Diagnostic criteria for Manic Depression and Schizophrenia. Detailed list of symptoms for both Bipolar Disorder and Schizophrenia.

1. 

   (2) Criteria for Manic Episode

   • A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
   • During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
     1. inflated self-esteem or grandiosity
     2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
     3. more talkative than usual or pressure to keep talking
     4. flight of ideas or subjective experience that thoughts are racing
     5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
     6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
     7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
   • The symptoms do not meet criteria for a Mixed Episode
   • The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
   • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

   (3) Criteria for Mixed Episode

   • The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.
   • The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
   • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

   (4) Criterion A of Schizophrenia

   • Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated):
     • delusions
     • hallucinations
     • disorganized speech (e.g., frequent derailment or incoherence)
     • grossly disorganized or catatonic behavior
     • negative symptoms, i.e., affective flattening, alogia, or avolition
   • Only one symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.
2. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.
3. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness.
4. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

next: Causes of Schizoaffective Disorder
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Some believe the cause of schizoaffective disorder is associated with schizophrenia, others think it's related to mood disorders.

The cause of schizoaffective disorder remains unknown and subject to continuing speculation. Some investigators believe schizoaffective disorder is associated with schizophrenia and may be caused by a similar biological predisposition. Others disagree, stressing schizoaffective disorder's similarities to mood disorders such as depression and bipolar disorder (manic depression). They believe its more favorable course and less intense psychotic episodes, are evidence that schizoaffective disorder and mood disorders share a similar cause.

Many researchers, however, believe schizoaffective disorder may owe its existence to both disorders. These researchers believe that some people have a biologic predisposition to symptoms of schizophrenia that varies along a continuum of severity. On one end of the continuum are people who are predisposed to psychotic symptoms but never display them. On the other end of the continuum are people who are destined to develop outright schizophrenia. In the middle are those who may at some time show symptoms of schizophrenia, but require some other major trauma to set the progression of the disease into motion. It may be an early brain injury--either through a complicated delivery, prenatal exposure to the flu virus or illicit drugs; or it may be emotional, nutritional or other deprivation in early childhood. In this view, major life stresses, or a mood disorder like depression or bipolar disorder, may be sufficient to trigger the psychotic symptoms. In fact, patients with schizoaffective disorder frequently experience depressed mood or mania within days of the appearance of psychotic symptoms. Some clinicians believe that "schizomanic" patients are fundamentally different from "schizodepressed" types; the former are similar to bipolar patients, while the latter are a very heterogeneous group.

Symptoms of schizoaffective disorder vary considerably from patient to patient. Delusions, hallucinations, and evidence of disturbances in thinking--as observed in full-blown schizophrenia--may be seen. Similarly mood fluctuations such as those observed in major depression or bipolar disorder may also be seen. These symptoms tend to appear in distinct episodes that impair the individual's ability to function well in daily life. But between episodes, some patients with schizoaffective disorder remain chronically impaired while some may do quite well in day-to-day living.

next: Associated Features of Schizoaffective Disorder
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Paul Jones wason the verge of committing suicide 6-years ago, when somehow he pulled himself together just enough to make it to the doctor's office where he was diagnosed with bipolar disorder. Today, the standup comedian, author, singer/songwriter tours the country talking about the ups and downs of his life and the stigma attached to mental illness. He's also written several books, including Dear World- A Suicide Letter.

Paul joined us to discuss the various aspects of his life with bipolar and how he copes with the stigma of mental illness.

Natalie is the HealthyPlace.com moderator

The people in blue are audience members.

Natalie: Good evening. I'm Natalie, your moderator for tonight's Bipolar chat conference. I want to welcome everyone to the HealthyPlace.com website. Besides having comprehensive information on all mental health conditions, we have a large social network. A social network is a place for people with mental health conditions as well as their family members and friends to meet each other, maintain blogs and provide and get support. It's free to join. All you do is set up a user account.

Tonight, we are talking about personal experiences of living with bipolar disorder along with the stigma attached to having a mental illness.

Our guest, Paul Jones, is not only a well-known stand-up comedian, but he's also an author, singer and songwriter. He is 42 years old, married, a father of three and was diagnosed with bipolar disorder at the age of 36; just 6 years ago. Paul is very involved with educating people about bipolar disorder and not only its effect on the individual but also on family members and friends. He's also written several books, including Dear World- A Suicide Letter, Life after Suicide: A Bipolar Journey, A Bipolar Discussion: From the Inside Looking In, and his most recent release My Five Key's to living with Bipolar Disorder.

Good evening, Paul, and welcome to the HealthyPlace.com website

Paul Jones: Evening to you and all. Thanks for having me.

Natalie You're an entertainer. Many famous actors and writers, including Robin Williams, Martin Lawrence, Ben Stiller and, of course, Patty Duke, all have bipolar. Some credit the disease with providing them with extraordinary creativity and so, in various articles and interviews, you'll see bipolar disorder even glamorized. In your case, how much truth is there to that?

Paul Jones: Indeed many "famous" and "successful" people have been diagnosed as Bipolar or Manic Depressive; depending on which title you prefer. I have been blessed over the years to have worked with so many very creative people and can say that I think probably 90% of them suffer from some sort of mental illness.

The fact is, I know this illness is not who I am, but it is a part of me, a part that has allowed me at times to do some pretty creative and incredible things. I attribute it to the ability to have many thoughts at a time.

The key is having someone around you who can do something with those thoughts. You know, harvest the good ones and throw away the bad.

Natalie Has it ever crossed your mind that you would not be as funny or productive if it weren't for bipolar disorder?

Paul Jones: To some degree, yes, it has -- but I have to tell you right now, I am not really a person who looks back at what could have been and or what should have been. One of the problems we have in our country right now is people are constantly trying to figure out what could have been. I have enough mental problems and trying to figure out the past is like sitting around planning on what you will buy when you win the lottery. It is a complete waste of time. Would have, could have, should have, all three have no place in my life.

Natalie So our audience can get a perspective, prior to your diagnosis, what was living with bipolar disorder like for you?

Paul Jones: Hell, Hell, Hell, and did I mention, Hell? I think I am not any different than most people living with this illness who have no idea what is wrong with them.

Natalie So, can you please describe what "hell" was like for you?

Paul Jones: I spent the last three-and-a-half years before the diagnoses in depression. No matter how hard I tried, I could not get out. I was on stage every single night making people laugh and praying I would get shot all at the same time. I lost my family, my money and my hope.

Natalie You went to the doctor in August 2000. In an article I read, you mention being extremely depressed at the time. But you had been dealing with this depression for a long time. What kept you from going to the doctor earlier?

Paul Jones: Stigma, Fear, Pride and Stupidity and not in that order. What keeps most people from facing a brain illness? All four of the above and more I am sure. No one wants to have a mental illness, do they? I know I did not. I would take cancer, diabetes, and such. If I have those, then I will have people come and visit me with food and stuff. Have a mental illness and you'll be labeled for the rest of your life.

Natalie And how has your life changed since your bipolar diagnosis?

Paul Jones: This could be a very long-winded answer. I will try and make it short.

My life, since being diagnosed, has been harder than it was prior. Why? Because the day I was diagnosed, I had to participate in my own recovery and mental health. I could no longer say, " I wonder what is wrong with me" because I knew. I could no longer sit in my room and say, "poor me" because I knew. I could no longer look at the mess I had made and blame it on other people -- because I knew.

Many people think being diagnosed makes it all go away. The fact is, nothing goes away, ever. You simply have to learn how to face and handle life again.

How is my life? My life is wonderful because I know. I know and I am back in the driver's seat. Still hitting bumps from time-to-time but I am driving and that is all that matters to me.

Natalie After you were diagnosed with bipolar, what, if anything, did you tell your family, your friends, co-workers? And how did they react?

Paul Jones: Well, this is simple. My license plate on my car reads BIPOLAR. Does that answer the question?

I am blessed to have people around me that have been used to me doing, saying and being who I want to be. So letting them know that I have a brain illness was no different than telling them that I had an enlarged prostate. How did they react? I have lost friends and family members because of it. But I have gained way more. The people I lost really meant nothing to me. The only people that mattered are the ones living in my house and me. I was tired of allowing my brain illness to ruin and run my life. Once I knew, again, I am driving this boat.

Natalie Stigma is a very big issue for people with a mental illness. Have you encountered that and, if so, how do you deal with it?

Paul Jones: STIGMA is the number one reason people do not go and get help. STIGMA is the number one reason I go out and speak. Yes, I have encountered STIGMA. As a matter of fact every single day I encounter it. Unfortunately, that is something I will deal with for the rest of my life; especially since I lead such a public life about my illness. I speak and that is how I deal with it. I go out and show young people that they can be whatever they want to be as long as they have desire, determination and drive.

Would we tell a diabetic child they cannot be successful or happy? NO.

Do we tell kids diagnosed with cancer they have no future? NO!

Then why would we tell our children that if they have a brain illness they cannot be happy or successful? I would stack a room full of Bipolar people up against a room full of diabetics any day. We will kick their read ends :-) Seriously. People who are Bipolar who are active in their treatment are just as, if not more productive than anyone else. The key here is "active in treatment."

Natalie Could you give us an example or two of times you have faced stigma from having bipolar disorder?

Paul Jones: I do not think I have to tell anyone here what it is like to lose your cool and have people ask if you have taken your meds. Usually, it is something simple. I also cannot get life insurance and or other types of insurance.

Natalie Paul, here is the first question from the audience.

aliwebb: When I am manic-mostly I am great. When I am down, it doesn't make a difference who loves me or who is supportive or anything good that happens or how good life is- nothing could feel worse than being alive and for no reason. Is your's ever so horrible?

