This blog is about Personality Disorders and my observations of other things of interest from a psychological perspective. Over the past few years, I have had quite a bit of first-hand experience with people who suffer from personality disorders. One in particular, who suffers from both a personality disorder and bulimia, really made an impression on me and left me with PTSD. I’m fine now, but before my experience with her, I had been unaware that the disorders existed to any practical ends. I’d heard of some of them and had preconcieved notions about those few, but no knowledge which was useful to deal with the situation. I would have been better equipped if I had known more. As a result of having seen what people who suffer from personality disorder might live through. That is, their feelings and the intensity of those feelings, and potential causes of the disorder, I want to make known whatever I can about the disorders. Also, about the behaviour of people with these disorders. I am not a psychologist, so what you will find here is only research and observation. I’m not qualified to, and wouldn’t dare to, diagnose. Perhaps you may find some of the information here useful.

I must make clear the distinction between unfavourable behaviour and a disorder. Many, if not all, of the less likeable traits of the people who have disorders, are present in people whose behaviour does not qualify them to have a disorder. In other words, since we all display the various traits which are also traits that those with personality disorders have, we know that these are spectrum disorders. The fact that these behaviours are common human behaviours is particularly salient. It means that it is more difficult to establish both when somebody has a personality disorder and which one they might have. The description given (ICD and DSM) is that the behaviours must be prolific and repeated and often engaged in against the person’s better interest. Each personality disorder is identified by a list of symptoms, of which a number must be observable in that individual or the person does not suffer from a personality disorder. It takes a lot of understanding to be able to identify a disorder, both of the subject of Personality Disorder and the individual. In most cases, these are developmental deficits, and these people are suffering. A common misconception is that they have advantages and that they may be a threat, that’s unlikely. The other thing I should point out is that a person can have more than one personality disorder or mental illness. Co-morbidity is more common than one might think.

My experience is that personality disorder is exceptionally severe, more severe than one might think.

Below is the context, descriptions of each of the classes and within those each of the personality disorders. I have supplemented this post with my own information. The rest is taken entirely from another site.

Personality disorders are a class of psychological conditions that are characterized by a pattern of long term behaviour that deviates from societal expectations and which create severe problems in relationships and society.

People who have personality disorders tend to be inflexible and manipulative. Although, unable to see the problems, most feel that their behaviours are justified and perfectly fine. They often have a tunnel-vision view of the world and have problems connecting with others in socially acceptable ways.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) has identified a list of personality disorders and classified them in three groups or clusters based on the nature of the symptoms, those are described below. The DSM-V and the ICD-11 classifications and descriptions differ from these.

Class A: Odd or eccentric disorders

Paranoid personality disorder

Characterized by suspiciousness and a deep mistrust of people, paranoid personalities often think of others as manipulative, cunning or dishonest. This kind of a person may appear guarded, secretive, and excessively critical.A pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

• Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.
• Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.
• Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.
• Reads hidden demeaning or threatening meanings into benign remarks or events.
• Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights.
• Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack.
• Has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner.

Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, or another Psychotic Disorder and is not due to the direct physiological effects of a general medical condition.

Associated Features

Individuals with Paranoid Personality Disorder are generally difficult to get along with and often have problems with close relationships. Their excessive suspiciousness and hostility may be expressed in overt argumentativeness, in recurrent complaining, or by quiet, apparently hostile aloofness.

Because individuals with Paranoid Personality Disorder lack trust in others, they have an excessive need to be self-sufficient and a strong sense of autonomy. They also need to have a high degree of control over those around them. They are often rigid, critical of others, and unable to collaborate, although they have great difficulty accepting criticism themselves. They may blame others for their own shortcomings. Because of their quickness to counterattack in response to the threats they perceive around them, they may be litigious and frequently become involved in legal disputes.

Individuals with this disorder may develop Major Depressive Disorder and may be at increased risk for Agoraphobia and Obsessive-Compulsive Disorder. Alcohol and other Substance Abuse or Dependence frequently occur. The most common co-occurring Personality Disorders appear to be Schizotypal, Schizoid, Narcissistic, Avoidant, and Borderline.

Diagnostic criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association

Schizoid personality disorder

People with schizoid personalities are emotionally distant and tend to prefer to be alone. They are generally immersed in their own thoughts and have little interest in bonding and intimacy with others.A pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

• Neither desires nor enjoys close relationships, including being part of a family.
• Almost always chooses solitary activities.
• Has little, if any, interest in having sexual experiences with another person.
• Takes pleasure in few, if any, activities.
• Lacks close friends or confidants other than first-degree relatives.
• Appears indifferent to the praise or criticism of others.
• Shows emotional coldness, detachment, or flattened affectivity.

Does not occur exclusively during the course of Schizophrenia, a Mood Disorder With Psychotic Features, another Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to the direct physiological effects of a general medical condition.

Associated Features

Individuals with Schizoid Personality Disorder may have particular difficulty expressing anger, even in response to direct provocation, which contributes to the impression that they lack emotion. Their lives sometimes seem directionless, and they may appear to “drift” in their goals.

Such individuals often react passively to adverse circumstances and have difficulty responding appropriately to important life events. Because of their lack of social skills and lack of desire for sexual experiences, individuals with this disorder have few friendships, date infrequently, and often do not marry. Occupational functioning may be impaired, particularly if interpersonal involvement is required, but individuals with this disorder may do well when they work under conditions of social isolation.

Individuals with Schizoid Personality Disorder often seem indifferent to the approval or criticism of others and do not appear to be bothered by what others may think of them. They may be oblivious to the normal subtleties of social interaction and often do not respond appropriately to social cues so that they seem socially inept or superficial and self-absorbed. They usually display a “bland” exterior without visible emotional reactivity and rarely reciprocate gestures or facial expressions, such as smiles or nods.

Diagnostic criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Schizotypal personality disorder

This disorder is characterized by odd and unusual “magical” beliefs. These individuals may have an eccentric way of behaving or dressing. They also tend to display outlandish beliefs such as believing that they can see the future or travel to other dimensions. People with this condition often have difficulty connecting with others and establishing long term relationships. Overtime, they may develop a fear of social gatherings.

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions and eccentricities of behavior, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

• Ideas of reference (excluding delusions of reference).
• Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or “sixth sense”; in children and adolescents, bizarre fantasies or preoccupations).
• Unusual perceptual experiences, including bodily illusions .
• Odd thinking and speech (e.g., vague, circumstantial, metaphorical, overelaborate, or stereotyped).
• Suspiciousness or paranoid ideation.
• Inappropriate or constricted affect.
• Behavior or appearance that is odd, eccentric, or peculiar.
• Lack of close friends or confidants other than first-degree relatives.
• Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.

Individuals with Schizotypal Personality Disorder experience interpersonal relatedness as problematic and are uncomfortable relating to other people. Although they may express unhappiness about their lack of relationships, their behavior suggests a decreased desire for intimate contacts. As a result, they usually have no or few close friends or confidants other than a first-degree relative.

Associated Features

Individuals with Schizotypal Personality Disorder often seek treatment for the associated symptoms of anxiety, depression, or other dysphoric affects rather than for the personality disorder features per se. Particularly in response to stress, individuals with this disorder may experience transient psychotic episodes (lasting minutes to hours), although they usually are insufficient in duration to warrant an additional diagnosis such as Brief Psychotic Disorder or Schizophreniform Disorder.

In some cases, clinically significant psychotic symptoms may develop that meet criteria for Brief Psychotic Disorder, Schizophreniform Disorder, Delusional Disorder, or Schizophrenia.

Over half may have a history of at least one Major Depressive Episode. From 30% to 50% of individuals diagnosed with this disorder have a concurrent diagnosis of Major Depressive Disorder when admitted to a clinical setting.

