SavvySugar

Definition: Grace Period

SavvySugar — Tue, 02 Sep 2008 15:30:46 -0700

A grace period is the period from the date a statement was prepared by the issuer (statement date) to the payment-due date. No interest will be charged if the whole balance is paid by the end of the period. These interest-free grace periods typically last 25 days, but 20-day periods are becoming more common.

When you're looking for a credit card, avoid cards that don't offer a grace period, because you'll end up paying interest immediately upon purchase. It pays to search for a card with a longer grace period, because the amount of time you have interest-free affects how much interest you'll end up paying overall.

Source

Make Mine an Old-Fashioned - Perfume, That Is

BellaSugar — Thu, 25 Feb 2010 10:59:14 -0800

It seems like the stream of new fragrances these days is neverending, with every celebrity and design house pumping out at least a couple of scents every season. But what about the classics, the scents of the past? I'm not talking about Chanel No. 5, which has a cult following and survives as much on Coco's legendary life as on the scent itself. Instead, I'm talking about fragrances like Estée Lauder's classic Youth Dew, created in 1953, or Creed's Fleurissimo, concocted in honor of Grace Kelly's marriage to Prince Ranier of Monaco. Older fragrances unfold differently, usually over a longer period of time, tend to be more complex, and have a lot more sillage. To learn more about these old-fashioned perfumes and see a gallery of ones you can try for yourself, read more.

Get a Handle on Your Credit Card Debt With a "Clean Card"

SavvySugar — Mon, 04 Jan 2010 12:00:57 -0800

If you’re like millions of other Americans, one of your resolutions for 2010 is to get on top of your credit card debt. Paying it all off in one fell swoop would be the ideal way to go about it, but unless you also plan to win the lottery this year, that’s probably not an option. Author Bob Sullivan has a completely doable suggestion for wrapping your head around your credit card debt and paying it down quickly. To see his tips, read more.

Sullivan suggests keeping two credit cards: one "clean card," used for everyday purchases and paid off in full every month. This card will still allow you to take advantage of the 30-day grace period and keep boosting your credit score, without racking up interest on your balance. The other card is a line-of-credit card, only used for big, emergency purchases that you can’t pay off in full.

The real advantage to Sullivan’s strategy is eliminating "revolving debt" - balances that you’re constantly adding to and subtracting from, not to mention paying interest on. You’ll still be making monthly payments on your line-of-credit card, but you’ll be able to pay the balance off relatively quickly and you’ll always know exactly how much debt you have.

How do you plan to tackle your credit card debt in the new year?

Source: Flickr User Andres Rueda

Behind the Seams: Cartier's Luminescent Legacy

FabSugar — Tue, 22 Dec 2009 16:00:22 -0800

Just in time for the holidays, Cartier celebrates 100 years in America with an extensively sparkly exhibit. San Francisco's Legion of Honor is hosting an exclusive exhibit through April 18. The collection houses more than 200 objects, starting with the Belle Époque through to the 1960s and '70s; jewelry of the gilded age and art-deco period surround platinum-set diamond tiaras, mystery clocks, and exotic creatures. The real stunners are the royal pieces worn by high society and Hollywood legends; an exotic flamingo brooch made for the Duchess of Windsor, diamond bangles worn by screen legend Gloria Swanson, and - my favorite - Princess Grace of Monaco's Cartier engagement jewelry (pictured). There's no denying Cartier's pukka power. Here's to another 100 years of diamonds, rubies, and emeralds.

View Slideshow ›

Buzz Interview: Holly Hunter on Saving Grace

BuzzSugar — Mon, 14 Jul 2008 14:30:33 -0700

Saving Grace has already earned Holly Hunter a Golden Globe nomination, and few would be shocked to hear her name on Thursday when the Emmy nominations are announced. Hunter plays an Oklahoma City detective who lives large for better or for worse - throwing herself into her work but also drinking, smoking, and sleeping with the wrong people. She's also being visited by Earl, an unusual angel who encourages Grace to set her life straight.

The show's second season premieres tonight at 10 p.m. EDT and PDT on TNT, and last week, Hunter spoke with some reporters about her character, the show's second season, and her feelings about making the jump from movies to TV. Here are some highlights:

On whether Grace changes at all this season:
"I think she changes all the time, actually. I think there's give and take inside her. There's always movement. She's very kinetic. And I think she's also kinetic in a psychological way. . . . The most thrilling thing about her is how live she is. So many people are truly asleep for long periods in their days and their lives. I think Grace spends an extraordinary amount of her time really awake, awake to a real, true curiosity about why people do what they do. She also is a real tester of what people are capable of and what she herself is capable of."

On what opened the door for Saving Grace to exist:
"What preceded that was the success of The Shield and Rescue Me and The Sopranos - really started the wild, wild west in cable. FX and HBO kind of started this new idea, which was real character drama, and a character who does anti-heroic things, not just a character who's quirky but a character who straddles two worlds - one world being highly charged with questionable thoughts and behavior, such as Denis Leary and Tony Soprano and Vic Mackey. Those characters live in a more similar vein to how Grace lives, except that Grace is a woman. That's where cable is really kind of taking off. It's given women opportunities to play highly controversial characters, women who are doing things that maybe they wouldn't have been able to do on television 10 years ago, like Weeds on Showtime or Glenn Close in Damages or Minnie Driver in The Riches, women who were living lives of real, deep grayness."

To find out what Hunter thought was the toughest part of transitioning to TV, read more.

On what it feels like to work in TV after so many years in movies:
"It's really a high. You feel the wind blowing in your hair when you do a series, in the best of times. Other times it's just trying to catch up. But I'll tell you, this work is very fulfilling, and it's great for me as an actress to get to adapt and be flexible. You're demanded to be very flexible and very adaptable and be very much a problem solver on a set like this. I kind of used the skills that I've developed over these years doing feature films and just kind of accelerated them to make this series."

On what she did to prepare for the leap to TV:
"I called Dylan McDermott, cause he'd done The Practice. I called Dylan because he's a buddy and I so respect him, and he'd done a David E. Kelley series, which is so particular. I was asking him something I'd never asked an actor before, which was: How do you memorize all those lines? That was a very pertinent question for the first time in my career. With David E. Kelley, the actors - they never stop talking! And I just asked him, 'What gives? How do you do this every week?' That has never been a concern of mine, I memorize the entire script before I start shooting a feature - it's never been a big deal. Dylan said, 'It's going to be a scary ride when you first get on, and your memory is going to become a very well-used muscle.' . . . Memorizing a script for two days, having only two days to memorize it and then just shooting it - it's dicey."

Source

FABTV: Chris Cunningham for Gucci

FabSugarUK — Fri, 17 Apr 2009 09:00:20 -0700

If you're not already familiar with the name Chris Cunningham, then perhaps you are familiar with his work. He's the director behind Madonna's "Frozen" video and Grace Jones' Dazed and Confused shoot. He has now teamed up with Gucci to produce this video for Flora starring Abbey Lee.

It was shot over a four day period in Latvia. Riccardo Ruini, who developed the concept for the commercial with Frida Giannini and Cunningham, explained, “Foremost in our minds was a desire to avoid the heroine being perceived as passive or dreamy. We wanted to portray the female as an active character who brings to life in an active way the Flora personality by controlling the nature around her." As always, let us know what you think!

Back to Basics: Six Money Related Words and Phrases

SavvySugar — Wed, 18 Mar 2009 13:30:07 -0700

There's no such thing as being too well-versed in the world of money words and phrases. Check out these six definitions to refresh your memory, or learn something new about the jargon of funny money.

Interchange Fees	Piggybacking	Debt Snowball Plan
Grace Period	Spot Budgeting	Standard Deduction

Fibromyalgia

FitSugar — Wed, 08 Oct 2008 17:35:02 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Causes

People with fibromyalgia have decreased activity in opioid receptors in parts of the brain that affect mood and the emotional aspect of pain, researchers have found. This might explain why fibromyalgia patients are likely to experience depression, and are not very responsive to opioid painkillers.
Researchers have identified a conflict between sensory perception and nervous system processing in people with fibromyalgia. One study suggests that people with the condition might have greater awareness of, or less tolerance for, movement problems (such as tremor) that don't match with their expected sensory feedback. This mismatch in sensory signals might enhance the perception of pain.

Treatment

New research adds to the evidence that exercise relieves some of the symptoms of fibromyalgia. Women with fibromyalgia who took part in a program that combined aerobic, strength training, and flexibility exercises had better physical and emotional function, as well as reduced symptoms. Another study found that an at-home exercise program improved upper body pain and function, especially in women who were having functional difficulties at the beginning of the study.
An anti-convulsant medication, gabapentin (Neurontin), significantly improved pain in fibromyalgia patients compared to placebo. Patients who took gabapentin also reported that they slept better and felt less tired.
The selective serotonin-reuptake inhibitor paroxetine (Paxil) significantly lowered patient scores on a fibromyalgia symptom questionnaire, and was well-tolerated, although the drug do much for their pain.

Introduction

Fibromyalgia is a syndrome of unknown causes that results in lasting, sometimes debilitating, muscle pain and fatigue. Fibromyalgia is also known as fibrositis or fibromyositis.

Pain. The primary symptom of fibromyalgia is pain. The pain can be in one place or all over. The exact locations of the pain are called tender points. The pain of fibromyalgia is often is described as follows:

Tender point pain occurs in local sites, usually in the neck and shoulders. The pain then spreads out from these areas. The actual pain starts at the muscles. The joints are not affected. There are no lumps or nodes associated with these points of pain, and no signs of inflammation (swelling). People diagnosed with fibromyalgia feel pain in at least 11 of 18 specific tender points.
Widespread pain described as stiffness, burning, and aching. The pain also "radiates," or spreads, to nearby areas. Most patients report feeling some pain all the time. Many describe it as "exhausting." The pain can vary depending on the time of day, weather changes, physical activity, and the presence of stressful situations. The pain is often more intense after disturbed sleep.