Paul Jones: It was, yes. I have to tell you this. After multiple affairs and pushing my children all but out of my life, I finally realized I needed to get some serious help. I used to sleep in my closet when I was on the road. Imagine! A 30-year old man sleeping in closets and under beds.

Lavendar: My fiancée is bipolar. What would you suggest I do to be able to help him effectively cope with everything?

Paul Jones: Let me ask this: is he seeking, getting and complying with help? That is the big issue. If he is not getting help or being compliant, there is not much you can do. You cannot force insulin on a diabetic, therefore they loose a foot. I am very harsh when it comes to compliance. I have not missed one single pill since being diagnosed

Lavendar: Yes, he is.

Paul Jones: Then you are lucky. Be supportive and all should be good. He has to stay compliant. Good luck.

Linds... thats me!: Hi Paul can you tell us what your LOWS are like?

Paul Jones: I am very lucky today. Since re-working my medication about 7 months ago, I am happy to say I have been pretty stable. Prior to being successful with medications, the lows where a very, very dark place for me, just as for most. I spent most of my days hiding. I only came out when it was time to get on stage and do a show. I cried in my car almost every road trip. As a stand up comic, you spend a great deal of time alone. Being depressed and alone is hell. I never want to be there again.

Natalie Here's a good question, Paul.

kf: I am compliant, but how did you deal with people from your past when you were ill?

Paul Jones: Well. are you ready for my answer? Do not ask if you do not want it.

To heck with them.

In that I mean this: I cannot change one single thing I did. Nothing I do, say or try and do will make it go away. I made many phone calls. I did not say I was sorry. I said I was sad that those things happened. One of the tough things we have to do is get through the past. You cannot drive your car looking behind you. Come to terms with it and move ahead.

Fragileheart: How has shame affected your ability to function and get help? Has shame been an issue for you?

Paul Jones: I was filled with Shame, Guilt, Sadness and downright Sickened by me....by me. I could not get past the fact that I had let something as simple as a brain illness control my life. I was sad that I let all that time go. All I had to do was seek help and at the very least I could say I was doing something. It is not easy to keep my brain healthy, but then again nothing in life is easy, except failing.

kitcatz: There's such a fine line between feeling good and hypomania, which always leads to mania. How do you know the difference and how do you cope?

Paul Jones: I do a lot of self evaluation. I am healthy enough now that I know and remember what it was like to be Whacko. I no longer will make a big purchase without letting 30 days pass. I do not start any major projects without having the prior one finished. I own a productions company so this is key for me. I have to try very hard to keep myself in check. Then I have my wife and children who are a major part of my treatment. They are no longer out of the loop. They are the loop.

Natalie Paul, you wrote a book entitled "Dear World- A Suicide Letter" describing a period in time in which you were seriously contemplating suicide; in fact, on the verge of committing suicide. It is not uncommon for people with bipolar disorder to think about suicide. What was going on in your life and in your thoughts at that time?

Paul Jones: Dear World- A Suicide Letter is just that. It is my Suicide Letter. I was sitting at my desk, writing my final words. I was going to kill myself that morning. It is not a book that was written, it is the actual letter itself which I was talked in to publishing. Had I not sat down to write the letter that morning I would be dead right now. I would have never gone home that day. What was going through my mind? Nothing, nothing but being dead. I was dead, I was a dead man walking. I was tired of fighting, I was finished with the pain, I was done.

Natalie What kept you from committing suicide?

Paul Jones: After writing for over 7 hours I had come to the conclusion that I was lying to my children. I was lying to all the kids I had coached for all the years in soccer. I have told my kids and the children on my team " you never, ever quit" and here I was quitting. Once I realized I would be remembered as a liar, that was all it took. I hate liars, I cannot stand liars and there was no way my children were going to look back on everything I had told them and say I lied. I did not stay alive for my children that day, I am alive today because I refuse to be remembered as a liar.

Natalie You are now taking medications to stabilize your moods and control the manic and depressive episodes. How do you feel about that?

Paul Jones: If I was a Diabetic I would take meds. If I had high blood pressure I would take meds. This is no different to me, I am in. You have a pill that can and will allow me to live life. I am IN.

Natalie I know this may be getting a little personal, but are you feeling any side-effects from the medications and how are you dealing with that?

Paul Jones: You can ask me anything. I am a open book. I can run for office without fear.

Side Effects....got to love them. I could go on for hours here due to the meds taken over the years. But I will give you two:

SEX - Once I realized my equipment was not working the way it once had I immediately called my doctor - at 3am by the way. I said, "hey Steve, I am lying here next to my wife at 3 am naked and we are just talking" You learn how to deal with things, you really do. My equipment working properly is important yes, but if my brain is sick I could really care less about it and or my wife anyway. So again, you have to decide what is the most important thing.

Next is FAT FAT FAT - I gained a lot of pounds for me due to? Nope not what you're thinking. The answer is not because of my medicine. I gain the pounds because I increased my food intake and did nothing in the form of exercise. Again, you have to participate. Late November I got out of the shower in my hotel room and as I pulled the shower curtain to there was this huge fat guy in my room. I took a close look and low and behold it was me. I could not believe what I have allowed myself to become. December 1 I started back to the gym at 243 pounds and today, March 27 I am about 197.

Participate. Like I said, we know what we have to do... we are just un willing to do it.

Natalie When you meet someone, do you introduce yourself as having BP within a first conversation?

Paul Jones: My license plate says BIPOLAR on my Car.....does that answer it?

I do not say hi my name is Paul and I am Bipolar......EVERY ONE ...HI PAUL,

I do not hide from it but usually it does come up. They see my car or they have read my books.

Natalie: We have more questions from the audience.

lisaann: You said you have been doing really well since your med change 7 months ago. What do you do if the symptoms reappear? How do you cope with the recurrence of them? I find that the biggest challenge of this illness.

Paul Jones: You are correct. I do not jump until I do a little searching.
1-Is my depression due to life....you know, "life sucks...."
2- Have I done something wrong? Have I been eating too much bad stuff, have a drank something wrong or such?
3- Have I been getting too much sleep?

If the answer is no to all, then I pick up the phone and call my doc. If I have to start over, I start over. I have had to do it 3 times now and will do it again I am sure.

Gene7768: Looking back now, how long do you think you had the disease, when did it start, and why did you not realize you had it?

Paul Jones: I can see that it all started around age 11. As a child, I had no clue what was wrong. I was not about to tell my parents I wanted to kill myself. Heck, Dad would have said, don't use my tools and mom would have said do not get blood on the carpet. As I grew older I knew I had an issue but was not willing to be labeled.. The truth is I was labeled, I was the one doing it.

allie82: Do you hear voices with bipolar disorder?

Paul Jones: I personally do not hear voices per se. I do, however, have or had strong feelings that I should do something like give my money away or start a huge project.

Natalie Allie82 - if you are hearing voices, that is significant and can be a dangerous signal of psychosis and I hope you'll talk to your doctor about that right away. For everyone here, go here if you are looking for detailed bipolar information.

Linds: How do you cope with people around you that don't suffer from the illness. I find it hard to connect with people. I'm losing friends because of this and its only making me worse. How do you deal with people like that?

Paul Jones: Look....you cannot make people understand what you have. They will either decide to realize it is real or not.

How do I deal with people who do not think it is real? Do you really want to know? I get rid of them from my life. Poisonous people have no place in my life. I have a hard enough time with my own life. I do not have time to try and educate the uneducable. Does that make sense? We try too darn hard to make others understand.. Try and get yourself better, then work on the other. You are a wonderful person I am sure. Treat yourself like one.

Linds: Definitely does make sense. Thanks Paul. You are legend, and I love Robin Williams too.

Paul Jones: Thanks much. I try.....:-)

One more thing Linds. Please stop letting other people bring you down.. Take those people out of your life plan for right now. You deserve a good life. Go and get it. Take care of your brain. It needs. you to take care of it. Feed it right, treat it good.

Natalie Paul, do you see a therapist of some sort? If so, do you find that helpful and in what way?

Paul Jones: Honestly, my speaking has become my therapy. It works out well because I like to talk and I do not have to share the stage. I know that groups are good for people. They just do not fit in with my life. I am on the road a ton, I speak to thousands of people a year. I call those my sessions. You have to share and I get a chance to share everyday.

Natalie What other things do you do to stay healthy -- when it comes to bipolar?

Paul Jones: I am working out, drinking tons of fresh water, eating right and most importantly, I stopped smoking.

Natalie When you compare yourself before the diagnosis of bipolar disorder and now 6 years later, how do you feel about yourself?

Paul Jones: I am AWESOME...I mean that. I feel so much better about myself, my life and what I am doing. I love to drive my car and in this case, my brain is my car. I am blessed to have this illness, I am blessed to have all the mistakes I have in my past. I am blessed to have gone through all the hard times I have. It is because of my past that today is so grand. Without the past and learning from it I would not be who and or what I am. My children would not be who they are. My wife and I would not be getting ready to celebrate our 25th anniversary. I am blessed. I would not change one thing, not one. Because changing anyone thing may alter the way today is and I am golden with today. It is not easy, and it is not always great but that is called life, and I for one, am enjoying the ride.

Linds: Absolute legend.

peacefuldolphin: That is great BPBoy.

teet: You are awesome.

kitcatz says: Thank you.

Gene7768 says: Thank you so much.

chrisuk says: Thank you Paul.

Paul Jones: Thanks.

Natalie Our time is up tonight. Thank you, Paul, for being our guest, for sharing your personal experiences with bipolar disorder and for answering audience questions. We appreciate you being here.

Paul Jones: Thanks for asking me.

Natalie: Thank you, everybody, for coming. I hope you found the chat interesting and helpful.

Good night everyone.