Diagnostic criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Class B: Dramatic, emotional or erratic disorders

Antisocial/psychopath personality disorder

Individuals with this disorder are known to be manipulative, irresponsible, and have a history of legal difficulties. They show little respect for the rights of others and feel no remorse for their actions. They also leave a trail of unfulfilled promises and broken hearts.

Antisocial personalities are also at high risk for drug abuse (e.g., alcoholism; meth) since many are “rush” seekers. While they seldom suffer from depression or anxiety, they often use drugs to relieve boredom and irritability.

Antisocial Personality Disorder is a term that has replaced sociopathy, and psychopathy, in the DSM IV manual to describe a disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following:

• Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest.
• Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.
• Impulsivity or failure to plan ahead.
• Irritability and aggressiveness, as indicated by repeated physical fights or assaults.
• Reckless disregard for safety of self or others.
• Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.
• Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.

The individual is at least age 18 years.

There is evidence of Conduct Disorder with onset before age 15 years.

The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

Diagnostic Features

Individuals with Antisocial Personality Disorder may frequently carry out acts that are criminal in nature, such as vandalism, stealing, or pursuing other illegal activity. People with this disorder disregard the feelings and rights of others. They are manipulative, deceiving and destructive for the sake of obtaining personal revenue/profit or pleasure (e.g., money, power).

Individuals with Antisocial Personality Disorder may be unconcerned about having mistreated or hurt someone else (e.g., “he didn’t feel a thing anyway”, “he had it coming”, “one less loser in the world”). They may blame the victims for being unwise, vulnerable, or deserving to be hurt; these individuals may downplay the destructive consequences of their actions; and/or be completely indifferent. They generally fail to improve or correct their behavior. They may rationalize that “only the strong survive”, and that they are entitled to anything they wish at the expense of others.

They may egocentric and have an arrogant self-appraisal (e.g., other people are inferior and social norms don’t apply to them) and may appear overly opinionated, cocky, and self-absorbed. They may also appear charismatic, charming, and possess a flair with words (e.g., using sophisticated language that might impress people who are unfamiliar with a particular topic).

These individuals may also be highly promiscuous and manipulative with their partners. Individuals with Antisocial Personality Disorder may be negligent as parents, as evidenced by wasteful spending and drug abuse. These individuals often spend many years going in-and-out of prison. They are also more likely to die early, often by violent means (e.g., homicides, accidents, drug abuse), than individuals in the general population.

Course

Antisocial Personality Disorder is a chronic condition but becomes less pronounced as the person grows older, usually by the 40s and up. During this time, there is a gradual decrease in criminal behaviors and drug abuse.

Family and Background

Antisocial Personality Disorder is more common among biological relatives of those with the disorder than among the general population. The risk to biological relatives of females with the disorder tends to be higher than the risk to biological relatives of males with the disorder. Biological relatives of persons with this disorder are also at increased risk for a Somatization Disorder and Substance-Related Disorders.

Adoption studies have shown that both genetic and environmental factors contribute to the risk of this group of disorders. Both adopted and biological children of parents with Antisocial Personality Disorder have an increased risk of developing Antisocial Personality Disorder, Somatization Disorder, and Substance-Related Disorders. Adopted-away children resemble their biological parents more than their adoptive parents, but the adoptive family environment may influence the risk of developing Antisocial Personality Disorder.

Diagnostic criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Borderline personality disorder

Borderline personalities are impulsive and have extreme views of people as either “all good” or “bad”.

These people are unstable in relationships and have a strong fear of abandonment. They may form an intense personal attachment with someone they barely know and end it without no apparent reason. They might also engage in a “pull” and “push” behavior that usually ends with their partner leaving permanently.

Self-mutilation, suicidal gestures or attention-seeking destructive behaviors are not uncommon. Borderline personalities are three times more likely to be female.

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

• Frantic efforts to avoid real or imagined abandonment.
• A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.
• Identity disturbance: markedly and persistently unstable self-image or sense of self.
• Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in.
• Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.
• affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
• Chronic feelings of emptiness.
• Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).
• Transient, stress-related paranoid ideation or severe dissociative symptoms.

The individual is at least age 18 years.

There is evidence of Conduct Disorder with onset before age 15 years.

The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

Diagnostic Features

Individuals with Borderline Personality Disorder may have a pattern of undermining themselves at the moment a goal is about to be realized (e.g., dropping out of school just before graduation; regressing severely after a discussion of how well therapy is going; destroying a good relationship just when it is clear that the relationship could last). Some individuals develop psychotic-like symptoms (e.g., hallucinations, body-image distortions, ideas of reference, and hypnagogic phenomena) during times of stress. Individuals with this disorder may feel more secure with transitional objects (i.e., a pet or inanimate possession) than in interpersonal relationships.

Associated Features

Premature death from suicide may occur in individuals with this disorder, especially in those with co-occurring Mood Disorders or Substance-Related Disorders. Physical handicaps may result from self-inflicted abuse behaviors or failed suicide attempts. Recurrent job losses, interrupted education, and broken marriages are common. Physical and sexual abuse, neglect, hostile conflict, and early parental loss or separation are more common in the childhood histories of those with Borderline Personality Disorder. Common co-occurring Axis I disorders include Mood Disorders, Substance-Related Disorders, Eating Disorders (notably Bulimia), Posttraumatic Stress Disorder (PTSD) , and Attention-Deficit/Hyperactivity Disorder. Borderline Personality Disorder also frequently co-occurs with the other Personality Disorders.

Course

There is considerable variability in the course of Borderline Personality Disorder. The most common pattern is one of chronic instability in early adulthood, with episodes of serious affective and impulsive dyscontrol and high levels of use of health and mental health resources. The impairment from the disorder and the risk of suicide are greatest in the young-adult years and gradually wane with advancing age.

Although the tendency toward intense emotions, impulsivity, and intensity in relationships is often lifelong, individuals who engage in therapeutic intervention often show improvement beginning sometime during the first year. During their 30s and 40s, the majority of individuals with this disorder attain greater stability in their relationships and vocational functioning. Follow-up studies of individuals identified through outpatient mental health clinics indicate that after about 10 years, as many as half of the individuals no longer have a pattern of behavior that meets full criteria for Borderline Personality Disorder.

Diagnostic criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Histrionic personality disorder

People with this condition engage in persistent attention-seeking behaviors that include innapropriate sexual behavior and exaggerated emotions. They can be oversensitive about themselves and constantly seek reasurrance or approval from others.

Excessive need to be the center of attention, low tolerance for frustration, blaming others for failures are also characteristics of the histrionic personality.

This is pervasive pattern of excessive emotionality and attention seeking, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

• Is uncomfortable in situations in which he or she is not the center of attention.
• Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.
• Displays rapidly shifting and shallow expression of emotions.
• Consistently uses physical appearance to draw attention to self.
• Has a style of speech that is excessively impressionistic and lacking in detail.
• Shows self-dramatization, theatricaility, and exaggerated expression of emotion.
• Is suggestible, i.e., easily influenced by others or circumstances.
• Considers relationships to be more intimate than they actually are.

Diagnostic Features

The essential feature of Histrionic Personality Disorder is pervasive and excessive emotionality and attention-seeking behavior. This pattern begins by early adulthood and is present in a variety of contexts.

Individuals with Histrionic Personality Disorder are uncomfortable or feel unappreciated when they are not the center of attention. Often lively and dramatic, they tend to draw attention to themselves and may initially charm new acquaintances by their enthusiasm, apparent openness, or flirtatiousness.

