Dizziness (Dizzy)

Introduction to dizziness (feeling dizzy)

Dizziness is one of the most common symptoms that will prompt a person to seek medical care. The term dizziness (or dizzy) means different things to different people, so it is difficult to define. Does "feeling dizzy" mean lightheadedness or the feeling of weakness and almost passing out? Or does it refer to the sensation of vertigo, in which a person feels as if they have just gotten off a merry-go-round?

Dizziness (lightheadedness) is often caused by a decrease in blood supply to the brain, while vertigo may be caused by disturbances of the inner ear and the balance centers of the brain. It is important that the health care practitioner understand what you mean when you complain of dizziness. You may be asked additional questions so that the proper direction can be taken for a diagnosis and treatment.

What are some common causes of dizziness?

While classifying dizziness into lightheadedness and vertigo categories may help understand how the body works, sometimes it is worthwhile to review common reasons why people might complain of dizziness.

Low blood pressure

Dizziness, lightheadedness, and the feeling of passing out is a common complaint in people who have low blood pressure. When the blood pressure is too low, not enough oxygen-rich blood is being delivered to the brain, and its function can be affected. If the brain's blood supply is decreased too much, the person may pass out (syncope).

In addition to feeling dizzy, associated symptoms may include:

• sweating,
  
• nausea and vomiting,
  
• shortness of breath, and
  
• chest pain.

Low blood pressure may be the result of an underlying illness or disease, or it may be a normal physiologic condition. Some common reasons for low blood pressure include the following:

• Anemia (decreased red blood cell count)
  
• Bleeding
  
• Dehydration (loss of water in the body) often occurs with infections that cause vomiting and diarrhea. Fever also can cause a significant amount of water loss due to increased metabolic rate and excessive sweating as the body tries to cool itself.
  
• Heat-related illnesses associated with dehydration such as heat cramps, heat exhaustion, or heat stroke (a medical emergency).
  
• Side effects of certain medications used to control blood pressure and heart rate. Examples include:
  
  • beta blockers (propranolol [Inderal, Inderal LA], atenolol [Tenormin], metoprolol, [Lopressor, Toprol XL]), which block adrenalin receptors in the heart and may limit the ability of the heart rate to increase in response to changes of position, decreased red blood cell count, or dehydration.
    
  • Nitroglycerin and isosorbide mononitrate (Imdur), a long acting nitroglycerin, are medications that are prescribed to dilate blood vessels in the heart to treat angina. However, these medications may also cause other blood vessels in the body to dilate and be unable to respond to the body's needs.
    
  • Diuretics that can cause dehydration
    
  • ACE inhibitors that slow the heart rate, and
    
  • medications for erectile dysfunction that can dilate blood vessels.
    
• Alcohol use
  
• Pregnancy

Postural or orthostatic hypotension

In individuals who are dehydrated or anemic, blood pressure readings may be normal when they are lying flat, however, the lack of fluid is unmasked when they stand up quickly. The lack of blood to the brain causes dizziness and lightheadedness. This feeling may pass in a few seconds as the body adapts. However, if dehydration or medications (for example, beta blockers) prevent the body from reacting by constricting blood vessels and increasing the heart rate, the dizziness may persist to the point at which the patient passes out (faints, syncope).

Some diseases are associated with an inability to compensate for changes in body position (autonomic dysfunction). Normally when a person stands, blood vessels contract to increase blood pressure slightly,  and the heart rate increases to push blood up to the brain (pushing against gravity). In autonomic dysfunction, a person may become dizzy when they move from a lying position to sitting or standing up.  Examples of these diseases include diabetes, Addison's disease, or Parkinson's disease).

Orthostatic hypotension is a common symptom with Shy-Drager syndrome. Shy-Drager syndrome is a rare disease in which the autonomic nervous system degenerates and cannot provide the routine control mechanisms for the body including heart rate, blood pressure, and bowel and bladder function.

High blood pressure

High blood pressure, or hypertension, is known as the "silent killer" since it often has no symptoms, even if blood pressure readings are markedly elevated. On occasion, a person may complain of headache, nausea, or dizziness, although the complaints don't necessarily correlate with the degree of blood pressure elevation.

However, if the blood pressure is elevated and the person has symptoms, there is a need to bring the blood pressure under control relatively quickly. The more severe the symptoms, the quicker blood pressure control needs to be achieved. For example, if a person is having chest pain or stroke symptoms associated with high blood pressure, the blood pressure needs to be controlled immediately.

Diabetes

Dizziness is a common complaint in persons with diabetes, and may be caused by low blood sugar (hypoglycemia), high blood sugar (hyperglycemia), or autonomic dysfunction (see previously).

• Hypoglycemia or low blood sugar (hypo=low +glyc=sugar =emia=blood) occurs because of an inadequate amount of glucose in the blood. A person with diabetes can develop hypoglycemia from an inadequate amount of food intake, or from taking too much medication (insulin or oral tablets), which results in low blood sugar levels. In this situation the person experiences dizziness or lightheadedness because the brain lacks glucose to function properly. Persons with diabetes and their families need to recognize the symptoms of hypoglycemia, including dizziness, sweating, confusion, and coma as treatment needs to be given immediately. Oral sugar-containing foods or a glucagon injection may be life-saving for the patient.
  
• Hyperglycemia (hyper=high +glyc=sugar +emia=blood) also causes dizziness. High blood sugar levels occur because there is not enough insulin available to allow cells to use glucose for energy metabolism. (Interestingly, brain cells do not need insulin to use glucose.) High blood sugars cause a variety of metabolic responses in the body leading to dehydration, anaerobic metabolism, and changes in the acid-based balance. This may result in a life-threatening condition referred to as diabetic ketoacidosis. 

Endocrine diseases

• Diabetes (discussed previously) if not well controlled is one of the main endocrine diseases that may cause dizziness.
  
• Thyroid disease: Abnormalities of the thyroid may also cause dizziness as one of its symptoms.
  
  • Hyperthyroidism (too much thyroid hormone) may cause palpitations, shortness of breath, lightheadedness, and dizziness.
    
  • Hypothyroidism (too little thyroid hormone) may cause low blood pressure and a decreased heart rate leading to dizziness, weakness, lethargy, and chills.
  
  
• Addison's disease: Addison's disease occurs when the adrenal glands do not produce enough cortisol to meet the needs of the body. Cortisol is a naturally occurring steroid produced by the body and is part of the stress response (often termed the "fight or flight" response). If cortisol levels are low, a patient may experience weakness, fatigue, dizziness, lightheadedness, low blood sugar, and low blood pressure.

Hyperventilation

While the body may use hyperventilation or rapid breathing to help with acid-base balance, it may also occur as a response to an emotionally stressful situation. In hyperventilation syndrome, the rapid breathing blows off some of the body's carbon dioxide, leading to a tingling sensation in the hands and feet, and around the mouth. Dizziness and lightheadedness are associated symptoms. The symptoms may increase the perceived emotional stress and cause even more hyperventilation. In severe hyperventilation, carbon monoxide levels drop enough to cause carpopedal spasm, in which the hands and feet become claw-like and difficult to move. Symptoms of hyperventilation resolve relatively quickly once the breathing rate returns to normal.

