Agoraphobia

Overview

Agoraphobia (ag-uh-ruh-FOE-be-uh) is a type of anxiety disorder in which you fear and avoid
places or situations that might cause you to panic and make you feel trapped, helpless or
embarrassed. You fear an actual or anticipated situation, such as using public transportation,
being in open or enclosed spaces, standing in line, or being in a crowd.
The anxiety is caused by fear that there's no easy way to escape or get help if the anxiety
intensifies. Most people who have agoraphobia develop it after having one or more panic
attacks, causing them to worry about having another attack and avoid the places where it may
happen again.
People with agoraphobia often have a hard time feeling safe in any public place, especially
where crowds gather. You may feel that you need a companion, such as a relative or friend, to
go with you to public places. The fear can be so overwhelming that you may feel unable to
leave your home.
Agoraphobia treatment can be challenging because it usually means confronting your fears. But
with psychotherapy and medications, you can escape the trap of agoraphobia and live a more
enjoyable life.
Symptoms

Typical agoraphobia symptoms include fear of:

 Leaving home alone

 Crowds or waiting in line
 Enclosed spaces, such as movie theaters, elevators or small stores
 Open spaces, such as parking lots, bridges or malls
 Using public transportation, such as a bus, plane or train
These situations cause anxiety because you fear you won't be able to escape or find help if you
start to feel panicked or have other disabling or embarrassing symptoms.
In addition:

 Fear or anxiety almost always results from exposure to the situation

 Your fear or anxiety is out of proportion to the actual danger of the situation
 You avoid the situation, you need a companion to go with you, or you endure the
situation but are extremely distressed
 You experience significant distress or problems with social situations, work or other
areas in your life because of the fear, anxiety or avoidance
 Your phobia and avoidance usually lasts six months or longer
Panic disorder and agoraphobia
Some people have a panic disorder in addition to agoraphobia. Panic disorder is a type of
anxiety disorder in which you experience sudden attacks of extreme fear that reach a peak
within a few minutes and trigger intense physical symptoms (panic attacks). You might think
that you're totally losing control, having a heart attack or even dying.
Fear of another panic attack can lead to avoiding similar circumstances or the place where it
occurred in an attempt to prevent future panic attacks.
Signs and symptoms of a panic attack can include:

 Rapid heart rate

 Trouble breathing or a feeling of choking
 Chest pain or pressure
 Lightheadedness or dizziness
 Feeling shaky, numb or tingling
 Excessive sweating
 Sudden flushing or chills
 Upset stomach or diarrhea
 Feeling a loss of control
 Fear of dying
When to see a doctor
Agoraphobia can severely limit your ability to socialize, work, attend important events and even
manage the details of daily life, such as running errands.
Don't let agoraphobia make your world smaller. Call your doctor if you have signs or symptoms
listed above.
Causes

Biology — including health conditions and genetics — temperament, environmental stress and
learning experiences may all play a role in the development of agoraphobia.
Risk factors

Agoraphobia can begin in childhood, but usually starts in the late teen or early adult years —
usually before age 35 — but older adults can also develop it. Women are diagnosed with
agoraphobia more often than men are.
Risk factors for agoraphobia include:
 Having panic disorder or other phobias
 Responding to panic attacks with excessive fear and avoidance
 Experiencing stressful life events, such as abuse, the death of a parent or being attacked
 Having an anxious or nervous temperament
 Having a blood relative with agoraphobia
Complications

Agoraphobia can greatly limit your life's activities. If your agoraphobia is severe, you may not
even be able to leave your home. Without treatment, some people become housebound for
years. You may not be able to visit with family and friends, go to school or work, run errands, or
take part in other normal daily activities. You may become dependent on others for help.
Agoraphobia can also lead to or be associated with:

 Depression
 Alcohol or drug abuse
 Other mental health disorders, including other anxiety disorders or personality disorders
Prevention

There's no sure way to prevent agoraphobia. However, anxiety tends to increase the more you
avoid situations that you fear. If you start to have mild fears about going places that are safe,
try to practice going to those places over and over again before your fear becomes
overwhelming. If this is too hard to do on your own, ask a family member or friend to go with
you, or seek professional help.
If you experience anxiety going places or have panic attacks, get treatment as soon as possible.
Get help early to keep symptoms from getting worse. Anxiety, like many other mental health
conditions, can be harder to treat if you wait.

Understanding GAD - and the Symptoms

Generalized Anxiety Disorder (GAD) is characterized by persistent and excessive worry about a
number of different things. People with GAD may anticipate disaster and may be overly
concerned about money, health, family, work, or other issues. Individuals with GAD find it
difficult to control their worry. They may worry more than seems warranted about actual
events or may expect the worst even when there is no apparent reason for concern.  

GAD is diagnosed when a person finds it difficult to control worry on more days than not for at
least six months and has three or more symptoms. Learn more about symptoms. This
differentiates GAD from worry that may be specific to a set stressor or for more limited period
of time.
GAD affects 6.8 million adults, or 3.1% of the U.S. population, in any given year. Women are
twice as likely to be affected. The disorder comes on gradually and can begin across the life
cycle, though the risk is highest between childhood and middle age. Although the exact cause
of GAD is unknown, there is evidence that biological factors, family background, and life
experiences, particularly stressful ones, play a role.

Sometimes just the thought of getting through the day produces anxiety. People with GAD
don’t know how to stop the worry cycle and feel it is beyond their control, even though they
usually realize that their anxiety is more intense than the situation warrants. All anxiety
disorders may relate to a difficulty tolerating uncertainty and therefore many people with GAD
try to plan or control situations. Many people believe worry prevents bad things from
happening so they view it is risky to give up worry. At times, people can struggle with physical
symptoms such as stomachaches and headaches.

When their anxiety level is mild to moderate or with treatment, people with GAD can function
socially, have full and meaningful lives, and be gainfully employed. Many with GAD may avoid
situations because they have the disorder or they may not take advantage of opportunities due
to their worry (social situations, travel, promotions, etc). Some people can have difficulty
carrying out the simplest daily activities when their anxiety is severe.

Learn more symptoms.

Treatment Information:

A number of types of treatment can help with GAD. Supportive and interpersonal therapy can
help. Cognitive behavioral treatment (CBT) has been more researched and specifically targets
thoughts, physical symptoms and behaviors including the over-preparation, planning and
avoidance that characterizes GAD. Mindfulness based approaches and Acceptance
Commitment Therapy have also been investigated with positive outcome. All therapies
(sometimes in different ways) help people change their relationship to their symptoms. They
help people to understand the nature of anxiety itself, to be less afraid of the presence of
anxiety, and to help people make choices independent of the presence of anxiety. The adult
CBT treatments for GAD have been modified for children and teens and show positive
outcomes.

There are a number of medication choices for GAD, usually the SSRIs either alone or in
combination with therapy.  

Relaxation techniques, meditation, yoga, exercise, and other alternative treatments may also
become part of a treatment plan.

Other anxiety disorders, depression, or substance abuse often accompany GAD, which rarely
occurs alone; co-occurring conditions must also be treated with appropriate therapies.

WHAT IS SUBSTANCE-INDUCED ANXIETY DISORDER?

Substance-induced anxiety disorder is nervousness, restlessness, or panic caused by taking a
drug or stopping a drug.
If you had anxiety before you started using the drug, even if the drug makes your symptoms
worse, it is not considered a substance-induced anxiety disorder.

WHAT IS THE CAUSE?

The brain makes chemicals that affect thoughts, emotions, and actions. Without the right
balance of these chemicals, there may be problems with the way you think, feel, or act. Many
drugs change the amounts of these chemicals.
Some drugs can cause anxiety while you are taking them. Other drugs can cause anxiety for
several weeks after you stop taking them. Drugs and medicines that can cause anxiety include:

 Alcohol and illegal drugs such as cocaine and LSD

 Nonprescription medicines such as some decongestants
 Caffeine
 Prescription medicines such as stimulants, steroids, and medicines to treat asthma,
Parkinson’s disease, and thyroid problems

WHAT ARE THE SYMPTOMS?

The symptoms may start while you are taking the drugs or within a few days after you stop
taking them. Besides feeling nervous and worried, symptoms may include:

 Thinking that bad things will happen or that you will never get better
 Having trouble falling asleep or waking up often during the night
 Having trouble concentrating or remembering things
 Fearing that you are losing control of yourself and will go crazy or will die
  Losing weight because you don't feel like eating, or because your stomach hurts or you
have vomiting or diarrhea
 Having chills, hot flashes, sweating, shaking, numbness, or a pounding heartbeat
 Having trouble breathing, trouble swallowing, or chest pain

HOW IS IT DIAGNOSED?
Your healthcare provider will ask how much and how often you use nonprescription,
prescription, and illegal drugs. Be honest about the medicines and drugs you use. Your provider
needs this information to give you the right treatment. He will also ask about your symptoms,
medical history and give you a physical exam. You may have tests or scans to help make a
diagnosis.

HOW IS IT TREATED?
See your healthcare provider if you believe that a medicine may be causing anxiety. Your
healthcare provider may prescribe a change in medicine or treatment for your symptoms. Do
not change the dosage or stop taking any prescribed medicine unless your healthcare provider
has given you instructions to do so.
Drug abuse and dependence can be treated. For any treatment to be successful, you must want
to stop using drugs. Do not try to use alcohol and other drugs to reduce withdrawal symptoms.
Your healthcare provider may prescribe medicine to help you get through withdrawal.
Self-help groups such as Cocaine Anonymous, support groups, and therapy may be helpful. You
might be treated in a substance abuse treatment program. Your healthcare providers and
counselors will work with you to develop a treatment program.
Therapy
Substance-induced anxiety disorder can be treated with either group or individual therapy.
Therapy in a group with other people who have substance abuse problems is often very helpful.
In some cases, medicines for depression or anxiety may help you to stop substance abuse.
Discuss the options with your healthcare provider or therapist.
Other Treatments
Learning ways to relax may help. Yoga and meditation may also be helpful. You may want to
talk with your healthcare provider about using these methods along with medicines and
therapy.
Claims have been made that certain herbal and dietary products help control cravings or
withdrawal symptoms. Supplements are not tested or standardized and may vary in strengths
and effects. They may have side effects and are not always safe. Before you take any
supplement, talk with your healthcare provider.
Overview

Experiencing occasional anxiety is a normal part of life. However, people with anxiety disorders
frequently have intense, excessive and persistent worry and fear about everyday situations.
Often, anxiety disorders involve repeated episodes of sudden feelings of intense anxiety and
fear or terror that reach a peak within minutes (panic attacks).

These feelings of anxiety and panic interfere with daily activities, are difficult to control, are out
of proportion to the actual danger and can last a long time. You may avoid places or situations
to prevent these feelings. Symptoms may start during childhood or the teen years and continue
into adulthood.

Examples of anxiety disorders include generalized anxiety disorder, social anxiety disorder
(social phobia), specific phobias and separation anxiety disorder. You can have more than one
anxiety disorder. Sometimes anxiety results from a medical condition that needs treatment.

Whatever form of anxiety you have, treatment can help.

Symptoms

Common anxiety signs and symptoms include:

 Feeling nervous, restless or tense

 Having a sense of impending danger, panic or doom

 Having an increased heart rate

 Breathing rapidly (hyperventilation)

 Sweating

 Trembling

 Feeling weak or tired

 Trouble concentrating or thinking about anything other than the present worry

 Having trouble sleeping

 Experiencing gastrointestinal (GI) problems

  Having difficulty controlling worry

 Having the urge to avoid things that trigger anxiety

Several types of anxiety disorders exist:

 Agoraphobia (ag-uh-ruh-FOE-be-uh) is a type of anxiety disorder in which you fear and

often avoid places or situations that might cause you to panic and make you feel trapped,
helpless or embarrassed.

 Anxiety disorder due to a medical condition includes symptoms of intense anxiety or

panic that are directly caused by a physical health problem.

 Generalized anxiety disorder includes persistent and excessive anxiety and worry about
activities or events — even ordinary, routine issues. The worry is out of proportion to the
actual circumstance, is difficult to control and affects how you feel physically. It often
occurs along with other anxiety disorders or depression.

 Panic disorder involves repeated episodes of sudden feelings of intense anxiety and fear
or terror that reach a peak within minutes (panic attacks). You may have feelings of
impending doom, shortness of breath, chest pain, or a rapid, fluttering or pounding heart
(heart palpitations). These panic attacks may lead to worrying about them happening
again or avoiding situations in which they've occurred.

 Selective mutism is a consistent failure of children to speak in certain situations, such as

school, even when they can speak in other situations, such as at home with close family
members. This can interfere with school, work and social functioning.

 Separation anxiety disorder is a childhood disorder characterized by anxiety that's

excessive for the child's developmental level and related to separation from parents or
others who have parental roles.

 Social anxiety disorder (social phobia) involves high levels of anxiety, fear and
avoidance of social situations due to feelings of embarrassment, self-consciousness and
concern about being judged or viewed negatively by others.

 Specific phobias are characterized by major anxiety when you're exposed to a specific

object or situation and a desire to avoid it. Phobias provoke panic attacks in some people.

 Substance-induced anxiety disorder is characterized by symptoms of intense anxiety or

panic that are a direct result of misusing drugs, taking medications, being exposed to a
toxic substance or withdrawal from drugs.
  Other specified anxiety disorder and unspecified anxiety disorder are terms for anxiety
or phobias that don't meet the exact criteria for any other anxiety disorders but are
significant enough to be distressing and disruptive.
When to see a doctor

See your doctor if:

 You feel like you're worrying too much and it's interfering with your work, relationships
or other parts of your life

 Your fear, worry or anxiety is upsetting to you and difficult to control

 You feel depressed, have trouble with alcohol or drug use, or have other mental health
concerns along with anxiety

 You think your anxiety could be linked to a physical health problem

 You have suicidal thoughts or behaviors — if this is the case, seek emergency treatment
immediately

Your worries may not go away on their own, and they may get worse over time if you don't
seek help. See your doctor or a mental health provider before your anxiety gets worse. It's
easier to treat if you get help early.

