It is generally agreed that the treatment of multiple personality disorder (MPD) can be a demanding and arduous experience for patient and psychiatrist alike. Difficulties and crisis are intrinsic to the condition, and occur despite therapists' experience and skill. Seasoned clinicians may react with greater composure, and exploit the therapeutic potential of these events more effectively, but are unable to prevent them (C. Wilbur, personal communication, August 1983). In order to appreciate why these patients often prove so difficult, it is helpful to explore certain aspects of the condition's etiology and the patients' was of functioning.

Etiology

The etiology of MPD is unknown, but a wealth of case reports, shared experience, and data from large series^1-3 suggests that MPD is a dissociative response to the traumatic overwhelming of a child's non-dissociative defenses.⁴ The stressor cited most commonly is child abuse. The Four Factor Theory, derived from the retrospective review of 73 cases, and confirmed prospectively in over 100 cases, indicates that MPD develops in an individual who has the capacity to dissociate (Factor 1).⁴ This appears to tap the biological substrate of hypnotizability, without implying its compliance dimensions. Such a person's adaptive capacities are overwhelmed by some traumatic events or circumstances (Factor 2), leading to the enlistment of Factor 1 into the mechanisms of defense. Personality formation develops from natural psychological substrates which are available as building blocks (Factor 3). Some of these are imaginary companionships, ego-states,⁵ hidden observer structures, ⁶ state-dependent phenomena, the vicissitudes of libidinal phases, difficulties in the intrapsychic management of introjection/identification/internalization processes, miscarried of introjection/identification/internalization processes, miscarried mechanisms of defense, aspects of the separation-individuation continuum (especially rapprochement issues), and problems in the achievement of cohesive self and object representation. What leads to the fixation of dividedness is (Factor 4) a failure on the part of significant others to protect the child against further overwhelming, and/or to provide positive and nurturing interactions to allow traumata to be "metabolized" and early or incipient dividedness to be abandoned.

The implications for treatment can only receive brief comment. The clinician is facing a dissociative or hynotic⁷ pathology, and may encounter amnesia, distortions of perception and memory, positive and negative hallucinations, regressions, and revivifications. His patient has been traumatized, and needs to work through extremely painful events. Treatment is exquisitely uncomfortable: it is, in itself, a trauma. Hence resistance is high, the evocation of dissociative defenses within sessions is common, and recovery of memories may be heralded by actions which recapitulate often are dominated by the images of those who have been abusive.

Because of the diversity of Factor 3 substrates, no two MPD patients are structurally the same. MPD is the final common pathway of many different combinations of components and dynamics. Generalizations from accurate observations of some cases may prove inapplicable to others. It is difficult to feel "conceptually comfortable" with these patients. Also, since these patients have not been adequately protected or soothed (Factor 4), their treatment requires a consistent availability, a willingness to hear out all personalities with respect and without taking sides, and a high degree of tolerance so that the patient can be treated without being excessively retraumatized, despite the considerable (and sometimes inordinate and exasperating) demands their treatment makes on the therapist, who will be tested incessantly.

Switching and battles for dominance can create an apparently unending series of crises.

The Instability Of The MPD Patient

An individual suffering MPD has certain inherent vulnerabilities. The very presence of alters precludes the possibility of an ongoing unified and available observing ego and disrupts autonomous ego activities such as memory and skills. Therapeutic activity with one personality may not impact on others. The patient may be unable to address pressing concerns when some personalities maintain they are not involved, others have knowledge which would be helpful but are inaccessible, and still others regard the misfortunes of the other alters to be to their advantage.

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A therapeutic split between the observing and experiencing ego, so crucial to insight therapy, may not be possible. Cut off from full memory and pensive self-observation, alters remain prone to react in their specialized patterns. Since action is often followed by switching, they find it difficult to learn from experience. Change via insight may be a late development, following a substantial erosion of dissociative defenses.

The activities of the personalities may compromise the patients' access to support systems. Their inconsistent and disruptive behaviors, their memory problems and switching, can make them appear to be unreliable, or even liars. Concerned others may withdraw. Also, traumatizing families who learn that the patient is revealing long-hidden secrets may openly reject the patient during therapy.

Switching and battles for dominance can create an apparently unending series of crises. Patients resume awareness in strange places and circumstances for which they cannot account. Alters may try to punish or coerce one another, especially during treatment. For example, one commonly finds personalities which identified with the aggressor-traumatizer and try to punish or suppress personalities which reveal information or cooperate with therapy. Conflicts among alters can lead to a wide variety of quasi-psychotic symptomatology. Ellenberger⁸ observed that cases of MPD dominated by battles between alters were analogous to what was called "lucid possession." Unfortunately, emphasis on the phenomena of amnesia in MPD has led to underrecognition of this type of manifestation. The author has described the prevalence of special hallucinations, passive influence phenomena, and "made" feelings, thoughts, and actions in MPD. ⁹ As amnestic barriers are broached, such episodes may increase, so that positive progress in therapy may be accompanied by symptomatic worsening and severe dysphoria.

An analogous situation prevails when memories come forward as distressing hallucinations, nightmares, or actions. It is difficult to conserve of a more demanding and painful treatment. Long-standing repressions must be undone, the highly efficient defenses of dissociation and switching must be abandoned, and less pathological mechanisms developed. Also, the alters, in order to allow fusion/integration to occur, must give up their narcissistic investments in their identities, concede their convictions of separateness, and abandon aspirations for dominance and total control. They must also empathize, compromise, identify, and ultimately coalesce with personalities they had long avoided, opposed, and reflected.

Adding to the above is the pressure of severe moral masochistic and self-destructive trends. Some crises are provoked; others, once underway, are allowed to persist for self-punitive reasons.

The Therapist's Reactions

Certain therapist reactions are nearly universal. ¹⁰ Initial excitement, fascination, overinvestment, and interest in documenting differences among alters yield to feelings of bewilderment, exasperation, and a sense of being drained by the patient. Also normative is concern over colleagues' skepticism and criticism. Some individuals find themselves unable to move beyond these reactions. Most psychiatrists who consulted the author felt overwhelmed by their first MPD cases. ¹⁰ They had not appreciated the variety of clinical skills which would be required, and had not anticipated the vicissitudes of the treatment. Most had little prior familiarity with MPD, dissociation, or hypnosis, and had to acquire new knowledge and skills.

Many psychiatrists found these patients extraordinarily demanding. They consumed substantial amounts of their professional time, intruded into their personal and family lives, and led to difficulties with colleagues. Indeed it was difficult for the psychiatrists to set reasonable and nonpunitive limits, especially when the patients may not have had access to anyone else able to relate to their problems, and the doctors knew the treatment process often exacerbated their patients' distress. It was also difficult for dedicated therapists to contend with patients whose alters frequently abdicated or undercut the therapy, leaving the therapist to "carry" the treatment. Some alters attempted to manipulate, control, and abuse the therapists, creating considerable tension in sessions.

A Psychiatrist's empathic capacities may be sorely tested. It is difficult to "suspend disbelief," discount one's tendency to think in monistic concepts, and feel along with the separate personalities' experiences of themselves. having achieved that, it is further challenging to remain in empathic touch across abrupt dissociative defenses and sudden personality switches. It is easy to become frustrated and confused, retreat to a cognitive and less effectively-demanding stance, and undertake an intellectualized therapy in which the psychiatrist plays detective. Also, empathizing with an MPD patient's experience of traumatization is grueling. One is tempted to withdraw, intellectualize, or defensively ruminate about whether or not the events are "real." The therapist must monitor himself carefully. If the patient senses his withdrawal, he may feel abandoned and betrayed. Yet if he moves from the transient trial identification of empathy to the engulfing experience of counteridentification, an optimal therapeutic stance is lost, and the emotional drain can be ennervating.

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The Practical Psychopharmcology Of MPD

Kline and Angst tersely state pharmacological treatment of MPD is not indicated. ¹¹ There is general consensus 1) that drugs do not affect the core psychopathology of MPD; and 2) that, nonetheless, it is sometimes necessary to attempt to palliate intense dysphoria and/or to try to relieve target symptoms experienced by one, some, or all personalities. At this point in time treatment is empirical and informed by anecdotal experience rather than controlled studies.

Different personalities may present with symptom profiles which seem to invite the use of medication, yet the symptom profile of one may be so much at variance with another's as to suggest different regimens. A given drug may affect personalities differently. Alters who experience no effect, exaggerated effects, paradoxical reactions, appropriate responses, and various side effects may be noted in a single individual. Allergic responses in some but not all alters has been reported and reviewed. ¹² The possible permutations in a complex case are staggering.