Individuals with Histrionic Personality Disorder may have difficulty achieving emotional intimacy in romantic or sexual relationships. Without being aware of it, they often act out a role (e.g., “victim” or “princess”) in their relationships to others. They may seek to control their partner through emotional manipulation or seductiveness on one level, whereas displaying a marked dependency on them at another level. Individuals with this disorder often have impaired relationships with same-sex friends because their sexually provocative interpersonal style may seem a threat to their friends’ relationships. These individuals may also alienate friends with demands for constant attention. They often become depressed and upset when they are not the center of attention.

They may crave novelty, stimulation, and excitement and have a tendency to become bored with their usual routine. These individuals are often intolerant of, or frustrated by, situations that involve delayed gratification, and their actions are often directed at obtaining immediate satisfaction. Although they often initiate a job or project with great enthusiasm, their interest may lag quickly. Longer-term relationships may be neglected to make way for the excitement of new relationships.

Diagnostic criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Narcissistic personality disorder

Narcissistic personalities have a blown up perception of themselves and an excessive desire for attention and admiration. Individuals with this disorder have a false sense of entitlement and little respect for other people’s feelings. They are oversensitive to criticism and often blame others for their failures.

Prone to outbursts of anger and irritability, the narcissistic personality tends to be manipulative in interspersonal relationships. But deep beneath the surface lies a vulnerable self-esteem, susceptible to depression and feelings of inferiority.

Narcissistic Personality Disorder is a condition that is defined by a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

• Has a grandiose sense of self-importance (e.g.., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).
• Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.
• Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).
• Requires excessive admiration.
• Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations.
• Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends.
• Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.
• Is often envious of others or believes that others are envious of him or her.
• Shows arrogant, haughty behaviors or attitudes.

Associated Features

Vulnerability in self-esteem makes individuals with Narcissistic Personality Disorder very sensitive to “injury” from criticism or defeat. Although they may not show it outwardly, criticism may haunt these individuals and may leave them feeling humiliated, degraded, hollow, and empty. They may react with disdain, rage, or defiant counterattack. Such experiences often lead to social withdrawal or an appearance of humility that may mask and protect the grandiosity.

Interpersonal relations are typically impaired due to problems derived from entitlement, the need for admiration, and the relative disregard for the sensitivities of others. Though overweening ambition and confidence may lead to high achievement, performance may be disrupted due to intolerance of criticism or defeat. Sometimes vocational functioning can be very low, reflecting an unwillingness to take a risk in competitive or other situations in which defeat is possible.

Sustained feelings of shame or humiliation and the attendant self-criticism may be associated with social withdrawal, depressed mood, and Dysthymic or Major Depressive Disorder . In contrast, sustained periods of grandiosity may be associated with a hypomanic mood. Narcissistic Personality Disorder is also associated with Anorexia Nervosa and Substance-Related Disorders (especially related to cocaine). Histrionic, Borderline, Antisocial, and Paranoid Personality Disorders may be associated with Narcissistic Personality Disorder.

Diagnostic criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Class C: Anxious or fearful disorders

Avoidant personality disorder

This disorder is described by chronic social withdrawal, feelings of inferiority, over-sensitivity and social withdrawal.

People with avoidant personality disorder are constantly fearful of rejection and ridicule. They form relationships only with people that they trust. The pain of rejection is so strong that these individuals prefer to isolate rather than risk disappointment.

A pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

• Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.
• Is unwilling to get involved with people unless certain of being liked.
• Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.
• Is preoccupied with being criticized or rejected in social situations.
• Is inhibited in new interpersonal situations because of feelings of inadequacy.
• Views self as socially inept, personally unappealing, or inferior to others.
• Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

Associated Features

Individuals with Avoidant Personality Disorder often vigilantly appraise the movements and expressions of those with whom they come into contact. Their fearful and tense demeanor may elicit ridicule and derision from others, which in turn confirms their self-doubts.

The major problems associated with this disorder occur in social and occupational functioning. The low self-esteem and hypersensitivity to rejection are associated with restricted interpersonal contacts. These individuals may become relatively isolated and usually do not have a large social support network that can help them weather crises. They desire affection and acceptance and may fantasize about idealized relationships with others. The avoidant behaviors can also adversely affect occupational functioning because these individuals try to avoid the types of social situations that may be important for meeting the basic demands of the job or for advancement.

Other disorders that are commonly diagnosed with Avoidant Personality Disorder include Mood and Anxiety Disorders (especially Social Phobia of the Generalized Type) . Avoidant Personality Disorder is often diagnosed with Dependent Personality Disorder , because individuals with Avoidant Personality Disorder become very attached to and dependent on those few other people with whom they are friends. Avoidant Personality Disorder also tends to be diagnosed with Borderline Personality Disorder and with the Cluster A Personality Disorders (i.e., Paranoid, Schizoid, or Schizotypal Personality Disorders) .

Diagnostic criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Dependent personality disorder

Individuals with this condition have an abnormal desire to be nurtured that leads to submissive and clinging behavior. Dependent personalities have difficulty making their own decisions and seek others to take over most important areas in their lives.

They will often go to great length to obtain nurturance from others, have separation anxiety when alone and desperately seek another partner when a close relationship ends.

Dependent Personality Disorder

A pervasive and excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

• Has difficulty making everday decisions without an excessive amount of advice and reassurance from others.
• Needs others to assume responsibility for most major areas of his or her life.
• Has difficulty initiating projects or doing things on his or her own (because of a lack of self-confidence in judgment or abilities rather than a lack of motivation or energy).
• Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.
• Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.
• Urgently seeks another relationship as a source of care and support when a close relationship ends.
• Is unrealistically preoccupied with fears of being left to take care of himself or herself.

Individuals with Dependent Personality Disorder may go to excessive lengths to obtain nurturance and support from others, even to the point of volunteering for unpleasant tasks if such behavior will bring the care they need.They are willing to submit to what others want, even if the demands are unreasonable. Their need to maintain an important bond will often result in imbalanced or distorted relationships. They may make extraordinary self-sacrifices or tolerate verbal, physical, or sexual abuse.

When a close relationship ends (e.g., a breakup with a lover; the death of a caregiver), individuals with Dependent Personality Disorder may urgently seek another relationship to provide the care and support they need.

Associated Features

Individuals with Dependent Personality Disorder are often characterized by pessimism and self-doubt, tend to belittle their abilities and assets, and may constantly refer to themselves as “stupid.”

Dependent Personality Disorder often co-occurs with other Personality Disorders, especially Borderline, Avoidant, and Histrionic Personality Disorders . Chronic physical illness or Separation Anxiety Disorder in childhood or adolescence may predispose the individual to the development of this disorder.

Diagnostic criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Obsessive-compulsive personality disorder (OCPD)

Not to be confused with OCD. People with OCPD are perceived as strict and demanding by others. They have a persistent preoccupation with perfectionism, orderliness, and efficiency, at the expense of interpersonal relationships. They also show an excessive devotion to work, productivity and exhibit rigidness and stubbornness.

People with OCPD usually have a negative view of life and often become withdrawn and depressed.

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

• Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.
• Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met).
• Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity).
• Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification).
• Is unable to discard worn-out or worthless objects even when they have no sentimental value.
• Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things.
• Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes.
• Shows rigidity and stubbornness.

Associated Features

When rules and established procedures do not dictate the correct answer, decision making may become a time-consuming, often painful process. Individuals with Obsessive-Compulsive Personality Disorder may have such difficulty deciding which tasks take priority or what is the best way of doing some particular task that they may never get started on anything.

Individuals with this disorder usually express affection in a highly controlled or stilted fashion and may be very uncomfortable in the presence of others who are emotionally expressive. Their everyday relationships have a formal and serious quality, and they may be stiff in situations in which others would smile and be happy (e.g., greeting a lover at the airport).

Many of the features of Obsessive-Compulsive Personality Disorder overlap with “type A” personality characteristics (e.g., preoccupation with work, competitiveness, and time urgency), and these features may be present in people at risk for myocardial infarction. There may be an association between Obsessive-Compulsive Personality Disorder and Mood and Eating Disorders .

