Definition

Assertiveness training is a form of behavior therapy designed to help people stand up for themselves—to empower themselves, in more contemporary terms. Assertiveness is a response that seeks to maintain an appropriate balance between passivity and aggression. Assertive responses promote fairness and equality in human interactions, based on a positive sense of respect for self and others.

Assertiveness training has a decades-long history in mental health and personal growth groups, going back to the women’s movement of the 1970s. The approach was introduced to encourage women to stand up for themselves appropriately in their interactions with others, particularly as they moved into graduate education and the workplace in greater numbers. The original association of assertiveness training with the women’s movement in the United States grew out of the discovery of many women in the movement that they were hampered by their inability to be assertive. Today, assertiveness training is used as part of communication training in settings as diverse as schools, corporate boardrooms, and psychiatric hospitals, for programs as varied as substance abuse treatment, social skills training, vocational programs, and responding to harassment.

Purpose

The purpose of assertiveness training is to teach persons appropriate strategies for identifying and acting on their desires, needs, and opinions while remaining respectful of others. This form of training is tailored to the needs of specific participants and the situations they find particularly challenging. Assertiveness training is a broad approach that can be applied to many different personal, academic, health care, and work situations.

Learning to communicate in a clear and honest fashion usually improves relationships within one’s life. Women in particular have often been taught to hide their real feelings and preferences, and to try to get their way by manipulation or other indirect means. Specific areas of intervention and change in assertiveness training include conflict resolution, realistic goal-setting, and stress management. In addition to emotional and psychological benefits, taking a more active approach to self-determination has been shown to have positive outcomes in many personal choices related to health, including being assertive in risky sexual situations; abstaining from using drugs or alcohol; and assuming responsibility for self-care if one has a chronic illness like diabetes or cancer.

Precautions

There are a few precautions with assertiveness training. One potential caution would be to remain within assertive responses, rather than become aggressive in standing up for oneself. Some participants in assertiveness training programs who are just learning the techniques of appropriate assertiveness may “overdo” their new behaviors and come across as aggressive rather than assertive. Such overcompensation would most likely disappear with continued practice of the techniques.

One additional precaution about assertiveness training is that it should not be regarded as the equivalent of martial arts training or similar physical self-defense techniques. It is important to distinguish between contexts or situations in which verbal assertiveness is appropriate and useful, and those in which it is irrelevant. In some situations, a person’s decision to leave the situation or seek help because they sense danger is preferable to an encounter with a criminal.

Description

Assertiveness training is often included within other programs, but “stand-alone” programs in self-assertion are often given in women’s centers or college counseling centers. Corporate programs for new personnel sometimes offer assertiveness training as part of communication or teamwork groups, or as part of a program on sexual harassment.

Assertiveness training typically begins with an information-gathering exercise in which participants are asked to think about and list the areas in their life in which they have difficulty asserting themselves. Very often they will notice specific situations or patterns of behavior that they want to focus on during the course. The next stage in assertive training is usually role-plays designed to help participants practice clearer and more direct forms of communicating with others. The role-plays allow for practice and repetition of the new techniques, helping each person learn assertive responses by acting on them. Feedback is provided to improve the response, and the role-play is repeated. Eventually, each person is asked to practice assertive techniques in everyday life, outside the training setting. Role-plays usually incorporate specific problems for individual participants, such as difficulty speaking up to an overbearing boss; setting limits to intrusive friends; or stating a clear preference about dinner to one’s spouse. Role-plays often include examples of aggressive and passive responses, in addition to the assertive responses, to help participants distinguish between these extremes as they learn a new set of behaviors.

Assertiveness training promotes the use of “I” statements as a way to help individuals express their feelings and reactions to others. A commonly used model of an “I” statement is “when you _________, I feel ___________”, to help the participant describe what they see the other person as doing, and how they feel about that action. “I” statements are often contrasted with “you” statements, which are usually not received well by others. For example, “When you are two hours late getting home from work, I feel both anxious and angry,” is a less accusing communication than “You are a selfish and inconsiderate jerk for not telling me you would be two hours late.” Prompts are often used to help participants learn new communication styles. This approach helps participants learn new ways of expressing themselves as well as how it feels to be assertive.

Learning specific techniques and perspectives, such as self-observation skills, awareness of personal preferences and assuming personal responsibility are important components of the assertiveness training process. Role-play and practice help with self-observation, while making lists can be a helpful technique for exploring personal preferences for those who may not have a good sense of their own needs and desires. Participants may be asked to list anything from their ten favorite movies or pieces of music to their favorite foods, places they would like to visit, subjects that interest them, and so on.

Preparation

Preparation for assertiveness training varies from person to person. For some participants, no preparation is needed before practicing the techniques; for others, however, individual counseling or therapy may help prepare the individual for assertiveness training. For participants who may be more shy and feel uncomfortable saying “no” or speaking up for themselves, a brief course of individual therapy will help to prepare them psychologically and emotionally to use assertive techniques.

Aftercare

Aftercare can involve ongoing supportive therapy, again based on the individual’s level of comfort in using the assertive techniques. For those who are comfortable using the techniques on their own, a supportive social network or occasional participation in a support group will be enough to help maintain the new behavioral patterns. The ultimate goal is for each participant to self-monitor effectively his or her use of assertive techniques on an ongoing basis.

Risks

There are minimal risks associated with assertiveness training. Personal relationships may be affected if those around the participant have difficulty accepting the changes in their friend or family member. This risk, however, is no greater than that associated with any other life change.

Another potential risk is that of overcompensating in the early stages of training by being too aggressive. With appropriate feedback, participants can usually learn to modify and improve their responses.

People who are very shy or self-conscious, or who were harshly treated as children, may also experience anxiety during the training as they work toward speaking up and otherwise changing their behaviors. The anxiety may be uncomfortable, but should decrease as the person becomes more comfortable with the techniques and receives encouragement from others in the program.

Normal results

An enhanced sense of well-being and more positive self-esteem are typical results from assertiveness training. Many participants report that they feel better about themselves and more capable of handling the stresses of daily life. In addition, people who have participated in assertiveness training have a better sense of boundaries, and are able to set appropriate and healthy limits with others. Being able to set appropriate limits (such as saying “no”) helps people to avoid feeling victimized by others.

A healthy sense of self-determination and respect for others is the ultimate outcome of assertiveness training. Such a balance helps each person work better with others, and make appropriate decisions for themselves.

Abnormal results

Unusual results may include becoming too aggressive in setting boundaries, as if the individual is overcompensating. With appropriate training, role-play, and feedback, this response can be re-learned. Alternatively, for very shy individuals, a heightened sense of anxiety may be experienced when using the techniques initially. The nervousness or anxiety is usually due to the individual’s concern about others’ reactions to their assertive responses. Over time, the anxiety will usually decrease.

Definition

Asperger’s disorder, which is also called Asperger’s syndrome (AS) or autistic psychopathy, belongs to a group of childhood disorders known as pervasive developmental disorders (PDDs) or autistic spectrum disorders. The essential features of Asperger’s disorder are severe social interaction impairment and restricted, repetitive patterns of behavior and activities. It is similar to autism, but children with Asperger’s do not have the same difficulties in acquiring language that children with autism have.

In the mental health professional’s diagnostic hand book, the Diagnostic and Statistical Manual of Mental Disorders fourth edition text revised, or DSM-IV-TR, Asperger’s disorder is classified as a developmental disorder of childhood.

Description

AS was first described by Hans Asperger, an Austrian psychiatrist, in 1944. Asperger’s work was unavailable in English before the mid-1970s; as a result, AS was often unrecognized in English-speaking countries until the late 1980s. Before DSM-IV (published in 1994) there was no officially agreed-upon definition of AS. In the words of ICD-10, the European equivalent of the DSM-IV, Asperger’s is “a disorder of uncertain nosological validity.” (Nosological refers to the classification of diseases.) There are three major reasons for this lack of clarity: differences between the diagnostic criteria used in Europe and those used in the United States; the fact that some of the diagnostic criteria depend on the observer’s interpretation rather than objective measurements; and the fact that the clinical picture of Asperger’s changes as the child grows older.

Asperger’s disorder is one of the milder pervasive developmental disorders. Children with AS learn to talk at the usual age and often have above-average verbal skills. They have normal or above-normal intelligence and the ability to feed or dress themselves and take care of their other daily needs. The distinguishing features of AS are problems with social interaction, particularly reciprocating and empathizing with the feelings of others; difficulties with nonverbal communication (such as facial expressions); peculiar speech habits that include repeated words or phrases and a flat, emotionless vocal tone; an apparent lack of “common sense” a fascination with obscure or limited subjects (for example, the parts of a clock or small machine, railroad schedules, astronomical data, etc.) often to the exclusion of other interests; clumsy and awkward physical movements; and odd or eccentric behaviors (hand wringing or finger flapping; swaying or other repetitious whole-body movements; watching spinning objects for long periods of time).

