

What are the signs of being ADHD? Common ADHD symptoms include:

ADHD symptoms vary by individual. You or your child may experience all or just some of the above symptoms, along with others detailed in the DSM-V.
[ADHD Directory: Find an ADHD Specialist or Clinic Near You]
Many patients and clinicians describe ADHD as an iceberg, where most symptoms lay hiding under the surface - out of sight but ever present. If you think you or a loved one might have ADHD, take one of our free, anonymous tests below to see if you should seek a formal diagnosis.

What Are the 3 Types of ADHD?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) previously identified three types of ADHD:

Primarily hyperactive-impulsive type

Primarily inattentive type (formerly called ADD)

Primarily combined type

Primarily Hyperactive-Impulsive ADHD

People with primarily hyperactive-impulsive ADHD act "as if driven by a motor" with little impulse control - moving, squirming, and talking at even the most inappropriate times. They are impulsive, impatient, and interrupt others.

Primarily Inattentive ADHD (Formerly ADD)

People with the inattentive subtype of ADHD have difficulty focusing, finishing tasks, and following instructions. They are easily distracted and forgetful. They may be daydreamers who lose track of homework, cell phones, and conversations with regularity.

Experts believe that many children with the inattentive subtype of ADHD may go undiagnosed because they do not tend to disrupt the learning environment.
[Free Download: An In-Depth Guide to Inattentive ADHD]
Primarily Combined Type ADHD

Individuals with combined-type ADHD display a mixture of all the symptoms outlined above. A physician will diagnose patients with this Combined Type ADHD, of they meet the guidelines for Primarily Inattentive ADHD and Primarily Hyperactive-Impulsive ADHD. That is, they must exhibit 6 of the 9 symptoms identified for each sub-type.

How Do Physicians Diagnose the Type of ADHD?

These subtypes are now considered "presentations" in the most recent version of the DSM, the DSM-V. Researchers determined that people often move from one subtype to another. For example, a child may present as primarily hyperactive-impulsive in preschool, and lose much of the hyperarousal in adolescence to fit the primarily inattentive presentation. In college and adulthood, the same individual may transition to combined presentation.

The subtypes were primarily based on overt behavioral symptoms, and ignored less visible symptoms like emotional dysregulation, cognitive patterns, and sleep difficulties. Behavioral symptoms imperfectly capture the defining features of ADHD. Non-behavioral characteristics are increasingly recognized in research and diagnosis.

What Are the Symptoms of Each ADHD Subtype?

The symptoms of ADHD are spelled out in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), which lists nine symptoms that suggest ADHD-Primarily Inattentive and nine that suggest ADHD-Primarily Hyperactive/Impulsive. A child may be diagnosed with ADHD only if he or she exhibits at least six of nine symptoms from one of the lists below, and if the symptoms have been noticeable for at least six months in two or more settings - for example, at home and at school. What's more, the symptoms must interfere with the child's functioning or development, and at least some of the symptoms must have been apparent before age 12. Older teens and adults may need to consistently demonstrate just five of these symptoms in multiple settings.
What Are the 9 Symptoms of ADHD - Primarily Inattentive Type?

Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or during other activities (e.g., overlooks or misses details, work is inaccurate).

Often has difficulty sustaining attention in tasks or play activities (e.g., has difficulty remaining focused during lectures, conversations, or lengthy reading).

Often does not seem to listen when spoken to directly (e.g., mind seems elsewhere, even in the absence of any obvious distraction).

Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., starts tasks but quickly loses focus and is easily sidetracked).

Often has difficulty organizing tasks and activities (e.g., difficulty managing sequential tasks; difficulty keeping materials and belongings in order; messy, disorganized work; has poor time management; fails to meet deadlines).

Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (e.g., schoolwork or homework; for older adolescents and adults, preparing reports, completing forms, reviewing lengthy papers).

Often loses things necessary for tasks or activities (e.g., school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).

Is often easily distracted by extraneous stimuli (for older adolescents and adults, may include unrelated thoughts).

Is often forgetful in daily activities (e.g., doing chores, running errands; for older adolescents and adults, returning calls, paying bills, keeping appointments)

Take the Self-Test: Symptoms of Inattentive ADHD in Children

Take the Self-Test: Symptoms of Inattentive ADHD in Adults

What Are the 9 Symptoms of ADHD - Primarily Hyperactive-Impulsive Type?

Often fidgets with or taps hands or feet or squirms in seat.

Often leaves seat in situations when remaining seated is expected (e.g., leaves his or her place in the classroom, in the office or other workplace, or in other situations that require remaining in place).

Often runs about or climbs in situations where it is inappropriate. (Note: In adolescents or adults, may be limited to feeling restless.)

Often unable to play or engage in leisure activities quietly.

Is often "on the go," acting as if "driven by a motor" (e.g., is unable to be or uncomfortable being still for extended time, as in restaurants, meetings; may be experienced by others as being restless or difficult to keep up with).

Often talks excessively.

Often blurts out an answer before a question has been completed (e.g., completes people's sentences; cannot wait for turn in conversation).

Often has difficulty waiting his or her turn (e.g., while waiting in line).

Often interrupts or intrudes on others (e.g., butts into conversations, games, or activities; may start using other people's things without asking or receiving permission; for adolescents and adults, may intrude into or take over what others are doing)."

Take the Self-Test: Symptoms of Hyperactive & Impulsive ADHD in Children

Take the Self-Test: Symptoms of Hyperactive & Impulsive ADHD in Adults

What Causes ADHD?

The causes of ADHD remain somewhat unclear. Research suggests that genetics and heredity play a large part in determining who gets ADHD. However, scientists are still investigating whether certain genes, especially ones linked to the neurotransmitter dopamine, play a defined role in developing ADHD.

Additional research suggests that exposure to certain chemicals may increase a child's risk of having ADHD.

ADHD is not caused by bad parenting, too much sugar, or too many video games. ADHD is a brain-based, biological disorder. Brain imaging studies and other research show many physiological differences in the brains of individuals with ADHD.

How is ADHD Diagnosed?

There is no single test for ADHD. To make a diagnosis, your doctor will assess for any ADHD symptoms exhibited by you or your child in the past six months. They will also do a physical exam and review your medical history to rule out any other medical or psychiatric conditions that could be causing symptoms.

Your doctor or specialists will perform an assessment using the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), which details the symptoms listed above.

ADHD Diagnosis in Children

A child may be diagnosed with ADHD only if he or she exhibits at least six of nine symptoms outlined in DSM-V, and if the symptoms have been noticeable for at least six months in two or more settings - for example, at home and at school. What's more, the symptoms must interfere with the child's functioning or development, and at least some of the symptoms must have been apparent before age 12. Most children with ADHD receive a diagnosis in elementary school.

When diagnosing a child, your doctor or specialist may also review school records and questionnaires completed by your child's teacher and/or caretakers. They will likely talk with and observe your child, as well as conduct screening for learning disabilities. They will also rule out other conditions that share similar symptoms to ADHD.

ADHD Diagnosis in Adults

Older teens and adults may need to consistently demonstrate just five of these symptoms in multiple settings. For an adolescent or adult to receive a diagnosis of ADHD, the symptoms need to have been present before the age of 12. Symptoms must also not be better explained by another disorder.

ADHD in Children

According to the Centers for Disease Control and Prevention, 1 in 10 children between the age of 5 and 17 receive an ADHD diagnosis, making ADHD one of the most common childhood neurodevelopmental disorders in the U.S.

The symptoms of ADHD are often identified at school, as many children with ADHD have difficulty succeeding in a classroom setting. While teachers cannot diagnose ADHD, they are often the first to suspect ADHD in children as the symptoms typically affect school performance or disrupt the rest of the class.

Many symptoms of ADHD can be typical childhood behaviors, so it can be difficult to know if a child is displaying ADHD symptoms. Children with primarily hyperactive-impulsive ADHD may initially be seen as disruptive or misbehaving, as they are often hyper, impulsive, and impatient, and may interrupt at inappropriate times.

Boys are more than twice as likely as girls to receive an ADHD diagnosis, in part because ADHD is still wrongly considered a male disorder and because boys are more likely than girls to exhibit outward signs of hyperactivity.

Adult ADHD

ADHD is diagnosed in roughy 4.4% of the adult population in the U.S., although this figure is thought to be underreported, as up to 85% of children with ADHD are at risk for having the disorder as adults, and only 10.9% of adults with ADHD receive treatment.

Untreated ADHD in adults can negatively impact many aspects of life, including work, relationships, and mental health. Symptoms such as trouble managing time, impatience, disorganization, forgetfulness, and mood swings can all cause problems for an individual not actively taking steps to manage their ADHD.

Adult ADHD seldom exists alone. Roughly 60% to 70% of adults with ADHD have a comorbid disorder , such as anxiety, mood disorder, or substance abuse. If you suspect you may have adult ADHD, consult with your doctor or mental health professional about diagnosis and treatment so you can improve your well-being and quality of life.

ADHD Treatment

The best treatment strategies for ADHD are multimodal ones - combinations of several different, complementary approaches that work together to reduce symptoms. For one person, this ideal combination may include ADHD medication, nutrition, exercise, and behavioral therapy. For another, it may mean taking ADHD supplements and vitamins, practicing mindfulness, and spending lots of time outdoors in nature. More and more, pediatric and adult patients are pairing stimulant medication with digital therapies like EndeavorRx, which is available by prescription for patients age 8 to 12, or pinpointed apps like EndeavorOTC, a new mobile video game designed to improve focus in adults with ADHD.

Finding the right ADHD treatments - and managing them - takes research, planning, organization, and persistence. Early on, talk with your child's doctor about your options.

ADHD Medication

For children aged 6 and over or adults, medication may be an important part of the treatment plan. Finding the right medication to manage ADHD typically involves some trial and error but can lead to a significant reduction in symptoms.

The two main types of medication used to treat ADHD are stimulants and non-stimulants.

Central nervous system (CNS) stimulants, like Ritalin or Adderall, are the most prescribed ADHD medications. These ADHD medications work by increasing the amounts of the chemicals dopamine and norepinephrine in the brain, which help with focus. There are three categories of stimulant medications:

Short-acting (taken a few times a day)

Intermediate-acting (taken less often)

Long-acting (taken one a day)

If stimulants cause problematic side effects, or simply are not effective, your doctor may suggest trying a non-stimulant medication, like Strattera or Intuniv.

Non-stimulant ADHD medications are considered second-line or third-line treatments because the level of benefits and response rates are significantly lower. Meaning, stimulant medications are more effective at relieving symptoms for a larger percentage of people.

ADHD medications can have many benefits, as well as side effects. The decision to manage ADHD symptoms with medication can be a difficult one. Learn more about the risks and benefits of stimulants and non-stimulants, medication options, how to gauge effectiveness, and more.

What Is the Definition of ADHD?

"Attention deficit" is, some experts assert, a misleading name. "Attention deregulation" might be a more accurate description since most people with ADHD have more than enough attention - they just can't harness it in the right direction at the right time with any consistency. And so individuals with ADHD hyperfocus and lose track of time, or misplace their keys, or blurt out an unrelated thought when their focus breaks free from its chains.

Understanding ADHD: Next Steps

Sources

¹ "Data & Statistics." Centers for Disease Control and Prevention. Ed. Center for Disease Control. Centers for Disease Control and Prevention, 14 Feb. 2017. Web. 14 Mar. 2017.
² Association, American Psychiatric, ed. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington: American Psychiatric, 2014.
³ Association, American Psychiatric, ed. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington: American Psychiatric, 2014.
⁴ Thapar, Anita, and Evangelia Stergiakouli. "An Overview on the Genetics of ADHD." Xin li xue bao. Acta psychologica Sinica (Aug. 2008) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2854824/
⁵ Philip J. Landrigan, Jordan Slutsky. Are Learning Disabilities Linked to Environmental Factors? Learning Disabilities Worldwide. https://www.ldworldwide.org/environmental-toxins
⁶ Dovey, Dana. "Doctors May Soon Be Able To Diagnose ADHD With An MRI Scan." Medical Daily. IBT Media Inc., 30 Apr. 2014. Web. 14 Mar. 2017.
⁷ https://www.(d(.gov/nchs/fastats/adhd.htm
⁸ https://www.(d(.gov/nchs/fastats/adhd.htm
⁹ Kessler, R. C., Adler, L., Barkley, R., Biederman, J., Conners, C. K., Demler, O., Zaslavsky, A. M. (2006). The Prevalence and Correlates of Adult ADHD in the United States: Results from the National Comorbidity Survey Replication. American Journal of Psychiatry. 163, 716-723.
¹⁰ Donzelli, G., et al."The Association between Lead and Attention-Deficit/Hyperactivity Disorder: A Systematic Review." International Journal of Environmental Research and Public Health. January 2019, 16:3. doi: 10.3390/ijerph16030382

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What Is ADHD? Attention Deficit Hyperactivity Disorder in Children and Adults

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ADHD (attention deficit hyperactivity disorder) is a neurological disorder that impacts the parts of the brain that help us plan, focus on, and execute tasks. ADHD symptoms vary by sub-type - inattentive, hyperactive, or combined - and are often more difficult to diagnose in girls and adults.

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Evans, S., Schultz, B., DeMars, C., & Davis, H. (2011, September). Effectiveness of the challenging horizons after school program for young adolescents with adhd. Behavior Therapy. (42)3, 462-474. https://doi.org/10.1016/j.beth.2010.11.008

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https://www.cdc.gov/ncbddd/adhd/features/adhd-and-school-changes.html#:~:text=ADHD%20and%20schools&text=This%20can%20mean%20special%20education,organizing%20work%2C%20and%20frequent%20communication.

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Centers for Disease Control and Prevention

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Many children with attention-deficit/hyperactivity disorder (ADHD) struggle with school. Recently, children have faced a variety of changes in the way that they attend school. Some might be attending virtual classes; others might attend school in-person with many new rules. To help your child with ADHD adjust to these changes, learn about the resources available for parents.

ADHD and schools

Children with ADHD might experience more obstacles in their path to success than the average student.

Most children with ADHD receive some school services. This can mean special education services, such as individual or small group instruction with a special education teacher; or accommodations, such as changing how assignments, tasks, and tests are done, extra help with remembering and organizing work, and frequent communication. Together, teachers and parents can help children with ADHD succeed in school.

A changing school environment

In the recent past, many children experienced changes in their learning environment. Early in the COVID-19 pandemic, many schools switched from in-person schooling to distance schooling, including learning at home and online. Some schools continued with virtual-only schooling, others had a mix of in-person and virtual schooling, and some returned to in-person schooling, but with additional rules in place. Changes in COVID-19 Community Levels may mean more changes, and virtual schooling is an ongoing option in many areas.

School can present challenges for many children with ADHD. Because ADHD symptoms include difficulty with attention regulation, hyperactivity, and impulsivity, which can affect planning, organizing, and managing behavior, many children with ADHD struggle with change. Here are some of the challenges that children with ADHD can face in different learning environments:

Physical activity and movement are important for all children, but especially so for children with ADHD. Rules about keeping distance and more time spent with virtual learning can mean sitting still without moving for longer periods of time. Changes in after-school activities may mean fewer opportunities for active group play. Finding time to move may be especially important for children who struggle with hyperactivity.

Children with ADHD struggle more with boredom and putting mental effort into challenging tasks. Virtual learning or in-person school with more rules may lack the novelty and excitement. Teachers may need to find new ways to keep children with ADHD from being bored and keep them engaged in learning.

Children with ADHD are more likely than their peers to have some difficulties with social relationships, so having fewer opportunities to interact freely during the day may mean they need other ways to practice social skills and build on relationships.

Transitions can be challenging for children with ADHD, and having to spend time doing schoolwork, homework, and family activities in the same space where parents may also have to do their own work can create additional stress for students and parents.

Children with ADHD are likely to have other disorders in addition to ADHD, which can make coping with stress, change, and social isolation associated with virtual learning even more difficult. They may need additional support.

With changes in how school is being conducted, there is also the possibility that children who have special needs are not getting the services they need. The U.S. Department of Education has issued information for implementing special education services for schools that use distance learning.

However, some children with ADHD may respond positively to some of the changes. For example, virtual learning may provide fewer distractions for children who find it more difficult to tune out other people around them. More structured classrooms with more distance between students might help some children focus. With fewer activities in their daily schedules, some children may have more time to get the sleep they need. Since each child may react differently to changes in their environment, parents, teachers, and students need support that works for each individual child.

Working to help parents, students, and teachers

To help parents and students adapt to the changing environment, the National Resource Center on ADHD (NRC), a funded CDC partner, has worked to create resources and support for parents. These resources include advice for parents and teachers on

creating enough structure so that the child can learn new routines,

keeping the child engaged with learning,

managing difficulty with attention while coping with changes,

setting up the home learning environment,

helping children stay connected with other children, and

keeping children healthy and active.

Caring for a child with special needs can mean extra challenges. Parents of children with ADHD may experience extra stress from supporting their child while coping with changes and may need additional help. The NRC has created a parent toolkit, including information and resources to help parents understand more about ADHD and how to support their child, and tips and advice that help parents with their own stress during uncertain times.

CDC also provides information and resources for parents making decisions about schooling, coping with their own stress, and ensuring children's well-being.

Schools are a part of ADHD treatment

To meet the needs of children with ADHD, schools can

Be part of effective treatment plans for children with ADHD; and

Provide special education services or accommodations.

The American Academy of Pediatrics' recommendations for ADHD treatment state that school is a necessary part of any treatment plan. Behavioral classroom management focusing on positive responses is an evidence-based treatment for ADHD and can complement parent training in behavior management. The NRC also provides some tips for receiving treatment via when in-person treatment is not possible. Parents, teachers, healthcare providers, and older children and teens can collaborate to develop an approach that works best for each student.

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Many children with attention-deficit/hyperactivity disorder (ADHD) struggle with school. Recently, children have faced a variety of changes in the way that they attend school. Some might be attending virtual classes; others might attend school in-person with many new rules. To help your child with ADHD adjust to these changes, learn about the resources available for parents.

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https://www.healthychildren.org/English/health-issues/conditions/adhd/Pages/default.aspx

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Almost all children have times when their attention or behavior veers out of control. However, for some children, these types of behaviors are more than an occasional problem. Children with attention-deficit/hyperactivity disorder (ADHD) have behavior problems that are so frequent and severe that th…

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https://ct.counseling.org/2011/01/taking-care-of-yourself-as-a-counselor/

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Taking care of yourself as a counselor - Counseling Today

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Anyone who has flown on an airplane and listened to the flight attendant before takeoff has been cautioned what to do in the event the oxygen masks fall from the ceiling: Put on your own mask first before trying to help someone else. Counselor wellness experts say that idea has mileage on the ground…

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Taking care of yourself as a counselor

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https://www.healthline.com/health/anxiety/separation-anxiety#symptoms

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What is separation anxiety disorder?

Separation anxiety is a normal part of childhood development. It commonly occurs in babies between 8 and 12 months old, and usually disappears around age 2. However, it can also occur in adults.

Some children have symptoms of separation anxiety during their grade school and teenage years. This condition is called separation anxiety disorder or SAD. Three to four percent of children have SAD.

SAD tends to indicate general mood and mental health issues. Around one-third of children with SAD will be diagnosed with mental illness as an adult.

Symptoms of SAD occur when a child is separated from parents or caregivers. Fear of separation can also cause anxiety-related behaviors. Some of the most common behaviors include:

clinging to parents

extreme and severe crying

refusal to do things that require separation

physical illness, such as headaches or vomiting

violent, emotional temper tantrums

refusal to go to school

poor school performance

failure to interact in a healthy manner with other children

refusing to sleep alone

nightmares

SAD is more likely to occur in children with:

a family history of anxiety or depression

shy, timid personalities

low socioeconomic status

overprotective parents

a lack of appropriate parental interaction

problems dealing with kids their own age

SAD can also occur after a stressful life event such as:

moving to a new home

switching schools

divorce

the death of a close family member

Children that experience three or more of the above symptoms may be diagnosed with SAD. Your doctor may order additional tests to confirm the diagnosis.

Your doctor might also watch you interact with your child. This shows whether your parenting style affects how your child deals with anxiety.

Therapy and medication are used to treat SAD. Both treatment methods can help a child deal with anxiety in a positive way.

Therapy

The most effective therapy is cognitive behavioral therapy (CBT). With CBT, children are taught coping techniques for anxiety. Common techniques are deep breathing and relaxation.

Parent-child interaction therapy is another way to treat SAD. It has three main treatment phases:

Child-directed interaction (CDI), which focuses on improving the quality of the parent-child relationship. It involves warmth, attention, and praise. These help strengthen a child's feeling of safety.

Bravery-directed interaction (BDI), which educates parents about why their child feels anxiety. Your child's therapist will develop a bravery ladder. The ladder shows situations that cause anxious feelings. It establishes rewards for positive reactions.

Parent-directed interaction (PDI), which teaches parents to communicate clearly with their child. This helps to manage poor behavior.

The school environment is another key to successful treatment. Your child needs a safe place to go when they feel anxious. There should also be a way for your child to communicate with you if necessary during schools hours or other times when they're away from home. Finally, your child's teacher should encourage interaction with other classmates. If you have concerns about your child's classroom, speak with the teacher, principle, or a guidance counselor.

Medication

There are no specific medications for SAD. Antidepressants are sometimes used in older children with this condition if other forms of treatment are ineffective. This is a decision that must be carefully considered by the child's parent or guardian and the doctor. Children must be monitored closely for side effects.

family activities that are limited by negative behavior

parents with little to no time for themselves or each other, resulting in frustration

siblings that become jealous of the extra attention given to the child with SAD

Emotional and social development are both seriously affected by SAD. The condition can cause a child to avoid experiences crucial to normal development.