Diagnostic criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Supplementary Information:

Conduct Disorder

The essential feature of Conduct Disorder is a repetitive and persistent pattern of behavior by a child or teenager in which the basic rights of others or major age-appropriate societal norms or rules are violated.

These behaviors fall into four main groupings: aggressive conduct that causes or threatens physical harm to other people or animals, nonaggressive conduct that causes property loss or damage, deceitfulness or theft, and serious violations of rules time and time again.

Specific Symptoms of Conduct Disorder

Conduct Disorder is characterized by a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6_months:

Aggression to people and animals

• often bullies, threatens, or intimidates others.
• often initiates physical fights.
• has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
• has been physically cruel to people.
• has been physically cruel to animals.
• has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).
• has forced someone into sexual activity.

Destruction of property

• has deliberately engaged in fire setting with the intention of causing serious damage.
• has deliberately destroyed others’ property (other than by fire setting).

Deceitfulness or theft

• has broken into someone else’s house, building, or car.
• often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).
• has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery).

Serious violations of rules

• often stays out at night despite parental prohibitions, beginning before age 13 years.
• has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period).
• is often truant from school, beginning before age 13 years.

The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

Conduct Disorder is also categorized by the age of onset, and varies in severity from mild to severe:

• Childhood-Onset Type: this subtype is characterized by the onset of at least one criterion characteristic of Conduct Disorder prior to age 10 years.
• Adolescent-Onset Type: this subtype is characterized by the absence of any criteria characteristic of Conduct Disorder prior to age 10 years.

Severity of disorder

• • Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct problems.Cause only minor harm to other (e.g., lying, truancy, staying out after dark without permission).
  • Moderate: number of conduct problems and effect on others intermediate between “mild” and “severe” (e.g., stealing without confronting a victim, vandalism).
  • Severe: many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others (e.g., forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and entering).

Diagnostic criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Somatization Disorder

Individuals with this disorder have a history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.

Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:

• Four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination).
• Two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods).
• One sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy).
• One pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting).

Either (1) or (2):

• After appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication).
• When there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings.

The symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering).

Associated Features

These individuals are often inconsistent historians, so that a checklist approach to diagnostic interviewing may be less effective than a thorough review of medical treatments and hospitalizations to document a pattern of frequent somatic complaints. They often seek treatment from several physicians concurrently, which may lead to complicated and sometimes hazardous combinations of treatments.

These individuals commonly undergo numerous medical examinations, diagnostic procedures, surgeries, and hospitalizations, which expose the person to an increased risk of morbidity associated with these procedures. Major Depressive Disorder and Personality Disorders are the most frequently associated conditions.

Diagnostic criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Substance Abuse

A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:

• Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household).
• Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use).
• Recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct).
• Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights).

The symptoms have never met the criteria for Substance Dependence for this class of substance.

Diagnostic criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Eating Disorders

About one in 35 American adults has a binge eating disorder.

Eating disorders are conditions that involve abnormal eating habits that can range from insufficient to excessive food intake. According to the Binge Eating Disorder Association, one in 35 Americans has an eating disorder.

While the exact cause of most major disorders is poorly understood, most studies suggest that social factors such as peer pressure, family up-bringing and idealized body-types are strong precursors.

The two most common eating disorders are:

• Bulimia Nervosa
• Anorexia Nervosa

The following information is taken ad verbatim from the Diagnostic and Statistical Manual 4th Edition (DSM-IV):

Bulimia Nervosa

Bulimia is an eating disorder that is characterized by both of the following:

• Eating

In a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.

• Lack of control

A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).

Other symptoms include:

Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise.

The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months.

Self-evaluation is unduly influenced by body shape and weight.

The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

Specific type:

• Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.
• Non-purging Type: during this current episodes of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas.

Anorexia Nervosa

This condition is characterized by:

• Weight Loss
  

Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss leading to maintenance of body weight less than 85% of that expected; or failure to make expected weight gain during period of growth, leadin gto body weight less than 85% of that expected).

• Fear

Intense fear of gaining weight or becoming fat, even though underweight.

Other symptoms include:

Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of he seriousness of the current low body weight.

In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. (A woman is considered to have amenorrhea if her periods occur only following hormone, e.g., estrogent, administration.)

According to the National Institute of Mental Health, other symptoms might develop over time:

• Thinning of bones
  
• Brittle hair and nails
  
• Dry and yellowish skin
  
• Growth of fine hair over body (e.g. Lanugo)
  

Specific type:

• Restrictive Type: during the current episode of Anorexia Nervosa, the person has not regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)
• Binge-Eating/Purging Type: during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas).

Obsessive-Compulsive Disorder (OCD)

Approximately one in 50 American adults has Obsessive-Compulsive Disorder (OCD).

Obsessive-Compulsive Disorder is a psychiatric anxiety condition that affects 1 ouf ot 50 Americans each year according to a study by Gary Null, and author of Obsessive Compulsive Disorder.

It is characterized by repetitive behaviors, anxiety and difficulty coping with intruding thoughts (obsessions) and ritual behaviors (compulsions).

The symptoms of this condition can be time-consuming and exhausting for the individual, and can cause significant work and social distress (e.g., “Since I enjoy horror movies, I’m afraid that one day I might hurt someone.”)

Obsessive-Compulsive Disorder Symptoms

The following information is taken taken from the Diagnostic and Statistical Manual 4th Edition (DSM-IV) and the Center for Addiction and Mental Health (CAMH), and some of it is taken ad verbatim:

The symptoms are broken down to two categories: obsessions and compulsions.

Obsessions

• Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.
• The thoughts, impulses, or images are not simply excessive worries about real-life problems.
• The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action.
• The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion).

According to CAMH, there are six major common obsessions in OCD. These are: contamination, doubting, ordering, religious, aggressive, and sexual.

For example, victims of OCD will have a fear of shaking hands for fear or germs (contamination) or excessive fear of having blasphemous thoughts (religious).

Compulsions

• • • Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly.
    • The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

Other Symptoms

• • • • At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable.
      • The obsessions or compulsions cause marked distress, are time consuming (tkae more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.
      • The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical conditions.

According to CAMH, there are six major common compulsions in OCD. These are: cleaning/washing, ordering, checking, and hoarding.

For example, recurrent thoughts of getting into a car accident can result in a paralyzing anxiety that keeps the person from going to work; or the thoughts of germs might make an individual become extremely afraid of coming in touch with other people.

So What Causes OCD?

The exact nature of OCD or why it happens is still unknown.

Some recent studies indicate abnormalities with serotonin levels in the brain.

Serotonin is a neurotransmitter that is thought to regulate anxiety, sleep, appetite, and sex. Recent research suggests that OCD sufferers might have abnormally low levels of serotonin since they seem to benefit from serotonin-reuptake inhibitors (SSRIs) antidepressants such as Prozac or Celexa.

Treatment

Some of the most widely used treatments for OCID include Exposure and Response Prevention (ERP) and Cognitive Behavioral Therapy (CBT):

Exposure and Response Prevention (ERP)

“Exposure”: This is the process that involves partial or gradual expose to a real or imagined situation that triggers the anxiety.

Treatment generally starts with cues or situations that cause mild anxiety, and as the patient improves, he or she is gradually exposed to stronger anxiety provoking cues.

“Response prevention”: In this stage, patients learn better ways to control or resist the compulsion to perform ritualistic behaviors.

Cognitive Therapy (CT)

In cognitive therapy (often used with ERP), patients focus on the thoughts that cause unbearable distress and anxiety.

