Comprehensive information on DHEA supplements for impotence in men, reducing risk of osteoporosis in women with anorexia and treating depression. Learn about the usage, dosage, side-effects of DHEA.

• Overview
• Uses
• Dietary Sources
• Available Forms
• How to Take It
• Precautions
• Possible Interactions
• Supporting Research

Overview

Dehydroepiandrosterone (DHEA) is the most abundant androgen (male steroid hormone) secreted by the adrenal glands (small hormone producing glands which sit on top of the kidneys), and to a lesser extent, by the ovaries and testes. DHEA can also be converted into other steroid hormones, including testosterone and estrogen. Considerable interest in DHEA has developed in recent years with reports that it may play a role in the aging process. Circulating levels of DHEA peak at age 25 and then steadily decline with age. DHEA levels in 70-year-old individuals tend to be roughly 80 percent lower than those in young adults.

Some researchers consider DHEA a possible anti-aging hormone because DHEA deficiencies in older individuals have been associated with a number of medical conditions including breast cancer, cardiovascular disease, impaired memory and mental function, and osteoporosis. In addition, population-based studies have suggested that people with higher DHEA levels tend to live longer, healthier lives than those with lower levels of DHEA. However, low levels of DHEA being linked to certain diseases does not necessarily mean that DHEA supplements will reduce the risk or improve the outcome of these conditions.

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The United States Food and Drug Administration (FDA) removed DHEA supplements from the market in 1985 due to false claims about health benefits. However, since the passing of the US Dietary Supplement Health and Education Act of 1994, DHEA has made its way back on the market and its popularity continues to grow. Despite this growth and attention, support for the health claims, particularly as tested on people, is lacking. Plus, given that DHEA products are sold as dietary supplements, there is no control over their contents or the manufacturing practices of the companies that make the supplements. One independent evaluation found that the amount of DHEA in over the counter products ranged from 0% to 150% of what the content stated on the label.

 

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DHEA Uses

DHEA for Aging
Given that DHEA levels decline with advancing age, some researchers have investigated whether DHEA supplementation may slow or prevent age-related declines in mental and physical function. Preliminary results from the DHEAge study in France suggest that the hormone may slow bone loss, improve skin health, and enhance sexual drive in aging adults, particularly women older than 70 years of age. Animal studies that have shown a boost in memory for older rats taking DHEA supplements. Results from human studies, however, have been conflicting. Some studies have shown that DHEA improves learning and memory in those with low DHEA levels, but other studies have failed to detect any significant cognitive effects from DHEA supplementation. Further studies are needed to determine whether DHEA supplementation helps prevent or slow medical conditions associated with the aging process.

DHEA for Adrenal Insufficiency
As mentioned earlier, DHEA is one of the hormones made in the adrenal glands. When the adrenal glands do not make enough hormones, this is called adrenal insufficiency. Women with this condition who were given DHEA supplements reported improved sexuality and sense of well-being (including decreased feelings of depression and anxiety). Only a doctor can determine if you have adrenal insufficiency and if DHEA, along with other hormones, is needed. Adrenal insufficiency can be a medical emergency, particularly when first diagnosed. This is especially the case if your blood pressure is low, which can cause you to experience dizziness or lightheadedness. Another reason to seek medical attention right away in the case of adrenal insufficiency is swelling of the ankles or legs.

DHEA for Impotence
Studies suggest that DHEA supplementation may help impotent men have and sustain an erection.

DHEA for Osteoporosis
Studies have shown that DHEA cream applied to the inner thigh may boost bone density in older women.

DHEA for Anorexia Nervosa
Women with anorexia nervosa are at increased risk for bone fractures and can develop osteoporosis at a younger age than women without eating disorders. It has been observed that adolescents and young adults with anorexia nervosa tend to have low levels of DHEA. Some studies suggest that DHEA may help protect against bone loss in people who are anorexic.

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DHEA for Athletic Performance
Although DHEA supplements are widely used by athletes and body builders to boost muscle mass and burn fat, there is little evidence to support these claims. There are no published studies of the long-term effects of taking DHEA, particularly in the large doses used by athletes. Plus, the building blocks of testosterone, including DHEA, may adversely affect cholesterol in male athletes by lowering HDL ("good") cholesterol.

DHEA for Lupus
Lupus is an autoimmune disorder. Autoimmune diseases are a group of conditions in which a person's antibodies attack a part of their own body because the immune system believes the body part is foreign. Studies have shown that DHEA helps regulate the immune system and may play a role in the prevention and/or treatment of certain autoimmune diseases.

A recent review of scientific literature found that DHEA supplementation may reduce the need for medications and the frequency of flare-ups, enhance mental function, and boost bone mass in women with lupus. Further studies are needed to determine whether DHEA is safe and effective for both men and women with this condition, however.

DHEA for HIV
DHEA levels tend to be low in individuals infected with the human immunodeficiency virus (HIV), and these levels decline even further as the disease progresses. In one small study, DHEA supplementation improved mental function in men and women infected with HIV. However, studies have yet to demonstrate whether DHEA supplementation can improve immune function in people with this condition.

DHEA for Depression
In a preliminary study of individuals with major depression, DHEA significantly improved symptoms of depression compared to placebo. However, results of this study and others conducted to date on DHEA and depression are not conclusive. The potential value of using DHEA for depression, therefore, remains unclear, and the long-term effects of taking this supplement are unknown.

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DHEA for Obesity
The results of studies using DHEA to treat overweight people have been conflicting. While animal studies have found DHEA to be effective in reducing body weight, studies of men and women showed that DHEA produced no change in total body weight, although total body fat and LDL ("bad") cholesterol did improve. These differences may be due to the fact that higher dosages were used in the animal studies than in the human studies (such high doses would cause intolerable side effects in people). Further studies are needed to determine whether DHEA is an effective way to reduce body weight in obese people. Until the safety and effectiveness of DHEA is fully tested, it is best not to use this supplement for weight loss.

DHEA for Menopause
DHEA has gained some popularity among peri-menopausal women. They often used the supplement to alleviate symptoms of menopause including decreased sex drive, diminished skin tone, and vaginal dryness. In one recent study, DHEA supplements did raise levels of certain hormones in post-menopausal women. However, clinical studies regarding the value of DHEA for improving menopause symptoms have had conflicting results.

Those who believe in the use of DHEA claim that it relieves the menopausal symptoms described above without increasing the risk of breast cancer or cancer of the endometrium (lining to the uterus). The risk of each of these cancers may be increased with regular, prescription hormone replacement therapy. There is no proof, however, that DHEA does not stimulate these cancers as well. Women with breast cancer tend to have low levels of this hormone in their bodies. But replacement may lead to either inhibition or stimulation of growth of breast cancer cells.

DHEA for Inflammatory Bowel Disease (IBD)
DHEA levels appear to be low in people with ulcerative colitis and Crohn's disease. It is premature to say whether DHEA supplements have any impact, positive or negative, on these two bowel diseases.

 

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Dietary Sources of DHEA

DHEA is a hormone produced in the body and is not obtained through the diet.

 

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Available Forms

Most DHEA supplements are produced in laboratories from diosgenin, a plant sterol extracted from Mexican wild yams. Some extracts from wild yams are marketed as "natural DHEA." Advertisers claim that these "natural" extracts of diosgenin are converted into DHEA by the body. However, it takes several chemical reactions to convert diosgenin into DHEA, and there is no evidence that the body can make this conversion. For this reason, it is best to look for labels that list DHEA rather than diosgenin or wild yam extract. Also, it is important to select products that state it is pharmaceutical grade.

One way to avoid purchasing a product with contaminated DHEA is to purchase it through a professional healthcare provider.

DHEA is available in capsules, chewing gum, drops that are placed under the tongue, and topical creams.

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How to Take DHEA

DHEA is not recommended for people under the age of 40, unless DHEA levels are known to be low (<130 mg/dL in women and <180 mg/dL in men).

Pediatric

DHEA supplements should not be used in children.

Adult

Dosages for men and women differ. Men can safely take up to 50 mg/day, but women should generally not take more than 25 mg/day, although up to 50 mg has been used for women with anorexia, adrenal insufficiency, and other medical conditions under medical supervision. DHEA is produced by the body primarily in the morning hours. Taking DHEA in the morning will mimic the natural rhythm of DHEA production. Positive effects have been noted at dosages as low as 5 mg/day and the lower the dose the better.

 

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Precautions

Because of the potential for side effects and interactions with medications, dietary supplements should be taken only under the supervision of a knowledgeable healthcare provider.

DHEA is not recommended for people under 40 years of age, unless DHEA levels are known to be low (less than 130 mg/dL in women and less than 180 mg/dL in men). People taking DHEA should have their blood levels monitored every 6 months.

No studies have been conducted on the long-term safety of DHEA.

Because DHEA is a precursor of estrogen and testosterone, patients with cancers affected by hormones (such as breast, prostate, ovarian, and testicular cancer) should avoid this hormone supplement.

High doses of DHEA may inhibit the body's natural ability to make the hormone and also may be toxic to liver cells. At least one case of hepatitis has been reported.

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DHEA increases the production of the male hormone testosterone, so women should be aware of the risk of developing signs of masculinization (such as loss of hair on the head, deepening of the voice, hair growth on the face, weight gain around the waist, or acne), and men should be aware of the risks of excess testosterone (such as shrinkage of the testicles, aggressive tendencies including sexual aggression, male pattern baldness, and high blood pressure). Notify your health care provider if any of these symptoms occur.

Other adverse effects that have been reported include high blood pressure and reduced HDL ("good") cholesterol.

The International Olympic Committee and National Football League recently banned the use of DHEA by athletes because its effects are very similar to those of anabolic steroids.

 

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Possible Interactions

If you are currently being treated with any of the following medications, you should not use DHEA without first talking to your healthcare provider.

AZT (Zidovudine)
In a laboratory study, DHEA enhanced the effectiveness of an HIV medication known as AZT. However, scientific studies in humans are needed before DHEA can be used for this purpose in people.

Barbiturates
Animal studies suggest that DHEA may increase the effects of barbiturates, a class of medications often used to treat sleep disorders including butabarbital, mephobarbital, pentobarbital, and phenobarbital. However, scientific studies in humans are needed before it is known whether this same effect occurs in people and whether it is safe for DHEA and barbiturates to be used together.

Cisplatin
An animal study indicates that DHEA may increase the effectiveness of an anti-cancer medication known as cisplatin; further studies are needed to know if this effect applies to people.

Steroids
Laboratory studies suggest that DHEA may increase the effects of prednisolone, a steroid medication used to treat inflammation and other disorders. Additional research is needed to determine if this effect applies to people.

Estrogen

It is possible that DHEA may influence the level of estrogen in the body. For this reason, some women on estrogen replacement therapy may need to adjust their dosage. This should be discussed with your healthcare provider.

