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Social Anxiety Disorder - causes, symptoms, diagnosis, treatment, pathology

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National Institute of Mental Health (NIMH)

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What is anxiety?

Occasional anxiety is a normal part of life. Many people worry about things such as health, money, or family problems. But anxiety disorders involve more than temporary worry or fear. For people 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, schoolwork, and relationships.

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

What are the signs and symptoms of anxiety?

What are the risk factors for anxiety?

How is anxiety treated?

How can I find a clinical trial for anxiety?

Where can I learn more about anxiety?

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Learn about anxiety disorders, including signs and symptoms, types, risk factors, and potential treatments and therapies.

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doi: 10.1176/appi.focus.20150029.

Affiliation

¹ Dr. Chiu is assistant professor of psychology in psychiatry, and assistant attending psychologist for Weill Cornell Medical College, New York Presbyterian Hospital, New York City. Dr. Falk is instructor of psychology in clinical psychiatry with the Department of Psychiatry, Weill Cornell Medical College, New York City. Dr. Walkup is professor of psychiatry, DeWitt Wallace senior scholar, vice-chair of psychiatry, and director of the Division of Child and Adolescent Psychiatry, Weill Cornell Medical College and New York Presbyterian Hospital.

Free PMC article

Angela Chiu et al. Focus (Am Psychiatr Publ).

Free PMC article

doi: 10.1176/appi.focus.20150029.

Affiliation

¹ Dr. Chiu is assistant professor of psychology in psychiatry, and assistant attending psychologist for Weill Cornell Medical College, New York Presbyterian Hospital, New York City. Dr. Falk is instructor of psychology in clinical psychiatry with the Department of Psychiatry, Weill Cornell Medical College, New York City. Dr. Walkup is professor of psychiatry, DeWitt Wallace senior scholar, vice-chair of psychiatry, and director of the Division of Child and Adolescent Psychiatry, Weill Cornell Medical College and New York Presbyterian Hospital.

Abstract

Anxiety disorders represent the most common psychiatric illnesses affecting children and adolescents. Youths who suffer from anxiety disorders typically experience impairment in social, family, and educational domains of functioning. Despite the prevalence of youth anxiety disorders, identifying anxiety as the underlying cause can be a challenge. This article summarizes recent changes in diagnostic criteria in DSM-5, reviews core features of anxiety, and discusses how to recognize anxiety among youths. It also provides recommendations on how to differentiate anxiety from other diagnoses, with a focus on attention-deficit hyperactivity disorder. Suggestions for evidence-based assessment methods and instruments will be made. This article will also review the current evidence base for treatments and provide recommendations for managing refractory cases from a behavioral perspective. The scope of the review focuses on the following constellation of anxiety disorders: separation anxiety disorder, social anxiety disorder, panic disorder, agoraphobia, specific phobia, and generalized anxiety disorder. Although obsessive-compulsive disorder is not categorized with the other anxiety disorders in DSM-5, it will also be covered within this review.

Conflict of interest statement

The authors report no financial relationships with commercial interests.

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Treatment of Anxiety Disorders: A Systematic Review [Internet].

Swedish Council on Health Technology Assessment. Swedish Council on Health Technology Assessment. Stockholm: Swedish Council on Health Technology Assessment (SBU); 2005 Nov. SBU Yellow Report No. 171/1+2. Stockholm: Swedish Council on Health Technology Assessment (SBU); 2005 Nov. SBU Yellow Report No. 171/1+2. PMID: 28876726 Free Books & Documents. Review.

The relationship between obsessive-compulsive disorder and anxiety disorders: A question of diagnostic boundaries or simply severity of symptoms?

Vigne P, Simões BFT, de Menezes GB, Fortes PP, Dias RV, Laurito LD, Loureiro CP, Moreira-de-Oliveira ME, Albertella L, Lee RSC, Stangier U, Fontenelle LF. Vigne P, et al. Compr Psychiatry. 2019 Oct;94:152116. doi: 10.1016/j.comppsych.2019.152116. Epub 2019 Aug 8. Compr Psychiatry. 2019. PMID: 31421287

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Anxiety Disorders Among Children and Adolescents - PubMed

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Overview

There is a commonly held misconception that eating disorders are a lifestyle choice. Eating disorders are actually serious and often fatal illnesses that are associated with severe disturbances in people's eating behaviors and related thoughts and emotions. Preoccupation with food, body weight, and shape may also signal an eating disorder. Common eating disorders include anorexia nervosa, bulimia nervosa, and binge-eating disorder.

Signs and symptoms

Risk factors

Treatments and therapies

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Learn about eating disorders, including types (e.g., anorexia nervosa, bulimia nervosa), signs and symptoms, risk factors, and treatments and therapies.

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Eating disorders are about more than just fad diets and vanity; they are a serious mental illness that could ultimately cause the end of someone's life. It's estimated that as many as 30 million people in the U.S. suffer from an eating disorder. Approximately 4-10% of male and 10-20% of female college students are dealing with an eating disorder.

In spite of heightened awareness of some of the more common types of eating disorders, there are still many misconceptions. Let's take a look at some facts to help dispel the myths of eating disorders.

What is an Eating Disorder?

Eating disorders revolve around abnormal eating habits and often include physical changes.

For some, eating disorders involve limiting the amount of food that is consumed; for others, it involves uncontrollable eating. Some people with eating disorders become obsessed with diet and exercise. Others will eat large quantities of food and then vomit.

There is no single demographic at risk for eating disorders; they're diseases that can occur in people of any gender, race, religion, or socio-economic background.

Types of Eating Disorders

Let's take a look at the most common types of eating disorders and discuss some of the symptoms and effects of each.

Anorexia Nervosa

Anorexia is the most well-known eating disorder. When people think or talk about eating disorders, this is usually what they are referring to.

Anorexia is characterized by restricting food intake. This could be limiting oneself to only a particular food, for example carrot sticks, or limiting the amount of food and/or calories that are consumed.

People with anorexia are typically underweight, but this not always the case. Some people can have all the behaviors without the significant weight loss or without the appearance of losing weight. There are also those who have the binge-purge subtype. This means the person will restrict food intake most of the time but have times of eating too much food and following that with purging usually by vomiting.
Symptoms of Anorexia
The most common symptoms of anorexia include:

Fear of gaining weight

Distorted body image; seeing oneself as fat even when underweight

Frequent monitoring of weight

Restricting calories

Being underweight comparted to people of a similar age and height

Weight being linked to self-esteem and self-worth

While it is mostly women who suffer from anorexia, people of other genders can also become anorexic. According to one study, 0.9% of American women will suffer from anorexia in their lifetime.

Bulimia Nervosa

Like anorexia, bulimia tends to develop in adolescents and young adults and is more common in women. An estimated 1.5% of American women suffer from bulimia during their lifetimes.

Bulimia involves purging food from the body to reduce the number of calories consumed. This purging can take place through compensatory behaviors like vomiting, excessive exercise, laxatives, diuretics, or enemas.

Some bulimics eat large quantities of food in a short period of time and can become painfully full. Eating large quantities of food in a short period of time is called binging. The purging is often to reduce that painful feeling from overeating.

It is important to understand that bulimia is different from the binge purge sub-type of anorexia. Most bulimics maintain a normal body weight while most anorexics are underweight. Bulimics also do not typically restrict their food intake on a regular basis.
Symptoms of Bulimia
The most common symptoms of bulimia include:

Eating in a short period of time an amount of food that is definitively larger than what most individuals would eat in a similar time period under similar circumstances

Feeling of a lack of control over food and eating during an episode

Recurring inappropriate compensatory behaviors(purging) to avoid weight gain

Those suffering from bulimia often have physical repercussions for their behaviors. Those side effects may include:

Tooth decay and eroded tooth enamel

Severe dehydration

Acid reflux

Frequent sore throats

Ulcers

Intestinal distress

Electrolyte imbalances - levels of potassium, sodium, calcium, and other minerals can be too high or too low - this can result in a heart attack or a stroke

People suffering from bulimia often also have comorbid substance abuse issues, particularly alcohol abuse, or mental health issues like depression, anxiety, or bipolar.

Diabulimia

Diabulimia is the deliberate underuse of insulin in people with type 1 diabetes for the purpose of weight control.

Diabulimia may also be referred to as Eating Disorder-Diabetes Mellitus Type 1, which is any eating disorder that co-exists with diabetes.

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does not have a specific listing for diabulimia, but insulin manipulation is often viewed as a compensatory behavior or a purging behavior when discussing bulimia. The key difference and the reason there's a need to discuss this individually is because of the serious health risks posed by this behavior. With approximately 38% of females and 16% of males with type 1 diabetes having disordered eating behaviors, and the serious health risks it poses, it is important to be aware of this type of eating disorder.
Symptoms and Warning Signs of Diabulimia
The most common symptoms and warning signs of diabulimia include:

Secrecy about diabetes management

Neglect of diabetes management

Fear of low blood sugars

Fear and/or talk of "insulin makes me fat"

Anxiety about body image

Strict food rules

Avoiding eating with others

Preoccupation with food, weight, calories, or blood sugar levels

A1c continuously at 9.0 or higher

Fatigue and/or increased sleep

Increase in diabetes symptoms

As with untreated diabetes, there are a lot of significant physical issues that can occur. Those with diabulimia are at risk for retinopathy, peripheral neuropathy, kidney disease, liver disease, heart disease, coma, stroke, or even death. A 2008 study showed that diabulimia increased the risk of death threefold.

Binge Eating Disorder

When the DSM-5 was released in 2015, a new eating disorder was added, binge eating disorder.

People with binge eating disorder (BED) have lost control over his/her eating. Like the binge eating in bulimia, they tend to eat large quantities of food in a single sitting, more than an ordinary person would eat in that same situation. Unlike bulimia, however, there is no compensatory behaviors. Because of this, people with BED are often overweight.

BED is believed to be the most common eating disorder in the United States with an estimated 2.8% of adults in America suffering from BED within their lifetimes.
Symptoms of Binge Eating Disorder

The most common symptoms of binge eating disorder include:

Eating even when full or not hungry

Eating alone or in secret to avoid embarrassment

Eating unusually large quantities of food in a specific period of time

Eating much for rapidly than normal

Eating until uncomfortably full

Feeling disgusted or ashamed of oneself or feeling guilty after eating

A feeling of a lack of control when it comes to food and eating

Typically, those with BED are overweight or obese. This can increase the person's risk of medical complications like type 2 diabetes, stroke, and heart disease.

More than half of those with BED also have an anxiety and/or mood disorder.

Orthorexia

Orthorexia, sometimes called orthorexia nervosa, falls under the category of eating disorders not otherwise specified (EDNOS). While it is not recognized in the DSM-5 as its own type of eating disorder, it is becoming more and more common.

Unlike most other eating disorders, the focus of orthorexia is not on weight. Orthorexia is an obsession with healthy eating. People suffering from orthorexia develop fixations on eating only foods they deem to be pure or healthy.

While it may start out as a person just trying to become healthier, the obsession can lead to some serious negative consequences including malnutrition.
Symptoms of Orthorexia
The most common symptoms of orthorexia include:

An increased concern about the health of the ingredients of food

Compulsively checking the list of ingredients and nutrition labels

Cutting out multiple food groups (all sugar, all carbs, all meat, all animal products, all dairy, etc.)

A refusal and inability to eat anything except a narrow group of foods deemed healthy or pure

Spending hours a day thinking and worrying about what foods may be served at an upcoming function or meal

While it may start with good intentions of eating healthier, once the line is crossed into obsession orthorexia occurs.

People with orthorexia typically have another eating disorder, obsessive-compulsive tendencies, high anxiety, or a need for control.

Because there are no formal diagnostic criteria, it is difficult to get an accurate estimate of the number of people who suffer from orthorexia.

Rumination Disorder

Another eating disorder that was first discussed in the DSM-5 is rumination disorder.

In this eating disorder, a person voluntarily regurgitates food that he/she has already eaten. The person may re-chew the food, re-swallow the food, or spit the food out. This takes place within the first 30 minutes of eating.

This disorder can develop in infants between three and twelve months old. In those cases, it often disappears on its own. When this occurs in children and adults, it is more serious and typically requires treatment. When occurring in children, it can rob the child of the nutrients needed to grow and develop correctly.
Symptoms of Rumination Disorder
The most common symptoms of rumination disorder include:

Repeated regurgitation of food; the food may be re-chewed, re-swallowed, or spit out

The regurgitation is voluntary and is not due to any medical conditions

Weight loss

Tooth decay and bad breath

Frequent stomach aches

While this disorder is typically seen in children, it can also be seen in some adults. It is most commonly found in those with developmental disorders, intellectual disabilities, stress, or anxiety.