When they participate in these tasks, they learn to pay closer attention to the thoughts and feelings that trigger these emotions. From there on, they learn to find healthier ways to cope with obsessive thoughts.

Depression

An estimated 17.6 million Americans suffer from Depression each year.

Depression is a mood disorder characterized by feelings of sadness, despair and apathy.

According to the findings in “Rising rates of depression in today’s society” by Lambert KG, depression affects up to 1 in 6 people or 17.6 Americans each year.

Depressed persons may feel empty, hopeless, experience weight loss, and lose interests in social activities. Generally, most people go through a period where they feel low because of a particular incident such as failing a test or unable to find employment.

However, when this feeling lingers for an extended period of time, it can lead to a more serious condition known as Major Depressive Disorder.

The following information is taken taken from the Diagnostic and Statistical Manual 4th Edition (DSM-IV) and the Mayo Clinic, and some of it is taken ad verbatim:

Signs of depression

What are the signs of depression? For a diagnosis of Major Depressive Disorder, a person must have five (or more) of the following symptoms during the same 2-week period and represent a change from previous funcitoning; at least one of the symptoms is either depressed mood or loss of interest or pleasure.

Signs of depression include the following:

• Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
• Diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others).
• Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day.
• Insomnia or hypersomnia nearly every day.
• Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
• Fatigue or loss of energy nearly every day.
• Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
• Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
• Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Treatment

Recognizing the signs of depression is the first step towards recovery. The second step is seeking professional help.

Treatment for major depression varies, but it usually involves a combination of cognitive therapy and medication management.

Anti-depressants relieve some of the symptoms of depression, but do not cure it. Depression is a serious condition, and medication alone is rarely enough to combat the problem.

Medications

The most common medications used for depression fall in two large categories:

Serotonin re-uptake Inhibitors (SSRIs): Fluoxetine (Prozac), Citalopram (Celexa), Fluvoxamine (Luvox), Sertraline (Zoloft), and Paroxetine (Paxil).

Serotonin norepinephrine reuptake inhibitors (SNRIs): Desvenlafaxine (Pristiq), Duloxetine (Cymbalta) and Venlafaxine (Effexor) as some of the most frequently used.

These medications are not for everyone. Some individuals might experience side effects that might require to try another brand of medications. Less commonly used include: Monoamine oxidase inhibitors, Bupropion (Wellbutrin) and Tricyclics.

Did you know?

• In the US alone, 10% of women in the US and 4% of men are on anti-depressants.Source: USNews
• Anti-depressants are the most commonly prescribed medications in the US.For the year 2005, the Center of Disease Control and Prevention (CDC) examined 2.4 billion drug prescriptions. Of those, 118 million were for anti-depressants.Source: CDC

Psychotherapy is also recommended for the treatement of depression. Depending on the circumstance, and the severity of the signs of depression, the typical number of sessions varies between 8 to 12, and in some situations it can take up to 6 months to see a significant improvement.

People with depression benefit from support and ‘me’ time for healing. Even if they request to be alone, the fact that they know that you are there for them is already helpful.

Alternative Medicine

Omega 3 – Fatty Acids (3,000mg) – Research has shown that Omega 3 can be helpful in reducing the symptoms of depression in on some individuals. Check with your doctor to make sure you get it from a good brand.

Magnesium – New research published by the “Australian and New Zealand Journal of Psychiatry (2009)” has shown a decrease of depressive symptoms in people who took magnesium supplements regularly

Dysthymic Disorder

The diagnostic criteria for Dysthymic Disorder includes the following:

• Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
• Presence, while depressed, of two (or more) of the following:
  • Poor apetite or overeating.
  • Insomnia or hypersomnia
  • Low energy or fatigue.
  • Low self esteem.
  • Poor concentration or difficulty making decisions.
  • Feelings of hopelesness.
• During the 2-year period (1 year for children or adolescents) of the disturbance, the person has never been without the symptoms in Criteria A and B for more than 2 months at a time.
• No Major Depressive Episode (see Criteria for Major Depressive Episode) has been present during the first 2 years of the disturbance (1 year for children and adolescents); i.e., the disturbance is not better accounted for by chronic Major Depressive Disorder, or Major Depressive Disorder, In Partial Remission.
• There has never been a Manic Episode (see Criteria for Manic Episode), a Mixed Episode (see Criteria for Mixed Episode), or a Hypomanic Episode (see Criteria for Hypomanic Episode), and criteria have never been met for Cyclothymic Disorder.
• The disturbance does not occur exclusively during the course of a chronic Psychotic Disorder, such as Schizophrenia or Delusional Disorder.
• The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
• The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Associated Features

Several studies suggest that the most commonly encountered symptoms in Dysthymic Disorder may be feelings of inadequacy; generalized loss of interest or pleasure; social withdrawal; feelings of guilt or brooding about the past; subjective feelings of irritability or excessive anger; and decreased activity, effectiveness, or productivity.

Course

Dysthymic Disorder often has an early and insidious onset (i.e., in childhood, adolescence, or early adult life) as well as a chronic course. In clinical settings, individuals with Dysthymic Disorder usually have superimposed Major Depressive Disorder, which is often the reason for seeking treatment.

Diagnostic criteria summarized from:

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.

Anxiety

Anxiety Disorders affect over 40 million American adults, about 1 out of 7 people, in a given year.

Anxiety is a mental and physiological response to a stressor. It is characterized by fear, worry, irritability and related to situations perceived as uncontrollable or unavoidable.

Anxiety is considered a normal reaction to a problem and can be helpful in dangerious situations. When anxiety becomes excessive, it may fall under the classification of an anxiety disorder. The intensity and frequency of anxiety determines if it is a normal response or an abnormal reaction.

If your level of anxiety interferes with every day activities and impairs your ability to carry a normal life, you could have generalized anxiety disorder.

General anxiety disorder

Symptoms of general anxiety disorder can be categorized into two primary classes:

• Emotional

People with generalized anxiety disorder frequently experience constant worrying or obsession about small or large concerns. These can include frequent nightmares, obsessions about danger, irritability, and restlessness.

• Physiological

Some of the physiological symptoms include: heart palpitations, fatigue, high blood pressure, sweating, pupillary dilation and sweating.

Causes

As with many other mental conditions, anxiety is usually caused by a combination of genetics and environmental stressors. It usually involves the release of three key brain chemicals: serotonin, norepinephrine and dopamine.

Complications

Generalized anxiety disorder is a serious condition that if left untreated, can lead to, or worsen, other conditions such as irritable bowel syndrome, stomach ulcers, skin problems (acne), and insomnia.

Panic disorder

Panic disorder is a condition characterized by recurrent episodes of panic attacks

A panic attack is an sudden episode of extreme fear and apprehension . It is usually brief in duration, typically not lasting more than 30 minutes.

Panic attacks can be extremely frightening and often appear for no apparent reason. When panic attacks occur, they trigger severe emotional and physical reactions. During a typical episode, you might think you’re losing your mind or dying.

You might have experienced one or two panic attacks in your life. But if the panic attacks are more frequent and you are in constant fear of another one, you may have panic disorder.

Symptoms of panic disorder

• • • Heart palpitations, pounding heart, or rapid heart rate
    • Excessive sweating or having chills
    • Trembling or shaking
    • smothering or feelings of choking
    • Shortness of breath
    • Chest pains
    • Cramps or constipation
    • Feeling dazed, faint, or lightheaded
    • Depersonalization (being detached from oneself)
    • fear of that you are losing your mind
    • fear of death
    • paresthesias (Tingling or numbness in the hands and fingers)

Causes

Environmental factors such as an overly cautious view of the world expressed by parents and cumulative stress over time have been found to be correlated with panic attacks.

Panic disorder is also known to run in families, so heredity also plays a strong factor in who might get it.

Did you know?

