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Definition
By Mayo Clinic Staff

Narcissistic personality disorder is a mental disorder in which people have an inflated sense of their own importance and a deep need for admiration. Those with narcissistic personality disorder believe that they’re superior to others and have little regard for other people’s feelings. But behind this mask of ultra-confidence lies a fragile self-esteem, vulnerable to the slightest criticism.

Narcissistic personality disorder is one of several types of personality disorders. Personality disorders are conditions in which people have traits that cause them to feel and behave in socially distressing ways, limiting their ability to function in relationships and in other areas of their life, such as work or school.

Narcissistic personality disorder treatment is centered around psychotherapy.

It’s not known what causes narcissistic personality disorder. As with other mental disorders, the cause is likely complex. The cause may be linked to a dysfunctional childhood, such as excessive pampering, extremely high expectations, abuse or neglect. It’s also possible that genetics or psychobiology — the connection between the brain and behavior and thinking — plays a role in the development of narcissistic personality disorder.

Family therapy doesn’t automatically solve family conflicts or make an unpleasant situation go away. But it can help you and your family members understand one another better, and can provide you with skills to cope with challenging situations in a more effective way.

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What you can expect
By Mayo Clinic Staff

Family therapy typically brings several family members together for therapy sessions. However, a family member may also see a family therapist individually. Sessions typically take about 50 minutes to an hour. Family therapy is often short term — generally less than six months. However, how often you meet and the number of sessions you’ll need will depend on your family’s particular situation and the therapist’s recommendation.

During family therapy, you’ll examine your family’s ability to solve problems and express thoughts and emotions. You may explore family roles, rules and behavior patterns in order to identify issues that contribute to conflict — as well as ways to work through these issues. Family therapy may help you identify your family’s strengths, such as caring for one another, and weaknesses, such as difficulty confiding in one another.

For example, say that your adult son has depression. Your family doesn’t understand his depression or how best to offer support. Although you’re worried about your son’s health, conversations with your son or other family members erupt into arguments and you’re left feeling frustrated and angry. Communication diminishes, decisions go unmade, and the rift grows wider.

In such a situation, family therapy can help you pinpoint your specific challenges and how your family is handling them. Guided by your therapist, you’ll learn new ways to interact and overcome unhealthy patterns of relating to each other. You may set individual and family goals and work on ways to achieve them. In the end, your son may be better equipped to cope with his depression, and the entire family may achieve a sense of understanding and togetherness.

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How you prepare
By Mayo Clinic Staff

The only preparation needed for family therapy is to find a psychologist or another type of licensed therapist. You can ask your primary care doctor for a referral to a therapist. Family members or friends may give recommendations based on their experiences. Your health insurance company, employee assistance program, clergy, or state or local mental health agencies also may offer recommendations.

Before scheduling sessions with a therapist, consider whether the therapist would be a good fit for your family. Here are some things to consider and some questions to ask:
•Education and experience. What is your educational and training background? Are you licensed by the state? Are you accredited by the AAMFT or other professional organizations? What is your experience with my family’s type of problem?
•Location and availability. Where is your office? What are your office hours? Are you available in case of emergency?
•Length and number of sessions. How long is each session? How often are sessions scheduled? How many sessions should I expect to have?
•Fees and insurance. How much do you charge for each session? Are your services covered by my health insurance plan? Will I need to pay the full fee upfront? What is your policy on canceled sessions?

Definition
By Mayo Clinic Staff

Family therapy is a type of psychological counseling (psychotherapy) done to help family members improve communication and resolve conflicts. Family therapy is usually provided by a psychologist, clinical social worker or licensed therapist. These therapists have graduate or postgraduate degrees and may be credentialed by the American Association for Marriage and Family Therapy (AAMFT).

Family therapy is often short term. It may include all family members or just those most able to participate. Your specific treatment plan will depend on your family’s situation. Family therapy sessions can teach you skills to deepen family connections and get through stressful times, even after you’re done going to therapy sessions.

Why it’s done
By Mayo Clinic Staff

Family therapy can help you improve troubled relationships with your spouse, children, or other family members. You may address specific issues such as marital or financial problems, conflict between parents and children, or the effects of substance abuse or a mental illness on the entire family.

Your family may pursue family therapy along with other types of mental health treatment, especially if one of you has a mental illness or addiction that also requires individual therapy or rehabilitation treatment. For example, family therapy can help family members cope if a relative has schizophrenia — but the person who has schizophrenia should continue with his or her individualized treatment plan, which may include medications, one-on-one counseling or other treatment.

In the case of addiction, the family can attend family therapy while the person who has an addiction participates in residential treatment. Sometimes the family may participate in family therapy even if the addicted person hasn’t sought out his or her own treatment.

Family therapy can be useful in any family situation that causes stress, grief, anger or conflict. It can help you and your family members understand one another better and bring you closer together.

Self-esteem: 4 steps to feel better about yourself

If you have low self-esteem, harness the power of your own thoughts and beliefs to change how you feel about yourself. Start with these four steps to a healthier self-esteem.
By Mayo Clinic Staff

Low self-esteem can negatively affect virtually every facet of your life, including your relationships, your job and your health. But you can take steps to boost your self-esteem, even if you’ve been harboring a poor opinion of yourself since childhood. Start with these four steps.

Step 1: Identify troubling conditions or situations

Think about the conditions or situations that seem to deflate your self-esteem. Common triggers might include:
•A business presentation
•A crisis at work or home
•A challenge with a spouse, loved one, co-worker or other close contact
•A change in life circumstances, such as a job loss or a child leaving home

Step 2: Become aware of thoughts and beliefs

Once you’ve identified troubling conditions or situations, pay attention to your thoughts about them. This includes your self-talk — what you tell yourself — and your interpretation of what the situation means. Your thoughts and beliefs might be positive, negative or neutral. They might be rational, based on reason or facts, or irrational, based on false ideas.

