Monday, November 05, 2007

Impact of Obesity and Dieting

From: HealthyPlace.com

Introduction

In discussions about the theories, common problems, and treatment of repeat dieters or those dealing with issues of weight preoccupation, obesity and dieting are often interrelated. There are physical, psychological and social aspects to the problems of obesity. This is why the social work profession is ideally suited to understanding the problems and provide effective intervention.

Some controversy surrounds whether obesity is considered an "eating disorder." Stunkard (1994) has defined Night Eating Syndrome and Binge Eating Disorder as eating disorders that contribute to obesity. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV ™) (American Psychiatric Association, 1994) characterizes eating disorders as severe disturbances in eating behavior. It does not include simple obesity as an eating disorder because it is not consistently associated with a psychological or behavioral syndrome. Labeling obesity as an eating disorder that needs to be "cured" implies a focus on physical or psychological processes and does not include recognition of the social factors that may also have a contributive impact. Weight preoccupation and dieting behaviors will certainly have some aspects of an eating disorder and its psychological implications such as inappropriate eating behaviors or disturbances in body perception. In this paper, neither obesity or weight preoccupation are considered to be eating disorders. Labeling these as eating disorders does not provide any useful clinical or functional purpose and only serves to further stigmatize the obese and weight-preoccupied.

What is Obesity?

It is difficult to find an adequate or clear definition of obesity. Many sources discuss obesity in terms of percentage above normal weight using weight and height as parameters. Sources vary in their definitions as to what is considered "normal" or "ideal" versus "overweight" or "obese." Sources range in defining a person who is 10% above ideal as obese to 100% above ideal as obese (Bouchard, 1991; Vague, 1991). Even ideal weight is difficult to define. Certainly not all people of a certain height should be expected to weigh the same. Determining obesity by poundage alone is not always indicative of a weight problem.

Bailey (1991) has suggested that the use of measuring tools such as fat calipers or water submersion techniques where the percentage of fat is determined and considered within acceptable or non-acceptable standards is a better indicator of obesity. Waist-hip ratio measurements are also considered to be a better determination of risk factors due to obesity. The waist-hip ratio takes into account the distribution of fat on the body. If fat distribution is mainly concentrated at the stomach or abdomen (visceral obesity), the health risks for heart disease, high blood pressure, and diabetes increase. If fat distribution is concentrated at the hips (femoral or saggital obesity), there is considered to be somewhat less of a physical health risk (Vague, 1991).

Currently, the most common measurement of obesity is through the use of the Body Mass Index (BMI) scale. The BMI is based on the ratio of weight over height squared (kg/MxM). The BMI gives a broader range of weight that may be appropriate for a specific height. A BMI of 20 to 25 is considered to be within ideal body weight range. A BMI between 25 to 27 is somewhat at a health risk and a BMI above 30 is considered at significant health risk due to obesity. Most medical sources define a BMI of 27 or higher to be "obese." Although the BMI scale does not take into account musculature or fat distribution, it is the most convenient and presently most widely understood measure of obesity risk (Vague, 1991). For the purposes of this study, a BMI of 27 and above is considered to be obese. The terms obese or overweight are used interchangeably throughout this thesis and refer to those with a BMI of 27 or higher.

Obesity and Dieting Demographics

Berg (1994) reported that the most recent National Health and Nutrition Examination Survey (NHANES III) revealed that the average body mass index of American adults has risen from 25.3 to 26.3. This would indicate an almost 8 pound increase in the average weight of adults over the past 10 years. These statistics indicate that 35 percent of all women and 31 percent of men have BMIs over 27. The gains extend across all ethnic, age, and gender groups. Canadian statistics indicate that obesity is prevalent in the Canadian adult population. The Canadian Heart Health Survey (Macdonald, Reeder, Chen, & Depres, 1994) showed that 38% of adult males and 80% of adult females had BMIs of 27 or higher. This statistic has remained relatively unchanged over the past 15 years. Therefore, it clearly indicates that in North America, approximately one-third of the adult population is considered to be obese.

The NHANES III study reviewed the possible causes of the pervasiveness of obesity and took into consideration such issues as an increasing American sedentary lifestyle and the prevalence of eating food outside the home. It is interesting to note that in an era in which dieting has become almost the norm and profits from the diet industry are high, overall weight is increasing! This could this lend some credibility to the notion that dieting behaviors lead to increased weight gain.

In the Canadian survey, approximately 40% of men and 60% of women who were obese stated that they were trying to lose weight. It was estimated that 50% of all women are dieting at any one time and Wooley and Wooley (1984) estimated that 72% of adolescents and young adults were dieting. In Canada, it was striking to note that one third of women who had a healthy BMI (20-24) were trying to lose weight. It was disturbing to note that 23% of women in the lowest weight category (BMI under 20) wanted to further reduce their weight.

Physical Risks of Obesity and Dieting

There is evidence that suggests obesity is linked to increased sickness and death rates. The physical risks to the obese have been described in terms of increased risks of hypertension, gall bladder disease, certain cancers, elevated levels of cholesterol, diabetes, heart disease and stroke, and some associative risks with conditions such as arthritis, gout, abnormal pulmonary function, and sleep apnea (Servier Canada, Inc.,1991; Berg, 1993). However, increasingly there have been conflicting opinions about the health risks of being overweight. Vague (1991) suggests that the health risks of being overweight may be more determined by genetic factors, fat location, and chronic dieting. Obesity may not be a major risk factor in heart disease or premature death in those who do not have pre-existing risks. In fact, there are some indications that moderate obesity (about 30 pounds overweight) may be healthier than thinness (Waaler, 1984).

It has been hypothesized that it is not the weight that causes the physical health symptoms found in the obese. Ciliska (1993a) and Bovey (1994) suggest the physical risks manifested in the obese are a result of the stress, isolation and prejudice that are experienced from living in a fat-phobic society. In support for this contention, Wing, Adams-Campbell, Ukoli, Janney, and Nwankwo (1994) studied and compared African cultures which exhibited increased acceptance of higher levels of fat distribution. She found that there were no significant increases in health risks where obesity was an accepted part of the cultural composition.

The health risks of obesity are usually well known to the general public. The public is often less well informed about the health risks of dieting and other weight loss strategies such as liposuction or gastroplasty. Dieters have been known to experience a wide variety of health complications including cardiac disorders, gallbladder damage, and death (Berg, 1993). Diet-induced obesity has been considered a direct result of weight cycling due to the body regaining more and more weight after each diet attempt such that there is a resultant net gain (Ciliska, 1990). Therefore, the physical risks of obesity may be attributed to the repetitive pattern of dieting that created the obesity through a gradual net gain of weight after each diet attempt. It is believed that the physical health risk in people who repeatedly go through weight losses followed by weight gains is likely greater than if they were to stay the same weight "above" ideal (Ciliska, 1993b)

Causes of Obesity

The underlying causes of obesity are largely unknown (National Institute of Health [NIH], 1992). The medical community and general public hold the strongly entrenched belief that most obesities are caused by an excessive amount of caloric intake with low energy expenditure. Most treatment models assume the obese eat considerably more than the non-obese and that daily food intake must be restricted in order to ensure weight loss. This belief is directly opposed by Stunkard, Cool, Lindquist, and Meyers (1980), and Garner and Wooley (1991) who contend that most obese people do NOT eat more than the general population. There is often no difference in the amount of food consumed, speed of eating, bite size or total calories consumed between obese people and the general population. There is a great deal of controversy to these beliefs. On the one hand, overweight people often state that they do not eat more than their thin friends. However, many overweight people will self report that they do eat considerably more than they need. For many of the obese, dieting behaviors may have created a dysfunctional relationship with food such that they may have learned to turn to food increasingly to meet many of their emotional needs. (Bloom & Kogel, 1994).

It is not entirely clear whether normal weight people who are not weight preoccupied are able to tolerate or adapt to varying amounts of food in a more efficient fashion or whether the obese who have attempted calorie restricted diets may indeed have a food intake that is too high for their daily needs (Garner & Wooley, 1991). Through repeated dieting, dieters may be unable to read their own satiety signals and therefore will eat more than others (Polivy & Herman, 1983). The very act of dieting results in binge eating behaviors. It is known that the onset of binge behaviors occurs only after the experience of dieting. It is believed that dieting creates binge eating behavior that is difficult to stop even when the person is no longer on a diet (NIH, 1992).

Therefore, the evidence would suggest that obesity is caused by a multitude of factors that are difficult to determine. There may be genetic, physiologic, biochemical, environmental, cultural, socioeconomic, and psychological conditions. It is important to recognize that being overweight is not simply a problem of will power as it is commonly assumed (NIH, 1992).

Physiological Aspects of Dieting and Obesity

Physiological explanations of obesity look to such areas as genetic predispositions to weight gain, set point theory, different ranges of metabolism and the issue of "diet induced obesity." Some physiological evidence may indicate that obesity is more a physical rather than psychological issue. Mouse studies undertaken by Zhang, Proenca, Maffei, Barone, Leopold, and Freidman (1994) and twin studies conducted by Bouchard (1994) indicate that there may indeed be a genetic predisposition for obesity and fat distribution.

Metabolic rates are determined by genetic inheritance and have often been discussed in relation to obesity. It has been hypothesized that overweight people may alter their metabolism and weight through caloric restriction. At the onset of a calorie reduced diet the body loses weight. However, slowly, the body recognizes it is in "famine" conditions. Metabolism slows down considerably so that the body is able to maintains itself on fewer calories. In evolution, this was a survival technique that ensured a population, particularly the females, could survive in times of famine. Today, the ability for one's metabolism to slow with dieting means that weight loss efforts through dieting will usually not be effective (Ciliska, 1990).