Causes and symptoms

Causes

There is some indication that AS runs in families, particularly in families with histories of depression and bipolar disorder. Asperger noted that his initial group of patients had fathers with AS symptoms. Knowledge of the genetic profile of the disorder, however, is quite limited as of 2002.

In addition, about 50% of AS patients have a history of oxygen deprivation during the birth process, which has led to the hypothesis that the disorder is caused by damage to brain tissue before or during childbirth. Another cause that has been suggested is an organic defect in the functioning of the brain.

As of 2002, there is no known connection between Asperger’s disorder and childhood trauma, abuse or neglect.

Symptoms

In young children, the symptoms of AS typically include problems picking up social cues and understanding the basics of interacting with other children. The child may want friendships but find him- or herself unable to make friends.

Most children with Asperger’s are diagnosed during the elementary school years because the symptoms of the disorder become more apparent at this point. They include:

• Poor pragmatic language skills. This phrase means that the child does not use the right tone or volume of voice for a specific context, and does not understand that using humorous or slang expressions also depends on social context.
• Problems with hand-eye coordination and other visual skills.
• Problems making eye contact with others.
• Learning difficulties, which may range from mild to severe.
• Tendency to become absorbed in a particular topic and not know when others are bored with conversation about it. At this stage in their education, children with AS are likely to be labeled as “nerds.”
• Repetitive behaviors. These include such behaviors as counting a group of coins or marbles over and over; reciting the same song or poem several times; buttoning and unbuttoning a jacket repeatedly; etc.

Adolescence is one of the most painful periods of life for young people with Asperger’s, because social interactions are more complex in this age group and require more subtle social skills. Some boys with AS become frustrated trying to relate to their peers and may become aggressive. Both boys and girls with the disorder are often quite naive for their age and easily manipulated by “street-wise” classmates. They are also more vulnerable than most youngsters to peer pressure.

Little research has been done regarding adults with AS. Some have serious difficulties with social and occupational functioning, but others are able to finish their schooling, join the workforce, and marry and have families.

Demographics

Although the incidence of AS has been variously estimated between 0.024% and 0.36% of the general population in North America and northern Europe, further research is required to determine its true rate of occurrence—especially because the diagnostic criteria have been defined so recently. In addition, no research regarding the incidence of AS has been done on the populations of developing countries, and nothing is known about the incidence of the disorder in different racial or ethnic groups.

With regard to gender differences, AS appears to be much more common in boys. Dr. Asperger’s first patients were all boys, but girls have been diagnosed with AS since the 1980s. One Swedish study found the male/female ratio to be 4:1; however, the World Health Organization’s ICD-10 classification gives the male to female ratio as 8 to 1.

Diagnosis

As of early 2002, there are no blood tests or brain scans that can be used to diagnose AS. Until DSM-IV(1994), there was no “official” list of symptoms for the disorder, which made its diagnosis both difficult and inexact. Although most children with AS are diagnosed between five and nine years of age, many are not diagnosed until adulthood. Misdiagnoses are common; AS has been confused with such other neurological disorders as Tourette’s syndrome, or with attention-deficit disorder (ADD), oppositional defiant disorder(ODD), or obsessive-compulsive disorder(OCD). Some researchers think that AS may overlap with some types of learning disability, such as the nonverbal learning disability (NLD) syndrome identified in 1989.

The inclusion of AS as a separate diagnostic category in DSM-IVwas justified on the basis of a large international field trial of over a thousand children and adolescents. Nevertheless, the diagnosis of AS is also complicated by confusion with such other diagnostic categories as “high-functioning (IQ higher than 70) autism” or HFA, and “schizoid personality disorder of childhood.” Unlike schizoid personality disorder of childhood, AS is not an unchanging set of personality traits— AS has a developmental dimension. AS is distinguished from HFA by the following characteristics:

• Later onset of symptoms (usually around three years of age).
• Early development of grammatical speech; the AS child’s verbal IQ (scores on verbal sections of standardized intelligence tests) is usually higher than performance IQ (how well the child performs in school). The reverse is usually true for autistic children.
• Less severe deficiencies in social and communication skills.
• Presence of intense interest in one or two topics.
• Physical clumsiness and lack of coordination.
• Family is more likely to have a history of the disorder.
• Lower frequency of neurological disorders.
• More positive outcome in later life.

DSM-IV-TR criteria for Asperger’s disorder

The DSM-IV-TRspecifies the following diagnostic criteria for AS:

• The child’s social interactions are impaired in at least two of the following ways: markedly limited use of nonverbal communication (facial expressions, for example); lack of age-appropriate peer relationships; failure to share enjoyment, interests, or accomplishment with others; lack of reciprocity (turn-taking) in social interactions.
• The child’s behavior, interests, and activities are characterized by repetitive or rigid patterns, such as an abnormal preoccupation with one or two topics, or with parts of objects; repetitive physical movements; or rigid insistence on certain routines and rituals.
• The patient’s social, occupational, or educational functioning is significantly impaired.
• The child has normal age-appropriate language skills.
• The child has normal age-appropriate cognitive skills, self-help abilities, and curiosity about the environment.
• The child does not meet criteria for another specific PDD or schizophrenia.

To establish the diagnosis, the child psychiatrist or psychologist would observe the child, and would interview parents, possibly teachers, and the affected child (depending on the child’s age), and would gather a comprehensive medical and social history.

Other diagnostic scales and checklists

Other instruments that have been used to identify children with AS include Gillberg’s criteria, a six-item list compiled by a Swedish researcher that specifies problems in social interaction, a preoccupying narrow interest, forcing routines and interests on the self or others, speech and language problems, nonverbal communication problems, and physical clumsiness; and the Australian Scale for Asperger’s Syndrome, a detailed multi-item questionnaire developed in 1996.

Brain imaging findings

As of 2002, only a few structural abnormalities of the brain have been linked to AS. Findings include abnormally large folds in the brain tissue in the left frontal region, abnormally small folds in the operculum (a lid-like structure composed of portions of three adjoining brain lobes), and damage to the left temporal lobe (a part of the brain containing a sensory area associated with hearing). The first single photon emission tomography (SPECT) study of an AS patient found a lower-than-normal supply of blood to the left parietal area of the brain, an area associated with bodily sensations. Brain imaging studies on a larger sample of AS patients is the next stage of research.

Definition

Aromatherapy is a holistic treatment based on the external use of essential aromatic plant oils to maintain and promote physical, physiological, and spiritual wellbeing. The essential oils may be used in massage, added to a warm bath, used to moisten a compress that is applied to the affected part of the body, added to a vaporizer for inhalation, or diffused throughout a room.

The term aromatherapy (aromatherapie in the original French) was coined in 1928 by a French chemist, René Maurice Gattefossé, to describe the therapeutic use of aromatic substances (essential oils) in wound healing. Gattefossé discovered the healing properties of essential plant oils accidentally; after burning his hand in a laboratory accident, he found that lavender oil healed his burns in a very short time. He then experimented with plant oils in treating soldiers wounded in World War I, and found that there were several essential oils that speeded physical healing. As the practice of aromatherapy expanded, it came to incorporate a holistic emphasis on healing or invigorating all levels of a person’s being. In the United States and Great Britain, the contemporary practice of aromatherapy is often associated with naturopathy and Western herbal medicine. In Great Britain, aromatherapy is one of the most frequently used forms of alternative medicine; in the United States, many hospital-affiliated centers for the study of complementary and alternative medicine (CAM) offer aromatherapy as well as other alternative approaches. Aromatherapy has also been added to holistic nursing board examinations in the United States within the last few years.

Purpose

One of the basic concepts of mind/body medicine is that a positive frame of mind helps to keep people in good health. Aromatherapists maintain that essential oils derived from plants help people to slow down, relax from stress, and enjoy the sensory experiences of massage, warm water, and pleasant smells. Aromatherapy is thought to improve a person’s mental outlook and sense of well-being by affecting the limbic system via the olfactory nerve, or the sense of smell. The limbic system is the area of the brain that regulates emotions. Relaxing and pleasant smells stimulate emotional responses of pleasure and relaxation. From a holistic perspective, aromatherapy is a form of preventive health care. Most aromatherapists believe that aromatherapy should not be used as a substitute for mainstream medical or psychiatric care, but as an adjunct to it.

Aromatherapy is considered to be a useful complementary treatment for the relief of depression, anxiety, insomnia, panic disorder, stress-related physical disorders, menstrual cramps, and some gastrointestinal complaints. For example, peppermint oil calms gastrointestinal spasms when ingested, or taken by mouth. Arecent Scottish study found that aromatherapy has a measurably calming effect on the symptoms of dementia in elderly people.

Aromatherapy can be used by itself, or combined with Swedish massage, shiatsu, acupressure, reflexology, or light therapy to reinforce the positive results of these treatments.