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Supporting Research

Arlt W, Callies F, van Vlijmen JC, Koehler I, Reincke M, Bidlingmaier M, et al. Dehydroepiandrosterone replacement in women with adrenal insufficiency. N Engl J Med. 1999;341(14)-1013-1020.

Barnhart KT, Freeman E, Grisso JA. The effect of dehydroepiandrosterone supplementation to symptomatic perimenopausal women on serum endocrine profiles, lipid parameters, and health-related quality of life. J Clin Endocrinol Metab. 1999;84:3896-3902.

Barry NN, McGuire JL, van Vollenhoven RF. Dehydroepiandrosterone in systemic lupus erythematosus: relationship between dosage, serum levels, and clinical response. J Rheumatol. 1998;25(12):2352-2356.

Baulieu EE. Thomas G, Legrain S, et al. Dehydroepiandrosterone (DHEA), DHEA sulfate, and aging: contribution of the DHEAge study to a sociobiomedical issue. Proc Natl Acad Sci USA. 2000;97(8):4279-4284.

Broeder CE, Quindry MS, Brittingham K, et al. The Andro Project: Physiological and hormonal influences of androstenedione supplementation in men 35 to 65 years old participating in a high-intensity resistance training program. Arch Intern Med. 160:3093-3104.

Corrigan AB. Dehydroepiandrosterone and sport. [Review]. Med J Aust. 1999;171(4):206-8.

de la Torre B, Hedman M, Befrits R. Blood and tissue dehydroepiandrosterone sulphate levels and their relationship to chronic inflammatory bowel disease. Clin Exp Rheumatol. 1998;16:579-582.

Dyner TS, Lang W, Geaga J, et al. An open-label dose-escalation trial of oral dehydroepiandrosterone tolerance and pharmacokinetics in patients with HIV disease. J Acquir Immune Defic Syndr. 1993;6:459-465.

Flynn MA, Weaver-Osterholtz D, Sharpe-Timms KL, Allen S, Krause G. Dehydroepiandrosterone replacement in aging humans. J Clin Endocrinol Metabol. 199;84(5):1527-1533.

Gaby AR. Dehydroepiandrosterone. In: Pizzorno JE, Murray MT, eds. Textbook of Natural Medicine. Vol 1. 2nd ed. Edinburgh: Churchill Livingstone; 1999:695-701.

Genezzani AD, Stomati M, Strucchi C, Puccetti S, Luisi S, Genazzani AR. Oral dehydroepiandrosterone supplementation modulates spontaneous and growth hormone-releasing hormone-induced growth hormone and insulin-like growth factor-1 secretion in early and late postmenopausal women. Fertil Steril. 2001;76(2):241-248.

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Gordon C, Grace E, Emans SJ, Goodman E, Crawford MH, Leboff MS. Changes in bone turnover markers and menstrual function after short-term oral DHEA in young women with anorexia nervosa. J Bone Miner Res. 1999;14:136-145.

Hansen PA, Han DH, Nolte LA. DHEA protects against visceral obesity and muscle insulin resistance in rats fed a high-fat diet. Am J Physiol. 1997;273:R1704-R1708.

Hinson JP, Raven PW. DHEA deficiency syndrome: a new term for old age? [Commentary]. J Endocrinol. 1999;163:1-5.

Klann RC, Holbrook CT, Nyce JW. Chemotherapy of murine colorectal carcinoma with cisplatin and cisplatin plus 3'- deoxy-3'- azidothymidine. Anticancer Res. 1992;12:781-788.

Kurzman ID, Panciera DL, Miller JB, MacEwen EG. The effect of dehydroepiandrosterone combined with a low-fat diet in spontaneously obese dogs: a clinical trial. Obes Res. 1998;6(1):20-28.

Labrie F. DHEA as physiological replacement therapy at menopause. J Endocrinol Invest. 1998;21:399-401.

Labrie F, Diamond P, Cusan L, Gomez J-L, Belanger A, Candas B. Effect of 12-month dehydroepiandrosterone replacement therapy on bone, vagina, and endometrium in postmenopausal women. J Clin Endocrinol Metab. 1997;82:3498-3505.

Melchior CL, Ritzmann RF. Dehydroepiandrosterone enhances the hypnotic and hypothermic effects of ethanol and pentobarbital. Pharmacol Biochem Behav. 1992;43:223-227.

Meno-Tetang GML, Hon YY, Jusko WJ. Synergistic interaction between dehydroepiandrosterone and prednisolone in the inhibition of rat lymphocyte proliferation. Immunopharmacol Immunotoxicol. 1996;18(3):443-456.

Miller RA,Chrisp C. Lifelong treatment with oral DHEA sulfate does not preserve immune function, prevent disease, or improve survival in genetically heterogeneous mice. J Am Geriatr Soc. 1999;47(8):960-966.

Moffat SD, Zonderman AB, Harman SM, et al. The relationship between longitudinal declines in dehydroepiandrosterone sulfate concentrations and cognitive performance in older men. Arch Intern Med. 2000;160:2193-2198.

Mortola JF, Yen SS. The effects of oral dehydroepiandrosterone on endocrine-metabolic parameters in postmenopausal women. J Clin Endocrinol Metab. 1990;71(3)696-704.

Nestler JE, Barlascini CO, Clore JN, Blackard WG. Dehydroepiandrosterone reduces serum low density lipoprotein levels and body fat bud does not alter insulin sensitivity in normal men. J Clin Endocrinol Metab. 1988;66(1):57-61.

Parasrampuria J. Quality control of dehydroepiandrosterone dietary supplement products [Letter to the editor]. JAMA. 1998;280(18):1565.

Piketty C, Jayle D, Leplege A, et al. Double-blind placebo-controlled trial of oral dehydroepiandrosterone in patients with advanced HIV disease. Clin Endocrinol (Oxf). 2001;55(3):325-30.

Reiter WJ, Pycha A, Schatzl G, et al. Dehydroepiandrosterone in the treatment of erectile dysfunction: a prospective, double-blind, randomized, placebo-controlled study. Urology. 1999;53(3):590-595

Reynolds JE. Martindale: The Extra Pharmacopoeia. 31st ed. London, England: Royal Pharmaceutical Society; 1996:1504.

Schifitto G. Autonomic performance and dehydroepiandrosterone sulfate levels in HIV-1 infected individuals; relationship to TH1 and TH2 cytokine profile. Arch Neurol. 2000;57(7):1027-1032.

Stoll BA. Review:Dietary supplements of deydroepiandrosterone in relation to breast cancer risk. Eur J Clin Nut. 1999;53:771-775.

Tan RS, Pu SJ. The andropause and memory loss: is there a link between androgen decline and dementia in the aging male? Asian J Androl. 2001;3(3):169-174.

Vallee M, Mayo W, Le Moal M. Role of pregnenolone, dehydroepiandrosterone and their sulfate esters on learning and memory in cognitive aging. Brain Res Rev. 2001;37(1-3):301-312.

van Vollenhoven RF. Dehydroepiandrosterone for the treatment of systemic lupus erythematosus. Expert Opin Pharmacother. 2002;3(1):23-31.

van Vollenhoven RF, Morabito LM, Engleman EG, McGuire JL. Treatment of systemic lupus erythematosus with dehydroepiandrosterone: 50 patients treated up to 12 months. J Rheumatol. 1998;25(2):285-289.

Welle S, Jozefowicz R, Statt M. Failure of dehydroepiandrosterone to influence energy and protein metabolism in humans. J Clin Endocrinol Metab. 1990;71(5):1259-1264.

Williams JR. The effects of dehydroepiandrosterone on carcinogenesis, obesity, the immune system, and aging. Lipids. 2000;35(3):325-331.

Wolkowitz OM, Reus VI, Keebler A, Nelson N, Friedland M, Brizendine L, Roberts E. Double-blind treatment of major depression with dehydroepiandrosterone. Am J Psychiatry. 1999;156:646-649.

Yang J, Schwartz A, Henderson EE. Inhibition of 3' axido-3' deoxythymidine-resistant HIV-1 infection by dehydroepiandrosterone in vitro. Biochem Biophys Res Commun. 1994;201(3):1424-1432.

Yen SSC, Morales AJ, Khorram O. Replacement of DHEA in aging men and women. Potential remedial effects. Ann NY Acad Sci. 1995;774:128-142.

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Scientists are looking at what can preserve your mental capacities and hold off alzheimer's disease and dementia?

National Public Radio's Daniel Schorr is the kind of guy who would make any aging news junkie stand up and cheer. On July 19, 2006, Schorr turned 90, yet he still performs at an undiminished level in one of the most demanding jobs in today's media. He began his career at CBS News in 1953 and joined NPR as its senior news analyst at 69, an age at which many of his colleagues had long been put out to pasture. In his position, he has to pack his cerebral hard drive with massive amounts of information, and then he has to possess the Pentium-esque agility to mine that information for insights worthy of NPR's highly educated listeners. Schorr pulls off the challenge with effortless grace.

But Schorr's beat-the-clock competence calls attention to an issue with implications for everything from lifestyle choices to national social policy. Because of advances in medical science, people are living much longer than ever before. The US Census Bureau projects that the number of elderly aged 85 and older will more than triple from about 4 million today to about 14 million by 2040. That includes many of us reading this article.

Unfortunately, we won't all age like Daniel Schorr. Some of us will live out our dotage without all our marbles. Alzheimer's disease or other forms of dementia will rob us of our intellectual abilities, our short-term memories, our personalities, and even the ability to recognize the people we love the most. The prospect is terrifying—especially because researchers don't yet understand exactly what causes Alzheimer's (or dementia) or how to prevent it or even slow the destruction.

But they are making progress on those fronts. Lots of indicators point toward a health regimen that may preserve your mental capacities well into old age, and perhaps indefinitely. The even better news? If you're already practicing a healthy lifestyle as that concept is currently understood, you may be most of the way home.

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A New Understanding

No one fully knows what causes Alzheimer's but the research community is beginning to feel it's at least driving in the right neighborhood. Current thinking suggests that the disease results from a complex dance between several partners: lifestyle factors such as food choices, environmental factors such as educational level and previous head injuries, and a person's inherited genes. Recently, scientists have focused on the strong link between cardiovascular disease and Alzheimer's. Mounting evidence suggests that cardiovascular risk factors such as high cholesterol, high blood pressure, and poor dietary habits also significantly boost the risk for Alzheimer's in particular and cognitive decline in general.

For instance, a Finnish study involving nearly 1,500 subjects found that high cholesterol and blood pressure were even more tightly tied to Alzheimer's than the so-called APOE-4 gene, the genetic risk factor associated with the most common form of the illness. Other studies corroborate this connection by showing that controlling cholesterol and blood pressure levels helps keep the brain healthy.

In a similar vein (so to speak), researchers are also exploring a connection between diabetes and Alzheimer's. They've known for a while that having diabetes nearly doubles an individual's chance of developing Alzheimer's.