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Stress incontinence is the most common form of incontinence. It means you leak urine when you increase the pressure on the bladder, as in coughing, sneezing or exercise. It happens when the pelvic floor muscles that support the bladder are weakened. Childbirth is a common reason for a weak pelvic floor. The main treatment for stress incontinence is pelvic floor exercises. Surgery to tighten or support the bladder outlet can also help. Medication may be used in addition to exercises if you do not want, or are not suitable for, surgery.

This leaflet is part of our series on urinary incontinence

Overactive bladder syndrome
Pelvic floor exercises
Stress incontinence
Urge incontinence

Understanding urine and the bladder

The kidneys make urine continuously. A trickle of urine is constantly passing to the bladder down the ureters (the tubes from the kidneys to the bladder). You make different amounts of urine depending on how much you drink, eat and sweat.

The bladder is made of muscle and stores the urine. It expands like a balloon as it fills with urine. The outlet for urine (the urethra) is normally kept closed. This is helped by the muscles beneath the bladder that surround and support the urethra (the pelvic floor muscles).

Urinary tract
When a certain volume of urine is in the bladder, you become aware that the bladder is getting full. When you go to the toilet to pass urine, the bladder muscle squeezes (contracts) and the urethra and pelvic floor muscles relax to allow urine to flow out.

Complex nerve messages are sent between the brain, the bladder and the pelvic floor muscles. These tell you how full your bladder is and tell the correct muscles to contract or relax at the right time.

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Urodynamic Tests
Incontinence / Bladder Chart
Pelvic Floor Exercises

What is stress incontinence?

Stress incontinence occurs when urine leaks because there is a sudden extra pressure within the tummy (abdomen) and on the bladder. This pressure (or stress) is caused by things like coughing, laughing, sneezing or exercising (such as running or jumping). Weakened pelvic floor muscles cannot support the bladder and urine outlet (urethra) as well as they should. The pressure is too much for the bladder outlet to withstand and so urine leaks out. Small amounts of urine may leak but sometimes it can be quite a lot and can cause embarrassment. The diagram below shows how the pelvic floor muscles support the bladder and nearby structures.

How common is stress incontinence?

Stress incontinence is the most common form of urinary incontinence. It is estimated that about three million women in the UK are regularly incontinent. Overall this is about 4 in 100 adults, and well over half of these are due to stress incontinence. Stress incontinence becomes more common in older women. As many as 1 in 5 women over the age of 40 have some degree of stress incontinence.

It is likely that the true number of people affected is much higher. Many people do not tell their doctor about their incontinence, due to embarrassment. Some people wrongly think that incontinence is a normal part of ageing or that it cannot be treated. This is unfortunate, as many cases can be successfully treated or significantly improved.

Other types of incontinence

The second most common type of incontinence is urge incontinence. Briefly, urge incontinence occurs when you get an urgent desire to pass urine from an overactive bladder. Urine may leak before you have time to get to the toilet. Treatment is different to treatment for stress incontinence. See separate leaflet called Urge Incontinence for more details. Some people have both stress incontinence and urge incontinence. This is known as mixed incontinence.

There are also other, less common types of incontinence.

Note: you should always see your doctor if you develop incontinence. Each type has different treatments. Your doctor will assess you to determine the type of incontinence and advise on possible treatment options. See separate leaflet called Urinary Incontinence for a general overview and to understand what is likely to happen during the assessment by your doctor.

What causes stress incontinence?

Bladder
Most cases of stress incontinence are due to weakened pelvic floor muscles. Pelvic floor muscles are often weakened by childbirth. The pelvic floor muscles are a group of muscles that wrap around the underside of the bladder and back passage (rectum). Stress incontinence is common in women who have had children, particularly if they have had several vaginal deliveries. It is also more common with increasing age, as the muscles become weaker, particularly after the menopause. Stress incontinence is also more common in women who are obese. Stress incontinence can occur in men who have had some treatments for prostate cancer. This includes surgical removal of the prostate (prostatectomy), and radiotherapy.

What are the treatment options for stress incontinence?

First-line treatment involves strengthening the pelvic floor muscles with pelvic floor exercises. About 6 in 10 cases of stress incontinence can be cured or much improved with this treatment. If you are overweight and incontinent then you should first try to lose weight in conjunction with any other treatments. Surgery may be offered if the problem continues and is a significant problem. Medication may be used in addition to exercises if you do not want, or are not suitable for, surgery.

Strengthening the pelvic floor muscles – pelvic floor exercises

It is important that you exercise the correct muscles. Your doctor may refer you to a continence advisor or physiotherapist for advice on how to do pelvic floor exercises correctly. Below are instructions you can follow yourself at home.

Learning to exercise the correct muscles:
•Sit in a chair with your knees slightly apart. Imagine you are trying to stop wind escaping from your back passage (anus). You will have to squeeze the muscle just above the entrance to the anus. You should feel some movement in the muscle. Don’t move your buttocks or legs.
•Now imagine you are passing urine and are trying to stop the stream. You will find yourself using slightly different parts of the pelvic floor muscles to the first exercise (ones nearer the front). These are the ones to strengthen. If you are not sure that you are exercising the correct muscles, put a couple of fingers into your vagina. You should feel a gentle squeeze when doing the exercises.

