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Anxiety vs Anxiety Disorders Infographic

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Overview

Occasional anxiety is an expected part of life. You might feel anxious when faced with a problem at work, before taking a test, or before making an important decision. But anxiety disorders involve more than temporary worry or fear. For a person with an anxiety disorder, the anxiety does not go away and can get worse over time. The symptoms can interfere with daily activities such as job performance, school work, and relationships.

There are several types of anxiety disorders, including generalized anxiety disorder, panic disorder, and various phobia-related disorders.

Signs and Symptoms

Risk Factors

Treatments and Therapies

Join a Study

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Occasional anxiety is an expected part of life. You might feel anxious when faced with a problem at work, before taking a test, or before making an important decision. But anxiety disorders involve more than temporary worry or fear. For a person with an anxiety disorder, the anxiety does not go away and can get worse over time.

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anxiety
Do you struggle with anxiety? Here's how to recognize the signs, symptoms, and different types of anxiety-and find the relief you need.

What is anxiety?

Anxiety is a normal reaction to danger, the body's automatic fight-or-flight response that is triggered when you feel threatened, under pressure, or are facing a challenging situation, such as a job interview, exam, or first date. In moderation, anxiety isn't necessarily a bad thing. It can help you to stay alert and focused, spur you to action, and motivate you to solve problems. But when anxiety is constant or overwhelming-when worries and fears interfere with your relationships and daily life-you've likely crossed the line from normal anxiety into the territory of an anxiety disorder.

Since anxiety disorders are a group of related conditions rather than a single disorder, symptoms may vary from person to person. One individual may suffer from intense anxiety attacks that strike without warning, while another gets panicky at the thought of mingling at a party. Someone else may struggle with a disabling fear of driving, or uncontrollable, intrusive thoughts. Yet another may live in a constant state of tension, worrying about anything and everything. But despite their different forms, all anxiety disorders illicit an intense fear or worry out of proportion to the situation at hand.

While having an anxiety disorder can be disabling, preventing you from living the life you want, it's important to know that you're not alone. Anxiety disorders are among the most common mental health issues-and are highly treatable. Once you understand your anxiety disorder, there are steps you can take to reduce the symptoms and regain control of your life.

What is high-functioning anxiety?

"High-functioning anxiety" is a term you may have come across online. It's not a clinical diagnosis but is sometimes used to describe a person who manages to cope with the demands of daily life despite having anxiety. Outwardly, they may seem unflappable. But beneath their calm demeanor, they're plagued by anxious and negative thoughts.

If you have high-functioning anxiety, you might seem proactive, outgoing, organized, and achievement-oriented. You may even come off as a perfectionist or model student or employee. However, your underlying anxiety can still have health consequences, including irritability, insomnia, and muscle tension.

Different people experience anxiety symptoms in different ways. It's important to remember that some people are dealing with struggles that aren't always apparent.

Do I have an anxiety disorder?

If you identify with any of the following seven signs and symptoms, and they just won't go away, you may be suffering from an anxiety disorder:

1. Are you constantly tense, worried, or on edge?

2. Does your anxiety interfere with your work, school, or family responsibilities?

3. Are you plagued by fears that you know are irrational, but can't shake?

4. Do you believe that something bad will happen if certain things aren't done a certain way?

5. Do you avoid everyday situations or activities because they cause you anxiety?

6. Do you experience sudden, unexpected attacks of heart-pounding panic?

7. Do you feel like danger and catastrophe are around every corner?

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Signs and symptoms of anxiety disorders

In addition to the primary symptom of excessive and irrational fear and worry, other common emotional symptoms include:

Feelings of apprehension or dread.

Watching for signs of danger.

Anticipating the worst.

Trouble concentrating.

Feeling tense and jumpy.

Irritability.

Feeling like your mind's gone blank.

But anxiety is more than just a feeling. As a product of the body's fight-or-flight response, it also involves a wide range of physical symptoms, including:

Pounding heart.

Sweating.

Headaches.

Stomach upset.

Dizziness.

Frequent urination or diarrhea.

Shortness of breath.

Muscle tension or twitches.

Shaking or trembling.

Insomnia.

Because of these physical symptoms, anxiety sufferers often mistake their disorder for a medical illness. They may visit many doctors and make numerous trips to the hospital before their anxiety disorder is finally recognized.

The link between anxiety symptoms and depression

Many people with anxiety disorders also suffer from depression at some point. Anxiety and depression are believed to stem from the same biological vulnerability, which may explain why they so often go hand-in-hand. Since depression makes anxiety worse (and vice versa), it's important to seek treatment for both conditions.

What is an anxiety attack?

Anxiety attacks, also known as panic attacks, are episodes of intense panic or fear. They usually occur suddenly and without warning. Sometimes there's an obvious trigger-getting stuck in an elevator, for example, or thinking about the big speech you have to give-but in other cases, the attacks come out of the blue.

Anxiety attacks usually peak within 10 minutes, and they rarely last more than 30 minutes. But during that short time, you may experience terror so severe that you feel as if you're about to die or totally lose control. The physical symptoms are themselves so frightening that many people think they're having a heart attack. After an anxiety attack is over, you may worry about having another one, particularly in a public place where help isn't available or you can't easily escape.

Anxiety attack symptoms include:

Surge of overwhelming panic.

Feeling of losing control or going crazy.

Heart palpitations or chest pain.

Feeling like you're going to pass out.

Trouble breathing or choking sensation.

Hyperventilation.

Hot flashes or chills.

Trembling or shaking.

Nausea or stomach cramps.

Feeling detached or unreal.

It's important to seek help if you're starting to avoid certain situations because you're afraid of having a panic attack. The truth is that panic attacks are highly treatable. In fact, many people are panic free within just 5 to 8 treatment sessions.

Types of anxiety disorders and their symptoms

Anxiety disorders and closely related conditions include:

Generalized anxiety disorder (GAD)

If constant worries and fears distract you from your day-to-day activities, or you're troubled by a persistent feeling that something bad is going to happen, you may be suffering from generalized anxiety disorder (GAD). People with GAD are chronic worrywarts who feel anxious nearly all of the time, though they may not even know why. GAD often manifests in physical symptoms like insomnia, stomach upset, restlessness, and fatigue.

Panic attacks and panic disorder

Panic disorder is characterized by repeated, unexpected panic attacks, as well as fear of experiencing another episode. Agoraphobia, the fear of being somewhere where escape or help would be difficult in the event of a panic attack, may also accompany a panic disorder. If you have agoraphobia, you are likely to avoid public places such as shopping malls, or confined spaces such as an airplane.

Obsessive-compulsive disorder (OCD)

Obsessive-compulsive disorder (OCD) is characterized by unwanted thoughts or behaviors that seem impossible to stop or control. If you have OCD, you may feel troubled by obsessions, such as a recurring worry that you forgot to turn off the oven or that you might hurt someone. You may also suffer from uncontrollable compulsions, such as washing your hands over and over.

Hoarding disorder

Hoarding disorder is a chronic difficulty discarding possessions, accompanied by a dysfunctional attachment to even worthless items. It can lead to excessive accumulation of possessions (or animals) and a cluttered living space. You may attribute emotion to inanimate objects, have a strong sentimental attachment to items, or see the use in any object. These beliefs can make discarding items overwhelm you with feelings of anxiety, guilt, or sadness.

Phobias and irrational fears

A phobia is an unrealistic or exaggerated fear of a specific object, activity, or situation that in reality presents little to no danger. Common phobias include fear of animals (such as snakes and spiders), fear of flying, and fear of needles. In the case of a severe phobia, you might go to extreme lengths to avoid the object of your fear. Unfortunately, avoidance only strengthens the phobia.

Social anxiety disorder

If you have a debilitating fear of being viewed negatively by others and humiliated in public, you may have social anxiety disorder, also known as social phobia. It can be thought of as extreme shyness and in severe cases, social situations are avoided altogether. Performance anxiety (better known as stage fright) is the most common type of social phobia.

Post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (PTSD) is an extreme anxiety disorder that can occur in the aftermath of a traumatic or life-threatening event. PTSD can be thought of as a panic attack that rarely, if ever, lets up. Symptoms of PTSD include flashbacks or nightmares about the incident, hypervigilance, startling easily, withdrawing from others, and avoiding situations that remind you of the event.

Separation anxiety disorder

While separation anxiety is a normal stage of development, if anxieties intensify or are persistent enough to get in the way of school or other activities, your child may have separation anxiety disorder. They may become agitated at just the thought of being away from mom or dad and complain of sickness to avoid playing with friends or going to school.

Self-help for anxiety

Not everyone who worries a lot has an anxiety disorder. You may feel anxious because of an overly demanding schedule, lack of exercise or sleep, pressure at home or work, or even from too much caffeine. The bottom line is that if your lifestyle is unhealthy and stressful, you're more likely to feel anxious-whether or not you actually have an anxiety disorder.

These tips can help to lower anxiety and manage symptoms of a disorder:

Connect with others. Loneliness and isolation can trigger or worsen anxiety, while talking about your worries face to face can often make them seem less overwhelming. Make it a point to regularly meet up with friends, join a self-help or support group, or share your worries and concerns with a trusted loved one. If you don't have anyone you can reach out to, it's never too late to build new friendships and a support network.

Manage stress. If your stress levels are through the roof, stress management can help. Look at your responsibilities and see if there are any you can give up, turn down, or delegate to others.

Practice relaxation techniques. When practiced regularly relaxation techniques such as mindfulness meditation, progressive muscle relaxation, and deep breathing can reduce anxiety symptoms and increase feelings of relaxation and emotional well-being.

Exercise regularly. Exercise is a natural stress buster and anxiety reliever. To achieve the maximum benefit, aim for at least 30 minutes of aerobic exercise on most days (broken up into short periods if that's easier). Rhythmic activities that require moving both your arms and legs are especially effective. Try walking, running, swimming, martial arts, or dancing.

Get enough sleep. A lack of sleep can exacerbate anxious thoughts and feelings, so try to get seven to nine hours of quality sleep a night.

Be smart about caffeine, alcohol, and nicotine. Caffeine and alcohol can make anxiety worse. And while it may seem like cigarettes are calming, nicotine is actually a powerful stimulant that leads to higher, not lower, levels of anxiety. For help kicking the habit, see How to Quit Smoking.

Put a stop to chronic worrying. Worrying is a mental habit you can learn how to break. Strategies such as creating a worry period, challenging anxious thoughts, and learning to accept uncertainty can significantly reduce worry and calm your anxious thoughts.

When to seek professional help

While self-help coping strategies can be very effective, if your worries, fears, or anxiety attacks have become so great that they're causing extreme distress or disrupting your daily routine, it's important to seek professional help.

If you're experiencing a lot of physical symptoms, you should start by getting a medical checkup. Your doctor can check to make sure that your anxiety isn't caused by a medical condition, such as a thyroid problem, hypoglycemia, or asthma. Since certain drugs and supplements can cause anxiety, your doctor will also want to know about any prescriptions, over-the-counter medications, herbal remedies, and recreational drugs you're taking.

If your physician rules out a medical cause, the next step is to consult with a therapist who has experience treating anxiety disorders. The therapist will work with you to determine the cause and type of your disorder and devise a course of treatment.

Treatment

Anxiety disorders respond very well to therapy -and often in a relatively short amount of time. The specific treatment approach depends on the type of anxiety disorder and its severity. But in general, most are treated with therapy, medication, or some combination of the two. Cognitive-behavioral therapy and exposure therapy are types of behavioral therapy, meaning they focus on behavior rather than on underlying psychological conflicts or issues from the past. They can help with issues such as panic attacks, generalized anxiety, and phobias.

Cognitive-behavior therapy helps you identify and challenge the negative thinking patterns and irrational beliefs that fuel your anxiety.

Exposure therapy encourages you to confront your fears and anxieties in a safe, controlled environment. Through gradual exposure to the feared object or situation, either in your imagination or in reality, you gain a greater sense of control. As you face your fear without being harmed, your anxiety will diminish.

Medication

If you have anxiety that's severe enough to interfere with your ability to function, medication may help relieve some symptoms. However, anxiety medications can be habit forming and cause unwanted or even dangerous side effects, so be sure to research your options carefully. Many people use anti-anxiety medication when therapy, exercise, or self-help strategies would work just as well or better-minus the side effects and safety concerns. It's important to weigh the benefits and risks of medication so you can make an informed decision.

Authors: Melinda Smith, M.A., Lawrence Robinson, and Jeanne Segal, Ph.D.

References

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized Anxiety Disorder. Annals of Internal Medicine, 170(7), ITC49-ITC64. https://doi.org/10.7326/AITC201904020

Kandola, A., Vancampfort, D., Herring, M., Rebar, A., Hallgren, M., Firth, J., & Stubbs, B. (2018). Moving to Beat Anxiety: Epidemiology and Therapeutic Issues with Physical Activity for Anxiety. Current Psychiatry Reports, 20(8), 63. https://doi.org/10.1007/s11920-018-0923-x

Craske, M. G., & Stein, M. B. (2016). Anxiety. Lancet (London, England), 388(10063), 3048-3059. https://doi.org/10.1016/S0140-6736(16)30381-6

Borza, L. (2017). Cognitive-behavioral therapy for generalized anxiety. Dialogues in Clinical Neuroscience, 19(2), 203-208. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573564/

Park, S.-C., & Kim, Y.-K. (2020). Anxiety Disorders in the DSM-5: Changes, Controversies, and Future Directions. Advances in Experimental Medicine and Biology, 1191, 187-196. https://doi.org/10.1007/978-981-32-9705-0_12

Otte, C. (2011). Cognitive behavioral therapy in anxiety disorders: Current state of the evidence. Dialogues in Clinical Neuroscience, 13(4), 413-421. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263389/

Tolin, D. F. (2010). Is cognitive-behavioral therapy more effective than other therapies?: A meta-analytic review. Clinical Psychology Review, 30(6), 710-720. https://doi.org/10.1016/j.cpr.2010.05.003

Aylett, E., Small, N., & Bower, P. (2018). Exercise in the treatment of clinical anxiety in general practice - a systematic review and meta-analysis. BMC Health Services Research, 18(1), 559. https://doi.org/10.1186/s12913-018-3313-5

Anxiety Disorders. (2013). In Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425787.x05_Anxiety_Disorders

Mellifont, D. (2019). Neuro magnifico! An exploratory study critically reviewing news text reporting of anxiety-related work performance strengths, challenges and support measures. Work, 63(3), 435-446. https://doi.org/10.3233/WOR-192950

Signs You Have High-Functioning Anxiety - Cleveland Clinic. (n.d.). Retrieved August 28, 2022, from https://health.clevelandclinic.org/what-is-high-functioning-anxiety/

Anxiety Disorders - Guide to the different types of anxiety disorders, their symptoms, and how to get help. (National Institute of Mental Health)

Managing and Treating Anxiety - Treatment options for anxiety, including exercise and breathing techniques. (Better Health Channel)

Anxiety Disorders - Help for kids and teens. (TeensHealth)

Anxiety - Worksheet to help you cope. (Centre for Clinical Interventions)

Anxiety and Stress Disorders - Special health report from Harvard Medical School. (Harvard Health Publishing)

Hotlines and support

NAMI Helpline - Trained volunteers can provide information, referrals, and support for those suffering from anxiety disorders in the U.S. Call 1-800-950-6264. (National Alliance on Mental Illness)

Find a Therapist - Search for anxiety disorder treatment providers in the U.S. (Anxiety Disorders Association of America)

Support Groups - List of support groups in the U.S., Canada, Australia, and South Africa. (Anxiety and Depression Association of America)

Anxiety UK - Information, support, and a dedicated helpline for UK sufferers and their families. Call: 03444 775 774. (Anxiety UK)

Anxiety Canada - Provides links to services in different Canadian provinces. (Anxiety Disorders Association of Canada)

SANE Help Centre - Provides information about symptoms, treatments, medications, and where to go for support in Australia. Call: 1800 18 7263. (SANE Australia).

Helpline (India) - Provides information and support to those with mental health concerns in India. Call: 1860 2662 345 or 1800 2333 330. (Vandrevala Foundation).

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Anxiety Disorders and Anxiety Attacks - HelpGuide.org

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anxiety Anxiety is a normal reaction to danger, the body's automatic fight-or-flight response that is triggered when you feel threatened, under pressure, or are facing a challenging situation, such as a job interview, exam, or first date. In moderation, anxiety isn't necessarily a bad thing.

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Anxiety Attack Relief: How To Stop An Anxiety Attack

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Suffer from anxiety or panic? Get free anxiety relief solutions here: http://beatinganxiety.org/advice Anxiety attack relief can be hard to come by but and often an attack can make it feel as though it's the end of the world or that a person is about to die but thankfully with the right approach to dealing with anxiety attacks sufferers have a chance to minimize or even completely stop an anxiety attack.

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College Students | Anxiety and Depression Association of America, ADAA

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Active Minds CollegeStats.org (Understanding Drug and Alcohol Addiction on College Campuses) Guide to College Student Mental Health Minding Your Mind National Eating Disorders Association Promoting Student Mental Health Student Mental Health: A Guide to Identifying Disorders and Promoting Wellness The Jed Foundation

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Student Guide to Surviving Stress and Anxiety in College and Beyond

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Student Guide to Surviving Stress and Anxiety in College and Beyond

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Feelings of stress and anxiety are a part of life. Some levels of stress can actually be good for us, as the right kind of stress encourages us toward change and growth. However, when stress and anxiety exist for an extended period of time, they can become a burden or even a health risk. This guidebook will help you recognize and understand feelings of stress and anxiety and learn how to manage them so that they don't become overwhelming.

Meet the Expert

Melissa Cohen

What is Stress?

According to the American Psychological Association, there are three types of stress: acute, episodic acute and chronic.

Acute stress

Episodic acute

Chronic acute stress

QUIZ

How do you know you're stressed?

The following quiz will help you determine if you're stressed and if so, how much stress you're facing.

Symptoms and Signs

There are four primary types of symptoms of stress: physical, emotional, cognitive and behavioral. Depending on the individual and the cause of the stress, the number of symptoms from each category can vary. The below chart will give an overview of types of symptoms that may be present in someone suffering from stress.

Stressed Students

College Stress by the Numbers

Causes of College Stress

Living Away From Home

For many students, college is the first time they have lived away from home or been away from their family for any significant period of time. Besides that, it's a very unfamiliar environment. Everything is different - the food, the people and the living accommodations. Even though most students eventually get used to these new things without a problem, the first few weeks of college can create a stressful environment. This is true even if you are truly excited about the changes. Remember that even positive changes can induce stress.

There is also a change in the support environment. When there is a big test, bad day or confusing situation, family members and old friends are not readily available for support and if they are, it's through a telephone or computer rather than in person. This can be tough to adjust to, especially during those first few months.

Academic Demands and Test Anxiety

This may be the most common long-term cause of stress for college students. After all, that's why students go to college - to learn. When you don't get the results you think you should get, or you feel pressured to get certain academic results, this can cause a lot of stress. For some students, college is the first time they are academically challenged. If high school was a breeze for you, college may be the first time you get a low grade on a test. Consequently, test anxiety may be experienced for the first time or with increased intensity.

Test anxiety is anxiety that usually comes before or during the taking of tests. The symptoms can be physical and mental and usually inhibit your ability to perform as well as you otherwise could. Ways to manage or reduce the anxiety include:

Resources to help reduce text anxiety can be your school's academic services office, your family, classmates and the following websites:

Finances

In addition to being on your own physically and maybe even emotionally, you may also be on your own financially. Everything from rent and food to gas and entertainment is now your financial responsibility. You might find that you need to take on a part-time job when you aren't in class. Even if you have a scholarship or loan, or have a "full ride" that helps you pay for it all, there are still the required phone calls, questions, paperwork and deadlines that have to be met in order to ensure the funds keep coming.

Post-Graduate Plans

After college is over, then what? That's a huge question: Figuring out the answer is like laying out blueprints for the rest of your life. There are many stressors that can affect your plans, such as not having a job upon graduation, being forced to settle for a job you don't really want, or struggling to get into graduate schools. On the other hand, you might land a great job, but the prospect of paying back student loans is now starting to hang over your head. Ultimately, the fear of the unknown can really make a huge difference in how much stress you feel about your post-graduate life.

5 School Stress Busting Tips

No matter where you are in the school journey, these tips can help you cope with and manage the stress that comes along with it.

Get plenty of sleep.

Not getting enough sleep impairs academic performance and makes it harder to get through the day.

Think positive.

Research has shown that positive thinking may improve physical well-being, produce lower feelings of depression and produce lower levels of distress.

Have a stress "outlet."

This could be a social activity like going out or participating in intramural sports, finding a hobby or joining a social club.

Engage in relaxation techniques.

This can include things like slowly counting to ten, meditation, thinking positive thoughts, visualization or playing with a stress ball.

Talk to someone.

Sometimes just talking about what's stressful or having someone listen to your problems can drastically reduce stress.

Get Help for Student Stress

There are several resources available on campus to help you deal with students stress. The chart below can help point you in the right direction to find help on your school's campus.

Student Stress and Anxiety Help and Resources

Interview with an Expert

Learn what expert Melissa Cohen, LCSW Licensed Clinical Social Worker, has to say about stress and anxiety.

Career and Work Stress

When pursuing a career or entering the workforce, you can expect to deal with all sorts of stress - and it comes from all sides. You might face stress from your boss, your coworkers, the corporation or business itself, and much more. Here's a rundown of the stress that most people face in their career or work situation.

5 Work Stress Busting Tips

Every job is going to be stressful at some point. Whether you are working on a tight deadline or facing a make-or-break situation, here are a few ways that you can alleviate stress, at least to some extent.

Make the most of workday breaks.

Take some time to cool down and take a deep breath. A slow walk and deep breathing during the middle of the day can help center you.

Have a place to vent.

You might not want to discuss your work troubles work coworkers, as gossip can run rampant. But have someone you can talk to outside of work who will understand your situation.

Walk away.

Never let yourself become angry and lash out at work - that will be detrimental to your work experience and lead to more stress. Find some way to blow off steam.

Stay reasonable.

There are certain job standards you must live up to, but don't be pushed to go too far above what is reasonable for your pay grade. Never expect perfection!

Tweak your job description.

If you find that you are consistently doing work that is not in your job description, speak to your employer about either delegating that work to someone else or compensating you fairly for it.

Get Help for Career Stress

Career Stress Resources

Stress related to health conditions/issues

When you are facing a tough health condition or concern, stress tends to skyrocket. That's because in addition to the illness itself, there are many other issues to worry about while you are going through a trying time. Here's a brief rundown of the stress you might expect to feel when you get bad news from the doctor.

5 Health Conditions/Issues Stress Busting Tips

When stress becomes overwhelming, it's time to calm down. These tips can help you deal with health conditions or medical issues without blowing your top.

Get all the information you can.

Knowledge is power, and it can help you cope. The more you know about your condition and treatments, the more in-control you will feel.

Enlist help.

When you are faced with a debilitating medical condition, you cannot handle it alone. Recognize that you need help, and don't hesitate to reach out for it.

Have a good cry.

Trying to stay strong in the face of a serious medical condition might help at first, but over time the lack of "falling apart" can take a toll. You deserve the time to grieve the situation you are in; allow yourself to cry, scream, rant, and otherwise take out the stress before it makes you even sicker.

Make plans.

If your medical condition will be a temporary one, consider it a wake-up call, and start planning the rest of your life accordingly. If you are facing a terminal illness, make plans for the time you have left.

Find a spiritual advisor.

Even if you are not a religious or spiritual person, finding someone who can talk to you about "what comes after" might be a helpful step to put your illness in perspective.

Get help for health-related stress

Health-Related Stress Resources

Resources and Tools for Stress Management

Each person has different types of stressors. What bothers one person might not bother another. What seems overwhelming to one might be perfectly manageable to another. But when it comes to your particular kind of stress, you know when you feel it - and you know when it's becoming serious.

These stress reduction techniques can help anyone, no matter the situation. Whether you are in a hospital bed awaiting surgery, dealing with a boss who seems to be out to get you, or lonely at college while you await that next test that has you so anxious you can barely study, these tips can ease the worry you are dealing with and help you face the next hurdle with a more centered, calm mind.

Relaxation Techniques and Tools

Our expert Melissa Cohen, LCSW, has a few tips that can help ease stress. These are her best options for anyone facing a stressful time, including college students, parents, employees, and more.

Avoiding Stress

Wouldn't it be nice to avoid stress? Fortunately, there are some ways you can make that happen. Though there is no way to completely avoid stress, there are some ways to get a better handle on the things that cause it, how you respond to it, and what it does to you. These techniques can help you avoid stress.

Know your limitations

Jumping into something you can't handle can often leave you with stress and worry. When embarking on something new, know what your limitations are, and never bite off more than you can chew.

Have a good support system

When life gets tough, having someone to turn to can help. Your support system should include family, friends, and professionals if necessary.

Understand your triggers

What stresses you out? Learning to avoid things that make you anxious, nervous or worried can be enough to help you live a life filled with less stress.

Learn relaxation techniques

When stress comes calling, being able to relax can help you cope with it. Take the time to learn the techniques that make most sense to you.

Manage your time

Plan out your time wisely. This includes any situation, including school, career, or everyday life. Make sure to plan in plenty of downtime, too.

Learn to say no

When you say yes to everything, you eventually become overwhelmed. Make "no" a strong part your vocabulary, and only say yes to things that will be enjoyable for you.

Exercise

Getting active releases hormones that can help you relax, stay calm and cope with life's stressors. Even a small amount of exercise each day can work wonders.

Be more assertive

Learn to stand up for yourself and those around you. Never allow yourself to be bullied, whether it's by fellow students, coworkers, a boss or anyone else.

Stress Don'ts

There are very few absolutely certain things in life. But when it comes to stress, there are a few things that are simply destined to cause it. These stressors are serious for anyone who deals with them, and they can lead down a road that brings the worst stress you can imagine. If you are dealing with any of these issues, getting help right away - right now - is the only appropriate response.

Substance abuse

Though turning to drugs and alcohol might seem to relieve stress in the short term, it is a recipe for disaster. The negative problems that quickly result will turn your future into a nightmare.

Addiction

Any sort of addiction can quickly spiral into something you can't handle. Avoid anything that might seem to be an addictive trigger for you, including substances, gambling, and the like.

Abuse of any kind

If you are being abused by anyone, in any way, get help right now before it gets worse. Emotional, verbal, physical, sexual abuse - as well as other types - can send your stress levels off the charts.

Isolation

When you are feeling isolated for whatever reason, stress builds up to the breaking point. If you are suffering alone, without a support group or support system to help you, it's time to reach out. It might be tough, but there are people just like you who can benefit from the discussions you could have.

Good Stress/Bad Stress

Remember that not all stress is bad for you. Sometimes it's a very good thing. Stress can push you to succeed in areas that you believed were off-limits to you. It can propel you to do things that turn out to be great adventures. It can spur you to study harder, work longer hours, focus more on the things that matter, and take your good health into your own hands.

Stress can also have a very clear-cut purpose if you are ever in a dangerous situation. The "fight or flight" response is a very important biological urge that is designed to lead us out of harm's way. For instance, the urge to run when someone begins chasing you, or the instinctual need to fight back when you are confronted with a dangerous situation are both a result of this stress response. In that way, stress is a good thing, because it keeps you safe.

Healthy stress might make you feel anxious or worried for a time. Imagine the stress you feel when taking that big test, the one that your final grade is riding on. The stress might be tough, but it spurs you to study more, and that can drive you to a higher grade. Or imagine the worry you feel when you are struggling with a relationship issue. The worry doesn't feel good, but it leads you to talk things through more often, and that can lead to a better place in the relationship than what you experienced before the stress took hold.

So before you discount stress as being a terrible thing, think of times when it spurred you on to greater things. It might help you put stress in perspective the next time you feel overwhelmed by it.

Mindfulness

Being mindful of the things that are happening and the world around you
can help you cope with many things in life, including stress and anxiety.
Though there are many definitions for mindfulness, the general idea is the
same: It is a mental state that is focused on the moment, staying calm, and accepting and acknowledging how you feel, the sensations around you, the thoughts that come into your head, and the other things in your internal and external environment.

By "being in the moment" and embracing it, you can reduce or relieve stress and anxiety. In fact, mindfulness can work so well for some that it becomes a way of life, one that leads to a much better day-to-day existence.

What is it in relation to anxiety and stress?

Mindfulness has been proven to reduce stress and anxiety, and in some cases, actually prevent it from happening in the first place. Not only does mindfulness pull you out of your own head and help you see the bigger picture, it can reduce physical stressors that might make your mental state feel even worse. By focusing on the present, you are not dwelling on the mistakes of the past, nor are you overwhelmed by thoughts of the future. You are focused on the here and now, and that can allow your subconscious to work on the things that are bothering you.

How can you approach mindfulness?

Starting a routine of mindfulness can be tough, especially when you are entrenched in a fast-paced world. But it is definitely worth a shot.

Start by setting aside some time to focus on the here and now. This means choosing a quiet spot where you will not be disturbed, and where distractions are at a minimum. Focus on every aspect of your body, one at a time, starting with your breathing. Move up from your toes, focusing in the sensations you feel in every part of yourself, until you reach your head. What thoughts are there? What are you feeling at the moment? Just acknowledge those things, breathe in deep, but do nothing about them. The goal is to live in the moment, not look for solutions.

You can indulge in this during other times as well. For instance, while eating a meal, focus strongly on the flavors and textures as they move over your tongue. Focus on your breathing, the smells of the food, the motion of swallowing it. Try to be as deeply in that moment as you can be, and fill up your senses with what you find there.

Mindfulness Tips and Techniques

Ready to try it? These tips can help you get on track.

Meditate.

Listen to your body.

Let thoughts go.

Run through the sensory gamut.

Clench and release.

Try again.

Mindfulness resources

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Student Stress & Anxiety Guide | LearnPsychology.org

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Feelings of stress and anxiety are a part of life. Some levels of stress can actually be good for us, as the right kind of stress encourages us toward change and growth. However, when stress and anxiety exist for an extended period of time, they can become a burden or even a health risk.

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Mental Health has become a critical issue on college campuses. Here at BU, Behavioral Medicine clinicians report that the number of students in crisis coming in for help has increased sharply-from 647 in the 2014-2015 academic year to 906 last year. And the number of students needing medical transports for psychiatric evaluation has also risen, from 120 in the 2014-2015 academic year to 134 last year.

In light of this alarming trend, this week BU Today is republishing a special three-part series, " Mental Health Matters," that was originally published last October. We have updated the series to include new statistics and information.

When it was announced in spring 2014 that a Penn State study had found that anxiety had surpassed depression as the leading mental health issue facing college students, the story made national headlines. According to the study of more than 100,000 students by Penn's Center for Collegiate Mental Health, more than half of the students visiting campus health clinics listed anxiety as a concern. That finding was borne out by the American College Health Association (ACHA) 2015 National College Health Assessment survey, which reported that nearly one in six college students (15.8 percent) had been diagnosed with, or treated for, anxiety.

The same survey found that 21.9 percent of students said that within the last 12 months, anxiety had affected their academic performance, defined as receiving a lower grade on an exam or important project, receiving an incomplete, or dropping a course. That's up from 18.2 percent in the ACHA's 2008 survey. Meanwhile, 13.8 percent reported that in the last 12 months, depression had affected their academic performance, up from 11.2 percent in 2008.

