Diagnosis spotlight: anorexia nervosa

   

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When most people hear the word “anorexia,” they think of really skinny people. There is, however, a lot more to this disorder than ones weight. Anorexia nervosa is a disorder of both the body and the mind. It can have adverse effects in many areas of one’s life and should always be taken seriously.

First of all, it’s important to acknowledge that anorexia can happen to anyone, regardless of gender, age or race. A college boy could develop anorexia in response to athletic pressures, or transitioning out of independent living could instigate it for a senior citizen. The stressors that can lead to eating disorders are in all our lives and while young females are more at risk, it is important to acknowledge that that isn’t the whole population.

A hallmark trait of anorexia is the restriction of food intake. Someone with anorexia might create unhealthy diet plans, not giving the body the calories and nutrients it needs. Certain foods are avoided completely, leading to a very restricted diet of what has been called “safe foods.” 

For anorexia to be diagnosed, as opposed to another eating disorder, this restriction should lead to a low body weight. The DSM-V diagnostic criteria used by mental health professionals defines this as “less than minimally normal” for adults and “less than that minimally expected” for children and adolescents. 

Another criteria for anorexia is an intense fear of gaining weight or interfering with weight gain despite being at a low weight. This is often related to the final criteria. One of the following needs to be present: disturbance in how you perceive your body (thinking you’re fat when you’re not, for instance), your self-esteem being excessively influenced by the way you see your body or a failure to acknowledge the seriousness of the low body weight. 

Furthermore, there are two types of anorexia: binge-eating/purging type and restricting type. The former involves episodes of binge eating and/or purging behavior. Purging refers to expelling food from your body, like self-induced vomiting or misuse of laxatives or diuretics. The restricting type does not binge and/or purge, but loses weight through dieting, fasting and/or excessive exercise.

Anorexia also often accompanies other psychiatric illnesses. Depression, bipolar disorder, obsessive-compulsive disorder, personality disorders and self-injury are some of the more common comorbid conditions. This can make the anorexia even worse, as there is more internal turmoil. Getting treatment for other mental health – and physical – disorders can help in the recovery from anorexia.

If you or someone you love is experiencing these symptoms, it’s imperative that you seek out help from a qualified professional. Anorexia nervosa is the most deadly mental health disorder. It will wreak havoc on your body until it literally eats itself. You cannot survive without nutrition. But it’s not just your body. Suicide causes one in five anorexia deaths. It is so important to get help.

Find someone who specializes in eating disorders. They have their own specific challenges and your best shot at recovery is with someone experienced. There might also be local support groups you could join in addition to therapy. If the anorexia is severe or treatment-resistant, consider finding a treatment center. If serious physical symptoms develop, call 911 or get to an emergency room. Look out for fainting, seizures, irregular pulse and other symptoms that could be considered serious. Recovery from anorexia is essential, so don’t hesitate to get whatever help you need.

To learn more about supporting loved ones with eating disorders, read this.

What has been your experience with anorexia? What helped you or a loved one get better? Share your thoughts in the comments.

5 ways to support a loved one in inpatient treatment

Sometimes, mental illness or substance abuse requires more intensive treatment than can be provided on an outpatient basis. Situations like being suicidal, the inability to get substance abuse under control, going through a medication change or an eating disorder becoming life-threatening call for inpatient treatment. The amount of time someone is gone varies, too – rehab can take months while most stays at the psychiatric ward of a local hospital are only a few days. The uncertainty of how long it will take can make the situation even more distressing.

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While this is a lot to deal with for the patient, it also leaves loved ones not knowing what they can do. Visiting hours are often very restricted and you might not even know if your loved one wants you to come. Besides, these programs are sometimes pretty involved, with individual counseling, doctor’s visits, group therapy, psychoeducational classes and more. You want to help; it’s just hard to know what to do.

In these times, grand actions are not very viable. It’s the simple shows of support that end up being meaningful. Following is a list of suggestions for showing that you care. Keep in mind, however, that the rules and policies of each treatment center varies. If you are uncertain of whether a specific item is permitted, call the unit your loved one is staying at and ask a staff member. 