Request an Appointment at Mayo Clinic

Causes

The causes of anxiety disorders aren't fully understood. Life experiences such as traumatic
events appear to trigger anxiety disorders in people who are already prone to anxiety. Inherited
traits also can be a factor.

Medical causes

For some people, anxiety may be linked to an underlying health issue. In some cases, anxiety
signs and symptoms are the first indicators of a medical illness. If your doctor suspects your
anxiety may have a medical cause, he or she may order tests to look for signs of a problem.

Examples of medical problems that can be linked to anxiety include:

  Heart disease

 Diabetes

 Thyroid problems, such as hyperthyroidism

 Respiratory disorders, such as chronic obstructive pulmonary disease (COPD) and

asthma

 Drug misuse or withdrawal

 Withdrawal from alcohol, anti-anxiety medications (benzodiazepines) or other

medications

 Chronic pain or irritable bowel syndrome

 Rare tumors that produce certain fight-or-flight hormones

Sometimes anxiety can be a side effect of certain medications.

It's possible that your anxiety may be due to an underlying medical condition if:

 You don't have any blood relatives (such as a parent or sibling) with an anxiety disorder

 You didn't have an anxiety disorder as a child

 You don't avoid certain things or situations because of anxiety

 You have a sudden occurrence of anxiety that seems unrelated to life events and you
didn't have a previous history of anxiety
Risk factors

These factors may increase your risk of developing an anxiety disorder:

 Trauma. Children who endured abuse or trauma or witnessed traumatic events are at

higher risk of developing an anxiety disorder at some point in life. Adults who experience
a traumatic event also can develop anxiety disorders.

 Stress due to an illness. Having a health condition or serious illness can cause significant
worry about issues such as your treatment and your future.
  Stress buildup. A big event or a buildup of smaller stressful life situations may trigger
excessive anxiety — for example, a death in the family, work stress or ongoing worry
about finances.

 Personality. People with certain personality types are more prone to anxiety disorders
than others are.

 Other mental health disorders. People with other mental health disorders, such as
depression, often also have an anxiety disorder.

 Having blood relatives with an anxiety disorder. Anxiety disorders can run in families.

 Drugs or alcohol. Drug or alcohol use or misuse or withdrawal can cause or worsen

anxiety.
Complications

Having an anxiety disorder does more than make you worry. It can also lead to, or worsen,
other mental and physical conditions, such as:

 Depression (which often occurs with an anxiety disorder) or other mental health
disorders

 Substance misuse

 Trouble sleeping (insomnia)

 Digestive or bowel problems

 Headaches and chronic pain

 Social isolation

 Problems functioning at school or work

 Poor quality of life

 Suicide
Prevention

There's no way to predict for certain what will cause someone to develop an anxiety disorder,
but you can take steps to reduce the impact of symptoms if you're anxious:
 Get help early. Anxiety, like many other mental health conditions, can be harder to treat
if you wait.

 Stay active. Participate in activities that you enjoy and that make you feel good about
yourself. Enjoy social interaction and caring relationships, which can lessen your worries.

 Avoid alcohol or drug use. Alcohol and drug use can cause or worsen anxiety. If you're
addicted to any of these substances, quitting can make you anxious. If you can't quit on
your own, see your doctor or find a support group to help you.
ADHD is one of the most common neurodevelopmental disorders of childhood. It is usually first
diagnosed in childhood and often lasts into adulthood. Children with ADHD may have trouble
paying attention, controlling impulsive behaviors (may act without thinking about what the
result will be), or be overly active.

Signs and Symptoms

It is normal for children to have trouble focusing and behaving at one time or another.
However, children with ADHD do not just grow out of these behaviors. The symptoms continue,
can be severe, and can cause difficulty at school, at home, or with friends.

A child with ADHD might:

 daydream a lot
 forget or lose things a lot
 squirm or fidget
 talk too much
 make careless mistakes or take unnecessary risks
 have a hard time resisting temptation
 have trouble taking turns
 have difficulty getting along with others

Learn more about signs and symptoms

There are three different types of ADHD, depending on which types of symptoms are strongest
in the individual:

ADHD Fact Sheet

 Predominantly Inattentive Presentation: It is hard for the individual to organize or

finish a task, to pay attention to details, or to follow instructions or conversations. The
person is easily distracted or forgets details of daily routines.

 Predominantly Hyperactive-Impulsive Presentation: The person fidgets and talks a lot.

It is hard to sit still for long (e.g., for a meal or while doing homework). Smaller children
may run, jump or climb constantly. The individual feels restless and has trouble with
impulsivity. Someone who is impulsive may interrupt others a lot, grab things from
 people, or speak at inappropriate times. It is hard for the person to wait their turn or
listen to directions. A person with impulsiveness may have more accidents and injuries
than others.

 Combined Presentation: Symptoms of the above two types are equally present in the
person.

Because symptoms can change over time, the presentation may change over time as well.

Causes of ADHD
Scientists are studying cause(s) and risk factors in an effort to find better ways to manage and
reduce the chances of a person having ADHD. The cause(s) and risk factors for ADHD are
unknown, but current research shows that genetics plays an important role. Recent studies of
twins link genes with ADHD.1

In addition to genetics, scientists are studying other possible causes and risk factors including:

 Brain injury
 Exposure to environmental (e.g., lead) during pregnancy or at a young age
 Alcohol and tobacco use during pregnancy
 Premature delivery
 Low birth weight

Research does not support the popularly held views that ADHD is caused by eating too much
sugar, watching too much television, parenting, or social and environmental factors such as
poverty or family chaos. Of course, many things, including these, might make symptoms worse,
especially in certain people. But the evidence is not strong enough to conclude that they are
the main causes of ADHD.

Diagnosis
Deciding if a child has ADHD is a process with several steps. There is no single test to diagnose
ADHD, and many other problems, like anxiety, depression, sleep problems, and certain types of
learning disabilities, can have similar symptoms. One step of the process involves having a
medical exam, including hearing and vision tests, to rule out other problems with symptoms
like ADHD. Diagnosing ADHD usually includes a checklist for rating ADHD symptoms and taking
a history of the child from parents, teachers, and sometimes, the child.

Learn more about the criteria for diagnosing ADHD

Treatments
In most cases, ADHD is best treated with a combination of behavior therapy and medication.
For preschool-aged children (4-5 years of age) with ADHD, behavior therapy, particularly
training for parents, is recommended as the first line of treatment before medication is tried.
What works best can depend on the child and family. Good treatment plans will include close
monitoring, follow-ups, and making changes, if needed, along the way.

Learn more about treatments

Managing Symptoms: Staying Healthy

Being healthy is important for all children and can be especially important for children with
ADHD. In addition to behavioral therapy and medication, having a healthy lifestyle can make it
easier for your child to deal with ADHD symptoms. Here are some healthy behaviors that may
help:

 Developing healthy eating habits such as eating plenty of fruits, vegetables, and whole

grains and choosing lean protein sources
 Participating in daily physical activity based on age
 Limiting the amount of daily screen time from TVs, computers, phones, and other
electronics
 Getting the recommended amount of sleep each night based on age

Get Help!
If you or your doctor has concerns about ADHD, you can take your child to a specialist such as a
child psychologist or developmental pediatrician, or you can contact your local early
intervention agency (for children under 3) or public school (for children 3 and older).

The Centers for Disease Control and Prevention (CDC) funds the National Resource Center on
ADHDexternal icon, a program of CHADD – Children and Adults with Attention-
Deficit/Hyperactivity Disorder. Their website has links to information for people with ADHD and
their families. The National Resource Center operates a call center (1-800-233-4050) with
trained staff to answer questions about ADHD.
For more information on services for children with special needs, visit the Center for Parent
Information and Resources.external icon  To find the Parent Center near you, you can visit this
website.external icon

ADHD in Adults
ADHD often lasts into adulthood. For more information about diagnosis and treatment
throughout the lifespan, please visit the websites of the National Resource Center on
ADHDexternal icon and the National Institutes of Mental Healthexternal icon.

What Is ADHD?
ADHD stands for attention deficit hyperactivity disorder. It is a medical condition. A person with
ADHD has differences in brain development and brain activity that affect attention, the ability
to sit still, and self-control. ADHD can affect a child at school, at home, and in friendships.
 What Are the Signs of ADHD?

All kids struggle at times to pay attention, listen and follow directions, sit still, or wait their turn.
But for kids with ADHD, the struggles are harder and happen more often. 

Kids with ADHD may have signs from one, two, or all three of these categories:

 Inattentive. Kids who are inattentive (easily distracted) have trouble focusing their
attention, concentrating, and staying on task. They may not listen well to directions, may miss
important details, and may not finish what they start. They may daydream or dawdle too much.
They may seem absent-minded or forgetful, and lose track of their things.
 Hyperactive. Kids who are hyperactive are fidgety, restless, and easily bored. They may
have trouble sitting still, or staying quiet when needed. They may rush through things and make
careless mistakes. They may climb, jump, or roughhouse when they shouldn't. Without
meaning to, they may act in ways that disrupt others.
 Impulsive. Kids who are impulsive act too quickly before thinking. They often interrupt,
might push or grab, and find it hard to wait. They may do things without asking for permission,
take things that aren't theirs, or act in ways that are risky. They may have emotional reactions
that seem too intense for the situation.

Sometimes parents and teachers notice signs of ADHD when a child is very young. But it's
normal for little kids to be distractible, restless, impatient, or impulsive — these things don't
always mean that a child has ADHD.

Attention, activity, and self-control develop little by little, as children grow. Kids learn these
skills with help from parents and teachers. But some kids don't get much better at paying
attention, settling down, listening, or waiting. When these things continue and begin to cause
problems at school, home, and with friends, it may be ADHD.

How Is ADHD Diagnosed?

If you think your child has ADHD, make an appointment with your child's doctor. He or she
will give your child a check-up, including vision and hearing, to be sure something else isn't
causing the symptoms. The doctor can refer you to a child psychologist or psychiatrist if
needed.

To diagnose ADHD, doctors start by asking about a child's health, behavior, and activity. They
talk with parents and kids about the things they have noticed. Your doctor might ask you to
complete checklists about your child's behavior, and might ask you to give your child's teacher a
checklist too.
 After gathering this information, doctors diagnose ADHD if it's clear that:

 A child's distractibility, hyperactivity, or impulsivity go beyond what's usual for their age.

 The behaviors have been going on since the child was young.

 Distractibility, hyperactivity, and impulsivity affect the child at school and at home.

 A health check shows that another health or learning issue isn't causing the problems.

Many kids with ADHD also have learning problems, oppositional and defiant behaviors, or
mood and anxiety problems. Doctors usually treat these along with the ADHD.

How Is ADHD Treated?

Treatment for ADHD usually includes:

 Medicine. This activates the brain's ability to pay attention, slow down, and use more self-
control.
 Behavior therapy. Therapists can help kids develop the social, emotional, and planning skills
that are lagging with ADHD.
 Parent coaching. Through coaching, parents learn the best ways to respond to behavior
difficulties that are part of ADHD.
 School support. Teachers can help kids with ADHD do well and enjoy school more.

The right treatment helps ADHD improve. Parents and teachers can teach younger kids to get
better at managing their attention, behavior, and emotions. As they grow older, kids should
learn to improve their own attention and self-control.

When ADHD is not treated, it can be hard for kids to succeed. This may lead to low self-
esteem, depression, oppositional behavior, school failure, risk-taking behavior, or family
conflict.

What Can Parents Do?

If your child is diagnosed with ADHD:

 Be involved. Learn all you can about ADHD. Follow the treatment your child's health
care provider recommends. Keep all recommended appointments for therapy.
 Give medicines safely. If your child is taking ADHD medicine, always give it at the
recommended time and dose. Keep medicines in a safe place.
 Work with your child's school. Ask teachers if your child should have an IEP. Meet often
with teachers to find out how your child is doing. Work together to help your child do well
 Parent with purpose and warmth. Learn what parenting approaches are best for a child
with ADHD — and which can make ADHD worse. Talk openly and supportively about ADHD with
your child. Focus on your child's strengths and positive qualities.
 Connect with others for support and awareness. Join a support organization for ADHD
to get updates on treatment and other information.

What Causes ADHD?

It's not clear what causes the brain differences of ADHD. There's strong evidence that ADHD is
mostly inherited. Many kids who have ADHD have a parent or relative with it.

ADHD is not caused by too much screen time, poor parenting, or eating too much sugar.

ADHD can improve when kids get treatment, eat healthy food, get enough sleep and exercise,
and have supportive parents who know how to respond to ADHD.

Could I Have Attention-Deficit/Hyperactivity Disorder (ADHD)?

Do you feel that you have struggled throughout your life with poor concentration, inattention,
impulsivity, or getting organized? Have you wondered whether you might have attention
deficit/ hyperactivity disorder (ADHD)? Our society has become more aware of ADHD as a
condition that affects adults as well as children, and there are many adults who struggle with
 this disorder. At the same time, other life stressors or mental health conditions can cause
similar symptoms. Consider getting an evaluation from a psychiatrist or psychologist who has
experience in diagnosing ADHD. Getting an evaluation can help you find the right answer to
your struggles and identify the treatment you need to feel better.

What is ADHD?