It is tempting to avoid such a quagmire by declining to prescribe. However, distressing drug-responsive target symptoms and disorders may coexist with MPD. A failure to address them may leave the MPD inaccessible. The author has reported cross-over experiences on six MPD patients with major depression. ^4,1,3 He found if dissociation alone was treated, results were unstable due to mood problems. Relapse was predictable if medication was omitted. Medication alone sometimes reduced chaotic fluctuations which were chemically triggered, but did not treat the dissociation. An example is a depressed MPD woman who repeatedly relapsed on therapy alone. Placed on imipramine, she became euthymic but continued to dissociate. Therapy abated dissociation. With medication withdrawn, she relapsed in both depression and dissociation. Imipramine was reinstituted and fusion was achieved with hypnosis. On maintenance imipramine she has been asymptomatic in both dimensions for four years.

A psychiatrist's empathic capacities may be sorely tested

Depression, anxiety, panic attacks, agoraphobia, and hysteroid dysphoria may coexist with MPD and appear medication-responsive. However, response may be so rapid, transient, inconsistent across alters, and/or persist despite withdrawal of drugs, as to cause question. There may be no impact at all. The same holds for the insomnia, headaches, and pain syndromes which can accompany MPD. The author's experience is that, in retrospect, placeboid responses to the actual medications are more common than clear-cut "active drug" interventions.

Neither automatically denying nor readily acceding to the patient's requests for relief is reasonable. Several questions must be raises: 1)Is the distress part of a medication-responsive syndrome? 2)If the answer to 1) is yes, is it of sufficient clinical importance to outweigh possible adverse impacts of prescription? If the answer to 1) is no, whom would the drug treat (the physician's need to "do something." an anxious third party, etc.)? 3) Is there a non-pharmacological intervention which might prove effective instead? 4) Does the overall management require an intervention which the psychiatrist patient's "track record" in response to interventions similar to the one which is planned? 6) Weighing all considerations, do the potential benefits outweigh the potential risks? Medication abuse and ingestions with prescribed drugs are common risks.

Hypnotic and sedative drugs are frequently prescribed for sleep deprivation and disturbances. Initial failure or failure after transient success is the rule, and escape from emotional pain into mild overdose is common. Sleep disruption is likely to be a long-standing problem. Socializing the patient to accept this, shifting any other medication to bed-time (if appropriate), and helping the patient accept a regimen which provides a modicum of relief and a minimum of risk is a reasonable compromise.

Minor tranquilizers are useful as transient palliatives. When used more steadily, some tolerance should be expected. Increasing doses may be a necessary compromise if anxiety without the drug is disorganizing to the point of incapacitating the patient or forcing hospitalization. The author's major use of these drugs is for outpatients in crisis, inpatients, and for post-fusion cases which as yet have not developed good non-dissociative defenses.

...alters may emerge who are afraid, angry, or perplexed at being in the hospital.

Major tranquilizers must be used cautiously. There are ample anecdotal accounts of adverse effects, including rapid tardive dyskinesia, weakening of protectors, and patients' experiencing the drug's impact as an assault, leading to more splitting. Those rare MPD patients with bipolar trends may find these drugs helpful in blunting mania or agitation; those with hysterical dysphoria or severe headaches may be helped. Their major use has been for sedation when minor tranquilizers failed and/or tolerance has become an issue. Sometimes supervised sedation is preferable to hospitalization.

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When major depression accompanies MPD, response to tricyclic antidepressants can be gratifying. When symptoms are less straightforward, results are inconsistent. A trial of antidepressants is often indicated, but its outcome cannot be predicted. Ingestion and overdosage are common problems.

MAOI drugs are prone to abuse as one alter ingests forbidden substances to harm another, but can help patients with intercurrent atypical depression or hysteroid dysphoria. Lithium has proven useful in concomitant bipolar affective disorders, but has had no consistent impact on dissociation per se.

The author has seen a number of patients placed on anticonvulsants by clinicians familiar with articles suggesting a connection between MPD and seizure disorders. ^14,15 None were helped definitively: most responded to hypnotherapy instead. Two clinicians reported transient control of rapid fluctuation on Tegretol, yet over a dozen said it had no impact on their patients.

The Hospital Treatment Of Multiple Personality

Most admissions of known MPD patients occur in connection with 1) suicidal behaviors or impulses; 2) severe anxiety or depression related to de-repression, emergence of upsetting alters, or failure of a fusion; 3) fugue behaviors; 4) inappropriate behaviors of alters (including involuntary commitments for violence); 5) in connection with procedures or events in therapy during which a structured and protected environment is desirable; and 6) when logistic factors preclude outpatient care.

Very brief hospitalizations for crisis interventions rarely raise major problems. However, once the patient is on a unit for a while, certain problems begin to emerge unless one strong and socially-adapted alter is firmly in control.

On the part of the patients, alters may emerge who are afraid, angry, or perplexed at being in the hospital. Protectors begin to question procedures, protest regulations, and make complaints. Sensitive alters begin to pick up on staff's attitudes toward MPD; they try to seek out those who are accepting, and avoid those who are skeptical or rejecting. These lead to the patient's wishing to evade certain people and activities. Consequently, their participation in the milieu and cooperation with the staff as a whole may diminish. Rapidly, their protective style makes them group deviants and exerts polarize them, and the second toward protecting staff group cohesion from the patient. The patient experiences the latter phenomenon as rejection. Some alters are too specialized, young, inchoate, or inflexible to comprehend the unit accurately or conform their behavior within reasonable limits. They may view medication, rules, schedules, and restrictions as assaults, and/or repetitions of past traumata, and perceive to encapsulate the admission as a traumatic event, or to provide an alter which is compliant or pseudocompliant with treatment.

Other patients may be upset or fascinated by them. Some may feign MPD to evade their own problems, or scapegoat these individuals. MPD patients' switching can hurt those who try to befriend them. Some cannot help but resent that the MPD patient requires a great deal of staff time and attention. They may believe such patients can evade the accountability and responsibilities they cannot escape. A more common problem is more subtle. MPD patients openly manifest conflicts most patients are trying to repress. They threaten others' equilibria and are resented.

It is difficult to treat such patients without staff support. As noted, the patients are keenly perceptive of any hint of rejection. They openly fret over incidents with the therapist, staff, and other patients. Hence, they are seen as manipulative and divisive. This engenders antagonisms which can undermine therapeutic goals.

Also, such patients can threaten a milieu's sense of competence. The [patient becomes resented for the helplessness with the psychiatrist who, they feel, has inflicted an overwhelming burden upon them by admitting the patient.

The psychiatrist must try to protect patient, other patients, and staff from a chaotic situation. MPD patients do best in private rooms, where they retreat if overwhelmed. This is preferable to their felling cornered and exposing a roommate and milieu to mobilized protector phenomena. The staff must be helped to move from a position of impotence, futility, and exasperation to one of increasing mastery. Usually this requires considerable discussion, education, and reasonable expectations. The patients can be genuinely overwhelming. The staff should be helped in matter-of-fact problem solving vis-a-vis that particular patient. Concrete advice should precede general discussions of MPD, hypnosis, or whatever. Staff is with the patient 24 hours a day, and may be unsympathetic with the goals of a psychiatrist who appears to leave them to work out their own procedures, and then finds fault with what has occurred.

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The psychiatrist must be realistic. Almost inevitably, some staff will "disbelieve" in MPD and take essentially judgmental stances toward the patient (and the psychiatrist). In the author's experience it has seemed more effective to proceed in a modest and concrete educational manner, rather than "crusade." Deeply entrenched beliefs change gradually, if at all, and may not be altered during a given hospital course. It is better to work toward a reasonable degree of cooperation than to pursue a course of confrontation.

The following advice is offered, based on over 100 admissions of MPD patients:

1. A private room is preferable. Another patient is spared a burden, and allowing the patient a place of refuge diminishes crises.
2. Call the patient whatever he or she wants to be called. Treat all alters with equal respect. Insisting on a uniformity of names or the presence of one personality reinforces alters' need to prove they are strong and separate, and provokes narcissistic battles. Meeting them "as they are" reduces these pressures.
3. If an alter is upset it is not recognized, explain this will happen. Neither assume the obligation of recognizing each alter, nor "play dumb."
4. Talk through likely crises and their management. Encourage staff to call you in crises rather than feel pressed to extreme measures. They will feel less abandoned and more supported: there will be less chance of psychiatrist-staff splits and animosity.
5. Explain ward rules to the patient personally, having requested all alters to listen, and insist on reasonable compliance. When amnestic barriers or inner wars place an uncomprehending alter in a rule-breaking position, a firm but kindly and non-punitive stance is desirable.
6. Verbal group therapy is usually problematic, as are unit meetings. MPD patients are encouraged to tolerate unit meetings, but excused from verbal groups at first (at least) because the risk/benefit ratio is prohibitively high. However, art, movement, music, and occupational therapy groups are often exceptionally helpful.
7. Tell staff that it is not unusual for people to disagree strongly about MPD. Encourage all to achieve optimal therapeutic results by mounting a cooperative endeavor. Expect problematic issues to be recurrent. A milieu and staff, no less than a patient, must work things through gradually and, all too often, painfully. When egregious oppositionalism must be confronted, use extreme tact.
8. The patients should be told that the unit will do its best to treat them, and that they must do their best attend the tasks of the admission. Minor mishaps tend to preoccupy the MPD patient. One must focus attention on the issues which have the greatest priority.
9. Make it clear to the patient that no other individual should be expected to relate to the personalities in the same manner as the psychiatrist, who may elicit and work with all intensively. Otherwise, the patient may feel staff is not capable, or is failing, when staff is, in fact, supporting the therapy plan.

