Mood Disorders and Suicide - Clinical Case PDF

Topic 7: MOOD DISORDERS AND SUICIDE Clinical Case: Mary Mary M., a 38-year-old mother of four children, had been deeply depressed for about 2 months when she first went to see a psychologist. Three years earlier, she had returned to work when health care bills made it hard for her family to get by...

Topic 7: MOOD DISORDERS AND SUICIDE Clinical Case: Mary Mary M., a 38-year-old mother of four children, had been deeply depressed for about 2 months when she first went to see a psychologist. Three years earlier, she had returned to work when health care bills made it hard for her family to get by on her husband’s income as a high school teacher. About 7 months before her visit to the psychologist, she was laid off from her job as an administrative assistant, which was a serious blow to the family’s finances. She felt guilty about the loss of her job and became preoccupied with signs of her overall incompetence. Each night, she struggled for more than an hour to fall asleep, only to wake up frequently throughout the night. She had little appetite and as a result had lost 10 pounds. She also had little energy for and no interest in activities that she had enjoyed in the past. Household chores became impossible for her to do, and her husband began to complain. Their marriage had already been strained for 2 years, and her negativity and lack of energy contributed to further arguments. Finally, realizing that Mary’s symptoms were serious, Mr. M. cajoled her into making an appointment with a psychologist. MOOD DISORDERS The disorders described in this lesson used to be categorized under several general labels, such as “depressive disorders”, “affective disorders”, or even “depressive neuroses”. Beginning with the third edition of the Diagnostic and Statistical Manual (DSM-III), published by the American Psychiatric Association in 1980, these problems have been grouped under the heading mood disorders because they are characterized by gross deviations in mood. Major Depressive Episode The most commonly diagnosed and most severe depression is called a major depressive episode. The DSM-5 criteria describes it as an extremely depressed mood state that lasts at least 2 weeks and includes cognitive symptoms (such as feelings of worthlessness and indecisiveness) and disturbed physical functions (such as altered sleeping patterns, significant changes in appetite and weight, or a notable loss of energy) to the point that even the slightest activity or movement requires an overwhelming effort. The episode is typically accompanied by a general loss of interest in things and an inability to experience any pleasure from life, including interactions with family or friends or accomplishments at work or at school. Although all symptoms are important, evidence suggests that the most central indicators of a full major depressive episode are the physical changes (sometimes called somatic or vegetative symptoms). Anhedonia (loss of energy and inability to engage in pleasurable activities or have any “fun”) is more characteristic of these severe episodes of depression than are, for example, reports of sadness or distress. The duration of a major depressive episode, if untreated, is approximately 4 to 9 months. Manic Episode The second fundamental state in mood disorders is abnormally exaggerated elation, joy, or euphoria. In mania, individuals find extreme pleasure in every activity; some patients compare their daily experience of mania with a continuous sexual orgasm. ❑ They become extraordinarily active (hyperactive), require little sleep, and may develop grandiose plans, believing they can accomplish anything they desire. ❑ Speech is typically rapid and may become incoherent because the individual is attempting to express so many exciting ideas at once; this feature is typically referred to as flight of ideas. ❑ DSM-5 criteria for a manic episode require a duration of only 1 week, less if the episode is severe enough to require hospitalization. ❑ Hospitalization could occur, for example, if the individual was engaging in a self-destructive buying spree, charging thousands of dollars in the expectation of making a million dollars the next day. ❑ Irritability is often part of a manic episode, usually near the end. The duration of an untreated manic episode is typically 3 to 4 months. ❑ DSM-5 also defines a hypomanic episode, a less severe version of a manic episode that does not cause marked impairment in social or occupational functioning and need last only 4 days rather than a full week. (Hypo means “below”; thus, the episode is below the level of a manic episode.) Research suggests that manic episodes are characterized by dysphoric (anxious or depressive) features more commonly than was thought, and dysphoria can be severe. Individuals who experience either depression or mania are said to suffer from a unipolar mood disorder, because their mood remains at one “pole” of the usual depression-mania continuum. Someone who alternates between depression and mania is said to have a bipolar mood disorder traveling from one “pole” of the depression- elation continuum to the other and back again. An individual can experience manic symptoms but feel somewhat depressed or anxious at the same time; or be depressed with a few symptoms of mania. This episode is characterized as having “mixed features”. In fact, a strong body of evidence indicates that the two factors that most importantly describe mood disorders are severity and chronicity. Major Depressive Disorder The most easily recognized mood disorder is major depressive disorder, defined by the absence of manic, or hypomanic episodes before or during the disorder. If two or more major depressive episodes occurred and were separated by at least 2 months during which the individual was not depressed, the major depressive disorder is noted as being recurrent. Persistent Depressive Disorder (Dysthymia) Persistent Depressive Disorder shares many of the symptoms of major depressive disorder but differs in its course. There may be fewer symptoms but depression remains relatively unchanged over long periods, sometimes 20 or 30 years or more. ❑ Persistent depressive disorder (dysthymia) is defined as depressed mood that continues at least 2 years, during which the patient cannot be symptom free for more than 2 months at a time even though they may not experience all of the symptoms of a major depressive episode. ❑ This disorder differs from a major depressive disorder in the number of symptoms required, but mostly in the chronicity. ❑ It is considered more severe, since patients with persistent depression present with higher rates of comorbidity with other mental disorders, are less responsive to treatment, and show a slower rate of improvement over time. These individuals who suffer from both major depressive episodes and persistent depression with fewer symptoms are said to have double depression. In addition to rating severity of the episode as mild, moderate, or severe, clinicians use eight basic specifiers to describe depressive disorders. 1. with psychotic features (mood congruent or mood-incongruent) 2. with anxious distress (mild to severe) 3. with mixed features 4. with melancholic features 5. with atypical features 6. with catatonic features 7. with peripartum onset, and 8. with seasonal pattern Psychotic features specifiers Some individuals in the midst of a major depressive (or manic) episode may experience psychotic symptoms, specifically hallucinations (seeing or hearing things that aren’t there) and delusions (strongly held but inaccurate beliefs). Patients may also have somatic (physical) delusions, believing, for example, that their bodies are rotting internally and deteriorating into nothingness. Some may hear voices telling them how evil and sinful they are (auditory hallucinations). Such hallucinations and delusions are called mood congruent because they seem directly related to the depression. On rare occasions, depressed individuals might have other types of hallucinations or delusions such as delusions of grandeur (believing, for example, they are supernatural or supremely gifted) that do not seem consistent with the depressed mood. Psychotic features in general are associated with a poor response to treatment, greater impairment, and fewer weeks with minimal symptoms, compared with nonpsychotic depressed patients over a 10-year period. Anxious distress specifier The presence and severity of accompanying anxiety, whether in the form of comorbid anxiety disorders (anxiety symptoms meeting the full criteria for an anxiety disorder) or anxiety symptoms that do not meet all the criteria for disorders. For all depressive and bipolar disorders, the presence of anxiety indicates a more severe condition, makes suicidal thoughts, and completed suicide more likely, and predicts a poorer outcome from treatment. Mixed features specifier Predominantly depressive episodes that have several (at least three) symptoms of mania as described above would meet this specifier, which applies to major depressive episodes both within major depressive disorder and persistent depressive disorder Melancholic features specifier This specifier applies only if the full criteria for a major depressive episode have been met, whether in the context of a persistent depressive disorder or not. Melancholic specifiers include some of the more severe somatic (physical) symptoms, such as earlymorning awakenings, weight loss, loss of libido (sex drive), excessive or inappropriate guilt, and anhedonia (diminished interest or pleasure in activities). Catatonic features specifier This serious condition involves an absence of movement (a stuporous state) or catalepsy, in which the muscles are waxy and semi-rigid, so a patient’s arms or legs remain in any position in which they are placed. Catatonic symptoms may also involve excessive but random or purposeless movement. Atypical features specifier While most people with depression sleep less and lose their appetite, individuals with this specifier consistently oversleep and overeat during their depression and therefore gain weight, leading to a higher incidence of diabetes. Although they also have considerable anxiety, they can react with interest or pleasure to some things, unlike most depressed individuals. The atypical group also has more symptoms, more severe symptoms, more suicide attempts, and higher rate of comorbid disorders including alcohol abuse. Peripartum onset specifier Peri means “surrounding”, in this case the period of time just before and just after the birth. Typically, a somewhat higher incidence of depression is found postpartum (after the birth) than during the period of pregnancy itself. In another recent important study, 14% of 10,000 women who gave birth screened positively for depression and fully 19.3% of those depressed new mothers had serious thoughts of harming themselves. During the peripartum period (pregnancy and the 6-month period immediately following childbirth), early recognition of possible psychotic depressive (or manic) episodes is important, because in a few tragic cases a mother in the midst of an episode has killed her newborn child. More minor reactions in adjustment to childbirth— called the “baby blues”—typically last a few days and occur in 40% to 80% of women between 1 and 5 days after delivery. In peripartum depression, most people, including the new mother herself, have difficulty understanding why she is depressed, because they assume this is a joyous time. Seasonal pattern specifier This temporal specifier applies to recurrent major depressive disorder (and also to bipolar disorders). It accompanies episodes that occur during certain seasons (for example, winter depression). In bipolar disorder, individuals may become depressed during the winter and manic during the summer.) These episodes must have occurred for at least two years with no evidence of non-seasonal major depressive episodes occurring during that period of time. This condition is called seasonal affective disorder (SAD). ❖ Emerging evidence suggests that SAD may be related to daily and seasonal