SAD can also affect family life. Some of these problems may include:

If your child has SAD, speak with your doctor about treatment options and ways you can help manage its effect on family life.

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Separation Anxiety Disorder: Symptoms, Risk Factors & Diagnosis

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What is separation anxiety disorder? Separation anxiety is a normal part of childhood development. It commonly occurs in babies between 8 and 12 months old, and usually disappears around age 2. However, it can also occur in adults. Some children have symptoms of separation anxiety during their grade school and teenage years.

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https://www.psychologytoday.com/us/blog/the-intelligent-divorce/201304/divorce-and-separation-anxiety

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I promise I'll be better, Daddy please don't leave. -"Family Portrait," Pink

Divorce is a stressor; no doubt: It can raise your blood pressure and distract you into having an accident. Can the stress of a divorce affect your children? The answer, of course, is yes. But, it's not always as straightforward as it seems.

A number of child psychiatric disorders can be triggered by divorce. Today, we will focus on a common problem that's diagnosed in the face of a divorce; it's called Separation Anxiety Disorder.

Separation Anxiety Disorder is a clinical term that describes an extreme state of distress that's experienced when a person is separated from someone they're close to, like a mother or a father.

Now, it's somewhat normal for children to experience separation anxiety on occasion; most young kids have moments of such panic; but it's short-lived. Real Separation Anxiety Disorder is an extreme state. The child is terrified of being left alone. She's convinced, for instance, that robbers are about to come. Or, he believes that some strange creature in hiding in the basement. Or, sadly, she worries that Mommy or Daddy is going to die - tonight.

Some kids refuse to sleep alone.

Others will complain of feeling sick (when perfectly healthy), and become extremely clingy.

When it gets bad, some may even refuse to go to school.

Separation Anxiety and Divorce: Separation anxiety tends to be more severe in children who have foster or divorced parents, which is understandable because they are separated from and in some ways "lose" a parent. It's reported frequently in adopted kids as well.

Kids often experience their parents' divorce as a breaking of trust. After all, it's not something they asked for. They expected their family to last forever and when it comes to an end, it's like the bottom has fallen out. So don't be surprised if there's an increase in separation anxiety soon after a parent moves out.

And, children aren't the only ones affected by anxiety during the turmoil of a divorce. The lives of adults who go through a divorce are disrupted, and they also often experience stress and anxiety because they've lost someone too.

There is hope: First, make sure that you have the right diagnosis. Every child going through divorce is entitled to a miniature experience of Separation Anxiety Disorder. See if the symptoms last or disappear. They may well go away after a week or two. It's normal to be upset by something as big as a separation.

If your child has temporary separation anxiety symptoms, you may benefit from some of the following 10 pointers. I very much like Dawn Huebner's books. Identifying triggers, like rocky transitions with mom or dad, can be critical.

And, if it doesn't abate, get your child assessed. Talk therapy may help. Recently, there's been increasing interest in Cognitive Behavioural Therapy, medication or a combination of the two for the treatment of Separation Anxiety Disorder.
Separation Anxiety Pointers:

Keep a routine at home. Kids benefit from predictability and structure.

Respect your child's feelings. Fears are exaggerated when they are private.

What triggers the anxiety? Talk to your child to identify what makes it worse and rectify it if possible. Perhaps yelling between you and her dad is too much.

Recognize when reassurance is not enough. Don't delay getting help and be sure to intervene before it leads to school avoidance.

Keep calm during separation or goodbyes. Your child will take his cue from how you react. Having a special goodbye ritual like a special wave can be hugely reassuring and comforting.

Don't be afraid to use medication if required. They often work.

Try the Child Anxiety Book Series by Dawn Huebner. You can read it together.

Practice separation. When your child manages to separate without fuss, use positive reinforcement to praise him.

Consider eliminating scary television shows and movies for now. Children's fears may be exacerbated by the frightening scenes they see on TV or in the movies.

The Takeaway: Some children have a natural tendency towards anxiety. And, others will get triggered despite no past history. It doesn't really matter. Divorce is a stress, but it does die down over time. Things usually do get better.

It may be hard. You will feel guilty at times, and quite frustrated at others. These kids can be exasperating. But, they also are so very scared.

If you suspect that your child has the real thing, get help. Start with your pediatrician. He or she will know the best therapist to go to. Usually, treatment is quite effective. Finally, don't be afraid to get some support for yourself.

Anxiety, after all, is not only for kids.

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I promise I'll be better, Daddy please don't leave. -"Family Portrait," Pink Divorce is a stressor; no doubt: It can raise your blood pressure and distract you into having an accident. Can the stress of a divorce affect your children? The answer, of course, is yes.

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https://namitexas.org

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A family-based, grassroots support and advocacy organization.

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https://www.samhsa.gov/find-help/national-helpline

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Substance Abuse and Mental Health Services Administration

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Frequently Asked Questions - What is SAMHSA’s National Helpline?

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https://www.healthline.com/health/disruptive-mood-dysregulation-disorder

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What is disruptive mood dysregulation disorder?

Temper tantrums are a part of growing up. Many parents become skilled in anticipating the situations that may "set off" an emotional episode in their children. If your child is exhibiting tantrums that seem out of proportion, are difficult to control, or seem to be happening constantly, you may consider having your child evaluated for disruptive mood dysregulation disorder (DMDD).

DMDD is a psychiatric condition. It's typically only diagnosed in children. The main symptoms include irritability, emotional dysregulation, and behavioral outbursts. Outbursts are usually in the form of severe temper tantrums.

The condition was introduced in 2013. It was defined in the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5). DMDD was developed as a diagnosis to help reduce the overdiagnosis of bipolar disorder in children.

DMDD is classified as a depressive disorder. The common feature of all depressive disorders is a clinically significant impairment in mood. Mood may be described as a person's internal emotional experience.

In DMDD, the disturbance in mood is observable to others as anger and irritability. The key symptoms of DMDD that set it apart from other psychiatric conditions include:

Severe temper tantrums: These may take the form of verbal outbursts (yelling, screaming) or behavioral outbursts (physical aggression toward people or things).

Temper tantrums that aren't normal for a child's age: It's not uncommon for toddlers to have meltdowns or for older children to yell when they don't get their way. In DMDD, the tantrums aren't what you would expect for a child's developmental level in terms of how often they occur and how bad the episodes are. For example, you wouldn't expect an 11-year-old to regularly destroy property when they're angry.

Outbursts occur approximately three or more times a week: This isn't a hard-and-fast rule. For example, a child wouldn't be disqualified for diagnosis if they have two tantrums one week, but usually have more than two.

Irritable and angry mood between tantrums: Even when the child isn't in an explosive episode, caregivers will see a disturbance in mood for most of the day, nearly every day. Parents may regularly feel like they are "walking on eggshells" to avoid an episode.

Tantrums occur in multiple settings: DMDD may not be the right diagnosis if a child only has outbursts in certain situations, like with one parent or a particular caregiver. For diagnosis, symptoms should be present in at least two settings, such as at home, in school, or with peers.

In addition to the above symptoms, diagnosis requires that:

The disturbance in mood has been present most of the time for a year.

The child is between 6 to 17 years in age. Diagnosis isn't made before or after this age range.

The symptoms were present before the age of 10.

Finally, a child will only be diagnosed with DMDD if the tantrums aren't due to another condition, like autism spectrum disorder, a developmental disability, or the effects of substance abuse.

DMDD was introduced as a diagnosis to address what psychiatrists and psychologists believed to be the overdiagnosis of pediatric bipolar disorder. The key feature of bipolar disorders is the presence of manic or hypomanic episodes.

A manic episode is defined as a period of elevated, expansive, or irritable mood. In addition, a person also has an increase in goal-directed activity or energy. Hypomanic episodes are less severe versions of manic episodes. A person with bipolar disorder doesn't always experience manic episodes. They aren't a normal part of their daily functioning.

DMDD and bipolar disorders may both lead to irritability. Children with DMDD tend to be persistently irritable and angry, even when full-blown tantrums aren't present. Manic episodes tend to come and go. You may ask yourself if your child is persistently in a bad mood, or if their mood seems to be out of the ordinary. If it's persistent, they may have DMDD. If it's out of the ordinary, their doctor may consider a bipolar disorder diagnosis.

Additionally, the key feature of DMDD is irritability, while mania may also include:

euphoria, or extreme positive emotion

extreme excitement

sleeplessness

goal-directed behavior

Differentiating DMDD and bipolar isn't always straightforward and should be done by a professional. Talk to your child's doctor if you suspect either of these conditions.

One of over 3,200 children between the ages of 2 and 17 years found that between 0.8 and 3.3 percent of children meet criteria for DMDD. DMDD may be more common in children than among teens.

Specific risk factors for this disorder are still under investigation. Children with DMDD temperamental vulnerabilities, and at a young age may have been more prone to:

They may have previously met diagnostic criteria for:

Having a family member with a psychiatric condition may increase risk. Male children are more likely to present with DMDD. Also, children with DMDD are more likely to experience:

family conflict

social difficulties

school suspensions

live in settings of economic stress

If you're concerned that your child or a loved one may be experiencing this condition, you should get a professional assessment. Contacting your family doctor can be the first step. They can refer you to a specialist, such as a psychiatrist or psychologist. The specialist can conduct a formal assessment. Assessments may take place at a hospital, a specialized clinic, or a private office setting. It can even be made at school by a school psychologist.

DMDD is diagnosed by a medical doctor, psychologist, or nurse practitioner. Diagnosis is only made following an assessment. The assessment should involve an interview with caregivers and an observation or meeting with the child. Standardized questionnaires, school visits, and interviews with teachers or other caregivers may be part of the assessment.

Helping children with DMDD may involve psychotherapy or behavioral interventions, medication, or a combination of both. Non-medication treatments should be explored first. Treatments aren't necessarily specific for DMDD. There are a variety of approaches that are commonly used for various mental health difficulties in children.

Psychotherapy and behavioral interventions

During psychotherapy, parents and children meet with a therapist every week to work on developing better ways of relating to one another. Among older children, individual therapy, such as cognitive behavior therapy, can help children learn to more effectively think of and respond to situations that upset them. Additionally, there are approaches that focus on empowering parents to develop the most effective parenting strategies.

Medication

A variety of medications are used to treat emotional and behavioral problems in children. These should be discussed with a psychiatrist. Commonly used medications include antidepressants, stimulants, and atypical antipsychotics.

An important consideration for treatment

The most effective interventions for all emotional and behavioral problems in children involve parents and other caregivers. Because DMDD affects how children interact with family members, peers, and other adults, it's critical to consider these factors in treatment.

Left untreated, DMDD can develop into anxiety disorders or non-bipolar or unipolar depression in late adolescence and adulthood. As is the case with all mental health conditions in childhood, the best outcomes occur when assessment and intervention happen as early as possible. If you're concerned that your child may have DMDD or a similar condition, don't hesitate to contact a professional immediately.

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Disruptive Mood Dysregulation Disorder (DMDD): Treatment and More

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What is disruptive mood dysregulation disorder? Temper tantrums are a part of growing up. Many parents become skilled in anticipating the situations that may "set off" an emotional episode in their children. If your child is exhibiting tantrums that seem out of proportion, are difficult to control, or seem to be happening constantly, you may consider having your child evaluated for disruptive mood dysregulation disorder (DMDD).

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https://www.merckmanuals.com/professional/psychiatric-disorders/mood-disorders/depressive-disorders

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Depressive Disorders - Psychiatric Disorders - Merck Manuals Professional Edition

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Depressive Disorders - Etiology, pathophysiology, symptoms, signs, diagnosis & prognosis from the Merck Manuals - Medical Professional Version.

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https://www.psychologytoday.com/us/conditions/depressive-disorders

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Depressive disorders are characterized by persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities. Depression is not a passing blue mood, which almost everyone experiences from time to time, but a complex mind-body illness that interferes with everyday functioning. It not only darkens one's outlook, but it is also commonly marked by sleep problems and changes in energy levels and appetite. It alters the structure and function of nerve cells so that it disrupts the way the brain processes information and interprets experience. Despite feelings of hopelessness and worthlessness, depression is a treatable condition. It can be treated with psychotherapy or medication, or a combination of both.

Depression is a common condition in modern life. According to the National Institutes of Health, each year more than 16 million adults in the United States experience at least one episode of major depression. The likelihood that a person will develop depression at some point in life is approximately 10 percent. Prolonged social stress and major disruption of social ties are known risk factors for depression, and major negative life events such as loss of a loved one, or loss of a job, increase the subsequent risk of depression. Significant adversity early in life, such as separation from parents or parental neglect or abuse, may create vulnerability to major depression later in life by setting the nervous system to over-respond to stress.

Definition

A depressive disorder is a condition that involves the body, mood, and thoughts. It saps motivation and interferes with normal functioning of daily life. It typically causes pain both to the person experiencing the mood disturbance and those who care about him or her.

By definition, the symptoms must be present for at least two weeks. It is not a sign of personal weakness or a condition that can be willed or wished away. Depression tends to be episodic, with bouts lasting weeks or months. Although symptoms tend to remit spontaneously over time, some form of treatment is important to reduce the likelihood of recurrent episodes. Appropriate treatment can help most people who suffer from depression.

Depressive disorders come in different forms, as is the case with other illnesses such as heart disease. Three of the most common types of depressive disorders are described here. However, all forms are marked by variation in the number of symptoms as well as their severity and persistence.

Major depressive disorder, or major depression, is manifested in a persistently sad mood accompanied by a number of other symptoms that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. A disabling episode of depression may occur only once but more commonly occurs several times in a lifetime. Depression is more than a disorder only from the neck up. It also affects the function of many systems in the body. Researchers have established, for example, that immune function is often compromised in depressive states, and impaired immune function may in part underlie the link of depression to such other disorders as heart disease.

Dysthymic disorder, or persistent depressive disorder, also called dysthymia, involves symptoms of sad or down mood most days for most of the day over a long term (two years or longer) but the depressed mood is not disabling, although it impairs functioning to some degree. Many people with dysthymia also experience major depressive episodes at some time in their lives.

Some forms of depressive disorder involve a slight variation of features or develop under specific circumstances.

Premenstrual dysphoric disorder manifests in the week before the onset of menses, subsides within days after onset of menstruation, and remits in the week after menstruation. According to the National Institutes of Health, 3 to 8 percent of women of reproductive age meet strict criteria for premenstrual dysphoric disorder.

Major depression with psychotic features, or psychotic depression, occurs when a severe depressive illness is accompanied by delusions and hallucinations, The psychotic features may be mood-congruent with the depression-that is, consistent with the depressive themes of personal inadequacy, guilt, nihilism, or death. Or the delusions and hallucinations may be mood-incongruent, not involving such depressive themes.

Major depression with postpartum onset, or postpartum depression, is diagnosed if a woman develops a major depressive episode during pregnancy or within four weeks after delivery. It is estimated that 3 to 6 percent of women experience postpartum depression.

Major depression with seasonal patterns, or seasonal affective disorder (SAD), is characterized by the onset of a depressive illness during particular times of the year. Typically, the depression develops during the winter months, when there is limited natural sunlight, and completely remits in the spring and summer months. In a minority of cases of major depression with seasonal patterns, the depression occurs during the summer months. SAD may be effectively treated with light therapy, but nearly half of those with SAD do not respond to light therapy alone. Antidepressant medication and psychotherapy can reduce SAD symptoms, either alone or in combination with light therapy.

Symptoms

The following signs and symptoms are cataloged by the DSM-5 as signifiers of major depressive disorder and at least five must be present during the extended period of low mood or loss of pleasure in once-enjoyable pursuits.

Persistent sad, anxious, or empty mood most of the day, most days

Feelings of worthlessness or excessive guilt

Loss of interest or pleasure in activities that were once enjoyed, including sex

Persistent loss of energy or fatigue

Difficulty thinking, concentrating, remembering, or making decisions

Insomnia, early-morning awakening, or oversleeping (hypersomnia)

A significant change in appetite, resulting in unintended weight loss or weight gain

Observable psychomotor agitation or restlessness, or psychomotor slowing

Feelings of hopelessness or pessimism; recurrent thoughts of death or suicide, suicide attempts

Not everyone experiences every symptom, nor do people experience the same symptoms to the same degree. Symptoms may vary not only between individuals but over time in the same individual. Some people have observable behavioral changes, including disrupted sleep and appetite changes. Others have no physical symptoms but their outlook on life grows notably more pessimistic.

The most widely reported symptom of depression is low mood and a sense of hopelessness about life and one's own prospects. Many people can relate to such sentiments and have experienced them at some point. But for a person who is experiencing depression, this outlook is persistent and does not remit. If someone reports that they have felt this way for two weeks or more, they should be encouraged to seek professional help.

Causes

There is no single cause of depression. Rather, evidence indicates it results from a combination of genetic, biological, environmental, and psychological factors.

Research deploying brain-imaging-such as magnetic resonance imaging (MRI)-and other technologies shows that the brains of people who have depression look different than those of people without depression. The parts of the brain responsible for regulating mood, thinking, sleep, appetite, and behavior appear to function abnormally. But these changes do not reveal why the depression has occurred.

There are many pathways to depression. Genetic factors may play a complex role in setting the level of sensitivity to certain kinds of events, including the level of nervous system reactivity to stress and other challenges. Scientists know there is no single gene involved: many genes likely play a small role in contributing to vulnerability; acting together with environmental or other factors.

However, depression can occur in people without family histories of it as well. There is significant evidence that harsh early environments-especially experiences of severe adversity such as abuse or neglect in childhood -can create vulnerability to later depression by altering the sensitivity of the nervous system to distressing or threatening events.

Experiences of failure, rejection, social isolation, loss of a loved one, or frustration or disappointment in achieving a healthy relationship or any other life goal often precede an episode of depression. For that reason, many researchers regard the negative mood state of depression as a painful signal that basic psychological needs are not being met and that new strategies are needed. They also suggest that depression to some degree results from a lack of skills in processing negative feelings; some of the most effective therapies for depression teach what can be considered basic mental hygiene, cognitive and emotional tools for dealing with negative feelings. Trauma, which can overwhelm emotional processing mechanisms, is another common trigger for depressive episodes.
Depression in Women
Women experience depression about twice as often as men. Biological, life cycle, hormonal, and other factors-including experiential ones-unique to women may be linked to their higher depression rate. Researchers have shown that hormones directly affect brain regions that influence emotions and mood, and they are further exploring how hormone cycles can give rise to depressive states. Some women may be susceptible to the severe form of premenstrual syndrome called premenstrual dysphoric disorder (PMDD). Women are also vulnerable to depression after giving birth, when hormonal and physical changes, along with the new responsibility of caring for a helpless infant can be overwhelming. Many women also uniquely face such proven chronic stresses as juggling work and home responsibilities, single parenthood, domestic abuse, and caring for children and aging parents.

Ongoing research probes why some people faced with enormous challenges develop depression, while others with similar challenges do not.
Depression in Men
Millions of men in the U.S. and around the world also suffer the psychic pain of depression. Research and clinical evidence establish that while both women and men can develop the standard symptoms of depression, they often experience depression differently and may have different ways of coping with the symptoms. Men may be more willing to acknowledge fatigue, irritability, loss of interest in work or hobbies, and sleep disturbances rather than feelings of sadness, worthlessness, and excessive guilt. Some researchers question whether the standard definition of depression and the diagnostic tests based upon it adequately capture the condition as it occurs in men.

Depression can also affect the physical health of men differently from women. One study shows that, although depression is associated with an increased risk of coronary heart disease in both men and women, only men experience an elevated death rate.

Instead of acknowledging their feelings or seeking help in the form of appropriate treatment, men may turn to alcohol or drugs when they are distressed. They may also be angry, irritable, and, sometimes, violently abusive. Some men deal with emotional distress by throwing themselves compulsively into their work, attempting to hide their depression from themselves, family, and friends. Other men may respond to depression by engaging in reckless behavior, taking risks, and putting themselves in harm's way.

Encouragement and support from concerned family members can be lifesaving. In the workplace, employee assistance programs or worksite mental health programs can be particularly important in helping men understand depression as a real disorder that needs treatment.
Depression in the Elderly
Contrary to some popular thinking, depression is not a normal accompaniment to aging. On the contrary, older people tend to experience rising levels of satisfaction with their lives. However, when older adults do develop depression, the condition may be overlooked because it can manifest less in feelings of sadness or grief and more in irritability or general apathy. Elders often voice feelings of tiredness. Also, depression tends to affect memory, and in the elderly depression can show up as confusion or problems with attention. Aging brings many life changes that can be triggers for depression, including loss of a loved one, loss of employment and sense of purpose, loss of robustness, or good health.

In addition, medical conditions that occur more frequently with age, such as heart disease, stroke, and cancer, may cause depressive symptoms. Or the medications used for such conditions may carry side effects that contribute to depression.

There is a type of depression that develops in later life, known as vascular depression, sometimes also called arteriosclerotic depression or subcortical ischemic depression. It results from cerebrovascular damage that occurs with cardiovascular disease. Brain-imaging studies show that areas of blood vessel damage restrict blood flow to regions of the brain involved in emotion and mood regulation or to the brain's white matter. Those who develop vascular depression often have a history of hypertension or high blood pressure. Vascular depression may manifest in paranoia, aggressive tendencies, apathy, and slowing of movement. There are deficits in executive function. Diagnosis may involve magnetic resonance imaging (MRI) to detect vascular pathology in specific parts of the brain. Vascular depression tends not to respond to antidepressant medication; instead, the first line of approach may be forms of psychosocial support and or cognitive behavioral therapy.

The majority of older adults with depression improve when they receive treatment with psychotherapy, antidepressant medication, or a combination of the two. Research has shown that psychotherapy alone can be effective in prolonging periods free of depression.