This article was printed in PSYCHIATRIC ANNALS 14:1/JANUARY 1984

A lot has changed since that time. I'd like to encourage you to find the differences and similarities between then and now. Though many things have been learned over the years there is still a long ways to go!

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next:   The Treatment Of Multiple Personality Disorder (MPD): Current Concepts

The role of gender in Internet addiction

Briefly, gender influences the types of applications and underlying reasons for Internet addiction. Men tend to seek out dominance and sexual fantasy online, while women seek out close friendships, romantic partners, and prefer anonymous communication in which to hide their appearance. It seems to be a natural conclusion that attributes of gender played out in Cyberspace parallel the stereotypes men and women have in our society.

MEN:

Men more than women seemed to enjoy interactive on-line games which draw upon power and dominance. These on-line games differ from video games in that characters interact with one another allowing all the players to recognize each other's rank. A character's rank is formed as a player gains more strength and power through continued play time. Characters' holding top level ranks earn recognition and respect from other players. Not only is status achieved through these games, but more often men seek to dominant other players as characters have the power to blow up, stab, shoot, and kill other players in a game. Men seem to enjoy the aspects of violence and dominance in such interactive games.

Cybersex is another area men seemed more attracted to than women. To give a brief background on how Cybersex is achieved, let me explain more about the types through chat areas which exist on-line. The development of social interaction of virtual chat rooms allows people to converse with one another about a variety of topics. Some chat rooms are very sedate and dedicated exclusively to a particular topic such as sports, the stock market, or travel. In other cases, theme rooms become highly sexual and one enters such a room with that understanding as there is little way to misinterpret room titles such as "SubM4F" "HungBlM4F" or "MarriedM4Affair." While men and women alike enter such rooms exclusively looking for erotic chat, predominantly men remarked how addictive such sexual entertainment was to them. Married and single men alike discussed in great detail why Cybersex was so thrilling to them. The addiction grows from the ability to cruise such chat rooms looking for uninhibited Cybersex - things they would never do or say with their wives! One man commented, "I love my wife and I respect her too much to ever say such humiliating things to her. But on-line, there are Cybersluts - women just wanting sex. They don't mind and even encourage me to use them in a sluttish way. So, these women draw it out of me." Men also enjoyed the ability to download available and easily accessible Cyberporn. X-rated Web pages provide quick access to adult photos, moving video clips, 900 phone numbers of available women complete with photo and sound clippings, and catalogs of foreign women for marriage. In general, men were more openly drawn to the sexually explicit material accessible through the Internet.

WOMEN:

Women more often than men commented on how they sought out support, acceptance, and comfort through on-line relationships formed in chat rooms. Virtual communities gave women a sense of belonging and the ability to share the company of others in a non-threatening environment. Like Cindy, a graphic arts designer from Denver told me "I love the idea that I was able to make such close friends on-line. These people offered me so much strength, especially when I started my diet. When I was struggling to stay on it (the diet), I jumped on-line and asked for help. So many of my on-line friends were there to help me - it was so encouraging."

As men tended to look more for Cybersex, women tended to look more for romance in Cyberspace. In virtual chat areas such as "Romance Connection" "Sweettalk" or "Candlelight Affair" a woman can meet men to form intimate relationships. But like a soap opera, tender moments with a romantic stranger can lead to passion and progress into sexual dialogue. I should note that it is not unusual for women to engage in random Cybersex, but many times they preferred to form some type of relationship prior to sexual chat.

Women more than men enjoyed the ability to hide their appearance from others through anonymous electronic communication. The emphasis in American culture for women to be slim, blonde, and proportionate makes women who don't fit these characteristics feel unattractive and fear rejection from men based solely on their appearance. However, through anonymous on-line communication, women have the chance to meet men without having to be seen and judged. On-line, women can be overweight or just having a "bad hair" day and not feel awkward about their appearance. Conversely, attractive women also enjoy the benefit of meeting men without being judged as a "piece of ass." As one woman put it, "Guys get to know me for me, and they don't just think of me just as a woman to get into bed." For many attractive women who get hit upon in real life, the ability to anonymously interact with men makes them feel as if they are appreciated for their minds and not their bodies.

To learn more about gender differences, read Caught in the Net, as it outlines specific cases of how men and women differ when using the Internet.

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next: Has Your Relationship Been Hurt By A Cyberaffair?
~ all center for online addiction articles
~ all articles on addictions

Learn about treating dual diagnosis and what's involved in the treatment of a co-occuring addiction and mental illness.

Why is it important to treat both the psychological disorder and the alcohol/drug use?

When neither illness is treated, one illness can make the other worse. When only one illness is treated, treatment is less likely to be effective. When both illnesses are treated, the chances for a full and lasting recovery are greatly improved, and it is easier to return to a full and productive life.

How does recovery from dual disorders occur?

• Recovery must be the individual's choice. People cannot be "pushed" into giving up substances. Over time they can learn to manage both their illnesses and to get on with their lives in personally meaningful ways.
• The process of recovery begins as soon as someone enters a dual disorders treatment program or becomes committed to managing their illnesses.
• Recovery takes time, hope, and courage. For most people, recovery occurs over months or years.
• People in integrated dual disorders treatment programs learn to manage two long-term illnesses and build a new meaningful life without drugs. This process requires time, support, education, courage, and skills.
• You can help. Everyone in your loved one's life can help by offering support, hope, and encouragement.

What treatment is available for dual diagnosis?

Despite much research that supports its success, integrated treatment is still not made widely available to consumers. Those who struggle both with serious mental illness and substance abuse face problems of enormous proportions. Mental health services tend not to be well prepared to deal with patients having both afflictions. Often only one of the two problems is identified. If both are recognized, the individual may bounce back and forth between services for mental illness and those for substance abuse, or they may be refused treatment by each of them. Fragmented and uncoordinated services create a service gap for persons with co-occurring disorders.

Effective integrated treatment consists of the same health professionals, working in one setting, providing appropriate treatment for both mental health and substance abuse in a coordinated fashion. The caregivers see to it that interventions are bundled together; the patients, therefore, receive consistent treatment, with no division between mental health or substance abuse assistance. The approach, philosophy and recommendations are seamless, and the need to consult with separate teams and programs is eliminated.

Integrated treatment also requires the recognition that substance abuse counseling and traditional mental health counseling are different approaches that must be reconciled to treat co-occurring disorders. For instance, it is not enough merely to teach relationship skills to a person with bipolar disorder. They must also learn to explore how to avoid the relationships that are intertwined with their substance abuse.

Dual diagnosis services include different types of assistance that go beyond standard therapy or medication: assertive outreach, job and housing assistance, family counseling, even money and relationship management. The personalized treatment is viewed as long-term and can be begun at whatever stage of recovery the person is in. Positivity, hope and optimism are at the foundation of integrated treatment.

Self-help may also be useful.

Self-help groups, such as Alcoholics Anonymous or Double Trouble, are valuable to some people; it may be added to integrated dual disorders treatment, especially when the person has started on a path of recovery. Self-help groups such as Al-Anon, can be valuable to family members.

Why is it important to stay clean and sober when getting treatment?

Mixing alcohol or drugs with medication can have serious and dangerous effects. Many medications, including over-the-counter medications, interact with alcohol or drugs in harmful ways. It is also unlikely that you will benefit from talk therapy if you are under the influence.

What can family members and significant others do when a loved one is dealing with dual diagnosis or co-occuring disorders?

• Get support for yourself. Join a family support group and attend self-help groups.
• Support your loved one's efforts in their recovery process.
• Be clear that you care about your loved one, but that you can set limits around disruptive behaviors.
• Understand that relapse is part of the recovery process.
• Recognize that your loved one's self -esteem and understanding about the effects of drug use will improve with the recovery process.
• Have patience. Dual recovery may take months or years.
• Listen. Be positive. Do not criticize.
• Get information for yourself. The more you know, the more you will understand recovery and the more helpful you can be.
• Use your information and personal experience to advocate for dual disorders treatment.

Work with your loved one's dual disorders team. Your loved one's recovery process may benefit from your hopeful support.

Sources:

• NAMI (National Alliance for the Mentally Ill)
• Substance Abuse and Mental Health Services Administration
• NIH
• Depression and Bipolar Support Alliance

next: Signs Your Child is Using or Abusing Drugs or Alcohol
~ addictions library articles
~ all addictions articles

As an infant, I was unable to set boundaries except in my own way (as an infant, crying, spitting up, etc). As an infant, I wasn't aware of how to set boundaries in an adult way. As an adult, I am able to set boundaries (in that adult way), that I had to originally given up to someone, who I thought knew how to do that. I was wrong. I can choose to learn something new about setting boundaries in a healthier way.

