This is taken from Attention Research Update written by David Rabiner, Ph.D. This really is a fantastic resource which is well worth signing up to receive, it is also free to subscribe so you can't go wrong can you and you can gain regular updates of information and news of new research

The Multimodal Treatment Study of ADHD (MTA Study) is the largest ADHD treatment study ever conducted. A total of 597 children with ADHD-Combined Type (i.e., they had both inattentive and hyperactive-impulsive symptoms) were randomly assigned to 1 of 4 treatments: medication management, behavior modification, medication management + behavior modification (i.e., combined treatment), or community care (CC). Medication treatment and behavior therapy were selected because they had the most extensive evidence-base to support their efficacy, and alternative and/or less well-established ADHD treatments were not investigated.

The medication and behavioral treatment provided in the MTA study were far more rigorous than what children typically receive in community settings. Medication treatment began with an extensive double-blind trial to determine the optimum dose and medication for each child, and the ongoing effectiveness of children's treatment was carefully monitored so that adjustments could be made when necessary. The behavioral intervention included over 25 parent training sessions, an intensive summer camp treatment program, and extensive support provided by paraprofessionals in children's classrooms. In contrast, children in the community care condition (CC) received whatever treatments parents opted to pursue for their child in the community. Although this included medication treatment for the majority of children, it appeared that this treatment was not conducted with the same rigor as with children who received medication treatment from the MTA researchers.

The initial results from this landmark study examined children's outcomes 14 months after treatment began. Although results from this complex study do not lend themselves to a brief summary, the overall pattern suggested that children who received intensive medication management - either alone or in combination with behavior treatment - had more positive outcomes than children who receive behavior therapy alone or community care. Although this was not true for all the different outcome measures considered (e.g., ADHD symptoms, parent-child relations, oppositional behavior, reading, social skills, etc.) it was the case for primary ADHD symptoms as well as for a composite outcome measure that included measures from a broad array of different domains. There was also modest evidence that children who received combined treatment were doing better overall than children who received medication treatment alone.

In terms of the percentage of children within each group who were no longer showing clinically elevated levels of ADHD symptoms and symptoms of oppositional defiant disorder, results indicated that 68% of the combined group, 56% of the medication only group, 33% of the behavior therapy group, and only 25% of the community care group had levels of these symptoms that fell in the normal range. These figures highlight that intensive medication treatment was more likely to result in a normalized level of core ADHD and ODD symptoms than either behavior therapy or community care, and that combined treatment was associated with the highest rate of "normalization".
(For a more complete description of MTA treatments and the initially reported outcome results, please visit http://parentsubscribers.c.topica.com/maaclGpaa7D1Ub3aW2hb).

As noted above, the results previously reported for the MTA Study cover the period out to 14 months after children's treatment began. An important, but as yet unanswered question, is the extent to which treatment benefits persisted after children were no longer receiving the intensive treatments provided in the study. For example, did the benefits associated with carefully conducted medication treatment persist once children's treatment was no longer being monitored through the study? And, was there persistent evidence that the combination of careful medication treatment and intensive behavior therapy was superior overall to medication treatment alone?

The persistent effects of MTA treatments were examined in a study published recently in Pediatrics (MTA Cooperative Group, 2004. National Institute of Mental Health Multimodal Treatment Study of ADHD: 24-Month Outcomes of Treatment Strategies for ADHD, 113, 754-760.). In this report, the MTA researchers examined how children were faring 10 months after all study-related treatments had ended. During these 10 months, children were no longer receiving any treatment services from the researchers; instead, they received whatever interventions their parents selected for them from providers in their community.

Thus, children who had received medication treatment through the study may or may not have continued on medication. And, if their parents chose to continue medication treatment, they were no longer carefully monitored by MTA researchers so that treatment adjustments could be made when indicated. Similarly, children who received intensive behavior therapy were no longer be receiving such treatment through the study. Parents of these children could thus continue with behavioral intervention in whatever way they were able to. Or, they may have opted to begin treating their child with medication.

To examine whether treatment benefits persisted, the MTA researchers examined 24-month follow-up data on children in 4 different domains: core ADHD symptoms, symptoms of Oppositional Defiant Disorder (ODD; for a discussion of ODD please visit http://parentsubscribers.c.topica.com/maaclGpaa7D1Vb3aW2hb/), social skills, and reading. They also examined whether parents' use of negative ineffective discipline strategies differed according to children's initial treatment assignment.

RESULTS

In general, results from the 24-month outcome analyses were similar to those found at 14 months. For core symptoms of ADHD and ODD, children who had received intensive medication treatment - either alone or in combination with behavior therapy - had superior outcomes to those who received intensive behavior therapy only or community care. Some, but not all of the persistent benefit of having received intensive medication treatment depended on whether children received medication for some portion of the 10-month interval since study treatment services had ended.

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Compared to the magnitude of the differences that were evident at 14 months the superior outcomes for children who had received medication treatment from the researchers was reduced by about 50%. Children who had received combined treatment were not doing significantly better than those who received intensive medication treatment alone. And, those who received intensive behavioral treatment were not doing better than children who had received routine community care.

In order to better understand the clinical significance of these findings, the researchers examined the percentage of children in each group who had levels of ADHD and ODD symptoms at 24 months that fell within the normal range. These percentages were 48%, 37%, 32%, and 28% for the combined, medication only, behavior therapy, and community care groups respectively. Thus, as was found at the 14-month outcome assessment, normalization rates of ADHD and ODD symptoms was highest among children whose treatment included the intensive MTA medication component. It is noteworthy, however, that while the percentages of children with normalized symptom levels were essentially unchanged for the behavior therapy and community care groups, they had declined substantially for the combined (i.e., from 68% to 47%) and medication only (i.e., from 56% to 37%) groups.

For the other domains examined - social skills, reading achievement, and parents use of negative/ineffective discipline strategies there was no evidence of significant treatment group differences in 24-month outcomes. In the social skills domain, however, children who received combined treatment tended to be doing better than children who received intensive medication treatment alone. Similar results were found for parents' use of negative/ineffective discipline. Thus, there continued to be some indication that combined treatment may have been more effective in some domains that medication management only.

As a final analysis, the researchers examined the use of medication treatment for children in each group at the 24-month outcome period. Seventy percent of children in the combined group and 72% of children in the medication only group were still taking medication. In contrast, 38% of children in the behavior therapy group had been started on medication and 62% of children who received community care were on medication. The doses being received by children who had received medication treatment from MTA researchers were higher than for other children.

SUMMARY AND IMPLICATIONS

Results from this study indicate the persistent superiority of the intensive MTA medication treatment for ADHD and ODD symptoms, even after families were left to pursue whatever treatments they preferred and the intensive study-related treatments were replaced with care provided by community physicians. Although these persistent benefits are encouraging, it must be noted that they were less robust than they had been at the 14-month outcome assessment. In addition, there was no evidence that intensive medication treatment was associated with better 24-month outcomes in the other domains examined. Overall, therefore, it appears that the persistent benefits associated with carefully conducted medication treatment were relatively modest.

One likely reason for the dimunition in benefits associated with MTA medication treatment is that a number of children ended medication treatment completely after study-delivered services ended. In addition, it is unlikely that children who continued on medication received the same level of treatment monitoring as had been provided by MTA physicians. Had this careful monitoring of ongoing medication treatment effectiveness continued, it is possible that these children would have continued to do ever better than was found to be the case.

Although children who had received intensive behavior therapy alone were not faring quite as well, a substantial percentage, i.e., 32%, continued to show normalized levels of ADHD and ODD symptoms. Thus, this is additional evidence for the utility of behavior therapy for ADHD. It should be noted, however, that many parents whose child had received behavior therapy chose to begin medication treatment for their child.

In conclusion, results from this study indicate that the benefits of high quality medication treatment persist to some extent even when this treatment is no longer being provided. Although the persistent benefits were modest at best, the MTA authors note that even these modest effects may have important public health benefits. The results also suggest that even intensive multimodal treatment conducted over an extended period does not eliminate the adverse impact of ADHD for most children, and that high quality treatment services provided over many years is likely to be required to help most children reach their full potential.

Finally, these results highlight the pressing need to develop new interventions for ADHD whose efficacy is established through carefully conducted research. Even when provided in the most rigorous way possible, medication and behavior therapy were not successful in normalizing levels of ADHD and ODD symptoms for a large percentage of children. Thus, it seems very important for researchers to focus attention on developing alternative ADHD interventions, and perhaps to strategies for preventing the development of ADHD in the first place.

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Abstract

More than 5 million Americans suffer from eating disorders. Five percent of females and 1% of males have anorexia nervosa, bulimia nervosa, or binge eating disorder. It is estimated that 85% of eating disorders have their onset during the adolescent age period. Although Eating Disorders fall under the category of psychiatric diagnoses, there are a number of nutritional and medical problems and issues that require the expertise of a registered dietitian. Because of the complex biopsychosocial aspects of eating disorders, the optimal assessment and ongoing management of these conditions appears to be with an interdisciplinary team consisting of professionals from medical, nursing, nutritional, and mental health disciplines (1). Medical Nutrition Therapy provided by a registered dietitian trained in the area of eating disorders plays a significant role in the treatment and management of eating disorders. The registered dietitian, however, must understand the complexities of eating disorders such as comorbid illness, medical and psychological complications, and boundary issues. The registered dietitian needs to be aware of the specific populations at risk for eating disorders and the special considerations when dealing with these individuals.

POSITION STATEMENT

It is the position of the American Dietetic Association (ADA) that nutrition education and nutrition intervention, by a registered dietitian, is an essential component of the team treatment of patients with anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (EDNOS) during assessment and treatment across the continuum of care.

INTRODUCTION

Eating Disorders are considered to be psychiatric disorders, but unfortunately they are remarkable for their nutrition and medical-related problems, some of which can be life- threatening. As a general rule, eating disorders are characterized by abnormal eating patterns and cognitive distortions related to food and weight, which in turn result in adverse effects on nutrition status, medical complications, and impaired health status and function (2,3,4,5,6).

Many authors (7,8,9) have noted that anorexia nervosa is detectable in all social classes, suggesting that higher socioeconomic status is not a major factor in the prevalence of anorexia and bulimia nervosa. A wide range of demographics is seen in eating disorder patients. The major characteristic of eating disorders are the disturbed body image in which one's body is perceived as being fat (even at normal or low weight), an intense fear of weight gain and becoming fat, and a relentless obsession to become thinner (8).

Diagnostic criteria for anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (EDNOS) are identified in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (10) (See the Figure). These clinical diagnoses are based on psychological, behavioral, and physiological characteristics.

It is important to note that patients cannot be diagnosed with both anorexia nervosa (AN) and bulimia nervosa (BN) at the same time. Patients with EDNOS do not fall into the diagnostic criterion for either AN or BN, but account for about 50% of the population with eating disorders. If left untreated and behaviors continue, the diagnosis may change to BN or AN. Binge eating disorder is currently classified within the EDNOS grouping.

Over a lifetime, an individual may meet diagnostic criteria for more than one of these conditions, suggesting a continuum of disordered eating. Attitudes and behaviors relating to food and weight overlap substantially. Nevertheless, despite attitudinal and behavioral similarities, distinctive patterns of comorbidity and risk factors have been identified for each of these disorders. Therefore, the nutritional and medical complications and therapy can differ significantly (2,3,11).

Because of the complex biopsychosocial aspects of eating disorders, the optimal assessment and ongoing management of these conditions appear to be under the direction of an interdisciplinary team consisting of professionals from medical, nursing, nutritional and mental health disciplines (1). Medical Nutrition Therapy (MNT) provided by a registered dietitian trained in the area of eating disorders is an integral component of treatment of eating disorders.

COMORBID ILLNESS AND EATING DISORDERS

Patients with eating disorders may suffer from other psychiatric disorders as well as their eating disorder, which increases the complexity of treatment. Registered dietitians must understand the characteristics of these psychiatric disorders and the impact of these disorders on the course of treatment. The experienced dietitian knows to be in frequent contact with the mental health team member in order to have an adequate understanding of the patient's current status. Psychiatric disorders that are frequently seen in the eating disorder population include mood and anxiety disorders (eg, depression, obsessive compulsive disorder), personality disorders, and substance abuse disorders (12).