Articles by Paul Jones

• The Day I Was Diagnosed as Bipolar
• Sharing A Diagnosis of Bipolar Disorder With Family And Friends
• Techniques and Tools for Dealing With Bipolar Disorder

Disclaimer: Please note that HealthyPlace.com is NOT recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor and/or therapist BEFORE you implement them or make any changes in your treatment or lifestyle.

The prevalence of eating disorders among American women has increased dramatically in the past decade. In turn, the psychological community has expanded it's scope of research and study by focusing more attention on eating disorders and concentrating on other extended issues related to eating disorders. The desire to distinguish and understand a possible relationship between bulimia nervosa and depression has become a major focus within the field.

Information About Eating Disorders and Depression

• Depression Precedes Eating Disorder in Some Women

• Eating Disorders and Possible Co-Existing Illnesses or Additions

• Binge Eating and Self-Esteem

• The Psychological and Medical Risks of Eating Disorders

• Anorexic Men More Depressed, Anxious Than Peers

• Eating Disorders Linked to Suicide Risk

• Anorexic Women More Likely to Be Suicidal

Treatment of Depression:

• Eating Spuds Could Lighten SAD Winter Blues

• Don't Wait to Treat Early Forms of Bulimia

• Self Help Advice For Depressed Patients

For the most comprehensive information about Depression, visit our Depression Community Center here, at HealthyPlace.com.

next: Depression Precedes Eating Disorder in Some Women
~ all articles on depression and eating disorders
~ eating disorders library
~ all articles on eating disorders

Below you will find some of the psychological illnesses and addictions that can sometimes co-exist with an Eating Disorder.

In people who suffer from Eating Disorders Anorexia, Bulimia and/or Compulsive Overeating. In some cases, their Eating Disorder is a secondary symptom to an underlying psychological disorder (such as some people who also suffer with Multiple Personality Disorder), and in other cases, the psychological disorder may be secondary to the Eating Disorder (as with some people also suffering with Depression). Men and women may also suffer from both an Eating Disorder and other psychological disorder(s) that completely co-exist with one another... or they can suffer from an Eating Disorder and have little or no signs of an additional psychological disorder (Note: The longer a person suffer, the more probable that they may be dealing with Depression or Anxiety as well). It is important to the recovery process and treatment that all these issues are addressed, and that a proper diagnosis be determined.

Some of the psychological illness that can be (but are not always) found in people suffering with Anorexia, Bulimia and Compulsive Overeating are: Obsessive Compulsive Disorder, Depression, Post Traumatic Stress Disorder, BiPolar and BiPolar II Disorder, Borderline Personality Disorder, Panic Disorders and anxiety, and Dissociative Disorder and Multiple Personality Disorder.

In addition, some people suffering with an Eating Disorder may also be exhibiting other addictive or self-destructive behaviors. As an Eating Disorder is a reaction to a low self-esteem, and a negative means of coping with life and stress, so are other types of addictions. These can include alcoholism, drug addiction (illegal, prescription and/or over-the-counter medications), and self-injury, cutting and self-mutilation.

Harming oneself, also known as cutting, self-mutilation, or SIV (self-inflicted violence) is a coping mechanism that is sometimes found in people also suffering with an Eating Disorder. For some, they may find it easier to deal with real physical pain than to deal with their emotional pain, or some may feel emotionally numb and using SIV reminds them that they are alive. They may even feel that they deserve to be hurt. It can be used to block out emotional pain, or to make the person feel "strong". It is a way to cope with stress and anger, shame and guilt, sadness, and as a release for emotions that have built up inside. SIV can be mild to severe, but it should never be confused with a conscious attempt to commit suicide (though some may die as a result of their actions, this is relatively uncommon). SIV can include cutting, burning, punching, slapping, hitting oneself with an object, eye-pushing, biting and head-banging, and less common methods would be those that have long-lasting or life-long effects such as bone breaking, or amputation.

Suffering with an Eating Disorder, alone or combined with any other psychological illness or addiction, leaves each sufferer needing new and better ways to cope.

There is an indication that Eating Disorders may sometimes co-exist with ADD (Attention Deficit Disorder) and ADHD (Attention Deficit and Hyperactivity Disorder). Studies have shown that women who go undiagnosed as ADD (but do infact have it) are much more likely to develop an Eating Disorder. Some of the neurological symptoms of ADD/ADHD can be: holding onto negative thoughts and/or anger, as well as impulsivity both verbally (interrupting others) and in actions (acting before thinking). There may also be unexplained emotional negativity, depression, and even attempted suicide. To get a proper diagnosis, there is a whole criteria that needs to be met, so if you suspect you are living with ADHD or ADD, please visit one of the links below.

From the National ADD Association, "If untreated, individuals with ADHD may develop a variety of secondary problems as they move through life, including depression, anxiety, substance abuse, academic failure, vocational problems, marital discord, and emotional distress." There are many of the same possible co-existing psychological illnesses with ADHD/ADD as with an Eating Disorder, including: Depression, BiPolar Disorder, Post Traumatic Stress Disorder, and Obsessive Compulsive Disorder.

I have received e-mail from a good number of men who are simultaneously living with ADHD and an Eating Disorder, and I suspect there are many more, both men and women, doing the same.

Please, before jumping to any conclusions about yourself or a loved-one, research the information. Eating Disorders do not always co-exist with another psychological illness or addiction, but it is not uncommon to find that they do. Remember, many of these illnesses and conditions share similar symptoms. A proper diagnosis by a doctor is very important to successful treatment and recovery of the eating disorder.

next: Eating Disorders Linked to Suicide Risk
~ all articles on depression and eating disorders
~ eating disorders library
~ all articles on eating disorders

Advice for Depressed Patients

• Don't fight the depression--try and accept it as an illness.
• You cannot will the depression away, only accept it.
• Delay any big decisions about work, marriage or money until you feel better.
• Don't trust your memory right now--take notes and make lists. This will improve when you feel better.
• Waking through the night is very common. It's better to get out of bed until you feel sleepy again.
• Mornings are usually terrible. The day usually gets better towards evening.
• Avoid being home alone for long periods--the depressive thoughts can get worse when no one is around.
• Forget about trying to read technical or complicated material--you need your concentration to do this--stick to light novels and People magazine.
• Be careful about television--comedy and cartoons are okay, but anything else can depress you even more than you already are.
• Get outside at least once a day for a walk by yourself.
• Light exercise of any kind can be very helpful to your recovery.
• If you have to do some work, do it in the afternoon or early evening. Your energy and interest are best at these times.
• Try and keep busy, but only with projects that involve your hands, not heavy thinking tasks.
• Talking to loved ones or friends will be difficult for a while. Sympathetic people can actually make you feel worse. Until you feel better, cancel all non-essential social engagements.
• Suicidal or hopeless thoughts are common in depression and will go away once you start feeling better. Talking to someone about these thoughts can help make them go away.
• Your appetite for food is probably low and you may have lost weight. These are core symptoms of depression and will return to normal with treatment. In the meantime, eat small nutritious snacks and have other people cook for you.
• When you start to get better, you will notice a few minutes or more of feeling quite normal, but it doesn't last. These minutes become hours and then most of the day is pretty good. Full recovery takes longer, sometimes a couple of months.
• Don't be surprised if most people are confused by your condition and don't know what to say to you. No one can really understand your suffering unless they have had a major depression or have treated many depressed people--like your doctor.
• Once again, don't fight the depression--try and accept it as an illness. Your will be back to normal soon.

What My Family Can Do about My Depression

Most families worry about a member who is depressed. Some people feel angry and overwhelmed. It is difficult to understand why a depressed person is not "snapping out of it". The first thing to keep in mind is the depressed person cannot help feeling depressed. Sudden crying spells, angry outbursts, and hopeless statements like, "what's the point?" are common. This behaviour will disappear with treatment. You can help by distracting the depressed person by keeping them busy with tasks they can accomplish easily. Be patient and reassuring; help with decision-making and make sure the person gets to appointments with the doctor and takes the medication. Short conversations are better than long talks. As the person recovers, encourage them to be more active and resume their previous responsibilities. Suicide can be a worry. Asking about thoughts of suicide is not going to encourage a suicide attempt.

Talking about suicidal thoughts is often a great relief to the depressed person. However, anyone seriously thinking about taking their life is in need of urgent professional help to prevent a tragedy. Families should inform the doctor of any concerns they have.

Visit HealthyPlace Depression Community for extensive information.

Recommended Readings

Feeling Good: The New Mood Therapy - D. Burns, Signet, New York, 1980. A persuasive self-help guide for treating depression by a cognitive therapist. Includes charts, homework assignments to offer mechanisms for coping with problems such as procrastination, loneliness and negative thinking. Gives clear indicators for need of professional treatment. Highly recommended.

Overcoming Depression - D.F. Papolos, Harper and Row, New York, 1987. Excellent, practical overview of the symptoms and cause of depressive disorders with much useful advice for the patients and families. Highly recommended.

Your Brother's Keeper - J.R. Morrison, Nelson Hall Publications, Chicago, 1982. Also difficult to find in bookstores, but available in libraries. Good practical advice for families in regard to the treatment of mood disorders.

Rapid Relief From Emotional Distress - G. Emery, Fawcett Columbine, 1986. Practical, cognitive techniques to master mild depression.

Unfinished Business: Pressure Points in the Lives of Women - M. Scarf, Doubleday and Company, New York. 1980. A very useful description of psychological problems that can cause depression in women. Useful as a resource in the psychotherapy of depression.

A. Buchanan, F.R.C.P.(C) University of British Columbia, 1993 MDA NewsLetter - Jan/Feb 1995 Mood Disorder Association, Vancouver, B.C.