Heart conditions

The heart is an electrical pump and for it to work, the electrical conduction system must be operating properly to stimulate the heart muscle to squeeze in a coordinated fashion and pump blood to the body. The heart muscle itself must be strong enough to pump blood, and the valves in the heart must work properly to allow blood to flow in the direction intended during contraction.

• Conduction disturbances: Electrical conduction disturbances may make the heart beat too quickly (tachycardia) or too slowly (bradycardia), and either of these situations may result in an inadequate blood supply to the brain, causing dizziness or lightheadedness.
  
• Cardiomyopathy: Dizziness is also a symptom of cardiomyopathy (cardio=heart +myo=muscle + pathy= disease), a disease of the heart muscle, resulting in muscle that doesn't beat properly. Most commonly the weakness is due to atherosclerotic heart disease or ischemic cardiomyopathy (ischemic=decreased blood supply), in which the heart muscle itself doesn't get enough blood supply to work properly. Other cardiomyopathies may be due to diabetes, alcohol use, and viral infections.

Vasovagal syncope

Vasovagal syncope is a common cause of dizziness, lightheadedness, and fainting. The vagus nerve is overstimulated and causes the body's blood vessels to dilate and the heart to slow down. This anti-adrenaline effect decreases the ability of the heart to pump blood upward to the brain. Without blood flow, the brain turns off. In Victorian England, when this happened because young ladies' sensibilities were easily offended, this was called a swoon.

Some people faint at the sight of blood. Some parents faint when their child gets immunized. Many types of emotional and physical stressors can overstimulate stimulate the vagus nerve, thus causing dizziness, lightheadedness, and at times fainting (passing out).

Fainting is not normal. If a person is unconscious, the emergency medical system should be activated (call 911 if available), and medical care should be sought.

Dizziness and vertigo

Vertigo is often described as feeling dizzy, or a sensation of spinning. A person may specifically mention that the room seems to be spinning around them. Sometimes the complaint is loss of balance or loss of equilibrium. This often occurs because of irritation in the inner ear (the part of the ear that involves balance, not hearing).

The inner ear has two parts that help the body determine its position in space relative to gravity; 1) the semicircular canals and 2) the vestibule.

There are three semicircular canals that are aligned at right angles to each other. These canals are filled with fluid and are lined with a nerve-filled, crystal-encrusted membrane that transmits information to the cerebellum (the part of the brain that controls balance and coordination). The cerebellum collects information from the eyes (visual stimuli) and the nerve endings in muscles associated with proprioception (the perception of movement), to assist the brain in assessing where the body is in relationship to gravity and its surroundings.

Normally, when the head moves, fluid in the semicircular canals shift, and that information is relayed to the brain. When the head stops moving, the fluid stops as well, and that information is relayed to the brain.

In some cases there may be a short delay in the transmission of this information to the brain. For example, when a person rides on a merry-go-round or spins quickly around in circles, the fluid in the canals develop momentum and even though the body stops spinning, the fluid in the semicircular canals may continue to move. This causes vertigo, or a sensation of spinning, and may cause the person to fall or stumble. It also may be associated with vomiting. While these are symptoms attempt to provoke in play, they can be debilitating for an adult.

• Inflammation: In patients with vertigo, inflammation of the fluid or irritation of the crystals on the membrane that lines the walls of the semicircular canals may cause the spinning sensation even without much head movement. Often, only one canal is involved and the patient may be symptom-free if they don't move.
  
• Benign paroxysmal positional vertigo (BPPV): BPPV may be caused when the crystals in the inner ear become dislodged and irritate the semicircular canals. Often the cause is not found, but there may be an association with unusual positioning or movement of the head, for example, moving the head up and down while working on a computer. It is frequently seen in people older than 60 years of age.
  
• Labyrinthitis: Labyrinthitis (labyrinth=inner ear + itis=inflammation) may follow a viral infection which causes inflammation within the middle ear.
  
• Meniere's disease: This condition is a disorder of the flow of fluids of the inner ear; symptoms include vertigo, hearing loss, and tinnitus (ringing in the ears).
  
• Acoustic neuroma: This is a benign tumor of the ear that can be present with vertigo.
  
• Brain: Much less commonly, the cause of vertigo may arise in the brain. Stroke, tumors, seizures and multiple sclerosis may be associated with vertigo.

What are the symptoms experienced when a person feels dizzy?

• Lightheadedness is the feeling of weakness and faintness as if you are about to pass out. The symptoms tend to be short-lived, depending on the cause. There may be associated nausea, sweating, and blurred vision.
  
• If the cause is dehydration or bleeding, the symptoms may be brought on by standing quickly and may resolve somewhat by lying down (orthostatic hypotension)
  
• Heart rhythm disturbances may occur without warning and may be associated with palpitations. This may come and go or it may persist. The heart beat may be felt as too fast (often described as a pounding), too slow, and/or irregular.
  
• Vertigo is the sensation of spinning and may present without warning and be associated with nausea and vomiting. People with inner ear problems may be unable to move without generating symptoms.
  
• People with a cerebellar cause of vertigo such as a stroke or tumor may have associated coordination problems or difficulty walking.

When should I call the doctor for dizziness?

Dizziness is a common complaint and often has resolved by the time the patient arrives to see a health care practitioner. Usually there is no rush to seek care. However, while the complaint of dizziness is not often an emergency, care should be sought immediately if it is accompanied by any of the following:

• Chest pain, shortness of breath, or palpitations. These symptoms should not be ignored as they suggest the heart may be the source of the dizziness.
  
• Dehydration. Often there may be an associated illness including fever, vomiting, or diarrhea.
  
• People with diabetes may have dizziness due to low blood sugar (hypoglycemia) or high blood sugar (hyperglycemia), and may need emergent care to stabilize their insulin and medication requirements.
  
• Bleeding from any source.
  
• Altered mental status or thinking. This may include symptoms such as confusion, change in vision, change in speech, facial droop, weakness of one side of the body, or headache. These may be signs of stroke, bleeding in the brain, or tumor.
  
• Vertigo may cause significant problems with vomiting and may be debilitating. Often, medical care is needed to control symptoms even though the underlying problem is not serious.

How is dizziness diagnosed?

The diagnosis of dizziness begins with the health care practitioner evaluating whether the complaint of dizziness refers to lightheadedness or vertigo. Further direction continues once this distinction is made.

The key to the diagnosis of dizziness is a thorough history and physical examination. Often the diagnosis is made by listening to the patient's story. The health care practitioner may ask about triggers that cause and relieve the symptoms of dizziness, such as:

• "Is it related to changing positions quickly?" and
• "Does it resolve on its own or does the patient have to do something, like lie down to make it better?"