Although there are professional aromatherapists as well as practitioners of holistic medicine who offer aromatherapy among their other services, people can also use aromatherapy at home as part of self-care. There are many guides to the various techniques of aromatherapy and the proper use of essential plant oils available in inexpensive paperback editions.

Precautions

People who are interested in using essential oils at home should be careful to purchase them from reliable sources. The U. S. Food and Drug Administration (FDA) does not regulate the manufacture of essential plant oils. Consequently, instances of consumer fraud have been reported. In the case of essential oils, the most common form of fraud is substitution of synthetic compounds for natural essential oils, which are expensive to produce.

Another precaution is to avoid applying essential oils directly to the skin as a form of perfume. Some essential oils such as oil of orange or oil of peppermint are irritating to the skin if applied full-strength. When essential oils are used in massage, they are always diluted in a carrier oil.

A final precaution is to avoid taking essential oils internally without a consultation with a physician or naturopathist. Possible exceptions may be peppermint oil and aloe vera.

Description

Essential plant oils are prepared for use in aromatherapy in several different ways. Most are prepared by steam distillation, a process in which the flowers, leaves, or other plant parts are heated by steam from boiling water. The vapors that result then pass through a condenser that separates the scented water from the essential oil, which is siphoned off into a separate container. Other methods of extracting essential oils include expression, or squeezing, which is limited to citrus oils; enfleurage, in which flower petals are placed on a bed of purified fat that soaks up the essential oils; and maceration, in which the plant parts are crushed and covered with warm vegetable oil that absorbs the essential oils.

There are several different techniques for the use of essential oils in aromatherapy:

• Massage: This is the technique that most people associate with aromatherapy. For use in massage, essential oils are mixed with a vegetable carrier oil, usually wheatgerm, avocado, olive, safflower, grapeseed, or soya bean oil. A ratio that is commonly recommended is 2.5–5% essential oil to 95–97.5% carrier oil.
• Full-body baths: In this technique, the essential oil is added to a tubful of warm (but not hot) water as the water is running. The dosage of essential oil is usually 5–10 drops per bath.
• Hand or foot baths: These are often recommended to treat arthritis or skin disorders of the hands or feet as well as sore muscles. The hands or feet are soaked for 10–15 minutes in a basin of warm water to which 5–7 drops of essential oil have been added.
• Inhalations: This technique is used to treat sinus problems or such nasal allergies as hay fever. Two cups of water are brought to a boil and then allowed to cool for five to ten minutes. Two to five drops of essential oil are added to the steaming water, and the person leans over the container and inhales the fragrant vapors for five to ten minutes.
• Diffusion: This technique requires the use of a special nebulizer to disperse microscopic droplets of essential oil into the air, or a clay diffuser that allows the oil to evaporate into the air when it is warmed by a small votive candle or electric bulb. Diffusion is recommended for treating emotional upsets.
• Compresses: These are made by soaking four or five layers of cotton cloth in a solution of warm water and essential oil, wringing out the cloth so that it is moist but not dripping, and applying it to the affected part of the body. The compress is then covered with a layer of plastic wrap, followed by a pre-warmed towel, and kept in place for one or two hours. Aromatherapy compress es are used to treat wounds, sprains, bruises, sore muscles, menstrual cramps, and respiratory congestion.
• Aromatic salves: Salves are made by melting together 1 1/4 cup of vegetable oil and 1 oz of beeswax in a double boiler over medium heat, and adding the desired combination of essential oils.
• Internal use: Some essential oils such as oil of peppermint and cinnamon can be used to make teas or mouthwashes, or mixed with a glass of honey and water. The dose depends on the oil, but a physician, naturopathist, or other practitioner should be consulted.

Preparation

Aromatherapists recommend the use of fresh oils and oil mixtures in the techniques described above. Both essential oils and vegetable carrier oils deteriorate over time and should not be kept longer than one or two months; thus, it is best to mix only small quantities of massage oils or salves at any one time.

No special preparation for an aromatherapy treatment is required on the patient’s part.

Aftercare

Aromatherapy does not require any particular form of aftercare, although many patients like to rest quietly for a few minutes after a bath or massage with essential oils.

Risks

There are no risks involved in external aromatherapy when essential oils are diluted as recommended. Not all essential oils, however, should be taken internally. Benzoin and other essential oils derived from tree resins should not be used internally.

A few cases have been reported of dissociative episodes triggered by fragrances associated with traumatic experiences. Patients in treatment for post-traumatic stress disorder (PTSD) or any of the dissociative disorders should consult their therapist before they use aromatherapy.

Normal results

Normal results from aromatherapy include a sense of relaxation, relief from tension, and improved well-being.

Abnormal results

Abnormal results include skin irritations or other allergic reactions to essential oils, and the development of traumatic memories associated with specific smells.

Definition

Appetite-suppressant medications are drugs that promote weight loss by decreasing appetite or increasing the sensation of fullness.

Description

Obesity is a disease that affects millions of American adults, adolescents, and children, posing serious health risks. Medical professionals generally consider obesity to be a chronic illness requiring life-long treatment and management. It is often grouped with other chronic conditions, such as high blood pressure and diabetes, as a condition that can be controlled but not cured. One is considered obese if 20% over ideal body weight, according to standard height-weight charts, or if one’s Body Mass Index, or BMI, (a ratio of height to weight, indicaating the amount of fat tissue in the body) exceeds 30%.

The most important strategies for managing obesity are not medications but rather, a healthy diet coupled with moderate exercise. As in other chronic conditions, the use of prescription medications may assist in managing the condition for some individuals but it is never the sole treatment for obesity, nor is it ever considered a cure.

The class of medications used most often for weight loss are commonly referred to as “appetite suppressants.” These medications promote weight loss by helping to diminish appetite, and/or by increasing the subjective feeling of fullness. They work by increasing serotonin or catecholamines, two neurotransmitters (chemicals) in the brain that affect both mood and appetite.

Several prescription medications are currently approved for treatment of obesity. In general, the effects of these medications are modest, leading to an average initial weight loss of between 5 and 22 pounds; though studies show that weight returns after cessation of the drugs. There is considerable individual difference in response to these medications; some people experience greater weight loss than others. The goal of prescribing weight loss medication is to help the medically at-risk obese patient “jump-start” their weight loss effort and lose 10% or more of their starting body weight. When this can be accomplished, it usually leads to a reduction in risk for obesity-related illnesses, such as high blood pressure, heart disease and diabetes. Weight loss tends to be greatest during the first few weeks or months of treatment, leveling off after about six months. Research suggests that if a patient does not lose at least four pounds during the first four weeks on a particular medication, that medication is unlikely to be effective over the long run. Few studies have addressed safety or effectiveness of medications taken for more than a few months at a time. Little data exists on the long-term effectiveness of the drugs.

All but two of the prescription appetite suppressants in the United States have been approved by the U.S. Food and Drug Administration (FDA), for short-term use only. Short-term use generally means a few weeks or months at the longest. One appetite suppressant medication was approved for longer-term use within the past decade, but that drug, dexfenfluramine (Redux) was withdrawn from the market because of unacceptable risks associated with its use.

Another medication was approved within the past few years for longer-term use, up to a year and possibly longer, in significantly obese patients. This drug, an appetite suppressant, is called sibutramine (Meridia). Individuals with a history of heart disease, irregular heartbeat, high blood pressure, or history of stroke should not take sibutramine. All patients taking this medication should have their blood pressure monitored regularly.

A relatively new drug, orlistat (Xenical), was approved in 1999 by the FDA for at least a year or longer, as well. Orlistat is not an appetite suppressant, but rather, a member of a new class of anti-obesity drugs known as “lipase inhibitors.” These medications work by preventing enzymes in the gastrointestinal tract from breaking down dietary fats into smaller molecules that can be absorbed by the body. The result is that fat absorbed from food is decreased by about 30%. This effectively reduces the calories absorbed by the body by 30%, aiding in weight loss.

While the FDA regulates how a medication can be advertised or promoted by the manufacturer, these regulations do not constrain physicians from prescribing them as they believe appropriate. This practice of prescribing medications for conditions other than those for which they were approved, or at different dosages, or for different lengths of time, is known as “off-label” use. Many of the prescription medications available for weight management are used in an “off-label” manner.

Most of the side effects of prescription medications for weight loss are mild; but some very serious complications have been reported in recent years. They were so serious that two medications were voluntarily removed from the market by the manufacturers in 1997.These two medications, fenfluramine (Pondimin), and dexfenfluramine (Redux), were shown to be associated with a rare but very serious and potentially fatal disorder known as primary pulmonary hypertension (PPH), a disease of the lungs. Forty-five percent of patients with PPH die within four years of diagnosis.

