Showing posts with label disorder. Show all posts
Showing posts with label disorder. Show all posts
Saturday, July 12, 2008
Meningitis reference
Meningitis is inflammation of the protective membranes covering the brain and spinal cord, known collectively as the meninges. Meningitis may develop in response to a number of causes, usually bacteria, viruses and other pathogens, but also physical injury, cancer or certain drugs. While some forms of meningitis are mild and resolve on their own, meningitis is a potentially life-threatening condition due to the proximity of the inflammation to the brain and spinal cord. The potential for serious neurological damage or even death necessitates prompt medical attention and evaluation. Infectious meningitis, the most common form, is typically treated with antibiotics and requires close observation. Some forms of meningitis (such as those associated with meningococcus, mumps virus or pneumococcus infections) may be prevented with immunization.
Signs and symptoms
Severe headache is the most common symptom of meningitis (87 percent) followed by nuchal rigidity ("neck stiffness", found in 83%). The classic triad of diagnostic signs consists of nuchal rigidity (being unable to flex the neck forward), sudden high fever[1] and altered mental status. All three features are present in only 44% of all cases of infectious meningitis.[2] Other signs commonly associated with meningitis are photophobia (inability to tolerate bright light), phonophobia (inability to tolerate loud noises), irritability and delirium (in small children) and seizures (in 20-40% of cases). In infants (0-6 months), swelling of the fontanelle (soft spot) may be present.
Nuchal rigidity is typically assessed with the patient lying supine, and both hips and knees flexed. If pain is elicited when the knees are passively extended (Kernig's sign), this indicates nuchal rigidity and meningitis. In infants, forward flexion of the neck may cause involuntary knee and hip flexion (Brudzinski's sign). Although commonly tested, the sensitivity and specificity of Kernig's and Brudzinski's tests are uncertain.[3]
In "meningococcal" meningitis (i.e. meningitis caused by the bacteria Neisseria meningitidis), a rapidly-spreading petechial rash is typical, and may precede other symptoms. The rash consists of numerous small, irregular purple or red spots on the trunk, lower extremities, mucous membranes, conjunctiva, and occasionally on the palms of hands and soles of feet. Other clues to the nature of the cause may be the skin signs of hand, foot and mouth disease and genital herpes, both of which may be associated with viral meningitis.[4]
Meninigitis can be diagnosed after death has occurred. The findings from a post mortum are usually a diffuse (widespread) inflammation of the pia-arachnoid area. Neutrophil leucocytes tend to have migrated to the cerebrospinal fluid and the base of the brain, along with cranial nerves and the spinal cord, may be surrounded with pus—as may the meningeal vessels.[5]
Diagnosis
Investigations
Investigations include blood tests (electrolytes, liver and kidney function, inflammatory markers and a complete blood count) and usually X-ray examination of the chest. The most important test in identifying or ruling out meningitis is analysis of the cerebrospinal fluid (fluid that envelops the brain and the spinal cord) through lumbar puncture (LP). However, if the patient is at risk for a cerebral mass lesion or elevated intracranial pressure (recent head injury, a known immune system problem, localizing neurological signs, or evidence on examination of a raised ICP), a lumbar puncture may be contraindicated because of the possibility of fatal brain herniation. In such cases a CT or MRI scan is generally performed prior to the lumbar puncture to exclude this possibility. Otherwise, the CT or MRI should be performed after the LP, with MRI preferred over CT due to its superiority in demonstrating areas of cerebral edema, ischemia, and meningeal inflammation.
During the lumbar puncture procedure, the opening pressure is measured. A pressure of over 180 mm H2O is indicative of bacterial meningitis.
The cerebrospinal fluid (CSF) sample is examined for white blood cells (and which subtypes), red blood cells, protein content and glucose level. Gram staining of the sample may demonstrate bacteria in bacterial meningitis, but absence of bacteria does not exclude bacterial meningitis; microbiological culture of the sample may still yield a causative organism. The type of white blood cell predominantly present predicts whether meningitis is due to bacterial or viral infection. Other tests performed on the CSF sample include latex agglutination test, limulus lysates, or polymerase chain reaction (PCR) for bacterial or viral DNA. If the patient is immunocompromised, testing the CSF for toxoplasmosis, Epstein-Barr virus, cytomegalovirus, JC virus and fungal infection may be performed.
In bacterial meningitis, the CSF glucose to serum glucose ratio is < 0.4. The Gram stain is positive in >60% of cases, and culture in >80%. Latex agglutination may be positive in meningitis due to Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae, Escherichia coli, Group B Streptococci. Limulus lysates may be positive in Gram-negative meningitis.
Cultures are often negative if CSF is taken after the administration of antibiotics. In these patients, PCR can be helpful in arriving at a diagnosis. It has been suggested that CSF cortisol measurement may be helpful.[7]
Aseptic meningitis refers to non-bacterial causes of meningitis and includes infective etiologies such as viruses and fungi, neoplastic etiologies such as carcinomatous and lymphomatous meningitis, inflammatory causes such as sarcoidosis (neurosarcoidosis)) and chemical causes such as meningitis secondary to the intrathecal introduction of contrast media.
Although the term "viral meningitis" is often used in any patient with a mild meningeal illness with appropriate CSF findings, certain patients will present with clinical and CSF features of viral meningitis, yet ultimately be diagnosed with one of the other conditions categorized as "aseptic meningitis". This may be prevented by performing polymerase chain reaction or serology on CSF or blood for common viral causes of meningitis (enterovirus, herpes simplex virus 2 and mumps in those not vaccinated for this).[4]
A related diagnostic and therapeutic conundrum is the "partially treated meningitis", i.e. meningitis symptoms in patients who have already been receiving antibiotics (such as for presumptive sinusitis). In these patients, CSF findings may resemble those of viral meningitis, but antibiotic treatment may need to be continued until there is definitive positive evidence of a viral cause (e.g. a positive enterovirus PCR).[4]
Prediction rules
The Bacterial Meningitis Score predicts reliably whether a child (older than two months) may have infectious meningitis. In children with at least 1 risk factor (positive CSF Gram stain, CSF absolute neutrophil count ≥ 1000 cell/µL, CSF protein ≥ 80 mg/dL, peripheral blood absolute neutrophil count ≥ 10,000 cell/µL, history of seizure before or at presentation time) it had a sensitivity of 100%, specificity of 63.5%, and negative predictive value of 100%.[8]
Causes
Most cases of meningitis are caused by microorganisms, such as viruses, bacteria, fungi, or parasites, that spread into the blood and into the cerebrospinal fluid , Non-infectious causes include cancers, systemic lupus erythematosus and certain drugs. The most common cause of meningitis is viral, and often runs its course within a few days. Bacterial meningitis is the second most frequent type and can be serious and life-threatening. Numerous microorganisms may cause bacterial meningitis, but Neisseria meningitidis ("meningococcus") and Streptococcus pneumoniae ("pneumococcus") are the most common pathogens in patients without immune deficiency, with meningococcal disease being more common in children. Staphylococcus aureus may complicate neurosurgical operations, and Listeria monocytogenes is associated with poor nutritional state and alcoholism. Haemophilus influenzae (type B) incidence has been much reduced by immunization in many countries. Mycobacterium tuberculosis (the causative agent of tuberculosis) rarely causes meningitis in Western countries but is common and feared in countries where tuberculosis is endemic.
Initial treatment
Meningitis is a life-threatening condition and treatment should not be delayed for confirmation if suspected.[10] If a physician is present on scene then treatment should begin immediately with benzylpenicillin. High-flow oxygen should be administered as soon as possible, along with an intravenous fluids if hypotensive or in shock.[10]
Bacterial meningitis
Bacterial meningitis is a medical emergency and has a high mortality rate if untreated.[11] All suspected cases, however mild, need emergency medical attention. Empiric antibiotics must be started immediately, even before the results of the lumbar puncture and CSF analysis are known. Antibiotics started within 4 hours of lumbar puncture will not significantly affect lab results. Adjuvant treatment with corticosteroids reduces rates of mortality, severe hearing loss and neurological sequelae in adults, specifically when the causative agent is Pneumococcus.[12]
Age group Causes
Neonates Group B Streptococci, Escherichia coli, Listeria monocytogenes
Infants Neisseria meningitidis, Haemophilus influenzae, Streptococcus pneumoniae
Children N. meningitidis, S. pneumoniae
Adults S. pneumoniae, N. meningitidis, Mycobacteria, Cryptococci
The choice of antibiotic depends on local advice. In most of the developed world, the most common organisms involved are Streptococcus pneumoniae and Neisseria meningitidis: first line treatment in the UK is a third-generation cephalosporin (such as ceftriaxone or cefotaxime). In those under 3 years of age, over 50 years of age, or immunocompromised, ampicillin should be added to cover Listeria monocytogenes.[10] In the U.S. and other countries with high levels of penicillin resistance, the first line choice of antibiotics is vancomycin and a carbapenem (such as meropenem). In sub-Saharan Africa, oily chloramphenicol or ceftriaxone are often used because only a single dose is needed in most cases.
Staphylococci and gram-negative bacilli are common infective agents in patients who have just had a neurosurgical procedure. Again, the choice of antibiotic depends on local patterns of infection: cefotaxime and ceftriaxone remain good choices in many situations, but ceftazidime is used when Pseudomonas aeruginosa is a problem, and intraventricular vancomycin is used for those patients with intraventricular shunts because of high rates of staphylococcal infection. In patients with intracerebral prosthetic material (metal plates, electrodes or implants, etc.) then sometimes chloramphenicol is the only antibiotic that will adequately cover infection by Staphylococcus aureus (cephalosporins and carbapenems are inadequate under these circumstances).
Once the results of the CSF analysis are known along with the Gram-stain and culture, empiric therapy may be switched to therapy targeted to the specific causative organism and its sensitivities.[citation needed]
* Neisseria meningitidis (Meningococcus) can usually be treated with a 7-day course of IV antibiotics:
o Penicillin-sensitive -- penicillin G or ampicillin
o Penicillin-resistant -- ceftriaxone or cefotaxime
o Prophylaxis for close contacts (contact with oral secretions) -- rifampin 600 mg bid for 2 days (adults) or 10 mg/kg bid (children). Rifampin is not recommended in pregnancy and as such, these patients should be treated with single doses of ciprofloxacin, azithromycin, or ceftriaxone
* Streptococcus pneumoniae (Pneumococcus) can usually be treated with a 2-week course of IV antibiotics:
o Penicillin-sensitive -- penicillin G
o Penicillin-intermediate -- ceftriaxone or cefotaxime
o Penicillin-resistant -- ceftriaxone or cefotaxime + vancomycin
* Listeria monocytogenes is treated with a 3-week course of IV ampicillin + gentamicin.
* Gram negative bacilli -- ceftriaxone or cefotaxime
* Pseudomonas aeruginosa -- ceftazidime
* Staphylococcus aureus
o Methicillin-sensitive -- nafcillin
o Methicillin-resistant -- vancomycin
* Streptococcus agalactiae -- penicillin G or ampicillin
* Haemophilus influenzae -- ceftriaxone or cefotaxime
Viral meningitis
Patients diagnosed with mild viral meningitis may improve quickly enough to not require admission to a hospital, while others may be hospitalized for many more days for observation and supportive care. Overall, the illness is usually much less severe than bacterial meningitis.
Unlike bacteria, viruses cannot be killed by antibiotics. Drugs such as acyclovir may be employed if herpes virus infection is either suspected or demonstrated.[4]
Fungal meningitis
This form of meningitis is rare in otherwise healthy people but is a higher risk in those who have AIDS, other forms of immunodeficiency (an immune system that does not respond adequately to infections) and immunosuppression (immune system malfunction as a result of medical treatment). In AIDS, Cryptococcus neoformans is the most common cause of fungal meningitis; it requires Indian ink staining of the CSF sample for identification of this capsulated yeast. Fungal meningitis is treated with long courses of highly dosed antifungals.[13]
Complications
In children there are several potential disabilities which result from damage to the nervous system. These include sensorineural hearing loss, epilepsy, diffuse brain swelling, hydrocephalus, cerebral vein thrombosis, intra cerebral bleeding and cerebral palsy.[14] Acute neurological complications may lead to adverse consequences. In childhood acute bacterial meningitis deafness is the most common serious complication. Sensorineural hearing loss often develops during first few days of the illness as a result of inner ear dysfunction, but permanent deafness is rare and can be prevented by prompt treatment of meningitis.[15]
Those that contract the disease during the neonatal period and those infected by S. pneumoniae and gram negative bacilli are at greater risk of developing neurological, auditory, or intellectual impairments or functionally important behaviour or learning disorders which can manifest as poor school performance.[16]
In adults central nervous system complications include brain infarction, brain swelling, hydrocephalus, intracerebral bleeding; systemic complications are dominated by septic shock, adult respiratory distress syndrome and disseminated intravascular coagulation.[17] Those who have underlying predisposing conditions e.g. head injury may develop recurrent meningitis.[18] Case-fatality ratio is highest for gram-negative etiology and lowest for meningitis caused by H. influenzae (also a gram negative bacilli). Fatal outcome in patients over 60 years of age is more likely to be from systemic complications e.g. pneumonia, sepsis, cardio-respiratory failure; however in younger individuals it is usually associated with neurological complications.[18] Age more than 60, low Glasgow coma scale at presentation and seizure within 24 hours increase the risk of death among community acquired meningitis.[19]
Immunization
Vaccinations against Haemophilus influenzae (Hib) have decreased early childhood meningitis significantly.[20]
Vaccines against type A and C Neisseria meningitidis, the kind that causes most disease in preschool children and teenagers in the United States, have also been around for a while. Type A is also prevalent in sub-Sahara Africa and W135 outbreaks have affected those on the Hajj pilgrimage to Mecca. Immunisation with the ACW135Y vaccine against four strains is now a visa requirement for taking part in the Hajj.[21]
Vaccines against type B Neisseria meningitidis are much harder to produce, as its capsule is very weakly immunogenic masking its antigenic proteins. There is also a risk of autoimmune response, and the porA and porB proteins on Type B resemble neuronal molecules. A vaccine called MeNZB for a specific strain of type B Neisseria meningitidis prevalent in New Zealand has completed trials and is being given to many people in the country under the age of 20 free of charge. There is also a vaccine, MenBVac, for the specific strain of type B meningoccocal disease prevalent in Norway, and another specific vaccine for the strain prevalent in Cuba.[citation needed] According to reports released in May 2008, Novartis is in the advanced stages of testing a general meningococcus type B vaccine.[22]
Pneumococcal polysaccharide vaccine against Streptococcus pneumoniae is recommended for all people 65 years of age or older. Pneumococcal conjugate vaccine is recommended for all newborns starting at 6 weeks - 2 months, American Academy of Pediatrics (AAP) recommendations.[23]
Mumps vaccination has led to a sharp decline in mumps virus associated meningitis, which prior to vaccination occurred in 15% of all cases of mumps.[4]
Prophylaxis
In cases of meningococcal meningitis, prophylactic treatment of close relatives with antibiotics (e.g. rifampicin, ciprofloxacin or ceftriaxone) may reduce the risk of further cases.[24]
Epidemiology
Demography of meningococcal meningitis. Red: meningitis belt, orange: epidemic meningitis, grey: sporadic cases
Demography of meningococcal meningitis. Red: meningitis belt, orange: epidemic meningitis, grey: sporadic cases
Meningitis can affect anyone in any age group, from the newborn to the elderly.