Set point theory also relates to issues of metabolism. If one's metabolic rate is reduced to ensure survival, fewer calories are needed. The "set point" is lowered. Therefore, one will gain more weight when the diet stops ensuring a subsequent weight gain on fewer calories. This phenomena is often found in women who have endured a very low calorie liquid protein diet (VLCD) that consists of 500 calories per day. Weight is lost initially, stabilizes and when calories are increased to just 800 per day, weight is GAINED. It is believed that the set point is lowered and a resultant net gain occurs (College of Physicians and Surgeons of Alberta, 1994).

There has been discussion that the process of prolonged and repeated dieting puts the body at physical risk. Yo-yo dieting or weight cycling is the repeated loss and regain of weight. Brownell, Greenwood, Stellar, and Shrager (1986) suggested that repeat dieting will result in increased food efficiency that makes weight loss harder and weight regain easier. The National Task Force on the Prevention and Treatment of Obesity (1994) concluded that the long term health effects of weight cycling were largely inconclusive. It recommended that the obese should continue to be encouraged to lose weight and that there were considerable health benefits in remaining at a stable weight. This is an ironic suggestion in that most dieters do not intentionally try to regain weight once it has been lost.

Garner and Wooley (1991) have discussed how the prevalence of high fat foods in western society has challenged the adaptive capacity of the gene pool such that there is an increasing amount of obesity found in western populations. The belief that it is only the obese who overeat is sustained by stereotypical assumptions that non-obese individuals eat less. Normal weight individuals who eat a great deal will usually attract little or no attention to themselves. As Louderback (1970) wrote, "A fat person munching on a single stalk of celery looks gluttonous, while a skinny person wolfing down a twelve-course meal simply looks hungry."

Psychological Aspects of Dieting and Obesity

While stating that the physical consequences of weight cycling were unclear but likely not as serious as some would assume, the National Task Force on the Prevention and Treatment of Obesity (1994) stated that the psychological impact of weight cycling was in need of further investigation. The study did not address the devastating emotional impact that repeat dieters universally experience when they repeatedly attempt diets that result in failure. The psychological damage that has been attributed to dieting include depression, diminishment of self esteem, and the onset of binge eating and eating disorders (Berg, 1993).

People may overeat compulsively due to psychological reasons that may include sexual abuse, alcoholism, a dysfunctional relationship with food, or genuine eating disorders such as bulimia (Bass & Davis, 1992). Such individuals are believed to use food to cope with other issues or feelings in their lives. Bertrando, Fiocco, Fascarini, Palvarinis, and Pereria (1990) discuss the "message" that the overweight person may be trying to send. The fat may be a symptom or signal representative of the need for protection or a hiding place. It has been suggested that overweight family members are often found having family therapy issues as well. Dysfunctional family relationships have been known to be manifested in such areas as parent-child struggles involving eating disorders. I believe that similar issues can also be recognized in families where there are family members who are perceived to be overweight regardless as to the accuracy of this perception.

Self Esteem and Body Image

Studies suggest that obese women will have significantly lower self esteem and negative body image than normal weight women (Campbell, 1977; Overdahl, 1987). When individuals fail to lose weight, issues of low self esteem, repeated failures, and the feeling that they "didn't try hard enough" come into play. Embarking on a diet that ultimately results in failure or even a higher rebound weight will have a significant negative impact on self esteem and body image. Contempt of oneself and disturbance of body image are often seen in those that struggle with weight control issues (Rosenberg, 1981). Wooley and Wooley (1984) have stated that concern over weight leads to "a virtual collapse" of self esteem.

Body image is the picture a person has of her body, what it looks like to her and what she thinks it looks like to others. This can be accurate or inaccurate and is often subject to change. The relationship between body image and self esteem is complicated. Often dual feelings that "I am fat" and "therefore I am worthless" go hand in hand (Sanford & Donovan, 1993). Both body image and self esteem are perceptions that are actually independent of physical realities. Improving body image involves changing the way one thinks about one's body rather than undergoing physical change (Freedman, 1990). To improve body image and therefore improve self esteem, it is important for women to learn to like themselves and to take care of themselves through healthy lifestyle choices that do not emphasize weight loss as the only measure of good health.

Relationship With Food

Repeat dieters often learn to use food to cope with their emotions. Women's experiences with emotional eating have often been neglected, trivialized and misunderstood (Zimberg, 1993). Polivy and Herman (1987) contend that dieting often results in distinctive personality traits such as "passivity, anxiety and emotionality." It is interesting to note that these are characteristics often used to describe women in stereotypical ways.

Food is often used to feed or nurture oneself for both physical and psychological hunger. Food is used to literally swallow emotions. I believe that when people become weight or diet preoccupied, it is often "safer" to focus on food and eating than on underlying emotional issues. It is important for people to look closely at their relationship with food. Through repeated experiences of dieting, people will develop a skewed relationship with food. Food should not be a moral judgment as to whether or not you have been "good" or "bad" depending on what has been consumed. Similarly, a person's self worth should not be measured on the bathroom scale.

There is often the belief that if one can make "peace" with food, then the logical result will be that weight will then be lost (Roth, 1992). While it is important to look at one's relationship with food and have it become a less powerful influence in life, this will not necessarily lead to weight loss. Studies that have utilized a non-dieting approach resulting in food disempowerment have shown that weight remained approximately stable (Ciliska, 1990). It may be considered a positive result for a person to be able to resolve a distorted relationship with food and then be able to maintain a stable weight without the gains and losses that repeat dieters often undergo.

I believe that when people become weight or diet preoccupied, it is often "safer" to focus on food and eating than on emotional issues. That is, for some people it may be easier to focus on their weight than to focus on the overwhelming feelings that they have learned to cope with through eating behaviors. People use food to nurture themselves or to literally "swallow" their emotions. Food is often used to cope with emotions such as grief, sadness, boredom, and even happiness. If food loses its power to aid in distracting or avoiding difficult situations, it may be quite overwhelming to confront the issues that were previously avoided through weight preoccupation or abnormal eating. Additionally, the excessive focus on concerns about body weight and dieting may also serve as a functional distraction to other overwhelming life issues.

Social Impact of Dieting and Obesity

From a young age, a woman is often given the message that she must be beautiful to be worthy. Attractive people are not only seen as more attractive, they are seen as smarter, more compassionate and morally superior. Cultural ideals of beauty are often transient, unhealthy and impossible for most women to live up to. Women are encouraged to be delicate, frail or "waif-like." There is a very narrow range of what is considered to be "acceptable" body size. Shapes that are not within this range are met with discrimination and prejudice (Stunkard & Sorensen, 1993). Women are taught early in life to be wary of what they eat and to fear getting fat. Trusting one's body often evokes tremendous fear for most women. Our society teaches women that eating is wrong (Friedman, 1993). Young women have long been taught to control their bodies and appetites, both sexually and with food (Zimberg, 1993). Women are expected to constrain their appetites and pleasures (Schroff, 1993).

We live in an age where women are seeking equality and empowerment, yet are starving themselves through diet and weight preoccupation while assuming that they can keep up with their better fed (male) counterparts. The strong social pressure to be thin began after World-War II (Seid, 1994). Magazines began showing thinner images of models as both pornography and the women's movement increased (Wooley, 1994). Faludi (1991) states that when society makes women conform to such a thin standard, it becomes a form of oppression towards women and a way of ensuring their inability to compete on equal grounds. The emphasis on thinness in our culture not only oppresses women, it also serves as a form of social control (Sanford & Donovan, 1993).

The stereotypical view of the overweight held by society is that they are unfeminine, antisocial, out of control, asexual, hostile and aggressive (Sanford & Donovan, 1993). Zimberg (1993) questions whether weight preoccupation would be a problem for women if it did not exist alongside society's clear prejudice against fat people. "Public derision and condemnation of fat people is one of the few remaining social prejudices... allowed against any group based solely on appearance" (Garner & Wooley, 1991). It is assumed that the obese willingly bring their condition on themselves through lack of will power and self control. The discriminatory implications of being overweight are well known and are often accepted as "truths" in western society. Fat oppression, the fear and hatred of fat is so commonplace in Western cultures that it is rendered invisible (MacInnis, 1993). Obesity is seen as a danger sign in moralistic terms that may imply personality faults, weak wills and laziness.

The obese face discriminatory practices such as having lower acceptance rates in high ranking colleges, a reduced likelihood of being hired for jobs and a lower possibility of movement to a higher social class through marriage. These effects are more severe for women than men. Obese women are not a strong social force and are likely to be of lower status in income and occupation (Canning & Mayer,1966; Larkin & Pines, 1979). "Prejudice, discrimination, contempt, stigmatization and rejection are not only sadistic, fascist and intensely painful for fat people. These things have a serious effect on physical, mental and emotional health; an effect which is real, and must not be trivialized." (Bovey, 1994)

by Rhonda Zabrodski BSc, MSW, RSW

Tuesday, September 04, 2007

Chapter 7 Suicidal Behaviour

Source: Public Health Agency of Canada

Highlights

  • In 1998, 3,699 Canadians died as a result of suicide.
  • Suicide accounts for 24% of all deaths among 15-24 year olds and 16% among 25-44 year olds.
  • The mortality rate due to suicide among men is 4 times the rate among women.
  • Individuals between 15-44 years of age account for 73% of hospital admissions for attempted suicide.
  • Women are hospitalized in general hospitals for attempted suicide at 1.5 times the rate of men.