While thought to be uncommon, there is no real information about the number of people who suffer from rumination disorder. This may be because it happens more in children or because adults feel so much shame about this behavior.

Causes of Eating Disorders

While eating disorders typically appear in the teen years or young adulthood, eating disorders can develop in those younger or older than that. Eating disorders can occur in people of all genders. Eating disorders are not caused by vanity and fad diets alone. Biological, psychological, and societal influences can all contribute to an eating disorder.

Biological

Genetics: Eating disorders do tend to run in families. While it is still debated if this is a situation where nature or nurture is the cause of this trend, there has been research done looking into the genetics of eating disorders. So far, the research has been promising in finding some substantial genetic influence. Currently, it is estimated that 50-80% of the risk for anorexia or bulimia is genetic.

Type 1 diabetes: With approximately 38% of females and 16% of males with type 1 diabetes having disordered eating behaviors, including diabulimia, this becomes an important risk factor for developing an eating disorder.

History of dieting: Sometimes a history of dieting can lead to the development of binge eating or bulimia.

Psychological

Perfectionism: As we discussed, sometimes things like perfectionism can lead to the development of an eating disorder. A need to eat only the "perfect" foods or to look "perfect" can lead to disorders like anorexia, bulimia, diabulimia, orthorexia, or even rumination disorder.

Obsessive tendencies or a feeling of a loss of control: Obsessive tendencies and a need to feel in control can also lead to eating disorders. If a person is feeling as if he/she has no control over the things in his/her life, the person may turn to one thing that can be controlled - food.

Poor body image: Body image is how one feels about and in his/her body. This could be from feeling as if one were born to the wrong gender, from feeling overweight or disproportionate, or just having a different idea of what someone should look like. This can lead to controlling food intake in order to reach that ideal body image one has.

Depression and/or Anxiety: Many people with eating disorders also have depression and/or anxiety. It is also possible for the person to have other mental health issues like bipolar, obsessive-compulsive disorder, or schizophrenia. It is estimated that 33-50% of those with anorexia have a comorbid mood disorder and about 50% have an anxiety disorder.

Societal

Teasing and bullying: Being teased or bullied about weight is becoming a common reason for people to develop an eating disorder. With an increase in cyberbullying and a need to have a picture-perfect life on social media, this is becoming a more common reason for eating disorders to develop particularly in teenagers.

Trauma/abuse: A history of trauma or abuse can lead to the development of an eating disorder. For some, the trauma can lead to the feeling of being unworthy of food. For others, the feeling of "if I looked perfect, this wouldn't have happened to me" takes over and leads to the development of an eating disorder.

Lack of friendships/social support: Some people have reported turning to eating disorders, particularly binging and purging, after feeling bored. For others, they hope to be able to make friendships if they lose weight or are more attractive.

Seeking Treatment for an Eating Disorder

Eating disorders have the highest mortality rate of any mental illness. At least one person dies as a direct result of an eating disorder every 62 minutes.

It is important to know, however, that eating disorders are treatable. There is help available to those suffering from an eating disorder. You can visit the National Eating Disorders Association (NEDA) website for some useful tools. You can use this screening tool to determine if you or a loved one may be suffering from an eating disorder. You an also contact the NEDA helpline for support and resources.
National Eating Disorders Awareness Week (#NE Awareness) is February 25 - March 3, 2019. We're changing the conversation around food, body image, and eating disorders! Join the movement and #ComeAsYouAre, not as you think you should be. www.nedawareness.org. Rebecca Encao, MSMHC is both an instructor and a team lead for Southern New Hampshire University and has taught psychology and social science courses for SNHU since 2015. Prior to that she worked with eating disorder patients at Eating Recovery Center in Denver.

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Types of Eating Disorders: Symptoms, Causes and Effects

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Eating disorders are about more than just fad diets and vanity; they are a serious mental illness that could ultimately cause the end of someone's life. It's estimated that as many as 30 million people in the U.S. suffer from an eating disorder.

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Anorexia Recovery Story: How I Survived An Eating Disorder

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An eating disorder is any disorder characterized primarily by a pathological disturbance of attitudes and behaviors related to food, including anorexia nervosa, bulimia nervosa, and binge-eating disorder. Other eating-related disorders include pica and rumination, which are usually diagnosed in infancy or early childhood.

Adapted from APA Dictionary of Psychology

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An eating disorder is any disorder characterized primarily by a pathological disturbance of attitudes and behaviors related to food, including anorexia nervosa, bulimia nervosa, and binge-eating disorder. Other eating-related disorders include pica and rumination, which are usually diagnosed in infancy or early childhood. Adapted from APA Dictionary of Psychology

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Overview

If you have a mood disorder, your general emotional state or mood is distorted or inconsistent with your circumstances and interferes with your ability to function. You may be extremely sad, empty or irritable (depressed), or you may have periods of depression alternating with being excessively happy (mania).

Anxiety disorders can also affect your mood and often occur along with depression. Mood disorders may increase your risk of suicide.

Some examples of mood disorders include:

Major depressive disorder - prolonged and persistent periods of extreme sadness

Bipolar disorder - also called manic depression or bipolar affective disorder, depression that includes alternating times of depression and mania

Seasonal affective disorder (SAD) - a form of depression most often associated with fewer hours of daylight in the far northern and southern latitudes from late fall to early spring

Cyclothymic disorder - a disorder that causes emotional ups and downs that are less extreme than bipolar disorder

Premenstrual dysphoric disorder - mood changes and irritability that occur during the premenstrual phase of a woman's cycle and go away with the onset of menses

Persistent depressive disorder (dysthymia) - a long-term (chronic) form of depression

Disruptive mood dysregulation disorder - a disorder of chronic, severe and persistent irritability in children that often includes frequent temper outbursts that are inconsistent with the child's developmental age

Depression related to medical illness - a persistent depressed mood and a significant loss of pleasure in most or all activities that's directly related to the physical effects of another medical condition

Depression induced by substance use or medication - depression symptoms that develop during or soon after substance use or withdrawal or after exposure to a medication

For most people, mood disorders can be successfully treated with medications and talk therapy (psychotherapy).

When to see a doctor

If you're concerned that you may have a mood disorder, make an appointment to see your doctor or a mental health professional as soon as you can. If you're reluctant to seek treatment, talk to a friend or loved one, a faith leader, or someone else you trust.

Talk to a health care professional if you:

Feel like your emotions are interfering with your work, relationships, social activities or other parts of your life

Have trouble with drinking or drugs

Have suicidal thoughts or behaviors - seek emergency treatment immediately

Your mood disorder is unlikely to simply go away on its own, and it may get worse over time. Seek professional help before your mood disorder becomes severe - it may be easier to treat early on.

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Show references

1. Mood disorders fact sheet. National Institutes of Health. http://report.nih.gov/NIHfactsheets/ViewFactSheet.aspx?csid=48. Accessed Sept. 23, 2017.

2. Brown A. Allscripts EPSi. Mayo Clinic, Rochester, Minn. Aug. 3, 2017.

3. Overview of mood disorders. Merck Manual Professional Version. http://www.merckmanuals.com/professional/psychiatric-disorders/mood-disorders/overview-of-mood-disorders. Accessed Sept. 23, 2017.

4. Mood disorders. MentalHealth.gov. http://www.mentalhealth.gov/what-to-look-for/mood-disorders/index.html. Accessed Sept. 23, 2017.

5. Depressive disorders. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. http://dsm.psychiatryonline.org. Accessed Sept. 23, 2017.

6. Bipolar and related disorders. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. http://dsm.psychiatryonline.org. Accessed Sept. 23, 2017.

7. Hall-Flavin DK (expert opinion). Mayo Clinic, Rochester, Minn. Oct. 2, 2017.

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Overview

What is a mood disorder?

A mood disorder is a mental health problem that primarily affects a person's emotional state. It is a disorder in which a person experiences long periods of extreme happiness, extreme sadness, or both.

It is normal for someone's mood to change, depending on the situation. However, to be diagnosed with a mood disorder, symptoms must be present for several weeks or longer. Mood disorders can cause changes in your behavior and can affect your ability to deal with routine activities, such as work or school.

Two of the most common mood disorders are depression and bipolar disorder. This article will review these disorders and some of their many subtypes.

Depression (major or clinical depression). Depression is a common mental disorder. Grief or sadness is a typical response to a traumatic life event or crisis, such as the death of a spouse or family member, loss of a job, or a major illness. However, when the depression continues to be present even when stressful events are over or there is no apparent cause, physicians would then classify the depression as clinical or major depression. For a person to be diagnosed with clinical depression, symptoms must last for at least two weeks.

There are several different types of depression. Symptoms may vary depending on the form of the disorder.

Postpartum depression (peripartum depression) - This type of depression occurs during pregnancy or after delivery

Persistent depressive disorder (dysthymia) - This is a chronic form of depression that can last for at least two years. Symptoms may occasionally lessen in severity during this time.

Seasonal affective disorder (SAD) - This is another type of depression that occurs during certain seasons of the year. It typically starts in the late autumn or early winter and lasts until spring or summer. Less commonly, SAD episodes may also begin during the late spring or summer. Symptoms of winter seasonal affective disorder may resemble those of a major depression. They tend to disappear or lessen during spring and summer.

Psychotic depression - This is a type of severe depression combined with psychotic episodes, such as hallucinations (seeing or hearing things that others do not) or delusions (having fixed but false beliefs). The episodes may be upsetting or disturbing and often have a theme.

Depression related to a medical condition, medication, or substance abuse

Bipolar disorder (manic-depressive disorder). Bipolar disorder is defined by swings in mood from periods of depression to mania. When someone experiences a low mood, symptoms may resemble those of a clinical depression. Depressive episodes alternate with manic episodes or mania. During a manic episode, a person may feel elated or can also feel irritable or have increased levels of activity.

There are four basic types of bipolar disorder.

Bipolar I - This is the most severe form. Manic episodes last at least seven days or may be severe enough to require hospitalization. Depressive episodes will also occur, often lasting for at least two weeks. Sometimes symptoms of both mania and depression are present at the same time.

Bipolar II disorder - This disorder causes cycles of depression similar to those of bipolar I. A person with this illness also experiences hypomania, which is a less severe form of mania. Hypomanic periods are not as intense or disruptive as manic episodes. Someone with bipolar II disorder is usually able to handle daily responsibilities and does not require hospitalization.

Cyclothymia disorder (cyclothymia) - This type of bipolar disorder has sometimes been defined as a milder form of bipolar disorder. People with cyclothymia experience continuous irregular mood swings - from mild to moderate emotional "highs" to mild to moderate "lows" - for extended periods of time. In addition, changes in mood can occur quickly and at any time. There are only short periods of normal mood. For an adult to be diagnosed with cyclothymic, symptoms have to be experienced for at least 2 years. For children and adolescents, the, symptoms must persist for at least one year.

"Other" or "unspecified" bipolar disorder - Symptoms of this type of bipolar disorder do not meet the criteria for one of the other types but people still have significant, abnormal changes in mood.

Other mood disorders

Premenstrual dysphoric disorder - This type of mood disorder occurs seven to 10 days before menstruation and goes away within a few days of the start of the menstrual period. Researchers believe this disorder is brought about by the hormonal changes related to the menstrual cycle. Symptoms may include anger, irritability, tension, decreased interest in usual activities, and sleep problems.

Intermittent explosive disorder - This is a lesser-known mood disorder marked by episodes of unwarranted anger. It is commonly referred to as "flying into a rage for no reason." In an individual with intermittent explosive disorder, the behavioral outbursts are out of proportion to the situation.

Symptoms and Causes

What causes mood disorders?

There may be several underlying factors, depending on the type of the disorder. Various genetic, biological, environmental, and other factors have been associated with mood disorders.

Risk factors include:

Family history

Previous diagnosis of a mood disorder

Trauma, stress or major life changes in the case of depression

Physical illness or use of certain medications. Depression has been linked to major diseases such as cancer, diabetes, Parkinson's disease and heart disease.

Brain structure and function in the case of bipolar disorder

What are the symptoms of common mood disorders?

Symptoms depend on the type of mood disorder that is present.