Abuse and trauma may precede the eating disorder in some patients (13). The registered dietitian must consult with the primary therapist on how to best handle the patient's recall of abuse or dissociative episodes that may occur during nutrition counseling sessions.

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ROLE OF THE TREATMENT TEAM

The care of patients with eating disorder involves expertise and dedication of an interdisciplinary team (3,12,14). Since it is clearly a psychiatric disorder with major medical complications, psychiatric management is the foundation of treatment and should be instituted for all patients in combination with other treatment modalities. A physician familiar with eating disorders should perform a thorough physical exam. This may involve the patient's primary care provider, a physician specializing in eating disorders, or the psychiatrist caring for the patient. A dental exam should also be performed. Medication management and medical monitoring are the responsibilities of the physician(s) on the team. Psychotherapy is the responsibility of the clinician credentialed to provide psychotherapy. This task may be given to a social worker, a psychiatric nurse specialist (advanced practice nurse), psychologist, psychiatrist, a licensed professional counselor or a master's level counselor. In inpatient and partial hospitalization settings, nurses monitor the status of the patient and dispense medications while recreation therapists and occupational therapists assist the patient in acquiring healthy daily living and recreational skills. The registered dietitian assesses the nutritional #status, knowledge base, motivation, and current eating and behavioral status of the patient, develops the nutrition section of the treatment plan, implements the treatment plan and supports the patient in accomplishing the goals set out in the treatment plan. Ideally, the dietitian has continuous contact with the patient throughout the course of treatment or, if this is not possible, refers the patient to another dietitian if the patient is transitioning from an inpatient to an outpatient setting.

Medical nutrition therapy and psychotherapy are two integral parts of the treatment of eating disorders. The dietitian working with eating disorder patients needs a good understanding of personal and professional boundaries. Unfortunately, this is not often taught in traditional training programs. Understanding of boundaries refers to recognizing and appreciating the specific tasks and topics that each member of the team is responsible for covering. Specifically, the role of the registered dietitian is to address the food and nutrition issues, the behavior associated with those issues, and assist the medical team member with monitoring lab values, vital signs, and physical symptoms associated with malnutrition. The psychotherapeutic issues are the focus of the psychotherapist or mental health team member.

Effective nutrition therapy for the patient with an eating disorder requires knowledge of motivational interviewing and cognitive behavioral therapy (CBT) (15). The registered dietitian's communication style, both verbal and nonverbal, can significantly affect the patient's motivation to change. Motivational Interviewing was developed because of the idea that individual's motivation arises from an interpersonal process (16). CBT identifies maladaptive cognitions and involves cognitive restructuring. Erroneous beliefs and thought patterns are challenged with more accurate perceptions and interpretations regarding dieting, nutrition, and the relationship between starvation and physical symptoms (2,15).

The transtheoretical model of change suggests that an individual progresses through various stages of change and uses cognitive and behavioral processes when attempting to change health-related behavior (17,18). Stages include precontemplation, contemplation, preparation, action, and maintenance. Patients with eating disorders often progress along these stages with frequent backsliding along the way to eating disorder recovery. The role of the nutritional therapist is to help move patients along the continuum until they reach the maintenance stage.

MEDICAL CONSEQUENCES AND INTERVENTION IN EATING DISORDERS

Nutritional factors and dieting behaviors may influence the development and course of eating disorders. In the pathogenesis of anorexia nervosa, dieting or other purposeful changes in food choices can contribute enormously to the course of the disease because of the physiological and psychological consequences of starvation that perpetuate the disease and impede progress toward recovery (2,3,6,19,20). Higher prevalence rates among specific groups, such as athletes and patients with diabetes mellitus (21), support the concept that increased risk occurs with conditions in which dietary restraint or control of body weight assume great importance. However, only a small proportion of individuals who diet or restrict intake develop an eating disorder. In many cases, psychological and cultural pressures must exist along with physical, emotional, and societal pressures for an individual to develop an eating disorder.

ANOREXIA NERVOSA

Medical Symptoms Essential to the diagnosis of AN is that patients weigh less than 85% of that expected. There are several ways to determine 20 years of age) a BMI <18.5 is considered underweight and a BMI <17.5 is diagnostic for AN (6,22). For postmenarchal adolescents and adults a standard formula to determine average body weight (ABW) for height can also be used (100 lb for 5 ft of height plus 5 lb for each inch over 5 ft tall for women and 106 lb. For 5 ft of height plus 6 lb for each additional inch). The 85th % of ABW can be diagnostic of AN (5). For children and young adults up to the age of 20 the #percent of average weight-for-height can be calculated by using CDC growth charts or the CDC body mass index charts (23). Because children are still growing, the BMIs increase with age in children and therefore the BMI percentiles must be used, not the actual numbers. Individuals with BMIs less than the 10th percentile are considered underweight and BMIs less than 5th percentile are at risk for AN (3,5-7). In all cases, the patient's body build, weight history, and stage of development (in adolescents) should be considered.

Physical anorexia symptoms can range from lanugo hair formation to life threatening cardiac arrhythmias. Physical characteristics include lanugo hair on face and trunk, brittle listless hair, cyanosis of hands and feet, and dry skin. Cardiovascular changes include bradycardia (HR <60 beats/min), hypotension ( systolic <90 mm HG), and orthostatic hypotension (2,5,6). Many patients, as well as some health providers, attribute the low heart rate and low blood pressure to their physical fitness and exercise regimen. However, Nudel (24) showed these lower vital signs actually altered cardiovascular responses to exercise in patients with AN. A reduced heart mass has also been associated with the reduced blood pressure and pulse rate (25- #30). Cardiovascular complications have been associated with death in AN patients.

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Anorexia nervosa can also significantly affect the gastrointestinal tract and brain mass of these individuals. Self-induced starvation can lead to delayed gastric emptying, decreased gut motility, and severe constipation. There is also evidence of structural brain abnormalities (tissue loss) with prolonged starvation, which appears early in the disease process and may be of substantial magnitude. While it is clear that some reversibility of brain changes occurs with weight recovery, it is uncertain whether complete reversibility is possible. To minimize the potential long-term physical complication of AN, early recognition and aggressive treatment is essential for young people who develop this illness (31-34).

Amenorrhea is a primary characteristic of AN. Amenorrhea is associated with a combination of hypothalamic dysfunction, weight loss, decreased body fat, stress, and excessive exercise. The amenorrhea appears to be caused by an alteration in the regulation of gonadotropin-releasing hormone. In AN, gonadotropins revert to prepubertal levels and patterns of secretion (4,7,35).

Osteopenia and osteoporosis, like brain changes, are serious and possibly irreversible medical complications of anorexia nervosa. This may be serious enough to result in vertebra compression and stress fractures (36-37). Study results indicate that some recovery of bone may be possible with weight restoration and recovery, but compromised bone density has been evident 11 years after weight  restoration and recovery (38,39). In adolescents, more bone recovery may be possible. Unlike other conditions in which low circulating estrogen concentrations are associated with bone loss (eg, perimenopause), providing exogenous estrogen has not been shown to preserve or restore bone mass in the anorexia nervosa patient (40). Calcium supplementation alone (1500 mg/dL) or in combination with estrogen has not been observed to promote increased bone density (2). Adequate calcium intake may help to lessen bone loss (6). Only weight restoration has been shown to increase bone density.

In patients with AN, laboratory values usually remain in normal ranges until the illness is far advanced, although true laboratory values may be masked by chronic dehydration. Some of the earliest lab abnormalities include bone marrow hypoplasia, including varying degrees of leukopenia and thrombocytopenia (41-43). Despite low-fat and low-cholesterol diets, patients with AN often have elevated cholesterol and abnormal lipid profiles. Reasons for this include mild hepatic dysfunction, decreased bile acid secretion, and abnormal eating patterns (44). Additionally, serum glucose tends to be low, secondary to a deficit of precursors for gluconeogenesis and glucose production (7). Patients with AN may have repeated episodes of hypoglycemia.

Despite dietary inadequacies, vitamin and mineral deficiencies are rarely seen in AN. This has been attributed to a decreased metabolic need for micronutrients in a catabolic state. Additionally, many patients take vitamin and mineral supplements, which may mask true deficiencies. Despite low iron intakes, iron deficiency anemia is rare. This may be due to decreased needs due to amenorrhea, decreased needs in a catabolic state and altered states of hydration (20). Prolonged malnutrition leads to low levels of zinc, vitamin B12, and folate. Any low nutrient levels should be treated appropriately with food and supplements as needed.

Medical and Nutritional Management

Treatment for anorexia nervosa may be inpatient or outpatient based, depending upon the severity and chronicity of both the medical and behavioral components of the disorder. No single professional or professional discipline is able to provide the necessary broad medical, nutritional, and psychiatric care necessary for patients to recover. Teams of professionals who communicate regularly must provide this care. This teamwork is necessary whether the individual is undergoing inpatient or outpatient treatment.

Although weight is a critical monitoring tool to determine a patient's progress, each program must individualize its own protocol for weighing the patient on an inpatient program. The protocol should include who will do the weighing, when the weighing will occur, and whether or not the patient is allowed to know their weight. In the outpatient setting, the team member weighing the patient may vary with the setting. In a clinic model, the nurse may weigh the patient as part of her responsibilities in taking vital signs. The patient then has the opportunity to discuss their reaction to the weight when seen by the registered dietitian. In a community outpatient model, the nutrition session is the appropriate place for weighing the patient, discussing reactions to weight and providing explanations for weight changes. In some cases such as a patient expressing suicidality, alternatives to the weight procedure may be used. For example, the patient may be weighed with their back to the scale and not told their weight, the mental health professional may do the weighing or if the patient is medically stable the weight for that visit may be skipped. In such cases, there are many other tools to monitor the patient's medical condition, such as vital signs, emotional health, and laboratory measurements.

Outpatient

In AN the goals of outpatient treatment are to focus on nutritional rehabilitation, weight restoration, cessation of weight reduction behaviors, improvement in eating behaviors, and improvement in psychological and emotional state. Clearly weight restoration alone does not indicate recovery, and forcing weight gain without psychological support and counseling is contraindicated. Typically, the patient is terrified of weight gain and may be struggling with hunger and urges to binge but the foods he/she allows himself/herself are too limited to enable sufficient energy intake (3,45). Individualized guidance and a meal plan that provides a framework for meals and snacks and food choices (but not a rigid diet) is helpful for most patients. The registered dietitian determines the individual caloric needs and with the patient develops a nutrition plan that allows the patient to meet these nutrition needs. In the early treatment of AN, this may be done on a gradual basis, increasing the caloric prescription in increments to reach the necessary caloric intake. MNT should be targeted at helping the patient understand nutritional needs as well as helping them begin to make wise food choices by increasing variety in diet and by practicing appropriate food behaviors (2). One effective counseling technique is CBT, which involves challenging erroneous beliefs and thought patterns with more accurate perceptions and interpretations regarding dieting, nutrition and the relationship between starvation and physical symptoms (15). In many cases, monitoring skinfolds can be helpful in determining composition of weight gain as well as being useful as an educational tool to show the patient the composition of any weight gain (lean body mass vs. fat mass). Percent body fat can be estimated from the sum of four skinfold measurements (triceps, biceps, subscapular and suprailiac crest) using the calculations of Durnin (46-47). This method has been validated against underwater weighing in adolescent girls with AN (48). Bioelectrical impedance analysis has been shown to be unreliable in patients with AN secondary to changes in intracellular and extracellular fluid changes and chronic dehydration (49,50).

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The registered dietitian will need to recommend dietary supplements as needed to meet nutritional needs. In many cases, the registered dietitian will be the team member to recommend physical activity levels based on medical status, psychological status, and nutritional intake. Physical activity may need to be limited or initially eliminated with the compulsive exerciser who has AN so that weight restoration can be achieved. The counseling effort needs to focus on the message that exercise is an activity undertaken for enjoyment and fitness rather than a way to expend energy and promote weight loss. Supervised, low weight strength training is less likely to impede weight gain than other forms of activity and may be psychologically helpful for patients (7). Nutrition therapy must be ongoing to allow the patient to understand his/her nutritional needs as well as to adjust and adapt the nutrition plan to meet the patient's medical and nutritional requirements.