These findings don't surprise mental health clinicians at BU.

"We have all become less able to tolerate ambiguity and the unknown due to the incredible technological advances we have seen," says Carrie Landa, director of Behavioral Medicine at Student Health Services. "Immediacy is sometimes the antidote to anxiety: having to wait for anything-a text, an exam grade, 'How am I going to do?'-all create anticipatory anxiety. Unfortunately, there are many things in life that aren't quickly resolved and waiting is necessary."

In the 2015 Healthy Minds study, an annual web-based survey examining mental health on college campuses, the number of BU students who score positive on a measure of depression was larger, at 23 percent, than the number who scored positive on a measure of anxiety, 17 percent. In fact, depression and anxiety are two sides of the same coin, says Dori Hutchinson (SAR'85,'96), director of services at BU's Center for Psychiatric Rehabilitation and a Sargent College clinical associate professor. Both are treatable with therapy, lifestyle changes, and medication when indicated-and sometimes a combination of all three.

What's normal and when to seek help

Every student feels stressed out at one time or another, especially during midterms and finals. And it's normal for students to feel blue on occasion, too. So when do those feelings become reason for more concern?

"When your mood state interferes with your ability to function at school," Hutchinson says, "like when you're finding you can't get to class, and you don't want to hang out with your friends or teammates, and you're having difficulty concentrating because you're feeling so distressed-that's when we want to reach out and help you."

"Often it is more important to manage your emotional reaction to stress than to try to change the stressful situation, which may not be fully under your control."
-Lisa Smith

Other warning signs are prolonged feelings of sadness or despair, excessive anxiety or panic, isolation or withdrawal from typical daily activities, thoughts of self-harm or suicide, giving away possessions, changes in personal hygiene, and excessive use of alcohol or other drugs, which are often used by students experiencing social anxiety to self-medicate.

"When any emotions or behaviors are a big change from your regular, day-to-day functioning, it's important to stop and ask yourself what's going on," says Landa. "We see normal anxiety morph into distress when a student is having panic attacks, can't sleep or slow themselves down, persistently worries or obsesses about what's next, or is having other physical symptoms consistent with anxiety. When day-to-day functioning is affected, but before it's impaired, that's when to get help. Similarly, with depression, everyone experiences a low mood day or a disappointment they just can't shake off, whether that's because of a bad grade, a relationship ending, or a fight with a friend. But when feelings of sadness, loneliness, or low self-worth become the norm, reaching out is really important."

"We know that stress can be a trigger of psychological conditions, especially in the context of unpredictability and uncontrollability. This seems to be inherent in the transition to college," says Lisa Smith, director of BU's Center for Anxiety & Related Disorders and a College of Arts & Sciences clinical associate professor of psychological and brain sciences. "At the point where your emotions are interfering with your life or are causing significant distress is when you would want to take action to adjust your emotional functioning in response to stress.

"Often it is more important to manage your emotional reaction to stress than to try to change the stressful situation, which may not be fully under your control," she says. "I often think that if students were given an Emotions 101 course in high school or college, they would be much better equipped to know how emotions work well versus what emotional coping strategies only serve to heighten anxiety and depression. It's often surprisingly counterintuitive."

For many students, Smith says, a brief program of cognitive-behavioral treatment can help them shift to more effective emotion management.

Despite the fact that depression and anxiety are treatable, many students are reluctant to admit they have a problem and to seek help.

Case in point: Victoria Pae (CAS'16). During freshman year, she says, she felt overwhelmed by stress and anxiety, but she was afraid to seek help. "Everyone was doing so much, everyone was so on top of their games, it seemed like they had it all together," says Pae, a double major in neuroscience and psychology, who as a high school student had done very well academically and in extracurricular activities. "You're seeing everyone excelling above you. And even though you have the ability to excel too, you're too scared of making a fool of yourself to actually try to do it."

Pae found it hard to admit she had a problem. She kept her feelings of anxiety and being overwhelmed to herself. "I didn't want to tell myself that I needed to get help, so I didn't," she says. "I just told myself, it's all in my head, get over it."

"A colleague of mine has started calling it the 'game face' that students put on, that tells everybody else in the world, 'I'm just fine, I'm handling it, look at me juggling school, extracurricular activities, and work,'" says Katharine Mooney (SPH'12), director of Wellness & Prevention Services at Student Health Services. "But that's not how they're feeling...they feel really alone, isolated, that no one else feels like they do. And that's just not the case."

Rather than confront her feelings, Pae says, she would party with friends. Her grades began to suffer as well. But at the beginning of her sophomore year, she started working with the BU chapter of the student mental-health group Active Minds, which works to make people more aware of mental health issues, reduce prejudice against those with mental health challenges, and direct students to behavioral health resources on campus.

"I was teaching students that it's OK to receive support, but here I was with a mental health disorder and not seeking help. I thought that was very hypocritical," Pae says. The spring after she joined Active Minds, she began to see an off-campus therapist to help treat her anxiety.

"I won't say I'm 100 percent OK now, as I still have my moments of self-doubt and of neglecting self-care," Pae says, "but I'm definitely doing better than I was a couple of years ago."

A chance for everyone to be screened

Tomorrow, October 5, all students, as well as faculty and staff, can receive free, confidential screenings for depression and anxiety as part of National Depression Screening Day.

The screenings, brief anonymous questionnaires with multiple choice answers, are being offered on both the Charles River and Medical Campuses and take only two to three minutes to complete. The questionnaire asks about eating and sleeping habits and having feelings of hopelessness, suicidal thoughts, or an inability to stop worrying. The results can help determine if someone is experiencing depression, anxiety, a mood disorder, or even post-traumatic stress.

A clinician will review the answers on site and discuss what the proper next steps might be and provide referral cards directing students to Behavioral Medicine, the Center for Anxiety & Related Disorders, or the Center for Psychiatric Rehabilitation. Everyone who is screened receives information about counseling and other services, regardless of whether they show symptoms of anxiety and depression. No appointment is needed.

"Sometimes a screening can be lifesaving, while other times it helps facilitate the small change that allows someone to go from feeling okay to feeling good."
-Carrie Landa

"If your score is high, we say, 'What can we do to help?' and direct them toward resources on campus," Hutchinson says.

The screenings will be held at three locations on the Charles River Campus: at both the George Sherman Union Link and the Yawkey Center for Student Services dining room, from noon to 3 p.m. and in the FitRec lobby, from 3:30 to 6:30 p.m. Screenings on the Medical Campus will be in the School of Medicine L-Instructional Building lobby, from 4 to 6:30 p.m. At each site, clinicians will be on hand for confidential feedback and there free chocolate will be given out.

During last year's National Depression Screening Day event at BU, 445 people came for checkups, Hutchinson says, and 19 percent were referred to Behavioral Medicine for appointments or other follow-ups. Six students received urgent care after noting that they were in extreme distress. The first year BU held the screenings, in 2008, one person was hospitalized after the questionnaire revealed suicidal impulses.

"That may have helped save his life and put him on the path to wellness," says Hutchinson.

The screenings coincide with the semester kicking into high gear. "The honeymoon is over, the schoolwork is hard-it might be growing," Hutchinson says. "Midterms are right around the corner, and if someone is living with depression, it can worsen. The screenings are really a way for our community to say, we care about you."

Landa urges everyone to avail themselves of the opportunity to be screened Wednesday. "National Depression Screening Day is a great opportunity to check in with yourself, be able to quickly look at some key behaviors and feelings that are markers for wellness. Sometimes a screening can be lifesaving, while other times it helps facilitate the small change that allows someone to go from feeling okay to feeling good."

Pae says her experience with anxiety made her realize the benefits of getting help. "I think a lot of students...are scared to admit that they're stressed and worried their life might be crumbling before their eyes," she says. The former president of BU's Active Minds chapter, Pae says the group emphasizes that "whether the difficulties you're going through are major or minor, it's OK to seek help."
Those seeking free, confidential mental health counseling can contact Student Health Services Behavioral Medicine (617-353-3569) (available 24 hours for psychiatric emergencies), the Center for Psychiatric Rehabilitation (617-353-3549), the Danielsen Institute (617-353-3047), and the Center for Anxiety & Related Disorders (617-353-9610). Faculty and staff with mental health issues can contact BU's Faculty & Staff Assistance office (617-353-5381). The Samaritans of Boston suicide prevention hotline is 877-870-4673. The Active Minds student support group is best reached through its Facebook page. For crises related to crime and interpersonal or sexual violence, BU's Sexual Assault Response & Prevention Center crisis counselors are available 24 hours a day, 7 days a week (617-353-SARP) (7277). If you, or someone you know, have questions about their drug or alcohol use, Wellness & Prevention Services can help (617-358-0485). Students who require academic or other accommodations for a psychological disability can also consult BU's Disability Services (617-353-3658). Accommodations and services could include testing modifications, reduced course load, developing skills in self-advocating with faculty, executive functioning coaching, and more. Services are free and confidential. Next, in the final installment of our series "Mental Health Matters," we'll look at healthy ways of coping with stress and where to seek help at BU.

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Anxiety: The Most Common Mental Health Diagnosis in College Students | BU Today | Boston University

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Mental Health has become a critical issue on college campuses. Here at BU, Behavioral Medicine clinicians report that the number of students in crisis coming in for help has increased sharply-from 647 in the 2014-2015 academic year to 906 last year.

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If you are looking for help and up to date information on eating disorders, you've come to the right place. We'll tell you how to find the right eating disorder treatment, try to answer all your questions and provide you with all the eating disorders information you need, including some relevant eating disorder statistics that may shock you. We want you to be fully informed so you can begin the recovery process. This site will help you understand the causes of eating disorders as well has how to get treatment.
Getting Eating Disorder Help
If you are worried that you have an eating disorder you're probably feeling anxious, confused overwhelmed, and scared. All of these feelings are relevant to the effects of malnutrition on your brain and body. The human body uses food and nutrition in order to build itself, function properly and deal with stress, so eating disorders have both physical and mental effects even if you have not lost any weight. That's right, although most people with eating disorders suffer the symptom of weight loss - you can be underweight, normal or overweight and still have an eating disorder! Eating disorders, like people, come in all shapes and sizes. Here is more on who gets eating disorders.

You might not know where to turn and you might feel nobody understands. We do, and there is help available to you. You just have to take that first step and reach out.

Start by talking to a loved one about how you are feeling and the thoughts you are having around food. Then ask them to help you find an eating disorders specialist. Your doctor or counselor can refer you to a specialist if needed.

If you're not sure where to go for treatment, check out our list of eating disorder treatment centers. You can also find more information about getting eating disorder help here.

If you're having serious health problems, like passing out, feeling too weak to get up or feeling disoriented or confused, call your doctor right way or go to the nearest emergency room. If you're feeling depressed and suicidal, go to the emergency room or call 911.
The Recovery Process
Eating disorder treatment is a long and complex process. Often, it begins with medical care to treat the physical health problems that result from eating disorders, like malnutrition, nutritional deficiencies, dehydration, ulcers and heart trouble. Some sufferers will require inpatient treatment. This can be a very effective way to help them regain the weight that they have lost. Establishing a normal body weight is a vital part of recovery, as a malnourished body does not have the resources required to recover from an eating disorder. Then individual, group, and family counseling helps sufferers learn how to overcome the behavioral processes that are often apparent with eating disorders. Family counseling is recommended to teach family members how to support one another and the sufferer. Nutritional counseling and education, as well as carefully planned menus and support during mealtimes and snacks, will help sufferers begin eating a healthful diet again.

Some people need residential treatment in the beginning, until they are medically and psychologically stabilized. Other people are able to begin with outpatient treatment. A qualified treatment provider can advise you about the best level of care to meet your needs.

The recovery process can be scary, try to take it one step at a time and know that it will all be worth it in the end.

Follow this link for more information about the recovery process.
For More Assistance
If you're not sure where to start, try our eating disorders information page. If you're feeling discouraged or hopeless, please take a moment to read this letter of hope. If you have any questions or if we can assist you in any way, please feel free to email us and we'll do our best to help. We care and we want you to get the eating disorder help that you need.

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If you are looking for help and up to date information on eating disorders, you've come to the right place. We'll tell you how to find the right eating disorder treatment, try to answer all your questions and provide you with all the eating disorders information you need, including some relevant eating disorder statistics that may shock you.

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National Eating Disorder Association

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Trade book publisher specializing in books about eating disorders.

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Eating Disorders Anonymous

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Eating Disorders Anonymous (EDA) is a fellowship of individuals who share their experience, strength and hope with each other that they may solve their common problems and help others to recover from their eating disorders.

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Eating Disorders | Anorexia | Bulimia | Binge Eating Disorder | Compulsive Overeating | The Something Fishy Website on Eating Disorders

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Eating Disorders -- Anorexia, Bulimia, Binge Eating Disorder, Compulsive Overeating. Eating Disorders definitions, signs and symptoms, physical dangers, online support and much more.

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National Association of Anorexia Nervosa and Associated Disorders

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Change the Way You Think About Recovery

At ANAD's 2017 Conference

Join an Online ANAD Support Group!

Now, it's Easier than EVER to Get the Support You Need

Are you an Eating Disorder Professional? Join ANAD's Online Treatment Directory!

My story is messy. Messy, traumatic, terribly unbearable, yet oddly beautiful. My story was written long before I was even born and it was up to me to bring it...

Voice /vois/ noun: the distinctive tone or style of a literary work or author. We all have the ability to be heard, it's whether or not we can get people to...

"You need other people. There's a great freedom in knowing that. And accepting that. And letting people in. Letting them help you." (Author, Blake Nelson). It was not until relatively...

TREATMENT CENTER PARTNERS

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ANAD * National Association of Anorexia Nervosa and Associated Disorders

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At ANAD's 2017 Conference Now, it's Easier than EVER to Get the Support You Need Are you an Eating Disorder Professional? Join ANAD's Online Treatment Directory! My story is messy. Messy, traumatic, terribly unbearable, yet oddly beautiful. My story was written long before I was even born and it was up to me to bring it...

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The School Counselor's Role in Addressing Eating Disorders

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The School Counselor's Role in Addressing Eating Disorder

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School Strategies for Assisting Students With Eating Disorders

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student assistance program; eating disorders; counseling; medical practitioner; school cafeteria;

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School strategies for assisting students with eating disorders

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student assistance program; eating disorders; counseling; medical practitioner; school cafeteria;

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Addressing Eating Disorders in Middle School and High School

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Addressing Eating Disorders in Middle and High Schools
Thursday, February 2, 2012 ( 0 Comments)

by Lauren Muhlheim, Psy.D., CEDS

For F.E.A.S.T. February 2012

Lauren Muhlheim, Psy.D., CEDS is a clinical psychologist and eating disorder specialist in private practice in Los Angeles, California. She provides evidence-based treatments including cognitive behavioral therapy and Maudsley Family Based Therapy for adults and adolescents with a variety of problems including eating disorders, anxiety, and depression. She is a candidate for advanced certification in FBT. She also consults with schools, families, and M.D.s in the foreign community in Shanghai regarding eating disorders.Addressing Eating Disorders in Middle and High Schools

Addressing Eating Disorders in Middle and High Schools

Eating disorders, including anorexia nervosa and bulimia nervosa, are serious mental illnesses with onset commonly during the early teen years. They have serious medical consequences, are notoriously difficult to treat, and in many cases require specialized treatment.

Middle schools and High schools have an obligation to provide resources to support children with eating disorders as well as aid in their prevention. Charged with the care of children who may be suffering from these disorders for the majority of their waking day, schools need to be aware of the needs of children in treatment. In many cases schools may be an important partner in treatment. Through the power of the social milieu, they can also play a significant role in prevention.

Common eating disorders and their prevalence

Anorexia nervosa is characterized by a failure to maintain a healthy body weight, intense fear of gaining weight, and distorted body image. Bulimia nervosa is characterized by recurrent and frequent episodes of eating unusually large amounts of food (e.g., binge-eating), and feeling a lack of control over the eating. This binge eating is followed by a type of behavior that compensates for the binge, such as purging (e.g., vomiting, excessive use of laxatives or diuretics), fasting and/or excessive exercise.

Unlike people with anorexia who usually bear the obvious physical marks of their disorder, people with bulimia can have weight within the normal range for their height and age. For this reason, bulimia nervosa in student populations is often under-reported and under-diagnosed.

Prevalence rates of eating disorders are increasing worldwide. Anorexia nervosa is the third most common chronic illness among adolescents. The prevalence of eating disorders among adolescents in America is estimated to be 3.4% for girls and 1.5% for boys. In one study of American adolescents in the 5 th through 12 th grades, 13% of girls and 7% of boys reported engaging in both binge eating and purging behavior. However, a far higher proportion of youth report less severe symptoms of disordered eating and shape and weight concerns. US studies have reported that 50% of girls 11 - 13 see themselves as overweight and 80% of 13-year-olds have attempted to lose weight.

Eating disorder risk factors

It is now recognized that between 50 and 80 percent of a person's risk of an eating disorder is due to genetic factors. Previous theories of etiology focused primarily on family dynamics and sociocultural causes. We now know that families do not cause eating disorders. We also know that anorexia nervosa existed long before the current cultural ideal of thinness, so sociocultural explanations for anorexia are only one piece of the puzzle. Personality traits of anxiety and perfectionism are associated with or believed to contribute to eating disorders.

Regardless of contributing factors, in almost all cases of eating disorders dieting or caloric restriction (intentional or not) is usually the trigger. If someone genetically predisposed to an eating disorder never diets, they likely will never develop an eating disorder. Therefore an appropriate target for primary prevention is the prevention of dieting.

Warning signs

The following behaviors might indicate that a student has an eating disorder. However, not all students with eating disorders will display these behaviors; and even though a student displays some of these symptoms, he or she might not have a disorder - so be careful when applying this as a guide.

Skipping lunch Seeking out snacks frequently

Avoiding high fat foods, eating only health foods, or consuming a very narrow variety of foods

Throwing away food

Avoiding food in social situations

Playing with or taking apart foods (e.g., removing cheese from pizza)

Secrecy around eating

Using the restroom immediately after eating

Weight loss, weight gain, or fluctuation in weight

Frequent attempts at dieting

Obsession with maintaining low weight to enhance performance in sports, dance, acting, or modeling

Excessive exercise in physical education class, sports, dance, etc.

Continually talking about food, weight, and body image or disparaging comments about their appearance

Preoccupation with dieting or exercise

Fatigue or dizziness

Wearing baggy clothing

Calluses or scars on the knuckle (from sticking their fingers down their throat)

Importance of Early Intervention

Eating disorders must be addressed from both a medical and a mental health perspective for full recovery to occur. Early intervention is crucial. The sooner one gets help, the greater the likelihood that they will get better. Without early intervention eating disorders may become chronic, or even fatal.

Research on people with bulimia nervosa showed a better recovery rate if they receive treatment early in their illness. If treated within the first 5 years, the recovery rate is 80%. If not treated until after 15 years of symptoms, recovery falls to 20%. Among those patients with anorexia nervosa who do not get early intensive treatment, a portion will remain chronically ill; of this portion, up to 20% may die of the disorder.

Treatment Recommendations

The malnutrition caused by an eating disorder dramatically alters mood, behavior, and thinking. Research shows that normalization of eating habits and weight restoration are the crucial first steps towards recovery. Those who are underweight must gain weight. Those who eat erratically must resume regular daily consumption and digestion of three meals and two to three snacks. Those who purge must stop.

For adolescents with eating disorders, the best-researched and most successful treatment is Maudsley Family Based Therapy or FBT. This approach focuses on using the strength of the entire family working together to beat the eating disorder. Parents are charged with re-nourishing their child during family meals.

FBT offers a number of advantages over traditional treatments. FBT allows the child in treatment to remain in their home with the support of their family. With some exceptions, children receiving FBT are able to continue to attend school. By teaching the family skills in confronting eating disordered behaviors, FBT creates a more consistent treatment environment than an inpatient treatment program that eventually returns the child to a family not equipped to deal with relapse. FBT is also cost-effective compared to inpatient or residential treatment. FBT is supported by a number of resources to make it available even in communities where there may not be a specialist available. There are FBT manuals for both parents and therapists to learn the approach. There is an international support network and numerous resources for parents doing FBT.

Two organizations in the United States, the National Association of Anorexia Nervosa and Associated Disorders (ANAD) and the National Eating Disorders Association (NEDA) have published guidelines for schools in dealing with eating disorders. The following recommendations have been largely culled from the guidelines by ANAD and NEDA.

Prevention

Schools should provide an environment that promotes and models healthy behaviors and healthy body image. The school cafeteria should provide nutritious food and unhealthy foods should be removed from vending machines.

Schools should provide a curriculum that promotes healthy flexible eating and size acceptance. An excellent curriculum for schools is Healthy Body Image: Teaching Kids to Eat and Love Their Bodies Too by Kathy Kater (2005). The curriculum should discourage dieting and counting of calories. There should be no anti-obesity messages and no rigid rules about nutrition. The school should provide education and awareness about eating disorders. There should be a policy in place for students to report teasing, bullying, or harassment based on weight or appearance. Ideally, the school should review all materials in the school (books, posters, etc.) to ensure they include all body shapes, sizes, and racial groups. Students of all sizes should be encouraged to participate in school activities such as band, cheerleading, student government, theater groups, etc. Children should never be weighed in public nor should they be told their BMI or told to lose weight. In the event of a obesity-related health risk, the concern over unhealthy eating behaviors should be expressed by a physician, not the school.

Being Prepared

It is important that schools are responsive in dealing with eating disorders. Children spend a majority of their time in school and teachers have the opportunity to observe and interact with students in a variety of social, academic, and eating-related contexts. School personnel may become aware of a problem before the family.

In order for schools to identify and support children who have a disorder, the school should be up to date on evidence-based treatments. Faculty should receive training in identifying eating disorders and early intervention. Staff should receive training in sensitively addressing students showing signs of eating disorders. Ideally, there should be a designated resource person such as the school counselor or team to guide interventions for eating disorders.

The school should have resources available to which to refer students with eating disorders.

Early Intervention

Talking with the student and parents. If a teacher has concerns about a student, the designated resource person/team can help guide the intervention and decide who speaks to the child. They also need to determine when parents are informed about the concern. Sometimes eating disorders can develop very suddenly and parents may not be aware there is an issue. I believe parents need to be informed early because the cost of waiting can be severe when it comes to eating disorders.

Parents may react in many ways when a school brings the issue to their attention. Denial is often encountered when eating disorder behavior is confronted and a student (and sometime even parents) may be unreceptive to the suggestion that anything is wrong. The school needs to be sensitive to the feelings and concerns of the parents, which may include shame, feeling blamed, and concerns about confidentiality.

A school staff member should begin by telling the family they are concerned and offer specific information about the student's behavior. The family should be educated about eating disorders, the importance of early intervention, and available resources. It is best if the school is clear about what services they can provide and who at the school will be a family liaison so the family has the opportunity to develop a supportive relationship with a school staff member, usually the school counselor. The school should work with the parents to decide collaboratively on the next steps the school will take with the student and family. The goal of this is to try to get the parents to acknowledge the problem and accept the school as a partner in the treatment.

Working with a child in treatment. Once referrals to medical and mental health resources (locally and internationally) are provided, the student should receive supportive counseling and medical monitoring. The school needs to communicate with any outside team members that are providing treatment. The school should discuss with the parents who will monitor the child (the school or an outside treatment provider), what kind of monitoring will be involved, and how this information will be communicated among the school, parents, and treatment providers (in accordance with confidentiality, laws, and other school policies). It may be appropriate or convenient to have the school nurse conduct periodic assessments and follow-up such as weight checks and pulse and blood pressure checks.

Even in cases where the family minimizes or ignores the severity of the eating disorder, the school needs to both show its concern for the student's safety and protect itself from liability. The school should expect guidance from a treatment team on whether the student is safe to participate in PE, sports, field trips, and the like. It may be appropriate for the school to set hard limits on strenuous activities for children with eating disorders - intense athletic activity is not going to help a low-weight student recover.

Accomodations to the student. The designated person should work with the treatment team and school to ensure that the intertwined medical, psychological, and academic needs of a student in recovery are taken into account. The student may need a reduced course load, a shortened school day, time off for appointments, days off for bed rest, extra snacks, meal monitoring during school lunches, release from health and physical education classes, or other accommodations. In some cases, students may need to take a leave of absence from school to attend a residential or inpatient treatment program. In these cases the school may be able to provide lessons to the child in treatment. Children returning from residential treatment may need help reintegrating into school and getting caught up on work.

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Addressing Eating Disorders in Middle and High Schools - F.E.A.S.T.

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Thursday, February 2, 2012 ( 0 Comments) For F.E.A.S.T. February 2012 Lauren Muhlheim, Psy.D., CEDS is a clinical psychologist and eating disorder specialist in private practice in Los Angeles, California. She provides evidence-based treatments including cognitive behavioral therapy and Maudsley Family Based Therapy for adults and adolescents with a variety of problems including eating disorders, anxiety, and depression.

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College Students and Eating Disorders - Child Mind Institute

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Be aware of eating disorders in college students. Child Mind Institute shares why anorexia and bulimia most often start in the college years.

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National Institute of Mental Health

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National Institute of Mental Health (NIMH)

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Learn about depression, including types, signs and symptoms, risk factors, treatments and therapies, and things you can do to help during treatment.

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Anxiety and Depression Association of America

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450 million people

More than 450 million people around the world live with mental illnesses.*

*Source: World Health Organization

Losing a loved one, getting fired from a job, going through a divorce, and other difficult situations can lead a person to feel sad, lonely and scared. These feelings are normal reactions to life's stressors. Most people feel low and sad at times. However, in the case of individuals who are diagnosed with depression as a psychiatric disorder, the manifestations of the low mood are much more severe and they tend to persist.

Depression occurs more often in women than men. Some differences in the manner in which the depressed mood manifests has been found based on sex and age. In men it manifests often as tiredness, irritability and anger. They may show more reckless behavior and abuse drugs and alcohol. They also tend to not recognize that they are depressed and fail to seek help. In women depression tends to manifest as sadness, worthlessness, and guilt. In younger children depression is more likely to manifest as school refusal, anxiety when separated from parents, and worry about parents dying. Depressed teenagers tend to be irritable, sulky, and get into trouble in school. They also frequently have co-morbid anxiety, eating disorders, or substance abuse. In older adults depression may manifest more subtly as they tend to be less likely to admit to feelings of sadness or grief and medical illnesses which are more common in this population also contributes or causes the depression.

Types of Depression

There are different types of depressive disorders, and while there are many similarities among them, each depressive disorder has its own unique set of symptoms.

The most commonly diagnosed form of depression is Major Depressive Disorder. In 2015, around 16.1 million adults aged 18 years or older in the U.S. had experienced at least one major depressive episode in the last year, which represented 6.7 percent of all American adults. Depression is the leading cause of disability in the United States among people ages 15-44.

Major depression is characterized by at least five of the diagnostic symptoms of which at least one of the symptoms is either an overwhelming feeling of sadness or a loss of interest and pleasure in most usual activities. The other symptoms that are associated with major depression include decrease or increase in appetite, insomnia or hypersomnia, psycho motor agitation or retardation, constant fatigue, feelings of worthlessness or excessive and inappropriate guilt, recurrent thoughts of death and suicidal ideation with or without specific plans for committing suicide, and cognitive difficulties, such as, diminished ability to think, concentrate and take decisions. The symptoms persist for two weeks or longer and represent a significant change from previous functioning. Social, occupational, educational, or other important functioning is also impacted. For instance, the person may start missing work or school, or stop going to classes or their usual social activities.

Another type of depression is called Persistent depressive disorder (dysthymia). The essential feature of this mood disorder is a low, dark or sad mood that is persistently present for most of the day and on most days, for at least 2 years (children and adolescents may experience predominantly irritability and the mood persist for at least 1 year). For the individual to receive the diagnosis of persistent depressive disorder they should also have two of the diagnostic symptoms which include poor appetite or overeating, insomnia or hypersomnia, low energy or fatigue, low self-esteem, poor concentration, difficulty making decisions, or feelings of hopelessness. During this period, any symptom-free intervals last no longer than two months. The symptoms are not as severe as with major depression. Major depression may precede persistent depressive disorder, and major depressive episodes may also occur during persistent depressive disorder.

Premenstrual dysphoric disorder is another manifestation of depression which is a severe and sometimes disabling extension of premenstrual syndrome (PMS). Although regular PMS and Premenstrual dysphoric disorder (PMDD) both have physical and emotional symptoms, the mood changes in PMDD are much more severe and can disrupt social, occupational, and other important areas of functioning. In both PMDD and PMS, symptoms usually begin seven to 10 days before the start of a menstrual period and continue for the first few days of the period. Both PMDD and PMS may also cause breast tenderness, bloating, fatigue, and changes in sleep and eating habits. PMDD is characterized by emotional and behavioral symptoms that are more severe, such as sadness or hopelessness, anxiety or tension, extreme moodiness, irritability or anger.

Some medical conditions can trigger depressive symptoms in individuals. This is called depressive disorder due to another medical condition. Endocrine and reproductive system disorders are commonly associated with depressive symptoms. For example, people with low levels of the thyroid hormone (hypothyroidism) often experience fatigue, weight gain, irritability, memory loss, and low mood. When the hypothyroidism is treated it usually reduces the depression. Cushing's syndrome is another hormonal disorder caused by high levels of the hormone cortisol which can also cause depressive symptoms. Other conditions that have been found to cause depression include conditions such as HIV/AIDS, diabetes, strokes, Parkinson's disease etc.

Adjustment Disorder with Depressed Mood is diagnosed when symptoms of depression are triggered within 3 months of onset of a stressor. The stressor usually involves a change of some kind in the life of the individual which he/she finds stressful. Sometimes the stressor can even be a positive event such as a new job, marriage, or baby which is nevertheless stressful for the individual. The distress is typically out of proportion to the expected reaction and the symptoms cause significant distress and impairment in functioning. The symptoms typically resolve within 6 months when the person begins to cope and adapt to the stressor or the stressor is removed. Treatment tends to be time limited and relatively simple since some additional support during the stressful period helps the person recover and adapt.

Another type of depression is related to changes in the length of days or seasonality. This type of depression is called Seasonal affective disorder (SAD). People with SAD suffer the symptoms of a Major Depressive Disorder only during a specific time of year, usually winter. This appears to be related to the shorter days of winter, and the lack of sunlight in many parts of the country.

Depression and Anxiety Disorders: Not the Same

Depression and anxiety disorders are different, but people with depression often experience symptoms similar to those of an anxiety disorder, such as nervousness, irritability, and problems sleeping and concentrating. But each disorder has its own causes and its own emotional and behavioral symptoms.

Many people who develop depression have a history of an anxiety disorder earlier in life. There is no evidence one disorder causes the other, but there is clear evidence that many people suffer from both disorders.
Sources:
1. https://www.nimh.nih.gov/health/publications/depression/index.shtml#pub1
2. https://www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adults.shtml
3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
4. Sadock, B. J., Sadock, V. A., & Ruiz, P. (2009). Comprehensive Textbook of Psychiatry (Ninth edition.) Philadelphia: Wolters Kluwer.
Read more information about depression from the National Institute of Mental Health.
Read more information about depression from the World Health Organization
Additional Resources

MoodNetwork

If you have have experienced depression and bipolar disorder, you will be able to track your progress, share information, ask questions, and evaluate your treatments. How? Become a participant in the MoodNetwork. Participants will also be contributing to the largest pool of data ever collected about mood disorders, which will lead to evaluating treatments and helping to set priorities for future research studies.