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The female athlete triad is defined as the combination of disordered eating, amenorrhea and osteoporosis. This disorder often goes unrecognized. The consequences of lost bone mineral density can be devastating for the female athlete. Premature osteoporotic fractures can occur, and lost bone mineral density may never be regained. Early recognition of the female athlete triad can be accomplished by the family physician through risk factor assessment and screening questions. Instituting an appropriate diet and moderating the frequency of exercise may result in the natural return of menses. Hormone replacement therapy should be considered early to prevent the loss of bone density. A collaborative effort among coaches, athletic trainers, parents, athletes and physicians is optimal for the recognition and prevention of the triad. Increased education of parents, coaches and athletes in the health risks of the female athlete triad can prevent a potentially life-threatening illness. (Am Fam Physician 2000;61:3357-64,3367.)

According to Title IX of the Educational Assistance Act, any college that accepts federal funding must provide equal opportunities for women and men to participate in athletic programs. Last year marked the 25th anniversary of the passage of Title IX legislation, which dramatically increased the number of women who participate in sports at all competitive levels. Increased participation in exercise can result in a myriad of proven short- and long-term benefits. However, potential adverse health consequences are associated specifically with the overzealous female athlete. The family physician, who may recognize pathologic conditions that are related to exercise, usually has multiple opportunities to intervene.

Definitions and Prevalence

The female athlete triad is a combination of three interrelated conditions that are associated with athletic training: disordered eating, amenorrhea and osteoporosis. Patients with disordered eating may engage in a wide range of harmful behaviors, from food restriction to bingeing and purging, to lose weight or maintain a thin physique. Many athletes do not meet the strict criteria for anorexia nervosa or bulimia nervosa that are listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (Table 1), but will manifest similar disordered eating behaviors as part of the triad syndrome.1

Amenorrhea that is related to athletic training and weight fluctuation is caused by changes in the hypothalamus. These changes result in decreased levels of estrogen. Amenorrhea in the female athlete triad may be classified as primary or secondary. In patients with primary amenorrhea, there is no spontaneous uterine bleeding in the following situations: (1) by the age of 14 years without the development of secondary sexual characteristics, or (2) by the age of 16 years with otherwise normal development. Secondary amenorrhea is defined as the six-month absence of menstrual bleeding in a woman with primary regular menses or a 12-month absence with previous oligomenorrhea.

Osteoporosis is defined as the loss of bone mineral density and the inadequate formation of bone, which can lead to increased bone fragility and risk of fracture. Premature osteoporosis puts the athlete at risk for stress fractures as well as more devastating fractures of the hip or vertebral column. The morbidity associated with osteoporosis is significant, and lost bone density may be irreplaceable.

Although the exact prevalence of the female athlete triad is unknown, studies have reported disordered eating behavior in 15 to 62 percent of female college athletes. Amenorrhea occurs in 3.4 to 66 percent of female athletes, compared with only 2 to 5 percent of women in the general population.2-7 Some components of the female athlete triad are often undetected because of the secretive nature of disordered eating behavior and the commonly held belief that amenorrhea is a normal consequence of training.

Recognition of Risk Factors

Athletic pursuits that emphasize low body weight and a lean physique include gymnastics, figure skating, ballet, distance running, diving and swimming.

The development of poor self-image and pathogenic weight control behaviors in the female athlete may be caused by many factors. Frequent weigh-ins, punitive consequences for weight gain, pressure to "win at all costs," an overly controlling parent or coach, and social isolation caused by intensive involvement in sports may increase an athlete's risk. Societal perpetuation of the ideal body image may intensify the endeavor for a thin physique.Athletic endeavors such as gymnastics, figure skating, ballet, distance running, diving and swimming that emphasize low body weight and a lean physique can also increase the risk of developing the female athlete triad.2,4

Prevention

Prevention of the female athlete triad through education is crucial. Coaches, parents and teachers are often unaware of the impact they have on athletes. During adolescence and young adulthood, these athletes may receive comments or instructions that seem to encourage or demand maladaptive patterns of diet and exercise. According to one small study,2 75 percent of female college gymnasts who were told by their coaches that they were overweight used pathogenic behaviors to control their weight. The physician may recognize such patterns and be able to intervene before the development of the female athlete triad.

Screening

The optimal time to screen athletes for the female athlete triad is during the preparticipation sports physical examination. The physician might also screen for the triad during acute visits for fractures, weight change, disordered eating, amenorrhea, bradycardia, arrhythmia and depression, and also during visits for routine Papanicolaou smears.8

A history of amenorrhea is one of the easiest ways to detect the female athlete triad in its earliest stages. Evidence suggests that menstrual history may predict current bone density in female athletes.9 In a study of young female athletes, longer, more consistent patterns of amenorrhea were found to have a linear correlation with measures of bone density. Amenorrhea should not be discounted by the family physician as a benign consequence of athletic training. During preparticipation physical examinations at the University of California, Los Angeles, most women whose menstruation had stopped for three months or more had been told by their family physicians that amenorrhea was normal in athletes.10

While taking a patient's history, especially when asking about disordered eating practices, the physician should focus initially on the past. The patient may feel less threatened when discussing past eating behaviors. Patients are more likely to confirm that they have previously induced vomiting or used laxatives than to admit to current disordered eating patterns. A screening history for the female athlete triad is outlined in Table 2.

Diagnosis

In the beginning, the symptoms of the female athlete triad may be subtle. On physical and laboratory examination, however, the presence of symptoms such as fatigue, anemia, electrolyte abnormalities or depression caused by dieting may alert the physician to the diagnosis.5 Some of the most common signs and symptoms of disordered eating in the female athlete triad are listed in Table 3.

Amenorrhea secondary to excessive exercise is not a clinical diagnosis, nor one that can be made by laboratory testing. It is a diagnosis of exclusion. A history and physical examination should be completed for every female athlete with amenorrhea to rule out other treatable causes. The differential diagnosis of amenorrhea is listed in Table 4. Recently published review articles discuss the differential diagnosis and evaluation of amenorrhea in further detail.11

There is a lack of published evidence to guide the physician in the cost-effective use of bone density testing for female athletes who are at risk for osteoporosis. Osteoporosis is defined as bone density 2.5 standard deviations below normal for the patient's age.8 Early studies of osteoporosis in female athletes focused on the loss of bone mineral density in the vertebral column.12 In recent studies, prolonged amenorrhea was found to affect multiple axial and appendicular skeletal sites, including those that were subjected to impact loading during exercise.12,13 Because the risk of bone loss increases with the duration of amenorrhea, a dual energy x-ray absorptiometry (DEXA) scan or similar study should be considered in athletes with amenorrhea lasting at least six months.

A position paper published by the American College of Sports Medicine recommends that short-term amenorrhea be considered a warning symptom for the female athlete triad and suggests medical evaluation within the first three months.8 At the time of examination, the patient should be educated about the risks of irreplaceable bone loss that can occur after only three years of amenorrhea. Documentation of the loss of bone density may enhance patient compliance with recommendations for changes in eating behaviors and training regimens, and may convince the patient to start estrogen replacement therapy.14

Prognosis

Preservation of bone mineral density is one of the many reasons to screen female athletes and diagnose the female athlete triad early in its course. Postmenopausal women lose most of their bone mass and density in the first four to six years after menopause. If this is also true of amenorrheic athletes, intervention is needed before bone mass is irreversibly lost.9

Recent studies indicate that peak bone mass occurs at a younger age than was previously believed. Several studies have shown that the average age of peak bone mass is closer to 18 to 25 years rather than the currently accepted age of 30 years.15-18 If this is true, efforts to affect females with delayed or interrupted menses should begin during adolescence.

One study evaluated previously amenorrheic women who had resumed normal menses. After the first 14 months, their bone mineral density increased by an average of 6 percent. However, this trend did not continue. The rate of increase slowed to 3 percent the following year and reached a plateau at a bone mineral density that was well below the normal level for their age.9 Again, this finding shows the paramount importance of early intervention in preventing irreversible loss of bone mineral density.

Severe disordered eating patterns may put the athlete at risk for more significant morbidity or even death. In nonathletes, the mortality rate in treated anorexia nervosa can range from 10 to 18 percent.7 Even though most women with the triad do not meet strict criteria for anorexia or bulimia, they still appear to have a greater risk of mortality than that of the general population.7

Treatment

In addition to having a fundamental role in the diagnosis of the female athlete triad, the family physician has an integral part in coordinating the management of this condition. While a multidisciplinary approach to treatment has not been studied, many patients may benefit from a treatment plan that involves consultation with subspecialists. Involvement of a psychiatrist or psychologist and a dietician who specialize in the management of the female athlete triad may facilitate prompt improvement. Often, athletic trainers or coaches are the persons closest to the athlete. Their insights and support may be crucial to the success of any treatment plan.

Lifestyle Changes
Optimal treatment of the female athlete triad includes instruction from a dietician to educate and monitor the patient for adequate nutrition and to help the patient attain and maintain a goal weight. The patient, dietician and physician should agree on a goal weight, with consideration for the weight requirements for participation in the patient's chosen sport. A weight gain of 0.23 to 0.45 kg (0.5 to 1 lb) per week until the goal weight is achieved is a reasonable expectation. Helping the patient focus on optimal health and performance instead of weight is important. The patient need not stop exercising completely. Exercise activity should be decreased by 10 to 20 percent, and weight should be monitored closely for two to three months. 5

Hormone Replacement Therapy
No published longitudinal studies are available on the long-term benefits of hormone replacement therapy (HRT) to slow or reverse the loss of bone mineral density in these young women. Most of the evidence for the use of HRT has been extrapolated from data that support its use in postmenopausal women. Both oral contraceptives and cyclic estrogen/ progesterone have been used to treat amenorrhea of the triad. While hormonal therapy will treat the amenorrhea, the ultimate goal is the return of regular menses through proper nutrition, revised training regimens and maintenance of reasonable body weight.