During the refeeding phase (especially in the early refeeding process), the patient needs to be monitored closely for signs of refeeding syndrome (51). Refeeding syndrome is characterized by sudden and sometimes severe hypophosphatemia, sudden drops in potassium and magnesium, glucose intolerance, hypokalemia, gastrointestinal dysfunction, and cardiac arrhythmias (a prolonged QT interval is a contributing cause of the rhythm disturbances) (27,52,53). Water retention during refeeding should be anticipated and discussed with the patient. Guidance with food choices to promote normal bowel function should be provided as well (2,45). A weight gain goal of 1 to 2 pounds per week for outpatient and 2 to 3 pounds for inpatients is recommended. In the beginning of therapy the registered dietitian will need to see the patient on a frequent basis. If the patient responds to medical, nutritional, and psychiatric therapy, nutrition visits may be less frequent. Refeeding syndrome can be seen in both the outpatient and inpatient settings and the patient should be monitored closely during the early refeeding process. Because more aggressive and rapid refeeding is initiated on the inpatient units, refeeding syndrome is more commonly seen in these units. (2,45).

Inpatient

Although many patients may respond to outpatient therapy, others do not. Low weight is only one index of malnutrition; weight should never be used as the only criterion for hospital admission. Most patients with AN are knowledgeable enough to falsify weights through such strategies as excessive water/fluid intake. If body weight alone is used for hospital admission criteria, behaviors may result in acute hyponatremia or dangerous degrees of unrecognized weight loss (5). All criteria for admission should be considered. The criteria for inpatient admission include (5,7,53):

Severe malnutrition (weight <75% expected weight/height) Dehydration Electrolyte disturbances Cardiac dysrhythmia (including prolonged QT) Physiological instability

severe bradycardia (45/min) hypotension hypothermia (36° C) orthostatic changes (pulse and blood pressure)

Arrested growth and development Failure of outpatient treatment Acute food refusal Uncontrollable binge eating and purging Acute medical complication of malnutrition (e.g., syncope, seizures, cardiac failure, pancreatitis, etc.) Acute psychiatric emergencies (e.g., suicidal ideation, acute psychoses) Comorbid diagnosis that interferes with the treatment of the eating disorder (e.g., severe depression, obsessive compulsive disorder, severe family dysfunction).

The goals of inpatient therapy are the same as outpatient management; only the intensity increases. If admitted for medical instability, medical and nutrition stabilization is the first and most important goal of inpatient treatment. This is often necessary before psychological therapy can be optimally effective. Often, the first phase of inpatient treatment is on a medical unit to medically stabilize the patient. After medical stabilization the patient can be moved to an inpatient psychiatric floor or discharged home to allow the patient to try outpatient treatment. If a patient is admitted for psychiatric instability but is medically stable, the patient should be admitted directly to a psychiatric floor or facility (7,54,55).

The registered dietitian should guide the nutrition plan. The nutrition plan should help the patient, as quickly as possible, to consume a diet that is adequate in energy intake and nutritionally well balanced. The registered dietitian should monitor the energy intake as well as body composition to ensure that appropriate weight gain is achieved. As with outpatient therapy, MNT should be targeted at helping the patient understand nutritional needs as well as help the patient to begin to make wise food choices by increasing variety in diet and by practicing appropriate food behaviors (2). In very rare instances, enteral or parenteral feeding may be necessary. However, risks associated with aggressive nutrition support in these patients are substantial, including hypophosphatemia, edema, cardiac failure, seizures, aspiration of enteral formula and death (2,55). Reliance on foods (rather than enteral or parenteral nutrition support) as the primary method of weight restoration contrib#utes significantly to successful long-term recovery. The overall goal is to help the patient normalize eating patterns and learn that behavior change must involve planning and practicing with real food.

Partial Hospitalizations

Partial hospitalizations (day treatment) are increasingly utilized in an attempt to decrease the length of some inpatient hospitalizations and also for milder AN cases, in place of a hospitalization. Patients usually attend for 7 to 10 hours per day, and are served two meals and 1 to 2 snacks. During the day, they participate in medical and nutritional monitoring, nutrition counseling, and psychotherapy, #both group and individual. The patient is responsible for one meal and any recommended snacks at home. The individual who participates in partial hospitalization must be motivated to participate and be able to consume an adequate nutritional intake at home as well as follow recommendations regarding physical activity (11).

Recovery

Recovery from AN takes time. Even after the patient has recovered medically they may need ongoing psychological support to sustain the change. For patients with AN, one of their greatest fears is reaching a low healthy weight and not being able to stop gaining weight. In long-term follow-up the registered dietitian's role is to assist the patient in reaching an acceptable healthy weight and to help the patient maintain this weight over time. The registered dietitian's counseling should focus on helping the patient to consume an appropriate, varied diet to maintain weight and appropriate body composition

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BULIMIA NERVOSA

Bulimia Nervosa (BN) occurs in approximately 2 to 5% of the population. Most patients with BN tend to be of normal weight or moderately overweight and therefore are often undetectable by appearance alone. The average onset of BN occurs between mid-adolescence and the late 20s with a great diversity of socioeconomic status. A full syndrome of BN is rare in the first decade of life. A biopsychosocial model seems best for explaining the etiology of BN (55). The individual at risk for the disorder may have a biological vulnerability to depression that is exacerbated by a chaotic and conflicting family and social role expectations. Society's emphasis on thinness often helps the person identify weight loss as the solution. Dieting then leads to binging, and the cyclical disorder begins (56,57). A subgroup of these patients exists where the binging proceeds dieting. This group tends to be of a higher body weight (58). The patient with BN has an eating pattern which is typically chaotic although rules of what should be eaten, how much and what constitutes good and bad foods occupy the thought process for the majority of the patient's day. Although the amount of food consumed that is labeled a binge episode is subjective, the criteria for bulimia nervosa requires other measures such as the feeling of out-of-control behavior during the bingeing (See Figure).

Although the diagnostic criteria for this disorder focuses on the binge/purge behavior, much of the time the person with BN is restricting her/his diet. The dietary restriction can be the physiological or psychological trigger to subsequent binge eating. Also, the trauma of breaking rules by eating something other than what was intended or more than what was intended may lead to self-destructive binge-eating behavior. Any subjective or objective sensation of stomach fullness may trigger the person to purge. Common purging methods consist of selfinduced vomiting with or without the use of syrup of ipecac, laxative use, diuretic use, and excessive exercise. Once purged, the patient may feel some initial relief; however, this is often followed by guilt and shame. Resuming normal eating commonly leads to gastrointestinal complaints such as bloating, constipation and flatulence. This physical discomfort as well as the guilt from binging often results in a cyclical pattern as the patient tries to get back on track by restricting once again. Although the focus is on the food, the binge/purge behavior is often a means for the person to regulate and manage emotions and to medicate psychological pain (59).

Medical Symptoms

In the initial assessment, it is important to assess and evaluate for medical conditions that may play a role in the purging behavior. Conditions such as esophageal reflux disease (GERD) and helicobacter pylori may increase the pain and the need for the patient to vomit. Interventions for these conditions may help in reducing the vomiting and allow the treatment for BN to be more focused. Nutritional abnormalities for patients with BN depend on the amount of restriction during the non-binge episodes. It is important to note that purging behaviors do not completely prevent the utilization of calories from the binge; an average retention of 1200 calories occurs from binges of various sizes and contents (60,61).

Muscle weakness, fatigue, cardiac arrhythmias, dehydration and electrolyte imbalance can be caused by purging, especially self-induced vomiting and laxative abuse. It is common to see hypokalemia and hypochloremic alkalosis as well as gastrointestinal problems involving the stomach and esophagus. Dental erosion from self-induced vomiting can be quite serious. Although laxatives are used to purge calories, they are quite ineffective. Chronic ipecac use has been shown to cause skeletal myopathy, electrocardiographic changes and cardiomyopathy with consequent congestive heart failure, arrhythmia and sudden death (2).

Medical and Nutritional Management of Bulimia Nervosa As with AN, interdisciplinary team management is essential to care. The majority of patients with BN are treated in an outpatient or partial hospitalization setting. Indications for inpatient hospitalization include severe disabling symptoms that are unresponsive to outpatient treatment or additional medical problems such as uncontrolled vomiting, severe laxative abuse withdrawal, metabolic abnormalities or vital sign changes, suicidal ideations, or severe, concurrent substance abuse (12).

The registered dietitian's main role is to help develop an eating plan to help normalize eating for the patient with BN. The registered dietitian assists in the medical management of patients through the monitoring of electrolytes, vital signs, and weight and monitors intake and behaviors, which sometimes allows for preventive interventions before biochemical index change. Most patients with BN desire some amount of weight loss at the beginning of treatment. It is not uncommon to hear patients say that they want to get well but they also want to lose the number of pounds that they feel is above what they should weigh. It is important to communicate to the patient that it is incompatible to diet and recover from the eating disorder at the same time. They must understand that the primary goal of intervention is to normalize eating patterns. Any weight loss that is achieved would occur as a result of a normalized eating plan and the elimination of binging. Helping patients combat food myths often requires specialized nutrition knowledge. The registered dietitian is uniquely qualified to provide scientific nutrition education (62). Given that there are so many fad diets and fallacies about nutrition, it is not uncommon for other members of the treatment team to be confused by the nutrition fallacies. Whenever possible, it is suggested that either formal or informal basic nutrition education inservices be provided for the treatment team.

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307.1 Anorexia Nervosa

Diagnostic criteria for 307.1 Anorexia Nervosa

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

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

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

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

Specify type:

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

Binge-Eating/Purging Type: during the current episode of Anorexia Nervosa, the person has regularly engaged in binge-eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas)

307.51 Bulimia Nervosa

Diagnostic criteria for 307.51 Bulimia Nervosa A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

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

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

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

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

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

E. The disturbance dose not occur exclusively during episodes of Anorexia Nervosa.

Specify type:

Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas

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

307.50 Eating Disorder Not Otherwise Specified

The Eating Disorder Not Otherwise Specified category is for disorders of eating that do not meet the criteria for any specific Eating Disorder. Examples include:

1. For females, all of the criteria for Anorexia Nervosa are met except that the individual has regular menses.

2. All of the criteria for Anorexia Nervosa are met except that, despite significant weight loss, the individual's current weight is in the normal range.

3. All of the criteria for Bulimia Nervosa are met except that the binge-eating inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than 3 months.

4. The regular use of inappropriate compensatory behavior by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies).

5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food.

6. Binge-eating disorder; recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of Bulimia Nervosa (see p. 785 for suggested research criteria).

Binge-Eating Disorder

Research criteria for binge eating disorder A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:

1. eating, in a discrete period of time1 (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances

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

B. The binge-eating episodes are associated with three (or more) of the following:

1. eating much more rapidly than normal

2. eating until feeling uncomfortably full

3. eating large amounts of food when not feeling physically hungry

4. eating alone because of being embarrassed by how much one is eating

5. feeling disgusted with oneself, depressed, or very guilty after overeating

C. Marked distress regarding binge eating is present.

D. The binge eating occurs, on average, at least 2 days, 1 a week for 6 months.

E. The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa.

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Normalized eating plan and the stop of binge eating. Helping patients combat food myths often requires specialized nutrition knowledge. The registered dietitian is uniquely qualified to provide scientific nutrition education (62). Given that there are so many fad diets and fallacies about nutrition, it is not uncommon for other members of the treatment team to be confused by the nutrition fallacies. Whenever possible, it is suggested that either formal or informal basic nutrition education inservices be provided for the treatment team.

Cognitive-behavioral therapy is now a well-established treatment modality for BN (15,63). A key component of the CBT process is nutrition education and dietary guidance. Meal planning, assistance with a regular pattern of eating, and rationale for and discouragement of dieting are all included in CBT. Nutrition education consists of teaching about body weight regulation, energy balance, effects of starvation, misconceptions about dieting and weight control and the physical consequences of purging behavior. Meal planning consists of three meals a day, with one to three snacks per day prescribed in a structured fashion to help break the chaotic eating pattern that continues the cycle of binging and purging. Caloric intake should initially be based on the maintenance of weight to help prevent hunger since hunger has been shown to substantially increase the susceptibility to binging. One of the hardest challenges of normalizing the eating pattern of the person with BN is to expand the diet to include the patient's self-imposed "forbidden" or "feared" foods. CBT provides a structure to plan for and expose patients to these foods from least feared to most feared, while in a safe, structured, supportive environment. This step is critical in breaking the all or none behavior that goes along with the deprive-binge cycle.