Medications for weight loss

Prescription medications

Prescription medications currently prescribed for weight loss include:

• Generic name: Diethylpropion (Trade names: Tenuate, Tenuate dospan)
• Generic name: Mazindole (Trade name: Sanorex)
• Generic name: Orlistat (Trade name: Xenical)
• Generic name: Phendimetrazine (Trade names: Bontril, Plegine, Prelu-2, X-Troxine)
• Generic name: Phentermine (Trade name: Adipex-P, Fastin, Ionamin, Oby-trim)
• Generic name: Sibutramine (Trade name: Meridia)

Some antidepressant medications have been studied for use as possible appetite depressants, because they frequently depress appetite in the early weeks and months of use. Research indicates, however, that while individuals may lose weight initially during antidepressant treatment, a tendency to lose only modest amounts of weight arises after six months. Furthermore, most patients who lose weight early in antidepressant medication treatment tend to regain the weight while still using the medication.

Amphetamines and similar medications were frequently prescribed in the United States, during the 1960s and 70s, as appetite suppressants. However, because of their addictive potential, they are not prescribed today for weight control, except by a remainder of “diet doctors” who defy political correctness and continue to distribute them.

SINGLE DRUG TREATMENT. The medications listed above are currently used to treat obesity. In general, these medications are modestly effective, especially when used in conjunction with a healthy diet and moderate exercise. Average weight losses between five and 22 pounds can be expected beyond those seen with non-drug obesity treatments, when only a low-calorie diet and exercise regimen are followed. There is considerable individual variation in response to weight-loss medications; some people experience more weight loss than others.

COMBINED DRUG TREATMENT. Combined drug treatment using fenfluramine and phentermine (“fen/phen”) is no longer available due to the withdrawal of fenfluramine from the market. There is little information about the safety or effectiveness of other prescription drug combinations for weight loss. Until further research is conducted on safety or effectiveness, using combinations of medications for weight loss is not advised unless a patient is participating in a research study.

POTENTIAL BENEFITS OF APPETITE SUPPRESSANT TREATMENT. Short-term use of appetite suppressant medications has been shown to modestly reduce health risks for obese individuals. Studies have found that these medications can lower blood pressure, blood cholesterol, blood fats (triglycerides), and decrease insulin resistance (the body’s ability to utilize blood sugar). Long-term studies need to be conducted to determine if weight loss assisted by appetite suppressant medications can improve health long-term.

POTENTIAL RISKS OF APPETITE SUPPRESSANT TREATMENT. All prescription medications used to treat obesity, with the exception of orlistat, are controlled substances. This means that doctors need to follow rigid guidelines when prescribing them. Although abuse and dependence are uncommon with non-amphetamine appetite suppressant medications, doctors need to exercise caution when prescribing them, especially for patients with a history of alcohol or drug abuse.

DEVELOPMENT OF TOLERANCE. Studies of appetite suppressant medications indicate that an individual’s weight tends to level off after four to six months of treatment. While some patients and doctors may be concerned that this indicates growing tolerance to the medications, the leveling off may indicate that the medication has reached its limit of effectiveness. Current research is not clear regarding whether weight gained with continued medication is due to drug tolerance, or to reduced effectiveness of the medication over time.

SIDE EFFECTS. Because obesity is a condition affecting millions of Americans, many of whom are basically healthy, the side effects of using powerful medications such as appetite suppressants are of great concern. Most side effects of these medications are mild and diminish as treatment continues. Rarely, serious and even fatal outcomes have been reported. The FDA-approved appetite suppressant medications that affect serotonin (fenfluramine and dexfenfluramine) have been withdrawn from the market. Medications that affect catecholamine levels (such as phentermine, dietylpropion, and mazindol) may cause symptoms of sleeplessness, nervousness, and euphoria.

Primary pulmonary hypertension (PPH) is a rare but potentially fatal disease that affects the blood vessels in the lungs and causes death within four years in 45% of its victims. Patients who use the appetite suppressant medications that are prescribed for a use of three months are at increased risk of developing this condition if used longer. Estimates are that between 1 in 22,000 and 1 in 44,000 individuals will develop the disorder each year. While the risk of developing PPH is very small, doctors and patients should be aware of this potentially deadly complication when they consider the risks and benefits of using appetite suppressant medications for long-term treatment of obesity. Patients taking appetite suppressants should contact their doctors if they experience shortness of breath, chest pain, faintness, or swelling in the lower legs and ankles. The vast majority of cases of PPH related to appetite suppressant use have occurred in patients taking fenfluarmine or dexfenfluramine, either alone or in combination with each other or other drugs, such as phentermine. There have been only a few cases of PPH reported among patients taking phentermine alone, although the possibility that phentermine alone may be associated with PPH cannot be ruled out at this time.

Animal research has suggested that appetite suppressant medications affecting the neurotransmitter serotonin, such as fenfluramine and dexfenfluramine, can damage the central nervous system. These findings have not been reported in humans. Some patients have reported depression or memory loss when using appetite suppressant medications alone or in combination, but it is not known if these problems are actually caused by the medications or by other factors.

Definition

Anxiety is an unpleasant emotion triggered by anticipation of future events, memories of past events, or ruminations about the self.

Description

Stimulated by real or imagined dangers, anxiety afflicts people of all ages and social backgrounds. When the anxiety results from irrational fears, it can disrupt or disable normal life. Some researchers believe anxiety is synonymous with fear, occurring in varying degrees and in situations in which people feel threatened by some danger. Others describe anxiety as an unpleasant emotion caused by unidentifiable dangers or dangers that, in reality, pose no threat. Unlike fear, which is caused by realistic, known dangers, anxiety can be more difficult to identify and to alleviate.

Rather than attempting to formulate a strict definition of anxiety, most psychologists simply make the distinction between normal anxiety and neurotic anxiety, or anxiety disorders. Normal (sometimes called objective) anxiety occurs when people react appropriately to the situation causing the anxiety. For example, most people feel anxious on the first day at a new job for any number of reasons. They are uncertain how they will be received by coworkers, they may be unfamiliar with their duties, or they may be unsure they made the correct decision in taking the job. Despite these feelings and any accompanying physiological responses, they carry on and eventually adapt. In contrast, anxiety that is characteristic of anxiety disorders is disproportionately intense. Anxious feelings interfere with a person’s ability to carry out normal or desired activities. Many people experience stage fright—the fear of speaking in public in front of large groups of people. There is little, if any, real danger posed by either situation, yet each can stimulate intense feelings of anxiety that can affect or derail a person’s desires or obligations. Sigmund Freud described neurotic anxiety as a danger signal. In his id-ego-superego scheme of human behavior, anxiety occurs when unconscious sexual or aggressive tendencies conflict with physical or moral limitations.

According to a standard manual for mental health clinicians, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revised (also known as the DSM-IV-TR), the following disorders are considered anxiety disorders:

• Panic disorder without agoraphobia—A person with this disorder suffers from recurrent panic attacks and worries about experiencing more attacks, but agoraphobia is not present. Panic attacks are sudden attacks of intense fear or apprehension during which the sufferer may experience shortness of breath, increased heart rate, choking, and/or a fear of losing control. Agoraphobia is anxiety about places or situations from which escape might be difficult, or in which help might not be available.
• Panic disorder with agoraphobia—A person with this disorder also experiences recurrent panic attacks but also has agoraphobia. The anxiety about certain places or situations may lead to avoidance of those places or situations.
• Agoraphobia without history of panic disorder—The person with this disorder suffers from agoraphobia and experiences panic-like symptoms but does not experience recurring panic attacks.
• Specific phobias—A person diagnosed with a specific phobia suffers from extreme anxiety when he or she is exposed to a particular object or situation. The feared stimuli may include: particular animals (dogs, spiders, snakes, etc.), situations (crossing bridges, driving through tunnels), storms, heights, and many others.
• Social phobia—A person with social phobia fears social situations or situations in which the individual is expected to perform. These situations may include eating in public or speaking in public, for example.
• Obsessive-compulsive disorder—A person with this disorder feels anxiety in the presence of a certain stimulus or situation, and feels compelled to perform an act (a compulsion) to neutralize the anxiety. For example, upon touching a doorknob, a person may feel compelled to wash his or her hands four times, or more.
• Post-traumatic stress disorder—This disorder may be diagnosed after a person has experienced a traumatic event, and long after the event, the person still mentally re-experiences the event along with the same feelings of anxiety that the original event produced.
• Acute stress disorder— Disorder with similar symptoms to post-traumatic stress disorder, but is experienced immediately after the traumatic event. If this disorder persists longer than one month, the diagnosis may be changed to post-traumatic stress disorder.
• Generalized anxiety disorder—A person who has experienced six months or more of persistent and excessive worry and anxiety may receive this diagnosis.
• Anxiety due to a general medical condition—Anxiety that the clinician deems is caused by a medical condition.
• Substance-induced anxiety disorder—Symptoms of anxiety that are caused by a drug, a medication, or a toxin.
• Anxiety disorder not otherwise specified—This diagnosis may be given when a patient’s symptoms do not meet the exact criteria for each of the above disorders as specified by DSM-IV-TR.