The "Meningitis Belt" is an area in sub-Saharan Africa which stretches from Senegal in the west to Ethiopia in the east in which large epidemics of meningococcal meningitis occur (this largely coincides with the Sahel region). It contains an estimated total population of 300 million people. The largest epidemic outbreak was in 1996, when over 250,000 cases occurred and 25,000 people died as a consequence of the disease.
History
Meningitis was first described in the 1020s in Avicenna's The Canon of Medicine,[25] and again more accurately by Avenzoar of al-Andalus in the 12th century.[26] Symptoms of the disease were also noted in 1805 by the Swiss Gabinetto Vieusseux (a scientific-literary association) during an outbreak in Geneva, Switzerland. In 1887, Dr. Anton Weichselbaum (1845-1920) of Vienna became the first to isolate the specific germ, meningococcus.[27]
In the 19th century, meningitis was a scourge of the Japanese imperial family, playing the largest role in the horrendous pre-maturity mortality rate the family endured. In the mid-1800s, only the Emperor Kōmei and two of his siblings reached maturity out of fifteen total children surviving birth. Kōmei's son, the Emperor Meiji, was one of two survivors out of Kōmei's six children, including an elder brother of Meiji who would have taken the throne had he lived to maturity. Five of Meiji's 15 children survived, including only his third son, Emperor Taishō, who was feeble-minded, perhaps as a result of having contracted meningitis himself. By Emperor Hirohito's generation the family was receiving modern medical attention. As the focal point of tradition in Japan, during the Tokugawa Shogunate the family was denied modern "Dutch" medical treatment then in use among the upper caste; despite extensive modernization during the Meiji Restoration the Emperor insisted on traditional medical care for his children.
Meningococcal disease reference
Meningococcal disease describes infections caused by Neisseria meningitidis (also termed meningococcus) and carries a high mortality rate if untreated. Whilst best known as a cause of meningitis, wide spread blood infection (septicemia) is more damaging and dangerous.
Types of infection
Septicemia
Meningococcal septicemia, like many gram-negative blood infections, can cause disseminated intravascular coagulation (DIC), a condition where blood starts to clot throughout the body, sometimes causing ischemic tissue damage. DIC also causes bleeding, when the clotting factors are used up, causing the characteristic purpuric rash.
Prevention
The most important form of prevention is a vaccine against Neisseria meningitidis. Different countries have different strains of the bacteria and therefore use different vaccines. Five serogroups, A, B, C, Y and W135 are responsible for virtually all cases of the disease in humans. Vaccines are currently available against four of the five strains, and a vaccine against the B strain is in development. Menactra and Menomune are two commonly used vaccines. Unfortunately, there is currently no evidence that any of the current vaccines offer significant protection beyond three years.
Additionally, basic hygiene measures, such as handwashing and not sharing drinking cups, can reduce the incidence of infection by limiting exposure.
When a case is confirmed, all close contacts with the infected person can be offered antibiotics to reduce the likelihood of the infection spreading to other people.
Types of infection
Septicemia
Meningococcal septicemia, like many gram-negative blood infections, can cause disseminated intravascular coagulation (DIC), a condition where blood starts to clot throughout the body, sometimes causing ischemic tissue damage. DIC also causes bleeding, when the clotting factors are used up, causing the characteristic purpuric rash.
Prevention
The most important form of prevention is a vaccine against Neisseria meningitidis. Different countries have different strains of the bacteria and therefore use different vaccines. Five serogroups, A, B, C, Y and W135 are responsible for virtually all cases of the disease in humans. Vaccines are currently available against four of the five strains, and a vaccine against the B strain is in development. Menactra and Menomune are two commonly used vaccines. Unfortunately, there is currently no evidence that any of the current vaccines offer significant protection beyond three years.
Additionally, basic hygiene measures, such as handwashing and not sharing drinking cups, can reduce the incidence of infection by limiting exposure.
When a case is confirmed, all close contacts with the infected person can be offered antibiotics to reduce the likelihood of the infection spreading to other people.
Menopause reference
Menopause is the complete shutting down of the female reproductive system. The word literally means the permanent physiological, or natural, cessation of menstrual cycles, from the Greek roots 'meno' (month) and 'pausis' (cessation). In other words, menopause is the natural and permanent stopping of the monthly female reproductive cycles, and in human females who still have a uterus, this is traditionally indicated by a permanent absence of monthly periods or menstruation.
The word is most commonly used in regard to human females, where menopause happens more or less in midlife, signaling the end of the fertile phase of a woman's life. Menopause is perhaps most easily understood as the opposite process to menarche.
Menopause in women cannot be defined simply as the permanent "stopping of the monthly periods", because in reality what is happening to the uterus is quite secondary to the process. For medical reasons, the uterus is sometimes surgically removed (hysterectomy) in a younger woman, and after this her periods will cease permanently, and the woman will technically be infertile, but as long as at least one of her ovaries is still functioning, the woman will not have entered menopause. This is because even without the uterus, still, ovulation and the release of the sequence of reproductive hormones that are an essential part of the reproductive cycles, will continue until the time of menopause is reached.
Menopause is triggered by the faltering, shutting down, or surgical removal of the ovaries, which are a part of the body's endocrine system of hormone production, in this case the hormones which make reproduction possible and influence sexual behavior.
The process of the ovaries shutting down is a phenomenon which involves the entire cascade of a woman's reproductive functioning, from brain to skin, and this major physiological event usually has some effect on almost every aspect of a woman's body and life.
It is worth pointing out however that the menopause transition, and post-menopause itself, is a natural life change, not a disease state or a disorder. The transition itself can be challenging for a number of women, but for others it is not difficult.
Overview
Menopause starts as the ovaries begin to fail to be able to produce an egg or ovum every month. Since the process of producing and ripening the egg is also what creates several of the key hormones involved in the monthly cycle, this in turn interrupts the regular pattern of the hormone cycles, and gradually leads to the somewhat chaotic and long-drawn out shutting down of the whole reproductive system.
The break-up in the pattern of the menstrual cycles not only causes the levels of most of the reproductive hormones to drop over time, but also causes the reproductive hormones to fall out of phase with one another, which often leads to extreme and unpredictable fluctuations in the levels, which itself can cause numerous effects in many women, such as hot flashes.
After a number of years of erratic functioning, the ovaries almost completely stop producing progesterone and two out of the three estrogen hormones: estradiol and estriol. Estrone is one estrogen which is still produced in reasonable amounts in post-menopausal women. Testosterone levels decrease; however, a decrease in testosterone levels begins gradually in young adulthood. Testosterone levels are thought not to drop significantly during the menopause transition because the stroma of the postmenopausal ovary and the adrenal gland still continue to secrete small amounts of testosterone, even during post-menopause.
Because of the various hormonal changes, the reproductive system ceases to function.
Menopause is the end of the reproductive years rather than the beginning, and thus it is the opposite of menarche. Nonetheless, it can usefully be compared with that event. The menopause transition years are in many ways similar to puberty in reverse. The psychological and social challenges of the Change are also somewhat similar to those encountered during adolescence.
Age of onset
The average age of menopause in the Western world is 51 years, and the normal age range for the occurrence of menopause is somewhere between the age of 45 and 55.
Last period ever occurring between the ages of 55 to 60 is known as a "late menopause". An "early menopause" on the other hand is defined as last period ever between the age of 40 to 45.
Rarely the ovaries stop working at a very early age, anywhere from the age of puberty to age 40, and this is known as premature ovarian failure (POF), also commonly referred to as "premature menopause". 1% of women experience POF, and it is not considered to be due to the normal effects of aging. Some known causes of premature menopause include autoimmune disorders, thyroid disease, diabetes mellitus, chemotherapy, and radiotherapy. However, in the majority of spontaneous cases of premature menopause, the cause is unknown.
Premature menopause is diagnosed or confirmed by measuring the levels of follicle stimulating hormone (FSH) and luteinizing hormone (LH); the levels of these hormones will be abnormally high if menopause has occurred. Rates of premature menopause have been found to be significantly higher in fraternal and identical twins; approximately 5% of twins reach menopause before the age of 40. The reasons for this are not completely understood. Transplants of ovarian tissue between identical twins have been successful in restoring fertility.
Menopause in other species
Menopause in the animal kingdom appears perhaps to be somewhat uncommon, although the incidence in different species has by no means been thoroughly researched. However, it is already quite apparent that humans are not the only species that experience it. Menopause has been observed in rhesus monkeys[1], some cetaceans[2], as well as in a variety of other species of vertebrates including the guppy, the platyfish, the budgerigar, the laboratory rat and mouse, the opossum, and all manner of primates[3]
Menopause in human evolution
The Grandmother hypothesis suggests that menopause evolved in humans because it promotes the survival of grandchildren. According to this hypothesis, post reproductive women feed and care for children, adult nursing daughters, and grandchildren whose mothers have weaned them. Human babies require large and steady supplies of glucose to feed the growing brain. In infants in the first year of life, the brain consumes 60% of all calories, so both babies and their mothers require a dependable food supply. Some evidence suggests that hunters contribute less than half the total food budget of most hunter-gatherer societies, and often much less than half, so that foraging grandmothers can contribute substantially to the survival of grandchildren at times when mothers and fathers are unable to gather enough food for all the children. In general, selection operates most powerfully during times of famine or other privation. So although grandmothers might not be necessary during good times, many grandchildren cannot survive without them during times of famine.
Social and psychological significance
The shutting down of the female reproductive system in midlife ushers in the third part of a woman's life. Many women in Western culture live long enough that half of their adult life is spent in post-menopause. The menopause transition is a major life change, similar to menarche in the magnitude of its social and psychological significance. In the ancient past, menarche and menopause were considered to mark the transitions from "maiden" to "matron", and from "matron" to "crone". Whereas the significance of the changes that surround menarche is still fairly well recognized, in countries such as the USA, the social and psychological ramifications of the menopause transition are frequently ignored or underestimated.
Menopause
Clinically speaking, menopause is a date: for those women who still have a uterus, menopause is defined as the day after a woman's final period finishes. This date is fixed retrospectively, once 12 months have gone by with no menstrual flow at all.
In common everyday parlance however, the word "menopause" is usually not used to refer to one day, but to the whole of the menopause transition years. This span of time is also referred to as the change of life, the change, or the climacteric and more recently is known as "perimenopause", (literally meaning "around menopause").
Perimenopause
In biomedicine, perimenopause means the menopause transition years, the years both before and after the last period (although the "last period" can be determined only retroactively). During perimenopause, many women find that they undergo symptoms of hormonal fluctuation, such as hot flashes, that cause them to seek medical advice. Mood changes, insomnia, fatigue, memory problems, and other "symptoms" formerly associated with menopause are sometimes considered to be unrelated. Depression in women is sometimes associated with the midlife and linked to menopause, but this too is a questionable association. Not enough research has been done to clarify any of these issues. However, for cultural reasons, even women who are asymptomatic or have minor symptoms may find themselves in a psychosocial transition.
During perimenopause, the production of most of the reproductive hormones, including the estrogens, progesterone and testosterone, diminishes and becomes more irregular, often with wide and unpredictable fluctuations in levels. During this period, fertility diminishes, but is not considered to reach zero until the official date of menopause is reached, and this date, as previously mentioned, can only be determined retrospectively.
Symptoms of the menopause transition can begin as early as age 35, although most women who become aware of them do so about 10 years later, often in their mid to late 40s. The duration of perimenopause with noticeable effects can be a few years, ten years or even longer.
The actual duration and severity of perimenopause in any individual woman cannot be predicted in advance or during the process.
One piece of recent research appears to show that melatonin supplementation in perimenopausal women can produce a highly significant improvement in thyroid function and gonadotropin levels, as well as restoring fertility and menstruation and preventing the depression associated with the menopause[4].
Perimenopause is a relatively new term. The use of it has criticized by some cultural commentators[who?][citation needed], because they feel that it extends the negative connotations of menopause (namely symptomology) over many more years of a woman's life.
Premenopause
Premenopause is a word used to describe the years leading up to the last period ever, when the levels of reproductive hormones are already becoming lower and more erratic, and the effects of hormone withdrawal may be present.
Postmenopause
Postmenopause is all of the time in a woman's life that take place after her last period ever, or more accurately, all of the time that follows the point when her ovaries become inactive.