Discontinuing purging and normalizing eating patterns are a key focus of treatment. Once accomplished, the patient is faced with fluid retention and needs much education and understanding of this temporary, yet disturbing phenomenon. Education consists of information about the length of time to expect the fluid retention and information on calorie conversion to body mass to provide evidence that the weight gain is not causing body mass gain. In some cases, utilization of skinfold measurements to determine percent body fat may be helpful in determining body composition changes. The patient must also be taught that continual purging or other methods of dehydration such as restricting sodium, or using diuretics or laxatives will prolong the fluid retention.

If the patient is laxative dependent, it is important to understand the protocol for laxative withdrawal to prevent bowel obstruction. The registered dietitian plays a key role in helping the patient eat a high fiber diet with adequate fluids while the #physician monitors the slow withdrawal of laxatives and prescribes a stool softener.

A food record can be a useful tool in helping to normalize the patient's intake. Based on the patient's medical, psychological and cognitive status, food records can be individualized with columns looking at the patient's thoughts and reactions to eating/not eating to gather more information and to educate the patient on the antecedents of her/his behavior. The registered dietitian is the expert in explaining to a patient how to keep a food record, reviewing food records and understanding and explaining weight changes. Other members of the team may not be as sensitive to the fear of food recording or as familiar with strategies for reviewing the record as the registered dietitian. The registered dietitian can determine whether weight change is due to a fluid shift or a change in body mass.

Medication management is more effective in treating BN than in AN and especially with patients who present with comorbid conditions (11,62). Current evidence cites combined medication management and CBT as most effective in treating BN, (64) although research continues to look at the effectiveness of other methods and combinations of methods of treatment.

EATING DISORDERS NOT OTHERWISE SPECIFIED (EDNOS)

The large group of patients who present with EDNOS consists of subacute cases of AN or BN. The nature and intensity of the medical and nutritional problems and the most effective treatment modality will depend on the severity of impairment and the symptoms. These patients may have met all criteria for anorexia except that they have not missed three consecutive menstrual periods. Or, they may be of normal weight and purge without binging. Although the patient may not present with medical complications, they do often present with medical concerns.

EDNOS also includes Binge Eating Disorder (BED) which is listed separately in the appendix section of the DSM IV (See Figure) in which the patient has binging behavior without the compensatory purging seen in Bulimia Nervosa. It is estimated that prevalence of this disorder is 1 to 2% of the population. Binge episodes must occur at least twice a week and have occurred for at least 6 months. Most patients diagnosed with BED are overweight and suffer the same medical problems faced by the nonbinging obese population such as diabetes, high blood pressure, high blood cholesterol levels, gallbladder disease, heart disease and certain types of cancer.

The patient with binge eating disorder often presents with weight management concerns rather than eating disorder concerns. Although researchers are still trying to find the treatment that is the most helpful in controlling binge eating disorder, many treatment manuals exist utilizing the CBT model shown effective for Bulimia Nervosa. Whether weight loss should occur simultaneously with CBT or after a period of more stable, consistent eating is still being investigated (65,66,67)

In a primary care setting, it is the registered dietitian who often recognizes the underlying eating disorder before other members of the team who may resist a change of focus if the overall objective for the patient is weight loss. It is then the registered dietitian who must convince the primary care team and the patient to modify the treatment plan to include treatment of the eating disorder.

THE ADOLESCENT PATIENT

Eating disorders rank as the third most common chronic illness in adolescent females, with an incidence of up to 5%. The prevalence has increased dramatically over the past three decades (5,7). Large numbers of adolescents who have disordered eating do not meet the strict DSM-IV-TR criteria for either AN or BN but can be classified as EDNOS. In one study, (68) more than half of the adolescents evaluated for eating disorders had subclinical disease but suffered a similar degree of psychological distress as those who met strict diagnostic criteria. Diagnostic criteria for eating disorders such as DSMIV- TR may not be entirely applicable to adolescents. The wide variability in the rate, timing and magnitude of both height and weight gain during normal puberty, the absence of menstrual periods in early puberty along with the unpredictability of #menses soon after menarche, and the lack of abstract concepts, limit the application of diagnostic criteria to adolescents (5,69,70).

Because of the potentially irreversible effects of an eating disorder on physical and emotional growth and development in #adolescents, the onset and intensity of the intervention in adolescents should be lower than adults. Medical complications in adolescents that are potentially irreversible include: growth retardation if the disorder occurs before closure of the epiphyses, pubertal delay or arrest, and impaired acquisition of peak bone mass during the second decade of life, increasing the risk of osteoporosis in adulthood (7,69).

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Adolescents with eating disorders require evaluation and treatment focused on biological, psychological, family, and social features of these complex, chronic health conditions. The expertise and dedication of the members of a treatment team who work specifically with adolescents and their families are more important than the particular treatment setting. In fact, traditional settings such as a general psychiatric ward may be less appropriate than an adolescent medical unit. Smooth transition from inpatient to outpatient care can be facilitated by an interdisciplinary team that provides continuity of care in a comprehensive, coordinated, developmentally oriented manner. Adolescent health care specialists need to be familiar with working not only with the patient, but also with the family, school, coaches, and other agencies or individuals who are important influences on healthy adolescent development (1,7).

In addition to having skills and knowledge in the area of eating disorders, the registered dietitian working with adolescents needs skills and knowledge in the areas of adolescent growth and development, adolescent interviewing, special nutritional needs of adolescents, cognitive development in adolescents, and family dynamics (71). Since many patients with eating disorders have a fear of eating in front of others, it can be difficult for the patient to achieve adequate intake from meals at school. Since school is a major element in the life of adolescents, dietitians need to be able to help adolescents and their families work within the system to achieve a healthy and varied nutrition intake. The registered dietitian needs to be able to provide MNT to the adolescent as an individual but also work with the family while maintaining the confidentiality of the adolescent. In working with the family of an adolescent, it is important to remember that the adolescent is the patient and that all therapy should be planned on an individual basis. Parents can be included for general nutrition education with the adolescent present. It is often helpful to have the RD meet with adolescent patients and their parents to provide nutrition education and to clarify and answer questions. Parents are often frightened and want a quick fix. Educating the parents regarding the stages of the nutrition plan as well as explaining the hospitalization criteria may be helpful.

There is limited research in the long-term outcomes of adolescents with eating disorders. There appear to be limited prognostic indicators to predict outcome (3,5,72). Generally, poor prognosis has been reported when adolescent patients have been treated almost exclusively by mental health care professionals (3,5). Data from treatment programs based in adolescent medicine show more favorable outcomes. Reviews by Kriepe and colleagues (3, 5, 73) showed a 71 to 86% satisfactory outcome when treated in adolescent-based programs. Strober and colleagues (72) conducted a long-term prospective follow-up of severe AN patients admitted to the hospital. At follow-up, results showed that nearly 76% of the cohort meet criteria for full recovery. In this study, approximately 30% of patients had relapses following hospital discharge. The authors also noted that the time to recovery ranged from 57 to 79 months.

POPULATIONS AT HIGH RISK

Specific population groups who focus on food or thinness such as athletes, models, culinary professionals, and young people who may be required to limit their food intake because of a disease state, are at risk for developing an eating disorder (21). Additionally, risks for developing an eating disorder may stem from predisposing factors such as a family history of mood, anxiety or substance abuse disorders. A family history of an eating disorder or obesity, and precipitating factors such as the dynamic interactions among family members and societal pressures to be thin are additional risk factors (74,75).

The prevalence of formally diagnosable AN and BN in males is accepted to be from 5 to 10% of all patients with an eating disorder (76,77). Young men who develop AN are usually members of subgroups (eg, athletes, dancers, models/ performers) that emphasize weight loss. The male anorexic is more likely to have been obese before the onset of the symptoms. Dieting may have been in response to past teasing or criticisms about his weight. Additionally, the association between dieting and sports activity is stronger among males. Both a dietary and activity history should be taken with special emphasis on body image, performance, and sports participation on the part of the male patient. These same young men should be screened for androgenic steroid use. The DSM- IVTR diagnostic criterion for AN of <85th percentile of ideal body weight is less useful in males. A focus on the BMI, nonlean body mass (percent body fat), and the height-weight ratio are far more useful in the assessment of the male with an eating disorder. Adolescent males below the 25th percentile for BMI, upper arm circumference, and subscapular and triceps skinfold thicknesses, should be considered to be in an unhealthy, malnourished state (69).

HUNGER/SATIETY CUES IN MANAGING AN EATING DISORDER

With the emergence of the nondieting approach to the treatment of disordered eating and obesity, it would seem that the use of hunger/satiety cues in managing an eating disorder may assist in resuming normal eating patterns. At this point in time, research suggests that eating-disordered patients have predominantly "abnorma" patterns of hunger and fullness, indicating a confusion of these concepts. Whether or not normal patterns of hunger and satiety resume after the normalization of weight and eating behaviors has yet to be determined (79- 81).

CONCLUSION

Eating disorders are complex illnesses. To be effective in treating individuals who suffer from these illnesses, the expert interaction between professionals in many disciplines is required. The registered dietitian is an integral member of the treatment team and is uniquely qualified to provide the medical nutrition therapy for patients with eating disorders. The registered dietitian working with this population must understand the complexities and the long-term commitment involved. Entry-level dietetics provides the basics of assessment and nutrition counseling, but working with this population requires advanced level training, which may come from a combination of self-study, continuing education programs and supervision by another experienced registered dietitian and/or an eating disorder therapist. Knowledge and practice using motivational interviewing and cognitive-behavioral therapy will enhance the effectiveness of counseling this population. Practice groups of the American Dietetic Association such as Sports, Cardiovascular, and Sports Nutrition (SCAN) and the Pediatric Nutrition Practice Group (PNPG) as well as other eating disorders organizations such as the Academy of Eating Disorders and the International Association of Eating Disorder Professionals provide workshops, newsletters and conferences which are helpful for the registered dietitian.

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Elderly persons with depression have poor chances of full recovery, especially if they are older than 75, according to a study published in this month's issue of the Archives of General Psychiatry.

The study's primary goal was to analyze the natural history of late-life depression, systematically comparing those who did with those who did not fulfill rigorous diagnostic criteria.

Aartjan T. F. Beekman, M.D., Ph.D., of the department of psychiatry at Vrije University in Amsterdam, and colleagues studied the natural history of depression among elderly men and women aged 55 to 85 over a six-year period. They studied data from 277 participants in the Longitudinal Aging Study Amsterdam, a 10-year study of the well being and functioning of the elderly in the Netherlands.

The patients chosen were previously diagnosed with depression. The average age for participants was 71.8 years, and about 65 percent were female.

Depression is a common disorder among the elderly but has not been well studied, according to the study.

The study's findings appeared in the article, The Natural History of Late-Life Depression, a 6-Year Prospective Study in the Community, which indicated that although depression is generally regarded to be highly treatable throughout the life cycle, most elderly persons with depression remain untreated.

"This is an alarming finding, since it shows that a lot of older persons suffer from this condition over a very long time," Brenda Penninx, Ph.D., associate professor of geriatrics and director of the Geriatric Research Center at Wake Forest University School of Medicine, told MHW. "The majority of persons in this study did not seek treatment for their depressive condition."

Penninx, one of the researchers, continued, "Indeed, it can be expected that appropriate treatment (which could be antidepressant medication, psychotherapy, exercise, social activity or combinations of these) could have reduced the chronicity of depressive symptoms," she said. "However, this was not studied in this longitudinal cohort study."

Researchers conducted interviews at the beginning of the study, at three years and at six years. In between interviews, participants completed questionnaires sent through the mail every five months for the first three years and every six months for the last three years.

During each interview, the participants' form of depression was identified using the Diagnostic Interview Schedule, a common test in epidemiological research of the elderly. Four types emerged: subthreshold depression (207 participants), dysthymia (a mild, chronic form of depression) (25 participants); major depressive disorder (MDD) (23 participants); and a combination of dysthymia and MDD (22 participants).

The researchers analyzed remission in the four diagnostic subgroups, which revealed that persons with sub-threshold depression were most likely to have recovered by the end of the study. Those with a combination of dysthymia and MDD faced the most serious prognosis -- few elderly persons who were diagnosed with this disorder recovered within the six-year period. Also, persons who were 75 to 85 years old at the beginning of the study had more severe and persistent symptoms than younger participants.