Diabetes, itself a cardiovascular risk factor, can create vascular problems, and vascular disease increases the risk of Alzheimer's. Some scientists have also proposed that Alzheimer's may be a third form of diabetes (besides Type 1 and Type 2) that directly leads to brain cell death and other abnormalities associated with Alzheimer's. And poorly controlled diabetes—with wildly fluctuating blood sugar levels—is also thought to heighten the risk of getting Alzheimer's.

The most current study in this area points to increased Alzheimer's risk for people with high blood sugar or "pre-diabetes." Elevated blood sugar sends an early signal that Type 2 diabetes lurks on the horizon. The social implications for the US look ominous given the fact that many more people currently suffer from pre-diabetes than Type 2 diabetes, which currently runs rampant in this country, the end result of the obesity epidemic. The diabetes findings, from a Swedish study, were presented at the Tenth International Conference on Alzheimer's Disease and Related Disorders, a major conference held in Madrid in July 2006. The essential message to the public is clear: If you protect yourself against diabetes by controlling your weight, exercising, and eating a healthy diet (see below), you may as a bonus preserve your gray matter, as well.

One last uncomfortable thought: Scientists now recognize that Alzheimer's can be present in the brain without seeming to affect a person's thinking or behavior. "You could be completely normal and have that pathology," says leading Alzheimer's researcher David Bennett, MD, director of Rush University's Alzheimer's Disease Center, "so I think that the biggest thing that is changing is the recognition that the disease is a much larger problem than has historically been recognized."

Keeping Dementia at Bay

As researchers' understanding of Alzheimer's and other forms of cognitive decline grows, so does their confidence in a group of lifestyle options that may ratchet down the risk for these diseases. Students of healthy living will find the laundry list that follows pretty darn familiar, at least those items related to diet and exercise. When it comes to these two lifestyle categories, one size seems to fit nearly all.

For instance, a previous article in this magazine (Fall 2006) suggested that a heart-healthy diet not only offers protection against cardiovascular disease but also colon cancer, diabetes, and prostate cancer. Add Alzheimer's to the pile. Here are the details, plus the rest of the easy steps that can, as the Alzheimer's Association puts it, "maintain your brain." Healthy Eating Low fat. Low cholesterol. Dark-skinned veggies and fruit. Cold-water fish such as halibut, mackerel, salmon, trout, and tuna. Nuts such as almonds, pecans, and walnuts. If you've studied healthy eating and applied what you've learned, you're already eating this way. And recent research suggests that your brain will thank you.

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For example, Finnish researchers presenting at the above-mentioned Madrid conference discovered that subjects whose diets included loads of saturated fat (mainly fats from meat and dairy products) performed less well on memory or thinking tests and had double the risk of mild cognitive impairment, which can foreshadow Alzheimer's. On the other hand, people who consumed more polyunsaturated fats or fish did better on tests of memory, coordination, reasoning, and decision-making.

Many scientists believe the antioxidant properties of the fruits and vegetables contribute to brain health. Same with the nuts, which contain the antioxidant vitamin E. And the fish teem with omega-3 fatty acids, which the human body apparently needs but doesn't make.

Some research suggests that the B vitamins, especially B6, B12, and the folates, also provide protection, but the results are confusing. In observational trials, in which researchers gather data on a group of healthy people over a span of years without any intervention, the vitamins seem to have had a beneficial effect. In interventional trials, that is where the researchers give the subjects supplements, the vitamins have either shown no effect or, in the case of B6, an unexpectedly negative one. What seems to matter most is the food on your plate, not the pills in the bottle. "I wouldn't particularly advise the vitamin supplements because I don't think there is any great evidence that if you eat a balanced diet that vitamin supplements would provide anything else," says Hugh Hendrie, MB, ChB, DSc. Hendrie recently headed a comprehensive review of research on cognitive and behavioral changes in aging people for the NIH.

Exercise

Well-regarded research led by Eric Larson, MD, MPH, of the GroupHealth Center for Health Studies in Seattle, Washington, has shown that people who exercise regularly lower their risk of Alzheimer's disease and other forms of dementia, or at least delay the onset by several years. People who have Alzheimer's also do better with exercise such as walking—it slows the rate of physical decline and seems to prevent some behavioral problems associated with the illness, such as agitation. "Just doing things that keep a person active and engaged and allow their muscles to stay as strong as they can at the end stages of life in many cases seems to improve their lives," says Larson.

Of course, exercise also helps stave off cardiovascular disease, weight gain, diabetes, and stroke, all of which are themselves risk factors for cognitive decline, including Alzheimer's. Keep in mind, though, that the research showing the beneficial effects of physical activity pertains only to leisure-time exercise. In studies of work-related physical activity, no similar impact has shown up.

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Mental stimulation

A widely held line of thinking among Alzheimer's researchers called the "cognitive reserve" hypothesis goes like this: If you build up your brain through mental stimulation throughout your life and keep mentally active, you also build a bulwark against the illness—so much so, in fact, that even if you have Alzheimer's-type damage in your brain, it may not show up in your actual mental abilities or behavior.

Not surprisingly then, higher levels of education are also associated with significantly better protection against the disease. Larson has done studies that compare largely uneducated, rural populations in Taiwan to populations in the US and Japan, where the education level is high. Dementia occurs 10 to 20 years earlier in the rural Taiwanese than in comparably aged residents of the other two countries, he says. In fact, education offers so much protection, well-educated folks can more or less become couch potatoes late in life and not suffer that much or at all for it. In research with older subjects doing crossword puzzles, playing Go, and the like, it's the less-educated, blue-collar types who show the most benefit.

Social interaction

People with active social lives seem to age better with respect to dementia. The effect compares to that produced by education, says Bennett: "The larger your social network, the less effect a unit of Alzheimer's pathology."

The entire Alzheimer's and dementia picture is clouded with paradox. As Bennett puts it, "Almost everyone [of a certain age] has the pathology of Alzheimer's disease but in fact some people's memory is quite well preserved in spite of having a lot of pathology, and other people's memory is impaired despite having just a little bit." You could argue then that whether or not you get Alzheimer's boils down to luck. But too many studies suggest otherwise. If you eat well, exercise—both your body and your brain—and take part in a wide mix of social activities, you stand a better chance of dodging Alzheimer's and dementia—and you'll be a healthier and happier old codger to boot.

Source: Alternative Medicine

next: Alternative Treatment Strategy for Alzheimer's Disease

A description of the types of drug treatment approaches and drug treatment programs effective in reducing and ending drug addiction.

Research studies on drug addiction treatment have typically classified drug treatment programs into several general types or modalities, which are described in the following text. Drug treatment approaches and individual programs continue to evolve, and many programs in existence today do not fit neatly into traditional drug addiction treatment classifications.

Agonist Maintenance Treatment

Agonist maintenance treatment for opiate addicts usually is conducted in outpatient settings, often called methadone treatment programs. These programs use a long-acting synthetic opiate medication, usually methadone or LAAM, administered orally for a sustained period at a dosage sufficient to prevent opiate withdrawal, block the effects of illicit opiate use, and decrease opiate craving. Patients stabilized on adequate, sustained dosages of methadone or LAAM can function normally. They can hold jobs, avoid the crime and violence of the street culture, and reduce their exposure to HIV by stopping or decreasing injection drug use and drug-related high-risk sexual behavior.

Patients stabilized on opiate agonists can engage more readily in counseling and other behavioral interventions essential to recovery and rehabilitation. The best, most effective opiate agonist maintenance programs include individual and/or group counseling, as well as provision of, or referral to, other needed medical, psychological, and social services.

Patients stabilized on adequate sustained dosages of methadone or LAAM can function normally.

Further Reading:

Ball, J.C., and Ross, A. The Effectiveness of Methadone Treatment. New York: Springer-Verlag, 1991.

Cooper, J.R. Ineffective use of psychoactive drugs; Methadone treatment is no exception. JAMA Jan 8; 267(2): 281-282, 1992.

Dole, V.P.; Nyswander, M.; and Kreek, M.J. Narcotic Blockade. Archives of Internal Medicine 118: 304-309, 1996.

Lowinson, J.H.; Payte, J.T.; Joseph, H.; Marion, I.J.; and Dole, V.P. Methadone Maintenance. In: Lowinson, J.H.; Ruiz, P.; Millman, R.B.; and Langrod, J.G., eds. Substance Abuse: A Comprehensive Textbook. Baltimore, MD, Lippincott, Williams & Wilkins, 1996, pp. 405-414.

McLellan, A.T.; Arndt, I.O.; Metzger, D.S.; Woody, G.E.; and O'Brien, C.P. The effects of psychosocial services in substance abuse treatment. JAMA Apr 21; 269(15): 1953-1959, 1993.

Novick, D.M.; Joseph, J.; Croxson, T.S., et al. Absence of antibody to human immunodeficiency virus in long-term, socially rehabilitated methadone maintenance patients. Archives of Internal Medicine Jan; 150(1): 97-99, 1990.

Simpson, D.D.; Joe, G.W.; and Bracy, S.A. Six-year follow-up of opioid addicts after admission to treatment. Archives of General Psychiatry Nov; 39(11): 1318-1323, 1982.

Simpson, D.D. Treatment for drug abuse; Follow-up outcomes and length of time spent. Archives of General Psychiatry 38(8): 875-880, 1981.

Narcotic Antagonist Treatment Using

Narcotic antagonist treatment using Naltrexone for opiate addicts usually is conducted in outpatient settings although initiation of the medication often begins after medical detoxification in a residential setting. Naltrexone is a long-acting synthetic opiate antagonist with few side effects that is taken orally either daily or three times a week for a sustained period of time. Individuals must be medically detoxified and opiate-free for several days before naltrexone can be taken to prevent precipitating an opiate abstinence syndrome. When used this way, all the effects of self-administered opiates, including euphoria, are completely blocked. The theory behind this treatment is that the repeated lack of the desired opiate effects, as well as the perceived futility of using the opiate, will gradually over time result in breaking the habit of opiate addiction. Naltrexone itself has no subjective effects or potential for abuse and is not addicting. Patient noncompliance is a common problem. Therefore, a favorable treatment outcome requires that there also be a positive therapeutic relationship, effective drug addiction counseling or therapy, and careful monitoring of medication compliance.

Patients stabilized on naltrexone can hold jobs, avoid crime and violence, and reduce their exposure to HIV.

Many experienced clinicians have found naltrexone most useful for highly motivated, recently detoxified patients who desire total abstinence because of external circumstances, including impaired professionals, parolees, probationers, and prisoners in work-release status. Patients stabilized on naltrexone can function normally. They can hold jobs, avoid the crime and violence of the street culture, and reduce their exposure to HIV by stopping injection drug use and drug-related high-risk sexual behavior.