A review of systems is a series of questions that review the patient's body functions. Questions may be asked about associated symptoms including fever, vomiting, diarrhea, chest pain, shortness of breath, palpitations, or abnormal bleeding. The past medical history may be reviewed, and this includes reviewing  medications the patient is currently taking.

A thorough physical examination will likely be done, this may include:

Vital signs: Taking the patient's blood pressure and pulse rate lying down and standing (called orthostatic or postural vital signs) often will indicate the fluid status of the body. In patients who are dehydrated or bleeding, the vital signs may rise on changing position. However, patients taking medications such as beta blockers will not generate in increased pulse rate.

Tailored physical examination: Often, the physical examination is tailored to the patient based upon the information provided in the patient's medical history. For example, a woman with a heavy menstrual period may need a pelvic examination, or a patient with cough and shortness of breath may need a closer examination of the heart and lungs.

Imaging studies and blood tests: The need for imaging studies and/or and blood tests will depend on the concerns the health care practitioner and patient have in regard to the cause of the dizziness. Common tests that may be ordered include:

• complete blood count (CBC) to screen for anemia or infection,
  
• evaluation of electrolytes,
  
• blood sugar tests,
  
• kidney function tests, and
  
• thyroid tests.

X-rays, CT scans, and MRI may be indicated depending upon the patient's needs.

How is vertigo diagnosed?

The diagnosis of vertigo is most often made based upon history and clinical presentation. If the patient is experiencing a spinning sensation that worsens by a change in position, and lessens by lying still, the health care practitioner can confirm the cause of dizziness as vertigo.

Further history may be taken to make certain that the symptom of vertigo is isolated to an inner ear condition and not due to a problem in the brain (for example, a stroke).

Neurological examination

Physical examination will focus on the neurologic examination and may involve looking at eye movements. With vertigo, nystagmus may be present. This is an involuntary movement of the eyes, slow and smooth in one direction with fast twitches in the other. It is the eyes' attempt to compensate for the abnormal signals being created in the inner ear.

The patient's hearing may be tested to assess potential hearing loss. This may be seen in Meniere's Disease or with an acoustic neuroma, but not necessarily with labyrinthitis or benign positional vertigo.

The rest of the neurologic examination may be done to look for one-sided weakness, loss of coordination, or loss of balance as potential signs of stroke.

Evaluation for BPPV or labyrinthitis is often complete at this point, although depending upon the health care practitioner's concerns, further testing may be indicated. Referral may be made to a physical therapist specially trained in vestibular therapy.

If there is confusion as to the potential cause of vertigo, imaging of the brain may be needed. Magnetic resonance imaging (MRI) may be indicated since this test evaluates the cerebellum more accurately. Computerized tomography (CT scan) may be used in an emergency to assess bleeding

How is dizziness treated?

Dizziness treatment

Dizziness is a symptom, not a disease, and treatment will be directed to the underlying cause. For example, dizziness or lightheadedness due to dehydration from gastroenteritis may require intravenous fluids and medications to stop the vomiting and diarrhea, while dizziness or lightheadedness from a heart rhythm condition may require admission to the hospital and specialized testing and treatment.

Vertigo treatment

• Vertigo from inner ear problems may often be treated with maneuvers to reposition the crystals and debris in the semicircular canals.
  
• Depending upon the reason for the inner ear inflammation, oral steroid medications to decrease that inflammation might be prescribed.
  
• Over-the-counter or prescription medication is occasionally recommended or prescribed to help with vertigo. Meclizine (Antivert) may help with control of mild symptoms.
  
• In patients with intractable symptoms and vomiting, intravenous diazepam (Valium) may be considered.
  
• Patients with Meniere's Disease or acoustic neuroma are usually referred to an ear, nose, and throat specialist (otolaryngologist, ENT physician) for further evaluation and care.

Dizziness At A Glance

• Dizziness is a symptom that is often applies to a variety of sensations including lightheadedness and vertigo. Vertigo is the sensation of spinning, while lightheadedness is typically considered near fainting, and weakness.
  
• Conditions that may cause dizziness in a patient include low blood pressure, high blood pressure, dehydration, medications, postural or orthostatic hypotension, diabetes, endocrine disorders, hyperventilation, heart conditions, and vasovagal syncope.
  
• Vertigo is most often caused by a problem in the balance centers of the inner ear called the vestibular system and causes the sensation of the room spinning. It may be associated with vomiting. Symptoms often are made worse with position changes. Those with significant symptoms and vomiting may need intravenous medication and hospitalization.
  
• Vertigo is also the presenting symptom in patients with Meniere's Disease and acoustic neuroma, conditions that often require referral to an ENT specialist.
  
• Most often, dizziness or lightheadedness is a temporary situation that resolves spontaneously without a specific diagnosis being made.

Hyperthyroidism

What is hyperthyroidism?

Hyperthyroidism is a condition in which an overactive thyroid gland is producing an excessive amount of thyroid hormones that circulate in the blood. ("Hyper" means "over" in Greek). Thyrotoxicosis is a toxic condition that is caused by an excess of thyroid hormones from any cause. Thyrotoxicosis can be caused by an excessive intake of thyroid hormone or by overproduction of thyroid hormones by the thyroid gland. Because both physicians and patients often use these words interchangeably, we will take some liberty by using the term "hyperthyroidism" throughout this article.

What are thyroid hormones?

Thyroid hormones stimulate the metabolism of cells. They are produced by the thyroid gland. The thyroid gland is located in the lower part of the neck, below the Adam's apple. The gland wraps around the windpipe (trachea) and has a shape that is similar to a butterfly formed by two wings (lobes) and attached by a middle part (isthmus).

The thyroid gland removes iodine from the blood (which comes mostly from a diet of foods such as seafood, bread, and salt) and uses it to produce thyroid hormones. The two most important thyroid hormones are thyroxine (T4) and triiodothyronine (T3) representing 99.9% and 0.1% of thyroid hormones respectively. The hormone with the most biological activity (for example, the greatest effect on the body) is actually T3. Once released from the thyroid gland into the blood, a large amount of T4 is converted to T3 - the more active hormone that affects the metabolism of cells.

Thyroid hormone regulation--the chain of command

The thyroid itself is regulated by another gland located in the brain, called the pituitary. In turn, the pituitary is regulated in part by thyroid hormone that is circulating in the blood (a "feedback" effect of thyroid hormone on the pituitary gland) and in part by another gland called the hypothalamus, also a part of the brain.

The hypothalamus releases a hormone called thyrotropin releasing hormone (TRH), which sends a signal to the pituitary to release thyroid stimulating hormone ( TSH). In turn, TSH sends a signal to the thyroid to release thyroid hormones. If overactivity of any of these three glands occurs, an excessive amount of thyroid hormones can be produced, thereby resulting in hyperthyroidism.