After analysis of the severity and duration of symptoms over the six-year period, researchers found that 23 percent of participants had true remissions, 12 percent had remission with a few recurrences, 32 percent had more than one remission followed by a persistent recurrence of symptoms, and 32 percent had chronic depression.

According to Penninx, a lot of older depressed persons may not receive appropriate treatment because their depression is not recognized, which may be due to "... ignorance of physicians or more focus on other somatic conditions, which could leave less time for addressing emotional health," she said.

Seniors may feel that depression is affiliated with aging or does not deserve a physician's attention, Penninx added.

"The implications of the study are that the burden of depression for elderly persons in the community is even more severe than previously thought," the researchers said. "The data clearly demonstrate the need for interventions that are helpful, acceptable and economically feasible to be performed on a larger scale."

Source: Mental Health Weekly 12(28):3-4, 08/2002. © 2002 Manisses Communications Group, Inc.

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Eating Disorders among African American Women

Abstract: A review of published studies reveals a serious deficit in scope of eating disorders among African American women. While the "Prevalence of Eating Disorders Among African American Women" (Mulholland & Mintz, 2001), and "A Comparison of Black and White Women With Binge Eating Disorder" (Pike, Dohm, Stiegel-Moore, Wilfley, & Fairburn, 2001) offer substantial findings in an area of under representation, the findings of these studies leave many vacancies in the true picture of eating disorders among African American women. Sufficient examination of the relationship of familial roles, cultural influences, and unique stressors to African American women are not prevalent in the available studies and are not evaluated as substantial influences on maladaptive eating regulation responses.

The exclusion of women from prominent research studies, such as research on heart disease, cancer, and aging, has been well documented. This exclusion has resulted in the development of research and clinical studies, which specifically concentrate on women. When examining studies conducted on eating disorders, there is a major focus on infants, children, and adult women, Caucasian women.There is a deficit of research studies, which evaluate the prevalence of eating disorders among African-American women.  Upon evaluation of the literature, there is reason to question if a true picture of eating disorders among African-American women has been identified.

Principles and Practice of Psychiatric Nursing (Stuart & Laraia, 2001) defines eating disorders as the use of food "... to satisfy unmet emotional needs, to moderate stress, and to provide rewards or punishments". Further, "the inability to regulate eating habits and the frequent tendency to overuse or under use food interferes with biological, psychological, and sociocultural integrity" (Stuart & Laraia, 2001, p. 526-527). Anorexia nervosa, bulimia nervosa, and binge eating disorder are illnesses associated with maladaptive eating regulation responses and are most commonly seen in women. Decisive factors for anorexia nervosa established by the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV) include extreme weight loss, fear of fat, and loss of menstruation. Bulimia nervosa is defined by self-esteem that is unduly influenced by weight and shape and both binge eating and inappropriate compensatory behaviors (e.g., self-induced vomiting) at specified frequencies. Binge eating disorder not otherwise specified (EDNOS) is appropriate for "disorders of eating that do not meet the criteria for any specific Eating Disorder" (American Psychiatric Association, 1994, p. 550). DSM-IV (1994) lists six examples of EDNOS, including meeting all the criteria for anorexia except loss of menstruation, meeting all the criteria for bulimia except frequency, use of inappropriate compensatory behaviors after eating small amounts of food, and binge eating in the absence of inappropriate compensatory behaviors (binge-eating disorder). Eating disorders in the United States is experienced about the same among Hispanics and whites, is more common among Native Americans, and is less common among blacks and Asians (Stuart & Laraia, 2001). Because many women do not meet diagnostic criteria, yet are symptomatic by occasionally engage in behaviors characteristic of eating disorders, including self-induced vomiting, use of laxatives, and binge eating, it is important to evaluate women who are symptomatic of eating disorders.

In "Prevalence of Eating Disorders Among African American Women" (Mulholland & Mintz, 2001), a significant study was conducted at a large public university in the Midwestern United States that identified two percent (2%) of African American women participants as eating disordered. In contrast, "A Comparison of Black and White Women With Binge Eating Disorder" (Pike, Dohm, Stiegel-Moore, Wilfley, & Fairburn, 2001) evaluates differences in Caucasian and African American women with an eating disorder; the research showed that the women differ in all aspects of binge eating disorder. Further inspection of these clinical studies is necessary to evaluate whether eating disorders in African American women exists, and whether significant support is available to identify prevalence of eating disorders among this subgroup.

Even though very few studies have been conducted on African American women and eating disorders, there is a significant push to cover the prevalence of eating disorders among minority women. Amy M. Mulholland, and Laurie B. Mintz (2001) conducted a survey to examine the effect of maladaptive eating regulation responses among African American women. Their study's purpose was "... to examine prevalence rates of anorexia, bulimia, and especially EDNOS" as well as ..." prevalence rates for women considered symptomatic (i.e., those that had some symptoms but no actual disorders)" (Mulholland & Mintz, 2001). The sample of the survey was obtained from African American females attending a predominantly Caucasian university in the Midwestern United States. The results of the survey was reported in "Prevalence of Eating Disorders Among African American Women" (Mulholland & Mintz, 2001) and identified that two percent (2%) of the 413 viable participants were classified as eating disordered with all of the eating disordered women having one of the four types of EDNOS. Twenty-three percent (23%) of non-eating disordered participants were symptomatic and seventy-five percent (75%) were asymptomatic. The findings are reflective of a group of African American women who are a minority in their environment.

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According to The Journal of Blacks in Higher Education (2002), which collects statistics bearing on the relative status of blacks and whites, the number of African Americans enrolled in college was 1,640,700 in 1999. Currently, African Americans represent only eleven percent (11%) of all undergraduates (U.S. Department of Education). Therefore, a true representation of the sample of African American women in the Mulholland & Mintz study is minimal to the broader population of African American women in the United States. The study does recognize "... findings of less eating-disorder symptoms among African American women at predominantly Black versus predominantly Caucasian universities" (Gray et al., 1987; Williams, 1994), but without acknowledging the probable effects of acculturation of those women surveyed. If the African American women surveyed sought to assume the values, attributes, and behavior of their Caucasian peers in order to become an accepted members of the culture, in this case the University, then how can a true prevalence of the eating disorders among the African American subgroup be identified? The small percentage of African American women identified as being eating disordered (2%) and those non-eating disordered participants identified as symptomatic (23%) may have been influenced by the activities of their Caucasian peers who are eating disordered.

The study excludes external influences that African Americans face; it does not address the day-to-day discrimination African American women face in American society. Further study is needed to examine how stressors such as racism, classism, and sexism influence maladaptive eating regulation responses among African American women and other minorities. As the study implies, there is vast emerging literature on the unique factors associated with eating disorders among African Americans women, which needs to be shared with young women.

As "A Comparison of Black and White Women With Binge Eating Disorder" (Pike et al., 2001) has identified when surveying women diagnosed with binge eating disorder, African American women reported less concern with body shape, weight, and eating than their Caucasian counterparts. This study identified that African American culture impacts attitudinal concern of body image among African American women; African American society is more accepting of larger body shapes and less concerned with dietary restraint. The women recruited for the study were limited; "exclusion criteria were age over 40 and under 18 years, physical conditions know to influence eating habits or weight, current pregnancy, presence of psychotic disorder, not being white or black, or not being born in the United States" (Pike et al., 2001). The study identified that the African American women surveyed experienced higher weight and more frequent binge eating; however, sources of the stressors which stimulate binge eating was not identified. An evaluation of degree of acculturation and other stressors such as racism, classism, and sexism on African American women and their eating disorder was identified by the study as an area of further investigation though not evaluated in the comparison.

Women have been consistently excluded from research studies, and the impact of this phenomenon on African American women is substantial. African American culture is steeped in family and has a strong matriarch thread. African American women are demonstrative and favor conveying love through food. Meals and times of breaking bread are avenues of socialization in African American families and communities.

As African Americans enter mainstream American via work and school, the acculturation phenomenon invades the most sacred of African American culture--food. The prevalence of eating disorders among African American women has not reached epidemic proportions; however, the potential is there. African American women face stressors tri-fold; racism, classism, and sexism have long been recognized as stressors unique to African American women compared to their Caucasian counterparts. The research must then follow to examine how African American women respond, and if maladaptive eating regulation responses are identified then counseling programs need to be available to African American women--the barriers to healthcare must be superceded to empower African American women to nourish future generations of physically sound men and women.

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A self-administered depression scale for those over 65.

CHOOSE THE BEST ANSWER FOR HOW YOU FELT THIS PAST WEEK

*	Are you basically satisfied with your life?	yes	NO
	Have you dropped many of your activities and interests?	YES	no
	Do you feel that your life is empty?	YES	no
	Do you often get bored?	YES	no
*	Are you hopeful about the future?	yes	NO
	Are you bothered by thoughts you can't get out of your head?	YES	no
*	Are you in good spirits most of the time?	yes	NO
	Are you afraid that something bad is going to happen to you?	YES	no
*	Do you feel happy most of the time?	yes	NO
	Do you often feel helpless?	YES	no
	Do you often get restless and fidgety?	YES	no
	Do you prefer to stay at home, rather than going out and doing new things?	YES	no
	Do you frequently worry about the future?	YES	no
	Do you feel you have more problems with memory than most?	YES	no
*	Do you think it is wonderful to be alive now?	yes	NO
	Do you often feel downhearted and blue?	YES	no
	Do you feel pretty worthless the way you are now?	YES	no
	Do you worry a lot about the past?	YES	>no
*	Do you find life very exciting?	yes	NO
	Is it hard for you to get started on new projects?	YES	no
*	Do you feel full of energy?	yes	NO
	Do you feel that your situation is hopeless?	YES	no
	Do you think that most people are better off than you are?	YES	no
	Do you frequently get upset over little things?	YES	no
	Do you frequently feel like crying?	YES	no
	Do you have trouble concentrating?	YES	no
*	Do you enjoy getting up in the morning?	yes	NO
	Do you prefer to avoid social gatherings?	YES	no
*	Is it easy for you to make decisions?	yes	NO
*	Is your mind as clear as it used to be?	yes	NO

*Appropriate (nondepressed) answers=yes.
All others=no
or count number of CAPITALIZED (depressed) answers

Normal	5 + / - 4
Mildly depressed	15 + / - 6
Very depressed	23 + / - 5

Score: _____ (Number of "depressed" answers - ones that are capitalized)

Note: This is a self-report inventory. The validity of the result depends entirely on your honesty.

next: Seniors With Late Life Depression May Not Recover
~ depression library articles
~ all articles on depression

The INDEX

Listowner: Dr. Sam Vaknin

Click on the title to go to the relevant section of the index:

• Narcissism The Pathology
• Narcissists and their Emotions
• Narcissists and their Supply Sources
• Narcissists in Therapy
• How to Cope with a Narcissist?
• Narcissists and Women
• The Narcissist and His Mate /Colleague / Partner / Spouse / Family
• Narcissists in the Workplace
• Narcissism and Historical Figures
• Co-Morbidity (Narcissism with other Mental Health Disorders) and Dual Diagnosis (Narcissism with Substance Abuse)
• Our Narcissistic Culture
• Sam Vaknin, NPD
• My Journals (First Published on Suite101)