changes in the production of melatonin, a hormone secreted by the pineal gland. ❖ Light therapy is a promising treatment for seasonal affective disorder, often providing relief from depressive symptoms in just a few days. ❖ In phototherapy, a current treatment, most patients are exposed to 2 hours of bright light (2,500 lux) immediately on awakening. If the light exposure is effective, the patient begins to notice a lifting of mood within 3 to 4 days and a remission of winter depression in 1 to 2 weeks. The mean age of onset for major depressive disorder is 30 years, based on a large (43,000) and representative sample of the population of the United States, but 10% of all people who develop major depression are 55 or older when they have their first episode. Kessler and colleagues compared four age groups and found that fully 25% of people 18 to 29 years had already experienced major depression, a rate far higher than the rate for older groups when they were that age. Rohde et al. also looked at the incidence of major depressive disorder and four age groups spanning a longer period of time. They found that in children ages 5 to 12, 5% had experienced major depressive disorder. The acute grief most of us would feel eventually evolves into what is called integrated grief, in which the finality of death and its consequences are acknowledged, and the individual adjusts to the loss. When grief lasts beyond typical time, mental health professionals again become concerned. After 6 months to a year or so, the chance of recovering from severe grief without treatment is considerably reduced, and for approximately 7% of bereaved individuals), a normal process becomes a disorder. At this stage, suicidal thoughts increase substantially and focus mostly on joining the beloved deceased. Many of the psychological and social factors related to mood disorders in general, including a history of past depressive episodes, also predict the development of what is called the syndrome of complicated grief, although this reaction can develop without a preexisting depressed state. ***Refer to your DSM-5 for the full diagnostic criteria for MDD. Premenstrual Dysphoric Disorder (PMDD) Basically, clinicians identified a small group of women, from 2% to 5%, who suffered from severe and sometimes incapacitating emotional reactions during the premenstrual period. But strong objections to making this condition an official diagnosis were based on concerns that women who were experiencing a very normal monthly physiological cycle, as part of being female, would now be classified as having a disorder, which would be very stigmatizing. A combination of physical symptoms, severe mood swings and anxiety are associated with incapacitation during this period of time. Disruptive Mood Dysregulation Disorder (DMDD) Most important observation in this disorder is that these children show no evidence of periods of elevated mood (mania), which has been a requirement for a diagnosis of bipolar disorder. These cases also differ from more typical conduct or ADHD conditions as well, since it is the intense negative affect that seems to be driving the irritability and marked inability to regulate mood. In view of the distinctive features of this condition reviewed above, it seemed very important to better describe these children up to 12 years of age as suffering from a diagnosis termed disruptive mood dysregulation disorder rather than have them continue to be mistakenly diagnosed with bipolar disorder or perhaps conduct disorder. Bipolar Disorders The key-identifying feature of bipolar disorders is the tendency of manic episodes to alternate with major depressive episodes in an unending roller-coaster ride from the peaks of elation to the depths of despair. Bipolar II disorder, in which major depressive episodes alternate with hypomanic episodes rather than full manic episodes. The criteria for bipolar I disorder are the same, except the individual experiences a full manic episode. As in the criteria set for major depressive disorder, for the manic episodes to be considered separate, there must be a symptom-free period of at least 2 months between them. There is one specifier that is unique to bipolar I and II disorders: rapid-cycling specifier. Some people move quickly in and out of depressive or manic episodes. An individual with bipolar disorder who experiences at least four manic or depressive episodes within a year is considered to have a rapid-cycling pattern, which appears to be a severe variety of bipolar disorder that does not respond well to standard treatments. In most cases, rapid cycling tends to increase in frequency over time and can reach severe states in which patients cycle between mania and depression without any break. When this direct transition from one mood state to another happens, it is referred to as rapid switching or rapid mood switching and is a particularly treatment-resistant form of the disorder. Fortunately, rapid cycling does not seem to be permanent, because only 3% to 5% of patients continue with rapid cycling across a 5-year period, with 80% returning to a non-rapid-cycling pattern within 2 years. Cyclothymic Disorder (Cyclothymia) A milder but more chronic version of bipolar disorder called cyclothymic disorder is similar in many ways to persistent depressive disorder. Like persistent depressive disorder, cyclothymic disorder is a chronic alternation of mood elevation and depression that does not reach the severity of manic or major depressive episodes. Much of the time, such individuals are just considered moody. Statistics, onset and others facts about bipolar disorder The average age of onset for bipolar I disorder is from 15 to 18 and for bipolar II disorder from 19 and 22, although cases of both can begin in childhood. Rates of completed suicide are 4 times higher in people with bipolar disorder than for people with recurrent major depression. The best estimates of the worldwide prevalence of mood disorders suggest that approximately 16% of the population experience major depressive disorder over a lifetime and approximately 6% have experienced a major depressive disorder in the last year. Studies indicate that women are twice as likely to have mood disorders as men, but the imbalance in prevalence between males and females is accounted for solely by major depressive disorder and persistent depressive disorder (dysthymia), because bipolar disorders are distributed approximately equally across gender. The general conclusion is that depressive disorders occur less often in prepubertal children than in adults but rise dramatically in adolescence. Major depressive disorder in adolescents is largely a female disorder, as it is in adults, with puberty seemingly triggering this sex imbalance.  There is some evidence that 3-month-old babies can become depressed! Infants of depressed mothers display marked depressive behaviors (sad faces, slow movement, lack of responsiveness) even when interacting with a non-depressed adult. Childhood depression (and mania) is often associated with and sometimes misdiagnosed as attention deficit/hyperactivity disorder (ADHD) or, more often, conduct disorder in which aggression and even destructive behavior are common. But, once again, many of these children might now meet criteria for disruptive mood dysregulation disorder, which would better account for this comorbidity. Causes In family studies, we look at the prevalence of a given disorder in the first-degree relatives of an individual known to have the disorder (the proband). Increasing severity, recurrence of major depression, and earlier age of onset in the proband is associated with the highest rates of depression in relatives. A number of twin studies suggest that mood disorders are heritable. Note from the studies just described that bipolar disorder confers an increased risk of developing some mood disorder in close relatives, but not necessarily bipolar disorder. In other words, if one identical twin is unipolar, there is an 80% chance the other twin is unipolar as opposed to bipolar. The best estimates of genetic contributions to depression fall in the range of approximately 40% for women but seem to be significantly less for men (around 20%). Evidence supports the assumption of a close relationship among depression, anxiety, and panic (as well as other emotional disorders). Remember that the apparent primary function of serotonin is to regulate our emotional reactions. For example, we are more impulsive, and our moods swing more widely, when our levels of serotonin are low. Current thinking is that the balance of the various neurotransmitters and their interaction with systems of self-regulation are more important than the absolute level of any one neurotransmitter. In the context of this delicate balance, there is continued interest in the role of dopamine, particularly in relationship to manic episodes, atypical depression, or depression with psychotic features. For example, the dopamine agonist L-dopa seems to produce hypomania in bipolar patients, along with other dopamine agonists. During the past several years, most attention has shifted away from a focus on neurotransmitters to the endocrine system and the “stress hypothesis” of the etiology of depression. This hypothesis focuses on overactivity in the hypothalamic–pituitary–adrenocortical (HPA) axis, which produces stress hormones. Investigators have also discovered that neurotransmitter activity in the hypothalamus regulates the release of hormones that affect the HPA axis. These neurohormones are an increasingly important focus of study in psychopathology. This connection led to the development of what was thought to be a biological test for depression, the dexamethasone suppression test (DST). Dexamethasone is a glucocorticoid that suppresses cortisol secretion in normal participants. When this substance was given to patients who were depressed, however, much lesssuppression was noticed than in normal participants, and what did occur didn’t last long. However, later research demonstrated that individuals with other disorders, particularly anxiety disorders, also demonstrate non-suppression, which eliminated its usefulness as a test to diagnose depression. Recognizing that stress hormones are elevated in patients with depression (and anxiety) researchers have begun to focus on the consequences of these elevations. Individuals experiencing heightened levels of stress hormones over a long period undergo some shrinkage of a brain structure called the hippocampus. But the new finding, at least in animals, is that longterm overproduction of stress hormones makes the organism unable to develop new neurons (neurogenesis). Thus, some theorists suspect that the connection between high stress hormones and depression is the suppression of neurogenesis in the hippocampus. Evidence reveals that healthy girls at risk for developing depression because their mothers suffer from recurrent depression have reduced hippocampal volume compared with girls with nondepressed mothers. This finding suggests that low hippocampal volume may precede and perhaps contribute to the onset of depression. Scientists have already observed that successful treatments for depression, including electroconvulsive therapy, seem to produce neurogenesis in the hippocampus, thereby reversing this process. More recently, it has been demonstrated in animal laboratories that exercise increases neurogenesis, which could possibly be one mechanism of action in successful psychological treatments utilizing exercise, such as behavioral activation. Stress and trauma are among the most striking unique contributions to the etiology of all psychological disorders. Most people who develop depression report losing a job, getting divorced, having a child, or graduating from school and starting a career. But, as with most issues in the study of psychopathology, the significance of a major event is not easily discovered, so most investigators have stopped simply asking patients whether something bad (or good) happened and have begun to look at the context of the event, as well as the meaning it has for the individual. People