Hypothalamus - TRH

Pituitary- TSH

Thyroid- T4 and T3

The rate of thyroid hormone production is controlled by the pituitary gland. If there is an insufficient amount of thyroid hormone circulating in the body to allow for normal functioning, the release of TSH is increased by the pituitary in an attempt to stimulate the thyroid to produce more thyroid hormone. In contrast, when there is an excessive amount of circulating thyroid hormone, the release of TSH is reduced as the pituitary attempts to decrease the production of thyroid hormone.

What causes hyperthyroidism?

Some common causes of hyperthyroidism include:

• Graves' Disease
  
• Functioning adenoma ("hot nodule") and toxic multinodular goiter (TMNG)
  
• Excessive intake of thyroid hormones
  
• Abnormal secretion of TSH
  
• Thyroiditis (inflammation of the thyroid gland)
  
• Excessive iodine intake

Graves' Disease

Graves' disease, which is caused by a generalized overactivity of the thyroid gland, is the most common cause of hyperthyroidism. In this condition, the thyroid gland usually is renegade, which means it has lost the ability to respond to the normal control by the pituitary gland via TSH. Graves' disease is hereditary and is up to five times more common among women than men. Graves' disease is thought to be an autoimmune disease, and antibodies that are characteristic of the illness may be found in the blood. These antibodies include thyroid stimulating immunoglobulin (TSI antibodies), thyroid peroxidase antibodies (TPO), and TSH receptor antibodies. The triggers for Grave's disease include:

• stress,
  
• smoking,
  
• radiation to the neck,
  
• medications, and
  
• infectious organisms such as viruses.

Graves' disease can be diagnosed by a standard, nuclear medicine thyroid scan which shows diffusely increased uptake of a radioactively-labeled iodine. In addition, a blood test may reveal elevated TSI levels.

Grave's disease may be associated with eye disease (Graves' ophthalmopathy) and skin lesions (dermopathy ). Ophthalmopathy can occur before, after, or at the same time as the hyperthyroidism. Early on, it may cause sensitivity to light and a feeling of "sand in the eyes." The eyes may protrude and double vision can occur. The degree of ophthalmopathy is worsened in those who smoke. The course of the eye disease is often independent of the thyroid disease, and steroid therapy may be necessary to control the inflammation that causes the ophthalmopathy. In addition, surgical intervention may be required. The skin condition (dermopathy) is rare and causes a painless, red , lumpy skin rash that appears on the front of the legs.

Functioning Adenoma and Toxic Multinodular Goiter

The thyroid gland (like many other areas of the body) becomes lumpier as we get older. In the majority of cases, these lumps do not produce thyroid hormones and require no treatment. Occasionally, a nodule may become "autonomous," which means that it does not respond to pituitary regulation via TSH and produces thyroid hormones independently. This becomes more likely if the nodule is larger that 3 cm. When there is a single nodule that is independently producing thyroid hormones, it is called a functioning nodule. If there is more than one functioning nodule, the term toxic, multinodular goiter is used. Functioning nodules may be readily detected with a thyroid scan.

Excessive intake of thyroid hormones

Taking too much thyroid hormone medication is actually quite common. Excessive doses of thyroid hormones frequently go undetected due to the lack of follow-up of patients taking their thyroid medicine. Other persons may be abusing the drug in an attempt to achieve other goals such as weight loss. These patients can be identified by having a low uptake of radioactively-labelled iodine (radioiodine) on a thyroid scan.

Abnormal secretion of TSH

A tumor in the pituitary gland may produce an abnormally high secretion of TSH (the thyroid stimulating hormone). This leads to excessive signaling to the thyroid gland to produce thyroid hormones. This condition is very rare and can be associated with other abnormalities of the pituitary gland. To identify this disorder, an endocrinologist performs elaborate tests to assess the release of TSH.

Thyroiditis (inflammation of the thyroid)

Inflammation of the thyroid gland may occur after a viral illness (subacute thyroiditis). This condition is association with a fever and a sore throat that is often painful on swallowing. The thyroid gland is also tender to touch. There may be generalized neck aches and pains. Inflammation of the gland with an accumulation of white blood cells known as lymphocytes (lymphocytic thyroiditis) may also occur. In both of these conditions, the inflammation leaves the thyroid gland "leaky," so that the amount of thyroid hormone entering the blood is increased. Lymphocytic thyroiditis is most common after a pregnancy and can actually occur in up to 8% of women after delivery. In these cases, the hyperthyroid phase can last from 4 to 12 weeks and is often followed by a hypothyroid (low thyroid output) phase that can last for up to 6 months. The majority of affected women return to a state of normal thyroid function. Thyroiditis can be diagnosed by a thyroid scan.

Excessive iodine intake

The thyroid gland uses iodine to make thyroid hormones. An excess of iodine may cause hyperthyroidism. Iodine-induced hyperthyroidism is usually seen in patients who already have an underlying abnormal thyroid gland. Certain medications, such as amiodarone (Cordarone), which is used in the treatment of heart problems, contain a large amount of iodine and may be associated with thyroid function abnormalities.

What are the symptoms of hyperthyroidism?

Hyperthyroidism is suggested by several signs and symptoms; however, patients with mild disease usually experience no symptoms. In patients older than 70 years, the typical signs and symptoms also may be absent. In general, the symptoms become more obvious as the degree of hyperthyroidism increases. The symptoms usually are related to an increase in the metabolic rate of the body.

Common symptoms include:

• Excessive sweating
  
• Heat intolerance
  
• Increased bowel movements
  
• Tremor (usually fine shaking)
  
• Nervousness; agitation
  
• Rapid heart rate
  
• Weight loss
  
• Fatigue
  
• Decreased concentration
  
• Irregular and scant menstrual flow

In older patients, irregular heart rhythms and heart failure can occur. In its most severe form, untreated hyperthyroidism may result in "thyroid storm," a condition involving high blood pressure, fever, and heart failure. Mental changes, such as confusion and delirium, also may occur.

How is hyperthyroidism diagnosed?

Hyperthyroidism can be suspected in patients with:

• tremors,
  
• excessive sweating,
  
• smooth velvety skin,
  
• fine hair,
  
• a rapid heart rate, and
  
• an enlarged thyroid gland.

There may be puffiness around the eyes and a characteristic stare due to the elevation of the upper eyelids. Advanced symptoms are easily detected, but early symptoms, especially in the elderly, may be quite inconspicuous. In all cases, a blood test is needed to confirm the diagnosis.

The blood levels of thyroid hormones can be measured directly and usually are elevated with hyperthyroidism. However, the main tool for detection of hyperthyroidism is measurement of the blood TSH level. As mentioned earlier, TSH is secreted by the pituitary gland. If an excess amount of thyroid hormone is present, TSH is "down-regulated" and the level of TSH falls in an attempt to reduce production of thyroid hormone. Thus, the measurement of TSH should result in low or undetectable levels in cases of hyperthyroidism. However, there is one exception. If the excessive amount of thyroid hormone is due to a TSH-secreting pituitary tumor, then the levels of TSH will be abnormally high. This uncommon disease is known as "secondary hyperthyroidism."