Narcissism The Pathology

Archive 1 Excerpt 5: Epidemiology of Narcissism
Archive 1 Excerpt 13: Self Defeating and Self Destructive Behaviors
Archive 1 Excerpt 16: The vocations of Narcissist
Archive 1 Excerpt 17: Lazy Narcissists
Archive 2 Excerpt 3: Narcissistic Identity
Archive 2 Excerpt 4: Narcissists, Right and Wrong
Archive 2 Excerpt 6: Narcissists have Tables of Emotional Resonance
Archive 2 Excerpt 7: Contradictory Behaviors of Narcissists
Archive 2 Excerpt 10: Narcissists and Manipulation
Archive 3 Excerpt 1: Narcissists and Chemical Imbalances
Archive 3 Excerpt 7: NPD and Dual Diagnoses
Archive 3 Excerpt 9: From "Narcissism and the Search for Interiority" by Donald Kalsched
Archive 4 Excerpt 3: Narcissistic Self Absorption
Archive 5 Excerpt 3: Narcissism as Self-definition
Archive 5 Excerpt 6: Devaluing the Significant Other
Archive 5 Excerpt 7: Should the Narcissist be Held Accountable for his Actions?
Archive 5 Excerpt 13: The Internalized Voice of the Narcissist
Archive 6 Excerpt 1: Narcissists and Ego Dystony
Archive 6 Excerpt 8: Degrees of Narcissism
Archive 6 Excerpt 14: Unified Dysfunction Theory
Archive 7 Excerpt 4: The Enemy
Archive 7 Excerpt 6: Narcissists as Drug Addicts
Archive 7 Excerpt 7: Alexander Lowen
Archive 7 Excerpt 15: Narcissistic Myths
Archive 8 Excerpt 1: Do Infants Trigger their Own Abuse?
Archive 8 Excerpt 4: Superego
Archive 8 Excerpt 7: The Human Machine
Archive 8 Excerpt 8: Conscience
Archive 9 Excerpt 3: Inverted Narcissism
Archive 10 Excerpt 1: The Exposure of the Narcissist
Archive 10 Excerpt 3: Narcissists, Disagreements and Criticism
Archive 10 Excerpt 4: Unresolved Conflicts
Archive 10 Excerpt 10: Fortress Narcissism
Archive 10 Excerpt 11: Inverted Narcissists
Archive 11 Excerpt 1: The Productive Narcissist
Archive 11 Excerpt 8: Self Confidence and Real Achievements
Archive 12 Excerpt 1: The Narcissist and Total Institutions
Archive 12 Excerpt 3: The Denial Mechanisms of the Narcissist
Archive 12 Excerpt 5: Traumas and Personality Disorders
Archive 12 Excerpt 8: The Narcissist a Gift to Humanity
Archive 12 Excerpt 10: Forms of Aggression
Archive 12 Excerpt 11: Narcissist the Sadist
Archive 12 Excerpt 12: Somatic versus Cerebral Narcissists
Archive 13 Excerpt 1: The Formation of a Narcissist as a Reaction to His Narcissistic Parents
Archive 13 Excerpt 3: Narcissism The Individualist's Reaction
Archive 14 Excerpt 1: Abusive Parents
Archive 14 Excerpt 3: Narcissistic Regression versus NPD
Archive 14 Excerpt 8: Narcissism and Genetics
Archive 15 Excerpt 1: Money and the Narcissist
Archive 15 Excerpt 6: Sexual Abuse
Archive 17 Excerpt 4: Narcissism as an Adaptive Strategy
Archive 17 Excerpt 5: The Zombie Narcissist
Archive 18 Excerpt 2: Narcissism is an Addiction
Archive 18 Excerpt 4: Emotional Investment in Pathology and Healing
Archive 18 Excerpt 5: The Emergence of the True Self
Archive 18 Excerpt 6: Bonding with "God"
Archive 18 Excerpt 7: Group Sex as seen by the Narcissist
Archive 18 Excerpt 8: Overt and Covert
Archive 19 Excerpt 2: Hating Love
Archive 19 Excerpt 5: Cognitive Distortions and the Narcissist
Archive 19 Excerpt 6: Sexual versus other forms of Abuse
Archive 19 Excerpt 7: The Narcissist and his Dead Ones
Archive 20 Excerpt 1: There is no Goal
Archive 20 Excerpt 2: Inverted Narcissists Once More
Archive 20 Excerpt 3: Losing Control
Archive 20 Excerpt 10: The Pleasures of the Somatic Narcissist
Archive 21 Excerpt 1: Narcissistic Healing through LOVE or through PAIN?
Archive 21 Excerpt 4: Inverted Narcissists ARE Narcissists
Archive 21 Excerpt 6: Fulfilling Others' Dreams
Archive 22 Excerpt 4: Narcissists and Control
Archive 22 Excerpt 6: Is Narcissism Learned? Can it be Unlearned?
Archive 23 Excerpt 2: Vindictive Narcissists
Archive 23 Excerpt 4: The Good Enough Mother
Archive 24 Excerpt 1: The Restrained Narcissist
Archive 24 Excerpt 9: Narcissism
Archive 24 Excerpt 10: Addicted
Archive 24 Excerpt 11: False Self
Archive 24 Excerpt 12: Worth and Grandiosity
Archive 27 Excerpt 1: Types of Narcissists
Archive 28 Excerpt 2: Eye Contact
Archive 28 Excerpt 3: Narcissism Forming
Archive 28 Excerpt 5: More about the False Self and the True Self
Archive 30 Excerpt 4: Narcissists ARE Appearances
Archive 30 Excerpt 7: The Rational Narcissist
Archive 31 Excerpt 1: Euphoria and Dysphoria
Archive 31 Excerpt 3: On the Move
Archive 31 Excerpt 5: N-magnets a Bad Metaphor
Archive 31 Excerpt 6: Ideas of Reference
Archive 33 Excerpt 1: Mirror Gazing
Archive 33 Excerpt 2: More on the Grandiosity Gap
Archive 33 Excerpt 3: Self-Awareness and Healing
Archive 33 Excerpt 4: Narcissistic Vulnerability
Archive 34 Excerpt 2: When can a Classic Narcissist become an Inverted Narcissist?
Archive 34 Excerpt 3: The Forms of Abuse
Archive 34 Excerpt 4: The Psychopath and the Narcissist
Archive 34 Excerpt 7: Amelioration of Narcissism
Archive 34 Excerpt 8: Inside, Outside
Archive 35 Excerpt 2: Can Narcissists be Helped by Hypnosis?
Archive 35 Excerpt 3: Predicting the Narcissist
Archive 36 Excerpt 2: Pathological Narcissism Under-diagnosed

Narcissists and their Emotions

Archive 2 Excerpt 1: A Letter to a Narcissist
Archive 3 Excerpt 8: Narcissists imitating Emotions
Archive 4 Excerpt 5: PDs and Self-Mourning
Archive 4 Excerpt 9: Self Pity and Grief
Archive 5 Excerpt 2: Pathological Envy
Archive 5 Excerpt 4: Narcissistic Ups and Downs
Archive 5 Excerpt 9: Narcissists put on a show regarding their "emotions"?
Archive 6 Excerpt 11: I am Very Sad
Archive 7 Excerpt 2: My Shame
Archive 8 Excerpt 5: Emotional Daltonism
Archive 11 Excerpt 9: Communicating Emotions
Archive 11 Excerpt 10: Possessive Jealousy
Archive 13 Excerpt 4: Somatizing Our Emotions
Archive 13 Excerpt 5: The "Love" of the Narcissist
Archive 14 Excerpt 2: Hatred and Anger
Archive 16 Excerpt 3: Narcissists Feel Deceitful
Archive 17 Excerpt 6: Imitated Empathy
Archive 17 Excerpt 7: Narcissism and Self Loathing
Archive 17 Excerpt 9: The Deception that is the Narcissist
Archive 21 Excerpt 3: Being IN LOVE and LOVING
Archive 21 Excerpt 7: Not to Feel Anything
Archive 23 Excerpt 5: Vindicating One's Self Loathing
Archive 25 Excerpt 1: Resistance is Futile?
Archive 25 Excerpt 4: Fight!
Archive 25 Excerpt 7: Falling in Love with Ourselves
Archive 26 Excerpt 4: Aggression
Archive 26 Excerpt 5: To Live and to Grieve
Archive 26 Excerpt 6: Anticipatory Panic
Archive 26 Excerpt 7: My Warden
Archive 26 Excerpt 8: Love, this Bastard
Archive 30 Excerpt 1: Narcissists are Never Happy
Archive 30 Excerpt 3: Being Embarrassed
Archive 30 Excerpt 6: People are Tired
Archive 32 Excerpt 4: Loving and Believing that You Love

Narcissists and their Supply Sources

Archive 1 Excerpt 1: Why does the narcissist devalue his source of secondary narcissistic supply?
Archive 5 Excerpt 8: Narcissists Getting Tired of their Sources of Supply
Archive 6 Excerpt 12: The Narcissistic Hunt
Archive 6 Excerpt 15: Humbling Oneself
Archive 10 Excerpt 2: Could Negative Input be Narcissistic supply?
Archive 10 Excerpt 5: The Narcissist wants to be liked?
Archive 10 Excerpt 6: Old Sources of Narcissistic Supply (NS)
Archive 14 Excerpt 5: Deleting Past Sources of Narcissistic Supply
Archive 17 Excerpt 8: In Pursuit of Narcissistic Supply
Archive 24 Excerpt 3: Myself as a Source of Narcissistic Supply to Others, or: The Existence of Others
Archive 24 Excerpt 5: Is there an Ideal Source of Supply?
Archive 24 Excerpt 8: You are a Source of Supply
Archive 29 Excerpt 2: Human Supply
Archive 32 Excerpt 2: From Desperation to Happiness
Archive 32 Excerpt 3: Internal Combustion and External Propulsion
Archive 32 Excerpt 5: The Art of Un-Being
Archive 32 Excerpt 6: The Narcissist's Refrigerator

Narcissists in Therapy

Archive 1 Excerpt 2: Narcissistic Mental Health Professionals
Archive 1 Excerpt 4: NPD Treatments SSRI
Archive 1 Excerpt 9: Cultural Sensitivity of Therapists
Archive 1 Excerpt 11: Psychodynamic versus Cognitive-Behavioral Treatments
Archive 1 Excerpt 14: Narcissism not curable?
Archive 3 Excerpt 7: NPD and Dual Diagnoses
Archive 4 Excerpt 8: Psychodynamic Therapies
Archive 5 Excerpt 10: Narcissists Facing their Diagnosis
Archive 6 Excerpt 7: Narcissists and Group Therapy
Archive 7 Excerpt 1: Can Narcissists be Cured?
Archive 11 Excerpt 11: Pessimism versus Realism in the Treatment of Narcissists
Archive 12 Excerpt 4: Therapy
Archive 12 Excerpt 6: Narcissists and Medication
Archive 12 Excerpt 13: The Narcissist and the Therapist
Archive 24 Excerpt 6: Destruction and Construction
Archive 26 Excerpt 9: Going to Therapy
Archive 26 Excerpt 10: Official Psychology and NPD

How to Cope with a Narcissist?

Archive 1 Excerpt 3: How to Cope with a Narcissist
Archive 3 Excerpt 3: Should I leave him?
Archive 6 Excerpt 15: Humbling Oneself
Archive 7 Excerpt 3: Luring a Narcissist
Archive 15 Excerpt 2: Treating your Narcissist
Archive 15 Excerpt 4: What to tell your Narcissist?
Archive 19 Excerpt 4: Leaving a Narcissist
Archive 20 Excerpt 5: How to Assuage a Narcissist
Archive 21 Excerpt 2: The Narcissist in Court
Archive 31 Excerpt 7: Fighting Back
Archive 34 Excerpt 9: How does the Narcissist Perceive my Indifference to his Abuse?