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Further Reading:

Cornish, J.W.; Metzger, D.; Woody, G.E.; Wilson, D.; McLellan, A.T.; Vandergrift, B.; and O'Brien, C.P. Naltrexone pharmacotherapy for opioid dependent federal probationers. Journal of Substance Abuse Treatment 14(6): 529-534, 1997.

Greenstein, R.A.; Arndt, I.C.; McLellan, A.T.; and O'Brien, C.P. Naltrexone: a clinical perspective. Journal of Clinical Psychiatry 45 (9 Part 2): 25-28, 1984.

Resnick, R.B.; Schuyten-Resnick, E.; and Washton, A.M. Narcotic antagonists in the treatment of opioid dependence: review and commentary. Comprehensive Psychiatry 20(2): 116-125, 1979.

Resnick, R.B. and Washton, A.M. Clinical outcome with naltrexone: predictor variables and followup status in detoxified heroin addicts. Annals of the New York Academy of Sciences 311: 241-246, 1978.

Outpatient Drug-Free Treatment

Outpatient drug-free treatment in the types and intensity of services offered. Such treatment costs less than residential drug treatment or inpatient treatment and often is more suitable for individuals who are employed or who have extensive social supports. Low-intensity programs may offer little more than drug education and admonition. Other outpatient models, such as intensive day treatment, can be comparable to residential programs in services and effectiveness, depending on the individual patient's characteristics and needs. In many outpatient programs, group counseling is emphasized. Some outpatient programs are designed to treat patients who have medical or mental health problems in addition to their drug disorder.

Further Reading:

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Foerg, F.E.; Donham, R.; and Badger, G.J. Incentives to improve outcome in outpatient behavioral treatment of cocaine dependence. Archives of General Psychiatry 51, 568-576, 1994.

Hubbard, R.L.; Craddock, S.G.; Flynn, P.M.; Anderson, J.; and Etheridge, R.M. Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors 11(4): 291-298, 1998.

Institute of Medicine. Treating Drug Problems. Washington, D.C.: National Academy Press, 1990.

McLellan, A.T.; Grisson, G.; Durell, J.; Alterman, A.I.; Brill, P.; and O'Brien, C.P. Substance abuse treatment in the private setting: Are some programs more effective than others? Journal of Substance Abuse Treatment 10, 243-254, 1993.

Simpson, D.D. and Brown, B.S. Treatment retention and follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors 11(4): 294-307, 1998.

Long-Term Residential Treatment

Long-Term Residential Treatment provides care 24 hours per day, generally in nonhospital settings. The best-known residential treatment model is the therapeutic community (TC), but residential treatment may also employ other models, such as cognitive-behavioral therapy.

TCs are residential programs with planned lengths of stay of 6 to 12 months. TCs focus on the "resocialization" of the individual and use the program's entire "community," including other residents, staff, and the social context, as active components of treatment. Addiction is viewed in the context of an individual's social and psychological deficits, and treatment focuses on developing personal accountability and responsibility and socially productive lives. Treatment is highly structured and can at times be confrontational, with activities designed to help residents examine damaging beliefs, self-concepts, and patterns of behavior and to adopt new, more harmonious and constructive ways to interact with others. Many TCs are quite comprehensive and can include employment training and other support services on site.

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Therapeutic communities focus on the "resocialization" of the individual and use the program's entire "community" as active components of treatment.

Short-Term Residential Programs

Short-Term Residential Programs provide intensive but relatively brief residential treatment based on a modified 12-step approach. These programs were originally designed to treat alcohol problems, but during the cocaine epidemic of the mid-1980s, many began to treat illicit drug abuse and addiction. The original residential treatment model consisted of a 3 to 6-week hospital-based inpatient treatment phase followed by extended outpatient therapy and participation in a self-help group, such as Alcoholics Anonymous. Reduced health care coverage for substance abuse treatment has resulted in a diminished number of these programs, and the average length of stay under managed care review is much shorter than in early programs.

Further Reading:

Hubbard, R.L.; Craddock, S.G.; Flynn, P.M.; Anderson, J.; and Etheridge, R.M. Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors 11(4): 291-298, 1998.

Miller, M.M. Traditional approaches to the treatment of addiction. In: Graham A.W. and Schultz T.K., eds. Principles of Addiction Medicine, 2nd ed. Washington, D.C.: American Society of Addiction Medicine, 1998.

Medical Detoxification

is a process whereby individuals are systematically withdrawn from addicting drugs in an inpatient or outpatient setting, typically under the care of a physician. Detoxification is sometimes called a distinct treatment modality but is more appropriately considered a precursor of treatment, because it is designed to treat the acute physiological effects of stopping drug use. Medications are available for detoxification from opiates, nicotine, benzodiazepines, alcohol, barbiturates, and other sedatives. In some cases, particularly for the last three types of drugs, detoxification may be a medical necessity, and untreated withdrawal may be medically dangerous or even fatal.

Compared with patients in other forms of drug treatment, the typical TC resident has more severe problems, with more co-occurring mental health problems and more criminal involvement. Research shows that TCs can be modified to treat individuals with special needs, including adolescents, women, those with severe mental disorders, and individuals in the criminal justice system.

Further Reading:

Leukefeld, C.; Pickens, R.; and Schuster, C.R. Improving drug abuse treatment: Recommendations for research and practice. In: Pickens, R.W.; Luekefeld, C.G.; and Schuster, C.R., eds. Improving Drug Abuse Treatment, National Institute on Drug Abuse Research Monograph Series, DHHS Pub No. (ADM) 91-1754, U.S. Government Printing Office, 1991.

Lewis, B.F.; McCusker, J.; Hindin, R.; Frost, R.; and Garfield, F. Four residential drug treatment programs: Project IMPACT. In: Inciardi, J.A.; Tims, F.M.; and Fletcher, B.W. eds. Innovative Approaches in the Treatment of Drug Abuse. Westport, CN: Greenwood Press, 1993, pp. 45-60.

Sacks, S.; Sacks, J.; DeLeon, G.; Bernhardt, A.; and Staines, G. Modified therapeutic community for mentally ill chemical abusers: Background; influences; program description; preliminary findings. Substance Use and Misuse 32(9); 1217-1259, 1998.

Stevens, S.J., and Glider, P.J. Therapeutic communities: Substance abuse treatment for women. In: Tims, F.M.; De Leon, G.; and Jainchill, N., eds. Therapeutic Community: Advances in Research and Application, National Institute on Drug Abuse Research Monograph 144, NIH Pub. No. 94-3633, U.S. Government Printing Office, 1994, pp. 162-180.

Stevens, S.; Arbiter, N.; and Glider, P. Women residents: Expanding their role to increase treatment effectiveness in substance abuse programs. International Journal of the Addictions 24(5): 425-434, 1989.

Detoxification is a precursor of treatment.

Detoxification is not designed to address the psychological, social, and behavioral problems associated with addiction and therefore does not typically produce lasting behavioral changes necessary for recovery. Detoxification is most useful when it incorporates formal processes of assessment and referral to subsequent drug addiction treatment.

Further Reading:

Kleber, H.D. Outpatient detoxification from opiates. Primary Psychiatry 1: 42-52, 1996.

National Institute of Drug Abuse, "Principles of Drug Addiction Treatment: A Research Based Guide."

Last updated September 27, 2006.

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Depression Affects the Workplace

As a supervisor, you may notice that some employees seem less productive and reliable than usual-- they may often call in sick or arrive late to work, have more accidents, or just seem less interested in work. These individuals may be suffering from a very common illness called clinical depression. While it is not your job to diagnose depression, your understanding may help an employee get needed treatment.

• Each year, depression affects more than 19 million American adults, often during their most productive years--between the ages of 25 and 44.
• Untreated clinical depression may become a chronic condition that disrupts work, family, and personal life.
• Depression results in more days in bed than many other ailments (such as ulcers, diabetes, high blood pressure, and arthritis) according to a recent large-scale study published by the Rand Corporation.

In addition to personal suffering, depression takes its toll at the workplace:

• At any one time, 1 employee in 20 is experiencing depression.
• Estimates of the cost of depression to the nation in 1990 range from $30-$44 billion. Of the $44 billion, depression accounts for close to $12 billion in lost work days and an estimated $11 billion in other costs associated with decreased productivity.

"Major depression and bipolar disorder accounted for 11% of all days lost from work in 1987, " reported the medical director of a public utility company.

There is, however good news. More than 80% of depressed people can be treated quickly and effectively. The key is to recognize the symptoms of depression early and to receive appropriate treatment. Unfortunately, nearly two out of three people with depression do not receive the treatment they need.

Many companies are helping employees with depression by providing training on depressive illnesses for supervisors, employee assistance, and occupational health personnel. Employers are also making appropriate treatment available through employee assistance programs and through company-sponsored health benefits. Such efforts are contributing to significant reductions in lost time and job-related accidents as well as marked increases in productivity.

Depression Is More Than the Blues

Everyone gets the blues or feels sad from time to time. However, if a person experiences these emotions intensely or for two weeks or longer, it may signal clinical depression, a condition that requires treatment.

Clinical depression affects the total person--body, feelings, thoughts, and behaviors--and comes in various forms. Some people have a single bout of depression; others suffer recurrent episodes. Still others experience the severe mood swings of bipolar disorder--sometimes called manic-depressive illness--with moods alternating between depressive lows and manic highs.

Symptoms of Depression Include

• Persistent sad or "empty" mood
• Loss of interest or pleasure in ordinary activities, including sex
• Decreased energy, fatigue, being "slowed down"
• Sleep disturbances (insomnia, early-morning waking or oversleeping)
• Eating disturbances (loss of appetite and weight, or weight gain)
• Difficulty concentrating, remembering, making decisions
• Feelings of hoplessness, pessimism
• Feelings of guilt, worthlessness, helplessness
• Thoughts of death or suicide; suicide attempts
• Irritability
• Excessive crying
• Chronic aches and pains that don't respond to treatment

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Symptoms of Mania Include

• Inappropriate elation
• Irritability
• Decreased need for sleep
• Increased energy and activity
• Increased talking, moving, and sexual activity
• Racing thoughts
• Disturbed ability to make decisions
• Grandiose notions
• Being easily distracted

In the Workplace, Symptoms of Depression Often May Be Recognized by

• Decreased productivity
• Morale problems
• Lack of cooperation
• Safety risks, accidents
• Absenteeism
• Frequent statements about being tired all the time
• Complaints of unexplained aches and pains
• Alcohol and drug abuse

Get an Accurate Diagnosis

If five or more of the symptoms of depression or mania persist for more than two weeks, or are interfering with work or family life, a thorough diagnosis is needed. This should include a complete physical checkup and history of family health problems as well as an evaluation of possible symptoms of depression.

Depression Affects Your Employees

John had been feeling depressed for weeks though he didn't know why. He had lost his appetite and felt tired all the time. It wasn't until he couldn't get out of bed any more that his wife took him to a mental health professional for treatment. He soon showed improvement and was able to return to work.