With the goal of transforming the lives of nearly 54 million Americans affected by depression and bipolar disorder, the MoodNetwork is creating a community of patients, researchers, and clinicians. Participants will get involved in their own treatment as well as research for new treatments.

Mood disorders are complex conditions, and effective treatments can offer people substantial improvements. But clinicians are unable to match patients to treatments, and more research is needed to create personalized care. MoodNetwork needs your experience and your help.

Learn more about depression at BetterHelp.com.

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More than 450 million people around the world live with mental illnesses.* *Source: World Health Organization Losing a loved one, getting fired from a job, going through a divorce, and other difficult situations can lead a person to feel sad, lonely and scared. These feelings are normal reactions to life's stressors.

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Depression seems to pose an evolutionary paradox. Research in the US and other countries estimates that between 30 to 50 percent of people have met current psychiatric diagnostic criteria for major depressive disorder sometime in their lives. But the brain plays crucial roles in promoting survival and reproduction, so the pressures of evolution should have left our brains resistant to such high rates of malfunction. Mental disorders should generally be rare - why isn't depression?

This paradox could be resolved if depression were a problem of growing old. The functioning of all body systems and organs, including the brain, tends to deteriorate with age. This is not a satisfactory explanation for depression, however, as people are most likely to experience their first bout in adolescence and young adulthood.

Or, perhaps, depression might be like obesity - a problem that arises because modern conditions are so different from those in which we evolved. Homo sapiens did not evolve with cookies and soda at the fingertips. Yet this is not a satisfactory explanation either. The symptoms of depression have been found in every culture which has been carefully examined, including small-scale societies, such as the Ache of Paraguay and the !Kung of southern Africa - societies where people are thought to live in environments similar to those that prevailed in our evolutionary past.

There is another possibility: that, in most instances, depression should not be thought of as a disorder at all. In an article recently published in Psychological Review, we argue that depression is in fact an adaptation, a state of mind which brings real costs, but also brings real benefits.

One reason to suspect that depression is an adaptation, not a malfunction, comes from research into a molecule in the brain known as the 5HT1A receptor. The 5HT1A receptor binds to serotonin, another brain molecule that is highly implicated in depression and is the target of most current antidepressant medications. Rodents lacking this receptor show fewer depressive symptoms in response to stress, which suggests that it is somehow involved in promoting depression. (Pharmaceutical companies, in fact, are designing the next generation of antidepressant medications to target this receptor.) When scientists have compared the composition of the functional part of the rat 5HT1A receptor to that of humans, it is 99 percent similar, which suggests that it is so important that natural selection has preserved it. The ability to "turn on" depression would seem to be important, then, not an accident.

This is not to say that depression is not a problem. Depressed people often have trouble performing everyday activities, they can't concentrate on their work, they tend to socially isolate themselves, they are lethargic, and they often lose the ability to take pleasure from such activities such as eating and sex. Some can plunge into severe, lengthy, and even life-threatening bouts of depression.

So what could be so useful about depression? Depressed people often think intensely about their problems. These thoughts are called ruminations; they are persistent and depressed people have difficulty thinking about anything else. Numerous studies have also shown that this thinking style is often highly analytical. They dwell on a complex problem, breaking it down into smaller components, which are considered one at a time.

This analytical style of thought, of course, can be very productive. Each component is not as difficult, so the problem becomes more tractable. Indeed, when you are faced with a difficult problem, such as a math problem, feeling depressed is often a useful response that may help you analyze and solve it. For instance, in some of our research, we have found evidence that people who get more depressed while they are working on complex problems in an intelligence test tend to score higher on the test.

Analysis requires a lot of uninterrupted thought, and depression coordinates many changes in the body to help people analyze their problems without getting distracted. In a region of the brain known as the ventrolateral prefrontal cortex (VLPFC), neurons must fire continuously for people to avoid being distracted. But this is very energetically demanding for VLPFC neurons, just as a car's engine eats up fuel when going up a mountain road. Moreover, continuous firing can cause neurons to break down, just as the car's engine is more likely to break down when stressed. Studies of depression in rats show that the 5HT1A receptor is involved in supplying neurons with the fuel they need to fire, as well as preventing them from breaking down. These important processes allow depressive rumination to continue uninterrupted with minimal neuronal damage, which may explain why the 5HT1A receptor is so evolutionarily important.

Many other symptoms of depression make sense in light of the idea that analysis must be uninterrupted. The desire for social isolation, for instance, helps the depressed person avoid situations that would require thinking about other things. Similarly, the inability to derive pleasure from sex or other activities prevents the depressed person from engaging in activities that could distract him or her from the problem. Even the loss of appetite often seen in depression could be viewed as promoting analysis because chewing and other oral activity interferes with the brain's ability to process information.

But is there any evidence that depression is useful in analyzing complex problems? For one thing, if depressive rumination were harmful, as most clinicians and researchers assume, then bouts of depression should be slower to resolve when people are given interventions that encourage rumination, such as having them write about their strongest thoughts and feelings. However, the opposite appears to be true. Several studies have found that expressive writing promotes quicker resolution of depression, and they suggest that this is because depressed people gain insight into their problems.

There is another suggestive line of evidence. Various studies have found that people in depressed mood states are better at solving social dilemmas. Yet these would seem to have been precisely the kind of problems difficult enough to require analysis and important enough to drive the evolution of such a costly emotion. Consider a woman with young children who discovers her husband is having an affair. Is the wife's best strategy to ignore it, or force him to choose between her and the other woman, and risk abandonment? Laboratory experiments indicate that depressed people are better at solving social dilemmas by better analysis of the costs and benefits of the different options that they might take.

Sometimes people are reluctant to disclose the reason for their depression because it is embarrassing or sensitive, they find it painful, they believe they must soldier on and ignore them, or they have difficulty putting their complex internal struggles into words.

But depression is nature's way of telling you that you've got complex social problems that the mind is intent on solving. Therapies should try to encourage depressive rumination rather than try to stop it, and they should focus on trying to help people solve the problems that trigger their bouts of depression. (There are several effective therapies that focus on just this.) It is also essential, in instances where there is resistance to discussing ruminations, that the therapist try to identify and dismantle those barriers.

When one considers all the evidence, depression seems less like a disorder where the brain is operating in a haphazard way, or malfunctioning. Instead, depression seems more like the vertebrate eye-an intricate, highly organized piece of machinery that performs a specific function.
Are you a scientist? Have you recently read a peer-reviewed paper that you want to write about? Then contact Mind Matters co-editor Gareth Cook, a Pulitzer prize-winning journalist at the Boston Globe, where he edits the Sunday Ideas section.

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Paul W. Andrews, J. Anderson Thomson Jr.

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Depression seems to pose an evolutionary paradox. Research in the US and other countries estimates that between 30 to 50 percent of people have met current psychiatric diagnostic criteria for major depressive disorder sometime in their lives.

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National Institute of Mental Health

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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 disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability 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- defined by manic episodes that last at least 7 days, or by manic symptoms that are so severe that the person needs immediate hospital 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.

Bipolar II Disorder- defined by a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes that are typical of Bipolar I Disorder.

Cyclothymic Disorder (also called Cyclothymia)- defined by periods of hypomanic symptoms as well as periods of depressive symptoms lasting for at least 2 years (1 year in children and adolescents). However, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode.

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

Bipolar disorder is typically diagnosed during late adolescence (teen years) or early adulthood. Occasionally, bipolar symptoms can appear in children. Bipolar disorder can also first appear during a woman's pregnancy or following childbirth. 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

Treatments and Therapies

Join a Study

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Bipolar disorder (formerly called manic-depressive illness or manic depression) is a mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability 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.

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Mental Health America

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En Espanol:

Clinical Trials:

What is Bipolar Disorder?

Bipolar disorder is a mental health disorder characterized by extreme highs and lows in mood and energy. While everyone experiences ups and downs, the severe shifts that happen in bipolar disorder can have a serious impact on a person's life. More than 3.3 million American adults (1.7%) suffer from bipolar disorder in a given year. [1]

Contrary to how it is sometimes used in conversation, a diagnosis of bipolar disorder does not mean a person is highly emotional but rather refers to someone who experiences extended periods of mood and energy that are excessively high and or/irritable to sad and hopeless, with periods of normal mood in between.

It typically begins in adolescence or early adulthood and continues throughout life. It is often not recognized as an illness and people who have it may suffer needlessly for years.

Bipolar disorder can be extremely distressing and disruptive for those who have this disease, their spouses, family members, friends, and employers. Although there is no known cure, bipolar disorder is treatable, and recovery is possible. Individuals with bipolar disorder can and do have successful relationships and meaningful jobs. The combination of medication, therapy, healthy lifestyle, and support helps the vast majority of people return to productive, fulfilling lives.
"Bipolar disorder is treatable, and recovery is possible."
What Causes Bipolar Disorder?

Although a specific genetic link to bipolar disorder has not been pin pointed, research shows that bipolar disorder tends to run in families.

People may inherit a tendency to develop the illness, which can then be triggered by environmental factors such as distressing life events.

Brain development, structure and chemicals called neurotransmitters, which act as messengers between nerve cells, are also thought to play a role in the development of bipolar disorder.[2]

What are the Symptoms of Bipolar Disorder?

Bipolar disorder is often difficult to recognize and diagnose. It causes a person to have a high level of energy, unrealistically expansive thoughts or ideas, and impulsive or reckless behavior. These symptoms may feel good to a person, which may lead to denial that there is a problem.

Another reason bipolar disorder is difficult to diagnose is that its symptoms may appear to be part of another illness or attributed to other problems such as substance abuse, poor school performance, or trouble in the workplace.

Symptoms of bipolar disorder fall into two categories: mania and depression.

Mania
The symptoms of mania, which can last up to three months if untreated include:

Depression
An episode of depression can come before or after a manic, hypomanic, or normal period of mood. Symptoms include:

Excessive energy, activity, restlessness, racing thoughts and rapid talking (also called "pressured speech").

Extreme "high" or euphoric feelings-a person may feel "on top of the world" and even bad news or tragic events, can't change this.

Being easily irritated or distracted.

Decreased need for sleep-an individual may go days with little or no sleep without feeling tired.

Unrealistic beliefs in one's ability and powers-a person may experience feelings of exaggerated self-confidence or unwarranted optimism. This can lead to over ambitious work plans and the belief that nothing can stop him or her from accomplishing any task.

Uncharacteristically poor judgment-a person may make poor decisions which may lead to unrealistic involvement in activities, meetings and deadlines, reckless driving, spending sprees, and/or foolish business ventures.

Unusual sex drive or abuse of drugs (particularly cocaine, alcohol or sleeping medications).

Provocative, intrusive, or aggressive behavior-a person may become enraged or paranoid if his or her grand ideas are stopped, or extreme social plans are refused.

Signs of psychosis (learn more about psychosis here)

Persistent sad, anxious or empty mood.

Changes in sleep such as, getting too much or too little, or waking in the middle-of-the-night or unusually early in the morning

Reduced appetite and weight loss, or increased appetite accompanied by weight gain.

Irritability or restlessness

Difficulty concentrating, remembering or making decisions. These may often impact a person's ability to fulfill work, school or other life obligations.

Fatigue or loss of energy.

Persistent physical symptoms that don't respond to treatment, such as chronic pain or digestive issues (like upset stomach or diarrhea).

Feeling guilty, hopeless or worthless.

Thoughts of death or suicide, including suicide attempts.

If you or someone you know is in crisis, call 1-800-273-TALK (8255), visit your local emergency room or call 911.

What is the Difference Between Mania and Hypomania? [3]

Mania is when a person has:

at least 3 of the symptoms listed above for mania that last for at least one week, and

serious impairment in work or school functioning or in usual social activities or relationships with others, or

symptoms severe enough to require hospitalization to prevent a person from hurting their self or others, or

psychotic features.

Hypomania is when a person has:

at least 3 of the symptoms listed above for mania that last at least 4 days, and

a change in their ability to function that is not typical of that person when they aren't showing symptoms,

changes in mood and ability to function that are noticeable by others,

symptoms that are not severe enough to cause serious impairment in social or work/school functioning, or to necessitate hospitalization, and

no psychotic features.

In summary, hypomania is a less severe and more brief form of mania.

Diagnoses and Other Terms Associated with Bipolar Disorder

Bipolar I Disorder: Bipolar I Disorder is given when a person has at least one episode of mania. While a person with Bipolar I might only experience manic episodes, it often includes episodes of depression and hypomania. Hypomania includes the same symptoms of mania but can be shorter in duration and less severe. They do not include symptoms of psychosis or require hospitalization.

Bipolar II Disorder: Bipolar II Disorder includes at least one major depressive episode and at least one hypomanic episode. Individuals with bipolar II also tend to have longer periods of depression than people with bipolar I.

Cyclothymic Disorder: Sometimes called cyclothymia, this disorder includes episodes of hypomania and depressive symptoms that occur on a fairly regular basis. While changes in mood are not as extreme as those associated with Bipolar I and Bipolar II Disorders, it can still cause serious problems in a person's life and may later progress to symptoms of mania, hypomania, and depression.

Rapid Cycling: Rapid cycling is a term used when an individual experiences four or more episodes of hypomania, mania, or depression within a 12-month time period.

Mixed Episode: A mixed episode occurs when a person is experiencing symptoms of both depression and mania or hypomania at the same time. Individuals with bipolar disorders are at an increased risk for suicide, and this risk is thought to be especially high during mixed episodes.

What are the Treatments for Bipolar Disorders?

A combination of medication, therapy, lifestyle changes, and support from family, friends and peers help individuals with bipolar disorder to stabilize their mood and to live the lives they want. Finding the treatment plan that works best for a person is critical for recovery.

Medication: Common medications used in treating bipolar disorder are lithium, anticonvulsants, and mood stabilizers. Other medications used include antipsychotics, benzodiazepines, and beta-blockers. As with all medications, medications used to treat bipolar disorder can have mild to serious side effects so it is important to talk with your doctors about how you are feeling.
Learn more about medications.

Therapy: Both group and individual therapy can be helpful in bipolar disorder. Common types of therapy used are Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), and family-focused therapies.
Learn more about therapy.

Lifestyle changes: Healthy lifestyles changes can be an important part of overall recovery. This includes: sticking to a regular sleep schedule; reducing consumption of alcohol, caffeine, and similar substances; and exercising regularly. Some may use meditation, mind-body practices, and spirituality as resources as well.
Learn more about living a healthy lifestyle.

Support: Support and self-help groups are invaluable resources for learning coping skills, feeling accepted, and avoiding social isolation. In addition to in-person support groups and drop-in centers, there are many online communities where individuals can also find support. Additional support can be provided through employment, housing, and psychosocial rehabilitation programs.
Learn more about recovery and support.

Friends and family can also join support groups to better understand how to offer encouragement and support their loved ones.
Learn more about what you can do to support someone close to you.

From our Partners:

Read stories from people living with Bipolar Disorder on The Mighty.

Other Resources:

National Suicide Prevention Lifeline
1-800-273-TALK (8255)
http://www.suicidepreventionlifeline.org
Ryan Licht Sang Bipolar Foundation
www.ryanlichtsangbipolarfoundation.org
Juvenile Bipolar Research Foundation
914-468-1297
www.jbrf.org
Sources
National Foundation for Depressive Illness
1-800-239-1265
www.depression.org

Depression and Bipolar Support Alliance (DBSA)
1-800-826-3632
www.dbsalliance.org

[1] Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H.U. (2012). Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 21(3), 169-184. http://doi.org/10.1002/mpr.1359

[2] http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

[3] http://www.bipolarworld.net/Bipolar%20Disorder/Diagnosis/dsmv.htm (Adapted from DSM V)

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Bipolar Disorder: What You Need to Know Bipolar Disorder and African Americans Bipolar Disorder in Children Infographic: Life with Bipolar Mood Disorders "What is Bipolar Disorder?" A Guide to Hope and Recovery for African Americans Staying Well When You Have a Mental Illness PDF

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Bipolar

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At a recent forum on mental health in San Antonio put on by Clarity Child Guidance Center, author Cinda Johnson spoke about her daughter Linea's years-long descent into mental illness. She's written a book about her family's struggles. In today's TPR Lifeline, Bioscience-Medicine reporter Wendy Rigby focuses on bipolar disorder. Here's a transcript of the interview.

Rigby: The name of the book is Perfect Chaos: A Daughter's Journey to Survive Bipolar, A Mother's Struggle to Save Her. Cinda, why did you decide to write this book?

Johnson: Actually it began with Linea journaling. And she wrote and wrote and wrote through all of the experiences that she had. And I said 'let's share this book.' She said 'well, you have to write your part.' So I did and we ended up getting it published. We saw the inequities and inequality of treatment around mental illness as we entered this world of mental illness and felt like, you know, we have got to get our voice out there and advocate for treatment.

It shouldn't be based upon where you're born and who your parents are and how much money you have, the kind of healthcare you get. And we happen to have some resources that provided her good healthcare. But she was hospitalized with people that had nothing. And their outcomes are very different.

Rigby: Give people a little background. What is your daughter's diagnosis and how long did it take to get to that diagnosis?

Johnson: Her diagnosis is bipolar disorder. She had a lot of anxiety and depressions in high school. But I assumed it was something outside of her: her schedule, her overachieving tendencies. But looking back, I'm certain that that was the beginning of her illness.

She was diagnosed when she had a major crash at 19 while she was at college in Chicago. But she came home and was hospitalized and was diagnosed at the point.

Rigby: What are some of the specific characteristics of bipolar you would like people to know about?

Johnson: It starts with these sort of hints of what this illness is. But it takes awhile to diagnose that. Often times it typically comes in at the end of the teen years. But students in their high school years often have symptoms. So on the one hand we don't want to assume that every child that has anxiety as a 15-year-old is going to have bipolar disorder. But on the other hand I tell parents 'know the symptoms like you would strep throat, for instance. You know, when do you take your child to a doctor to find out? And so, there must be at least three episodes of depression and of hypomania or mania. And that can take a couple of years before that falls into place.

Rigby: She said over and over again to you 'I don't know why I'm feeling this way. I don't have any reason to be feeling this way.' Is that something parents should look out for?

Johnson: Yes. I was giving her the message of 'if you got more sleep...if your schedule was better.' Which meant try harder and this would go away. Which really was the wrong message to give. But we both were going down that road of 'how can we fix this?' rather than 'this is a brain disorder and we need a doctor.'

Rigby: How many times has your daughter been hospitalized and what kinds of therapies has she undergone that have helped her?

Johnson: She was hospitalized four times. She's had electroconvulsive treatment which is not for everyone. I'm not, you know, pushing it. But for her, it saved her life.

Rigby: So she's 30 years old now. How do you feel about her future?

Johnson: I feel very hopeful about her future. I'm at the point if something happened to me tomorrow, I know she'd be okay.

Rigby: You write in the introduction that love alone won't save someone with mental illness. Isn't it true that as family members, we think we can fix it all by loving them hard enough or well enough?

Johnson: Absolutely. And that leaves, I think, a feeling of loss that you couldn't do it, a feeling of grief. And I think we need to be able to deal with those feelings. There's something about mental illness that even though I know better, I still was wracking my brain to think 'how could I have done something differently to have prevented this?' And we know that's not true. But it's part of the stigma around mental illness.

People who do well with a mental illness don't have to tell anyone. And so we don't know how many people live productive lives and have jobs and have children and get married and have healthy partners in relationships. Part of it is sharing the book for that purpose...to share that story of hope.

Rigby: Cinda Johnson, one of the author's of Perfect Chaos, thank for talking to us.

Johnson: Thank you so much, Wendy.

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TPR Lifeline: Coping With A Diagnosis Of Bipolar Disorder

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At a recent forum on mental health in San Antonio put on by Clarity Child Guidance Center, author Cinda Johnson spoke about her daughter Linea's years-long descent into mental illness. She's written a book about her family's struggles. In today's TPR Lifeline, Bioscience-Medicine reporter Wendy Rigby focuses on bipolar disorder.

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TED-Ed video on Bipolar

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What is bipolar disorder? - Helen M. Farrell

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I just found an amazing website that I thought I'd share with you. It's called The Counseling Youth With Depression. It seems like more and more students each year suffer from depression. . .well maybe it's not more each year, but I think as a society we are more aware of those who are depressed and the need to help make life more manageable for them.
Counseling Youth With Depression website is designed with school counselors in mind. The purpose is to provide resources and depression rating scales to counselors. An interesting fact that was posted is:

One of the most vulnerable groups for completed suicide is the 18-24 age group. Adolescent suicide is the second leading cause of death, following accidents, among youth and young adults in the U.S. It is estimated that 500,000 teens attempt suicide every year with 5,000 succeeding. Many of these teens suffer from depression.

One of the great features of the website is the resources that it links you up to. Several depression rating scales with a description of who it is best for and who can administer it, as well as lesson for school counselors to use on the topic of helping students understand depression as well as icebreakers and other get to know you activities. I guess I never knew how many teens attempted suicide every year, even though I have had several students that I have administered the Columbia Suicide Severity Rating Scale to. For more info about this free product and extremely useful tool, see
this post. And in case you missed it, take a look at this post for more information about Kognito, an online program to help teachers determine how to refer kids in crisis to their counselor.
Do you have any tools that you use to determine the severity of depression a student is dealing with? If you do, please share. Leave a comment or join in the conversation through one of the ways below:

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I just found an amazing website that I thought I'd share with you. It's called The Counseling Youth With Depression . It seems like more and more students each year suffer from depression. .

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Teen Depression in School | Erika's Lighthouse

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Teen depression in school education must begin at school and should be hopeful, helpful and easy to implement.

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Closer Examination of Bipoloar Disorder in School Age Children

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A lack of sleep, poor eating habits, and not enough exercise make up a recipe for depression among college students. The stress that comes with academia - including pressure to get good grades, financial worries, failed relationships and conflicts with roommates - are enough to force some students to leave college or worse.

In fact, depression is the number one reason students drop out of school or die by suicide.

Depression Among College Students Statistics

Depression is an epidemic among college students. Some of the more alarming statistics:

1 out of every 4 college students suffers from some form of mental illness, including depression

44 percent of American college students report having symptoms of depression

75 percent of college students do not seek help for mental health problems

suicide is the third leading cause of death among college students

young people diagnosed with depression are five times more likely to attempt suicide than adults

19 percent of young people in the United States either contemplate or attempt suicide every year

4 out of every 5 college students who either contemplate or attempt suicide show clear warning signs

The Risks of Depression Among College Students

A recent U.K. study found that the current generation of university students are at a greater risk of anxiety and depression than their predecessors. The study by the Royal College of Psychiatrists found that many students are unprepared for university life and face higher debt and fewer job prospects than previous generations of students. Many students will simply drop out of school.

In addition to dropping out, depressed students are at a greater risk of developing problems such as substance abuse. In fact, more than two-thirds of young people with substance abuse issues also suffer from a diagnosable mental illness such as depression.

Depressed college students are more likely to binge drink, smoke marijuana, and participate in risky sexual behaviors to cope with emotional pain than are their non-depressed peers.

The Problem with Young Love

Often, a breakup will precipitate a bout of depression. This is especially true for young women.

College-aged women experience greater distress, ruminate on a former relationship longer, and ?have higher rates of sadness, anxiety, and overall negative emotions than do young men.

Risks of depression related to a breakup include intrusive thoughts, difficulty controlling those thoughts, and trouble sleeping. As many as 43 percent of students experience insomnia in the months following a breakup. Students that are most likely to become distressed after a breakup experienced neglect or abuse during childhood, had an insecure attachment style, felt more betrayed, and were more unprepared for the breakup.

Fortunately, the best therapy for depression precipitated by a breakup is time.

Cognitive behavioral therapy, interpersonal psychotherapy and, especially, complicated grief therapy have high success rates for helping to heal a broken heart.

Suicide and College Students

In the United States, suicide is the third leading cause of death in young people between the ages of 15 and 24. Young men die by suicide at five times the rate of young women, although female college students attempt suicide more often. The majority of young people who die by suicide do so with guns.

Depression is the biggest risk factor for suicidal youth. Other risk factors include:

substance abuse

a family history of depression and mental illness

a prior suicide attempt

stressful life events

access to guns

exposure to other students who have died as a result of suicide

self-harming behaviors such as burning or cutting

Diagnosing and Treating Depression in College Students

College is a stressful environment for most young people, therefore it's especially important for parents, friends, faculty, and counselors to get involved if they suspect a student is suffering from depression.

Students themselves are often reluctant to seek help due to social stigmas related to depression. A mental health evaluation that encompasses a student's developmental and family history, school performance, and any self-injurious behaviors should be performed to evaluate at-risk students before a treatment plan is made.

The best treatments for college-aged students suffering from depression are usually a combination of antidepressant medications and talk therapies such as cognitive behavioral therapy and ?interpersonal psychotherapy. Depressed students are also more likely to benefit from exercise, eating a healthy diet, and getting enough rest than many other groups.

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A lack of sleep, poor eating habits, and not enough exercise make up a recipe for depression among college students. The stress that comes with academia - including pressure to get good grades, financial worries, failed relationships and conflicts with roommates - are enough to force some students to leave college or worse.

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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.

What is conduct disorder?

Conduct disorder is a mental health condition that can affect children and teenagers. Kids who have conduct disorder seem to enjoy hurting people and doing bad things. They are unkind and often violent, and they don't care about other people's feelings. This behavior goes beyond normal teasing, bullying, or acting out.

Extreme bullying, hurting animals, and lying for no reason are all signs of conduct disorder. In younger kids, conduct disorder starts with pushing, hitting and biting. In older kids, conduct disorder can come with more extreme violent behavior and crimes like stealing, destroying things and setting fires.

All kids act out sometimes, so conduct disorder is only diagnosed when this extreme behavior shows up over a long period of time and isn't caused by the child's environment.

What are the symptoms of conduct disorder?

Symptoms of conduct disorder include:

Not caring about social norms of good behavior

Ignoring the rights and feelings of other people

Enjoying causing harm, lying or manipulating people

Committing physical or sexual violence

Hurting animals

In younger kids: lying for no real reason, stealing for the fun of it, and extreme bullying

In older kids: picking fights, lying, cheating, stealing, destroying property, and physically or emotionally abusing others

How is conduct disorder diagnosed?

Conduct disorder is different from just bad behavior or acting out, which most kids do at some point. Kids must show symptoms of conduct disorder for several months at a time to be diagnosed. Before diagnosing a child with conduct disorder, a professional will also try to figure out if their extreme behavior could be a reaction to problems at home. To be diagnosed, a child's enjoyment of causing pain must seem to come from something inside them.

What are the risk factors for conduct disorder?

Several things put kids at higher risk of developing conduct disorder:

Having a parent or sibling with conduct disorder

Having a biological parent who abuses alcohol or has depression, ADHD, bipolar disorder, or schizophrenia

Experiencing abuse or neglect

Being bullied or having friends who encourage negative behavior

How is conduct disorder treated?

Conduct disorder is hard to treat but treatment can work if the child's family, friends and teachers get involved. Treatment works better if it starts when the child is young.

In therapy for conduct disorder, the child learns healthier ways to interact with others. At the same time, the child's family and support system learn ways to communicate with the child. Children with conduct disorder usually stay in psychotherapy or behavioral therapy for a long time.

In younger children, therapy for conduct disorder usually involves teaching parents how to encourage good behavior. In adolescents, therapy may also focus on the child's relationships with friends, other kids, and adults at school (like teachers and principals).

There is no medication specifically for conduct disorder. But kids with conduct disorder sometimes have other disorders as well, like depression or bipolar disorder. Treating those other disorders with medication can help therapy for conduct disorder work better.

This guide was last reviewed or updated on February 23, 2023.

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Quick Guide to Conduct Disorder - 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. Conduct disorder is a mental health condition that can affect children and teenagers. Kids who have conduct disorder seem to enjoy hurting people and doing bad things.

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Conduct disorder is a repetitive and persistent pattern of behavior in children and adolescents in which the rights of others or basic social rules are violated. The child or adolescent usually exhibits these behavior patterns in a variety of settings-at home, at school, and in social situations-and they cause significant impairment in his or her social, academic, and family functioning.

What are the signs and symptoms of Conduct Disorder?

Behaviors characteristic of conduct disorder include:

Aggressive behavior that causes or threatens harm to other people or animals, such as bullying or intimidating others, often initiating physical fights, or being physically cruel to animals.

Non-aggressive conduct that causes property loss or damage, such as fire-setting or the deliberate destruction of others' property.

Deceitfulness or theft, such as breaking into someone's house or car, or lying or "conning" others.

Serious rule violations, such as staying out at night when prohibited, running away from home overnight, or often being truant from school.

Many youth with conduct disorder may have trouble feeling and expressing empathy or remorse and reading social cues. These youth often misinterpret the actions of others as being hostile or aggressive and respond by escalating the situation into conflict. Conduct disorder may also be associated with other difficulties such as substance use, risk-taking behavior, school problems, and physical injury from accidents or fights.

How common is Conduct Disorder?

Conduct disorder is more common among boys than girls, with studies indicating that the rate among boys in the general population ranges from 6% to 16% while the rate among girls ranges from 2% to 9%. Conduct disorder can have its onset early, before age 10, or in adolescence. Children who display early-onset conduct disorder are at greater risk for persistent difficulties, however, and they are also more likely to have troubled peer relationships and academic problems. Among both boys and girls, conduct disorder is one of the disorders most frequently diagnosed in mental health settings.

What does the research say about Conduct Disorder?

Recent research on Conduct Disorder has been very promising. For example, research has shown that most children and adolescents with conduct disorder do not grow up to have behavioral problems or problems with the law as adults; most of these youth do well as adults, both socially and occupationally. Researchers are also gaining a better understanding of the causes of conduct disorder, as well as aggressive behavior more generally. Conduct disorder has both genetic and environmental components. That is, although the disorder is more common among the children of adults who themselves exhibited conduct problems when they were young, there are many other factors which researchers believe contribute to the development of the disorder. For example, youth with conduct disorder appear to have deficits in processing social information or social cues, and some may have been rejected by peers as young children.

Despite early reports that treatment for this disorder is ineffective, several recent reviews of the literature have identified promising approaches treating children and adolescents with conduct disorder. The most successful approaches intervene as early as possible, are structured and intensive, and address the multiple contexts in which children exhibit problem behavior, including the family, school, and community. Examples of effective treatment approaches include functional family therapy, multi-systemic therapy, and cognitive behavioral approaches which focus on building skills such as anger management. Pharmacological intervention alone is not sufficient for the treatment of conduct disorder.

Conduct disorder tends to co-occur with a number of other emotional and behavioral disorders of childhood, particularly Attention Deficit Hyperactivity Disorder (ADHD)and Mood Disorders (such as depression). Co-occurring conduct disorder and substance abuse problems must be treated in an integrated, holistic fashion.
Why are assessment and treatment important?

Assessment and diagnosis of conduct disorder-or any emotional or behavioral disorder of childhood-should be done by a mental health professional, preferably one who is trained in children's mental health. Any diagnosis must be made in consultation with the child's family. The assessment process should include observation of the child, discussion with the child and family, the use of standardized instruments or structured diagnostic interviews, and history-taking ,including a complete medical and family / social history. When assessing and diagnosing any childhood emotional or behavioral disorder, the mental health professional should consider the social and economic context in which a child's behavior occurs.