A woman who still has her uterus can be declared to be in post-menopause once she has gone 12 full months with no flow at all, not even any spotting. When she reaches that point, she is one year into post-menopause. The reason for this delay in declaring a woman post-menopausal is because periods become very erratic at this time of life, and therefore a reasonably long stretch of time is necessary to be sure that the cycling has actually ceased completely.
In women who have no uterus, and therefore have no periods, post-menopause can be determined by a blood test which can reveal the very high levels of Follicle Stimulating Hormone (FSH) that are typical of post-menopausal women.
A woman's reproductive hormone levels continue to drop and fluctuate for some time into post-menopause, so any hormone withdrawal symptoms that a woman may be experiencing do not necessarily stop right away, but may take quite some time, even several years, to disappear completely.
Any period-like flow that might occur during post-menopause, even just spotting, must be reported to a doctor. The cause may in fact be minor, but the possibility of endometrial cancer must be checked for and eliminated.
The causes of menopause
The causes of menopause can be considered from complementary proximate (mechanistic) and ultimate (adaptive evolutionary) perspectives.
From a proximate perspective: A natural or physiological menopause is that which occurs as a part of a woman's normal aging process. It is the result of the eventual atresia of almost all oocytes in the ovaries. This causes an increase in circulating follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels as there are a decreased number of oocytes responding to these hormones and producing estrogen. This decrease in the production of estrogen leads to the perimenopausal symptoms of hot flashes, insomnia and mood changes, as well as post-menopausal osteoporosis and vaginal atrophy.
However, menopause can be surgically induced by bilateral salpingo-oophorectomy (removal of both ovaries and both fallopian tubes), which is often, but not always, done in conjunction with hysterectomy. Cessation of menses as a result of removal of the ovaries is called "surgical menopause". The sudden and complete drop in reproductive hormone levels usually produces extreme hormone-withdrawal symptoms such as hot flashes, etc.
As mentioned above, removal of the uterus, hysterectomy, does not itself cause menopause, although pelvic surgery can sometimes precipitate a somewhat earlier menopause, perhaps because of a compromised blood supply to the ovaries. Removing the ovaries however, causes an immediate and powerful "surgical menopause", even if the uterus is left intact.
Cigarette smoking has been found to decrease the age at menopause by as much as one year, and women who have undergone hysterectomy with ovary conservation go through menopause 3.7 years earlier than average. However, premature menopause (before the age of 40) is generally idiopathic.
An ultimate perspective on menopause has already been given above, in the "Menopause in human evolution" section.
Possible effects of perimenopause, the menopause transition time
As the body responds to the rapidly changing levels of natural hormones, a number of effects can appear. It is however worth pointing out, that not every woman experiences bothersome levels of these effects, and even in those women who do experience strong effects, the range of effects and the degree to which they appear is very variable from person to person.
Those effects that are due to low estrogen levels (for example vaginal atrophy and skin drying) remain present even after the menopause transition years are over, however, many of the effects that are caused by the extreme fluctuations in hormone levels (for example hot flashes and mood changes) usually disappear or improve significantly once the perimenopause transition time has been completed.
Both users and non-users of hormone replacement therapy identify lack of energy as the most frequent and distressing effect[5]
Other effects can include vasomotor symptoms such as hot flashes and palpitations, psychological effects such as depression, anxiety, irritability, mood swings, memory problems and lack of concentration, and atrophic effects such as vaginal dryness and urgency of urination.
The average woman also has increasingly erratic menstrual periods, due to skipped ovulations. Typically the timing of the flow becomes unpredictable. In addition the duration of the flow may be considerably shorter or longer than normal, and the flow itself may be significantly heavier or lighter than was previously the case, including sometimes long episodes of spotting. Early in the process it is not uncommon to have some 2-week cycles. Further into the process it is common to skip periods for months at a time, and these skipped periods may be followed by a heavier period. The number of skipped periods in a row often increases as the time of last period approaches.
As mentioned above, when a woman of menopausal age has not had a period or any spotting for 12 months, at that point she is considered to be one year into post-menopause. However, a period after 6 months of no flow at all is sometimes considered worthy of investigation by a doctor.
All the various possible perimenopause effects are caused by an overall drop, as well as dramatic but erratic fluctuations, in the absolute levels and relative levels of estrogens and progesterone. Some of the effects, such as formication, may be associated directly with hormone withdrawal.
Vasomotor instability
* hot flashes or hot flushes, including night sweats and, in a few people, cold flashes
* sleep disturbances, poor quality sleep, light sleep, insomnia
Urogenital atrophy, also known as vaginal atrophy, (main article: Atrophic vaginitis)
* thinning of the membranes of the vulva and the outer urinary tract, along with considerable shrinking and loss in elasticity of all of the outer and inner genital areas
* itching
* dryness
* bleeding
* watery discharge
* urinary frequency
* urinary urgency
* urinary incontinence
* increased susceptibility to inflammation and infection, for example vaginal candidiasis, and urinary tract infections
Skeletal
* osteopenia and the risk of osteoporosis gradually developing over time
* joint pain, muscle pain
* back pain
Skin, soft tissue
* breast atrophy
* skin thinning and becoming drier
* decreased elasticity of the skin
* formication, a sensation rather like pins and needles, more specifically like ants crawling on or under the skin
Psychological
* mood disturbance
* irritability
* fatigue
* memory loss, and problems with concentration
* depression and/or anxiety
Sexual
* decreased libido
* vaginal dryness and vaginal atrophy
* problems reaching orgasm
* dyspareunia or painful intercourse
One cohort study found that menopause was associated with hot flashes; joint pain and muscle pain; and depressed mood.[6] In the same study, it appeared that menopause was not associated with poor sleep, decreased libido, and vaginal dryness.[6]
Need for more education about menopause
Many women arrive at their menopause years without knowing anything about what they might expect, or when or how the process might happen, and how long it might take. Very often a woman has not been informed in any way about this stage of life by her physician or by her social group.
In the USA at least, there appears to be a lingering taboo which hangs over this subject. As a result, a woman who happens to undergo a strong perimenopause with a large number of different symptoms, may become confused and anxious, fearing that something abnormal is happening to her. There is a strong need for more information and more education on this subjec
Treatment
Perimenopause is a natural stage of life, not a disease or a disorder, and therefore it does not automatically require any kind of treatment. However when the bodily effects of perimenopause are severe and disruptive, they may be alleviated through medical treatments.
Hormone replacement therapy or HRT, known in Britain as Hormone Therapy or HT, and the SSRIs appear to provide the most reliable pharmaceutical relief. However, adverse effects of one kind of HRT (equine estrogen combined with a synthetic progestin) are now well documented. See the section below on "Adverse effects of conjugated equine estrogens".
A woman and her doctor should carefully review her situation, her complaints and her relative risk before determining whether the benefits of HT/HRT or other therapies outweigh the risks. Until more becomes understood about the possible risks, women who elect to use hormone replacement therapy are generally well advised to take the lowest effective dose of hormones for the shortest period possible, and to question their doctors as to whether certain forms might pose fewer dangers of clots or cancer than others.
Alternative dietary supplements for treatment of menopause symptoms afford anywhere from significant to moderate relief of these symptoms. Some botanical sources, referred to as phytoestrogens, are known to have an estrogenic effect on the body and therefore create a moderated estrogenic effect. Others, such as femarelle, were found to have Selective Estrogen Receptor Modulator (SERM) qualities [7], thereby reducing the safety risks involved in estrogenic-like treatments.
Hormone therapy, also known as hormone replacement therapy
In addition to relief from hot flashes, hormone therapy remains an effective treatment for osteoporosis.
In HT or HRT, one or more estrogens, usually in combination with progesterone, (and sometimes testosterone) are administered, not only to partially compensate for the body's loss of these hormones, but also in an attempt to keep the levels of these hormones in the body much more consistent than they are naturally in perimenopause.
In those women who have no uterus (usually due to a previous hysterectomy) estrogen alone is a suitable hormone therapy. Women who still have a uterus need to take progesterone in addition to estrogen, in order to ensure that the endometrium, the lining of the uterus, does not build up too much, which would be a risk for cancer of the endometrium.
There are several types of hormone therapies, with various possible side effects.
Conjugated equine estrogens
Conjugated equine estrogens contain estrogen molecules conjugated to hydrophilic side groups (e.g. sulfate) and are produced from the urine of pregnant Equidae (horses) mares. Premarin is the prime example of this, either alone or in Prempro, where it is combined with a synthetic progestin, medroxyprogesterone acetate. However Premarin, and especially Prempro, are associated with serious health risks.[8]
In January 2003, the FDA required Wyeth to affix a "black box" warning to PremPro, stating
"WARNING
Estrogens and progestins should not be used for the prevention of cardiovascular disease. The Women’s Health Initiative (WHI) reported increased risks of myocardial infarction, stroke, invasive breast cancer, pulmonary emboli, and deep vein thrombosis in postmenopausal women during 5 years of treatment with conjugated equine estrogens (0.625 mg) combined with medroxyprogesterone acetate (2.5 mg) relative to placebo
Adverse effects of conjugated equine estrogens
Women had been advised for many years by numerous doctors and drug company marketing efforts (at least in the USA) that hormone therapy with conjugated equine estrogens after menopause might reduce their risk of heart disease and prevent various aspects of aging. However, a large, randomized, controlled trial (the Women's Health Initiative) found that women undergoing HT or HRT with conjugated equine estrogens (Premarin), whether or not used in combination with a synthetic progestin (Premarin plus Provera, known as Prempro), had an increased risk of breast cancer, heart disease, stroke, and Alzheimer's disease. Although this increase in risk was small overall, it passed the thresholds that had been established by the researchers in advance as sufficient to ethically require stopping the study.
When these results were first reported in 2002, the popular media sensationalized the story and exaggerated the risk, while the manufacturer continued to attempt to minimize the degree of risk. However most news stories failed to mention that the average age of the women in WHI was 62 years old, significantly older than the time when most doctors start patients on HRT, and in fact many years into postmenopause. In order to enroll in the study, patients had to be asymptomatic of hot flashes, so they would not know whether they received the placebo. For these reasons WHI was not representative of generally accepted clinical practice.
The 2002 and 2003 announcements of the Women's Health Initiative of the American National Institute of Health and The Million Women Study of the UK Cancer Research and National Health Service collaboration respectively, that HRT treatment coincides with a increased incidence of breast cancer, heart attacks and strokes, lead to a sharp decline in HRT prescription throughout the world [9][10][11], which was followed by a decrease in breast cancer incidence [12][13][14].
On hearing the news about the WHI study, many women discontinued equine estrogens altogether, with or without their doctor's approval. The number of prescriptions written for Premarin and PremPro in the United States dropped within a year almost to half of their previous level. This sharp drop in usage was followed by large and successively larger drops in new breast cancer diagnoses, at six months, one year, and 18 months after the drop in Premarin and Prempro prescriptions, for a cumulative 15% drop by the end of 2003. However, the apparent meaning of this correlation is called into question by the fact that prescriptions of Prempro and Premarin fell dramatically in Canada as well, but no similarly dramatic drop in Canada's breast cancer rates was observed during the same time period. Studies designed to track the further progression of this trend after 2003 are under way, as well as studies designed to quantify how much of the drop was related to the reduced use of HT/HRT.
Other forms of hormone therapy
The adverse biological effects of xenoestrogens and progestins revealed by studies of Premarin and PremPro do not necessarily generalize to supplementation with human forms of estrogen and progesterone. For example, a pilot study reported in JAMA by Smith, Heckbert, et al.[15] found clinical evidence that oral conjugated equine estrogens caused clotting, but the other estrogen compound tested in the same study, bioidentical esterified estrogens, does not. conjugated equine estrogens were found to be associated with increased venous thrombotic risk. In sharp contrast, the study found that users of esterified estrogen had no increase in venous thrombotic risk.
Due to the controversy about Premarin-based hormone therapy, a number of doctors are now moving patients who request hormone therapy to help them through perimenopause, to bioidentical hormone products.
Estrace is a form of the precursor to estrogen in the human body known as estradiol, which products have produced fewer side effects than conjugated equine estrogens[16]. Prometrium is a bioidentical progesterone which can be used in conjunction with Estrace.
However, all hormone replacement therapies probably do carry some health risks, including high blood pressure, blood clots, and increased risks of breast and uterine cancers. Women who have had a hysterectomy seem to tolerate estrogen-only therapy better than mixed-hormone therapy.
Selective Estrogen Receptor Modulator's (SERM's)
SERM's are a category of drugs that act selectively as agonists or antagonists on the estrogen receptors throughout the body. While most SERM's are known to increase hot flushes, Femarelle (DT56a) decreases them[17][18]. In addition to the relieving effects on menopausal symptoms, Femarelle also increases bone mass density (BMD) [19], making it protective against osteoporotic fractures. These effects are achieved by an agonistic interaction with estrogen receptors in the brain and bone. On the other hand, an antagonist interaction with estrogen receptors in the breast [20] and uterus[21] [22], has no effect on these tissues.
Antidepressants
Antidepressants such as paroxetine (Paxil), Fluoxetine hydrochloride (Prozac), and Venlafaxine hydrochloride (Effexor) have been used with some success in the treatment of hot flashes, improving sleep, mood, and quality of life. There is a theoretical reason why SSRI antidepressants might help with memory problems-- they increase circulating levels of the neurotransmitter serotonin in the brain and restore hippocampal function. Prozac has been repackaged as Sarafem and is approved and prescribed for premenstrual dysphoric disorder (PMDD), a mood disorder often exacerbated during perimenopause and early menopause. PMDD has been found by PET scans to be accompanied by a sharp drop in serotonin in the brain and to respond quickly and powerfully to SSRIs.
Blood pressure medicines
About as effective as antidepressants for hot flashes, but without the other mind and mood benefits of antidepressants, are blood pressure medicines including clonidine (Catapres). These drugs may merit special consideration by women suffering both from high blood pressure and hot flashes.