Symptoms of major depression may include:

Feeling sad most of the time or nearly every day

Lack of energy or feeling sluggish

Feeling worthless or hopeless

Loss of appetite or overeating

Gaining weight or losing weight

Loss of interest in activities that formerly brought enjoyment

Sleeping too much or not enough

Frequent thoughts about death or suicide

Difficulty concentrating or focusing

Symptoms of bipolar disorder may include both depression and mania. Symptoms of hypomanic or manic episodes include:

Feeling extremely energized or elated

Rapid speech or movement

Agitation, restlessness, or irritability

Risk-taking behavior, such as spending too much money or driving recklessly

Unusual increase in activity or trying to do too many things at once

Racing thoughts

Insomnia or trouble sleeping

Feeling jumpy or on edge for no apparent reason

Diagnosis and Tests

How are mood disorders diagnosed?

Your doctor may perform a physical examination to rule out physiological causes for symptoms, such as a thyroid problem, other illnesses, or a vitamin deficiency. The doctor will ask about your medical history, any medications you are taking, and whether you or any family members have been diagnosed with a mood disorder. A mental health professional, such as a psychologist or psychiatrist, will conduct an interview or survey, asking questions about your symptoms, sleeping and eating habits, and other behavior.

Management and Treatment

How are mood disorders treated?

Treatment will depend on the specific illness and symptoms that are present. Usually, therapy involves a combination of medication and psychotherapy (also called "talk therapy"). Therapy sessions may be conducted by a psychologist, psychiatrist, or other health professional.
Medications to treat depression and/or bipolar disorders

Antidepressants - Many different medications are available to treat depression and depressive episodes of bipolar disorder. Some of the most widely used drugs are selective serotonin reuptake inhibitors (SSRIs). These include citalopram (Celexa®), escitalopram (Lexapro®), sertraline (Zoloft®), fluoxetine (Prozac®), and paroxetine (Paxil®). Serotonin and norepinephrine reuptake inhibitors (SNRIs) such as duloxetine (Cymbalta®) and venlafaxine (Effexor®) also are commonly prescribed and are similar to SSRIs in their action. Bupropion (Wellbutrin®) is used to treat depression and seasonal affective disorder. It works differently than SSRIs or SNRIs. Older types of antidepressants include tricylic antidepressants, monoamine oxidase inhibitors, and tetracyclic antidepressants. Although different types are found to work equally well, some antidepressants may be more effective depending on the individual. It is important to take the antidepressants as prescribed and continue taking them even if you feel better. Usually an antidepressant must be taken as prescribed for 4 to 6 weeks before it begins to work.

Mood stabilizers - These medications help to regulate the mood swings that occur with bipolar disorder or other disorders. They reduce abnormal brain activity. Mood stabilizers may also be prescribed along with antidepressants in some cases. Some of the most widely used mood stabilizers include lithium and anticonvulsant drugs, such as valproic acid (Valproic®), lamotrigine (Lamictal®), carbamazepine (Tegretol®), and oxecarbazepine (Trileptal®).

Antipsychotics - Patients with bipolar disorder who experience mania or mixed episodes may be treated with an atypical antipsychotic drug, such as aripiprazole (Abilify®). Atypical antipsychotics may also sometimes be used to treat depression, if symptoms are not controlled with an antidepressant alone.

Psychotherapy (talk therapy)
Patients with depression and other mood disorders may benefit from various types of psychotherapy or counseling sessions. Types of therapy include:

Cognitive-behavioral therapy

Interpersonal therapy

Problem-solving therapy

Brain stimulation therapies
Brain stimulation therapies are thought to work by causing changes in the chemicals in the brain that are known to be associated with symptoms of depression and bipolar disorders. There are several types of brain stimulation therapies including:

Electroconvulsive therapy (ECT) - ECT has long been used to treat severe depression or bipolar disorder in cases when medication or psychotherapy have been unsuccessful. Before having ECT, a patient is placed under general anesthesia and is given a muscle relaxant. Electrodes are placed in certain locations on the scalp or forehead. An electric current is passed through the brain to induce a seizure. The patient awakens after five to 10 minutes. The ECT sessions can be performed on an outpatient basis. Usually, two or three sessions per week are required, over a period of two weeks or more. Generally, six to 12 sessions are required.

Repetitive Transcranial Magnetic Stimulation (rTMS) - This noninvasive procedure uses a magnetic coil to apply short electromagnetic pulses to specific nerve cells in the brain. The magnet is positioned against the forehead, while pulses are sent through the skull. The procedure is used to treat major depression for patients who do not respond to at least one antidepressant drug.

Treatments for seasonal depression
Antidepressant medications, such as SSRIs and bupropion, and psychotherapy are used to treat seasonal affective disorder. In addition, patients may benefit from light therapy and vitamin D supplements.

Light therapy - This technique has long been used to treat SAD. It is based on the idea of supplementing natural sunlight with bright artificial light during the fall and winter. Patients may use a light box that provides cool-white fluorescent light. Each morning, the person is exposed to the artificial light for about 20 to 60 minutes. The light is about 20 times more intense than regular indoor lighting.

Outlook / Prognosis

What's the outlook for people with mood disorders?

Mood disorders such as depression and bipolar disorder may recur or be ongoing and therefore may require long-term or lifetime treatment. It is important to take your medications as prescribed. After starting your medications, it may take two to six weeks before you begin to notice a change in your symptoms. Do not stop taking your medication, even if you begin to feel better.

Discuss any concerns you have about changing or stopping medications with your doctor or another health professional. Ask your doctor whether you might need to try a different medication or have the dosage adjusted, if the one you are taking is ineffective or causes unpleasant side effects such as headaches, nausea, vomiting, or diarrhea.

Psychotherapy has been shown to be helpful treatment approach and is often used together with medication or brain stimulation therapy. Minor forms of depression can be treated with psychotherapy alone. Brain stimulation therapies are usually tried when other treatment options have not been successful, in people with severe symptoms, and in those who cannot tolerate the side effects of drug therapy. Every therapy has its potential role, as each patient with a mood disorder is unique.

Seek help immediately if you feel suicidal or have thoughts of harming yourself or others.

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Mood Disorders; Causes, Symptoms, Management & Treatment

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A mood disorder is a mental health problem that primarily affects a person's emotional state. It is a disorder in which a person experiences long periods of extreme happiness, extreme sadness, or both. It is normal for someone's mood to change, depending on the situation.

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Mood disorders (depression, mania/bipolar, everything in between)

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Advances in Understanding and Treating Mood Disorders

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Mood disorders, primarily major depression and bipolar disorder, are among the most debilitating psychiatric illnesses. Although significant progress has been made, there is much to be learned about their pathophysiology and much to be improved upon regarding their treatment. It is important to ackn…

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Depressive disorders are common in children and adolescents, with estimates for depressive episodes as high as 18.2% for girls and 7.7% for boys by age 17 years, and are a major cause of morbidity and even mortality.

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Conduct disorder is a group of behavioral and emotional problems that usually begins during childhood or adolescence. Children and adolescents with the disorder have a difficult time following rules and behaving in a socially acceptable way. They may display aggressive, destructive, and deceitful behaviors that can violate the rights of others. Adults and other children may perceive them as "bad" or delinquent, rather than as having a mental illness.

If your child has conduct disorder, they may appear tough and confident. In reality, however, children who have conduct disorder are often insecure and inaccurately believe that people are being aggressive or threatening toward them.

There are three types of conduct disorder. They're categorized according to the age at which symptoms of the disorder first occur:

Childhood onset occurs when the signs of conduct disorder appear before age 10.

Adolescent onset occurs when the signs of conduct disorder appear during the teenage years.

Unspecified onset means the age at which conduct disorder first occurs is unknown.

Some children will be diagnosed with conduct disorder with limited prosocial emotions. Children with this specific type of conduct disorder are often described as callous and unemotional.

Children who have conduct disorder are often hard to control and unwilling to follow rules. They act impulsively without considering the consequences of their actions. They also don't take other people's feelings into consideration. Your child may have conduct disorder if they persistently display one or more of the following behaviors:

aggressive conduct

deceitful behavior

destructive behavior

violation of rules

Aggressive Conduct

Aggressive conduct may include:

intimidating or bullying others

physically harming people or animals on purpose

committing rape

using a weapon

Deceitful Behavior

Deceitful behavior may include:

Destructive Behavior

Destructive conduct may include arson and other intentional destruction of property.

Violation of Rules

Violation of rules may include:

skipping school

running away from home

drug and alcohol use

sexual behavior at a very young age

Boys who have conduct disorder are more likely to display aggressive and destructive behavior than girls. Girls are more prone to deceitful and rule-violating behavior.

Additionally, the symptoms of conduct disorder can be mild, moderate, or severe:

Mild

If your child has mild symptoms, it means they display little to no behavior problems in excess of those required to make the diagnosis. Conduct problems cause relatively minor harm to others. Common issues include lying, truancy, and staying out after dark without parental permission.

Moderate

Your child has moderate symptoms if they display numerous behavior problems. These conduct problems may have a mild to severe impact on others. The problems may include vandalism and stealing.

Severe

Your child ha severe symptoms if they display behavior problems in excess of those required to make the diagnosis. These conduct problems cause considerable harm to others. The problems may include rape, use of a weapon, or breaking and entering.

Genetic and environmental factors may contribute to the development of conduct disorder.

Genetic Causes

Damage to the frontal lobe of the brain has been linked to conduct disorder. The frontal lobe is the part of your brain that regulates important cognitive skills, such as problem-solving, memory, and emotional expression. It's also home to your personality. The frontal lobe in a person with conduct disorder may not work properly, which can cause, among other things:

a lack of impulse control

a reduced ability to plan future actions

a decreased ability to learn from past negative experiences

The impairment of the frontal lobe may be genetic, or inherited, or it may be caused by brain damage due to an injury. A child may also inherit personality traits that are commonly seen in conduct disorder.

Environmental Factors

The environmental factors that are associated with conduct disorder include:

child abuse

a dysfunctional family

parents who abuse drugs or alcohol

poverty

The following factors may increase your child's risk of developing conduct disorder:

being male

living in an urban environment

living in poverty

having a family history of conduct disorder

having a family history of mental illness

having other psychiatric disorders

having parents who abuse drugs or alcohol

having a dysfunctional home environment

having a history of experiencing traumatic events

being abused or neglected

If your child is showing signs of conduct disorder, they should be evaluated by a mental health professional. They'll ask you and your child questions about their behavioral patterns to make a diagnosis. For a conduct disorder diagnosis to be made, your child must have a pattern of displaying at least three behaviors that are common to conduct disorder. Your child must also have shown at least one of the behaviors within the past six months. The behavioral problems must also significantly impair your child socially or at school.

Children with conduct disorder who are living in abusive homes may be placed into other homes. If abuse isn't present, your child's mental healthcare provider will use behavior therapy or talk therapy to help your child learn how to express or control their emotions appropriately. The mental healthcare provider will also teach you how to manage your child's behavior. If your child has another mental health disorder, such as depression or ADHD, the mental healthcare provider may prescribe medications to treat that condition as well.

Since it takes time to establish new attitudes and behavior patterns, children with conduct disorder usually require long-term treatment. However, early treatment may slow the progression of the disorder or reduce the severity of negative behaviors.

The long-term outlook for conduct disorder depends on the severity and frequency of your child's behavioral and emotional problems. Children who continuously display extremely aggressive, deceitful, or destructive behavior tend to have a poorer outlook. The outlook is also worse if other mental illnesses are present. However, getting a prompt diagnosis and receiving comprehensive treatment can significantly improve your child's outlook. Once treatment is received for conduct disorder and any other underlying conditions, your child has a much better chance of considerable improvement and hope for a more successful future.

Without treatment, your child is likely to have ongoing problems. They may be unable to adapt to the demands of adulthood, which can cause them to have problems with relationships and holding a job. They're also at an increased risk for substance abuse and problems with law enforcement. Your child may even develop a personality disorder, such as antisocial personality disorder, when they reach adulthood. This is why early diagnosis and treatment are critical. The earlier your child receives treatment, the better their outlook for the future will be.

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Conduct Disorder: Types, Causes, and Symptoms

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Conduct disorder is a group of behavioral and emotional problems that usually begins during childhood or adolescence. Children and adolescents with the disorder have a difficult time following rules and behaving in a socially acceptable way. They may display aggressive, destructive, and deceitful behaviors that can violate the rights of others.

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A conduct disorder refers to any of a group of serious emotional and behavioral problems in children and adolescents. Children with conduct disorders frequently behave in extremely troubling, socially unacceptable, and often illegal ways, though they feel justified in their actions and show little to no empathy for their victims. Others may view these children as simply "bad kids," without realizing they have a disorder. Conduct disorder may be diagnosed in adulthood, but symptoms most commonly appear around ages 8 to 16. Some children who have conduct disorder go on to develop a similar condition known as antisocial personality disorder in adults.