Accurate assessment and appropriate, individualized treatment will assure that all children are equipped to navigate the developmental milestones of childhood and adolescence and make a successful adaptation to adulthood. Treatment must be provided in the least restrictive setting possible.
What can I do if I'm concerned about a child?

Learn more about conduct disorder, including recent research on effective treatment approaches. Contact NMHA for additional resources on conduct disorder or other emotional or behavioral disorders of childhood.

Consult with a mental health professional, preferably one who is trained in children's mental health.

Explore the treatment options available. Treatment must be individualized to meet the needs of each child and should be family-centered and developmentally and culturally appropriate.

Find a family support group or organization in your community.

Sources
American Academy of Child and Adolescent Psychiatry. (1997). Practice parameters for the assessment and treatment of children and adolescents with conduct disorder. Journal of the

American Academy of Child and Adolescent Psychiatry, 36 (supplement); 122S-139S.

American Psychiatric Association. (1994). Diagnostic and Statistic Manual of Mental Disorders (4th edition). Washington, DC: American Psychiatric Association.
This Fact Sheet is one in a series of Fact Sheets that Mental Health America has produced on major childhood emotional and behavioral disorders, including bipolar disorder, depression, and anxiety disorders. This Fact Sheet is intended to generally inform the reader about this disorder and is not intended to be a substitute for proper assessment by a trained mental health professional.

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What is Conduct Disorder? Conduct disorder is a repetitive and persistent pattern of behavior in children and adolescents in which the rights of others or basic social rules are violated. The child or adolescent usually exhibits these behavior patterns in a variety of settings-at home, at school, and in social situations-and they cause significant impairment in his or her social, academic, and family functioning.

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Open in New Window--article on Conduct Disorder

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Conduct Disorder: Diagnosis and Treatment In Primary Care - American Family Physician

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Conduct disorder is a common childhood psychiatric problem that has an increased incidence in adolescence. The primary diagnostic features of conduct disorder include aggression, theft, vandalism, violations of rules and/or lying. For a diagnosis, these behaviors must occur for at least a six-month period.

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Kids and teens with conduct disorder are highly visible, demonstrating a complicated group of behavioral and emotional problems. Serious, repetitive, and persistent misbehavior is the essential feature of this disorder.
These behaviors fall into 4 main groups: aggressive behavior toward people or animals, destruction of property, deceitfulness or theft, and serious violations of rules.

To receive a diagnosis of conduct disorder, a youngster or adolescent must have displayed 3 or more characteristic behaviors in the past 12 months. At least 1 of these behaviors must have been evident during the past 6 months.

Diagnosing conduct disorder can be a dilemma because kids are constantly changing. This makes it difficult to discern whether the problem is persistent enough to warrant a diagnosis. In some cases, what appears to be conduct disorder may be a problem adjusting to acute or chronic stress. Many kids with conduct disorder also have learning disabilities and about 1/3 are depressed. Many kids stop exhibiting behavior problems when they are treated for depression.

The U.S. Department of Health and Human Services estimates that between 6 and 16 percent of males and 2 to 9 percent of females under age 18 have conduct disorder that ranges in severity from mild to severe.

Other serious disorders of childhood and adolescence commonly associated with conduct disorder are attention-deficit/hyperactivity disorder (AD/HD) or oppositional defiant disorder (ODD). The majority of kids and teens with conduct disorder may have lifelong patterns of antisocial behavior and be at higher risk for a mood or anxiety disorder. But for many, the disorder may subside in later adulthood.

The social context in which a student lives (poverty or a high crime area, for example) may influence what we view as antisocial behavior. In these cases, a diagnosis of conduct disorder can be misapplied to individuals whose behaviors may be protective or exist within the cultural context.

A youngster with suspected conduct disorder needs to be referred for a mental health assessment. If the symptoms are mild, the student may be able to receive services and remain in the regular school environment. More seriously troubled kids, however, may need more specialized educational environments.

Symptoms or Behaviors-

* Bullying or threatening classmates and other children
* Destruction of property
* Frequent physical fights; use of a weapon
* History of frequent suspension
* Little empathy for others and a lack of appropriate feelings of guilt and remorse
* Low self-esteem masked by bravado
* Lying to peers or teachers
* Poor attendance record or chronic truancy
* Stealing from peers or the school

Educational Implications-

Children with conduct disorder like to engage in power struggles. They often react badly to direct demands or statements such as: "You need to..." or "You must..." They may consistently challenge class rules, refuse to do assignments, and argue or fight with other children. This behavior can cause significant impairment in both social and academic functioning. They also work best in environments with high staff/student ratios, 1-to-1 situations, or self-contained programs when there is plenty of structure and clearly defined guidelines. Their frequent absences and their refusal to do assignments often leads to academic failure.

Instructional Strategies and Classroom Accommodations-

* Avoid "infantile" materials to teach basic skills. Materials should be age-appropriate, positive, and relevant to children' lives.
* Avoid escalating prompts such as shouting, touching, nagging, or cornering the student.
* Be aware that adults can unconsciously form and behaviorally express negative impressions of low-performing, uncooperative children. Try to monitor your impressions, keep them as neutral as possible, communicate a positive regard for the children, and give them the benefit of the doubt whenever possible.
* Consider the use of technology. Children with conduct disorder tend to work well on computers with active programs.
* Establish clear classroom rules. Rules should be few, fair, clear, displayed, taught, and consistently enforced. Be clear about what is nonnegotiable.
* Give the student options. Stay away from direct demands or statements such as: "You need to..." or "you must...."
* Have your children participate in the establishment of rules, routines, schedules, and expectations.
* Make sure curriculum is at an appropriate level. When work is too hard, children become frustrated. When it is too easy, they become bored. Both reactions lead to problems in the classroom.
* Maximize the performance of low-performing children through the use of individualized instruction, cues, prompting, the breaking down of academic tasks, debriefing, coaching, and providing positive incentives.
* Remember that kids with conduct disorder like to argue. Maintain calm, respect, and detachment. Avoid power struggles and don't argue.
* Remember that praise is important but needs to be sincere.
* Structure activities so the student with conduct disorder is not always left out or the last one picked.
* Children with conduct disorder often do well in programs that allow them to work outside the school setting.
* Systematically teach social skills including anger management, conflict resolution strategies, and how to be assertive in an appropriate manner. For example, discuss strategies that the children may use to calm themselves when they feel their anger escalating. Do this when the children are calm.

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Kids and teens with conduct disorder are highly visible, demonstrating a complicated group of behavioral and emotional problems. Serious, repetitive, and persistent misbehavior is the essential feature of this disorder. These behaviors fall into 4 main groups: aggressive behavior toward people or animals, destruction of property, deceitfulness or theft, and serious violations of rules.

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ADDA - Attention Deficit Disorder Association

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Written by Michelle Frank, Psy.D., as adapted and updated from Peter Jaska's article, "ADHD Facts" originally posted on the ADDA website in 1998

REFERENCES:

Auerbach, J.G., Atzaba-Poria, N., Berger, A., Landau, R., Arbelle, S., Raz, Y., & Ebstein, R. (2010). Dopamine risk and paternal ADHD symptomatology associated with ADHD symptoms in four and a half-year-old boys. Psychiatric Genetics, 20(4), 160-165. doi: 10.1097/YPG.0b013e32833a1f27.

Barkley, R., Murphy, K.R., & Fischer, M. (2008). ADHD in adults: What the science says. The Guildford Press: New York, NY.

Castellanos, X. (2002). Anatomic magnetic resonance imaging studies of Attention Deficit Hyperactivity Disorder.Dialogues in Clinical Neuroscience, 4(4), 444-448.

Castellanos, X., Lee, P., Sharp, W., Jeffries, N., Greenstein, D. Clasen, L., Blumenthall, J., . . . Rapoport, J. (2002). Developmental trajectories of brain volume abnormalities in children and adolescents with Attention Deficit/Hyperactivity Disorder. JAMA, 288(14), 1740-1748. doi:10.1001/jama.288.14.1740.

Cho, S., Son, J., Kim, B., Kim, J., Yoo, H., Hwang, J., Cho, D., Chung, U., & Park, T. (2012). Serotonin 2A receptor gene polymorphism in Korean children with Attention-Deficit/Hyperactivity Disorder. Psychiatry Investigations, 9(3), 269-277. doi:10.4306/pi.2012.9.3.269

Kessler, R., Adler, L., Barkley, R., Biederman, J., Conners, C., Demier, O., Faraone, S., . . . Zaslavsky, A. (2006). The prevalence and correclates of adult ADHD in the United States: results from the National Comorbidity Survey replication. The American Journal of Pyschiatry, 163(4), 716-723.

Faraone, S. (2007). What is the prevalence of adult ADHD? Results of a population screen of 966 adults. Journal of Attention Disorders, 9(2), 384-391. doi: 10.1177/1087054705281478

Gizer, I.R., Waldman, I.D., Abramowitz, A., Barr, C.L., Feng, Y., Wigg, K.G., Misener, V.L., & Rowe, D.C. (2008). Relations between multi-informant assessments of ADHD symptoms, DAT1, and DRD4. Abnormal Psychology, 117(4), 869-880. doi: 10.1037/a0013297.

Henrigquez, B.H., Henriquez, H.M., Carrasco, C.X, Rothhammer, A.P., Llop, R.E., Aboitiz, F., & Rothhammer, E.F. (2008) Combination of DRD4 and DAT1 genotypes is an important risk factor for attention deficit disorder with hyperactivity families living in Santiago, Chile. Revista Medica de Chile, 136(6), 719-724. doi: /S0034-98872008000600005.

Lee, S.S., Humphreys, K.L., Flory, K., Liu, R., & Glass, K. (2011). Prospective association of childhood Attention Defict/Hyperactivity Disorder (ADHD) and substance use and abuse/dependence: A meta-analytic review. Clinical Psychology Review, 31(3), 328-341. Doi: 10.1016/j.cpr.2011.01.006

McCarthy, H., Skokauskas, N., Mulligan, A., Donohoe, G., Mullins, D., Kelly, J., Johnson, K., . . . Frodi, T. (2013). Attention network hypoconnectivity with default and affective network hyperconnectivity in adults diagnosed with attention-deficit/hyperactivity disorder in childhood. JAMA Psychiatry, 70(12), 1320-1337. doi: 10.1001/jamapsychiatry.2013.2174.

Metin, B., Krebs, R.M., Wiersema, J.R., Verguts, T., Gasthuys, R., van der Meere, J.J., Achten.E., . . . Sonuga-Barke, E. (2014). Dysfunctional Modulation of Default Mode Network Activity in Attention-Deficit/Hyperactivity Disorder. Journal of Abnormal Psychology, 2014 (Oct 13) [Epub ahead of print].

Minde, K., Eakin, L., Hechtman, L., Ochs, E., Bouffard, R., Greenfield, B., & Looper, K. (2003). The psychosocial functioning of children and spouses of adults with ADHD. Jounral of Child Psychology and Psychiatry, 44(4), 627-646. doi: 10.1111/1469-7610.00150

Polanczyk, G., Silva de Lima, M., Horta, B.L. Biederman, J., & Rohde, L.A. (2007). The worldwide prevalence of ADHD: A systematic review and meta-regression analysis. The American Journal of Psychiatry, 164(6), 942-948.

Spencer, T.J., Biederman, J., & Michk, E. (2007). Attention-Deficit/Hyperactivity Disorder: Diagnosis, lifespan, comorbidities, and neurobiology. Pediatric Psychology, 32(6), 631-642. Doi: 10.1093/jpepsy/jsm005

Tomasi,D., &Vokow, N.D. (2014). Functional connectivity of substantia nigra and ventral tegmental area: maturation during adolescence and effects of ADHD. Cerebral Cortex, 24(4), 935-944. doi: 10.1093/cercor/bhs382.

Uddin, L.W., Kelly, A.M., Biswal, B.B., Margulies, D.S., Shehzad, Z., Shaw, D. Ghaffari, M., . . . Milham, M.P. (2008). Network homogeneity reveals decreased integrity of default-mode network in ADHD. Journal of Neuroscience Methods, 169(1), 249-254.

Volkow, N., Wang, G.J., Kollins, S., Wigal, T., Newcorn, J. Telang, F., Fowler, J., . . . Swanson, J. (2009). Evaluating dopamine reward pathway in ADHD: Clinical implications. JAMA, 302(10), 1084-1091. doi:10.1001/jama.2009.1308.

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Written by Michelle Frank, Psy.D., as adapted and updated from Peter Jaska's article, "ADHD Facts" originally posted on the ADDA website in 1998 REFERENCES: Auerbach, J.G., Atzaba-Poria, N., Berger, A., Landau, R., Arbelle, S., Raz, Y., & Ebstein, R. (2010). Dopamine risk and paternal ADHD symptomatology associated with ADHD symptoms in four and a half-year-old boys.

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With her long dark hair flying, Saorla Meenagh, 10, (pictured above) can execute a perfect switch leap, one leg out, one tucked under, her arms glued to her sides in classic Irish step-dancing style. Saorla, whose blue eyes, white skin, and sprinkle of freckles helped win her a modeling contract with a New York agency-on hold until her braces come off -also plays softball and Gaelic football, a soccer-like game her father, Seamus, a contractor, enjoyed when he was growing up in County Tyrone, Northern Ireland.

When asked her position on the team, Saorla wiggles in her seat at the family's dining room table. "I don't know-random positions," she says, as her mother, Kerri, a pediatric nurse practitioner quietly pushes her daughter's bare foot off the table where it has wandered for what may be the 10th time in half an hour. During that time, Saorla's actions are as scattered as pool balls in a break. She sits on her knees, then jiggles, then rocks, then circles photos in a stack of food magazines with a pen, turning off the TV, turning up the TV, turning down the TV, and making part of a bracelet on a Rainbow Loom before she finally loses interest. She rarely finishes a task and being with her can be as disconcerting as watching television with someone pressing the channel changer every 10 seconds.

Along with a gift for math and a love for Gaelic sports, Saorla has inherited something else from her father: attention deficit hyperactivity disorder, ADHD. People just meeting her find her adorably sweet, if quirky. But if she's not on her medication-which she isn't at the moment because we met at her family's home in a Philadelphia suburb during the summer-she is an exhausting ball of boundless energy. (While she's not at school, her mother gives her a medication holiday in order to boost her appetite, help her gain weight and grow, all things Vyvance interferes with.) "When we had her tested they said that in 20 years she was the most hyperactive child they ever tested," says Meenagh, gently removing that errant foot from the table yet again.

But Saorla's perpetual motion isn't what concerns Meenagh the most. Being fidgety and easily distracted are two of the most common and recognized symptoms of ADHD, often leading to poor performance in school, the most recognized fallout of the condition. But the 5% to 11% of American children 4 to 17 years of age who are diagnosed with the disorder-the numbers are up for debate depending on whom you talk to-also face a lifetime of increased risk for accidents, teen pregnancy, drug and alcohol abuse, smoking, and even dying prematurely. Overall, boys (13.2%) are more likely than girls (5.6%) to be given an ADHD diagnosis.

It's the fear for her child's future that makes Meenagh bristle when she hears someone-family, friends, strangers, even scientists-say that ADHD doesn't exist, that the symptoms are caused by poor parenting, food additives, or 21 st century life in the fast lane, lack of physical activity, or that they're just kids being kids, albeit less manageable than most. "A lot of people don't believe in it," she says. "I think that's because they've never experienced it firsthand."

To those naysayers, C. Keith Connors, professor emeritus of medical psychology at Duke University and creator of the Connors Rating Scales for diagnosing ADHD, says he always offers the same challenge: "Take one of these kids on a car trip for a day and see how you feel about it then."

It's easy to see why some dismiss ADHD as simply an artifact of modern life. After all, we're all on the information Autobahn. Most Americans are exposed to an average of 100,000 words a day-about the length of Mark Twain's The Adventures of Huckleberry Finn-very little of which we're able to absorb, according to a 2009 study on America's information consumption from the University of California, San Diego. We're also asked from a very young age to be still, nearly motionless, except for the tapping of our fingers on the computer keys. Ours is not a society tolerant of perpetual motion or daydreaming. At some point, we're all like the dog in the Pixar movie, Up, doing one thing and then responding to the real-life equivalent of "Squirrel!"

But ADHD isn't a disorder of the modern age. It may have been first described in the medical literature in 1763 by Scottish physician Sir Arthur Crichton, who observed patients so unable to focus that "the barking of dogs, an ill-tuned organ, or the scolding of women, are sufficient to distract patients of this description to such a degree, as almost approaches to the nature of delirium." Those patients, he noted, referred to their own symptoms, including anger "bordering on insanity," as "the fidgets."

The argument doesn't hold up either when ADHD's worldwide prevalence is factored in. It's found in developing countries, where the information speed limit is slower and the requirement to be sedentary 24/7 doesn't exist.

Yet there's an undeniable backlash against the diagnosis. Earlier this year, Chicago neurologist and ADHD specialist Dr. Richard Saul published a provocatively titled book, ADHD Does Not Exist, in which he proposes that ADHD is not an entity in itself but a cluster of symptoms that stem from more than 20 other conditions, including depression, anxiety, bi-polar disorder, and obsessive-compulsive disorder. Many of those, along with dysfunctional behavior conditions such as oppositional defiant disorder, characterized by aggression, tantrums and a propensity to argue with adults, and learning disabilities such as dyslexia, are often diagnosed as co-illnesses with ADHD. Saul criticizes the catchall-nature of an ADHD diagnosis, which he believes corrals a lot of real conditions into one.

Saul's theories hit home with a lot of people who are worried about statistics showing an increase in the number of ADHD diagnoses in the U.S. and the number of prescriptions filled every year for relatively powerful stimulant drugs such as Ritalin, Adderall and a host of new medications. Though these drugs are generally considered safe, they do have side effects, including anxiety-sometimes even paranoia-weight loss, insomnia, and growth retardation (about half an inch, which doesn't appear to be permanent). In some rare cases they can damage the heart. Since many of the drugs are appetite killers, some parents have to entice their children with small meals all day long. The side effects are why many children like Saorla take medication holidays during summer months or even on the weekends. They're also why doctors and parents have to carefully weigh whether the problems a child has if he or she goes unmedicated are worth the risk.

How prevalent has an ADHD diagnosis become? A survey of 76,000 parents conducted by the Centers for Disease Control (CDC) every four years estimates that one in 11 children had been diagnosed with ADHD by a health care professional, an increase of 42% between 2003 and 2014. "[That number] is preposterous," says Connors, who studied and treated ADHD for 50 years before retiring. "That would make it an epidemic." (See a map of ADHD prescriptions in the U.S.: What's With ADHD in the South)

One possible explanation for the frequency of the diagnosis is that the data collection method is imperfect. The National Survey of Children's Health is a phone survey and the figures on ADHD are collected on the basis of the answers to one question: "Has a doctor or other health care provider ever told you that [your child] had attention deficit disorder or attention-deficit/ hyperactivity disorder, that is, ADD or ADHD?" The type of "other health care provider" isn't established. ADHD experts say it is often a pediatrician who does not spend the kind of time it takes to make an accurate diagnosis. The gold standard of ADHD diagnosis is an analysis of questionnaires, like those Connors developed, filled out by parents, teachers and other people who interact with the child and observe classroom behavior. Each child can take hours to analyze.

"That's a luxury a pediatrician doesn't have," says Dr. Harold S. Koplewicz, MD, who founded the NYU Study Center and is founding president of the nonprofit Child Mind Institute in New York City. 'They get seven minutes face to face, [the doctor gives] them a prescription, and then 30 days later they come back to get it renewed."

(The CDC, however, defends its figures. They say the numbers from their parent survey hold up when they're compared to their own separate, more scientific study looking at insurance claims and field assessments. In this case, scientists in the field do a full 2.5-hour diagnostic evaluation of students for ADHD and other conduct and mental health disorders in 10,000 schools across the country, says epidemiologist Susanna Visser of the CDC's National Center on Birth Defects and Developmental Disabilities. "We come up with a similar estimate-8.5 to 10%," she says.)

And the drug stats aren't in question. The percentage of children taking drugs jumped by more than a quarter, from 4.8% of the population between 4 and 17 to 6.1% between 2007 and 2011 according to the CDC's survey. In fall 2011 and spring 2012, there was even a brief shortage of ADHD drugs, particularly generics, because the demand was outpacing the supply.

Along with quickie diagnoses in a pediatrician's office, part of the problem seems to stem from a misunderstanding of ADHD symptoms and the methods used to diagnose the disorder. The diagnosis is based on a checklist, found in the "bible" of mental health, the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), of 18 possible symptoms, any of which could describe the average child-even the average adult-some of the time. They include acting before thinking, being unable to delay gratification, staying motived to finish a boring task, keeping strong emotions in check, remembering an assignment and how to complete it, or planning ahead.

But three other factors play a pivotal role in determining whether a child has a disorder or is just quirky, inattentive, or high-spirited. To be diagnosed with ADHD, children must have most of those 18 symptoms, most of the time, in most areas of their lives, from home to school to the neighborhood playground.

"And, most important, there must be impairment," says leading ADHD expert Russell Barkley, PhD, clinical professor of psychiatry and pediatrics at the Medical University of South Carolina in Charleston. "They must be unable to function as well as others-and in fact, are often well below normal-in any of those domains."

Fourteen-year-old Zoe Williams "is just a fireball," says her mother, Monnica Williams, a Louisville, Kentucky, psychologist who has five children, three of whom have been diagnosed with ADHD. "She's the kid in the middle of the dance floor that all the other kids are watching, And she talks and talks and talks. Sometimes I have to say, 'Zoe, it's not that I don't want to hear what you have to say, but Mom needs a little talking timeout.'"

While kids with ADHD can be gregarious, their impulsiveness can create problems, often alienating others, including siblings, teachers, and classmates. They don't wait their turn, interrupt others, are easily frustrated, take wild risks, and their emotions can spill over like water at a rolling boil: They may be hot-headed, lash out violently, or have temper tantrums. All of this carries enormous social cost in school and on the playground.

Like autism, ADHD symptoms fall along a spectrum from mild to severe, so it's difficult to define what's typical. But, in general, for a child with attention deficits, trying to focus on one thing is akin to trying to discern the chirping of crickets in Times Square. They're forgetful, tend to procrastinate, and are disorganized. They have a hard time putting in the time and effort to achieve a goal, particularly if it's something like finishing a school project on a topic that doesn't interest them. (Paradoxically, they can also hyperfocus at times, confusing parents who can't understand why a child who can reach the 60 th level of World of Warcraft can't remember homework assignments or follow a simple set of instructions.)

Some are chronically late. "People with ADHD are blind to the future, which is why they never have anything done on time," says Barkley. "If you have an ADHD practice, a third of your patients are late or never show." (Those practices usually include adults; most ADHD symptoms persist into adulthood, though they may be milder.)

ADHD is divided into subtypes-children just with attention problems, those with impulse control and hyperactivity issues, and a group with a combination of the two. The latter is the most common, occurring in two-thirds to three-quarters of people, estimates Barkley.

Children with attention problems can have any or all of these symptoms, but may not be any more fidgety than the average child. Sometimes they're labeled merely ADD. On the other hand, children who are hyperactive as well as distractible may not be able to stop moving or even to stop talking, including to themselves. An internal conversation for most people can become a conference call on speakerphone for a child with ADHD.

So it's no surprise that the average ADHD-afflicted child has one to two negative interactions per minute with the people in their lives, says William Pelham, director of the Center for Children and Families at Florida International University who has authored or co-authored more than 300 papers on ADHD. "What that means is that most of these kids' interactions with other people are negative. They're not the ones invited to birthday parties or over to another kid's house to play."

That kind of rejection can be damaging to a child's self-esteem and heartbreaking for parents. "Saorla is such a good kid, such an empathetic kid, but if she's tired, she becomes 'Hurricane Saorla,'" says Meenagh. The minute Saorla learned to walk she climbed-everything, and not skillfully. She was impulsive, fearless and, probably as a result, accident-prone. The Meenaghs once had to call the police and fire department to get Saorla, then a toddler, out of a bathroom where she had barricaded herself behind a locked door and a drawer she pulled out.

During a class visit to the zoo, Saorla, who has trouble transitioning from one activity to another, balked at moving from one exhibit with the rest of the children and threw a classic "big blowout" tantrum-kicking and screaming-while her mother hauled her away. It's not unusual, says Meenagh, for those outbursts to go on for an hour.

"I was very aware that everyone was looking at us," she says. "I was mortified, but mainly I was scared that she was going to be labeled by the other parents as a kid other kids shouldn't be friends with."

Saorla does have friends, Meenagh is quick to note, but they're not her 10-year-old classmates at the local K-8 Catholic parochial school she attends. "She operates more at a seven-year-old level so her friends tend to be younger," says Meenagh. "She can be very silly-silly to the point that her classmates say she's too silly for them."

As much as Meenagh frets over her child's feelings now, she worries even more about Saorla's future. "I've read a lot about teenage girls with ADHD, how they don't fit in socially, how they have four to five times the rate of teen pregnancy and are four to five times more likely to be in car accidents. I worry about how this is going to play out."

Meenagh's fears are well-founded, says Barkley, author of Taking Charge of ADHD and several other books on raising difficult children and teens. "This is a very serious disorder." He rattles off a catalog of scary statistics: "As adults, people with ADHD are five times more likely to speed and three times more likely to have their licenses revoked than other people. They're more likely to experience accidental injuries-burns, poisoning, traffic accidents, all kinds of trauma-than other people. In fact, having ADHD makes you three times more likely to be dead by the age of 45."

Barkley is aware that he sounds alarmist, but he has good reason. ADHD struck close to home, and with tragic consequences. "I lost my twin brother, Ron, to it," he says. His brother was killed in a one-car accident after drinking. He was not wearing a seatbelt. "This isn't just professional for me, it's personal."

To say that ADHD is sometimes misdiagnosed-even over-diagnosed-is likely true, say many experts. But to say that it doesn't exist, as some critics claim, is "like saying the world is flat," says Edward Hallowell, a psychiatrist who treats ADHD at The Hallowell Centers in Cambridge, MA, and New York City and who has ADHD himself. "Those days are over. Today we have brain scans, genetic studies, twin studies that show that this is a highly inherited neurobiological disorder, not some made-up condition." Most of the doctors who treat people with ADHD agree that of course the condition exists, even if others like Richard Saul dispute it.

Sophisticated neuroimaging technology has allowed us to see what Crichton's 18 th century patients called "the fidgets" in the brain. Today, scientists believe most ADHD can be traced to a malfunction that develops in brain circuitry that controls what is broadly known as "executive functions" like planning, inhibition, and self-control. This master control board is located in the prefrontal cortex, the forward of the brain just below the forehead, and in the basal ganglia, the clusters of nerve cells found far deeper in the brain's gray matter.

Those regions work like the brain's filter; they regulate, among other things, impulse control, attention, the ability to resist distractions, rein in the emotions, think before acting, awareness of time, motivation and motion. If the filter is too porous, too many stimuli get through. "The way I describe it is that it's like having a Ferrari engine for a brain, but with bicycle brakes," says Hallowell.

Scans show that those brain regions in children with ADHD are smaller than they are in children in the general population. In one 2007 study done jointly by the Child Psychiatry Branch of the National Institute of Mental Health and McGill University in Montreal, brain scans of 223 children with ADHD showed that the thickening of cortical tissue was delayed by about three years compared to scans of a control group of equal numbers of normally developing youngsters. Size doesn't matter when it comes to intelligence-many children, like Saorla, have above average IQs-though it clearly has a major impact on behavior.

The ultimate source of these brain differences is likely genes-perhaps thousands of them. The heritability of ADHD is striking. Studies have found that children who have one parent with ADHD have up to a 50% chance of also having it and siblings are between five to seven times more likely to share it. (Saorla's older sister, Aisling, 12, beat those odds.) A large, British twin study, found that the heritability of ADHD approaches 80%. That means that 80% of the time, ADHD is an inherited (not an environmentally caused) condition, making it slightly less heritable than autism, around 90%, but about as genetically programmed as height.

"There are anywhere from 25 to 45 genes that are considered high-candidate genes for ADHD," says Barkley. "But there are several we're reliably sure of, and some of those are the genes related to dopamine regulation in the brain."

Dopamine is the brain's chemical messenger that is probably best known for its role in addiction to drugs, alcohol, sex, even, arguably, chocolate. But this chemical that carries information between nerve cells plays a far more important function in human life than providing us with a cocaine or cupcake high. It uses reward-the pleasurable feelings it supplies-to motivate us to pay attention, avoid distraction, to pick out the most relevant information circulating in short-term memory when solving a problem or completing a task. It also governs motion. The uncontrollable tremors in Parkinson's patients, for example, are caused by lack of dopamine. Without dopamine, we might starve to death: It's what motivates us to eat.

There are dopamine receptors on certain neurons (nerve cells) to which dopamine delivers its various messages, such as pay attention, control yourself, feel good, and do that thing that made you feel good again, the latter reflecting its role in promoting both addiction and learning. Dopamine transporters also protrude from the neurons that produce dopamine. Barkley describes them as "little vacuum cleaners" that absorb the unused dopamine in the brain so it can be used again.

One particular gene, DAT-1, has been implicated in both ADHD and bi-polar disorder and is very active in the basal ganglia and pre-frontal cortex, the brain regions that are smaller in people with ADHD. "DAT-1 genes build the dopamine transporters," explains Barkley. "A certain version of that gene that's longer than normal produces too many of those transporters-those vacuum cleaners-that are sucking up dopamine like there's no tomorrow before it even has a chance to bind to dopamine receptors. " Without dopamine, a personmay have difficulty learning and focusing, might have low motivation and become depressed.

There may also be mutations in dopamine-related genes that make neurons less receptive to dopamine's effects, he says. What that means is that in people with ADHD, there's less motivation-and pleasurable reward-for focusing, remembering, learning, planning ahead, and sitting still.

Other genes recently linked to the disorder strengthen the idea that ADHD is a fundamental communication system gone awry, a short-circuiting of the transmission between cells.

There are some non-genetic risk factors for ADHD: premature birth, maternal smoking and alcohol use, lead exposure, frequent maternal infections during pregnancy, and brain injuries. A 2009 German study found a significant link between having eczema, a rash caused by allergies, and developing ADHD symptoms, giving more credence to a controversial theory that at least some ADHD is the result of allergies or sensitivities to certain foods, food additives, or other environmental chemicals. Organophosphate pesticides-the kind used on most of the U.S. food supply-were linked to an increased risk of ADHD in a 2010 Harvard School of Public Health study which found that higher concentrations of pesticides in a child's urine doubled the child's chances of being diagnosed with the disorder. The takeaway: eat organic produce or at least wash your veggies. (See other approaches to try)

At most, however, these nongenetic factors only account for about 20% to 30% of cases, says Barkley. Ultimately, he believes, it will be genetic research that leads to more accurate diagnosis and treatment of ADHD, "telling us what caused a particular case and what drug to put someone on."

Perhaps more important, both the brain and gene research has given parents like Monnica Williams a way to fight back against the ignorance they encounter from the strangers in the supermarket who tell them they must be feeding their children too much sugar or, in Williams' case, the pastor who recommends regular spankings.