Definition

Anorexia nervosa (AN) is an eating disorder characterized by an intense fear of gaining weight and becoming fat. Because of this fear, the affected individual starves herself or himself, and the person’s weight falls to about 85% (or less) of the normal weight for age and height.

Description

AN affects females more commonly than males—90% of those affected are female. Typically, the disorder begins when an adolescent or young woman of normal or slightly overweight stature decides to diet. As weight falls, the intensity and obsession with dieting increases. Affected individuals may also increase physical exertion or exercise as weight decreases to lose more pounds. An affected person develops peculiar rules concerning exercise and eating. Weight loss and avoidance of food is equated in these patients with a sense of accomplishment and success. Weight gain is viewed as a sign of weakness (succumbing to eat food) and as failure. Eventually, the affected person becomes increasingly focused on losing weight and devotes most efforts to dieting and exercise.

Anorexia nervosa is a complex eating disorder that has biological, psychological, and social consequences for those who suffer from it. When diagnosed early, the prognosis for AN is good.

Causes and symptoms

Causes

The exact causes of AN are not currently known, but the current thinking about AN is that it is caused by multiple factors. There are several models that can identify risk factors and psychological conditions that predispose people to develop AN. The predisposing risk factors include:

• female gender
• perfectionism
• personality factors, including being eager to please other people and high expectations for oneself
• family history of eating disorders
• living in an industrialized society
• difficulty communicating negative emotions such as anger or fear
• difficulty resolving problems or conflict
• low self-esteem

Specialists in family therapy have demonstrated that dysfunctional family relationships and impaired family interaction can contribute to the development of AN. Mothers of persons with AN tend to be intrusive, perfectionistic, overprotective, and have a fear of separation. Fathers of AN-affected individuals are often described as passive, withdrawn, moody, emotionally constricted, obsessional, and ineffective. Sociocultural factors include the messages given by society and the culture about women’s roles and the thinness ideal for women’s bodies. Developmental causes can include adolescent “acting out” or fear of adulthood transition. In addition, there appears to be a genetic correlation since AN occurs more commonly in biological relatives of persons who have this disorder.

Precipitating factors are often related to the developmental transitions common in adolescence. The onset of menarche (first menstrual cycle) may be threatening in that it represents maturation or growing up. During this time in development, females gain weight as part of the developmental process, and this gain may cause a decrease in self-esteem. Development of AN could be a way that the adolescent retreats back to childhood so as not to be burdened by maturity and physical concerns. Autonomy and independence struggles during adolescence may be acted out by developing AN. Some adolescents may develop AN because of their ambivalence about adulthood or because of loneliness, isolation, and abandonment they feel.

Symptoms

Most of the physical symptoms associated with AN are secondary to starvation. The brain is affected— there is evidence to suggest alterations in brain size, neurotransmitter balance, and hormonal secretion signals originating from the brain. Neurotransmitters are the chemicals in the brain that transmit messages from nerve cell to nerve cell. Hormonal secretion signals modulate sex organ activity. Thus, when these signals are not functioning properly, the sex organs are affected. Significant weight loss (and loss in body fat, in particular) inhibits the production of estrogen, which is necessary for menstruation. AN patients experience a loss of menstrual periods, known as amenorrhea. Additionally, other physiologic systems are affected by the starvation. AN patients often suffer from electrolyte (sodium and potassium ion) imbalance and blood cell abnormalities affecting both white and red blood cells. Heart function is also compromised and a person affected with AN may develop congestive heart failure (a chronic weakening of the heart due to work overload), slow heart rate (bradycardia), and abnormal rates and rhythms (arrhythmias). The gastrointestinal tract is also affected, and a person with AN usually exhibits diminished gastric motility (movement) and delayed gastric emptying. These abnormalities may cause symptoms of bloating and constipation. In addition, bone growth is affected by starvation, and over the long term, AN patients can develop osteoporosis, a bone loss disease.

Physically, people with AN can exhibit cold hands and feet, dry skin, hair loss, headaches, fainting, dizziness, and lethargy (loss of energy). Individuals with AN may also develop lanugo (a fine downy hair normally seen in infants) on the face or back. Psychologically, these people may have an inability to concentrate, due to the problems with cognitive functioning caused by starvation. Additionally, they may be irritable, depressed, and socially withdrawn, and they obsessively avoid food. People affected with AN may also suffer from lowered body temperature (hypothermia), and lowered blood pressure, heart rate, glucose and white blood cells (cells that help fight against infection). They may also have a loss of muscle mass.

In order to diagnose AN, a patient’s symptoms must meet the symptom criteria established in the professional’s handbook, the Diagnostic and Statistical Manual of Mental Disorders, also called the DSM. These symptoms include:

• Refusal to maintain normal body weight, resulting in a weight that is less than 85% of the expected weight.
• Even though the affected person is underweight, he or she has an intense fear of gaining weight.
• Distorted body image, obsession with body weight as key factor in self-evaluation, or denial of the seriousness of the low body weight.
• Amenorrhea.

Demographics

AN is considered to be a rare illness. The prevalence even in high-risk groups and high-risk situations is approximately 0.5%–1%. Partial disorders (diagnosed when symptoms are present, but do not meet the full criteria as established in the DSM) are more commonly seen in psychological practice. The incidence (number of new cases) of AN has increased during the last 50 years due to increased societal concerns regarding body shape, weight, and appearance. Some occupations such as ballet dancing and fashion modeling may predispose persons to develop AN, due to preoccupation with physical appearance. This disorder usually affects women more than men in a ratio of between one to 20 and one to 10.

Diagnosis

Initial assessment usually includes a careful interview and history (clinical evaluation). A weight history, menstrual history, and description of daily food intake are important during initial evaluation. Risk factors and family history are also vital in suspected cases. Laboratory results can reveal anemia (low red blood cell count in the blood), lowered white blood cells, pulse, blood pressure, and body temperature. The decreased temperature in extremities may cause a slight red-purple discoloration in limbs (acrocynanosis). There are two psychological questionnaires that can be administered to aid in diagnosis, called the Eating Attitudes Test (EAT) and Eating Disorders Inventory (EDI). The disadvantage of these tests is that they may produce false-positive results, which means that a test result may indicate that the test taker has anorexia, when, actually, s/he does not.

Treatments

People affected with AN are often in denial, in that they don’t see themselves as thin or in need of professional help. Education is important, as is engagement on the part of the patient—a connection from the patient to her treatment, so that she agrees to be actively involved. Engagement is a necessary but difficult task in the treatment of AN. If the affected person’s medical condition has deteriorated, hospitalization may be required. Initially, treatment objectives are focused on reversing behavioral abnormalities and nutritional deficiencies. Emotional support and reassurance that eating and caloric restoration will not make the person overweight, are essential components during initial treatment sessions. Psychosocial (both psychological and social) issues and family dysfunction are also addressed, which may reduce the risk of relapsing behaviors. (Relapsing behaviors occur when an individual goes back to the old patterns that he or she is trying to eliminate.) At present, there is no standardized psychotherapeutic treatment model to address the multifactorial problems associated with AN. Cognitive-behavioral therapy (CBT) may help to improve and modify irrational perceptions and overemphasis of weight gain. Current treatment usually begins with behavioral interventions and should include family therapy (if age appropriate). Psychodynamic psychotherapy (also called exploratory psychotherapy) is often helpful in the treatment of AN. There are no medications to treat AN. Treatment for this disorder is often long term.

 

Definition

Amphetamines are a group of powerful and highly addictive substances that dramatically affect the central nervous system. They induce a feeling of well-being and improve alertness, attention, and performance on various cognitive and motor tasks. Closely related are the socalled “designer amphetamines,” the most well known of which is the “club drug” MDMA, best known as “ecstasy.” Finally, some over-the-counter drugs used as appetite suppressants also have amphetamine-like action. Amphetamine-related disorders refer to the effects of abuse, dependence, and acute intoxication stemming from inappropriate amphetamine and amphetamine-related drug usage.

Description

Several amphetamines are currently available in the United States. These include dextroamphetamine (Dexedrine), methamphetamine (Desoxyn), and methylphenidate (Ritalin). These Schedule II stimulants, known to be highly addictive, require a triplicate prescription that cannot be refilled. Amphetamines are also known as sympathomimetics, stimulants, and psychostimulants. Methamphetamine, the most common illegally produced amphetamine, goes by the street name of “speed,” “meth,” and “chalk.” When it is smoked, it is called “ice,” “crystal,” “crank,” and “glass.” Methamphetamine is a white, odorless, bitter-tasting crystalline powder that dissolves in water or alcohol.