Complementary and alternative therapies
Medical non-hormone treatments provide less than complete relief, and each has side effects.
In the area of complementary and alternative therapies, acupuncture treatment is promising. There are some studies indicating positive effects, especially on hot flashes [23][24][25] but also others [26] showing no positive effects of acupuncture regarding menopause.
There are claims that soy isoflavones are beneficial concerning menopause. However, one study [27] indicated that soy isoflavones did not improve or appreciably affect cognitive functioning in postmenopausal women.
Other remedies which in studies appear to be no better than a placebo at treating hot flashes and other menopause symptoms include red clover isoflavone extracts and black cohosh. Black cohosh can cause the stimulation of pre-existing breast cancer.
Other therapies
Vaginal moisturizers such as Replens can help women with thinning vaginal tissue or dryness, and lubricants such as K-Y Jelly or Astroglide, can help with lubrication difficulties that may be present during intercourse. It is worth pointing out that moisturizers and lubricants are different products for different issues: some women feel unpleasantly dry all of the time apart from during sex, and they may do better with moisturizers all of the time. Those who need only lubricants are fine just using the lubrication products during intercourse.
Low-dose prescription vaginal estrogen products such as Estrace cream or the Estring are generally a safe way to use estrogen topically, in order to help vaginal thinning and dryness problems (see vaginal atrophy) while only minimally increasing the levels of estrogen in the bloodstream.
In terms of managing hot flashes, lifestyle measures, such as drinking cold liquids, staying in cool rooms, using fans, removing excess clothing layers when a hot flash strikes, and avoiding hot flash triggers such as hot drinks, spicy foods, etc, may partially supplement (or even obviate) the use of medications for some women.
Individual counseling or support groups can sometimes be helpful to handle sad, depressed, anxious or confused feelings women may be having as they pass through what can be for some a very challenging transition time.
The word is most commonly used in regard to human females, where menopause happens more or less in midlife, signaling the end of the fertile phase of a woman's life. Menopause is perhaps most easily understood as the opposite process to menarche.
Menopause in women cannot be defined simply as the permanent "stopping of the monthly periods", because in reality what is happening to the uterus is quite secondary to the process. For medical reasons, the uterus is sometimes surgically removed (hysterectomy) in a younger woman, and after this her periods will cease permanently, and the woman will technically be infertile, but as long as at least one of her ovaries is still functioning, the woman will not have entered menopause. This is because even without the uterus, still, ovulation and the release of the sequence of reproductive hormones that are an essential part of the reproductive cycles, will continue until the time of menopause is reached.
Menopause is triggered by the faltering, shutting down, or surgical removal of the ovaries, which are a part of the body's endocrine system of hormone production, in this case the hormones which make reproduction possible and influence sexual behavior.
The process of the ovaries shutting down is a phenomenon which involves the entire cascade of a woman's reproductive functioning, from brain to skin, and this major physiological event usually has some effect on almost every aspect of a woman's body and life.
It is worth pointing out however that the menopause transition, and post-menopause itself, is a natural life change, not a disease state or a disorder. The transition itself can be challenging for a number of women, but for others it is not difficult.
Overview
Menopause starts as the ovaries begin to fail to be able to produce an egg or ovum every month. Since the process of producing and ripening the egg is also what creates several of the key hormones involved in the monthly cycle, this in turn interrupts the regular pattern of the hormone cycles, and gradually leads to the somewhat chaotic and long-drawn out shutting down of the whole reproductive system.
The break-up in the pattern of the menstrual cycles not only causes the levels of most of the reproductive hormones to drop over time, but also causes the reproductive hormones to fall out of phase with one another, which often leads to extreme and unpredictable fluctuations in the levels, which itself can cause numerous effects in many women, such as hot flashes.
After a number of years of erratic functioning, the ovaries almost completely stop producing progesterone and two out of the three estrogen hormones: estradiol and estriol. Estrone is one estrogen which is still produced in reasonable amounts in post-menopausal women. Testosterone levels decrease; however, a decrease in testosterone levels begins gradually in young adulthood. Testosterone levels are thought not to drop significantly during the menopause transition because the stroma of the postmenopausal ovary and the adrenal gland still continue to secrete small amounts of testosterone, even during post-menopause.
Because of the various hormonal changes, the reproductive system ceases to function.
Menopause is the end of the reproductive years rather than the beginning, and thus it is the opposite of menarche. Nonetheless, it can usefully be compared with that event. The menopause transition years are in many ways similar to puberty in reverse. The psychological and social challenges of the Change are also somewhat similar to those encountered during adolescence.
Age of onset
The average age of menopause in the Western world is 51 years, and the normal age range for the occurrence of menopause is somewhere between the age of 45 and 55.
Last period ever occurring between the ages of 55 to 60 is known as a "late menopause". An "early menopause" on the other hand is defined as last period ever between the age of 40 to 45.
Rarely the ovaries stop working at a very early age, anywhere from the age of puberty to age 40, and this is known as premature ovarian failure (POF), also commonly referred to as "premature menopause". 1% of women experience POF, and it is not considered to be due to the normal effects of aging. Some known causes of premature menopause include autoimmune disorders, thyroid disease, diabetes mellitus, chemotherapy, and radiotherapy. However, in the majority of spontaneous cases of premature menopause, the cause is unknown.
Premature menopause is diagnosed or confirmed by measuring the levels of follicle stimulating hormone (FSH) and luteinizing hormone (LH); the levels of these hormones will be abnormally high if menopause has occurred. Rates of premature menopause have been found to be significantly higher in fraternal and identical twins; approximately 5% of twins reach menopause before the age of 40. The reasons for this are not completely understood. Transplants of ovarian tissue between identical twins have been successful in restoring fertility.
Menopause in other species
Menopause in the animal kingdom appears perhaps to be somewhat uncommon, although the incidence in different species has by no means been thoroughly researched. However, it is already quite apparent that humans are not the only species that experience it. Menopause has been observed in rhesus monkeys[1], some cetaceans[2], as well as in a variety of other species of vertebrates including the guppy, the platyfish, the budgerigar, the laboratory rat and mouse, the opossum, and all manner of primates[3]
Menopause in human evolution
The Grandmother hypothesis suggests that menopause evolved in humans because it promotes the survival of grandchildren. According to this hypothesis, post reproductive women feed and care for children, adult nursing daughters, and grandchildren whose mothers have weaned them. Human babies require large and steady supplies of glucose to feed the growing brain. In infants in the first year of life, the brain consumes 60% of all calories, so both babies and their mothers require a dependable food supply. Some evidence suggests that hunters contribute less than half the total food budget of most hunter-gatherer societies, and often much less than half, so that foraging grandmothers can contribute substantially to the survival of grandchildren at times when mothers and fathers are unable to gather enough food for all the children. In general, selection operates most powerfully during times of famine or other privation. So although grandmothers might not be necessary during good times, many grandchildren cannot survive without them during times of famine.
Social and psychological significance
The shutting down of the female reproductive system in midlife ushers in the third part of a woman's life. Many women in Western culture live long enough that half of their adult life is spent in post-menopause. The menopause transition is a major life change, similar to menarche in the magnitude of its social and psychological significance. In the ancient past, menarche and menopause were considered to mark the transitions from "maiden" to "matron", and from "matron" to "crone". Whereas the significance of the changes that surround menarche is still fairly well recognized, in countries such as the USA, the social and psychological ramifications of the menopause transition are frequently ignored or underestimated.
Menopause
Clinically speaking, menopause is a date: for those women who still have a uterus, menopause is defined as the day after a woman's final period finishes. This date is fixed retrospectively, once 12 months have gone by with no menstrual flow at all.
In common everyday parlance however, the word "menopause" is usually not used to refer to one day, but to the whole of the menopause transition years. This span of time is also referred to as the change of life, the change, or the climacteric and more recently is known as "perimenopause", (literally meaning "around menopause").
Perimenopause
In biomedicine, perimenopause means the menopause transition years, the years both before and after the last period (although the "last period" can be determined only retroactively). During perimenopause, many women find that they undergo symptoms of hormonal fluctuation, such as hot flashes, that cause them to seek medical advice. Mood changes, insomnia, fatigue, memory problems, and other "symptoms" formerly associated with menopause are sometimes considered to be unrelated. Depression in women is sometimes associated with the midlife and linked to menopause, but this too is a questionable association. Not enough research has been done to clarify any of these issues. However, for cultural reasons, even women who are asymptomatic or have minor symptoms may find themselves in a psychosocial transition.
During perimenopause, the production of most of the reproductive hormones, including the estrogens, progesterone and testosterone, diminishes and becomes more irregular, often with wide and unpredictable fluctuations in levels. During this period, fertility diminishes, but is not considered to reach zero until the official date of menopause is reached, and this date, as previously mentioned, can only be determined retrospectively.
Symptoms of the menopause transition can begin as early as age 35, although most women who become aware of them do so about 10 years later, often in their mid to late 40s. The duration of perimenopause with noticeable effects can be a few years, ten years or even longer.
The actual duration and severity of perimenopause in any individual woman cannot be predicted in advance or during the process.
One piece of recent research appears to show that melatonin supplementation in perimenopausal women can produce a highly significant improvement in thyroid function and gonadotropin levels, as well as restoring fertility and menstruation and preventing the depression associated with the menopause[4].
Perimenopause is a relatively new term. The use of it has criticized by some cultural commentators[who?][citation needed], because they feel that it extends the negative connotations of menopause (namely symptomology) over many more years of a woman's life.
Premenopause
Premenopause is a word used to describe the years leading up to the last period ever, when the levels of reproductive hormones are already becoming lower and more erratic, and the effects of hormone withdrawal may be present.
Postmenopause
Postmenopause is all of the time in a woman's life that take place after her last period ever, or more accurately, all of the time that follows the point when her ovaries become inactive.
A woman who still has her uterus can be declared to be in post-menopause once she has gone 12 full months with no flow at all, not even any spotting. When she reaches that point, she is one year into post-menopause. The reason for this delay in declaring a woman post-menopausal is because periods become very erratic at this time of life, and therefore a reasonably long stretch of time is necessary to be sure that the cycling has actually ceased completely.
In women who have no uterus, and therefore have no periods, post-menopause can be determined by a blood test which can reveal the very high levels of Follicle Stimulating Hormone (FSH) that are typical of post-menopausal women.
A woman's reproductive hormone levels continue to drop and fluctuate for some time into post-menopause, so any hormone withdrawal symptoms that a woman may be experiencing do not necessarily stop right away, but may take quite some time, even several years, to disappear completely.
Any period-like flow that might occur during post-menopause, even just spotting, must be reported to a doctor. The cause may in fact be minor, but the possibility of endometrial cancer must be checked for and eliminated.
The causes of menopause
The causes of menopause can be considered from complementary proximate (mechanistic) and ultimate (adaptive evolutionary) perspectives.
From a proximate perspective: A natural or physiological menopause is that which occurs as a part of a woman's normal aging process. It is the result of the eventual atresia of almost all oocytes in the ovaries. This causes an increase in circulating follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels as there are a decreased number of oocytes responding to these hormones and producing estrogen. This decrease in the production of estrogen leads to the perimenopausal symptoms of hot flashes, insomnia and mood changes, as well as post-menopausal osteoporosis and vaginal atrophy.
However, menopause can be surgically induced by bilateral salpingo-oophorectomy (removal of both ovaries and both fallopian tubes), which is often, but not always, done in conjunction with hysterectomy. Cessation of menses as a result of removal of the ovaries is called "surgical menopause". The sudden and complete drop in reproductive hormone levels usually produces extreme hormone-withdrawal symptoms such as hot flashes, etc.
As mentioned above, removal of the uterus, hysterectomy, does not itself cause menopause, although pelvic surgery can sometimes precipitate a somewhat earlier menopause, perhaps because of a compromised blood supply to the ovaries. Removing the ovaries however, causes an immediate and powerful "surgical menopause", even if the uterus is left intact.
Cigarette smoking has been found to decrease the age at menopause by as much as one year, and women who have undergone hysterectomy with ovary conservation go through menopause 3.7 years earlier than average. However, premature menopause (before the age of 40) is generally idiopathic.
An ultimate perspective on menopause has already been given above, in the "Menopause in human evolution" section.
Possible effects of perimenopause, the menopause transition time
As the body responds to the rapidly changing levels of natural hormones, a number of effects can appear. It is however worth pointing out, that not every woman experiences bothersome levels of these effects, and even in those women who do experience strong effects, the range of effects and the degree to which they appear is very variable from person to person.
Those effects that are due to low estrogen levels (for example vaginal atrophy and skin drying) remain present even after the menopause transition years are over, however, many of the effects that are caused by the extreme fluctuations in hormone levels (for example hot flashes and mood changes) usually disappear or improve significantly once the perimenopause transition time has been completed.
Both users and non-users of hormone replacement therapy identify lack of energy as the most frequent and distressing effect[5]
Other effects can include vasomotor symptoms such as hot flashes and palpitations, psychological effects such as depression, anxiety, irritability, mood swings, memory problems and lack of concentration, and atrophic effects such as vaginal dryness and urgency of urination.
The average woman also has increasingly erratic menstrual periods, due to skipped ovulations. Typically the timing of the flow becomes unpredictable. In addition the duration of the flow may be considerably shorter or longer than normal, and the flow itself may be significantly heavier or lighter than was previously the case, including sometimes long episodes of spotting. Early in the process it is not uncommon to have some 2-week cycles. Further into the process it is common to skip periods for months at a time, and these skipped periods may be followed by a heavier period. The number of skipped periods in a row often increases as the time of last period approaches.
As mentioned above, when a woman of menopausal age has not had a period or any spotting for 12 months, at that point she is considered to be one year into post-menopause. However, a period after 6 months of no flow at all is sometimes considered worthy of investigation by a doctor.