1. Let him know you are there for him… 

An in-patient stay cuts someone away from the world, leaving most of society’s currently used methods of communication off limits. She likely won’t have access to her cell phone or the Internet. This brings up the question of the best way to show support. Even if your relationship is close, he might not be ready to accept you reaching out. A card or a letter is a non-threatening way to show support that allows her to decide if she wants to give you a call or invite you over to visit. Include your phone number, as he might not have it memorized.

2. …but respect her privacy. 

Because it is closed off, knowledge of what goes on within the program can seem mysterious to outsiders. Your curiosity might naturally be piqued, however. But unless you are the parent of a minor, you most likely don’t have a right to know what is going on. You have to trust that the treatment team has the situation under control and will make good decisions. If your loved one wants to talk about his treatment, he will. Be nonjudgmental and a good listener. Avoid giving advice at this time. Besides, after a long day of processing issues and psychoeducational material, hearing about the latest game or celebrity gossip might actually be relaxing. 

3. Pictures 

Due to risks of patients harming themselves or others, there are a lot of restricted items in the inpatient setting. Pieces of paper, however, are generally considered benign, so bring pictures. Don’t just stick with family portraits. Go to your loved one’s Facebook page and print out a few of her having fun with her friends or on a vacation. A picture of a beloved pet can also be appreciated. If your loved one has a strong attachment to a particular location, a photograph of a place that soothes her can also be calming. If permitted, bring Blu-Tack so he can hang them up. Frames will not be allowed, at least not with the glass in.

4. Entertainment 

Despite intensive treatment, there is downtime. If left with the facility’s resources, however, your loved one might spend a lot of time coloring pictures with crayons or playing checkers. While often highly regulated, entertainment is appreciated. Some books and magazines are restricted based on the content, but you probably won’t know until you get there, as it is very arbitrary. Less frequently, a center might allow an iPod or MP3 player. They may, however, require a small speaker, as headphones can be a safety risk. With this, it’s especially important to talk to the staff before you bring something over.

5. Something from home

It is normal to get homesick when in an inpatient setting, seeing as one is pulled away from all the comforts one is used to. Bringing something meaningful from home can ease some of that feeling. Take over a favorite stuffed animal, pillow or blanket. A small, unbreakable trinket with personal significance can be a lovely connection to home. Avoid brining valuable or irreplaceable items. Not all inpatient stays are planned, so a fresh change of clothes can be much appreciated. If you are allowed to bring food or treats, a comfort food can also mean a lot. A connection to life outside the treatment center can serve as a lifeline when treatment is at its toughest.

Have you spent time in an inpatient unit? What shows of support did you find helpful? Add to the list in the comments.

5 things suicidal people talk about

    

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Being suicidal can come with a wide range of symptoms and behaviors. It will manifest in as many different ways as there are people. But there are commonalities that tend to appear. One of those is what they talk about. If the following topics come up, you may want to pry further to check on the wellbeing of the person in question.

1. Wanting to die

The idea that suicidal people don’t talk about suicide is definitely a myth. They frequently give indications of their desire to die, sometimes even flat out saying that they want to commit suicide. Saying it does not mean that they won’t do it. Sometimes it’s more indirect, with statements like, “I wish I’d just get hit by a bus.” If someone says anything at all that indicates a desire to be dead, it should be pried
                                                                                                                    into.

2. Feeling stuck, hopeless and having no reason to live

Suicide sometimes happens because there seem to be no other options. Talking about hopelessness or entrapment can therefore be a warning that the person is headed in that direction. There are always options. We may not like them, but they are there. When suicidal, though, those options can seem to disappear. This topic is an indicator that should be taken seriously.

3. Being a burden

Being suicidal can make one feel like a waste of space. Suicidal individuals might feel like they are simply a problem in the lives of others. They might think that others would be better off without them. This can be especially true when illness is present that requires assistance. If the person can’t contribute in the same way others are contributing, it can set off thoughts about the lives of loved ones being better without him or her.

4. Suddenly making big improvements

Sometimes, suicide is preceded by a significant increase in mood. The person might be a lot happier and more positive. This can come from feeling at peace with the decision to actually end ones life. Talking about how something “won’t be a problem any longer” or “doesn’t matter anymore” can stem from the decision to not be around at all. The more rapid and extreme the change is, the more you should ask questions to see what’s really going on.