Symptoms

Symptoms of conduct disorder generally fall into four categories:

1. Aggressive behavior toward people and animals. This includes bullying, threatening, physical violence, use of a weapon, physical cruelty to people or animals, and forcing someone to perform a sexual act.

2. Property destruction, including setting fires and purposefully destroying property.

3. Deceit or theft, including lying, shoplifting, and breaking into someone else's property with the intent to steal.

4. Serious violations of rules, including breaking family rules, running away from home, and frequently skipping school before the age of 13.

For a diagnosis of conduct disorder, at least three of these behaviors must have occurred within the past year, with at least one occurring within the past six months. The number of symptoms exhibited, and the degree of injury or damage done, determines whether it is a case of mild, moderate, or severe conduct disorder.

Causes

While the cause is unclear, many possible factors can put a child at risk of developing conduct disorder. In addition to genetics, these include child abuse, impulsive behavior, low academic achievement, poor parental supervision, callous or unemotional parental attitude, antisocial parents or peers, trauma, poverty, and living in a high- crime neighborhood or attending a school with a high delinquency rate.

Treatment

With the right care, and a good support system in place, conduct disorder can be managed. The earlier the diagnosis, the more successful the treatment will be. Treatment is often long-term psychotherapy and behavior therapy to help the child learn healthier and more acceptable ways of thinking and behaving. In some cases, medication may be used to treat both the conduct disorder and any co-existing conditions that may be diagnosed. Additionally, shorter-term parent management training can help the family understand the problem, learn new ways of responding to the child, and rebuild the child-parent relationship.

References

American Psychiatric Association. Understanding Mental Disorders: Your Guide to DSM-5. 2015. American Psychiatric Publishing.

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5. American Psychiatric Association. 2013.

Find an expert on behavioral problems.

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A conduct disorder refers to any of a group of serious emotional and behavioral problems in children and adolescents. Children with conduct disorders frequently behave in extremely troubling, socially unacceptable, and often illegal ways, though they feel justified in their actions and show little to no empathy for their victims. Others may view these children as simply "bad kids," without realizing they have a disorder.

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Overview

What is conduct disorder?

Conduct disorder (CD) is a mental health condition that affects children and teens that's characterized by a consistent pattern of aggressive behaviors and actions that harm the well-being of others. Children with conduct disorder also often violate rules and societal norms.

Conduct disorder lies on a spectrum of disruptive behavioral disorders, which also includes oppositional defiant disorder (ODD). In some cases, ODD leads to CD.

Conduct disorder often occurs alongside other psychiatric conditions, including:

What is the difference between conduct disorder and personality disorders?

A personality disorder is a mental health condition that involves long-lasting, disruptive patterns of thinking, behavior, mood and relating to others. Most personality disorders begin in the teen years when personality further develops and matures. As a result, almost all people diagnosed with personality disorders are above the age of 18.

One exception to this is antisocial personality disorder (ASPD) - approximately 80% of people with this disorder will have started to show symptoms by the age of 11.

There's not much difference between conduct disorder (CD) and ASPD, but CD is typically diagnosed in children. If an adult meets the criteria for both conditions, then a mental health professional would give them a diagnosis of ASPD instead of CD.

Who does conduct disorder affect?

Conduct disorder affects children and adolescents. It can have early onset before age 10, but commonly develops in adolescence (between ages 10 years to 19 years).

The condition is more common in children assigned male at birth (AMAB) than children assigned female at birth (AFAB). The average age of presentation is 10 years to 12 years in children AMAB and 14 years to 16 years in children AFAB.

How common is conduct disorder?

Conduct disorder affects anywhere between 2% and 10% of children and adolescents in the United States.

Symptoms and Causes

What are the signs and symptoms of conduct disorder?

Characteristic behaviors of conduct disorder develop gradually over time. Children with conduct disorder tend to be impulsive and difficult to manage. They don't seem to be concerned about the feelings of other people.

The four core behaviors of conduct disorder include:

Aggression toward people and animals and/or violating others' basic rights.

Destruction of property.

Deceiving, lying and/or stealing.

Serious violations of rules.

Signs of aggressive behavior toward others include:

Bullying.

Physical violence (potentially with a weapon).

Verbal fights.

Threatening.

Forcing sexual activity.

Blaming others for their own behavior.

Hurting animals.

Signs of the destruction of property include:

Intentionally setting fires.

Vandalizing or destroying others' property.

Signs of deceiving, lying and stealing include:

Lying to get a favor or to avoid responsibilities.

Stealing from individual people or stores.

Breaking into houses or businesses.

Signs of violations of rules include:

Breaking rules without clear reason.

Not going to school (truancy).

Running away from home.

Frequently breaking any rules set by their parents.

Other common signs of conduct disorder include:

Heavy alcohol drinking and/or heavy substance use.

Engaging in frequent and risky sex.

Becoming easily frustrated.

Making no effort to hide their aggressive behaviors.

Not showing remorse for their actions.

Difficulty making and maintaining friendships.

It's important to note that occasional rebellious behavior is common during childhood and adolescence. The signs and symptoms that lead to the diagnosis of conduct disorder demonstrate a disruptive and repetitive pattern.

Signs of conduct disorder in adults

Adults who have conduct disorder may have difficulty keeping a job or maintaining relationships. They may be prone to illegal or dangerous behavior.

Symptoms of conduct disorder in an adult may be diagnosed as antisocial personality disorder.

What causes conduct disorder?

Researchers aren't sure what exactly causes conduct disorder (CD), but they think it's a complex combination of genetic/biological and environmental factors.

Genetic/biological factors:

Various studies show that certain characteristics of CD can be inherited, including antisocial behavior, impulsivity, temperament, aggression and insensitivity to punishment.

High testosterone levels are associated with aggression.

Traumatic brain injury, seizures and neurological damage can contribute to aggression.

Parental, familial and environmental factors:

Parents of adolescents with CD often have engaged in substance use and antisocial behaviors. They're also frequently diagnosed with ADHD, mood disorders, schizophrenia or antisocial personality disorder.

A home environment that lacks structure and adequate supervision with frequent conflicts between parents can lead to maladaptive behavior in children, which can lead to CD.

Children exposed to frequent domestic violence are more likely to develop CD.

Living in low social and economic environments with overcrowding and unemployment leads to economic and social stress with a lack of adequate parenting. CD affects more children living in low economic environments than not.

Availability of drugs and increased crime in a child's neighborhood increases their risk of developing CD.

It's important to note that conduct disorder can occur in children from high-functioning, healthy families.

Diagnosis and Tests

How is conduct disorder diagnosed?

A mental health professional diagnoses conduct disorder using criteria provided in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.

They diagnose conduct disorder in children or adolescents who've demonstrated three or more of the following behaviors in the previous 12 months, in addition to at least one in the previous six months:

Aggression toward people and/or animals.

Destruction of property.

Deceiving, lying or stealing.

Serious violations of parental rules.

These behaviors must be significant enough to impair functioning in relationships, at home, at school and/or at work.

Your child will likely need to see a child and adolescent psychologist or psychiatrist if they're showing signs of conduct disorder. These mental health professionals use specially designed interview and assessment tools to evaluate a child for a mental health condition.

Psychologists and psychiatrists often rely on reports from the child's parents, siblings, friends and teachers to get a full understanding of the child's behavior.

Management and Treatment

How is conduct disorder treated?

The go-to treatment for conduct disorder (CD) is multiple forms of psychotherapy (talk therapy) for your child and family, as well as community-based treatment.

Therapies include:

Parent management training: The goal of this therapy is to train the child's parents to set consistent discipline with proper rewarding of positive behaviors.

Psychotherapy: "Psychotherapy" is a term for a variety of treatment techniques that aim to help a person identify and change troubling emotions, thoughts and behaviors. Working with a mental health professional can provide support, education and guidance to the person and their family. Psychotherapy for conduct disorder usually needs to target family life and school with a focus on improving family dynamics, academic functioning and improving your child's behavior in the context of various environments.

Anger management training: The goal of anger management is to reduce both your child's emotional feelings and the physiological arousal that anger causes. You can't get rid of or totally avoid the things or people that make them angry, so anger management training teaches your child how to control their reactions.

Individual psychotherapy, such as cognitive behavioral therapy: Individual therapy for a child with conduct disorder focuses on developing problem-solving skills, strengthening relationships by resolving conflicts and learning skills to decline negative influences in their environment.

Community-based treatment: This treatment involves therapeutic schools and residential treatment centers that can provide a structured program to reduce disruptive behaviors.

Healthcare providers typically don't use medication to directly treat conduct disorder, but as other mental health conditions often occur alongside conduct disorder, your child may benefit from medication to manage these conditions.

Prevention

Can conduct disorder be prevented?

At this time, there's no known way to prevent conduct disorder, as it's likely caused by a complex combination of factors, but many of the related problems might be lessened with treatment. Seeking help as soon as symptoms appear can help decrease the disruption to your child's life, family and friendships.

Outlook / Prognosis

What is the prognosis (outlook) for conduct disorder?

The prognosis (outlook) for conduct disorder depends on how early the condition developed and if it was treated.

Usually, the disruptive behaviors of conduct stop during early adulthood, but in about one-third of cases, they continue. Many of these cases meet the criteria for antisocial personality disorder.

Early onset of the condition (before 10 years of age) is associated with a poorer prognosis and is strongly associated with a significant decline in school performance.

Some children and adolescents with conduct disorder develop other mental health conditions, including:

Depression and bipolar disorder may also develop in the teen years and early adulthood. Suicidal ideation can be a complication of these conditions. It's important to get your child immediate medical care if they're talking about or threatening suicide.

Living With

How do I take care of my child with conduct disorder?

If your child has conduct disorder, aside from getting them professional care, you can help them and yourself in the following ways:

Learn more about conduct disorder, including recent research on effective treatment approaches.

Talk to a mental health professional, preferably one who's trained in diagnosing and treating conduct disorder.

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

Find a family support group or organization in your community.

When should my child see their healthcare provider about conduct disorder?

If your child has been diagnosed with conduct disorder, and their behavior becomes more severe or further disrupts family or school life, talk to their mental health provider.

If your child displays behavior that harms or endangers others, such as other people or animals, or themselves, it's important to get them immediate medical care.
A note from Cleveland Clinic
Children and teens who are disobedient or aggressive can be very challenging for parents. While it's normal for young children and teens to show defiant behavior from time to time, frequent and disruptive aggressive behavior may indicate conduct disorder (CD).

Starting treatment early for conduct disorder is important, and the first step to treatment is to talk with a healthcare provider or a mental health provider. Don't be afraid to ask your provider questions. They're available to help.

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Conduct Disorder: What It Is, Symptoms & Treatment

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Conduct disorder is a psychiatric condition that affects children and teens that involves a consistent pattern of aggressive and disobedient behaviors.

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Disruptive, impulse control, and conduct disorders

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Overview

Obsessive-compulsive disorder (OCD) features a pattern of unwanted thoughts and fears known as obsessions. These obsessions lead you to do repetitive behaviors, also called compulsions. These obsessions and compulsions get in the way of daily activities and cause a lot of distress.

Ultimately, you feel driven to do compulsive acts to ease your stress. Even if you try to ignore or get rid of bothersome thoughts or urges, they keep coming back. This leads you to act based on ritual. This is the vicious cycle of OCD.

OCD often centers around certain themes, such as being overly fearful of getting contaminated by germs. To ease contamination fears, you may wash your hands over and over again until they're sore and chapped.

If you have OCD, you may be ashamed, embarrassed and frustrated about the condition. But treatment can be effective.

Symptoms

Obsessive-compulsive disorder usually includes both obsessions and compulsions. But it's also possible to have only obsession symptoms or only compulsion symptoms. You may or may not know that your obsessions and compulsions are beyond reason. But they take up a great deal of time, reduce your quality of life, and get in the way of your daily routines and responsibilities.

Obsession symptoms

OCD obsessions are lasting and unwanted thoughts that keeping coming back or urges or images that are intrusive and cause distress or anxiety. You might try to ignore them or get rid of them by acting based on ritual. These obsessions usually intrude when you're trying to think of or do other things.

Obsessions often have themes, such as:

Fear of contamination or dirt.

Doubting and having a hard time dealing with uncertainty.

Needing things to be orderly and balanced.

Aggressive or horrific thoughts about losing control and harming yourself or others.

Unwanted thoughts, including aggression, or sexual or religious subjects.

Examples of obsession symptoms include:

Fear of being contaminated by touching objects others have touched.