Fatigue and Sleep Disturbances. Another major complaint is fatigue. Some patients report that fatigue is more unbearable than their pain. Sleep disturbances, particularly restless legs syndrome, are also very common. Fatigue and sleep disturbances are almost universal in patients with fibromyalgia. Some experts believe that if these symptoms are not present, doctors should seek a diagnosis other than fibromyalgia.

Depression and Mood. Up to a third of patients have depression. Disturbances in mood and concentration are also very common. These conditions often go undiagnosed in patients with fibromyalgia.

Other Symptoms. The following symptoms may also be present:

Digestive problems, including irritable bowel syndrome with gas, and alternating diarrhea and constipation
Dizziness
Painful menstrual periods
Tension or migraine headaches
Tingling or numbness in the hands and feet
Urinary frequency caused by bladder spasms

Symptoms in Children. In general, children with fibromyalgia most often have sleep disorders and widespread pain.

Causes

The most common type is primary fibromyalgia, in which the causes are not known. Many experts believe that fibromyalgia is not a disease, but rather a chronic pain condition brought on by several abnormal body responses to stress. Physical injuries, emotional trauma, or viral infections such as Epstein-Barr may be triggers of the disorder, but none have proven to be a cause of primary fibromyalgia.

Research published in the December 2006 issue of Current Pain and Headache Reports found that the areas in the brain that are responsible for the sensation of pain are different in fibromyalgia patients from the same areas in healthy people.

People with fibromyalgia have been found to have decreased activity in opioid receptors in parts of the brain that affect mood and the emotional aspect of pain. This reduced response might explain why fibromyalgia patients are likely to havedepression, and are less responsive to opioid painkillers, researchers say.

Sleep disturbances are common in fibromyalgia. Both adult and young patients with fibromyalgia have a higher-than-average rate of a sleep disorder called periodic limb movement disorder (PLMD). PLMD used to be called nocturnal myoclonus. Patients with PLMD involuntarily contract their leg muscles every 20 - 40 seconds during sleep. This may occasionally wake up the patient.

Some researchers believe that fibromyalgia does not lead to poor sleeping patterns, but that sleep disturbances come first. Researchers continue to investigate the link between fibromyalgia and sleep.

In one study, healthy volunteers reported fibromyalgia-like pain after they had been subjected to disrupted deep sleep. Disturbed sleep appears to trigger factors in the immune system that cause inflammation, pain, fatigue, and lower tolerance to pain. A 2004 study found that patients with fibromyalgia have increased rates of cyclic alternating sleep pattern (CAP). Increased CAP produced serious sleep problems, which were strongly linked to symptom severity. Previous studies have also suggested that CAP may be related to PLMD.
A 2004 report found that sleep disorders that cause breathing problems are common in women with fibromyalgia.
Other biological measures of troubled sleep, however, such as levels of the hormone melatonin, which helps regulate circadian rhythms and the sleep-wake cycle, appear to be normal in most people with fibromyalgia.

Many abnormalities of hormonal, metabolic, and brain chemical activity have been described in studies of fibromyalgia patients. Changes appear to occur in several brain chemicals, although no regular pattern has emerged that fits most patients. Since there has been no clear cause-and-effect relationship established, this may be a result of the effects of pain and stress on the central nervous system, and not a cause of fibromyalgia.

Serotonin. Of particular interest to researchers is serotonin, an important nervous system chemical messenger found in the brain, gut, and other areas of the body. Serotonin plays important roles in feelings of well-being, adjusting pain levels, and promoting deep sleep. Serotonin abnormalities have been linked to many disorders, including depression, migraines, and irritable bowel syndrome. Lower serotonin levels have also been noted in some patients with fibromyalgia.

Stress Hormones. Researchers have also found abnormalities in the hormone system known as the hypothalamus-pituitary-adrenal gland (HAP) axis. The HAP axis controls important functions, including sleep, response to stress, and depression. Changes in the HAP axis appear to produce lower levels of the stress hormones norepinephrine and cortisol. (By contrast, levels of stress hormones in depression are higher than normal.) Deficiencies in the levels of stress hormones produce impaired and weaker responses to psychological or physical stresses. (Examples of physical stress include infection or exercise.)

The hypothalamus is a highly complex structure in the brain that regulates many important brain chemicals.

Click the icon to see an image of the adrenal glands.

Low Growth Hormone Levels. Some studies have reported low levels of insulin-like growth factor-1 (IGF-1) in about a third of fibromyalgia patients. IGF-1 is a hormone that is controlled by the adult growth hormone, and promotes bone and muscle growth. Low levels of growth hormone are related to impaired thinking, lack of energy, muscle weakness, and intolerance to cold. Studies suggest that changes in growth hormone likely stem from the hypothalamus in the brain. While researchers did not find a link between IGF-1 levels and fibromyalgia, a 2005 study indicated that serum growth hormone levels may be a marker of the disorder.

Abnormal Pain Perception and Substance P. Some studies have suggested that fibromyalgia may involve too much activity in the parts of the central nervous system that process pain (the nociceptive system). Brain scans of fibromyalgia patients have suggested abnormalities in pain processing centers. For example, researchers have detected up to three times the normal level of substance P in the cerebrospinal fluid of fibromyalgia patients. Substance P, a chemical messenger of the nervous system, is associated with increased pain perception.

Some fibromyalgia patients may also be oversensitive to external stimulation, and overly anxious about the sensation of pain. This increase in awareness is called generalized hypervigilance. One study compared patients with fibromyalgia or rheumatoid arthritis to those without chronic pain. Researchers then measured the different groups' responses to pain and noise. Of the three groups, the fibromyalgia patients were least tolerant, and most aware, of such stimuli. However, one analysis of studies on fibromyalgia found no strong support for the hypervigilance theory.

A conflict between sensory perception and nervous system processing might occur in people with fibromyalgia. Fibromyalgia patients have been found to have greater awareness of, or less tolerance for, movement problems (such as tremor) that don't match with their expected sensory feedback. This mismatch in sensory signals might enhance the perception of pain.

Fibromyalgia has symptoms that resemble those of some rheumatic illnesses, including rheumatoid arthritis and lupus (systemic lupus erythematosus). These are autoimmune diseases in which a defective immune system mistakenly attacks the body's own healthy tissue, producing inflammation and damage. The pain in fibromyalgia, however, does not appear to be due to autoimmune factors, and there is little evidence to support a role for an inflammatory response in fibromyalgia.

Although not primary causes, psychological and social factors may contribute to fibromyalgia in three ways:

They could make individuals susceptible to fibromyalgia.
They may play some role in triggering the onset of the condition.
They may perpetuate, or be responsible for, the condition.

Studies have reported a greater number of severe experiences of emotional and physical abuse in patients with fibromyalgia, compared with the general population. Most often, the abuse came from family members or partners. This suggests that post-traumatic stress disorder (PTSD) or chronic stress may play a strong role in the development of fibromyalgia in some patients. PTSD, an anxiety disorder, is a reaction to a specific traumatic event. Symptoms of this condition, which can last for years after the traumatic event, include emotional withdrawal, hopelessness, irritability, mood swings, sleep problems, inability to concentrate, and an excessive startle response to noise. Some evidence indicates that PTSD actually results in changes in the brain, possibly from long-term over-exposure to stress hormones.

Some research found muscle abnormalities in fibromyalgia patients. These problems can be classified as the following:

Biochemical abnormalities: For example, one study reported that fibromyalgia patients had lower levels of the muscle-cell chemicals phosphocreatine and adenosine triphosphate (ATP). Such chemicals regulate the level of calcium in muscle cells. Calcium is an important component in the muscles' ability to contract and relax. If ATP levels are low, calcium is not "pushed back" into the cells, and the muscle remains contracted.
Functional abnormalities: The pain and stress of the disease itself may harm muscle function.
Structural and blood flow abnormalities: Some researchers saw overly thickened capillaries (tiny blood vessels) in the muscles of fibromyalgia patients. The abnormal capillaries could produce lower levels of compounds essential for muscle function, as well as reduce the flow of oxygen-rich blood to the muscles.

To date, none of these abnormalities have a clearly defined relationship with fibromyalgia.

Risk Factors

About 3.7 million Americans have fibromyalgia. The condition affects 2% of Americans, including 3.4% of women and 0.5% of men.

Some evidence suggests that several factors may make people more susceptible to fibromyalgia. These risk factors include:

Being female
Coming from a very stressful culture or environment
Having a psychological vulnerability to stress
Having had difficult experiences in childhood

Nine out of 10 fibromyalgia patients are women. Women may be more prone to develop fibromyalgia during menopause.

The disorder usually occurs in people ages 20 - 60 years, though it can occur at any time. Some studies have noted peaks around age 35. Others note that fibromyalgia is most common in middle-aged women. In one study, cases of fibromyalgia increased with age, and reached a frequency of more than 7% among people in their 60s and 70s.

Juvenile Primary Fibromyalgia. This type of fibromyalgia appears in adolescents, typically after age 13, with a peak incidence at age 14. It is uncommon, but studies indicate that its incidence may be increasing. One study found that 1.2% of school children, all girls, met the criteria for fibromyalgia. Other studies have found an even higher frequency of fibromyalgia in children. Symptoms are similar to adult fibromyalgia, but outcomes may be better in young people.

Studies report a higher incidence of fibromyalgia among family members. It is not clear if genetic or psychological factors, or both, are involved.

One study reported that 28% of the children of mothers with fibromyalgia also develop the disorder. Offspring who developed fibromyalgia were no more likely to have psychological disorders than those who did not.
Another study noted that 66% of parents of children with fibromyalgia reported some sort of chronic pain. About 10% of them had fibromyalgia.

Diagnosis

There is no obvious, objective method for diagnosing fibromyalgia. The criteria used for studying fibromyalgia are very helpful, particularly if the patient does not have any accompanying disorder, such as depression or arthritis, which could complicate the diagnosis. Failure to meet the criteria, however, does not rule out fibromyalgia. Fibromyalgia should be suspected in any person with muscle and joint pain with no identifiable cause.