Although the blood tests mentioned previously can confirm the presence of excessive thyroid hormone, they do not point to a specific cause. If there is obvious involvement of the eyes, a diagnosis of Graves' disease is almost certain. A combination of antibody screening (for Graves' disease) and a thyroid scan using radioactively-labelled iodine (which concentrates in the thyroid gland) can help diagnose the underlying thyroid disease. These investigations are chosen on a case-by-case basis.

How is hyperthyroidism treated?

The options for treating hyperthyroidism include:

• Treating the symptoms
  
• Antithyroid drugs
  
• Radioactive iodine
  
• Surgery treating symptoms

Treating the symptoms

There are medications available to immediately treat the symptoms caused by excessive thyroid hormones, such as a rapid heart rate. One of the main classes of drugs used to treat these symptoms is the beta-blockers [for example, propranolol (Inderal), atenolol (Tenormin), metoprolol (Lopressor)]. These medications counteract the effect of thyroid hormone to increase metabolism, but they do not alter the levels of thyroid hormones in the blood. A doctor determines which patients to treat based on a number of variables including the underlying cause of hyperthyroidism, the age of the patient, the size of the thyroid gland, and the presence of coexisting medical illnesses.

Antithyroid Drugs

There are two main antithyroid drugs available for use in the United States, methimazole (Tapazole) and propylthiouracil ( PTU). These drugs accumulate in the thyroid tissue and block production of thyroid hormones. PTU also blocks the conversion of T4 hormone to the more metabolically active T3 hormone. The major risk of these medications is occasional suppression of production of white blood cells by the bone marrow (agranulocytosis). (White cells are needed to fight infection.) It is impossible to tell if and when this side effect is going to occur, so regular determination of white blood cells in the blood are not useful.

It is important for patients to know that if they develop a fever, a sore throat, or any signs of infection while taking methimazole or propylthiouracil, they should see a doctor immediately. While a concern, the actual risk of developing agranulocytosis is less than 1%. In general, patients should be seen by the doctor at monthly intervals while taking antithyroid medication. The dose is adjusted to maintain the patient in as close to a normal thyroid state as possible (euthyroid). Once the dosing is stable, patients can be seen at three month intervals if long-term therapy is planned.

Usually, long-term antithyroid therapy is only used for patients with Graves' disease, since this disease may actually go into remission under treatment without requiring treatment with thyroid radiation or surgery. If treated from one to two years, the data shows remission rates of 40%-70%. When the disease is in remission, the gland is no longer overactive, and antithyroid medication is not needed.

Recent studies also have shown that adding a pill of thyroid hormone to the antithyroid medication actually results in higher remission rates. The rationale for this may be that by providing an external source for thyroid hormone, higher doses of antithyroid medications can be given, which may suppress the overactive immune system in persons with Graves' disease. This type of therapy remains controversial, however. When long-term therapy is withdrawn, patients should continue to be seen by the doctor every three months for the first year, since a relapse of Graves' disease is most likely in this time period. If a patient does relapse, antithyroid drug therapy can be restarted, or radioactive iodine or surgery may be considered.

Radioactive Iodine

Radioactive iodine is given orally (either by pill or liquid) on a one-time basis to ablate a hyperactive gland. The iodine given for ablative treatment is different from the iodine used in a scan. (For treatment, the isotope iodine 131 is used, while for a routine scan, iodine 123 is used.) Radioactive iodine is given after a routine iodine scan, and uptake of the iodine is determined to confirm hyperthyroidism. The radioactive iodine is picked up by the active cells in the thyroid and destroys them. Since iodine is only picked up by thyroid cells, the destruction is local, and there are no widespread side effects with this therapy.

Radioactive iodine ablation has been safely used for over 50 years, and the only major reasons for not using it are pregnancy and breast-feeding. This form of therapy is the treatment of choice for recurring Graves' disease, patients with severe cardiac involvement, those with multinodular goiter or toxic adenomas, and patients who cannot tolerate antithyroid drugs. Radioactive iodine must be used with caution in patients with Graves' related eye disease since recent studies have shown that the eye disease may worsen after therapy. If a woman chooses to become pregnant after ablation, it is recommended she wait 8-12 months after treatment before conceiving.

In general, more than 80% of patients are cured with a single dose of radioactive iodine. It takes between 8 to 12 weeks for the thyroid to become normal after therapy. Permanent hypothyroidism is the major complication of this form of treatment. While a temporary hypothyroid state may be seen up to six months after treatment with radioactive iodine, if it persists longer than six months, thyroid replacement therapy (with T4 or T3) usually is begun.

Surgery

Surgery to partially remove the thyroid gland (partial thyroidectomy) was once a common form of treatment for hyperthyroidism. The goal is to remove the thyroid tissue that was producing the excessive thyroid hormone. However, if too much tissue is removed, an inadequate production of thyroid hormone (hypothyroidism) may result. In this case, thyroid replacement therapy is begun. The major complication of surgery is disruption of the surrounding tissue, including the nerves supplying the vocal cords and the four tiny glands in the neck that regulate calcium levels in the body (the parathyroid glands). Accidental removal of these glands may result in low calcium levels and require calcium replacement therapy.

With the introduction of radioactive iodine therapy and antithyroid drugs, surgery for hyperthyroidism is not as common as it used to be. Surgery is appropriate for:

• pregnant patients and children who have major adverse reactions to antithyroid medications.
  
• patients with very large thyroid glands and in those who have symptoms stemming from compression of tissues adjacent to the thyroid, such as difficulty swallowing, hoarseness, and shortness of breath.

What's best for you?

If you are concerned that you may have an excess amount of thyroid hormone, you should mention your symptoms to your doctor. A simple blood test is the first step in the diagnosis. From there, both you and your doctor can decide what the next step should be. If treatment is warranted, it is important for you to let your doctor know of any concerns or questions you have about the options available. Remember that thyroid disease is very common, and in good hands, the diseases that cause an excess of thyroid hormones can be easily diagnosed and treated.

Hyperthyroidism At A Glance

• Hyperthyroidism is a condition in which there is an excessive amount of thyroid hormones.
  
• Thyroid hormones regulate the metabolism of the cells.
  
• Normally, the rate of thyroid hormone production is controlled by the brain at the pituitary gland.
  
• There are many possible causes of hyperthyroidism.
  
• Common symptoms of hyperthyroidism include restlessness, tremors, weight loss despite an increased appetite, sweating, rapid heart rate, intolerance to heat, and frequent bowel movements.
  
• Treatments for hyperthyroidism include medications, ablation, and surgery.

Sciatica

What is sciatica?

Sciatica is pain in the lower extremity resulting from irritation of the sciatic nerve. The pain of sciatica is typically felt from the low back (lumbar area) to behind the thigh and radiating down below the knee. The sciatic nerve is the largest nerve in the body and begins from nerve roots in the lumbar spinal cord in the low back and extends through the buttock area to send nerve endings down the lower limb. The pain of sciatica is sometimes referred to as sciatic nerve pain.

What are causes of sciatica?