ADHD is defined as a persistent pattern of inattention and/or hyperactivity-impulsivity that

interferes with functioning or development.

 Inattention means a person wanders off task, lacks persistence, has difficulty sustaining
focus, and is disorganized; these problems are not due to defiance or lack of comprehension.
 Hyperactivity means a person moves about excessively when it is not appropriate,
and/or excessively fidgets, taps, or talks. In adults, it may appear as extreme restlessness or
wearing others out with their activity.
 Impulsivity means hasty actions that occur in the moment without a person thinking
first; or a desire for immediate rewards or inability to delay gratification. Impulsive actions may
have high potential for harm. An impulsive person may be socially intrusive and interrupt
others excessively or make important decisions without considering the long-term
consequences.

ADHD begins in childhood and is considered a developmental disorder, but a person may not
receive a diagnosis until adolescence or adulthood.

To receive a diagnosis of ADHD as an adult:

 Several symptoms must have been present before the age of 12.
 A person must have at least five symptoms of either inattention and/or hyperactivity-
impulsivity.
 The symptoms must be present in two or more settings, such as at home and at work.
 There must be evidence that the symptoms interfere with the person's functioning in
these settings.

Several other mental health conditions commonly occur with ADHD, including conduct disorder,
learning disorders, anxiety disorders, and depression.

How does ADHD affect adults?

Some children with ADHD continue to have the condition as adults.

Many adults who have ADHD don’t know it. These adults may feel that it is impossible to get
organized, stick to a job, or remember to keep appointments. Daily tasks such as getting up in
the morning, preparing to leave the house for work, arriving at work on time, and being
productive on the job can be especially challenging for adults with undiagnosed ADHD. These
adults may have a history of academic problems, problems at work, or difficult or failed
 relationships. Many have had multiple traffic accidents. Like teens, adults with ADHD may seem
restless and may try to do several things at once, most of them unsuccessfully. They also tend
to prefer "quick fixes," rather than taking the steps needed to achieve greater rewards.

A person may not be diagnosed with ADHD until adulthood because the condition was not
recognized by teachers or family at a younger age, the person has a mild form of ADHD, or he
or she managed fairly without the demands of adulthood. However, it is common for young
adults with undiagnosed ADHD to encounter academic problems in college because of the
intense concentration required by higher education.

Untreated ADHD in an adult can lead to significant problems with education, social and family
situations and relationships, employment, self-esteem, and emotional health. It is never too
late to recognize, diagnose, and treat ADHD and any other mental health condition that can
commonly occur with it. Effective treatment can improve the lives of many adults and their
families.

What are the symptoms of ADHD?

A person with inattention often:

 Fails to give close attention to details or makes careless mistakes at work or during other
activities
 Has difficulty sustaining attention in tasks, such as during lectures or lengthy reading
 Does not seem to listen when spoken to directly
 Does not follow through on instructions and fails to finish chores or duties in the
workplace
 Has difficulty organizing tasks and activities—for example, is messy and has poor time
management
 Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort
 Loses things necessary for tasks or activities, such as keys, wallets, and mobile phones
 Is easily distracted by unrelated thoughts or stimuli
 Is forgetful in daily activities, such as paying bills, keeping appointments, or returning
calls

A person with hyperactivity-impulsivity often:

 Fidgets with or taps hands or feet or squirms in seat

 Leaves seat in situations when remaining seated is expected
 Feels restless or is unable to be still for extended periods of time
 Is unable to engage in leisure activities quietly
 Talks excessively
 Blurts out an answer before a question has been completed
 Has difficulty waiting his or her turn, such as when waiting in line
 Interrupts or intrudes on others
 Some people with ADHD primarily have symptoms of inattention, while others have primarily
symptoms of hyperactivity-impulsivity. Some people have symptoms in both categories.

Problems with concentration and staying organized can be common for many busy adults;
however, an adult who is impaired both at work and at home, or in social situations, is more
likely to have ADHD.

What causes ADHD?

Scientists are not sure what causes ADHD, although many studies suggest that genes play a
large role. Like many other illnesses, ADHD probably results from a combination of factors. In
addition to genetics, researchers are looking at possible environmental factors and are studying
how brain injuries, nutrition, and the social environment might contribute to ADHD.

How is ADHD in adults diagnosed?

Adults who suspect they have ADHD should see a licensed mental health professional or doctor,
such as a psychologist or psychiatrist who has experience diagnosing ADHD, for an evaluation.

Stress, other mental health conditions, and physical conditions or illnesses can cause similar
symptoms to those of ADHD. Some of these include:

 Stress at work or home

 Lack of sleep
 Sleep apnea, a health condition in which a person has one or more pauses in breathing
or shallow breaths while sleeping, causing poor sleep quality and daytime sleepiness
 Lack of exercise
 Lack of proper nutrition
 Anxiety
 Depression
 Problems with the thyroid gland, a gland in the neck that makes the thyroid hormone,
which controls the body's metabolism

Therefore, a thorough evaluation will help the doctor find out what is causing the symptoms
and recommend effective treatment.

There is no one test that can diagnose ADHD. Mental health professionals use certain rating
scales to determine if an adult meets the diagnostic criteria for ADHD.

A thorough evaluation also includes looking at the person’s history of childhood behavior and
school experiences. To obtain this information, the doctor may interview spouses or partners,
parents, close friends, and other associates.

The person may also undergo a physical exam and various psychological tests that evaluate
working memory, executive functioning (abilities like planning and decision-making), and visual
and spatial skills or reasoning. The evaluation will also look at the person’s mood and whether
he or she struggles with other issues, such as anxiety, depression, or substance abuse. A
person’s medical history is also important, as previous health problems, trauma, or injury can
also be the cause of symptoms.

What are the treatments for ADHD in adults?

Adults with ADHD can be treated with behavioral interventions, medication, or a combination
of the two.

Medications

Stimulants such as methylphenidate and amphetamines are the most common type of
medication used for treating ADHD. In addition, a few no stimulant medications are also
available. Although not approved by the U.S. Food and Drug Administration (FDA) specifically
for the treatment of ADHD, antidepressants are sometimes used to treat adults with ADHD. An
adult who is offered a prescription for a stimulant for ADHD should tell his or her doctor about
all other medications that he or she takes. Medications for common adult health problems,
such as diabetes, high blood pressure, anxiety, and depression may interact badly with
stimulants. In this case, a doctor can offer other medication options.

For general information about stimulants and other medications used for treating mental
disorders, see the NIMH Mental Health Medications webpage. The FDA website has the latest
information on medication approvals, warnings, and patient information guides.

Psychotherapy

Psychotherapy, including cognitive behavioral therapy, can help an adult with ADHD to become
more aware of the deficit in attention and concentration and can provide the skills for
improving organization and efficiency in daily tasks. It can also address feelings of low self-
esteem and help adults with ADHD gain confidence, as well as control impulsive and risky
behaviors. A professional counselor or therapist can also help an adult with ADHD learn how to
organize his or her life and break large tasks down into smaller, more manageable steps.

Where can I turn if I feel alone in my diagnosis of ADHD?

In addition to the benefits of psychotherapy, adults with ADHD can gain social support and
better coping skills by talking with family, friends, and colleagues about their diagnosis. If the
people in their lives are aware of their diagnosis, they will better understand their behavior.
Psychotherapy for families and couples can help any relationship problems and teach everyone
involved about ADHD. There are also support groups just for adults with ADHD.

Some adults also find it helpful to obtain support from a professional life coach or ADHD coach
who can help with a variety of skills to improve daily functioning.
Body dysmorphic disorder (BDD)

Body dysmorphic disorder (BDD), or body dysmorphia, is a mental health condition where a
person spends a lot of time worrying about flaws in their appearance. These flaws are often
unnoticeable to others.

People of any age can have BDD, but it's most common in teenagers and young adults. It affects
both men and women.

Having BDD does not mean you are vain or self-obsessed. It can be very upsetting and have a
big impact on your life.

Symptoms of body dysmorphic disorder (BDD)

You might have BDD if you:

 worry a lot about a specific area of your body (particularly your face)
 spend a lot of time comparing your looks with other people's
 look at yourself in mirrors a lot or avoid mirrors altogether
 go to a lot of effort to conceal flaws – for example, by spending a long time combing
your hair, applying make-up or choosing clothes
 pick at your skin to make it "smooth"
BDD can seriously affect your daily life, including your work, social life and relationships.

BDD can also lead to depression, self-harm and even thoughts of suicide.

Getting help for BDD

You should visit a GP if you think you might have BDD.

They'll probably ask a number of questions about your symptoms and how they affect your life.

They may also ask if you have had any thoughts about harming yourself.

A GP may refer you to a mental health specialist for further assessment and treatment, or you
may be treated through your GP.
It can be very difficult to seek help for BDD, but it's important to remember that you have
nothing to feel ashamed or embarrassed about.

Seeking help is important because your symptoms probably will not go away without treatment
and may get worse.

Treatments for body dysmorphic disorder (BDD)

The symptoms of BDD can get better with treatment.

If you have relatively mild symptoms of BDD, you should be referred for a type of talking
therapy called cognitive behavioural therapy (CBT), which you have either on your own or in a
group.

If you have moderate symptoms of BDD, you should be offered either CBT or a type of
antidepressant medication called a selective serotonin reuptake inhibitor (SSRI).

If you have more severe symptoms of BDD or other treatments do not work, you should be
offered CBT together with an SSRI.

Cognitive behavioural therapy (CBT)

CBT can help you manage your BDD symptoms by changing the way you think and behave.

It helps you learn what triggers your symptoms, and teaches you different ways of thinking
about and dealing with your habits.

You and your therapist will agree on goals for the therapy and work together to try to reach
them.

CBT for treating BDD will usually include a technique known as exposure and response
prevention (ERP).

This involves gradually facing situations that would normally make you think obsessively about
your appearance and feel anxious.

Your therapist will help you to find other ways of dealing with your feelings in these situations
so that, over time, you become able to deal with them without feeling self-conscious or afraid.
You may also be given some self-help information to read at home and your CBT might involve
group work, depending on your symptoms.

CBT for children and young people will usually also involve their family members or carers.

Selective serotonin reuptake inhibitors (SSRIs)

SSRIs are a type of antidepressant.

There are a number of different SSRIs, but the 1 most commonly used to treat BDD is
called fluoxetine.

It may take up to 12 weeks for SSRIs to have an effect on your BDD symptoms.

If they work for you, you'll probably be asked to keep taking them for several months to
improve your symptoms further and stop them coming back.

There are some common side effects of taking SSRIs, but these will often pass within a few
weeks.

Your doctor will keep a close eye on you over the first few weeks.

It's important to tell them if you're feeling particularly anxious or emotional, or are having
thoughts of harming yourself.

If you're no longer having any symptoms, you'll probably be taken off SSRIs.

This will be done by slowly reducing your dose over time to help make sure your symptoms do
not come back (relapse) and to avoid any side effects of coming off the drug (withdrawal
symptoms), such as anxiety.

Adults younger than 30 will need to be carefully monitored when taking SSRIs as they may have
a higher chance of developing suicidal thoughts or trying to hurt themselves in the early stages
of treatment.

Children and young people may be offered an SSRI if they're having severe symptoms of BDD.

Medicine should only be suggested after they have seen a psychiatrist and been offered
therapy.
Further treatment

If treatment with both CBT and an SSRI has not improved your BDD symptoms after 12 weeks,
you may be prescribed a different type of SSRI or another antidepressant called clomipramine.

If you do not see any improvements in your symptoms, you may be referred to a mental health
clinic or hospital that specialises in BDD, such as the National OCD/BDD Service in London.

These services will probably do a more in-depth assessment of your BDD.

They may offer you more CBT or a different kind of therapy, as well as a different kind of
antidepressant.

Causes of body dysmorphic disorder (BDD)

We do not know exactly what causes BDD, but it might be associated with:

 genetics – you may be more likely to develop BDD if you have a relative with BDD,
obsessive compulsive disorder (OCD) or depression
 a chemical imbalance in the brain
 a traumatic experience in the past – you may be more likely to develop BDD if you were
teased, bullied or abused when you were a child
Some people with BDD also have another mental health condition, such as OCD, generalised
anxiety disorder or an eating disorder.

Things you can do to help with body dysmorphic disorder (BDD)

Support groups for BDD

Some people may find it helpful to contact or join a support group for information, advice and
practical tips on coping with BDD.

You can ask your doctor if there are any groups in your area, and the BDD Foundation has
a directory of local and online BDD support groups.

Obsessive Compulsive and Related Disorders

What is it?