More than four times as many men as women die by suicide in the U.S., even though women make more suicide attempts during their lives. In light of the research indicating that suicide is often associated with depression, the high suicide rate among men may reflect the fact that many men with depression do not seek adequate diagnosis and treatment.

Report remarks about suicide to the depressed person's therapist, if they have one. Invite the depressed person for walks, outings, to the movies, and other activities. Keep trying. Although diversions and company are needed, too many demands may increase feelings of failure. Remind your friend or relative that with time and treatment, the depression will lift. Psychology Today maintains a list of suicide prevention hotline resources in various countries as well as an extensive therapy directory.

Treatment

Depression, even in the most severe cases, is a highly treatable disorder. The sooner treatment begins, the more effective it is and the greater the likelihood that recurrence can be prevented.

Appropriate treatment for depression starts with a physical examination by a physician. A number of medications, as well as some medical conditions, including viral infections and thyroid disorder, can cause depression-like symptoms and must be ruled out. Once a physical cause of depression is ruled out, a psychological evaluation can be conducted, either by the examining physician or via referral to a mental health professional.

An evaluation should include a detailed inquiry into the history and nature of current symptoms and prior episodes and their management as well as any family history of depression and its treatment. From this information, the severity of current symptoms can be rated; this information serves as a baseline for measuring improvement over time and guides the course of treatment.

Once diagnosed, depression can be treated with psychotherapy, medication, or a combination of both. Medication may help reduce symptoms while psychotherapy addresses the negative thoughts, feelings, and beliefs that give rise to distress and that need to be managed in more productive ways.
Psychotherapies
For mild to moderate depression, psychotherapy is generally considered the best treatment option. Psychotherapy is important in helping patients develop strategies for dealing with the situations that give rise to depression and to effectively manage the negative thoughts and feelings that mark the distress. Both cognitive-behavioral therapy (CBT), and interpersonal therapy (IPT) have been widely tested and shown to be effective in treating depression. By teaching new ways of thinking and behaving, CBT gives people skills to disarm negative styles of thinking and behaving. IPT helps people understand and work through troubled personal relationships that may cause or exacerbate their depression.

Studies have indicated that for adolescents, a combination of medication and psychotherapy may be the most effective approach to treating major depression and reducing the likelihood of recurrence. Similarly, a study examining depression treatment among older adults found that patients who responded to initial treatment of medication and IPT were less likely to have recurring depression if they continued their combination treatment for at least two years.
Medications
Antidepressants target various neurochemicals-notably serotonin, norepinephrine, and dopamine -known to be involved in the relay of signals through various brain circuits. Nevertheless, it is not entirely clear how they work or why they can take weeks or months to produce a positive effect-the brain is a highly complex organ.

The most popular medications are called selective serotonin reuptake inhibitors (SSRIs). SSRIs include fluoxetine (Prozac), citalopram (Celexa), and sertraline (Zoloft), among others. Serotonin and norepinephrine reuptake inhibitors (SNRIs) are similar to SSRIs and include venlafaxine (Effexor) and duloxetine (Cymbalta). Now in use for decades, SSRIs and SNRIs coexist with older classes of antidepressants: tricyclics-named for their chemical structure-and monoamine oxidase inhibitors (MAOIs). The SSRIs and SNRIs tend to have fewer major side effects than the older drugs. However, medications affect everyone differently and there is no one-size-fits-all medication. Tricyclics and MAOIs remain important antidepressants. Finding a medication regimen that works for any particular patient may take trials of more than one antidepressant and more than one type of antidepressant.

Antidepressants typically take time to work. Patients must take regular doses for at least three to four weeks before they are likely to experience a full therapeutic effect and continue taking the medication to maintain improved mood and to prevent a relapse of the depression. Although antidepressants are not habit-forming or addictive, abruptly ending an antidepressant treatment can cause withdrawal symptoms or lead to a relapse. Some individuals, such as those with chronic or recurrent depression, may need to stay on the medication indefinitely.

Despite the relative safety and popularity of SSRIs and other antidepressants, some studies have suggested that they may have unintentional effects on some people, especially adolescents and young adults. The U.S. Food and Drug Administration requires a "black box" warning label on all antidepressant medications to alert the public about the potential increased risk of suicidal thinking or attempts in children, adolescents, and young adults taking antidepressants.

Side effects can limit the usefulness of SSRIs, SNRIs, tricyclics, and MAO inhibitors. People taking MAOIs must adhere to significant food and medicinal restrictions-from wine and cheese to decongestants-to avoid potentially serious interactions. Patients taking an MAO inhibitor should receive a complete list of prohibited foods, medicines, and substances at the time of prescription. The most common side effects of tricyclic antidepressants include dry mouth, constipation, difficulty emptying the bladder, sexual problems, blurred vision, dizziness, and daytime drowsiness. The most common side effects associated with SSRIs and SNRIs include headache, nausea, nervousness and insomnia, agitation, and decreased libido.

The newest medication in the antidepressant arsenal is ketamine, an agent long used safely as an anesthetic. In randomized, controlled trials, a molecular variant of ketamine, called esketamine, has recently been found safe and effective as a treatment for depression. Administered by nasal spray, it acts very rapidly to improve mood. Further, studies show that it also reduces suicidal thinking. It is not fully clear how esketamine produces its antidepressant effects, but the drug has a mechanism of action that is different from any other available antidepressant. It binds to NMDA receptors in the brain, blocking uptake of the excitatory neurotransmitter glutamate, which causes a rapid increase in glutamate levels. The glutamate burst ultimately strengthens neural circuits in areas of the brain involved in motivation, memory, and mood, known to be impaired in depression. The new drug, trade-named Spravuto, is intended for adults with treatment-resistant depression and, because of its potential for abuse, is administered in doctors' offices.
Herbal Therapy
Over the years, there has been considerable interest in the use of herbs for the treatment of both depression and anxiety. St. John's wort ( Hypericum perforatum), often used in Europe, has aroused interest in the United States as well, as it has been used for centuries in many folk and herbal remedies. A number of modern studies have tested the effectiveness of St. John's wort for depression.

According to the National Center for Complementary and Integrative Health: "St. John's wort isn't consistently effective for depression. Do not use it to replace conventional care or to postpone seeing your health care provider. St. John's wort limits the effectiveness of many prescription medicines. Combining St. John's wort and certain antidepressants can lead to a potentially life-threatening increase in your body's levels of serotonin, a chemical produced by nerve cells."
Neurostimulation Therapies
Electroconvulsive therapy (ECT) is useful, particularly for individuals whose depression is severe or life-threatening, or for those who cannot take antidepressant medication. ECT often is effective in cases where antidepressant medications do not provide sufficient relief of symptoms. In recent years, ECT has been much improved. A muscle relaxant is given before treatment, which is done under brief anesthesia. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a brief (about 30 seconds) seizure within the brain. The person receiving ECT does not consciously experience the electrical stimulus. For full therapeutic benefit, at least several sessions of ECT, typically given at the rate of three per week, are required.
Lifestyle Changes
Research shows that a number of factors in daily living have a positive effect on mood states. These include a nutrient-rich diet, physical activity, exposure to sunlight and outdoors, and social activity. Lifestyle changes that address these factors are increasingly considered a wise course in any treatment plan.
How to Help Yourself If You Are Depressed
Depressive disorders can make a person feel exhausted, worthless, helpless, and hopeless. Such negative thoughts and feelings make people feel like giving up. It is important to realize that such negative views are part of the disorder and typically do not reflect actual circumstances. Negative thinking fades as treatment begins to take effect. In the meantime:

Try to be with other people and to confide in someone; it is usually better than being alone and secretive.

Participate in activities that may make you feel better.

Even mild exercise, going to a movie or a ball game, or participating in religious, social, or other activities can help.

Expect your mood to improve gradually; it takes time.

Because depression distorts thinking, it is advisable to postpone important decisions until the depression lifts. Before deciding to make a significant transition-change jobs, get married, or divorce-discuss it with others who know you well and have a more objective view of your situation.

Let family and friends help you.

The most important thing anyone can do for a depressed person is to help him or her get an appropriate diagnosis and treatment. It may require making an appointment on their behalf and accompanying them to the doctor. Encouraging a loved one to stay in treatment is helpful.Emotional support is also invaluable. This involves understanding, patience, affection, and encouragement. Engage the depressed person in conversation and listen carefully. Do not disparage feelings expressed, but point out realities and offer hope.

National Institutes of Health

Archives of Internal Medicine

Psychopharmacology Bulletin

Find a depression therapist.

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Depressive disorders are characterized by persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities. Depression is not a passing blue mood, which almost everyone experiences from time to time, but a complex mind-body illness that interferes with everyday functioning.

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Quick guide to disruptive mood dysregulation disorder 

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Quick guide to disruptive mood dysregulation disorder 

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https://childmind.org/guide/disruptive-mood-dysregulation-disorder-a-quick-guide/

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Guides

Quick Guide to Disruptive Mood Dysregulation Disorder

What is disruptive mood dysregulation disorder (DMDD)?

Disruptive mood dysregulation disorder (DMDD) is a mental health disorder in which children are angry most of the time and have a lot of temper tantrums in reaction to things that don't seem like a big deal. Children with DMDD are not able to control their emotions like other children their age.

What are the symptoms of DMDD?

The symptoms of DMDD are:

Major temper tantrums that happen three or more times a week on average

Angry or irritable mood between tantrums

Being unable to control extreme emotions

Symptoms of DMDD usually show up before age 10.

DMDD is diagnosed when a child has temper tantrums that happen three or more times a week on average, along with an angry mood between tantrums. These symptoms last at least a year, and any break in the symptoms lasts less than three months. The symptoms have to show up with the child's family, friends and teachers, rather than in just one situation.

DMDD usually appears before age ten. It is not diagnosed before age six because temper tantrums are normal for young kids.

The goal in DMDD treatment is to help children learn to control their emotions and stop having temper tantrums. Treatment involves behavioral therapy and sometimes medication.

A combination of dialectical behavior therapy for children (DBT-C) and parent management training has been found to be very helpful in treating DMDD.

In DBT-C, the therapist doesn't tell the child they should not have angry feelings. Instead, they help the child gain skills to calm themselves down when their feelings get out of control. Parents also learn these skills so that they can help their child and practice staying calm themselves.

In parent management training, parents learn how to reward kids for good behavior instead of giving them attention for bad behavior.

When therapy is not an option or when therapy alone is not working, medication to help the child control their emotions is sometimes given. Antidepressants and stimulants are the most common medications for DMDD.

What are the risks of developing other disorders?

DMDD is different from other disorders that can look similar, like bipolar disorder, autism spectrum disorder and oppositional defiant disorder. But kids with DMDD can have certain other disorders at the same time, including ADHD, depression and anxiety.

Kids with DMDD also have a bigger chance of developing serious depression or anxiety as adults.

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Quick Guide to Disruptive Mood Dysregulation Disorder - Child Mind Institute

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Learn how to recognize and cope with disruptive mood dysregulation disorder (DMDD) in children. DMDD is a mental health disorder in which children are angry most of the time and have a lot of temper tantrums in reaction to things that don't seem like a big deal.

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https://www.webmd.com/bipolar-disorder/guide/bipolar-2-disorder

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What Is Bipolar II Disorder?

Bipolar II disorder (pronounced " bipolar two") is a form of mental illness. Bipolar II is similar to bipolar I disorder, with moods cycling between high and low over time.

However, in bipolar II disorder, the "up" moods never reach full-blown mania. The less-intense elevated moods in bipolar II disorder are called hypomanic episodes, or hypomania.

A person affected by bipolar II disorder has had at least one hypomanic episode in their life. Most people with bipolar II disorder suffer more often from episodes of depression. This is where the term "manic depression" comes from.

In between episodes of hypomania and depression, many people with bipolar II disorder typically live normal lives.
A Visual Guide to Understanding Bipolar Disorder

Who Is at Risk for Bipolar II Disorder?

Virtually anyone can develop bipolar II disorder. About 2.5% of the U.S. population suffers from some form of bipolar disorder - nearly 6 million people.

Most people are in their teens or early 20s when symptoms of bipolar disorder first start. Nearly everyone with bipolar II disorder develops it before age 50. People with an immediate family member who has bipolar are at higher risk.

What Are the Symptoms of Bipolar II Disorder?

During a hypomanic episode, elevated mood can manifest itself as either euphoria (feeling "high") or as irritability.

Symptoms during hypomanic episodes include:

Flying suddenly from one idea to the next

Having exaggerated self confidence

Rapid, "pressured" (uninterruptible) and loud speech

Increased energy, with hyperactivity and a decreased need for sleep

People experiencing hypomanic episodes are often quite pleasant to be around. They can often seem like the "life of the party" -- making jokes, taking an intense interest in other people and activities, and infecting others with their positive mood.

What's so bad about that, you might ask? Hypomania can also lead to erratic and unhealthy behavior. Hypomanic episodes can sometimes progress onward to full manias that affect a person's ability to function (bipolar I disorder). In mania, people might spend money they don't have, seek out sex with people they normally wouldn't, and engage in other impulsive or risky behaviors with the potential for dangerous consequences.

Continued

The vast majority of people with bipolar II disorder experience more time with depressive than hypomanic symptoms. Depressions can occur soon after hypomania subsides, or much later. Some people cycle back and forth between hypomania and depression, while others have long periods of normal mood in between episodes.

Untreated, an episode of hypomania can last anywhere from a few days to several months. Most commonly, symptoms continue for a few weeks to a few months.

Depressive episodes in bipolar II disorder are similar to "regular" clinical depression, with depressed mood, loss of pleasure, low energy and activity, feelings of guilt or worthlessness, and thoughts of suicide. Depressive symptoms of bipolar disorder can last weeks, months, or rarely years.

What Are the Treatments for Bipolar II Disorder?

Hypomania often masquerades as happiness and relentless optimism. When hypomania is not causing unhealthy behavior, it often may go unnoticed and therefore remain untreated. This is in contrast to full mania, which by definition causes problems in functioning and requires treatment with medications and possibly hospitalizations.

Continued

People with bipolar II disorder can benefit from preventive drugs that level out moods over the long term. These prevent the negative consequences of hypomania, and also help to prevent episodes of depression.
Mood Stabilizers
Lithium : This simple metal in pill form is highly effective at controlling mood swings (particularly highs) in bipolar disorder. Lithium has been used for more than 60 years to treat bipolar disorder. Lithium can take weeks to work fully, making it better for long-term treatment than for acute hypomanic episodes. Blood levels of lithium and other laboratory tests (such as kidney and thyroid functioning) must be monitored periodically to avoid side effects.

Carbamazepine ( Tegretol): This antiseizure drug has been used to treat mania since the 1970s. It's possible value for treating bipolar depression, or preventing future highs and lows, is less well-established. Blood tests to monitor liver functioning and white blood cell counts also are periodically necessary.

Lamotrigine ( Lamictal): This drug is approved by the FDA for the maintenance treatment of adults with bipolar disorder. It has been found to help delay bouts of mood episodes of depression, mania, hypomania (a milder form of mania), and mixed episodes in people being treated with standard therapy. It is especially helpful in preventing lows.

Continued

Valproate ( Depakote): This antiseizure drug also works to level out moods. It has a more rapid onset of action than lithium, and it can also be used "off label" for prevention of highs and lows.

Some other antiseizure medications, such as oxcarbazepine ( Trileptal), are also sometimes prescribed as "experimental" (less-proven) treatments for mood symptoms or associated features in people with bipolar disorder.
Antipsychotics
By definition, hypomanic episodes do not involve psychosis and do not interfere with functioning. Antipsychotic drugs, such as aripiprazole ( Abilify), asenapine ( Saphris), cariprazine ( Vraylar), quetiapine ( Seroquel), olanzapine ( Zyprexa), risperidone ( Risperdal), and ziprasidone ( Geodon) and others, are nevertheless sometimes used in hypomania and some (notably, Seroquel) are used for depression in bipolar II disorder.
Benzodiazepines
This class of drugs includes alprazolam ( Xanax), diazepam ( Valium), and lorazepam ( Ativan) and is commonly referred to as minor tranquilizers. They are used for short-term control of acute symptoms associated with hypomania such as insomnia or agitation.
Antidepressants
Seroquel and Seroquel XR are the only medications FDA-approved specifically for bipolar II depression. Common antidepressants such as fluoxetine ( Prozac), paroxetine ( Paxil), and sertraline ( Zoloft) are also sometimes used in bipolar II depression, and are thought to be less likely to cause or worsen hypomania than is the case in bipolar I disorder. Psychotherapy, such as cognitive-behavioral therapy, may also help.

Because bipolar II disorder typically involves recurrent episodes, continuous and ongoing treatment with medicines is often recommended for relapse prevention.

Can Bipolar II Disorder Be Prevented?

The causes of bipolar disorder are not well understood. It's not known if bipolar II disorder can be prevented entirely.

It is possible to reduce the risk for developing future episodes of hypomania or depression once bipolar disorder has developed. Regular therapy sessions with a psychologist or social worker, in combination with medication, can help efforts to stabilize mood, leading to fewer hospitalizations and feeling better overall. Psychotherapy can help people better recognize the warning signs of a developing relapse before it takes hold, and can also help to ensure that prescribed medicines are being taken properly.

How Is Bipolar II Disorder Different From Other Types of Bipolar Disorder?

People with bipolar I disorder experience full mania -- a severe, abnormally elevated mood with erratic behavior. Manic symptoms lead to serious disruptions in life, causing legal or major personal problems.

In bipolar II disorder, the symptoms of elevated mood never reach full-blown mania. Hypomania in bipolar II is a milder form of mood elevation. However, the depressive episodes of bipolar II disorder are often longer-lasting and may be even more severe than in bipolar I disorder. Therefore, bipolar II disorder is not simply a "milder" overall form of bipolar disorder.

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Bipolar II disorder (pronounced " bipolar two") is a form of mental illness. Bipolar II is similar to bipolar I disorder, with moods cycling between high and low over time. However, in bipolar II disorder, the "up" moods never reach full-blown mania. The less-intense elevated moods in bipolar II disorder are called hypomanic episodes, or hypomania.

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https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders

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https://www.webmd.com/bipolar-disorder/guide/bipolar-1-disorder

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What Is Bipolar I Disorder?

Bipolar I disorder (pronounced " bipolar one" and also known as manic-depressive disorder or manic depression) is a form of mental illness. A person affected by bipolar I disorder has had at least one manic episode in their life. A manic episode is a period of abnormally elevated or irritable mood and high energy, accompanied by abnormal behavior that disrupts life.

What Are the Treatments for Bipolar I Disorder?

Manic episodes in bipolar I disorder require treatment with drugs, such as mood stabilizers and antipsychotics, and sometimes sedative-hypnotics which include benzodiazepines such as clonazepam ( Klonopin) or lorazepam ( Ativan).
Mood Stabilizers
Valproate ( Depakote): This antiseizure medication also works to level out moods. It is faster acting than lithium for an acute episode of mania. It is also often used "off label" for prevention of new episodes. As a mood stabilizer that can be used by a "loading dose" method -- beginning at a very high dose -- valproate allows the possibility of significant improvement in mood as early as four to five days.

Antidepressants
Common antidepressants such as fluoxetine ( Prozac), paroxetine ( Paxil), and sertraline ( Zoloft) have not been shown to be as effective for treating depression in bipolar I disorder as in unipolar depression. In a small percentage of people, they can also set off or worsen a manic episode in a person with bipolar disorder. However, studies have shown that for bipolar II depression, some antidepressants (such as Prozac and Zoloft) may be safe and more helpful than in bipolar I depression. For these reasons, the first-line treatments for depression in bipolar disorder involve medicines that have been shown to have antidepressant properties but also no known risk for causing or worsening mania. The four FDA-approved treatments for bipolar depression are lurasidone ( Latuda), olanzapine- fluoxetine ( Symbyax) combination, quetiapine ( Seroquel) or quetiapine fumarate (Seroquel XR), and cariprazine ( Vraylar). Other mood-stabilizing treatments that are sometimes recommended for treating acute bipolar depression include lithium, Depakote, and lamotrigine ( Lamictal) (although none of these latter three medicines is FDA-approved specifically for bipolar depression). If these fail, after a few weeks a traditional antidepressant or other medicine may sometimes be added. Psychotherapy, such as cognitive-behavioral therapy, may also help.

People with bipolar I disorder (mania or depression) have a high risk for recurrences and usually are advised to take medicines on a continuous basis for prevention.
Electroconvulsive Therapy (ECT)
Despite its scary reputation, electroconvulsive therapy (ECT) is a safe and effective treatment for both manic and depressive symptoms. ECT is often used to treat severe forms of depression or mania in bipolar I disorder when medicines may not be effective or likely to work fast enough to bring symptom relief.

Can Bipolar I Disorder Be Prevented?

The causes of bipolar disorder are not well understood. It's not known if bipolar I disorder can be prevented entirely.

It is possible to lower the risk of episodes of mania or depression once bipolar disorder has developed. Regular therapy sessions with a psychologist or social worker can help people to identify factors that can destabilize mood (such as poor medication adherence, sleep deprivation, drug or alcohol abuse, and poor stress management), leading to fewer hospitalizations and feeling better overall. Taking medicine on a regular basis can help to prevent future manic or depressive episodes.

Antipsychotics
For severe manic episodes, traditional antipsychotics (such as The antipsychotic is approved for use -- either alone or with lithium or valproate ( Haldol, Loxapine, or Thorazine) as well as newer antipsychotic drugs -- also called atypical antipsychotics -- may be necessary. Cariprazine ( Vraylar) is a newly approved antipsychotic to treat manic or mixed episodes. Aripiprazole ( Abilify), asenapine ( Saphris), clozapine ( Clozaril), olanzapine ( Zyprexa), quetiapine ( Seroquel), risperidone ( Risperdal), and ziprasidone ( Geodon) are often used, and many other drugs are available. lurasidone ( ) Depakote) -- in cases of bipolar I depression. Antipsychotic medicines are also sometimes used for preventive treatment.
Benzodiazepines

Who Is at Risk for Bipolar I Disorder?