Doubts that you've locked the door or turned off the stove.

Intense stress when objects aren't orderly or facing a certain way.

Images of driving your car into a crowd of people.

Thoughts about shouting obscenities or not acting the right way in public.

Unpleasant sexual images.

Staying away from situations that can cause obsessions, such as shaking hands.

Compulsion symptoms

OCD compulsions are repetitive behaviors that you feel driven to do. These repetitive behaviors or mental acts are meant to reduce anxiety related to your obsessions or prevent something bad from happening. But taking part in the compulsions brings no pleasure and may offer only limited relief from anxiety.

You may make up rules or rituals to follow that help control your anxiety when you're having obsessive thoughts. These compulsions are beyond reason and often don't relate to the issue they're intended to fix.

As with obsessions, compulsions usually have themes, such as:

Washing and cleaning.

Checking.

Counting.

Ordering.

Following a strict routine.

Demanding reassurance.

Examples of compulsion symptoms include:

Hand-washing until your skin becomes raw.

Checking doors over and over again to make sure they're locked.

Checking the stove over and over again to make sure it's off.

Counting in certain patterns.

Silently repeating a prayer, word or phrase.

Trying to replace a bad thought with a good thought.

Arranging your canned goods to face the same way.

Severity varies

OCD usually begins in the teen or young adult years, but it can start in childhood. Symptoms usually begin over time and tend to vary in how serious they are throughout life. The types of obsessions and compulsions you have also can change over time. Symptoms generally get worse when you are under greater stress, including times of transition and change. OCD, usually thought to be a lifelong disorder, can have mild to moderate symptoms or be so severe and time-consuming that it becomes disabling.

When to see a doctor

There's a difference between being a perfectionist - someone who needs flawless results or performance - and having OCD. OCD thoughts aren't simply excessive worries about real issues in your life or liking to have things clean or arranged in a specific way.

If your obsessions and compulsions affect your quality of life, see your doctor or mental health professional.

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Causes

The cause of obsessive-compulsive disorder isn't fully understood. Main theories include:

Biology. OCD may be due to changes in your body's natural chemistry or brain functions.

Genetics. OCD may have a genetic component, but specific genes have yet to be found.

Learning. Obsessive fears and compulsive behaviors can be learned from watching family members or learning them over time.

Risk factors

Factors that may raise the risk of causing obsessive-compulsive disorder include:

Family history. Having parents or other family members with the disorder can raise your risk of getting OCD.

Stressful life events. If you've gone through traumatic or stressful events, your risk may increase. This reaction may cause the intrusive thoughts, rituals and emotional distress seen in OCD.

Other mental health disorders. OCD may be related to other mental health disorders, such as anxiety disorders, depression, substance abuse or tic disorders.

Complications

Issues due to obsessive-compulsive disorder include:

Excessive time spent taking part in ritualistic behaviors.

Health issues, such as contact dermatitis from frequent hand-washing.

Having a hard time going to work or school or taking part in social activities.

Troubled relationships.

Poor quality of life.

Thoughts about suicide and behavior related to suicide.

Prevention

There's no sure way to prevent obsessive-compulsive disorder. However, getting treated as soon as possible may help keep OCD from getting worse and disrupting activities and your daily routine.

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Obsessive-compulsive disorder (OCD) - Symptoms and causes

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OCD features unwanted thoughts and fears, or obsessions. These obsessions lead to repetitive behaviors, also known as compulsions, that get in the way of daily activities.

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National Institute of Mental Health (NIMH)

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Definition

Obsessive-compulsive disorder (OCD) is often a long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions), and behaviors (compulsions) that he or she feels the urge to repeat over and over.

Additional information about obsessive-compulsive disorder can be found on the NIMH Health Topics page on Obsessive-Compulsive Disorder.

Prevalence of Obsessive-Compulsive Disorder Among Adults

Based on diagnostic interview data from the National Comorbidity Survey Replication (NCS-R), Figure 1 shows past year prevalence of OCD among U.S. adults aged 18 or older.¹

An estimated 1.2% of U.S. adults had OCD in the past year.

Past year prevalence of OCD was higher for females (1.8%) than for males (0.5%).

Lifetime prevalence of OCD among U.S. adults was 2.3%.²

Figure 1

Obsessive-Compulsive Disorder with Impairment Among Adults

Of adults with OCD in the past year, degree of impairment ranged from mild to severe, as shown in Figure 2. Impairment was determined by scores on the Sheehan Disability Scale.

Among adults with OCD, approximately one half (50.6%) had had serious impairment.¹

Another 34.8% of adults with OCD had moderate impairment, and 14.6% had mild impairment.¹

Figure 2

Data Sources

References

1. Harvard Medical School, 2007. National Comorbidity Survey (NCSSC). (2017, August 21). Retrieved from https://www.hcp.med.harvard.edu/ncs/index.php. Data Table 2: 12-month prevalence DSM-IV/WMH-CIDI disorders by sex and cohort.

2. Harvard Medical School, 2007. National Comorbidity Survey (NCSSC). (2017, August 21). Retrieved from https://www.hcp.med.harvard.edu/ncs/index.php. Data Table 1: Lifetime prevalence DSM-IV/WMH-CIDI disorders by sex and cohort.

3. Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun;62(6):617-27. PMID: 15939839

Statistical Methods and Measurement Caveats

National Comorbidity Survey Replication (NCS-R)

Diagnostic Assessment and Population:

The NCS-R is a nationally representative, face-to-face, household survey conducted between February 2001 and April 2003 with a response rate of 70.9%. Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSM-IV) mental disorders were assessed using a modified version of the fully structured World Health Organization Composite International Diagnostic Interview (WMH-CIDI), a fully structured lay-administered diagnostic interview that generates both International Classification of Diseases, 10th Revision, and DSM-IV diagnoses. The DSM-IV criteria were used here. The Sheehan Disability Scale (SDS) assessed disability in work role performance, household maintenance, social life, and intimate relationships on a 0-10 scale. Participants for the main interview totaled 9,282 English-speaking, non-institutionalized, civilian respondents. Obsessive-compulsive disorder (OCD) was assessed in a subsample of 1,808 adults. The NCS-R was led by Harvard University.

Unlike the DSM-IV criteria used in the NCS-R, the current DSM-5 no longer places OCD in the anxiety disorder category. It is listed in a new DSM-5 category, "Obsessive-Compulsive and Related Disorders."

Survey Non-response:

In 2001-2002, non-response was 29.1% of primary respondents and 19.6% of secondary respondents. Reasons for non-response to interviewing include: refusal to participate (7.3% of primary, 6.3% of secondary); respondent was reluctant- too busy but did not refuse (17.7% of primary, 11.6% of secondary); circumstantial, such as intellectual developmental disability or overseas work assignment (2.0% of primary, 1.7% of secondary); and household units that were never contacted (2.0%).

For more information, see PMID: 15297905.

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Obsessive-compulsive disorder (OCD) is often a long-lasting disorder in which a person has uncontrollable, reoccurring thoughts (obsessions), and behaviors (compulsions) that he or she feels the urge to repeat over and over. Additional information about obsessive-compulsive disorder can be found on the NIMH Health Topics page on Obsessive-Compulsive Disorder.

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Obsessive Compulsive and Related Disorders: From the Biological Basis to a Rational Pharmacological Treatment

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For the clinician, obsessive compulsive and related disorders (OCRDs) as defined by the DSM-5 (American Psychiatric Association, 2013) are highly challenging. T

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According to the Diagnostic and Statistical Manual of Mental Disorders, conduct disorder (CD) comprises “A repetitive and persistent pattern of behavi…

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Psychotic disorders are mental health illnesses characterized by an impaired relationship with reality, usually with associated behavioral changes. There are several different psychotic disorders, and they each have diagnostic criteria described in the fifth edition of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5).

Psychotic disorders can be highly distressing, impacting a person's quality of life and ability to maintain self-care. However, most of these conditions can be managed with medication and therapy.

If you or a loved one is diagnosed with a psychotic disorder, it's important that you maintain consistent psychiatric care to help reduce the effects of your disorder on your life.

Types of Psychotic Disorders

The different types of psychotic disorders are:

Schizophrenia: Schizophrenia is characterized by delusions, hallucinations, disorganization, unusual behavior, and withdrawal.

Schizoaffective disorder: Schizoaffective disorder is characterized by a combination of psychotic features and mood symptoms.

Schizophreniform disorder: Schizophreniform disorder is characterized by symptoms of schizophrenia lasting for longer than one month and for less than six months.

Delusional disorder: This condition is characterized by delusions, without the other symptoms that are seen in schizophrenia.

Brief psychotic disorder: This condition is characterized by an episode of psychotic behavior that lasts for less than one month.

Substance-induced psychotic disorder: The short-term and long-term effects of certain drugs, such as LSD, can cause symptoms of psychosis.

Psychotic disorder due to a medical condition: Medical conditions can cause temporary or prolonged psychosis.

Psychotic Disorder Symptoms

Psychotic disorders are characterized by a loss of touch with reality characterized by altered thinking, perceptions, and behavior.

Often, people who have psychotic disorders also manifest behavioral symptoms. Symptoms of psychotic disorder are often characterized as positive or negative. Positive symptoms involve hallucinations, delusions, and disorganization. Negative symptoms involve behaviors such as withdrawal from others and diminished emotional expression.

Many psychotic disorders are lifelong illnesses, often beginning during early adulthood. They may progress or stabilize over time. Some psychotic disorders are limited in their duration, however, and can resolve.

Hallucinations

Hallucinations are false sensory experiences. The most common are visual hallucinations (seeing things that aren't real) or auditory hallucinations (hearing voices that aren't real). Other false sensations, such as smell, taste, or touch are less common with psychotic disorders, but they can occur.

Hallucinations can occur intermittently, and they may follow a theme, such as repeatedly hearing voices giving commands or seeing a specific type of animal or person that isn't really there.

Delusions are fixed false beliefs. Often, with psychotic disorders, the delusions involve a sense of persecution and a belief that people are involved in sabotaging or harming the person who is experiencing the delusion.

Sometimes delusions are grandiose, and a person might believe that they have supernatural or superhuman powers, or that they have a special designation that others cannot understand.

A person who has a psychotic disorder might share some of the details of their delusions with a few trusted people, but could be worried that everyone is in on the conspiracy or may avoid telling loved ones about the beliefs in an effort to protect them.

Behavioral Symptoms

Some of the behavioral effects of psychotic disorders include speaking incoherently, erratic or odd behaviors, agitation, and restlessness.

Negative symptoms of psychotic disorders can include apathy, withdrawal, lack of emotional expressions, and lack of self-care. Negative symptoms are not usually as disruptive as hallucinations and delusions, and they can go unnoticed by family and friends, and even by the person who is experiencing them.

A key characteristic of psychotic disorders is that a person may have a lack of insight into their symptoms-genuinely believing their hallucinations or delusions to be true, and may not perceive that the behavioral manifestations are unusual.

Complications

Psychotic disorders can result in a lack of self-care. This can cause a person to neglect things like eating, changing clothes, and/or bathing.

A person who has a psychotic disorder might not seek medical attention for symptoms like pain or discomfort, and this can allow physical problems to worsen-potentially leading to complications of infections, injuries, or medical illnesses. Medical problems can exacerbate the symptoms of a psychotic condition.

People who have a psychotic condition may experience suicidal ideation (thinking about suicide) or might attempt suicide.

Psychotic conditions have a strong genetic component. They are more common among people who have one or more family members with a psychotic disorder. However, a person can develop one of these conditions without having a family history, and a person who has family members with psychotic disorders will not necessarily develop one.

The specific genes involved in psychotic disorders are not well established. Psychotic disorders are associated with brain and neurotransmitter dysfunction. Disruption of dopamine and serotonin, among others, is believed to play a role in these conditions.

Certain psychotic disorders are associated with brain atrophy (shrinking) in certain parts of the brain, such as the frontal and/or temporal lobes. Sometimes the ventricles of the brain can be enlarged. And the presence of certain antibodies has also been associated with psychotic disorders, but the overall significance of immune dysfunction in psychotic disorders is not clear.

The diagnosis of psychotic disorders is based on a set of criteria that is used for each of these conditions. The criteria generally include a list of thoughts, behaviors, and duration of symptoms. Usually, diagnosis of a psychotic disorder requires that a person has a certain number or combination of the clinical criteria, not necessarily all of them.

If you are getting a medical evaluation for a possible psychotic disorder, your healthcare provider might discuss your symptoms with you, and may also listen to friends and family members that you have with you during your evaluation.