Obsessive-compulsive disorder or OCD is made up of two different parts:

 obsessions
 compulsions
Obsessions are unwanted thoughts, ideas or urges that are distressing. They may seem very
strange or have to do with things you wouldn't normally think about doing. You can't control
obsessions and they cause a lot of anxiety or 'bad feelings'.
Examples of common obsessions include: 
 concerns about cleanliness or infection (worries about dirt, germs or becoming ill)
 bad things happening (someone attacking you; causing a fire or flood)
 unwanted "bad" or "inappropriate" thoughts (unwanted thoughts about sex; fear of
killing oneself; sacrilegious thoughts)
 concerns about identity or morality (am I a good enough person; is what I'm doing
wrong?)
 feeling something is "just not right" (a need for things to be perfect, look a certain way
or be in a certain order)
Compulsions are things you keep doing to lessen feelings of distress or to prevent something
bad from happening. But, these behaviours or mental acts only work for a short time so you
need to keep repeating them and they start to interfere with daily life. For example, if a child or
youth has obsessions about getting very sick, they might stay away from sick people and ask
their parents again and again if they will be okay. Compulsions take up a lot of time and affect
the way you live. 
Examples of common compulsions include:
 staying away from things that are scary (knives, public toilets, things that trigger an
obsession)
 repeated behaviours (hand washing, arranging items, checking, erasing and rewriting)
 mental acts (telling yourself you'll be okay, counting, praying)
 causing others to act in certain ways (to keep telling you everything is okay, wash your
hands, stay out of your room)
Children and youth with OCD may have trouble controlling their emotions and become
extremely angry. They may not see that their obsessions or compulsions are unreasonable or
causing them problems.
How do I know?
Everyone has unwanted or unplanned thoughts at times. We may wander if the food has gone
bad or think "maybe I'll jump off this bridge". Lots of people also have particular ways in which
they like to do things or feel things need to be done (routines, superstitious habits). But people
with OCD often experience their obsessions and compulsions as very distressing. They struggle
to move on from their thoughts, behaviours, and experiences, and they have trouble enjoying
life as a result. 
For example, the disorder can take up a lot of their time and interfere with the way they
function:
 socially (avoid friends; quit sports; rejected by peers)
 at school or at work (stay home; struggle to concentrate; work takes much longer)
 with family (fighting; stress; the amount of time and money others spend trying to help)
 personally (feeling down and sick of being distressed; not able to enjoy hobbies)

What can go along with OCD?

People with OCD frequently also have other mental health challenges, like:
 an anxiety disorder
 a depressive disorder
 a tic disorder (more often in males with childhood onset OCD)
 attention-deficit/hyperactivity disorder (ADHD)
When OCD is untreated, it can cause many challenges. For example, children may stop
socializing with friends or become less engaged in school. Adults may have problems
with personal and work relationships. Some adults with untreated OCD have trouble managing
the demands of adult life on their own and rely more on family. 
What can be done?

There are two main treatments that can be helpful for individuals with OCD. These treatments
do not cure OCD, but they do help to manage and reduce the symptoms and to improve quality
of life. These treatments may also be used along with other therapies or medications in some
cases (another disorder, side effects, etc.). The most common and effective types of treatment
for obsessive compulsive disorder are:
1. Exposure and Response Prevention (ERP)
ERP is a type of Cognitive-behavioural Therapy (CBT). It helps those with OCD gradually face
their fear or distress while resisting their compulsions. ERP works very well for most people and
had long lasting benefits. That is why it is considered the first line treatment for OCD.
Treatment may be done on your own (self-help books), one to one with a therapist or in group
settings. It is usually helpful to involve family members in treatment.
2. Serotonin Reuptake Inhibitors (SRIs)
SRIs are a type of medication that helps to reduce the intensity of OCD symptoms. It is
recommended that SRIs be used along with ERP when an individual has severe symptoms.
 selective serotonin reuptake inhibitors (SSRIs)
 clomipramine
What are other disorders related to OCD?

The following disorders share certain characteristics or patterns with OCD. They are seen as
part of an obsessive-compulsive range or spectrum.
Body dysmorphic disorder: An over concern with a real or imagined defect or flaw in your
appearance and a constant focus on it or trying to fix it. The child or youth might constantly
compare their appearance to others or spend too much time looking in the mirror or grooming.
Others cannot see the defect or think it is a minor flaw.
Excoriation (skin-picking) disorder: Picking at skin that causes an injury or lesion in spite of
repeated attempts to decrease or stop.
Hording disorder: Serious problems with collecting or not getting rid of possessions regardless
of their real value. The individual is very upset with the idea of parting with possessions.
Trichotillomania (hair-pulling disorder): Pulling out hair causing hair loss in spite of repeated
attempts to decrease or stop. 
Where to from here?

Talk to your doctor and get help from a mental health professional by:
 Getting a mental health assessment and support through your local Child and Youth
Mental Health team (through a walk-in intake clinic in your community). 
 contacting a private psychologist or counsellor:
o visit the BC Psychological Association website or call 1-800-730-0522
o visit the BC Association of Clinical Counsellors website or call 1-800-909-6303
For more information about options for support and treatment in BC, visit the Find Help section
of our site.

Obsessive-compulsive and related disorders are a group of overlapping disorders that

generally involve intrusive, unpleasant thoughts and repetitive behaviors. Many of us
experience unwanted thoughts from time to time (e.g., craving double cheeseburgers when
dieting), and many of us engage in repetitive behaviors on occasion (e.g., pacing when
nervous). However, obsessive-compulsive and related disorders elevate the unwanted thoughts
and repetitive behaviors to a status so intense that these cognitions and activities disrupt daily
life. Included in this category are obsessive-compulsive disorder (OCD), body dysmorphic
disorder, and hoarding disorder.

Obsessive-Compulsive Disorders

People with obsessive-compulsive disorder (OCD) experience thoughts and urges that are

intrusive and unwanted (obsessions) and/or the need to engage in repetitive behaviors or
mental acts (compulsions). A person with this disorder might, for example, spend hours each
day washing his hands or constantly checking and rechecking to make sure that a stove, faucet,
or light has been turned off.
Obsessions are more than just unwanted thoughts that seem to randomly jump into our head
from time to time, such as recalling an insensitive remark a coworker made recently, and they
are more significant than day-to-day worries we might have, such as justifiable concerns about
being laid off from a job. Rather, obsessions are characterized as persistent, unintentional, and
unwanted thoughts and urges that are highly intrusive, unpleasant, and distressing (APA, 2013).
Common obsessions include concerns about germs and contamination, doubts (“Did I turn the
water off?”), order and symmetry (“I need all the spoons in the tray to be arranged a certain
way”), and urges that are aggressive or lustful. Usually, the person knows that such thoughts
and urges are irrational and thus tries to suppress or ignore them, but has an extremely difficult
time doing so. These obsessive symptoms sometimes overlap, such that someone might have
both contamination and aggressive obsessions (Abramowitz & Siqueland, 2013).
Compulsions are repetitive and ritualistic acts that are typically carried out primarily as a means
to minimize the distress that obsessions trigger or to reduce the likelihood of a feared event
(APA, 2013). Compulsions often include such behaviors as repeated and extensive hand
washing, cleaning, checking (e.g., that a door is locked), and ordering (e.g., lining up all the
pencils in a particular way), and they also include such mental acts as counting, praying, or
reciting something to oneself (Figure 1). Compulsions characteristic of OCD are not performed
out of pleasure, nor are they connected in a realistic way to the source of the distress or feared
event. Approximately 2.3% of the U.S. population will experience OCD in their lifetime (Ruscio,
Stein, Chiu, & Kessler, 2010) and, if left untreated, OCD tends to be a chronic condition creating
lifelong interpersonal and psychological problems (Norberg, Calamari, Cohen, & Riemann,
2008).

Body Dysmorphic Disorder

An individual with body dysmorphic disorder is preoccupied with a perceived flaw in her

physical appearance that is either nonexistent or barely noticeable to other people (APA, 2013).
These perceived physical defects cause the person to think she is unattractive, ugly, hideous, or
deformed. These preoccupations can focus on any bodily area, but they typically involve the
skin, face, or hair. The preoccupation with imagined physical flaws drives the person to engage
in repetitive and ritualistic behavioral and mental acts, such as constantly looking in the mirror,
trying to hide the offending body part, comparisons with others, and, in some extreme cases,
cosmetic surgery (Phillips, 2005). An estimated 2.4% of the adults in the United States meet the
criteria for body dysmorphic disorder, with slightly higher rates in women than in men (APA,
2013).

Hoarding Disorder

Although hoarding was traditionally considered to be a symptom of OCD, considerable evidence

suggests that hoarding represents an entirely different disorder (Mataix-Cols et al., 2010).
People with hoarding disorder cannot bear to part with personal possessions, regardless of
how valueless or useless these possessions are. As a result, these individuals accumulate
excessive amounts of usually worthless items that clutter their living areas (Figure 2). Often, the
quantity of cluttered items is so excessive that the person is unable use his kitchen, or sleep in
his bed. People who suffer from this disorder have great difficulty parting with items because
they believe the items might be of some later use, or because they form a sentimental
attachment to the items (APA, 2013). Importantly, a diagnosis of hoarding disorder is made only
if the hoarding is not caused by another medical condition and if the hoarding is not a symptom
of another disorder (e.g., schizophrenia) (APA, 2013).

Figure 2. Those who suffer from hoarding disorder have great difficulty in discarding
possessions, usually resulting in an accumulation of items that clutter living or work areas.
(credit: “puuikibeach”/Flickr)

Causes of OCD
The results of family and twin studies suggest that OCD has a moderate genetic component.
The disorder is five times more frequent in the first-degree relatives of people with OCD than in
people without the disorder (Nestadt et al., 2000). Additionally, the concordance rate of OCD
among identical twins is around 57%; however, the concordance rate for fraternal twins is 22%
(Bolton, Rijsdijk, O’Connor, Perrin, & Eley, 2007). Studies have implicated about two dozen
potential genes that may be involved in OCD; these genes regulate the function of three
neurotransmitters: serotonin, dopamine, and glutamate (Pauls, 2010). Many of these studies
included small sample sizes and have yet to be replicated. Thus, additional research needs to be
done in this area.

A brain region that is believed to play a critical role in OCD is the orbitofrontal cortex (Kopell &
Greenberg, 2008), an area of the frontal lobe involved in learning and decision-making
(Rushworth, Noonan, Boorman, Walton, & Behrens, 2011) (Figure 3). In people with OCD, the
orbitofrontal cortex becomes especially hyperactive when they are provoked with tasks in
which, for example, they are asked to look at a photo of a toilet or of pictures hanging
crookedly on a wall (Simon, Kaufmann, Müsch, Kischkel, & Kathmann, 2010). The orbitofrontal
cortex is part of a series of brain regions that, collectively, is called the OCD circuit; this circuit
consists of several interconnected regions that influence the perceived emotional value of
stimuli and the selection of both behavioral and cognitive responses (Graybiel & Rauch, 2000).
As with the orbitofrontal cortex, other regions of the OCD circuit show heightened activity
during symptom provocation (Rotge et al., 2008), which suggests that abnormalities in these
regions may produce the symptoms of OCD (Saxena, Bota, & Brody, 2001). Consistent with this
explanation, people with OCD show a substantially higher degree of connectivity of the
orbitofrontal cortex and other regions of the OCD circuit than do those without OCD (Beucke et
al., 2013).
Figure 3. Different regions of the brain may be associated with different psychological disorders.

The findings discussed above were based on imaging studies, and they highlight the potential
importance of brain dysfunction in OCD. However, one important limitation of these findings is
the inability to explain differences in obsessions and compulsions. Another limitation is that the
correlational relationship between neurological abnormalities and OCD symptoms cannot imply
causation (Abramowitz & Siqueland, 2013).

Autism Spectrum Disorder

What is autism spectrum disorder?

Autism spectrum disorder (ASD) is a developmental disorder that affects communication and
behavior. Although autism can be diagnosed at any age, it is described as a “developmental
disorder” because symptoms generally appear in the first two years of life.
 According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a guide
created by the American Psychiatric Association used to diagnose mental disorders, people with
ASD have:

 Difficulty with communication and interaction with other people

 Restricted interests and repetitive behaviors
 Symptoms that affect the person’s ability to function in school, work, and other areas of
life

Autism is known as a “spectrum” disorder because there is wide variation in the type and
severity of symptoms people experience.

ASD occurs in all ethnic, racial, and economic groups. Although ASD can be a lifelong disorder,
treatments and services can improve a person’s symptoms and ability to function. The
American Academy of Pediatrics recommends that all children be screened for autism. All
caregivers should talk to their child’s doctor about ASD screening or evaluation.

What are the signs and symptoms of ASD?

People with ASD have difficulty with social communication and interaction and have restricted
interests and repetitive behaviors. The list below gives some examples of the types of behaviors
that are common in people diagnosed with ASD. Not all people with ASD will have all behaviors,
but most will have several of the behaviors listed below.

Social communication/interaction behaviors may include:

 Making little or inconsistent eye contact

 Having a tendency not to look at or listen to people
 Rarely sharing enjoyment of objects or activities by pointing at or showing things to
others
 Failing to, or being slow to, respond to someone calling their name or to other verbal
attempts to gain attention
 Having difficulties with the back and forth of conversation
 Often talking at length about a favorite subject without noticing that others are not
interested or without giving others a chance to respond
 Having facial expressions, movements, and gestures that do not match what is being
said
 Having an unusual tone of voice that may sound sing-song or flat and robot-like
 Having trouble understanding another person’s point of view or being unable to predict
or understand other people’s actions

Restrictive/repetitive behaviors may include:

 Repeating certain behaviors or having unusual behaviors, such as repeating words or
phrases (a behavior called echolalia)
 Having a lasting intense interest in certain topics, such as numbers, details, or facts
 Having overly focused interests, such as with moving objects or with parts of objects
 Getting upset by slight changes in a routine
 Being more sensitive or less sensitive than other people to sensory input, such as light,
noise, clothing, or temperature

People with ASD may also experience sleep problems and irritability. Although people with ASD
experience many challenges, they may also have many strengths, including:

 Being able to learn things in detail and remember information for long periods of time
 Being strong visual and auditory learners
 Excelling in math, science, music, or art

What are the causes and risk factors for ASD?

Researchers don’t know the exact causes of ASD, but studies suggest that genes can act
together with influences from the environment to affect development in ways that lead to ASD.
Although scientists are still trying to understand why some people develop ASD and others
don’t, some factors that increase the risk of developing ASD include:

 Having a sibling with ASD

 Having older parents
 Having certain genetic conditions (For example, people with conditions such as Down
syndrome, fragile X syndrome, and Rett syndrome are more likely than others to have ASD.)
 Being born with a very low birth weight

Not everyone who has these risk factors develops ASD.