In 1990, the American College of Rheumatology (ACR) set the following criteria for the classification of fibromyalgia:

A. Widespread pain must be present for at least 3 months. This pain must appear in all of the following locations:

Both sides of the body
Above and below the waist
Along the length of the spine

B. Pain in at least 11 of 18 specific areas called tender points on the body. The pain experienced when pressing on a tender point is very localized and intensely painful (not just tender). Tender points are located in the following areas:

The left or right side of the back of the neck, directly below the hairline
The left or right side of the front of the neck, above the collar bone (clavicle)
The left or right side of the chest, right below the collar bone
The left or right side of the upper back, near where the neck and shoulder join
The left or right side of the spine in the upper back between the shoulder blades (scapula)
The inside of either arm, where it bends at the elbow
The left or right side of the lower back, right below the waist
Either side of the buttocks below the hip bones
Either kneecap

Other Factors. The ACR classification provides a guideline, but doctors will also use a patient's medical history and other symptoms to reach a diagnosis. Fibromyalgia is often diagnosed when other diseases have been excluded. Long-term symptoms that may indicate fibromyalgia include:

Fatigue
Headache
Morning stiffness
Numbness or tingling in the hands and feet
Sleep disturbance

The 18 fibromyalgia tender points are located throughout the body. According to the American College of Rheumatology, a diagnosis of fibromyalgia requires widespread body pain plus localized pain in 11 of these 18 specific points.

A doctor should always take a careful personal and family medical history, which would include a psychological profile and a history of any factors that might indicate disorders other than fibromyalgia. Such factors might include:

Infectious diseases
Muscle weakness
Physical injuries
Rashes
Recent weight change
Sexual, physical, or substance or alcohol abuse

Patients should report any drugs they take, including vitamins and over-the-counter or herbal medications.

Pressure on Tender Spots. Any physical examination for fibromyalgia requires that the doctor press firmly on all potential tender spots. They must be painful when pressed, not simply tender. In addition, for a doctor to reach a diagnosis of fibromyalgia, these tender sites should normally not show signs of inflammation (redness, swelling, or heat in the joints and soft tissue). The tender points may also change in location and sensitivity over time. A doctor, then, may recheck tender points that do not respond the first time, in patients who have other significant symptoms.

Detection of Other Causes of Symptoms. A health care provider will also examine nails, skin, mucous membranes, joints, spine, muscles, and bones to help rule out arthritis, thyroid disease, and other disorders.

No blood, urine, or other laboratory tests can provide a definitive diagnosis of fibromyalgia. If such tests show abnormal results, the doctor should look for other disorders. Tests for specific diseases depend on family histories and other symptoms. They may include:

Blood count
Sedimentation rate
Tests of certain antibodies
Thyroid and liver function tests

The doctor may suggest follow-up psychological profile testing, if laboratory results do not indicate a specific disease.

Conditions with Similar Symptoms

Between 10 - 30% of all doctor office visits are due to symptoms that resemble those of fibromyalgia, including fatigue, malaise, and widespread muscle pain. Since no laboratory test can confirm a diagnosis of fibromyalgia, doctors will usually first test for similar conditions. It should be noted that a diagnosis of many of the disorders below may not always rule out fibromyalgia, since it can accompany other common and similar conditions.

Several conditions overlap or often coexist with fibromyalgia, and have similar symptoms. It is not clear if these conditions cause fibromyalgia, are risk factors for the disorder, have causes in common with fibromyalgia, or have no relationship at all with it.

Chronic Fatigue Syndrome. There is a significant overlap between fibromyalgia and chronic fatigue syndrome (CFS). In a 2003 study, for example, 43% of CFS patients also had a diagnosis of fibromyalgia. As with fibromyalgia, the cause of CFS is unknown. A doctor can diagnose either disorder based only on symptoms reported by the patient. The two disorders share most of the same symptoms. They are also treated almost identically. The differences are primarily the following:

Pain with tender points is the primary symptom in fibromyalgia. Some patients with CFS exhibit similar tender pressure points. However, muscle pain is less prominent in patients with CFS.
Fatigue is the dominant symptom in CFS. It is severe and not relieved by rest or sleep, and it is not the result of excessive work or exercise.

Some doctors believe that fibromyalgia is simply an extreme type of chronic fatigue syndrome. There Some physical evidence, however, indicates that the two disorders are distinct, with treatments that are specific to each.

Myofascial Pain Syndrome. Myofascial pain syndrome can be confused with fibromyalgia and may also accompany it. Unlike fibromyalgia, myofascial pain tends to occur in trigger points, as opposed to tender points, and typically there is no widespread, generalized pain. Trigger-point pain occurs in tight muscles, and when the doctor presses on these points, the patient may experience a muscle twitch. Unlike tender points, trigger points are often small lumps, about the size of a pencil eraser.

Major Depression. The link between psychological disorders and fibromyalgia is very strong and problematic. Certain studies report that 50 - 70% of fibromyalgia patients have a lifetime history of depression. Only 18 - 36% of fibromyalgia patients, however, also have major depression, a severe form of depression.

Some studies found that people who have both psychological disorders and fibromyalgia are more likely to seek medical help, compared with patients who simply have symptoms of fibromyalgia. If this is the case, study results may be biased, favoring a higher-than-actual association between depression and fibromyalgia.

Depression most likely does not cause fibromyalgia, but it may increase susceptibility. Depressed feelings in people with fibromyalgia can certainly be normal responses to the pain and fatigue caused by this syndrome. Such emotions, however, are temporary and related to the situation a person is in. They are not considered to be a depression disorder. Unlike ordinary periods of sadness, an episode of major depression disorder can last many months.

Symptoms of major depression include the following:

Depressed mood every day
Feeling worthless or inappropriately guilty
Inability to concentrate or make decisions
Insomnia or excessive sleeping
Low energy every day
Restlessness or a sense of being slowed down
Significant weight gain or loss (of 10% or more of an individual's typical body weight)
Suicidal thoughts

If several of the above symptoms are present, and none of the physical symptoms (particularly the tender points) of fibromyalgia exist, the condition is most likely major depression.

Chronic Headache. Chronic primary headaches such as migraines are common in fibromyalgia patients. Some experts believe that migraine headaches and fibromyalgia may even share common defects in the systems that regulate certain chemical messengers in the brain, including serotonin and epinephrine (adrenaline). Low levels of magnesium have also been noted in patients with both fibromyalgia and migraines. In fact, chronic migraine sufferers who fail to benefit from usual therapies may also have fibromyalgia.

Symptoms of a migraine attack may include heightened sensitivity to light and sound, nausea, vision problems (auras), speech difficulty, and intense pain predominating on one side of the head.

Multiple Chemical Sensitivity. Multiple chemical sensitivity (MCS) is a term that describes conditions in which certain chemicals can cause symptoms similar to CFS or fibromyalgia in some people. Still, as with CFS and fibromyalgia, some experts are uncertain whether MCS is a medical condition or if it is psychologically based.

In one study, for example, CFS patients who believed their problem was chemically triggered were exposed to either an active chemical or a placebo (an inactive substance). Both groups reported symptoms, including those only exposed to a placebo. Because everyone is exposed to many chemicals on a daily basis, it is very difficult to determine whether chemicals are responsible for specific symptoms.

Experts have come up with criteria to help recognize MCS:

Symptoms can be produced by exposure to the chemical at levels lower than previously or usually tolerated.
Symptoms can be triggered by multiple substances that are chemically unrelated.
Symptoms involve multiple organ systems.
The condition is chronic.
The symptoms always happen with repeated exposure to a chemical. (These are often common chemicals found in popular products, such as perfumes, fabric softeners, and air fresheners.)
The symptoms improve when the chemical is removed.

Restless Legs Syndrome. About 15% of people with fibromyalgia have restless legs syndrome. Restless legs syndrome is an unsettling and poorly understood movement disorder that is sometimes described as a sense of unease and weariness in the lower leg that is aggravated by rest and relieved by movement.

Disorders Affected by the Sympathetic (also called Autonomic) Nervous System. Other conditions that commonly accompany fibromyalgia include:

Chest pain and heart palpitations
Mitral valve prolapse
Sudden drop in blood pressure

Certain stress-related disorders commonly occur with fibromyalgia, and have overlapping symptoms. In fact, some experts believe these disorders so often interact that they may all be part of one general condition.

Chemicals and environmental toxins -- exposure to various chemicals and environmental toxins such as solvents, pesticides, or heavy metals (cadmium, mercury, or lead) can cause fatigue, chronic pain, and other symptoms of fibromyalgia.
Irritable bowel syndrome
Osteoarthritis -- a common form of arthritis than can coexist with fibromyalgia. The two conditions may be confused, particularly in elderly people. Osteoarthritis, however, causes joint pain, not widespread or generalized pain.

Osteoarthritis is a chronic disease of the joint cartilage and bone. It is often thought to result from "wear and tear" on a joint, although there are other causes, such as congenital defects, trauma, and metabolic disorders. Joints appear larger, are stiff and painful, and usually feel worse the more they are used throughout the day.

Temporomandibular joint disorders

Some tests may be positive for one or more of these diseases. However, if the results are uncertain or weak, or if these conditions have been treated successfully, fibromyalgia should not be ruled out if the patient still meets the criteria for it.

Multiple sclerosis. This condition may have symptoms similar to those of fibromyalgia. Magnetic resonance imaging (MRI) scans often detect patches of tissue in the brain that confirm the presence of multiple sclerosis (MS). MRI findings combined with other tests and clinical findings usually make this diagnosis fairly certain. However, some patients may have symptoms that suggest MS, but diagnostic tests cannot confirm the diagnosis. Some of these patients may have symptoms similar to those of fibromyalgia.

Click the icon to see an image of multiple sclerosis.

Sjogren syndrome. This condition, characterized by dry eyes and mouth, is sometimes mistaken for fibromyalgia.

Autoimmune diseases. Rheumatoid arthritis, systemic lupus erythrometosis, and Sjogren syndrome are usually easy to diagnose but may develop slowly and be difficult to diagnose at first. Even if a doctor determines that a patient is most likely to have fibromyalgia, the doctor should keep track of any changes in symptoms over time in case one of these other illnesses is actually present.