What Is Suicidal Behaviour?

Suicidal behaviour is an important and preventable public health problem in Canada. While not in itself a mental illness, suicidal behaviour is highly correlated with mental illness and raises many similar issues. It usually marks the end of a long road of hopelessness, helplessness and despair. All people who consider suicide feel life to be unbearable.

Suicidal behaviour that does not result in death (attempted suicide) is a sign of serious distress and can be a turning point for the individual if he/she is given sufficient assistance to make the necessary life changes.1 For some individuals, particularly those with borderline personality disorder, suicidal behaviour is one of the results of the illness.

Warning Signs
Suicidal behaviour
  • Repeated expressions of hopelessness, helplessness or desperation
  • Signs of depression (loss of interest in usual activities, changes in sleep pattern, loss of appetite, loss of energy, expressing negative comments about self)
  • Loss of interest in friends, hobbies or previously enjoyed activities
  • Giving away prized possessions or putting personal affairs in order
  • Telling final wishes to someone close
  • Expressing suicidal thoughts
  • Expressing intent to commit suicide and having a plan, such as taking pills or hanging oneself at a specific place and time

How Common Is Suicidal Behaviour?

Suicide

Early in 2002, Statistics Canada produced a detailed summary report on suicide deaths and attempted suicide in Canada.2 According to the report, suicide is one of the leading causes of death in both men and women from adolescence to middle age.

In 1998, suicide caused the deaths of 3,699 Canadians (12.2 per 100,000): 46 individuals aged under 15 years; 562 aged 15-24 years; 1,596 aged 25-44 years; 1,038 aged 45-64 years; and 457 aged 65 years and over. This represented 2% of all deaths in Canada.

The actual number of suicide deaths may be considerably higher, however, either because information about the nature of the death may become available only after the original death certificate is completed, or because assessing whether the death was intentional may be difficult in some situations.2 When a cause of death is uncertain, the coroner may initially code the death as "undetermined" and confirm the death as a suicide only after investigation. This additional information does not appear in the mortality database. The stigma about suicide also influences coding on the death certificate.

In 1998, as in most years, overall mortality rates due to suicide among men were nearly 4 times higher than among women (19.5 versus 5.1 per 1,000, respectively).

Rates among women showed three peaks: in the late teens (15-19 years), in middle age (45-59 years) and among older seniors (80-84 years) (Figure 7-1). Mortality rates among men rose dramatically in the late teens (15-19 years) and early twenties (20- 24 years,) and continued high until middle age (40-44 years), when they started to decrease. Rates started to increase among 70-74 year olds and were highest among men 80 years of age and over.

Figure 7-1 Mortality rates due to suicide per 100,000 by age and sex, Canada, 1998

Suicide is a major cause of death in young people. Among individuals aged between 15 and 24 years, nearly onequarter (23.8%) of all deaths in 1998 were due to suicide (Figure 7-2). Among young men (15-24 years), suicide accounted for 26.3% of all deaths. Among all 25-44 yearolds, the proportion of deaths due to suicide was 15.9% overall and 19.3% for men.

Figure 7-2 Proportion of all deaths due to suicide by age and sex, Canada, 1998

From the 1950s to the mid-1980s suicide rates increased dramatically among men.3 This phenomenon was observed to a lesser degree among women. Between 1987 and 1998, however, mortality rates due to suicide changed very little, with perhaps a slight decrease among both men and women (Figure 7-3). Given minor variations in suicide rates from year to year, additional years' data will be required to determine whether suicide rates are, in fact, decreasing.

Figure 7-3 Mortality rate per 100,000 due to suicide by sex, Canada, 1987-98 (standardized to 1991 Canadian population)

In the later 1990s, mortality rates due to suicide among women in the 45-64 year age group appear to have decreased (Figure 7-4). Rates may have increased among younger women aged 15-24 years. Between 1987 and 1998, there was no consistent pattern in mortality rates due to suicide in the various age groups of men (Figure 7-5). The small number of deaths results in instability of the rates, making it difficult to interpret differences in the age groups.

Figure 7-4 Mortality rate per 100,000 due to suicide among women by age, Canada, 1987-98 (standardized to 1991 Canadian population)

Figure 7-5 Mortality rate per 100,000 due to suicide among men by age, Canada, 1987-98 (standardized to 1991 Canadian population)

Attempted Suicide

Attempted suicide that does not result in serious injury is usually treated in the community. In fact, many individuals do not see health professionals, but are helped by family or friends, or perhaps by no one at all. Assessing the incidence of attempted suicide is, therefore, very difficult. Individuals are sometimes hospitalized for their own protection and to address the underlying factors that precipitated the crisis. Hospitalization data provide some insight into suicide attempts, but must be interpreted with caution because they only provide part of the picture.

In 1999, women were 1.5 times more likely than men to be hospitalized because of attempted suicide (Figure 7-6). This relationship was apparent in all except those 70 years of age and older, where men were hospitalized at higher rates than women. Young women between 15 and 19 years of age had much higher hospitalization rates than any other age group of either sex. After the age of 50, hospitalization rates decreased markedly among both men and women.

Figure 7-6 Hospitalizations for attempted suicide* in general hospitals per 100,000 by age group and sex, Canada, 1999/2000

Between 1987 and 1999, rates of hospitalization for attempted suicide peaked in 1995 (Figure 7-7). Rates declined in the latter 1990s among both men and women.

Figure 7-7 Rates of hospitalization for attempted suicide* in general hospitals by sex, Canada, 1987/88-1999/2000 (standardized to 1991 Canadian population)

In the two youngest age groups of women (<15>

Figure 7-8 Rates of hospitalization for attempted suicide* in general hospitals among women by age, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)

In the latter part of the 1990s, the pattern of hospitalization rates for attempted suicide in men was similar to that in women (Figure 7-9). Rates decreased markedly among men between 15 and 24 years of age, and the rates in the middle age groups remained steady.

Figure 7-9 Rates of hospitalization for attempted suicide* in general hospitals among men by age, Canada, 1987/88-1999/2000 (standardized to 1991 Canadian population)

Discussion

The difference in rates of suicide and attempted suicide among men and women has several possible explanations.4 Although both men and women exhibit suicidal behaviour, men express their despair through fatal acts (by, for example, use of a firearm (26%) or hanging (40%)), and women are more likely to choose less lethal acts (such as an overdose of pills, from which they can be resuscitated).2

Youth suicide is a tragic event that relates, in part, to events associated with this life stage. Resolving the challenges that are part of youth development, such as identity formation, gaining acceptance and approval among peers, and gaining acceptance from families is a stressful time for teenagers.5 For example, loss of a valued relationship, interpersonal conflict with family and friends, and the perceived pressure for high scholastic achievement can be overwhelming. For those who are vulnerable to suicide because of other factors, these developmental stresses can create a serious crisis for which suicide may seem to be the only solution. The impulsiveness of youth and their lack of experience in dealing with stressful issues also contribute to the higher risk of suicide.

Seniors face related challenges. They, too, experience the loss of relationships, but more through the death and chronic illness of their friends and life partners. They may also experience loss of their physical and mental abilities. Symptoms of depression may not be recognized and treated as such. In addition, being constantly faced with their own mortality, they may choose death on their own terms.

Suicide rates among the Aboriginal population are 3 to 6 times the rate of the national average, depending on the community.6 Rates are particularly high among teenagers and young adults. A recent Royal Commission stated that, historically, government and institutional policies toward the Aboriginal peoples have created a social environment that directly contributes to the higher incidence of suicidal behaviours.7 Because of conflicting messages about the value of their own culture, many Aboriginal people do not have a strong sense of self. In addition, cultural instability has led to sexual abuse, family violence and substance abuse, which are associated with a high risk of suicide. Childhood separation, poverty and access to firearms also are contributing factors.

Impact of Suicide

'I feel as though I am in a crowded room, watching everyone around me dance, but I can't hear the music,' said Claire, a survivor who lost both her father and sister to suicide.8

When a loved one dies by suicide, family members in mourning are left alive, left behind, left alone.8

An individual's suicide affects everyone in his/ her circle of family and friends. To begin with, those close to the individual feel a huge sense of loss. To some degree, they blame themselves for what has happened and second-guess whether they could have done something to prevent the tragedy. They experience a mixture of emotions, including both abandonment and anger toward the person who took his/her own life.

Family and close friends often feel isolated because the stigma associated with suicide makes it difficult to share their feelings with others: they find it hard to believe that anyone else could understand their feelings. Support groups can help survivors both to cope with the death and to adjust to life without the individual.

Stigma Associated with Suicide

Stigma. is externally imposed by society for an unacceptable act and internally imposed by oneself for unacceptable feelings.8

In general, society does not condone suicide. This is, to some extent, a result of the influence of religion: some religious institutions refuse to bury a person on consecrated ground if he/she has committed suicide. Another factor is a traditional assumption in many societies that the state or the community has an economic and political interest in the life of its members, and that suicide is therefore an offence against the state. Life insurers may not pay benefits to survivors. Social and institutional judgments concerning suicide create a stigma that is felt intensely by family members. They may sense discussion among their friends, but because the subject is never broached directly they feel isolated and as though they are being blamed. If the individual also had a mental illness, the family and friends must cope with this stigma as well.