Doing the exercises:
•You need to do the exercises every day.
•Sit, stand or lie with your knees slightly apart. Slowly tighten your pelvic floor muscles under the bladder as hard as you can. Hold to the count of five, then relax. Repeat at least five times. These are called slow pull-ups.
•Then do the same exercise quickly for a second or two. Repeat at least five times. These are called fast pull-ups.
•Keep repeating the five slow pull-ups and the five fast pull-ups for five minutes.
•Aim to do the above exercises for about five minutes at least three times a day and preferably 6-10 times a day.
•Ideally, do each five-minute bout of exercise in a different position each time. That is, sometimes when sitting, sometimes when standing and sometimes when lying down.
•As the muscles become stronger, increase the length of time you hold each slow pull-up. You are doing well if you can hold each slow pull-up for a count of 10 (about 10 seconds).
•Do not squeeze other muscles at the same time as you squeeze your pelvic floor muscles. For example, do not use any muscles in your back, thighs, buttocks, or stomach.
•In addition to the specific times you set aside to do pelvic floor exercises, try to get into the habit of doing them whilst going about everyday life. Pelvic floor exercises could be done when answering the phone, washing up, travelling, etc.
•After several weeks the muscles will start to feel stronger. You may find you can squeeze the pelvic floor muscles for much longer without the muscles feeling tired.

It takes time, effort and practice to become good at these exercises. It is advised that you do these exercises for at least three months to start with. You should start to see the benefit after a few weeks. However, it often takes 8-20 weeks for most improvement to occur. After this time you may be cured from stress incontinence. If you are not sure that you are doing the correct exercises, ask a doctor, physiotherapist or continence advisor for advice.

If possible, continue pelvic floor exercises as a part of everyday life forever, to stop the problem recurring. Once incontinence has gone, you may only need to do 1-2 five-minute repetitions each day to keep the pelvic floor muscles strong and toned up and the incontinence away.

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B&BF – Bladder and Bowel Foundation

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Other ways of exercising pelvic floor muscles

Sometimes a continence advisor or physiotherapist will advise extra methods if you are having problems performing the pelvic floor exercises. These are in addition to those described above. Examples include:
•Electrical stimulation. Sometimes a special electrical device is used to stimulate the pelvic floor muscles, with the aim of making them contract and become stronger.
•Biofeedback. This is a technique to help you to make sure that you are exercising the correct muscles. For this, a physiotherapist or continence advisor inserts a small device into your vagina when you are doing pelvic floor exercises. When you squeeze the right muscles, the device makes a noise (or some other signal such as a display on a computer screen). This lets you know that you are squeezing the correct muscles.
•Vaginal cones. These are small plastic cones that you put inside your vagina for about 15 minutes, twice a day. The cones come in a set of different weights. At first, the lightest cone is used. You need to use your pelvic floor muscles to hold the cone in place. So, it is a way to help you to exercise your pelvic floor muscles. Once you can hold on to the lightest one comfortably, you move up to the next weight and so on.
•Other devices. There are various other devices that are sold to help with pelvic floor exercises. Basically, they all rely on placing the device inside the vagina, with the aim of helping the pelvic muscles to exercise and squeeze. There is little research evidence to show how well these devices work. It is best to get the advice from a continence advisor or physiotherapist before using any. One general point is that if you use one, it should be in addition to, not instead of, the standard pelvic floor exercises described above.

Surgery

Various surgical operations are used to treat stress incontinence. They tend only to be used when the pelvic floor muscle exercises have not helped. The operations aim to tighten or support the muscles and structures below the bladder.

The tension-free vaginal tape (TVT) procedure is the name of an operation often used to treat stress incontinence. It involves a sling of synthetic (man-made) tape being used to support the urethra and bladder neck. Sometimes a sling is made using tissue from another part of the patient’s own body, such as the tummy (abdominal) muscles.

Colposuspension is the name of another operation to support the urethra and treat stress incontinence.

If you have a vaginal prolapse there is a weakness of the support structures of the pelvis and one or more of the organs of the body drops down into the vagina. Commonly, the prolapse involves the bladder. This is known as a cystocoele. Surgical repair of this weakness (called an anterior repair) is often performed to treat the associated urinary incontinence. See separate leaflet called Genitourinary Prolapse for more information.

Other procedures involve injections of bulking agents around the bladder entrance, to keep it closed. These injections may be either natural materials (such as fat) or synthetic ones (such as silicone).

In general, surgery for stress incontinence is often successful.

Medication

Duloxetine (Yentreve®) is a medicine that is usually used to treat depression. However, it was found to help with stress incontinence separate to its effect on depression. It is thought to work by interfering with certain chemicals that are used in transmitting nerve impulses to muscles. This helps the muscles around the urine outlet (urethra) to contract more strongly.

One study showed that in about 6 in 10 women who took duloxetine, the number of urine leakages were halved compared to the time before they took the medication. Therefore, on its own, duloxetine is not likely to cure the incontinence but may help to make it less of a problem. However, duloxetine in addition to pelvic floor exercises may give a better chance of curing the incontinence than either treatment alone.

Duloxetine may be advised if pelvic floor exercises alone are not helping to treat your stress incontinence. It is usually advised in women who do not want to undergo surgery, or in women who have health problems that may mean that surgery is unsuitable.