Lyme Disease. Lyme disease is a bacterial disease transmitted by ticks. Health care providers can usually diagnose early Lyme disease correctly, but a delayed response or recurrence of this disorder may be mistaken for fibromyalgia. Some experts believe that 15 - 50% of patients referred to clinics for Lyme disease actually have fibromyalgia. Late Lyme disease can usually (but not always) be ruled out using blood tests that identify the organism that causes this disease. If fibromyalgia patients are incorrectly diagnosed and treated for Lyme disease with prolonged courses of antibiotics, the drugs may have serious side effects.

Drugs and Alcohol. Fatigue is a side effect of many prescription and over-the-counter medications, such as antihistamines. In addition, symptoms of dependency on, or abuse of, alcohol or drugs appear as constant fatigue. Health care providers should consider medications as a possible cause of fatigue if an individual has recently started, stopped, or changed medications. Withdrawal from caffeine can produce depression, fatigue, and headache.

Polymyalgia Rheumatica. Polymyalgia rheumatica is a condition that causes pain and stiffness, and generally occurs in older women. Tender points are also present with this disorder, although they almost always occur in the hip and shoulder area. Morning stiffness is common, and patients may also experience fever, weight loss, and fatigue. A higher-than-normal erythrocyte sedimentation rate (ESR) can suggest polymyalgia rheumatica. Elevated ESR, however, also occurs with other conditions. Polymyalgia rheumatica often gets better in about a year, but there is a risk of persistent disease. Worse, it is sometimes associated with a rare condition called temporal arteritis, which may cause blindness if not treated, so an accurate diagnosis of polymyalgia rheumatica is important.

Prognosis

Fibromyalgia can be mild or disabling, and the emotional toll can be substantial. About half of all patients have difficulty with routine daily activities, or are unable to perform them. An estimated 30 - 40% of patients have had to quit work or change jobs. In a 2003 study, patients with either CFS or fibromyalgia were more likely to suffer losses of jobs, possessions, and support from friends and family than were people suffering from other conditions that caused fatigue.

The pain, emotional consequences, or sleep disturbances that come with fibromyalgia may lead to self-medication and overuse of sleeping pills, alcohol, drugs, or caffeine.

Outlook in Adults. Some studies show that fibromyalgia symptoms remain stable over the long term, while others report a better outlook, with 25 - 35% of patients reporting improvement in pain symptoms over time. Studies suggest that regular exercise specifically improves the outlook. Those with a significant life crisis, or who were on disability, had a poorer outcome than others. Outcome was determined by improvements in the patients' ability to work, their own feelings about their condition, pain sensation, and levels of disturbed sleep, fatigue, and depression. Although the disease is life-long, it does not get worse and is not fatal.

Outlook in Children. Children with fibromyalgia tend to have a better outlook than adults with the disorder. Several studies reported that more than half of children with fibromyalgia recover in 2 - 3 years.

Treatment

Many patients with fibromyalgia are treated first with medication; however, the American Pain Society Fibromyalgia Panel recommends a combined approach using cognitive-behavioral therapy, education, medication, and exercise.

Fibromyalgia is a mysterious condition. Its causes are still largely unknown, as is how it inflicts damage. No strong evidence indicates that any single treatment (or combination of treatments) has any significant effect for most patients. However, in 2007 the U.S. Food and Drug Administration approved pregabalin (Lyrica) as the first drug treatment for fibromyalgia after a study showed the medicine reduced fibromyalgia pain by at least 50% in 63% of patients.

Treatment usually involves not only relieving symptoms but also changing a pateint's attitude about their disease. Treatment should also teach patients behaviors that help them cope.

Treatments usually involve trial and error:

Patients may start with physical therapy, exercise, stress reduction techniques, and cognitive-behavioral therapy.
If these methods fail to improve symptoms, an antidepressant or muscle relaxant may be added to the treatment. Doctors usually prescribe these drugs because they can may improve pain tolerance.
Patient education and programs that encourage coping skills are an important part of any treatment plan.

According to a 2005 study published in the Clinical Journal of Pain, a combination of non-drug therapies works just as well as drug therapy in improving pain, depression, and disability. This combination includes exercise, stress management, massage, and diet.

Patients must have realistic expectations about the long-term outlook of their condition, and their own individual abilities. It is important to understand that fibromyalgia can be managed, and patients can live a full life. The following tips may be helpful when starting a treatment program for fibromyalgia:

The goal of therapy is to relieve symptoms, not cure them.
Treatment must be tailored to each patient, and a combination approach is often needed.
Patients must begin all treatments with the attitude that these treatments are trial-and-error. There is no clear treatment solution. Patients and doctors need to work together to make the best choices for individual symptoms and concerns.
Treatments are long-lasting, in some cases life-long, and patients should not be discouraged by the return of symptoms (relapses).
Enlisting family members, partners, and close friends, particularly to help with exercise and stretching programs, can be helpful.
Becoming involved with support groups of fellow patients also benefits many patients. Support groups may also benefit family members, particularly parents of children with fibromyalgia. One study noted that the severity of the disorder increased in children whose parents were less able to cope with their child's pain.

The definition of improvement is personal. For example, some patients are pleased with only a 10% reduction in pain and other symptoms.

Lifestyle Changes

Many studies have shown that exercise is the most effective component in managing fibromyalgia, and patients must expect to take part in a long-term exercise program. Physical activity prevents muscle wasting, increases well-being, and, over time, reduces fatigue and pain. Many studies have also demonstrated the exercise can improve physical and emotional function, as well as reduce symptoms, including pain.

Programs often combine aerobic, strength-training, and flexibility exercises with self-management education. Some studies have shown improvements lasting for up to 9 months after the exercise program.

Graded Exercise. The basic approach used for fibromyalgia is called graded exercise. Graded exercise means you slowly increase the amount of your physical activity.

In general, graded exercise involves:

A very gradual program of activity, beginning with mild exercise and building in intensity over time.
Stretching exercises before exercising. A daily stretching routine can help relax tense muscles and prevent muscle soreness.
Walking, swimming, and using equipment such as treadmills or stationary bikes. Swimming and water therapy are good because they don't require putting weight on the joints.

Patients who try hard exercises too early actually experience an increase in pain, and are likely to become discouraged and quit.

Every patient must be prepared for relapses and setbacks, but should not get discouraged. Patients who do not respond to one type of exercise might consider experimenting with another form.

Physical therapy can be very helpful. Studies suggest that physical therapy may reduce muscle overload, lessen fatigue from poor posture and positioning, and help condition weak muscles.

Sleep is essential, particularly since sleep disruptions worsen pain. Many patients with fibromyalgia have trouble getting a restful and healing night's sleep. Those who are unable to sleep consistently have low improvement. Swing shift work, for example, is extremely hard on fibromyalgia patients. Poor sleep habits can add to sleep problems. Tips for good sleep habits include:

Avoid caffeine or alcohol 4 - 6 hours before bedtime.
Avoid drinking fluids right before bedtime so that needing to uriniate does not disturb your sleep.
Avoid exercising 6 hours before bedtime.
Avoid large meals before bedtime. A light snack, however, may help you sleep.
Avoid naps, especially in the evening or late afternoon.
Establish a regular time for going to bed and getting up in the morning. Maintain this schedule even on weekends and during vacation.
If you are unable to fall asleep after 15 or 20 minutes, go into another room and start a quiet activity. Return to bed when you feel sleepy.
Minimize light and maintain a comfortable, moderate temperature in the bedroom. Keep the bedroom well ventilated.
Use the bed only for sleep and sexual relations.

[For more information see In-Depth Report #27: Insomnia.]

Fibromyalgia patients should maintain a healthy diet low in animal fat and high in fiber, with plenty of whole grains, fresh fruits, and vegetables. Although everyone should be careful about calories from fats, some are healthy.

Omega-3 Fatty Acids. Oils containing omega-3 fatty acids are of particular interest for arthritic pain. Such oils are found in cold-water fish. You can also purchase these oils as supplements called EPA-DHA or omega 3.

Omega-3 fatty acids are a form of polyunsaturated fat that the body gets from food. Omega-3s are known as essential fatty acids (EFAs) because they are important for good health. These healthy fatty acids can be found in certain fish, dark green leafy vegetables, and some oils. Omega-3 fatty acids have anti-inflammatory properties, which help prevent blood clots, lower cholesterol and triglyceride levels, and reduce blood pressure. Omega-3s may also reduce the risks and symptoms of diabetes, stroke, rheumatoid arthritis, asthma, inflammatory bowel disease, ulcerative colitis, some cancers, and mental decline.

Vegetarian Diet. A vegan diet has no meat, dairy, or eggs and includes uncooked fruits, vegetables, nuts, and germinated seeds. The actual benefit of various vegetarian diets remains unproven.

Relaxation and stress-reduction techniques are proving to be helpful in managing chronic pain. Evidence shows that people with fibromyalgia have a more stressful response to daily conflicts and encounters than those without the disorder. Several relaxation and stress-reduction techniques may be helpful in managing chronic pain:

Biofeedback
Deep breathing exercises
Hypnosis
Massage therapy
Meditation
Muscle relaxation techniques

Biofeedback. Evidence from controlled trials does not suggest that biofeedback techniques may be very helpful for fibromyalgia patients. During a biofeedback session, electric leads are taped to a subject's head. The person is encouraged to relax using any method that works. Brain waves are measured and an audio signal sounds when alpha waves are detected. Alpha waves are brain waves that occur with a state of deep relaxation. By repeating the process, people using biofeedback connect the sound with the relaxed state, and learn to achieve relaxation on their own.

Meditation. Meditation, used for many years in Eastern cultures, is now widely accepted in this country as an effective relaxation technique. A number of studies are reporting its benefits for fibromyalgia patients who practice on a continued and regular basis. The practiced meditator can achieve the following physical benefits:

Reduced heart rate, blood pressure, adrenaline levels, and skin temperature while meditating.
Improved well-being.
Better sleep -- some research has reported an increase in melatonin levels in experienced meditators. Melatonin is important in regulating the sleep-wake cycle.
Less pain, possibly from reductions in levels of cortisol, a stress hormone.