Within the family, each member may blame him or herself or others for the death or may feel anger toward the individual who has died. Because they judge these emotions as unacceptable, maintaining silence often seems to be the best solution. The stigma against suicide operates, therefore, at two levels - social and personal. In either case, it acts as a major obstacle to frank discussion and emotional healing.

Causes of Suicidal Behaviour

The risk factors for suicidal behaviour are complex and the mechanisms of their interaction are not well understood. It is important to take an ecological perspective when considering the layers of influence on the individual. These layers include the self, family, peers, school, community, culture, society and the environment.5

A useful framework for categorizing the factors associated with suicidal behaviour includes four categories: predisposing factors, precipitating factors, contributing factors and protective factors.5

Predisposing Factors

Predisposing factors are enduring factors that make an individual vulnerable to suicidal behaviour. They include mental illness, abuse, early loss, family history of suicide and difficulty with peer relationships.

Research indicates that a very high proportion of people who kill themselves have a history of mental illness, such as depression, bipolar disorder, schizophrenia or borderline personality disorder. Of these, depression is the most common. This does not mean, however, that all people living with depression are suicidal.

Previous attempts at suicide serve as one of the strongest predictors of completed suicide.

Precipitating Factors

Precipitating factors are acute factors that create a crisis, such as interpersonal conflict or loss, pressure to succeed, conflict with the law, loss of stature in society, financial difficulties or rejection by society for some characteristic (such as ethnic origin or sexual orientation).

"The common stimulus in suicide is unendurable psychological pain.. The fear is that the trauma, the crisis, is bottomless - an eternal suffering. The person may feel boxed in, rejected, deprived, forlorn, distressed, and especially hopeless and helpless. It is the emotion of impotence, the feeling of being hopeless-helpless, that is so painful for many suicidal people. The situation is unbearable and the person desperately wants a way out of it."9

Contributing Factors

Contributing factors increase the exposure of the individual to either predisposing or precipitating factors. These include physical illness, sexual identity issues, unstable family, physical illness, risk-taking or self-destructive behaviour, suicide of a friend, isolation and substance abuse.

Protective Factors

Protective factors are those that decrease the risk of suicidal behaviour, such as personal resilience, tolerance for frustration, self-mastery, adaptive coping skills, positive expectations for the future, sense of humour and at least one positive healthy family relationship.

Prevention and Treatment

Using this framework of categories, suicide prevention programs must address the predisposing, precipitating, contributing and protective factors for suicidal behaviour:

  • Early identification and treatment programs address the predisposing factors.
  • Crisis intervention addresses the precipitating factors.
  • Treatment programs address the contributing factors.
  • Mental health promotion programs address the protective factors.

Many provinces, territories and communities have developed suicide prevention programs. Programs need to be both population-wide and targeted toward those who are at higher risk. A comprehensive program has a framework, goals and objectives and a commitment to adequate funding. Promotion of mental health of the entire Canadian population, reduction of risk factors and early recognition of those at risk of suicidal behaviour play essential roles in decreasing suicide and attempted suicide.

A comprehensive program has the following strategies.

  1. Increase public awareness and decrease the stigma associated with suicidal behaviour.
  2. Address determinants of health, including housing, income, education, employment and community attitudes.
  3. Implement prevention programs for youth, for individuals at high risk for suicidal behaviour, and for family members post-suicide.
  4. Provide and ensure equitable access to co-ordinated, integrated services, including crisis phone counselling and treatment of mental illnesses.
  5. Reduce access to lethal means of suicide, particularly firearms and lethal doses of prescription drugs. Since suicidal behaviour is often crisis-oriented and impulsive, restricting access to lethal means can substantially reduce the risk of the completion of a suicide attempt.10 This includes reducing access to firearms, bridges and dangerous sites, and medication.
  6. Train service providers and educators in the early identification of predisposing factors and crisis management.
  7. Conduct research and evaluation to inform the development of effective suicide prevention programs. These research efforts need to address the causes of suicidal behaviours, factors that increase risks for these behaviours, and factors that are protective and that may facilitate resiliency in vulnerable persons. Research must also evaluate the effectiveness of health and social services.

Future Surveillance Needs

Suicidal behaviour is a very serious manifestation of stress, hopelessness and despair.

Existing data provide a very limited profile of suicidal behaviour in Canada. The available hospitalization and mortality data need to be complemented with additional data to fully monitor suicidal behaviour in Canada. Priority data needs include:

  • Incidence and prevalence of suicidal behaviour by age, sex and other key variables (for example, socio-economic status, education and ethnicity)
  • Prevalence of other mental illnesses in association with suicidal behaviour
  • Impact of suicidal behaviour on the individual and family
  • Access to and use of primary and specialist health care services
  • Access to and use of public and private mental health services
  • Access to and use of mental health services in other systems, such as schools, employee assistance programs, and criminal justice programs and facilities
  • Stigma associated with suicidal behaviour
  • Access to the means of suicide
  • Treatment outcomes
  • Exposure to known or suspected risk and protective factors

References

  1. Bland RD, Dyck RJ, Newman SC, Orn H. Attempted suicide in Edmonton. Leenaars AA, Wenckstern S, Sakinofsky I, Dyck RJ, Kral MJ, Bland RC, ed., Suicide in Canada. Toronto: University of Toronto Press. 1998: 136.
  2. Langlois S, Morrison P. Suicide deaths and suicide attempts. Health Reports 2002;13:2:9-22. Statistics Canada Catalogue 83-003
  3. Sakinofsky I. The epidemiology of suicide in Canada. Leenaars AA, Wenckstern S, Sakinofsky I, Dyck RJ, Kral MJ, Bland RC, ed., Suicide in Canada. Toronto: University of Toronto Press. 1998: 38.
  4. Canetto SS, Sakinofsky I. The gender paradox in suicide. Suicide and Life Threatening Behavior 1998;28:1:1-23.
  5. White J. Comprehensive youth suicide prevention: a model for understanding. Leenaars AA, Wenckstern S, Sakinofsky I, Dyck RJ, Kral MJ, Bland RC, ed., Suicide in Canada. Toronto: University of Toronto Press, 1998: 165-226.
  6. Sinclair CM. Suicide in First Nations people. Leenaars AA, Wenckstern S, Sakinofsky I, Dyck RJ, Kral MJ, Bland RC, ed., Suicide in Canada. Toronto: University of Toronto Press, 1998: 165-78.
  7. Royal Commission on Aboriginal Peoples. Choosing Life: Special Report on Suicide Among Aboriginal People. Ottawa: Canadian Government Publishing, 1995: Chapter 3.
  8. Rosenfeld L. 'I can't hear the music'. Leenaars AA, Wenckstern S, Sakinofsky I, Dyck RJ, Kral MJ, Bland RC, ed., Suicide in Canada. Toronto: University of Toronto Press. 1998: 376.
  9. Leenaars AA. Suicide, euthanasia, and assisted suicide. Leenaars AA, Wenckstern S, Sakinofsky I, Dyck RJ, Kral MJ, Bland RC, ed., Suicide in Canada. Toronto: University of Toronto Press. 1998: 460-461.
  10. Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry 1999;56:617-626.

Tuesday, June 12, 2007

Chapter 6 Eating Disorders

From: Public Health Agency of Canada


Highlights

  • Approximately 3% of women will be affected by an eating disorder during their lifetime.
  • Eating disorders affect girls and women more than boys and men.
  • Factors believed to contribute to eating disorders include biological and personal factors as well as society's promotion of the thin body image.
  • Eating disorders carry with them a high risk of other mental and physical illnesses that can lead to death.
  • Since 1987, hospitalizations for eating disorders in general hospitals have increased by 34% among young women under the age of 15 and by 29% among 15-24 year olds.

What Are Eating Disorders?

Eating disorders involve a serious disturbance in eating behaviour - either eating too much or too little - in addition to great concern over body size and shape.1 This chapter addresses anorexia nervosa, bulimia nervosa and binge eating disorder (BED).

Eating disorders are not a function of will but are, rather, unhealthy eating patterns that "take on a life of their own." The voluntary eating of smaller or larger portions of food than usual is common, but for some people this develops into a compulsion and the eating behaviours become extreme.

Individuals with anorexia nervosa refuse to maintain a minimally normal body weight, carry an intense fear of gaining weight and have a distorted perception of the shape or size of their bodies.2

Individuals with bulimia nervosa undertake binge eating and then use compensatory methods to prevent weight gain, such as induced vomiting, excessive exercise or laxative abuse. They also place excessive importance on body shape and weight. In order for a diagnosis of bulimia nervosa to be made, the binge eating and compensatory behaviours must occur, on average, at least twice a week for 3 months.2

A diagnosis of binge eating disorder (BED) is made if the binge eating is not followed by some compensatory behaviour, such as vomiting, excessive exercise or laxative abuse. This disorder is often associated with obesity.

Symptoms
Eating Disorders
General
Distorted perception of the shape or size of one's own body
Anorexia Bulimia Binge Eating Disorder (BED)
  • Resistance to maintaining body weight at or above a minimally normal weight for age and height with an intense fear of gaining weight or becoming fat, even though underweight.
  • Recurrent episodes of binge eating, accompanied by inappropriate compensatory behaviour in order to prevent weight gain, such as selfinduced vomiting, use of laxatives, or excessive exercise.
  • Binge eating without compensatory behaviours, such as vomiting, excessive exercise or laxative abuse
  • Individuals are often obese.

How Common Are Eating Disorders?