While sciatica is most commonly a result of a lumbar disc herniation directly pressing on the nerve, any cause of irritation or inflammation of the sciatic nerve can reproduce the symptoms of sciatica. This irritation of nerves as a result of an abnormal intervertebral disc is referred to as radiculopathy. Aside from a pinched nerve from a disc, other causes of sciatica include irritation of the nerve from adjacent bone, tumors, muscle, internal bleeding, infections, injury, and other causes. Sometimes sciatica can occur because of irritation of the sciatic nerve during pregnancy.

What are risk factors for sciatica?

Risk factors for sciatica include degenerative arthritis of the lumbar spine, lumbar disc disease, and trauma or injury to the lumbar spine.

What are sciatica symptoms?

Sciatica causes pain, a burning sensation, numbness, or tingling radiating from the lower back and upper buttock down the back of the thigh to the back of the leg. The result is lumbar pain, buttock pain, hip pain, and leg pain. Sometimes the pain radiates around the hip or buttock to feel like hip pain. While sciatica is often associated with lower back pain (lumbago), it can be present without low back pain. Severe sciatica can make walking difficult if not impossible. Sometimes the symptoms of sciatica are aggravated by walking or bending at the waist and relieved by lying down. The pain relief by changing positions can be partial or complete.

How is sciatica diagnosed?

Sciatica is diagnosed with a physical exam and medical history. The typical symptoms and certain examination maneuvers help the health care professional to diagnose sciatica. Sometimes, X-rays and other tests, such as CT scan, MRI scan, and electromyogram, are used to further define the exact causes of sciatica.

What are treatment options for sciatica?

Bed rest has been traditionally advocated for the treatment of acute sciatica. But how useful is it?

To study the effectiveness of bed rest in patients with sciatica of sufficient severity to justify treatment with bed rest for two weeks, a research team in the Netherlands led by Dr. Patrick Vroomen randomly assigned 183 such patients to bed rest or, alternatively, to watchful waiting for this period.

To gauge the outcome, both primary and secondary measures were examined. The primary outcome measures were the global assessments of improvement after two and 12 weeks by the doctor and the patient. The secondary outcome measures were changes in functional status and in pain scores, absenteeism from work, and the need for surgical intervention. Neither the doctors who assessed the outcomes nor those involved in data entry and analysis were aware of the patients' treatment assignments.

The results, reported in the New England Journal of Medicine, showed that after two weeks, 64 of the 92 (70%) patients in the bed-rest group reported improvement, as compared with 59 of the 91 (65%) of the patients in the control (watchful-waiting) group. After 12 weeks, 87% of the patients in both groups reported improvement. The results of assessments of the intensity of pain, the aggravation of symptoms, and functional status revealed no significant differences between the two groups. The extent of absenteeism from work and rates of surgical intervention were similar in the two groups.

The researchers concluded that "among patients with symptoms and signs of a lumbosacral radicular syndrome, bed rest is not a more effective therapy than watchful waiting." Sometimes, conventional wisdom is not as wise as research!

Other treatment options for sciatica include addressing the underlying cause, medications to relieve pain and inflammation (including oral and injectable cortisone) and relax muscles, and physical therapy. A variety of low back conditioning and stretching exercises are employed to help people recover from sciatica. Surgical procedures can sometimes be required for persisting sciatica that is caused by nerve compression at the lower spine. Sometimes pain management specialists help with chronic sciatica conditions.

What is the outlook (prognosis) for patients with sciatica?

Depending on the precise cause of the sciatica and the duration of symptoms, the outlook for recovery from sciatica ranges from excellent to having long-term chronic symptoms.

Can sciatica be prevented?

Sciatica can be prevented only to the extent that low back trauma injuries can be avoided can sciatica.

Mental Health and Mental Illness

Mental health and mental illness facts

• Mental health is more than just being free of a mental illness. It is more of an optimal level of thinking, feeling, and relating to others.
• Mentally healthy individuals tend to have better medical health, productivity, and social relationships.
• Mental illness refers to all of the diagnosable mental disorders and is characterized by abnormalities in thinking, feelings, or behaviors.
• Some of the most common types of mental illness include anxiety, depressive, behavioral, and substance-abuse disorders.
• There is no single cause for mental illness. Rather, it is the result of a complex group of genetic, psychological, and environmental factors.
• While everyone experiences sadness, anxiety, irritability, and moodiness at times, moods, thoughts, behaviors, or use of substances that interfere with a person's ability to function well physically, socially, at work, school, or home are characteristics of mental illness.
• There is no one test that definitively indicates whether someone has a mental illness. Therefore, health-care practitioners diagnose a mental disorder by gathering comprehensive medical, family, and mental-health information.
• Talk therapy (psychotherapy) is usually considered the first line of care in helping a person with a mental illness. It is an important part of helping individuals with a mental disorder achieve the highest level of functioning possible.
• Psychotherapies that have been found to be effective in treating many mental disorders include family focused therapy, psycho-education, cognitive therapy, interpersonal therapy, and social rhythm therapy.
• Medications may play an important role in the treatment of a mental illness, particularly when the symptoms are severe or do not adequately respond to psychotherapy.
• A variety of factors can contribute to the prevention of mental-health disorders.
• Individuals with mental illness are at risk for a variety of challenges, but these risks can be greatly reduced with treatment, particularly when it is timely.

What is mental health?

Although it might seem easy to define mental health as the absence of mental illness, most experts agree that there is more to being mentally healthy. The U.S. Surgeon General has defined mental health as "a state of successful performance of mental function, resulting in productive activities, fulfilling relationships with people, and the ability to adapt to change and to cope with adversity." The state of being mentally healthy is enviable given the advantages it affords. For example, mentally healthy adults tend to report the fewest health-related limitations of their routine activities, the fewest full or partially missed days of work, and the healthiest social functioning (for example, low helplessness, clear life goals, high resilience, and high levels of intimacy in their lives).

What is mental illness?

Mental illness refers to all of the diagnosable mental disorders. Mental disorders are characterized by abnormalities in thinking, feelings, or behaviors. Highly common, about 46% of Americans can expect to meet the formal diagnostic criteria for some form of anxiety, depressive, behavioral, thought, or substance-abuse disorder during their lifetime.

What are common types of mental illness?

Some of the most common types of mental illness include anxiety, depressive, behavioral, and substance-abuse disorders. Examples of anxiety disorders include phobias, panic disorder, generalized anxiety disorder (GAD), social anxiety disorder, and obsessive compulsive disorder (OCD). Anxiety disorders are characterized by excessive worry to the point of interfering with the sufferer's ability to function. Examples of anxiety disorders include the following:

• Phobias: involve severe, irrational fear of a thing or situation. Examples of phobias include fear of heights (acrophobia), spiders (arachnophobia), and of venturing away from home (agoraphobia).
• Social anxiety disorder is the fear of being in social situations or feeling scrutinized, like when speaking in public.
• Generalized anxiety disorder (GAD) tends to result in the person either worrying excessively about many aspects of their life (like about money, family members, the future) or having a free-floating anxiety that is otherwise hard to describe. GAD is quite common, affecting about 10% of the population.
• Panic disorder is characterized by recurring episodes of sudden, severe, debilitating anxiety (panic) attacks that are immobilizing. Those episodes usually include symptoms like racing heart beat, shortness of breath, stomach upset, and trouble thinking. In order to be diagnosed as having panic disorder, the person must also either worry about having another attack or about what the attack means (for example, wondering if the symptoms of panic indicate they are having a heart attack).