become anxious and depressed when they decide that they have no control over the stress in their lives. These findings evolved into an important model called the learned helplessness theory of depression. The depressive attributional style is (1) Internal, in that the individual attributes negative events to personal failings (“it is all my fault”) (2) Stable, in that, even after a particular negative event passes, the attribution that “additional bad things will always be my fault” remains; and (3) Global, in that the attributions extend across a variety of issues. Aaron T. Beck suggested that depression may result from a tendency to interpret everyday events in a negative way. ❑ Arbitrary inference is evident when a depressed individual emphasizes the negative rather than the positive aspects of a situation. A high school teacher may assume he is a terrible instructor because two students in his class fell asleep. He fails to consider other reasons they might be sleeping (up all night partying, perhaps) and “infers” that his teaching style is at fault. ❑ As an example of overgeneralization, when your professor makes one critical remark on your paper, you then assume you will fail the class despite a long string of positive comments and good grades on other papers. ❑ According to Beck, people who are depressed think like this all the time. They make cognitive errors inthinking negatively about themselves, their immediate world, and their future, three areas that together are called the depressive cognitive triad. ❑ In a self-blame schema, individuals feel personally responsible for every bad thing that happens. With a negative self-evaluation schema, they believe they can never do anything correctly. Treatment of Mood Disorders  Four basic types of antidepressant medications are used to treat depressive disorders: selectiveserotonin reuptake inhibitors (SSRIs), mixed reuptake inhibitors, tricyclic antidepressants, and monoamine oxidase (MAO) inhibitors. Selective-serotonin reuptake inhibitors (SSRIs) specifically block the presynaptic reuptake of serotonin. This temporarily increases levels of serotonin at the receptor site, but again the precise long-term mechanism of action is unknown, although levels of serotonin are eventually increased. Perhaps the bestknown drug in this class is fluoxetine (Prozac). Prozac and other SSRIs have their own set of side effects, the most prominent of which are physical agitation, sexual dysfunction, low sexual desire, insomnia, and gastrointestinal upset. Another class of antidepressants (sometimes termed mixed reuptake inhibitors) seem to have somewhat different mechanisms of neurobiological action. The best known, venlafaxine (Effexor) is related to tricyclic antidepressants, but acts in a slightly different manner, blocking reuptake of norepinephrine as well as serotonin. MAO inhibitors work differently. As their name suggests, they block the enzyme MAO that breaks down such neurotransmitters as norepinephrine and serotonin. The result is roughly equivalent to the effect of the tricyclics. Tricyclic antidepressants were the most widely used treatments for depression before the introduction of SSRIs but are now used less commonly. The best-known variants are probably imipramine (Tofranil) and amitriptyline (Elavil). Tricyclic antidepressants seem to have their greatest effect by down-regulating norepinephrine, although other neurotransmitter systems, particularly serotonin, are also affected. Finally, there was a great deal of interest several years ago in the antidepressant properties of the natural herb St. John’s wort (hypericum). St. John’s wort produces few side effects and is relatively easy to produce. Some preliminary evidence suggests the herb also somehow alters serotonin function. But the National Institutes of Health in the United States completed a major study examining its effectiveness, and surprisingly, this large study found no benefits from St. John’s wort compared with placebo. Clinicians and researchers have concluded that recovery from depression, although important, may not be the most important therapeutic outcome. A more important goal is often to delay the next depressive episode or even prevent it entirely. Another type of antidepressant drug, lithium carbonate, is a common salt widely available in the natural environment. The side effects of therapeutic doses of lithium are potentially more serious, however, than the side effects of other antidepressants. Dosage has to be carefully regulated to prevent toxicity (poisoning) and lowered thyroid functioning, which might intensify the lack of energy associated with depression. Substantial weight gain is also common. Lithium, however, has one major advantage that distinguishes it from other antidepressants: It is also often effective in preventing and treating manic episodes. Therefore, it is most often referred to as a mood-stabilizing drug. Thus, although effective, lithium provides many people with inadequate therapeutic benefit. Patients who don’t respond to lithium can take other drugs with antimanic properties, including anticonvulsants such as carbamazepine and valproate (Divalproex), as well as calcium channel blockers such as verapamil. Valproate has recently overtaken lithium as the most commonly prescribed mood stabilizer for bipolar disorder and is equally effective, even for patients with rapid- cycling symptoms. But newer studies show that these drugs have one distinct disadvantage. They are less effective than lithium in preventing suicide. Thus, lithium remains the preferred drug for bipolar disorder. When someone does not respond to medication (or in an extremely severe case), clinicians may consider a more dramatic treatment, electroconvulsive therapy (ECT), the most controversial treatment for psychological disorders after psychosurgery. In current administrations, patients are anesthetized to reduce discomfort and given muscle- relaxing drugs to prevent bone breakage from convulsions during seizures. Electric shock is administered directly through the brain for less than a second, producing a seizure and a series of brief convulsions that usually lasts for several minutes. We do not really know why ECT works. Repeated seizures induce massive functional and perhaps structural changes in the brain, which seems to be therapeutic. There is some evidence that ECT increases levels of serotonin, blocks stress hormones, and promotes neurogenesis in the hippocampus. Recently, another method for altering electrical activity in the brain by setting up a strong magnetic field has been introduced. This procedure is called transcranial magnetic stimulation (TMS), and it works by placing a magnetic coil over the individual’s head to generate a precisely localized electromagnetic pulse. Vagus nerve stimulation involves implanting a pacemaker-like device that generates pulses to the vagus nerve in the neck, which, in turn, is thought to influence neurotransmitter production in the brain stem and limbic system. Beck’s cognitive therapy grew directly out of his observations of the role of deep-seated negative thinking in generating depression. Clients are taught that errors in thinking can directly cause depression. Treatment involves correcting cognitive errors and substituting less depressing and (perhaps) more realistic thoughts and appr Related cognitive-behavioral approaches to depression include the Cognitive-Behavioral Analysis System of Psychotherapy (CBASP), which integrates cognitive, behavioral, and interpersonal strategies and focuses on problem-solving skills, particularly in the context of important relationships. Finally, mindfulness-based cognitive therapy (MBCT) integrates meditation with cognitive therapy. MBCT has been evaluated and found effective for the most part in the context of preventing relapse or recurrence in patients who are in remission from their depressive episode. Babyak and colleagues demonstrated that programmed aerobic exercise 3 times a week was as effective as treatment with anti-depressive medication (Zoloft) or the combination of exercise and Zoloft after 4 months. It was noted above that there is some new evidence that exercise increases neurogenesis in the hippocampus, which is known to be associated with resilience to depression. Interpersonal psychotherapy (IPT) focuses on resolving problems in existing relationships and learning to form important new interpersonal relationships. After identifying life stressors that seem to precipitate the depression, the therapist and patient work collaboratively on the patient’s current interpersonal problems. Typically, these include one or more of four interpersonal issues: 1. dealing with interpersonal role disputes, such as marital conflict; 2. adjusting to the loss of a relationship, such as grief over the death of a loved one; 3. acquiring new relationships, such as getting married or establishing professional relationships; and 4. identifying and correcting deficits in social skills that prevent the person from initiating or maintaining important relationships. After helping identify the dispute, the next step is to bring it to a resolution. First, the therapist helps the patient determine the stage of the dispute. ✓ Negotiation stage. Both partners are aware it is a dispute, and they are trying to renegotiate it. ✓ Impasse stage. The dispute smolders beneath the surface and results in low-level resentment, but no attempts are made to resolve it. ✓ Resolution stage. The partners are taking some action, such as divorce, separation, or recommitting to the marriage. Studies comparing the results of cognitive therapy and IPT with those of antidepressant drugs and other control conditions have found that psychological approaches and medication are equally effective immediately following treatment, and all treatments are more effective than placebo conditions, brief psychodynamic treatments, or other appropriate control conditions for both major depressive disorder and persistent depressive disorder.  Ellen Frank and her colleagues developed a psychological treatment that regulates circadianrhythms by helping patients regulate their eating and sleep cycles and other daily schedules as well as cope more effectively with stressful life events, particularly interpersonal issues. In an evaluation of this approach, called interpersonal and social rhythm therapy (IPSRT), patients receiving IPSRT survived longer without a new manic or depressive episode compared with patients undergoing standard, intensive clinical management. Suicide Suicide is officially the 11th leading cause of death in the United States. Suicide is overwhelmingly a white phenomenon. Most minority groups, including African Americans and Hispanics, seldom resort to this desperate alternative. For teenagers, suicide was the third leading cause of death behind unintentional injury such as motor vehicle accidents and homicide in 2007. Adolescents and adults do not only attempt suicide. Several reports exist of children 2 to 5 years of age who had attempted suicide at least once, many injuring themselves severely and suicide is the fifth leading cause of death from ages 5 to 14. Regardless of age, in every country around the world except China, males are 4 times more likely to commit suicide than females. Males generally choose far more violent methods, such as guns and hanging; females tend to rely on less violent options, such as drug overdose. Uniquely in China, more women commit suicide than men, particularly in rural settings. Suicide, particularly among women, is often portrayed in classical Chinese literature as a reasonable solution to problems. A rural Chinese woman’s family is her entire world, and suicide is an honorable solution if the family collapses. In addition to completed suicides, three other important indices of suicidal behavior are suicidal ideation (thinking seriously about suicide), suicidal plans (the formulation of a specific method for killing oneself), and suicidal attempts (the person survives). Also, distinguish “attempters” (selfinjurers with the intent to die) from “gesturers” (self- injurers who intend not