An important goal for both religious and therapeutic meditation practices is to quiet the mind, essentially to relax thought. This redirection of brain activity from thoughts and worries to the senses disrupts the stress response and prompts relaxation and renewed energy. Several meditation techniques are available. Some may be more useful for fibromyalgia than others.

Breath meditation. Other meditative forms involve focusing on the present moment and observing (but not examining or judging) one's thoughts. During breath meditation, one sits upright with the spine straight and the eyes closed. The subject begins to breathe regularly and continues to observe the outward exhalation of the breath. As the mind wanders, one simply notes the thoughts as a fact and returns to the breath. A variant of this technique called mindfulness meditation has been helpful for fibromyalgia patients. It involves focusing on the present moment and letting thoughts pass without the accompanying breathing exercises.
Fixed point meditation involves focusing on a stationary object, mental image (such as a candle flame), or internal sound (such as a mantra). When the mind begins to wander, the meditator gently brings concentration back to the central image or sound. This exercise promotes focus, but it is often experienced as a thinking exercise. A popular variety of this type of meditation is known as transcendental meditation, or TM.
Mini-meditation. This method involves heightening awareness of the immediate surrounding environment. One should first choose a simple routine activity when alone. For example, while washing dishes concentrate on the feel of the water and dishes. Allow the mind to wander to any immediate sensory experience, such as sounds outside the window, smells from the stove, or colors in the room. If the mind begins to think about the past or future, abstractions, or worries, redirect it gently back.

People who try meditation for the first time should understand that it can be difficult to quiet the mind, and should not be discouraged by lack of immediate results. Some recommend meditating for no longer than 20 minutes in the morning after awakening and then again in the early evening before dinner. Even once a day is helpful. A person should probably not meditate before going to bed, because it causes some people to wake up in the middle of the night, alert and unable to return to sleep.

Hypnosis. In one small, short-term controlled study, hypnosis was more effective than physical therapy in improving function and reducing pain.

Massage Therapy. Massage therapy is thought to stimulate the parasympathetic nervous system, which slows down the heart and relaxes the body. In one study, patients who were given 30-minute massage sessions twice a week experienced lower stress and anxiety and less pain after 5 weeks compared to a group receiving an alternative therapy called transcutaneous electrical stimulation (TENS).

Because of the difficulties in treating fibromyalgia, many patients seek alternative therapies. Everyone should be wary of those who promise a quick cure or urge the purchase of expensive but potentially dangerous treatments.

Although some studies have reported benefit from these treatments, there is not enough evidence to recommend them. In one analysis, evidence was weakest on the advantages of so-called manipulative ("hands-on") approaches, such as chiropractic treatments.

Acupuncture. Studies continue to report conflicting results on acupuncture's ability to relieve pain. Several small studies suggest that it offers some benefit, especially to those who cannot take medicines because of their side effects. A larger controlled study found that inserting needles at fibromyalgia-related pressure points was no better at relieving pain for fibromyalgia than randomly inserting needles ("sham acupuncture"). A 2006 review of five randomized, controlled trials did not find enough evidence to support the use of acupuncture for fibromyalgia.

Click the icon to see an image of acupuncture.

Chiropractic or Osteopathic Manipulation. Chiropractic or osteopathic manipulation may also help some patients. While some studies have reported pain relief and improved sleep with osteopathic manipulation, larger controlled studies are needed to clearly identify whether manipulation is an effective treatment. Osteopathic techniques may include manipulation of the spine or muscle tissue release. Note that there is always some very small risk for adverse effects from any of these techniques. For example, in rare cases manipulation of the neck has caused stroke or damage to the large blood vessels in the neck.

Hydrotherapy and Similar Treatments. Hydrotherapy, also called balneotherapy, involves soaking in water, such as hot tubs, pools, or baths, to help relieve pain.

Herbal or Natural Remedies. Some alternative agents are being investigated for fibromyalgia:

Melatonin, a natural hormone associated with the sleep-wake cycle, may have benefits for some patients with fibromyalgia.
S-adenosylmethionine (SAMe) is a natural substance that has antidepressant, anti-inflammatory, and analgesic properties. It has shown some benefit in controlled studies.

It is extremely important for patients to realize that any herbal remedy or natural medicine that has positive effects most likely has negative side effects and toxic reactions, just as any conventional drug does. You should consult a doctor before using any untested products or dietary supplements. You should also discuss with your doctor any potential interactions between the supplements and any medications you take.

Generally, manufacturers of herbal remedies and dietary supplements do not need approval from the U.S. Food and Drug Administration to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even deadly side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.

Behavioral Therapy

Studies continue to show that fibromyalgia patients feel better when they deal with the specific conditions of their disorder and their lives. Cognitive-behavioral therapy (CBT) enhances a patient's belief in their own abilities and helps them develop methods for dealing with stressful situations. CBT, also called cognitive therapy, is a known, effective method for dealing with chronic pain from arthritic conditions. Some evidence also suggests that cognitive-behavioral therapy can help some patients with fibromyalgia.

Although the effects of CBT and other non-medication treatments for fibromyalgia do not always last over the long-term, they may help certain groups of people, particularly those with a high level of psychological stress.

CBT may be particularly useful for addressing insomnia, one of the hallmark symptoms of fibromyalgia. Patients who received CBT for insomnia woke up 50% less at night, and had fewer symptoms of insomnia and improved mood.

The Goals of CBT. The primary goals of CBT are to change any unclear or mistaken ideas and self-defeating behaviors. Using specific tasks and self-observation, patients learn to think of pain as something other than a negative factor that controls their life. Over time, the idea that they are helpless against the pain goes away and, instead, they learn that they can manage the pain.

Cognitive therapy is particularly helpful in defining and setting limits -- a behavior that is extremely important for these patients. Many fibromyalgia patients live their lives in extremes. They first become heroes or martyrs, pushing themselves too far until they collapse. This collapse reverses the way they view themselves, and they then think of themselves as complete failures, unable to cope with the simplest task. One important aim of cognitive therapy is to help such patients discover a middle route. Patients learn to prioritize their responsibilities and drop some of the less important tasks or delegate them to others. Learning these coping skills can eventually lead to a more manageable life. Patients learn to view themselves and others with a more flexible attitude.

The Procedure. Cognitive therapy usually does not last long, typically 6 - 20 one hour sessions. Patients also receive homework, which usually includes keeping a diary and trying tasks they have avoided because of negative attitudes.

A typical cognitive therapy program may involve the following measures:

Keep a Diary. Patients are usually asked to keep a diary, a key part of cognitive therapy. The diary serves as a general guide for setting limits and planning activities. Patients use the diary to track any stress factors, such as a job or a relationship that may be making the pain worse or better.
Confront Negative or Discouraging Thoughts. Patients are taught to challenge and reverse negative beliefs. For example, "I'm not good enough to control this disease, so I'm a total failure" becomes the coping statement, "Where is the evidence that I can control this disease?"
Set Limits. Limits are designed to keep both mental and physical stress within manageable levels, so that patients do not become discouraged by getting "in over their heads." For example, tasks are broken down into incremental steps, and patients focus on one at a time.
Seek out Pleasurable Activities. Patients list a number of enjoyable low-energy activities that they can conveniently schedule.
Prioritize. Patients learn to drop some of the less critical tasks or delegate them to others.

Patients should learn to accept that relapses occur, and that over-coping and accomplishing too much too soon can often cause a relapse of symptoms. Patients should respect these relapses and back off. They should not consider them a sign of failure.

Research also shows that patient education can be effective in treating fibromyalgia, especially when combined with CBT, exercise, and other therapies. Educational programs can take the form of group discussions, lectures, or printed materials, although there isn't any clear evidence on which type of education works best.

Cognitive therapy may be expensive and not covered by insurance. Alternative and effective approaches that are free or less costly include strong, intelligently managed support groups or group psychotherapy. In one center, educational discussion groups were as effective, or even more so, than a cognitive therapy program. Such results are not typical in all centers, of course. Therapeutic success varies widely depending on the skill of the therapist.

Medications

Typically the first choice in drug treatment of fibromyalgia has consisted of an antidepressant or a muscle relaxant. The goal has been to improve sleep and pain tolerance. Medications from other drug classes (such as sleeping aids and pain relievers) may also be prescribed. Patients receive drug treatments in combination with exercise, patient education, and behavioral therapies. In 2007 the Food and Drug Administration approved Pregabalin (Lyrica) as the first drug for the treatment of fibromyalgia.

Pregabalin is an anti-epileptic. Also called anti-seizure drugs and anti-convulsants, these medicines affect the chemical messenger gamma aminobutyric acid (GABA), which helps prevent nerve cells from over-firing.

Pregabalin was previously approved in 2004 to treat nerve pain and diabetic peripheral neuropathy. A 2005 study of 529 patients with fibromyalgia reported that 450 mg per day of pregabalin reduced pain and improved sleep quality and fatigue symptoms. Study results presented in November 2006 showed pregabalin cut fibromyalgia pain by at least 50% in 63% of patients, and the effect was long-lasting. The study, lasting 6 months, was one of the longest controlled studies of pregabalin in fibromyalgia to date. The most common side effects include mild-to-moderate dizziness and sleepiness. Pregabalin can impair motor function and cause problems with concentration and attention. Patients should talk to their doctor about whether pregabalin may impair their ability to drive.

Studies have shown that another anti-convulsant, gabapentin (Neurontin), which is approved for treatment of postherpetic neuralgia, affects pain transmission pathways and may relieve pain associated with fibromyalgia when compared with placebo. Patients who took gabapentin also reported that they slept better and were less tired.

The main classes of antidepressants used for treating fibromyalgia are tricyclics, selective serotonin-reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). Although these drugs are antidepressants, doctors prescribe them to improve sleep and relieve pain in non-depressed patients with fibromyalgia. The dosages used for managing fibromyalgia are generally lower than dosages prescribed for treating depression. If a patient has depression in addition to fibromyalgia, higher doses may be required.