Virtually anyone can develop bipolar I disorder. About 2.5% of the U.S. population suffers from bipolar disorder -- almost 6 million people.

Most people are in their teens or early 20s when symptoms of bipolar disorder first appear. Nearly everyone with bipolar I disorder develops it before age 50. People with an immediate family member who has bipolar are at higher risk.

What Are the Symptoms of Bipolar I Disorder?

During a manic episode in someone with bipolar disorder, elevated mood can manifest itself as either euphoria (feeling "high") or as irritability.

Abnormal behavior during manic episodes includes:

Flying suddenly from one idea to the next

Rapid, "pressured" (uninterruptible), and loud speech

Increased energy, with hyperactivity and a decreased need for sleep

Inflated self-image

Excessive spending

Hypersexuality

Substance abuse

People in manic episodes may spend money far beyond their means, have sex with people they wouldn't otherwise, or pursue grandiose, unrealistic plans. In severe manic episodes, a person loses touch with reality. They may become delusional and behave bizarrely.

Untreated, an episode of mania can last anywhere from a few days to several months. Most commonly, symptoms continue for a few weeks to a few months. Depression may follow shortly after, or not appear for weeks or months.

Many people with bipolar I disorder experience long periods without symptoms in between episodes. A minority has rapid-cycling symptoms of mania and depression, in which they may have distinct periods of mania or depression four or more times within a year. People can also have mood episodes with "mixed features," in which manic and depressive symptoms occur simultaneously, or may alternate from one pole to the other within the same day.

Depressive episodes in bipolar disorder are similar to "regular" clinical depression, with depressed mood, loss of pleasure, low energy and activity, feelings of guilt or worthlessness, and thoughts of suicide. Depressive symptoms of bipolar disorder can last weeks or months, but rarely longer than one year.

How Is Bipolar I Different From Other Types of Bipolar Disorder?

People with bipolar I disorder experience full episodes of mania -- the often severe abnormally elevated mood and behavior described above. These manic symptoms can lead to serious disruptions in life (for example, spending the family fortune, or having an unintended pregnancy).

In bipolar II disorder, the symptoms of elevated mood never reach full-blown mania. They often pass for extreme cheerfulness, even making someone a lot of fun to be around -- the "life of the party." Not so bad, you might think -- except bipolar II disorder usually involves extensive and disabling periods of significant depression, which can often be harder to treat than if episodes of hypomania had never occurred.

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Bipolar I disorder (pronounced " bipolar one" and also known as manic-depressive disorder or manic depression) is a form of mental illness. A person affected by bipolar I disorder has had at least one manic episode in their life. A manic episode is a period of abnormally elevated or irritable mood and high energy, accompanied by abnormal behavior that disrupts life.

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https://www.nimh.nih.gov/health/topics/bipolar-disorder

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National Institute of Mental Health (NIMH)

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Overview

Bipolar disorder (formerly called manic-depressive illness or manic depression) is a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration. These shifts can make it difficult to carry out day-to-day tasks.

There are three types of bipolar disorder. All three types involve clear changes in mood, energy, and activity levels. These moods range from periods of extremely "up," elated, irritable, or energized behavior (known as manic episodes) to very "down," sad, indifferent, or hopeless periods (known as depressive episodes). Less severe manic periods are known as hypomanic episodes.

Bipolar I disorder is defined by manic episodes that last for at least 7 days (nearly every day for most of the day) or by manic symptoms that are so severe that the person needs immediate medical care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks. Episodes of depression with mixed features (having depressive symptoms and manic symptoms at the same time) are also possible. Experiencing four or more episodes of mania or depression within 1 year is called "rapid cycling."

Bipolar II disorder is defined by a pattern of depressive episodes and hypomanic episodes. The hypomanic episodes are less severe than the manic episodes in bipolar I disorder.

Cyclothymic disorder (also called cyclothymia) is defined by recurring hypomanic and depressive symptoms that are not intense enough or do not last long enough to qualify as hypomanic or depressive episodes.

Sometimes a person might experience symptoms of bipolar disorder that do not match the three categories listed above, and this is referred to as "other specified and unspecified bipolar and related disorders."

Bipolar disorder is often diagnosed during late adolescence (teen years) or early adulthood. Sometimes, bipolar symptoms can appear in children. Although the symptoms may vary over time, bipolar disorder usually requires lifelong treatment. Following a prescribed treatment plan can help people manage their symptoms and improve their quality of life.

Signs and symptoms

Risk factors

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Learn about bipolar disorder, including signs and symptoms, types, risk factors, how it is diagnosed, and potential treatments and therapies.

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What is anorexia nervosa?

Anorexia nervosa is a life-threatening eating disorder. It is defined as self-starvation in order to maintain an abnormally low body weight. Low body weight is described as weighing less than the minimum that is considered normal for the person's age, sex, stage of growth and development, and physical health. Individuals with anorexia nervosa have an intense fear of gaining weight or becoming fat and have a distorted self-image of their body weight and shape. Extreme weight loss in people with anorexia nervosa can lead to dangerous health problems and even death.

Who gets anorexia nervosa?

Anorexia nervosa can occur in people of any age, sex, race, gender, ethnicity, economic status, as well as individuals of all body weights, shapes and sizes. Anorexia nervosa is most commonly seen in adolescents and young adult females, although it also occurs in males and is increasing in numbers in children and older adults.

What are the health harms of anorexia nervosa?

Not getting enough nutrients (malnutrition) and starvation affects nearly every system of the body.

Effects on the heart. Slow heart rate (bradycardia), low blood pressure (hypotension) and orthostatic hypotension are common effects of starvation. These complications increase the risk of ventricular arrhythmia and sudden cardiac death. The heart itself can lose some of its muscle mass, which can lead to mitral valve prolapse.

Effects on the brain. Starvation affects the brain's structure - including decreased brain tissue and brain activity and function. Functions impaired include decision making, ability to concentrate/focus, memory issues, emotional control, appetite regulation, mood and reward pathways.

Effects on the digestive tract. Starvation can cause abdominal discomfort and pain, bloating, constipation, feelings of being full, as well as lead to fatty liver disease (steatosis).

Effects on the body's hormones. Starvation can cause missed menstrual periods (amenorrhea) and reduced levels of female hormones, low testosterone levels, delayed puberty and physical growth, underactive thyroid (hypothyroidism), euthyroid sick syndrome, and in older individuals, increased the risk of weak bones (osteopenia), bone loss (osteoporosis) and stress fractures.

Effects on the body from vomiting (purging). Exposure to stomach acid can wear down the enamel on teeth and enlarge the salivary glands. Loss of water and electrolyte/acid-base imbalances can cause a loss of potassium and lead to rhabdomyolysis (damaged skeletal muscle) and kidney damage.

Many of these complications can improve and be reversed as weight is regained. However, if anorexia nervosa has been ongoing for years, bone loss, physical growth, and structural brain changes may not fully recover.

What are the symptoms and behaviors of people with anorexia nervosa?

Physical signs and symptoms include:

Significant weight loss over several weeks or months

Unexplained change in growth curve or body mass index (in still growing child/adolescent)

Feeling tired

Slow or irregular heart beat

Sleep problems

Poor concentration/focus

Memory loss

Feeling cold all the time

Dizziness

Fainting

Absent or irregular menstrual periods

Chest pain, heart palpitations

Low blood pressure (hypotension)

Shortness of breath

Swelling (edema)

Swelling in the neck area

Dental cavities, erosion of tooth enamel

Bloating, abdominal pain or discomfort

Blood in vomit

Heartburn (gastroesophageal reflux)

Constipation

Hemorrhoids

Muscle weakness, loss of muscle mass

Dry skin, brittle nails, hair loss/thinning hair, growth of fine hair on the body (lanugo)

Poor wound healing

Bluish or purple coloring of the hands and feet

Emotional and behavioral symptoms include:

Binge eating or purging behavior

Continuing to diet even when thin or when weight is very low

Having an unusual interest in food, calories, fat grams and dieting

Sudden change in eating behavior - becoming a vegetarian/vegan; interest in certain food types or certain food groups, or eliminating certain food types or food groups

Intense fear of gaining weight

Strange eating habits or routines, such as eating in secret, eating foods in a certain order, rearranging foods on a plate

Feeling fat, even if underweight

Inability to realistically assess one's own body weight

Striving for perfection and being very self-critical

Undue influence of body weight or shape on self-esteem

Depression, anxiety, or irritability

Obsessive/compulsive symptoms and behaviors

Infrequent or irregular menstrual periods in females

Laxative, diuretic, diet pill or appetite suppressants, or enema use

Purposely not taking insulin (in people who have diabetes) to lose weight

Frequent illness

Wearing loose clothing to hide weight loss

Compulsive exercising or extreme physical training

Feeling worthless or hopeless

Withdrawal from friends and social events

Inability to describe one's emotions

Doesn't enjoy life; thoughts of self-harm or suicide

What causes anorexia nervosa?

The exact cause of anorexia nervosa is not known, but research suggests that a combination of certain personality traits, emotions and thinking patterns, as well as biological and environmental factors might be responsible.

People with anorexia nervosa may use food and eating/not eating as a way to gain a sense of control when other areas of their lives are very stressful or when they feel overwhelmed. Feelings of inadequacy, low self-esteem, anxiety, anger, or loneliness also might contribute to the development of the disorder. In addition, people with eating disorders might have troubled relationships or have a history of being teased about their size or weight. Pressure from peers and a society that equates thinness and physical appearance with beauty also can have an impact on the development of anorexia nervosa.

There is no single path to an eating disorder. For many, irregular eating behaviors (also called "disordered eating") represents an inappropriate (doctors may say, "maladaptive") coping strategy that becomes permanent over time. This pathway to disordered eating is true for some, but not all, who develop this set of illnesses.

Eating disorders also might have physical causes. Changes in hormones that control how the body and mind maintain mood, appetite, thinking, and memory might foster eating disorders. The fact that anorexia nervosa tends to run in families also suggests that a susceptibility to the disorder might be inherited.

Last reviewed by a Cleveland Clinic medical professional on 06/27/2019.

References

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

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Eating Disorders: Anorexia Nervosa | Cleveland Clinic

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Anorexia nervosa is a life-threatening eating disorder. It is defined as self-starvation in order to maintain an abnormally low body weight. Low body weight is described as weighing less than the minimum that is considered normal for the person's age, sex, stage of growth and development, and physical health.

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What Is Binge Eating?

Binge eating involves consuming large quantities of food very quickly, even when not hungry, and to the point of being uncomfortable. Almost everyone overeats once in a while, but it can also become a disorder.

Binge eating disorder (BED) is a serious but treatable condition that involves recurrent episodes of consuming large quantities of food. BED was formally added to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013.﻿﻿

In addition to eating large food in excess and to the point of discomfort, the condition is also characterized by feeling out of control when eating and a sense of shame or guilt over the behavior.

Episodes of overeating that are classified as binge eating can significantly and negatively impact your health and well-being, making it especially important to identify the signs and symptoms of binge eating and get help if necessary.

The two main symptoms of binge eating are:﻿﻿

Eating a larger than normal amount of food over a short period of time

Feeling that this eating behavior is out of control

The binge-eating episodes are also marked by three or more of the following symptoms:﻿﻿

Feeling uncomfortably full

Eating faster than normal

Eating when not hungry

Feelings of disgust, guilt, or sadness

Eating alone out of embarrassment

How do you know if your overeating is just an occasional overindulgence or a serious binging issue? Some health experts may consider isolated episodes of binge eating to be normal. But if a habit of binge eating starts to have a significant impact on your life, it should be cause for concern.

In order to be diagnosed with BED, people must also experience marked distress, not engage in compensatory behaviors such as purging, and experience at least one binge eating episode once a week for three months.﻿﻿

In order to make a diagnosis, your doctor will ask you questions about your recent and past eating behaviors. Binge eating may vary in terms of severity. Some people may experience milder symptoms and binge eat around once each week, while others may have more severe symptoms and binge 14 or more times per week.﻿﻿

Complications of Binge Eating

The exact causes of binge eating are not known. Some of the possible risk factors include:

Genetics: Research suggests that binge eating disorder may have a strong genetic component.﻿﻿

Family history: You may be much more likely to develop an eating disorder if someone in your immediate family also has an eating disorder.﻿﻿

Other psychological conditions: Most people with binge eating disorder also have another mental health condition such as depression, anxiety, or a substance use disorder.﻿﻿

Dieting and body image issues: Research suggests that people who develop binge eating disorder tend to have a negative body image and have a history of dieting and overeating.﻿﻿

Not all excessive eating is the same, so it is important to distinguish between overeating and binge eating.

Overeating

Overeating happens to everyone. You might indulge in too many slices of pizza, go back for seconds of a favorite meal, or even find yourself consuming too much popcorn as you watch a late-night movie.

There are no set guidelines for how much food is too much to be considered "normal" overeating. If you overeat on one or multiple occasions, you may want to ask yourself a few questions.

Are you eating an amount of food larger than what most people would eat under the same circumstances and in the same amount of time?

How do you feel after you overeat?

The feelings binge eaters experience during and after overeating range from intense pleasure to disgust.

An example of overeating would be getting up to get seconds during a holiday meal. An example of binge eating would be eating a large amount of food in a short amount of time and feeling as if you were out of control.

In general, binge eaters tend to eat more often than those who experience the occasional bout of overeating. Note that continually snacking throughout the day (grazing) is not considered binge eating.

Binge Eating

In a general sense, binge eating differs from "normal" overeating in several ways:﻿﻿

Food is consumed more rapidly

Control over the amount of food consumed is lost

Feelings of disgust, regret, or guilt are experienced after the episode

Eating may occur alone due to embarrassment over the amount of food consumed

Those who have a binge eating disorder may say they feel a loss of control over what and how much they eat during an episode of overeating. Some binge eaters say they feel driven to eat as if it were a compulsion that cannot be ignored.

Some binge eaters may hide food in odd places or even steal food from others. People may also eat alone due to feelings of embarrassment or shame over how much they eat.

If you feel that your eating habits are unhealthy and/or if your eating is causing marked distress, there is good news. Effective treatments are available that can help people manage their eating behaviors and overcome binge eating. These treatments may include psychotherapy, medications, or a combination of both.

Psychotherapy

Cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) are proven to be effective treatments for binge eating disorder. CBT focuses on identifying and changing negative thought patterns that contribute to unwanted behaviors.﻿﻿

Ask your doctor for advice or look for professional help in your community. By finding a qualified counselor, such as a licensed clinical social worker or psychologist, you will take an important step toward gaining control of binge eating.

Medications

There are some medications that may also be a valuable part of treatment. Medications that may be prescribed include antidepressants, anti-anxiety drugs, and drugs that help control appetite and compulsions.

Vyvanse (lisdexamfetamine), a drug traditionally used to treat attention deficit hyperactivity disorder (ADHD), may also be prescribed to treat binge-eating disorder.﻿﻿ In 2015, the Food and Drug Administration (FDA) approved the use of lisdexamfetamine in the treatment of binge eating disorder in adults.

In addition to getting appropriate treatment and outside support, there are also things that you can do that will help you control or prevent episodes of binge eating.

Recognize when you are hungry. Sometimes people binge eat when they get over-hungry. Learn to recognize your hunger cues and focus on eating a healthy meal or snack before you reach the point of being over-hungry.

Eliminate binge foods from your home. If you know that there are foods that are more likely to trigger a binge-eating episode, get rid of them, and avoid keeping those items in your house.

Focus on your food. Don't eat when you are distracted by a TV program, movie, book, or other activity. Turn off your devices and keep mealtime a separate activity.

Keep a food journal. Writing down everything that you eat can help you watch for patterns. Note how you were feeling since emotions can often trigger overeating or binge eating.﻿﻿

Avoid boredom. You are much more likely to overeat when you are feeling bored, so look for ways to fill your time with activities that are productive and enjoyable.

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The Differences Between Binge Eating and Overeating

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Binge eating involves consuming large quantities of food very quickly, even when not hungry, and to the point of being uncomfortable. Almost everyone overeats once in a while, but it can also become a disorder. Binge eating disorder (BED) is a serious but treatable condition that involves recurrent episodes of consuming large quantities of food.

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National Association of Anorexia Nervosa and Associated Disorders

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Eating Disorder Statistics | General & Diversity Stats | ANAD

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ANAD's eating disorder statistics provide specific insights into various types of disorders and the diverse populations affected.

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https://www.verywellmind.com/eating-disorders-4157252

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What's An Eating Disorder?

Formally classified as "feeding and eating disorders" in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the term "eating disorders" represents a group of complex mental health conditions that can seriously impair health and social functioning.

Because of the physical nature of their defining symptoms, eating disorders can cause both emotional distress and significant medical complications. They also have the highest mortality rate of any mental disorder.

Types of Eating Disorders

There are many types of feeding and eating disorders, and they all come with their own defining characteristics and diagnostic criteria. The eating disorders formally recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) include the following.

Binge Eating Disorder (BED)

Binge eating disorder, the most recently recognized eating disorder, is the most common. It is characterized by repeated episodes of binge eating-defined as the consumption of a large amount of food accompanied by a feeling of loss of control. It is found in higher rates among people of larger body sizes. Weight stigma is commonly a confounding element in the development and treatment of BED.

Bulimia Nervosa (BN)

Bulimia nervosa involves recurrent episodes of binge eating followed by compensatory behaviors, or those designed to make up for the calories consumed. These behaviors may include vomiting, fasting, excessive exercise, and laxative use.

Anorexia Nervosa (AN)

Anorexia nervosa is characterized by the restricted intake of food, leading to a lower than expected body weight, fear of weight gain, and disturbance in body image. Many people are unaware that anorexia nervosa can also be diagnosed in individuals with larger bodies. Although anorexia is the eating disorder that receives the most attention, it is actually the least common.

Other Specified Feeding and Eating Disorder (OSFED)

Other specified feeding and eating disorder is a catchall category that includes a wide range of eating problems that cause significant distress and impairment but do not meet the specific criteria for anorexia nervosa, bulimia nervosa, or binge eating disorder. OSFED and unspecified feeding or eating disorder (UFED) replaced the eating disorder not otherwise specified (EDNOS) category in previous versions of the DSM.

People diagnosed with OSFED often feel invalidated and unworthy of help, which is not true. OSFED can also be as severe as other eating disorders and include subclinical eating disorders.

Research shows that many people with subclinical eating disorders will develop full eating disorders. Subclinical eating disorders can also describe a phase that many people in recovery pass through on their way to full recovery.

Avoidant/Restrictive Food Intake Disorder (ARFID)

Previously called selective eating disorder, avoidant/restrictive food intake disorder (ARFID) is an eating disorder that involves a restricted food intake in the absence of the body image disturbance commonly seen in anorexia nervosa. It is manifested by persistent failure to meet appropriate nutritional and/or energy needs.

Orthorexia Nervosa

Orthorexia nervosa is not an official eating disorder in the DSM-5, though it has attracted a great deal of recent attention as a proposed diagnosis for future editions. It differs from other eating disorders because the unhealthy obsession does not typically come from a desire to lose weight. Further, the focus is not on food quantity but rather food quality.

Orthorexia nervosa is an unhealthy obsession with healthy eating and involves adhering to a theory of healthy eating to the point that one experiences health, social, and occupational consequences.

Other Eating Disorders

In addition to the ones listed above, other eating disorders include:

Symptoms of an Eating Disorder

Although symptoms of different eating disorders vary greatly, some may indicate a reason to investigate further. What's more, if your thoughts and/or behaviors surrounding food, weight, or body image are causing distress and impacting daily functioning, it's time to seek help.

Dietary restriction

Frequent weight changes or being significantly underweight

Negative body image

Presence of binge eating

Presence of excessive exercise

Presence of purging, laxative, or diuretic use

Excessive thoughts surrounding food, body image, and weight

Mental Effects

Eating disorders often occur along with other mental disorders, most often anxiety disorders, including:﻿﻿

Anxiety disorders usually predate the onset of an eating disorder. Often, people with eating disorders also experience depression and score high on measures of perfectionism.

Physical Effects

Because sufficient intake of nutritionally balanced foods is essential for regular functioning, eating disorders can significantly affect physical and mental operations. A person does not have to be underweight to experience the medical consequences of an eating disorder. Eating disorders affect every system of the body and can lead to physical health problems like:

Brain mass loss

Cardiovascular problems

Gastrointestinal issues (e.g., chronic constipation, gastroesophageal reflux)

Dental problems

Disrupted sleep patterns

Fainting spells

Hair loss or downy hair all over the body (called lanugo)

Loss of menstrual period post-puberty (or delayed first period)

Musculoskeletal injuries and pain

Weakened bones

Diagnosis of Eating Disorders

Medical physicians or mental health professionals, including psychiatrists and psychologists, can diagnose eating disorders. Often, a pediatrician or primary care doctor will diagnose an eating disorder after noticing symptoms during a regular check-up or after a parent or family member expresses concern over their loved one's behavior.

Although there is no one laboratory test to screen for eating disorders, your doctor can use a variety of physical and psychological evaluations as well as lab tests to determine your diagnosis, including:

A physical exam, during which your provider will check your height, weight, and vital signs

Lab tests, including a complete blood count, liver, kidney, and thyroid function tests, urinalysis, X-ray, and an electrocardiogram

Psychological evaluation, which includes personal questions about your eating behaviors, binging, purging, exercise habits, and body image

There are also multiple questionnaires and assessment tools used to assess a person's symptoms, including:

Eating Disorder Inventory

SCOFF Questionnaire

Eating Attitudes Test

Eating Disorder Examination Questionnaire (EDE-Q)

Who Is Diagnosed?