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Narcissists and Women

Archive 5 Excerpt 12: Male Narcissists and Women
Archive 6 Excerpt 6: Narcissists are Misogynists
Archive 9 Excerpt 4: Narcissists and Women
Archive 13 Excerpt 6: Misogynism Once More ...
Archive 26 Excerpt 1: Women

The Narcissist and His Mate / Colleague / Partner / Spouse / Family

Archive 1 Excerpt 6: Rescue Fantasies
Archive 1 Excerpt 7: Loving a Narcissist
Archive 2 Excerpt 2: Narcissists in the Family
Archive 3 Excerpt 3: Should I leave him?
Archive 3 Excerpt 4: Significant Others, Significant Roles
Archive 3 Excerpt 6: Humans as Instruments
Archive 4 Excerpt 4: Narcissists as Friends
Archive 5 Excerpt 11: Narcissists and Happy Marriages
Archive 5 Excerpt 16: The Narcissist as Body Snatcher
Archive 6 Excerpt 2: VoNPD (Victims of NPD)
Archive 6 Excerpt 3: Surrounded by Inferiors
Archive 6 Excerpt 4: Narcissists Hurting Others
Archive 6 Excerpt 12: The Narcissistic Hunt
Archive 6 Excerpt 13: WHY?
Archive 6 Excerpt 15: Humbling Oneself
Archive 7 Excerpt 3: Luring a Narcissist
Archive 7 Excerpt 5: Victim or Survivor?
Archive 8 Excerpt 3: Disinterested Narcissists
Archive 8 Excerpt 12: Accusing the Victims
Archive 9 Excerpt 5: Narcissists and their Ex's
Archive 9 Excerpt 6: Narcissists Victimize
Archive 10 Excerpt 7: Hurting Others
Archive 10 Excerpt 8: Narcissists and Intimacy
Archive 11 Excerpt 2: Abandoning the Narcissist
Archive 11 Excerpt 3: Unloving the Sick or Needy Spouse
Archive 11 Excerpt 4: Moving On
Archive 11 Excerpt 5: Inspirational Messages
Archive 11 Excerpt 6: The Phases of Mourning
Archive 11 Excerpt 7: Forgiving Enemies, Forgetting Friends
Archive 12 Excerpt 7: NPD Son
Archive 12 Excerpt 14: Being Nice to Others
Archive 13 Excerpt 2: The Test of Archaic Chinese
Archive 14 Excerpt 4: Narcissists and Abandonment
Archive 15 Excerpt 2: Treating your Narcissist
Archive 15 Excerpt 4: What to tell your Narcissist?
Archive 15 Excerpt 5: Narcissists Hate Happy People
Archive 16 Excerpt 4: Healing through Hatred
Archive 18 Excerpt 3: You are not to Blame!
Archive 19 Excerpt 3: Living with a Narcissist
Archive 19 Excerpt 4: Leaving a Narcissist
Archive 20 Excerpt 5: How to Assuage a Narcissist
Archive 20 Excerpt 6: Don't Kiss Me without Permission
Archive 20 Excerpt 8: Love as Domination
Archive 21 Excerpt 8: The Presumption of Understanding the Narcissist A Piece of Irony
Archive 22 Excerpt 5: Meaningful to Who?
Archive 23 Excerpt 6: The Narcissist as a Meaningful Other
Archive 24 Excerpt 7: Punishing Others
Archive 25 Excerpt 2: Narcissists as Vampires
Archive 25 Excerpt 3: The Need to be Hopeful
Archive 25 Excerpt 5: The Narcissist as Predator
Archive 25 Excerpt 6: Seeking Help
Archive 26 Excerpt 2: Do not be Afraid
Archive 26 Excerpt 11: Loving Narcissism
Archive 27 Excerpt 3: Love
Archive 27 Excerpt 4: It is not What you DO
Archive 27 Excerpt 5: You know what you have to DO
Archive 27 Excerpt 6: Presumptions
Archive 27 Excerpt 7: Humanizing the Beast
Archive 28 Excerpt 4: The Human Maelstroms
Archive 28 Excerpt 6: Detoxifying
Archive 30 Excerpt 2: The Off-Handed Narcissist
Archive 30 Excerpt 5: Personal Incompatibility
Archive 31 Excerpt 2: Saying Goodbye
Archive 31 Excerpt 4: Creating Dependence
Archive 31 Excerpt 5: N-magnets a Bad Metaphor
Archive 31 Excerpt 7: Fighting Back
Archive 32 Excerpt 1: How to Protect my Son from Narcissism?
Archive 33 Excerpt 5: Narcissists, Violence and Domestic Abuse
Archive 34 Excerpt 1: Follies a Deux
Archive 34 Excerpt 6: The Professional Victims
Archive 35 Excerpt 1: How to Leave a Narcissist
Archive 35 Excerpt 4: Narcissists and Children

Narcissists in the Workplace

Archive 2 Excerpt 11: The Narcissist Employer

Narcissism and Historical Figures

Archive 1 Excerpt 8: Hitler and Narcissism
Archive 1 Excerpt 12: Bill Clinton a Narcissist?

Co-Morbidity (Narcissism with other Mental Health Disorders) and Dual Diagnosis (Narcissism with Substance Abuse)

Archive 4 Excerpt 1: HPD (Histrionic Personality Disorder) and Somatic NPD
Archive 4 Excerpt 2: Narcissists and Depression
Archive 4 Excerpt 6: DID and NPD
Archive 4 Excerpt 7: NPD and ADHD
Archive 4 Excerpt 11: BPD, NPD and other Cluster B PDs
Archive 7 Excerpt 8: NPDs and other PDs
Archive 7 Excerpt 9: Incest without Sex?
Archive 7 Excerpt 10: NPD and DID
Archive 7 Excerpt 11: Plasticity
Archive 8 Excerpt 2: Narcissism, Wife Beating and Alcoholism
Archive 8 Excerpt 9: BPD and NPD
Archive 8 Excerpt 10: The Personality Disordered
Archive 8 Excerpt 11: Robert Hare
Archive 8 Excerpt 13: Multiple Diagnoses and NPD
Archive 9 Excerpt 2: Schizotypal Personality Disorder
Archive 12 Excerpt 9: Co-dependents and Narcissists
Archive 12 Excerpt 11: Narcissist the Sadist
Archive 19 Excerpt 1: The Hated-Hating Personality Disordered
Archive 20 Excerpt 4: The Borderline Narcissist A Psychotic?
Archive 20 Excerpt 7: The Root of Evil
Archive 21 Excerpt 5: Masochism and Narcissism
Archive 22 Excerpt 1: Narcissists and Sexual Perversions
Archive 22 Excerpt 3: Hysteroid Dysphoria
Archive 23 Excerpt 7: On the Irrelevance of Labeling
Archive 27 Excerpt 2: The Inverted Narcissist A Masochist?
Archive 28 Excerpt 7: NPD, AsPD
Archive 34 Excerpt 5: The Diagnostic and Statistics Manual (DSM)

Our Narcissistic Culture

Archive 1 Excerpt 10: NPD, culture and normalcy
Archive 1 Excerpt 15: Narcissism and Culture
Archive 1 Excerpt 16: The vocations of Narcissists
Archive 2 Excerpt 5: In Defense of Narcissists
Archive 2 Excerpt 8: From "The Alchemist" by Paulo Coelho
Archive 2 Excerpt 9: Narcissism's Gifts to Humanity
Archive 3 Excerpt 5: Lasch, the Cultural Narcissist
Archive 4 Excerpt 10: Should we License Parents?
Archive 5 Excerpt 1: Jeffrey Satinover on the Myth of Narcissus
Archive 5 Excerpt 5: Narcissists and the Order of the World
Archive 6 Excerpt 5: Narcissists and Art
Archive 6 Excerpt 9: Narcissism and Evil
Archive 6 Excerpt 10: Why do Narcissists Exist?
Archive 7 Excerpt 12: A Core of Values?
Archive 7 Excerpt 13: Licensing Parents (continued)
Archive 7 Excerpt 14: Nations as Patients
Archive 8 Excerpt 6: Atheism
Archive 9 Excerpt 1: Love and Sex
Archive 10 Excerpt 9: Personality Disorders are Culture-Dependent?
Archive 12 Excerpt 2: The Cultural Roots of one Narcissist
Archive 12 Excerpt 15: Prostituting our Selves
Archive 14 Excerpt 7: Narcissism and Nihilism
Archive 15 Excerpt 7: Punishing Evil
Archive 15 Excerpt 8: Psychology
Archive 18 Excerpt 1: Linear Time, Cyclical Time
Archive 18 Excerpt 9: Oh, God
Archive 23 Excerpt 3: Narcissistic Thoughts about Humanity
Archive 36 Excerpt 1: Politicians as Narcissists

Sam Vaknin, NPD

Archive 3 Excerpt 2: Personal Anecdote
Archive 3 Excerpt 10: Sam Vaknin, NPD
Archive 5 Excerpt 14: My Role in the List
Archive 5 Excerpt 15: This Paradoxical List...
Archive 6 Excerpt 11: I am Very Sad
Archive 6 Excerpt 16: The Time before Narcissism
Archive 7 Excerpt 2: My Shame
Archive 14 Excerpt 6: Realizations
Archive 15 Excerpt 3: Forgetting my Self
Archive 16 Excerpt 1: Self Destructing Narcissists
Archive 16 Excerpt 2: The Fear of Being Loved
Archive 17 Excerpt 1: Interview with a Narcissist
Archive 17 Excerpt 2: Another One ... (Interview)
Archive 17 Excerpt 3: Email Exchange in preparation for an interview granted to Bob Goodman of "Natterbox"
Archive 20 Excerpt 9: My Guardian Angel
Archive 22 Excerpt 2: I Hate Birthdays
Archive 23 Excerpt 1: Interview at Amazon UK
Archive 24 Excerpt 2: About Myself (what else?)
Archive 24 Excerpt 3: Myself as a Source of Narcissistic Supply to Others, or: The Existence of Others
Archive 24 Excerpt 4: Right Now I am Enraged
Archive 26 Excerpt 3: The Information Addict
Archive 28 Excerpt 1: The Digital Narcissist (SEX)
Archive 29 Excerpt 1: Here you are, Madam
Archive 29 Excerpt 2: Human Supply
Archive 29 Excerpt 3: The Time of the Narcissist
Archive 29 Excerpt 4: Abuse
Archive 29 Excerpt 5: Success
Archive 29 Excerpt 6: Rejection
Archive 35 Excerpt 5: Why do I Write Poetry?
Archive 36 Excerpt 3: Interview The Narcissist as an Author
Archive 37 Excerpt 1: Application to the Media
Archive 37 Excerpt 3: Second Interview with Amazon
Archive 37 Excerpt 4: Interview to JustViews
Archive 37 Excerpt 5: Revisiting Myself
Archive 37 Excerpt 6: Interview to Independent Success!
Archive 38 Excerpt 1: Interview with Babel Magazine
Archive 39 Excerpt 1: Interview with Inscriptions Magazine
Archive 39 Excerpt 2: Correspondence with the New York Times
Archive 39 Excerpt 3: Interview with Writing Tips
Archive 41 Excerpt 1: Interview with New York Press
Archive 41 Excerpt 2: Interview with Modern Author

next: Born Aliens

The term "Adonis Complex" is not a medical term. It is being utilized to describe a variety of body image concerns which have been plaguing boys and men especially through the last decade. It does not describe any one body image problem of men, rather all the distortions collectively.

The term was extracted from Greek mythology which depicted Adonis as half man and half god who was considered the ultimate in masculine beauty. Adonis' body, according to sixteenth-century perspectives, was representative of the ultimate in male physique. According to mythology so beautiful was his body that he won the love of Aphrodite, queen of all gods.

One of the most famous renderings of Adonis was depicted by the Renaissance painter Titian. His painting shows Adonis with Aphrodite clut

ching his body with her arms. In Titan's painting Adonis looks heavy and out of shape in comparison to the men's physiques today which are seen splashed on the covers of magazines, in advertisements, and at gyms. (It could also be noted that Aphrodite, queen of the gods for the sixteenth century, appears quite full figured in comparison to what is considered the "ideal body" women today are striving for.)

This painting dramatically illustrates the fluidity of society over the ages with respect to its varying thoughts of the "ideal" or the "beautiful" human body. The development of the "Adonis Complex" shows that men are being targeted as vigorously as women have been for decades creating destructive obsessional disturbances concerning their own bodies. Men's body image concerns range from minor annoyances to serious and sometimes even life-threatening obsessions. They can present as manageable dissatisfaction at one end of the spectrum to extreme psychiatric body image disorders.

In the past decade the "Adonis Complex" has been seen in increasing numbers of boys and men who have become fixated on achieving a perfect, Adonis-like type body. The authors of The Adonis Complex, The Secret Crises of Male Body Obsession, term this fixation "Muscle Dysmorphia" as an excessive preoccupation with body size and muscularity. Men who find themselves caught up in these obsessions soon discover their lives can begin spiraling out of control. Their lives often are dramatically affected by these obsessions jeopardizing careers as well as relationships with friends and loved ones.

next: Eating Disorder in Males
~ eating disorders library
~ all articles on eating disorders

Many caregivers forget about themselves and their needs and eventually burn out. Here are some helpful suggestions for those caring for the mentally ill.

Supporting Someone with Bipolar - For Family and Friends

Dedicated to those family members and friends who are primary caregivers of a loved one or friend with a mental illness.