Tricyclics. Tricyclic antidepressants cause drowsiness and can be helpful for improving sleep. The tricyclic drug most commonly used for fibromyalgia is amitriptyline (Elavil, Endep), which produces modest benefits with pain, but which can lose effectiveness over time. Other tricyclics include desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil), amoxapine (Asendin), and nortriptyline (Pamelor, Aventyl).

Generally, only small doses of tricyclic antidepressants are needed to relieve fibromyalgia. Therefore, although tricyclics have several side effects, these side effects may be less frequent in fibromyalgia patients than in those taking tricyclics for depression. Side effects most often reported include:

Blurred vision
Difficulty urinating
Dizziness
Drowsiness
Dry mouth
Heart rhythm disturbances
Sexual dysfunction
Weight gain

As with all medications, tricyclics must be taken as directed. An overdose can be life-threatening.

Unfortunately, not all patients respond to tricyclics, and their effects wear off in some patients, sometimes after only a month.

Selective Serotonin-Reuptake Inhibitors. Selective serotonin-reuptake inhibitors (SSRIs) increase serotonin levels in the brain, which may have specific benefits for fibromyalgia patients. Commonly prescribed SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), and fluvoxamine (Luvox). Studies suggest they may improve sleep, fatigue, and well-being in many patients. Studies are mixed on whether they improve pain. SSRIs should be taken in the morning, since they may cause insomnia. Common side effects are agitation, nausea, and sexual dysfunction, including delay or loss of orgasm and low sex drive.

Serotonin-Norepinephrine Reuptake Inhibitors. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are also known as dual inhibitors because they act directly on two chemical messengers in the brain -- norepinephrine and serotonin. These drugs include:

Duloxetine (Cymbalta) is gaining attention as a treatment for fibromyalgia. In a 2004 study, 207 patients with fibromyalgia were randomized to receive either 60 mg of duloxetine twice a day or placebo for 12 weeks. Duloxetine significantly improved pain and tenderness and was effective for both depressed and non-depressed patients. Duloxetine was most effective for women, but very few men were enrolled in this trial.
Venlafaxine (Effexor) is similar to fluoxetine (Prozac) in effectiveness and tolerability for most patients. As with SSRIs, and unlike other newer antidepressants, venlafaxine impairs sexual function. Although clinical trials have shown that the drug is safe and effective in most people, there have been reports of changes in blood pressure. There have also been reports of problems with the electrical system of the heart when taking this drug. These side effects may cause serious problems in elderly patients. Some patients report severe withdrawal symptoms, including dizziness and nausea.
Milnacipran (Ixel) is under investigation and is not yet approved in the United States. It is specifically being researched for helping people with fibromyalgia and similar pain syndromes. In a 2004 study of 125 patients, milnacipran improved fibromyalgia pain and other symptoms, including fatigue, sleep, and depression.

Cyclobenzaprine (Flexeril) relaxes muscle spasms in specific locations without affecting overall muscle function. Cyclobenzaprine is related to the tricyclic antidepressants and has similar side effects, including drowsiness, dry mouth, and dizziness. A 2004 review of five randomized controlled trials found that patients who received cyclobenzaprine were three times more likely to report improvement in fibromyalgia symptoms than patients who received placebo.

Zolpidem (Ambien) or other newer sleep medications such as zaleplon (Sonata) and eszopiclone (Lunesta) may improve sleep for patients who suffer from insomnia.

Pain relief is of major concern for patients with fibromyalgia. Pain relievers for fibromyalgia include:

Tramadol (Ultram), used alone or in combination with acetaminophen (Tylenol), is commonly prescribed for relief of fibromyalgia pain. Its most common side effects are drowsiness, dizziness, constipation, and nausea. Tramadol should not be used in combination with tricyclic antidepressants.
For relief of mild pain, acetaminophen is most often recommended. Anti-inflammatory drugs, which are commonly used for arthritic conditions, are less useful for the pain of fibromyalgia, since the pain is not caused by muscle or joint inflammation. Anti-inflammatory drugs include corticosteroids and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen (Advil).
Capsaicin (Zostrix) is an ointment prepared from the active ingredient in hot chili peppers. Capsaicin is helpful in relieving painful areas in other disorders. It may have some value for fibromyalgia patients.
Opioids, or narcotics, may be used occasionally by certain patients with moderate-to-severe pain, or those with significant problems performing everyday tasks. Such patients should use narcotics only if they cannot find relief with other, less potent treatments. Some patients may get combinations of narcotic pain relievers and acetaminophen for periodic pain. Some physicians prescribe opioids, such as oxycodone (Roxicodone) or morphine sulfate (Duramorph), for patients who need ongoing relief. However, the benefit of opioids in fibromyalgia treatment is highly controversial. Physicians should take a careful medical and psychological profile of the patient before prescribing opioids. The patients should be evaluated periodically for continuing pain relief, side effects, and indications of dependence.
Pramipexole, a drug used to treat Parkinson’s disease and restless legs syndrome, may help relieve pain and fatigue in people with fibromyalgia, according to one study. Pramipexole stimulates production of dopamine, a chemical messenger in the brain. Researchers compared pramipexole with a dummy pill (placebo). After 3.5 months, 36% of those who took pramipexole said they felt much better, compared to 9% of those who received a dummy pill. Overall, patients had a 50% or greater decrease in pain.
One small 2005 study conducted in Spain suggests that the atypical antipsychotic olanzapine (Zyprexa) may be a beneficial add-on therapy for patients with fibromyalgia. Although proven effective for some chronic pain conditions, olanzapine and other antipsychotics cause unpleasant and potentially serious side effects.

Tropisetron. Tropisetron (Navoban) is a drug used to reduce vomiting during chemotherapy. European studies suggest that it may also help patients with fibromyalgia by reducing pain, dizziness, and depression, and by improving sleep. Fatigue and dizziness are the most common side effects.

Much of the pain patients experience occurs where muscles join tendons or bones, particularly when the muscles are stretched. Stretching or flexibility exercises are part of the warm-up and cool-down routines of any regular exercise program. Stretching techniques may also use injections or cooling agents to inactivate the pressure points so that muscles can be more effectively stretched. These techniques must be performed by a person other than the patient, usually a family member or close friend. With either injections or the spray, the benefits may last from a few days to weeks. Neither the spray nor the injection is useful without muscle stretching.

Spray and Stretch. One technique is known as "spray and stretch." This method uses the following approach:

The patient must be in a comfortable position.
The partner presses on suspected tender points and the patient reports any pain.
The points, when targeted, are sprayed with either ethyl chloride (Chloroethane) or Fluori-Methane. These chemicals are not numbing medicines. They cool the blood vessels in the skin to inactivate the tender points. Numbing skin creams do not appear to be effective for this treatment.
The spray bottle is held upside-down about 12 - 18 inches from the targeted area. The patient's face should be covered if the spray is being used near the head.
The patient's partner then slowly stretches the affected muscle.

After the procedure, the muscle should feel looser, and the patient should have a greater range of motion with that muscle.

Trigger-Point Injections. In some cases, "trigger-point injections" of a numbing drug, such as lidocaine, may be used for particularly painful tender points as an aid to stretching.

The injection causes intense, but brief, pain in the trigger point. After the medication has taken effect, however, the muscle's ability to stretch is much greater.
There is some soreness afterward, which can be severe. After an injection, spraying the whole muscle with cooling agents may inactivate less severe tender points.
In some cases, injections may be needed several times over 6 - 8 weeks.

Resources

www.rheumatology.org -- American College of Rheumatology
www.niams.nih.gov -- National Institute of Arthritis and Musculoskeletal and Skin Diseases
www.arthritis.org -- Arthritis Foundation
www.fmaware.org -- National Fibromyalgia Foundation
www.fmpartnership.org -- National Fibromyalgia Partnership
www.fmnetnews.com -- Fibromyalgia Network
www.aapainmanage.org -- American Academy of Pain Management
www.ampainsoc.org -- American Pain Society
www.medicalacupuncture.org -- American Association of Medical Acupuncture
www.asch.net -- American Society of Clinical Hypnosis
www.aabt.org -- Association for Advancement of Behavior Therapy
www.clinicaltrials.gov -- Find a clinical trial

References

Arnold LM, Goldenberg DL, Stanford SB, Lalonde JK, Sandhu HS, Keck PE, et al. Gabapentin in the treatment of fibromyalgia: a randomized, double-blind, placebo-controlled multicenter trial. Arthritis & Rheumatism. 2007;56:1336-1344.

Assefi NP, Sherman KJ, Jacobsen C, Goldberg J, Smith WR, Buchwald D. A randomized clinical trial of acupuncture compared with sham acupuncture in fibromyalgia. Ann Intern Med. 2005; 143(1): 10-9.

Da Costa D, Abrahamowicz M, Lowensteyn I, Bernatsky S, Dritsa M, Fitzcharles MA, Dobkin PL. A randomized clinical trial of an individualized home-based exercise programme for women with fibromyalgia. Rheumatology. 2005;44:1422-1427.

Harris RE, Clauw DJ. How Do We Know That the Pain in Fibromyalgia Is "Real"? Current Pain and Headache Reports. 2006;10:403-7.

Harris RE, Clauw DJ, Scott DJ, McLean SA, Gracely RH, Zubieta JK. Decreased central u-opioid receptor availability in fibromyalgia. J Neurosci. 2007;27:10000-10006.

Holman AJ, Myers RR. A Randomized, Double-Blind, Placebo-Controlled Trial of Pramipexole, a Dopamine Agonist, in Patients With Fibromyalgia Receiving Concomitant Medications. Arthr Rheum. 2005; 52(: 2495-2505.

Mannerkorpi K, Henriksson C. Non-pharmacological treatment of chronic widespread musculoskeletal pain. Best Pract Res Clin Rheumatol. 2007;21:513-534.