Contrary to popular belief, eating disorders do not only affect teenage girls. They occur in people of all genders, ages, races, ethnicities, and socioeconomic statuses. They are, however, more commonly diagnosed in women.

Men are underrepresented in eating disorder statistics-the stigma of having a condition associated primarily with women often keeps them from seeking help and getting diagnosed. Furthermore, eating disorders may also present differently in men.

Eating disorders have been diagnosed in children as young as age 6 and in older adults and seniors. The different ways eating disorders manifest in these populations can contribute to their unrecognizable nature, even by professionals.

While eating disorders affect people of all ethnic backgrounds, they are often overlooked in non-white populations due to stereotyping. The mistaken belief that eating disorders only affect affluent white females has contributed to the lack of public health treatment for others-the only option available to many underserved and marginalized populations.

And although not well-studied, it is postulated that the experience of discrimination and oppression among transgender populations contribute to higher rates of eating and other disorders among transgender individuals.

Causes of Eating Disorders

Eating disorders are complex illnesses. While we do not definitively know what causes them, some theories exist.

It appears that 50% to 80% of the risk for developing an eating disorder is genetic, but genes alone do not predict who will develop an eating disorder. It is often said that "genes load the gun, but environment pulls the trigger."

Certain situations and events-often called "precipitating factors"-contribute to or trigger the development of eating disorders in those who are genetically vulnerable.

Some environmental factors implicated as precipitants include:

It has also become common to blame eating disorders on the media. While media influence is recognized as a complicating factor, it isn't considered an underlying cause of eating disorder development in individuals. Ultimately, a person must also have a genetic vulnerability for eating disorders to develop.

Treatment for Eating Disorders

Early intervention is associated with an improved outcome, so please do not delay seeking assistance. Life may even need to be put on hold while you focus on getting well. And once you are well, you will be in a much better position to appreciate what life has to offer. Help is available in various formats, although it is common to start treatment with the lowest level of care and progress to higher levels as needed.

Some people with bulimia nervosa and binge eating disorder may explore self-help or guided-self help based on cognitive-behavioral therapy (CBT) principles. The person may work through a workbook, manual, or web platform to learn about the disorder and develop skills to overcome and manage it. Self-help is contraindicated for anorexia nervosa.

Cognitive Behavioral Therapy (CBT)

CBT is the best-studied outpatient therapy for adult eating disorders and includes the following elements:﻿﻿

Family-Based Treatment (FBT)

Family-based treatment (FBT) is the best-studied treatment for children and adolescents with eating disorders.﻿﻿ Essentially, the family is a vital part of the treatment team. Parents commonly provide meal support, which allows the young person to recover in their home environment. Another important element of FBT is externalizing the eating disorder.

Nutritional Therapy

A registered dietitian can help you learn (or relearn) the components of a healthy diet and motivate you to make the needed changes.

Weekly Outpatient Treatment

Weekly outpatient treatment is the usual starting point for those who have access to treatment and typically includes treatment by a team of professionals, including a therapist, a dietitian, and a medical doctor. Other successful outpatient therapies for adult eating disorders include:

Intensive Treatment

For people needing a higher level of care, treatment is available at multiple levels, including intensive outpatient, partial hospitalization, residential, and hospital levels of care. In these settings, a multidisciplinary team almost always provides treatment.

Coping With an Eating Disorder

Caring for your physical and mental health will go a long way toward helping you cope with an eating disorder. In addition to talking to a therapist or joining a support group (like Eating Disorders Anonymous), seek support from a trusted friend or family member who can be there for you along your path to recovery.

Beyond self-care, it's also essential to identify a few healthy distractions you can turn to when you find yourself obsessing about food and weight or experiencing the urge to turn to disordered eating or behaviors. Here are a few to consider:

Explore a new hobby, like photography, painting, or knitting

Invest in an adult coloring book

Practice mindfulness meditation

Take a leisurely walk

Try a yoga class or DVD

Write in a journal

A Word From Verywell

Recovery from an eating disorder isn't easy. It takes courage, but it is possible with the right support system in place.

If you are the parent of a minor with an eating disorder, then it is wise for you to seek treatment on their behalf. Supporting a child with an eating disorder is hard work, but there are resources for you. If your loved one with an eating disorder is an adult, you can still play an important role in helping them too.

Since people with eating disorders often do not believe they have a problem. Family members and significant others play a critical role in getting them help. Although recovery from an eating disorder can be challenging and sometimes long, it is possible.

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Formally classified as "feeding and eating disorders" in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the term "eating disorders" represents a group of complex mental health conditions that can seriously impair health and social functioning. Because of the physical nature of their defining symptoms, eating disorders can cause both emotional distress and significant medical complications.

# data[].attributes.attachment_link.readable_text
Feeding and Eating Disorders, from DSM-5(R) Selections, is a custom-published product crafted around a specific disorder cited in DSM-5. This selection provides a comprehensive overview of the process of diagnosing sleep-wake disorders while serving as a reference guide to assist in the diagnosis of individual patients. The disorder-specific resource is an invaluable addition to the DSM-5(R) collection and an important contribution to the mental health profession.

This book contains the critical disorder-specific content from these four titles: - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(R)) - DSM-5(R) Clinical Cases- DSM-5(R) Self-Exam Questions- DSM-5(R) Guidebook

# data[].attributes.attachment_link.description
Feeding and Eating Disorders, from DSM-5(R) Selections, is a custom-published product crafted around a specific disorder cited in DSM-5. This selection provides a comprehensive overview of the process of diagnosing sleep-wake disorders while serving as a reference guide to assist in the diagnosis of individual patients.

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Rise in Eating Disorder Cases during Pandemic

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Rise in Eating Disorder Cases during Pandemic

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LULU GARCIA-NAVARRO, HOST:

Since the pandemic began, children's hospitals have seen a surge in admissions for eating disorders. And many parents feel desperate, knowing their child is sick but unable to access treatment because of a chronic shortage of therapists and programs that can help them. Kate Wells at Michigan Radio has this story of one family's struggle. And a note to our listeners - this story discusses eating disorders in detail.

GARCIA-NAVARRO: Amelia Haywood (ph) is a little bit nervous to talk about this, but she really wants to. She sits next to her mom in their home in suburban Grand Rapids, Mich. Her long, brown hair hangs loose over a red athletic jacket.

AMELIA HAYWOOD: Yeah. So my name is Amelia. I'm 15 years old. I play volleyball. And about six months ago, I was diagnosed with anorexia nervosa.

KATE WELLS, BYLINE: This disease has sent her to the emergency room four times. And she has been admitted to three different hospitals. It began in March of 2020 when the lockdown started. Suddenly, a girl who had been this athletic, high-achieving eighth-grader just felt lost.

HAYWOOD: People are dying. Everyone's getting sick. You can't see your friends. It was hard because I felt like I didn't have any control over anything except what I ate and how I exercised.

WELLS: So she was like, you know, I'm just going to eat healthy. I'm going to stay in shape. But as the shutdowns and isolation stretched into summer and then fall and then winter, her focus on food and exercise became more intense. It started to consume her. She would make these elaborate meals. And she'd post pictures to Instagram but then actually give them to her sister and lie and say she'd already eaten. She would skip time with friends to fit in yet another run. And she wore baggy sweats to cover up the weight loss. By January, Amelia just felt drained and exhausted all the time.

HAYWOOD: I had, like, basically no emotions. I was just, like, numb. All I wanted to do was, like, lay in my bed.

WELLS: So one Sunday morning, Amelia's mom, Jennifer Ackerman-Haywood (ph), confronted her daughter.

JENNIFER ACKERMAN-HAYWOOD: I just went in there. And I said, Amelia, I know something's up with you. And I'm not going to leave your room until, you know, as long as it takes. You can take your time telling me. But I'm not going anywhere until we have - we have to have a discussion about this because I'm very concerned.

HAYWOOD: And I finally said, I'm struggling with food. It was probably, like, the hardest thing I've ever said in my entire life because I was so scared.

ACKERMAN-HAYWOOD: I immediately was like, of course. Like, this explains everything. Like - and I could kind of like flashback the last month and kind of seeing her decline into a withdrawn person. And I immediately was like, OK. I think she has an eating disorder.

WELLS: The very next day, Jennifer brought Amelia to the pediatrician's. And that is when Amelia was first diagnosed with anorexia. But Jennifer says no one ever alerted her at an earlier checkup that Amelia's growth levels had slowed dramatically. And it wasn't until three weeks after Amelia's diagnosis that Jennifer found out Amelia's EKG had shown her heart rate had become dangerously low.

ACKERMAN-HAYWOOD: And I just thought, wow. We were that close to that. And we didn't know.

WELLS: Two months later, Amelia was so sick, she needed to be admitted to the hospital. Hospitals across the country have seen a surge of patients like Amelia. During the first year of the pandemic, a nationwide network of 15 different hospitals reported their average admissions for adolescent eating disorders doubled. Dr. Terry Bravender treats eating disorders at the University of Michigan CS Mott Children's Hospital. It's one of the places that Amelia was treated.

TERRY BRAVENDER: These are kids whose bodies are failing because of their poor nutritional intake. And the medical hospital is really a safety net rescue for them so that they don't starve to death.

WELLS: Experts believe the pandemic's isolation, social disruption and trauma acted as kind of a mass trigger for many kids and teens who were genetically predisposed to these diseases. Samantha DeCaro is a psychologist with the Renfrew Center. It's a national network of eating disorder clinics.

SAMANTHA DECARO: So the pandemic has created the perfect storm for an eating disorder and disordered eating in the past. It has resulted in a relapse.

WELLS: Even before the pandemic, there was already a shortage of therapists and specialists who know how to treat these illnesses. Doctors say they are hearing from frantic parents who are calling 20, even 60 therapists and cannot get their kid in anywhere. Amelia's mom, Jennifer, says navigating her daughter's illness felt like being in a maze.

ACKERMAN-HAYWOOD: It seems insane because if your child gets a cancer diagnosis or something else, you know, there's a protocol for cancer. You know, there's a protocol for some of these other illnesses out there. There isn't a universal protocol for eating disorders.

WELLS: Amelia kept getting sicker over the spring. And doctors eventually recommended that she get residential treatment at a psychiatric hospital that treats eating disorders.

HAYWOOD: Being able to talk to people who are going through the same thing helped me so much and realize that I'm not alone.

WELLS: Amelia is home now. She is doing so much better. She's on medication. She gets regular therapy. She's back to a healthy weight. She still has days where she struggles with old thought patterns about her body and food. But she wants others to know that it is possible to get better.

HAYWOOD: And I can - I'm starting to get activity back. I'm - I can hang out with my friends and live my life how I want to live. And I know it's really hard to just, like, reach out. But at the end of the day, it's so worth it.

WELLS: This fall, Amelia will be a sophomore. Like so many other kids, she is still grappling with the ways that the pandemic changed her. But she's no longer alone in her bedroom, feeling numb. Now, even on the hardest days, she's got help. For NPR News, I'm Kate Wells in Ann Arbor, Mich.

Copyright © 2021 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

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Children's Hospitals Saw Rise In Eating Disorder Cases During Pandemic

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LULU GARCIA-NAVARRO, HOST: Since the pandemic began, children's hospitals have seen a surge in admissions for eating disorders. And many parents feel desperate, knowing their child is sick but unable to access treatment because of a chronic shortage of therapists and programs that can help them.

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Texas Model for Comprehensive School Counseling Programs 

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Texas Model for Comprehensive School Counseling Programs 

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Reference:
Karl, S. (2014, December) Anorexia nervosa. American Counseling Association Practice Briefs. https://learn-us-east-1-prod-fleet02-xythos.content.blackboardcdn.com/5fb6991aeccdc/5499777?X-Blackboard-Expiration=1667206800000&X-Blackboard-Signature=0shIecu8%2BU7KkVT830g%2F7QVS3igSbTw5aDNLCc6vZkk%3D&X-Blackboard-Client-Id=100963&response-cache-control=private%2C%20max-age%3D21600&response-content-disposition=inline%3B%20filename%2A%3DUTF-8%27%27anorexia-nervosa.pdf&response-content-type=application%2Fpdf&X-Amz-Security-Token=IQoJb3JpZ2luX2VjEIP%2F%2F%2F%2F%2F%2F%2F%2F%2F%2FwEaCXVzLWVhc3QtMSJIMEYCIQDRLfUTkntGaFihhvDy7dlJUUxeXjZ%2B4%2BgZVkdxyvQyhgIhAI%2Bux4zmbAm%2Fd1Zje%2F4R%2FL%2FMY9S4eZ2rBl7A3FyWTmzFKswECGwQAhoMNjM1NTY3OTI0MTgzIgwqxz4wPBuCPdMyzU0qqQShS7loFRfCuwo78LE4dPJDzqHhOuHvBHkjf%2B5s7ItJInJfGSiPU%2F8HBqcBh4KuHrpJYz9YFYptmEHFn1XnDvChjWV0STV8gcKhrkOzLcUlSi1bukU4P549SIpZVKzkRBShevwLtloz0L0T9%2BmIMmYQeS%2Fz89ikqijvoxdqkoL9K1xb%2Fp21NwM2kqW8Ie5dKJPDneInyd2jcmR9%2BF2MUf5HHxDhjt8BDpt3BAt6hNspHO%2B6Wn8MR4niEXjhTuKwdHEz%2Bw9CUyvaJWt6g%2BNhrdZ8BWnHAvcNNdjLUZ2lwTKu58IVtJpedm4Cnq9Qm%2F%2FDTG3wfPPV4VAYJ0OvoYOt7TVa6uJer%2BHXTTer53h48XfYKP7UFZOdxLlQ2L4818qLneMquD6tKf788bDfWYIbPyjBJ79l2XEt7Tz7NAv1Vj0RMCJ40YFJk9%2BwxXyyMoo5FB5m2zTGfBYxiwMnSRlJlcfqjuEUPRltMZfpzmhbwM48P843a452aqNTentO85R%2B3TpOVngCmtM3qTY6MGb02EFtZR2%2FZWEcMZLy0zO4WRrDVmvm2KioJBmUxBUfgogA6FDpjf4Aa2xu8d6a9T01nLLHKt5uemINQw1f4NBDkf5ryDgFXKiuwu1nFXvUDFLVhVQZI49hYXK90RXcp38ABOgQ5fd2IwpVeWR4P2bv65i88vdsYyhCB9dFzFW93WuVr3XWKiC7Z%2Br1%2BA0tyw7zXXFqKFJmlbdyhsaKMIHw%2FJoGOqgBU6aNh0FDMxlLlQJ8GurvPHBk73GfTYiH%2Bu%2B%2Bk%2FUGcifWjgAktsNvxI%2BaZVaMRH0M6e8QLkU7iDrBnC3vsVBqS0cUiWNlBJJBl1H6HMYca1lWPubVsOv6wtJz61Xzh4Y4X8y4p5QEHTxfswrTXVVkSzm3hX5F08iwIjxcM9OKCRkk7KTgRSPGJfENYh29lx9Pbtluv8Ro1lBRDbHM8UuFF0sWjgVkWCXH&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20221031T030000Z&X-Amz-SignedHeaders=host&X-Amz-Expires=21600&X-Amz-Credential=ASIAZH6WM4PLSTHHT7PD%2F20221031%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Signature=e7595884db651b4cf0b1a61157bc221ff4ce2d146635be99909927a89494a100

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Teaching Students with Emotional Disturbances: 8 Tips for Teachers

# data[].attributes.subject
Teaching Students with Emotional Disturbances: 8 Tips for Teachers

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https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596

# data[].attributes.attachment_link.title
Diagnostic and Statistical Manual of Mental Disorders

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Anxiety Disorders | NAMI: National Alliance on Mental Illness

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Discover the symptoms, causes, diagnosis advice, treatment options and related conditions of anxiety disorders.

# data[].attributes.body
https://www.counseling.org/resources/aca-code-of-ethics.pdf

Reference:
American Counseling Association. (2014). 2014 ACA code of ethics.  Retrieved from https://www.counseling.org/resources/aca-code-of-ethics.pdf.

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https://www.psychiatry.org/patients-families/stigma-and-discrimination

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https://www.nimh.nih.gov/health/publications/social-anxiety-disorder-more-than-just-shyness

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National Institute of Mental Health (NIMH)

# data[].attributes.attachment_link.readable_text
Are you afraid of being judged by others? Are you self-conscious in everyday social situations? Do you avoid meeting new people due to fear or anxiety? If you have been feeling this way for at least 6 months and these feelings make it hard for you to do everyday tasks-such as talking to people at work or school-you may have social anxiety disorder.

Social anxiety disorder is an intense, persistent fear of being watched and judged by others. This fear can affect work, school, and other daily activities. It can even make it hard to make and keep friends. The good news is social anxiety disorder is treatable. Learn more about the symptoms of social anxiety disorder and how to find help.

What is social anxiety disorder?

Social anxiety disorder is a common type of anxiety disorder. A person with social anxiety disorder feels symptoms of anxiety or fear in situations where they may be scrutinized, evaluated, or judged by others, such as speaking in public, meeting new people, dating, being on a job interview, answering a question in class, or having to talk to a cashier in a store. Doing everyday things, such as eating or drinking in front of others or using a public restroom, also may cause anxiety or fear due to concerns about being humiliated, judged, and rejected.

The fear that people with social anxiety disorder have in social situations is so intense that they feel it is beyond their control. For some people, this fear may get in the way of going to work, attending school, or doing everyday things. Other people may be able to accomplish these activities but experience a great deal of fear or anxiety when they do. People with social anxiety disorder may worry about engaging in social situations for weeks before they happen. Sometimes, they end up avoiding places or events that cause distress or generate feelings of embarrassment.

Some people with the disorder do not have anxiety related to social interactions but have it during performances instead. They feel symptoms of anxiety in situations such as giving a speech, competing in a sports game, or playing a musical instrument on stage.

Social anxiety disorder usually starts during late childhood and may resemble extreme shyness or avoidance of situations or social interactions. It occurs more frequently in females than in males, and this gender difference is more pronounced in adolescents and young adults. Without treatment, social anxiety disorder can last for many years, or even a lifetime.

What are the signs and symptoms of social anxiety disorder?

When having to perform in front of or be around others, people with social anxiety disorder may:

Blush, sweat, or tremble.

Have a rapid heart rate.

Feel their "mind going blank," or feel sick to their stomach.

Have a rigid body posture, or speak with an overly soft voice.

Find it difficult to make eye contact, be around people they don't know, or talk to people in social situations, even when they want to.

Feel self-consciousness or fear that people will judge them negatively.

Avoid places where there are other people.

What causes social anxiety disorder?

Risk for social anxiety disorder may run in families, but no one knows for sure why some family members have it while others don't. Researchers have found that several parts of the brain are involved in fear and anxiety and that genetics influences how these areas function. By studying how the brain and body interact in people with social anxiety disorder, researchers may be able to create more targeted treatments. In addition, researchers are looking at the ways stress and environmental factors play a role in the disorder.

How is social anxiety disorder treated?

If you're concerned you may have symptoms of social anxiety disorder, talk to a health care provider. After discussing your history, a health care provider may conduct a physical exam to ensure that an unrelated physical problem is not causing your symptoms. A health care provider may refer you to a mental health professional, such as a psychiatrist, psychologist, or clinical social worker. The first step to effective treatment is to get a diagnosis, usually from a mental health professional.

Social anxiety disorder is generally treated with psychotherapy (sometimes called "talk therapy"), medication, or both. Speak with a health care provider about the best treatment for you.

Psychotherapy

Cognitive behavioral therapy (CBT), a research-supported type of psychotherapy, is commonly used to treat social anxiety disorder. CBT teaches you different ways of thinking, behaving, and reacting to situations to help you feel less anxious and fearful. CBT also can help you learn and practice social skills, which is very important for treating social anxiety disorder. CBT has been well studied and is the gold standard for psychotherapy.

Exposure therapy is a CBT method that focuses on progressively confronting the fears underlying an anxiety disorder to help you engage in activities you have been avoiding. Exposure therapy is sometimes used along with relaxation exercises. CBT delivered in a group therapy format also can offer unique benefits for social anxiety disorder.

Another treatment option for social anxiety disorder is acceptance and commitment therapy (ACT). ACT takes a different approach than CBT to negative thoughts and uses strategies such as mindfulness and goal setting to reduce your discomfort and anxiety. Compared to CBT, ACT is a newer form of psychotherapy treatment, so less data are available on its effectiveness. However, different therapies work for different types of people, so it can be helpful to discuss what form of therapy may be right for you with a mental health professional.

For more information on psychotherapy, visit the National Institute of Mental Health (NIMH) psychotherapies webpage.

Medication

Health care providers may prescribe medication to treat social anxiety disorder. Different types of medication can be effective in treating this disorder, including:

Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs)

Beta-blockers

Anti-anxiety medications, such as benzodiazepines

SSRI and SNRI antidepressants are commonly used to treat depression, but they also can help treat the symptoms of social anxiety disorder. They may take several weeks to start working. Antidepressants may also cause side effects, such as headaches, nausea, or difficulty sleeping. These side effects are usually not severe, especially if the dose starts off low and is increased slowly over time. Talk to your health care provider about any side effects that you may experience.

Beta-blockers can help control some of the physical symptoms of social anxiety disorder, such as rapid heart rate, sweating, and tremors. Beta-blockers are commonly the medication of choice for the "performance anxiety" type of social anxiety disorder.

Benzodiazepines, which are anti-anxiety sedative medications, are powerful and begin working right away to reduce anxious feelings. These medications can be very effective in rapidly decreasing anxiety, but some people build up a tolerance to them and need higher and higher doses to get the same effect. Some people even become dependent on them. Therefore, a health care provider may prescribe them only for brief periods of time if you need them.