It is estimated that 3% of women will be affected by eating disorders in their lifetime.3 Approximately 0.5% to 4% of women will develop anorexia nervosa during their lifetime, and about 1 to 4% will develop bulimia.1 BED affects about 2% of the population.4

Impact of Eating Disorders

Who Is Affected by Eating Disorders?

Anorexia nervosa and bulimia predominantly affect young women. Some studies have found that young men represent only about 10% of individuals with the disorder.1 An Ontario study found that 0.3% of men ages 15-64 and 2.1% of women had anorexia nervosa or bulimia.5 In most cases, BED starts during adolescence or young adulthood. Men are more likely to be affected by BED than by other eating disorders.

Although most of the treatment of an eating disorder is provided in the community, occasionally hospitalization is needed. Hospitalization data provide a partial description of who is affected by severe eating disorders. The results must be viewed with caution, however, since this is only a subset of those with eating disorders.

In 1999, women in all age groups had higher rates of hospitalization than men for eating disorders (Figure 6- 1). Females accounted for 94% of all hospital admissions for eating disorders. Adolescents of both sexes between the ages of 10 and 19 years had the highest rates of hospitalization.

Figure 6-1 Hospitalizations for eating disorders* in general hospitals per 100,000 by age group, Canada, 1999/2000.

How Do Eating Disorders Affect People?

Individuals with anorexia and bulimia may recover after a single episode of the disorder. Others may have a fluctuating pattern of weight gain and relapse. Still others will continue to have issues with food and weight throughout their lives. A lifetime history of substance use disorders, drug or alcohol problems at the time of diagnosis and longer duration of symptoms before diagnosis are associated with poorer long-term outcomes.6

Individuals with anorexia and bulimia may develop serious physical problems such as heart conditions, electrolyte imbalance and kidney failure that can lead to death. Eating disorders may cause long-term psychological, social and health problems even after the acute episode has been resolved.7

Anorexic individuals are more susceptible to major depression, alcohol dependence and anxiety disorders, either at the time of their illness or later in life.8,9 Suicide is also a possible outcome.

An eating disorder causes young people to miss school, work and recreational activities. The physical weakness associated with the illness also seriously affects their social interaction with friends and their involvement in life in general. Friends also have difficulty knowing how to react and how to help.

Families of individuals with eating disorders also live under great stress. They may blame themselves, feel anxious about their loved one's future, worry that the family member will die, and face the stigma associated with having a child with a mental illness. Parents especially experience the tension between their natural protective instinct to force healthy behaviours on the child (which can often make the situation worse) and the child's need to take control over his/her illness and health.

Stigma Associated with Eating Disorders

Anorexia nervosa and bulimia nervosa do not have the same public manifestation as other mental illnesses. In general, public embarrassment due to unusual behaviour is not an issue. Essentially, these illnesses are a private family affair. As a result, the stigma associated with eating disorders comes from the mistaken impression that others (parents in particular) are to blame for the illness. The stigmatization isolates parents from their peers and other family members.

Individuals with BED who are obese must contend with negative societal attitudes toward obesity. These attitudes isolate them, and the loss of self-esteem exacerbates the illness.

Causes of Eating Disorders

Eating disorders are complex syndromes strongly associated with other mental illnesses, such as mood, personality and anxiety disorders. This suggests that the development of the disease results from a combination of biological, psychological and social factors. In addition, the secondary effects of the maladaptive eating practices themselves likely contribute to the disorder. Steiger and Séguin have written an excellent in-depth discussion of the etiology of eating disorders.1

Table 6-1 Summary of Possible Risk Factors for the Development of Eating Disorders

Eating-Specific Factors
(Direct Risk Factors)
Generalized Factors
(Indirect Risk Factors)
Biological Factors
  • ED-specific genetic risk
  • Physiognomy and body weight
  • Appetite regulation
  • Energy metabolism
  • Gender
  • Genetic risk for associated disturbance
  • Temperament
  • Impulsivity
  • Neurobiology (e.g., 5-HT mechanisms)
  • Gender
Psychological Factors
  • Poor body image
  • Maladaptive eating attitudes
  • Maladaptive weight beliefs
  • Specific values or meanings assigned to food, body
  • Overvaluation of appearance
  • Poor self-image
  • Inadequate coping mechanisms
  • Self-regulation problems
  • Unresolved conflicts, deficits, posttraumatic reactions
  • Identity problems
  • Autonomy problems
Developmental Factors
  • Identifications with body-concerned relatives, or peers
  • Aversive mealtime experiences
  • Trauma affecting bodily experience
  • Overprotection
  • Neglect
  • Felt rejection, criticism
  • Traumata
  • Object relationships (interpersonal experience)
Social Factors
  • Maladaptive family attitudes to eating, weight
  • Peer-group weight concerns
  • Pressures to be thin
  • Body-relevant insults, teasing
  • Specific pressures to control weight (e.g., through ballet, athletic pursuits)
  • Maladaptive cultural values assigned to body
  • Family dysfunction
  • Aversive peer experiences
  • Social values detrimental to stable, positive self-image
  • Destabilizing social change
  • Values assigned to gender
  • Social isolation
  • Poor support network
  • Impediments to means of self-definition

Treatment of Eating Disorders

Eating disorders can be treated and a healthy weight restored. Earlier diagnosis results in improved outcomes. Treatment is most effective if started in the early stages of the disorder. Therefore, routine assessment of teenaged girls for the early signs of an eating disorder can help identify those who would benefit from treatment.

Success of treatment depends on a comprehensive plan,10 including the following:

  • Monitoring of physical symptoms
  • Behavioural therapy
  • Cognitive therapy
  • Body image therapy
  • Nutritional counselling
  • Education
  • Medication, if necessary

Treatment has changed dramatically over time.11 The previous emphasis on long-term psychotherapy and potentially harmful medications has been replaced with nutritional stabilization as the initial approach. Once the nutritional status has improved, then a variety of psychotherapy methods (cognitive/analytical, family and cognitive/ behavioural) are used to improve functioning. Unfortunately, a recent review of psychological treatments of anorexia nervosa found that much more research needs to be done in this area.12

According to a recent review of the pharmacological treatment of eating disorders, numerous studies have shown that anti-depressants are useful in the treatment of bulimia nervosa.3 Some medications are also useful in treating BED. Unfortunately, studies have not identified any effective drugs in treating anorexia nervosa. The treatment of coexisting mental illnesses, such as depression, anxiety and alcoholism, is essential.

For people who have been ill for many years with anorexia nervosa, brief time-limited admissions to hospital to stabilize weight loss and treat metabolic complications, combined with supportive psychotherapy, are more effective than coercive hospital treatment with overly ambitious goals.

Most treatment of eating disorders takes place in the community, but hospitalization data give some indication of serious disease in the population.

In 1999, among teenagers, an eating disorder was the diagnosis most responsible for determining the length of stay in hospital, likely associated with the life threatening biochemical changes in the body (Figure 6- 2). Among older individuals, eating disorders were more likely to be an associated condition.

Figure 6-2 Hospitalizations for eating disorders in general hospitals per 100,000 by contribution to length of stay and age group, Canada, 1999/2000.

Rates of hospitalization for eating disorders among women increased by 20% between 1987 and 1999 (Figure 6-3). Rates among men remained stable.

Figure 6-3 Rates of hospitalization per 100,000 for eating disorders* in general hospitals by sex, Canada, 1987/88-1999/2000 (standardized to 1991 Canadian population)

From 1987 to 1999, women aged <15>

Figure 6-4 Rates of hospitalization per 100,000 for eating disorders* in general hospitals among women by age, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)

Rates of hospitalization for eating disorders among men between 1987 and 1999 were very unstable because of small numbers (Figure 6-5).

Figure 6-5 Rates of hospitalization per 100,000 for eating disorders* in general hospitals among men by age, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)

The average length of stay in general hospitals due to eating disorders decreased in the mid-1990s and in 1999 was 27.5 days (Figure 6-6).

Figure 6-6 Average length of stay in general hospitals due to eating disorders*, Canada, 1987/88-1999/2000.

Discussion of Hospitalization Data

The hospitalization data support clinical findings that more women than men are affected by eating disorders. In general hospitals, 93% of individuals hospitalized for eating disorders are women. Hospitalization rates are very high among adolescents, consistent with the onset of eating disorders in this age group.

Among older individuals, eating disorders are more likely to be an associated, rather than primary, condition as the reason for the length of stay in hospital. This may reflect the more severe complications associated with the condition that appear once the disease has been present for a period of time.

Rates of hospitalization for eating disorders in general hospital are increasing among young women. Whether this signals an increase in the disorder or rather an increase in the use of hospitalization in treating the disorder requires further research.

Future Surveillance Needs

Eating disorders are common among young women and they can lead to death. They are difficult to treat, but early diagnosis results in improved outcomes.

Existing data provide a very limited profile of eating disorders in Canada. The available hospitalization data needs to be complemented with additional data to fully monitor these disorders in Canada. Priority data needs include:

  • Incidence and prevalence of each of the eating disorders by age, sex and other key variables (for example, socio-economic status, education and ethnicity).
  • Impact of eating disorders on the quality of life of the individual and family.
  • Access to and use of primary and specialist health care services and community programs.
  • Stigma associated with eating disorders.
  • Attitude toward body image in the general population.
  • Access and use of public and private mental health services.
  • Access and use of mental health services in other systems, such as schools.
  • Treatment outcomes.
  • Exposure to known or suspected risk and protective factors.