To protect all that I am (the discovery of myself), I can choose to set boundaries that protect me. Boundaries are clear and quick. Clarity is important. Over explaining is control for approval's sake. I can choose not to control by "over" explaining.

Anger is a tool I use to set boundaries. Anger is not control. Anger warns that action will be taken to protect myself. 

Examples of Boundaries with Anger

• "That Hurts! . . . , don't do that!" (and continue until it is acknowledged or walk away).*
• "That pisses me off! . . . , don't do that!" *
• "No!" *
• "Stop! _____________ you're pissing me off!" *
• "Stop! _____________ now!" *
• "Quit! _____________ now!" *
• "Don't call me that!" (in response to a name, a label, etc.) *
• "Don't touch me!"* "Don't! _____________ Don't do that!" *

* Remove the control (the victim or victimstance) and the fear from the anger in the presentation (your voice and body language).

NOTE: The use of threat or destructive bargaining i.e. "You'd better not, or else . . . . . ," or "If you do this, I'm gonna have so and so . . . . ," is a part of coercion and not a part of anger. Because, it denotes control which is a part of rage. Rage is anger with control and/ or abuse.

Examples of Boundaries without Anger

• "I prefer _____________ "(and continue until it is acknowledged or walk away). * *
• "No. . . , I don't like that." *
• "No. . . , I don't need that." *
• "No. . . , I'd prefer not to, but thanks for asking." * "I need you to quit what you're doing. . . ., It's pissing me off." *

* Remove the control (the victim or victimstance) and the fear from the anger in the presentation (your voice and body language).

Special Considerations

"Taking my inventory is a boundary violation."

Note: To someone taking my inventory,

"You're not allowed to discuss my behavior with me or discuss my behavior with someone else in my presence. If there is something about your own behavior that you wish to talk about, I'll listen; but I won't listen to you talk about me."t;

And if they continue . . . .

I say, "Don't!" - or - "Excuse me, what is your question?" ; * (what is it that you would like to know about me that you presume to know)

* To divert the invasion and allow them to take responsibility for (own) their own perceptions in the form of answering a question verses an attack.

Performance appraisals, credit checks, scholastic grading, personality tests or profiles, and intake interviews may all be distorted into a dehumanizing type of inventory taking. If someone needs to know something about me, they may choose to ask me and not presume. "Presumption" is a block to communication. The difference between inventory taking and non-inventory taking is the difference between an attack and a question. Forced presumptions and forced helping are both boundary violations. The key word is "forced;" the use of force. Forced listening (being forced to listen) is also a boundary violation. If I'm forced to be present in an attack of me, I can choose not to listen.

Examples of Last resort Boundaries

(With or without anger as needed)

• "I need you to go now!" (and continue until it is acknowledged or walk away). *
• "I need you to go. I need time to myself." *
• "I need to go." *
• "Excuse me." (And walk away).
• Physically leave the room.
• Physically leave the conversation.
• "I don't want (see examples below) "

Examples:

• To have a relationship with you (and continue until it is acknowledged or walk away). *
• To do this *
• A drink *
• To eat this *
• Any *
• Talk about this *

* Remove the control (the victim or victimstance) and the fear from the anger in the presentation (your voice and body language).

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Examples of Extended Space Boundaries

(With or without anger as needed)

1- "______________ is not allowed in my house, apartment, car, office, room, etc." (and continue until it is acknowledged or walk away).

Examples: drinking, stealing, gambling, smoking, spanking, snooping, fighting, food, candy, running, throwing things, breaking things, a person (their name), drawing on the walls, etc.

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2- "_____________ are not allowed in my house, apartment, car, office, room, etc." (and continue until it is acknowledged or walk away).

Examples: guns, weapons, drugs, cats, dogs, pets, you, fireworks, explosives, etc.

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3- "Don't touch that."(and continue until it is acknowledged or walk away).

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4- "I need you to ___________."(and continue until it is acknowledged or walk away).

Examples: turn down your stereo, stop that, call before you come, take that somewhere away from me, take that outside, stop calling, etc.

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5- "Don't call after (insert time) ." (and continue until it is acknowledged).

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6- "Don't call before (insert time) ." (and continue until it is acknowledged).

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7- "Don't call me ___________." (and continue until it is acknowledged).

Examples: here, at work, etc.

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In each of the cases above, I move from a non-victim stand point (non-victimstance). I do not try to project guilt or shame as a way to control and maintain a boundary. When people feel guilty or ashamed, they react in angry and hurt ways. This is not caring for myself (by I approaching boundary setting from a victim's point of view). I go slow and learn over time. In childhood my boundaries were shamed and violated. The terror persists and needs to be cared for in a nurturing way (like going slow and taking time to practice).

Boundary Violations (against me or my children)

When I recognize one of these destructive control behaviors in use, I set a boundary to protect myself and my children. Addict parents or other addicts in general will continue to use me until I've mastered boundary setting. I accept the times I am unable to set a boundary. I accept the time it takes to practice.

Two , three, and four-year-old children are usually great teaching resources for setting boundaries. When a child in this age group is touched in an uncomfortable way by another child or adult, they usually respond almost immediately with, "Don't!" or "No!" They'll even hit back in a way to say, "Stop what you are doing!" And if someone removes something that they consider to be theirs, they let that person know that a boundary violation has occurred by hitting, crying, spitting, biting, sticking their tongue out, etc. Boundary-less addict parents or other adults will inadvertently train or socialize this natural and intuitive boundary setting skill out of a child in order to get their own needs met (not the child's needs). In this way they are unknowingly using the child as a drug to "feel better." When I need to remind myself of the natural and intuitive boundary setting response available to me, I can observe young children socializing together.

In situations were the boundary is an emotional or spiritual requirement, I imagine a thick pool of water surrounding my being entirely. The water whirls about me in an un-ending spin. As words (or hostile/disapproving body language) that are un-kind, or loaded with bad energy, hit the outer borders of the water, they are swept out to the waters edge and then spun out into the universe (like setting a golf ball on a spinning record, it is thrown out to the outside of the record and does not stay in the middle). The words are thrown clear of ever reaching the thought processes of my mind. Any words that might get through are also returned to the water to be thrown out into the universe or can be batted with a baseball bat back out to the universe. It takes practice to visualize either of these ideas, but is possible with time.

next: Big Book (Alcoholics Anonymous) Homepage
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A few months ago, while riding in my brother's car in Israel, I listened to a talk-show psychologist answer questions. A seventeen year old woman called in. She said that when she went to bed at night she couldn't sleep because she thought of important people in her life dying. "Stop," the psychologist said, interrupting her. "You don't need to say anything more. I don't need any more history. There is a simple solution. Make an appointment with your internist. Have him give you a prescription for anti-depressants. You don't need more than that--nothing more complicated or time-consuming. Take the pills. You will feel better."

This snap advice gave me pause. I wondered: is this the kind of psychological evaluation being conducted in doctors' offices throughout the world? Once depression is diagnosed, no matter how mild or severe, is the treatment plan a foregone conclusion? I worry that general practitioners offices are becoming the drive-thru window for antidepressants. Economic factors support a "don't ask, don't tell" culture in the doctor's office when it comes to taking a detailed psychological history. Was this young woman sexually abused? Was she subject to childhood emotional or physical neglect? Was she traumatized by a death in the family? Does a general practitioner have the time (and expertise) to explore issues of deep psychological significance with patients before making a decision about the most appropriate treatment?

Certainly it is possible the young woman's problem is biologically based - if so, altering the biochemistry may "fix" the disorder. But what if her fears are based upon deeper psychological issues, not revealed in a cursory psychological exam? By taking anti-depressants, the symptoms are reduced and the client feels better. But psychological issues still linger in the background.

Does this matter? Should we concern ourselves with addressing underlying psychological issues when we can simply treat the symptoms?

There are three reasons why treating the underlying psychological issues is important.

First, there may come a time when the client must go off medication because of side effects, medical condition, reduced effectiveness, or simply because he or she prefers to be drug free. If the underlying psychological issues have not been treated, the symptoms may return in full force. If these issues aren't treated, the client may be held hostage by a drug they can't or may not want to take their whole life.

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Second, underlying psychological issues may interfere with the development (or choosing) of healthy relationships, which in turn may contribute to the client's depression. For example, "little voices," (people who ask for little from their partners, but instead emotionally twist themselves into a pretzel to earn a "place" in their partner's world--see Little Voices link below) may feel better after taking anti-depressants, but without psychological help, they will have no insight into how their relationship is contributing to their depression. As a result, they may remain in the destructive relationship for years, and continually require anti-depressants to counter the effects. Even if they are able to end a bad relationship, if the psychological issues go untreated, they are apt to repeat their mistake and make another bad choice (see Why do People Choose One Bad Relationship After Another.)