How is ASD diagnosed?

Doctors diagnose ASD by looking at a person’s behavior and development. ASD can usually be
reliably diagnosed by the age of two. It is important for those with concerns to seek out an
assessment as soon as possible so that a diagnosis can be made, and treatment can begin.

Diagnosis in Young Children

Diagnosis in young children is often a two-stage process.

Stage 1: General Developmental Screening During Well-Child Checkups

Every child should receive well-child checkups with a pediatrician or an early childhood health
care provider. The American Academy of Pediatrics recommends that all children be screened
 for developmental delays at their 9-, 18-, and 24- or 30-month well-child visits, and specifically
for autism at their 18- and 24-month well-child visits. Additional screenings might be needed if
a child is at high risk for ASD or developmental problems. Children at high risk include those
who have a family member with ASD, have some ASD behaviors, have older parents, have
certain genetic conditions, or who were born at a very low birth weight.

Parents’ experiences and concerns are very important in the screening process for young
children. Sometimes the doctor will ask parents questions about their child’s behaviors and
combine those answers with information from ASD screening tools and with his or her
observations of the child. To read more about ASD screening tools, visit the Centers for Disease
Control and Prevention’s (CDC) website at www.cdc.gov/ncbddd/autism/hcp-screening.html.

Children who show developmental differences during this screening process will be referred for
a second stage of evaluation.

Stage 2: Additional Evaluation

This second evaluation is with a team of doctors and other health professionals who are
experienced in diagnosing ASD.

This team may include:

 A developmental pediatrician—a doctor who has special training in child development

 A child psychologist and/or child psychiatrist—a doctor who has specialized training in
brain development and behavior
 A neuropsychologist—a doctor who focuses on evaluating, diagnosing, and treating
neurological, medical, and neurodevelopmental disorders
 A speech-language pathologist—a health professional who has special training in
communication difficulties

This second evaluation may assess:

 Cognitive level or thinking skills

 Language abilities
 Age-appropriate skills needed to complete daily activities independently, such as eating,
dressing, and toileting

Because ASD is a complex disorder that sometimes occurs along with other illnesses or learning
disorders, the comprehensive evaluation may include blood tests and a hearing test.

The outcome of this evaluation will result in a formal diagnosis and recommendations for
treatment.
 Diagnosis in Older Children and Adolescents

ASD symptoms in older children and adolescents who attend school are often first recognized
by parents and teachers and then evaluated by the school’s special education team. The
school’s team may perform an initial evaluation and then recommend these children visit their
primary health care doctor or a doctor who specializes in ASD for additional testing.

Parents may talk with these doctors about their child’s social difficulties, including problems
with subtle communication. These subtle communication issues may include problems
understanding tone of voice, facial expressions, or body language. Older children and
adolescents may have trouble understanding figures of speech, humor, or sarcasm. Parents
may also find that their child has trouble forming friendships with peers.

Diagnosis in Adults

Diagnosing ASD in adults is often more difficult than diagnosing ASD in children. In adults, some
ASD symptoms can overlap with symptoms of other mental health disorders, such as anxiety
disorder or attention-deficit/hyperactivity disorder (ADHD).

Adults who notice signs and symptoms of ASD should talk with a doctor and ask for a referral
for an ASD evaluation. Although testing for ASD in adults is still being refined, adults can be
referred to a neuropsychologist, psychologist, or psychiatrist who has experience with ASD. The
expert will ask about:

 Social interaction and communication challenges

 Sensory issues
 Repetitive behaviors
 Restricted interests

Information about the adult’s developmental history will help in making an accurate diagnosis,
so an ASD evaluation may include talking with parents or other family members.

Getting a correct diagnosis of ASD as an adult can help a person understand past challenges,
identify his or her strengths, and obtain the right kind of help. Studies are now under way to
determine the types of services and supports that are most helpful for improving the
functioning and community integration of transition-age youth and adults with ASD.

What are treatments for ASD?

Treatment for ASD should begin as soon as possible after diagnosis. Early treatment for ASD is
important because proper care can reduce individuals’ difficulties while helping them learn new
skills and make the most of their strengths.
 The wide range of issues facing people with ASD means that there is no single best treatment
for ASD. Working closely with a doctor or health care professional is an important part of
finding the right treatment program.

Medication

A doctor may use medication to treat some symptoms that are common with ASD. With
medication, a person with ASD may have fewer problems with:

 Irritability
 Aggression
 Repetitive behavior
 Hyperactivity
 Attention problems
 Anxiety and depression

Read more about the latest news and information on medication warnings, patient medication
guides, or newly approved medications at the Food and Drug Administration’s website
at www.fda.gov.

Behavioral, Psychological, and Educational Therapy

People with ASD may be referred to doctors who specialize in providing behavioral,
psychological, educational, or skill-building interventions. These programs are typically highly
structured and intensive and may involve parents, siblings, and other family members. These
programs may help people with ASD:

 Learn life skills necessary to live independently.

 Reduce challenging behaviors.
 Increase or build upon strengths.
 Learn social, communication, and language skills.

Other Resources

There are many social services programs and other resources that can help people with ASD.
Here are some tips for finding these additional services:

 Contact your doctor, local health department, school, or autism advocacy group to learn
about special programs or local resources.
 Find an autism support group. Sharing information and experiences can help individuals
with ASD and/or their caregivers learn about treatment options and ASD-related programs.
 Record conversations and meetings with health care providers and teachers. This
information helps when it’s time to make decisions about which programs might best meet an
individual’s needs.
 Keep copies of doctors’ reports and evaluations. This information may help an individual
qualify for special programs.

Where can I find resources about ASD?

For more information about ASD, visit:

 Eunice Kennedy Shriver National Institute of Child Health and Human Development

 National Institute of Neurological Disorders and Stroke
 National Institute on Deafness and Other Communication Disorders
 Centers for Disease Control and Prevention
 Interagency Autism Coordinating Committee

What are clinical trials?

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases
and conditions. The goal of clinical trials is to determine if a new test or treatment works and is
safe. Although individual participants may benefit from being part of a clinical trial, participants
should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge
so that others may be better helped in the future.

Researchers at NIMH and around the country conduct many studies with patients and healthy
volunteers. We have new and better treatment options today because of what clinical trials
uncovered years ago. Be part of tomorrow’s medical breakthroughs. Talk to your doctor about
clinical trials, their benefits and risks, and whether one is right for you.

Bipolar disorder is a mental illness that causes dramatic shifts in a person’s mood, energy and
ability to think clearly. People with bipolar experience high and low moods—known as mania
and depression—which differ from the typical ups-and-downs most people experience.

The average age-of-onset is about 25, but it can occur in the teens, or more uncommonly, in
childhood. The condition affects men and women equally, with about 2.8% of U.S.
adults experiencing bipolar disorder each year. Approximately 83% of cases of bipolar disorder
are classified as "severe".

If left untreated, bipolar disorder usually worsens. However, with a good treatment plan
including psychotherapy, medications, a healthy lifestyle, a regular schedule and early
identification of symptoms, many people live well with the condition.

Symptoms
Symptoms and their severity can vary. A person with bipolar disorder may have distinct manic
or depressed states but may also have extended periods—sometimes years—without
symptoms. A person can also experience both extremes simultaneously or in rapid sequence.

Severe bipolar episodes of mania or depression may include psychotic symptoms such as
hallucinations or delusions. Usually, these psychotic symptoms mirror a person’s extreme
mood. People with bipolar disorder who have psychotic symptoms can be wrongly diagnosed as
having schizophrenia.

Mania. To be diagnosed with bipolar disorder, a person must have experienced at least one
episode of mania or hypomania. Hypomania is a milder form of mania that doesn’t include
psychotic episodes. People with hypomania can often function well in social situations or at
work. Some people with bipolar disorder will have episodes of mania or hypomania many times
throughout their life; others may experience them only rarely.

Although someone with bipolar may find an elevated mood of mania appealing—especially if it
occurs after depression—the “high” does not stop at a comfortable or controllable level. Moods
can rapidly become more irritable, behavior more unpredictable and judgment more impaired.
During periods of mania, people frequently behave impulsively, make reckless decisions and
take unusual risks.

Most of the time, people in manic states are unaware of the negative consequences of their
actions. With bipolar disorder, suicide is an ever-present danger because some people become
suicidal even in manic states. Learning from prior episodes what kinds of behavior signals “red
flags” of manic behavior can help manage the symptoms of the illness.

Depression. The lows of bipolar depression are often so debilitating that people may be unable
to get out of bed. Typically, people experiencing a depressive episode have difficulty falling and
staying asleep, while others sleep far more than usual. When people are depressed, even minor
decisions such as what to eat for dinner can be overwhelming. They may become obsessed with
feelings of loss, personal failure, guilt or helplessness; this negative thinking can lead to
thoughts of suicide.

The depressive symptoms that obstruct a person’s ability to function must be present nearly
every day for a period of at least two weeks for a diagnosis. Depression associated with bipolar
disorder may be more difficult to treat and require a customized treatment plan.

Causes

Scientists have not yet discovered a single cause of bipolar disorder. Currently, they believe
several factors may contribute, including:
  Genetics. The chances of developing bipolar disorder are increased if a child’s parents or
siblings have the disorder. But the role of genetics is not absolute: A child from a family
with a history of bipolar disorder may never develop the disorder. Studies of identical
twins have found that, even if one twin develops the disorder, the other may not.
 Stress. A stressful event such as a death in the family, an illness, a difficult relationship,
divorce or financial problems can trigger a manic or depressive episode. Thus, a person’s
handling of stress may also play a role in the development of the illness.
 Brain structure and function. Brain scans cannot diagnose bipolar disorder, yet
researchers have identified subtle differences in the average size or activation of some
brain structures in people with bipolar disorder.

Diagnosis

To diagnose bipolar disorder, a doctor may perform a physical examination, conduct an

interview and order lab tests. While bipolar disorder cannot be seen on a blood test or body
scan, these tests can help rule out other illnesses that can resemble the disorder, such as
hyperthyroidism. If no other illnesses (or medicines such as steroids) are causing the symptoms,
the doctor may recommend mental health care.

To be diagnosed with bipolar disorder, a person must have experienced at least one episode of
mania or hypomania. Mental health care professionals use the Diagnostic and Statistical
Manual of Mental Disorders (DSM) to diagnose the “type” of bipolar disorder a person may be
experiencing. To determine what type of bipolar disorder a person has, mental health care
professionals assess the pattern of symptoms and how impaired the person is during their most
severe episodes.

Four Types Of Bipolar Disorder

1. Bipolar I Disorder is an illness in which people have experienced one or more episodes
of mania. Most people diagnosed with bipolar I will have episodes of both mania and
depression, though an episode of depression is not necessary for a diagnosis. To be
diagnosed with bipolar I, a person’s manic episodes must last at least seven days or be
so severe that hospitalization is required.

2. Bipolar II Disorder is a subset of bipolar disorder in which people experience depressive

episodes shifting back and forth with hypomanic episodes, but never a “full” manic
episode.
 3. Cyclothymic Disorder or Cyclothymia is a chronically unstable mood state in which
people experience hypomania and mild depression for at least two years. People with
cyclothymia may have brief periods of normal mood, but these periods last less than
eight weeks.

4. Bipolar Disorder, “other specified” and “unspecified” is when a person does not meet
the criteria for bipolar I, II or cyclothymia but has still experienced periods of clinically
significant abnormal mood elevation.

Treatment

Bipolar disorder is treated and managed in several ways:

 Psychotherapy, such as cognitive behavioral therapy and family-focused therapy.

 Medications, such as mood stabilizers, antipsychotic medications and, to a lesser extent,
antidepressants.
 Self-management strategies, like education and recognition of an episode’s early
symptoms.
 Complementary health approaches, such as aerobic exercise meditation, faith and
prayer can support, but not replace, treatment.

The largest research project to assess what treatment methods work for people with bipolar
disorder is the Systematic Treatment Enhancement for Bipolar Disorder, otherwise known as
Step-BD. Step-BD followed over 4,000 people diagnosed with bipolar disorder over time with
different treatments.

Related Conditions

People with bipolar disorder can also experience:

 Anxiety
 Attention-deficit hyperactivity disorder (ADHD)
 Posttraumatic stress disorder (PTSD)
 Substance use disorders/dual diagnosis

People with bipolar disorder and psychotic symptoms can be wrongly diagnosed
with schizophrenia. Bipolar disorder can be also misdiagnosed as Borderline Personality
Disorder (BPD).
These other illnesses and misdiagnoses can make it hard to treat bipolar disorder. For example,
the antidepressants used to treat OCD and the stimulants used to treat ADHD may worsen
symptoms of bipolar disorder and may even trigger a manic episode. If you have more than one
condition (called co-occurring disorders), be sure to get a treatment plan that works for you.

Overview

Bipolar disorder, formerly called manic depression, is a mental health condition that causes
extreme mood swings that include emotional highs (mania or hypomania) and lows
(depression).

When you become depressed, you may feel sad or hopeless and lose interest or pleasure in
most activities. When your mood shifts to mania or hypomania (less extreme than mania), you
may feel euphoric, full of energy or unusually irritable. These mood swings can affect sleep,
energy, activity, judgment, behavior and the ability to think clearly.

Episodes of mood swings may occur rarely or multiple times a year. While most people will
experience some emotional symptoms between episodes, some may not experience any.

Although bipolar disorder is a lifelong condition, you can manage your mood swings and other
symptoms by following a treatment plan. In most cases, bipolar disorder is treated with
medications and psychological counseling (psychotherapy).