Behavioral disorders (like attention deficit hyperactivity disorder [ADHD], oppositional defiant disorder, or conduct disorder) are characterized by problems conforming to the tenets of acceptable behavior. The most common behavior disorder is ADHD; this condition includes symptoms of inattention and/or hyperactivity and impulsivity. While it used to be considered primarily a disorder of boys, it is now understood to be just as likely to occur in girls and that it can persist into adulthood in about half of children with ADHD.

Dementia, including Alzheimer's dementia, is characterized by a problem with thinking, involving both memory problems and other forms of thinking. These are also known as cognitive problems and include difficulties with language or with identifying or recognizing things despite having no medical cause for these issues such as stroke or a brain tumor.

Depressive disorders involve feelings of sadness that interfere with the individual's ability to function or, as with adjustment disorder, persist longer than most people experience in reaction to a particular life stressor. Examples of depressive disorders include the following:

• Major depression involves the sufferer feeling depressed most days and for most of each day for at least two weeks in a row. Along with sadness, the individual with major depression experiences a number of other associated symptoms, like irritability, loss of motivation or interest in activities they usually enjoy, hopelessness, and increased or decreased sleep, appetite, and/or weight. The person might also exhibit thoughts, plans, or attempts to harm themselves. Women with postpartum depression tend to experience many of the above symptoms for weeks to months after giving birth.
• Dysthymia sufferers experience depression and milder levels of the symptoms of major depression. In dysthymia, the symptoms are fairly consistent for more than two years in adults and one year in children and adolescents.
• Bipolar disorder, also called manic depression, is a mental illness that is characterized by severe mood swings, repeated episodes of depression, and at least one episode of mania in the person's lifetime. Bipolar disorder is one kind of mood disorder that afflicts more than 1% of adults in the United States, up to as many as 4 million people.

Substance use disorders, like substance abuse and substance dependence, involve the use of a substance that interferes with the social, emotional, physical, educational, or vocational functioning of the person using it. These disorders afflict millions of people and a variety of legal (for example, alcohol and inhalants like household cleaners) and/or illegal (for example, marijuana in most states, cocaine, Ecstasy, and opiates) substances may be involved.

Developmental disorders, like a learning disability, Asperger's disorder, or mental retardation, are often included in diagnostic manuals for mental disorders, but this group of conditions does not by definition mean the person involved has a problem with their mood.

It is important to understand that the list of conditions above is by no means exhaustive. This article focuses on the more common mental illnesses; illnesses like eating disorders and schizophrenia, that are less common but perhaps quite devastating to the life of the person with the condition, are omitted. 

What are the causes and risk factors for mental illness?

One frequently asked question about mental illness is if it is hereditary. Most mental disorders are not directly passed from one generation to another genetically, and there is no single cause for mental illness. Rather, it is the result of a complex group of genetic, psychological, and environmental factors. Genetically, it seems that more often than not, there seems to be a genetic predisposition to developing a mental illness. Everything from mood, behavioral, developmental, and thought disorders are thought to have a genetic risk for developing the condition.

Medical conditions may predispose an individual to developing a mental illness. For example, depression is more likely to occur with certain medical illnesses. These "co-occurring" conditions include heart disease, stroke, diabetes, cancer, hormonal disorders (especially perimenopause or hypothyroidism, known as "low thyroid"), Parkinson's disease, and Alzheimer's disease. While it does not appear that allergies cause depression or visa versa, people who suffer from nonfood allergies have been found to be somewhat more vulnerable to also having depression compared to people who do not have allergies. Some medications used for long periods, such as prednisone, certain blood pressure medicines, sleeping pills, antibiotics, and even birth control pills, in some cases, can cause depression or make an existing depression worse. Some antiseizure medications, like lamotrigine (Lamictal), topiramate (Topamax), and gabapentin (Neurontin), may be associated with a higher risk of suicide. Despite the impact that taking certain medications or having a medical illness can have on a person's emotional state, clinical depression should not be considered a normal or natural reaction to either issue. It should therefore always be aggressively treated.

Environmentally, the risks of developing mental illness can even occur before birth. For example, the risk of schizophrenia is increased in individuals whose mother had one of certain infections during pregnancy. Difficult life circumstances during childhood, like the early loss of a parent, poverty, bullying, witnessing parental violence; being the victim of emotional, sexual, or physical abuse or of physical or emotional neglect; and insecure attachment have all been associated with the development of schizophrenia as well. Even factors like how well represented an ethnic group is in a neighborhood can be a risk or protective factor for developing a mental illness. For example, some research indicates that ethnic minorities may be more at risk for developing mental disorders if there are fewer members of the ethnic group to which the individual belongs in their neighborhood.

Stress has been found to be a significant contributor to the development of most mental illnesses, including bipolar disorder. For example, gay, lesbian, and bisexual people are thought to experience increased emotional struggles associated with the multiple social stressors associated with coping with reactions to their homosexuality or bisexuality in society. Unemployment significantly increases the odds ratio of an individual developing a psychiatric disorder. It almost quadruples the odds of developing drug dependence and triples the odds of having a phobia or a psychotic illness like schizophrenia. Being unemployed more than doubles the chances of experiencing depression, generalized anxiety disorder (GAD), and obsessive-compulsive disorder. 

What are symptoms and signs of mental illness?

While everyone experiences sadness, anxiety, irritability, and moodiness at times, moods, thoughts, behaviors, or use of substances that interfere with a person's ability to function well physically, socially, at work, school, or home are characteristics of mental illness. Mental illness can have virtually any physical symptom associated with it, from insomnia, headaches, stomach upset to even paralysis. Socially, the person with a mental illness may avoid or have trouble making or keeping friends. Emotional problems can result in the person being unable to focus and therefore perform at work or school.

How is mental illness diagnosed?

There is no one test that definitively indicates that someone has a mental illness. Therefore, health-care practitioners diagnose a mental disorder by gathering comprehensive medical, family, and mental-health information. Patients tend to benefit when the professional takes into account their client's entire life and background. This includes but is not limited to the person's gender, sexual orientation, cultural, religious and ethnic background, and socioeconomic status. The symptom sufferer might be asked to fill out a self-test that the professional will review if the person being evaluated is able to complete it. The practitioner will also either perform a physical examination or request that the individual's primary-care doctor or other medical professional perform one. The medical examination will usually include lab tests to evaluate the person's general health and to explore whether or not the individual has a medical condition that might produce psychological symptoms.