"I got lots and lots of advice from friends and family and well-meaning busybodies telling me that all they needed was more discipline, more structure, a change in diet. My kids have structure, discipline, and they're all eating natural organic food," says Williams, whose oldest son has ADHD and at the age of four, drew up an escape plan to get out of his daycare center. He made it to the front office before he was stopped. He recently graduated from Penn with a degree in physics. "ADHD is not just another word for bad parenting."

One of the clues that lead researchers to look at the dopamine genes as possible markers of ADHD is the effect of methylphenidate-the drug known as Ritalin, a central nervous system stimulant and one of the early drugs used to treat ADHD. "Ritalin blocks those transformers that remove dopamine from the brain," says Barkley. "That increases the amount of time that dopamine has to bind to neuron receptors."

And in 70% to 90% of children who take Ritalin or one of the other stimulant drugs prescribed for ADHD, there's an instant behavior change: They can focus, control their emotions, keep internal conversations from becoming constant babble, and sit still long enough to learn. The meds aren't perfect though. "Their attention is still shorter than average with medication," says Koplewicz. "They're closer to average but not better than average."

But the drugs work so well on symptoms that sales barely slowed in 2006 when the FDA-briefly-required them to carry a black box warning because of a small number (less than 50 over 10 years) of reported deaths, mostly related to heart damage. Another FDA panel withdrew the black box warning within a month.

So why does stimulant medication given to high-energy kids calm them down? That's what baffled physician Charles Bradley in 1937 when he gave benzedrine, the only stimulant available at the time, to neurologically impaired kids for the severe headaches they suffered as the result of neurological exams during which most of the cerebrospinal fluid around their brains was drained. Benzedrine-known in '60s drug parlance as "bennies"-did nothing for their headaches, but it did improve their behavior and school performance and in some even tamed their fidgeting and emotional outbursts.

Today we know that stimulants such as Ritalin, Adderall and Vyvanse, like other drugs, have the opposite effect on children than the one they have on adults. For adults, they're "speed"; in children with ADHD, they act more like a powerful new set of brakes for that racing Ferrari engine. (There's no conclusive evidence that amphetamine drugs do anything beneficial for kids who don't have ADHD.)

The proliferation of prescriptions has alarmed both conventional experts in ADHD who believe the drugs are godsends and their medical opposites who think they're unnecessary. Moving cautiously is important, they say, not just because the drugs can have serious side effects, but also because they don't cure ADHD. Diet, exercise, parenting techniques and therapy are extremely important as well.

Yet the majority of children with ADHD are getting only medication. "And we've known for 40 years that drugs [alone] don't change any of the bad outcomes for which ADHD kids are at risk," says the Center For Children and Family's Pelham. "It improves the DSM [Diagnostic and Statistic Manual] symptoms, but it doesn't improve impairment. Giving a child a pill doesn't change parenting or social skills. Achievement in school is just as bad as if they haven't had any treatment. The probability of graduating is exactly the same and it's not good." In other words, drugs don't work on outcomes without the other piece of the puzzle-behavioral training that involves good parenting skills. (Drug Guide: Choosing the Right Medication)

Parents turn to drugs alone for a number of reasons. First, most of the pills work almost immediately to reduce the worst symptoms and they're fairly easy to get. They're usually covered by insurance, which makes them cheaper and less labor-intensive than going to parenting classes to learn science-based techniques that can change a child's behavior or chauffeuring a kid to weekly therapy to learn appropriate social skills.

Parenting and behavior therapy is "a much longer term process, but it's what lays down new neuronal skills based on learning which is much different than taking a pill that lets in a flood of dopamine and changes the child's brain for a moment," says Pelham.

Experts such as Pelham, Koplewicz, Hallowell, and Barkley are all proponents of medication, but not necessarily as a first-line treatment.

Pelham was part of the large, federally-sponsored, multi-site Multimodal Treatment of ADHD (MTA) study in the '90s which found that medications alone and a combination of drug and behavioral treatment were both superior to both behavioral therapy alone and to management of children with ADHD by a regular, non-specialist pediatrician.

He laments that the takeaway from the MTA research has been that pills alone work. His own research found that just under 40% of children who start with parent and behavioral therapy often don't need medication, and those that still do, can get by with lower dosages.

Pelham and other experts hold that while bad parenting doesn't cause ADHD, good parenting can help mitigate it. Research has produced evidence that good parenting can even trump bad genes. For example, in a 2012 study, University of Oregon scientists looked at the effects of parenting styles on children ages 18-21 months and later with children 3-4 years old, with the dopamine-related 7 repeat allele gene, which occurs in about 25% of children with ADHD. They found that children whose parents scored highest in "parent effectiveness"-meaning how supportive they were and how well they interacted with their children-were less likely to have symptoms such as inattention and excessive risk-taking than children of parents who had lower scores.

Pelham's program-and there are other, similar ones, many community- and school-based-involves eight to 12 weeks of training, and most of it is for parents, not kids. Mothers and fathers learn to use positive reinforcement to encourage good behavior, age-appropriate punishments such as time-outs and loss of privileges to discourage bad behavior and a daily report card prepared by a child's teacher that emphasizes a child's successes on that day. They also learn how to give instructions to a child whose short-term (working) memory is impaired and who finds it tougher than normal to keep distractions at bay. Parents practice ways to minimize their responses to minor annoyances-like a 10-year-old who repeatedly puts her feet on the dining room table.

"Evidence of the past decade is that what improves parent-child interactions helps a child with ADHD do better," says Child Mind's Koplewicz, who uses similar techniques in his practice. "Parents who focus on the negatives reinforce negative behavior. How many times do you say, 'Are you deaf? Didn't you hear me tell you to clean up your room?' instead of 'thank you for cleaning up your room' when they do it? I have kids who come into my office and when you ask them if they're a good boy or a bad boy they say they're bad because that's their experience with the world. This does not help."

In a column published recently in the New York Times, Richard A. Friedman, director of the psychopharmacology clinic at Weill Cornell Medical College, drew on the Kenya study, to suggest that many children with the genetic version of ADHD might benefit from education plans tailored to their needs for hands-on, fast-paced experiences high in novelty that, while unlikely to reduce their need for medication, could turn their disability into an asset.

Kerri Meenagh was fortunate. She'd learned about ADHD when she was studying for her pediatric nursing degree. But she still needed to spend time with the local school psychologist and a parent group called CHADD (Children and Adults with Attention-Deficient/Hyperactivity Disorder) to remind her how important it was to never consider Saorla a willful and disobedient child. "We need to remember that the way her brain works is different," she says. "It's not that she won't control herself, it's that she can't. "

That, she said, changed some of the expectations she and her husband have for their daughter-and themselves.

"We're both Catholics, so one of our goals was to go to Mass every Sunday. While most kids can find something to occupy them for 45 minutes at Mass, Saorla has to go to the bathroom at least three times. So we go to Mass and Saorla has to go to the bathroom three times. It doesn't matter-every Sunday we meet our goal," she says. "You adjust your expectations. I know she's disorganized and forgetful and will spill her juice or milk every day. If I know that happens because she has a brain disorder, why would I get upset?"

The fact is, she takes delight in her daughter's exuberance and individualism. "She sometimes puts together some interesting outfits but she really doesn't care what other people think about her. I'm happy she's her own person."

And Saorla seems to gravitate towards activities that channel some of her risk taking and her copious energy, particularly performing. "When they told the third graders this year that they could try out for the school musical, she was one of only two third graders who tried out for the lead," says Meenagh, laughing. "Her sister was horrified at her audacity. She didn't get the lead, but she did get a speaking part. And she was a hit."

When it comes to Irish dancing or performing, Saorla is an audience magnet. Her energy and expression make her a delight to watch. "And she seems to know that this is a way she can have positive experiences with people," says Meenagh. "They really enjoy her. Performing makes her feel proud of herself and very confident. All that energy is more acceptable on stage and that's where she feels at home."

Nationally, the rates of ADHD diagnoses and medical treatment are on the rise, but the CDC's map reveals dramatic differences between states, with a prevalence of ADHD diagnosis and drug treatment in the south.

What's at work here? That's what Stephen Hinshaw, PhD, vice chair of psychology in the department of psychiatry at the University of California in Berkeley wanted to know when he teamed with Berkeley health economist Richard M. Scheffler PhD, to drill down into the statistics. Here's what they found:

* Policy Change They traced the bump in ADHD diagnosis and treatment to education policies implemented in the south and midwest in the 1990s and the whole country after No Child Left Behind was introduced in 2001. These policies punished schools, usually by cutting their funding, if they didn't raise their kids' test scores. That meant there was a payoff if states with increased ADHD diagnoses, says Hinshaw, particularly among the poor where they rose an astonishing 60% between 2003 and 2007, compared to only 10% among kids from middle and upper class families. For one thing, a diagnosis can lead to treatment that could help underachieving students do better in the classroom and, as a result, increase mean test scores.

* Funding But "the more nefarious explanation," says Hinshaw, is that school districts pick up a get out of jail free card by having more children diagnosed with ADHD. Thanks to a Supreme Court Ruling, kids with ADHD are considered special education students whose test scores are not taken into account when a district's performance is tallied. Having a lot of students diagnosed with ADHD allows the districts to simply drop the scores of their lowest achievers and not lose any funding. "This was what policy people call an unintended consequence," says Hinshaw. "I'm sure the authors of No Child Left Behind didn't plan for this to happen."

* Poverty Many of the districts with the highest rate of ADHD are also districts with a lot of folks living within 200% of the poverty line. Once ADHD was considered a "white middle class boy" diagnosis," says Hinshaw, but since the 1990s, it has been a reimbursable condition under Medicaid, the federal health insurance program for the poor. However, Medicaid covers ADHD assessments and medication, but not other therapies which may also explain why rates of drug treatment are also on the rise. "As a result of all these policies and laws, Medicaid kids are more likely to have an ADHD diagnosis than middle class kids for the first time in history," says Hinshaw. There may be other environmental factors that account for the statistical rise in ADHD, says Hinshaw, "but right now, this is as close to a smoking gun as we've got."

Parents often go through a period of trial and error as they and their doctor try to find the right medication for their child. Here are some of the pros and cons of the most popular ADHD drugs
Stimulants

How they work: Increase levels of the neurotransmitter dopamine in the brain, stimulating cognition, attention and focus

* Ritalin and Methlphenidate-based Drugs
Ritalin LA, Ritalin SR, Methylin, Metadate, Focalin, Concerta, Quillivant XR

Duration: Lasts from 3-4 hours (Ritalin) to 10 hours (Quivallent XR)

Pros: Effective in 755 of the people who take it. The drug can be safely used in preschoolers. Newer, longer-lasting, once-a-day medications are available, including Ritalin LA, Ritalin SR, Metadate CD and Metadate ER, Concerta, Daytrana (a patch); Focalin XR, (a capsule filled with pellets that can be opened and hidden in food), and Quivallent XR, (a liquid)

Cons: May be habit-forming; can cause slowed growth, loss of appetite and weight, irritability, and surge of ADHD symptoms (called rebound symptoms) as it wears off. Ritalin and generics must be taken 2 to 3 times a day. They can increase anxiety and tics and are not as effective in toddlers as they are in older children; greater risk of side effects for younger children. Very rare side effects include sudden death.

* Adderall (mixed amphetamine)
Adderall XR, Vyvanse

Duration: 4-5 hours (Adderall) to 10-12 hours (Adderall RX, Vyvanse)

Pros: Effective in individuals who need a stronger drug than Ritalin, particularly teens and adults. Adderall XR and Vyvanse wear off more slowly with fewer rebound symptoms. Vyvanse is a once-daily pill for children 6 years and older.

Cons: May be habit-forming; can cause slowed growth, loss of appetite and weight, irritability, and restlessness. Very rare side effects include sudden death.

*Dexedrine, Dextrostat, Dexedrine Spansul

Duration: 4-5 hours (Dexedrine, Dextrostat) to 5-10 hours (Dexedrine Spansul)

Pros: Approved for children under six, slightly longer-acting than Ritalin. Dexedrine Spansul can eliminate mid-day doses in young children.

Cons: May be habit-forming and has the same potential side effects as other stimulants (see above.)

Nonstimulants

How they work: Increases dopamine circulating in the blood by decreasing blood pressure. Intuniv and Tenex may be combined with a stimulant for children who are very hyperactive, aggressive, and emotionally explosive.

* Strattera
blood pressure drugs Intuniv (time-released guanfacine; Tenex), Clonidine, Catapres, Kapvay; and some antidepressants

Duration: Up to 24 hours

Pros: These nonhabit-forming drugs can be an alternative to stimulants, though they're usually used with them. They target specific symptoms like extreme hyperactivity and aggressiveness. Blood pressure drugs can also help children sleep and may treat anxiety, nervous habits and tics, and bedwetting.

Cons: Can be sedating. Clonidine drugs have cardiac effects that may make them inappropriate for children. Antidepressants can increase suicidal thoughts and actions in children and teens.

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With her long dark hair flying, Saorla Meenagh, 10, (pictured above) can execute a perfect switch leap, one leg out, one tucked under, her arms glued to her sides in classic Irish step-dancing style.

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School-Wide Strategies for Managing Defiance/Non-Compliance

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Students who are defiant or non-compliant can be among the most challenging to teach. They can frequently interrupt instruction, often do poorly academically, and may show little motivation to learn. There are no magic strategies for managing the behaviors of defiant students. However, research shows that certain techniques tend to work best with these children and youth: (1) Give the student positive teacher recognition. Even actions as simple as greeting the student daily at the classroom door or stopping by the student's desk to ask 'How are you doing?' can over time turn strained relationships into positive ones. (2) Monitor the classroom frequently and intervene proactively to redirect off-task students before their mild misbehaviors escalate into more serious problems. (3) Avoid saying or doing things that are likely to anger or set off a student. Speak calmly and respectfully, for example, rather than raising your voice or using sarcasm. (4) When you must intervene with a misbehaving student, convey the message to the student that you will not tolerate the problem behavior-but that you continue to value and accept the student. (5) Remember that the ultimate goal of any disciplinary measure is to teach the student more positive ways of behaving. Punishment generally does not improve student behaviors over the long term and can have significant and lasting negative effects on school performance and motivation. (6) Develop a classroom 'crisis response plan' to be implemented in the event that one or more students display aggressive behaviors that threaten their own safety or the safety of others. Be sure that your administrator approves this classroom crisis plan and that everyone who has a part in the plan knows his or her role. One final thought: While you can never predict what behaviors your students might bring into your classroom, you will usually achieve the best outcomes by remaining calm, following pre-planned intervention strategies for misbehavior, and acting with consistency and fairness when intervening with or disciplining students. Here are other ideas for managing defiant or non-compliant students:

Allow the Student a 'Cool-Down' Break (Long, Morse, & Newman, 1980). Select a corner of the room (or area outside the classroom with adult supervision) where the target student can take a brief 'respite break' whenever he or she feels angry or upset. Be sure to make cool-down breaks available to all students in the classroom, to avoid singling out only those children with anger-control issues. Whenever a student becomes upset and defiant, offer to talk the situation over with that student once he or she has calmed down and then direct the student to the cool-down corner. (E.g., "Thomas, I want to talk with you about what is upsetting you, but first you need to calm down. Take five minutes in the cool-down corner and then come over to my desk so we can talk.")

Ask Open-Ended Questions (Lanceley, 1999). If a teacher who is faced with a confrontational student does not know what triggered that student's defiant response, the instructor can ask neutral, open-ended questions to collect more information before responding. You can pose 'who', 'what', 'where', 'when', and 'how' questions to more fully understand the problem situation and identify possible solutions. Some sample questions are "What do you think made you angry when you were talking with Billy?" and "Where were you when you realized that you had misplaced your science book?" One caution: Avoid asking 'why"'questions (e.g., "Why did you get into that fight with Jerry?") because they can imply that you are blaming the student.

Assign a Reflective 'Processing' Essay After Misbehavior (Boynton & Boynton, 2005; Mayer & Ybarra, 2004; Walker, Colvin, & Ramsey, 1995). The student who gets into a conflict must write and submit to the teacher a brief 'process' plan outlining how they will improve their behavior. At minimum, the plan would state: (1) the role the student played in the conflict, (2) the part that other participants may have taken in the incident, (3) the student's suggestions for finding the best resolution to the problem, and (4) how the student can act in the future to prevent the conflict from recurring. NOTE: Some teachers use a pre-printed structured questionnaire containing these 4 items for the student to complete.

Do Not Get Entangled in Arguments (Walker & Walker, 1991). The careful teacher avoids being dragged into arguments or unnecessary discussion when disciplining students. When you must deliver a command to, confront, or discipline a student who is defiant or confrontational, be careful not to get 'hooked' into a discussion or argument with that student. If you find yourself being drawn into an exchange with the student (e.g., raising your voice, reprimanding the student), immediately use strategies to disengage yourself (e.g., by moving away from the student, repeating your request in a business-like tone of voice, imposing a pre-determined consequence for noncompliance).

Emphasize the Positive in Teacher Requests (Braithwaite, 2001). When an instructor's request has a positive 'spin', that teacher is less likely to trigger a power struggle and more likely to gain student compliance. Whenever possible, avoid using negative phrasing (e.g., "If you don't return to your seat, I can't help you with your assignment"). Instead, restate requests in positive terms (e.g., "I will be over to help you on the assignment just as soon as you return to your seat").

Expand the Range of Classroom Behavior Interventions (Sprick, Borgmeier, & Nolet, 2002). The teacher who has developed an array of in-class consequences for minor misbehaviors can prevent students from being sent to the principal's office or to in-school detention. First, list those common misbehaviors that you believe should typically be handled in the classroom (e.g. being late to class, talking out). When finished, categorize your list of misbehaviors into 3 groups: 'Level 1' (mild) misbehaviors, 'Level 2' (medium) misbehaviors, and 'Level 3' (more serious) misbehaviors. Then, list next to each level of problem behaviors a range of in-class consequences that you feel appropriately match those types of misbehavior. For example, you may decide that a 'soft' reprimand would be a choice to address Level 1 misbehaviors, while a phone call to the parent would be a choice for Level 3 misbehaviors. NOTE: In-class consequences are intended for minor misbehaviors. You should notify an administrator whenever students display behaviors that seriously disrupt learning or pose a risk to the safety of that student or to others.

Give Praise That is Specific and Does Not Embarrass the Student (Sprick, Borgmeier, & Nolet, 2002). Defiant students can respond well to adult praise but only when it is sincere and specific, and is not embarrassing. Ideally, the teacher should deliver praise as soon as possible after the positive behavior. Praise should be specific and descriptive-because vague, general praise can sound fake and does not give the student any useful information about how their behavior meets or exceeds the teacher's expectations. For older students who tend to dislike being praised in a highly public manner, the teacher can use a more indirect or low-key approach (e.g., writing a note of praise on the student's graded assignment, praising the student in a private conversation, calling the student's parent to praise the student).

Give Problem Students Frequent Positive Attention (Sprick, Borgmeier, & Nolet, 2002). Teachers should make an effort to give positive attention or praise to problem students at least three times more frequently than they reprimand them. The teacher gives the student the attention or praise during moments when that student is acting appropriately--and keeps track of how frequently they give positive attention and reprimands to the student. This heavy dosing of positive attention and praise can greatly improve the teacher's relationship with problem students.

Have the Student Participate in Creating a Behavior Plan (Walker, Colvin, & Ramsey, 1995). Students can feel a greater sense of ownership when they are invited to contribute to their behavior management plan. Students also tend to know better than anyone else what triggers will set off their problem behaviors and what strategies they find most effective in calming themselves and avoiding conflicts or other behavioral problems.

Increase 'Reinforcement' Quality of the Classroom (Dunlap & Kern, 1996; Mayer & Ybarra, 2004). If a student appears to be defiant or non-compliant in an effort to escape the classroom, the logical solution is to make the classroom environment and activities more attractive and reinforcing for that student. Unfortunately, the student who fails repeatedly at academics can quickly come to view school as punishment. Some ideas to increase motivation to remain in the classroom are to structure lessons or assignments around topics of high interest to the target student, to increase opportunities for cooperative learning (which many students find reinforcing), and to adjust the target student's instruction so that he or she experiences a high rate of success on classwork and homework.

Keep Responses Calm, Brief, and Businesslike (Mayer, 2000; Sprick, Borgmeier, & Nolet, 2002). Because teacher sarcasm or lengthy negative reprimands can trigger defiant student behavior, instructors should respond to the student in a 'neutral', business-like, calm voice. Also, keep responses brief when addressing the non-compliant student. Short teacher responses give the defiant student less control over the interaction and can also prevent instructors from inadvertently 'rewarding' misbehaving students with lots of negative adult attention.

Listen Actively (Lanceley, 1999; Long, Morse, & Newman, 1980). The teacher demonstrates a sincere desire to understand a student's concerns when he or she actively listens to and then summarizes those concerns. Many students lack effective negotiation skills in dealing with adults. As a result, these students may become angry and defensive when they try to express a complaint to the teacher-even when that complaint is well founded. The instructor can show that he or she wants to understand the student's concern by summing up the crucial points of that concern (paraphrasing) in his or her own words. Examples of paraphrase comments include 'Let me be sure that I understand you correctly...', 'Are you telling me that...?', 'It sounds to me like these are your concerns:...' When teachers engage in 'active listening' by using paraphrasing, they demonstrate a respect for the student's point of view and can also improve their own understanding of the student's problem.

Offer the Student a Face-Saving Out (Thompson & Jenkins, 1993). Students sometimes blunder into potential confrontations with their teachers; when this happens, the teacher helps the student to avoid a full-blown conflict in a manner that allows the student to save face. Try this face-saving de-escalation tactic: Ask the defiant student, "Is there anything that we can work out together so that you can stay in the classroom and be successful?" Such a statement treats the student with dignity, models negotiation as a positive means for resolving conflict, and demonstrates that the instructor wants to keep the student in the classroom. It also provides the student with a final chance to resolve the conflict with the teacher and avoid other, more serious disciplinary consequences. Be prepared for the possibility that the student will initially give a sarcastic or unrealistic response (e.g., "Yeah, you can leave me alone and stop trying to get me to do classwork!"). Ignore such attempts to hook you into a power struggle and simply ask again whether there is any reasonable way to engage the student's cooperation. When asked a second time, students will often come up with workable ideas for resolving the problem. If the student continues to be non-compliant, however, simply impose the appropriate consequences for that misbehavior.

Proactively Interrupt the Student's Anger Early in the Escalation Cycle (Long, Morse, & Newman, 1980; Walker, Colvin, & Ramsey, 1995). The teacher may be able to 'interrupt' a student's escalating behaviors by redirecting that student's attention or temporarily removing the student from the setting. If the student is showing only low-level defiant or non-compliant behavior, you might try engaging the student in a high-interest activity such as playing play an educational computer game or acting as a classroom helper. Or you may want to briefly remove the student from the room ('antiseptic bounce') to prevent the student's behavior from escalating into a full-fledged confrontation. For example, you might send the student to the main office on an errand, with the expectation that-by the time the child returns to the classroom-he or she will have calmed down.

Project Calmness When Approaching an Escalating Student (Long, Morse, & Newman, 1980; Mayer, 2000; Walker, Colvin, & Ramsey, 1995). A teacher's chances of defusing a potential confrontation with an angry or defiant student increase greatly if the instructor carefully controls his or her behavior when first approaching the student. Here are important tips: Move toward the student at a slow, deliberate pace, and respect the student's private space by maintaining a reasonable distance. If possible, speak privately to the student, using a calm and respectful voice. Avoid body language that might provoke the student, such as staring, hands on hips, or finger pointing. Keep your comments brief. If the student's negative behaviors escalate despite your best efforts, move away from the student and seek additional adult assistance or initiate a crisis-response plan.

Relax Before Responding (Braithwaite, 2001). Educators can maintain self-control during a tense classroom situation by using a brief, simple stress-reduction technique before responding to a student's provocative remark or behavior. When provoked, for example, take a deeper-than-normal breath and release it slowly, or mentally count to 10. As an added benefit, this strategy of conscious relaxation allows the educator an additional moment to think through an appropriate response--rather than simply reacting to the student's behavior.

Reward Alternative (Positive) Behaviors (Mayer & Ybarra, 2004; Walker, Colvin, & Ramsey, 1995). The instructor can shape positive behaviors by selectively calling on the student or providing other positive attention or incentives only when the student is showing appropriate social and academic behaviors. The teacher withholds positive attention or incentives when the student misbehaves or does not engage in academics.

State Teacher Directives as Two-Part Choice Statements (Walker, 1997). When a student's confrontational behavior seems driven by a need for control, the teacher can structure verbal requests to both acknowledge the student's freedom to choose whether to comply and present the logical consequences for non-compliance (e.g., poor grades, office disciplinary referral, etc.). Frame requests to uncooperative students as a two-part statement. First, present the negative, or non-compliant, choice and its consequences (e.g., if a seatwork assignment is not completed in class, the student must stay after school). Then state the positive behavioral choice that you would like the student to select (e.g., the student can complete the seatwork assignment within the allotted work time and not stay after school). Here is a sample 2-part choice statement, 'John, you can stay after school to finish the class assignment or you can finish the assignment now and not have to stay after class. It is your choice.'

Use a 'Buddy Teacher' for Brief Student Breaks (Boynton & Boynton, 2005). Sending a mildly non-compliant student on a short visit to a neighboring classroom can give both the teacher and student a needed break. Arrange with an instructor in a nearby room for either of you to send a student to the other's room whenever you need a short respite from the student. Set aside a seating area in each classroom for student visitors. NOTE: These timeouts should be used only sparingly and should NOT be used if the student appears to find the breaks rewarding or to seek them as a way to avoid work.

Use Non-Verbal and Para-Verbal Behaviors to Defuse Potential Confrontations (Braithwaite, 2001; Long, Morse, & Newman, 1980; Walker, Colvin, & Ramsey, 1995). When interacting with defiant or confrontational students, teachers can use non-verbal and para-verbal techniques such as non-threatening body language, soft tone of voice, or strategic pauses during speech, to reduce tensions. For example, if a student is visibly agitated, you may decide to sit down next to the student at eye level (a less threatening posture) rather than standing over that student. Or you might insert a very brief 'wait time' before each response to the student, as these micro-pauses tend to signal calmness, slow a conversation down and help to prevent it from escalating into an argument.

Use 'Soft' Reprimands (Sprick, Borgmeier, & Nolet, 2002). The teacher gives a brief, gentle signal to direct back to task any students who is just beginning to show signs of misbehavior or non-compliance. These 'soft' reprimands can be verbal (a quiet word to the student) or non-verbal (a significant look). If a soft reprimand is not sufficient to curb the student's behaviors, the teacher may pull the student aside for a private problem-solving conversation or implement appropriate disciplinary consequences.

Validate the Student's Emotion by Acknowledging It (Lanceley, 1999). When the teacher observes that a student seems angry or upset, the instructor labels the emotion that seems to be driving that student's behavior. 'Emotion labeling' can be a helpful tactic in deescalating classroom confrontations because it prompts the student to acknowledge his or her current feeling-state directly rather than continuing to communicate it indirectly through acting-out behavior. A teacher, for example, who observes a student slamming her books down on her desk and muttering to herself after returning from gym class might say to the student, "You seem angry. Could you tell me what is wrong?" Once a powerful emotion such as anger is labeled, the teacher and student can then talk about it, figure out what may have triggered it, and jointly find solutions that will mitigate it. Emotion labeling should generally be done in a tentative manner ("John, you sound nervous...", "Alice, you appear frustrated..."), since one can never know with complete certainty what feelings another person is experiencing.

References

Boynton, M. & Boynton, C. (2005). The educator's guide to preventing and solving discipline problems. Alexandria, VA: Association for Supervision and Curriculum Development.

Braithwaite, R. (2001). Managing aggression. New York: Routledge.

Dunlap, G., & Kern, L. (1996). Modifying instructional activities to promote desirable behavior: A conceptual and practical framework. School Psychology Quarterly, 11, 297-312.

Lanceley, F.J. (1999). On-scene guide for crisis negotiators. Boca Raton, FL: CRC Press.

Long, N.J., Morse, W.C., Newman, R.G. (1980). Conflict in the classroom. Belmont, CA: Wadsworth Publishing Company.

Mayer, G.R. & Ybarra, W. J. (2004). Teaching alternative behaviors schoolwide: A resource guide to prevent discipline problems. Los Angeles, CA: Los Angeles County Office of Education. Retrieved March 19, 2006, from http://www.lacoe.edu/includes/templates/document_frame.cfm?toURL=/DocsFo...

Mayer, G.R. (2000). Classroom management: A California resource guide. Los Angeles, CA: Los Angeles County Office of Education. Retrieved September 16, 2010, from http://wwwstatic.kern.org/gems/schcom/ClassroomManagement.pdf

Sprick, R. S., Borgmeier, C., & Nolet, V. (2002). Prevention and management of behavior problems in secondary schools. In M. A. Shinn, H. M. Walker & G. Stoner (Eds.), Interventions for academic and behavior problems II: Preventive and remedial approaches (pp.373-401). Bethesda, MD: National Association of School Psychologists.

Thompson, G.J., & Jenkins, J.B. (1993). Verbal judo: The gentle art of persuasion. New York: William Morrow.

Walker, H. M., Colvin, G., Ramsey, E. (1995). Antisocial behavior in school: Strategies and best practices. Pacific Grove, CA: Brooks/Cole Publishing.

Walker, H.M. (1997). The acting-out child: Coping with classroom disruption. Longmont, CO: SoprisWest. Walker, H.M., & Walker, J.E. (1991). Coping with noncompliance in the classroom: A positive approach for teachers. Austin, TX: Pro-Ed, Inc.

Jim's Hints

Least Restrictive Behavioral Interventions. The Utah State Office of Education has put online its series of 'Least Restrictive Behavioral Interventions'. The page contains a very useful collection of 'preliminary strategies' that represent good classroom management and can reduce the likelihood that misbehavior will occur. If students do misbehave, the site also provides two collections of intervention ideas: 'Positive Intervention Strategies' and 'Mildly Intrusive Contingent Procedures'. The expectation is that educators will first try positive interventions and only use the more intrusive techniques if misbehaviors are chronic or more serious.

Oppositional Defiant Disorder Fact Sheet. This 'Fact Sheet' on Oppositional Defiant Disorder (ODD) provides a clinical description of the disorder and links to fact sheets on related topics, such as 'Conduct disorder' and 'Children's threats: When are they serious?' These fact sheets were created by the American Academy of Child and Adolescent Psychiatry.

Safe & Responsve Schools. The Safe & Responsive Schools Project seeks to make schools safer through a framework of (1) creating a positive climate, (2) early identification and intervention for students at risk for problem behaviors, and (3) the development of effective responses to address serious misbehavior. Along with other violence-prevention planning resources, Safe & Responsive Schools offers a series of useful 'Fact Sheets' that offer guidance to schools on improving the behavioral climate through anger management, increased parent involvement, and other strategies. Dr.Russell J. Skiba, Indiana University and Dr. Reece L. Peterson, University of Nebraska-Lincoln developed the site.

Working With Defiant Kids: Articles Online. This on-line collection of research-based articles and general education articles on defiant and non-compliant students contains practical teacher-friendly advice for managing classroom misbehaviors. The site is sponsored by Heartland Area Educational Agency 11.