Depression can affect your workers' productivity judgment, ability to work with others, and overall job performance. The inability to concentrate fully or make decisions may lead to costly mistakes or accidents. In addition, it has been shown that depressed individuals have high rates of absenteeism and are more likely to abuse alcohol and drugs, resulting in other problems on and off the job.

Unfortunately, many depressed people suffer needlessly because they feel embarrassed, fear being perceived as weak, or do not recognize depression as a treatable illness.

Treatments Are Effective

As many as 80% of people with depression can be treated effectively, generally without missing much time from work or needing costly hospitalization.

Mary couldn't sleep at night and had trouble staying awake and concentrating during the day. After visiting the doctor and being put on medication for depression, she found that her symptoms disappeared and her work and social life improved.

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Effective treatments for depression include medication, psychotherapy, or a combination of both. These treatments usually begin to relieve symptoms in a matter of weeks.

WHAT CAN A SUPERVISOR DO?

As a supervisor, you can:

• Learn about depression and the sources of help.

Reading this brochure is a good first step. Familiarize yourself with your company's health benefits. Find out if your company has an employee assistance program (EAP) that can provide on-site consultation or refer employees to local resources.

Recognize when an employee shows signs of a problem affecting performance which may be depression-related and refer employees appropriately.

As a supervisor, you cannot diagnose depression. You can, however, note changes in work performance and listen to employee concerns. If your company does not have an EAP, ask a counselor for suggestions on how best to approach an employee who you suspect is experiencing work problems that may be related to depression.

When a previously productive employee begins to be absent or tardy frequently, or is unusually forgetful and error-prone, he/she may be experiencing a significant health problem.

• Discuss changes in work performance with the employee. You may suggest that the employee seek consultation if there are personal concerns. Confidentiality of any discussion with the employee is critical.

If an employee voluntarily talks with you about health problems, including feeling depressed or down all the time, keep these points in mind:

• Do not try to diagnose the problem yourself.
• Recommend that any employee experiencing symptoms of depression seek professional consultation from an EAP counselor or other health or mental health professional.
• Recognize that a depressed employee may need a flexible work schedule during treatment. Find out about your company's policy by contacting your human resources specialist.
• Remember that severe depression may be life-threatening to the employee, but rarely to others. If an employee makes comments like "life is not worth living" or "people would be better off without me,'' take the threats seriously. Immediately call an EAP counselor or other specialist and seek advice on how to handle the situation.

What Can a Supervisor Say to a Depressed Person?

"I'm concerned that recently you've been late to work often and aren't meeting you performance objectives...I'd like to see you get back on track. I don't know whether this is the case for you, but if personal issues are affecting your work, you can speak confidentially to one of our employee assistance counselors. The service was set up to help employees."

Professional Help Is Available From:

• Physicians
• Mental health specialists
• Employee assistance programs
• Health maintenance organizations
• Community mental health centers
• Hospital departments of psychiatry or outpatient psychiatric clinics
• University or medical school affiliated programs
• State hospital outpatient clinics
• Family service/social agencies
• Private clinics and facilities

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Our women folk have suggested certain attitudes a wife may take with the husband who is recovering. Perhaps they created the impression that he is to be wrapped in cotton wool and placed on a pedestal. Successful readjustment means the opposite. All members of the family should meet upon the common ground of tolerance, understanding and love. This involves a process of deflation. The alcoholic, his wife, his children, his "in-laws", each one is likely to have fixed ideas about the family's attitude towards himself or herself. Each is interested in having his or her wishes respected. We find the more one member of the family demands that the others concede to him, the more resentful they become. This makes for discord and unhappiness.

And why? Is it not because each wants to play the lead? Is not each trying to arrange the family show to his liking? Is he not unconsciously trying to see what he can take from the family live rather than give?

Cessation of drinking is but the first step away from a highly strained, abnormal condition. A doctor said to us, "Years of living with an alcoholic is almost sure to make any wife or child neurotic. The entire family is, to some extent, ill." Let families realize, as they start their journey, that all will not be fair weather. Each in his turn may be footsore and may straggle. There will be alluring shortcuts and bypaths down which they may wander and lose their way.

Suppose we tell you some of the obstacles a family will meet; suppose we suggest how they may be avoided even converted to good use for others. The family of an alcoholic longs for the return of happiness and security. They remember when father was romantic, thoughtful, and successful. Today's life is measured against that of other years and, when it falls short, the family may be unhappy.

Family confidence in dad is rising high. The good old days will soon be back, they think. Sometimes they demand that dad bring them back instantly! God, they believe, almost owes this recompense on a long overdue account. But the head of the house has spent years in pulling down the structures of business, romance, friendship, health these things are now ruined or damaged. It will take time to clear away the wreak. Though old buildings will eventually be replaced by finer ones, the new structures will take years to complete.

Father knows he is to blame; it will take him many seasons of hard work to be restored financially, but he shouldn't be reproached. Perhaps he will never have much money again. But the wise family will admire him for what he is trying to be, rather than for what he is trying to get.

Now and then the family will be plagued by specters from the past, for the drinking career of almost every alcoholic has been marked by escapades, funny, humorous, shameful, or tragic. The first impulse will be to bury these skeletons in a dark closet and padlock the door. The family may be possessed by the idea that future happiness can only be based upon forgetfulness. We think such a view is self centered and in direct conflict with the new way of living.

Henry Ford once made a wise remark to the effect that experience is the thing of supreme value in life. That is true only if one is willing to turn the past to good account. we grow by our willingness to face and rectify errors and convert them into assets. The alcoholic's past thus becomes the principle asset of the family and frequently it is almost the only one!

This painful past may be of infinite value to other families still struggling with their problem. We think each family which has been relieved owes something to those who have not, and when occasion requires, each member of it should be only too willing to bring former mistakes, no matter how grievous, out of their hiding places. Showing others who suffer how we were given help is the very thing which makes life seem so worth while to us now. Cling to the thought that, in God's hands, the dark past is the greatest possession you have the key to life and happiness for others. With it you can avert death and misery for them.

It is possible to dig up past misdeeds so they become a blight, a veritable plague. For example, we know of situations in which the alcoholic or his wife have had love affairs. In the first flush of spiritual experience they forgave each other and drew closer together. The miracle of reconciliation was at hand. Then, under one provocation or another, the aggrieved one would unearth the old affair and angrily cast its ashes about. A few of us have had these growing pains and they hurt a great deal. Husbands and wives have sometimes been obliged to separate for a time until new perspective, new victory over hurt pride could be re-won. In most cases, the alcoholic survived this ordeal without relapse, but not always. So we think that unless some good and useful purpose is to be served, past occurrences should not be discussed.

We families of Alcoholics Anonymous keep few skeletons in the closet. Everyone knows about the others' alcoholic troubles. This is a condition which, in ordinary life, would produce untold grief; there might be scandalous gossip, laughter at the expense of other people, and a tendency to take advantage of intimate information. Among us, these are rare occurrences. We do talk about each other a great deal, but we almost invariably temper such talk by a spirit of love and tolerance.

Another principle we observe carefully is that we do not relate intimate experiences of another person unless we are sure he would approve. We find it better, when possible, to stick to our own stories. A man may criticize or laugh at himself and it will affect others favorably, but criticism or ridicule coming from another often produces the contrary effect. Members of a family should watch such matters carefully, for one careless, inconsiderate remark has been known to raise the very devil. We alcoholics are sensitive people. It takes some of us a long time to outgrow that serious handicap.

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Many alcoholics are enthusiasts. They run to extremes. At the beginning of recovery a man will take, as a rule, one of two directions. He may plunge into a frantic attempt to get on his feet in business, or he may be so enthralled by his new life that he talks or thinks of little else. In either case certain family problems will arise. With these we have had experience galore.

We think it dangerous if he rushes headlong at his economic problems. The family will be affected also, pleasantly at first, as they feel their money troubles are about to be solved, then not so pleasantly as they find themselves neglected. Dad may be tired at night and preoccupied by day. He may take small interest in the children and may show irritation when reproved for his delinquencies. If not irritable, he may seem dull and boring, not gay and affectionate as the family would like him to be. Mother may complain of inattention. They are all disappointed, and often let him feel it. Beginning which such complaints, a barrier arises. He is straining every nerve to make up for list time. He is striving to recover fortune and reputation and feels he is doing very well.

Sometimes mother and children don't think so. Having been neglected and misused in the past, they think father owes the more than they are getting. They want him to make a fuss over them. They expect him to give them the nice times they used to have before he drank so much, and to show his contrition for what they suffered. But dad doesn't give freely of himself. Resentment grows. He becomes still less communicative. Sometimes he explodes over a trifle. The family is mystified. They criticize, pointing out how he is falling down on his spiritual program.

This sort of thing can be avoided. Both father and the family are mistaken, though each side may have some justification. It is of little use to argue and only makes the impasse worse. The family must realize that dad, though marvelously improved, is still convalescing. They should be thankful he is sober and able to be of this world once more. Let them praise his progress. Let them remember that his drinking wrought all kinds of damage that may take long to repair. If they sense these things, they will not take so seriously his periods of crankiness, depression, or apathy, which will disappear when there is tolerance, love, and spiritual understanding.

The head of the house ought to remember that he is mainly to blame for what befell his home. He can scarcely square the account in his lifetime. But he must see the danger of over concentration on financial success. Although financial recovery is on the way for many of us, we found we could not place money first. For us, material well-being always followed spiritual progress; it never preceded.

Since the home has suffered more than anything else, it is well that a man exert himself there. He is not likely to get far in any direction if he fails to show unselfishness and love under his own roof. We know there are difficult wives and families, but the man who is getting over alcoholism must remember he did much to make them so.

As each member of a resentful family begins to see his shortcomings and admits them to the others, he lays a basis for helpful discussion. These family talks will be constructive if they can be carried on without heated argument, self-pity, self justification or resentful criticism. Little by little, mother and children will see they ask too much, and father will see he gives too little. Giving, rather than getting, will become the guiding principle.

Assume on the other hand that father has, at the outset, a stirring spiritual experience. Overnight, as it were, he is a different man. He becomes a religious enthusiast. He is unable to focus on anything else. As soon as his sobriety begins to be taken as a matter of course, the family may look at their strange new dad with apprehension, then with irritation. There is talk about spiritual matters morning, noon and night. He may demand that the family find God in a hurry, or exhibit amazing indifference to them and say he is above worldly considerations, He may tell mother who has been religious all her life, that she doesn't know what it is all about, and that she had better get his brand of spirituality while there is yet time.

When father takes this tack, the family may react unfavorably. They may be jealous of a God who has stolen dad's affections. While grateful that he drinks no more, they may not like the idea that God has accomplished the miracle where they failed. They often forget father was beyond human aid. They may not see why their love and devotion did not straighten him out. Dad is not spiritual after all, they say. If he means to right his past wrongs, why all this concern for everyone in the world but his family? What about his talk that God will take care of them? They suspect father is a bit balmy!