The final reason applies to parents and people who will have children. Anti-depressants may help parents to be more attentive, less preoccupied, and more patient. However, they will not provide the necessary awareness and self-consciousness to prevent psychological issues, such as "voicelessness," from being passed to the next generation. Since these issues are the precursors to depression, narcissism, and other disorders, by not addressing them, we are putting our children at risk. Simply put, anti-depressants, by themselves, will not break the intergenerational cycle of voicelessness. A thoughtful and well-trained therapist helps us fully understand our personal histories, reveals how hidden messages have influenced our lives, and teaches us how not to unconsciously repeat our parents' mistakes.

About the author: Dr. Grossman is a clinical psychologist and author of the Voicelessness and Emotional Survival web site.

next: Vulnerability: the roots of compassion

The rush to put everyone online has connected us all--to our keyboards. And some folks can't quit, sacrificing work and sleep to what some call netomania.

When Pam, a lab research assistant at a Midwestern company, was called in for her annual review recently, her boss was sympathetic about the sharp decline in her job performance. He knew that Pam, a recovering alcoholic, had been battling manic depression and grieving over a death in her family. What he didn't know, however, was that Pam had been spending up to six hours of her workday sending e-mail to friends and playing electronic games. The consequences of Pam's compulsion extend beyond the work time lost. "Sometimes I forget where I'm at, and I might put the wrong solution on a slide and blow the experiment for the day," she admits. "I have many times told myself I'm not going to use the computer today," Pam reflects. "Then I say, 'Maybe just one game ...'"

What sounds like a confession at a meeting of Computer Addicts Anonymous --an organization that doesn't exist yet but could become the 12-step program of the new millennium--describes a disturbing dependency that may be affecting millions of computer users who succumb to the siren song of cyberspace, not just at home but during office hours. It is a compulsion so relatively new and scantily studied that doctors can't agree on what to call it--Internetomania, problematic use of the Internet, compulsive computer use, Internet addiction, and just plain computer addiction are a few monikers--let alone what causes it. A recent study by a group of psychiatrists at the University of Cincinnati suggests that people hooked on the Internet may also suffer from underlying but treatable illnesses such as manic depression, anxiety disorders and substance abuse. But the jury is still out on whether compulsive computer use is a disorder in its own right--like pathological gambling--or a symptom of another illness.

Defining Addiction to the Internet

If the model used to measure the prevalence of other addictions--compulsive overeating, for example--is applied to this one, there could be as many as 15 million computer addicts. "The problem is far more common than people are willing to acknowledge in terms of loss of productivity or damage to the economy, as well as harm on a personal level," says Dr. Donald Black, a professor of psychiatry at the University of Iowa College of Medicine. Black, having already studied pathological gamblers and compulsive shoppers, has begun a study of compulsive computer users, since observing that some of the people in his department were spending enormous amounts of time in front of their terminals yet getting little work done.

That's one sign of computer abuse in the work force, agrees Kimberly Young, a professor of psychology at the University of Pittsburgh and author of Caught in the Net (John Wiley & Sons). Other signs include startled looks and furtive attempts to cover up the screen when supervisors approach work spaces, an inordinate increase in mistakes from employees who had previously made few--"Their attention is being pulled in another direction," explains Young--and a sudden decrease of interaction with colleagues. "A lot of relationships they're making online take the place of the co-workers," Young says.

The University of Cincinnati study found that problematic computer users tend to be most mesmerized by interactive pursuits--frequenting chat rooms and other multiuser domains, writing e-mail, surfing the Web, playing games. These can serve as a haven for workers from procrastination, boredom and feelings of isolation at work; the fantasy world they offer can be an attractive alternative to the daily grind. "It's an altered state of reality," reports Young. "It's like a drug rush." Depression, she and others believe, can be a result of--not the cause of--compulsive computer use: after someone has been parading his impressive alter ego around chat rooms or playing a power game, coming back to reality can be a real downer.

Experts recommend that managers call in their companies' employee-assistance programs to help in such cases, but aid for the afflicted is scarce. In addition to traditional offline therapy, Young offers a virtual clinic with chat rooms and e-mail counseling on her website--an approach that University of Cincinnati psychiatrist Dr. Toby Goldsmith likens to "taking an alcoholic to an A.A. meeting in a bar." Goldsmith reports that some of the participants in her group's study are having success curbing their computer compulsion after taking mood stabilizers, sometimes combined with antidepressants.

Total abstinence is an impractical solution, experts agree--especially for people who must use modern technology in their work. "It's like an eating disorder: one must learn to eat normally in order to survive," suggests Dr. Maressa Hecht Orzack, founder and coordinator of Computer Addiction Services at McLean Hospital in Belmont, Mass. Orzack tries to get her patients to recognize the triggers for their destructive behavior and come up with alternative ways for them to feel better.

Jeffrey, a 46-year-old East Coast lawyer who attributes the loss of a lucrative job in part to his preoccupation with the game Minesweeper, made it a practice at his next job to get up and get a glass of water or have direct contact with co-workers, whenever he felt the urge coming on. He finally removed the games not only from his own computer but from those of his secretary and his boss, who never noticed they were missing.

Orzack suggests that compulsive computer users might create a schedule that rewards them for finishing their work by giving them a break to do what they want on the computer. "I don't know if companies would go for that," Orzack muses. "But they might have to learn that people do have needs and can't be forced to be isolated for great lengths of time." Pam, who has still not sought help, is withdrawing further: she has just bought a pocket computer to use outside her office.

What Can You Do?

Is one of your employees battling an Internet addiction? Here are the warning signs of Internet addiction, according to Caught in the Net, by Kimberly S. Young:

• Productivity Loss: Though logging more overtime hours than ever, employees fail to meet deadlines or get the job done right.
• Skipped Lunches: Suddenly forsaking coffee breaks and social lunches with co-workers, employees stay riveted to their computers.
• Excessive Fatigue: Late nights surfing the Web at home coupled with extra hours to keep up at work mean lots of lost sleep.
• Guilty Looks: When an unexpected visitor enters an employee's usually private cubicle or office, he or she may appear startled, shift in the chair and quickly type a command.
• More Mistakes: Because they often toggle back and forth quickly between work tasks and Net play, employees suffer from lack of concentration.

And here's what to do about it:

• Set the Rules: Create an Internet code of conduct for your company and require that employees sign it. Include information on privacy and accepted Internet use.
• Ask Questions: If you notice a pattern of Internet addiction, ask your employee directly about his or her online activity.
• Find Help: Refer an Internet-addicted employee to a counselor through your company's employee-assistance program or other outreach program.
• Tighten Access: Every employee may not need access to the whole Internet. Consider blocking chat channels or newsgroups for those with no reason to use them.

Source: Time Magazine

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next: Are You An Internet Addict?
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Imagine another young child. Sam is off working on detachment today so let's choose Sal. Imagine Sal to be a young child of three or four years of age. To Sal, an adult looks like a twenty-four-foot giant. There is no doubt in Sal's mind that a giant of this size could wipe him or her out of existence. As a child, Sal is physically and emotionally unable to protect him or herself against an entity of this size.

Continuing with the sneeze scenario, imagine that after the expulsion (the sneeze) a twenty-four-foot giant were to yell violently and terrorize Sal for doing the expulsion (the sneezing).

Imagine the giant to be screaming and angry. The terror associated with a screaming-angry-twenty-four-foot giant would be overwhelming to a child. If the giant were to scream and disapprove of Sal in anger for sneezing, what would the effects be?

Answer: Terror and Shame

As a result of the giant's abusive behavior, Sal has learned that sneezing will be associated with being terrorized and shamed, i.e. abused. Each time Sal sneezes he or she will be associating sneezing with terror, shame, abuse, and the need to survive. Sal's stress cycle for sneezing will never feel peaceful. Feeling peaceful is an experience unique to each person. Feeling peaceful; for me is:

The Lack of Fear, Anxiety, Pain, and internal Chaos

If a peaceful state is not achieved in a stress cycle, that cycle will feel unresolved or incomplete.

The expulsion inhibitor in Sal's case was a twenty-four-foot giant. The giant's angry reaction to Sal's sneeze, scared Sal and prevented Sal from feeling peaceful, complete, or a sense of resolution about the sneeze. This incomplete cycle will influence Sal's future cycles for sneezing. Future cycles will also feel incomplete, unresolved, or not peaceful unless the original cycle is resolved.

next: Section III: Acceptance of Myself
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Terrorhood

I find myself reacting in a way that I believe keeps me safe, from a childhood that's not over yet. It's over.

We heal in relationship with ourselves and with others. To talk, to express myself...
Nature's way to relieve the internal pressures (stress cycles) that build up each day.
A way to keep me clear and clutter free.