One retrospective study of amenorrheic runners compared hormonal therapy with placebo over 24 to 30 months. The regimen included either conjugated estrogen in a dosage of 0.625 mg per day or an estradiol transdermal patch in a dosage of 50 µg per day. Both were given in combination with medroxyprogesterone in a dosage of 10 mg per day for 14 days per month. Patients receiving hormonal therapy showed a significant increase in bone mineral density, while those in the control group showed nonsignificant decreases of less than 2.5 percent.19 Small studies have also supported the use of oral contraceptives in persons with athletic amenorrhea.20 Retrospective studies have shown that athletes with a history of oral contraceptive use may have a decreased risk of stress fracture.13,21

While little direct evidence is available on the appropriate timing for initiation of HRT, considering hormone therapy after six months of amenorrhea seems prudent. Irreversible bone loss can occur after only three years of amenorrhea.6 Patients who already have evidence of early bone mineral density loss (osteopenia) on the basis of bone densitometry/DEXA scanning should be strongly encouraged to start hormonal therapy.

Estrogen may be replaced in a variety of ways. Oral contraceptives are frequently used and are advantageous if birth control is also desired. Hormone replacement regimens as prescribed for postmenopausal women are also feasible options. No single treatment regimen has been proved to be the most beneficial for the female athlete triad. Some options for estrogen replacement therapy are listed in Table 5.5,22 Progesterone should be included in any treatment regimen to prevent the endometrial hyperplasia that can result from use of unopposed estrogen.

Additional Pharmacotherapy
Research has shown that athletes who had a higher incidence of stress fractures also had lower calcium intakes and less frequent use of oral contraceptives.11 The recommended dietary allowance of calcium is 1,200 to 1,500 mg per day for females between 11 and 24 years of age.23 Surveys of females between 12 and 19 years of age have shown an inadequate average daily calcium intake of less than 900 mg per day.23 Additional daily supplementation of 400 to 800 IU of vitamin D will also facilitate the absorption of calcium. Treatments for osteoporosis, such as bisphosphonates and calcitonin, have not been tested specifically in younger patients with the female athlete triad. However, the physician should consider all available treatment options for athletes with frank osteoporosis on the basis of DEXA scanning (more than 2.5 standard deviations below age-specific norms). Options for the treatment of osteoporosis have been discussed in detail in a number of recent review articles.24,25

Depending on the severity of the eating disorder, a selective serotonin reuptake inhibitor (SSRI) may be indicated for treatment of a specific disorder. Benzodiazepines have also been suggested by one author for the treatment of a patient with severe mealtime anxiety.26 A psychiatric evaluation may help with the assessment of depression or eating disorders, and with the selection of medications.

Family Involvement Involvement of the family is crucial to the success of treatment. Family members should be included in treatment plans from the beginning, particularly with adolescent patients. Although at first the physician's intervention may appear to be detrimental to the child's athletic career, education about the significance of the female athlete triad may motivate parents to participate in a treatment program.

The Authors

JULIE A. HOBART, M.D., is residency faculty and assistant professor of family medicine at the University of Cincinnati/Mercy ­Franciscan Hospitals Family Medicine Residency Program, Cincinnati, Ohio. Dr. Hobart received her medical degree from Ohio State University College of Medicine, Columbus, and completed a residency in family medicine and a faculty development fellowship at the University of Cincinnati/Franciscan Hospitals.

DOUGLAS R. SMUCKER, M.D., M.P.H., is assistant professor and codirector of research in the Department of Family Medicine at the University of Cincinnati College of Medicine. Dr. Smucker completed his medical degree and served a residency in family practice at the Medical College of Ohio in Toledo. He also completed a primary care research fellowship and a residency in preventive medicine at the University of North Carolina at Chapel Hill School of Medicine.

REFERENCES

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:539-50.
2. Rosen LW, Hough DO. Pathogenic weight-control behaviors of female college gymnasts. Phys Sports Med 1988;16:140-3.
3. Rosen LW, McKeag DB, Hough DO, Curley V. Pathogenic weight-control behavior in female athletes. Phys Sports Med 1986;14:79-84.
4. Sundgot-Borgen J. Risk and trigger factors for the development of eating disorders in female elite athletes. Med Sci Sports Exerc 1994;26:414-9.
5. Otis CL. Exercise-associated amenorrhea. Clin Sports Med 1992;11:351-62.
6. Shangold M, Rebar RW, Wentz AC, Schiff I. Evaluation and management of menstrual dysfunction in athletes. JAMA 1990;263:1665-9.
7. Nattiv A, Agostini R, Drinkwater B, Yeager KK. The female athlete triad. The inter-relatedness of disordered eating, amenorrhea, and osteoporosis. Clin Sports Med 1994;13:405-18.
8. Otis CL, Drinkwater B, Johnson M, Loucks A, Wilmore J. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc 1997;29:i-ix.
9. Drinkwater BL, Bruemner B, Chesnut CH 3d. Menstrual history as a determinant of current bone density in young athletes. JAMA 1990;263:545-8.
10. Skolnick AA. 'Female athlete triad' risk for women. JAMA 1993;270:921-3.
11. Kiningham RB, Apgar BS, Schwenk TL. Evaluation of amenorrhea. Am Fam Physician 1996;53:1185-94.
12. Rencken ML, Chesnut CH 3d, Drinkwater BL. Bone density at multiple skeletal sites in amenorrheic athletes. JAMA 1996;276:238-40.
13. Myburgh KH, Hutchins J, Fataar AB, Hough SF, Noakes TD. Low bone density is an etiologic factor for stress fractures in athletes. Ann Intern Med 1990;113:754-9.
14. Mandelbaum BR, Nattiv A. Gymnastics. In: Reider B, ed. Sports medicine: the school-age athlete. 2d ed. Philadelphia: Saunders, 1996.
15. Matkovic V, Jelic T, Wardlaw GM, Ilich JZ, Goel PK, Wright JK, et al. Timing of peak bone mass in Caucasian females and its implication for the prevention of osteoporosis. Inference from a cross-sectional model. J Clin Invest 1994;93:799-808.
16. Lu PW, Briody JN, Ogle GD, Morley K, Humphries IR, Allen J, et al. Bone mineral density of total body, spine, and femoral neck in children and young adults: a cross-sectional and longitudinal study. J Bone Miner Res 1994;9:1451-8.
17. Vuori I. Peak bone mass and physical activity: a short review. Nutr Rev 1996;54:S11-4.
18. Young D, Hopper JL, Nowson CA, Green RM, Sherwin AJ, Kaymakci B, et al. Determinants of bone mass in 10- to 26-year-old females: a twin study. J Bone Miner Res 1995;10:558-67.
19. Cumming DC. Exercise-associated amenorrhea, low bone density, and estrogen replacement therapy. Arch Intern Med 1996;156:2193-5.
20. DeCherney A. Bone-sparing properties of oral contraceptives. Am J Obstet Gynecol 1996;174:15-20.
21. Bennell KL, Malcolm SA, Thomas SA, Ebeling PR, McCrory PR, Wark JD. Risk factors for stress fractures in female track-and-field athletes: a retrospective analysis. Clin J Sport Med 1995;5:229-35.
22. Fagan KM. Pharmacologic management of athletic amenorrhea. Clin Sports Med 1998;17:327-41.
23. NIH Consensus conference. Optimal calcium intake. NIH Consensus Development Panel on Optimal Calcium Intake. JAMA 1994;272:1942-8.
24. American College of Obstetricians and Gynecologists. ACOG educational bulletin. Osteoporosis. No. 246, April 1998 (replaces No. 167, May 1992). Int J Gynaecol Obstet 1998;62:193-201.
25. Lane JM, Nydick M. Osteoporosis: current modes of prevention and treatment. J Am Acad Orthop Surg 1999;7:19-31.
26. Joy E, Clark N, Ireland ML, Martire J, Nattiv A, Varechok S. Team management of the female athlete triad. Part 2: optimal treatment and prevention tactics. Phys Sportsmed 1997;25:55-69.

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Dieting behaviors and nutrition can have an enormous impact on the gynecologic health of adolescents. Teenaged patients with

anorexia nervosa can have hypothalamic suppression and amenorrhea. In addition, these adolescents are at high risk of osteoporosis and fractures. Unfortunately, data suggest that estrogen replacement, even in combination with nutritional supplementation, does not appear to correct the loss of bone density in these patients. Approximately one half of adolescents with bulimia nervosa also have hypothalamic dysfunction and oligomenorrhea or irregular menses. Generally, these abnormalities do not impact bone density and can be regulated with interval dosing of progesterone or regular use of oral contraceptives. In contrast, the obese adolescent with menstrual irregularity frequently has anovulation and hyperandrogenism, commonly referred to as polycystic ovary syndrome. Insulin resistance is thought to play a role in the pathophysiology of this condition. While current management usually involves oral contraceptives, future treatment may include insulin-lowering medications, such as metformin, to improve symptoms. Because all of these patients are potentially sexually active, discussion about contraception is important. (Am Fam Physician 2001;64:445-50.)

Adolescence is a time of tremendous growth and development, in which nutrition plays a key role. The adolescent growth spurt accounts for approximately 25 percent of adult height and 50 percent of adult weight.1 Moreover, girls develop reproductive capacity during this time. Adolescents with disordered eating behaviors, such as anorexia nervosa, bulimia nervosa or obesity, frequently have menstrual abnormalities that reflect their abnormal nutritional intake. In this article, we will address these three common adolescent conditions and describe the pathophysiology and management of the abnormal menstrual patterns that accompany each.