References

  1. Steiger H, Séguin JR. Eating disorders: anorexia nervosa and bulimia nervosa. Million T, Blaneyu PH, David R, ed., Oxford Textbook of Psychopathology. New York: Oxford University Press, 1999: 365-88.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: American Psychiatric Association, 1994.
  3. Zhu AJ, Walsh BT. Pharmacologic treatment of eating disorders. Can J Psychiatry 2002;47:3:227- 34.
  4. Bruce, B., & Agras, S.. Binge eating in females: A population-based investigation. Int J Eat Disord 1992;12:365-373.
  5. Woodside DB, Garfinkel PE, Lin E, Goering P, Kaplan AS, Goldbloom DS et al. Comparisons of men with full or partial eating disorders, men without eating disorders, and women with eating disorders in the community. Am J Psychiatry 2001;158:570-574.
  6. Keel PK, Mitchell JE, Miller KB, Davis TL, Crow SJ. Long-term outcome of bulimia nervosa. Arch Gen Psychiatry 1999;56:63-69.
  7. Lewinsohn PM, Striegel-Moore RH, Seeley JR. Epidemiology and natural course of eating disorders in young women from adolescence to young adulthood. J Am Acad Child Adolesc Psychiatry 2000;39:1284-1292.
  8. American Psychiatric Association Work Group on Eating Disorders. Practice guidelines for the treatment of patients with eating disorders. Am J Psychiatry 2000;157:1suppl:1-39.
  9. Sullivan PF, Bulik CM, Fear JL, Pickering A. Outcome of anorexia nervosa: a case-control study. Am J Psychiatry 1998;155:939-946.
  10. Steiger H, Champagne J. Les troubles d l'alimentation : l'anorexie nerveuse et la boulimie. Habimana E (ed.), Psychopathologie de l'enfant et de l'adolescent: approche intégrative. Paris: Christian Morin, 1999.
  11. Garfinkel PE. Eating disorders (guest editorial). Can J Psychiatry 2002;47:3:225-6.
  12. Kaplan AS. Psychological treatments for anorexia nervosa: a review of published studies and promising new directions. Can J Psychiatry 2002;47:3:235-42.

Wednesday, May 16, 2007

Chapter 5 Personality Disorders

From: Public Health Agency of Canada

Highlights

  • Based on US data, about 6% to 9% of the population has a personality disorder.
  • Personality disorders exist in several forms. Their influence on interpersonal functioning varies from mild to serious.
  • Onset usually occurs during adolescence or in early adulthood.
  • Anti-social personality disorder is frequently found among prisoners (up to 50%).
  • Of hospitalizations for personality disorders in general hospitals, 78% are among young adults between 15 and 44 years of age.

What Are Personality Disorders?

Personality disorders cause enduring patterns of inner experience and behaviour that deviate from the expectations of society, are pervasive, inflexible and stable over time, and lead to distress or impairment.1

"Personality is seen today as a complex pattern of deeply imbedded psychological characteristics that are largely non-conscious and not easily altered, which express themselves automatically in almost every area of functioning."2

Personality characteristics or traits are expressed on a continuum of social functioning. Personality disorders reflect personality traits that are used inappropriately and become maladaptive.2 To some degree, this classification is arbitrary.

Some deviations may be quite mild and interfere very little with the individual's home or work life; others may cause great disruption in both the family and society. Specific situations or events trigger the behaviours of a personality disorder. In general, individuals with personality disorders have difficulty getting along with others and may be irritable, demanding, hostile, fearful or manipulative.

Symptoms
Personality Disorders
  • Difficulty getting along with other people. May be irritable, demanding, hostile, fearful or manipulative.
  • Patterns of behaviour deviate markedly from society's expectations and remain consistent over time.
  • Disorder affects thought, emotion, interpersonal relationships and impulse control.
  • The pattern is inflexible and occurs across a broad range of situations.
  • Pattern is stable or of long duration, beginning in childhood or adolescence.

Personality disorders exist in many forms.1 Classification of personality disorders is arbitrary. Each person is unique, however, and can display mixtures of patterns.

Table 5-1 Types of Personality Disorders

TypePatterns
Borderline Personality DisorderInstability in interpersonal relationships, selfimage and affects, and marked impulsivity.
Antisocial Personality DisorderDisregard for, and violation of, the rights of others.
Histrionic Personality DisorderExcessive emotionality and attention seeking.
Narcissistic Personality DisorderGrandiosity, need for admiration, and lack of empathy.
Avoidant Personality DisorderSocial inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation.
Dependent Personality DisorderSubmissive and clinging behaviour related to an excessive need to be taken care of.
Schizoid Personality DisorderDetachment from social relationships and a restricted range of emotional expression.
Paranoid Personality DisorderDistrust and suspiciousness in which others' motives are interpreted as malevolent.
Obsessive-Compulsive PersonalityDisorder Preoccupation with orderliness, perfectionism and control.
Schizotypal Personality DisorderAcute discomfort in close relationships, cognitive or perceptual distortions, and eccentricities of behaviour.

How Common Are Personality Disorders?

Canadian data on the prevalence of personality disorders are lacking. United States estimates of the prevalence of diagnosis of any personality disorder, however, range from 6% to 9%, depending upon the criteria used for definition.3

Epidemiological studies most often measure and report antisocial personality disorder. A 1991 Ontario survey estimated that the 1- year prevalence rate of antisocial personality disorder in the general population was 1.7%.4 According to the Edmonton study in the 1980s, 1.8% of the population had an antisocial personality disorder in the 6-month period before the survey, and 3.7% reported a personality disorder at some point in their lives.5,6 Estimates of the prevalence of other personality disorders range from 1% to 10% of the population.

Impact of Personality Disorders

Who Develops a Personality Disorder?

There is a sex difference in the personality disorder types. For example, antisocial personality disorder is more common among men, while borderline personality disorder is more common among women. The dependent and hysterical personality disorders are also more common among women. Labelling biases among health professionals may lead to some of the sex differences.

Ideally, data from a population survey would provide information on the age/sex distribution of individuals with personality disorders. Statistics Canada's Canadian Community Health Survey (CCHS) will provide prevalence of self-reported obsessivecompulsive personality disorder in the future.

At the present time, however, hospitalization data provide the best available description of individuals with personality disorders. These data have limitations, however, because most people with personality disorders, unless they show suicidal behaviour, are treated in the community rather than in hospitals. Many are never diagnosed or treated. Individuals with borderline personality disorder have higher rates of admission than individuals with other disorders because of their high rate of suicidal behaviour. These limitations must be kept in mind, then, when interpreting the data presented in this report.

Among both women and men, the highest rates of hospitalization for personality disorders were among individuals between the ages of 15 and 44 years (Figure 5-1). Over three-quarters (78%) of all admissions were between these ages and rates were higher among women than men.

Figure 5-1 Hospitalizations for personality disorders* in general hospitals per 100,000 by age group, Canada, 1999/2000

What Are the Effects of Personality Disorders?

Although the onset of personality disorders usually occurs in adolescence or early adulthood, they can also become apparent in mid-adulthood. To some extent, the timing depends on the type of personality disorder and the situation or events surrounding the individual. For example, borderline personality disorder usually peaks in adolescence and early adulthood, and then becomes less prominent by mid-adulthood. On the other hand, narcissistic personality disorder may not be identified until middle age when the individual experiences the sense of loss of opportunity or faces personal limitations.

Since personality disorders usually develop in adolescence or early adulthood, they occur at a time when most people develop adult relationship skills, obtain education, establish careers and generally "build equity" in their lives. The use of maladaptive behaviours during this life stage has implications that extend for a lifetime.

A history of alcohol abuse, drug abuse, sexual dysfunction, generalized anxiety disorder, bipolar disorder, obsessive-compulsive disorder, depressive disorder, eating disorder, and suicidal thoughts or attempts often accompany personality disorders.3 Up to onehalf of prisoners have antisocial personality disorder because its associated behavioural characteristics (such as substance abuse, violence and vagrancy) lead to criminal behaviour.3 Other social consequences of personality disorders include:

  • Spousal violence
  • Child maltreatment
  • Poor work performance
  • Suicide
  • Gambling

Personality disorders have a major effect on the people who are close to the individual. The individual's fixed patterns make it difficult for them to adjust to various situations. As a result, other people adjust to them. This creates a major strain on all relationships among family and close friends and in the workplace. At the same time, when other people do not adjust, the individual with the personality disorder can become angry, frustrated, depressed or withdrawn. This establishes a vicious cycle of interaction, causing the individuals to persist in the maladaptive behaviour until their needs are met.

Stigma Associated with Personality Disorders

Since the behaviours shown in some personality disorders remain close to what is considered "normal", others often assume that the individuals can easily change their behaviour and solve the interpersonal problem. When the behaviour persists, however, it may be perceived as a lack of will or willingness to change. The fixed nature of the trait is not well understood by others.

Causes of Personality Disorders

Personality disorders likely result from the complex interplay of early life experience, genetic and environmental factors. In principle, genetic factors contribute to the biological basis of brain function and to basic personality structure. This structure then influences how individuals respond to and interact with life experiences and the social environment. Over time, each person develops distinctive patterns or ways of perceiving their world and of feeling, thinking, coping and behaving.

Although little is known to date about possible biological correlates of personality disorder, individuals with personality disorders may have impaired regulation of the brain circuits that control emotion. This difficulty, combined with psychological and social factors such as abuse, neglect or separation, puts an individual at higher risk of developing a personality disorder. Strong attachments within the family or a supportive network of people outside the family, in the school and in the community help an individual develop a strong sense of self-esteem and strong coping abilities. Opportunities for personal growth and for developing unique abilities can enhance a person's self-image. This supportive environment may provide some protection against the development of a personality disorder.