All the various possible perimenopause effects are caused by an overall drop, as well as dramatic but erratic fluctuations, in the absolute levels and relative levels of estrogens and progesterone. Some of the effects, such as formication, may be associated directly with hormone withdrawal.
Vasomotor instability
* hot flashes or hot flushes, including night sweats and, in a few people, cold flashes
* sleep disturbances, poor quality sleep, light sleep, insomnia
Urogenital atrophy, also known as vaginal atrophy, (main article: Atrophic vaginitis)
* thinning of the membranes of the vulva and the outer urinary tract, along with considerable shrinking and loss in elasticity of all of the outer and inner genital areas
* itching
* dryness
* bleeding
* watery discharge
* urinary frequency
* urinary urgency
* urinary incontinence
* increased susceptibility to inflammation and infection, for example vaginal candidiasis, and urinary tract infections
Skeletal
* osteopenia and the risk of osteoporosis gradually developing over time
* joint pain, muscle pain
* back pain
Skin, soft tissue
* breast atrophy
* skin thinning and becoming drier
* decreased elasticity of the skin
* formication, a sensation rather like pins and needles, more specifically like ants crawling on or under the skin
Psychological
* mood disturbance
* irritability
* fatigue
* memory loss, and problems with concentration
* depression and/or anxiety
Sexual
* decreased libido
* vaginal dryness and vaginal atrophy
* problems reaching orgasm
* dyspareunia or painful intercourse
One cohort study found that menopause was associated with hot flashes; joint pain and muscle pain; and depressed mood.[6] In the same study, it appeared that menopause was not associated with poor sleep, decreased libido, and vaginal dryness.[6]
Need for more education about menopause
Many women arrive at their menopause years without knowing anything about what they might expect, or when or how the process might happen, and how long it might take. Very often a woman has not been informed in any way about this stage of life by her physician or by her social group.
In the USA at least, there appears to be a lingering taboo which hangs over this subject. As a result, a woman who happens to undergo a strong perimenopause with a large number of different symptoms, may become confused and anxious, fearing that something abnormal is happening to her. There is a strong need for more information and more education on this subjec
Treatment
Perimenopause is a natural stage of life, not a disease or a disorder, and therefore it does not automatically require any kind of treatment. However when the bodily effects of perimenopause are severe and disruptive, they may be alleviated through medical treatments.
Hormone replacement therapy or HRT, known in Britain as Hormone Therapy or HT, and the SSRIs appear to provide the most reliable pharmaceutical relief. However, adverse effects of one kind of HRT (equine estrogen combined with a synthetic progestin) are now well documented. See the section below on "Adverse effects of conjugated equine estrogens".
A woman and her doctor should carefully review her situation, her complaints and her relative risk before determining whether the benefits of HT/HRT or other therapies outweigh the risks. Until more becomes understood about the possible risks, women who elect to use hormone replacement therapy are generally well advised to take the lowest effective dose of hormones for the shortest period possible, and to question their doctors as to whether certain forms might pose fewer dangers of clots or cancer than others.
Alternative dietary supplements for treatment of menopause symptoms afford anywhere from significant to moderate relief of these symptoms. Some botanical sources, referred to as phytoestrogens, are known to have an estrogenic effect on the body and therefore create a moderated estrogenic effect. Others, such as femarelle, were found to have Selective Estrogen Receptor Modulator (SERM) qualities [7], thereby reducing the safety risks involved in estrogenic-like treatments.
Hormone therapy, also known as hormone replacement therapy
In addition to relief from hot flashes, hormone therapy remains an effective treatment for osteoporosis.
In HT or HRT, one or more estrogens, usually in combination with progesterone, (and sometimes testosterone) are administered, not only to partially compensate for the body's loss of these hormones, but also in an attempt to keep the levels of these hormones in the body much more consistent than they are naturally in perimenopause.
In those women who have no uterus (usually due to a previous hysterectomy) estrogen alone is a suitable hormone therapy. Women who still have a uterus need to take progesterone in addition to estrogen, in order to ensure that the endometrium, the lining of the uterus, does not build up too much, which would be a risk for cancer of the endometrium.
There are several types of hormone therapies, with various possible side effects.
Conjugated equine estrogens
Conjugated equine estrogens contain estrogen molecules conjugated to hydrophilic side groups (e.g. sulfate) and are produced from the urine of pregnant Equidae (horses) mares. Premarin is the prime example of this, either alone or in Prempro, where it is combined with a synthetic progestin, medroxyprogesterone acetate. However Premarin, and especially Prempro, are associated with serious health risks.[8]
In January 2003, the FDA required Wyeth to affix a "black box" warning to PremPro, stating
"WARNING
Estrogens and progestins should not be used for the prevention of cardiovascular disease. The Women’s Health Initiative (WHI) reported increased risks of myocardial infarction, stroke, invasive breast cancer, pulmonary emboli, and deep vein thrombosis in postmenopausal women during 5 years of treatment with conjugated equine estrogens (0.625 mg) combined with medroxyprogesterone acetate (2.5 mg) relative to placebo
Adverse effects of conjugated equine estrogens
Women had been advised for many years by numerous doctors and drug company marketing efforts (at least in the USA) that hormone therapy with conjugated equine estrogens after menopause might reduce their risk of heart disease and prevent various aspects of aging. However, a large, randomized, controlled trial (the Women's Health Initiative) found that women undergoing HT or HRT with conjugated equine estrogens (Premarin), whether or not used in combination with a synthetic progestin (Premarin plus Provera, known as Prempro), had an increased risk of breast cancer, heart disease, stroke, and Alzheimer's disease. Although this increase in risk was small overall, it passed the thresholds that had been established by the researchers in advance as sufficient to ethically require stopping the study.
When these results were first reported in 2002, the popular media sensationalized the story and exaggerated the risk, while the manufacturer continued to attempt to minimize the degree of risk. However most news stories failed to mention that the average age of the women in WHI was 62 years old, significantly older than the time when most doctors start patients on HRT, and in fact many years into postmenopause. In order to enroll in the study, patients had to be asymptomatic of hot flashes, so they would not know whether they received the placebo. For these reasons WHI was not representative of generally accepted clinical practice.
The 2002 and 2003 announcements of the Women's Health Initiative of the American National Institute of Health and The Million Women Study of the UK Cancer Research and National Health Service collaboration respectively, that HRT treatment coincides with a increased incidence of breast cancer, heart attacks and strokes, lead to a sharp decline in HRT prescription throughout the world [9][10][11], which was followed by a decrease in breast cancer incidence [12][13][14].
On hearing the news about the WHI study, many women discontinued equine estrogens altogether, with or without their doctor's approval. The number of prescriptions written for Premarin and PremPro in the United States dropped within a year almost to half of their previous level. This sharp drop in usage was followed by large and successively larger drops in new breast cancer diagnoses, at six months, one year, and 18 months after the drop in Premarin and Prempro prescriptions, for a cumulative 15% drop by the end of 2003. However, the apparent meaning of this correlation is called into question by the fact that prescriptions of Prempro and Premarin fell dramatically in Canada as well, but no similarly dramatic drop in Canada's breast cancer rates was observed during the same time period. Studies designed to track the further progression of this trend after 2003 are under way, as well as studies designed to quantify how much of the drop was related to the reduced use of HT/HRT.
Other forms of hormone therapy
The adverse biological effects of xenoestrogens and progestins revealed by studies of Premarin and PremPro do not necessarily generalize to supplementation with human forms of estrogen and progesterone. For example, a pilot study reported in JAMA by Smith, Heckbert, et al.[15] found clinical evidence that oral conjugated equine estrogens caused clotting, but the other estrogen compound tested in the same study, bioidentical esterified estrogens, does not. conjugated equine estrogens were found to be associated with increased venous thrombotic risk. In sharp contrast, the study found that users of esterified estrogen had no increase in venous thrombotic risk.
Due to the controversy about Premarin-based hormone therapy, a number of doctors are now moving patients who request hormone therapy to help them through perimenopause, to bioidentical hormone products.
Estrace is a form of the precursor to estrogen in the human body known as estradiol, which products have produced fewer side effects than conjugated equine estrogens[16]. Prometrium is a bioidentical progesterone which can be used in conjunction with Estrace.
However, all hormone replacement therapies probably do carry some health risks, including high blood pressure, blood clots, and increased risks of breast and uterine cancers. Women who have had a hysterectomy seem to tolerate estrogen-only therapy better than mixed-hormone therapy.
Selective Estrogen Receptor Modulator's (SERM's)
SERM's are a category of drugs that act selectively as agonists or antagonists on the estrogen receptors throughout the body. While most SERM's are known to increase hot flushes, Femarelle (DT56a) decreases them[17][18]. In addition to the relieving effects on menopausal symptoms, Femarelle also increases bone mass density (BMD) [19], making it protective against osteoporotic fractures. These effects are achieved by an agonistic interaction with estrogen receptors in the brain and bone. On the other hand, an antagonist interaction with estrogen receptors in the breast [20] and uterus[21] [22], has no effect on these tissues.
Antidepressants
Antidepressants such as paroxetine (Paxil), Fluoxetine hydrochloride (Prozac), and Venlafaxine hydrochloride (Effexor) have been used with some success in the treatment of hot flashes, improving sleep, mood, and quality of life. There is a theoretical reason why SSRI antidepressants might help with memory problems-- they increase circulating levels of the neurotransmitter serotonin in the brain and restore hippocampal function. Prozac has been repackaged as Sarafem and is approved and prescribed for premenstrual dysphoric disorder (PMDD), a mood disorder often exacerbated during perimenopause and early menopause. PMDD has been found by PET scans to be accompanied by a sharp drop in serotonin in the brain and to respond quickly and powerfully to SSRIs.
Blood pressure medicines
About as effective as antidepressants for hot flashes, but without the other mind and mood benefits of antidepressants, are blood pressure medicines including clonidine (Catapres). These drugs may merit special consideration by women suffering both from high blood pressure and hot flashes.
Complementary and alternative therapies
Medical non-hormone treatments provide less than complete relief, and each has side effects.
In the area of complementary and alternative therapies, acupuncture treatment is promising. There are some studies indicating positive effects, especially on hot flashes [23][24][25] but also others [26] showing no positive effects of acupuncture regarding menopause.
There are claims that soy isoflavones are beneficial concerning menopause. However, one study [27] indicated that soy isoflavones did not improve or appreciably affect cognitive functioning in postmenopausal women.
Other remedies which in studies appear to be no better than a placebo at treating hot flashes and other menopause symptoms include red clover isoflavone extracts and black cohosh. Black cohosh can cause the stimulation of pre-existing breast cancer.
Other therapies
Vaginal moisturizers such as Replens can help women with thinning vaginal tissue or dryness, and lubricants such as K-Y Jelly or Astroglide, can help with lubrication difficulties that may be present during intercourse. It is worth pointing out that moisturizers and lubricants are different products for different issues: some women feel unpleasantly dry all of the time apart from during sex, and they may do better with moisturizers all of the time. Those who need only lubricants are fine just using the lubrication products during intercourse.
Low-dose prescription vaginal estrogen products such as Estrace cream or the Estring are generally a safe way to use estrogen topically, in order to help vaginal thinning and dryness problems (see vaginal atrophy) while only minimally increasing the levels of estrogen in the bloodstream.
In terms of managing hot flashes, lifestyle measures, such as drinking cold liquids, staying in cool rooms, using fans, removing excess clothing layers when a hot flash strikes, and avoiding hot flash triggers such as hot drinks, spicy foods, etc, may partially supplement (or even obviate) the use of medications for some women.
Individual counseling or support groups can sometimes be helpful to handle sad, depressed, anxious or confused feelings women may be having as they pass through what can be for some a very challenging transition time.
Mental disorder reference
Mental disorder or mental illness are terms used to refer to a psychological or physiological pattern that occurs in an individual and is usually associated with distress or disability that is not expected as part of normal development or culture. The recognition and understanding of mental disorders has changed over time. Definitions, assessments, and classifications of mental disorders can vary, but guideline criterion listed in the ICD, DSM and other manuals are widely accepted by mental health professionals. Categories of diagnoses in these schemes may include dissociative disorders, mood disorders, anxiety disorders, psychotic disorders, eating disorders, developmental disorders, personality disorders, and many other categories. In many cases there is no single accepted or consistent cause of mental disorders, although they are widely understood in terms of a diathesis-stress model and biopsychosocial model. Mental disorders have been found to be common, with over a third of people in most countries reporting sufficient criteria at some point in their life. Mental health services may be based in hospitals or in the community. Mental health professionals diagnose individuals using different methodologies, often relying on case history and interview. Psychotherapy and psychiatric medication are two major treatment options, as well as supportive interventions. Treatment may be involuntary where legislation allows. Several movements campaign for changes to mental health services and attitudes, including the Consumer/Survivor Movement. There are widespread problems with stigma and discrimination.
History
Eight women representing prominent mental diagnoses in the nineteenth century.
Eight women representing prominent mental diagnoses in the nineteenth century.
Main article: History of mental disorders
A number of mental disturbances, such as melancholy, hysteria and phobia, were described long ago in Ancient Greece and Rome, while others such as schizophrenia may not have been recognized.[1] Hippocrates considered the idea that mental illness may be related to biology.[2]
Psychiatric theories and treatments for mental illness developed in Muslim psychology and Islamic medicine in the medieval Islamic world from the 8th century, where the first psychiatric hospitals were built.[3] The Baghdad Hospital was run by the Persian physician Rhazes. Unlike most ancient and medieval societies which believed mental illness to be caused by either demonic possession or as punishment from a God, Islamic neuroethics held a more sympathetic attitude towards the mentally ill, as exemplified in Sura 4:5 of the Qur'an, which considers the mentally ill to be unfit to manage property but must be treated humanely and be kept under care by a guardian.[4]
Medieval Europe had focused on demonic possession as the explanation of aberrant behavior.[5] Paracelsus used the word lunatic to describe behavior thought to be caused by the lunar effect.[6] Many other terms for mental disorder that found their way into everyday use have been traced to initial use in the 16th and 17th centuries.[7] Shakespeare and his contemporaries frequently depicted mental disorders in their plays.[8] Conditions of "shell shock" came to be recognized in war veterans. From the early study of mental illness through individuals such as Philippe Pinel, Sigmund Freud, and Alois Alzheimer, much has changed in the development and understanding of mental illness and continues to change today.