to die but to influence or manipulate somebody or communicate a cry for help). Causes The great sociologist Emile Durkheim defined a number of suicide types, based on the social or cultural conditions in which they occurred. One type is “formalized” suicides that were approved of, such as the ancient custom of hara-kiri in Japan, in which an individual who brought dishonor to himself or his family was expected to impale himself on a sword. Durkheim referred to this as altruistic suicide. Durkheim also recognized the loss of social supports as an important provocation for suicide; he called this egoistic suicide. Anomic suicides are the result of marked disruptions, such as the sudden loss of a high-prestigejob. (Anomie is feeling lost and confused). Finally, fatalistic suicides result from a loss of control over one’s own destiny. The mass suicide of 39 Heaven’s Gate cult members in 1997 is an example of this type because the lives of those people were largely in the hands of Marshall Applewhite, a supreme and charismatic leader. Sigmund Freud believed that suicide (and depression, to some extent) indicated unconscious hostility directed inward to the self rather than outward to the person or situation causing the anger. Risk Factors Edward Shneidman pioneered the study of risk factors for suicide. Among the methods he and others have used to study those conditions and events that make a person vulnerable is psychological autopsy. The psychological profile of the person who committed suicide is reconstructed through extensive interviews with friends and family members who are likely to know what the individual was thinking and doing in the period before death. If a family member committed suicide, there is an increased risk that someone else in the family will also. In fact, recent research found that among depressed patients, the strongest predictor of suicidal behavior was having a family history of suicide. This may not be surprising, because so many people who kill themselves are depressed or have some related mental disorder, and these disorders run in families. A variety of evidence suggests that low levels of serotonin may be associated with suicide and with violent suicide attempts. As we have noted, extremely low levels of serotonin are associated with impulsivity, instability, and the tendency to overreact to situations. Perhaps the most important risk factor for suicide is a severe, stressful event experienced as shameful or humiliating, such as a failure (real or imagined) in school or at work, an unexpected arrest, or rejection by a loved one. Physical and sexual abuse are also important sources of stress. Why would anyone want to copy a suicide? First, suicides are often romanticized in the media: An attractive young person under unbearable pressure commits suicide and becomes a martyr to friends and peers by getting even with the (adult) world for creating such a difficult situation. Also, media accountsoften describe in detail the methods used in the suicide, thereby providing a guide to potential victims. Treatment In this assessment using the Stroop test, people who demonstrated an implicit association between the words death/suicide and self, even if they weren’t aware of it, were 6 times more likely to make a suicide attempt in the next 6 months than those without this specific association; thus, this assessment is a better predictor of suicide attempts than both patients’ own predictions and clinicians’ predictions. In summary, the clinician must assess for (1) suicidal desire (ideation, hopelessness, burdensomeness, feeling trapped); (2) suicidal capability (past attempts, high anxiety and/or rage, available means); and (3) suicidal intent (available plan, expressed intent to die, preparatory behavior). If all three conditions are present, immediate action is required. An important step is limiting access to lethal weapons for anyone at risk for suicide. A recent analysis suggests that this may be the most powerful part of a suicide prevention program. Telephone hotlines and other crisis intervention services also seem to be useful. Empirical research indicates that cognitive-behavioral interventions can be efficacious in decreasing suicide risk. One of the more important studies to date has demonstrated that 10 sessions of cognitive therapy for recent suicide attempters cuts the risk of additional attempts by 50% over the next 18 months. Topic 8: SUBSTANCE-RELATED AND ADDICTIVE DISORDERS The term substance refers to chemical compounds that are ingested to alter mood or behavior. Psychoactive substances alter mood, behavior, or both.  Substance use is the ingestion of psychoactive substances in moderate amounts that does not significantly interfere with social, educational, or occupational functioning. Substance intoxication is our physiological reaction to ingested substances—drunkenness or getting high. For many of the substances we discuss here, intoxication is experienced as impaired judgment, mood changes, and lowered motor ability (for example, problems walking or talking). Substance Abuse. Defining substance abuse by how much of a substance is ingested is problematic. For example, is drinking two glasses of wine in an hour abuse? Three glasses? Six? Is taking one injection of heroin considered abuse? The fifth edition of the Diagnostic and Statistical Manual (DSM-5) defines substance abuse in terms of how significantly it interferes with the user’s life. If substances disrupt your education, job, or relationships with others, and put you in physically dangerous situations (for example, while driving) you would be considered a drug abuser. Drug dependence is usually described as addiction. Although we use the term addiction routinely when we describe people who seem to be under the control of drugs, there is some disagreement about how to define addiction, or substance dependence: ❑ In one definition, the person is physiologically dependent on the drug or drugs, requires increasingly greater amounts of the drug to experience the same effect (tolerance), and will respond physically in a negative way when the substance is no longer ingested (withdrawal). ✓ Tolerance and withdrawal are physiological reactions to the chemicals being ingested. ✓ Withdrawal from alcohol can cause alcohol withdrawal delirium, in which a person can experience frightening hallucinations and body tremors. ✓ Withdrawal from many substances can bring on chills, fever, diarrhea, nausea and vomiting, and aches and pains. ✓ Not all substances are physiologically addicting, however. For example, you do not go through severe physical withdrawal when you stop taking LSD. ✓ Cocaine withdrawal has a pattern that includes anxiety, lack of motivation, and boredom. ✓ Withdrawal from cannabis includes such symptoms as nervousness, appetite change, and sleep disturbance. ❑ Another view of substance dependence uses the “drug-seeking behaviors” themselves as a measure of dependence. The repeated use of a drug, a desperate need to ingest more of the substance (stealing money to buy drugs, standing outside in the cold to smoke), and the The previous version of the DSM considered substance abuse and substance dependence as separate diagnoses. The DSM-5 combines the two into the general definition of substance-related disorders based on research that suggests the two co-occur. Instead, substance-related disorders are now described by levels of severity; including mild (i.e., the person exhibits only two or three of the 11 criteria met), moderate (i.e., four or five criteria met), or severe (i.e., six or more criteria met). “Can you use drugs and not abuse them?” The answer to the first question is yes. Some people drink wine or beer regularly without drinking to excess. And contrary to popular belief, some people use drugs such as heroin, cocaine, or crack (a form of cocaine) occasionally (for instance, several times a year) without abusing them. “Can you abuse drugs and not become addicted to or dependent on them?” It may seem counterintuitive, but dependence can be present without abuse. For example, cancer patients who take morphine for pain may become dependent on the drug—build up a tolerance and go through withdrawal if it is stopped—without abusing it. In early editions of the DSM, alcoholism and drug abuse weren’t treated as separate disorders. Instead, they were categorized as “sociopathic personality disturbances”— a forerunner of the current antisocial personality disorder because substance use was seen as a symptom of other problems. It was considered a sign of moral weakness, and the influence of genetics and biology was hardly acknowledged. The DSM-5 term substance-related disorders include 11 symptoms that range from relatively mild (e.g., substance use results in a failure to fulfill major role obligations) to more severe (e.g., occupational, or recreational activities are given up or reduced because of substance use). DSM-5 removed the previous symptom that related to substance-related legal problems and added a symptom that indicates the presence of craving or a strong desire to use the substance. SIX GENERAL CATEGORIES OF SUBSTANCES: 1. Depressants: These substances result in behavioral sedation and can induce relaxation. They include alcohol (ethyl alcohol) and the sedative and hypnotic drugs in the families of barbiturates (for example, Seconal) and benzodiazepines (for example, Valium, Xanax). 2. Stimulants: These substances cause us to be more active and alert and can elevate mood. Included in this group are amphetamines, cocaine, nicotine, and caffeine. 3. Opiates: The major effect of these substances is to produce analgesia temporarily (reduce pain) and euphoria. Heroin, opium, codeine, and morphine are included in this group. 4. Hallucinogens: These substances alter sensory perception and can produce delusions, paranoia, and hallucinations. Cannabis and LSD are included in this category. 5. Other Drugs of Abuse: Other substances that are abused but do not fit neatly into one of the categories here include inhalants (for example, airplane glue), anabolic steroids, and other over the counter and prescription medications (for example, nitrous oxide). These substances produce a variety of psychoactive effects that are characteristic of the substances described in the previous categories. 6. Gambling Disorder: As with the ingestion of the substances just described, individuals who display gambling disorder are unable to resist the urge to gamble which, in turn, results in negative personal consequences (e.g., divorce, loss of employment). DEPRESSANTS Depressants primarily decrease central nervous system activity. Their principal effect is to reduce our levels of physiological arousal and help us relax. Included in this group are alcohol and the sedative, hypnotic, and anxiolytic drugs, such as those prescribed for insomnia. These substances are among those most likely to produce symptoms of physical dependence, tolerance, and withdrawal. Alcohol Use Disorder. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. Alcohol is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 4. Craving, or a strong desire or urge to use alcohol. 5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. 8. Recurrent alcohol use in situations in which it is physically hazardous. 9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. 10. Tolerance, as defined by either or both of the following: a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of alcohol. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal). b. Alcohol (or closely related substance such as benzodiazepine) is taken to relieve or avoid withdrawal symptoms. Effects Alcohol affects many parts of the body. 1. After it is ingested, it passes through the esophagus. 2. And into the stomach, where small amounts are absorbed. 3. From there, most of it travels to the small intestine, where it is easily absorbed into the bloodstream. 4. The circulatory system distributes the alcohol throughout the body, where it contacts every major organ, including the heart. 5. Some of the alcohol goes to the lungs, where it vaporizes and is exhaled, a phenomenon that is the basis for the breathalyzer test that measures levels of intoxication. 