Some general lifestyle measures which may help
•Your GP may refer you to the local continence adviser. Continence advisors can give advice on treatments, especially pelvic floor exercises. If incontinence remains a problem, they can also give lots of advice on how to cope. Examples include the supply of various appliances and aids such as incontinence pads, etc.
•Getting to the toilet. Make this as easy as possible. If you have difficulty getting about, consider special adaptations like a handrail or a raised seat in your toilet. Sometimes a commode in the bedroom makes life much easier.
•Obesity. Stress incontinence is more common in women who are obese. Weight loss is advised in those who are overweight or obese. It has been shown that losing a modest amount of weight can improve urinary incontinence in overweight and obese women. Even just 5-10% weight loss can help symptoms.
•Smoking can cause cough which can aggravate symptoms of incontinence. It would help not to smoke.

Can stress incontinence be prevented?

If you do regular pelvic floor exercises (as described above) during pregnancy and after you have a baby then stress incontinence is less likely to develop following childbirth and in later life. Maintaining an average weight for your height will also help.

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Attention deficit hyperactivity disorder (ADHD) is a common condition that mainly affects behaviour. It is usually diagnosed in children but can affect adults. Symptoms include persistent restlessness, impulsiveness and/or inattention. The diagnosis is made after a detailed assessment. Treatment includes parent training programmes and sometimes medication. Diet may be a factor and may be worth considering.

What is attention deficit hyperactivity disorder?

Attention deficit hyperactivity disorder (ADHD) is also known as attention deficit disorder (ADD) and hyperkinetic disorder. It is a fairly common condition that mainly affects a child’s behaviour. There may also be problems with the child’s intellectual, social and psychological development as a result of the behaviour.

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What are the symptoms of attention deficit hyperactivity disorder?

Children with ADHD show persistent restlessness, impulsiveness and/or inattention. These features are seen in more than one setting. For example, at school and at home. They are also seen in more than one activity. For example, in schoolwork and in relationships. They occur at a level greater than expected for their age and cause significant disruption to the child’s daily life.

There are three subtypes of ADHD:
•Hyperactive-impulsive subtype. Some features of this type of ADHD are that a child may fidget a lot, run around in inappropriate situations, have difficulty playing quietly and may talk excessively. They may interrupt others and have trouble waiting their turn in games, in conversations and also in queues.
•Inattention subtype. In this subtype, a child may have trouble concentrating and paying attention, may make careless mistakes, may not listen or follow through on instructions and may be easily distracted. They may also be forgetful in daily activities, lose essential items such as school books or toys, and have trouble organising activities.
•Combined subtype. If a child has this subtype, they have features of both of the other subtypes.

Children with ADHD are also more likely than average to have other problems such as anxiety and depression, conduct disorders and co-ordination difficulties. Some children with ADHD also have reading difficulties and dyslexia.

Note: many children, especially those under the age of five, are inattentive and restless. This does not necessarily mean that they have ADHD.

What causes attention deficit hyperactivity disorder?

The cause of ADHD is not known. It is thought that there may be subtle changes in parts of the brain which control impulses and concentration. Although the main cause of ADHD is not known, various factors are thought to increase the risk of a child developing ADHD. These include:
•Genetics. Genes are passed on to a child from each parent. Our genes determine how our body functions, what we look like and sometimes what diseases we will get. Some studies have shown that certain genes are related to ADHD. A child may therefore be more likely to have ADHD if there is another family member such as mother, father, brother or sister with ADHD.
•Antenatal problems. If a mother drinks alcohol, smokes or takes heroin while she is pregnant, this may increase the risk of her child developing ADHD.
•Obstetric problems. This means problems that occur when a baby is born, such as a difficult labour causing lack of oxygen to the brain. Babies with very low birthweight have an increased risk of developing ADHD.
•Severe deprivation. If a child is severely neglected early in life, this may increase their risk of developing ADHD.

Factors in a child’s upbringing such as poor parenting, watching a lot of TV or DVDs, family stress, etc, do not cause ADHD. However, such factors may make the behaviour of a child with ADHD worse. Diet may be a factor (discussed further later).

How common is attention deficit hyperactivity disorder?

ADHD affects around 5 in 100 school-aged children in the UK. It is around three times more common in boys than in girls. Although ADHD is usually diagnosed in children aged 3-7 years, it may not be recognised until much later in life. Sometimes it is not diagnosed until adulthood.

How is attention deficit hyperactivity disorder diagnosed?

There is no simple test to diagnose ADHD. If your child’s teacher or doctor suspect that your child may have ADHD, it is likely that your child will be referred to a specialist who will be able to confirm the diagnosis by doing an assessment, and start any treatment. This specialist may be a specialist paediatrician (children’s doctor), a child psychiatrist, a member of your local Child and Adolescent Mental Health Service, or an adult psychiatrist. The type of specialist depends on the age of your child and also the availability of services in your local area.

The assessment may involve a discussion with you and your child as well as a physical examination. The specialist may ask for a report from the school and may even want to observe your child doing certain tasks. You and your child may also see a nurse or other healthcare professionals for further testing and assessment.

There are a few aims of this assessment. These include:
•To confirm whether your child definitely has ADHD.
•To make sure that there are no other reasons that explain your child’s behaviour. For example, a hearing difficulty, epilepsy or thyroid problem.
•To identify any other problems your child may have. For example, anxiety, low self-esteem or a learning difficulty.

For a doctor to make a firm diagnosis of ADHD, there are strict criteria that need to be fulfilled. For example, the symptoms of inattention and/or hyperactivity and impulsivity need to be present for at least six months. They also need to be causing problems in your child’s life as well as being different from what would be expected for their age. They also must have started to occur before the age of seven, and be present in more than one setting. For example, at home and at school. In addition, other causes for your child’s symptoms may need to be ruled out. For example, depression or anxiety.

What are the treatment options?