Your healthcare provider will also ask about your medical and psychiatric history, any stresses you are undergoing, medications or recreational drugs that you take, and your family medical and psychiatric history as well.

Some of the symptoms of psychotic disorders occur due to other medical, neurological, and psychological conditions. If your assessment does not meet the criteria for a psychotic disorder and/or there is concern that you also might have another medical condition, you might have further diagnostic testing.

There are no blood tests or imaging tests that are considered indicative or that can confirm psychotic disorders. However, diagnostic tests may be used to rule out other potential causes of the symptoms.

Diagnostic tests you might need include:

These tests can help determine if there are other causes of your symptoms. For example, a brain tumor, which can be identified with brain imaging studies, might cause visual hallucinations.

Encephalitis (a brain infection), which could be identified with brain imaging or LP, can cause changes in behavior. Some types of liver disease can cause mental status changes that can seem similar to psychotic disorders.

The treatment of a psychotic disorder is tailored to the underlying condition and may include a combination of prescription medication and counseling. You may be prescribed one or more antipsychotic medications, and you might also be prescribed a medication for treatment of a mood disorder if present.

Your healthcare provider will likely also recommend that you have counseling or psychotherapy as part of your treatment plan for your psychotic disorder.

Medications used to treat psychotic disorders include typical antipsychotics and atypical antipsychotics. Medications in both of these categories can control symptoms, and your healthcare provider will work with you to determine which might be best for managing your condition.

Some typical antipsychotics include:

Haldol (haloperidol)

Prolixin (fluphenazine)

Navane (thiothixene)

Adasuve (loxapine)

Mellaril (thioridazine)

Stelazine (trifluoperazine)

The most common side effect of these medications is sleepiness. Typical antipsychotics are associated with extrapyramidal side effects -tremors, spasms, muscle rigidity, and diminished control of movement. Side effects can diminish with medication adjustments, but sometimes extrapyramidal symptoms remain even after the medication is discontinued.

Some atypical antipsychotics include:

Clozaril (clozapine)

Abilify (aripiprazole)

Risperdal (risperidone)

Zyprexa (olanzapine)

Seroquel (quetiapine)

Atypical antipsychotics are not as likely to cause extrapyramidal side effects as typical antipsychotics. They can cause side effects, including constipation, sleepiness, weight gain, high cholesterol, and decreased sex drive.

You might have episodes during which the effects of your psychotic condition worsen substantially, necessitating in-patient treatment. During this time, you will be kept safe, and your medication may be adjusted. Any other medical problems that you have (like an infection) would be managed as well.

Living with a psychotic disorder can be challenging. You might have fluctuations in your symptoms, and you can experience side effects from your medications.

It can be difficult for you to keep up with employment, and your relationships and social life can be affected as well. The social stigma can affect your life and the lives of your family members.

As you are coping with your condition, it's important that you know that your psychotic disorder is not something that you or anyone else is to blame for. It is an illness, just like any other medical condition. You might consider some approaches that could help you cope with your condition to optimize your quality of life.

Counseling/Therapy

Managing your psychotic illness doesn't have to stop with controlling the symptoms. You might have concerns or apprehensions about your condition. Speaking with a professional therapist or with your psychiatrist about any feelings you have about your condition can help.

Join a Support Group

Sometimes, interacting with others who are going through the same things you are going through can help you feel less alone. Be sure to give yourself a chance to find a group that makes you feel comfortable.

Some support groups are moderated by a professional, and you might find a professionally moderated group to be a good type of group for you. When you feel that the time is right, you can also be a valuable source of support for others who are searching for hope and camaraderie.

Family/Community

How much you want to share about your condition is up to you. But since psychotic illnesses are characterized by altered perceptions of reality, it would be beneficial for you if you can talk about your condition with one or more people who you trust. They can get help for you if your symptoms worsen or if you need urgent medical attention.

Caregiver Support

Psychiatric disorders affect the quality of life of the people who are experiencing them, as well as the lives of family, friends and loved ones. If someone who is a part of your life is showing the symptoms of a psychotic disorder or has been diagnosed with a psychotic illness, the condition can cause distress for you as well.

Even though you want to maintain a relationship with your parent, sibling, spouse, child, or friend suffering from psychosis-but you might not know how best to do so when they have a psychotic disorder.

Talking with someone who you care about when they are not in touch with reality can be overwhelming and you might not know how much you should engage in a discussion about their delusions or hallucinations.

It may be important that you seek professional guidance as you navigate the challenges that your loved one's illness can pose in your own life, rather than trying to reinvent the wheel and learn how to do it on your own.

Consider seeking professional counseling or therapy and/or joining a support group so you can learn how to manage your relationship and how to participate in their care in the way that works best for you.

You and the person who you care about might also decide that you can accompany them to their healthcare appointments and/or help them as they manage their medical and psychiatric care.

You should also make sure that you or another trusted friend, family member, or caregiver understand the signs of an emergency that might necessitate urgent medical attention-and have a plan in place for getting urgent medical help right away if needed.

A Word From Verywell

You can have an emotionally and physically healthy life if you are living with a psychotic disorder. This involves maintaining consistent psychiatric and medical care.

Because insight may be impaired in psychotic illness, it can be difficult to know when your symptoms are recurring or when medication adjustments are needed. Having a routine for taking your medications and going to your medical appointments can help with this process.

A community support structure from family, friends, and your healthcare team can help optimize the quality of life for a person who is living with a psychotic illness.

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Psychotic disorders are mental health illnesses characterized by an impaired relationship with reality, usually with associated behavioral changes. There are several different psychotic disorders, and they each have diagnostic criteria described in the fifth edition of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5).

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SOURCES:

Cardiff and Vale Action for Mental Health: "Practical Guidelines for Caring for the Person With Paraphrenia (Late Onset Psychosis)."

Centre for Addiction and Mental Health: "The Different Types of Psychosis," "What is Psychosis?"

Harvard Medical School: "Delusional Disorder."

Medscape: "Brief Psychotic Disorder," "Shared Psychotic Disorder."

MentalHealth.gov: "Psychotic Disorders."

National Alliance on Mental Illness: "Early Psychosis and Psychosis," "Mental Health Medications," "Psychotherapy," "Schizophrenia," "Support."

National Drug & Alcohol Research Centre: "Psychosis + Substance Use."

NHS: "Psychosis -- Causes."

Ohio State University: "A Beautiful Mind: Analyzing How Schizophrenia is Portrayed in Movies versus Reality."

Personality and Individual Differences: "A psychobiographical analysis of Brian Douglas Wilson: Creativity, drugs, and models of schizophrenic and affective disorders."

Sadock, Benjamin J. Kaplan & Sadock's Concise Textbook of Clinical Psychiatry, 2008.

Slate: "Two Flew Over the Cuckoo's Nest."

Brian Wilson website.

Reviewed by Jennifer Casarella on November 08, 2019

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SOURCES: Cardiff and Vale Action for Mental Health: "Practical Guidelines for Caring for the Person With Paraphrenia (Late Onset Psychosis)." Centre for Addiction and Mental Health: "The Different Types of Psychosis," "What is Psychosis?" Harvard Medical School: "Delusional Disorder." Medscape: "Brief Psychotic Disorder," "Shared Psychotic Disorder." MentalHealth.gov: "Psychotic Disorders."

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This severe mental disorder can result in hallucinations, delusions, and extremely disordered thinking and behavior that interfere with daily living.

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Affiliations

¹ Department of Psychiatry & Behavioral Sciences, Vanderbilt University Medical Center, 1601 23rd Ave S, Nashville, TN, 37212, USA. Julia.sheffield@vumc.org.

² Department of Psychological & Brain Sciences, Washington University St. Louis, 1 Brookings Dr., St. Louis, MO, 63130, USA.

³ Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, USA.

⁴ Department of Radiology, Washington University in St. Louis, St. Louis, MO, USA.

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Affiliations

¹ Department of Psychiatry & Behavioral Sciences, Vanderbilt University Medical Center, 1601 23rd Ave S, Nashville, TN, 37212, USA. Julia.sheffield@vumc.org.

² Department of Psychological & Brain Sciences, Washington University St. Louis, 1 Brookings Dr., St. Louis, MO, 63130, USA.

³ Department of Psychiatry, Washington University in St. Louis, St. Louis, MO, USA.

⁴ Department of Radiology, Washington University in St. Louis, St. Louis, MO, USA.

Abstract

Individuals with disorders that include psychotic symptoms (i.e. psychotic disorders) experience broad cognitive impairments in the chronic state, indicating a dimension of abnormality associated with the experience of psychosis. These impairments negatively impact functional outcome, contributing to the disabling nature of schizophrenia, bipolar disorder, and psychotic depression. The robust and reliable nature of cognitive deficits has led researchers to explore the timing and profile of impairments, as this may elucidate different neurodevelopmental patterns in individuals who experience psychosis. Here, we review the literature on cognitive deficits across the life span of individuals with psychotic disorder and psychotic-like experiences, highlighting the dimensional nature of both psychosis and cognitive ability. We identify premorbid generalized cognitive impairment in schizophrenia that worsens throughout development, and stabilizes by the first-episode of psychosis, suggesting a neurodevelopmental course. Research in affective psychosis is less clear, with mixed evidence regarding premorbid deficits, but a fairly reliable generalized deficit at first-episode, which appears to worsen into the chronic state. In general, cognitive impairments are most severe in schizophrenia, intermediate in bipolar disorder, and the least severe in psychotic depression. In all groups, cognitive deficits are associated with poorer functional outcome. Finally, while the generalized deficit is the clearest and most reliable signal, data suggests specific deficits in verbal memory across all groups, specific processing speed impairments in schizophrenia and executive functioning impairments in bipolar disorder. Cognitive deficits are a core feature of psychotic disorders that provide a window into understanding developmental course and risk for psychosis.

Keywords: Bipolar Disorder; Cognitive Impairment; Depression; Development; Psychosis; Schizophrenia.

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national center for biotechnology information

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Cognitive Deficits in Psychotic Disorders: A Lifespan Perspective - PubMed

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1 Department of Psychiatry & Behavioral Sciences, Vanderbilt University Medical Center, 1601 23rd Ave S, Nashville, TN, 37212, USA. Julia.sheffield@vumc.org. 2 Department of Psychological & Brain Sciences, Washington University St. Louis, 1 Brookings Dr., St. Louis, MO, 63130, USA. 3 Department of Psychiatry, Washington University in St. Louis, St.

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Abstract

Narcolepsy is an uncommon chronic, neurological disorder characterized by abnormal manifestations of rapid eye movement sleep and perturbations in the sleep-wake cycle. Accurate diagnosis of psychotic symptoms in a person with narcolepsy could be difficult due to side effects of stimulant treatment (e.g., hallucinations) as well as primary symptoms of narcolepsy (e.g., sleep paralysis and hypnagogic and/or hypnapompic hallucinations). Pertinent articles from peer-reviewed journals were identified to help understand the complex phenomenology of psychotic symptoms in patients with narcolepsy. In this ensuing review and discussion, we present an overview of narcolepsy and outline diagnostic and management approaches for psychotic symptoms in patients with narcolepsy.

Keywords: psychosis, narcolepsy, comorbidity, stimulants, antipsychotics

Overview of Narcolepsy

Clinicians should be aware that perceptual disturbances like hypnic hallucinations restricted to awakening and falling asleep are not sufficient to diagnose the patient with a psychotic disorder. A detailed sleep history with focus on timing and relationship of such hallucinations to sleep can provide a clue to the true nature of these symptoms. Furthermore, a primary psychotic disorder, such as schizophrenia, can occur comorbidly with narcolepsy, leading to a diagnostic and therapeutic challenge for clinicians.

Narcolepsy and Psychosis

Narcolepsy is an uncommon chronic, neurological disorder characterized by chronic sleepiness, markedly disorganized sleep-wake behaviors, and abnormal manifestations of REM sleep.8 Incidence of narcolepsy usually peaks in adolescence or early adulthood, and prevalence in the general population appears to vary with ethnicity and familial risk. The estimated prevalence is as low as 0.002 percent in the Israeli population, as high as 0.02 percent in the Japanese population, and up to five percent in families with significant genetic predisposition.9 The age of onset varies from early childhood to the 50s, with two peaks: a larger peak that occurs at around 15 years of age and a smaller peak at approximately 36 years of age.10

The pathophysiology of narcolepsy appears to be related to deficiency of hypocretin neurons in the hypothalamus secondary to a degenerative process like gliosis.11 According to the International Classification of Sleep Disorders ( ICSD) criteria,12 narcolepsy is usually diagnosed by the following classic tetrad of symptoms: EDS, inability to move after awakening in conscious state (sleep paralysis), sudden loss of muscle tone (cataplexy), and REM phenomena (e.g., hypnagogic and hypnapompic hallucinations).