At the start of the 20th century there were only a dozen officially recognized mental health conditions.[citation needed]. By 1952 there were 192 and the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSM-IV) today lists 374.
[edit] Classification
Main article: Classification of mental disorders
The definition and classification of mental disorder is a key issue for the mental health professions and for users and providers of mental health services. Most international clinical documents use the term "mental disorder" rather than "mental illness". There is no single definition and the inclusion criteria are said to vary depending on the social, legal and political context. In general, however, a mental disorder has been characterized as a clinically significant behavioral or psychological pattern that occurs in an individual and is usually associated with distress, disability or increased risk of suffering. There is often a criterion that a condition should not be expected to occur as part of a person's usual culture or religion. The term "serious mental illness" (SMI) is sometimes used to refer to more severe and long-lasting disorder. A broad definition can cover mental disorder, mental retardation, personality disorder and substance dependence. The phrase "mental health problems" may be used to refer only to milder or more transient issues.
There are currently two widely established systems that classify mental disorders - Chapter V of the International Classification of Diseases (ICD-10), produced by the World Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) produced by the American Psychiatric Association (APA). Both list categories of disorder and provide standardized criteria for diagnosis. They have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain. Other classification schemes may be in use more locally, for example the Chinese Classification of Mental Disorders. Other manuals may be used by those of alternative theoretical persuasions, for example the Psychodynamic Diagnostic Manual.
Some approaches to classification do not employ distinct categories based on cut-offs separating the abnormal from the normal. They are variously referred to as spectrum, continuum or dimensional systems. There is a significant scientific debate about the relative merits of a categorical or a non-categorical system. There is also significant controversy about the role of science and values in classification schemes, and about the professional, legal and social uses to which they are put.
Disorders
There are many different categories of mental disorder, and many different facets of human behavior and personality that can become disordered.[9][10][11][12]
The state of anxiety or fear can become disordered, so that it is unusually intense or generalized over a prolonged period of time. Commonly recognized categories of anxiety disorders include specific phobia, Generalized anxiety disorder, Social Anxiety Disorder, Panic Disorder, Agoraphobia, Obsessive-Compulsive Disorder, Post-traumatic stress disorder. Relatively long lasting affective states can also become disordered. Mood disorder involving unusually intense and sustained sadness, melancholia or despair is know as Clinical depression (or Major depression), and may more generally be described as Emotional dysregulation. Milder but prolonged depression can be diagnosed as dysthymia. Bipolar disorder involves abnormally "high" or pressured mood states, known as mania or hypomania, alternating with normal or depressed mood. Whether unipolar and bipolar mood phenomena represent distinct categories of disorder, or whether they usually mix and merge together along a dimension or spectrum of mood, is under debate in the scientific literature.[13]
Patterns of belief, language use and perception can become disordered. Psychotic disorders centrally involving this domain include Schizophrenia and Delusional disorder. Schizoaffective disorder is a category used for individuals showing aspects of both schizophrenia and affective disorders. Schizotypy is a category used for individuals showing some of the traits associated with schizophrenia but without meeting cut-off criteria.
The fundamental characteristics of a person that influence his or her cognitions, motivations, and behaviors across situations and time - can be seen as disordered due to being abnormally rigid and maladaptive. Categorical schemes list a number of different personality disorders, such as those classed as eccentric (e.g. Paranoid personality disorder, Schizoid personality disorder, Schizotypal personality disorder), those described as dramatic or emotional (Antisocial personality disorder, Borderline personality disorder, Histrionic personality disorder, Narcissistic personality disorder) or those seen as fear-related (Avoidant personality disorder, Dependent personality disorder, Obsessive-compulsive personality disorder).
There may be an emerging consensus that personality disorders, like personality traits in the normal range, incorporate a mixture of more acute dysfunctional behaviors that resolve in relatively short periods, and maladaptive temperamental traits that are relatively more stable.[14] Non-categorical schemes may rate individuals via a profile across different dimensions of personality that are not seen as cut off from normal personality variation, commonly through schemes based on the Big Five personality traits.[15]
Other disorders may involve other attributes of human functioning. Eating practices can be disordered, at least in relatively rich industrialized areas, with either compulsive over-eating or under-eating or binging. Categories of disorder in this area include Anorexia nervosa, Bulimia nervosa, Exercise Bulimia or Binge eating disorder. Sleep disorders such as Insomnia also exist and can disrupt normal sleep patterns. Sexual and gender identity disorders, such as Dyspareunia or Gender identity disorder or ego-dystonic homosexuality. People who are abnormally unable to resist urges, or impulses, to perform acts that could be harmful to themselves or others, may be classed as having an impulse control disorder, including various kinds of Tic disorders such as Tourette's Syndrome, and disorders such as Kleptomania (stealing) or Pyromania (fire-setting). Substance-use disorders include Substance abuse disorder. Addictive gambling may be classed as a disorder. Inability to sufficiently adjust to life circumstances may be classed as an Adjustment disorder. The category of adjustment disorder is usually reserved for problems beginning within three months of the event or situation and ending within six months after the stressor stops or is eliminated. People who suffer severe disturbances of their self-identity, memory and general awareness of themselves and their surroundings may be classed as having a Dissociative identity disorder, such as Depersonalization disorder or Dissociative Identify Disorder itself (which has also been called multiple personality disorder, or "split personality".). Factitious disorders, such as Munchausen syndrome, also exist where symptoms are experienced and/or reported for personal gain.
Disorders appearing to originate in the body, but thought to be mental, are known as somatoform disorders, including Somatization disorder. There are also disorders of the perception of the body, including Body dysmorphic disorder. Neurasthenia is a category involving somatic complaints as well as fatigue and low spirits/depression, which is officially recognized by the ICD-10 but not by the DSM-IV.[16] Memory or cognitive disorders, such as amnesia or Alzheimer's disease exist.
Some disorders are thought to usually first occur in the context of early childhood development, although they may continue into adulthood. The category of Specific developmental disorder may be used to refer to circumscribed patterns of disorder in particular learning skills, motor skills, or communication skills. Disorders which appear more generalized may be classed as pervasive developmental disorders (PDD) also known as autism spectrum disorders (ASD); these include autism, Asperger's, Rett syndrome, childhood disintegrative disorder and other types of PDD whose exact diagnosis may not be specified. Other disorders mainly or first occurring in childhood include Reactive attachment disorder; Separation Anxiety Disorder; Oppositional Defiant Disorder; Attention Deficit Hyperactivity Disorder.
Causes
Numerous factors have been linked to the development of mental disorders. In many cases there is no single accepted or consistent cause currently established. A common view held is that disorders often result from genetic vulnerabilities combining with environmental stressors (Diathesis-stress model). An eclectic or pluralistic mix of models may be used to explain particular disorders. The primary paradigm of contemporary mainstream Western psychiatry is said to be the biopsychosocial (BPS) model - incorporating biological, psychological and social factors - although this may not be applied in practice. Biopsychiatry has tended to follow a biomedical model, focusing on "organic" or "hardware" pathology of the brain. Psychoanalytic theories have been popular but are now less so. Evolutionary psychology may be used as an overall explanatory theory. Attachment theory is another kind of evolutionary-psychological approach sometimes applied in the context for mental disorders. A distinction is sometimes made between a "medical model" or a "social model" of disorder and related disability.
Genetic studies have indicated that genes often play an important role in the development of mental disorders, via developmental pathways interacting with environmental factors. The reliable identification of connections between specific genes and specific categories of disorder has proven more difficult.
Environmental events surrounding pregnancy and birth have also been implicated. Traumatic brain injury may increase the risk of developing certain mental disorders. There have been some tentative inconsistent links found to certain viral infections, to substance misuse, and to general physical health.
Abnormal functioning of neurotransmitter systems has been implicated, including serotonin, norepinephrine, dopamine and glutamate systems. Differences have also been found in the size or activity of certain brains regions in some cases. Psychological mechanisms have also been implicated, such as cognitive and emotional processes, personality, temperament and coping style.
Social influences have been found to be important, including abuse, bullying and other negative or stressful life experiences. The specific risks and pathways to particular disorders are less clear, however. Aspects of the wider community have also been implicated, including employment problems, socioeconomic inequality, lack of social cohesion, problems linked to migration, and features of particular societies and cultures.
Diagnosis
Many mental health professionals, particularly psychiatrists, seek to diagnose individuals by ascertaining their particular mental disorder. Some professionals, for example some clinical psychologists, may avoid diagnosis in favor of other assessment methods such as formulation of a client's difficulties and circumstances.[17] The majority of mental health problems are actually assessed and treated by family physicians during consultations, who may refer on for more specialist diagnosis in acute or chronic cases. Routine diagnostic practice in mental health services typically involves an interview (which may be referred to as a mental status examination), where judgements are made of the interviewee's appearance and behavior, self-reported symptoms, mental health history, and current life circumstances. The views of relatives or other third parties may be taken into account. A physical examination to check for ill health or the effects of medications or other drugs may be conducted. Psychological testing is sometimes used via paper-and-pen or computerized questionnaires, which may include algorithms based on ticking off standardized diagnostic criteria, and in relatively rare specialist cases neuroimaging tests may be requested, but these methods are more commonly found in research studies than routine clinical practice.[18][19] Time and budgetary constraints often limit practicing psychiatrists from conducting more thorough diagnostic evaluations.[20] It has been found that most clinicians evaluate patients using an unstructured, open-ended approach, with limited training in evidence-based assessment methods, and that inaccurate diagnosis may be common in routine practice.[21] Comorbidity is very common in psychiatric diagnosis, i.e. the same person given a diagnosis in more than one category of disorder.
Treatment
Mental health services may be based in hospitals, clinics or the community. Often an individual may engage in different treatment modalities. They may be under case management (sometimes referred to as "service coordination"), use inpatient or day treatment, utilize a psychosocial rehabilitation program, and/or take part in an Assertive Community Treatment program. Individuals may be treated against their will in some cases, especially if assessed to be at high risk to themselves or others. Services in some countries are increasingly based on a Recovery model that supports an individual's journey to regain a meaningful life
Psychotherapy
A major option for many mental disorders is psychotherapy. There are several main types. Cognitive behavioral therapy (CBT) is widely used and is based on modifying the patterns of thought and behavior associated with a particular disorder. Psychoanalysis, addressing underlying psychic conflicts and defenses, has been a dominant school of psychotherapy and is still in use. Systemic therapy or family therapy is sometimes used, addressing a network of significant others as well as an individual. Some psychotherapies are based on a humanistic approach. There are a number of specific therapies used for particular disorders, which may be offshoots or hybrids of the above types. Mental health professionals often employ an eclectic or integrative approach. Much may depend on the therapeutic relationship, and there may be problems with trust, confidentiality and engagement.
Medication
A major option for many mental disorders is psychiatric medication. There are several main groups. Antidepressants are used for the treatment of clinical depression as well as often for anxiety and other disorders. There are a number of antidepressants beginning with the tricylics, moving through a wide variety of drugs that modify various facets of the brain chemistry dealing with intercellular communication. Beta-blockers, developed as a heart medication, is also used as an antidepressant. Anxiolytics are used for anxiety disorders and related problems such as insomnia. Mood stabilizers are used primarily in bipolar disorder. Lithium A (a metal) and Lamictal (an epileptic drug) are notable for treating both mania and depression. The others, mainly targeting mania rather than depression, are a wide variety of epilepsy medications and antipsychotics. Antipsychotics are used for psychotic disorders, notably for positive symptoms in schizophrenia. Stimulants are commonly used, notably for ADHD. Despite the different conventional names of the drug groups, there can be considerable overlap in the kinds of disorders for which they are actually indicated. There may also be off-label use. There can be problems with adverse effects and adherence.
Other
Electroconvulsive therapy (ECT) is sometimes used in severe cases when other interventions for severe intractable depression have failed. Psychosurgery has in the past been synonymous with the "frontal lobotomy." While this form of psychosurgery is no longer used, there are four other techniques that are used today. These methods are used only as a last resort for people who have not responded to medications and therapy, and are functionally crippled by their disorder. The disorders for which psychosurgery has been used for for intractable mood and anxiety disorders, such as Obsessive-Compulsive Disorder.[22]
Psychoeducation may be used to provide people with the information to understand and manage their problems. Creative therapies are sometimes used, including music therapy, art therapy or drama therapy. Lifestyle adjustments and supportive measures are often used, including peer support, self-help and supported housing or employment. Some advocate dietary supplements based on published randomized double-blind, placebo controlled trials.[23] Many things have been found to help at least some people. A placebo effect may play a role in any intervention.