The treatments recommended depend on how severe the condition is as well as the age of your child. Ideally, treatment should involve a team of professionals, experienced and trained in ADHD. The team may include a doctor, teacher, nurse, social worker, occupational therapist, mental healthcare professional or psychologist. Treatments include drug and nondrug treatments.

Nondrug treatments for attention deficit hyperactivity disorder

Generally, for preschool children or for older children with mild-to-moderate ADHD, the first step is usually for you (parent or guardian) to be referred to a parent training programme. Sometimes your child will also be referred for a group treatment programme aimed at improving behaviour. The parent programme may include such things as:
•Learning skills to manage and reduce problem behaviour.
•Learning more effective ways to communicate with your child.
•Helping you to understand your child’s emotions and behaviours.

Your child’s schoolteacher may be invited to be involved in the treatment process. They may be able to use certain techniques in the classroom to help your child learn and function better. Family therapy may also be helpful.

In more severe ADHD, or where the above treatments have not succeeded, medication is usually recommended.

Drug treatments for attention deficit hyperactivity disorder

There are three main drugs licensed for the treatment of ADHD in the UK. Methylphenidate (trade name of Ritalin®) is the most commonly used drug. Atomoxetine and dexamfetamine are other drugs that may also be used. Drug treatments are not usually given to children aged under six years. Drug treatment is done under the supervision of a specialist in childhood behavioural disorders.

How effective is drug treatment?

The drugs used for ADHD have been used for many years and in many children with good effect. A number of studies have shown that drug treatment with or without intensive behavioural training programmes is more effective than behavioural training programmes alone.

How does the methylphenidate work?

Methylphenidate is a type of stimulant drug. It works by increasing the amount of a brain chemical called dopamine in certain parts of the brain. The parts that it works on are responsible for self-control and attention. Increasing the amount of dopamine in these areas of the brain stimulates them to work better. This then helps to focus your child’s attention and improve concentration.

How do I give methylphenidate to my child?

Usually, your child will start on a low dose such as 5 mg three times a day and will be carefully monitored for side-effects. This dose is often increased gradually, usually over 4-6 weeks, to a maximum of 20 mg three times daily according to how well it is working and whether side-effects occur. The most common side-effects to look out for with methylphenidate are insomnia (difficulty with sleep), loss of appetite and weight loss.

Once the total daily dose has been determined, it may be possible for your child to switch to a once-daily long-acting version of methylphenidate.

When your child is on medication, they should be reviewed regularly to check that the dose is working and that there are minimal side-effects. Your child will also have their height, weight, pulse and blood pressure measured at regular intervals.

It is good for this review to include feedback from those who are in regular contact with your child, such as teachers, family members and other carers.

How quickly does methylphenidate work?

The short-acting methylphenidate begins working within about 20 minutes and lasts for 3-4 hours. The longer-acting version takes longer to start working but lasts for about 12 hours and gives a more stable level of drug in the bloodstream throughout the day. It may take several weeks to see the full benefit of medication.

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HACSG – The Hyperactive Children’s Support Group
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How long will my child be on medication?

It is common to continue medication for several years. Once children become teenagers, it is recommended to trial off the medication each year. This is to make sure that medication is still necessary.

Sometimes methylphenidate causes unacceptable side-effects or is not effective. In this situation one of the two other drugs mentioned above may be used. Dexamfetamine is another type of stimulant. Atomoxetine is a different type of drug that works on a chemical called noradrenaline in the brain.

There are other drugs that may be used for ADHD but these are usually only recommended if the above drugs are not effective.

Are the drugs safe?

The use of drugs to treat ADHD is controversial. This is mostly because some people are worried about their effectiveness as well as the possibility of side-effects. Also, there is the possibility of the drugs being misused or abused. However, guidelines from the National Institute for Health and Clinical Excellence (NICE) advise that they are still useful and important in the treatment of severe ADHD and in milder forms when other treatments have not been effective. The benefits of drugs usually outweigh any risks in children with ADHD, aged over six years and in adolescents.

The drugs do not seem to have an addictive potential when used in children. There are reports of the drugs being abused in teenagers and adults. However, it is likely that the risk of substance abuse with street drugs such as cocaine in someone with untreated ADHD is greater than the risk of abuse of the prescribed drugs.

This controversy is largely unfounded because both scientific studies and years of experience have shown that these drugs are generally safe and effective.

What about diet?

Dietary changes for the treatment of ADHD have been widely used for many years. They take the form of:
•Supplements with substances thought to be lacking. For example, supplements of fatty acids such as omega 3 and omega 6, and/or:
•Cutting out foods thought to be harmful. For example, cutting out foods containing artificial colouring and other additives.

An authoritative guideline on ADHD was published by NICE in 2008. The guideline came to the conclusion that there is no good evidence that dietary changes can help children with ADHD. However, NICE advised that “assessment of ADHD should include asking about foods or drinks that appear to influence their hyperactive behaviour. If there is a clear link, healthcare professionals should advise parents or carers to keep a diary of food and drinks taken and ADHD behaviour. If the diary supports a relationship between specific foods and drinks and behaviour, then referral to a dietitian should be offered.”

Since the NICE guideline was issued, some interesting new research has been published . A study (cited at the end) followed 100 children with ADHD over several weeks. The researchers compared a group of children with ADHD who were given a strict restricted diet with those who were not. Of those in the restricted diet group over half showed a marked improvement in their symptoms. Not many foods were included in the restricted diet. The foods allowed consisted of those thought least likely to cause symptoms and allergies, such as rice, turkey, lamb, a few vegetables, pears and water. However, it is thought that if symptoms improved with a strict diet, new foods can then be gradually introduced over time to see which food or foods may trigger worsening symptoms.