He is not so unbalanced as they might think. Many of us have experienced dad's elation. We have indulged in spiritual intoxication. Like a gaunt prospector, belt drawn in over the last ounce of food, our pick struck gold. Joy at our release from a lifetime of frustration knew no bounds. Father feels he has struck something better than gold. For a time he may try to hug the new treasure to himself. He may not see at once that he has barely scratched a limitless lode which will pay dividends only if he mines if for the rest of his life and insists on giving away the entire product.

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If the family cooperates, dad will soon see that he is suffering from a distortion of values. He will perceive that his spiritual growth is lopsided, that for an average man like himself, a spiritual life which does not include his family obligations may not be so perfect after all. If the family will appreciate that dad's current behavior is but a phase of his development, all will be well. In the midst of an understanding and sympathetic family, these vagaries of dad's spiritual infancy will quickly disappear.

The opposite may happen should the family condemn and criticize. Dad may feel that for years his drinking has placed him on the wrong side of every argument, but that now he has become a superior person with God on his side. If the family persists in criticism, this fallacy may take a still greater hold on father. Instead of treating the family as he should, he may retreat further into himself and feel he has spiritual justification for so doing.

Though the family does not fully agree with dad's spiritual activities, they should let him have his head. Even if he displays a certain amount of neglect and irresponsibility towards the family, it is well to let him go as far as he likes in helping other alcoholics. During those first days of convalescence, this will do more to insure his sobriety than anything else. Though some of his manifestations are alarming and disagreeable, we think dad will be on a firmer foundation than the man who is placing business or professional success ahead of spiritual development. He will be less likely to drink again, and anything is preferable to that.

Those of us who have spent much time in the world of spiritual make-believe have eventually seen the childishness of it. This dream has been replaced by a great sense of purpose, accompanied by a growing consciousness of the power of God in our lives. We have come to believe He would like us to keep our heads in the clouds with Him, but that our feet ought to be firmly planted on earth. That is where our fellow travelers are, and that is where our work must be done. These are the realities for us. We have found nothing incompatible between a powerful spiritual experience and a life of sane and happy usefulness.

One more suggestion: Whether the family has spiritual convictions or not, they may do well to examine the principles by which the alcoholic member is trying to live. They can hardly fail to approve these simple principles, though the head of the house still fails somewhat in practicing them. Nothing will help the man who is off on a spiritual tangent so much as the wife who adopts a sane spiritual program, making a better practical use of it.

There will be other profound changes in the household. Liquor incapacitated father for so many years that mother became head of the house. She met these responsibilities gallantly. By force of circumstances, she was often obliged to treat father as a sick or wayward child. Even when he wanted to assert himself he could not, for his drinking placed him constantly in the wrong. Mother made all the plans and gave the directions. When sober, father usually obeyed. Thus mother, through no fault of her own, became accustomed to wearing the family trousers. Father, coming suddenly to life again, often begins to assert himself. This means trouble, unless the family watches for these tendencies in each other and comes to a friendly agreement about them.

Drinking isolates most homes from the outside world. Father may have laid aside for years all normal activities clubs, civic duties, sports. When he renews interest in such things, a feeling of jealousy may arise. The family may feel they hold a mortgage on dad, so big that no equity should be left for outsiders. Instead of developing new channels of activity for themselves, mother and children demand that he stay home and make up the deficiency.

At the very beginning, the couple ought to frankly face the fact that each will have to yield here and there if the family is going to play an effective part in the new life. Father will necessarily spend much time with other alcoholics, but this activity should be balanced. New acquaintances who know nothing of alcoholism might be made and thoughtful considerations given their needs. The problems of the community might engage attention. Though the family has no religious connections, they may wish to make contact with or take membership in a religious body.

Alcoholics who have derided religious people will be helped by such contacts. Being possessed of a spiritual experience, the alcoholic will find he has much in common with these people, though he may differ with them on many matters. If he does not argue about religion, he will make new friends and is sure to find new avenues of usefulness and pleasure. He and his family can be a bright spot in such congregations. He may bring new hope and new courage to many a priest, minister, or rabbi, who gives his all to minister to our troubled world. We intend the foregoing as a helpful suggestion only. So far as we are concerned, there is nothing obligatory about it. As non denominational people, we cannot make up others' minds for them. Each individual should consult his own conscience.

We have been speaking to you of serious, sometimes tragic things. We have been dealing with alcohol in its worst aspect. But we aren't a glum lot. If newcomers could see no joy or fun in our existence, they wouldn't want it. We absolutely insist on enjoying life. We try not to indulge in cynicism over the state of the nations, nor do we carry the world's troubles on our shoulders. When we see a man sinking into the mire that is alcoholism, we give him first aid and place what we have at his disposal. For his sake, we do recount and almost relive the horrors of our past. But those of us who have tried to shoulder the entire burden and trouble of others find we are soon overcome by them.

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So we think cheerfulness and laughter make for usefulness. Outsiders are sometimes shocked when we burst into merriment over a seemingly tragic experience out of the past. But why shouldn't we laugh? We have recovered, and have been give the power to help others.

Everyone knows that those in bad health, and those who seldom play, do not laugh much. So let each family play together or separately, as much as their circumstances warrant. We are sure God wants us to be happy, joyous, and free. We cannot subscribe to the belief that this life is a vale of tears, though it once was just that for many of us. But it is clear that we made our own misery. God didn't do it. Avoid then, the deliberate manufacture of misery, but if trouble comes, cheerfully capitalize it as an opportunity to demonstrate His omnipotence.

Now about health: A body badly burned by alcohol does not often recover overnight nor do twisted think and depression vanish in a twinkling. We are convinced that a spiritual mode of living is a most powerful health restorative. We, who have recovered from serious drinking, are miracles of mental health. But we have seen remarkable transformations in our bodies. Hardly one of our crowd now shows any mark of dissipation.

But this does not mean that we disregard human health measures. God has abundantly supplied this world with fine doctors, psychologists, and practitioners of various kinds. Do not hesitate to take your health problems to such persons. Most of them give freely of themselves, that their fellows may enjoy sound minds and bodies. Try to remember that though God has wrought miracles among us, we should never belittle a good doctor or psychiatrist. Their services are often indispensable in treating a newcomer and in following his case afterward.

One of the many doctors who had the opportunity of reading this book in manuscript form told us that the use of sweets was often helpful, of course depending upon a doctor's advice. He thought all alcoholics should constantly have chocolate available for its quick energy value at times of fatigue. He added that occasionally in the night a vague craving arose which would be satisfied by candy. Many of us have noticed a tendency to eat sweets and have found this practice beneficial.

A word about sex relations. Alcohol is so sexually stimulating to some men that they have overindulged. Couples are occasionally dismayed to find that when drinking is stopped the man tends to be impotent. Unless the reason is understood, there may be an emotional upset. Some of us had this experience, only to enjoy, in a few months, a finer intimacy than ever. There should be no hesitancy in consulting a doctor or psychologist if the condition persists. We do not know of many cases where this difficulty lasted long.

The alcoholic may find it hard to reestablish friendly relations with his children. Their young minds were impressionable while he was drinking. Without saying so, they may cordially hate him for what he has done to them and to their mother. The children are sometimes dominated by a pathetic hardness and cynicism. They cannot seem to forgive and forget. This may hang on for months, long after their mother has accepted dad's new way of living and thinking.

In time they will see that he is a new man and in their own way they will let him know it. When this happens, then can be invited to join in morning meditation and then they can take part in the daily discussion without rancor or bias. From that point on, progress will be rapid. Marvelous results often follow such a reunion.

Whether the family goes on a spiritual basis or not, the alcoholic member has to if he would recover. The others must be convinced of his new status beyond the shadow of a doubt. Seeing is believing to most families who have lived with a drinker.\

Here is a case in point: One of our friends is a heavy smoker and coffee drinker. There was no doubt he overindulged. Seeing this, and meaning to be helpful, his wife commenced to admonish him about it. He admitted he was overdoing these things, but frankly said that he was not ready to stop. His wife is one of those persons who really feels there is something rather sinful about these commodities, so she nagged and her intolerance finally threw him into a fit of anger. he got drunk.

Of course our friend was wring dead wrong. He had to painfully admit that and mend his spiritual fences. Though he is now a most effective member of Alcoholics Anonymous, he still smokes and drinks coffee, but neither his wife nor anyone else stands in judgment. She sees she was wrong to make a burning issue out of such a matter when his more serious ailments were being rapidly cured.

We have three little mottoes which are apropos. Here they are:

First Things First
Live and Let Live
Easy Does It.

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I can't hold a job or even run my own business for very long. People - co-workers, clients, suppliers - complain that I create a "bad atmosphere", that I am a "difficult person", that they have to walk on brittle eggshells lest I explode, humiliate them, expose their errors and their weaknesses, or simply walk away.

At the workplace, I connive and collude and spread malicious gossip and complain and grumble and insult profusely and make everyone utterly miserable. I project my fears and foibles unto others. I impose my paranoid set of mind. I am full with ideas of reference - convinced that people are talking about me, conspiring against me, berating me behind my back, out to get me.

I have caused the disintegration of teams and dreams and firms too many to enumerate. Like a ghost, like a poison, I permeated everything, destabilizing, provoking, sowing fear and doubt and mutual suspicion, leading inexorably to recriminations and internecine fighting.

Yet, I have done none of this intentionally or with deliberation. These are the unwanted and inadvertent outcomes of my disorder. My grandiose fantasies make me undertake tasks far beyond my capabilities - and then flunk them spectacularly. My sense of entitlement - never commensurate with my achievements - breeds in me a deep-seated conviction of deprivation and discrimination and a wrathful attitude towards those who will not kowtow and instantaneously cater to my inflated needs. My paranoia paints the world in the penumbral hues of suspicion and intrigue.

There is no way to appease me or to stop me. I am the terminator - ever in flux, ever evasive, omnipresent, and all- pervasive. I am the shadow on the wall, the whisper behind the water cooler, the muffled smirking in the corner. I am the traitorous employee, the snitch, the industrial spy, the venomous co-worker, the malicious on-looker. I desert the sinking ship first.

Despite my grandiose self-image, I constantly feel like a cheat. I know that the self people perceive is my FALSE self. I know that I am false and vain and prone to modulation by the vicissitudes of my narcissistic supply. I realize how frivolous, how ephemeral, how unreal I am. In an effort to cover up for these shortcomings I lie and I exaggerate. I dent my credibility and risk my reputation daily in my struggle to sustain a figment of my own pathology. I crush and violently demean any doubter of my skills, any questioner of my qualifications, any threat - perceived or real - to my facade.

I wrote this about the Narcissist in the Workplace:

"The narcissist always seeks new thrills and stimuli.