Symptoms

There are several types of bipolar and related disorders. They may include mania or hypomania
and depression. Symptoms can cause unpredictable changes in mood and behavior, resulting in
significant distress and difficulty in life.

 Bipolar I disorder. You've had at least one manic episode that may be preceded or
followed by hypomanic or major depressive episodes. In some cases, mania may trigger a
break from reality (psychosis).

 Bipolar II disorder. You've had at least one major depressive episode and at least one
hypomanic episode, but you've never had a manic episode.
  Cyclothymic disorder. You've had at least two years — or one year in children and
teenagers — of many periods of hypomania symptoms and periods of depressive
symptoms (though less severe than major depression).

 Other types. These include, for example, bipolar and related disorders induced by
certain drugs or alcohol or due to a medical condition, such as Cushing's disease, multiple
sclerosis or stroke.

Bipolar II disorder is not a milder form of bipolar I disorder, but a separate diagnosis. While the
manic episodes of bipolar I disorder can be severe and dangerous, individuals with bipolar II
disorder can be depressed for longer periods, which can cause significant impairment.

Although bipolar disorder can occur at any age, typically it's diagnosed in the teenage years or
early 20s. Symptoms can vary from person to person, and symptoms may vary over time.

Mania and hypomania

Mania and hypomania are two distinct types of episodes, but they have the same symptoms.
Mania is more severe than hypomania and causes more noticeable problems at work, school
and social activities, as well as relationship difficulties. Mania may also trigger a break from
reality (psychosis) and require hospitalization.

Both a manic and a hypomanic episode include three or more of these symptoms:

 Abnormally upbeat, jumpy or wired

 Increased activity, energy or agitation

 Exaggerated sense of well-being and self-confidence (euphoria)

 Decreased need for sleep

 Unusual talkativeness

 Racing thoughts

 Distractibility

 Poor decision-making — for example, going on buying sprees, taking sexual risks or
making foolish investments
Major depressive episode

A major depressive episode includes symptoms that are severe enough to cause noticeable
difficulty in day-to-day activities, such as work, school, social activities or relationships. An
episode includes five or more of these symptoms:

 Depressed mood, such as feeling sad, empty, hopeless or tearful (in children and teens,
depressed mood can appear as irritability)

 Marked loss of interest or feeling no pleasure in all — or almost all — activities

 Significant weight loss when not dieting, weight gain, or decrease or increase in appetite
(in children, failure to gain weight as expected can be a sign of depression)

 Either insomnia or sleeping too much

 Either restlessness or slowed behavior

 Fatigue or loss of energy

 Feelings of worthlessness or excessive or inappropriate guilt

 Decreased ability to think or concentrate, or indecisiveness

 Thinking about, planning or attempting suicide

Other features of bipolar disorder

Signs and symptoms of bipolar I and bipolar II disorders may include other features, such as
anxious distress, melancholy, psychosis or others. The timing of symptoms may include
diagnostic labels such as mixed or rapid cycling. In addition, bipolar symptoms may occur during
pregnancy or change with the seasons.

Symptoms in children and teens

Symptoms of bipolar disorder can be difficult to identify in children and teens. It's often hard to
tell whether these are normal ups and downs, the results of stress or trauma, or signs of a
mental health problem other than bipolar disorder.
Children and teens may have distinct major depressive or manic or hypomanic episodes, but
the pattern can vary from that of adults with bipolar disorder. And moods can rapidly shift
during episodes. Some children may have periods without mood symptoms between episodes.

The most prominent signs of bipolar disorder in children and teenagers may include severe
mood swings that are different from their usual mood swings.

Cyclothymia

Cyclothymic Personality Symptoms, Causes, and Treatment

What is Cyclothymia?

Most people have heard of bipolar disorder (manic depressive disorder), where individuals
experience cycles of highs and lows (mania and depression). But, what is cyclothymia
(cyclothymic disorder)? Cyclothymia is a rare mood disorder which has similar characteristics of
bipolar disorder, just in a milder and more chronic form. If you are suffering from cyclothymia,
you experience cyclic highs and lows that are persistent for at least two years or more. With
cyclothymic disorder, your lows are a mild depression – not characteristic of full major
depression. Your highs are classified as symptomatic of hypomania – a less severe form of
mania. During your highs, your mood elevates for a time before returning to its baseline. During
your lows you feel mildly depressed. In between your elevated and depressed moods, you are
likely to feel like yourself.
Everyone has their ups and downs, right? What distinguishes cyclothymia from regular mood
swings? Cyclothymia can increase your chances of developing bipolar disorder (estimates vary
widely from a 15% to 50% increased risk of being diagnosed with bipolar disorder if suffering
from cyclothymia) and your highs and lows interfere with your daily life functions and
relationships – so it’s essential to seek treatment to get a handle on the disorder before it
becomes fully disruptive.

It is estimated that the rate of occurrence of cyclothymia in the general population is between
0.4% to 1%, with it equally affecting men and women. Women, however, are more likely to
seek treatment. While typical onset of the disorder occurs during adolescence, its onset is
consistently hard to identify. Risk of suffering from Attention-Deficient/Hyperactivity
Disorder, substance abuse, and sleep disorders are elevated among individuals suffering from
cyclothymic disorder.
What are the Symptoms?

The standard diagnostic criteria from the American Psychiatric Association states that to be

diagnosed with cyclothymia, you must meet all of the following:

 Multiple periods of hypomanic symptoms that do not meet criteria for a hypomanic

episode and multiple periods of depressive symptoms that do not meet criteria for a
major depressive episode for at least two years (one year for children and adolescents)

 Throughout the two year (one for children and adolescents) time frame, symptoms
of hypomania and depression have been present for at least half the time, with no more
than two consecutive months showing no symptoms

 Criteria for a major depressive episode, manic episode, or hypomanic episode have
never been met

 Other mental disorders (e.g., schizoaffective disorder, schizophrenia, delusional

disorder) have been ruled as the contributing factor to hypomanic and depressive
symptoms

 Hypomanic and depressive symptoms are not related to medications, substance

abuse, or other medical conditions

 Hypomanic and depressive symptoms cause significant disruption in

social, occupational, or other functional areas

If you or someone you know is suffering from cyclothymia, depressive signs and symptoms may
include the following:

 Feelings of sadness, emptiness, and hopelessness

 Irritability

 Feeling tearful

 Sleep disturbances – sleeping much more or much less than usual

 Restlessness

 Feelings of worthlessness and guilt

 Fatigue
 Concentration problems

 Suicidal thoughts

 Loss of interest in activities once considered pleasurable

 Weight changes – due to eating much more or much less than usual

 Lack of motivation

 Impaired judgment, planning, or problem-solving abilities

 Low self-esteem

 Pessimism

 Loneliness

 Submissiveness

 Social withdrawal

 Difficulty handling conflict

 Lacking meaning and purpose in life

If you or someone you know is suffering from cyclothymia, hypomanic signs and symptoms may
include the following:

 Euphoric state – exaggerated sense of well-being and happiness

 Inflated self-esteem

 Inflated optimism

 Irritability and agitation

 Decreased need for sleep

 Racing thoughts

 Poor judgment resulting in risky behaviors

 Talking more than usual

 Excessive physical activity

 Easily distracted

 Concentration problems

 Increased drive to perform or reach goals

 Hyperactivity – inability to sit still

 Emotional instability – overreacting to events

 Reckless thrill seeking (e.g., gambling, sports)

 Impulsivity

 Irresponsibility

What are the Causes and Risk Factors?

Like most mental health disorders, the exact cause of cyclothymia is unknown. However, the
genetic component of cyclothymia is strong. For cyclothymia, major depression, and bipolar
mood disorders, a family history indicates a greater risk of development. Twin studies suggest
that the risk of developing cyclothymia is 2-3 times more likely if an identical twin is diagnosed
with the disorder, pointing to the strong genetic component of the mood disorder.

Environmental factors are also a likely contributing factor to being diagnosed with cyclothymia.
As with bipolar disorder and major depression, certain life events may increase your chances of
developing cyclothymia. These include things like physical or sexual abuse or other traumatic
experiences and prolonged periods of stress.

Cyclothymia Tests and Diagnoses

If you think you might be suffering from cyclothymia, seek the help of your medical doctor or
mental health provider. Your doctor will likely perform a series of tests to make sure the causes
of your depressive and hypomanic symptoms are not due to an underlying medical condition or
medication you are taking.

Your mental health provider will perform a series of assessments to diagnose the occurrence of
cyclothymia, with the ultimate diagnosis being made on your mood history. During your
psychological evaluation, the doctor will ask about your family history of mood disorders and
might ask you to complete a daily diary of your moods to indicate mood swings that occur
during a typical day.

Treatment Options

Medications and psychotherapy are the common treatment options prescribed to patients
living with cyclothymia. Treatment is usually a chronic, lifelong process, with the aim to
decrease your depressive and hypomanic symptoms and to decrease your risk of developing
bipolar disorder.

Currently, there are no known medications that can effectively treat cyclothymia, though, your
doctor may prescribe commonly used medications known to treat bipolar disorder to ease your
symptoms and reduce their frequency. Commonly prescribed drug treatments include the use
of anticonvulsants and atypical antipsychotics – such as Lithium and Quetiapine.
Antidepressants have not been shown to be effective in the treatment of cyclothymia.

More research is needed to successfully conclude the benefits of psychotherapy, or talk

therapy, in the treatment of cyclothymia. However, some of the common methods used to
treat bipolar disorder are also used in the treatment of cyclothymia, including:

 Cognitive Behavioral Therapy (CBT) – a focus on changing negative thoughts and

beliefs into positive ones; stress management techniques; identification of trigger points

 Dialectical Behavioral Therapy (DBT) – teaches awareness, distress tolerance, and

emotional regulation

 Interpersonal and Social Rhythm Therapy (IPSRT) – a focus on the stabilization of

daily rhythms – especially related to sleep, wake, and mealtimes; routines being
indicative of helping stabilize moods

Living with Cyclothymia

Less than half of individuals living with cyclothymia develop bipolar disorder. In most,
cyclothymia is a chronic disorder that remains prevalent throughout the lifetime. In others,
cyclothymia seems to dissipate and resolve itself over time.

The effects of cyclothymia can be detrimental to social, family, work, and romantic
relationships. In addition, the impulsivity associated with hypomanic symptoms can lead to
poor life choices, legal issues, and financial difficulties. Research has also shown that if you are
suffering from cyclothymic disorder, you are more likely to abuse drugs and alcohol.

To decrease the negative effects of cyclothymia on your daily life, take your medications as
directed, do not use alcohol or take recreational drugs, track your moods to provide helpful
information to your mental health provider about the effectiveness of treatment, get plenty of
sleep, and exercise regularly.

BIPOLAR DISORDER
OTHER FORMS OF BIPOLAR DISORDER

Substance/Medication-Induced Bipolar and Related Disorder

This condition occurs when the mood disturbance symptoms occur during or soon after taking a substance
or stopping use of a substance that is capable of producing the bipolar symptoms. These symptoms can
include an elevated or irritable mood, or depressed mood that may or may not occur with a loss of interest
in or pleasure from activities.

The determination of the substance involved can be identified through blood or urine tests to confirm the
initial diagnosis.

If hypomania or mania symptoms are appearing after use of an antidepressant medication or symptoms
are ongoing, then that is an indicator of a true bipolar disorder being present.

Bipolar and Related Disorder Due to Another Medical Condition

This diagnosis is used when symptoms are produced by a medical condition (not another mental health
condition). There must be evidence from a health history, physical examination or lab tests that the
symptoms are directly related to another medical condition. The mood symptoms cannot be the result of
another mental health condition, only a medical one. They must also be causing a lot of stress or problems
with school, work, relationships with others, or daily activities

Other Specified Bipolar and Related Disorder

This category applies when symptoms cause significant distress or impairment, but do not meet the full
criteria for any of the other disorders in this category. This is used when the clinician specifies the reasons
that criteria are not meet (for example, not quite enough days or symptoms displayed to trigger the full
diagnosis). A few examples of specifiers could include:

Short-duration hypomanic episodes (2-3 days) and major depressive episodes

Hypomanic episodes with insufficient symptoms and major depressive episodes
Hypomanic episode without prior major depressive episode
Short-duration cyclothymia (less than 24-months)

Unspecified Bipolar and Related Disorder

This diagnosis is used to describe situations where the clinician chooses not to specify the reason that the
criteria for one of the other types are met or when there is not enough information available to make a
more specific diagnosis.

Depression

Overview

Depression (major depressive disorder or clinical depression) is a common but serious mood disorder. It
causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping,
eating, or working. To be diagnosed with depression, the symptoms must be present for at least two
weeks.

Some forms of depression are slightly different, or they may develop under unique circumstances, such as:

Persistent depressive disorder (also called dysthymia) is a depressed mood that lasts for at least
two years. A person diagnosed with persistent depressive disorder may have episodes of major depression
along with periods of less severe symptoms, but symptoms must last for two years to be considered
persistent depressive disorder.
Postpartum depression is much more serious than the “baby blues” (relatively mild depressive and
anxiety symptoms that typically clear within two weeks after delivery) that many women experience after
giving birth. Women with postpartum depression experience full-blown major depression during
pregnancy or after delivery (postpartum depression). The feelings of extreme sadness, anxiety, and
exhaustion that accompany postpartum depression may make it difficult for these new mothers to
complete daily care activities for themselves and/or for their babies.
Psychotic depression occurs when a person has severe depression plus some form of psychosis,
such as having disturbing false fixed beliefs (delusions) or hearing or seeing upsetting things that others
cannot hear or see (hallucinations). The psychotic symptoms typically have a depressive “theme,” such as
delusions of guilt, poverty, or illness.
Seasonal affective disorder is characterized by the onset of depression during the winter months,
when there is less natural sunlight. This depression generally lifts during spring and summer. Winter
depression, typically accompanied by social withdrawal, increased sleep, and weight gain, predictably
returns every year in seasonal affective disorder.
Bipolar disorder is different from depression, but it is included in this list is because someone with
bipolar disorder experiences episodes of extremely low moods that meet the criteria for major depression
(called “bipolar depression”). But a person with bipolar disorder also experiences extreme high – euphoric
or irritable – moods called “mania” or a less severe form called “hypomania.”