Hypnagogic hallucinations occur during the "falling asleep" phase (more common) and hypnapompic hallucinations occur during the "awakening from sleep" phase (less common). Diagnosis of narcolepsy without cataplexy can be made in the presence of EDS if one of the associated symptoms (hypnagogic hallucinations, automatic behaviors, sleep paralysis, and/or disrupted sleep) is present together with the following polysomnographic abnormalities: average sleep latency less than eight minutes or presence of two sleep-onset REM periods (SOREMPs) during the multiple sleep latency test (MSLT).

Multiple case reports describe the difficulties of diagnosing psychotic symptoms in presence of narcolepsy.15-17 Psychotic symptoms in patients with narcolepsy have the following three possible explanations: co-occurring primary psychotic illness (e.g., schizophrenia),15,20 an iatrogenic occurrence due to treatment with stimulants,16 or a narcoleptic psychosis viewed as delusional elaboration of hypnic hallucinations.1,17 Patients with narcolepsy who experience prominent REM phenomena, such as hypnic hallucinations, may attach significance to a particular vivid hallucination, often followed by attempts to explain the hallucination. This could lead to delusional explanations of such hallucinatory experiences. Such patients may exhibit bizarre and disorganized behaviors suggestive of a primary psychotic illness. Patients with episodes of sleep paralysis in narcolepsy have described such episodes as "electricity shooting through the body" and described vivid visual hallucinations (e.g., "aliens standing next to my bed"). These episodes were associated with ensuing patient narratives, such as being "abducted by aliens." It appears that these narratives have significant cultural influences.1 A specific example of this is in patients who experience breathing difficulties and sleep paralysis. These events have been described by patients as a person sitting on their chests (vivid hallucination). The specific description of who is "sitting" on the patient's chest within the narrative may vary from culture to culture (e.g., an old hag or witch may be described by a patient in Newfoundland or the US while "kanashibari," a term related to supernatural powers, may be described by a patient in Japan).22

It has been suggested that about seven percent of patients with a diagnosis of schizophrenia actually have a psychotic variant of narcolepsy;1 however, larger studies to confirm these findings are lacking. Although an earlier study showed that patients with schizophrenia were four times as likely to have narcolepsy-associated antigens, such as HLA DR15 and DQ6, compared to normal controls,23 there appears to be insufficient evidence at this time to suggest any shared pathology between narcolepsy and psychotic illnesses. In this regard, studies into rare genetic syndromes, such as succinic semialdehyde dehydrogenase deficiency (g-hydroxybutyric aciduria), which present with neurological deficits (e.g., hypotonia, seizures, impaired language development, psychotic symptoms in adolescence and late-adulthood, and sleep difficulties consistent with narcolepsy) may help provide further insights into possible neurobiological interactions between psychosis and narcolepsy.24 However, Walterfang et al25 argue against a specific narcoleptic form of psychosis in an extensive review. They point out that the following pathological mechanisms are largely absent in primary psychotic disorders compared to narcolepsy: significant REM sleep phenomena, associations with HLA antigens like HLA DR15, DQ6 and DQB1*0602 (an allele of DQ1), TNF-alpha gene polymorphisms, and evidence of hypocretin neuron disruption.25

Thus, the key diagnostic challenges in co-occurring narcolepsy and psychosis would be the following: A) to distinguish the psychosis-like symptoms of narcolepsy (REM sleep-related hallucinations) from positive symptoms of schizophrenia, and/or B) to establish a temporal relationship between initiation of stimulant medications and onset and continuation of psychotic symptoms or, conversely, reduction in psychotic symptoms upon cessation of stimulants.

Stimulant-induced Psychosis

A recent review by the US Food and Drug Administration (FDA) of all pharmaceutical company-sponsored trials reveals that "transient psychotic states" (hallucinosis) occur in 0.25 percent of children on stimulants (1 in 400). These hallucinations tend to wane 3 to 7 days after discontinuation of the stimulant.26

A more recent review of manufacturers' data by the FDA in children at risk of psychosis and/or mania with stimulants showed an average rate of adverse events, such as psychosis and mania, at 1.48 per 100 persons in a year. A total of 865 case reports of psychosis, mania, or similar events were identified in post-marketing surveillance with the most common symptoms of hallucinations related to stimulants being "visual and/or tactile" hallucinations.27

Another review found the presence of psychotic symptoms in chronic amphetamine-dependent patients to be as high as 40 percent, mostly at higher doses. One to 15 percent of these patients experienced continued psychotic symptoms even after several days of abstinence.28

Psychosis during treatment of narcolepsy with stimulants is dose dependent (i.e., it is less likely at low doses and more likely at high doses and with chronic treatment).28 However, most patients with narcolepsy treated with high-dose methylphenidate for an extended period of time do not develop psychosis.29,30

Chronic use of stimulants results in reduction in dopamine transporter density31,32 and possibly a persistent hyperdopaminergic state. Although it can be argued that this persistent hyperdopaminergic state could be responsible for evolving psychotic symptoms in patients with narcolepsy and chronic stimulant therapy, vulnerability studies have not established duration criteria that define such a relationship.

Whether emergence of psychosis in patients treated for narcolepsy with licit doses of stimulants might indicate an underlying biological vulnerability to psychosis is largely unknown. A common neurobiological pathway for such a model is unclear, although it is possibly mediated via the dopaminergic system,33,34 and genetic factors also appear to have a mediating role in emergence of psychotic symptoms during treatment with stimulants.35

A systematic review of stimulant psychosis showed that 50 to 70 percent of patients with schizophrenia or history of acute psychosis with stimulants show a worsening in response to a single dose of stimulant, even when such patients have been adherent with an antipsychotic medication. The authors point out that although the long-term effect of stimulants on sensitization is unknown, continued antipsychotic treatment at low doses may prevent the development of chronic, persistent psychosis.36 This conclusion may thus have therapeutic implications for patients with comorbid narcolepsy and psychotic disorder.

Differentiating Core Symptoms of Psychosis from Symptoms of Narcolepsy

Criteria for distinguishing whether psychotic symptoms represent hypnic experiences of narcolepsy or a primary psychotic disorder have been elaborated in a study comparing 148 narcoleptic patients to 21 patients with acute schizophrenia and 128 healthy controls.37 In this study, hallucinations in narcolepsy (compared to hallucinations in schizophrenia) were sleep-related (up to 80% of the experiences) and were associated with other symptoms of narcolepsy; they were posture-dependent (increased in supine position), unlike in schizophrenia wherein hallucinations are not posture-dependent; and the content of hallucinations in narcolepsy was of "visual-kinetic" quality (e.g., "I felt like I was flying or falling," or "I felt like someone was in the room with me"), whereas in schizophrenia, hallucinations are mostly auditory.

A recent study utilizing schedules for clinical assessment in neuropsychiatry (SCAN 2.1) to compare psychotic symptoms between 60 patients with narcolepsy, 102 patients with schizophrenia, and 120 matched population controls concluded that hallucinations in patients with narcolepsy, compared to patients with schizophrenia, tend to be sleep-related, multimodal or holistic in nature (i.e., combination of visual, auditory, tactile), and were associated with reduced frequency of concurrent delusions.38 Compared to population controls, patients with narcolepsy were not shown to have increased prevalence of formal psychotic disorders in this study.

Early reports of dream-like or hallucinatory experiences in narcolepsy noted the preponderance of the following descriptions: flying, falling, and skimming or sliding during cataplexy episodes.39,40 Such visual-kinetic experiences could represent REM sleep intrusion into wakefulness, often accompanied by nonvolitional REM leading to sensations of flying. Such vivid visual-kinetic experiences are rare in patients with schizophrenia.

Diagnostic and Treatment Complexities

According to the American Academy of Sleep Medicine (AASM), practice parameters for treatment of narcolepsy,41 modafinil, sodium oxybate, amphetamine, methamphetamine, dextroamphetamine, methylphenidate, and selegiline are effective treatments for excessive sleepiness. The AASM practice parameters recommend tricyclic antidepressants and fluoxetine for cataplexy, sleep paralysis, and hypnagogic hallucinations associated with narcolepsy. Levels of recommendations, however, within these parameters are varied for each of these medications due to differences in published clinical evidence supporting their uses.

After stimulants are gradually discontinued, modafinil can be initiated and titrated to 400mg/day to target symptoms of narcolepsy. The mechanism of action of modafinil is yet to be elucidated although it was proposed that GABA, glutamate, histamine, and hypocretin systems are involved.43 Recently, modafinil has been shown to occupy catecholamine and dopamine transporters in brain.44 At least four double-blind, randomized trials of modafinil in narcolepsy have shown improvements in sleepiness symptoms, with continuation of improvement seen in a few open-label extension studies.43 Caution should be exercised as modafinil was shown to be associated with mania45,46 and psychosis47 in case reports. Regular monitoring of symptoms of EDS using Epworth Sleepiness Scale (ESS) as well as clinical monitoring for worsening psychosis and/or affective symptoms can be useful.

Armodafinil is an R-enantiomer of modafinil with a longer half-life and was recently approved by the FDA for improving wakefulness in patients with excessive sleepiness associated with obstructive sleep apnea/hypopnea syndrome (OSAHS), narcolepsy, and shift work sleep disorder. Armodafinil appears to be well tolerated and efficacious in patients with narcolepsy at 150mg and 250mg doses;48 however, it will not be commercially available until 2010 pending further clinical data.

If psychotic symptoms persist at least 7 to 10 days after cessation of stimulants, initiation of an antipsychotic medication should be considered. Although any antipsychotic medication can be helpful in targeting psychotic symptoms in such a complex clinical situation, aripiprazole might be potentially useful given its unique mechanism of action as a dopamine (D2) partial agonist, serotonin (5-HT1A) partial agonist, and serotonin (5-HT2A) antagonist. Recent evidence suggests that activation of postsynaptic dopamine (D1 or D2) receptors increases wakefulness, and selective stimulation of dopamine D2 autoreceptors or blockade of dopamine D1 or D2 receptors produces sedation. Activation of serotonergic 5-HT1A receptors leads to increased dopamine release in ventral tegmental area (VTA), which in turn may lead to wakefulness; however, effects of serotonergic 5-HT2A receptor activation are still unclear.49

In adult studies, the antipsychotics olanzapine and risperidone were shown to increase Stage 2 sleep and Delta sleep and suppress REM sleep; whereas, quetiapine appears to have lesser REM suppressant effects.50,51 Therefore, abrupt discontinuation of these medications can result in REM rebound and REM-related hallucinations. Effects of aripiprazole on REM sleep architecture are unknown.

Possible utility of aripiprazole in comorbid psychosis and narcolepsy was hypothesized in some reviews,15,16 but there are no published case reports of aripiprazole's effectiveness in this clinical scenario. While aripiprazole is considered to be one of the least sedating atypical antipsychotics, caution should be exercised as it may cause sedation and worsen symptoms of narcolepsy. Case reports exist about worsening psychotic symptoms on aripiprazole.52,53 Although antiadrenergic effects of aripiprazole appear to be low compared to clozapine, there is a published report on clozapine-induced cataplexy;54 therefore, it is reasonable to monitor for worsening narcolepsy symptoms (e.g., cataplexy) in patients on aripiprazole. There are no known drug-drug interactions between modafinil and aripiprazole.

If psychotic symptoms improve but narcoleptic symptoms persist on modafinil therapy, a reasonable choice would be to rechallenge the patient with stimulants after explaining the risks and benefits of such medication. In such cases, monitoring for re-emergence of psychotic symptoms is essential. In one study, psychotic symptoms improved upon initiation of stimulants in some patients with narcolepsy, especially when these patients had worsening of symptoms on antipsychotics. These patients were misdiagnosed as having treatment resistant-schizophrenia when actually they had treatable variants of narcolepsy.1

Another choice to consider for narcoleptic symptoms is sodium oxybate, either as monotherapy or in addition to modafinil. Sodium oxybate is a sodium salt of the central nervous system (CNS) depressant gamma-hydroxy butyrate (GHB), and it appears to activate excitatory GHB receptors at low doses, stimulate inhibitory gamma-amino butyric acid (GABA) receptors at higher doses, and possibly cause both dopamine and serotonin release. The recommended starting dose is 4.5g a night divided into two equal doses of 2.25g, which may be adjusted up to a maximum of 9g per night in increments of 1.5g per night at 1- to 2-week intervals.55

In cases of narcolepsy where cataplexy presents as the major debilitating symptom in addition to EDS, sodium oxybate has demonstrated statistically significant improvements in both symptoms, either as monotherapy or in combination with modafinil, in clinical trials.56 Clinicians should, however, note that symptoms of psychosis-like paranoia and hallucinations can be potential and infrequent side effects of sodium oxybate. Therefore, use of sodium oxybate in comorbid narcolepsy and psychosis should be avoided as much as possible. If initiated, monitoring for emergence or worsening of psychotic symptoms during the initiation and dose escalation phases should be undertaken.