5. Saying goodbye

It is normal to want a sense of closure. That’s why suicidal people sometimes go around and say goodbye to or make amends with others. It might be in an indirect way, such as, “I value our friendship and would miss it if we were away from each other,” or, “If anything happens to me, I want you to know…” The hypotheticals might not be so hypothetical after all, so it’s important to look out for these statements.

In combination with other warning signs, especially, it is important to take action. Always make sure that the person you care about has resources. There are suicide hotlines, doctors, therapists and community mental health organizations. If you aren’t sure of what to do, you can reach out to these resources as well and ask for appropriate advice. If you believe suicide is imminent or there is an actual attempt, call 911 or take the person to the emergency room. It may cause some upset in the short term, but having an angry loved one is better than having a dead one.

Have you talked to someone and worried about suicidality? How did you know that you needed to reach out?

Substance abuse and mental health

Mental illness has a potentially devastating companion. Substance abuse and dependence are common in people who are struggling with their mental health. According to the National Alliance on Mental Illness, 29 percent of those who are diagnosed as mentally ill abuse either alcohol or drugs. That's almost one-third. Looking at it the other way around, over one-third of all alcohol abusers and more than one-half of all drug abusers struggle with mental illness.

  

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This creates an entire population of mental health patients with very distinctive needs. Treating a mental illness becomes much more difficult when substance abuse and dependence are involved. If you have a predisposition towards a certain illness, but it has yet to manifest, substances can trigger it. When you are already struggling, substances can make your symptoms worse. On the other hand, mental illness can make you want to self-medicate and thus can cause a substance abuse problem. The two feed into each other.

When you are abusing or dependent on a substance, you cannot engage in treatment for your mental illness in the same way you can when sober. Your mind will simply not work the way it needs to in order for you to heal from your mental health issues. In addition, sometimes these substances can interfere some with medications. This is why it is so important
                                                                                                                  to get help for substance abuse problems. 

There are, of course, rehab and treatment centers specifically for detoxing. For some people, this is the best route to go. But it's worth knowing that there are also treatment facilities that cater specifically to people with the dual diagnosis of mental illness and substance abuse. There are entire programs that are designed to help with the specific needs of this population. When evaluating facilities, ask about these types of programs. Some of them will be listed as psychiatric hospitals, so don't rule those out when you are searching for a treatment center.

More in-depth information on substance abuse and mental illness can be found at the Substance Abuse and Mental Health Services Administration's website. You can also call them at 1-800-662-4357. The primary purposes of this helpline is to refer people to treatment options in their area. The National Institute on Drug Abuse offers a helpful guide for evaluating treatment centers on this page.

Have you or someone you love experienced problems with both mental illness and substance abuse? Share your stories and insights in the comments.

Women's mental health concerns

Happy International Women’s Day! In honor of this worldwide celebration of women, let’s take a look at mental health issues that are of special concern to females.

Mood disorders

According to Columbia University Medical Center, women are twice as likely as men to have a mood disorder. In addition, the WHO reports that depressive disorders account for 42% of neuropsychiatric disability among women, compared to 29% of men. Mood disorders can cause serious impairment in all areas of functioning. Report any serious or unusual changes in mood to your doctor so you can be screened for mood disorders.

Female biology

Women have a host of medical concerns that don’t affect men. The menstrual cycle – both monthly and across the lifetime – can cause significant symptoms. Premenstrual dysphoric disorder became an official diagnosis is the latest psychiatric manual and menopause can trigger new mental health issues in previously healthy women. Fertility (or lack thereof) also has huge implications for mental health and there are mental health services that exist specifically to deal with these concerns.

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Postpartum conditions

The physical changes associated with pregnancy and childbirth have psychological implications as well. The most common way this is seen is with postpartum depression. For up to a year following child birth, the mother can enter a depressive state much like what is seen in major depressive disorder. This might include a focus on the child, such as obsessing over her newborn’s health or even thoughts of hurting the baby. Less common is postpartum psychosis, wherein women experience delusions and hallucinations that affect their behavior. This may require hospitalization. A final condition associated with child birth is birth-related post traumatic stress disorder. This comes from a dangerous birth experience that threatened death or serious harm for mother and/or child. For more about PTSD symptoms, read this.