The narcissist is notorious for his low threshold of and lack of resistance to boredom. His behaviour is impulsive and his biography tumultuous precisely because of his need to introduce uncertainty and risk to what he regards as "stagnation" or "slow death" (i.e., routine). Most interactions in the workplace are part of the rut - and thus constitute a reminder of this routine - deflating the narcissist's grandiose fantasies.

Narcissists do many unnecessary, wrong and even dangerous things in pursuit of the stabilization of their inflated self-image.

Narcissists forever shift the blame, pass the buck, and engage in cognitive dissonance. They "pathologize" the other, foster feelings of guilt and shame in her, demean, debase and humiliate in order to preserve their sense of grandiosity and their compulsive control.

Narcissists are pathological liars. They think nothing of it because their very self is FALSE, an invention.

Here are a few useful guidelines:

• Never disagree with the narcissist or contradict him.

• Never offer him any intimacy.

• Look awed by whatever attribute matters to him (for instance: by his professional achievements or by his good looks, or by his success with women and so on).

• Never remind him of life out there and if you do, connect it somehow to his sense of grandiosity. If the narcissist bought new office equipment - a mundane, drab, and dreary job - so unworthy of the narcissist's time - aggrandize the purchase thus: "This is the BEST equipment I have ever seen in ANY workplace", "We got this fax EXCLUSIVELY - it is the FIRST ever sold here", etc.

• Do not make any comment, which might directly or indirectly impinge on the narcissist's self-image, omnipotence, judgment, omniscience, skills, capabilities, professional record, or even omnipresence.

• Bad sentences start with: "I think you overlooked ... made a mistake here ... you don't know ... do you know ... you were not here yesterday so ... you cannot ... you should ...

• "Should" and "ought to" are perceived as rude impositions. Narcissists react very badly to instructions, however helpful and given with the best intentions. They interpret them as restrictions on their freedom.

• Sentences starting with "I" are equally disastrous. Never mention the fact that you are a separate, autonomous entity. Narcissists regard others as extensions of their selves.

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next: The Objects of the Narcissist

Thoughtful quotes about parenting and motherhood.

Words of Wisdom

"I found out, almost after it was too late, that my children were not born to learn from my experiences; they were born to learn from their own..." (Richard Bode)

"It is a wise father that knows his own child." (Shakespeare

"Nobody knows a mother like her daughter." (Nancy Friday)

"The mother's lap is the child's first classroom" (old proverb)

"There is nothing in human nature more resonant with charges than the flow of energy between two biologically alike bodies, one of which has lain in amniotic bliss inside the other, one of which has labored to give birth to the other. The Materials are here for the deepest mutuality and the most painful estrangement." (Adrienne Rich)

"Dear son, So often parents think of their children as failing investments whose cost in time and money outweighs the return. Whenever I find myself thinking of you in that way, I picture God looking at me. (Hugh Prather)

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"...our parents always fail us massively and decisively. Why is this so? Because they are limited human beings; and for the same reason we, too, will fail our children. (Larry Jaffee)

" ...a mother must not feel obligated to give up herself. Not unless she wants to raise a motherless child." (Lisa Cronin Wohl)

"There are only two lasting bequests we can hope to give our children. One of these is roots; the other, wings." (Hodding Carter)

"Children have never been very good at listening to their elders, but they have never failed to imitate them." (James Baldwin)

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Are you constantly chatting up sexual partners online, engaged in erotic chat, or involved in cybersex? Take our cybersex addiction test. Answer "yes" or "no" to the following statements

1. Do you routinely spend significant amounts of time in chat rooms and private messaging with the sole purpose of finding cybersex?
2. Do you feel preoccupied with using the Internet to find online sexual partners?
3. Do you frequently use anonymous communication to engage in sexual fantasies not typically carried out in real-life?
4. Do you anticipate your next on-line session with the expectation that you will find sexual arousal or gratification?
5. Do you find that you frequently move from cybersex to phone sex (or even real-life meetings)?
6. Do you hide your on-line interactions from your significant other?
7. Do you feel guilt or shame from your on-line use?
8. Did you accidentally become aroused by cybersex at first, and now find that you actively seek it out when you log on-line?
9. Do you masturbate while online while engaged in erotic chat?
10. Do you provide less investment with your real-life sexual partner only to prefer cybersex as a primary form of sexual gratification?

If you answered "yes" to any of the above questions, you may be addicted to cybersex. With the availability of adult web sites and chat rooms, more and more people like yourself have come to realize their initial curiosity has turned into an addiction.

Why wait until it is too late to seek out help? Find out more about cybersexual addiction and contact our Virtual Clinic today to receive fast, caring, and confidential advice on how to deal with your addiction. Our Virtual Clinic is also designed to help family members, such as a spouse or parent, to deal with the addicted loved one in your home. Professional help is available directly with Dr. Kimberly Young, Founder and President of the Center for Internet Addiction Recovery.

And read Caught in the Net, the first recovery book for Cybersexual Addiction. The book provides effective tools that help couples communicate and rebuild their relationship after a cyberaffair. Click here to order Caught in the Net

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Many bipolar kids have learning disabilities or other problems. Here are some ideas to help your bipolar child be a better student.

Educators can significantly reduce classroom stresses for children with bipolar disorder, thereby allowing them to succeed in school. Academic stresses, like other stresses, can destabilize a child with bipolar disorder. Regular meetings between parents and school faculty, such as teachers, guidance counselors, or nurses, will allow collaboration to develop helpful school structure and strategies for the child. The child may need particular changes (accommodations/modifications) to the workload. Bipolar disorder may need to be considered be a "disability," just like a broken arm or asthma.

Accommodations, modifications, and school strategies may include the following:

• Check-in on arrival to see if the child can succeed in certain classes that day. Where possible, provide alternatives to stressful activities on difficult days.
• Accommodate late arrival due to inability to awaken, which may be a medication side effect or a seasonal problem
• Allow more time to complete certain types of assignments
• Adjust the homework load to prevent the child from becoming overwhelmed
• Adjust expectations until symptoms improve. Helping a child make more attainable goals when symptoms are more severe is important, so that the child can have the positive experience of success.
• Anticipate issues such as school avoidance if there are unresolved social and/or academic problems
• Anticipate social difficulties and reduce opportunities for possible bullying by others. Children with bipolar disorder are often on a different "wavelength" than their peers and their behavior may be viewed as unusual. It is not uncommon for them to be socially isolated, and they may be targets for bullying. More often than other children, they may be ill-equipped to handle teasing in an appropriate way.
• Allow children to discreetly and frequently accommodate needs caused by medication side effects, such as excessive thirst and frequent bathroom breaks
• Set up a procedure that allows the child to quickly and safely exit from an overwhelming situation. Designate a place and staff member that is always available when the child needs to de-stress.

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• Expect and accommodate learning and cognitive difficulties, which may vary in severity from day to day. Despite normal or high intelligence, many children and adolescents with bipolar disorder have processing and communication deficits that hinder learning and create frustration.
• Use alternative discipline approaches if children are unable to control their behavior. Traditional approaches to discipline are unlikely to produce the desired results, and an approach that is effective one day may not work the next day. Alternative strategies include providing additional time and then repeating a request, developing a list of options from which children may choose, and designating a special place for students to go during times of stress.
• Because transitions may be particularly difficult for these children, allow extra time for moving to another activity or location. When a child with bipolar disorder refuses to follow directions or to transition to the next task, schools and families should remember that anxiety may be the cause, rather than intentional inflexibility or oppositionality.
• Use behavioral plans at school that are consistent with those used at home. Please refer to "Interventions At Home," above, for details regarding behavioral plans.
• Encourage the child to help develop interventions. Enlisting the child in the task will lead to more successful strategies and will foster the child's ability to problem-solve.
• Please click on School-Based Interventions for a more complete list of school accommodations for children with bipolar disorder

Flexibility and a supportive environment are essential for a student with bipolar disorder to achieve success in school. Parents and school faculty may be able to identify particular problem times, such as transition times or unstructured periods, and develop remedies to reduce the child's difficulties in those situations.

Sources:

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC: American Psychiatric Association, 1994
• Dulcan, MK and Martini, DR. Concise Guide to Child and Adolescent Psychiatry, 2nd Edition. Washington, DC: American Psychiatric Association, 1999
• Lewis, Melvin, ed. Child and Adolescent Psychiatry: A Comprehensive Textbook, 3rd Edition. Philadelphia: Lippincott Williams and Wilkins, 2002

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Many people are asking for help concerning internet disorders - addictions to cybersex, cyber-relationships, online stock trading and gambling, computer games.

by Kimberly Young, Molly Pistner, James O'Mara, and Jennifer Buchanan
University of Pittsburgh

Paper published in CyberPsychology & Behavior, 3(5), 475-479, 2000

Abstract

Anecdotal evidence has suggested that mental health practitioners' report increased caseloads of clients whose primary complaint involves Internet. However, little is known about the incidence, associated behaviors, attitudes of practitioners, and interventions involved related to this relatively new phenomenon. Therefore, this study surveyed therapists who have treated clients suffering from cyber-related problems to gather such outcome information. Respondents reported an average caseload of nine clients who they classified as Internet-addicted, with a range between two to fifty clients treated within the past year. Five general subtypes of Internet addiction were categorized based upon the most problematic types of online applications, and they include addictions to Cybersex, Cyber-relationships, online stock trading or gambling, information surfing, and computer games. Treatment strategies included cognitive-behavioral approaches, sexual offender therapy, marital and family therapy, social skills training, and pharmacological interventions. Based upon their client encounters, efforts to initiate support groups and recovery programs specializing in the treatment of Internet addiction were being considered. Finally, based upon the findings, this paper examines the impact of cyber-disorders on future research, treatment, and public policy issues for the new millennium.

Introduction

Among a small but growing body of research, the term addiction has extended into the psychiatric lexicon to identify problematic Internet use associated with significant social, psychological, and occupational impairment.^1-10 Symptoms include a preoccupation with the Internet, increased anxiety when off-line, hiding or lying about the extent of on-line use, and impairment to real-life functioning. In particular, this research argued that addictive use of the Internet directly lead to social isolation, increased depression, familial discord, divorce, academic failure, financial debt, and job loss.

Such cyber-related issues not only appear to be a growing social concern, but anecdotal evidence has suggested that mental health practitioners ranging from college counselors, martial therapists, to drug and alcohol counselors report increased caseloads of clients whose primary complaint involves Internet. A few comprehensive treatment centers for Computer/Internet Addiction Recovery have even emerged in response to these new cases. However, outcome data related to the reason for referral, primary complaints, the associated behaviors, attitudes of practitioners, and interventions applied to this new phenomenon have yet to be collected. Therefore, this study is the first to survey therapists who have treated clients whose primary or underlying complaint involves the Internet to gather such outcome data and to utilize the results for future research, treatment, and public policy recommendations.