GHB has high abuse potential, with notoriety for use in "date rape" and "rave parties" by adolescents and young adults. The FDA has, therefore, currently classified sodium oxybate as a schedule I substance.57 A history of illicit substance dependence in adolescents or adults with narcolepsy can be a deterrent for initiation of sodium oxybate. However, it has been suggested in animal studies,58 that patients with narcolepsy, in general, have a lower chance of addiction due to a deficiency in hypocretin (orexin), a hypothalamic neuropeptide that regulates sleep-wake cycle, feeding behaviors, and energy homeostasis, and was recently implicated in reward systems.59,60 Nevertheless, given the concerns over possible diversion and abuse of sodium oxybate, a restricted drug distribution system called Xyrem Success Program was created. This system incorporates a post-marketing surveillance program that includes centralized distribution and dispensing, maintaining a registry of physicians and patients, provision of educational materials for patients and physicians, involvement of trained staff in pharmacies, and a method to track prescription shipments.61

Another concern with use of sodium oxybate appears to be its relatively narrow therapeutic index and risk associated with overdose. A recent review indicated that GHB withdrawal syndrome is associated with emergent delirium and psychotic symptoms that are often persistent.62 Whether patients previously on stimulants who have experienced psychosis are more prone to delirium with sodium oxybate or GHB still remains unclear.

Conclusions

As a symptom of many psychiatric disorders across the age spectrum, sleep disturbances often complicate the course and treatment of the underlying psychiatric symptoms. Identification of symptoms of narcolepsy assumes importance due to significant implications for diagnosis, treatment, and outcomes. Bizarre descriptions of hypnic hallucinations and sleep paralysis symptoms may lead to diagnostic misinterpretations of patients as psychotic, anxious, and/or depressed. Patients may experience extensive life-threatening medical consequences if REM hallucinations lead to delusional elaboration. When primary psychotic disorders, such as schizophrenia, co-occur with narcolepsy, it can lead to significant diagnostic/therapeutic challenges, as well as worsening in psychosocial impairments (e.g., lack of self care, social withdrawal, and depressed mood). Given such the psychosocial consequences associated with co-occurring narcolepsy and psychosis, clinicians should be mindful of comorbid sleep disorders in psychiatric illnesses and the need for careful attention to routine history taking to prevent misdiagnosis and treatment approaches that may worsen either condition. This discussion regarding diagnosis and treatment of narcolepsy can be useful to monitor both primary psychotic symptoms and psychotic phenomena associated with narcolepsy, when they co-occur.

References

12. The International Classification of Sleep Disorders, Second Edition. Westchester, NY: American Academy of Sleep Medicine; 2005. American Academy of Sleep Medicine. [ Google Scholar]

44. Madras BK, Xie Z, Lin Z, et al. Modafinil occupies dopamine and norepinephrine transporters [ in vivo and modulates the transporters and trace amine activity in vitro. J Pharmacol Exp Ther. 2006;319(2):561-569. [ PubMed] Google Scholar]

Articles from Psychiatry (Edgmont) are provided here courtesy of Matrix Medical Communications

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Complex Diagnostic and Treatment Issues in Psychotic Symptoms Associated with Narcolepsy

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Narcolepsy is an uncommon chronic, neurological disorder characterized by abnormal manifestations of rapid eye movement sleep and perturbations in the sleep-wake cycle. Accurate diagnosis of psychotic symptoms in a person with narcolepsy could be difficult due to side effects of stimulant treatment (e.g., hallucinations) as well as primary symptoms of narcolepsy (e.g., sleep paralysis and hypnagogic and/or hypnapompic hallucinations).

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Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act, and helps determine how we handle stress, relate to others, and make choices.

Mental health is important at every stage of life, from childhood and adolescence through adulthood. Over the course of your life, if you experience mental health problems, your thinking, mood, and behavior could be affected.

Mental Health Conditions

Mental illnesses are disorders, ranging from mild to severe, that affect a person's thinking, mood, and/or behavior. According to the National Institute of Mental Health, nearly one-in-five adults live with a mental illness.

Many factors contribute to mental health conditions, including:

Biological factors, such as genes or brain chemistry

Life experiences, such as trauma or abuse

Family history of mental health problems

Some mental health topics include:

A Serious Mental Illness (SMI) is a mental illness that interferes with a person's life and ability to function. Despite common misperceptions, having an SMI is not a choice, a weakness, or a character flaw. It is not something that just "passes" or can be "snapped out of" with willpower.

View SAMHSA's Public Message about Serious Mental Illnesses.

Early Warning Signs & Symptoms

Not sure if you or someone you know is living with mental health problems? Experiencing one or more of the following feelings or behaviors can be an early warning sign of a problem:

Eating or sleeping too much or too little

Pulling away from people and usual activities

Having low or no energy

Feeling numb or like nothing matters

Having unexplained aches and pains

Feeling helpless or hopeless

Smoking, drinking, or using drugs more than usual

Feeling unusually confused, forgetful, on edge, angry, upset, worried, or scared

Yelling or fighting with family and friends

Experiencing severe mood swings that cause problems in relationships

Having persistent thoughts and memories you can't get out of your head

Hearing voices or believing things that are not true

Thinking of harming yourself or others

Inability to perform daily tasks like taking care of your kids or getting to work or school

Do you think someone you know may have a mental health problem? Talking about mental health can be difficult. Learn about common mental health myths and facts and read about ways to help you get the conversation started.

Tips for Living Well with a Mental Health Condition

Having a mental health condition can make it a struggle to work, keep up with school, stick to a regular schedule, have healthy relationships, socialize, maintain hygiene, and more.

However, with early and consistent treatment-often a combination of medication and psychotherapy-it is possible to manage these conditions, overcome challenges, and lead a meaningful, productive life.

Today, there are new tools, evidence-based treatments, and social support systems that help people feel better and pursue their goals. Some of these tips, tools and strategies include:

Stick to a treatment plan. Even if you feel better, don't stop going to therapy or taking medication without a doctor's guidance. Work with a doctor to safely adjust doses or medication if needed to continue a treatment plan.

Keep your primary care physician updated. Primary care physicians are an important part of long-term management, even if you also see a psychiatrist.

Learn about the condition. Being educated can help you stick to your treatment plan. Education can also help your loved ones be more supportive and compassionate.

Practice good self-care. Control stress with activities such as meditation or tai-chi; eat healthy and exercise; and get enough sleep.

Reach out to family and friends. Maintaining relationships with others is important. In times of crisis or rough spells, reach out to them for support and help.

Develop coping skills. Establishing healthy coping skills can help people deal with stress easier.

Get enough sleep. Good sleep improves your brain performance, mood and overall health. Consistently poor sleep is associated with anxiety, depression, and other mental health conditions.

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Mental health includes our emotional, psychological, and social well-being. It affects how we think, feel, and act, and helps determine how we handle stress, relate to others, and make choices.

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Centers for Disease Control and Prevention

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Mental health is important at every stage of life, from childhood and adolescence through adulthood. It is an important part of overall health and well-being and includes our emotional, psychological, and social well-being. It affects how we think, feel, and act.

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Episode Description

Trigger Warning: Mentions of suicide/self-harm
In this episode, we talked about the experiences and struggles we have had with mental health. It turned into us sharing the way our life has been affecting our mental health so I hope that's okay. We

See all episodes

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Listen to this episode from Teenager Therapy on Spotify. Trigger Warning: Mentions of suicide/self-harm In this episode, we talked about the experiences and struggles we have had with mental health. It turned into us sharing the way our life has been affecting our mental health so I hope that's okay.

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Sound Therapy To Reduce Anxiety, Mental Health & Depression ( GUARANTEED )

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Listen to this episode from Relaxing music on Spotify. Divine talks- Please copy pest in YouTube for full video - https://youtu.be/yMHE-EQaFEs Sleep Music Delta Waves: Relaxing Music to Help you Sleep, Deep Sleep, Inner Peace and Autogenic Training. Relaxing Sounds for Relaxation Meditation, Tai Chi and Reiki.

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The School Counselor and Student Mental Health

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Students' unmet mental health needs can be a significant obstacle to student academic, career and social/emotional development and even compromise school safety. Even so, most students in need do not receive adequate mental health supports (Centers for Disease Control and Prevention [CDC], 2013).

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Mental Health and the School Counselor's Role

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The School Counselor's Role in Student Mental Health

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Educate teachers, administrators, families and community stakeholders about the mental health concerns of students, including recognition of the role environmental factors have in causing or exacerbating mental health issues, and provide resources and information

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Addressing Mental Health Needs in Our Schools: Supporting the Role of School Counselors

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Traci P. Collins School counselors are a well-positioned resource to reach the significant number of children and adolescents with mental health problems. In this special school counseling issue of The Professional Counselor, some articles focus on systemic, top-down advocacy efforts as the point of intervention for addressing child and adolescent mental health.

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Section 504 Accommodations & Modifications | Forming a Section 504 Plan | Navigate Life Texas

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If your child needs special accommodations at school with the way content is taught, supported, or tested, you might be able get assistance through a Section 504 plan.

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IDEA was originally enacted by Congress in 1975 to ensure that children with disabilities have the opportunity to receive a free appropriate public education, just like other children. The law has been revised many times over the years.
In Spanish | En español - Sobre la Ley IDEA
The most recent amendments were passed by Congress in December 2004, with final regulations published in August 2006 (Part B for school-aged children) and in September 2011 (Part C, for babies and toddlers). So, in one sense, the law is very new, even as it has a long, detailed, and powerful history.

Summaries of IDEA

If you're looking for summaries of what the law requires (rather than its word-for-word statute or regulations), try the Center for Parent Information and Resources' website:

Services for babies and toddlers to the third birthday (Part C of IDEA):
http://www.parentcenterhub.org/repository/partc/

Services for school-aged children, including preschoolers (Part B of IDEA):
http://www.parentcenterhub.org/repository/partb/

Exact Words of IDEA Itself

To read IDEA's verbatim language can be a big help in understanding why local practices in schools and early childhood settings are as they are. Here is the place to connect with that language. Use the links below to explore the actual words of our nation's special education law.

Access the entire IDEA law
PDF version | HTML version

Part B Regulations: Services for School-Aged Children
PDF version | HTML version
Part C Regulations: Early Childhood Intervention for Babies and Toddlers
HTML version
Guidance on IDEA from the U.S. Department of Education

The Office of Special Education Programs (OSEP) at the U.S. Department of Education regularly provides guidance to the field on IDEA. All are intended to clarify elements of the law and its regulations, and are an important part of understanding IDEA and how to implement it. To connect with this federal guidance, visit our page IDEA Guidance from the DOE.

Part B State Performance Plans (SPP) Letters and Annual Performance Report (APR) Letters

The reauthorized Individuals with Disabilities Education Act (IDEA), signed on December 3, 2004, required that, not later than one year after the date of enactment of the reauthorized IDEA, each state is required to have in place a performance plan evaluating the state's implementation of Part B and describing how the state will improve such implementation. This plan is called the Part B State Performance Plan (SPP) and is required to be posted on the state's website.
http://www2.ed.gov/fund/data/report/idea/partbspap/allyears.html#tx
In addition, each state reports annually to the public on the performance of each of its local educational agencies according to the targets in its SPP. The state also reports annually to the Secretary on its performance in meeting its SPP targets. This report is called the Part B Annual Performance Report (APR), this report must also be posted on the state's website.

IDEA, The Manual for Parents and Students about Special Education Services in Texas
Adapted from an article by the Center for Parent Information and Resources http://www.parentcenterhub.org/
IDEA, The Manual for Parents and Students about Special Education Services in Texas, a free publication from the Arc of Texas and Disability Rights Texas, is an invaluable resource for families trying to understand the Texas special education system and is available online in both English and Spanish.

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IDEA | Individuals with Disabilities Education Act

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IDEA was originally enacted by Congress in 1975 to ensure that children with disabilities have the opportunity to receive a free appropriate public education, just like other children. The law has been revised many times over the years.