This new study is encouraging. However, further research is needed to confirm the findings and to establish the place of dietary changes in the treatment of ADHD.

So, in short, diet probably does not cause ADHD, but a change in diet may help in some cases, but not in all cases. It may be that some children are negatively affected by certain foods or additives. If you notice that a particular ingredient or food makes your child’s symptoms worse, then take a note of it and discuss this further with your doctor or a dietician. And also, it has to be stressed – do not try a strict restrictive diet for your child by yourself. If you think that diet may be a factor, it is strongly advised that you ask your GP to refer you to a qualified dietician. A dietician can advise, and make sure that any limited diet contains the full range of nutrients that a growing child requires.

It is, however, recommended that all people with ADHD have at least a normal healthy balanced diet, and also do some regular exercise.

Is there anything else available for older children or adults?

In older children, there may be some benefit gained from psychological treatment such as cognitive behavioural therapy (CBT) or social skills’ training. These techniques aim to teach your child more about why they act and react the way that they do. They also give them strategies to use to help them to improve their behaviour and daily functioning.

In adults, medication is recommended as part of a comprehensive treatment programme. This should also include psychological treatment, advice on behavioural management and assistance with education and employment.

What is the prognosis (outlook)?

Up to 8 in 10 children with ADHD will continue to experience symptoms into their teenage years. This decreases to about 5 in 10 who continue to have some symptoms into adulthood. With age, the symptoms may alter. For example, a child who was always restless may feel a lot of inner tension as an adult. It is also likely that the symptoms will reduce in severity and cause less disruption over time. As mentioned, treatment can often improve symptoms.

Children with ADHD are more likely than average to have other problems as adults, such as unemployment, relationship difficulties, substance misuse and crime. However, treatment aimed at improving behaviour at an early age aims to reduce the long-term impact of the condition.

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Panic disorder is a condition where you have recurring panic attacks. Many people with panic disorder also develop agoraphobia. This means you avoid many places, and may not even go out from your home, due to fear of having a panic attack in a public place. Treatment with cognitive behavioural therapy and/or antidepressant medicines works well in over half of cases.

This leaflet is part of our series on anxiety and phobias

Agoraphobia
Generalised Anxiety Disorder
Obsessive-compulsive Disorder
Panic Disorder
Social Anxiety Disorder

What is a panic attack?

A panic attack is a severe attack of anxiety and fear which occurs suddenly, often without warning, and for no apparent reason. In addition to the anxiety, various other symptoms may also occur during a panic attack. These include one or more of the following:
•A thumping heart (palpitations).
•Sweating and trembling.
•Dry mouth.
•Hot flushes or chills.
•Feeling short of breath, sometimes with choking sensations.
•Chest pains.
•Feeling sick (nauseated), dizzy, or faint.
•Fear of dying or going crazy.
•Numbness, or pins and needles.
•Feelings of unreality, or being detached from yourself.

The physical symptoms that occur with panic attacks do not mean there is a physical problem with the heart, chest, etc. The symptoms mainly occur because of an overdrive of nervous impulses from the brain to various parts of the body during a panic attack. This overdrive of nervous impulses can lead to the body producing hormones which include adrenaline (epinephrine). This is sometimes referred to as a ‘fight or flight’ response. This kind of reaction is normal in people when we feel we are in danger. During a panic attack the body can react in the same way.

During a panic attack you tend to over-breathe (hyperventilate). If you over-breathe you blow out too much carbon dioxide which changes the acidity in the blood. This can then cause more symptoms such as confusion and cramps, and make palpitations, dizziness, and pins and needles worse. This can make the attack seem even more frightening, and make you over-breathe even more, and so on. It can sometimes result in a faint. A panic attack usually lasts 5-10 minutes, but sometimes they come in waves for up to two hours.

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What is panic disorder?

At least 1 in 10 people have occasional panic attacks. If you have panic disorder it means that you have repeated (recurring) panic attacks. The frequency of attacks can vary. About 1 in 50 people have panic disorder.

In panic disorder, there may be an initial event which causes panic but then the attacks after that are not always predictable. If you have panic disorder, you also have ongoing worry about having further attacks and/or worry about the symptoms that you get during attacks. For example, you may worry that the thumping heart (palpitations) or chest pains that you get with panic attacks are due to a serious heart problem. Some people worry that they may die during a panic attack.

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What causes panic attacks?

Panic attacks usually occur for no apparent reason. The cause is not clear. Slight abnormalities in the balance of some brain chemicals (neurotransmitters) may play a role. This is probably why medicines used for treatment work well. Anyone can have a panic attack, but they also tend to run in some families. Stressful life events such as bereavement may sometimes trigger a panic attack.

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Panic disorder, agoraphobia and other fears

Some people with panic disorder worry about having a panic attack in a public place where it is difficult to get out of, or where help may not be available, or where it can be embarrassing. This may cause them to develop agoraphobia. About 1 in 3 people with panic disorder also develop agoraphobia. See separate leaflet called Agoraphobia.

If you have agoraphobia you have a number of fears of various places and situations. So, for example, you may be afraid to:
•Be in an open place.
•Enter shops, crowds, and public places.
•Travel in trains, buses, or planes.
•Be on a bridge or in a lift.
•Be in a cinema, restaurant, etc, where there is no easy exit.
•Be anywhere far from your home – many people with agoraphobia stay inside their home for most or all of the time.

You may also develop other irrational fears. For example, you may think that exercise or certain foods cause the panic attacks. Because of this you may fear (develop a phobia) for certain foods, or avoid exercise, etc.