• New research supports the notion that people who suffer from panic attacks often have difficulty with assertiveness and over-sensitivity.
• Their communication style, though well mannered and polite, is also characteristically un-assertive. This rather careful approach of communicating seems to contribute to preoccupation about what others might think and, subsequently, panic attacks. Source: Bourne, E. (2005).

Some medications are also known to cause panic attacks in some individuals. Alcohol withdrawal and benzodiazepine withdrawal are the most well known to cause these effects as a rebound withdrawal symptom of their tranquillizing properties.

• • • An existing predisposition to psychiatric illnesses such as anxiety or depression.
    • Lifetime experiences that includes the amount and severity of trauma since early childhood.
    • The distinctive traits of a person’s personality – often called the temperament.
    • The way the brain controls the release of stress hormone, such as adrenaline, during the “flight-or-fight” response.

Treatment

Panic disorder is usually treated with a combination of cognitive-behavioral therapy (CBT) and medication management. Psychoanalytic therapy is also used for the treatment of panic disorder. Research has shown that both types of therapy yield the most promising results than other forms of therapy.

• • • Cognitive behavioral therapy: This type of therapy works by using a blend of both cognitive and behavioral therapy. CBT examines the correlation between thought patterns and maladaptive or self-destructive behaviors. The therapy then includes modifying the thinking habits and the behavior.With CBT, your therapist might teach you good breathing and relaxation techniques. In addition, he/she might help you re-create the symptoms of panic disorder in a safe environment. This is an important step because with the help of a professional, you will gradually master the skills that will help you overcome this condition. This technique can also help you successfully confront situations that you might normally avoid, such as going to the mall or to a social event.
    • Psychoanalytic therapy: Psychodynamic theory believes that the past – poor childhood memories or other unresolved conflicts – is the cause for conditions that last into adulthood, for instance, poor self-image, depression, or a sense of feeling unfinished. This type of treatment is typically more long-term than some of the other types of therapy.With psychoanalytic therapy, your therapist might not try to re-create a panic attack. Instead, he/she will try to analyze your past and identify the internal emotional struggle that could be the cause of the symptoms. This approach can take time so please be patient.

Medications

Currently, the U.S. Food and Drug Administration (FDA) has approved several medications for anxiety and panic disorder. These include:

• Benzodiazepines. These medications, like Alprazolam (Xanax) and Diazepam (Valium), can help relax and sleep better. Individuals who take these medications sometimes experience memory problems or dependency.
• Antidepressants. These can include Fluoxetine (Prozac), Sertraline (Zoloft) and Citalopram (Celexa) . Antidepressants can be useful in reducing the sympsoms of co-occurring conditions, such as anxiety or depression.

Attention Deficit/Hyperactivity Disorder (ADHD)

Adhd is the most frequently diagnosed behavioral disorder of childhood and affects 3 – 5% of school aged children worldwide.

Attention-Deficit/Hyperactivity Disorder (ADHD) is a chronic condition characterized by inattention and hyper-activeness that can last well into adulthood. Adults with ADHD often have difficulties maintaining long term relationships, perform poorly in school or at work and tend to have low self-esteem.

In most people, symptoms of ADHD start before the age of seven.

A diagnosis of ADHD can be difficult for parents and children. However, treatment can help, and the majority of children with ADHD grow up to be successful adults.

Symptoms

The symptoms of ADHD can be divided in three sub-categories: innatention, hyperactivity and impulsivity.

Innatention

• Frequently makes careless errors in the classroom , work, or other activities.
• Difficulty listening when spoken directly
• Experiences problems with completing chores, schoolwork, or duties.
• Regularly has difficulty with organization and planning.
• Often forgets important items necessary for work or school (e.g., notebook, pencil).
• Becomes easily sidetracked by external distractions

Hyperactivity

• Regular fidgeting with hands or feet.
• Talking excessively.
• Difficulty engaging in regular activities appropriately.
• Constantly feeling the urge to move or be “on the go”

Impulsivity

• Frequently answers questions before they have been completed.
• Difficulty awaiting turn.
• Often interrupts conversations.

So what causes ADHD?

While there is a lot that isn’t known about ADHD, researchers have identified important factors that could play a role:

Changes in the brain – Recent studies have revealed less activity in the areas of the brain that control activity and attention than in normal children.

Heredity – Attention deficit disorder can run in families. Studies have shown that about one child with ADHD out of three has a relative with the same condition.

Exposure to drugs – Pregnant women who smoke are at a higher risk of having a child with ADHD. Similarly, women who abuse recreational drugs or prescribed medications are also more likely to have children with this condition. Scientists have hypothesized that alcohol and drugs impair brain activity by restricting blood flow to the nerve cells that produce neurotransmitters such as dopamine or serotonin.

Exposure to environmental toxins – Children that live in older buildings are at risk of chronic lead exposure, which can result in highly disruptive behaviors and attention problems.

Did you know?

• A few experts suggest a link between ADHD and creativity. Some have shown that brain patterns in individuals with ADHD are similar to that of highly creative individuals Source: Health Central

New Medications

Medications and counseling is often the preferred choice of treatment and can be divided into two groups: stimulants and non-stimulants.

Stimulants

Examples of stimulants include: Adderall, Dexedrine, Concerta and Ritalin. These are available in fast-release (about 4 hours) and long-release acting (6 to 12 hours) forms.

Many parents prefer the slow-release option for their children because of its longer lasting effects. However, it might take up to three hours to kick in.

Stimulants help manage impulsive behavior and strengthen attention span by increasing the release of neurotransmitters such as epinephrine and norepinephrine, that transmit signals between nerve cells.

Even so, the effects of these medications fade away rapidly. Furthermore, the proper dosage differs from person to person and from child to child, therefore it will take a little extra time at first to get the right dosage.

Common side-effects can include nervousness, irritability (as the medication wears off), problems sleeping and weight loss. Some children develop ‘tics’ or unusual gestures (exaggerated grimace), but these tend to go away when the dosage is reduced.

Non-stimulants

Atomoxetine (Strattera) is the most popular non-stimulant to treat ADHD. It is usually used when stimulant medications are no longer effective or cause side effects.

Aside from reducing ADHD symptoms, atomoxetine has shown to also reduce anxiety.

Common side effects can include nausea, sedation and weight loss. Atomoxetine has also been linked to liver problems in some children. Call your doctor immediately if you notice yellowing of the skin (jaundice) or dark-colored urine.

Natural Treatment

Some research has shown that alternative medicine treatments can help to reduce ADHD symptoms. These include:

• Yoga. There’s increasing support yoga might help relieve symptoms of ADHD. Yoga instructors who teach children with ADHD noted an improvement in their behavior over time, and have said that the practice can help improves the ability to concentrate and relax.
• Vitamin supplements. Vitamins are definitely important for health and well being, but there is still no real evidence that vitamin therapy can control symptoms of ADHD. High doses of vitamins that exceed the recommended dietary allowance can be dangerous. Always consult with a physician if you think you have a vitamin deficiency.
• Special diets. Most diets for ADHD involve eating organic foods, and avoiding high mercury fish as much as possible. Other diets encourage eliminating high calorie junk food (such as pizzas, sodas) and replacing it with healthier alternatives like whole grains, fruit and lean meat. Recent studies have shown that some children improve with these diet changes. However, most current scientific research is still yet to find a direct link between diet and ADHD.
• Herbal supplements. Several people have experienced positive results from taking herbal supplements like hypericum, ginkgo biloba and ginseng, and some research has shown that they may help with ADHD. Other supplements that may be useful: N-acetyl-cysteine, Phosphatidylserine, Alpha lipoic acid, and Coenzyme Q-10. All of these nutrients have been clinically proven to enhance brain performance.
• DHA Suplements/fatty acids. These fats such as DHA, an omega-3 fatty acid, are necessary for the mind to perform properly. The jury is still out there on whether these supplements may improve ADHD symptoms.