6. As alcohol passes through the liver, it is broken down or metabolized into carbon dioxide and water by enzymes Gamma aminobutyric acid (GABA) system, seems to be particularly sensitive to alcohol. GABA, as you will recall, is an inhibitory neurotransmitter. Because the GABA system seems to act on our feelings of anxiety, alcohol’s antianxiety properties may result from its interaction with the GABA system. In contrast to the GABA system, the glutamate system is excitatory, helping neurons fire. It is suspected to involve learning and memory, and it may be the avenue through which alcohol affects our cognitive abilities. Blackouts, the loss of memory for what happens during intoxication, may result from the interaction of alcohol with the glutamate system. The serotonin system also appears to be sensitive to alcohol. This neurotransmitter system affects mood, sleep, and eating behavior and is thought to be responsible for alcohol cravings. The long-term effects of heavy drinking are often severe. Withdrawal from chronic alcohol use typically includes hand tremors and, within several hours, nausea or vomiting, anxiety, transient hallucinations, agitation, insomnia, and, at its most extreme, withdrawal delirium (or delirium tremens—the DTs), a condition that can produce frightening hallucinations and body tremors. Consequences of long-term excessive drinking include liver disease, pancreatitis, cardiovascular disorders, and brain damage. More seriously, two types of organic brain syndromes may result from long-term heavy alcohol use: dementia and Wernicke- Korsakoff syndrome. 1. Dementia, (or neurocognitive disorder), involves the general loss of intellectual abilities and can be a direct result of neurotoxicity or “poisoning of the brain” by excessive amounts of alcohol. 2. Wernicke-Korsakoff syndrome results in confusion, loss of muscle coordination, and unintelligible speech; it is believed to be caused by a deficiency of thiamine; a vitamin metabolized poorly by heavy drinkers. Fetal alcohol syndrome (FAS) is now generally recognized as a combination of problems that can occur in a child whose mother drank while she was pregnant. These problems include fetal growth retardation, cognitive deficits, behavior problems, and learning difficulties. In addition, children with FAS often have characteristic facial features. Physical characteristics of fetal alcohol syndrome (FAS) include skin folds at the corners of the eyes, low nasal bridge, short nose, groove between nose and upper lip, small head circumference, small eye opening, small midface, and thin upper lip. We metabolize alcohol with the help of an enzyme called alcohol dehydrogenase (ADH). Three different forms of this enzyme have been identified (beta-1, beta-2, and beta-3 ADH). Among children with FAS, beta-3 ADH may be prevalent according to new research. Statistics on Use and Abuse Whites report the highest frequency of drinking (56.8%); drinking is lowest among Asians (40.0%). Men, however, were more likely to report several binges in the 2-week period. The same survey found that students with a grade point average of A had no more than 3 drinks per week, whereas D and F students averaged 11 alcoholic drinks per week. Despite these and other problems, Jellinek agreed to analyze the data, and he developed a fourstage model for the progression of alcoholism based on this limited information. According to his model, individuals go through a prealcoholic stage (drinking occasionally with few serious consequences), a prodromal stage (drinking heavily but with few outward signs of a problem), a crucial stage (loss of control, with occasional binges), and a chronic stage (the primary daily activities involve getting and drinking alcohol). Attempts by other researchers to confirm this progression of stages have not been successful. Early use of alcohol may predict later abuse. A study of almost 6,000 lifetime drinkers found that drinking at an early age—from ages 11 to 14— was predictive of later alcohol-related disorders. Finally, statistics often link alcohol with violent behavior. Numerous studies have found that many people who commit such violent acts as murder, rape, and assault are intoxicated at the time of the crime. Alcohol does not cause aggression, but it may increase a person’s likelihood of engaging in impulsive acts and it may impair the ability to consider the consequences of acting impulsively. Sedative-, Hypnotic-, or Anxiolytic-Related Disorders The general group of depressants also includes sedative (calming), hypnotic (sleep-inducing), and anxiolytic (anxiety-reducing) drugs.  Barbiturates (which include Amytal, Seconal, and Nembutal) are a family of sedative drugs first synthesized in Germany in 1882. They were prescribed to help people sleep and replaced such drugs as alcohol and opium. Barbiturates were widely prescribed by physicians during the 1930s and 1940s, before their addictive properties were fully understood. By the 1950s, they were among the drugs most abused by adults in the United States. At low doses, barbiturates relax the muscles and can produce a mild feeling of well-being. Larger doses can have results similar to those of heavy drinking: slurred speech and problems walking, concentrating, and working. At extremely high doses, the diaphragm muscles can relax so much that they cause death by suffocation. Overdosing on barbiturates is a common means of suicide. Benzodiazepines (which today include Valium, Xanax, and Ativan) have been used since the 1960s, primarily to reduce anxiety. These drugs were originally touted as a miracle cure for the anxieties of living in our highly pressured technological society. In general, benzodiazepines are considered much safer than barbiturates, with less risk of abuse and dependence. Reports on the misuse of Rohypnol, however, show how dangerous even these benzodiazepine drugs can be. Rohypnol (otherwise known as “forget-me-pill,” “roofenol,” “roofies,” “ruffies”) gained a following among teenagers in the 1990s because it has the same effect as alcohol without the telltale odor. There have been numerous incidents of men giving the drug to women without their knowledge, however, making it easier for them to engage in date rape. Like the barbiturates, benzodiazepines are used to calm an individual and induce sleep. In addition, drugs in this class are prescribed as muscle relaxants and anticonvulsants (anti-seizure medications). People who use them for nonmedical reasons report first feeling a pleasant high and a reduction of inhibition, similar to the effects of drinking alcohol. Sedative, hypnotic, and anxiolytic drugs affect the brain by influencing the GABA neurotransmitter system, although by mechanisms slightly different from those involving alcohol. As a result, when people use alcohol with any of these drugs or combine multiple types there can be synergistic effects. In other words, if you drink alcohol after taking a benzodiazepine or barbiturate or combine these drugs, the total effects can reach dangerous levels. Statistics Barbiturate use has declined, and benzodiazepine use has increased since 1960. Of those seeking treatment for substance related problems, less than 1% present problems with benzodiazepines compared with other drugs of abuse. Those who do seek help with abuse of these drugs tend to be female, Caucasian, and over the age of 35. STIMULANTS Included in this group are caffeine (in coffee, chocolate, and many soft drinks), nicotine (in tobacco products such as cigarettes), amphetamines, and cocaine. You probably used caffeine when you got up this morning. In contrast to the depressant drugs, stimulants—as their name suggests— make you more alert and energetic. Stimulant-Related Disorders Amphetamines At low doses, amphetamines can induce feelings of elation and vigor and can reduce fatigue. You feel “up”. After a period of elevation, however, you come back down and “crash,” feeling depressed or tired. Amphetamines are manufactured in laboratories; they were first synthesized in 1887 and later used as a treatment for asthma and as a nasal decongestant. Because amphetamines also reduce appetite, some people take them to lose weight. Long-haul truck drivers, pilots, and some college students trying to “pull allnighters” use amphetamines to get an extra energy “boost” and stay awake. Amphetamines are prescribed for people with narcolepsy, a sleep disorder characterized by excessive sleepiness. Some of these drugs (Ritalin, Adderall) are even given to children with attentiondeficit/hyperactivity disorder (ADHD). DSM-5 diagnostic criteria for intoxication in amphetamine use disorders include significant behavioral symptoms, such as euphoria or affective blunting (a lack of emotional expression), changes in sociability, interpersonal sensitivity, anxiety, tension, anger, stereotyped behaviors, impaired judgment, and impaired social or occupational functioning. In addition, physiological symptoms occur during or shortly after amphetamine or related substances are ingested and can include heart rate or blood pressure changes, perspiration or chills, nausea or vomiting, weight loss, muscular weakness, respiratory depression, chest pain, seizures, or coma. Severe intoxication or overdose can cause hallucinations, panic, agitation, and paranoid delusions. An amphetamine called methylene-dioxymethamphetamine (MDMA), first synthesized in 1912 in Germany, was used as an appetite suppressant. Recreational use of this drug, now commonly called Ecstasy, rose sharply in the late 1980s. Its effects are described by users in a variety of ways: Ecstasy makes you “feel happy” and “love everyone and everything”; “music feels better” and “it’s more fun to dance”; “You can say what is on your mind without worrying what others will think”. A purified, crystallized form of amphetamine, called methamphetamine (commonly referred to as “crystal meth” or “ice”), is ingested through smoking. This drug causes marked aggressive tendencies and stays in the system longer than cocaine, making it particularly dangerous. Amphetamines stimulate the central nervous system by enhancing the activity of norepinephrine and dopamine. Specifically, amphetamines help the release of these neurotransmitters and block their reuptake, thereby making more of them available throughout the system. Cocaine Cocaine replaced amphetamines as the stimulant of choice in the 1970s. Cocaine is derived from the leaves of the coca plant, a flowering bush indigenous to South America. Latin Americans have chewed coca leaves for centuries to get relief from hunger and fatigue. Like amphetamines, in small amounts cocaine increases alertness, produces euphoria, increases blood pressure and pulse, and causes insomnia and loss of appetite. The effects of cocaine are short lived; for Danny they lasted less than an hour, and he had to snort repeatedly to keep himself up. During these binges, he often became paranoid, experiencing exaggerated fears that he would be caught or that someone would steal his cocaine. Such paranoia— referred to as cocaine-induced paranoia—is common among persons with cocaine use disorders, occurring in two thirds or more. Cocaine also makes the heart beat more rapidly and irregularly, and it can have fatal consequences, depending on a person’s physical condition and the amount of the drug ingested. We saw that alcohol can damage the developing fetus. It has also been suspected that the use of cocaine (especially crack) by pregnant women may adversely affect their babies. Crack babies appear at birth to be more irritable than normal babies and have long bouts of highpitched crying. They were originally thought to have permanent brain damage, although recent research suggests that the effects are less dramatic than first feared. Some work suggests that many children born to mothers who have used cocaine during pregnancy may have decreased birth weight and decreased head circumference and are at increased risk for later behavior problems. Statistics White males account for about a third of all admissions to emergency