Support groups e

No Panic
Anxiety Alliance

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Dealing with a panic attack

To ease a panic attack, or to prevent one from getting worse, breathe as slowly and as deeply as you can. Really focus on your breathing. Learning and using relaxation techniques may help. Many people find that deep breathing exercises are useful. This means taking a long, slow breath in, and very slowly breathing out. If you do this a few times, and concentrate fully on breathing, you may find it quite relaxing.

Some people find that moving from chest breathing to tummy (abdominal) breathing can be helpful. Sitting quietly, try putting one hand on your chest and the other on your abdomen. You should aim to breathe quietly by moving your abdomen with your chest moving very little. This encourages the lower chest muscle (diaphragm) to work efficiently and may help you avoid over-breathing.

What is the treatment for panic attacks and panic disorder?

No treatment is needed if you have just an occasional panic attack. It may help if you understand about panic attacks. This may reassure you that any physical symptoms you get during a panic attack are not due to a physical disease. It may help to know how to deal with a panic attack.

Treatment can help if you have repeated (recurring) attacks (panic disorder). The main aim of treatment is to reduce the number and severity of panic attacks.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is a type of specialist talking treatment. It is probably the most effective treatment. Studies show that it works well for over half of people with panic disorder (and agoraphobia).
•Cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as panic attacks and agoraphobia. The therapist helps you to understand your current thought patterns. In particular, to identify any harmful, unhelpful, and false ideas or thoughts which you have. For example, the ideas that you may have at the beginning of a panic attack, wrong beliefs about the physical symptoms, how you react to the symptoms, etc. The aim is then to change your ways of thinking to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful. Therapy is usually done in weekly sessions of about 50 minutes each, for several weeks.
•Behavioural therapy aims to change behaviours which are harmful or not helpful. This may be particularly useful if you have agoraphobia with panic disorder where you avoid various situations or places. The therapist also teaches you how to control anxiety when you face up to the feared situations and places. For example, by using breathing techniques.
•Cognitive behavioural therapy (CBT) is a mixture of the two where you may benefit from changing both thoughts and behaviours.

If you have CBT and it works, the long-term outlook may be better than with treatment with antidepressants. However, CBT may not be available in every area, and does not suit everyone.

Antidepressant medicines

These usually work well to prevent panic attacks in more than half of cases. (These medicines are often used to treat depression, but have been found to work well for panic disorder too, even if you are not depressed.) They work by interfering with brain chemicals (neurotransmitters) – such as serotonin – which may be involved in causing symptoms of panic.
•Antidepressants do not work straightaway. It takes 2-4 weeks before their effect builds up and may take up to eight weeks to work fully. A common problem is that some people stop the medicine after a week or so as they feel that it is doing no good. You need to give them time to work.
•Antidepressants are not tranquillisers, and are not usually addictive.
•There are several types of antidepressants, each with various pros and cons. For example, they differ in their possible side-effects. However, selective serotonin reuptake inhibitor (SSRI) antidepressants are the ones most commonly used to treat panic disorder.
•If SSRIs do not work, imipramine or clomipramine is sometimes used.

Note: after first starting an antidepressant, in some people some anxiety symptoms become worse for a few days before they start to improve.

If it works, it is usual to take an antidepressant for panic disorder for at least a year. At the end of a course of treatment, you should not stop an antidepressant suddenly, but you should reduce the dose gradually under the supervision of a doctor. In about half of people who are successfully treated, there is a return of panic attacks when treatment is stopped. An option then is to take an antidepressant long-term. The attacks are less likely to return once you stop antidepressants if you have had a cognitive behavioural course (see below).

A combination of CBT and antidepressants may work better than either treatment alone

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The female reproductive system consists of the ovaries, Fallopian tubes, uterus, vagina and the vulva. At birth all the woman’s immature follicles lie dormant in the ovaries. No more are produced. This is an important consideration – eg, in childhood leukaemias and chemotherapy, as they may need to be preserved to safeguard future fertility potential of the child.

Puberty/menarche
•Puberty is a process of maturation of the sexual and secondary sexual characteristics, with menarche (onset of menstrual bleeding) as a step within that process.
•The ovarian follicles lie dormant from birth until puberty arrives and the rising hormones lead to the maturation of several ovarian follicles per month; usually only one matures and is released.
•Normal menstruation is the monthly cycle of blood loss per vagina, resulting from the breakdown of the uterine lining when implantation of a fertilised ovum does not occur. Menstruation is not a sign of ovulation, but of the fact that the hormonal controls and the reproductive tract’s responses to it work.
•Normal menstrual loss is about 25 ml per day for 4-5 days per month. The amount of blood loss varies between individuals but tends to get heavier with age.
•Menarche is the start of the first menstrual period. Menarche has occurred at a younger age during the last century. This may be due to improved nutrition (and subsequent weight) in the population.
•The average age of menarche is 13 years, but it can be as early as 8 years and as late as 18 years and still be normal. Premature or delayed menarche should be investigated – ie before 8 years or after 16 years.[1]
•Normal menstruation then occurs in a monthly cycle until menopause, unless interrupted by pregnancy. A cycle may last between 21-35 days.

Hormonal control

MENSTRUAL CYCLE DIAGRAM
The menstrual cycle is under the control of three sets of hormones:
•Gonadotrophin-releasing hormones – leutinising hormone-releasing hormone (LHRH) and follicle-stimulating hormone-releasing hormone (FSHRH).
•Gonadotrophins – luteinising hormone (LH) and follicle-stimulating hormone (FSH).
•Ovarian hormones – oestrogen and progesterone.