One of the most important functions of living is to express myself. Expressing myself is how I clean stress out of my system. Stress is caused by internal pressures that build up each day in the natural course of exposing myself to my environment.

Stress is natural and takes on many forms but all these forms have a common pattern.

The Background

All stress has a cycle. The cycle of stress is moving from a peaceful state to an uncomfortable state and back to a peaceful state (figure 1). An uncomfortable state is not a negative state; it is only a state which is other than peaceful.

Stress may be divided into two categories, "bio-stressors" and "emotional stressors." Bio-stressors are biological forces which act on the body. Some examples of bio-stressors are listed below.

Examples of Bio-stressors

• Gas - gas build up in the stomach and/or intestines
• Urine - urine build up in the bladder
• Feces - feces build up in the bowel
• Dust build up in the nose
• Flem in the throat
• Hot climatic conditions, heat
• Physical pain
• An itch
• Viruses, colds, diseases
• Nausea in the stomach
• Inactivity

Each bio-stressor moves a person from a peaceful state to an uncomfortable state and, depending upon the course of action chosen, back to a peaceful state again. Emotional-stressors are emotional forces which act on the body. Some examples of emotional-stressors are listed below.

Examples of Emotional Stressors

• Joy
• Grief
• Terror
• Shame
• Embarrassment
• Frustration
• Anger
• Inadequacy
• Jealousy (specifically the fear of being abandoned)
• Envy (specifically the fear of being inadequate or "not good enough")
• Extreme boredom
• Helplessness
• Resentment (anger and/or hurt hidden or repressed)
• Finding something humorous
• Needs for relieving loneliness
• Needs for sexual gratification
• Hurt
• Fear (nervousness, anxious, hypervigilance)
• Denial and repression (keeping something secrete from myself, or from someone else as a way to control myself)

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Emotional-stressors move a person from a peaceful state to an uncomfortable state and, depending upon the course of action chosen, back to a peaceful state again.

The uncomfortable state is referred to as the "stress response." The stress response is made up of the internal pressures and/ or anxieties that the body feels a need to expel during the course of living each day. The stress response is natures' cue for a person to move into a course of action. The goal of this action is to move the body from an uncomfortable state back to a peaceful state.

Some stress cycles are easier to move through than others. Consider the bio-stressor "Dust in the nose," and the cycle that accompanies it (figure 2).

From the peaceful state, the body moves to an uncomfortable state as the bio-stressor dust in the nose acts on the body. This is the natural stress response to dust in the nose. The stress response is the body's cue to move into action. The goal of the action is to resolve the stress cycle back the peaceful state. In this case, the action of sneezing could resolve the cycle back to the peaceful state (figure 3).

The action taken to resolve the cycle is called the "Expulsion." In this example, the expulsion is a sneeze.

next: Setting Boundaries
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Suicide is the third leading cause of death for teens and young adults, and parents may be aware that teens who have suffered abuse or depression are at higher risk. The results of a recent study suggest that adopted teens also may be more likely to attempt suicide than their peers who live with their biological parents.

Researchers from the University of Cincinnati Medical Center in Cincinnati, Ohio, used data from a national survey of adolescent health to identify 214 adopted and 6,363 nonadopted teens. The teens completed questionnaires and interviews at home and in school, and the parents of the teens were asked to complete separate questionnaires. Teens were asked questions about their general and emotional health, including questions about self-image, depressive symptoms, and whether they had attempted suicide during the past year. Teens also identified whether they participated in risky behaviors such as smoking, drinking alcohol, using drugs, or having sexual intercourse. The survey also asked teens to answer questions about their school performance, and both teens and parents were asked to respond to questions about family relationships.

More than 3% of all teens in the study reported suicide attempts within the last year. Almost 8% of the adopted teens reported suicide attempts, compared to just over 3% of the nonadopted teens. Teens who attempted suicide were more likely to be female, and were more than four times as likely as teens who didn't attempt suicide to have received mental health counseling in the past year. In addition, teens who attempted suicide were more likely to report risky behaviors, including using cigarettes, alcohol, and marijuana, to have had sexual intercourse, and to be aggressive and impulsive. Adoption, depression, mental health counseling in the past year, female gender, cigarette use, delinquency, low self-image, and aggression were all factors that increased a teen's likelihood of attempting suicide. Teens who perceived themselves as highly connected to their families were less likely to have attempted suicide regardless of whether they were adopted or not.

What This Means to You: Attempted suicide is more common among teens who live with adoptive parents than teens who live with biological parents, although it is important to note that the majority of adopted teens do not attempt suicide. Depression, aggression, substance abuse, and low self-esteem, as well as adoption, may place a teen at higher risk for attempted suicide. Talk to your teen about whether he has ever considered suicide, particularly if your teen has any of these risk factors; if you think your child needs help, talk to your teen's doctor or a psychologist or psychiatrist for advice.

Source: Pediatrics, August 2001

The National Hopeline Network 1-800-SUICIDE provides access to trained telephone counselors, 24 hours a day, 7 days a week. Or for a crisis center in your area, go here.

next: Family Mental Health History
~ depression library articles
~ all articles on depression

Major depression and dysthymia affect twice as many women as men. This two-to-one ratio exists regardless of racial and ethnic background or economic status. The same ratio has been reported in ten other countries all over the world.¹² Men and women have about the same rate of bipolar disorder (manic-depression), though its course in women typically has more depressive and fewer manic episodes. Also, a greater number of women have the rapid cycling form of bipolar disorder, which may be more resistant to standard treatments.⁵

A variety of factors unique to women's lives are suspected to play a role in developing depression. Research is focused on understanding these, including: reproductive, hormonal, genetic or other biological factors; abuse and oppression; interpersonal factors; and certain psychological and personality characteristics. And yet, the specific causes of depression in women remain unclear; many women exposed to these factors do not develop depression. What is clear is that regardless of the contributing factors, depression is a highly treatable illness.

The Many Dimensions of Depression in Women

Investigators are focusing on the following areas in their study of depression in women:

The Issues of Adolescence

Before adolescence, there is little difference in the rate of depression in boys and girls. But between the ages of 11 and 13 there is a precipitous rise in depression rates for girls. By the age of 15, females are twice as likely to have experienced a major depressive episode as males.² This comes at a time in adolescence when roles and expectations change dramatically. The stresses of adolescence include forming an identity, emerging sexuality, separating from parents, and making decisions for the first time, along with other physical, intellectual, and hormonal changes. These stresses are generally different for boys and girls, and may be associated more often with depression in females. Studies show that female high school students have significantly higher rates of depression, anxiety disorders, eating disorders, and adjustment disorders than male students, who have higher rates of disruptive behavior disorders.⁶

Adulthood: Relationships and Work Roles

Stress in general can contribute to depression in persons biologically vulnerable to the illness. Some have theorized that higher incidence of depression in women is not due to greater vulnerability, but to the particular stresses that many women face. These stresses include major responsibilities at home and work, single parenthood, and caring for children and aging parents. How these factors may uniquely affect women is not yet fully understood.

For both women and men, rates of major depression are highest among the separated and divorced, and lowest among the married, while remaining always higher for women than for men. The quality of a marriage, however, may contribute significantly to depression. Lack of an intimate, confiding relationship, as well as overt marital disputes, have been shown to be related to depression in women. In fact, rates of depression were shown to be highest among unhappily married women.

Reproductive Events

Women's reproductive events include the menstrual cycle, pregnancy, the postpregnancy period, infertility, menopause, and sometimes, the decision not to have children. These events bring fluctuations in mood that for some women include depression. Researchers have confirmed that hormones have an effect on the brain chemistry that controls emotions and mood; a specific biological mechanism explaining hormonal involvement is not known, however.

Many women experience certain behavioral and physical changes associated with phases of their menstrual cycles. In some women, these changes are severe, occur regularly, and include depressed feelings, irritability, and other emotional and physical changes. Called premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD), the changes typically begin after ovulation and become gradually worse until menstruation starts. Scientists are exploring how the cyclical rise and fall of estrogen and other hormones may affect the brain chemistry that is associated with depressive illness.¹⁰

Postpartum mood changes can range from transient "baby blues" immediately following childbirth to an episode of major depression to severe, incapacitating, psychotic depression. Studies suggest that women who experience major depression after childbirth very often have had prior depressive episodes even though they may not have been diagnosed and treated.

Pregnancy (if it is desired) seldom contributes to depression, and having an abortion does not appear to lead to a higher incidence of depression. Women with infertility problems may be subject to extreme anxiety or sadness, though it is unclear if this contributes to a higher rate of depressive illness. In addition, motherhood may be a time of heightened risk for depression because of the stress and demands it imposes.

Menopause, in general, is not asssociated with an increased risk of depression. In fact, while once considered a unique disorder, research has shown that depressive illness at menopause is no different than at other ages. The women more vulnerable to change-of-life depression are those with a history of past depressive episodes.