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School-Wide Strategies for Managing... DEFIANCE / NON-COMPLIANCE

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Students who are defiant or non-compliant can be among the most challenging to teach. They can frequently interrupt instruction, often do poorly academically, and may show little motivation to learn. There are no magic strategies for managing the behaviors of defiant students.

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Strategies to Work with Students with Oppositional Defiant Disorder

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TEDx Talk Conduct Disorder

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The challenge of early conduct disorder: Derek Patton at TEDxLaunceston

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Derek Patton explores the role of positive language - specifically, the language of virtues - in engaging with young people with conduct disorders. Derek is a child and family psychologist finishing his PhD on the topic of teacher dialogue that develops children's thinking abilities at the University of Melbourne's Graduate School of Education.

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TEDx Talk ADHD

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Cultivating Compassion for the ADHD Child | Dr. Francine Conway | TEDxAdelphiUniversity

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National Institute of Mental Health (NIMH)

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Learn about obsessive-compulsive disorder, including signs and symptoms, risk factors, treatments and therapies, and links to other resources to learn more.

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Obsessive-compulsive disorder is an intrusive condition that remains difficult to treat. This is due, in part, to the causes behind the disorder remaining hidden. Recent research, however, points the finger at brain inflammation.

Obsessive-compulsive disorder (OCD) is characterized by uncontrollable obsessions and compulsions. Individuals with OCD may experience intrusive thoughts that produce anxiety or a need to repeat certain actions to relieve pent-up anxiety.

Common obsessions in OCD revolve around cleanliness, sexual taboos, aggressive thoughts, and symmetry.

Affecting an estimated 1 percent of people in the United States, around half of OCD cases are classed as severe.

OCD is generally treated with talking therapies - in particular, a type of cognitive behavior therapy called exposure and response prevention is recommended. There are also some medications available, with selective serotonin reuptake inhibitors being the most commonly prescribed. Currently, however, therapies only work for around 70 percent of OCD-affected individuals.

One of the biggest stumbling blocks to finding good treatments is that the physical causes of OCD are not known.

Inflammation and OCD

Breaking research published this week in JAMA Psychiatry takes a look at the role of brain inflammation in OCD. The senior author of the study is Dr. Jeffrey Meyer, head of the Neuroimaging Program in Mood & Anxiety at the Centre for Addiction and Mental Health in Toronto, Canada.

Inflammation is a natural process; it is a normal component of the immune response and a standard reaction to injury. However, if the level of inflammation is inappropriate or continues for too long, it can have negative consequences. For instance, in a number of diseases including rheumatoid arthritis and atherosclerosis, inflammation is heavily involved.
Growing evidence suggests that certain psychiatric conditions may involve neuroinflammation, some of which include major depressive disorder, schizophrenia, and bipolar.
Dr. Meyer and his team set out to understand whether inflammation in the brain could play a role in the development of OCD. To this end, they recruited 40 participants, comprising 20 with OCD and 20 without. Each was scanned using positron emission tomography that had been adapted to pinpoint and measure inflammation in the brain.

Specifically, the researchers were able to selectively dye microglia, which are cells that act as the nervous system's most prominent immune defense and which are activated during inflammation. The researchers measured levels of microglia in six brain regions known to be important in OCD, including the orbitofrontal cortex and anterior cingulate cortex.

The results were clear: in the brain regions associated with OCD, individuals with the disorder had 32 percent more inflammation when compared with people without the condition.

"This finding represents one of the biggest breakthroughs in understanding the biology of OCD, and may lead to the development of new treatments."

Dr. Jeffrey Meyer

From inflammation to treatment

Another interesting finding was that individuals who reported the highest levels of stress when trying to stop themselves from acting on compulsions also had the highest levels of inflammation in a particular brain region.

As so many diseases involve inflammation, there are already a range of drugs designed to tackle it. Because these drugs already exist on the market, it may be a fruitful avenue of research in the hunt for more effective treatments for OCD.

"Medications developed to target brain inflammation in other disorders could be useful in treating OCD," Dr. Meyer says. "Work needs to be done to uncover the specific factors that contribute to brain inflammation, but finding a way to reduce inflammation's harmful effects and increase its helpful effects could enable us to develop a new treatment much more quickly."

Studies are now under way that examine the possibility of designing a blood marker test that could distinguish which patients would benefit most from anti-inflammatory drugs.

Although, as ever, more research is needed, this finding could mark a significant move forward in understanding and treating OCD.

Learn how certain gene mutations can cause OCD-like behaviors.

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Obsessive-compulsive disorder is an intrusive condition that remains difficult to treat. This is due, in part, to the causes behind the disorder remaining hidden. Recent research, however, points the finger at brain inflammation. Obsessive-compulsive disorder (OCD) is characterized by uncontrollable obsessions and compulsions.

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OCD Misconceptions

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Dr. Elizabeth McIngvale, assistant professor in the Menninger Department of Psychiatry and Behavioral Sciences

While most people have heard of obsessive compulsive disorder (OCD), there are many misconceptions about what it truly means to have it. A Baylor College of Medicine expert discusses these common misconceptions and gives her advice on the best treatment options for OCD.

" OCD is characterized by having compulsions and obsessions that are caused by unwanted, intrusive thoughts. Individuals don't want these thoughts, and it causes anxiety and they engage in repetitive rituals, which don't bring them any joy or pleasure. It's something that they do because they feel like they have to in order to get rid of that thought," said Dr. Elizabeth McIngvale, assistant professor in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor.

She explained that one of the misconceptions about OCD is that there is just one, general type but in reality, there are many different categories of the disorder. Some of the main categories are:

Contamination OCD: This often includes the fear of germs, the fear of blood-borne illnesses and the fear of household or environmental contaminants.

Scrupulosity OCD: This is a form of OCD where individuals find themselves engaging in repetitive rituals around prayer, morals or beliefs. They get stuck in these types of behaviors and do them with a moral or religious base.

Checking OCD: Individuals with this type of OCD may repetitively check their locks or their household appliances and engage in a lot of checking rituals to prevent something bad from happening.

Symptomatic OCD: This can be very similar to hypochondriasis where individuals have intrusive thoughts that they have contracted an illness of some type and get sucked into engaging in compulsions around fears of having a disease.

Perfectionism OCD: This form of OCD can involve rereading or rewriting documents for hours, checking to make sure that everything is done right even though the individual knows it is done correctly.

Sexual intrusive thoughts: These are unwanted, intrusive thoughts around sexual behaviors that individuals often find grotesque, appalling or repulsive, and they engage in different rituals to get rid of the thought.

Harming intrusive thoughts: Individuals fear that they might violently harm somebody or act out even though there is no history and/or intent to do so. A compulsion for individuals with this type of OCD is often to get rid of all the sharp objects in their house or remove all of the items that could be used as weapons.

Another big misconception about OCD is that it is a personality disorder, said McIngvale. There is a personality disorder called obsessive compulsive personality disorder (OCPD) but it is much different than OCD, she said.

"Obsessive compulsive personality disorder, in my opinion, is often what society thinks OCD is. People with OCPD might organize their closet perfectly, have all of their items color-coded and organized by type or category, or if you open their fridge all of their labels are lined up perfectly and everything has a place. However, individuals with OCPD often talk about the fact that there's not an unwanted, intrusive thought and there's no fear attached to these behaviors. They just organize things a certain way or do these kind of compulsive behaviors because it makes them feel better," McIngvale said. "However, with OCD, it is something that individuals don't enjoy - there's nothing they like about it, they are doing it because they feel like they have to in order to get rid of the intrusive thought or fear. It is debilitating and draining and not something that makes the individual feel better and more productive when they are done."

McIngvale also emphasized that it is incorrect to use OCD as an adjective. She gave the example of the improper use of the term as when someone says, "My co-worker is so OCD."

For individuals who think that they have OCD, McIngvale recommends finding a behavioral therapist who specializes in exposure with response prevention therapy, which is a specific form of cognitive behavioral therapy that is offered for OCD. It is the most researched, effective and well-known treatment for OCD. She added that the individual also meet with a psychiatrist who specializes in OCD for medication options for OCD.

"Unfortunately, OCD is one of the disorders that takes, on average, about 25 years for people to get a diagnosis and proper treatment, but I really want to make sure that everybody with OCD knows that there is hope and there is help available," McIngvale said.

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Expert discusses common OCD misconceptions

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While most people have heard of obsessive compulsive disorder (OCD), there are many misconceptions about what it truly means to have it. A Baylor College of Medicine expert discusses these common misconceptions and gives her advice on the best treatment options for OCD.

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What is OCD? | International OCD Foundation

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Obsessive compulsive disorder (OCD) is a mental health disorder that affects people of all ages and walks of life, and occurs when a person gets caught in a cycle of obsessions and compulsions. Obsessions are unwanted, intrusive thoughts, images, or urges that trigger intensely distressing feelings.…

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Dr. Jeffrey Schwartz got a phone call at 3 p.m., a script before 5 p.m. and the next afternoon he was there, sitting with Leonardo DiCaprio, exploring the intricacies of one of the most debilitating mental illnesses in medicine.

DiCaprio was tackling the role of Howard Hughes in The Aviator, a part requiring him to arc - as Hughes did - from genius billionaire to shaggy recluse, caught in the grip of obsessive-compulsive disorder. Schwartz's books, Brain Lock and The Mind and the Brain, had established him as one of the world's foremost authorities on the underlying mechanisms and treatment of obsessive-compulsive disorder, a condition that plagues sufferers with unreasonable thoughts and fears, which in turn compel repetitive behavior.

He would not teach DiCaprio the mannerisms of people with OCD, Schwartz announced on day one. Instead, he would show him "how to become a person with OCD," so his brain was "like the brain of a person who has the disease."

The message was ominous, but DiCaprio proved game to try. He quickly pointed Schwartz to a particular segment of the script. "Right here, for three pages, I only have one line," he said. Show me the blueprints, repeated 46 times, with minor variations.

Schwartz explained that people afflicted with OCD engage in a wide variety of problematic behaviors - compulsive hand washing, door opening, repetitive checking of ovens and doors, even repeating the same word, phrase or sentence. The cause, at a neurological level, is hyperconnectivity between two brain regions, the orbitofrontal cortex and the caudate nucleus, creating a tidal wave of unfounded mortal fear and triggering habitual response as the only way to attain calm. But the worst part is that, despite recognition that all these thoughts and behaviors are irrational, the OCD sufferer feels driven to obey them, nonetheless.

Schwartz walked DiCaprio through the underlying neurology to help him understand that, for Hughes, those four words - show me the blueprints - held a magical power, offering him an escape from his fear. "Those words, he's repeating them like his life depends on them," Schwartz advised. "But he also understands that this doesn't make any sense."

In the 2004 film that eventually emerged, this scene is perhaps the most painful to watch. DiCaprio, as Hughes, twists the sentence in new directions with each rephrasing, emphasizing different words and employing different cadences. Sometimes he races through the sentence almost under his breath. Other times, he slows down, seeking the right combination of sounds, the right rhythm, to free himself from the fear roiling in his gut. All the while, his face betrays a tortured self-revulsion.

DiCaprio left The Aviator with an Oscar-nominated performance and perhaps a mild case of the disease. It reportedly took him about a year to get back to normal. And today, his willful descent into the illness and subsequent recovery represents one of the most dramatic public examples in our popular culture of neuroplasticity - the ability of the brain to change in shape, function, configuration or size.

But Schwartz says mainstream science has yet to come to grips with an experience like DiCaprio's, based on what Schwartz calls "self-directed neuroplasticity," the ability to rewire your brain with your thoughts. This kind of power doesn't only rescue his patients, he says. It rescues free will.

The notion that we have free will flies in the face of much modern neuroscientific research, which suggests an ever-increasing number of our "choices" are somehow hardwired into us - from which candidate we vote for to which flavor of ice cream tops our cone. In fact, neuroscientists like David Eagleman and Sam Harris have released best-selling books offering that we are, at bottom, high-functioning, delusional robots.

And so, at a time when free will is on the run, few of our culture's most prominent thinkers agree with Jeffrey Schwartz - a scientist, as it happens, who is entirely comfortable with being disagreeable.

OCD Family

On a warm, fall evening, Schwartz leads me to the campus at the University of California in Los Angeles to witness an OCD group therapy session. Short and squarely built with tight, curly hair and the stooped shoulders of an aged wrestler, Schwartz ambles through the parking lot until he spots one of his patients and calls out to him, warmly, by name.

"How you doing?" he says.

The man, smoking a cigarette and leaning against a brick wall just outside the entrance to Schwartz's building, waves and indicates with a hand gesture, pointing inside, that he'll talk in the group session. Schwartz nods, turning to me as we pass him. "Uh-oh," he says. "Maybe things aren't going so well for him."

Schwartz takes the last couple of strides ahead of me and opens the door to the Semel Institute for Neuroscience and Human Behavior, a three-story glass and brick collection of classrooms and labs. "Well," he says, cocking an eyebrow at me. "Here we go. These are my people."

Walking into a room filled with Schwartz's patients is like walking in on a band of revolutionaries. They have that easy air of familiarity and quiet sense of accomplishment. They greet Schwartz, their leader, warmly. People speak of regaining time previously lost to their compulsions. One man, an actor, says he feels confident enough to audition for parts again.

Paula Scott, the senior client among them, captures just how dramatic their trip has been. "When I first met Jeffrey," Paula says, "I was thinking about killing myself. Now, I am not even struggling with my OCD." Paula's illness is still present, but the condition no longer torments her, no longer controls her. OCD is just something she handles as she goes about her day.

All is Suffering

The insights underlying Schwartz's groundbreaking techniques can be traced back to his youth. The Holocaust had ravaged his bloodline, a heavy legacy about which an elder relative educated him. "I remember he told me that it was my job to live for these people who had died," says Schwartz, "and he didn't mean that as some sort of metaphor, or to inspire me. He meant it literally."

While other kids his age played, he spent long hours in the library, reading through Holocaust trial transcripts. On page after page, he read testimony about people who performed horrifying acts for the sake of power, money or simply to get along in a country suddenly steeped in the wicked. He emerged, he says, with an image "of humanity as being fallen and in need of some kind of help."

His college years, spent at the University of Rochester, yielded another influence: the focusing power of mindfulness, a Buddhist practice in which adherents learn to view their own thoughts and impulses with complete impartiality. Aided by mindfulness, Schwartz did so well in school he was accepted as an honors scholar in philosophy in Edinburgh, Scotland.

When he embarked on his career in medicine, he knew he wanted, somehow, to combine all these elements: He wanted to demonstrate that the Buddhist practice of mindfulness could help us choose something other than holocausts and heal our fallen humankind.

Schwartz got the chance in 1983, when he agreed to work with UCLA neuropsychiatrist Lewis Baxter to tease out the mechanism of OCD. The Baxter team would be using the then-new positron emission tomography (PET) scanner, a hulking imaging machine Schwartz remembers "looking like something out of 2001: A Space Odyssey. "

To conduct a PET scan, technicians injected patients with a biologically active tracer particle made partly of positrons (positively charged electrons) and attached to some other molecule with a role in metabolism, like water or glucose. By tracking the positrons emitted as the tracer breaks down, the machine can capture images of biological processes. In this case, Schwartz and Baxter aimed to follow blood flow in the brain.

While the team worked, Schwartz scoured the literature for insight and found a largely overlooked study by neuroscientist Edmund Rolls. Rolls used monkeys to investigate the orbitofrontal cortex (OFC), an area of the brain associated with decision-making. The brains of the monkeys were imaged as they grew comfortable licking a bar in order to obtain a sweet liquid. Then they were imaged licking the same bar after the liquid was replaced with a salty brine.

Rolls found activity in the OFC spiked when the monkeys were surprised by the new liquid. It was an ingenious study, Schwartz thought. Rolls had revealed the OFC to act as an error detection circuit. It made sense then to look at the OFC in relation to OCD, which fills patients with mortal fear that something is wrong.

Around the same time, Schwartz suggested the team investigate the caudate nucleus, a tail-shaped structure near the OFC that serves as the habit center of the brain. The caudate nucleus, he thought, might act as a kind of nexus for OCD - a traffic hub where rational thinking in the cerebral cortex meets the more primitive, emotion-ruled centers of the brain's limbic system. It would be a natural ground zero for the noxious brew of repetition and terror to collide.

The research took many months. But one day Baxter took Schwartz aside to say, "We've got it."

The data were clear. OCD subjects, as opposed to healthy controls, demonstrated significant hyperactivity in the OFC and caudate - even at rest. The images turned up in PET scans as bursts of color, rendering these brain regions as small fires, perpetually burning and, clearly, altering the functioning of the brain even when no episode was underway.

Free Will Therapy

Now that the neural circuitry of OCD was identified, researchers could test therapies. Using imaging technologies like PET, they could see if a given treatment tempered the fire in the brain.

For Schwartz, this was the chance to invoke his interest in mindfulness. He imagined a woman caught in the grips of ceaselessly washing her hands, yet aware her hands weren't dirty. Able to reflect on the bizarreness of her thoughts and her behavior, she continues to wash only because it seems like the only way to ease her fear that she is contaminated.

In this sense, OCD reflects a key aspect of mindfulness meditation - granting the patient a detached perspective from his or her own thoughts. Schwartz speculated that this awareness could enable a mindfulness-based treatment strategy. After all, if the point of mindfulness is to stand back dispassionately from all our ideas and impulses, couldn't an OCD patient use mindfulness to step back even from mortal fears and compulsions? Perhaps mindfulness could help rewire the OCD circuit in the brain.

Schwartz met one of his earliest patients, Paula Scott, in 1987, when she was deep in the throes of a case of OCD so surreal and severe she regularly contemplated suicide. Paula's illness manifested as the irrational fear that her boyfriend was an alcoholic and drug addict.

Schwartz thought Paula's case was particularly compelling because the repetitive behavior she chose to alleviate her fear demonstrated just how aware she really was. She knew, for instance, that if she constantly peppered her boyfriend with questions about drug and alcohol use, he'd realize something was off. "I had to find a way to conceal my feelings from him," she says, "while still giving in to the compulsion."

Her solution: question him rigorously without tipping him off to her particular fear. She asked him multiple questions about his day, essentially asking him to walk her through what he ate for breakfast, when he got to work, what he did that morning, and with whom he ate lunch, seeing if he might slip and say something that hinted at drug addiction.

Others joined Paula in Schwartz's therapy group. They spoke of rubbing their hands raw to avoid contaminating themselves and, by extension, their loved ones. They talked of being late for work because they spent so much time checking the oven and the door locks. And each week, Schwartz urged his patients to experience their OCD symptoms the way a mindfulness practitioner, in meditation, strives to experience every thought - dispassionately, without succumbing to emotion.

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Dr. Jeffrey Schwartz got a phone call at 3 p.m., a script before 5 p.m. and the next afternoon he was there, sitting with Leonardo DiCaprio, exploring the intricacies of one of the most debilitating mental illnesses in medicine.

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Supporting Students with OCD

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OCD is like an unwelcome guest with bad manners. It moves into a mind - and it doesn't want to leave.
Students with OCD may appear to be daydreaming, distracted, disinterested, or even lazy. They may seem unfocused and unable to concentrate. But they are really very busy focusing on their nagging urges or confusing, stressful, and sometimes terrifying OCD thoughts and images. They may also be focused on completing rituals, either overtly or covertly, to relieve their distress.

While frustrating to educators, OCD may be torture for the students who have it. This disorder may be difficult to identify because its observable symptoms are similar to other conditions and mental disorders, and mental rituals cannot be observed. Symptoms in children and adolescents can change over time, and they tend to wax and wane for no apparent reason. School personnel who have a good understanding of the variety of behaviors that may signal OCD are better equipped to initiate a plan to assist the student.

The Effect of OCD on Academic Performance

Even very bright and motivated students can struggle with OCD. Although students with OCD typically have average to above-average intelligence levels, they may be unable to learn the same way others do because their focus is frequently on their obsessions or compulsions. Depending on the severity of the symptoms, some students find it difficult to learn and, for some, it's almost impossible to concentrate on and complete schoolwork.

Although they want to pay attention, participate in discussions or presentations, study, and complete homework, they feel compelled to respond to their obsessions or urges.

Students who have untreated OCD re likely to have a very difficult time concentrating in the classroom and completing homework assignments. They may experience overwhelming anxiety or strong urges, possibly describing the feeling of mounting anxiety or intensifying urges as if they were a rising volcano or a tea kettle about to boil - and relief comes when the pressure is released. Unfortunately, the release is usually a compulsive behavior that may be disruptive to learning and possibly to the classroom.

It may not be long before the student who has OCD falls behind and sees a drop in grades. In some cases, academic performance deteriorates abruptly and dramatically. And it may be nearly impossible to catch up unless a student can learn to manage the symptoms. For these reasons, it's important that school personnel take OCD seriously and work with the student and the family to provide support.

What Does OCD Look Like at School?

A student may enter a classroom at the beginning of the school year with a diagnosis of OCD, or the disorder may develop later. Whenever a student begins to falter - academically, socially, or emotionally - educators need to intervene. A proactive approach can make an impressive difference in a student's coping ability, academic performance, and interpersonal capabilities.

The first step is being aware of the behaviors that can signal OCD. The disorder includes a wide variety of symptoms in children and adolescents, which are not always obvious. It is important to keep in mind that OCD symptoms can look like other disorders, so it is critical that a mental health specialist trained in OCD and related disorders conduct a diagnostic assessment OCD can be confused for symptoms of ADHD and anxiety disorders, as well as acting out" or misbehavior not associated with a neurobiological disorder. Also, OCD changes in nature or scope from one set of obsessions and compulsions to another, with differing behaviors, and symptoms can worsen and or seem to disappear, often for no obvious reason.

Common Symptoms of OCD at School

Below are common OCD symptoms of children and adolescents in school.

Obsession: Fears of germs or contamination
Compulsions
* Repeatedly washing hands, using antibacterial wipes or hand-sanitizer
* Protecting what is perceived as clean space -- personal desk, locker, or other property
* Avoiding touching surfaces that others may have touched, such as doorknobs, desks, shared supplies, lab tables or equipment, computer keyboards, paints, paste, soap, cafeteria trays, etc.
* Avoiding contact play or sports either because of a fear of catching a disease or fear of contaminating another student
* Avoiding the use of bathrooms
* Seeking reassurance that they or others are not sick or dirty
* Refusing to share items or supplies with others
* Refusing to eat in the cafeteria
* Avoiding certain products because they may contain poison, such as substances used in chemistry

Obsession: Fears that harm, illness, or death, will befall oneself or others; fear of causing harm to oneself or others, including violent or aggressive obsessions (Note: People with OCD who have violent or aggressive thoughts do not have a history of violence or act upon these urges or ideas.)
Compulsions
* Checking behavior, such as making sure doors or windows are locked or turning light switches on and off repeatedly
* Reading a paragraph over and over again to prevent harm from coming to a loved one, another person, or a pet.
* Asking the teacher for reassurance that the student is safe
* Avoiding leaving a perceived safe zone (classroom); avoiding going into unsafe zones (lunch or recess areas) or open spaces such as a gymnasium
* Unreasonable avoidance of peers, teachers, for fear of causing them harm

Obsession: Fears that harm, illness, or death, will befall oneself or others; fear of causing harm to oneself or others, including violent or aggressive obsessions ( Note: People with OCD who have violent or aggressive thoughts do not act upon these urges or ideas OR have a history of violence.)
Compulsions
* Checking behavior, such as making sure doors or windows are locked or turning light switches on and off repeatedly
* Reading a paragraph over and over again to prevent harm from coming to a loved one, another person, or a pet.
* Asking the teacher for reassurance that the student is "safe"
* Avoiding leaving a perceived "safe" zone (classroom); avoiding going into "unsafe" zones (lunch or recess areas) or open spaces such as a gymnasium
* Unreasonable avoidance of peers, teachers, for fear of causing them harm

Obsession: Fears, feelings, or urges related to numbers
Compulsions
* Counting, touching, or saying words a certain number of times due to believing in a magical significance to certain numbers or using those numbers to keep harm away; counting the number of steps between locations and having to start over if interrupted
* Touching objects a certain number of times; not being able to move on unless this touching has been accomplished
* Reading words or pages a certain number of times
* Going back and forth through doorways a certain number of times before it's OK to enter the room
* Avoiding using certain numbers that are perceived as unlucky or not safe; only using numbers that are perceived as safe or lucky. (math problems may be answered improperly, pages may not be read or pages may be numbered out of sequence )

Obsession: Fears, feelings, or urges related to discarding items because something bad will happen; feelings of incompleteness if something is discarded or the need document and preserve all life experiences; fears of contamination; need to buy items in multiples of a particular number; not discarding objects to avoid repetitive rituals such as washing or checking. (Note: This form of hoarding is related to the obsessions and compulsions of OCD and is distinct from hoarding disorder.)
Compulsions
* Saving scraps of paper, candy wrappers, bottle caps, broken items, or other useless items; inability to part with unneeded things
* Keeping books, toys, food, school papers, clothing, or other items for fear that they might be needed sometime in the future
* Buying every item in a store that one has touched (and therefore contaminated) to prevent others from being contaminated
* Accumulating items or objects in a particular area (desk drawer) because they are contaminated and cannot be touched
* Buying multiples of the same item (buying three of everything because it's a magic number)

Obsession: Scrupulosity, or the excessive fear of violating religious or moral rules
Compulsions
* Apologizing or confessing that something is wrong, such as breaking religious, classroom, or school rules
* Constantly seeking reassurance that a task has been completed right or perfectly; seeking affirmation that a mistake was not made
* Saying prayers a certain number of times; excessive praying to atone for being bad; repeatedly confessing perceived sins or bad behavior
* Repetitive praying, confessing to neutralize or undo bad thoughts, intrusive sexual thoughts, or visions of cursing or blaspheming in school or church
* Avoiding answering questions for fear of telling a lie

Obsession: Fears, feelings, or urges related to symmetry or order
Compulsions
* Constantly evening up books or other items on a shelf or desk; aligning edges to be even
* Rearranging items to be in a certain order, such as by color or alphabetical order
* Avoiding a room with square tiles because seeing the tiles would require tracing each of the edges visually
* Fears, feelings, or urges related to sexual content
* Seeking reassurance that one is not gay or lesbian, despite being heterosexual
* Excessive praying to atone for having inappropriate sexual thoughts or images
* Avoiding magazines, books, DVDs, websites, or other media for fear of seeing sexual content

Obsession: Excessive doubting or dread of uncertainty
Compulsions
* Constantly rechecking to see that everything is in a backpack or book bag
* Asking to leave the classroom to recheck a locker or its contents
* Avoiding a school locker to prevent checking the lock over and over again

Obsession: Fears, feelings, or urges related to having something just right or perfect
Compulsions
* Getting up and sitting down repeatedly at a desk, until feeling just right
* Repeatedly revising the way letters, words, or numbers are written to make them look just right; getting stuck rewriting the same letter or word
* Repeatedly filling in circles on answer sheets; getting stuck on one or two questions because too much time is spent carefully filling in the circles, erasing, refilling until it looks perfect
* Erasing and rewriting words over and over
* Extreme slowness with activities or school work until everything is just right
* Repeating various actions for no apparent reason
* Avoiding a hallway until walking in it until it feels just right

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OCD is like an unwelcome guest with bad manners. It moves into a mind - and it doesn't want to leave. Students with OCD may appear to be daydreaming, distracted, disinterested, or even lazy. They may seem unfocused and unable to concentrate.

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Once again, David Muir, as "20/20" continues. Reporter: 15-year-old Bridget sits in the waiting room two seats apart from her mother. Her obsessive compulsive disorder, her fear of contamination, prevents her from sitting any closer. You'll remember the last time they worked the entire time on simply sitting on the same couch. No. Don't. Don't. Okay. Reporter: Karen has not been able to hug her own daughter for months now. And it is Bridget who's in the driver's seat. It is a painstaking process every time. It's taken seven full therapy sessions just to get this far down the couch. Her mother slowly moving her body closer. All is going well until her mother reaches for her purse to pay the therapist.xd No, it's too close. Get it away. Reporter: Bridget is afraid getting close to that purse will contaminate her. Bridget tells the doctor she is done. And outside, she shows us how even leaving together is not easy. Now, she has to come out and I close the door. Because if she touches the door, then I can't touch the door anymore.u! Reporter: All of this is irrational, and Bridget, like S! Many children with OCD, knows that, but she's still afraid that her mother and the rest of her family at home is contaminated. And Bridget refuses to go there. Her mother is about to drive her nearly an hour away back to her ç grandmother's. Remember, that is where Bridget is now living instead. I can't put my feet or my shoes on the ground, so I take them off and then put them on top, and then I sit sideways. Reporter: For Bridget, everything is complicated, even the simplest of things, like getting into the car. She takes off her shoes, because they can't touch the floor of the family car.e1 So I can't be too close to her. Before, I used to have to sit on my feet and they would become numb. Reporter: While inside another car, another mother and daughter in their own relentless fight against OCD. What are you trying to tell your OCD? To get lost. Okay. Reporter: 14-year-old Michelle Leclair, who hasn't been able to step inside her school for four months now. Her mother, Diane, had to quit her job as a teacher to work full-time helping Michelle fight her OCD. When she was going to school,!uñ she would cry for an hour and a half every night, saying how difficult it was to go to school, but I couldn't touch her. Reporter: Michelle's OCD also involves contamination, but her fear is different. Her family is fine. It's the kids at school she's afraid of, afraid they're dirty.r she can't go to school or anywhere in public where she has seen the other students. We had to go, like, hours away just to go get, like, a pair of pants or get cleaning supplies because everything around here was contaminated. All the stores were, because the kids from school had been there. Reporter: It is a crippling fear that has left her isolated at home. Her laundry has to be done separately from the rest of the family. And one laundry cycle often isn't enough to convince Michelle her clothes are clean. Even the washer has to be washed. She showers incessantly at home, blistering hot water. At one point, her parents couldn't even get her out of the shower, not even when there was a brand new puppy waiting for her. We were gonna go get him puppy toys and take him to the store and she was so excited that whole day. And after an hour in the shower, I'm like, "We need to leave if you want to go," and she couldn't do it. I pulled her out of the shower, and she just sat on the floor, rocked and cried.0& Reporter: Her OCD taking over her life. Doctors say, with children who have OCD, Michelle plunged into depression. I became suicidal because I couldn't touch anything. You can't enjoy anything. So there wasn't really a point in living anymore. Reporter: A far different portrait from the little girl who was once a straight "A" student, a dancer, who loved dressing up, a child who once proudly displayed her smile. Your school situation will be -- Reporter: When we first met up with her, she'd already begun therapy with Dr. Weg. And now, she and her mother are taking the next step on their own, actually practicing going to school when the halls are empty. And they're headed to their first stop, the locker room. My heart is beating much faster now. And then, so I touch the doorframe and then do the door handle. Reporter: The doctor has told Michelle to touch what she's afraid of, what's dirty, and then to touch her own skin to prove that there's nothing to be afraid of. The doctor has told her to keep track of her anxiety on a scale of 1 to 10. Like a seven. Touch the walls because you're not touching anything. You're taking little baby steps. Michelle, you're not touching the walls. Touch your hands, your arms, your face. I'm contaminating myself so that no part of me is considered, like, clean. Right now, if you could do anything in the world, what would you be going to do? Leave. Take a shower. Reporter: With the locker room now barely conquered, the next battleground, gym class. It's been five months since she stepped foot inside the gym. Can you go over and touch the basketball? Do you want to hit me? Yeah. Now, you know kids touched that, right? What does it feel like? I think the germs are, like, coming into me and, like, going through my blood. Reporter: Her full-time coach, her mother, taking careful note of her progress. I'm very proud of what you did. You touched the walls, you sat on the, the bench. Reporter: A proud mother and her daughter leaving school after their own sort of gym practice. While back in the therapist's office, Bridget is about to take a huge step too. It's been eight hours of intense therapy with Dr. Weg, and she still has not allowed her mother to touch her. It's been months since mother and daughter have hugged. All right. That's pretty good. Reporter: Bridget and her mother grasp a small wand between them. This is huge. Bridget? Find your center. Show her who's boss. Do it, do it, do it, do it. Just stay with it. Just hold on. Reporter: This is the first time Bridget has touched her mother in four months. I need your fingers. All of my fingers? Yes. There it is. That feels really good. No, it doesn't. It's very difficult for parents to come in and not believe that they've done something wrong, that their kid has all these fears and, and strange and bizarre fears. What did I do wrong? Reporter: Once her fear subsides, the doctor pushes Bridget to hold that hand again. Let's have the hand back. Good for you, good for you. Okay. Reporter: And as we were about to learn, Bridget's OCD fight is far from over. What was it that led to this? No.