ADHD counseling and therapy

In many cases children and adults with ADHD have other conditions such as anxiety and depression. The most effectivce outcomes generally take place when a group approach is used, with parents, counselors or doctors working with each other.

Counseling types:

• Cognitive/Behavioral therapy. Children/adults with ADHD learn to talk about living with this condition learn newer approaches to cope better with their symptoms.
• Family therapy. This type of therapy can help parents better deal with the stress of raising a child with ADHD, as well as gain new awareness about this condition.
• Social skills training. Many children with ADHD lack socially appropriate social skills. This training can help children improve social behaviors.
• Parenting skills training. Like family therapy, this can help parents learn more about this condition, and identify more effective ways to guide their child’s behavior.

Post-Traumatic Stress Syndrome (PTSD)

Over 5.2 million Americans suffer from PTSD, and about 7.8 million people in the US will suffer from PTDS at least once during the course of their lives.

Post-tramatic Stress Disorder (PTSD), is an anxiety disorder that can develop after an exposure to a severe traumatic event.

Some traumatic events include rape, military combat, abuse or accidents.

This condition may also involve the fear of death or harm, where the individual is overwhelmed and unable to cope normally. A person with PTSD can re-experience the original trauma months or years after it occurred through flashbacks or nightmares as well as experience increased arousal such as insomnia, anger or extreme paranoia.

PTSD can develop at any age, including childhood. However, this condition is more common in women. This can be due to the fact that females are more likely to become victims of physical violence, harm, and rape than men.

Symptoms

Symptoms of PTSD can be categorized into three primary classes:

• Re-living.

People with PTSD frequently re-experience the terrifying event through intrusive thoughts and recollections of the trauma. These can include frequent nightmares, out-of-the-blue flashbacks, and in some cases, hallucinations.

• • • Avoiding.

The person will gradually distance from others, places, or any circumstances that can bring back the memory of the trauma. Eventually this can result in depression and family and friends.

• • • Increased arousal.

This class is characterized by extreme emotions such as difficulties relating to other people, an inability to express closeness like before; insomnia; frequent anger outbursts; moments of rage; difficulty concentrating and restlessness.

Causes

As with many other mental conditions, PTSD is usually caused by a combination of the following:

• • • • An existing predisposition to psychiatric illnesses such as anxiety or depression.
      • Lifetime experiences that includes the amount and severity of trauma since early childhood.
      • The distinctive traits of a person’s personality – often called the temperament.
      • The way the brain controls the release of stress hormone, such as adrenaline, during the “flight-or-fight” response.

So who gets PTSD?

People respond to stress differently, and everyone is different in the manner they handle a stressful event. Also, the level of assistance and guidance a person gets may affect the severity of symptoms.

Did you know?

Although most individuals (50-90%) encounter trauma over a lifetime, only about 8% develop full symptoms of PTSD

Source: Arch Gen Psychiatry.

PTSD got the attention of the medical community by military personnel and war veterans. It has been called a number of different names such as battle fatigue or gross stress reaction for soldiers who returned from World War II.

However, PTSD can occur in anyone who has experienced a traumatic event. Individuals who have been abused as children or exposed to repeated life-threatening events are at high risk for PTSD. Victims of sexual abuse and physical trauma face the greatest risk for developing PTSD.

Treatment

The main treatment for PTSD generally consists of psychotherapy and medication management. Not everyone is the same, so some people might respond better with one type of treatment than another.

However, it is recommended that a person with PTSD seek a phsycian/clinician who is experienced with this condition. Some individuals with this disorder might have to try different treatments to find out what works for him or her.

A person with PTSD that is also going through ongoing trauma, such as being in a physically abusive relationship, would need assistance for both problems. Other ongoing problems that need to be addressed can include depression, panic attacks, substance abuse, and suicidal ideations.

Psychotherapy

Different types of therapy can be effective in treating PTSD. Some methods target the symptoms of PTSD directly, and others address the social, family or work related problems. A doctor/mental health therapist can use different therapies depending on the person.

A useful therapy in the treatment of PTSD is cognitive behavioral therapy (CBT). This type consists of three parts:

• • • Exposure Therapy.This part of CBT gradually exposes people to the trauma they experienced before in a safe environment. It consists of visual imagery, journaling, and it might include visits to the place where the trauma occurred. The therapist uses these techniques to help people better cope with their feelings.
  • Cognitive restructuring. Here the therapist helps the person makes sense of traumatic memories. Sometimes, the individual might remember them different as how they happened. Hence, they will often feel guilt or shame for events that were not their fault. The therapist can help them visualize the memories in a more realistic way.
• Stress inoculation training. This part of CBT aims at reducing PTSD symptoms by coaching people how to control anxiety. It is intended to help patients mentally prepare for an upcoming stressor or recurrent memory. As with cognitive restructuring, this therapy helps individuals see traumatic events in healthier way.

There are other types of treatment available such as EMDR. People with PTSD should consult with his/her therapist about this and other treatment options as well.

EMDR: Eye movement desensitization and reprocessing

EMDR is a specialized form of treatment that is used exclusively for PTSD and related conditions. It is seldom used alone, and designed to be used as part of a conventional therapy regimen.

EMDR was first discovered in 1987 by Francine Shapiro. During a walk in a park, she observed that eye movements seemed to reduce the influence of distressing thoughts. Since then, she developed a set of standardized procedures and principles that help treat PTSD.

EMDR is best described as an information processing therapy with eight phases of treatment. It focuses on past experiences and the current situations that trigger the emotions associated with them.

One of the procedures is “dual simulation” which consists of bilateral eye movements or taps. During the eight phases of treatment, the person relives past traumatic experiences while at the same time focuses on a set of external stimuli. Throughout this time, people experience new insight, changes in memories, and new associations.

EMDR has been subjected to several scientific studies. There have been 13 controlled studies overall, and each yielded a range of results that varied across studies. In 1998, The Journal of Traumatic Stress published one of the most promising studies about the efficacy of EMDR. Sixty women with PTSD in Colorado Springs, Colorado, were randomly assigned to either “active-listening” or EMDR therapy. After just two sessions, the women in the EMDR group exhibited fewer symptoms of PTSD than the “active-listening” group.

Medications

Currently, the U.S. Food and Drug Administration (FDA) has approved two anti-depressants for the treatment of PTSD. These include:

• Sertraline (Zoloft)
• Paroxetine (Paxil)

Both can help control PTSD symptoms such as excessive worrying, irritability, feeling numb, and anger. Consuming these medications may help individuals follow through with therapy.

There are other types of medications that your doctor may prescribe.

• Benzodiazepines. These medications, like Alprazolam (Xanax) and Diazepam (Valium), can help relax and sleep better. Individuals who take these medications sometimes experience memory problems or dependency.
• Antipsychotics. Like Haloperidol (Haldol) and Aripiprazole (Abilify), antispsychotics are medications that are usually given to people with other mental conditions, like schizophrenia. Patients on them might experience weight gain and are at higher risk for developing diabetes.
• Other antidepressants. These can include Fluoxetine (Prozac) and Citalopram (Celexa) . Antidepressants can be useful in reducing the sympsoms of co-occuring conditions, such as anxiety or depression.

Stigma

People and war veterans with PTSD are often stigmatized by friends and employers, making it hard for them to find a job.

Even as the military continues to work on overcoming the stigma of seeking help for mental health issues, many active-duty service members still don’t seek help because of the fear that they may be relieved from the service.

Recently, Carter Ham, a four star Army general who commands U.S. soldiers in Europe admitted to suffering from PTSD. This brave example is critical to changing the military’s “macho” culture.