Both psychotherapy and medication can take some time to work. Many people try more than one medication before finding the best one for them. A health care provider can work with you to find the best medication, dose, and duration of treatment for you. People with social anxiety disorder usually obtain the best results with a combination of medication and CBT or other psychotherapies.

For basic information about these and other mental health medications, visit NIMH's Mental Health Medications webpage. Visit the U.S. Food and Drug Administration (FDA) website for the latest warnings, patient medication guides, and information on newly approved medications.

Support Groups

Many people with social anxiety find support groups helpful. In a group of people who all have social anxiety disorder, you can receive unbiased, honest feedback about how others in the group see you. This way, you can learn that your thoughts about judgment and rejection are not true or are distorted. You also can learn how others with social anxiety disorder approach and overcome the fear of social situations.

Support groups are available both in person and online. However, any advice you receive from a support group member should be used cautiously and does not replace treatment recommendations from a health care provider.

Both psychotherapy and medication can take some time to work. A healthy lifestyle also can help combat anxiety. Make sure to get enough sleep and exercise, eat a healthy diet, and turn to family and friends who you trust for support. To learn more ways to take care of your mental health, visit NIMH's Caring for Your Mental Health webpage.

How can I support myself and others with social anxiety disorder?

Educate Yourself

A good way to help yourself or a loved one who may be struggling with social anxiety disorder is to seek information. Research the warning signs, learn about treatment options, and keep up to date with current research.

Communicate

If you are experiencing social anxiety disorder symptoms, have an honest conversation about how you're feeling with someone you trust. If you think that a friend or family member may be struggling with social anxiety disorder, set aside a time to talk with them to express your concern and reassure them of your support.

Know When to Seek Help

If your anxiety, or the anxiety of a loved one, starts to cause problems in everyday life-such as avoiding social situations at school, at work, or with friends and family-it's time to seek professional help. Talk to a health care provider about your mental health.

Are there clinical trials studying social anxiety disorder?

NIMH supports a wide range of research, including clinical trials that look at new ways to prevent, detect, or treat diseases and conditions-including social anxiety disorder. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct clinical trials with patients and healthy volunteers. Talk to a health care provider about clinical trials, their benefits and risks, and whether one is right for you. For more information, visit NIMH's clinical trials webpage.

Finding Help

Behavioral Health Treatment Services Locator

This online resource, provided by the Substance Abuse and Mental Health Services Administration (SAMHSA), helps you locate mental health treatment facilities and programs. Find a facility in your state by searching SAMHSA's online Behavioral Health Treatment Services Locator . For additional resources, visit NIMH's Help for Mental Illnesses webpage.

Talking to a Health Care Provider About Your Mental Health

Communicating well with a health care provider can improve your care and help you both make good choices about your health. Find tips to help prepare for and get the most out of your visit at Taking Control of Your Mental Health: Tips for Talking With Your Health Care Provider. For additional resources, including questions to ask a provider, visit the Agency for Healthcare Research and Quality website .

If you or someone you know is in immediate distress or is thinking about hurting themselves,call the National Suicide Prevention Lifeline toll-free at 1-800-273-TALK (8255). You also can text the Crisis Text Line (HELLO to 741741) or use the Lifeline Chat on the National Suicide Prevention Lifeline website .

Reprints

The information in this publication is in the public domain and may be reused or copied without permission. However, you may not reuse or copy the images. Please cite the National Institute of Mental Health as the source. Read our copyright policy to learn more about our guidelines for reusing NIMH content.

For More Information

MedlinePlus (National Library of Medicine) ( en español )

ClinicalTrials.gov ( en español )

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
National Institutes of Health
NIH Publication No. 22-MH-8083
Revised 2022

# data[].attributes.attachment_link.title
Social Anxiety Disorder: More Than Just Shyness

# data[].attributes.attachment_link.description
Information about social anxiety disorder, including common signs and symptoms, treatment options, and how to find help.

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https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders

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https://www.mayoclinic.org/diseases-conditions/social-anxiety-disorder/diagnosis-treatment/drc-20353567

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https://www.hopkinsmedicine.org/health/conditions-and-diseases/generalized-anxiety-disorder

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https://www.healthcentral.com/article/types-of-anxiety-disorders

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ASCA Ethical Standards for School Counselors

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ASCA Ethical Standards for School Counselors

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https://www.schoolcounselor.org/About-School-Counseling/Ethical-Legal-Responsibilities/ASCA-Ethical-Standards-for-School-Counselors-(1)

Reference:
American School Counselor Association (2022). ASCA ethical standards for school counselors. American School Counselor Association. https://www.schoolcounselor.org/About-School-Counseling/Ethical-Legal-Responsibilities/ASCA-Ethical-Standards-for-School-Counselors-(1)

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ASCA Ethical Standards for School Counselors - American School Counselor Association (ASCA)

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School-Based Anxiety Treatments for Children & Adolescents

# data[].attributes.subject
School-Based Anxiety Treatments for Children & Adolescents

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3399129/

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Child Adolesc Psychiatr Clin N Am. Author manuscript; available in PMC 2013 Jul 1.

Published in final edited form as:

Kathleen Herzig-Anderson, PhD, a Daniela Colognori, PsyD, a Jeremy K. Fox, PhD, Catherine E. Stewart, BA, a and Carrie Masia Warner, PhD a, b,*

SUMMARY

School-based empirically supported treatments for anxiety disorders are a promising avenue for providing necessary intervention to distressed youth who would otherwise never receive treatment. Sustaining such programs in school settings should be viewed as a multiple-stage process, from integration of the program into the institution and maintenance of the intervention to responding to institutional change and ownership of the program by the school.51 Given the scarce resources available to schools, additional research on embedding programs into the school culture and maximizing existing resources is essential to enhancing the sustainability of school-based interventions for anxiety disorders and reaching youth in need.

Keywords: Anxiety, School-based treatment, Children, Adolescents, Dissemination

Anxiety disorders are common among children and adolescents; however, anxious youth are rarely identified.1 Unlike disruptive behavior disorders, anxiety disorders often go unnoticed by teachers and parents because clinically anxious youth are generally compliant, follow rules, and do not draw attention. Therefore, it is not surprising that anxious youth are the least likely among youth with psychiatric disorders to receive treatment.2 Furthermore, even when youth access services, it is unclear what type of treatment they receive. Although several empirically supported treatments for anxious youth exist,3-5 more than 80% of community-based treatment for anxious youth is not supported by scientific evidence.6,7 There are also many barriers to treatment in traditional settings (eg, community clinics and independent clinicians), including stigma, long waitlists, and high costs.8 Taken together, these factors underscore the importance of exploring alternative venues and methods for identifying and treating youth with anxiety disorders.

ADVANTAGES OF SCHOOL-BASED TREATMENT

Schools are viewed as a promising avenue for providing mental health services to children and adolescents. Schools are already the main point-of-entry into the mental health service system for youth,9-12 with one study showing that more than 70% of mental health treatment for youth is provided by schools.10 In addition, because schools offer relatively convenient and inexpensive services, barriers to accessing specialty care, such as financial and transportation difficulties, can be eliminated.13,14 For example, school-based mental health clinics have been found to increase service utilization for both low-income adolescents15 as well as adolescents enrolled in a health maintenance organization.16 In light of common stigmas associated with mental health care, school-based treatment may also promote more positive attitudes toward mental health services among youth,17,18 especially when offered among a variety of other routine educational and counseling services. Access to treatment in schools may normalize mental health care and may therefore increase the likelihood of students in need receiving treatment.

For these reasons, school-based treatments are receiving increasing attention as a venue to address the unmet mental health needs of youth, particularly those with anxiety disorders.19 School-based treatments are particularly appropriate for anxiety disorders as schools provide unique opportunities for identification of anxious youth, treatment, and generalization of skills. For example, youth may display significant anxiety in academic and social settings at school that is not apparent or easily triggered in a more comfortable home environment with family support.20 Schools are also optimal for the treatment of anxiety disorders, as there are ample opportunities to help students confront the many anxiety-provoking situations present at school. Specifically, exposure exercises at school could focus on exams and tests for youth with generalized anxiety disorder and achievement-oriented worries. Socially anxious youth may be helped to face negative evaluation fears associated with public speaking, performance in gym and music classes, and approaching unfamiliar peers and authority figures. Additionally, peers and teachers may be enlisted to assist in exposures to feared situations. In sum, these factors indicate that schools are advantageous settings for the treatment of anxiety disorders in children and adolescents.

Although schools are ideal venues for anxiety disorder treatment in youth, only in recent years has the transportability of efficacious cognitive-behavioral treatments for anxiety disorders to schools been evaluated. This article will review four school-based treatments for anxiety disorders that have shown promise in controlled trials (see Table 1 for an overview and Table 2 for links to treatment manuals). This will be followed by a discussion of issues and challenges related to delivering anxiety treatments in a school environment and important areas for future research.

Table 1

Treatment

Number and
Length of
Sessions

Format

Treatment Components

Parent/Teacher
Components

Overview of
Effectiveness in
Schools

Implementation
Strengths and
Limitations

Cool Kids21

Eight 1-hour
sessions

Group

Psychoeducation, cognitive
restructuring, graduated
exposure, coping with
bullying, social skills,
assertiveness

Two parent
information
sessions on
parenting
strategies and
ways for parents
to manage their
own anxiety

Significantly greater
decreases in self-
and teacher-
reported anxiety
when compared
to waitlist control

Strengths:
* Group format
* Includes dealing with
bullying, social skills,
and assertiveness
components.
Limitations:
* Unknown if superior
to attention control
or other treatments.
* Use of community
mental health
workers is
unsustainable.

Baltimore Child
Anxiety Treatment
Study in the
Schools
(BCATSS)24-26

Ten 45-
minute
sessions24
or twelve
35-minute
sessions25

Group24 and
individual25,26

Psychoeducation, cognitive
restructuring, graduated
exposure, self-reward,
contingency
management, relaxation
skills, problem solving,
relapse prevention

Up to three sessions
include parents to
provide parenting
strategies and
psychoeducation.

Significantly greater
decreases in self-
and clinician-rated
anxiety compared
to attention-
support control in
one small study.
Another small
study found no
difference
compared to usual
care.

Strengths:
* Includes self-reward,
contingency
management, and
problem solving.
* Shown to be effective
with urban African
American youth.
Limitations:
* No teacher
components
* Individual format25,26

Cognitive-Behavioral
Intervention for
Trauma in Schools
(CBITS)28

Ten 1-hour
sessions

Group

Psychoeducation, cognitive
restructuring, graduated
exposure, processing of
traumatic memories,
relaxation skills, social
problem-solving skills,
adaptive coping skills

Two parent
education
meetings, one
teacher education
meeting

Two studies found
significantly
greater reductions
in PTSD symptoms
compared to
waitlist control.
One study found
significantly
greater reductions
in depressive
symptoms
compared to
waitlist control.

Strengths:
* Includes social
problem-solving
skills, processing
traumatic memories,
and adaptive coping
skills.
* Shown to be effective
with minor
adaptations for
urban multicultural
populations.
Limitations:
* Unknown whether it
is more effective
than attention
control.
* Use of school-based
psychiatric social
workers is not a
model most schools
have the resources to
replicate.

Support for Students
Exposed to Trauma
(SSET33;an
adaptation of
CBITS)

Ten 45-
minute
sessions
(one class
period)

Group

Psychoeducation, cognitive
restructuring, graduated
exposure, processing
traumatic memories,
relaxation skills, adaptive
coping, problem solving

Parent phone calls.
Can be
implemented by
teachers.

Small improvements
found in PTSD and
depressive
symptoms at 3-
month follow-up
in one study.

Strengths:
* Designed to be
implemented by
teachers and school
counselors.
Limitations:
* Only one study
without enough
power to determine
if modest results are
significant
* No significant parent
component

Skills for Academic
and Social Success
(SASS)35

Twelve 40-
minute
sessions

Group

Psychoeducation, cognitive
restructuring, graduated
exposure, social skills,
peer generalization
(through social events)

Two parent
meetings
including
psychoeducation
and parenting
strategies, two
teacher meetings

Significantly greater
number of
students were
classified as
responders to
treatment
compared to
waitlist and
attention control.

Strengths:
* Inclusion of social
skills and peer
generalization social
events
Limitations:
* To date, shown to be
effective only when
implemented by
clinical psychologists,
although study
examining SASS in
school counselors is
underway.

COOL KIDS

Treatment Description

The Cool Kids Program: School Version21 is an eight-session cognitive-behavioral intervention for anxiety symptoms in children, which was adapted for the school environment from previous group treatments for anxiety disorders.22 Sessions focus on core cognitive-behavioral treatment (CBT) components, such as psychoeducation, cognitive restructuring, and graduated exposure to anxiety-provoking situations. Additionally, Cool Kids includes sessions on assertiveness, coping with bullying, and social skills. Treatment sessions last about 1 hour each and are conducted during the school day in groups of eight to ten children. Two parent information sessions address parenting strategies as well as concepts taught to the children, which parents are encouraged to use to manage their own anxiety.

Evidence for Cool Kids

Mifsud and Rapee21 evaluated Cool Kids in a sample of 91 children (ages 9-10) by randomizing nine schools in low-income communities in Australia to either Cool Kids or a waitlist control.21 Students scoring in the clinical range of the Revised Manifest Anxiety Scale,23 a self-report measure of anxiety, were selected to participate. Groups were co-led by a school counselor and an experienced community mental health worker. Compared to the control, children in the Cool Kids condition showed significantly greater decreases in self- and teacher-reported anxiety both at post-treatment and 4-month follow-up. This study suggests that Cool Kids is a promising school-based intervention; however, since delivery by experienced community mental health workers is not a sustainable model, further research is needed to evaluate its effectiveness when delivered only by school-based providers.

BALTIMORE CHILD ANXIETY TREATMENT STUDY IN THE SCHOOLS

Treatment Description

Baltimore Child Anxiety Treatment Study in the Schools (BCATSS) 24-26 is designed to provide mental health treatment for inner-city adolescents with anxiety disorders as an integrated part of established school-based mental health clinics. The treatment was adapted from a previously supported group CBT program.5,27 The BCATSS program was tailored for the school environment and an urban, lower socioeconomic status, predominantly African American population (eg, examples were changed to be culturally relevant). Based on feedback from school mental health professionals, BCATSS was implemented individually during 12 weekly sessions (35 minutes each).25 This CBT program is comprised of psychoeducation, relaxation skills, problem solving, cognitive restructuring, relapse prevention and graduated in-vivo exposures to feared situations reinforced by self-reward and contingency contracts. The BCATSS intervention has a modular approach, allowing the clinician flexibility in choosing which core CBT skills ("modules") to deliver in a particular session based on the needs of the student.25 Optional parent sessions (one to three) were also added to increase involvement.26

Evidence for BCATSS

The BCATSS treatment has been evaluated in two small randomized controlled trials. Preliminary support for Ginsburg and Drake's24 adaptation of group CBT for a predominantly inner-city African American population was demonstrated in a small randomized controlled study ( N = 12) comparing BCATSS to an attention-support control in 14- to 17-year-old adolescents diagnosed with generalized anxiety disorder, social phobia, specific phobia, and/or agoraphobia. Two advanced psychology graduate students with training in CBT implemented the program. Results showed that self- and clinician-rated anxiety symptoms were significantly lower after treatment in the CBT group compared to the control group. In addition, 80% of the control group continued to meet criteria for an anxiety disorder after treatment, versus only 25% of the CBT group.

The second randomized controlled trial25,26 compared the BCATSS CBT program to usual care (UC) in a small study of 7- to 17-year-old ( M = 10.28) inner-city African American youth with anxiety disorders ( N = 32). Therapists were school-based master's and doctoral level clinicians, trained primarily in social work, counseling, or psychology. Because there was only one clinician per school, the same clinician implemented both conditions.25 Clinicians were explicitly instructed to exclude CBT techniques in the usual care condition and instead implement nonspecific strategies, such as art and supportive therapy.26 Results showed no differences across conditions at post-treatment, with 50% of CBT participants and 46% of UC participants no longer meeting criteria for an anxiety disorder. Similar results were found at 1-month follow-up: 42% of participants in the CBT group and 57% in the UC group no longer met criteria for an anxiety disorder. A central methodologic limitation was that CBT-trained clinicians also delivered usual care, resulting in poor treatment differentiation across conditions. Per review of 25% of UC therapy sessions, 56% contained CBT techniques, despite ongoing coaching to exclude these components. In addition, although the authors rated how much of the module content (eg, psychoeducation, exposure) was delivered (adherence), they did not report how skillfully these specific techniques were conducted (competence). Therefore, it is possible that the implementation quality impacted treatment outcome. Another possibility is that novice therapists may be more effective with structured rather than flexible treatments, as the latter may require more expertise to determine the appropriate module to deliver. Clearly, several questions remain unanswered, and thus additional research examining the value of modular treatments may be necessary.

COGNITIVE-BEHAVIORAL INTERVENTION FOR TRAUMA IN SCHOOLS

Treatment Description

Cognitive-Behavioral Intervention for Trauma in Schools (CBITS)28 is a school-based group treatment developed for youth ages 10 to 15 with clinically significant symptoms of posttraumatic stress disorder (PTSD) and depression secondary to trauma exposure (excluding sexual abuse). CBITS was designed to be implemented by mental health clinicians in an urban multicultural environment. CBITS is generally comprised of ten one-hour weekly group treatment sessions (five to eight students per group), one to three individual sessions, two optional parent education meetings, and one teacher education meeting.28,29 The treatment elements of CBITS include psychoeducation, relaxation, adaptive coping skills, cognitive restructuring techniques, graduated imaginal exposure to traumatic memories, processing of traumatic memories, and social problem solving skills. Imaginal exposure through writing and drawing is initially conducted in individual sessions and subsequently in the group. CBITS sessions present skills using a combination of didactic presentation, developmentally appropriate examples, worksheets, and games. The focus of treatment is the generalization of concepts learned in treatment sessions to real-life situations by applying them to a given child's specific difficulties.28

Evidence for CBITS

Two randomized controlled trials have shown support for CBITS compared to a waitlist control in youth with clinically significant PTSD symptoms secondary to exposure to community violence.28,30 In both studies, CBITS was implemented by psychiatric social workers based in the school districts' mental health clinic. The first study ( N = 199) found that third through eighth graders (mean age = 11.4 years; SD = 1.7) with clinically elevated PTSD symptoms participating in CBITS had significantly lower PTSD symptoms post-treatment compared to waitlist control.30 Small adaptations for this study included reducing group sessions from ten to eight and increasing parent sessions from two to four, which focused on themes of loss and separation common to immigration. Similarly, Stein and colleagues28 found that sixth graders ( N = 126) participating in CBITS reported significantly greater reductions in PTSD and depressive symptoms compared to those in the waitlist control group three months and six months post-treatment. These two studies provide evidence for the effectiveness of CBITS for PTSD symptoms when implemented in urban multicultural schools.

The feasibility of school-based group CBITS compared to clinic-based individual Trauma Focused-Cognitive-Behavioral Therapy (TF-CBT) was supported by an investigation of fourth to eighth graders ( N = 118) with elevated PTSD symptoms 15-months post-Hurricane Katrina in New Orleans.31 Three components of CBITS were not delivered in this study due to resource and time limitations: the individual session prior to the start of group, teacher informational meetings and in two of the three schools, parent meetings. The CBITS treatment was implemented by school-based mental health professionals, while TF-CBT was conducted by social workers and psychologists employed at a community mental health center.32 Although youth in both treatment groups showed clinically significant improvements in PTSD symptoms at 10-month follow-up, CBITS was far more accessible to participants as 98% of youth randomized to CBITS were enrolled in treatment compared to only 23% of youth assigned to TF-CBT. This highlights the greater ability of school-based treatments to reach and retain distressed youth compared to treatments delivered in traditional community mental health settings.

Support for Students Exposed to Trauma

Support for Students Exposed to Trauma (SSET),33 an adaptation of CBITS, was designed to be implemented by school counselors and teachers to increase accessibility. SSET delivers the components of CBITS in 10 weekly group sessions utilizing a lesson plan format and omits the individual and parent meetings included in CBITS. SSET showed superiority to a waitlist control in 76 sixth to eighth graders scoring at least 11 on the Child PTSD Symptom Scale 34 (ie, moderate to high PTSD symptoms) subsequent to exposure to violence within the last year. Students in the SSET group showed small improvements in PTSD and depressive symptoms at 3-month follow-up. While these decreases appeared to be more substantial than those of the waitlist control, the small sample size limited the statistical power to detect effects. Although additional studies are needed, these preliminary findings suggest that SSET is a feasible intervention for PTSD symptoms that can be delivered by school personnel.

SKILLS FOR ACADEMIC AND SOCIAL SUCCESS

Treatment Description

Skills for Academic and Social Success (SASS)35 is a school-based group CBT program for adolescents with social anxiety disorder adapted from Social Effectiveness Therapy for Children (SET-C), an efficacious group treatment for children with social anxiety disorder.3,36 Like SET-C, SASS focuses on gradual exposure, social skills, and peer generalization. However, SASS includes adaptations for adolescents (eg, addition of realistic thinking) and the school environment (eg, shorter sessions, involvement of teachers). SASS consists of 12 weekly 40-minute (ie, one class period) group sessions, two individual meetings, two parent meetings, two teacher meetings, four social events with outgoing peers, and two booster sessions. Social skills training includes initiating and maintaining conversations, nonverbal behaviors (eg, maintaining good eye contact), and assertiveness. Graduated in vivo exposures to feared social situations are often integrated into the school environment, for example, volunteering to answer a question in class, talking with a teacher, or giving an oral presentation. Individual meetings focus on setting goals and problem solving any obstacles to treatment. To increase generalization of skills and exposure to real-world settings, the four social events are conducted with group members and outgoing peers together in settings adolescents often spend time in, such as bowling or laser tag. Parent meetings include psychoeducation, parenting strategies including preventing their child's avoidance, and rewarding nonanxious behavior. Teacher meetings focus on the goals of SASS, education regarding social anxiety, and enlisting teachers' help with classroom exposures.