Specific Cultural Considerations

As for depression in general, the prevalence rate of depression in African American and Hispanic women remains about twice that of men. There is some indication, however, that major depression and dysthymia may be diagnosed less frequently in African American and slightly more frequently in Hispanic than in Caucasian women. Prevalence information for other racial and ethnic groups is not definitive.

Possible differences in symptom presentation may affect the way depression is recognized and diagnosed among minorities. For example, African Americans are more likely to report somatic symptoms, such as appetite change and body aches and pains. In addition, people from various cultural backgrounds may view depressive symptoms in different ways. Such factors should be considered when working with women from special populations.

Victimization

Studies show that women molested as children are more likely to have clinical depression at some time in their lives than those with no such history. In addition, several studies show a higher incidence of depression among women who have been raped as adolescents or adults. Since far more women than men were sexually abused as children, these findings are relevant. Women who experience other commonly occurring forms of abuse, such as physical abuse and sexual harassment on the job, also may experience higher rates of depression. Abuse may lead to depression by fostering low self-esteem, a sense of helplessness, self-blame, and social isolation. There may be biological and environmental risk factors for depression resulting from growing up in a dysfunctional family. At present, more research is needed to understand whether victimization is connected specifically to depression.

Poverty

Women and children represent seventy-five percent of the U.S. population considered poor. Low economic status brings with it many stresses, including isolation, uncertainty, frequent negative events, and poor access to helpful resources. Sadness and low morale are more common among persons with low incomes and those lacking social supports. But research has not yet established whether depressive illnesses are more prevalent among those facing environmental stressors such as these.

Depression in Later Adulthood

At one time, it was commonly thought that women were particularly vulnerable to depression when their children left home and they were confronted with "empty nest syndrome" and experienced a profound loss of purpose and identity. However, studies show no increase in depressive illness among women at this stage of life.

As with younger age groups, more elderly women than men suffer from depressive illness. Similarly, for all age groups, being unmarried (which includes widowhood) is also a risk factor for depression. Most important, depression should not be dismissed as a normal consequence of the physical, social, and economic problems of later life. In fact, studies show that most older people feel satisfied with their lives.

About 800,000 persons are widowed each year. Most of them are older, female, and experience varying degrees of depressive symptomatology. Most do not need formal treatment, but those who are moderately or severely sad appear to benefit from self-help groups or various psychosocial treatments. However, a third of widows/widowers do meet criteria for major depressive episode in the first month after the death, and half of these remain clinically depressed 1 year later. These depressions respond to standard antidepressant treatments, although research on when to start treatment or how medications should be combined with psychosocial treatments is still in its early stages. ⁴,⁸

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Depression is a Treatable Illness

Even severe depression can be highly responsive to treatment. Indeed, believing one's condition is "incurable" is often part of the hopelessness that accompanies serious depression. Such individuals should be provided with the information about the effectiveness of modern treatments for depression in a way that acknowledges their likely skepticism about whether treatment will work for them. As with many illnesses, the earlier treatment begins, the more effective and the greater the likelihood of preventing serious recurrences. Of course, treatment will not eliminate life's inevitable stresses and ups and downs. But it can greatly enhance the ability to manage such challenges and lead to greater enjoyment of life.

The first step in treatment for depression should be a thorough examination to rule out any physical illnesses that may cause depressive symptoms. Since certain medications can cause the same symptoms as depression, the examining physician should be made aware of any medications being used. If a physical cause for the depression is not found, a psychological evaluation should be conducted by the physician or a referral made to a mental health professional.

Types of Treatment for Depression

The most commonly used treatments for depression are antidepressant medication, psychotherapy, or a combination of the two. Which of these is the right treatment for any one individual depends on the nature and severity of the depression and, to some extent, on individual preference. In mild or moderate depression, one or both of these treatments may be useful, while in severe or incapacitating depression, medication is generally recommended as a first step in the treatment.³ In combined treatment, medication can relieve physical symptoms quickly, while psychotherapy allows the opportunity to learn more effective ways of handling problems.

Antidepressant Medications

There are several types of antidepressant medications used to treat depressive disorders. These include newer medications-chiefly the selective serotonin reuptake inhibitors (SSRIs)-and the tricyclics and monoamine oxidase inhibitors (MAOIs). The SSRIs-and other newer medications that affect neurotransmitters such as dopamine or norepinephrine-generally have fewer side effects than tricyclics. Each acts on different chemical pathways of the human brain related to moods. Antidepressant medications are not habit-forming. Although some individuals notice improvement in the first couple of weeks, usually antidepressant medications must be taken regularly for at least 4 weeks and, in some cases, as many as 8 weeks, before the full therapeutic effect occurs. To be effective and to prevent a relapse of the depression, medications must be taken for about 6 to 12 months, carefully following the doctor's instructions. Medications must be monitored to ensure the most effective dosage and to minimize side effects. For those who have had several bouts of depression, long-term treatment with medication is the most effective means of preventing recurring episodes.

The prescribing doctor will provide information about possible side effects and, in the case of MAOIs, dietary and medication restrictions. In addition, other prescribed and over-the-counter medications or dietary supplements being used should be reviewed because some can interact negatively with antidepressant medication. There may be restrictions during pregnancy.

For bipolar disorder, the treatment of choice for many years has been Lithium, as it can be effective in smoothing out the mood swings common to this disorder. Its use must be carefully monitored, as the range between an effective dose and a toxic one can be relatively small. However, lithium may not be recommended if a person has pre-existing thyroid, kidney, or heart disorders or epilepsy. Fortunately, other medications have been found helpful in controlling mood swings. Among these are two mood-stabilizing anticonvulsants, carbamazepine (Tegretol^®) and valproate (Depakene^®). Both of these medications have gained wide acceptance in clinical practice, and valproate has been approved by the Food and Drug Administration for first-line treatment of acute mania. Studies conducted in Finland in patients with epilepsy indicate that valproate may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who began taking the medication before age 20. ¹¹ Therefore, young female patients should be monitored carefully by a physician. Other anticonvulsants that are being used now include lamotrigine (Lamictal^®) and gabapentin (Neurontin^®); their role in the treatment hierarchy of bipolar disorder remains under study.

Most people who have bipolar disorder take more than one medication. Along with lithium and/or an anticonvulsant, they often take a medication for accompanying agitation, anxiety, insomnia, or depression. Some research indicates that an antidepressant, when taken without a mood stabilizing medication, can increase the risk of switching into mania or hypomania, or of developing rapid cycling, in people with bipolar disorder. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician.

Herbal Therapy

In the past few years, much interest has risen in the use of herbs in the treatment of both depression and anxiety. St. John's wort (Hypericum perforatum), an herb used extensively in the treatment of mild to moderate depression in Europe, has recently aroused interest in the United States. St. John's wort, an attractive bushy, low-growing plant covered with yellow flowers in summer, has been used for centuries in many folk and herbal remedies. Today in Germany, Hypericum is used in the treatment of depression more than any other antidepressant. However, the scientific studies that have been conducted on its use have been short-term and have used several different doses.

To address increasing American interests in St. John's wort, the National Institutes of Health conducted a clinical trial to determine the effectiveness of the herb in treating adults who have major depression. Involving 340 patients diagnosed with major depression, the eight-week trial randomly assigned one-third of them to a uniform dose of St. John's wort, one-third to a commonly prescribed SSRI, and one-third to a placebo. The trial found that St. John's wort was no more effective than the placebo in treating major depression.¹³ Another study is looking at the effectiveness of St. John's wort for treating mild or minor depression.

Other research has shown that St. John's wort can interact unfavorably with other medications, including those used to control HIV infection. On February 10, 2000, the FDA issued a Public Health Advisory letter stating that the herb appears to interfere with certain medications used to treat heart disease, depression, seizures, certain cancers, and organ transplant rejection. The herb also may interfere with the effectiveness of oral contraceptives. Because of these potential interactions, patients should always consult with their doctors before taking any herbal supplement.

Psychotherapy for Depression

Several types of psychotherapy-or "talk therapy"-can help people with depression.

In mild to moderate cases of depression, psychotherapy is also a treatment option. Some short-term (10 to 20 week) therapies have been very effective in several types of depression. "Talking" therapies help patients gain insight into and resolve their problems through verbal give-and-take with the therapist. "Behavioral" therapies help patients learn new behaviors that lead to more satisfaction in life and "unlearn" counter-productive behaviors. Research has shown that two short-term psychotherapies, interpersonal and cognitive-behavioral, are helpful for some forms of depression. Interpersonal therapy works to change interpersonal relationships that cause or exacerbate depression. Cognitive-behavioral therapy helps change negative styles of thinking and behaving that may contribute to the depression.