Coping and support

If you think that you might have problems caused by a past trauma, contact your health care provider or therapist. You can also take additional actions outside of conventional therapy to help yourself cope. Some of the things you can do include:

• Don’t self medicate. These medications, like Alprazolam (Xanax) and Diazepam (Valium), can help relax and sleep better. Individuals who take these medications sometimes experience memory problems or dependency.
• Follow your health professional’s instructions. Talk to someone. Keep in touch with loyal friends and loved ones. You dont have to talk about what happened, unless you choose to. Simply spending quality time with family and friends can be therapeutic and comforting.
• Look after yourself. Get enough rest, consume a well balanced eating plan, exercise and remember to relax. Stay away from caffeine and smoking, which often can aggravate nervousness.
• Stay active. Whenever you feel nervous, relax and take a short walk or explore a pastime acticity to refocus.
• Consider joining a support group. Most residential areas have support groups specifically created to help people. Talk to your health care consultant for help finding one, look in your local phone directory, or speak to your community’s directory of social resources system.

When someone you love has PTSD

PTSD can significantly strain a marriage or a relationship. People close to them often get “compassion fatigue”, which is a term that describes the feelings of depression and helplessness that they go through.

Hearing about the trauma can be extremely difficult for a loved one. It might cause a person to remember difficult events from the past. The person that you thought you knew might seem like a completely different person – irritable and moody, or withdrawn and sad.

If your loved one has PTSD, you might find it hard to hear about their trauma. You might even feel powerless that you can’t cure their symptoms or speed up their recovery.

In order to take care of a family member, it’s essential to make your mental health a priority. Exercise, socialize with friends or participate in any outgoing activities that may help you replenish. If you continue to have difficulty coping, don’t hesitate to seek for help. A doctor or mental health therapist can help you better work through your feelings and emotions.

Resources

DoD Military Family Support: http://www.nmfa.org

National Center for PTSD: http://www.ncptsd.org

Veterans Benefits Information: http://www.va.gov

Health Benefits Eligibility: http://www.va.gov/elig

Vocational Rehabilitation and Employment: http://www.vba.va.gov/bln/vre/index.htm

Military One Source: http://www.militaryonesource.mil or 800-342-9642

Women Veterans Health Strategic Health Care Group: http://www.va.gov/wvhp/

A Kids Website: http://www.va.gov/kids

VA Readjustment Counseling Service (Vet Centers): http://www.va.gov/rcs/

VA Health Benefits Call Center: 1-877-222-8387

Veterans Benefit Administration: 1-800-827-1000http://www.vba.va.gov

War Related Illness & Injury Study Center: http://www.warrelatedillness.va.gov/

Battle Mind Training: http://www.battlemind.org

National Suicide Prevention Lifeline: 1-800-273-TALK (8255)

Online citations

EMDR. Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Post-traumatic Stress Disorder. Practice Guideline for the Treatment of Patients with Acute Stress Disorder and Post-traumatic Stress Disorder. EMDR Institute, Inc.

Post-Traumatic Stress Disorder. Comprehensive overview covers symptoms, causes, treatment and coping with this brain disorder. The Mayo-Clinic.

EMDR-PTSD. Depression Guide.

EMDR-FAQ. EMDR-Therapy.

PTSD Resources for Survivors and Caregivers. Gift from Within.

Post-Traumatic Stress & Dissociative Conditions.Traumatic Stress Education & Advocacy. Sidran Institute.

Post Traumatic Stress Disorder.WebMD.

Panic Disorder. Comprehensive overview covers symptoms, causes, treatment and coping with panic disorder. The Mayo-Clinic.

Panic Attack Symptoms. Provides information on panic disorder & treatment. WebMD.

Personality Disorders. Comprehensive overview of personality disorders.Mental Health America (MHA)

Histrionic Personality Disorder. Information on histrionic personality disorder.National Center for Biotechnological Information

Narcissistic Personality Disorder. Guide on information about narcissistic personality disorder.Mayo Clinic.

Avoidant Personality Disorder. Overview of the symptoms of avoidant personality disorder.MedlinePlus.

Do You Really Need That Antidepressant?Article on the use of anti-depresseants. USNews.

Depression. Depression (Major Depression). The Mayo-Clinic.

Major Depression. PubMed Health.

Anti-depressants. The Center for Disease Control & Prevention.

DSM-IV: Diagnostic and Statistical Manual of Mental Disorders. DSM-IV

ADHD: Comprehensive overview covers symptoms, causes, treatment and coping with this brain disorder. The Mayo-Clinic.

ADHD and Creativity: Reviews some of the treatment options for schizophrenia. Health Central.

Citations

American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association, 1994

Lambert KG. “Rising rates of depression in today’s society: Consideration of the roles of effort-based rewards and enhanced resilience in day-to-day functioning”. Neuroscience & Biobehavioral Reviews, 2006; 30 (4): 497–510.

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association.

Barker, P. (2009). Psychiatric and Mental Health Nursing: The Craft of Caring. Oxford University Press, USA. 166–167.

Bourne, E. (2005). The Anxiety and Phobia Workbook, 4th Edition: New Harbinger Press.

Coryell W, Noyes R, Clancy J (June 1982). “Excess mortality in panic disorder. A comparison with primary unipolar depression”. Arch. Gen. Psychiatry 39 (6): 701–3.

Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R)

Ohman, A. (2000). Fear and anxiety: Evolutionary, cognitive, and clinical perspectives. In M. Lewis & J. M. Haviland-Jones (Eds.). Handbook of emotions. (573-593). New York: The Guilford Press.

American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association.

Rossi A et al. (2000). Pattern of comorbidity among anxious and odd personality disorders: the case of obsessive–compulsive personality disorder. CNS Spectr. Sep; 5(9): 23–6.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association, 1994

Barabasz M “Efficacy of hypnotherapy in the treatment of eating disorders”. The International Journal of Clinical and Experimental Hypnosis, 2007; 55 (3): 318–35. Retrieved 9-10-2010 from: https://www.ncbi.nlm.nih.gov/pubmed/17558721

Manning, Y., & Murphy, B. An introduction to anorexia nervosa and bulimia nervosa. Nursing Standard, 2003; 18.14-16, 45.

Walsh JM, Wheat ME, Freund K. “Detection, evaluation, and treatment of eating disorders the role of the primary care physician”. Journal of General Internal Medicine 15, 2000; (8): 577–90.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association, 1994

Eva M Cybulska. “Obsessive Compulsive disorder, the brain and electroconvulsive therapy”. British Journal of Hospital Medicine, 2006; 67(2):77-82

Hyman, B. M., & Pedrick, C. The OCD workbook: Your guide to breaking free from obsessive–compulsive disorder (2nd ed.). Oakland, CA: New Harbinger, pp. 2005, 125-126.

Moritz S, Jelinek L, Klinge R, Naber D. Fight fire with fireflies! Association Splitting: a novel cognitive technique to reduce obsessive thoughts. Behavioural and Cognitive Psychotherapy, 2007; 35, 631-635

Jensen, P.S., and Kenny, D.T. (2004). The effects of yoga on the attention and behavior of boys with attention deficit hyperactivity disorder (ADHD). Journal of Attention Disorders. 7(4): 205-16.

Jensen PS, Garcia JA, Glied S (September 2005). “Cost-effectiveness of ADHD treatments: findings from the multimodal treatment study of children with ADHD”. The American Journal of Psychiatry 162 (9): 1628–36. doi:10.1176/appi.ajp.162.9.1628. PMID 16135621. http://ajp.psychiatryonline.org/article.aspx?articleid=177754

American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association.

Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB (December 1995). “Posttraumatic stress disorder in the National Comorbidity Survey”. Arch Gen Psychiatry52 (12): 1048–60. PMID 7492257.