For biologically predisposed individuals, the major developmental challenges that are a normal part of adolescence and early adulthood - separation from family, selfi-dentity, and independence - may be the precipitating factors for the development of the personality disorder. This may explain why personality disorders usually begin in these years.

Treatment of Personality Disorders

Personality disorders are difficult to treat because of self-denial about the presence of the problem and the pessimism of health professionals based on a lack of success in previous efforts.

Intensive individual and group psychotherapy, combined with anti-depressants and mood stabilizers, can be at least partially effective for some people. Difficulties arise from both the persistence of symptoms and the negative impact of these symptoms on the therapeutic relationship.

Individuals with borderline personality disorder have more frequent hospitalizations, use outpatient psychotherapy more often, and make more visits to emergency rooms than individuals with other personality disorders.7

In 1999, in all age groups, personality disorders were more likely to be a contributing rather than the main factor determining length of stay in hospital (Figure 5-2). This reflects the fact that personality disorders are associated with other conditions, such as suicidal behaviour, that may need hospitalization.

Figure 5-2 Hospitalizations for personality disorders in general hospitals per 100,000 by by contribution to length of stay and age group, Canada, 1999/2000

Rates of hospitalization for personality disorders among both men and women increased during the early 1990s and decreased in the later years of the decade (Figure 5-3).

Figure 5-3 Rates of hospitalization for personality disorders* in general hospitals by sex, Canada, 1987/88-1999/2000 (standardized to 1991 Canadian population)

The increase in hospitalization rates for personality disorders in the early 1990s was due to an increase among women in the 15-24 and 25-44 year age groups (Figure 5-4). These same age groups, along with those 65 years of age and older, showed a decline in the later 1990s.

Figure 5-4 Rates of hospitalization for personality disorders* in general hospitals among women by age, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)

Between 1987 and 1999, men aged 15- 24 years showed the greatest decrease in hospitalization rates for personality disorders (Figure 5- 5). During the early 1990s, rates of hospitalization increased slightly among men aged 25-44 years, and this was followed by a slight decrease later in the decade.

Figure 5-5 Rates of hospitalization for personality disorders* in general hospitals among men by age, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)

The average length of stay in general hospitals due to personality disorders was 9.5 days in 1999, a decrease of nearly 50% since 1991 (Figure 5-6).

Figure 5-6 Average length of stay in general hospitals due to personality disorders*, Canada, 1987/88-1999/2000

Discussion of Hospitalization Data

Most personality disorders are treated outside of the hospital. Thus, the hospitalization data provide a very limited picture of personality disorders in Canada.

The higher rates of hospitalization for personality disorder in general hospitals among young women than men supports the clinical experience that women are more likely to have borderline personality disorder with its associated suicidal behaviour, leading to hospitalization.

High rates among adolescents and young adults support the negative impact of these disorders on young people at a critical time in their lives.

The length of stay in hospital associated with personality disorders decreased during the 1990s. Further research is needed to determine the reason for this trend: What has been the impact on hospital bed closures on length of stay and treatment outcome? Have treatment methods changed and have outcomes improved?

Future Surveillance Needs

Personality disorders are common in the general population, causing not only a great deal of personal and family distress but also impairment of social functioning.

Existing data provide a very limited profile of personality disorders in Canada. The available hospitalization data needs to be complemented with additional data to fully monitor these disorders in Canada. Priority data needs include:

  • Incidence and prevalence of each of the personality disorders by age, sex and other key variables (for example, socio-economic status, education and ethnicity)
  • Impact of personality disorders on the quality of life of the individual and family
  • Access to and use of primary and specialist health care services
  • Impact of personality disorders on the workplace and the economy
  • Impact of personality disorders on the legal and penal systems
  • Stigma associated with personality disorders
  • Access to and use of public and private mental health services
  • Access to and use of mental health services in other systems, such as schools, criminal justice programs and facilities, and employee assistance programs
  • Treatment outcomes
  • Exposure to known or suspected risk and protective factors

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: American Psychiatric Association, 1994.
  2. Millon T, Blaneyu PH, Davis R, ed. Oxford Textbook of Psychopathology. New York: Oxford University Press, 1999:510.
  3. Samuels JF, Nestadt G, Romanoski AJ, Folstein MF, McHugh PR. DSM-III personality disorders in the community. Am J Psychiatry 1994;151:1055-1062.
  4. Offord DR, Boyle MH, Campbell D, Goering P, Lin E, Wong M, Racine YA. One-year prevalence of psychiatric disorder in Ontarians 15 to 64 years of age. Can J Psychiatry 1996;41:559-563.
  5. Bland RC, Newman SC, Orn H. Period prevalence of psychiatric disorders in Edmonton. Acta Psychiatr Scand 1988;77(Suppl 338):33-42.
  6. Bland RC, Orn H, Newman SC. Lifetime prevalence of psychiatric disorders in Edmonton. Acta Psychiatr Scand 1988;77(Suppl 338):24-32.
  7. Bender DS, Dolan RT, Skodol AE, Sanislow CA, Dyck IR, McGlashan TH, Shea MT, Zanarini MC, Oldham JM, Gunderson JG. Treatment utilization by patients with personality disorders. Am J Psychiatry 2001;158:295-302.

Sunday, May 13, 2007

Chapter 4 Anxiety Disorders

From: Public Health Agency of Canada

Highlights

  • Anxiety disorders affect 12% of the population, causing mild to severe impairment.
  • For a variety of reasons, many individuals may not seek treatment for their anxiety; they may consider the symptoms mild or normal, or the symptoms themselves may interfere with help-seeking.
  • Anxiety disorders can be effectively treated in the community setting.
  • Hospitalization rates for anxiety disorders in general hospitals are twice as high among women as men.
  • The highest rates of hospitalization for anxiety disorders in general hospitals are among those aged 65 years and over.
  • Since 1987, hospitalization rates for anxiety disorders in general hospitals have decreased by 49%.

What Are Anxiety Disorders?

Individuals with anxiety disorders experience excessive anxiety, fear or worry, causing them either to avoid situations that might precipitate the anxiety or to develop compulsive rituals that lessen the anxiety. Everyone feels anxious in response to specific events - but individuals with an anxiety disorder have excessive and unrealistic feelings that interfere with their lives in their relationships, school and work performance, social activities and recreation.

Symptoms
Anxiety Disorders
  • Intense and prolonged feelings of fear and distress that occur out of proportion to the actual threat or danger
  • Feelings of fear and distress that interfere with normal daily functioning

Types of Anxiety Disorders 1

Generalized Anxiety Disorder (GAD)

Excessive anxiety and worry about a number of events or activities occurring for more days than not over a period of at least 6 months with associated symptoms (such as fatigue and poor concentration).

Specific Phobia

Marked and persistent fear of clearly discernible objects or situations (such as flying, heights and animals).

Post Traumatic Stress Disorder

Flashbacks, persistent frightening thoughts and memories, anger or irritability in response to a terrifying experience in which physical harm occurred or was threatened (such as rape, child abuse, war or natural disaster).

Social Phobia, also known as Social Anxiety Disorder

Exposure to social or performance situations almost invariably provokes an immediate anxiety response that may include palpitations, tremors, sweating, gastrointestinal discomfort, diarrhoea, muscle tension, blushing or confusion, and which may meet criteria for the panic attack in severe cases.

Obsessive-Compulsive Disorder

Obsessions : Persistent thoughts, ideas, impulses or images that are intrusive and inappropriate and that cause marked anxiety or distress. Individuals with obsessions usually attempt to ignore or suppress such thoughts or impulses or to counteract them by other thoughts or actions (compulsions).

Compulsions : Repetitive behaviours (such as hand washing, ordering or checking) or mental acts (such as praying, counting or repeating words) that occur in response to an obsession or in a ritualistic way.

Panic Disorder

Presence of recurrent, unexpected panic attacks, followed by at least 1 month of persistent concern about having additional attacks, worry about the implication of the attack or its consequences, or a significant change in behaviour related to the attacks. There are three clusters of symptoms: reexperiencing, avoidance and numbing, and arousal.

Panic disorders are sometimes associated with agoraphobia - anxiety about, or the avoidance of, places or situations from which escape might be difficult or embarrassing, or in which help may not be available in the event of a panic attack or panic-like symptoms.

The essential feature of the panic attack is a discrete period of intense fear or discomfort that is accompanied by at least 4 of 13 physical symptoms, such as:

  • Palpitations, increased heart rate or pounding heart
  • Sweating
  • Trembling or shaking
  • Sensations of shortness of breath or smothering
  • Feeling of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Dizziness, unsteadiness, lightheadedness or fainting
  • De-realization or de-personalization
  • Fear of losing control or going crazy
  • Fear of dying
  • Paresthesias (numbness or tingling sensation)
  • Chills or hot flashes

How Common Are Anxiety Disorders?

Combined anxiety disorders affect approximately 12% of Canadians: about 9% of men and 16% of women during a one-year period.2 As a group, anxiety disorders represent the most common of all mental illnesses.

Table 4-1 One-Year Prevalence of Anxiety Disorders in Canada.

Type of Anxiety Disorder Canada (Ages 15-64 years)
% with anxiety disorder 2-4
Generalized Anxiety Disorder 1.1
Specific Phobia 6.2 - 8.0
Post Traumatic Stress Disorder ---
Social Phobia 6.7
Obsessive Compulsive Disorder 1.8
Panic Disorder 0.7

Impact of Anxiety Disorders

Who Is Affected by Anxiety Disorders?