rooms for cocaine related problems (29%) followed by black males (23%), white females (18%), and black females (12%). Tobacco-Related Disorders DSM-5 does not describe an intoxication pattern for tobacco related disorders. Rather, it lists withdrawal symptoms, which include depressed mood, insomnia, irritability, anxiety, difficulty concentrating, restlessness, and increased appetite and weight gain. Nicotine in small doses stimulates the central nervous system; it can relieve stress and improve mood. But it can also cause high blood pressure and increase the risk of heart disease and cancer. High doses can blur your vision, cause confusion, lead to convulsions, and sometimes even cause death. Smoking has been linked with signs of negative affect, such as depression, anxiety, and anger. There is a complex and bi-directional relationship between cigarette smoking and negative affect. In other words, being depressed increases your risk of becoming dependent on nicotine, and at the same time, being dependent on nicotine will increase your risk of becoming depressed. Caffeine-Related Disorders Caffeine is the most common of the psychoactive substances, used regularly by almost 90% of all Americans. Called the “gentle stimulant” because it is thought to be the least harmful of all addictive drugs, caffeine can still lead to problems such as similar to that of other drugs (e.g., interfering with social and work obligations). This drug is found in tea, coffee, many cola drinks sold today, and cocoa products. As most of you have experienced firsthand, caffeine in small doses can elevate your mood and decrease fatigue. In larger doses, it can make you feel jittery and can cause insomnia. Because caffeine takes a relatively long time to leave our bodies (about 6 hours), sleep can be disturbed if the caffeine is ingested in the hours close to bedtime. As with other stimulants, regular caffeine use can result in tolerance and dependence on the drug. Those of you who have experienced headaches, drowsiness, and a generally unpleasant mood when denied your morning coffee have had the withdrawal symptoms characteristic of this drug. Opioids The word opiate refers to the natural chemicals in the opium poppy that have a narcotic effect (they relieve pain and induce sleep). Opiates induce euphoria, drowsiness, and slowed breathing. High doses can lead to death if respiration is completely depressed. Opiates are also analgesics, substances that help relieve pain. People are sometimes given morphine before and after surgery to calm them and help block pain. Withdrawal from opioids can be so unpleasant that people may continue to use these drugs despite a sincere desire to stop. Even so, people who cease or reduce their opioid intake begin to experience symptoms within 6 to 12 hours; these include excessive yawning, nausea and vomiting, chills, muscle aches, diarrhea, and insomnia— temporarily disrupting work, school, and social relationships. Heroin—the most commonly abused opiate. Cannabis-Related Disorders Marijuana is the name given to the dried parts of the cannabis or hemp plant (its full scientific name is Cannabis sativa). Cannabis grows wild throughout the tropical and temperate regions of the world, which accounts for one of its nicknames, “weed”. Reactions to cannabis usually include mood swings. Otherwise normal experiences seem extremely funny, or the person might enter a dreamlike state in which time seems to stand still. Users often report heightened sensory experiences, seeing vivid colors, or appreciating the subtleties of music. Controversy surrounds the use of cannabis for medicinal purposes. However, there appears to be an increasing database documenting the successful use of cannabis and its by-products for the symptoms of certain diseases. In Canada, for example, cannabis products are available for medical use, including an herbal cannabis extract (Sativex—delivered in a nasal spray), dronabinol (Marinol), nabilone (Cesamet), and the herbal form of cannabis that is typically smoked. These cannabis derived products are prescribed for chemotherapy-induced nausea and vomiting, HIVassociated anorexia, neuropathic pain in multiple sclerosis, and cancer pain. Unfortunately, marijuana smoke may contain as many carcinogens as tobacco smoke, although one long-term study that followed more than 5,000 men and women over 20 years suggested that occasional use does not appear to have a negative effect on lung functioning. Most cannabis users inhale the drug by smoking the dried leaves in marijuana cigarettes; others use preparations such as hashish, which is the dried form of the resin in the leaves of the female plant. Hallucinogen-Related Disorders Albert Hoffmann experienced the first recorded “trip” on LSD. Ingesting what he thought was an infinitesimally small amount of this drug, which he referred to in his notes as LSD-25, he waited to see what subtle changes might come over him as a result. Thirty minutes later he reported no change, but some 40 minutes after taking the drug he began to feel dizzy and had a noticeable desire to laugh. Riding his bicycle home, he hallucinated that the buildings he passed were moving and melting. By the time he arrived home, he was terrified he was losing his mind. LSD (d-lysergic acid diethylamide), sometimes referred to as “acid”, is the most common hallucinogenic drug. It is produced synthetically in laboratories, although naturally occurring derivatives of this grain fungus (ergot) have been found historically. The DSM-5 diagnostic criteria for hallucinogen intoxication are similar to those for cannabis: perceptual changes such as the subjective intensification of perceptions, depersonalization, and hallucinations. Physical symptoms include pupillary dilation, rapid heartbeat, sweating, and blurred vision. Stories in the popular press about people who jumped out of windows because they believed they could fly or who stepped into moving traffic with the mistaken idea that they couldn’t be hurt have provided for sensational reading. People do report having “bad trips”; these are the sort of frightening episodes in which clouds turn into threatening monsters or deep feelings of paranoia take over. Usually someone on a bad trip can be “talked down” by supportive people who provide constant reassurance that the experience is the temporary effect of the drug and it will wear off in a few hours. Other Drugs of Abuse Inhalants include a variety of substances found in volatile solvents—making them available to breathe into the lungs directly. Some common inhalants that are used abusively include spray paint, hair spray, paint thinner, gasoline, amyl nitrate, nitrous oxide (“laughing gas”), nail polish remover, felt-tipped markers, airplane glue, contact cement, dry-cleaning fluid, and spot remover. ❑ A typical person who engages in inhalant use tends to be male, Caucasian, live in rural or small towns, have higher levels of anxiety and depression, and show more impulsive and fearless temperaments. ❑ The high associated with the use of inhalants resembles that of alcohol intoxication and usually includes dizziness, slurred speech, incoordination, euphoria, and lethargy. Unfortunately, use can also increase aggressive and antisocial behavior, and long-term use can damage bone marrow, kidneys, liver, and the brain. If users are startled, this can cause a cardiac event that can lead to death (called “sudden sniffing death”).  Anabolic–androgenic steroids (more commonly referred to as steroids or “roids” or “juice”) are derived from or are a synthesized form of the hormone testosterone. The legitimate medical uses of these drugs focus on people with asthma, anemia, breast cancer, and males with inadequate sexual development. However, the anabolic action of these drugs (that can produce increased body mass) has resulted in their illicit use by those wishing to try to improve their physical abilities by increasing muscle bulk. Steroid use differs from other drug use because the substance does not produce a desirable high but instead is used to enhance performance and body size. Dependence on the substance therefore seems to involve the desire to maintain the performance gains obtained rather than a need to re-experience an altered emotional or physical state. Dissociative anesthetics—causes drowsiness, pain relief, and the feeling of being out of one’s body. Their ability to heighten a person’s auditory and visual perception, as well as the senses of taste and touch, has been incorporated into the activities of those who attend nightclubs, all-night dance parties (raves), or large social gatherings of primarily gay men. Causes of Substance-Related Disorders Drug abuse and dependence, once thought to be the result of moral weakness, are now understood to be influenced by a combination of biological and psychosocial factors. 1. Biological Dimensions Familial and Genetic Influences Twin studies of smoking, for example, indicate a moderate genetic influence. Researchers studied more than 1,000 pairs of male twins and questioned them about their use of cannabis, cocaine, hallucinogens, sedatives, stimulants, and opiates. The findings—which may have major implications for how we approach treatment and prevention—suggest that there are common genetic influences on the use of all of these drugs. 2. Neurobiological Influences Amphetamines and cocaine act directly on the dopamine system. We now understand that other neurotransmitters in addition to dopamine—including serotonin and norepinephrine—are also involved in the brain’s reward system. Aspirin is a negative reinforcer: We take it not because it makes us feel good but because it stops us from feeling bad. 3. Psychological Dimensions Positive Reinforcement The feelings that result from using psychoactive substances are pleasurable in some way, and people will continue to take the drugs to recapture the pleasure. The social contexts for drug taking may encourage its use, even when the use alone is not the desired outcome. Negative Reinforcement Many people are likely to initiate and continue drug use to escape from unpleasantness in their lives. In addition to the initial euphoria, many drugs provide escape from physical pain (opiates), from stress (alcohol), or from panic and anxiety (benzodiazepines). People who experience other types of trauma such as sexual abuse are also more likely to abuse alcohol. 4. Cognitive Dimensions What people expect to experience when they use drugs influences how they react to them. A person who expects to be less inhibited when she drinks alcohol will act less inhibited whether she actually drinks alcohol or a placebo she thinks is alcohol. 5. Social Dimensions Exposure to psychoactive substances is a necessary prerequisite to their use and possible abuse, as previously discussed. You could probably list a number of ways people are exposed to these substances—through friends, through the media, and so on. When parents do not provide appropriate supervision, their children tend to develop friendships with peers who supported drug use. 6. Cultural Dimensions Cultural factors such as machismo (male dominance in Latin cultures), marianismo (female Latin role of motherly nurturance and identifying with the Virgin Mary), spirituality, and tiu lien (“loss of face” among Asians, that can lead to shame for not living up to cultural expectations) are just a few cultural viewpoints that can affect drug use and treatment in either a positive or negative way. On the other hand, in certain cultures, including Korea, people are expected to drink alcohol heavily on certain social occasions. As we have seen before, exposure to these substances, in addition to social pressure for heavy and frequent use, may facilitate their abuse, and this may explain the high alcohol abuse rates in countries like Korea. An Integrative Model Access to a drug is a necessary but not a sufficient condition for abuse or dependence. Treatment of Substance-Related Disorders The personal motivation to work on a drug problem appears to be important but not necessarily essential in the treatment of substance abuse. Because substance abuse arises from so many influences, it should not be surprising that treating people with substance-related disorders is not a simple matter of finding just the right drug or the best way to change thoughts or behavior. 