This transcript has been automatically generated and may not be 100% accurate.

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Video: Children Face What They Fear Most to Conquer OCD

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Once again, David Muir, as "20/20" continues. Reporter: 15-year-old Bridget sits in the waiting room two seats apart from her mother. Her obsessive compulsive disorder, her fear of contamination, prevents her from sitting any closer. You'll remember the last time they worked the entire time on simply sitting on the same couch.

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This section is designed specifically for college-aged adults/young adults. When living with OCD it can often be exhausting, confusing and frustrating. We hope that you will find videos in this section that are designed just for you with helpful tools. With the proper treatment you can gain control of your OCD and get your life back!

Choose a title below to view related OCD videos

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This section is designed specifically for college-aged adults/young adults. When living with OCD it can often be exhausting, confusing and frustrating. We hope that you will find videos in this section that are designed just for you with helpful tools. With the proper treatment you can gain control

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Most children and parents will have some distress or upset - so how do I know when a child or family needs additional help?

Ask your patients (and their parents) about reactions and coping.

Listen for ongoing or severe traumatic stress symptoms.

Consider a referral for a more thorough evaluation with a mental health professional if:

Traumatic stress reactions are severe or prolonged (more than a month).

Traumatic stress reactions interfere with recovery or with returning to normal activities.

Consider: Is the child participating in daily activities to the extent possible given their medical condition? Are stress reactions interfering with treatment adherence? Are new fears or worries troubling the child or parent?

Steps for making a referral Effective mental health treatment for traumatic stress Online resources - help in finding a mental health professional Distinguishing between types of mental health professionals
Therapist Resource Guide: There are many ongoing stressors that children and families endure after diagnosis of an illness or an injury. This guide focuses specifically on medical traumatic stress and responses that children and families may have.

Steps for making a referral

Mention concerns you have identified.
Say something like: "I'm concerned that (you are / your child is) having these upsetting thoughts and feelings. It might be useful to talk with a specialist who can help your family more."

Involve child and family in making a plan.
Ask for their ideas about what is needed now
Say something like: "What issues or difficulties are impacting you / your family the most right now? What would help make things better?"

Ask for permission to offer advice. Present advice as range of possibilities; be sure to incorporate patient/family ideas

Say something like: "I have some suggestions that have helped other patients in the past in situations similar to yours. May I share them with you?"

Range of possibilities might include: patient education materials / websites; speaking with social worker, local clergy, school counselor; seeking out support group, referral to therapist / community mental health center.

Ask about their readiness to act on this now or in the future.
Say something like: "Is this (suggested plan) something you would be willing to do when you leave today, or if you need it next week...month?"

Ask about barriers to potential plans / referrals, and strategies to overcome barriers.
Say something like: "What kinds of things would interfere with following-up on this plan we just discussed? How can we work through this so you end up getting the help you need.?"

Involve the child and parent in setting the agenda*:*Adapted from Wissow et al. (2008)

Keep the door open.

If your patient or their parents are not quite ready to act on a suggested referral now, arrange to follow up to see how your patient is doing.

You might say: "I'd like to talk with you again in a few weeks to see how things are going."

Promote continuity of care.
If your care for this patient is ending, ask permission to communicate your concerns about traumatic stress reactions or risk factors to the child's primary care provider, or to other providers who will continue to take care of this patient.

Facilitating collaboration between pediatric health care and mental health providers: The American Academy of Pediatrics Task Force on Mental Health has developed tools to facilitate collaboration between pediatric health care providers and mental health professionals, including a Physician Referral and Feedback Form template

Effective mental health treatment for traumatic stress

There are very good and helpful treatments for children who continue to have traumatic stress symptoms.
What treatment approaches are effective?
Evidence-based treatments include cognitive-behavioral treatment approaches, and in particular Trauma-Focused Cognitive Behavior Therapy (TF-CBT).

Click here for a fact sheet about effective treatments for youth trauma from the National Child Traumatic Stress Network.

A recent article includes informative summaries of effective mental health treatments for child traumatic stress symptoms, and guidance for health care professionals:
Cohen, J, Kelleher, K, Mannarino, A.. Identifying, treating, and referring traumatized children: The role of pediatric providers. Archives of Pediatric and Adolescent Medicine 2008;162(5):447-452 How can I help parents find effective treatment for their child?
When helping parents find a counselor or therapist to help their child with traumatic stress symptoms, you might suggest that they ask prospective therapists questions such as:

Do you have experience working with children after trauma?

What is your approach to working with this type of problem?

What is your success rate?

How do you work with parents?

The National Child Traumatic Stress Network offers useful tips and information about finding a mental health professional to help children and their families after trauma.

Online resources - help in finding a mental health professional

The National Child Traumatic Stress Network (NCTSN) has trauma-trained, child mental health professionals and community-based treatment centers in 35 states in the US. For information about or referral to a NCTSN center near you, please go to the NCTSN Organizational Members site.
American Psychological Association - Psychologist Locator National Association of Social Workers - Find a Licensed Social Worker American Academy of Child and Adolescent Psychiatrists - Psychiatrist Finder Anxiety Disorders Association of America - Find a Therapist Sidran Institute Help Desk - Locate Trauma Resources ISTSS Clinician Directory - Find a Clinician, Counselor or Mental Health Professional
Distinguishing between types of mental health professionals

Psychologists are professionals who have earned a doctoral degree (Ph.D. or Psy.D.) after 4-6 years of graduate-level training in human behavior and development, psychological testing and evaluation, and psychotherapy. Psychologists are licensed by the state in which they practice.

Psychiatrists are physicians (M.D. or D.O.) who have completed medical school, plus additional advanced training in the evaluation and treatment of psychiatric disorders and emotional and behavioral problems. Psychiatrists are licensed by the state in which they practice. As medical doctors, psychiatrists can prescribe and monitor medications.

Clinical Social Workers are professionals who have earned a master's degree (M.S.W.) after 2-3 years of graduate training. Clinical Social Workers are licensed by the state in which they practice (LCSW or similar credential - varies by state).

Marriage and Family Therapists are professionals who have completed a master's degree (M.A. or M.S.) after 2-3 years of graduate training. Some Marriage and Family Therapists have completed a required amount of clinical hours and passed a state-administered examination to become licensed marriage and family therapist (LMFT).

Licensed Professional Counselors (LPC) & Licensed Mental Health Counselors (LMHC) are mental health professionals who have earned a master's degree (M.A. or M.S.) after 2-3 years of graduate training and have obtained a required amount of clinical experience and passed a state-administered licensing examination.

For more information on the training and credentialing of mental health professionals, see Mayo Clinic: Mental health providers.

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When and How to Refer for Mental Health Care

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Pediatric providers can follow specific steps to determine if and how to refer a child and familiy for further mental health services after a medically traumatic event. Providers can also become familiar with current evidence-based treatments and online resources for mental health services for traumatic stress.

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Journal of the American Academy of Psychiatry and the Law

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Delusional Disorder

In DSM-5, people who show bizarre delusions are now eligible for the diagnosis of delusional disorder, which is a significant change. The criteria also include a more modest change, as course specifiers are now more detailed. The subtypes of delusions are unchanged from DSM-IV, but clinicians may now also specify if the person's delusions show "bizarre content." The addition of bizarre delusions to the diagnostic criteria may increase slightly the frequency of this uncommon diagnosis, which DSM-5 estimates has a lifetime prevalence of 0.2 percent (Ref. 1, p 92). In a recent article, bizarre delusions were rarely (<2%) identified as the sole reason for a DSM-IV diagnosis of schizophrenia, so the number of people whose diagnosis would change from schizophrenia to delusional disorder is likely to be low. It is hard to predict how the shift of bizarre delusions to the criteria for delusional disorder will affect treatment; the small research literature on the treatment of delusional disorder suggests that long-term treatment with antipsychotic medication may lead to a modest decrease in the intensity of delusions. It is unknown whether people who have delusional disorder with bizarre content will show a similar response to antipsychotic medication. Given the strong likelihood of persistent symptoms in a person with delusional disorder, assessment of the risk of violence based on bizarre delusions will require, as always, a careful evaluation of the individual and his symptoms, particularly if the delusions involve an identifiable individual (e.g., a family member or neighbor) or a group of people (e.g., police officers), thus putting that person or group at risk of violence.

Brief Psychotic Disorder

The core diagnostic criteria for brief psychotic disorder are essentially unchanged: the symptoms must persist for one month or less, and the person must recover fully after the psychosis ends. The criteria now require the acute onset of at least one symptom: delusions, hallucinations, or disorganized speech. Grossly disorganized or catatonic behavior remains as a fourth possible symptom but is not sufficient alone to make the diagnosis. The impact of this minor revision on forensic psychiatry is likely to be minimal.

Schizophreniform Disorder

The diagnosis of schizophreniform disorder is little changed. The A, B, C, and D criteria are identical to those in DSM-IV. The text for the specifier "with good prognostic features" has been slightly revised (Ref. 1, p 97). Schizophreniform disorder remains intermediate in symptom duration between brief psychotic disorder and schizophrenia. It has no corollary in the International Classification of Diseases (ICD) scheme, in which a diagnosis of schizophrenia may be made after one month of symptoms of psychosis. The forensic impact of the minor changes in the criteria for schizophreniform disorder in DSM-5 should be minimal.

Schizophrenia

Critics have described the DSM-5 criteria for schizophrenia as an evolution, not a breakthrough. The DSM-IV criteria for schizophrenia were quite reliable and diagnoses made with these criterion were stable over time, so only modest changes were made in DSM-5. The five symptoms of the A criterion, which are familiar to clinicians, have been retained, but one of the two symptoms needed to diagnose schizophrenia must be delusions, hallucinations, or disorganized thinking and speech. Schneiderian first-rank symptoms (i.e., bizarre delusions or auditory hallucinations, either conversing among themselves or providing a running commentary) are no longer sufficient to qualify a person for a diagnosis of schizophrenia. Research on these symptoms found that they had no prognostic relevance and were not linked to a family history of schizophrenia; removing the Schneiderian symptoms from the A criteria was estimated to affect fewer than 2 percent of diagnoses. In another change based on recent research, the negative symptoms have been limited to two choices: "diminished emotional expression or avolition" (Ref. 1, p 99). Negative symptoms are often overlooked in criminal forensic evaluations, which typically focus on the link between positive symptoms of psychosis and behavior, but a lack of volition may have important implications for deciding whether a defendant possessed mens rea at the time of the alleged offense. In civil forensic evaluations, negative symptoms are well known as a primary cause of disability in schizophrenia.

DSM-5 does not identify any subtypes of schizophrenia (e.g., paranoid or disorganized), due to the frequent comorbidity among the DSM-IV subtypes and their poor reliability, low stability, and limited prognostic value. In contrast, the course specifiers for schizophrenia in DSM-5 are almost completely new. There are two main categories of course specifiers, first episode and multiple episodes, each of which may be described as acute, in partial remission, or in full remission; the specifier continuous is the only holdover from DSM-IV (Ref. 1, pp 99-100). These specifiers should allow clinicians to describe accurately the present clinical status of a person with schizophrenia. The specifiers are likely to see regular use in correctional psychiatry, where ongoing treatment is the norm, and in civil forensic evaluations, where the specifiers may be helpful in commitment and disability evaluations. The course specifiers are not as likely to be a factor in criminal evaluations of competence or sanity.

The connection between a given mental disorder and a risk of violence is not prominent in the psychosis and mood disorders sections of DSM-5. The closest DSM-5 comes to this topic is in the description of "associated features supporting diagnosis" of schizophrenia, which includes the observation that "hostility and aggression can be associated with schizophrenia, although spontaneous and random assault is uncommon. Aggression is more frequent for younger males and for individuals with a history of violence, non-adherence with treatment, substance abuse and impulsivity" (Ref. 1, p 101). Beyond this statement, DSM-5 has little to say about the risk of violence associated with psychosis. The "Cautionary Statement for Forensic Use of DSM-5," which precedes the sections of diagnostic criteria, does not mention risk of violence.

Schizoaffective Disorder

Schizoaffective disorder was considered for removal from DSM-5, in favor of a dimensional approach to the diagnosis of the psychotic disorders. This proposal was based on the low reliability of this diagnosis compared with other psychotic disorders, recent research that suggested that schizoaffective disorder is intermediate between schizophrenia and bipolar disorder and may not be a separate diagnostic entity, and the limited clinical utility of a diagnosis that practitioners make without adhering to criteria. However, because the available research findings "are not yet compelling enough to justify a move to a more neurodevelopmentally continuous model of psychosis" (Ref. 16, p 131), schizoaffective disorder was retained, with revised criteria. In particular, the requirement for the presence of a mood episode was strengthened, such that "mood symptoms sufficient to meet criteria for a mood episode must be present for at least half of the total duration of the illness from the onset of the first psychosis" to make a diagnosis of schizoaffective disorder (Ref. 15, pp 23-4). Schizoaffective disorder diagnosed with DSM-IV criteria has been shown to be an unstable diagnosis. Field trials of the DSM-5 criteria for schizoaffective disorder showed good test-retest reliability when rigorously applied, so it is possible the new criteria will also lead to a more stable diagnostic entity.

The forensic implications of the changes in the criteria for schizoaffective disorder in DSM-5 are not clear. A proper diagnosis of schizoaffective disorder requires that a person meet all of the criteria for schizophrenia and all of the criteria for an episode of bipolar disorder or depression, with the exception of impaired function. DSM-5 estimates the prevalence of schizoaffective disorder to be one-third that of schizophrenia (Ref. 1, p 107), so it should be an uncommon disorder. Although it is important to make as accurate a diagnosis as possible to treat effectively, the alternatives to schizoaffective disorder (i.e., schizophrenia with a mood component or a mood disorder with psychosis), should also lead clinicians to treat with appropriate classes of medication. Otherwise, the forensic implications of the changes to schizoaffective disorder should be modest; the main concern will continue to be appropriate and consistent use of the criteria.

Catatonia

In DSM-5, catatonia is recognized as a separate clinical entity, though not as an independent disorder. It can be diagnosed whenever it is present, but only in the context of a mental disorder, a medical disorder, or an unspecified condition. If a person meets 3 of the 12 criteria, the specifier "with catatonia" should be added to diagnoses of most of the serious mental disorders in DSM-5 (Ref. 1, pp 119-120), to "facilitate its appropriate recognition and specific treatment." Catatonia was once considered a common presentation of schizophrenia, but its reported prevalence in schizophrenia declined over the course of the 20th century; in recent research, though, catatonia was found in up to 10 percent of people with an acute psychiatric disorder, nearly half of whom had a mood disorder and only a quarter of whom had a psychotic disorder. Improved awareness of catatonia could have implications for forensic practice. In the criminal realm, catatonia could certainly contribute to a finding of incompetence to stand trial, but it is unlikely to be an element of an insanity defense, as only one of the 12 symptoms, agitation, might be a precursor to illegal activity. The primary outcome of recognition of catatonia, though, would be the impact on the person with catatonia, as this condition can be treated effectively.

Attenuated Psychosis Syndrome and Shared Psychotic Disorder

The Psychotic Disorders Work Group considered adding attenuated psychosis syndrome as a new diagnosis to DSM-5, but instead decided to place it in Section III as a condition for further study, after field trial data showed that it was not diagnosed reliably by clinicians. Attenuated psychosis syndrome is meant to describe people who show "recent onset of modest, psychotic-like symptoms and clinically relevant distress and disability" (Ref. 23, p 32). In addition, the person who experiences the symptoms must recognize them as unusual and experience sufficient distress or disability to seek clinical evaluation. Despite the clear guidance in the DSM-5 that conditions in Section III are not intended for clinical use, this syndrome is not just in Section III, but is also specifically identified in "Other Specified Schizophrenic Spectrum and Other Psychotic Disorder" as one of four examples of alternative presentations of a psychotic disorder; where it is labeled "other psychotic disorder, attenuated psychosis syndrome" (Ref. 1, p 122).

The diagnosis of attenuated psychosis syndrome may contribute to a finding of incompetence to stand trial, as young adults are at highest risk for this disorder and are at highest risk for arrest, but it is unlikely to be the single reason for such a finding, given the absence of overt psychosis. Attenuated psychosis is also unlikely to be a precursor to an insanity verdict, as this syndrome is meant to identify people with symptoms that are "psychosis-like but below the threshold for a full psychiatric disorder" (Ref. 1, p 783). Attenuated psychosis may appear more frequently in civil forensic evaluations, in the context of employment and disability assessments.

Shared psychotic disorder ( folie à deux), which was present in DSM-IV as a separate disorder, exists in DSM-5 only in the section on other specified schizophrenic spectrum and other psychotic disorders, as "delusional symptoms in partner of individual with delusional disorder" (Ref. 1, p 122). The presence of shared psychotic disorder in DSM-5 will allow continued recognition of this disorder, which, although rare, is occasionally seen in forensic cases, both criminal and civil.

Specifiers for Mood Disorders

DSM-5 includes multiple specifiers to describe the Bipolar and Depressive Disorders (Ref. 1, pp 149-54, 184-8), as part of a mixed categorical-dimensional approach. The specifiers are meant "to define a more homogeneous subgrouping of individuals with the disorder who share certain characteristics ... and to convey information that is relevant to the management of the individual's disorder" (Ref. 1, pp 21-2). The presence of new and more detailed descriptive specifiers for the bipolar and depressive disorders may have some impact on forensic psychiatry. The specifiers are intended to be used to describe the course of a person's disorder and should not affect the frequency of the underlying diagnosis, but some specifiers may have implications for suicide risk. In addition, these specifiers may be useful in forensic contexts where a prediction of future course may be helpful, such as sentencing, civil commitment, and child custody.

The specifier of "with anxious distress" (Ref. 1, p 149) is the only entirely new one. It was added to account for the high prevalence of symptoms of anxiety in both manic and depressed states and because "a substantial body of research conducted over the past two decades points to the importance of anxiety as relevant to prognosis and treatment decision-making" in bipolar and depressive disorders. The addition of this specifier should encourage the identification of anxiety in people who have a bipolar or depressive disorder, which should lead to improved management of suicide risk, as anxiety is a risk factor for suicide. Conversely, a lack of recognition of anxiety in the medical record or treatment plan could have implications for malpractice liability in cases of attempted or completed suicide.

The DSM-IV specifier of postpartum onset has been replaced in DSM-5 by "with peri-partum onset," which may be applied if the mood episode occurs during pregnancy or within four weeks of delivery. The explanatory note for this specifier makes it clear that it was added to improve the recognition of bipolar and depressive episodes during pregnancy, in order to prevent postpartum psychosis, which is often linked to a mood disorder and is a major risk factor for infanticide (Ref. 1, pp 152-3). The addition of peri-partum onset will thus have forensic implications, both for the management of bipolar and depressive disorders in pregnancy and for the review of cases of infanticide.

The DSM-IV entity of a mixed episode of bipolar disorder has been replaced with the specifier "with mixed features" (Ref. 1, p 149-50), which can be applied to bipolar I, bipolar II, major depressive, and persistent depressive disorders. Thus, a person with hypomania or mania who shows some symptoms of depression and a person with depression who shows some symptoms consistent with hypomania or mania should be designated as "with mixed features." Although the mixed-features specifier will "better account for the highly prevalent subsyndromal presentations" (Ref. 28, p 30) of both manic and depressed states, its addition does not solve the problems of the overlap between unipolar and bipolar depression or the gray zone of the boundary between bipolar disorder and schizoaffective disorder. As a result, debate on the applicability of this specifier to a particular person could be vigorous. The DSM-5 criteria for the specifier of mixed features have also been criticized for including euphoria and excluding agitation and irritability, thus moving away from Kraepelin's original concept of mixed depression as a fairly common clinical entity. Overall, the impact this specifier will have on forensic practice is unclear.

The specifier "with seasonal pattern" now includes all mood episodes (mania, hypomania, and depression) in the introduction and the criteria, instead of being limited, as in DSM-IV, only to episodes of depression. However, the explanatory note makes it clear that "the essential feature is the onset and remission of major depressive episodes at characteristic times of the year" (Ref. 1, p 153), which retains the intent of the DSM-IV criteria.

The criteria for the specifiers "with melancholic features" and "with atypical features" are largely unchanged from DSM-IV, but a detailed note on the use of each specifier has been added to the text for each. The criteria for the specifier "with psychotic features" are essentially unchanged and have no explanatory note. The criteria for "with rapid cycling" are also unchanged, but a second explanatory note was added to clarify that each of the four episodes needed in one year to qualify for this diagnosis must be marked by full remission or a switch of polarity.

Bipolar I Disorder

The Mood Disorders Work Group introduced the criteria for the bipolar disorders by noting "the bipolar I disorder criteria represent the modern understanding of the classic manic-depressive disorder" (Ref. 1, p 123). There are two changes in the criteria for bipolar I disorder in DSM-5. First, a person with mania must show elated or irritable mood or both and increased energy or activity, which modestly tightens the criteria for a manic episode. Second, "excessive involvement in activities" no longer requires these activities to be pleasurable, just to have "a high potential for painful consequences" (Ref. 1, p.134), which can be seen as a modest loosening of the criteria. The work group also clarified that mania induced by treatment with antidepressant medication counts as a manic episode for the purpose of diagnosing bipolar I disorder. The DSM-5 criteria for bipolar disorder are unlikely to have a significant impact on forensic psychiatry and are unlikely to solve the debate over whether bipolar disorder is overdiagnosed or underdiagnosed.

The prevalence of self-reported bipolar disorder in correctional populations is likely to remain high so long as people who report mood swings are given a prescription for a mood-stabilizing medication and a diagnosis of some form of bipolar disorder by clinicians. If the DSM-5 criteria for the diagnosis of bipolar disorder are used appropriately, the frequency of this phenomenon should decrease. However, even though the DSM-IV diagnosis of bipolar disorder NOS has been removed, DSM-5 has added "other specified bipolar and related disorders" (Ref. 1, p 148) and "unspecified bipolar disorder" (Ref. 1, p 149), which are likely to be used to describe people who report subjective mood instability that does not meet criteria for bipolar I or bipolar II disorder. In particular, the choices under other specified bipolar and related disorder include four variant presentations, including one that is also listed in Section III (depressive episodes with short-duration mania), which could account for several bipolar presentations that do not include a true manic or hypomanic episode. The report of a prior diagnosis of bipolar disorder in a forensic evaluation should prompt thorough, open-ended questioning of the person's psychiatric history, searching for evidence of true manic or hypomanic episodes.

Bipolar II Disorder

The DSM-5 diagnosis of bipolar II continues to require at least one episode of current or past hypomania and at least one episode of current or past major depression, with no history of an episode of mania. There is a new focus in the criteria on the functional impact of the symptoms of depression in bipolar II, as the section on the diagnostic features notes that this disorder often presents with major depression and urges clinicians to ask for a history of hypomania in people who are depressed (Ref. 1, p 135). In addition, because people who have bipolar II disorder often experience repeated or prolonged episodes of depression, DSM-5 makes a point of describing bipolar II disorder as not less severe than bipolar I disorder. The observations made above regarding the prevalence of diagnoses of bipolar I disorder also apply to bipolar II disorder.

Cyclothymic Disorder

The diagnosis of cyclothymic disorder requires a two-year history of many episodes of not-quite hypomania and not-quite major depression. DSM-IV permitted this diagnosis to remain active if an episode of mania, hypomania, or major depression occurred after the first two years of subsyndromal symptoms. The DSM-5 criteria hold that "criteria for a major depressive, manic or hypomanic episode have never been met." In addition, the DSM-5 criteria clarify that hypomanic or depressive symptoms must be present at least half of the time during the required two-year period (Ref. 1, pp 139-40). These changes in the criteria will further restrict the prevalence of this relatively rare disorder, but their impact on forensic practice is likely to be minimal, as this disorder is uncommon in criminal forensic evaluations and is not a major cause of disability.

Major Depressive Disorder

The primary criteria for the diagnosis of major depression in DSM-5 are largely unchanged from DSM-IV, with one potentially significant exception. DSM-IV permitted a diagnosis of depression in a bereaved person only if the symptoms had been present for more than two months or if they had caused marked functional impairment. However, research on bereavement and depression found little reason for such a distinction. The Mood Disorders Work Group therefore proposed that symptoms of depression in the context of bereavement or other significant loss would qualify for a diagnosis of major depression, which would have removed the "normal bereavement" exception for depression found in DSM-IV and present in the ICD. This proposal was met with strong criticism by many clinicians and the public, who felt that the new disorders inappropriately turned a normal psychological reaction to loss into a form of psychopathology.

The Mood Disorders Work Group did not reinstate the bereavement exception, but instead added a note to the depression criteria to explain that "responses to a significant loss ... may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode ... should also be carefully considered" (Ref. 1, p 161). This change to the criteria for major depression could have an impact on civil forensic psychiatric evaluations. If bereavement is no longer a barrier to a diagnosis of depression, this diagnosis can be made in survivors of wrongful or negligent deaths, which could increase claims for damages.

A more subtle change in the criteria for depression in DSM-5 can be found in the description of depressed mood, where a person who is depressed is "sad, empty or hopeless"; in DSM-IV the phrase was "sad or empty." Thus, a feeling of hopelessness alone is enough to meet the criterion for depressed mood, which could increase the frequency of the diagnosis of depression. Hopelessness has long been recognized as a risk factor for suicide, so the recognition of this symptom as characteristic of depression should encourage clinicians to inquire about hopelessness and then to take it into account in their suicide risk assessment.

A major concern for all clinicians who use the DSM is the reliability of the disorders described in the manual. Major depression does not fare well in this regard; the inter-rater reliability of DSM-5 major depression showed a κ coefficient of 0.28, well below the coefficients for the DSM-III (between 0.60 and 0.80) and DSM-IV (between 0.40 and 0.80) criteria.

Persistent Depressive Disorder (Dysthymia)

The diagnosis of persistent depressive disorder is new to DSM-5 and is meant to combine the DSM-IV disorders of dysthymia and chronic major depression, defined as two or more years of continuous major depression. The decision to merge these diagnostic concepts was based on research that suggested that chronic depression was prevalent in the community and could be distinguished from nonchronic depression. The A, B, and C criteria for persistent depressive disorder are unchanged from the DSM-IV criteria for dysthymia, but the D criterion now reads "criteria for a major depressive disorder may be continuously present for two years" (Ref. 1, p 168). The relationship between persistent depressive disorder and major depression in DSM-5 is somewhat confusing and leads to conflicting recommendations. For example, a person "whose symptoms meet major depressive disorder criteria for two years should be given a diagnosis of persistent depressive disorder as well as major depressive disorder" (Ref. 1, p 169), whereas for a person who meets criteria for persistent depressive disorder, "if the symptom criteria are sufficient for a diagnosis of a major depressive episode at any time during this period, then the diagnosis of major depression should be noted, but it is not coded as a separate diagnosis but rather as a specifier" (Ref. 1, pp 170-1). The proper diagnosis of a person with chronic depression may thus become a fruitful area for cross-examination, given the multiple ways a person with chronic symptoms of depression could be coded. The impact of persistent depressive disorder in clinical practice may be modest, outside of the possible confusion of proper diagnosis, as people who have dysthymia or chronic depression respond to similar treatment.

Premenstrual Dysphoric Disorder

This disorder was in Appendix B of DSM-IV (Ref. 37, pp 715-18) but has been moved to the main text in DSM-5. The research criteria laid out in DSM-IV have been modified for DSM-5. This diagnosis is based on the presence of specific symptoms in the week before onset of menses followed by resolution of the symptoms after onset. The symptoms must include one or more of marked affective lability, irritability or anger, depressed mood or hopelessness, and anxiety or tension, as well as one or more of an additional seven symptoms, with a total of at least five symptoms. The criteria specifically note that "Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles" (Ref. 1, p 172), which means it will be difficult to make this diagnosis on the basis of a single evaluation; although two cycles of daily ratings are technically not required, it will be easy to challenge a diagnosis made without these data. The addition of premenstrual dysphoric disorder to DSM-5 may open up new avenues in civil forensic evaluations, most likely in the area of disability evaluations, and may make an appearance in criminal evaluations if affective instability and anger due to this disorder contribute to an individual's violent behavior.

View Abstract

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The criteria for the major psychotic disorders and mood disorders are largely unchanged in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), with a few important exceptions: a new assessment tool for the psychotic disorders based on dimensional assessment, a new scheme of specifiers for the mood disorders, the addition of three new depressive disorders, and recognition of catatonia as a separate clinical entity.

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National Institute of Mental Health (NIMH)

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What is schizophrenia?

Schizophrenia is a serious mental illness that affects how a person thinks, feels, and behaves. People with schizophrenia may seem like they have lost touch with reality, which can be distressing for them and for their family and friends. The symptoms of schizophrenia can make it difficult to participate in usual, everyday activities, but effective treatments are available. Many people who receive treatment can engage in school or work, achieve independence, and enjoy personal relationships.

What are the signs and symptoms of schizophrenia?

What are the risk factors for schizophrenia?

How is schizophrenia treated?

How can I find help for schizophrenia?

How can I find a clinical trial for schizophrenia?

Where can I learn more about schizophrenia?

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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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schizophrenia is a disorder which affects approximately 1% of the world population, has a 10% suicide rate, an estimated $20 billion in lost productivity and $11.1 billion in medical costs in the United States in 1980 (Andreasen, 1995). The primary characteristics are disturbed language, communication, thought and perception (Davidson, 1993 p. 1). There are two distinct types of symptoms, the positive (abnormal activity, such as delusions and hallucinations) and the negative (lack of activity, such as avolition, affective blunting) (Andreasen, 1995). Davidson (1993, p. 2) also identifies three phases of the disease process, each of which presents its own unique problems. Onset begins with social skill deterioration, and difficulty completing everyday tasks. The acute phase encompasses such items as delusions, hallucinations, and distorted thinking. Finally, the remission phase is marked by the passing of the distortions, with a return to more normal functioning, although oftentimes not as effectively as before the onset. Depending upon the phase and severity of the disease, a patient may have severely different psychological fields as well (Anscombe, 1987). However, Green (1996) points out that in a literature review, it has been shown that the degree of psychosis does not act as an indicator of the subsequent recovery.