Examples of other types of depressive disorders newly added to the diagnostic classification of DSM-
5 include disruptive mood dysregulation disorder (diagnosed in children and adolescents) and
premenstrual dysphoric disorder (PMDD).

Signs and Symptoms

If you have been experiencing some of the following signs and symptoms most of the day, nearly every
day, for at least two weeks, you may be suffering from depression:

Persistent sad, anxious, or “empty” mood

Feelings of hopelessness, or pessimism
Irritability
Feelings of guilt, worthlessness, or helplessness
Loss of interest or pleasure in hobbies and activities
Decreased energy or fatigue
Moving or talking more slowly
Feeling restless or having trouble sitting still
Difficulty concentrating, remembering, or making decisions
Difficulty sleeping, early-morning awakening, or oversleeping
Appetite and/or weight changes
Thoughts of death or suicide, or suicide attempts
Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or
that do not ease even with treatment

Not everyone who is depressed experiences every symptom. Some people experience only a few
symptoms while others may experience many. Several persistent symptoms in addition to low mood are
required for a diagnosis of major depression, but people with only a few – but distressing – symptoms may
benefit from treatment of their “subsyndromal” depression. The severity and frequency of symptoms and
how long they last will vary depending on the individual and his or her particular illness. Symptoms may
also vary depending on the stage of the illness.

Risk Factors

Depression is one of the most common mental disorders in the U.S. Current research suggests that
depression is caused by a combination of genetic, biological, environmental, and psychological factors.

Depression can happen at any age, but often begins in adulthood. Depression is now recognized as
occurring in children and adolescents, although it sometimes presents with more prominent irritability
than low mood. Many chronic mood and anxiety disorders in adults begin as high levels of anxiety in
children.

Depression, especially in midlife or older adults, can co-occur with other serious medical illnesses, such as
diabetes, cancer, heart disease, and Parkinson’s disease. These conditions are often worse when
depression is present. Sometimes medications taken for these physical illnesses may cause side effects
that contribute to depression. A doctor experienced in treating these complicated illnesses can help work
out the best treatment strategy.

Risk factors include:

Personal or family history of depression

Major life changes, trauma, or stress
Certain physical illnesses and medications

Treatment and Therapies

Depression, even the most severe cases, can be treated. The earlier that treatment can begin, the more
effective it is. Depression is usually treated with medications, psychotherapy, or a combination of the two.
If these treatments do not reduce symptoms, electroconvulsive therapy (ECT) and other brain stimulation
therapies may be options to explore.

Quick Tip: No two people are affected the same way by depression and there is no "one-size-fits-all" for
treatment. It may take some trial and error to find the treatment that works best for you.

Medications

Antidepressants are medicines that treat depression. They may help improve the way your brain uses
certain chemicals that control mood or stress. You may need to try several different antidepressant
medicines before finding the one that improves your symptoms and has manageable side effects. A
medication that has helped you or a close family member in the past will often be considered.

Antidepressants take time – usually 2 to 4 weeks – to work, and often, symptoms such as sleep, appetite,
and concentration problems improve before mood lifts, so it is important to give medication a chance
before reaching a conclusion about its effectiveness. If you begin taking antidepressants, do not stop
taking them without the help of a doctor. Sometimes people taking antidepressants feel better and then
stop taking the medication on their own, and the depression returns. When you and your doctor have
decided it is time to stop the medication, usually after a course of 6 to 12 months, the doctor will help you
slowly and safely decrease your dose. Stopping them abruptly can cause withdrawal symptoms.

Please Note: In some cases, children, teenagers, and young adults under 25 may experience an increase in
suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting
or when the dose is changed. This warning from the U.S. Food and Drug Administration (FDA) also says
that patients of all ages taking antidepressants should be watched closely, especially during the first few
weeks of treatment.

If you are considering taking an antidepressant and you are pregnant, planning to become pregnant, or
breastfeeding, talk to your doctor about any increased health risks to you or your unborn or nursing child.

To find the latest information about antidepressants, talk to your doctor and visit www.fda.gov.

You may have heard about an herbal medicine called St. John's wort. Although it is a top-selling botanical
product, the FDA has not approved its use as an over-the-counter or prescription medicine for depression,
and there are serious concerns about its safety (it should never be combined with a prescription
antidepressant) and effectiveness. Do not use St. John’s wort before talking to your health care provider.
Other natural products sold as dietary supplements, including omega-3 fatty acids and S-
adenosylmethionine (SAMe), remain under study but have not yet been proven safe and effective for
routine use. For more information on herbal and other complementary approaches and current research,
please visit the National Center for Complementary and Integrative Health website.

Psychotherapies

Several types of psychotherapy (also called “talk therapy” or, in a less specific form, counseling) can help
people with depression. Examples of evidence-based approaches specific to the treatment of depression
include cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), and problem-solving therapy.
More information on psychotherapy is available on the NIMH Psychotherapies webpage.

Brain Stimulation Therapies

If medications do not reduce the symptoms of depression, electroconvulsive therapy (ECT) may be an
option to explore. Based on the latest research:

ECT can provide relief for people with severe depression who have not been able to feel better
with other treatments.
Electroconvulsive therapy can be an effective treatment for depression. In some severe cases
where a rapid response is necessary or medications cannot be used safely, ECT can even be a first-line
intervention.
Once strictly an inpatient procedure, today ECT is often performed on an outpatient basis. The
treatment consists of a series of sessions, typically three times a week, for two to four weeks.
ECT may cause some side effects, including confusion, disorientation, and memory loss. Usually
these side effects are short-term, but sometimes memory problems can linger, especially for the months
around the time of the treatment course. Advances in ECT devices and methods have made modern ECT
safe and effective for the vast majority of patients. Talk to your doctor and make sure you understand the
potential benefits and risks of the treatment before giving your informed consent to undergoing ECT.
ECT is not painful, and you cannot feel the electrical impulses. Before ECT begins, a patient is put
under brief anesthesia and given a muscle relaxant. Within one hour after the treatment session, which
takes only a few minutes, the patient is awake and alert.

Other more recently introduced types of brain stimulation therapies used to treat medicine-resistant
depression include repetitive transcranial magnetic stimulation (rTMS) and vagus nerve stimulation (VNS).
Other types of brain stimulation treatments are under study. You can learn more about these therapies on
the NIMH Brain Stimulation Therapies webpage.

If you think you may have depression, start by making an appointment to see your doctor or health care
provider. This could be your primary care practitioner or a health provider who specializes in diagnosing
and treating mental health conditions. Visit the NIMH Find Help for Mental Illnesses if you are unsure of
where to start.

Beyond Treatment: Things You Can Do

Here are other tips that may help you or a loved one during treatment for depression:

Try to be active and exercise.

Set realistic goals for yourself.
Try to spend time with other people and confide in a trusted friend or relative.
Try not to isolate yourself, and let others help you.
Expect your mood to improve gradually, not immediately.
Postpone important decisions, such as getting married or divorced, or changing jobs until you feel
better. Discuss decisions with others who know you well and have a more objective view of your situation.
Continue to educate yourself about depression.

What is pica?

Pica is a compulsive eating disorder in which people eat nonfood items. Dirt, clay, and flaking paint are the
most common items eaten. Less common items include glue, hair, cigarette ashes, and feces. The disorder

is more common in children, affecting 10% to 30% of young children ages 1 to 6. It can also occur in

children and adults with intellectual and developmental disabilities, such as autism. On rare occasions,

pregnant women crave strange, nonfood items. For these women, pica often involves eating dirt and may

be related to an iron and zinc deficiency.

Symptoms of pica
 Pica symptoms are related to the nonfood item he or she has eaten. They include:

 Stomach upset.

 Stomach pain.

 Blood in the stool (which may be a sign of an ulcer that developed from eating nonfood items).

 Bowel problems (such as constipation or diarrhea).

These symptoms are the result of the toxic, poisonous, and bacterial content of the nonfood items.

Repeatedly eating nonfood items over a period of time can cause:

 Lead poisoning (from eating paint chips that contain lead).

 An intestinal blockage or tear (from eating hard objects, such as rocks).

 Injuries to teeth.

 Infections (from organisms and parasites that get inside the body and cause disease).

How is pica diagnosed?

Many typical children chew on things such as their nails and ice, or mouth their toys and hair. These are

normal habits. But a person diagnosed with pica repeatedly eats nonfood items, even if they make him or

her sick. They should be seen by a doctor.

 Your doctor will look at your child’s physical symptoms. These could include stomach upset or

bowel problems.

 If your child is in a high-risk group for pica (they have intellectual or developmental disabilities),

your doctor may ask if you have seen your child eating nonfood items and for how long.

 If the behavior has occurred for a month or more, your doctor may diagnose it as pica.

 Your doctor may order tests, such as blood tests or X-rays. These can check for possible anemia,

look for toxins in the blood, and find blockages in the intestines.
 Your doctor may order a blood test to check your child’s iron and zinc levels. Not having enough of

these vitamins is considered a trigger for eating dirt and clay in some cases.

Pica treatment

Treatment for pica will address several areas. Your doctor will address your child’s illness from having

eaten nonfood items. For example, your doctor will treat your child’s constipation, diarrhea, ulcer,

intestinal tear, infection, or any combination of illnesses. If your doctor finds your child doesn’t have

enough iron or zinc, he or she will address that with a vitamin supplement and dietary recommendations.

Another focus of treatment will address the underlying cause of your child’s pica diagnosis. Your doctor

will discuss your child’s home environment, educate you as a parent, and refer your child to a behavioral

or mental health specialist.

Can pica be prevented or avoided?

Pica cannot be prevented. Proper nutrition may help some children keep from developing it. If you pay

close attention to eating habits and supervise children who tend to put things into their mouths, you may

be able to catch the disorder early, before complications can happen. If your child has been diagnosed

with pica, you can reduce his or her risk of eating nonfood items by keeping those items out of reach in

your home. Be sure to monitor your child’s outside play, as well.

Living with pica

Most children outgrow pica as they get older. It usually goes away in a few months. However, high-risk

populations, such as children and adults with intellectual or developmental disabilities, may need
continued monitoring of their behavior and environment.

Overview

Rumination syndrome is a condition in which people repeatedly and unintentionally spit up (regurgitate)
undigested or partially digested food from the stomach, rechew it, and then either reswallow it or spit it
out.

Because the food hasn't yet been digested, it reportedly tastes normal and isn't acidic, as vomit is.
Rumination typically happens at every meal, soon after eating.

It's not clear how many people have this disorder. Treatment may include behavioral therapy or
medications. Behavioral therapy that involves teaching people to breathe from the diaphragm is the usual
treatment of choice.

Symptoms

 Effortless regurgitation, typically within 10 minutes of eating

 Abdominal pain or pressure relieved by regurgitation

 A feeling of fullness

 Bad breath

 Nausea

 Unintentional weight loss

Rumination syndrome isn't usually associated with retching.

When to see a doctor

Consult a doctor if you or your child persistently regurgitates food.

Causes

The precise cause of rumination syndrome isn't clear. But it appears to be caused by an increase in
abdominal pressure.

Rumination syndrome is frequently confused with bulimia nervosa, gastroesophageal reflux disease
(GERD) and gastroparesis. Some people have rumination syndrome and linked to rectal evacuation
disorder, in which poor coordination of pelvic floor muscles leads to chronic constipation.

The condition has long been known to occur in infants and people with developmental disabilities. It's now
clear that the condition isn't related to age, as it can occur in children, teens and adults. Rumination
syndrome is more likely to occur in people with anxiety, depression or other psychiatric disorders.

Complications

Untreated, rumination syndrome can damage the tube between your mouth and stomach (esophagus).

Rumination syndrome can also cause:

 Unhealthy weight loss

 Malnutrition

 Dental erosion

 Bad breath

 Embarrassment

 Social isolation

What is ARFID?
Avoidant/restrictive food intake disorder (ARFID) is an eating or feeding disturbance that is characterized
by a persistent failure to meet appropriate nutritional and/or energy needs. This can lead to one or more
of the following issues:
 Significant weight loss (or failure to achieve expected weight gain or faltering growth in a child)
 Significant nutritional deficiency
 Dependence on oral nutritional supplements or enteral feeding (the delivery of a nutritionally
complete feed, containing protein, carbohydrate, fat, water, minerals and vitamins, directly into
the stomach, duodenum or jejunum)
  Marked interference with psychosocial functioning
ARFID is often associated with a psychiatric co-morbidity, especially anxiety and obsessive compulsive
disorder. The true prevalence of ARFID is unknown, due in large part to a lack of understanding of the
diagnosis. We do know that ARFID affects both genders and is more common in children and young
adolescents; however, it can occur in late adolescence and adulthood as well. 

It’s also important to understand what ARFID is not. ARFID is NOT:

 Associated with body image issues or any abnormalities related to how one perceives their body
weight or shape
 The result of a lack of available food
 A culturally sanctioned practice
 Explained by another medical or mental disorder (“If we treat that issue, then this eating problem
will go away”).
The health risks and developmental consequences for children and adolescents with ARFID can be serious
and long lasting. As a further complication, ARFID is difficult to accurately diagnose. Assessment by a
clinical professional trained in the disorder is essential.