Electroconvulsive Therapy

For individuals whose depression is severe or life threatening or for those who cannot take antidepressant medication, electroconvulsive therapy (ECT) is useful.³ This is particularly true for those with extreme suicide risk, severe agitation, psychotic thinking, severe weight loss or physical debilitation as a result of physical illness. Over the years, ECT has been much improved. A muscle relaxant is given before treatment, which is done under brief anesthesia. Electrodes are placed at precise locations on the head to deliver electrical impulses. The stimulation causes a brief (about 30 seconds) seizure within the brain. The person receiving ECT does not consciously experience the electrical stimulus. At least several sessions of ECT, usually given at the rate of three per week, are required for full therapeutic benefit.

Treating Recurrent Depression

Even when treatment is successful, depression may recur. Studies indicate that certain treatment strategies are very useful in this instance. Continuation of antidepressant medication at the same dose that successfully treated the acute episode can often prevent recurrence. Monthly interpersonal psychotherapy can lengthen the time between episodes in patients not taking medication.

The Path to Healing

Reaping the benefits of treatment begins by recognizing the signs of depression. The next step is to be evaluated by a qualified professional. Although depression can be diagnosed and treated by primary care physicians, often the physician will refer the patient to a psychiatrist, psychologist, clinical social worker, or other mental health professional. Treatment is a partnership between the patient and the health care provider. An informed consumer knows her treatment options and discusses concerns with her provider as they arise.

If there are no positive results after 2 to 3 months of treatment, or if symptoms worsen, discuss another treatment approach with the provider. Getting a second opinion from another health or mental health professional may also be in order.

Here, again, are the steps to healing:

• Check your symptoms against this list.
• Talk to a health or mental health professional.
• Choose a treatment professional and a treatment approach with which you feel comfortable.
• Consider yourself a partner in treatment and be an informed consumer.
• If you are not comfortable or satisfied after 2 to 3 months, discuss this with your provider. Different or additional treatment may be recommended.
• If you experience a recurrence, remember what you know about coping with depression and don't shy away from seeking help again. In fact, the sooner a recurrence is treated, the shorter its duration will be.

Depressive illnesses make you feel exhausted, worthless, helpless, and hopeless. Such feelings make some people want to give up. It is important to realize that these negative feelings are part of the depression and will fade as treatment begins to take effect.

Self-Help for Treatment of Depression

Along with professional treatment, there are other things you can do to help yourself get better. If you have depression, it may be extremely difficult to take any action to help yourself. But it is important to realize that feelings of helplessness and hopelessness are part of the depression and do not accurately reflect actual circumstances. As you begin to recognize your depression and begin treatment, negative thinking will fade.

To help yourself:

• Engage in mild activity or exercise. Go to a movie, a ballgame, or another event or activity that you once enjoyed. Participate in religious, social or other activities.
• Set realistic goals for yourself.
• Break up large tasks into small ones, set some priorities and do what you can as you can.
• 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. Do not expect to suddenly "snap out of" your depression. Often during treatment for depression, sleep and appetite will begin to improve before your depressed mood lifts.
• 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.
• Remember that positive thinking will replace negative thoughts as your depression responds to treatment.

Where to Get Help for Depression

If unsure where to go for help, ask your family doctor, OB/GYN physician, or health clinic for assistance. You can also check the Yellow Pages under "mental health," "health," "social services," "suicide prevention," "crisis intervention services," "hotlines," "hospitals," or "physicians" for phone numbers and addresses. In times of crisis, the emergency room doctor at a hospital may be able to provide temporary help for an emotional problem and will be able to tell you where and how to get further help.

Listed below are the types of people and places that will make a referral to, or provide, diagnostic and treatment services.

• Family doctors
• Mental health specialists such as psychiatrists, psychologists, social workers, or mental health counselors
• Health maintenance organizations
• Community mental health centers
• Hospital psychiatry departments and outpatient clinics
• University- or medical school-affiliated programs
• State hospital outpatient clinics
• Family service/social agencies
• Private clinics and facilities
• Employee assistance programs
• Local medical and/or psychiatric societies

If you are thinking about harming yourself, or know someone who is, tell someone who can help immediately.

• Call your doctor.
• Call 911 or go to a hospital emergency room to get immediate help or ask a friend or family member to help you do these things.
• Call the toll-free, 24-hour hotline of the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255); TTY: 1-800-799-4TTY (4889) to talk to a trained counselor.
• Make sure you or the suicidal person is not left alone.

Source: National Institute of Mental Health - 2008.

HELPFUL BOOKS

Many books have been written on major depression and bipolar disorder. The following are a few that may help you understand these illnesses better.

Andreasen, Nancy. The Broken Brain: The Biological Revolution in Psychiatry. New York: Harper & Row, 1984.

Carter, Rosalyn. Helping Someone With Mental Illness: A Compassionate Guide for Family, Friends and Caregivers. New York: Times Books, 1998.

Duke, Patty and Turan, Kenneth. Call Me Anna, The Autobiography of Patty Duke. New York: Bantam Books, 1987.

Dumquah, Meri Nana-Ama. Willow Weep for Me, A Black Woman's Journey Through Depression: A Memoir. New York: W.W. Norton & Co., Inc., 1998.

Fieve, Ronald R. Moodswing. New York: Bantam Books, 1997.

Jamison, Kay Redfield. An Unquiet Mind, A Memoir of Moods and Madness. New York: Random House, 1996.

The following three booklets are available from the Madison Institute of Medicine, 7617 Mineral Point Road, Suite 300, Madison, WI 53717, telephone 1-608-827-2470:

Tunali D, Jefferson JW, and Greist JH, Depression & Antidepressants: A Guide, rev. ed. 1997.

Jefferson JW and Greist JH. Divalproex and Manic Depression: A Guide, 1996 (formerly Valproate guide).

Bohn J and Jefferson JW. Lithium and Manic Depression: A Guide, rev. ed. 1996.

References:

¹ Blehar MC, Oren DA. Gender differences in depression. Medscape Women's Health, 1997;2:3. Revised from: Women's increased vulnerability to mood disorders: Integrating psychobiology and epidemiology. Depression, 1995;3:3-12.

² Cyranowski JM, Frank E, Young E, Shear MK. Adolescent onset of the gender difference in lifetime rates of major depression. Archives of General Psychiatry, 2000; 57:21-27.

³ Frank E, Karp JF, and Rush AJ. Efficacy of treatments for major depression. Psychopharmacology Bulletin, 1993;29:457-75.

⁴ Lebowitz BD, Pearson JL, Schneider LS, Reynolds CF, Alexopoulos GS, Bruce ML, Conwell Y, Katz IR, Meyers BS, Morrison MF, Mossey J, Niederehe G, and Parmelee P. Diagnosis and treatment of depression in late life: Consensus statement update. Journal of the American Medical Association, 1997;278:1186-90.

⁵ Leibenluft E. Issues in the treatment of women with bipolar illness. Journal of Clinical Psychiatry (supplement 15), 1997;58:5-11.

⁶ Lewisohn PM, Hyman H, Roberts RE, Seeley JR, and Andrews JA. Adolescent psychopathology: 1. Prevalence and incidence of depression and other DSM-III-R disorders in high school students. Journal of Abnormal Psychology, 1993;102:133-44.

⁷ Regier DA, Farmer ME, Rae DS, Locke BZ, Keith SJ, Judd LL, and Goodwin FK. Comorbidity of mental disorders with alcohol and other drug abuse: Results from the epidemiologic catchment area (ECA) study. Journal of the American Medical Association, 1993;264:2511-8.

⁸ Reynolds CF, Miller MD, Pasternak RE, Frank E, Perel JM, Cornes C, Houck PR, Mazumdar S, Dew MA, and Kupfer DJ. Treatment of bereavement-related major depressive episodes in later life: A controlled study of acute and continuation treatment with nortriptyline and interpersonal psychotherapy. American Journal of Psychiatry, 1999;156:202-8.

⁹ Robins LN and Regier DA (Eds). Psychiatric Disorders in America, The Epidemiologic Catchment Area Study. New York: The Free Press, 1990.

¹⁰ Rubinow DR, Schmidt PJ, and Roca CA. Estrogen-serotonin interactions: Implications for affective regulation. Biological Psychiatry, 1998;44(9):839-50.

¹¹ Vainionpaa LK, Rattya J, Knip M, Tapanainen JS, Pakarinen AJ, Lanning P, Tekay, A, Myllyla, VV, Isojarvi JI. Valproate-induced hyperandrogenism during pubertal maturation in girls with epilepsy. Annals of Neurology, 1999;45(4):444-50.

¹² Weissman MM, Bland RC, Canino GJ, Faravelli C, Greenwald S, Hwu HG, Joyce PR, Karam EG, Lee CK, Lellouch J, Lepine JP, Newman SC, Rubin-Stiper M, Wells JE, Wickramaratne PJ, Wittchen H, and Yeh EK. Cross-national epidemiology of major depression and bipolar disorder. Journal of the American Medical Association, 1996;276:293-9.

¹³ Hypericum Depression Trial Study Group. Effect of Hypericum perforatum (St. John's wort) in major depressive disorder: a randomized controlled trial. Journal of the American Medical Association, 2002; 287(14): 1807-1814.

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