McCabe CS, Cohen H, Blake DR. Somaesthetic disturbances in fibromyalgia are exaggerated by sensory-motor conflict: implications for chronicity of the disease? Rheumatology. 2007;46:1587-1592.

Mease P. Fibromyalgia syndrome: review of clinical presentation, pathogenesis, outcome measures, and treatment. J Rheumatol Suppl. 2005;32(10):2063.

Rico-Villademoros F, Hidalgo J, Dominguez I, García-Leiva JM, Calandre EP. Atypical antipsychotics in the treatment of fibromyalgia: a case series with olanzapine. Prog Neuropsychopharmacol Biol Psychiatry. 2005; 29(1): 161-4.

Rooks DS, Gautam S, Romeling M, Cross ML, Stratigakis D, Evans B, et al. Group exercise, education, and combination self-management in women with fibromyalgia. Arch Intern Med. 2007;167;2192-2200.

Van Koulil S, Effting M, Kraaimaat FW, van Lankveld W, van Helmond T, Cats H, et al. Cognitive-behavioural therapies and exercise programmes for patients with fibromyalgia; state of the art and future directions. Ann Rheum Dis. 2007;66:571-581.

Zheng L, Faber K. Review of the Chinese medical approach to the management of fibromyalgia. Curr Pain Headache Rep. 2005;9(5): 307-12.

Review Date:
12/17/2007
Reviewed By:
Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission (www.urac.org). URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.'s editorial policy, editorial process and privacy policy. A.D.A.M. is also a founding member of Hi-Ethics and subscribes to the principles of the Health on the Net Foundation (www.hon.ch).

A.D.A.M. Copyright

The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Call 911 for all medical emergencies. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997-2010 A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.

adam.com

Gossip Girl Rundown: Episode 10, "Bonfire of the Vanity"

BuzzSugar — Tue, 11 Nov 2008 12:30:01 -0800

On this week's Gossip Girl, love is in the air for Serena, who is aglow with feelings for Aaron the artist. Also glowing? Eleanor Waldorf! Yes, Blair's mother has become totally smitten with Cyrus, a man Blair imagines to be as charming as Cary Grant ("Maybe a dashing stepdad is just what I need"). And because Blair is turning 18, she's determined to remain as poised as as possible, a la Grace Kelly, and welcome Cyrus with open arms.

Then there are the Humphrey kids, who have, to Rufus's horror, cynically traded their souls away in return for fame and fortune. Jenny and Agnes are in a "business partnership" together and looking for some representation, and Dan is back to writing about "Charlie Trout," to his mentor's great pleasure. Ready to chat? Just read more.

First of all: How exasperating are both Agnes and Jenny in this episode? Yes, Agnes turns out to be a highly unstable, unreliable friend to Jenny, but jeez, Jenny was very angry last night. She stomps around and screams and cries, and it's just very stressful to watch.
Agnes sets Jenny's clothing on fire! That was intense and totally crazy. I personally would have wrestled that you-know-what down to the ground to save my blood, sweat, and tears, but Jenny opts for crying.
And then there's Dan, who's playing with fire in his own way, sneaking around Bart Bass for a story he's suddenly commissioned to write for New York Magazine. The entire time, I was thinking Dan's totally out of his mind to mess with the Bass family - how about you?
Of course he uncovers controversy in Bart's past via an unnamed source and excitedly tells Rufus it's just like All the President's Men!
And then there are Serena and Aaron. He texts her maps all the time? And she follows his little maps around and they meet and make out in places all over New York? It's way too shmoopy for me and makes me feel like they're just setting Serena up to fall.

Then Aaron asks Serena to pose for him. Blair warns that being someone's muse is a bad idea, and Serena points out that Picasso had muses, to which Blair replies, "A guy starts out in his blue period, and everything’s great, but it’s only a matter of time before he's all into cubism and it's some other girl's eye coming out of her forehead."
And it turns out Aaron has lots of "muses," aka other girls he dates. While I guess he has a point that he would like to see other people, having his ladies overlap like that is just rude. At first Serena says thanks but no thanks to the whole open relationship thing but later decides she's not some stuffy conventional Upper East Sider and hops on board the free-love train.
She's so free, in fact, that she goes on a date with Aaron in broad daylight in her nightie. Freeing? Or highly indecent? You be the judge.
I love Blair's response to finding out Aaron has lots of muses: "I would tell you that I told you so but now that I'm 18 I'll refrain."
Cyrus (played by playwright Wallace Shawn) turns out to be Aaron's father. He also turns out to be a tiny little man and not very dashing in Blair's eyes ("I was expecting Cary Grant and got Danny DeVito!").
Blair then becomes determined to kick Cyrus out of her and Eleanor's life ("Screw Grace Kelly. I need a scheme. That tiny man must have a big secret.") but ends up bonding with him (he brings her Cyndi Lauper!).

So Dan does the right thing (I guess? I mean, someone died in a fire because of Bart Bass, and Dan's the only one who knows but decides to bury the information. This show sends my moral compass into a tizzy) and Jenny's homeless, again. How many GG episodes will end with sad Jenny schlepping her stuff around the streets of New York with only her eyeliner to keep her warm? Blair respects Cyrus, but he's making himself a little too comfortable in her home, and Serena fancies herself a free spirit. I can't wait to hear your thoughts on last night's episode!

Sound off below, and to check out all the clothes, head to CelebStyle!

Photos courtesy of The CW

Anorexia nervosa

FitSugar — Wed, 08 Oct 2008 17:34:55 -0700

Overview

Signs and Symptoms
Causes
Risk Factors
Diagnosis
Preventive Care
Treatment
Other Considerations
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

People who intentionally starve themselves into an emaciated state yet remain convinced that they are overweight are suffering from a condition known as anorexia nervosa. Anorexia is a severe emotional disorder that is increasingly common, especially among young women in industrialized countries where cultural expectations encourage women to be thin. Fueled by popular fixations with thin and lean bodies, anorexia is also affecting a growing number of men, particularly athletes and those in the military. People with anorexia are terrified of becoming obese and refuse to maintain a normal weight, putting themselves in danger of starvation.

Anorexia rarely begins in people who are older than 40 years of age. It most commonly appears in the teenage years, affecting up to 3 in 100 adolescents. Although anorexia seldom emerges before puberty, associated mental conditions, such as depression and obsessive-compulsive behavior, are usually more severe when it does. The onset of anorexia is often preceded by a traumatic or stressful event and it is usually accompanied by other emotional difficulties. Anorexia is a life-threatening condition that can result in death from starvation, heart failure, electrolyte imbalance, or suicide.

There are two main types of anorexia nervosa:

Restricting Type -- characterized by dieting, fasting, or excessive exercise
Binge-Eating/Purging Type (anorexic-bulimic) -- characterized by self-induced vomiting or misuse of laxatives, enemas, or diuretics. Binge eating may or may not occur, and purging (vomiting) is common even after small amounts of food have been eaten. This type carries greater medical risk.

Signs and Symptoms

The primary sign of anorexia nervosa is severe weight loss, accompanied by any number of physical and psychological symptoms and unusual behaviors related to food, eating, or exercise. A person for whom a healthy weight would be 125 pounds, for example, may drop 20, or even as much as 60, pounds below this. At the same time, the person may insist that they are overweight.

Physical Signs

Scanty or absent menstrual periods
Thinning hair
Dry skin
Cold or swollen hands and feet
Bloated or upset stomach

Psychological Signs

Distorted perception of self (that is, a great difference between how an individual believes they look and their actual physical appearance)
Inability to remember things
Poor judgment
Refusal to acknowledge the gravity of the illness
Obsessive-compulsive behavior (excessive need to control personal environment)
Depression (feelings of ineffectiveness, loss of interest in friends and former activities, lack of spontaneity, rigid thinking, lack of initiative, flattened emotional response, irritability, insomnia, and diminished interest in sex)

Behavioral Symptoms

Unusual behaviors related to food or eating (for example, hoarding or concealing food, refusing to eat in public, eating only one type of food, ritually cutting food into tiny pieces, intense study of diets and calories, planning and preparing elaborate meals for others)
Compulsive exercising
Preoccupation with body size or body image
Preoccupation with weight control, dieting

Causes

There is no specific cause of anorexia. Medical experts agree that several factors work together in a complex fashion to lead to the eating disorder. These may include:

Severe trauma or emotional stress (such as the death of a loved one or sexual abuse) during puberty or prepuberty.
Abnormalities in brain chemistry. Changes in serotonin levels, a brain chemical that regulates appetite, may contribute to other symptoms of anorexia nervosa such as depression, impulsiveness, obsessive behaviors, or other mood disorders. In addition, the process of purging may deplete tryptophan, an amino acid necessary for the production of serotonin, leading to further imbalances.
A cultural environment that puts a high value on thin or lean bodies.
Overbearing, controlling, and critical parents who do not show emotional warmth.
A tendency toward perfectionism, fear of being ridiculed or humiliated, a desire to always be perceived as being "good." A belief that being perfect is necessary in order to be loved. Because perfection is impossible, the inability to attain perfection reinforces the person's sense of being unworthy of being loved. Not eating, according to some experts, is a passive act of revenge directed toward those who will never love the person because of his or her lack of perfection.
Family history of anorexia. About one-fifth of those with anorexia have a relative with an eating disorder. In fact, it is common to discover that someone with anorexia has a mother or sister with this eating disorder as well. If one identical twin has anorexia, the other has more than a 50% chance of also developing it. It is not clear, however, to what extent this family connection is due to heredity or to learned behavior.
Infection. Some researchers report an association between beta-hemolytic streptococcal infection, or Epstein Barr virus (the virus that causes mononucleosis), and development of anorexia.