Anorexia Nervosa

Once described by Hilde Bruch as the "relentless pursuit of thinness,"2 anorexia is a disorder that plagues approximately 0.5 to 1.0 percent of adolescents.3 The diagnostic criteria have evolved to those described in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., and are summarized in Table 1.4 The intense fear of weight gain and the lack of self-esteem cannot be overstated and are factors that make this condition so painful for the young patient with anorexia. In addition, certain personality traits such as being perfectionistic, obsessive-compulsive, socially withdrawn, high-achieving (but rarely satisfied) and depressed are often noted in these patients. The patient with anorexia may exclusively restrict dietary intake (restrictive subtype) or may experience episodes of binging and purging (bulimic subtype).4

While the female adolescent with anorexia frequently experiences symptoms of anorexia such as weakness, dizziness or fatigue, she often seeks help (or is brought for medical attention by a distressed parent) because her weight loss has resulted in amenorrhea. The precise mechanism of amenorrhea in the patient with anorexia is not known. However, the severe caloric restriction suppresses the hypothalamic-pituitary axis.5 Biochemical mediators that have been implicated in this process include cortisol, leptin, growth hormone and insulin-like growth factor I6-9; all of these mediators play a role. The result is a dramatic suppression of the pituitary production of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Without normal cycling of LH and FSH, the circulating level of estrogen is very low and ovulation will not occur. Fertility is therefore compromised in these patients.

The patient with anorexia also is at high risk of developing osteopenia and frank osteoporosis.10 Although the pathophysiology of osteoporosis is not well understood, it is known that adolescence is a critical time of bone mineralization. Estrogen appears to play a major role,11 although nutritional factors are also crucial.12 One study13 compared patients who had anorexia with those who had hypothalamic amenorrhea from other etiologies and found that those with anorexia had more profound osteopenia, supporting the theory that nutrition also plays an important role. Normalization of the patient's weight appears to be the single most important factor in regaining bone density.14 Even when this is achieved, bone may not remineralize to normal levels.

The key goals of managing patients with anorexia are overall improvement of body weight and normalization of eating patterns. For example, while oral contraceptives have successfully restored menses in such patients in clinical trials, they do not appear to substantially mitigate the osteoporosis. One study15 that examined women with amenorrhea from various causes suggested that prolonged treatment with oral contraceptives and calcium supplementation (duration of more than 12 months) may have a beneficial effect, but other studies16 do not support this finding.

In the adolescent with anorexia nervosa, normalization of body weight is the single most important factor in regaining bone density.

A recent, small study17 found that the use of oral dehydroepiandrosterone had a favorable effect on bone turnover in young women with anorexia; however, additional studies are necessary. Because some physicians use the return of menses to demonstrate regained health in the patient, they may not want to mask this outcome with the use of oral contraceptives. Therefore, evidence to date does not support the routine use of oral contraceptives in the management of patients with anorexia, but newer modalities may be on the horizon.

Osteoporosis is of concern not only later in life when the patient becomes postmenopausal but also during the adolescent years. The patient with anorexia characteristically exercises frequently and strenuously, and may be prone to stress fractures even after a short duration of the disorder. These patients must be informed about the risk of osteoporosis and fractures, and must be assessed with a bone mineral density study to ascertain their individual risk of pathologic fractures. In the female athlete, this is a particular concern. Eating disorders in these athletes are prevalent, and the triad of a menstrual disorder, an eating disorder and osteoporosis, or the "female athlete triad,"18 makes these patients quite vulnerable to fractures.

Bulimia Nervosa

Just as the diagnostic criteria for anorexia have been redefined over the years, so too have the criteria for bulimia. The current diagnostic criteria are detailed in Table 2.4 Whereas the prominent features of anorexia are the caloric restriction and resulting underweight, the prominent elements of bulimia are episodes of binge eating (large amounts of food with a lack of control) and the compensatory behaviors that follow, in a patient who is either normal weight or overweight. The compensatory behaviors include self-induced vomiting, abuse of laxatives and diuretics, over-exercise, caloric restriction and abuse of diet pills. Usually the patient suffers painful remorse after the behaviors but is unable to control the impulse to repeat them. The young woman with bulimia characteristically has low self-esteem, is depressed and/or anxious, and has poor impulse control. She typically engages in other risky behaviors, such as substance abuse, unprotected sexual activity, self-mutilation and suicide attempts.

While amenorrhea is a diagnostic criterion for anorexia, menstrual irregularity occurs in only about one half of patients with bulimia, probably because these women rarely achieve underweight when irregularity occurs. The mechanism appears to be related to hypothalamic-pituitary function. One study19 that examined body weight as a predictive factor of abnormal menstruation in patients with bulimia concluded that when current weight was less than 85 percent of a patient's past high weight, abnormal 24-hour secretion of LH is likely. This study followed another study20 that suggested decreased pulsatile LH secretion as a factor. Another very small study21 showed elevated levels of free testosterone in patients with bulimia.

The oligomenorrhea in patients with bulimia does not, however, appear to impact their bone mineral density. According to one study22 that compared patients with anorexia, patients with bulimia and matched control patients, bone mineral density in those patients with bulimia was similar to that in the control patients. Interestingly, this study also showed that weight-bearing exercise had a protective effect in patients with bulimia that did not occur in those with anorexia. Therefore, osteoporosis may not be a concern in patients with bulimia, particularly those who exercise regularly.

If menstrual irregularity occurs in the adolescent with bulimia, a limited evaluation is necessary. After completing a careful history and physical examination, the laboratory work-up depends on the particular pattern seen. If significant oligomenorrhea is reported, it may be helpful to obtain the patient's levels of LH and FSH, thyroid-stimulating hormone, prolactin, and total and free testosterone. If androgenization is present, obtaining a dehydroepiandrosterone sulfate level will help to evaluate adrenal function.  If a patient has not menstruated in three months or more, a progesterone challenge test (administration of medroxyprogesterone acetate [Provera] in a dosage of 10 mg daily for seven days) would be indicated. A withdrawal bleed two to seven days after treatment indicates sufficient levels of estrogen. In a chronically anovulatory teenaged patient who is not underweight and who has an elevated androgen level and positive results on the progesterone challenge test, one must assume that the patient has chronically circulating unopposed estrogen. In this situation, it is necessary to induce a withdrawal bleed at least every three months to reduce the risk of endometrial cancer later in life. This is done by repeating progesterone administration every three months or by cycling with combined oral contraceptive pills.

A few small studies have demonstrated that metformin (Glucophage) improves menstrual function and hyperandrogenism in patients with polycystic ovary syndrome.

Obesity

Obesity is a rapidly increasing, preventable cause of morbidity and mortality in the United States. Unfortunately, it frequently begins long before adulthood. Current estimates of the prevalence of obesity in youth as measured by the third National Health and Nutrition Examination Survey range from 11 to 24 percent.23 Estimates vary because measurement techniques, instruments and the actual definitions of overweight and obesity frequently differ from study to study. The importance of defining obesity and overweight is to determine when an adolescent is at risk of negative health consequences related to their weight. For example, while some researchers rely on the body mass index (BMI = weight in kilograms divided by height in meters squared),24 others use fat distribution, or waist-to-hip ratio.25-27

One large, prospective study28 demonstrated a direct correlation between increasing BMI (i.e., higher than 25) and increasing risk of premature death. If approximately one third of obese adolescents are predicted to be obese as adults,29 one may assume that the prevention or treatment of obesity can have a major impact on the future health of these patients.

Obesity may or may not impact the gynecologic health of an adolescent female. The effects of obesity are mediated primarily through hormonal changes. Insulin resistance is a well-established consequence of obesity.30,31 When it occurs, it can become so profound that it lowers glucose tolerance and precipitates type 2 diabetes mellitus (formerly known as non ­insulin-dependent diabetes mellitus), even during adolescence.

Insulin resistance also increases circulating levels of insulin, which elevate androgen production. A number of mechanisms for this have been found, including the lowering of sex-hormone ­binding globulin, increased androgen production by direct stimulation or indirectly by the production of insulin-like growth factor I. The relationship between insulin and androgens is thought to be the underlying trigger of polycystic ovary syndrome (PCOS), which is also known as functional ovarian hyperandrogenism.32 PCOS is a frequent cause of menstrual dysfunction in the adolescent.

PCOS is defined by elevated androgen associated with anovulation, which manifests clinically as oligomenorrhea and/or dysfunctional uterine bleeding. While it usually occurs in obese patients, it also may occur in patients with a normal weight. Hyperandrogenism can also lead to other undesirable effects such as hirsutism, acne, acanthosis nigricans and, less commonly, clitoromegaly. Because of the anovulation and the lack of progesterone production, a state of unopposed estrogen is induced. As mentioned earlier, this state increases the risk of endometrial cancer. Lowered fertility is also characteristic.

The diagnosis of PCOs is a clinical one; however, certain laboratory data, such as elevated androgen levels, can help to support the diagnosis. An elevated LH:FSH ratio may also be found but is not necessary for diagnosis. When evaluating the patient with suspected PCOS, it also is necessary to rule out other potential hormonal abnormalities such as thyroid disease, hyperprolactinemia or adrenal abnormalities. It is important to note, however, that ultrasonographic evidence of polycystic ovaries is not necessary for diagnosis and, in fact, polycystic ovaries may occur in normally menstruating patients.

Management of PCOS in the adolescent depends on each patient's clinical presentation. Most patients can be treated with combined oral contraceptives. This can reduce the potential worsening of the negative consequences of the syndrome, such as acanthosis nigricans, hirsutism, acne and glucose intolerance.33 This allows regular shedding of the endometrial lining of the uterus and lowers the patient's risk of endometrial cancer. If a patient is adverse to starting oral contraceptives, oral progesterone (Prometrium) may be used in a dosage of 10 mg daily for seven days, given every three months, to induce a withdrawal bleed. However, this will not alter the androgenic manifestations. In the young woman with severe hirsutism, spironolactone (Aldactone) in a dosage of 50 mg twice daily may be used as an effective alternative when the patient does not feel comfortable using oral contraceptives.