Schizophrenia can be expressed in a patient through positive and/or negative symptoms. Both positive and negative symptoms generally result in learning difficulties, though through different mechanisms. This specifically includes (for positive symptoms), derailment, tangentiality, incoherence, illogicality, circumstantiality, pressure, distractible speech and clanging (Andreasen, Arndt, Alliger, Miller, & Flaum, 1995). For negative symptoms, the effects include psychomotor poverty, amotivation, apathy, loss of self-esteem, and reduced concern for reward and reinforcements (Hogarty and Flesher, 1992).

The results of both spectrums are exhibited in learning deficits in different areas, including: decreased attention, poor abstract thinking, poor planning and problem solving, poor memory, decreased verbal skills, poor organizational skills (Davidson, 1993, pp. 4-5), selection between relevant and irrelevant stimuli, poor flexible shifting of attention, poor comparison of earlier stimuli to current stimuli, altered evaluative higher processes (Brenner, 1986, pp. 138-139), impoverished cognitive schema, visual impairments, and chunking impairments (Hogarty and Flesher, 1992).

Schizophrenia can also be defined as an inability to sustain an intentional focus to attention. This inability can lead to a lack of control over the mental processes. The patient is at times passive within their own mind. Additionally, according to Hogarty and Flesher (1992), it appears that the patient has an inability to "self-edit", resulting in both verbal and internal established but inappropriate responses. A result of this inability to direct a train of thought, access to long-term memory is compromised (Anscombe, 1987).

(Brenner, Hodel, Roder, & Corrigan, 1992) provide the following pictorial description (Figure 1), which shows the "vicious circles" that serve to decrease cognitive functioning and the ability to learn

Effects on Cognitive Function

General Tests

Schizophrenic patients have been studied extensively for cognitive functioning. Although not all schizophrenic patients exhibit cognitive deficits (Back et al., 1996), there is ample data to show that these defects do occur with regularity.

General testing of Schizophrenics shows that in specific tests, such as the Hiscock Forced-Choice Method, schizophrenics with cognitive impairments scored with 84.72% accuracy, compared to 97.44% accuracy for those with no cognitive impairment. Additionally, the time on Rey Dot Counting differed significantly. Cognitively impaired schizophrenics took over 4.6 seconds, while those without impairment were under 3 seconds (Back et al., 1996).

Extrapyramidal symptoms (EPS) are a result of long-term antipsychotic use in schizophrenic patients. Aside from the cognitive deficits attributable to the actual disease process, it appears that the EPS itself involves the presentation of additional difficulties in learning. While some noncognitive aspects of EPS such as bradykinesia can alter the results when testing for neuropsychological deficits, statistical analysis shows that neuropsychological deficits as a result of increasing severity of EPS in the area of learning are not related to the physical manifestations (Palmer, Heaton, & Jeste, 1999).

The decreased ability on these tasks is the result of deficits in two general areas, memory and attention. These are inextricably linked within the context of learning.

Attention

Attention can be divided into two subcategories: preattentive (automatic), and selective (effortful) (Anscombe, 1987). It has been suggested that the preattentive processes are impaired, with alternative stimuli in the environment not being filtered properly. However, it is the selective attention that has been found to be more affected. It appears that schizophrenics have difficulty with the first stages of processing new material, focusing on the stimuli with selective attention (Anscombe, 1987). This can be seen in the act of the patient's attention being captured by an irrelevant word or thought. It is as if the selective attention required to process the stimuli has been sublimated. This loss of selective attention allows the initial, preattentive forms of attention to proceed with no controls. Patients describe it as follows:

If I am reading, I may suddenly get bogged down at a word. It may be any word, even a simple word that I know well. When this happens, I can't get past it. It's as if I am being hypnotized by it. It's as if I am seeing the word for the first time and in a different way from anyone else. It's not so much that I absorb it, it's more like it absorbs me. (Anscombe, 1987)

It's not that I can't concentrate right, it's just that I can't concentrate on the major issues. I get fogged up with all the different bits and lose the important things in the picture. I find myself paying attention to all sorts of tiny things instead of getting on with the things I should be doing. (van den Bosch, J., 1994)

A theory of this is given by Knight (1984), who has shown through Visual Backward Masking (VBM) tests, that if a significant visual stimuli is presented and immediately followed by a meaningless pattern, the identification of the significant stimuli is reduced in Schizophrenic patients. This effect is lessened as the length of time between significant stimulus and masking stimulus are presented, but never reaches the level of the control group.

If successful in bringing the stimuli to the forefront of the consciousness to process, it must be selectively acted on and compared with previous experience. Once again, this ability is impaired. Conversely to short-term and simple recognition memories, which do not require active attention, searching memory for previous experiences requires long-term memory which is based upon directed attention, which is impaired (Anscombe, 1987). This is due to the attention in the schizophrenic being inflexible. The attention may be caught by another stimuli, during the act of searching long-term memory and it will remain there, not shifting back regardless of the amount of interest it actually holds.

Memory

Memory deficits in Schizophrenia can be severe. One instructor says:

He has trouble remembering words. If I ask him to give me another word for car, he can't. But if I put five words down and ask him to find one which means car, he'll get it. He has little memory for things from one moment to the next. He'll read two paragraphs and not remember a thing when we goto the questions. (Davidson, 1993, p. 45-46)

This statement itself is indicative of difficulty with retrieval of information from memory. There is also diffifficulty with recognition (though not as severe), short- and long-term memory (with short-term memory storage being more severe) (Davidson, 1993, p. 46).

Lack of attention span is indicated as a major contributor to this. Two students describe their problems with attention:

My mind is flying all over my work and I can't seem to assimilate. I can't recognize what I have done. I can't seem to remember what I did yesterday. Someone asks me to think about a problem or something and I find that I can't think. I have to go back over anything I learn, many, many times. I rely almost entirely on what I learned before I got sick. (Davidson, 1993, p. 46)

I need help remembering little things because I don't pay attention. I'm not paying attention right now. I get distracted pretty easy. If there were a dog barking outside, I'd listen to that. I can't stand a lot of noise when I'm working. I come to a word like that one there and I start playing around with it. (Davidson, 1993 p. 47)

medications can positively affect the attention span deficits in schizophrenic patients. By decreasing the stimuli that are disctracting, they enable the patient to spend more quality time on the task at hand. However, medications themselves can also affect the memory processes.

Drowsiness, as experienced with antipsychotic and antiparkinsonian medications, is itself a distractor, with the mind wandering more often, making staying on task more difficult. The antiparkinsonian drugs have additionally been shown to create problems with short term memory (Davidson, 1993, p. 48)

Improving Learning

There are a number of ways in which the ability to learn can be affected. These include internal cognitive compensation by the patient, hospitalization s, medications, therapy, and educator activities.

Cognitive Compensations

Patients in an acute stage of Schizophrenia percieve the world as a mass of information, without an overlying view to bring it together. They are unable to process sequentially and holistically, as do most people. Instead, they revert to analytical and sequential thinking (van den Bosch, 1994). This action in itself shows the symptom of the disease. People without the illness will also revert to this thinking, but only in new or unexpected situations. The fact that the Schizophrenic does so constantly infers that they are viewing the world with little regard for stored memories and ability to see it as a whole.

They have difficulty reacting, as they cannot compare the action that has been taken by the stimulus inducing person, to a historical perspective of "Does this mean they are mad, sad,etc." They must try to pick up on any available clues to infer the meaning of their environment. With the extra mental strain required to attempt to ferret out the truth, the whole from the details, comes hyperawareness of the surrounding world via all senses. The patient sees more acutely, hears tones more readily, but still isn't able to react appropriately.

Additionally, the patient will often take control of many functions normally processed, autonomically, such as motor control. This splits the attention even further, ending with more confusion, and less motor control. This can result in some of the negative symptoms of Schizophrenia such as decreased purposeful movement. (van den Bosch, 1994).

These compensations, while a necessary but unwilled act on part of the patient, are not beneficial in the holistic sense. They are mentally exhausting to the patient.

Hospitalizations

Hospitalizations, with over 50% of the sufferers requiring 2 or more hospitalization periods (Davidson, 1993, p. 1), also affect learning. Motivation can be greatly decreased when a person has to interrupt their studies and lifestyle on a frequent basis. Clearly, avoiding hospitalizations as much as possible allows the patient to continue with as normal a lifestyle as possible, and increases self-esteem and motivation.

Medications

Medications used to treat Schizophrenia can be very efficacious in decreasing delusions, hallucinations and thought disorders, resulting in an increased learning ability. When used judiciously, it has been shown in some studies to be up to a 20% percentile rank increase in various cognitive measures (Forness & Kavale, 1988), although as shown below, other learning functions are hampered. The antipsychotics, which are most commonly used, act to sedate the senses, decreasing (filtering) the flow of information that is received. They have the ability to increase vigilance, but have no noticeable effect on memory (Corrigan & Penn, 1995). However, the medications themselves can have side-effects which hinder learning. These include: Drowsiness, blurred vision, and extrapyramidal effects such as akathisia (Davidson, 1993, p. 7). Extrapyramidal symptoms are controlled via antiparkinsonian drugs, which have their own side-effects such as blurring and drying of the eyes, and dry mouth. The antiparkinsonian medications have the side-effect of decreasing verbal memory, as well (Corrigan & Penn, 1995).

Drowsiness affects the ability to pay attention and stay on task, also affecting memory. It can be described as thinking through molasses. Blurring of the eyes makes it difficult for the patient to read, especially with near vision. Dry eyes can make eye wear difficult to use due to constant itching of the eyes. A dry mouth may interrupt lessons, as a patient may need to take frequent drinks of fluids. Extrapyramidal symptoms can cause a difficulty in writing from tremors, inability to stay on task due to restlessness, and disinterest in activities from akinesia.

The effects of medication on a patient, as a result, have to be carefully evaluated. Doses that are too high can cause an increase in cognitive functioning problems as well as other side effects (Brown & Sawyer, 1998, p. 49). Doses that are too low may not provide enough filtration of the stimuli. It is a careful balancing act to minimize the total disruption (unfiltered stimuli + side-effects) to the patient. Only in this way can we reach the optimum level of functioning, which will vary from patient to patient. Additionally, medication side-effects may pass with time, being more severe with initial dosing, and decreasing with the body's acclimation to the medication over time.

Cognitive and Psychosocial Therapy

Cognitive and Psychosocial therapies have long been assumed to have no place in the remission of an acute psychotic episode. This was the place for medication. According to Beck and Rector (1998), this assumption is untrue. Using cognitive therapy similar to that used with depressed patients, they believe that gentle questioning and empirical testing regarding delusions and hallucinations can help in the abatement of active psychosis. Once the psychotic episode is in remission, the therapies can focus on the integration of the patient back into the classroom, workplace, and social settings.

It has been hypothesized that patients with Schizophrenia can be treated similarly to those with traumatic brain injury (TBI). However, this comparison fails upon closer inspection. While TBI's have an insult and infarction to the brain, it is almost always to the higher level processes and the outer layers of the brain, often the prefrontal cortex, in those that respond to cognitive rehabilitation. In contrast, it is hypothesized those with Schizophrenia have dysfunctions resulting from errors in the brainstem and midbrain structures as well as the prefrontal cortex (Hogarty & Flesher, 1992).

Seeming to support this view, psychosocial therapy does not have a strong track record as supported by research evidence in the outcome of Schizophrenia according to Scott & Dixon (1995). They note that "on average, individual treatment does not play an important role in reducing symptoms", and psychodynamic theory failed "... to exert any beneficial outcomes, either alone, or in combination with antipsychotic medications." They continue to note that studies suggest that Group psychotherapy in an institutional setting may actually be more harmful than beneficial, while in an outpatient setting there has been no consistent effect on the psychopathology of the disease. In contrast, Beck & Rector (1998) believe that cognitive therapy can reduce positive symptoms, as stated above, as well as negative symptoms. However, their studies were done with patients who were actively psychotic, not those in remission and attempting to return to normal daily routines.

Psychosocial skills training has been shown to have positive impacts on the patient with Schizophrenia when followed at one year, but these gains had been lost by the second year. Additionally higher complexity tasks were less like to be generalized into the novel situtations of life, as compared to simpler tasks such as meeting a person's eyes. There has been defined an optimum setting and method for producing these results. They include (Liberman & Green., 1992):

Engagement of patients in brief, assimilable dialogs to engage them in personalized goal setting and endorsement of training objectives.

Video demonstrations of the skills to be learned, with Socratic questions and answers to promote vigilance in the video viewing.

Role-play exercises in which the patients practice those skills previously observed in the viedo and during which abundant reinforcement, cuing, prompting, and coaching are provided.

Problem-solving exercises in which the trainer leads the patients through a series of challenges or obstacles to the successful implementation of the skills in their natural environments, requiring the patients to inductively learn how to overcome these obstacles by using a problem-solving method.

In vivo homework exercises in which the trainer gradually fades back from the patients as they use the skills learned earlier in real-life situations.

Keeping the training settings uncluttered and devoid of distrating stimuli.

Posting graphic charts for clear and simple visual cuing of the learning objectives; capitalizing on dual-channel inputs, both auditory and visual.

Using differential feedback, including mild social censure or disapproval as well as exuberant positive praise, for inappropriate and appropriate responsiveness to training steps.

Using task analyses to break down knowledge and skills to be learned, so that learning can proceed incrementally with a shaping paradigm of reinforcing successive approximations.

Employing overlearning and repetition and other generalization-promoting techniques for transfer of learning from training to real-life settings.

There has been an addtional type of therapy, supportive psychotherapy (Scott & Dixon, 1995), which has begun to show impact upon the patient, but is still in the stages of growth. This therapy includes items such as strengthing the theraputic alliance, enacting environmental interventions, setting limits and prohibitions, and undermining maladaptive defenses while strenghtening adaptive defenses. Brenner, Hodel, Roder & Corrigan (1992) show us a model of the relationship between social and cognitive skills. It must be identified, as noted in figure 2, what the goal of the therapy is, in order to determine what skills and abilities are to the outcomes.

It must be noted, that all forms of therapy are based upon the assumption that the patient has sufficient cognitive functioning and learning ability to benefit. According to Corrigan and Penn (1995), the level of learning ability has been shown to be directly related to outcomes of therapy.

Strategies for Help

Educators and therapists can help patients achieve their optimum learning with understanding and assistance in a number of areas, including: attendance, attention, vision problems, comprehension, delusions and hallucinations, sedation, regression, problem solving and organization, responsiveness, extrapyramidal symptoms.

Patients with Schizophrenia may have attendance problems for a number of reasons including, hospitalizations, "drug holidays" (times when a drug is stopped for a period of time, often to give relief from side-effects), and frustration with progress. Encouraging patients to return to school, being compassionate rather than angry, and working with times that side-effects of medication are less severe all can encourage the best attendance possible. (Davidson, 1993, p. 97-98)

Attention problems with from both the illness and medication occur from having to switch tasks frequently, or from distractors. Actions that will help students to maintain maximum attention include: keeping projects short, and uncomplicated, using auditory, visual and stimulus (alternate writing with reading, etc.), and asking questions concretely to refocus the student (Davidson, 1993, p. 101-102). Additionally, it has been shown that attention remediation has been helpful in attention span deficits. Options for this include training in self-instruction during a task and training by computer (Medalia, Aluma, Tryon, & Merriam, 1998).

Vision problems affect the students ability to stay on task, as they can either not see clearly, or are constantly having to rub their eyes. Patients with blurred vision can see at a distance better than near. Using big print, colored paper (or wearing colored, such as yellow, sunglasses), avoidance of flourescent lights, and magnifying glasses have been shown to be of help. Dry eyes can be assisted through the use of saline drops (Davidson, 1993, pp. 102-103).

Comphrehension is affected in schizophrenics due to their decreased ability to think abstractly, as well as decreased attention. Keeping the material to be understood short and succinct, and then asking questions that are concrete can assist in the comprehension and retainment of the material (Davidson, 1993, p. 108).

Delusions and Hallucinations are very detrimental to learning, as the patient is in a psychological state in which their reality is altered. There are a number of ways to assist this patients during their learning process. Avoidance of emotionally charged situations can help prevent the triggering of delusions. They are more likely to learn factual information, rather than emotional. Additionally, many patients with Schizophrenia have identified strategies that they can use to either "encapsulate" (essentially, to put in the background) or decrease the severity of the attack. Asking the student about these strategies beforehand, so that the instructor can coach them to use them when needed is beneficial. Continuing to stay with the subject matter, and not become a therapist to the patient during these times, with frequent cues to refocus the attention is also successful (Davidson, 1993, pp. 110, 114-115).

Sedation is a common side-effect of many of the medications used to treat Schizophrenia. Accommodation for the student is paramount. Completing more complex tasks earlier in the day is useful. Physical activity can help to offset sedation, even just a short walk when they are feeling particularly fatigued. Taking a short nap, even for a half hour has been found to be beneficial by students as well (Davidson, 1993 pp. 111-112).

Mental regression in the form of the loss of abstract thinking ability can also be seen in the schizophrenic patient. The use of less abstract and more concrete questions is the best. The same end result can be achieved, although with a more circuitous route (Davidson, 1993 pp. 118-119).

The patient may also be suffering from deficits with problem solving and organization. Teaching the student to actively and consciously problem solve is essential (such as: identify the problem, making a plan, following the plan, evaluating the results). Writing the problem and solution out for a number of different scenarios can be beneficial (Davidson, 1993 pp. 122-123).

A lack of responsiveness to the task at hand, or to the environment in general is not uncommon in schizophrenic patients. This is a difficult situation to deal with, as you are not provided with feedback as you continue. While there is no outside expression, these patients may still be experiencing internal sensation, and not be able to express it. Keeping a positive attitude, and not withdrawing from the student is important.

Extrapyramidal symptoms are physical manifestations that result from the use of antipsychotics over a long time period. There are no specific interventions that can be used other than promoting tolerance. This includes within the class setting, where other learners need to be educated about the physical manifestations, and within the educator, that the learner will often not provide neat work, and written work may not be always within the given timelines.

Memory impairment, particularly implicit as discussed earlier, can be offset by using "errorless learning" (O'Carrol, Russell, Lawrie & Johnstone, 1999). When a patient is asked the answer to a question, and they provide the wrong answer, and are eventually told the right answer, they are participating in "errorful learning" such as when a patient is told "I am thinking of something clear, cold, and wet" and then are given the chance to answer until they guess correctly or a given time period elapses. Errorless learning is when a learner is told the situation and then the answer such as "I am thinking of something clear, cold, and wet, I am thinking of ice.", the learner will remember that answer. In the errorful learning, there are two hypotheses: that the patient has difficulty determining whether a stimulus was internally or externally generated after a time lag occurs; and all answers being remembered via implicit memory, with subsequent confusion. With errorless learning, with only one answer being provided, the patient has only one stimulus to remember, and is more likely to remember it correctly.

Conclusion

Schizophrenia is a disease that strikes many people while they are young, while they are still in their learning and formative years. As a result, the deficits in attention and memory that result have long-lasting consequences for the remainder of their lives.

It has been shown that there are a number of treatments available for Schizophrenia, but none of them cure the underlying pathologies that result in impaired learning. Medical treatments such as medication have been shown to have positive impacts, but also carry their own burdens, which in turn hamper the learning process, even when used judiciously. Cognitive and psychosocial therapies in the past have not shown great success with long-lasting changes. However, as we learn more about the way the human animal learns, and the effects of the disease, we are discovering more ways in which we can effect changes for longer periods of time. Many of these are outlined within this paper.

In the end result, the burden of enabling patients to learn falls to both the patient and the educator working with them. There are many simple changes, also noted, that can be made to the educational process that will assist the patient in focusing attention, and storing information more effectively. It is, in the end, a position that requires extra effort, but the skills can be easily learned, and possibly generalized to other populations with organic brain disorders.

References

Andreasen, N.C. (1995). Symptoms, signs, and diagnosis of Schizophrenia. Lancet, 346, 477-482.

Andreasen, N.C., Arndt, S., Alliger, R., Miller, D., & Flaum, M. (1995). Symptoms of Schizophrenia: methods, meanings, and mechanisms. Archive of General Psychiatry, 52, 341-351. Back, C., Boone, K.B., Edwards, C., Parks, C., Burgoyne, K., & Silver, B. (1996). The performance of schizophrenics on three cognitive tests of malingering, rey 15-Item memory test, rey dot counting, and hiscock forced-choice method, Assessment, 3(4), 449-457.

Anscombe, R. (1987). The disorder of consciousness in Schizophrenia. Schizophrenia Bulletin, 13(2), 241-260.

Back, C., Boone, K.B., Edwards, C., Parks, C., Burgoyne, K., & Silver, B. (1996). The performance of schizophrenics on three cognitive tests of malingering, rey 15-Item memory test, rey dot counting, and hiscock forced-choice method, Assessment, 3(4), 449-457.

Beck, A.T., Rector, N.A. (1998). Cognitive therapy for schizophrenic patients. Harvard mental health Letter, 15(6), 4-7.

Brenner, H.D. (1986). On the importance of cognitive disorders in treatment and rehabilitation. In Strauss, J.S., Boker, W., & Brenner, H.D. (Eds.), Psychosocial Treatment of Schizophrenia (pp. 136-151). Toronto: Hans Huber Publishers.

Brenner, H.D., Hodel, B., Roder, V., & Corrigan, P. (1992). Treatment of cognitive dysfunction and behavioral deficits in Schizophrenia. Schizophrenia Bulletin, 18(1), 21-26.

Brown, R.T. & Sawyer, M.G. (1998). Medications for school-age children. New York: Guilford Press.

Corrigan, P.W., & Penn, D. L. (1995). The effects of antipsychotic and antiparkinsonian medication on psychosocial skill learning. Clinical Psychology: Science and Practice, 2(3), 251-262.

Davidson, H. (1993). Just ask: a handbook for educators. Calgary: Detselig Enterprises Ltd.

Forness, S.R. & Kavale, K.A. (1988). Psychopharmacologic treatment: a note on classroom effects. Journal of Learning Disabilities, 21(3), 144-147.

Green, M.F. (1996). What are the functional consequences o neurocognitive deficits in Schizophrenia?. American Journal of Psychiatry, 153(3), 321-330.

Hogarty, G.E. & Flesher, S. (1992). Cognitive remediation in Schizophrenia: proceed... with caution!. Schizophrenia Bulletin, 18(1), 51-57.

Knight, R.A. (1984). Converging models of cognitive deficit in Schizophrenia. In Spaulding, W.D., & Cole, J.K. (Eds.), Theories of Schizophrenia and psychosis. Lincoln: University of Nebraska Press.

Liberman, R.P., & Green, M.F. (1992). Wither cognitive-behavioral therapy for Schizophrenia. Schizophrenia Bulletin, 18(1), 27-35.

Medalia, A., Aluma, M., Tryon, W., & Merriam, A.E. (1998). Effectiveness of attention training in Schizophrenia. Schizophrenia Bulletin, 24(1), 147-152.

O'Carrol, R.E., Russell, H.H., Lawrie, S.M. & Johnstone, C. (1999). Errorless learning and the cognitive rehabilitation of memory-impaired schizophrenic patients. Psychological Medicine, 29(1), 105-112.

Palmer, B.W., Heaton, R.K., & Jeste, D.V. (1999). Extrapyramidal symptoms and neuropsychological deficits in Schizophrenia. Biological Psychiatry, 45, 791-794.

Scott, J.E. & Dixon, L.B. (1995). Psychological interventions for Schizophrenia. Schizophrenia Bulletin, 21(4), 621-630.

van den Bosch, R.J. (1994). Context and cognition in Schizophrenia. In Boer, J.A., Westenberg, H.G.M., & Pragg, H.M. (Eds.), Advances in the Neurobiology of SchizophreniaChichester: Wiley.

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schizophrenia is a disorder which affects approximately 1% of the world population, has a 10% suicide rate, an estimated $20 billion in lost productivity and $11.1 billion in medical costs in the United States in 1980 (Andreasen, 1995). The primary characteristics are disturbed language, communication, thought and perception (Davidson, 1993 p.

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Schizophrenia Definition
Schizophrenia is a mental disorder or illness that affects as many of 2 million Americans each year. It is a mental disorder that cannot be cured and can have severe and even disabling symptoms that can affect individuals their entire lives. Many people estimate that as many as one percent of the world population is affected by schizophrenia. Many believe that the disorder can effect men and women equally; but most would agree that men are often effected at earlier ages and often more severely than women. (Grohol, n.d.). Some others think that the numbers of people affected by Schizophrenia are closer to nearly 1 in every 100 people, as does Professor John McGrath of Queensland Centre for Mental Health Research. There is a strong believe by some that schizophrenia does occur more often in males than it does in females and that in different areas of the world the numbers of cases of schizophrenia differ. (Prevalence of, 2005). The only thing that the professional seem to agree fully on is that that is no clear cause for this disorder.

Symptoms
As is true with most mental illnesses or disorders, symptoms do not always fit exactly and can actually represent a variety of illnesses and disorders; so it is very important to rule out all possible physical problems and ailments before considering schizophrenia as a diagnosis. Also it is worth noting that many mental illnesses and disorders share common symptoms, and schizophrenia is no different in this respect. There are several symptoms associated with Schizophrenia.
* Distorted perceptions of Reality. Because schizophrenics live an existence that includes delusions and hallucinations, they often have a much skewed view of reality. They often find themselves living in their own world or reality.
* Hallucinations and Illusions. Hallucinations and illusions are very common for people suffering from schizophrenia. Hallucinations can occur by use of any sense perception, but auditory (hearing voices) is the most common for of hallucination for schizophrenics. These voices can talk to the schizophrenic, advice them, carry on regular conversations with them, and direct them to do certain things. An Illusions is a real sensory stimulus, but one that the schizophrenic individual interrupts wrongly.
* Delusions. A delusion is considered a false belief that has no rational basis. A person with schizophrenia may have feeling of being persecuted or spied upon.
* Disordered thinking. The schizophrenic is often not able to think clearly or "think straight".
* Emotional Expression. Those suffering from schizophrenia often show little to no emotion and even go as far as changing their speech patterns to expression filled speech to a monotone flat speech.
* Normal versus Abnormal degrees. Though everyone that is considered normal may exhibit some of the symptoms listed above some of the time; schizophrenics exhibits at least 2 or more of the symptoms in a more chronic or persistent manner. (Grohol, n.d.)

Types of Schizophrenia
There different types of sub-categories of schizophrenia. All of the sub-categories of schizophrenia are defined and recognized by their main characteristic or symptoms.
* Paranoid Schizophrenia. The main symptoms that are exhibited in this sub-category are feeling of persecution or conspiracy and auditory hallucinations.
* Disorganized Subtype. This sub-category is characterized with severe inability to organize and arrange daily living activities such as bathing, dressing, and eating. Hallucinations and delusions are usually less seen in this sub-category.
* Catatonic Subtype. This sub-category is one of the most severe degrees of schizophrenia. An example of the sub-category might be a person lying in the fatal position and able to respond to any stimulus. This state of schizophrenia can also include repetitive and meaningless sounds and movements though. In other words, the person can be void of any real communication but still make mimicking sounds or movements mocking those people around.
* Undifferentiated subtype. This sub-category is used for individuals with a diagnosis of schizophrenia, but that do not fit clearly into one of the other sub-categories. It is a sort of "catch all" sub-category.
* Residual subtype. This sub-category refers to individuals with a schizophrenic diagnosis, but that are not currently exhibiting any of the severe symptoms associated with the illness. These could be persons on medication or persons with a period of a type of remission or rather absence of the more severe symptoms. (Bengtson, 2001).

Treatment
As with most mental illnesses and disorders, schizophrenics benefit from a variety of treatments and medications. There seems to be two main issues to first address when caring for someone with schizophrenia and those are; make sure the person is taking their medication regularly and try to provide a safe and secure home environment. Those are just the beginning steps and there are more specific treatments that are available.

In all cases of schizophrenia, antipsychotic medications are almost always utilized. Some of the older medications have been available since the 1950's. These drugs; Thorazine, Haldol, Prolixin, Navane, and others were referred to as "neuroleptics" because they caused neurological side effects and had little effect on the emotional expressiveness of the patients. Since 1989 a new series of medications have been introduced including; Clozaril, Risperdal, Zyprexa, Abilify, and some others. These medication generally take two to four weeks to really take effect and have fewer side effects neurologically, but they all do still have some and varied side effects. It may take time to adjust the medication to obtain the correct dosage for each individual. One major draw back to these new medications is that failure to use them or irregular use can cause the schizophrenic individual to relapse more quickly. Still with all of the side effects and problems, antipsychotic medications are required for most schizophrenic patients.

Schizophrenics often have problems with daily living skills, relationships, communication skills and motivation. For these reasons it is almost imperative that schizophrenics get some type of psychosocial assistance. Sessions with psychologists or psychiatrists are very important to these patients' social growth. This is even more so important since the majority of cases begin at the early teen ages when social growth is so important. Family counseling with the patient in a group setting is also important. Between medications and proper counseling, most schizophrenics are able to live near normal lives. (Schizophrenia, 2006).

Educating Individuals with Schizophrenia
To this point we have discussed what people diagnosed with schizophrenia can do to help themselves, and even what family and relations can do to help; but there is still the issue of how to educate these individuals in our classrooms. There are several good suggestions as to how educators can address the problems faced with teaching students with schizophrenia. The first and foremost important issue for the educator placed in this position is to be well educated about the illness. Be ware of available treatments, causes, and symptoms so that you can discuss intelligently with parents or students issues concerning education. Reduce stress in the room as much as possible. Work with the student with schizophrenia to help them set realistic academic and social goals. Establish regular meetings with the family or student to discuss issues, problems, or successes. As much as possible, encourage participation and interaction between the student with the illness and other students. (Basic facts, 2001).

Accommodations and Modifications
With many disorders, disabilities, and illnesses there can be a variety of problems and learning problems associated with the person. Many schizophrenics can have learning disabilities in connection with their mental disorders. Addressing accommodations and modifications for individuals with schizophrenia is as individual as each person. There are many accommodations that can be used to make the schizophrenic's academic experience a positive one.

Stress seems to be one thing that can worsen the schizophrenic's chances for success. Relieving stress from the environment is one thing that should be used. Allowing the student to have a quiet secluded place to complete assignments and tests is one way to provide the student with a stress free environment. Internet courses are also a way for these students to be able to complete courses in a safe and stress free environment. The main accommodation that can be provided is priority registration. With priority registration students can choose times and teachers that will best fit into their routine and fit their needs. These are just a very few accommodations that are readily available for these students.

Schizophrenia is an illness that affects many Americans and people world wide. It is an illness that can be disabling if not treated appropriately; but can be just a minor hindrance if treated properly and addressed early. With the number of cases growing and with the prime time for onset of schizophrenia being generally early teens and early twenties, school age students are greatly affected. It becomes important for educators to become more aware of the disease and more aware of how to address this illness and the students that have it.

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Teaching and Understanding Students with Schizophrenia

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Schizophrenia Definition Schizophrenia is a mental disorder or illness that affects as many of 2 million Americans each year. It is a mental disorder that cannot be cured and can have severe and even disabling symptoms that can affect individuals their entire lives.