Women report and are diagnosed with some anxiety disorders more frequently than men. This may reflect the differences between men and women in their health-service-seeking behaviours, however, rather than true differences in prevalence.

Ideally, data from a population survey would provide information on the age/sex distribution of individuals with anxiety disorders. Statistics Canada's Canadian Community Health Survey (CCHS) will provide these data in the future.

At the present time, hospitalization data provide the best available description of individuals with anxiety disorders. These data have limitations, however, because most people with anxiety disorders are treated in the community rather than in hospitals, and many do not receive treatment at all. As a result, the data represents only a subset of all those with anxiety disorders, and the results must be interpreted with caution.

In 1999, women were hospitalized for anxiety disorders at higher rates than men in every age category (Figure 4-1). Young women aged between 15 and 19 years had much higher rates of hospitalization than the immediately adjacent age groups. Women and men over the age of 65 had the highest rates of hospitalization.

Figure 4-1 Hospitalizations for anxiety disorders* in general hospitals per 100,000 by age group, Canada, 1999/2000

How Does It Affect Them?

Symptoms of anxiety disorders often develop during early adulthood. Although the majority of people have mild or no impairment, anxiety disorders can seriously restrict an individual's education, work, recreation and social activities because he / she avoids situations that precipitate the symptoms.

Individuals severely affected by anxiety disorders are also more likely to have either another type of anxiety disorder, major depression or dysthymia, alcohol or substance abuse, or a personality disorder.5 This compounds the impact of the anxiety disorder and presents challenges for effective treatment.

Economic Impact

Because they are so common, anxiety disorders have a major economic impact.6 They contribute to lost productivity due to both time away from work and unemployment. Other associated costs include claims on disability insurance.

Heavy use of the emergency department and primary care system in reaction to physical symptoms also contributes to significant health care costs.

Stigma Associated with Anxiety Disorders

Because anxiety disorders are the extension of what most people perceive as normal worry and concern, those who experience them may fear that others would label their excessive worry and fear as simply a weakness. As a result, they may try to ignore the seriousness of their condition and deal with it themselves. They often avoid seeking help and suffer in silence.

Causes of Anxiety Disorders

The development of anxiety disorders appears to result from a complex interplay of genetic, biological, developmental and other factors such as socio-economic and workplace stress. A variety of theories have been proposed to explain how these factors contribute to the development of the disorder.7

The first is experiential: people may learn their fear from an initial experience, such as an embarrassing situation, physical or sexual abuse, or the witnessing of a violent act. Similar subsequent experiences serve to reinforce the fear.

A second theory relates to cognition or thinking, in that people believe or predict that the result of a specific situation will be embarrassing or harmful. This may occur, for example, if parents are over-protective and continually warn against potential problems.

A third theory focuses on a biological basis. Research suggests that the amygdala, a structure deep within the brain, serves as a communication hub that signals the presence of a threat and triggers a fear response or anxiety. It also stores emotional memories and may play a role in the development of anxiety disorders. The children of adults with anxiety disorders are at much greater risk of an anxiety disorder than is the general population,4 which may imply a genetic factor, an effect of parenting practices, or both.

Treatment of Anxiety Disorders

Early recognition and appropriate management are imperative in order to enhance the quality of life of individuals with anxiety disorders. Proper recognition and management also help to prevent common secondary disorders, such as depression and abuse of drugs and alcohol.

The delay in seeking and receiving a diagnosis and treatment may be due to a number of factors, such as stigma, a lack of human resources, restrictive government funding systems and lack of knowledge. In addition, family physicians may not always recognize the pattern in an individual's symptoms that would lead them to a correct diagnosis. Too often, the symptoms are not taken seriously and an individual with an anxiety disorder is labelled as being emotionally unstable. Education of both the public and family physicians would help to solve this problem.

A recent review of anxiety disorders suggests that effective treatments include drug therapy (with anti-depressants or anti-anxiety drugs) and cognitive-behavioural therapy, which helps people turn their anxious thoughts into more rational and less anxietyproducing ideas.8 Support groups for individuals and families can also help develop the tools for minimizing and coping with the symptoms.

Anxiety disorders can be well managed in the primary care setting. Creating access to experts in cognitive-behaviour therapy through a shared-care model can help family physicians provide optimal care for the individuals they are treating.

When individuals with anxiety disorders are hospitalized, another associated condition is usually responsible for determining their length of stay (Figure 4-2).

Figure 4-2 Hospitalizations for anxiety disorders in general hospitals per 100,000 by by contribution to length of stay and age group, Canada, 1999/2000

Overall, hospitalization rates for anxiety disorders decreased dramatically between 1987 and 1999, by 50% among women and 46% among men, with a combined reduction of 49% (Figure 4-3).

Figure 4-3 Rates of hospitalization per 100,000 for anxiety disorders* in general hospitals by sex, Canada, 1987/88-1999/2000 (standardized to 1991 Canadian population)

Between 1987 and 1999, hospitalization rates for anxiety disorders decreased by 45% among women aged 25-44 years, and by 62% in both the 45-64 and 65+ year age groups (Figure 4-4). Among girls under 15 years of age, even though hospitalization rates remained low, there was a 52% increase over the time period.

Figure 4-4 Rates of hospitalization per 100,000 for anxiety disorders* in general hospitals among women by age, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)

Among men, the reduction in hospitalization rates for anxiety disorder in each age group reflected the reduction reported by women: a reduction of 42% among men aged 25-44 years; 58% among men aged 45-64 years; and 61% among those 65+ years of age (Figure 4-5). For boys under the age of 15 years, rates increased by 49%.

Figure 4-5 Rates of hospitalization per 100,000 for anxiety disorders* in general hospitals among men by age, Canada, 1987/88- 1999/2000 (standardized to 1991 Canadian population)

The average length of stay in general hospitals due to anxiety disorders changed very little between 1987 and 1999 (Figure 4-6).

Figure 4-6 Average length of stay in general hospitals due to anxiety disorders*, Canada, 1987/88-1999/2000

Discussion of Hospitalization Data

Since most anxiety disorders are treated outside of hospitals, hospitalization data provide a very limited picture of these disorders in Canada. The data do support the view that anxiety disorders are associated with other health problems and it is usually these, rather than anxiety disorders, that lead to hospitalization.

The decrease in hospitalization rates for anxiety may be due to bed closures and a refocusing of hospital services to ambulatory services. Hospitalizations for anxiety disorders in general hospitals among seniors have shown a dramatic decrease (much greater than any other age group) since 1987. This trend reflects the pattern for the same age group for major depression. Further research is needed to determine the reason for this trend: Is the prevalence of the disorders decreasing? Have treatment methods changed? Have outcomes improved?

The higher rates of hospitalization for anxiety disorders in general hospitals among women than men prompt several research questions: Are anxiety disorders really more common among women? Are women more likely to seek treatment than men? Are women treated differently than men, with greater use of hospitalization?

Hospitalization rates for anxiety disorders have a pronounced peak among women between 15 and 19 years of age. This peak is also found in hospitalization rates for depression and personality disorders. This suggests that women in this age group are vulnerable to mental illnesses. The reasons for this phenomenon require further clarification through research.

Future Surveillance Needs

Anxiety disorders are common among Canadians, causing not only a great deal of personal distress but also impairment of social and occupational functioning. Anxiety disorders can be effectively treated with a combination of medication and cognitive behavioural therapy.

Existing data provide a very limited profile of anxiety disorders in Canada. The available hospitalization data need to be complemented with additional data to fully monitor these disorders in Canada. Priority data needs include:

  • Incidence and prevalence of each of the anxiety disorders by age, sex and other key variables (for example, socio-economic status, education and ethnicity).
  • Impact of anxiety disorders on the quality of life of the individual and family.
  • Access to and use of primary and specialist health care services.
  • Impact of anxiety disorders on the workplace and the economy.
  • Stigma associated with anxiety disorders.
  • Access to and use of public and private mental health services.
  • Access to and use of mental health services in other systems, such as schools, criminal justice programs and facilities, and employee assistance programs.
  • Treatment outcomes.
  • Exposure to known or suspected risk and protective factors.

References

  1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: American Psychiatric Association, 1994.
  2. Offord DR, Boyle MH, Campbell D, Goering P, Lin E, Wong M et al. One-year prevalence of psychiatric disorder in Ontarians 15 to 64 years of age. Can J Psychiatry 1996;41:559-563.
  3. Bland RC, Newman SC, Orn H. Period prevalence of psychiatric disorders in Edmonton. Acta Psychiatr Scand 1988;77(Suppl 338):33-42.
  4. Dick CL, Bland RC, Newman SC. Epidemiology of psychiatric disorder in Edmonton: panic disorder. Acta Psychiatr Scand 1994;Suppl 376:45-53.
  5. Eaton WW, Kessler RC, Wittchen HU, Magee WJ. Panic and panic disorder in the United States. Am J Psychiatry 1994;151:413-420.
  6. Adult Mental Health Division, British Columbia Ministry of Health. The Provincial Strategy Advisory Committee for Anxiety Disorders. A Provincial Anxiety Disorders Strategy, 2002.
  7. Millon T, Blaneyu PH, Davis R, ed. Oxford Textbook of Psychopathology. New York: Oxford University Press, 1999.
  8. Antony MM, Swinson RP. Anxiety disorders and their treatment: a critical review of the evidencebased literature. Ottawa: Health Canada, 1996.