The leaves of the East African bush Catha edulis can be chewed for their stimulant effects. This drug, cathinone or Khat, has an effect on most of the central nervous system, in addition providing the other properties of amphetamines. Illegal laboratories have begun making methcathinone, which has effects similar to cathinone. Methcathinone, also known as “crank,” is easily synthesized from ephedrine or pseudoephedrine.

Amphetamines were initially produced for medical use, and were first used in nasal decongestants and bronchial inhalers. Early in the 1900s, they were also used to treat several medical and psychiatric conditions, including narcolepsy (a rare condition in which an individuals falls asleep at dangerous and inappropriate moments and cannot maintain normal alertness), attention-deficit disorders, obesity, and depression. They are still used to treat these disorders today.

Amphetamine-like substances called ephedrine and propranolamine are available over the counter in the United States and are used as nasal decongestants. Phenylpropanolamine is also used as an appetite suppressant, and is available over the counter as well. These are less potent than the classic amphetamines, but are still subject to abuse, partly because of their ready availability and low price.

In the 1970s, governmental agencies initiated restrictions increasing the difficulty of obtaining amphetamines legally through prescription. During this same time period, a drug chemically related to the amphetamines began to be produced. This so-called designer drug, best known as “ecstasy,” but also as MDMA, XTC, and Adam, has behavioral effects that combine amphetamine-like and hallucinogen-like properties.

The structure of amphetamines differs significantly from that of cocaine, even though both are stimulants with similar behavioral and physiological effects. Like cocaine, amphetamine results in an accumulation of the neurotransmitter dopamine. It is this excessive dopamine concentration that appears to produce the stimulation and feelings of euphoria experienced by the user. Cocaine is much more quickly metabolized and removed from the body, whereas amphetamines have a much longer duration of action. A large percentage of the drug remains unchanged in the body, leading to prolonged stimulant effects.

The handbook that mental health professionals use to diagnose mental disorders is the Diagnostic and Statistical Manual of Mental Disorders, also known as the DSM. The 2000 edition of this manual (the Fourth Edition Text Revision, also known as DSM-IV-TR) describes four separate amphetamine-related disorders. These are:

• Amphetamine dependence, which refers to chronic or episodic binges (known as “speed runs”), with brief drug-free periods of time in between use.
• Amphetamine abuse, which is less severe than dependence. Individuals diagnosed with amphetamine abuse have milder but nevertheless still substantial problems due to their drug usage.
• Amphetamine intoxication, which refers to serious maladaptive behavioral or psychological changes that develop during, or shortly after, use of an amphetamine or related substance.
• Amphetamine withdrawal, which refers to symptoms that develop within a few hours to several days after reducing or stopping heavy and prolonged amphetamine use. Withdrawal symptoms are, in general, opposite to those seen during intoxication and include fatigue, vivid and unpleasant dreams, insomnia or hypersomnia (too much sleep), increased appetite and agitation or slowing down.

Causes and symptoms

Causes

All amphetamines are rapidly absorbed when taken orally, and even more rapidly absorbed when smoked, snorted, or injected. Tolerance develops with both standard and designer amphetamines, leading to the need for increasing doses by the user.

The classic amphetamines, dextroamphetamine, methamphetamine, and methylphenidate, produce their primary effects by causing the release of catecholamines, especially dopamine, in the brain. These effects are particularly strong in areas of the brain associated with pleasure, specifically, the cerebral cortex and the limbic system, known as the “reward pathway.” The effect on this pathway is probably responsible for the addicting quality of the amphetamines. Catecholamines are any of several compounds found naturally in the body and act as hormones or neurotransmitters in the sympathetic nervous system. Dopamine, an intermediate substance that emerges from the biosynthesis of ephinephrine and norepinephrine, is one of those compounds.

Designer amphetamines, most notably MDMA, causes the release of catecholamines, dopamine and norepinephrine; and in addition, releases serotonin. Serotonin, also a neurotransmitter, produces hallucinogenic effects. The clinical effects of designer amphetamines blend the effects of classic amphetamines with those of hallucinogenic drugs, such as LSD.

Symptoms

CLASSIC AMPHETAMINES. According to the DSM-IVTR, symptoms of heavy, chronic, or episodic use of amphetamine, known as amphetamine dependence, can be very serious. Amphetamine dependence is characterized by compulsive drug-seeking and drug use leading to functional and molecular changes in the brain. Aggressive or violent behavior may occur, especially when high doses are ingested. The individual may develop anxiety or paranoid ideas, also with the possibility of experiencing terrifying psychotic episodes that resemble schizophrenia, with visual or auditory hallucinations, delusions such as the sensation of insects creeping on the skin, known as “formication.” hyperactivity, hypersexuality, confusion, and incoherence. Amphetamine-induced psychosis differs from true psychosis in that despite other symptoms, the disorganized thinking that is a hallmark of schizophrenia tends to be absent. Amphetamine dependence consistently affects relationships at home, school and/or work.

Amphetamine abuse is less serious than dependence, but can cause milder versions of the symptoms described above, as well as problems with family, school, and work. Legal problems may stem from aggressive behavior while using, or from obtaining drugs illegally. Individuals may continue to use despite the awareness that usage negatively impacts all areas of their lives.

Acute amphetamine intoxication begins with a “high” feeling which may be followed by feelings of euphoria. The user experiences enhanced energy, becoming more outgoing and talkative, and more alert. Other symptoms include anxiety, tension, grandiosity, repetitive behavior, anger, fighting, and impaired judgment.

In both acute and chronic intoxication, the individual may experience dulled feelings, along with fatigue or sadness, and social withdrawal. These behavioral and psychological changes are accompanied by other signs and symptoms including increased or irregular heartbeat, dilation of the pupils, elevated or lowered blood pressure, heavy perspiring or chills, nausea and/or vomiting, motor agitation or retardation, muscle weakness, respiratory depression, chest pain, and eventually confusion, seizures, coma, or a variety of cardiovascular problems, including stroke. With amphetamine overdoses, death can result if treatment is not received immediately. Long-term abuse can lead to memory loss as well, and contributes to increased transmission of hepatitis and HIV/AIDs. Impaired social and work functioning is another hallmark of both acute and chronic intoxication.

Following amphetamine intoxication, a “crash” occurs with symptoms of anxiety, shakiness, depressed mood, lethargy, fatigue, nightmares, headache, perspiring, muscle cramps, stomach cramps, and increased appetite. Withdrawal symptoms usually peak in two to four days and are gone within one week. The most serious withdrawal symptom is depression, possibly very severe and leading to suicidal thoughts.

DESIGNER AMPHETAMINES. Use of so-called designer amphetamines, the best-known of which is MDMA, leads to symptoms of classic amphetamine use. Users report a sense of feeling unusual closeness with other people and enhanced personal comfort. They describe seeing an increased luminescence of objects in the environment, although these hallucinogenic effects are less than those caused by other hallucinogens, such as LSD. Some psychotherapists have suggested further research into the possible use of designer amphetamines in conjunction with psychotherapy. This idea is highly controversial, however.

Like classic amphetamines, use of MDMA produces cardiovascular effects of increased blood pressure, heart rate, and heart oxygen consumption. People with preexisting heart disease are at increased risk of cardiovascular catastrophe resulting from MDMA use. MDMA is not processed and removed from the body quickly, and remains active for a long period of time. As a result, toxicity may rise dramatically when users take multiple doses over brief time periods, leading to harmful reactions such as dehydration, hyperthermia, and seizures.

MDMA tablets often contain other drugs, such as ephedrine, a stimulant, and dextromethorphan, a cough suppressant with PCP-like effects at high doses. These additives increase the harmful effects of MDMA. It appears also to have toxic effects on the brain’s serotonin system. In tests of learning and memory, MDMA users perform more poorly than nonusers. Research with primates show that MDMA can cause long-lasting brain damage. Exposure to MDMA during the period of pregnancy in which the fetal brain is developing is associated with learning deficits that last into adulthood.

Demographics

Classic amphetamines

Amphetamine dependence and abuse occur at all levels of society, most commonly among 18- to 30-year-olds. Intravenous use is more common among individuals from lower socioeconomic groups, and has a male-to-female ratio of three or four to one. Among non-intravenous users, males and females are relatively equally divided.

An annual study known as the Monitoring the Future Study, or MTF, examines drug use and attitudes related to drugs held by American teenagers. It focuses primarily on teens in the eighth, 10th, and 12th grades, but also on young adults across the country. Recent data on methamphetamine use showed that in 1997, 4.4% of 12th graders had tried crystal methamphetamine at least once in their lifetime. This represented an increase from 2.7% in 1990. Also in 1997, 2.3% of seniors reported having used crystal methamphetamine at least once during the past year. This represented an increase from 1.3% in 1990.