Prevalence
WHO estimated that about 450 million people worldwide currently suffer from some form of mental or behavioural disorder.[26] One in four people will suffer from mental illness at some time in life, according to a report from the WHO.[27][28]
Numerous large-scale surveys of the prevalence of mental disorders in adults in the general population have been carried out since the 1980s based on self-reported symptoms assessed by standardized structured interviews, usually carried out over the phone. Mental disorders have been found to be common, with over a third of people in most countries reporting sufficient criteria at some point in their life.[29] The World Health Organization is currently undertaking a global survey of 26 countries in all regions of the world, based on ICD and DSM criteria.[1] The first published figures on the 14 country surveys completed to date, indicate that, of those disorders assessed, anxiety disorders are the most common in all but 1 country (prevalence in the prior 12-month period of 2.4% to 18.2%) and mood disorders next most common in all but 2 countries (12-month prevalence of 0.8% to 9.6%), while substance disorders (0.1%-6.4%) and impulse-control disorders (0.0%-6.8%) were consistently less prevalent. The United States, Colombia, the Netherlands and Ukraine tended to have higher prevalence estimates across most classes of disorder, while Nigeria, Shanghai and Italy were consistently low, and prevalence was lower in Asian countries in general. Cases of disorder were rated as mild (prevalence of 1.8%-9.7%), moderate (prevalence of 0.5%-9.4%) and serious (prevalence of 0.4%-7.7%).[30] However, these are widely believed to be underestimates, due to poor diagnosis (especially in countries without affordable access to mental health services) and low reporting rates, in part because of the predominant use of self-report data, rather than semi-structured instruments such as the Structured Clinical Interview for DSM-IV (SCID); actual lifetime prevalence rates for mental disorders are estimated to be between 65% and 85%.
A review that pooled surveys in different countries up to 2004 found overall average prevalence estimates for any anxiety disorder of 10.6% (in the 12 months prior to assessment) and 16.6% (in lifetime prior to assessment), but that rates for individual disorders varied widely. Women had generally higher prevalence rates than men, but the magnitude of the difference varied.[31] A review that pooled surveys of mood disorders in different countries up to 2000 found 12-month prevalence rates of 4.1% for major depressive disorder (MDD), 2% for dysthymic disorder and 0.72% for bipolar 1 disorder. The average lifetime prevalence found was 6.7% for MDD (with a relatively low lifetime prevalence rate in higher-quality studies, compared to the rates typically highlighted of 5%-12% for men and 10%-25% for women), and rates of 3.6% for dysthymia and 0.8% for Bipolar 1.[32]
Previous widely cited large-scale surveys in the United States were the Epidemiological Catchment Area (ECA) survey and subsequent National Comorbidity Survey (NCS). The NCS was replicated and updated between 2000 and 2003 and indicated that, of those groups of disorders assessed, nearly half of Americans (46.4%) reported meeting criteria at some point in their life for either a DSM-IV anxiety disorder (28.8%), mood disorder (20.8%), impulse-control disorder (24.8%) or substance use disorders (14.6%). Half of all lifetime cases had started by age 14 years and 3/4 by age 24 years.[33] In the prior 12-month period only, around a quarter (26.2%) met criteria for any disorder - anxiety disorders 18.1%; mood disorders 9.5%; impulse control disorders 8.9%; and substance use disorders 3.8%. A substantial minority (23%) met criteria for more than two disorders. A minority (22.3%) of cases were classed as serious, 37.3% as moderate and 40.4% as mild.[34][35]
A 2004 cross-European study found that approximately one in four people reported meeting criteria at some point in their life for one of the DSM-IV disorders assessed, which included mood disorders (13.9%), anxiety disorders (13.6%) or alcohol disorder (5.2%). Approximately one in ten met criteria within a 12-month period. Women and younger people of either gender showed more cases of disorder[36]
A 2005 review of 27 studies have found that 27% of adult Europeans is or has been affected by at least one mental disorder in the past 12 months. It was also found that the most frequent disorders were anxiety disorders, depressive, somatoform and substance dependence disorders.[37]
A 2005 review of prior surveys in 46 countries on the prevalence of schizophrenic disorders, including a prior 10-country WHO survey, found an average (median) figure of 0.4% for lifetime prevalence up to the point of assessment and 0.3% in the 12-month period prior to assessment. A related figure not given in other studies (known as lifetime morbid risk), reported to be an accurate statement of how many people would theoretically develop schizophrenia at any point in life regardless of time of assessment, was found to be “about seven to eight individuals per 1,000.” (0.7/0.8%). The prevalence of schizophrenia was consistently lower in poorer countries than in richer countries (though not the incidence) but the prevalence did not differ between urban/rural areas or men/women (although incidence did).[38]
Studies of the prevalence of personality disorders (PDs) have been fewer and smaller-scale, but a broader Norwegian survey found a similar overall prevalence of almost 1 in 7 (13.4%), based on meeting personality criteria over the prior five year period. Rates for specific disorders ranged from 0.8% to 2.8%, with rates differing across countries, and by gender, educational level and other factors.[39] A US survey that incidentally screened for personality disorder found an overall rate of 14.79%.[40]
Approximately 7% of a preschool pediatric sample were given a psychiatric diagnosis in one clinical study, and approximately 10% of 1- and 2-year-olds receiving developmental screening have been assessed as having significant emotional/behavioral problems based on parent and pediatrician reports.
Stigma of mental illness
A large proportion of individuals who suffer from the symptoms of a mental illness will avoid seeking treatment for their symptoms because of the social stigma[2] associated with having a mental illness. The US Surgeon General acknowledged this in 1999:
Powerful and pervasive, stigma prevents people from acknowledging their own mental health problems, much less disclosing them to others.[51]
As a result many people feel the need to keep their mental illness a secret, and will deny the symptoms that they are experiencing. Two thirds of the people who would benefit from treatment for a mental illness do not receive treatment.[52] As with many physical illnesses, the prognoses of a mental illness can worsen the longer that a mental illness remains untreated. The added anxiety of fearing a mental illness diagnoses can also be detrimental to an individual's mental health, this effect can greatly exacerbate an anxiety disorder or mood disorder. Efforts are being undertaken worldwide to eliminate the stigma of mental illness.
Violence
The public fear of violence due to mental illness is a contentious topic. One US national survey indicated that a far higher percentage of Americans rated individuals described as displaying the characteristics of a mental disorder (for example Schizophrenia or Substance Use Disorder) as "likely to do something violent to others" compared to those described as being 'troubled'.[70] Research indicates, on balance, a higher than average number of violent acts by some individuals with certain diagnoses, notably antisocial or psychopathic personality disorders, but conflicting findings about specific symptoms (for example links between psychosis and violence in community settings) - but the mediating factors of such acts are most consistently found to be mainly socio-demographic and socio-economic factors such as being young, male, of lower socio-economic status and, in particular, substance abuse (including alcohol).[71][72][24] Findings consistently indicate that it is many times more likely that people diagnosed with a serious mental illness living in the community will be the victim rather than the perpetrator of violence.[71][73] Violence by or against individuals with mental illness typically occurs in the context of complex social interactions (including in atmosphere of mutually high "expressed emotion"), including within a family setting,[74] as well as being an issue in healthcare settings[75] and the wider community.
History
Eight women representing prominent mental diagnoses in the nineteenth century.
Eight women representing prominent mental diagnoses in the nineteenth century.
Main article: History of mental disorders
A number of mental disturbances, such as melancholy, hysteria and phobia, were described long ago in Ancient Greece and Rome, while others such as schizophrenia may not have been recognized.[1] Hippocrates considered the idea that mental illness may be related to biology.[2]
Psychiatric theories and treatments for mental illness developed in Muslim psychology and Islamic medicine in the medieval Islamic world from the 8th century, where the first psychiatric hospitals were built.[3] The Baghdad Hospital was run by the Persian physician Rhazes. Unlike most ancient and medieval societies which believed mental illness to be caused by either demonic possession or as punishment from a God, Islamic neuroethics held a more sympathetic attitude towards the mentally ill, as exemplified in Sura 4:5 of the Qur'an, which considers the mentally ill to be unfit to manage property but must be treated humanely and be kept under care by a guardian.[4]
Medieval Europe had focused on demonic possession as the explanation of aberrant behavior.[5] Paracelsus used the word lunatic to describe behavior thought to be caused by the lunar effect.[6] Many other terms for mental disorder that found their way into everyday use have been traced to initial use in the 16th and 17th centuries.[7] Shakespeare and his contemporaries frequently depicted mental disorders in their plays.[8] Conditions of "shell shock" came to be recognized in war veterans. From the early study of mental illness through individuals such as Philippe Pinel, Sigmund Freud, and Alois Alzheimer, much has changed in the development and understanding of mental illness and continues to change today.
At the start of the 20th century there were only a dozen officially recognized mental health conditions.[citation needed]. By 1952 there were 192 and the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition (DSM-IV) today lists 374.
[edit] Classification
Main article: Classification of mental disorders
The definition and classification of mental disorder is a key issue for the mental health professions and for users and providers of mental health services. Most international clinical documents use the term "mental disorder" rather than "mental illness". There is no single definition and the inclusion criteria are said to vary depending on the social, legal and political context. In general, however, a mental disorder has been characterized as a clinically significant behavioral or psychological pattern that occurs in an individual and is usually associated with distress, disability or increased risk of suffering. There is often a criterion that a condition should not be expected to occur as part of a person's usual culture or religion. The term "serious mental illness" (SMI) is sometimes used to refer to more severe and long-lasting disorder. A broad definition can cover mental disorder, mental retardation, personality disorder and substance dependence. The phrase "mental health problems" may be used to refer only to milder or more transient issues.
There are currently two widely established systems that classify mental disorders - Chapter V of the International Classification of Diseases (ICD-10), produced by the World Health Organization (WHO), and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) produced by the American Psychiatric Association (APA). Both list categories of disorder and provide standardized criteria for diagnosis. They have deliberately converged their codes in recent revisions so that the manuals are often broadly comparable, although significant differences remain. Other classification schemes may be in use more locally, for example the Chinese Classification of Mental Disorders. Other manuals may be used by those of alternative theoretical persuasions, for example the Psychodynamic Diagnostic Manual.
Some approaches to classification do not employ distinct categories based on cut-offs separating the abnormal from the normal. They are variously referred to as spectrum, continuum or dimensional systems. There is a significant scientific debate about the relative merits of a categorical or a non-categorical system. There is also significant controversy about the role of science and values in classification schemes, and about the professional, legal and social uses to which they are put.
Disorders
There are many different categories of mental disorder, and many different facets of human behavior and personality that can become disordered.[9][10][11][12]
The state of anxiety or fear can become disordered, so that it is unusually intense or generalized over a prolonged period of time. Commonly recognized categories of anxiety disorders include specific phobia, Generalized anxiety disorder, Social Anxiety Disorder, Panic Disorder, Agoraphobia, Obsessive-Compulsive Disorder, Post-traumatic stress disorder. Relatively long lasting affective states can also become disordered. Mood disorder involving unusually intense and sustained sadness, melancholia or despair is know as Clinical depression (or Major depression), and may more generally be described as Emotional dysregulation. Milder but prolonged depression can be diagnosed as dysthymia. Bipolar disorder involves abnormally "high" or pressured mood states, known as mania or hypomania, alternating with normal or depressed mood. Whether unipolar and bipolar mood phenomena represent distinct categories of disorder, or whether they usually mix and merge together along a dimension or spectrum of mood, is under debate in the scientific literature.[13]
Patterns of belief, language use and perception can become disordered. Psychotic disorders centrally involving this domain include Schizophrenia and Delusional disorder. Schizoaffective disorder is a category used for individuals showing aspects of both schizophrenia and affective disorders. Schizotypy is a category used for individuals showing some of the traits associated with schizophrenia but without meeting cut-off criteria.
The fundamental characteristics of a person that influence his or her cognitions, motivations, and behaviors across situations and time - can be seen as disordered due to being abnormally rigid and maladaptive. Categorical schemes list a number of different personality disorders, such as those classed as eccentric (e.g. Paranoid personality disorder, Schizoid personality disorder, Schizotypal personality disorder), those described as dramatic or emotional (Antisocial personality disorder, Borderline personality disorder, Histrionic personality disorder, Narcissistic personality disorder) or those seen as fear-related (Avoidant personality disorder, Dependent personality disorder, Obsessive-compulsive personality disorder).
There may be an emerging consensus that personality disorders, like personality traits in the normal range, incorporate a mixture of more acute dysfunctional behaviors that resolve in relatively short periods, and maladaptive temperamental traits that are relatively more stable.[14] Non-categorical schemes may rate individuals via a profile across different dimensions of personality that are not seen as cut off from normal personality variation, commonly through schemes based on the Big Five personality traits.[15]
Other disorders may involve other attributes of human functioning. Eating practices can be disordered, at least in relatively rich industrialized areas, with either compulsive over-eating or under-eating or binging. Categories of disorder in this area include Anorexia nervosa, Bulimia nervosa, Exercise Bulimia or Binge eating disorder. Sleep disorders such as Insomnia also exist and can disrupt normal sleep patterns. Sexual and gender identity disorders, such as Dyspareunia or Gender identity disorder or ego-dystonic homosexuality. People who are abnormally unable to resist urges, or impulses, to perform acts that could be harmful to themselves or others, may be classed as having an impulse control disorder, including various kinds of Tic disorders such as Tourette's Syndrome, and disorders such as Kleptomania (stealing) or Pyromania (fire-setting). Substance-use disorders include Substance abuse disorder. Addictive gambling may be classed as a disorder. Inability to sufficiently adjust to life circumstances may be classed as an Adjustment disorder. The category of adjustment disorder is usually reserved for problems beginning within three months of the event or situation and ending within six months after the stressor stops or is eliminated. People who suffer severe disturbances of their self-identity, memory and general awareness of themselves and their surroundings may be classed as having a Dissociative identity disorder, such as Depersonalization disorder or Dissociative Identify Disorder itself (which has also been called multiple personality disorder, or "split personality".). Factitious disorders, such as Munchausen syndrome, also exist where symptoms are experienced and/or reported for personal gain.
Disorders appearing to originate in the body, but thought to be mental, are known as somatoform disorders, including Somatization disorder. There are also disorders of the perception of the body, including Body dysmorphic disorder. Neurasthenia is a category involving somatic complaints as well as fatigue and low spirits/depression, which is officially recognized by the ICD-10 but not by the DSM-IV.[16] Memory or cognitive disorders, such as amnesia or Alzheimer's disease exist.