When the patient is overweight, a weight loss of at least 10 percent can improve the hormonal profile and the clinical manifestations of PCOS. Unfortunately, even with the best multidisciplinary programs, weight loss is difficult to achieve and even more difficult to maintain in many patients. Because insulin is thought to play a major role in the etiology of PCOS, researchers have begun to examine the regulation of insulin as a way to control PCOS. For example, a few recent, small studies have demonstrated that metformin (Glucophage) improves menstrual function and hyperandrogenism in patients with PCOS.34 Therefore, metformin or similar insulin-lowering medications may become the treatment of the future for PCOS.

Final Comment

An important note for the family physician caring for adolescent patients is the management of contraception in the patient who has an eating disorder or who is overweight. One must not assume, even in the morbidly obese patient, that an adolescent female is not sexually active. Therefore, it is essential to question all teenaged patients in a confidential, nonjudgmental manner about their sexual and gynecologic history and to assess their desire for contraception. Condoms alone or condoms plus spermicide are the options that have the fewest possible side effects. In the past, oral contraceptives have been associated with increased weight gain; however, the low-dose pills currently being used are much less likely to have this effect.35 In addition, for those adolescent patients who are identified as having PCOS, low-dose oral contraceptives will accomplish contraception while also lowering androgen levels. The hormonal contraception options that are more likely to cause weight gain are those with long-acting progestin, such as medroxyprogesterone acetate (Depo-Provera) and levonorgestrel (Norplant). These may be used as a last resort in patients whose need for contraception may override the potential harm from additional weight gain.

The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported.

The Authors

MARJORIE KAPLAN SEIDENFELD, M.D., is an assistant clinical professor of pediatrics in the Division of Adolescent Medicine at the Mount Sinai School of Medicine of the City University of New York, N.Y. Dr. Kaplan received her medical degree from the Mount Sinai School of Medicine and completed a residency in pediatrics and a post-doctoral fellowship in adolescent medicine at Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, N.Y.

VAUGHN I. RICKERT, PSY.D., is director of research at the Mount Sinai Adolescent Health Center and associate professor in the Department of Pediatrics, Mount Sinai School of Medicine. He completed his doctoral degree in clinical psychology at Central Michigan University, Mt. Pleasant, and an internship at Johns Hopkins University School of Medicine, Baltimore, Md.

Address correspondence to Vaughn I. Rickert, Psy.D., Mount Sinai Adolescent Health Center, 320 E. 94th St., New York, NY 10128 (e-mail: vaughn.rickert@mountsinai.org). Reprints are not available from the authors.

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17. Gordon CM, Grace E, Emans SJ, Crawford MH, Leboff MS. Changes in bone turnover markers and menstrual function after short-term oral DHEA in young women with anorexia nervosa. J Bone Miner Res 1999;14:136-45.
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32. Acien P, Quereda F, Matallin P, Villarroya E, Lopez-Fernandez JA, Acien M, et al. Insulin, androgens, and obesity in women with and without polycystic ovary syndrome: a heterogeneous group of disorders. Fertil Steril 1999;72:32-40.
33. Pasquali R, Gambineri A, Anconetani B, Vicennati V, Colitta D, Caramelli E, et al. The natural history of the metabolic syndrome in young women with the polycystic ovary syndrome and the effect of long-term oestrogen-progestagen treatment. Clin Endocrinol 1999;50:517-27.
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Judith Asner, MSW, discusses the guilt and shame associated with having bulimia or any of the other eating disorders. Ms. Asner has been working with bulimics for over 20 years and says "many feel guilty about having bulimia; bingeing and purging."

We also talked about tools used in recovering from bulimia: food journals used to track hunger and fullness, meal planning, eating disorders support groups, and an eating disorders treatment specialist.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

David: Good Afternoon, or evening, if you are overseas. I'm David Roberts. I'm the moderator for today's conference. I want to welcome everyone to HealthyPlace.com.

Our topic is "Surviving Bulimia." Our guest is Judith Asner, MSW. Ms. Asner is a licensed therapist in Washington, D.C. and specializes in working with bulimics as well as other eating disorder sufferers and their families. She also runs the "Beat Bulimia" site inside the HealthyPlace.com Eating Disorders Community.

Good afternoon, Judith, and welcome back to HealthyPlace.com. We appreciate you being our guest this afternoon. We, literally, receive dozens of emails every week from people talking about the shame, the guilt, and the deception involved in having an eating disorder like bulimia. So I'd like to address that first. How does someone cope with that?

Judith Asner: I think the first step is understanding that the eating disorders and the addictive disorders are based on shame, but the person who created this shame in the young person is usually the one who should be feeling the shame--the perpetrator, not the victim. Many eating disorders (ED) are often linked to abuse (sexual abuse, physical abuse, emotional abuse), in which a child is innocent and suffers early insult or irrational guilt, where there is really nothing to feel guilty about. This is just an illness like any other and one does not have to be ashamed of having these symptoms.

David: Unfortunately though, a lot of people do feel guilty about having bulimia and are ashamed to tell anyone about it. How would you suggest they handle that?

Judith Asner: You start by picking an empathic helping person, who has also been through personal struggles, one who understands what it's like to struggle against life difficulties--a teacher, a nurse a sympathetic parent or a loving sibling. It's helpful to find someone who will wrap their arms around you and offer you comfort; someone who has some psychological sophistication as well.

David: Judith, we get many people who write us saying that rather than telling anyone about their eating disorder, they want to handle recovery on their own. What do you think about that concept of handling bulimia recovery on your own?

Judith Asner: It's a stretch to tell someone and it's a risk. However, if you don't tell someone, you'll suffer deeply by yourself and I don't believe we are meant to suffer alone. I believe we are here to help each other. I think it's really tough because the mere act of unburdening your secret and heart to another human being is so freeing, and hearing acceptance from another human being without recrimination is so validating. If you try to do this on your own, you miss the opportunity to see that people are good and willing to help you. All studies show that friendship enhances health and the immune system and isolation increases mental and physical illness. We are interactive beings. As a psychotherapist, I believe that cure is easier when we help each other. The illness is already isolating, but if you are absolutely intent on doing this by yourself, then nothing can sway you. Try It. Every person has his or her right to do it their way.

There are wonderful self-help books out there. For example: Overcoming Overeating, When Women Stop Hating Their Bodies, Feeling Good, The Path, and Taming the Gremlin.

If you want to overcome an eating disorder, keep a journal and let your journal become your mirror and your friend. Stay in touch with your feelings, plan your menus, write down your feelings after you eat instead of purging. In other words, use your journal as your key to your own psyche.

David: That's helpful, Judith. Here are a few audience comments on sharing the news of your eating disorder with someone else and the idea of recovering from bulimia on your own:

recoverednow: I never could have done it on my own. My eating disorder had me. The only way I could break free is through inpatient eating disorder treatment.

gillian1: I have told my mum about my bulimia, but she handled it badly so I covered up what I said with lying. The problem is that I told my doctor before I told my mum. So I am seeing a psychiatrist. Mum is determined to stop me from seeing her.

nymphet: I always regret the day I told my boyfriend about my eating disorder. I also find it discouraging, the way my parents treat me since they found out about my eating disorder.

thingal: I still don't want to admit that I have a problem. I am disgusted with what I do.

florecita: When people know, they try to guard you all the time even though I'm not doing it.

recoverednow: Journaling is excellent advice!!!

Judith Asner: A food journal and meal planning are 2 of the most important tools in overcoming an eating disorder. Changing your negative self talk, self-concept is also important. You can do this with the guidance of Dr. David Burns' book, Feeling Good.

David: Could you go into a bit more detail about the food journal and what that is and what doing one accomplishes?

Judith Asner: A food journal brings order to a chaotic eating situation. Bulimia was originally called dietary chaos syndrome. A person with bulimia, as you all know, binges in an uncontrolled way. A food diary will do the following:

• it will allow you to plan your meals ahead of time.
• it will enable you to have the food you need at hand.
• it will serve as a map, just as road map serves on a trip.
• it will also allow you to track hunger and fullness on a scale of 1 to 10; 1 being the hungriest and 10 being the fullest - it will reacquaint you with that dimension of eating.

By using the food journal, you will begin to know when you are really hungry versus when you eat and are not hungry. It will allow you to track your negative thoughts before you binge. Instead of binge eating, you sit down with your food journal and you can say, "Hey what's going on. If I'm not hungry, why am I going off on a binge?"

And then you begin to explore your inner self. Are you bored, angry, insulted, tired, excited? You can explore these feelings.

David: We have a lot of audience questions, Judith. Let's get to them:

cassiana24: Do you really think I have an eating disorder if I only vomit once or twice a week?

Judith Asner: Cassiana, yes that is an eating disorder. That's bulimia.

fineanddandy: Earlier, you mentioned guilt and shame being tied to sexual abuse. But what if a person has grown up in a great environment. Is it your parent's or your fault, then, that you have bulimia or an eating disorder?

Judith Asner: It's no one's fault. It's just the way things come together. It can be a great environment with wonderful people, but they may have high expectations or it may be how you perceive what you see in the media. It doesn't mean that the people aren't wonderful. There are cultural and other influences, not just the family. TV, peer groups, and the fashion industry are factors also.

Usually there is some element of self-esteem, when a person meets cultural expectations and ideal body types and some sense of dissatisfaction with the self.

David: Here's a question from a concerned parent:

latlat: What do parents do who have teenagers who refuse help with bulimia? My 16-year-old daughter refuses counseling. How can I get her to a clinic?

Judith Asner: latlat, I think the parents need to get support or the parent will get very depressed. I suggest support groups for parents with eating disordered children. By going to a support group, the parents will typically get some distance from the illness that will allow the teenager to get some treatment eventually. I think the parents need to first get help for themselves.