According to the 2000 National Household Survey on Drug Abuse, approximately 8.8 million Americans have tried methamphetamine at some time during their lives. Data from the 2000 Drug Abuse Warning Network (DAWN), which collects information on drug usage problems from emergency room departments in 21 metropolitan areas found that methamphetamine-related problems increased from 10,400 in 1999 to 13,500 in 2000, an increase of 30%.

Treatment admissions reports by the National Institute of Drug Abuse (NIDA) Community Epidemiology Work Group, or CEWG, showed that as of June 2001, methamphetamine usage continued to be the leading drug of abuse among clients in treatment in the San Diego area and Hawaii. Methamphetamine is the most prevalent illegal drug in San Diego. Both San Francisco and Honolulu also reported substantial methamphetamine use problems during the late 1990s. Increased use was also reported in Denver, Los Angeles, Minneapolis/St.Paul, Phoenix, Seattle, and Tucson.

Definition

Amphetamines are a group of drugs that stimulate the central nervous system. Some of the brand names of amphetamines sold in the United States are Dexedrine, Biphetamine, Das, Dexampex, Ferndex, Oxydess II, Spancap No 1, Desoxyn, and Methampex. Some generic names of amphetamines include amphetamine, dextroamphetamine, and methamphetamine.

Purpose

Amphetamines stimulate the nervous system and are used in the treatment of depression, attention-deficit disorder, obesity, and narcolepsy, a disorder that causes individuals to fall asleep at inappropriate times during the day. Amphetamines produce considerable side effects and are especially toxic in large quantities. Amphetamines are commonly abused recreational drugs and are highly addictive.

Description

Amphetamines are usually given orally and their effects can last for hours. Amphetamines produce their effects by altering chemicals that transmit nerve messages in the body.

Recommended dosage

The typical dose for amphetamines in the treatment of narcolepsy in adults ranges from 5 mg to 60 mg per day. These daily doses are usually divided into at least two small doses taken during the day. Doses usually start on the low end of the range and are increased until the desired effects occur. Children over the age of 12 years with narcolepsy receive 10 mg per day initially. Children between the ages of six and 12 years start with 5 mg per day. The typical dose for adults with obesity ranges from 5 mg to 30 mg per day given in divided doses. The medication is usually given about one-half hour to one hour before meals.

The typical starting dose of amphetamines given to children with attention-deficit disorder over the age of six years is 5 mg per day. This is increased by 5 mg per day over a period of time until the desired effect is achieved. Children under the age of six years with this condition are usually started at 2.5 mg per day.

Precautions

People who are taking amphetamines should not stop taking these drugs suddenly. The dose should be lowered gradually and then discontinued. Amphetamines should only be used while under the supervision of a physician. People should generally take the drug early in the day so that it does not interfere with sleep at night. Hazardous activities should be avoided until the person’s condition has been stabilized with medication. The effects of amphetamine can last up to 20 hours after the medication has last been taken. Amphetamine therapy given to women for medical reasons does not present a significant risk to the developing fetus for congenital disorders. In such cases, there may be mild withdrawal in the newborn. However, illicit use of amphetamines for non-medical reasons presents a significant risk to the fetus and the newborn because of uncontrolled doses.

Amphetamines are highly addictive and should be used only if alternative approaches have failed. They should be used with great caution in children under three years of age, anyone with a history of slightly elevated blood pressure, people with neurological tics, and in individuals with Tourette’s syndrome. Amphetamines should not be taken by individuals with a history of an overactive thyroid, those with moderate-to-severe high blood pressure, those with the eye disease called glaucoma, those who have severe arteriosclerosis (hardening of the arteries), or anyone with psychotic symptoms (hallucinations and delusions). Individuals with a history of drug abuse, psychological agitation, or cardiovascular system disease should also not receive amphetamine therapy. In addition, patients who have taken MAO inhibitors, a type of antidepressant, within the last 14 days should not receive amphetamines. MAO inhibitors include phenelzine (Nardil), and tranylcypromine (Parnate).

Side effects

The most common side effects that are associated with amphetamines include the development of an irregular heartbeat, increased heart rate, increased blood pressure, dizziness, insomnia, restlessness, headache, shakiness, dry mouth, metallic taste, diarrhea, constipation, and weight loss. Other side effects can include changes in sexual drive, nausea, vomiting, allergic reactions, chills, depression, irritability, and other problems involving the digestive system. High doses, whether for medical purposes or illicit ones, can cause addiction, dependence, increased aggression, and, in some cases, psychotic episodes.

Interactions

Patients taking amphetamines should always tell their physicians and dentists that they are using this medication. Patients should consult their physician before taking any over-the-counter medication while taking amphetamines. The interaction between over-the-counter cold medications with amphetamine, for instance, is particularly dangerous because this combination can significantly increase blood pressure. Such cold medications should be avoided when using amphetamine unless a physician has carefully analyzed the combination.

The combination of amphetamines and antacids slows down the ability of the body to eliminate the amphetamine. Furazolidone (Furoxone) combined with amphetamine can significantly increase blood pressure. Sodium bicarbonate can reduce the amount of amphetamine eliminated from the body and dangerously increase amphetamine levels in the body. Certain medications taken to control high blood pressure, including guanadrel (Hylorel) and guanethidine (Ismelin), MAO inhibitors, and selegiline (Eldepryl) should not be used in conjunction with amphetamines. In addition, tricyclic antidepressants [including desipramine (Norpramin) and imipramine (Tofranil)], antihistamines, and anticonvulsant drugs should not be combined with amphetamines.

Definition

Amoxapine is an oral tricyclic antidepressant. Formerly sold in the United States under the brand name Asendin, it is now manufactured and sold only under its generic name.

Purpose

Amoxapine is used primarily to treat depression and to treat the combination of symptoms of anxiety and depression. Like most antidepressants of this chemical and pharmacological class, amoxapine has also been used in limited numbers of patients to treat panic disorder, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, enuresis (bed-wetting), eating disorders such as bulimia nervosa, cocaine dependency, and the depressive phase of bipolar (manic-depressive) disorder. It has also been used to support smoking cessation programs.

Description

Tricyclic antidepressants act to change the balance of naturally occurring chemicals in the brain that regulate the transmission of nerve impulses between cells. Amoxapine acts primarily by increasing the concentration of norepinephrine and serotonin (both chemicals that stimulate nerve cells) and, to a lesser extent, by blocking the action of another brain chemical, acetylcholine. Amoxapine shares most of the properties of other tricyclic antidepressants, such as amitriptyline, clomipramine, desipramine, imipramine, nortriptyline, protriptyline, and trimipramine. Studies comparing amoxapine with these other drugs have shown that amoxapine is no more or less effective than other antidepressants of its type. Its choice for treatment is as much a function of physician preference as any other factor.

The therapeutic effects of amoxapine, like other antidepressants, appear slowly. Maximum benefit is often not evident for at least two weeks after starting the drug. People taking amoxapine should be aware of this and continue taking the drug as directed even if they do not see immediate improvement.

Recommended dosage

As with any antidepressant, amoxapine must be adjusted by the physician to produce the desired therapeutic effect. Amoxapine is available as 25-mg, 50-mg, 100-mg, and 150-mg oral tablets. Therapy is usually started at 100 to 150 mg per day and increased to 200 to 300 mg daily by the end of the first week. If no improvement is seen at this dose after two weeks, the physician may increase the dose up to 400 mg per day in outpatients and up to 600 mg per day in hospitalized patients. Doses up to 300 mg may be given in single or divided doses. Doses of more than 300 mg per day should be divided in two or three doses daily.

Because of changes in drug metabolism of older patients, starting at about age 60, the initial dose of amoxapine should be adjusted downward to 50 to 75 mg per day and increased to 100 to 150 mg daily by the end of the first week. Some older patients may require up to 300 mg daily, but doses should never be increased beyond that.

Precautions

Like all tricyclic antidepressants, amoxapine should be used cautiously and with close physician supervision in people, especially the elderly, who have benign prostatic hypertrophy, urinary retention, and glaucoma, especially angle-closure glaucoma (the most severe form). Before starting treatment, people with these conditions should discuss the relative risks and benefits of treatment with their doctors to help determine if amoxapine is the right antidepressant for them.

A common problem with tricyclic antidepressants is sedation (drowsiness, lack of physical and mental alertness). This side effect is especially noticeable early in therapy. In most patients, sedation decreases or disappears entirely with time, but until then patients taking amoxapine should not perform hazardous activities requiring mental alertness or coordination. The sedative effect is increased when amoxapine is taken with other central nervous system depressants, such as alcoholic beverages, sleeping medications, other sedatives, or antihistamines. It may be dangerous to take amoxapine in combination with these substances. Amoxapine may increase the possibility of having seizures. Patients should tell their physician if they have a history of seizures, including seizures brought on by the abuse of drugs or alcohol. These people should use amoxapine only with caution and be closely monitored by their physician.