1. Be gentle with yourself.
2. Remind yourself that you are a loving helper, not a magician. None of us can change anyone else - we can only change the way that we relate to others.
3. Find a place where you can be a hermit - use it every day - or when you need to.
4. Learn to give support, praise and encouragement to those about you - and learn to accept it in return.
5. Remember that in the light of all the pain we see around us, we are bound to feel helpless at times. We need to be able to admit this without shame. Just in caring and in being there, we are doing something important.
6. Learn to vary your routine often and to change your tasks whenever possible.
7. Learn to know the difference between complaining that relieves tension and the complaining that reinforces it.
8. On your way home from work, focus on one good thing that happened during the day.
9. Become a resource to yourself! Be creative and open to new approaches to old things.
10. Use the support you give to others or a "buddy" system regularly. Use these as a support, for reassurance and to redirect yourself.
11. Avoid "shop talk" during your breaks or when you are socializing with colleagues.
12. Learn to use the expression "I choose to..." rather than expressions like "I have to...," "I ought to..." or "I should..."
13. Learn to say "I won't..." rather than "I can't..."
14. Learn to say "no" and mean it. If you can't say "no," what is your "yes" worth?
15. Aloofness and indifference are far more harmful than admitting to an inability to do more.
16. Above all else - learn to laugh and to play

next: When A Close Friend Has A Mental Illness
~ bipolar disorder library
~ all bipolar disorder articles

Interview with Cliff Bostock

Cliff Bostock, MA, is a doctoral student in depth psychology at Pacifica Graduate Institute and a practitioner of soulwork, a post-Jungian modality of personal growth which is based on the archetypal psychology of James Hillman. His work has been featured in Common Boundary Magazine. He lives in Atlanta where he also authors a weekly dining column and a psychology column. For more information about him consult his website, Soulwork.

Tammie: "How do you describe "Soulwork?"

Cliff: It's a facilitated process of learning to live from a place of deep imagination, in a fully embodied way. It is an aesthetic psychology in which images are treated as autonomous expressions of soul. To follow the image, to use the phrase employed by James Hillman, is to discover the "telos," direction of the soul's path, its destiny. This telos is also clearly illuminated in the body, which is also a metaphorical field.

Tammie: What led you to soulwork?

Cliff: My destiny, basically. As a kid, I couldn't decide whether to be a writer or a doctor. I chose to be a writer, an artist. Then, during my recovery from addictions, I became very interested in transpersonal psychology. I went back to school and got an MA in psychology and trained at the nation's only residential center for transpersonal treatment. Thus, I began to move toward the coalescence of my two childhood impulses --as writer and healer. After a few years of supervised practice as a psychotherapist, I began to feel completely disenchanted with transpersonal and humanistic psychology. They either spiritualized all issues or reduced them to family systems outcomes. I then discovered the soul-based archetypal psychology of James Hillman. My effort, since then, has been to develop a praxis based on his work but one that includes more attention to body and spirit.

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continue story below

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Tammie: You maintain that inhibitions and blocks to personal growth are more than personal symptoms but are symptoms of the world in which we live. Will you elaborate on that?

Cliff: I mean that what we call pathology is a global or community disorder borne by the individual. Hillman uses the example of eating disorders, I think. They are really "food" disorders. We live in a world in which food is distributed inequitably, in which people are needlessly starving. So-called "eating disorders" to my mind are expressions of that. If you send a compulsive overeater as part of his treatment to do volunteer work in a soup kitchen, the person makes a radical transformation.

The apparent increase of violence among children is, I think, an expression of the way children are hated in this culture. Isn't it bizarre that members of the middle class fill therapy offices to work on the "inner child" while child abuse rages? If you want to work on your "inner child," go do some work with real children. The idealization of the inner child is a kind of reaction formation to anger about the reality of childhood -- which is NOT a state of innocence, which is NOT a time when we usually get what we need. Another example: ADD is an expression of the mania culture requires to sustain capitalism. Also: Borderline disorder, where the self is completely projected outward, is a symptom of the profound relatavizing of postmodern culture.

Tammie: What is deep imagination?

Cliff: This is really an expression of depth psychology -- penetration of the psyche's depths to the archetypal field. In the depths of the psyche, images live autonomously, awaiting personification. When they remain unconscious, they tend to make themselves known as symptoms. The gods are archetypal processes of the imagination in its depths. When they were banished, as Jung said, they became diseases, or symptoms, what we call pathology.

Tammie: You've bravely shared (and received a great deal of angry protests from therapists) that you're disenchanted with psychotherapy. Why is that?

Cliff: This would take a book. Modern psychotherapy -- the praxis developed 100 years ago -- contained two conflicting impulses. One was scientific and the other was aesthetic. Freud was a scientist (as was Jung) but he regarded the narratives of his patients as "healing fictions". Freud recognized the symbolizing and metaphorizing character of the psyche and Jung extended this even further as his career proceeded.

In the time since then, psychology as a healing practice, has fallen increasingly under the influence of science, medicine. Thus, what was recognized by Freud and Jung as metaphorical -- such as unlikely tales of satanic cult abuse, etc. -- has become increasingly literalized in modern practice. "The reality of the psyche is lived in the death of the literal," said Gaston Bachelard. Conversely, the more symptoms are treated as literal, the more soul, psyche, is driven into materialism and compulsion (and the more it has to be medicated). The tragedy of modern psychological praxis is this loss of imagination, the understanding that the psyche by its nature fictionalizes through the exercise of the fantasy we call memory.

My experience with clients, and as a client, has been that psychotherapy reduces symptoms to predictable causes. This is in the "air," so to speak, no matter how much you try to avoid it. Clients come in with their own diagnoses -- from ADD to PTSD and "low self esteem" to "sexual addiction." I am sure that these diagnoses and their prescribed treatment have some merit, but quite honestly I just haven't seen people who tell themselves the narratives of these disorders making much progress.

When I began working with people in my Greeting the Muse workshops for blocked writers and artists, I saw them making rapid progress through the active engagement of the imagination. In these, pathology is viewed as the natural expression of the soul -- the way into the soul. There is no "healing" in the traditional sense, just deepening of awareness, experience, appreciation. The best metaphor is probably alchemy -- where a "conjunction" of opposites is sought, not a displacement of the symptom with something. Jung spoke of the transcendent function, where two opposites are held and transcended. There is no sacrifice of the original quality of the "wound," but its transcendence holds it differently.

I made a personal decision to stop calling myself a psychotherapist because of this experience. On the other hand, I have learned that my work is NOT for everyone. People with dissociative disorders, for example, do not do well in work that uses a lot of active imagination. Nor do I mean to suggest, in the least, that medications aren't of value for many people. But I do MY best work outside the paradigm of medical science. I even regard medication as alchemy.

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Tammie: What does "growing down" into life mean to you?

Cliff: It means the rooting of soul in the "underworld." We live in an over-spiritualized culture. Although I value the spiritual, our problem is learning the way our symptoms and our pathology, our shadow motivations, reveal our destiny. The spiritual has become one of our time's greatest means of repression.

Tammie: How does the spiritual repress?

Cliff: Of course, I don't mean that the spiritual inherently represses. It's just my experience that in many forms of religiosity, especially so-called New Age spirituality, problems become spiritualized and not dealt with. The classic example, of course, is the way anger is demonized as everything from sin to "toxicity" when in practice, as you know, its expression is a necessary step toward forgiveness, resolution of grief and any other problem in which the client feels disempowered. Another problem is the way people develop a "things are as they should be" kind of thinking which sabotages activism. Fundamentalism, which has become a political movement the world over, is another example of subsuming authoritarian, controlling agendas in religious dogma.

I hasten to say that, in my view, this is a misdirection of the religious impulse -- a repression, not a bonafide expression of it. Were the spiritual allowed authentic expression in all areas of life, the world would certainly be very different.

Tammie: What would your definition of wholeness be?

Cliff: It would probably be pretty consistent with Jung's idea of individuation -- the shadow brought into consciousness. In all honesty, though, "wholeness" is one of those words that suggests something false to me. My whole point here is that our soul, our nature, is revealed in our wound. I think this is why the "freak" has held such fascination and created such awe in every culture throughout time. I asked a client once who she wanted to be marooned with on a dessert island -- Doris Day or Bergman. The tormented" personality is the one who offers us the most richness and stimulation ---opportunity for soulmaking -- in life.

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Tammie: Do you believe that pain is a valuable teacher and if so, what has your own pain taught you?

Cliff: I have done Buddhist meditation practices for years, and I think I mainly follow Buddhism's lead. I do not think there is any INHERENT value in suffering. On the other hand, as the Buddha said, life IS suffering. So one is left wanting to avoid needless suffering but knowing that a lot of suffering is inevitable. So, you have the choice of how you imagine your suffering. You can call it a teacher but you don't have to call it inherently a good thing. I am thinking of Viktor Frankl. He might say his experience in the death camps taught him something but he'd never say the Holocaust was of inherent value. I think this distinction is really important. Something of value can be (but isn't always) constellated in your relationship to suffering, but it doesn't make suffering a good thing.

And yet, ultimately and crazily, you can end up in the curious place of thanking the gods for your suffering. -- if you transcend it (and I REALLY want to make the point that some suffering simply cannot be transcended). This idea was unimaginable to me even five years ago. My childhood was very unhappy and lonely. I dealt with it by retreating into my imagination and this fed the part of me that later became a successful writer. I would NEVER tell a parent that to encourage his child's artistic talent he reject and isolate the kid. But I do know this fed my own creativity. It could have severely damaged someone else -- and perhaps had I not had the opportunities I did, it might have damaged me more.

I think it's dangerous, to say nothing of hubris-filled, to ever tell anyone they should appreciate their suffering. One can only hold the space for that possibility. It is not everyone's fate.

Tammie: If your life is your message, then what message do you see your life being?

Cliff: I spent a great deal of my life's energies worried about being an outsider, being unconventional. If my life illuminates anything for people, I hope it's that -- as I said earlier -- these wounds and symptoms, these things we call pathologies that make us different, really are the marks of our character and our soul's path."

next:Kris Raphael on "Soul Urges."

An important phase of my recovery program has been learning to love myself. Loving myself means I have given up the futile and endless search for a source of love outside of me, based on or drawn from external people or things. Self-love has meant discovering the limitless Source of love within me. I am no longer dependent upon externals to supply an unhealthy neediness for love, worth, or validation.

(In this context, love is broadly defined as unconditional acceptance and nurturing of myself and others.)

Ironically, part of what drove my neediness for love was shame. My shame grew from my acute awareness of my neediness. Because I was ashamed, I therefore did not perceive myself as being a lovable or worthwhile person. My shame, in turn, resulted in low self-esteem and deeper shame.

A significant breakthrough occurred when I finally admitted my shame about my feelings of low self-worth (both to myself and to another person). Admitting the shame liberated me from it.

Previously, I had worked very hard to deny both my shame and my low self-worth, because I desperately wanted to deny that low self-worth was one of my core issues. Because of the denial, my shame and my low self-worth persisted—one feeding endlessly on the other. By denying my shame and my low self-worth, I remained bound to it. By admitting my shame and my low self-worth, and more importantly, accepting both as a part of myself, I released myself from the shame, freed myself to accept myself unconditionally, and gave myself permission to start loving and esteeming all of me.

Continued belief in myself as a lovable and worthwhile person no longer depends upon an external source or upon external affirmation. I no longer "need" another person to constantly affirm my worth or relieve my shame by loving me (i.e., since no one loves me, I must not be worth loving). I can give myself all the affirmation and love I need. Since my need for love and external affirmation is no longer an issue, the shame associated with my low self-worth is gone.

I am a lovable and worthwhile person!

Now I can affirm it and truly believe it. Equally important, I now have an abundance of genuine self-love, which I can draw upon and give away love to others.

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To use an analogy, it's just as if I had an empty account in my "love" bank. I was erroneously waiting and longing for someone else to make the needed deposits, unaware that I could have been making huge deposits for myself all along. Now I have an abundance of love to give away. Because I have love to give away, I am truly a love-able person. I am no longer needy; I am healthy, and thus, even more lovable. By embracing and accepting my shame and my low self-worth, I empowered myself to change. I have an infinite Source and reserve of love and self-esteem for myself.

The paradox of learning self-love is this—the more love I give myself, the more love I have to give away. The love account is never depleted. I can now give healthy love from the abundance of my own love and my own wholeness. True recovery is about giving clean, healthy, unconditional love, not getting love. My life is now characterized by an ever-expanding circle of love, rather than a downward spiral deeper into shame.

Finally, all this healthy self-love unlocks the door to true self-esteem. Self-esteem and self-love are co-requisite. Because I am able to love myself and others unconditionally, I esteem myself; I hold myself in high regard; I value myself; I perceive myself as an able-to-give-love, worthwhile person. The abundance of my self-love is the clean, healthy gift of unconditional love I can now bring to all my relationships.

next: Detachment