1. Biological Treatments Agonist Substitution Agonist substitution involves providing the person with a safe drug that has a chemical makeup similar to the addictive drug (therefore the name agonist). Methadone is an opiate agonist that is often given as a heroin substitute. Although it does not give the quick high of heroin, methadone initially provides the same analgesic (pain reducing) and sedative effects. Research suggests that when addicts combine methadone with counseling, many reduce their use of heroin and engage in less criminal activity. Addiction to cigarette smoking is also treated by a substitution process. The drug—nicotine—is provided to smokers in the form of gum, patch, inhaler, or nasal spray, which lack the carcinogens included in cigarette smoke; the dose is later tapered off to lessen withdrawal from the drug. Antagonist Treatments Antagonist drugs block or counteract the effects of psychoactive drugs, and a variety of drugs that seem to cancel out the effects of opiates have been used with people dependent on a variety of substances. The most often prescribed opiate-antagonist drug, naltrexone, has had only limited success with individuals who are not simultaneously participating in a structured treatment program. When it is given to a person who is dependent on opiates, it produces immediate withdrawal symptoms, an extremely unpleasant effect. A person must be free from these withdrawal symptoms completely before starting naltrexone, and because it removes the euphoric effects of opiates, the user must be highly motivated to continue treatment. Acamprosate also seems to decrease cravings in people dependent on alcohol, and it works best with highly motivated people who are also participating in psychosocial interventions. Aversive Treatment In addition to looking for ways to block the euphoric effects of psychoactive drugs, clinicians in this area may prescribe drugs that make ingesting the abused substances extremely unpleasant. The expectation is that a person who associates the drug with feelings of illness will avoid using the drug. The most commonly known aversive treatment uses disulfiram (Antabuse) with people who are alcohol dependent. Antabuse prevents the breakdown of acetaldehyde, a by-product of alcohol, and the resulting buildup of acetaldehyde causes feelings of illness. People who drink alcohol after taking Antabuse experience nausea, vomiting, and elevated heart rate and respiration. Efforts to make smoking aversive have included the use of silver nitrate in lozenges or gum. This chemical combines with the saliva of a smoker to produce a bad taste in the mouth. 2. Psychosocial Treatments Inpatient Facilities Inpatient care can be extremely expensive. Although some people do improve as inpatients, they may do equally well in outpatient care that is significantly less expensive. Alcoholics Anonymous and Its Variations Without question, the most popular model for the treatment of substance abuse is a variation of the Twelve Steps program first developed by Alcoholics Anonymous (AA). An important component is the social support it provides through group meetings. The Twelve Steps of AA are the basis of its philosophy. In them, you can see the reliance on prayer and a belief in God. Because participants attend meetings anonymously and only when they feel the need to, conducting systematic research on its effectiveness has been unusually difficult. Component Treatment Most comprehensive treatment programs aimed at helping people with substance abuse and dependence problems have a number of components thought to boost the effectiveness of the “treatment package”. The negative associations can also be made by imagining unpleasant scenes in a technique called covert sensitization; the person might picture herself beginning to snort cocaine and be interrupted with visions of herself becoming violently ill. One component that seems to be a valuable part of therapy for substance use is contingency management. Here, the clinician and the client together select the behaviors that the client needs to change and decide on the reinforcers that will reward reaching certain goals, perhaps money or small retail items like CDs. Another package of treatments is the community reinforcement approach. First, a spouse, friend, or relative who is not a substance user is recruited to participate in relationship therapy to help the abuser improve relationships with other important people. Second, clients are taught how to identify the antecedents and consequences that influence their drug taking. Third, clients are given assistance with employment, education, finances, or other social service areas that may help reduce their stress. Fourth, new recreational options help the person replace substance use with new activities. There is now strong empirical support for the effectiveness of this approach with alcohol and cocaine abusers. Obstacles to successful treatment for substance use and dependence include a lack of personal awareness that one has a problem and an unwillingness to change. An increasingly common intervention approach that directly addresses these needs is referred to as Motivational Enhancement Therapy (MET). MET is based on the work of Miller and Rollnick, who proposed that behavior change in adults is more likely with empathetic and optimistic counseling (the therapist understands the client’s perspective and believes that he or she can change) and a focus on a personal connection with the client’s core values. Cognitive-behavioral therapy (CBT) is an effective treatment approach for many psychological disorders and it is also one of the most well designed and studied approaches for treating substance dependence. This treatment addresses multiple aspects of the disorder, including a person’s reactions to cues that lead to substance use (for example, being among certain friends) and thoughts and behaviors to resist use. Marlatt and Gordon’s relapse prevention treatment model looks at the learned aspects of dependence and sees relapse as a failure of cognitive and behavioral coping skills. Therapy involves helping people remove any ambivalence about stopping their drug use by examining their beliefs about the positive aspects of the drug (“There’s nothing like a cocaine high”) and confronting the negative consequences of its use (“I fight with my wife when I’m high”). Prevention Over the past few years, the strategies for preventing substance abuse and dependence have shifted from education-based approaches (for example, teaching schoolchildren that drugs can be harmful) to more wide-ranging approaches, including changes in the laws regarding drug possession and use and community-based interventions. GAMBLING DISORDER The DSM-5 criteria for gambling disorder set forth the associated behaviors that characterize people who have this addictive disorder. These include the same pattern of urges we observe in the other substance-related disorders. Note to the parallels with substance dependence, with the need to gamble increasing amounts of money over time and the “withdrawal symptoms” such as restlessness and irritability when attempting to stop. These parallels to substance-related disorders led to the re- categorization of gambling disorder as an “Addictive Disorder” in DSM-5. Abnormalities in the dopamine system (which may account for the pleasurable consequences of gambling) and the serotonin system (involved in impulsive behavior) have been found in some studies of pathological gamblers. Treatment of gambling problems is difficult. Those with gambling disorder exhibit a combination of characteristics—including denial of the problem, impulsivity, and continuing optimism (“One big win will cover my losses!”)—that interfere with effective treatment. Treatment is often similar to substance dependence treatment, and there is a parallel Gambler’s Anonymous that incorporates the same 12-step program we discussed previously. Cognitive-behavioral interventions are also being studied, with one study including a variety of components—setting financial limits, planning alternative activities, preventing relapse, and imaginal desensitization. Topic 9: EATING DISORDERS AND SLEEP-WAKE DISORDERS In DSM-5, eating disorders are in a chapter called “Feeding and Eating Disorders” that also includes childhood disorders such as pica (eating nonfood substances for extended periods) and rumination disorders (repeated regurgitation of foods). In bulimia nervosa, out of control eating episodes, or binges, are followed by self-induced vomiting, excessive use of laxatives, or other attempts to purge (get rid of) the food. In anorexia nervosa, the person eats nothing beyond minimal amounts of food, so body weight sometimes drops dangerously. In binge-eating disorder, individuals may binge repeatedly and find it distressing, but they do not attempt to purge the food. The chief characteristic of these related disorders is an overwhelming, all-encompassing drive to be thin. Anorexia nervosa has the highest mortality rate of any psychological disorder reviewed in this book, including depression. Eating disorders were included for the first time as a separate group of disorders in the fourth edition of the Diagnostic and Statistical Manual (DSM-IV), published by the American Psychiatric Association in 2000. Eating disorders, particularly bulimia, were not found in developing countries, where access to sufficient food is so often a daily struggle; only in the West, where food was generally plentiful, have they been rampant. Now this has changed; evidence suggests that eating disorders are going global. For example, recent studies show estimates of prevalence in China and Japan are approaching those in the United States and other Western countries. More than 90% of the severe cases are young females who live in a socially competitive environment. Increasingly, this group of girls and young women with eating disorders seek one another out on the Internet through “pro-ana” (anorexia) and “pro-mia” (bulimia) websites and social networks, where they find support and, in some cases, inspiration. In these disorders, unlike most others, the strongest contributions to etiology seem to be sociocultural rather than psychological or biological factors. Obesity is not considered an official disorder in the DSM, but we consider it here because it is thought to be one of the most dangerous epidemics confronting public health authorities around the world today. Bulimia Nervosa The hallmark of bulimia nervosa is eating a larger amount of food—typically, more junk food than fruits and vegetables—than most people would eat under similar circumstances. Just as important as the amount of food eaten is that the eating is experienced as out of control, a criterion that is an integral part of the definition of binge eating. Another important criterion is that the individual attempts to compensate for the binge eating and potential weight gain, almost always by purging techniques. Techniques include self-induced vomiting immediately after eating, as in the case of Phoebe, and using laxatives (drugs that relieve constipation) and diuretics (drugs that result in loss of fluids through greatly increased frequency of urination). Some exercise excessively (although rigorous exercising is more usually a characteristic of anorexia nervosa.) Others fast for long periods between binges. Bulimia nervosa was subtyped in DSM-IV-TR into purging type (e.g., vomiting, laxatives, or diuretics) or non-purging type (e.g., exercise and/or fasting). But the non- purging type has turned out to be quite rare, accounting for only 6% to 8% of patients with bulimia. Furthermore, these studies found little evidence of any differences between purging and non-purging types of bulimia, nor were any differences evident in severity of psychopathology, frequency of binge episodes, or prevalence of major depression and panic disorder. As a result, this