You can't force an uncooperative person into treatment. You can only go to treatment for yourself and then hopefully the teenager will become curious with the process and want to join in. Now if the eating disorder, bulimia or anorexia, becomes life-threatening, a parent can force the teenager into treatment.

David: When a parent finds out that their child has an eating disorder, it's a shock to many. And, of course, they are scared and want to take immediate action. Judith, what do you think about a parent who tries to FORCE their child into treatment?

Judith Asner: I think it's a difficult position, but what do you mean by force?

David: Either literally drag the child into the counselor's office, or punish the child if they don't get treatment. Sort of a tit-for-tat type thing.

Judith Asner: Punishment doesn't help anything. A teenager is a child, so they need to be treated differently. I think you can appeal to their intellect and you can talk to them and have an interchange. You can present them with literature on the facts of eating disorders and talk to them about your concerns and try to encourage them to seek help, but punishment doesn't help.

Also an intervention is an option for a teenager. An intervention is a loving event, not a punitive one. It's a gathering where people say, "We're here because we care about you, and we're not going to let you die."

David: One final suggestion, then we'll move onto the next question. You may get a more positive response from the child by saying something like "if you don't want treatment now, that's up to you. But if things get worse, or you change your mind, we are here to support you and you can start treatment then." It leaves the options open, without setting up a standoff.

Judith Asner: Don't punish someone for being sick.

David: Here's the next question:

Keatherwood: I've been anorexic and bulimic most my life. I've pretty much beat the anorexia, but the bulimia seems to be much harder to get control of. My therapist considers it a form of self-harm, but I just see it as a way to get thin again. I don't binge. I just do it when I feel I've eaten to much. Can't it just be a way to lose weight, not a psychological problem?

Judith Asner: Keatherwood, considering the history, it seems like it's the last part of a longstanding disorder but it's gotten a lot better over time. Maybe working carefully with a registered dietitian can help you lose weight without purging.

David: Here are some audience comments on what's been said so far:

Christian: I am all for living in the solution. I was one of ten children and my parents did the best they could. Yet I hid the bulimia for a long time; I was so ashamed of having such a gross coping mechanism. I have always been afraid of my older siblings and of not being perfect. I have been in recovery a long time but recently relapsed. I am a grown woman with a happy marriage and 2 babies that I had thought I might not be able to have because of the damage done in my teens and twenties.

margnh: I will never admit it because people think you have horrible control and will act differently around you.

Lindsey03: I'm scared. My fake parents now know about what happened before and I'm afraid they will punish me like my real parents did. They also don't let me purge and I guess that's good, but that's scary too.

margnh: My doctor told me I should never plan my eating.

recoverednow: Yes, I did the meal planning also - following hospital staff advice and followed the meal plan they provide me.

gillian1: That depresses me, seeing how much I have eaten.

nymphet: I tried keeping journals, but never liked the idea at all and gave up.

eccchick: Today, I feel so scared, sad and depressed because I ate something and kept it down.

latlat: I've done that. Got treatment for myself. My daughter doesn't care and is not affected by my actions. How do you force them?

willy: What do you think a person should do when they think they have an eating disorder? I mean, is there anyone special to go to and how do you start out the conversation with the person?

Judith Asner: Willy, you should find out who specializes in treating eating disorders. If you go to my website, in my last newsletter, there are some resources that can help you find an eating disorders treatment specialist in your area.

Once you find an eating disorders treatment specialist and call them up--it's very easy. They know why you are there and help you. You'll find that you won't be uncomfortable because they are familiar with what's going on. Chances are the eating disorders treatment specialist has had anorexia or bulimia too.

David: One thing you can do is call the local psychological association and get a referral in your community. You can also call your family doctor or a local psychiatric center for a referral.

Judith, what advice can you give a teenager who wants to tell their parents, but may be afraid or doesn't know how to break the ice. What, specifically, could they say?

Judith Asner: I think a teen has to do it. Just say it, "I have an eating disorder." You just have to bite the bullet and say the words.

hungrygirl: What do you do when you feel like you have dealt with the underlying issues as much as you can, and you are still addicted to the behavior of self-harm with food or just addicted to eating in a self-destructive manner.

Judith Asner: That's a very tough question. Very often, therapy will address underlying issues and there will still be residual eating disorders that have not gone into remission. I wonder if you saw a general psychotherapist or an eating disorder specialist for your treatment, because that's a very common occurrence.

awiah: I am a 37 year old SWF. I have been bulimic since I was 11. I have tried almost every known antidepressant (and many other types of prescription drugs) and am still very actively bulimic. I understand the need for family and friends' support. I understand the use of a food journal to control the amount of food intake and educate one on their level of hunger. But what does one do when they have outlived the patience of their families and everyone else?

Judith Asner: How about going to daily meetings of Overeaters Anonymous or eating disorders support groups that deal with bulimia specifically? By doing this, you'll find a sponsor that will not get tired of you and you'll get support from the group and by working through the program. Also, there is information in the HealthyPlace.com Eating Disorders Community.

awiah: Yes, I have been at Renfrew for 3 months and have had years-and-years of out-patient therapy with different doctors - both eating disorders treatment specialists and generalists.

Judith Asner: Awiah, I'm really sorry. I know how frustrating that could be. Maybe coaching could help you.

Monica2000: What are we supposed to do when people think our ED is for attention. What are we to do if we get really depressed and just want to purge more?

Judith Asner: Monica, stay away from those people. Tell them you don't need there opinions. Stay away from any negative people as much as you can and be around supportive people. People with bulimia are highly sensitive.

David: Apparently, some of the things being said today have struck a chord with the audience. Here are some comments:

florecita: My stepmom cooks a lot of food all the time; pork and those kinds of meals. We live with her, but I don't know how can I tell her because that will make it harder for me.

nymphet: My mum never does anything more than yelling at me all the time. I don't really feel so much ashamed, but people who know about this think I should be ashamed.

hungrygirl: It was a general person, but I work on the issues, feelings, etc. a lot on my own. The eating behavior seems to have a will outside of myself; like I'm doing it and don't even realize it anymore. Maybe I just didn't make the connection between the eating and the emotions? I don't know.

gillian1: That's easier said than done. I tried to tell my parents, but I had to think of a cover story when she was far from happy.

eccchick: Sometimes I feel like I don't want to get better. Most of the time I like the attention my friends and family are giving me. They are showing me they care. I want to know they love me. I want them to tell me I am horrible.

dreamer05: I agree with the fact that the parents need to get help themselves. If they really want to help, they need to educate themselves about this disease. Granted, they many not want to because it may be hard. Parents may not understand why the sufferer is doing this to themselves. Oftentimes, people think that we have control over this disease because it's not cancer or aids.

David: Here are a few more audience comments, then onto more questions:

eccchick: I know it sounds horrible, maybe I am, but sometimes I feel like I don't want the help. I like the attention it gets me, my friends and family show me they care

margnh: Planning makes you think about the food all the time, as with the journal. It is not entertaining enough to preoccupy me.

recoverednow: Changing the negative self-talk is extremely difficult. Eating Disorders tend to feed the negative self-concept. It isn't always abuse that leads to an eating disorder. My disorder was "based on" fear of abandonment and the need to please.

AmyGIRL: Can bulimia cause you to have a violent temper?

Judith Asner: It can certainly be upsetting and make you feel out of control, angry with yourself and others. There is a lot of self-rage in bulimia.

David: Some people have asked for additional information about bulimia. Here are the bulimia symptoms and how to diagnose bulimia.

hungrygirl: How does the coaching work exactly? Specifically, what kinds of interactions can you expect to have with a coach?

Judith Asner: The coach is there to ask you important questions to help you look at what you are doing with your life, how you may be lying to yourself, what your real truths are, and how you can live your truth and live the life you really desire. It's usually by phone. There is also group coaching by phone, where a group can talk together in a conference call. For example, a group of 20 people over a conference call can be talking about meal plans, shame, etc. It's similar to what we are doing now, only it's over the phone instead of inside a chatroom.

dreamer05: You mentioned something about talking to people about it and telling them that you have a problem. What happens when you do that and they leave you? Essentially, they're telling you that they can't handle it. I see that as them not loving you because they are giving up on you when you finally ask for help. What do you see it as?

Judith Asner: Dreamer, they just can't handle it and you should let the person leave, let that person go. That would not be the person for you. You could never be your true self with that person and that person can never love all of you because the eating disorder is a part of you at that moment.

eccchick: Does it make me horrible because I like the attention I get from people. My family and friends know that I am sick. I want to know that they care. I want to know that I am loved. I am scared of losing my friends. Maybe I'm not really sick. In a way, I like what I am doing. Losing the weight is something I have become good at. Am I horrible?

Judith Asner: That does not make you horrible. It sounds like a desperate cry for attention and love. Are there other ways to get love? Do you have to be sick to get attention? Do you feel that you are not lovable unless you are sick? Are there some positive ways to get attention? What you are speaking of is "secondary gain" and that's the attention that one gets from having the illness. But there are certainly healthier ways to get attention. Can you think of some? Maybe you can be the best tennis player, or the greatest friend, best writer, sweetest person; anything else but sick. It sounds like you doubt your worth, eccchick. If I were you eccchick, I would start a campaign for a charitable cause and get your picture in the newspapers. Doing something for someone should make anyone feel good.

David: Here's the link to the HealthyPlace.com Eating Disorders Community. Thank you, Judith, for being our guest today and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large eating disorders community here at HealthyPlace.com. You will always find people interacting with various sites.

Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com

Judith Asner: Thank you for inviting me. I hope that some of the people who were writing about their shame will realize there is nothing to be ashamed about. It's just a symptom of a problem like depression, etc. There are many people willing to help and many resources. Most importantly, never give up on yourself.

David: Have a good evening everyone. And thank you for coming.

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.