In asking questions about mental-health symptoms, the counselor or other mental-health professional often explores if the individual suffers from hallucinations or delusions, depression and/or manic symptoms, anxiety, substance abuse, as well as some personality disorders (for example, schizotypal personality disorder) and developmental disorders (for example, autism spectrum disorders). Since some of the symptoms of any one mental disorder can also occur in other mental illnesses, the mental-health screening is to determine if the individual suffers from a psychotic depressive, bipolar, anxiety, behavioral, substance abuse, or personality disorder.

In addition to providing treatment that is appropriate to the diagnosis, determining the presence of mental illnesses that may co-occur (be comorbid) and addressing those issues is important when trying to improve the life of individuals with a mental illness. For example, people with schizophrenia are at increased risk of having a substance abuse, depressive, or anxiety disorder and of committing suicide. 

What is the treatment for a mental health problem?

Psychotherapies

Talk therapy (psychotherapy) is usually considered the first line of care in helping a person with a mental illness. It is an important part of helping individuals with a mental disorder achieve the highest level of functioning possible. These interventions are therefore seen by some as being forms of occupational therapy for people with mental illness. While medication can be quite helpful in alleviating and preventing overt symptoms for many psychiatric conditions, they do not address the many complex social and psychological issues that can play a major role in how the person with such a disease functions at work, at home, and in his or her relationships. For example, since about 60% of people with bipolar disorder take less than 30% of their medications as prescribed, any support that can promote compliance with treatment and otherwise promote the health of individuals in the mentally disordered population is valuable.

Psychotherapies that have been found to be effective in treating many mental disorders include family focused therapy, psycho-education, cognitive therapy, interpersonal therapy, and social rhythm therapy. Family focused therapy involves education of family members about the disorder and how to help (psycho-education), communication-enhancement training, and teaching family members problem-solving skills training. Psycho-education services involve teaching the person with the illness and their family members about the symptoms of the sufferer, as well as any warning signs (for example, change in sleep pattern or appetite, increased irritability) that the person is beginning to experience another episode of the illness, when applicable. In cognitive behavioral therapy, the mental-health professional works to help the person with a psychiatric condition identify, challenge, and decrease negative thinking and otherwise dysfunctional belief systems. The goal of interpersonal therapy tends to be identifying and managing problems the sufferers of a mental illness may have in their relationships with others. Social rhythm therapy encourages stability of sleep-wake cycles, with the goal of preventing or alleviating the sleep disturbances that may be associated with a psychiatric disorder.

Medications

Medications may play an important role in the treatment of a mental illness, particularly when the symptoms are severe or do not adequately respond to psychotherapy. For example, treatment of bipolar disorder with medications tends to address two aspects: relieving already existing symptoms of mania or depression and preventing symptoms from returning. Medications that are thought to be particularly effective in treating manic and mixed symptoms include olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), paliperidone (Invega), and asenapine (Saphis). These medications belong to a group of medications called neuroleptics and are known for having the ability to work quickly compared to many other psychiatric medications. As a group of medications, side effects that occur most often include sleepiness, dizziness, and increased appetite. Weight gain, which may be associated with higher blood sugar, higher lipid levels, and sometimes increased levels of a hormone called prolactin may also occur. Although older medications in this class that were not mentioned here are more likely to cause muscle stiffness, shakiness, and very rarely uncoordinated muscle twitches (tardive dyskinesia) that can be permanent, health-care practitioners appropriately monitor the people they treat for these potential side effects as well. Mood-stabilizer medications like lithium, divalproex (Depakote), carbamazepine (Tegretol), and lamotrigine (Lamictal) can be useful in treating active (acute) symptoms of manic or mixed episodes. These medications may take a bit longer to work compared to the neuroleptic medications, and some (for example, lithium, divalproex, and carbamazepine) require monitoring of medication blood levels. Further, some of these medications can be associated with birth defects when taken by pregnant women.

Antidepressant medications are the primary medical treatment for the anxiety characterized by anxiety disorders, as well as the depressive symptoms of depressive disorders and bipolar disorder. Examples of those medications that are commonly prescribed for those purposes include serotonergic (SSRI) medications like fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro) and combination serotonergic/adrenergic medications (SNRIs) like venlafaxine (Effexor) and duloxetine (Cymbalta), as well as buproprion (Wellbutrin), which is a dopaminergic antidepressant.

Medications like clonazepam (Klonopin) and lorazepam (Ativan) from the benzodiazepine group are often used to treat anxiety, particularly when it is sudden and severe, as in panic attacks. Medications from the beta-blocker family (for example, propranolol [Inderal]) are sometimes used to treat the physical symptoms associated with anxiety as well.

Alzheimer's and other forms of dementia are often treated with medications like memantine (Namenda), galantamine (Razadyne), donezepil (Aricept), rivastigmine (Exelon), and tacrine (Cognex). These medications tend to slow the progression of dementia, thereby helping sufferers of dementia remain functional longer than they would without treatment.

Despite its stigmatized history, electroconvulsive therapy (ECT) can be a viable treatment for people whose symptoms of depression, bipolar, or thought disorder have inadequately responded to psychotherapies and a number of medication trials. Although alternative treatments for mood disorders like St. John's wort or ginkgo biloba are not recognized standard care for bipolar disorder, as many as one-third of some patients being treated for a mental illness use them. 

Can mental health disorders be prevented?

A variety of factors can contribute to the prevention of mental-health disorders. For example, people who feel less isolated and alone tend to be less likely to develop a mental-health disorder. Those who engage in regular practice of endurance exercise seem to have a more favorable self-image, more resistance to drug and alcohol addiction, and a higher sense of general physical and psychological well-being compared to those who do not exercise regularly. Adolescents who engage regularly in physical activity are characterized by lower levels of anxiety and depression compared to their more sedentary counterparts.

Clear communication by parents about the negative effects of alcohol, as well as about their expectations regarding drug use, has been found to significantly decrease alcohol and other drug use in teens. Adequate parental supervision has also been found to be a deterrent to substance use in children and adolescents. Alcohol and other drug use has been found to occur most often between the hours of 3 p.m. and 6 p.m., immediately after school and prior to parents' arrival home from work. Teen participation in extracurricular activities has therefore been revealed to be an important measure in preventing use of alcohol in this age group. Parents can also help educate teens about appropriate coping and stress-management strategies. For example, 15- to 16-year-olds who use religion to cope with stress tend to use drugs significantly less often and have less problems as a result of drinking than their peers who do not use religion to cope.

What is the prognosis for mental-health problems?

Individuals with mental illness are at risk for a variety of challenges. For example, children who have either a father or mother who have been psychiatrically hospitalized seem to be at higher risk of dying from sudden infant death syndrome (SIDS). Depression in adults can lead to a significantly greater likelihood of health risk factors such as a lack of physical activity, smoking, binge drinking, obesity, high blood pressure, high cholesterol, and poor health. Fortunately, treatment for mental illness can go a long way to restoring the emotional and behavioral health of individuals with mental illness.