distinction was dropped in DSM-5. Recent investigations confirm that the major features of the disorder (bingeing, purging, over concern with body shape, and so on) “cluster together” in someone with this problem, which strongly supports the validity of the diagnostic category. Medical consequences of chronic bulimia One is salivary gland enlargement caused by repeated vomiting, which gives the face a chubby appearance. This was noticeable with Phoebe. Repeated vomiting also may erode the dental enamel on the inner surface of the front teeth as well as tear the esophagus. More important, continued vomiting may upset the chemical balance of bodily fluids, including sodium and potassium levels. This condition, called an electrolyte imbalance, can result in serious medical complications if unattended, including cardiac arrhythmia (disrupted heartbeat), seizures, and renal (kidney) failure, all of which can be fatal. Surprisingly, young women with bulimia also develop more body fat than age- and weight-matched healthy controls, the very effect they are trying to avoid! Intestinal problems resulting from laxative abuse are also potentially serious; they can include severe constipation or permanent colon damage. Finally, some individuals with bulimia have marked calluses on their fingers or the backs of their hands caused by the friction of contact with the teeth and throat when repeatedly sticking their fingers down their throat to stimulate the gag reflex. Anorexia Nervosa Individuals with anorexia nervosa (which literally means a “nervous loss of appetite”— an incorrect definition because appetite often remains healthy) differ in one important way from individuals with bulimia. Both anorexia and bulimia are characterized by a morbid fear of gaining weight and losing control overeating. The major difference seems to be whether the individual is successful at losing weight. People with anorexia are proud of both their diets and their extraordinary control. People with bulimia are ashamed of both their eating issues and their lack of control. Although decreased body weight is the most notable feature of anorexia nervosa, it is not the core of the disorder. Many people lose weight because of a medical condition, but people with anorexia have an intense fear of obesity and relentlessly pursue thinness. As with bulimia nervosa, anxiety disorders and mood disorders are often present in individuals with anorexia. Interestingly, one anxiety disorder that seems to co-occur often with anorexia is obsessive-compulsive disorder (OCD). Substance abuse is also common in individuals with anorexia nervosa, and, in conjunction with anorexia, is a strong predictor of mortality, particularly by suicide. DSM-5 specifies two subtypes of anorexia nervosa. In the restricting type, individuals diet to limit calorie intake; in the binge-eating–purging type, they rely on purging. Unlike individuals with bulimia, binge-eating–purging anorexics binge on relatively small amounts of food and purge more consistently, in some cases each time they eat. Subtyping may not be useful in predicting the future course of the disorder but rather may reflect a certain phase or stage of anorexia, a finding confirmed in a more recent study. For this reason, DSM-5 criteria specify that subtyping refer only to the last 3 months.  Another key criterion of anorexia is a marked disturbance in body image. One common medical complication of anorexia nervosa is cessation of menstruation (amenorrhea), which also occurs relatively often in bulimia. This feature can be an objective physical index of the degree of food restriction but is inconsistent because it does not occur in all cases. Because of this inconsistency, amenorrhea was dropped as a diagnostic criterion in DSM-5. Other medical signs and symptoms of anorexia include dry skin, brittle hair or nails, and sensitivity to or intolerance of cold temperatures. Also, it is relatively common to see lanugo, downy hair on the limbs and cheeks. Cardiovascular problems, such as chronically low blood pressure and heart rate, can also result. If vomiting is part of the anorexia, electrolyte imbalance and resulting cardiac and kidney problems can result, as in bulimia. Binge-Eating Disorder Beginning in the 1990s, research focused on a group of individuals who experience marked distress because of binge eating but do not engage in extreme compensatory behaviors and therefore cannot be diagnosed with bulimia. After classification in DSM-IV as a disorder needing further study, BED is now included as a full-fledged disorder in DSM-5. Evidence that supports its elevation to disorder status includes somewhat different patterns of heritability compared with other eating disorders, as well as a greater likelihood of occurring in males and a later age of onset. There is also a greater likelihood of remission and a better response to treatment in BED compared with other eating disorders. But Hudson and colleagues concluded that BED is a disorder caused by a separate set of factors from obesity without BED and is associated with more severe obesity. It’s also increasingly clear that individuals with BED have some of the same concerns about shape and weight as people with anorexia and bulimia, which distinguishes them from individuals who are obese without BED. Statistics Among those who present for treatment, the overwhelming majority (90% to 95%) of individuals with bulimia are women. Males with bulimia have a slightly later age of onset, and a large minority are predominantly gay males or bisexual. Male athletes in sports that require weight regulation, such as wrestling, are another large group of males with eating disorders. Among women, adolescent girls are most at risk. Although the study was conducted prior to the publication of DSM-5, the 3-month duration required for BED (or subthreshold BED), found in DSM-5, rather than the 6 months required in DSM-IV-TR, was used. Finally, if binge eating occurred at least twice a week for 3 months—even if it was just a symptom of the four other disorders rather than a separate condition— the case was listed under “Any binge eating.” The median age of onset for all eating-related disorders occurred in a narrow range of 18 to 21 years. Causes of Eating Disorders The cultural imperative for thinness directly results in dieting, the first dangerous step down the slippery slope to anorexia and bulimia. Levine and Smolak refer to “the glorification of slenderness” in magazines and on television, where most females are thinner than the average American woman. Grabe, Ward, and Hyde, reviewing 77 studies, demonstrated a strong relationship between exposure to media images depicting the thin-ideal body and body image concerns in women. Friendship cliques tended to share the same attitudes toward body image, dietary restraint, and the importance of attempts to lose weight. Olivardia, Pope, and Hudson have described a syndrome in men, particularly male weightlifters, that they initially termed “reverse anorexia nervosa”. Men with this syndrome reported they were extremely concerned about looking small, even though they were muscular. Biological processes are quite active in the regulation of eating and thus of eating disorders, and substantial evidence points to the hypothalamus as playing an important role. Low levels of serotonergic activity, the system most often associated with eating disorders, are associated with impulsivity generally and binge eating specifically. Clinical observations over the years have indicated that many young women with eating disorders have a diminished sense of personal control and confidence in their own abilities and talents. They also display more perfectionistic attitudes, perhaps learned, or inherited from their families which may reflect attempts to exert control over important events in their lives. They also perceive themselves as frauds, considering false any impressions they make of being adequate, self-sufficient, or worthwhile. In this sense, they feel like impostors in their social groups and experience heightened levels of social anxiety, which may explain why they choose social groups with similar attitudes towards eating and body shape. Treatment of Eating Disorders Bulimia Nervosa In the CBT-E pioneered by Fairburn The first stage is teaching the patient the physical consequences of binge eating and purging, as well as the ineffectiveness of vomiting and laxative abuse for weight control. The adverse effects of dieting are also described, and patients are scheduled to eat small, manageable amounts of food five or six times per day with no more than a 3-hour interval between any planned meals and snacks, which eliminates the alternating periods of overeating and dietary restriction that are hallmarks of bulimia. In later stages of treatment, CBT-E focuses on altering dysfunctional thoughts and attitudes about body shape, weight, and eating. Coping strategies for resisting the impulse to binge and/or purge are also developed, including arranging activities so that the individual will not spend time alone after eating during the early stages of treatment. The investigators found that, for those who completed treatment, CBT was significantly superior to IPT at the end of treatment, with 45% recovered in the CBT group versus 8% in the IPT group. The investigators concluded that CBT is the preferred psychological treatment for bulimia nervosa because it worked significantly faster. Nevertheless, it is intriguing, again, that IPT was almost as effective after 1 year even though this treatment concentrates not directly on disordered eating patterns but rather on the interpersonal relationships of the patient. There is also good evidence that family therapy directed at the painful conflicts present in families with an adolescent who has an eating disorder can be helpful. CBT remains the preferred treatment for bulimia and is superior to medication alone. Binge-Eating Disorder  In contrast to results with bulimia, it appears that IPT is every bit as effective as CBT for binge eating. But, in a study examining the effectiveness of the anti-depressant drug Prozac compared with CBT for BED, Prozac was ineffective (compared with placebo) and Prozac did not add anything to CBT when the two treatments were combined. Interestingly, widely available behavioral weight loss programs for obese patients with BED, such as weight watchers have some positive effect on binging, but not nearly so much as CBT. Fortunately, it appears that self-help procedures may be useful in the treatment of BED. Anorexia Nervosa In anorexia, the most important initial goal is to restore the patient’s weight to a point that is at least within the low normal range. If body weight is below 85% of the average healthy body weight for a given individual or if weight has been lost rapidly and the individual continues to refuse food, inpatient treatment is recommended, because severe medical complications, particularly acute cardiac failure, could occur if weight is not restored immediately. If the weight loss has been more gradual and seems to have stabilized, weight restoration can be accomplished on an outpatient basis. For restricting anorexics, the focus of treatment must shift to their marked anxiety over becoming obese and losing control of eating, as well as to their undue emphasis on thinness as a determinant of self-worth, happiness, and success. Carter et al. reported similar findings and both studies demonstrate the ineffectiveness of nutritional counseling alone. In addition, every effort is made to include the family to accomplish two goals. First, the negative and dysfunctional communication in the family regarding food and eating must be eliminated and meals must be made more structured and reinforcing. Second, attitudes toward body shape and image distortion are discussed at some length in family sessions. Family therapy directed at the goals mentioned above seems effective, particularly with young girls (less than 19 years of age) with a short history of the disorder. The drugs generally considered the most effective for bulimia are the same antidepressant medications pro