Violence against women

Women are more susceptible to physical and sexual violence than men. The WHO estimates that violence against women has a lifetime prevalence rate ranging from 16-50%. They have also found that at least one in five women experience rape or attempted rape in her lifetime. Other estimates are higher. Women generally have a physical disadvantage compared to men and can also be bound by the gender roles of their societies. This leads women to be more vulnerable to dating violence, sexual assault and domestic violence. 

The unique mental health concerns facing women mean that we should pay careful attention to these areas of life. All of these issues can be addressed with appropriate intervention, but it requires getting help. Talk to your doctor or mental health professional if you believe you are struggling with any of these concerns. In the U.S., you can also call any of the following hotlines:

Depression and Bipolar Support Alliance: 1-800-826-3632

Postpartum Support International: 1-800-994-4773

National Center for Posttraumatic Stress Disorder: 1-802-296-6300

National Domestic Violence Hotline: 1-800-799-7233

National Sexual Assault Hotline: 1-800-656-4673

National Suicide Prevention Hotline: 1-800-273-8255

Concerns entering therapy, part 1 of 2

It’s normal to feel some anxiety about starting therapy. Whether you starting the process for the first time or switching clinicians, a lot of concerns can come up. You should not let this get in the way of seeking treatment, but you should not ignore it, either. It’s perfectly okay and valid to be apprehensive. Let’s take a look at some of the questions that might come up.

Will you believe me?

The people in our lives, as well-intentioned as they may be, don’t always respond positively and supportively to everything we tell them. That’s where therapy comes in. We go to talk about things we might not otherwise discuss. It’s a safe environment where you should not be afraid to bring up anything.

But doing your homework is certainly warranted. Look for someone who has experience with your particular concerns. If the therapist specializes in your area, you’re probably not going to tell him something he hasn’t already heard. Even if you do, he will have the background to understand what you are communicating. For instance, if you are having hallucinations, you might want to see someone who works with schizophrenia and psychosis.

This question is of particular concern to trauma survivors. Trauma touches on some of the most horrific and extreme aspects of human existence. Sadly, there are no limits to what is possible and, by extension, to what you might ask your therapist to believe. Know that sometimes, the trauma was planned out to deliberately be “unbelievable.” Some abusers set up situations that seem impossible in order to discredit victims should they say something in the future. So don’t be afraid to talk to someone just because your story is “out there.”

For more information about choosing the right therapist, visit here and here.

Will I be diagnosed as "crazy"?

"Crazy" is a societal concept, not a diagnosis. Everyone has a slightly different definition and there is no standard for craziness. Your therapist will not, however, call you crazy. Yes, you might be diagnosed with something. That's okay. With about one in four American adults struggling with a mental illness in any given year, you're not alone.

Some people are actually relieved that there is a name for what they are going through. It gives them something they can look to in order to better understand themselves and what they are going through. If you don't want to know what your diagnosis is, though, just say so to your therapist. Explain that you'd rather not be told what you have and that wish should be respected. As long as the therapist knows what is going on, she should be able to treat you just as effectively whether or not you know your diagnosis.

Will I be hospitalized?

There are very few circumstances in which you would be hospitalized. The standard is that you must be a danger to yourself or others. Examples include being suicidal, psychotic or delirious. But don't think that the thought of killing yourself or the presence of some hallucinations automatically get you committed. Hospitalization is taken very seriously and is a last resort. Other options, like staying with a family member or friend, are usually considered first.


I will post again on Sunday going over a few more concerns you might have. If there is anything you would like me to cover, please leave a comment.

Part 2

Can you keep a secret?

One of the reasons that people seek out professional counseling instead of just talking to people already in their lives is that the conversations are confidential. While some people find talking to strangers uncomfortable, others find it liberating to be able to disclose details of their lives without the knowledge and involvement of other parties.

While an ethical mental health professional can be trusted with sensitive information, it's important to know the limits. The nature of their work means that they will encounter sensitive information that occasionally must be acted upon. Each therapist should provide information on when confidentiality must be broken before treatment begins. If this is not done (or if it's been a while and you've forgotten), ask your therapist to give you a copy of her policies. 