Methods

Subjects: Participants were therapists who responded to: (a) postings on relevant electronic discussion groups (e.g., NetPsy) and (b) those who searched for the keywords "Internet" or "addiction" on popular Web search engines (e.g., Yahoo) to find The Center for On-Line Addiction web site where the survey existed.

Measures: A survey was constructed that could be administered and collected electronically. The survey consisted of both open-ended and closed-ended questions and was divided into three sections. The first section contained questions related to incidence rates, primary complaints, the presence of other addiction problems or psychiatric conditions, and interventions utilized. The second section assessed therapists' attitudes regarding addictive use of the Internet on a five-point likert scale that ranged from (1) strongly agree to (5) strongly disagree. The last section gathered demographic information such as gender, years of practice, professional affiliation, and country of origin.

Procedures: An offline pilot study first established that the survey instrument was reliable and valid. The survey then existed as a Web page implemented on a UNIX-based server that captured the answers into a text file. Answers were sent in a text file directly to the principal investigator's e-mail box for analysis. Results yielded a total of 44 responses within a six-month period with 35 valid responses. These responses were then analyzed using frequency counts, means, standard deviations, and content analyses.

Results

The sample included 23 females and 12 males with an average of 14 years of clinical practice. Their affiliations ranged as follows: 65% worked in private practice, 20% were employed by a community mental health clinic, 10% worked in a university counseling center, and 5% were employed in a drug and alcohol rehabilitation center. Approximately 87% of survey respondents were from the United States, and 13% were from United Kingdom and Canada.

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Table 1 suggests that clients are most likely to present with direct complaints of compulsive Internet use, relationship difficulties, or a prior addiction problem and are less likely to present with a psychiatric illness. Respondents noted that 80% of their clients used email, 70% chat rooms, 10% newsgroups, 30% interactive online games, and 65% used the World-Wide-Web (primarily to view pornography or to utilize online trading or auction house services). Respondents reported an average caseload of nine clients who they classified as Internet-addicted, with a range of two to fifty clients treated within the past year. It should be noted that 95% of the respondents reported that the problem was more widespread than these numbers indicate.

Internet Addiction is a broad term covering a wide-variety of behaviors and impulse-control problems.¹³ Qualitative results gleaned from this study suggest that five specific sub-types of Internet addiction could be categorized:

1. Cybersexual Addiction - compulsive use of adult web sites for cybersex and cyberporn.
2. Cyber-relationship Addiction - over-involvement in online relationships.
3. Net Compulsions - obsessive online gambling, shopping, or online trading.
4. Information Overload - compulsive web surfing or database searches.
5. Computer Addiction - obsessive computer game playing (e.g., Doom, Myst, or Solitaire).

Qualitative analysis indicated that a leading factor underlying pathological or compulsive use of the Internet was the anonymity of electronic transactions. Specifically, anonymity was associated with four general areas of dysfunction:

1. Encouraged deviant, deceptive, and even criminal acts such as viewing and downloading obscene images (e.g., pedophilia, urination, or bondage fantasies) or illegal images (e.g., child pornography) widely available on adult web sites. It should be noted that the evidence indicates that clients who entertained deviant sexual fantasies involving children and adolescents did not attempt to contact children or adolescents beyond the Internet. Commentary suggested that the existence of deviant fantasies did not necessarily equate with or reliably predict that the sexual molestation of children will occur or has occurred. The behavior began out of curiosity and soon became an obsession. In cases of Cybersexual addiction, sex offender psychotherapy was offered to reduce potential risk.
2. Provided a virtual context that allowed overly shy or self-conscious individuals to interact in a socially safe and secure environment. Over-reliance upon on-line relationships resulted in significant problems with real life interpersonal and occupational functioning. In such cases, cognitive-behavioral and interpersonal psychotherapy techniques were applied in to reduce avoidant behavior and to enhance social skills.

1. Interactive components of the Internet facilitated cyberaffairs or extramarital relationships formed on-line that negatively impacted marital or family stability, primarily leading to separation and divorce. Individual and marital therapy and family therapy were used when couples' worked towards reconciliation after the online infidelity.
2. The ability to develop alternative online personas, dependent upon a user's mood or desires, that provided a subjective escape from emotional difficulties (e.g., stress, depression, anxiety) or problematic situations or personal hardships (e.g., job burnout, academic troubles, sudden unemployment, marital discord). The immediate psychological escape found within the "fantasy" on-line environment served as a primary reinforcement for the compulsive behavior. Underlying mood disorders and psychosocial issues were treated with psychotherapy and pharmacological interventions as appropriate.

Table 2 shows a summary of attitudes maintained among therapists who have treated compulsive use of the Internet. Not surprisingly, respondents strongly agreed that addictive use of the Internet is a serious problem akin to other established addictions, felt that the problem was underestimated and that more attention and research in this area was necessary. Respondents considered the implementation of an Internet addiction support group at their agency to provide intervention and believed that moderation of compulsive use was possible.

Discussion

Approximately 83 million Americans are currently online with that number expected to grow by 12 million in the next year alone.¹¹ As the popularity of the Internet rapidly continues to grow, cyber-disorders may pose a serious clinical threat, as little is understood about the treatment implications of this relatively new and often unrecognized phenomenon. Due to the Internet's encouraged use for retail and business applications, it is highly likely that the nature and scope of the familial, social, and occupational consequences may be underestimated. Therefore, public policy matters concerning the marketing and promotion of the Internet should be considered from a mental health perspective. As a profession, prevention programs, recovery centers, support groups, and the integration of training workshops specializing in Internet addiction should be encouraged to address the emergence of such cyber-related problems.

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New areas of research should include the development of standard diagnostic instruments to assess cyber-disorders and systematic intake evaluations to further understand the role of compulsive use of the Internet in other established addictions (e.g., alcoholism, sexual compulsivity, pathological gambling) and psychiatric conditions (e.g., major depression, bipolar disorder, ADD).

Research should also include the development of models that identify or explain the motivation underling such pathological online behavior. For example, The ACE Model developed by Young (1999) explains how Accessibility, Control, and Excitement play a significant role in the development of Internet compulsions.¹² According to the model, Internet addiction develops due to three discriminate underlying rewards. The three variables include: (a) the accessibility of information, interactive areas, and pornographic images; (b) the personal control and perceived privacy of electronic interactions; and (c) internal feelings excitement leading to a mental "high" related to Net usage. Models such as this facilitate our general understanding of the disorder and guide in later treating planning.

Most important, as young children frequent the Internet, it is important that research also investigate the growing incidence of on-line pedophilia and the risks posed to children. Furthermore, it is important to note that the diagnosis of pedophilia only requires that an individual entertain intense reoccurring sexual fantasies about children¹³ and does not require that actual molestation to take place. Therefore, as a growing number of criminal cases involve the possession of illegal images downloaded from the Internet, the psychological field should closely examine the relationship between viewing child pornography and the actual risk of child molestation. Finally, the limitations of this study such as a low sample size, the lack of randomization, and the questionable accuracy of online survey methods are recognized, and therefore, these results should be interrupted with caution.

Table 1: Primary Client Complaints and Clinical Response

Questions	Yes	No
1. Have you seen a rise in the number of clients who spend an excessive amount of time using the Internet?	80%(28)	20%(7)
2. Have you seen clients who appear "addicted" to the Internet?	85%(30)	15%(5)
3. Have you seen clients who present themselves as having relationship difficulties (e.g. breakups, withdrawn from others, few friends) and later discover it is related to addictive use of the Internet?	74%(26)	16%(9)
4. Have you seen clients who present themselves with clinically related issues (e.g. depression, bi-polar disorder, anxiety) and later discover it is related to addictive use of the Internet?	30%(10)	70%(25)
5. Have you seen clients who are addicted to the Internet who also suffer from a prior addiction history (alcoholism, over-eating, or sex addictions)?	60%(21)	40%(14)
6. Has your program considered a support group for those clients who suffer from an addiction to the Internet?	40%(14)	60%(21)
7. Do you feel the problem is more widespread than the number of cases indicates?	94%(33)	6% (2)
8. Do you believe moderation is possible to treat addictive Internet use?	60%(21)	40%(14)
9. Did your clients form new relationships on-line?	91%(32)	9% (3)
10. Did your clients form a new persona on-line?	66%(23)	34%(12)

Table 2: Attitudes of Therapists treating cases of Pathological Internet Use

Statement	1	2	3	4	5
I feel that addictive use of the Internet may become a significant problem in our society.	35%	55%	10%	0%	0%
I feel that mental health practitioners need to pay more attention to the ramifications of addictive use of the Internet.	40%	55%	0%	5%	0%
I feel that addictive use of the Internet can be as serious as other established addictions (e.g. alcoholism) in terms of psychological and family problems.	50%	35%	10%	0%	5%
I feel that counselors do not take Internet addiction seriously as a legitimate disorder.	30%	20%	35%	10%	0%
I feel that more research is needed to better understand the nature of addictive Internet use.	0%	5%	10%	30%	50%

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References

1. Brenner, V. (1997). The results of an on-line survey for the first thirty days. Paper presented at the 105th annual meeting of the American Psychological Association, August 18, 1997. Chicago, IL.
2. Griffiths, M. (1997). Does Internet and computer addiction exist? Some case study evidence. Paper presented at the 105th annual meeting of the American Psychological Association, August 15, 1997. Chicago, IL.
3. Krant, R., Patterson, M., Lundmark, V., Kiesler, S. , Mukopadhyay, T., & Scherlis, W. (1998) Internet Paradox: A social technology that reduces social involvement and psychological well-being? American Psychologist, 53, 1017-1031.
4. Morahan-Martin, J. (1997). Incidence and correlates of pathological Internet use. Paper presented at the 105th annual meeting of the American Psychological Association, August 18, 1997. Chicago, IL.
5. Scherer, K. (1997). College life online: Healthy and unhealthy Internet use. Journal of College Development, 38, 655-665.
6. Shotton, M. (1991). The costs and benefits of "computer addiction." Behaviour and Information Technology, 10, 219 - 230.
7. Young, K.S. & Rogers, R. (1997a). The relationship between depression and Internet addiction. CyberPsychology and Behavior, 1, 25-28.
8. Young, K. S. (1997b). What makes on-line usage stimulating? Potential explanations for pathological Internet use. Paper presented at the 105th annual meeting of the American Psychological Association, August 15, 1997. Chicago, IL.
9. Young, K. S. (1998a) Internet addiction: The emergence of a new clinical disorder. CyberPsychology and Behavior, 3, 237-244.
10. Young, K.S. (1998b). Caught in the Net: How to recognize the signs of Internet addiction and a winning strategy for recovery. New York, NY: John Wiley & Sons.
11. IntelliQuest (1999). Press Release, latest survey reported by IntelliQuest Information Group, Inc. of Austin, Texas.
12. Young, K. S. (1999). Net compulsions: The latest treads in the area of Internet addiction.
13. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders. (4th ed.) Washington, DC: Author

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