The gonadotrophin hormone-releasing factors from the hypothalamus control the release of the pituitary hormones; the gonadotrophins – FSH and LH. They are produced by the anterior pituitary and control the ovarian hormones oestrogen and progesterone.
•During the follicular phase a rise in FSH from the pituitary stimulates the development of several follicles on the surface of the ovary. Each follicle contains an egg. Later, as the FSH level decreases, only one follicle continues to develop. This follicle also produces oestrogen.
•The LH peaks mid-cycle, triggering the release of the ovum – ovulation, which usually occurs 16-32 hours after the surge begins. The LH level falls a couple of days later.
•The oestrogen level from the ovaries increases gradually towards ovulation and peaks during the LH surge.
•The progesterone level starts to rise towards follicle release, preparing the endometrial lining of the uterus for implantation.
•Post-ovulation – the luteal phase – levels of LH and FSH decrease. The ruptured follicle closes (after releasing the egg) and forms a corpus luteum, which produces progesterone. If the ovum is fertilised, the progesterone levels are maintained by the corpus luteum and the endometrium is maintained.
•If the ovum is not fertilised the corpus luteum starts to degenerate and progesterone and oestrogen levels start to fall. The endometrial blood vessels constrict and the endometrial lining breaks down and is shed.
•The hormonal swings may be associated with changes in mood and libido, and with headaches in some women. However, some studies have not demonstrated good evidence for premenstrual mood symptoms.[2]
•The first day of the cycle is counted as the first day of the bleed – Day 1. The cycle runs from the first day of menstruation to the next first day.
•The typical changes of the menstrual cycle may allow natural family planning, if a woman wishes. Several methods are available, including calendar, temperature and cervical mucus observation, or palpating the cervix.[3]

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Range of problems

Abnormalities in menstruation may include:
•Quantity: usually perceived as too great a loss – menorrhagia. This is usually defined as a loss above 80 mls per menses and may cause iron-deficiency anaemia.
•Timing: may be too frequent (polymenorrhoea – more than one period per calendar month) or infrequent (oligomenorrhoea or amenorrhoea).
•Duration of bleeding: normal range is 3-7 days.
•Time of onset: precocious puberty (before 8 years) or delayed puberty (after 16 years).

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Intermenstrual and Postcoital Bleeding
Menorrhagia
Genitourinary History and Examination (Female)
Premenstrual Syndrome

Aetiology of abnormal bleeding

Non-reproductive causes
•Systemic disease disorders of blood coagulation – eg, von Willebrand’s disease or prothrombin deficiency, leukaemia, idiopathic thrombocytopenic purpura and hypersplenism.
•Hypothyroidism – can sometimes be associated with menorrhagia or intermenstrual bleeding (IMB).
•Cirrhosis – associated with reduced ability of the liver to metabolise oestrogens, and hypoprothrombinaemia.

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Diseases of the reproductive tract
•The most common causes during fertile age are those related to pregnancy – eg, threatened, incomplete or missed abortion, ectopic pregnancy. Trophoblastic disease should be considered in women with recent pregnancy.
•Malignancies – endometrial and cervical carcinoma are the most common; also ovarian carcinoma.
•Endometritis – usually presents as intermenstrual spotting.
•Fibroids, endometrial polyps and adenomyosis.
•Cervical lesions – erosions, polyps and cervicitis – can present as postcoital spotting.
•Iatrogenic – hormones used for contraception or hormone replacement therapy (HRT) or management of other conditions. Some psychotropic drugs (eg, risperidone).

Dysfunctional uterine bleeding (DUB) is defined as abnormal uterine bleeding in the absence of organic disease.
•It usually presents as heavy menstrual bleeding (menorrhagia). The diagnosis of DUB can only be made once all other causes of abnormal or heavy uterine bleeding have been excluded. The pathophysiology is largely unknown.
•The National Institute for Health and Care Excellence (NICE) defines heavy menstrual bleeding as ‘excessive menstrual blood loss which interferes with the woman’s physical, emotional, social and material quality of life, and which can occur alone or in a combination with other symptoms’.[4]

Investigations and management

These will depend on the possible cause. Further detailed information will be found by following the links to the separate dedicated article.

Support groups e

Women’s Health Concern
National Association for Premenstrual Syndrome

Find support near you ▶

Other factors that may affect the menstrual cycle

NB: fertility can return before the first period after childbirth.
•Breast-feeding can delay the return of normal menstruation postpartum, particularly if exclusive and may form the basis for the lactation amenorrhoea method (LAM) of contraception for the first six months of the baby’s life.
•Rapid weight change – increase or decrease.
•Body weight below a certain level – eg, in eating disorders – particularly anorexia nervosa.
•Emotional stress – eg, fear of pregnancy/phantom pregnancy.
•Significant Illness.
•Drugs – eg, hormones, cytotoxics.
•Combined oral contraceptive pill (COCP) – this causes an artificial withdrawal bleed – ie early menopause or pregnancy can be masked.
•Normal menstruation can be affected by any failure of the clotting system in the body.

Coping with normal menstruation

How a woman chooses to deal with the physical blood loss is a matter of personal preference. Modern developments of extra-absorbent disposable towels and discreet tampons have made managing menses easier.
•Period pains (dysmenorrhoea) respond well to anti-inflammatories – eg, mefenamic acid.
•Some women may need a combination of towels and tampons for overnight use, to prevent soiling bed linen.
•Sometimes women may wish to postpone their cycle because of holidays, etc. This can be achieved by:
•Norethisterone 5 mg tds.
•Tricycling the COCP; running packs together and omitting the pill-free week. This can happen for a maximum of three months.

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