In general, the exceptions apply in these four situations:

1. Danger to self or others

If you threaten to hurt yourself or another person, your therapist will have to evaluate what actions are appropriate to keep all parties safe. Factors such as the the presence of an exact plan, directness of the threat, severity and the ability to follow through with it are all taken into consideration.

Don't hold me to these, as this is not an exact science, but here are some examples:

Should not report: 

"I'm so mad at my husband that I wish he'd get hit by a bus." 

"I wish I had a gun so I could shoot myself."

"If I catch my wife cheating again, I'll kill them both." (Contingent on followup questions suggesting it's a sentiment, not a plan.)

Should report:

"I bought a bunch of pills and alcohol so that when I go to bed tonight, I'll never wake up."

"I carry a knife so that when I see him, I can stab him repeatedly."

"After this, I'm gonna head over to my uncle's house and take care of him for good."

A threat of harm to self can be responded to as needed in the situation, ranging from calling a friend to come over for the night to forced hospitalization. As far as threats to others, law enforcement will usually be contacted, although the potential victim(s) may as well. Past crimes aren't held to the same standard as imminent threats, with a couple of exceptions.

2. Child or elder abuse

Because children and elders are considered vulnerable populations, reporting abuse and neglect of these groups is an obligation by law. Some states require everyone to be mandated reporters while others limit the duty to both therapists and some other groups, which may include teachers, health care professionals and law enforcement. 

The appropriate course of action is that when there is a reasonable suspicion of abuse, a report is made. The reporter gives relevant information to another agency, which then decides what the appropriate course of action is. Information leading to a report does not necessarily have to come from the victim or even be a verbal confession. A child with cuts and bruises of different ages with no compelling explanation, a mother who mentions her boyfriend's mistreatment of her son and a teenager mentioning that her underaged friend is a victim of incest are all cases that will most likely be reported. An adult discussing abuse from his childhood, however, will probably not require further action unless, for instance, he has a younger brother who is in the same environment and is likely to be abused as well. A therapist is also not forced to report situations between adults, such as domestic violence in the home of a childless couple. 

The same standards will often transfer to elders and possibly disabled individuals. 

If you have questions about reporting abuse, receiving support or available services, call 1-800-4-A-CHILD (1-800-422-4453). This will not create an official report, but the people on the line can help you find out the next steps. If you are unsure about a situation, please call. It's not a commitment and it's okay to just ask a question.

3. Court order

Occasionally, mental health professionals are asked by the courts to provide information about their clients. This does not mean that any time someone is arrested, the therapist is called to confirm the offense. The principle of confidentiality is so important to therapy that mental health professionals will only reveal the least amount of information required of them and only when presented with official orders. There are also limitations on what can be asked of them, as it has to be relevant. In a murder trial, your therapist can be asked to confirm that you confessed to being at the crime scene, but probably won't answer about whether or not you're having an affair (unless it's directly related to the case). 

This exception rarely comes into play, but it has to be mentioned. The point of therapy is to help you get better, so that should take precedence over the possibility that some day five years from now your therapist will be called upon to answer if you smoked some weed. (She won't.)

4. Medical records

A limited amount of information is given to your insurance company in order to qualify you for treatment. This usually is a diagnostic code showing what you are receiving treatment for. It's not comprehensive and it doesn't involve details; it's just a way of indicating what you are receiving treatment for so that they can cover you. This is a current issue, though, and if this is a concern, learn more about what is required in your area and by your insurance company.

Outside of this, your information may be disclosed to other health care providers with your permission. This will require you signing forms and you get to specify what, exactly can and can't be released and for how long. This applies to the medical field in general, so if you want your wife to be able to get your test results for you when you aren't at home next week, ask for the paperwork!

The topic of mandatory reporting is not without controversy, but these are general descriptions of the current standards. Please don't be afraid of opening up because the information may get out. Breaking confidentiality unless it's absolutely necessary would ruin the whole point of the entire field, so it's an ethical (and legal) obligation that is taken very seriously. 

If confidentiality is a concern, talk to your mental health professional. He'll be able to give you more information on local laws and his own stance on these issues.