Some disorders are thought to usually first occur in the context of early childhood development, although they may continue into adulthood. The category of Specific developmental disorder may be used to refer to circumscribed patterns of disorder in particular learning skills, motor skills, or communication skills. Disorders which appear more generalized may be classed as pervasive developmental disorders (PDD) also known as autism spectrum disorders (ASD); these include autism, Asperger's, Rett syndrome, childhood disintegrative disorder and other types of PDD whose exact diagnosis may not be specified. Other disorders mainly or first occurring in childhood include Reactive attachment disorder; Separation Anxiety Disorder; Oppositional Defiant Disorder; Attention Deficit Hyperactivity Disorder.
Causes
Numerous factors have been linked to the development of mental disorders. In many cases there is no single accepted or consistent cause currently established. A common view held is that disorders often result from genetic vulnerabilities combining with environmental stressors (Diathesis-stress model). An eclectic or pluralistic mix of models may be used to explain particular disorders. The primary paradigm of contemporary mainstream Western psychiatry is said to be the biopsychosocial (BPS) model - incorporating biological, psychological and social factors - although this may not be applied in practice. Biopsychiatry has tended to follow a biomedical model, focusing on "organic" or "hardware" pathology of the brain. Psychoanalytic theories have been popular but are now less so. Evolutionary psychology may be used as an overall explanatory theory. Attachment theory is another kind of evolutionary-psychological approach sometimes applied in the context for mental disorders. A distinction is sometimes made between a "medical model" or a "social model" of disorder and related disability.
Genetic studies have indicated that genes often play an important role in the development of mental disorders, via developmental pathways interacting with environmental factors. The reliable identification of connections between specific genes and specific categories of disorder has proven more difficult.
Environmental events surrounding pregnancy and birth have also been implicated. Traumatic brain injury may increase the risk of developing certain mental disorders. There have been some tentative inconsistent links found to certain viral infections, to substance misuse, and to general physical health.
Abnormal functioning of neurotransmitter systems has been implicated, including serotonin, norepinephrine, dopamine and glutamate systems. Differences have also been found in the size or activity of certain brains regions in some cases. Psychological mechanisms have also been implicated, such as cognitive and emotional processes, personality, temperament and coping style.
Social influences have been found to be important, including abuse, bullying and other negative or stressful life experiences. The specific risks and pathways to particular disorders are less clear, however. Aspects of the wider community have also been implicated, including employment problems, socioeconomic inequality, lack of social cohesion, problems linked to migration, and features of particular societies and cultures.
Diagnosis
Many mental health professionals, particularly psychiatrists, seek to diagnose individuals by ascertaining their particular mental disorder. Some professionals, for example some clinical psychologists, may avoid diagnosis in favor of other assessment methods such as formulation of a client's difficulties and circumstances.[17] The majority of mental health problems are actually assessed and treated by family physicians during consultations, who may refer on for more specialist diagnosis in acute or chronic cases. Routine diagnostic practice in mental health services typically involves an interview (which may be referred to as a mental status examination), where judgements are made of the interviewee's appearance and behavior, self-reported symptoms, mental health history, and current life circumstances. The views of relatives or other third parties may be taken into account. A physical examination to check for ill health or the effects of medications or other drugs may be conducted. Psychological testing is sometimes used via paper-and-pen or computerized questionnaires, which may include algorithms based on ticking off standardized diagnostic criteria, and in relatively rare specialist cases neuroimaging tests may be requested, but these methods are more commonly found in research studies than routine clinical practice.[18][19] Time and budgetary constraints often limit practicing psychiatrists from conducting more thorough diagnostic evaluations.[20] It has been found that most clinicians evaluate patients using an unstructured, open-ended approach, with limited training in evidence-based assessment methods, and that inaccurate diagnosis may be common in routine practice.[21] Comorbidity is very common in psychiatric diagnosis, i.e. the same person given a diagnosis in more than one category of disorder.
Treatment
Mental health services may be based in hospitals, clinics or the community. Often an individual may engage in different treatment modalities. They may be under case management (sometimes referred to as "service coordination"), use inpatient or day treatment, utilize a psychosocial rehabilitation program, and/or take part in an Assertive Community Treatment program. Individuals may be treated against their will in some cases, especially if assessed to be at high risk to themselves or others. Services in some countries are increasingly based on a Recovery model that supports an individual's journey to regain a meaningful life
Psychotherapy
A major option for many mental disorders is psychotherapy. There are several main types. Cognitive behavioral therapy (CBT) is widely used and is based on modifying the patterns of thought and behavior associated with a particular disorder. Psychoanalysis, addressing underlying psychic conflicts and defenses, has been a dominant school of psychotherapy and is still in use. Systemic therapy or family therapy is sometimes used, addressing a network of significant others as well as an individual. Some psychotherapies are based on a humanistic approach. There are a number of specific therapies used for particular disorders, which may be offshoots or hybrids of the above types. Mental health professionals often employ an eclectic or integrative approach. Much may depend on the therapeutic relationship, and there may be problems with trust, confidentiality and engagement.
Medication
A major option for many mental disorders is psychiatric medication. There are several main groups. Antidepressants are used for the treatment of clinical depression as well as often for anxiety and other disorders. There are a number of antidepressants beginning with the tricylics, moving through a wide variety of drugs that modify various facets of the brain chemistry dealing with intercellular communication. Beta-blockers, developed as a heart medication, is also used as an antidepressant. Anxiolytics are used for anxiety disorders and related problems such as insomnia. Mood stabilizers are used primarily in bipolar disorder. Lithium A (a metal) and Lamictal (an epileptic drug) are notable for treating both mania and depression. The others, mainly targeting mania rather than depression, are a wide variety of epilepsy medications and antipsychotics. Antipsychotics are used for psychotic disorders, notably for positive symptoms in schizophrenia. Stimulants are commonly used, notably for ADHD. Despite the different conventional names of the drug groups, there can be considerable overlap in the kinds of disorders for which they are actually indicated. There may also be off-label use. There can be problems with adverse effects and adherence.
Other
Electroconvulsive therapy (ECT) is sometimes used in severe cases when other interventions for severe intractable depression have failed. Psychosurgery has in the past been synonymous with the "frontal lobotomy." While this form of psychosurgery is no longer used, there are four other techniques that are used today. These methods are used only as a last resort for people who have not responded to medications and therapy, and are functionally crippled by their disorder. The disorders for which psychosurgery has been used for for intractable mood and anxiety disorders, such as Obsessive-Compulsive Disorder.[22]
Psychoeducation may be used to provide people with the information to understand and manage their problems. Creative therapies are sometimes used, including music therapy, art therapy or drama therapy. Lifestyle adjustments and supportive measures are often used, including peer support, self-help and supported housing or employment. Some advocate dietary supplements based on published randomized double-blind, placebo controlled trials.[23] Many things have been found to help at least some people. A placebo effect may play a role in any intervention.
Prevalence
WHO estimated that about 450 million people worldwide currently suffer from some form of mental or behavioural disorder.[26] One in four people will suffer from mental illness at some time in life, according to a report from the WHO.[27][28]
Numerous large-scale surveys of the prevalence of mental disorders in adults in the general population have been carried out since the 1980s based on self-reported symptoms assessed by standardized structured interviews, usually carried out over the phone. Mental disorders have been found to be common, with over a third of people in most countries reporting sufficient criteria at some point in their life.[29] The World Health Organization is currently undertaking a global survey of 26 countries in all regions of the world, based on ICD and DSM criteria.[1] The first published figures on the 14 country surveys completed to date, indicate that, of those disorders assessed, anxiety disorders are the most common in all but 1 country (prevalence in the prior 12-month period of 2.4% to 18.2%) and mood disorders next most common in all but 2 countries (12-month prevalence of 0.8% to 9.6%), while substance disorders (0.1%-6.4%) and impulse-control disorders (0.0%-6.8%) were consistently less prevalent. The United States, Colombia, the Netherlands and Ukraine tended to have higher prevalence estimates across most classes of disorder, while Nigeria, Shanghai and Italy were consistently low, and prevalence was lower in Asian countries in general. Cases of disorder were rated as mild (prevalence of 1.8%-9.7%), moderate (prevalence of 0.5%-9.4%) and serious (prevalence of 0.4%-7.7%).[30] However, these are widely believed to be underestimates, due to poor diagnosis (especially in countries without affordable access to mental health services) and low reporting rates, in part because of the predominant use of self-report data, rather than semi-structured instruments such as the Structured Clinical Interview for DSM-IV (SCID); actual lifetime prevalence rates for mental disorders are estimated to be between 65% and 85%.
A review that pooled surveys in different countries up to 2004 found overall average prevalence estimates for any anxiety disorder of 10.6% (in the 12 months prior to assessment) and 16.6% (in lifetime prior to assessment), but that rates for individual disorders varied widely. Women had generally higher prevalence rates than men, but the magnitude of the difference varied.[31] A review that pooled surveys of mood disorders in different countries up to 2000 found 12-month prevalence rates of 4.1% for major depressive disorder (MDD), 2% for dysthymic disorder and 0.72% for bipolar 1 disorder. The average lifetime prevalence found was 6.7% for MDD (with a relatively low lifetime prevalence rate in higher-quality studies, compared to the rates typically highlighted of 5%-12% for men and 10%-25% for women), and rates of 3.6% for dysthymia and 0.8% for Bipolar 1.[32]
Previous widely cited large-scale surveys in the United States were the Epidemiological Catchment Area (ECA) survey and subsequent National Comorbidity Survey (NCS). The NCS was replicated and updated between 2000 and 2003 and indicated that, of those groups of disorders assessed, nearly half of Americans (46.4%) reported meeting criteria at some point in their life for either a DSM-IV anxiety disorder (28.8%), mood disorder (20.8%), impulse-control disorder (24.8%) or substance use disorders (14.6%). Half of all lifetime cases had started by age 14 years and 3/4 by age 24 years.[33] In the prior 12-month period only, around a quarter (26.2%) met criteria for any disorder - anxiety disorders 18.1%; mood disorders 9.5%; impulse control disorders 8.9%; and substance use disorders 3.8%. A substantial minority (23%) met criteria for more than two disorders. A minority (22.3%) of cases were classed as serious, 37.3% as moderate and 40.4% as mild.[34][35]
A 2004 cross-European study found that approximately one in four people reported meeting criteria at some point in their life for one of the DSM-IV disorders assessed, which included mood disorders (13.9%), anxiety disorders (13.6%) or alcohol disorder (5.2%). Approximately one in ten met criteria within a 12-month period. Women and younger people of either gender showed more cases of disorder[36]
A 2005 review of 27 studies have found that 27% of adult Europeans is or has been affected by at least one mental disorder in the past 12 months. It was also found that the most frequent disorders were anxiety disorders, depressive, somatoform and substance dependence disorders.[37]
A 2005 review of prior surveys in 46 countries on the prevalence of schizophrenic disorders, including a prior 10-country WHO survey, found an average (median) figure of 0.4% for lifetime prevalence up to the point of assessment and 0.3% in the 12-month period prior to assessment. A related figure not given in other studies (known as lifetime morbid risk), reported to be an accurate statement of how many people would theoretically develop schizophrenia at any point in life regardless of time of assessment, was found to be “about seven to eight individuals per 1,000.” (0.7/0.8%). The prevalence of schizophrenia was consistently lower in poorer countries than in richer countries (though not the incidence) but the prevalence did not differ between urban/rural areas or men/women (although incidence did).[38]
Studies of the prevalence of personality disorders (PDs) have been fewer and smaller-scale, but a broader Norwegian survey found a similar overall prevalence of almost 1 in 7 (13.4%), based on meeting personality criteria over the prior five year period. Rates for specific disorders ranged from 0.8% to 2.8%, with rates differing across countries, and by gender, educational level and other factors.[39] A US survey that incidentally screened for personality disorder found an overall rate of 14.79%.[40]
Approximately 7% of a preschool pediatric sample were given a psychiatric diagnosis in one clinical study, and approximately 10% of 1- and 2-year-olds receiving developmental screening have been assessed as having significant emotional/behavioral problems based on parent and pediatrician reports.
Stigma of mental illness
A large proportion of individuals who suffer from the symptoms of a mental illness will avoid seeking treatment for their symptoms because of the social stigma[2] associated with having a mental illness. The US Surgeon General acknowledged this in 1999:
Powerful and pervasive, stigma prevents people from acknowledging their own mental health problems, much less disclosing them to others.[51]
As a result many people feel the need to keep their mental illness a secret, and will deny the symptoms that they are experiencing. Two thirds of the people who would benefit from treatment for a mental illness do not receive treatment.[52] As with many physical illnesses, the prognoses of a mental illness can worsen the longer that a mental illness remains untreated. The added anxiety of fearing a mental illness diagnoses can also be detrimental to an individual's mental health, this effect can greatly exacerbate an anxiety disorder or mood disorder. Efforts are being undertaken worldwide to eliminate the stigma of mental illness.
Violence
The public fear of violence due to mental illness is a contentious topic. One US national survey indicated that a far higher percentage of Americans rated individuals described as displaying the characteristics of a mental disorder (for example Schizophrenia or Substance Use Disorder) as "likely to do something violent to others" compared to those described as being 'troubled'.[70] Research indicates, on balance, a higher than average number of violent acts by some individuals with certain diagnoses, notably antisocial or psychopathic personality disorders, but conflicting findings about specific symptoms (for example links between psychosis and violence in community settings) - but the mediating factors of such acts are most consistently found to be mainly socio-demographic and socio-economic factors such as being young, male, of lower socio-economic status and, in particular, substance abuse (including alcohol).[71][72][24] Findings consistently indicate that it is many times more likely that people diagnosed with a serious mental illness living in the community will be the victim rather than the perpetrator of violence.[71][73] Violence by or against individuals with mental illness typically occurs in the context of complex social interactions (including in atmosphere of mutually high "expressed emotion"), including within a family setting,[74] as well as being an issue in healthcare settings[75] and the wider community.
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