ARFID vs. anorexia

ARFID is often confused with anorexia nervosa because weight loss and nutritional deficiency are common
shared symptoms between the two disorders. However, the primary difference between ARFID and
anorexia is that ARFID lacks the drive for thinness that is so common for individuals with anorexia. 
Overview

Anorexia (an-o-REK-see-uh) nervosa — often simply called anorexia — is an eating disorder characterized
by an abnormally low body weight, an intense fear of gaining weight and a distorted perception of weight.
People with anorexia place a high value on controlling their weight and shape, using extreme efforts that
tend to significantly interfere with their lives.

To prevent weight gain or to continue losing weight, people with anorexia usually severely restrict the
amount of food they eat. They may control calorie intake by vomiting after eating or by misusing laxatives,
diet aids, diuretics or enemas. They may also try to lose weight by exercising excessively. No matter how
much weight is lost, the person continues to fear weight gain.

Anorexia isn't really about food. It's an extremely unhealthy and sometimes life-threatening way to try to
cope with emotional problems. When you have anorexia, you often equate thinness with self-worth.

Anorexia, like other eating disorders, can take over your life and can be very difficult to overcome. But with
treatment, you can gain a better sense of who you are, return to healthier eating habits and reverse some
of anorexia's serious complications.

Symptoms

The physical signs and symptoms of anorexia nervosa are related to starvation. Anorexia also includes
emotional and behavioral issues involving an unrealistic perception of body weight and an extremely
strong fear of gaining weight or becoming fat.

It may be difficult to notice signs and symptoms because what is considered a low body weight is different
for each person, and some individuals may not appear extremely thin. Also, people with anorexia often
disguise their thinness, eating habits or physical problems.

Physical symptoms

Physical signs and symptoms of anorexia may include:

 Extreme weight loss or not making expected developmental weight gains

 Thin appearance

 Abnormal blood counts

 Fatigue

 Insomnia

 Dizziness or fainting

 Bluish discoloration of the fingers

 Hair that thins, breaks or falls out

 Soft, downy hair covering the body

 Absence of menstruation

 Constipation and abdominal pain

 Dry or yellowish skin

 Intolerance of cold
  Irregular heart rhythms

 Low blood pressure

 Dehydration

 Swelling of arms or legs

 Eroded teeth and calluses on the knuckles from induced vomiting

Some people who have anorexia binge and purge, similar to individuals who have bulimia. But people with
anorexia generally struggle with an abnormally low body weight, while individuals with bulimia typically
are normal to above normal weight.

Emotional and behavioral symptoms

Behavioral symptoms of anorexia may include attempts to lose weight by:

 Severely restricting food intake through dieting or fasting

 Exercising excessively

 Bingeing and self-induced vomiting to get rid of food, which may include the use of laxatives,
enemas, diet aids or herbal products

Emotional and behavioral signs and symptoms may include:

 Preoccupation with food, which sometimes includes cooking elaborate meals for others but not
eating them

 Frequently skipping meals or refusing to eat

 Denial of hunger or making excuses for not eating

 Eating only a few certain "safe" foods, usually those low in fat and calories

 Adopting rigid meal or eating rituals, such as spitting food out after chewing

 Not wanting to eat in public

 Lying about how much food has been eaten

 Fear of gaining weight that may include repeated weighing or measuring the body
  Frequent checking in the mirror for perceived flaws

 Complaining about being fat or having parts of the body that are fat

 Covering up in layers of clothing

 Flat mood (lack of emotion)

 Social withdrawal

 Irritability

 Insomnia

 Reduced interest in sex

Bulimia nervosa is a serious, potentially life-threatening eating disorder characterized by a cycle of
bingeing and compensatory behaviors such as self-induced vomiting designed to undo or compensate for
the effects of binge eating.

DIAGNOSTIC CRITERIA

According to the DSM-5, the official diagnostic criteria for bulimia nervosa are:

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the
following:
Eating, in a discrete period of time (e.g. within any 2-hour period), an amount of food that is
definitely larger than most people would eat during a similar period of time and under similar
circumstances.
A sense of lack of control over eating during the episode (e.g. a feeling that one cannot stop
eating or control what or how much one is eating).

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

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

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

The disturbance does not occur exclusively during episodes of anorexia nervosa.
WARNING SIGNS & SYMPTOMS OF BULIMIA NERVOSA

Emotional and behavioral 

 In general, behaviors and attitudes indicate that weight loss, dieting, and control of food are
becoming primary concerns 

Evidence of binge eating, including disappearance of large amounts of food in short periods of time
or lots of empty wrappers and containers indicating consumption of large amounts of food  

Evidence of purging behaviors, including frequent trips to the bathroom after meals, signs and/or
smells of vomiting, presence of wrappers or packages of laxatives or diuretics 

Appears uncomfortable eating around others 

Develops food rituals (e.g. eats only a particular food or food group [e.g. condiments], excessive
chewing, doesn’t allow foods to touch) 

Skips meals or takes small portions of food at regular meals 

Disappears after eating, often to the bathroom

Any new practice with food or fad diets, including cutting out entire food groups (no sugar, no
carbs, no dairy, vegetarianism/veganism)

Fear of eating in public or with others

Steals or hoards food in strange places  

Drinks excessive amounts of water or non-caloric beverages  

Uses excessive amounts of mouthwash, mints, and gum  

Hides body with baggy clothes  

Maintains excessive, rigid exercise regimen – despite weather, fatigue, illness, or injury—due to the
need to “burn off ” calories  

Shows unusual swelling of the cheeks or jaw area  

Has calluses on the back of the hands and knuckles from self- induced vomiting 

Teeth are discolored, stained  

Creates lifestyle schedules or rituals to make time for binge-and-purge sessions  

Withdraws from usual friends and activities 

Looks bloated from fluid retention  

Frequently diets  

Shows extreme concern with body weight and shape  

 Frequent checking in the mirror for perceived flaws in appearance

Has secret recurring episodes of binge eating (eating in a discrete period of time an amount of food
that is much larger than most individuals would eat under similar circumstances); feels lack of control over
ability to stop eating  

Purges after a binge (e.g. self-induced vomiting, abuse of laxatives, diet pills and/or diuretics,
excessive exercise, fasting)  

Extreme mood swings

Physical 

Noticeable fluctuations in weight, both up and down 

Body weight is typically within the normal weight range; may be overweight

Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.) 

Difficulties concentrating 

Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood
cell counts, slow heart rate) 

Dizziness 

Fainting/syncope 

Feeling cold all the time 

Sleep problems 

Cuts and calluses across the top of finger joints (a result of inducing vomiting)

Dental problems, such as enamel erosion, cavities, and tooth sensitivity 

Dry skin 

Dry and brittle nails 

Swelling around area of salivary glands 

Fine hair on body 

Thinning of hair on head, dry and brittle hair (lanugo) 

Cavities, or discoloration of teeth, from vomiting 

Muscle weakness 

Yellow skin (in context of eating large amounts of carrots) 

 Cold, mottled hands and feet or swelling of feet 

Menstrual irregularities — missing periods or only having a period while on hormonal

contraceptives (this is not considered a “true” period) 

Poor wound healing 

Impaired immune functioning

Many people with bulimia nervosa also struggle with co-occurring conditions, such as:

Self-injury (cutting and other forms of self-harm without suicidal intention)

Substance abuse

Impulsivity (risky sexual behaviors, shoplifting, etc.)

Diabulimia (intentional misuse of insulin for type 1 diabetes)
Learn more about co-occurring conditions >

HEALTH CONSEQUENCES OF BULIMIA NERVOSA

The recurrent binge-and-purge cycles of bulimia can affect the entire digestive system and can lead to
electrolyte and chemical imbalances in the body that affect the heart and other major organ functions.  

The body is generally resilient at coping with the stress of eating disordered behaviors, and laboratory
tests can generally appear perfect even as someone is at high risk of death. Electrolyte imbalances can kill
without warning; so can cardiac arrest. Therefore, it’s incredibly important to understand the many ways
that eating disorders affect the body.

Binge eating disorder (BED) is a severe, life-threatening, and treatable eating disorder characterized by
recurrent episodes of eating large quantities of food (often very quickly and to the point of discomfort); a
feeling of a loss of control during the binge; experiencing shame, distress or guilt afterwards; and not
regularly using unhealthy compensatory measures (e.g., purging) to counter the binge eating. It is the most
common eating disorder in the United States.

BED is one of the newest eating disorders formally recognized in the DSM-5. Before the most recent
revision in 2013, BED was listed as a subtype of EDNOS (now referred to as OSFED). The change is
important because some insurance companies will not cover eating disorder treatment without a DSM
diagnosis. 

DIAGNOSTIC CRITERIA

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the
following: 
 Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that
is definitely larger than what most people would eat in a similar period of time under similar
circumstances.
A sense of lack of control over eating during the episode (e.g., a feeling that one cannot
stop eating or control what or how much one is eating).

The binge eating episodes are associated with three (or more) of the following: 
Eating much more rapidly than normal.

Eating until feeling uncomfortably full.

Eating large amounts of food when not feeling physically hungry.

Eating alone because of feeling embarrassed by how much one is eating.

Feeling disgusted with oneself, depressed, or very guilty afterward.

Marked distress regarding binge eating is present.

The binge eating occurs, on average, at least once a week for 3 months.

The binge eating is not associated with the recurrent use of inappropriate compensatory behaviors
(e.g., purging) as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or
anorexia nervosa.
WARNING SIGNS & SYMPTOMS OF BINGE EATING DISORDER

Emotional and behavioral 

Evidence of binge eating, including disappearance of large amounts of food in short periods of time
or lots of empty wrappers and containers indicating consumption of large amounts of food.

Appears uncomfortable eating around others 

Any new practice with food or fad diets, including cutting out entire food groups (no sugar, no
carbs, no dairy, vegetarianism/veganism)

Fear of eating in public or with others

Steals or hoards food in strange places  

Creates lifestyle schedules or rituals to make time for binge sessions  

Withdraws from usual friends and activities 

Frequently diets  

Shows extreme concern with body weight and shape  

 Frequent checking in the mirror for perceived flaws in appearance

Has secret recurring episodes of binge eating (eating in a discrete period of time an amount of food
that is much larger than most individuals would eat under similar circumstances); feels lack of control over
ability to stop eating  

Disruption in normal eating behaviors, including eating throughout the day with no planned
mealtimes; skipping meals or taking small portions of food at regular meals; engaging in sporadic fasting or
repetitive dieting

Developing food rituals (e.g., eating only a particular food or food group [e.g., condiments],
excessive chewing, and not allowing foods to touch).

Eating alone out of embarrassment at the quantity of food being eaten

Feelings of disgust, depression, or guilt after overeating

Fluctuations in weight

Feelings of low self-esteem

Physical 

Noticeable fluctuations in weight, both up and down 

Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.) 

Difficulties concentrating
HEALTH CONSEQUENCES OF BINGE EATING DISORDER

The health risks of BED are most commonly those associated with clinical obesity, weight stigma, and
weight cycling (aka, yo-yo dieting). Most people who are labeled clinically obese do not have binge eating
disorder. However, of individuals with BED, up to two-thirds are labelled clinically obese; people who
struggle with binge eating disorder tend to be of normal or higher-than-average weight, though BED can
be diagnosed at any weight.

Other Specified Feeding or Eating Disorder (OSFED)

What is OSFED?

Anorexia, bulimia, and binge eating disorder are diagnosed according to a list of expected behavioural,
psychological, and physical symptoms. Sometimes a person’s symptoms don’t exactly fit the expected
symptoms for any of these three specific eating disorders. In that case, they might be diagnosed with an
“other specified feeding or eating disorder” (OSFED).

OSFED is every bit as serious as anorexia, bulimia, or binge eating disorder, and people suffering from
OSFED are every bit as deserving and in need of treatment – their eating disorder is just presenting in a
different way. It is common for symptoms to not fit with the exact diagnostic criteria for anorexia,
bulimia, or binge eating disorder – OSFED accounts for a large percentage of eating disorders.

Some specific examples of OSFED include:

 Atypical anorexia – where someone has all the symptoms a doctor looks for to diagnose
anorexia, except their weight remains within a “normal” range.
 Bulimia nervosa (of low frequency and/or limited duration) – where someone has all of the
symptoms of bulimia, except the binge/purge cycles don’t happen as often or over as long a period
of time as doctors would expect.
 Binge eating disorder (of low frequency and/or limited duration) – where someone has all of
the symptoms of binge eating disorder, except the binges don’t happen as often or over as long a
period of time as doctors would expect.
 Purging disorder – where someone purges, for example by being sick or using laxatives, to affect
their weight or shape, but this isn’t as part of binge/purge cycles.
 Night eating syndrome – where someone repeatedly eats at night, either after waking up from
sleep, or by eating a lot of food after their evening meal.

Like any other eating disorder, OSFED is a very serious mental illness that is not only about the way the
person treats food but about underlying thoughts and feelings. The eating disorder may be a way of
coping with these thoughts, or a way of feeling in control.

People with OSFED may work to hide their illness and someone may have been ill for a long time before
physical symptoms appear, if they do at all. Any of the symptoms associated with bulimia, anorexia,
or binge eating disorder can be part of OSFED, and these would come with the same short-term and
long-term risks that they present in the case of these specific eating disorders. As with other eating
disorders, it will probably be changes in the person’s behaviour and feelings that those around them
notice first, before any physical signs appear. 

.