Amoxapine may increase heart rate and stress on the heart. It may be dangerous for people with cardiovascular disease, especially those who have recently had a heart attack, to take this drug or other antidepressants in the same pharmacological class. In rare cases in which patients with cardiovascular disease must receive amoxapine, they should be monitored closely for cardiac rhythm disturbances and signs of cardiac stress or damage.

Side effects

Amoxapine shares side effects common to all tricyclic antidepressants. The most frequent of these are dry mouth, constipation, urinary retention, increased heart rate, sedation, irritability, dizziness, and decreased coordination. As with most side effects associated with tricyclic antidepressants, the intensity is highest at the beginning of therapy and tends to decrease with continued use.

Dry mouth, if severe to the point of causing difficulty speaking or swallowing, may be managed by dosage reduction or temporary discontinuation of the drug. Patients may also chew sugarless gum or suck on sugarless candy in order to increase the flow of saliva. Some artificial saliva products may give temporary relief.

Men with prostate enlargement who take amoxapine may be especially likely to have problems with urinary retention. Symptoms include having difficulty starting a urine flow and more difficulty than usual passing urine. In most cases, urinary retention is managed with dose reduction or by switching to another type of antidepressant. In extreme cases, patients may require treatment with bethanechol, a drug that reverses this particular side effect. People who think they may be experiencing any side effects from this or any other medication should tell their physicians.

Interactions

Dangerously high blood pressure has resulted from the combination of tricyclic antidepressants, such as amoxapine, and members of another class of antidepressants known as monoamine oxidase (MAO) inhibitors. Because of this, amoxapine should never be taken in combination with MAO inhibitors. Patient taking any MAO inhibitors, for example Nardil (phenelzine sulfate) or Parmate (tranylcypromine sulfate), should stop the MAO inhibitor then wait at least 14 days before starting amoxapine or any other tricyclic antidepressant. The same holds true when discontinuing amoxapine and starting an MAO inhibitor.

Amoxapine may decrease the blood pressure–lowering effects of clonidine. Patients who take both drugs should be monitored for loss of blood-pressure control and the dose of clonidine may be increased as needed.

The sedative effects of amoxapine are increased by other central nervous system depressants such as alcohol, sedatives, sleeping medications, or medications used for other mental disorders such as schizophrenia. The anticholinergic effects of amoxapine are additive with other anticholinergic drugs such as benztropine, biperiden, trihexyphenidyl, and antihistamines.

Definition

The amnestic disorders are a group of disorders that involve loss of memories previously established, loss of the ability to create new memories, or loss of the ability to learn new information. As defined by the mental health professional’s handbook, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (2000), also known as DSM-IV-TR, the amnestic disorders result from two basic causes: general medical conditions that produce memory disturbances; and exposure to a chemical (drug of abuse, medication, or environmental toxin). An amnestic disorder whose cause cannot be definitely established may be given the diagnosis of amnestic disorder not otherwise specified.

Description

The amnestic disorders are characterized by problems with memory function. There is a range of symptoms associated with the amnestic disorders, as well as differences in the severity of symptoms. Some people experience difficulty recalling events that happened or facts that they learned before the onset of the amnestic disorder. This type of

amnesia is called retrograde amnesia. Other people experience the inability to learn new facts or retain new memories, which is called anterograde amnesia. People with amnestic disorders do not usually forget all of their personal history and their identity, although memory loss of this degree of severity occurs in rare instances in patients with dissociative disorders.

Causes and symptoms

Causes

In general, amnestic disorders are caused by structural or chemical damage to parts of the brain. Problems remembering previously learned information vary widely according to the location and the severity of brain damage. The ability to learn and remember new information, however, is always affected in an amnestic disorder.

Amnestic disorder due to a general medical condition can be caused by head trauma, tumors, stroke, or cerebrovascular disease (disease affecting the blood vessels in the brain). Substance-induced amnestic disorder can be caused by alcoholism, long-term heavy drug use, or exposure to such toxins as lead, mercury, carbon monoxide, and certain insecticides. In cases of amnestic disorder caused by alcoholism, it is thought that the root of the disorder is a vitamin deficiency that is commonly associated with alcoholism, known as Korsakoff’s syndrome. The causes of transient global amnesia, or TGA, are unclear.

Symptoms

In addition to problems with information recall and the formation of new memories, people with amnestic disorders are often disoriented with respect to time and space, which means that they are unable to tell an examiner where they are or what day of the week it is. Most patients with amnestic disorders lack insight into their loss of memory, which means that they will deny that there is anything wrong with their memory in spite of evidence to the contrary. Others will admit that they have a memory problem but have no apparent emotional reaction to their condition. Some persons with amnestic disorders undergo a personality change; they may appear apathetic or bland, as if the distinctive features of their personality have been washed out of them.

Some people experiencing amnestic disorders confabulate, which means that they fill in memory gaps with false information that they believe to be true. Confabulation should not be confused with intentional lying. It is much more common in patients with temporary amnestic disorders than it is in people with long-term amnestic disorders.

Transient global amnesia (TGA) is characterized by episodes during which the patient is unable to create new memories or learn new information, and sometimes is unable to recall past memories. The episodes occur suddenly and are generally short. Patients with TGA often appear confused or bewildered.

Demographics

The overall incidence of the amnestic disorders is difficult to estimate. Amnestic disorders related to head injuries may affect people in any age group. Alcohol-induced amnestic disorder is most common in people over the age of 40 with histories of prolonged heavy alcohol use. Amnestic disorders resulting from the abuse of drugs other than alcohol are most common in people between the ages of 20 and 40. Transient global amnesia usually appears in people over 50. Only 3% of people who experience transient global amnesia have symptoms that recur within a year.

Diagnosis

Amnestic disorders may be self-reported, if the patient has retained insight into his or her memory problems. More often, however, the disorder is diagnosed because a friend, relative, employer, or acquaintance of the patient has become concerned about the memory loss or recognizes that the patient is confabulating, and takes the patient to a doctor for evaluation. Patients who are disoriented, or whose amnesia is associated with head trauma or substance abuse, may be taken to a hospital emergency room.

The doctor will first examine the patient for signs or symptoms of traumatic injury, substance abuse, or a general medical condition. He or she may order imaging studies to identify specific areas of brain injury, or laboratory tests of blood and urine samples to determine exposure to environmental toxins or recent consumption of alcohol or drugs of abuse. If general medical conditions and substance abuse are ruled out, the doctor may administer a brief test of the patient’s cognitive status, such as the mini-mental state examination or MMSE. The MMSE is often used to evaluate a patient for dementia, which is characterized by several disturbances in cognitive functioning (speech problems, problems in recognizing a person’s face, etc.) that are not present in amnestic disorders. The doctor may also test the patient’s ability to repeat a string of numbers (the so called digit span test) in order to rule out delirium. Patients with an amnestic disorder can usually pay attention well enough to repeat a sequence of numbers where as patients with delirium have difficulty focusing or shifting their attention. In some cases the patient may also be examined by a neurologist (a doctor who specializes in disorders of the central nervous system)

If there is no evidence of a medical condition or substance use that would explain the patient’s memory problems, the doctor may test the patient’s memory several times in order to rule out malingering or a factitious disorder. Patients who are faking the symptoms of an amnestic disorder will usually give inconsistent answers to memory tests if they are tested more than once.

DSM-IV-TR specifies three general categories of amnestic disorders. These are: amnestic disorder due to a general medical condition, substance-induced persisting amnestic disorder, and amnestic disorder not otherwise specified. The basic criterion for diagnosing an amnestic disorder is the development of problems remembering information or events that the patient previously knew, or inability to learn new information or remember new events. In addition, the memory disturbance must be sufficiently severe to affect the patient’s social and occupational functioning, and to represent a noticeable decline from the patient’s previous level of functioning. DSM-IV-TR also specifies that the memory problems cannot occur only during delirium, dementia, substance use or withdrawal.

Treatments

There are no treatments that have been proved effective in most cases of amnestic disorder, as of 2002. Many patients recover slowly over time, and sometimes recover memories that were formed before the onset of the amnestic disorder. Patients generally recover from transient global amnesia without treatment. In people judged to have the signs that often lead to alcohol-induced persisting amnestic disorder, treatment with thiamin may stop the disorder from developing.

Prognosis

Amnestic disorders caused by alcoholism do not generally improve significantly over time, although in a small number of cases the patient’s condition improves completely. In many cases the symptoms are severe, and in some cases warrant long-term care for the patient to make sure his or her daily needs are met. Other substance induced amnestic disorders have a variable rate of recovery, although in many cases full recovery does eventually occur. Transient global amnesia usually resolves fully.

Prevention

Amnestic disorders resulting from trauma are not generally considered preventable. Avoiding exposure to environmental toxins, refraining from abuse of alcohol or other substances, and maintaining a balanced diet may help to prevent some forms of amnestic disorders.