Evidence for SASS

Support for SASS has been provided by two randomized controlled trials. The first investigation compared SASS to a waitlist control in urban parochial high school students with social anxiety disorder ( N = 35).37 Groups were co-led by a clinical psychologist and a psychology graduate student. Results found that 94% of SASS participants were classified as responders based on their improved functioning at post-treatment, versus only 12% of the control group. In addition, 67% of SASS participants, compared to only 6% of controls, no longer met criteria for social anxiety disorder post-treatment. Lower clinician-rated diagnostic severity and self-reported social anxiety and social avoidance were found for the SASS group at post-treatment and 9-month follow-up.

The second trial examined the specific efficacy of SASS compared to a credible attention control in adolescents aged 14 to 16 ( N = 36) with a primary diagnosis of social anxiety disorder.1 The attention control group, equal in time and adult attention, included relaxation training and four social events without outgoing peers. Results demonstrated superiority of SASS, with more than 82% of SASS participants classified as responders, compared to 7% of those in the attention control. Importantly, only 41% of SASS participants continued to meet criteria for social anxiety disorder post-treatment, while all control participants still qualified for the disorder. Students receiving SASS also exhibited greater overall improvement and lower clinician-rated social anxiety severity at post-treatment and 6-month follow-up.

Currently, Masia Warner and colleagues are conducting a large, federally funded, randomized controlled trial of SASS implemented by school guidance counselors to investigate its transportability to school settings.38 This study will examine whether school personnel without specialized training in CBT can effectively deliver a cognitive-behavioral intervention. Positive findings would highlight the potential effectiveness of a more sustainable model of evidence-based care delivered by school personnel to reach underserved youth with social anxiety disorder.

Summary of School-Based Anxiety Treatments

Studies of school-based treatment programs for anxiety disorders in youth suggest promise for effectively delivering these evidence-based programs in schools. However, several gaps in our current knowledge exist. One shortcoming has been the reliance on specialized mental health clinicians to deliver interventions, which is costly and resource intensive. Researchers have called for training school-based personnel (eg, school counselors and teachers) to deliver these evidence-based interventions, but it remains unknown whether they can do so effectively. In addition, surprisingly few investigations of school-based anxiety treatments have investigated the impact of intervention on academic and other school-related variables upon which schools are evaluated (eg, grades, standardized test scores, attendance). Overall, many questions remain regarding methods to facilitate successful implementation and sustainability of school-based mental health programs. The following section focuses on several areas requiring additional exploration, such as the integration of treatments into school culture, improving identification of anxious youth, and the utilization of school-based personnel as treatment providers.

IMPLICATIONS FOR RESEARCH AND PRACTICE

School Culture and Context

Efforts to increase the accessibility of evidence-based treatments to youth with anxiety disorders may be bolstered by a better understanding of factors affecting the ability of schools to adopt and sustain mental health programs. Consideration of school context, such as school climate, resources, and the impact of educational accountability, will likely influence whether schools will accept and prioritize these treatments.39 Because schools' main focus is education, future studies providing evidence that school-based treatments positively affect academics and other variables aligning with school values are essential to increasing uptake and sustainability of school-based treatments. Further research on methods to better integrate mental health programs into the school culture may also improve the acceptability of programs to important stakeholders, such as school administrators. For example, incorporating treatment components into the general classroom curriculum has been found to increase program sustainability for universal intervention programs.40 Applying this concept to targeted students with anxiety disorders, such as evaluating integration of school-based programs into existing student services (eg, guidance counseling) or extracurricular activities (eg, club format), may also increase feasibility. Finally, future research should examine optimal methods to maximize schools' existing resources to manage students' mental health needs. For instance, Ringeisen and colleagues39 suggest replacing the current individualized case management approach to school-based mental health care with a model combining classroom-based intervention and as-needed group treatment or consultation from specialized clinicians. This innovative model, along with other methods to improve integration of mental health services into the existing school culture, is critical to increasing long-term sustainability of school-based mental health programs.

Identification of Clinically Anxious Students

Another essential area for future study will be testing methods for enhancing recognition or detection of youth with anxiety disorders. Research on the ability of school personnel to identify youth with internalizing disorders has focused mostly on teachers rather than more specialized personnel such as counselors, and findings have been inconclusive. Not surprisingly, teachers are generally more likely to recognize externalizing behaviors than internalizing problems such as anxiety and depression.41,42 There is some evidence to suggest that youth are more likely to access services when school personnel (eg, teachers, school counselors) are made aware of their anxiety rather than parents or other adults.43 This indicates that research on educating and training school personnel in the identification of anxiety, through observation or school-wide screenings, is critical to increasing early detection and treatment.44,45 Studies examining the accuracy and sensitivity of self-report measures in predicting anxiety disorders would clarify the effectiveness and efficiency of utilizing these measures in school-wide screenings to identify anxious youth. Of course, a challenge of improving methods for identifying anxious youth is the resulting increase in referrals for mental health care, which schools may not be equipped to handle. This highlights the importance of increasing the availability of mental health care providers through school-based treatments.

School-Based Treatment Providers

To date, the majority of investigations of school-based interventions have been implemented by mental health clinicians employed by research teams. Because the costs and feasibility of hiring mental health clinicians are prohibitive for most schools, there is a significant need to establish the effectiveness of school-based interventions for anxiety disorders when delivered by school personnel. With specialized training, supervision, and support, school guidance counselors may be ideal candidates to be trained in the implementation of mental health interventions. School counselors are present in all high schools, typically comprise a large team, and enter their profession to assist and guide youth.46 Furthermore, a recent national survey revealed that 90% of guidance counselors wanted reductions in administrative tasks and caseloads to increase time for assisting students and receiving training.47 This indicates that guidance counselors may be open to opportunities to receive training in school-based treatments, especially because guidance counselors are routinely asked to manage their students' emotional needs.

However, the literature has shown that efficacious treatments delivered in research settings often show reduced effectiveness in clinical settings.48 It has been theorized that treatment fidelity, defined as adequate adherence to a treatment manual and competence in delivery,49 is related to treatment outcome.50 Further research is needed to document this relationship and to identify what levels of fidelity are sufficient for treatment response, which has the potential to inform training approaches and supervision. The ongoing study by Masia Warner and colleagues examining whether school counselors can effectively implement a group CBT program for adolescents with social anxiety disorder will contribute to this gap in the literature.

​

School-based empirically supported treatments for anxiety disorders are a promising avenue for providing necessary intervention to distressed youth who would otherwise never receive treatment.

Sustaining such programs in school settings should be viewed as a multiple-stage process, from integration of the program into the institution and maintenance of the intervention to responding to institutional change and ownership of the program by the school.

Given the scarce resources available to schools, additional research on embedding programs into the school culture and maximizing existing resources is essential to enhancing the sustainability of school-based interventions for anxiety disorders and reaching youth in need.

Acknowledgments

This work was supported by NIMH Grant No. R01MH081881 awarded to Carrie Masia Warner, PhD.

Footnotes

The authors have nothing to disclose.

REFERENCES

13. Catron T, Harris VS, Weiss B. Posttreatment results after 2 years of services in the Vanderbilt school-based counseling project. In: Epstein MH, Kutash K, Duchnowski A, editors. Outcomes for children and youth with emotional and behavioral disorders and their families: programs and evaluation best practices. PRO-ED; Austin (TX): 1998. pp. 633-40. [ Google Scholar]

27. Ginsburg G, Silverman W, Kurtines W. Cognitive-behavioral group therapy. In: Eisen A, Kearney C, Schaefer C, editors. Clinical handbook of anxiety disorders in children and adolescents. Jason Aronson; Northvale (NJ): 1995. pp. 521-49. [ Google Scholar]

29. Jaycox LH, Morse LK, Tanielian T, et al. [Accessed May 16, 2012];How schools can help students recover from traumatic experiences: a tool kit for supporting long-term recovery 2006. Available at:http://www.rand.org/pubs/technical_reports/TR413.html.

35. Masia C, Beidel DC, Fisher PH, et al. Skills for academic and social success. New York University School of Medicine; New York: 1999. [ Google Scholar]

38. Masia Warner C, Ryan J, Colognori D, et al. Adapting treatment of social anxiety disorder for delivery in schools: training school counselors to deliver a cognitive-behavioral intervention. In: Gallagher R, editor. How to keep from getting schooled: dissemination and implementation of empirically-based programs for children and adolescents in educational settings; Symposium presented at the 45th annual meeting of the Association for Behavioral and Cognitive Therapies; Toronto, ON. November 2011; Chair. [ Google Scholar]

41. Burnett-Zeigler I, Lyons JS. Youth characteristics associated with intensity of service use in a school-based mental health intervention. J Child Fam Stud. 2011 DOI: 10.1007/s10826-011-9555-z. [ Google Scholar]

43. Colognori D, Ryan JL, Fox JK, et al. Mental health service utilization in a community sample of socially anxious adolescents. In: Masia Warner C, Ryan J, editors. Mental health service utilization in youth: deficiencies of availability, awareness, and use of evidence-based treatments; Symposium presented at the 45th annual meeting of the Association for Behavioral and Cognitive Therapies; Toronto, ON. November 2011; Co-Chairs. [ Google Scholar]

47. Bridgeland J, Bruce M. [Accessed December 27, 2011];National survey of school counselors: counseling at a crossroads 2011. Available at: http://media.collegeboard.com/digitalServices/pdf/nosca/11b_4230_NarReport_BOOKLET_WEB_111104.pdf.

# data[].attributes.attachment_link.title
School-Based Anxiety Treatments for Children and Adolescents

# data[].attributes.attachment_link.description
Child Adolesc Psychiatr Clin N Am. Author manuscript; available in PMC 2013 Jul 1. Published in final edited form as: Kathleen Herzig-Anderson, PhD, a Daniela Colognori, PsyD, a Jeremy K. Fox, PhD, Catherine E.

# data[].attributes.headline
Appropriate/Inappropriate Activities for School Counselors 

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Appropriate/Inappropriate Activities for School Counselors 

# data[].attributes.headline
ASCA School Counselor Professional Standards & Competencies

# data[].attributes.subject
ASCA School Counselor Professional Standards & Competencies

# data[].attributes.headline
Addressing Anxiety in School Settings: Information for Counselors

# data[].attributes.subject
Addressing Anxiety in School Settings: Information for Counselors

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Centers for Disease Control and Prevention

# data[].attributes.attachment_link.readable_text
Being mentally healthy during childhood means reaching developmental and emotional milestones and learning healthy social skills and how to cope when there are problems. Mentally healthy children have a positive quality of life and can function well at home, in school, and in their communities.

Mental disorders among children are described as serious changes in the way children typically learn, behave, or handle their emotions, which cause distress and problems getting through the day. Many children occasionally experience fears and worries or display disruptive behaviors. If symptoms are serious and persistent and interfere with school, home, or play activities, the child may be diagnosed with a mental disorder.

Mental health is not simply the absence of a mental disorder. Children who don't have a mental disorder might differ in how well they are doing, and children who have the same diagnosed mental disorder might differ in their strengths and weaknesses in how they are developing and coping, and in their quality of life. Mental health as a continuum and the identification of specific mental disorders are both ways to understand how well children are doing.

What are common childhood mental disorders?

Among the more common mental disorders that can be diagnosed in childhood are attention-deficit/hyperactivity disorder (ADHD), anxiety (fears or worries), and behavior disorders.

Learn more about childhood mental disorders, symptoms, and treatment.

Other childhood disorders and concerns that affect how children learn, behave, or handle their emotions can include learning and developmental disabilities, autism, and risk factors like substance use and self-harm.

Read more about related conditions.

What are the symptoms of childhood mental disorders?

Symptoms of mental disorders change over time as a child grows, and may include difficulties with how a child plays, learns, speaks, and acts, or how the child handles their emotions. Symptoms often start in early childhood, although some disorders may develop during the teenage years. The diagnosis is often made in the school years and sometimes earlier; however, some children with a mental disorder may not be recognized or diagnosed as having one.

Can childhood mental disorders be treated?

Childhood mental disorders can be treated and managed. There are many treatment options based on the best and most current medical evidence. Parents and doctors should work closely with everyone involved in the child's treatment-teachers, coaches, therapists, and other family members. Taking advantage of all the resources available will help parents, health professionals, and educators guide the child towards success. Early diagnosis and appropriate services for children and their families can make a difference in the lives of children with mental disorders.

Get help finding treatment

If you have concerns about a child, you can use these resources to help you find a healthcare provider familiar with treatment options.

Who is affected?

Childhood mental disorders affect many children and families. Boys and girls of all ages and ethnic/racial backgrounds and living in all regions of the United States experience mental disorders. Based on the National Research Council and Institute of Medicine report, which gathered findings from previous studies, it is estimated that in 2007, 13-20% of children living in the United States (up to 1 out of 5 children) experienced a mental disorder in a given year, costing individuals, families, and society an estimated $247 billion per year.

What is the impact of mental disorders in children?

Mental health is important to overall health. Mental disorders are chronic health conditions-conditions that last a long time and often don't go away completely-that can continue through the lifespan. Without early diagnosis and treatment, children with mental disorders can have problems at home, in school, and in forming friendships. Mental disorders can also interfere with a child's healthy development, causing problems that can continue into adulthood.

Public health includes mental health

Supporting children's mental health also includes making sure children meet developmental milestones, understanding what to do when there is a concern, supporting positive parenting strategies, and improving access to care.

CDC works with partner agencies to better understand mental health and mental disorders and the impact they have on children.
Read more about research on children's mental health.
What you can do

Parents: You know your child best. Talk to your child's healthcare professional if you have concerns about the way your child behaves at home, in school, or with friends.

Youth: It is just as important to take care of your mental health as it is to take care of your physical health. If you are angry, worried or sad, don't be afraid to talk about your feelings and reach out to a trusted friend or adult.

Healthcare professionals: Early diagnosis and appropriate treatment based on updated guidelines are very important. There are resources available to help diagnose and treat children's mental disorders.

Teachers/school administrators: Early identification is important so that children can get the help they need. Work with families and healthcare professionals if you have concerns about the mental health of a child in your school.

Resources

# data[].attributes.attachment_link.description
Learn more about mental health, mental disorders, treatments, prevention, and public health research on children's mental health.

# data[].attributes.body
https://www.cdc.gov/childrensmentalhealth/basics.html

https://www.psychiatry.org/patients-families/stigma-and-discrimination

# data[].attributes.attachment_link.provider_name
Centers for Disease Control and Prevention

# data[].attributes.attachment_link.readable_text
Being mentally healthy during childhood means reaching developmental and emotional milestones and learning healthy social skills and how to cope when there are problems. Mentally healthy children have a positive quality of life and can function well at home, in school, and in their communities.

Mental disorders among children are described as serious changes in the way children typically learn, behave, or handle their emotions, which cause distress and problems getting through the day. Many children occasionally experience fears and worries or display disruptive behaviors. If symptoms are serious and persistent and interfere with school, home, or play activities, the child may be diagnosed with a mental disorder.

Mental health is not simply the absence of a mental disorder. Children who don't have a mental disorder might differ in how well they are doing, and children who have the same diagnosed mental disorder might differ in their strengths and weaknesses in how they are developing and coping, and in their quality of life. Mental health as a continuum and the identification of specific mental disorders are both ways to understand how well children are doing.

What are common childhood mental disorders?

Among the more common mental disorders that can be diagnosed in childhood are attention-deficit/hyperactivity disorder (ADHD), anxiety (fears or worries), and behavior disorders.

Learn more about childhood mental disorders, symptoms, and treatment.

Other childhood disorders and concerns that affect how children learn, behave, or handle their emotions can include learning and developmental disabilities, autism, and risk factors like substance use and self-harm.

Read more about related conditions.

What are the symptoms of childhood mental disorders?

Symptoms of mental disorders change over time as a child grows, and may include difficulties with how a child plays, learns, speaks, and acts, or how the child handles their emotions. Symptoms often start in early childhood, although some disorders may develop during the teenage years. The diagnosis is often made in the school years and sometimes earlier; however, some children with a mental disorder may not be recognized or diagnosed as having one.

Can childhood mental disorders be treated?

Childhood mental disorders can be treated and managed. There are many treatment options based on the best and most current medical evidence. Parents and doctors should work closely with everyone involved in the child's treatment-teachers, coaches, therapists, and other family members. Taking advantage of all the resources available will help parents, health professionals, and educators guide the child towards success. Early diagnosis and appropriate services for children and their families can make a difference in the lives of children with mental disorders.

Get help finding treatment

If you have concerns about a child, you can use these resources to help you find a healthcare provider familiar with treatment options.

Who is affected?

Childhood mental disorders affect many children and families. Boys and girls of all ages and ethnic/racial backgrounds and living in all regions of the United States experience mental disorders. Based on the National Research Council and Institute of Medicine report, which gathered findings from previous studies, it is estimated that in 2007, 13-20% of children living in the United States (up to 1 out of 5 children) experienced a mental disorder in a given year, costing individuals, families, and society an estimated $247 billion per year.

What is the impact of mental disorders in children?

Mental health is important to overall health. Mental disorders are chronic health conditions-conditions that last a long time and often don't go away completely-that can continue through the lifespan. Without early diagnosis and treatment, children with mental disorders can have problems at home, in school, and in forming friendships. Mental disorders can also interfere with a child's healthy development, causing problems that can continue into adulthood.

Public health includes mental health

Supporting children's mental health also includes making sure children meet developmental milestones, understanding what to do when there is a concern, supporting positive parenting strategies, and improving access to care.

CDC works with partner agencies to better understand mental health and mental disorders and the impact they have on children.
Read more about research on children's mental health.
What you can do

Parents: You know your child best. Talk to your child's healthcare professional if you have concerns about the way your child behaves at home, in school, or with friends.

Youth: It is just as important to take care of your mental health as it is to take care of your physical health. If you are angry, worried or sad, don't be afraid to talk about your feelings and reach out to a trusted friend or adult.

Healthcare professionals: Early diagnosis and appropriate treatment based on updated guidelines are very important. There are resources available to help diagnose and treat children's mental disorders.

Teachers/school administrators: Early identification is important so that children can get the help they need. Work with families and healthcare professionals if you have concerns about the mental health of a child in your school.

Resources

# data[].attributes.attachment_link.description
Learn more about mental health, mental disorders, treatments, prevention, and public health research on children's mental health.

# data[].attributes.body
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3399129/

https://www.counseling.org/docs/default-source/vistas/article_62.pdf?sfvrsn=20677d2c_10

# data[].attributes.attachment_link.readable_text
Child Adolesc Psychiatr Clin N Am. Author manuscript; available in PMC 2013 Jul 1.

Published in final edited form as:

Kathleen Herzig-Anderson, PhD, a Daniela Colognori, PsyD, a Jeremy K. Fox, PhD, Catherine E. Stewart, BA, a and Carrie Masia Warner, PhD a, b,*

SUMMARY

School-based empirically supported treatments for anxiety disorders are a promising avenue for providing necessary intervention to distressed youth who would otherwise never receive treatment. Sustaining such programs in school settings should be viewed as a multiple-stage process, from integration of the program into the institution and maintenance of the intervention to responding to institutional change and ownership of the program by the school.51 Given the scarce resources available to schools, additional research on embedding programs into the school culture and maximizing existing resources is essential to enhancing the sustainability of school-based interventions for anxiety disorders and reaching youth in need.

Keywords: Anxiety, School-based treatment, Children, Adolescents, Dissemination

Anxiety disorders are common among children and adolescents; however, anxious youth are rarely identified.1 Unlike disruptive behavior disorders, anxiety disorders often go unnoticed by teachers and parents because clinically anxious youth are generally compliant, follow rules, and do not draw attention. Therefore, it is not surprising that anxious youth are the least likely among youth with psychiatric disorders to receive treatment.2 Furthermore, even when youth access services, it is unclear what type of treatment they receive. Although several empirically supported treatments for anxious youth exist,3-5 more than 80% of community-based treatment for anxious youth is not supported by scientific evidence.6,7 There are also many barriers to treatment in traditional settings (eg, community clinics and independent clinicians), including stigma, long waitlists, and high costs.8 Taken together, these factors underscore the importance of exploring alternative venues and methods for identifying and treating youth with anxiety disorders.

ADVANTAGES OF SCHOOL-BASED TREATMENT

Schools are viewed as a promising avenue for providing mental health services to children and adolescents. Schools are already the main point-of-entry into the mental health service system for youth,9-12 with one study showing that more than 70% of mental health treatment for youth is provided by schools.10 In addition, because schools offer relatively convenient and inexpensive services, barriers to accessing specialty care, such as financial and transportation difficulties, can be eliminated.13,14 For example, school-based mental health clinics have been found to increase service utilization for both low-income adolescents15 as well as adolescents enrolled in a health maintenance organization.16 In light of common stigmas associated with mental health care, school-based treatment may also promote more positive attitudes toward mental health services among youth,17,18 especially when offered among a variety of other routine educational and counseling services. Access to treatment in schools may normalize mental health care and may therefore increase the likelihood of students in need receiving treatment.

For these reasons, school-based treatments are receiving increasing attention as a venue to address the unmet mental health needs of youth, particularly those with anxiety disorders.19 School-based treatments are particularly appropriate for anxiety disorders as schools provide unique opportunities for identification of anxious youth, treatment, and generalization of skills. For example, youth may display significant anxiety in academic and social settings at school that is not apparent or easily triggered in a more comfortable home environment with family support.20 Schools are also optimal for the treatment of anxiety disorders, as there are ample opportunities to help students confront the many anxiety-provoking situations present at school. Specifically, exposure exercises at school could focus on exams and tests for youth with generalized anxiety disorder and achievement-oriented worries. Socially anxious youth may be helped to face negative evaluation fears associated with public speaking, performance in gym and music classes, and approaching unfamiliar peers and authority figures. Additionally, peers and teachers may be enlisted to assist in exposures to feared situations. In sum, these factors indicate that schools are advantageous settings for the treatment of anxiety disorders in children and adolescents.

Although schools are ideal venues for anxiety disorder treatment in youth, only in recent years has the transportability of efficacious cognitive-behavioral treatments for anxiety disorders to schools been evaluated. This article will review four school-based treatments for anxiety disorders that have shown promise in controlled trials (see Table 1 for an overview and Table 2 for links to treatment manuals). This will be followed by a discussion of issues and challenges related to delivering anxiety treatments in a school environment and important areas for future research.

Table 1

Treatment

Number and
Length of
Sessions

Format

Treatment Components

Parent/Teacher
Components

Overview of
Effectiveness in
Schools

Implementation
Strengths and
Limitations

Cool Kids21

Eight 1-hour
sessions

Group

Psychoeducation, cognitive
restructuring, graduated
exposure, coping with
bullying, social skills,
assertiveness

Two parent
information
sessions on
parenting
strategies and
ways for parents
to manage their
own anxiety

Significantly greater
decreases in self-
and teacher-
reported anxiety
when compared
to waitlist control

Strengths:
* Group format
* Includes dealing with
bullying, social skills,
and assertiveness
components.
Limitations:
* Unknown if superior
to attention control
or other treatments.
* Use of community
mental health
workers is
unsustainable.

Baltimore Child
Anxiety Treatment
Study in the
Schools
(BCATSS)24-26

Ten 45-
minute
sessions24
or twelve
35-minute
sessions25

Group24 and
individual25,26

Psychoeducation, cognitive
restructuring, graduated
exposure, self-reward,
contingency
management, relaxation
skills, problem solving,
relapse prevention

Up to three sessions
include parents to
provide parenting
strategies and
psychoeducation.

Significantly greater
decreases in self-
and clinician-rated
anxiety compared
to attention-
support control in
one small study.
Another small
study found no
difference
compared to usual
care.

Strengths:
* Includes self-reward,
contingency
management, and
problem solving.
* Shown to be effective
with urban African
American youth.
Limitations:
* No teacher
components
* Individual format25,26

Cognitive-Behavioral
Intervention for
Trauma in Schools
(CBITS)28

Ten 1-hour
sessions

Group

Psychoeducation, cognitive
restructuring, graduated
exposure, processing of
traumatic memories,
relaxation skills, social
problem-solving skills,
adaptive coping skills

Two parent
education
meetings, one
teacher education
meeting

Two studies found
significantly
greater reductions
in PTSD symptoms
compared to
waitlist control.
One study found
significantly
greater reductions
in depressive
symptoms
compared to
waitlist control.

Strengths:
* Includes social
problem-solving
skills, processing
traumatic memories,
and adaptive coping
skills.
* Shown to be effective
with minor
adaptations for
urban multicultural
populations.
Limitations:
* Unknown whether it
is more effective
than attention
control.
* Use of school-based
psychiatric social
workers is not a
model most schools
have the resources to
replicate.

Support for Students
Exposed to Trauma
(SSET33;an
adaptation of
CBITS)

Ten 45-
minute
sessions
(one class
period)

Group

Psychoeducation, cognitive
restructuring, graduated
exposure, processing
traumatic memories,
relaxation skills, adaptive
coping, problem solving

Parent phone calls.
Can be
implemented by
teachers.

Small improvements
found in PTSD and
depressive
symptoms at 3-
month follow-up
in one study.

Strengths:
* Designed to be
implemented by
teachers and school
counselors.
Limitations:
* Only one study
without enough
power to determine
if modest results are
significant
* No significant parent
component

Skills for Academic
and Social Success
(SASS)35

Twelve 40-
minute
sessions

Group

Psychoeducation, cognitive
restructuring, graduated
exposure, social skills,
peer generalization
(through social events)

Two parent
meetings
including
psychoeducation
and parenting
strategies, two
teacher meetings

Significantly greater
number of
students were
classified as
responders to
treatment
compared to
waitlist and
attention control.

Strengths:
* Inclusion of social
skills and peer
generalization social
events
Limitations:
* To date, shown to be
effective only when
implemented by
clinical psychologists,
although study
examining SASS in
school counselors is
underway.

COOL KIDS

Treatment Description

The Cool Kids Program: School Version21 is an eight-session cognitive-behavioral intervention for anxiety symptoms in children, which was adapted for the school environment from previous group treatments for anxiety disorders.22 Sessions focus on core cognitive-behavioral treatment (CBT) components, such as psychoeducation, cognitive restructuring, and graduated exposure to anxiety-provoking situations. Additionally, Cool Kids includes sessions on assertiveness, coping with bullying, and social skills. Treatment sessions last about 1 hour each and are conducted during the school day in groups of eight to ten children. Two parent information sessions address parenting strategies as well as concepts taught to the children, which parents are encouraged to use to manage their own anxiety.

Evidence for Cool Kids

Mifsud and Rapee21 evaluated Cool Kids in a sample of 91 children (ages 9-10) by randomizing nine schools in low-income communities in Australia to either Cool Kids or a waitlist control.21 Students scoring in the clinical range of the Revised Manifest Anxiety Scale,23 a self-report measure of anxiety, were selected to participate. Groups were co-led by a school counselor and an experienced community mental health worker. Compared to the control, children in the Cool Kids condition showed significantly greater decreases in self- and teacher-reported anxiety both at post-treatment and 4-month follow-up. This study suggests that Cool Kids is a promising school-based intervention; however, since delivery by experienced community mental health workers is not a sustainable model, further research is needed to evaluate its effectiveness when delivered only by school-based providers.

BALTIMORE CHILD ANXIETY TREATMENT STUDY IN THE SCHOOLS

Treatment Description

Baltimore Child Anxiety Treatment Study in the Schools (BCATSS) 24-26 is designed to provide mental health treatment for inner-city adolescents with anxiety disorders as an integrated part of established school-based mental health clinics. The treatment was adapted from a previously supported group CBT program.5,27 The BCATSS program was tailored for the school environment and an urban, lower socioeconomic status, predominantly African American population (eg, examples were changed to be culturally relevant). Based on feedback from school mental health professionals, BCATSS was implemented individually during 12 weekly sessions (35 minutes each).25 This CBT program is comprised of psychoeducation, relaxation skills, problem solving, cognitive restructuring, relapse prevention and graduated in-vivo exposures to feared situations reinforced by self-reward and contingency contracts. The BCATSS intervention has a modular approach, allowing the clinician flexibility in choosing which core CBT skills ("modules") to deliver in a particular session based on the needs of the student.25 Optional parent sessions (one to three) were also added to increase involvement.26

Evidence for BCATSS

The BCATSS treatment has been evaluated in two small randomized controlled trials. Preliminary support for Ginsburg and Drake's24 adaptation of group CBT for a predominantly inner-city African American population was demonstrated in a small randomized controlled study ( N = 12) comparing BCATSS to an attention-support control in 14- to 17-year-old adolescents diagnosed with generalized anxiety disorder, social phobia, specific phobia, and/or agoraphobia. Two advanced psychology graduate students with training in CBT implemented the program. Results showed that self- and clinician-rated anxiety symptoms were significantly lower after treatment in the CBT group compared to the control group. In addition, 80% of the control group continued to meet criteria for an anxiety disorder after treatment, versus only 25% of the CBT group.

The second randomized controlled trial25,26 compared the BCATSS CBT program to usual care (UC) in a small study of 7- to 17-year-old ( M = 10.28) inner-city African American youth with anxiety disorders ( N = 32). Therapists were school-based master's and doctoral level clinicians, trained primarily in social work, counseling, or psychology. Because there was only one clinician per school, the same clinician implemented both conditions.25 Clinicians were explicitly instructed to exclude CBT techniques in the usual care condition and instead implement nonspecific strategies, such as art and supportive therapy.26 Results showed no differences across conditions at post-treatment, with 50% of CBT participants and 46% of UC participants no longer meeting criteria for an anxiety disorder. Similar results were found at 1-month follow-up: 42% of participants in the CBT group and 57% in the UC group no longer met criteria for an anxiety disorder. A central methodologic limitation was that CBT-trained clinicians also delivered usual care, resulting in poor treatment differentiation across conditions. Per review of 25% of UC therapy sessions, 56% contained CBT techniques, despite ongoing coaching to exclude these components. In addition, although the authors rated how much of the module content (eg, psychoeducation, exposure) was delivered (adherence), they did not report how skillfully these specific techniques were conducted (competence). Therefore, it is possible that the implementation quality impacted treatment outcome. Another possibility is that novice therapists may be more effective with structured rather than flexible treatments, as the latter may require more expertise to determine the appropriate module to deliver. Clearly, several questions remain unanswered, and thus additional research examining the value of modular treatments may be necessary.

COGNITIVE-BEHAVIORAL INTERVENTION FOR TRAUMA IN SCHOOLS

Treatment Description

Cognitive-Behavioral Intervention for Trauma in Schools (CBITS)28 is a school-based group treatment developed for youth ages 10 to 15 with clinically significant symptoms of posttraumatic stress disorder (PTSD) and depression secondary to trauma exposure (excluding sexual abuse). CBITS was designed to be implemented by mental health clinicians in an urban multicultural environment. CBITS is generally comprised of ten one-hour weekly group treatment sessions (five to eight students per group), one to three individual sessions, two optional parent education meetings, and one teacher education meeting.28,29 The treatment elements of CBITS include psychoeducation, relaxation, adaptive coping skills, cognitive restructuring techniques, graduated imaginal exposure to traumatic memories, processing of traumatic memories, and social problem solving skills. Imaginal exposure through writing and drawing is initially conducted in individual sessions and subsequently in the group. CBITS sessions present skills using a combination of didactic presentation, developmentally appropriate examples, worksheets, and games. The focus of treatment is the generalization of concepts learned in treatment sessions to real-life situations by applying them to a given child's specific difficulties.28

Evidence for CBITS

Two randomized controlled trials have shown support for CBITS compared to a waitlist control in youth with clinically significant PTSD symptoms secondary to exposure to community violence.28,30 In both studies, CBITS was implemented by psychiatric social workers based in the school districts' mental health clinic. The first study ( N = 199) found that third through eighth graders (mean age = 11.4 years; SD = 1.7) with clinically elevated PTSD symptoms participating in CBITS had significantly lower PTSD symptoms post-treatment compared to waitlist control.30 Small adaptations for this study included reducing group sessions from ten to eight and increasing parent sessions from two to four, which focused on themes of loss and separation common to immigration. Similarly, Stein and colleagues28 found that sixth graders ( N = 126) participating in CBITS reported significantly greater reductions in PTSD and depressive symptoms compared to those in the waitlist control group three months and six months post-treatment. These two studies provide evidence for the effectiveness of CBITS for PTSD symptoms when implemented in urban multicultural schools.

The feasibility of school-based group CBITS compared to clinic-based individual Trauma Focused-Cognitive-Behavioral Therapy (TF-CBT) was supported by an investigation of fourth to eighth graders ( N = 118) with elevated PTSD symptoms 15-months post-Hurricane Katrina in New Orleans.31 Three components of CBITS were not delivered in this study due to resource and time limitations: the individual session prior to the start of group, teacher informational meetings and in two of the three schools, parent meetings. The CBITS treatment was implemented by school-based mental health professionals, while TF-CBT was conducted by social workers and psychologists employed at a community mental health center.32 Although youth in both treatment groups showed clinically significant improvements in PTSD symptoms at 10-month follow-up, CBITS was far more accessible to participants as 98% of youth randomized to CBITS were enrolled in treatment compared to only 23% of youth assigned to TF-CBT. This highlights the greater ability of school-based treatments to reach and retain distressed youth compared to treatments delivered in traditional community mental health settings.

Support for Students Exposed to Trauma

Support for Students Exposed to Trauma (SSET),33 an adaptation of CBITS, was designed to be implemented by school counselors and teachers to increase accessibility. SSET delivers the components of CBITS in 10 weekly group sessions utilizing a lesson plan format and omits the individual and parent meetings included in CBITS. SSET showed superiority to a waitlist control in 76 sixth to eighth graders scoring at least 11 on the Child PTSD Symptom Scale 34 (ie, moderate to high PTSD symptoms) subsequent to exposure to violence within the last year. Students in the SSET group showed small improvements in PTSD and depressive symptoms at 3-month follow-up. While these decreases appeared to be more substantial than those of the waitlist control, the small sample size limited the statistical power to detect effects. Although additional studies are needed, these preliminary findings suggest that SSET is a feasible intervention for PTSD symptoms that can be delivered by school personnel.

SKILLS FOR ACADEMIC AND SOCIAL SUCCESS

Treatment Description

Skills for Academic and Social Success (SASS)35 is a school-based group CBT program for adolescents with social anxiety disorder adapted from Social Effectiveness Therapy for Children (SET-C), an efficacious group treatment for children with social anxiety disorder.3,36 Like SET-C, SASS focuses on gradual exposure, social skills, and peer generalization. However, SASS includes adaptations for adolescents (eg, addition of realistic thinking) and the school environment (eg, shorter sessions, involvement of teachers). SASS consists of 12 weekly 40-minute (ie, one class period) group sessions, two individual meetings, two parent meetings, two teacher meetings, four social events with outgoing peers, and two booster sessions. Social skills training includes initiating and maintaining conversations, nonverbal behaviors (eg, maintaining good eye contact), and assertiveness. Graduated in vivo exposures to feared social situations are often integrated into the school environment, for example, volunteering to answer a question in class, talking with a teacher, or giving an oral presentation. Individual meetings focus on setting goals and problem solving any obstacles to treatment. To increase generalization of skills and exposure to real-world settings, the four social events are conducted with group members and outgoing peers together in settings adolescents often spend time in, such as bowling or laser tag. Parent meetings include psychoeducation, parenting strategies including preventing their child's avoidance, and rewarding nonanxious behavior. Teacher meetings focus on the goals of SASS, education regarding social anxiety, and enlisting teachers' help with classroom exposures.

Evidence for SASS

Support for SASS has been provided by two randomized controlled trials. The first investigation compared SASS to a waitlist control in urban parochial high school students with social anxiety disorder ( N = 35).37 Groups were co-led by a clinical psychologist and a psychology graduate student. Results found that 94% of SASS participants were classified as responders based on their improved functioning at post-treatment, versus only 12% of the control group. In addition, 67% of SASS participants, compared to only 6% of controls, no longer met criteria for social anxiety disorder post-treatment. Lower clinician-rated diagnostic severity and self-reported social anxiety and social avoidance were found for the SASS group at post-treatment and 9-month follow-up.

The second trial examined the specific efficacy of SASS compared to a credible attention control in adolescents aged 14 to 16 ( N = 36) with a primary diagnosis of social anxiety disorder.1 The attention control group, equal in time and adult attention, included relaxation training and four social events without outgoing peers. Results demonstrated superiority of SASS, with more than 82% of SASS participants classified as responders, compared to 7% of those in the attention control. Importantly, only 41% of SASS participants continued to meet criteria for social anxiety disorder post-treatment, while all control participants still qualified for the disorder. Students receiving SASS also exhibited greater overall improvement and lower clinician-rated social anxiety severity at post-treatment and 6-month follow-up.

Currently, Masia Warner and colleagues are conducting a large, federally funded, randomized controlled trial of SASS implemented by school guidance counselors to investigate its transportability to school settings.38 This study will examine whether school personnel without specialized training in CBT can effectively deliver a cognitive-behavioral intervention. Positive findings would highlight the potential effectiveness of a more sustainable model of evidence-based care delivered by school personnel to reach underserved youth with social anxiety disorder.

Summary of School-Based Anxiety Treatments

Studies of school-based treatment programs for anxiety disorders in youth suggest promise for effectively delivering these evidence-based programs in schools. However, several gaps in our current knowledge exist. One shortcoming has been the reliance on specialized mental health clinicians to deliver interventions, which is costly and resource intensive. Researchers have called for training school-based personnel (eg, school counselors and teachers) to deliver these evidence-based interventions, but it remains unknown whether they can do so effectively. In addition, surprisingly few investigations of school-based anxiety treatments have investigated the impact of intervention on academic and other school-related variables upon which schools are evaluated (eg, grades, standardized test scores, attendance). Overall, many questions remain regarding methods to facilitate successful implementation and sustainability of school-based mental health programs. The following section focuses on several areas requiring additional exploration, such as the integration of treatments into school culture, improving identification of anxious youth, and the utilization of school-based personnel as treatment providers.

IMPLICATIONS FOR RESEARCH AND PRACTICE

School Culture and Context

Efforts to increase the accessibility of evidence-based treatments to youth with anxiety disorders may be bolstered by a better understanding of factors affecting the ability of schools to adopt and sustain mental health programs. Consideration of school context, such as school climate, resources, and the impact of educational accountability, will likely influence whether schools will accept and prioritize these treatments.39 Because schools' main focus is education, future studies providing evidence that school-based treatments positively affect academics and other variables aligning with school values are essential to increasing uptake and sustainability of school-based treatments. Further research on methods to better integrate mental health programs into the school culture may also improve the acceptability of programs to important stakeholders, such as school administrators. For example, incorporating treatment components into the general classroom curriculum has been found to increase program sustainability for universal intervention programs.40 Applying this concept to targeted students with anxiety disorders, such as evaluating integration of school-based programs into existing student services (eg, guidance counseling) or extracurricular activities (eg, club format), may also increase feasibility. Finally, future research should examine optimal methods to maximize schools' existing resources to manage students' mental health needs. For instance, Ringeisen and colleagues39 suggest replacing the current individualized case management approach to school-based mental health care with a model combining classroom-based intervention and as-needed group treatment or consultation from specialized clinicians. This innovative model, along with other methods to improve integration of mental health services into the existing school culture, is critical to increasing long-term sustainability of school-based mental health programs.

Identification of Clinically Anxious Students

Another essential area for future study will be testing methods for enhancing recognition or detection of youth with anxiety disorders. Research on the ability of school personnel to identify youth with internalizing disorders has focused mostly on teachers rather than more specialized personnel such as counselors, and findings have been inconclusive. Not surprisingly, teachers are generally more likely to recognize externalizing behaviors than internalizing problems such as anxiety and depression.41,42 There is some evidence to suggest that youth are more likely to access services when school personnel (eg, teachers, school counselors) are made aware of their anxiety rather than parents or other adults.43 This indicates that research on educating and training school personnel in the identification of anxiety, through observation or school-wide screenings, is critical to increasing early detection and treatment.44,45 Studies examining the accuracy and sensitivity of self-report measures in predicting anxiety disorders would clarify the effectiveness and efficiency of utilizing these measures in school-wide screenings to identify anxious youth. Of course, a challenge of improving methods for identifying anxious youth is the resulting increase in referrals for mental health care, which schools may not be equipped to handle. This highlights the importance of increasing the availability of mental health care providers through school-based treatments.

School-Based Treatment Providers

To date, the majority of investigations of school-based interventions have been implemented by mental health clinicians employed by research teams. Because the costs and feasibility of hiring mental health clinicians are prohibitive for most schools, there is a significant need to establish the effectiveness of school-based interventions for anxiety disorders when delivered by school personnel. With specialized training, supervision, and support, school guidance counselors may be ideal candidates to be trained in the implementation of mental health interventions. School counselors are present in all high schools, typically comprise a large team, and enter their profession to assist and guide youth.46 Furthermore, a recent national survey revealed that 90% of guidance counselors wanted reductions in administrative tasks and caseloads to increase time for assisting students and receiving training.47 This indicates that guidance counselors may be open to opportunities to receive training in school-based treatments, especially because guidance counselors are routinely asked to manage their students' emotional needs.

However, the literature has shown that efficacious treatments delivered in research settings often show reduced effectiveness in clinical settings.48 It has been theorized that treatment fidelity, defined as adequate adherence to a treatment manual and competence in delivery,49 is related to treatment outcome.50 Further research is needed to document this relationship and to identify what levels of fidelity are sufficient for treatment response, which has the potential to inform training approaches and supervision. The ongoing study by Masia Warner and colleagues examining whether school counselors can effectively implement a group CBT program for adolescents with social anxiety disorder will contribute to this gap in the literature.

​

School-based empirically supported treatments for anxiety disorders are a promising avenue for providing necessary intervention to distressed youth who would otherwise never receive treatment.

Sustaining such programs in school settings should be viewed as a multiple-stage process, from integration of the program into the institution and maintenance of the intervention to responding to institutional change and ownership of the program by the school.

Given the scarce resources available to schools, additional research on embedding programs into the school culture and maximizing existing resources is essential to enhancing the sustainability of school-based interventions for anxiety disorders and reaching youth in need.

Acknowledgments

This work was supported by NIMH Grant No. R01MH081881 awarded to Carrie Masia Warner, PhD.

Footnotes

The authors have nothing to disclose.

REFERENCES

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# data[].attributes.attachment_link.title
School-Based Anxiety Treatments for Children and Adolescents

# data[].attributes.attachment_link.description
Child Adolesc Psychiatr Clin N Am. Author manuscript; available in PMC 2013 Jul 1. Published in final edited form as: Kathleen Herzig-Anderson, PhD, a Daniela Colognori, PsyD, a Jeremy K. Fox, PhD, Catherine E.