Risk Factors

Age and gender -- anorexia is most common in teens and young adult women.
Early onset of puberty
Living in an industrialized country
Depression -- although depression is associated with the development of anorexia, it does not cause the disorder. Depression in a family member also appears to increase the likelihood of developing an eating disorder.
Obsessive-compulsive disorder (OCD) or other anxiety disorders -- OCD is present in up to two-thirds of people with anorexia. OCD associated with an eating disorder is often accompanied by a compulsive ritual around food (such as cutting it into tiny pieces). Phobia, another type of anxiety disorder that may also be present in someone with an eating disorder, and OCD tend to emerge before the eating disorder, while panic attacks may develop after the diagnosis is made.
Avoidant or narcissistic personality disorders -- approximately one-third of those with the restricting type of anorexia have avoidant personalities, which is characterized by feelings of inadequacy, social inhibition, extreme sensitivity to negative comments or criticism, and avoidance of interpersonal relationships, both at work and on an intimate level. Borderline personality disorder (exceptionally unstable interpersonal relationships, extremely poor self-image, and excessively impulsive behaviors) may be a risk factor as well, but such individuals are more likely to develop bulimia.
Participation in sports and professions that put emphasis on a lean body (such as dance, gymnastics, running, figure skating, horse racing, modeling, wrestling, acting)
Difficulty dealing with stress (pessimism, tendency to worry, refusal to confront difficult or negative issues)
History of sexual abuse or other traumatic event
Dieting

Diagnosis

While your doctor will rely on points discussed in Signs and Symptoms -- such as excessive weight loss, refusal to maintain normal body weight, and distorted self-perception -- the doctor will also ask a series of questions to better determine whether or not anorexia is present. The SCOFF questionnaire, developed in Great Britain, is proving to be a very reliable method for diagnosing anorexia. A "yes" response to at least two of the following questions is a strong indicator of an eating disorder:

S: "Do you feel sick because you feel full?"
C: "Do you lose control over how much you eat?"
O:"Have you lost more than 13 pounds recently?"
F: "Do you believe that you are fat when others say that you are thin?"
F: "Does food and thoughts of food dominate your life?"

If an eating disorder is suspected, the doctor will order several laboratory tests. These serve to determine blood count (to assess for signs of anemia that may be related to lack of iron or vitamin B12), levels of electrolytes (minerals such as potassium, calcium, and magnesium), amylase (serum amylase is elevated when there is frequent vomiting), and protein, and kidney, liver, and thyroid functions. Your doctor may also order an electrocardiogram (which gives a graphic record of the electrical activity of the heart). This may be abnormal if there is a deficiency in an electrolyte or nutrient such as potassium or calcium. If a diagnosis of anorexia is made, the doctor will require frequent office visits to monitor the condition. It is best for a person with anorexia to work with a multidisciplinary team including a doctor, a psychologist or psychiatrist, and a registered dietitian.

Preventive Care

The most effective prevention strategy is the development, from an early age, of healthy eating habits and a strong body image. Cultural values that place a premium on lean or thin bodies need to be questioned. Education about the life-threatening nature of anorexia is also an important part of prevention.

In those who have already been diagnosed and treated for anorexia, avoiding recurrence of the eating disorder is the primary goal.

Family and friends should be urged not to focus on the patient's condition or on issues of food or weight. Mealtimes, for example, should be reserved for social interaction and relaxation, without any discussion of the disease.
Careful and frequent monitoring of weight and other physical signs by the health care provider can reveal signs of a relapse.
Cognitive or other forms of psychotherapy can help the person to develop coping skills and change the unhealthy thought processes that underlie anorexia nervosa.
Family therapy is helpful in addressing underlying contributing factors in the home environment and in enlisting the support and understanding of family members.

Treatment

Anorexia demands a multi-pronged treatment plan that addresses both the physical and psychological aspects of this disorder. Cognitive-behavioral therapy, often in combination with antidepressants, is a very effective therapeutic approach for treatment of eating disorders. Complementary and alternative methods of treatment (such as the use of herbs and mind-body medicine) are valuable adjuncts to usual ways of stimulating appetite, addressing nutritional problems, and helping the patient to develop a healthier body image and to learn to deal more productively with stress.

In general, the most important aspect of treating anorexia is restoring weight and preventing starvation. Hospitalization may be necessary, particularly under the following circumstances:

Continuing weight loss, in spite of outpatient treatment
Body mass index (BMI) -- BMI is a measurement that takes into account a person's height and weight) 30% below normal. The normal range is a BMI of 19 - 24.
Irregular heart rhythm
Severe depression
Suicidal tendencies
Low potassium levels
Low blood pressure

Generally, adequate weight gain (1 - 2 pounds per week) and appropriate changes in behavior require a 10 - 12 week hospital stay. To avoid bloating, abdominal upset, and fluid retention, those who are severely malnourished are started on a diet of 1,500 calories a day, gradually increasing to as much as 3,500 calories. Because anorexia triggers changes in metabolism, high caloric intake may be necessary to stimulate weight gain.

Unfortunately, there is no completely effective treatment for anorexia nervosa, and recovery can take many years. Even after some weight gain, many people with anorexia remain quite thin and risk of relapse is very high. Several social influences may make recovery difficult:

Friends or family who express admiration or envy of the patient's thinness
Dance instructors or athletic coaches who put a premium on having a very lean body
Denial on the part of parents or other family members
A patient's persistent belief that emaciation is not only normal but also attractive and that purging is the only way to avoid becoming overweight

Involving friends, family members, and others in the treatment of the individual, with education for everyone regarding the gravity of the disease, may diminish these influences.

Lifestyle

Treating anorexia nervosa involves major lifestyle changes. The person must not only alter eating habits but also adjust their self perception to no longer hold a distorted body image. The following lifestyle changes may help in this process:

Establishing regular eating habits and a healthy diet
Developing a support system and participating in a support group for help with stress and emotional issues
Cutting back on exercise if obsessive exercise has been part of the disease. Once sufficient weight gain has been established, controlled exercise regimens can be a positive reinforcement for appropriate eating habits and a way to reduce gastrointestinal distress.

Medications

Anorexia nervosa in some ways resembles other major psychiatric disorders, such as depression and obsessive-compulsive disorder, because people with anorexia exhibit some of the symptoms of these disorders (for example obsessive behavior, lack of enjoyment from life, and severely distorted perception of reality, in this case, of the body). This has led to the use of antidepressants for anorexia, particularly selective serotonin reuptake inhibitors (SSRIs), because these drugs are first-line treatments for OCD and depression. Medications, however, may not work alone and should be used in conjunction with a multidisciplinary approach that includes nutritional interventions and psychotherapy.

Serotonin Reuptake Inhibitors

Fluoxetine

Studies suggest that fluoxetine may increase weight and improve mood over several months in people with anorexia nervosa and depression. Similarly positive results were obtained in a preliminary study of anorexics whose body weight had already been partly restored.

Tricyclic Antidepressants

This class of antidepressants, including imipramine and desipramine, tend to be more effective for bulimia than anorexia.

Clomipramine

One study suggests that clomipramine has the potential to stimulate weight gain and improve symptoms of anorexia.

Antihistamines

Cyproheptadine

In one study, using high doses of cyproheptadine hydrochloride, which is thought to stimulate appetite, decreased the number of days necessary to achieve appropriate weight gain and relieved depression in those with restricting type anorexia.

Hormones

Estrogen together with progesterone may help restore normal menstrual cycles. This, however, does not generally have any effect on weight.

Nutrition and Dietary Supplements

Anorexics with low body weight, low BMI, and low serum albumin (the main protein in blood) levels are at increased risk for vitamin and mineral deficiency. Vitamin abnormalities may contribute to cognitive difficulties such as poor judgment or memory loss and other psychiatric conditions. These deficiencies can often be corrected with dietary interventions.

There are natural therapies, including dietary supplements, that may help the general health and well-being of a person struggling with anorexia to become more balanced. Always tell your health care provider about the herbs and supplements you are using or considering using, as some supplements may interfere with conventional treatments.

Following these nutritional tips may help reduce symptoms:

Avoid coffee and other stimulants, alcohol, and tobacco.
Drink 6 - 8 glasses of filtered water daily. However, do not fill up on water only.
Quality protein sources, such as organic meat and eggs, whey, and vegetable protein shakes, should be used as part of balanced program aimed at gaining muscle mass and preventing wasting. Talk with your health care provider about the best way for you to put on weight.
Try to avoid refined sugars, such as candy and soft drinks.

You may address nutritional deficiencies with the following supplements:

A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-vitamins and trace minerals, such as magnesium, calcium, zinc, and selenium.
Omega-3 fatty acids, such as fish oil, 1 - 2 capsules or 1 tablespoonful oil two to three times daily, to help decrease inflammation and improve immunity. Essential fatty acids play a critical role in brain function and hormone regulation, key health issues in the anorexic individual.
Vitamin C, 500 - 1,000 mg one to three times daily, as an antioxidant and for immune support.
Coenzyme Q10, 100 - 200 mg at bedtime, for antioxidant, immune, and muscular support.
5-hydroxytryptophan (5-HTP), 50 mg two to three times daily, for mood stabilization.
Creatine, 5 - 7 grams daily, when needed for muscle weakness and wasting.
Probiotic supplement (containing Lactobacillus acidophilus), 5 - 10 billion CFUs (colony forming units) a day, for maintenance of gastrointestinal and immune health. You should refrigerate your probiotic supplements for best results.
L-glutamine, 500 - 1,000 mg three times daily, for support of gastrointestinal health and immunity.
Dihydroepiandosterone (DHEA), start at 5 mg three times a day and work up to 100 mg per day for 7 - 12 months for hormonal effects. It is recommended to use DHEA under the supervision of a qualified health care professional. If adverse effects develop, discontinue use.
Melatonin, 2 - 5 mg one hour before bedtime, for sleep and immune protection.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, you should work with your health care provider to get your problem diagnosed before starting any treatment. You may use herbs as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, you should make teas with 1 tsp. herb per cup of hot water. Steep covered 5 - 10 minutes for leaf or flowers, and 10 - 20 minutes for roots. Drink 2 - 4 cups per day. You may use tinctures alone or in combination as noted.

Ashwagandha (Withania somniferum) standardized extract, 450 mg one to two times daily, for general health benefits and stress.
Fenugreek (Trigonella foenum-graecum), 250 - 500 mg two to three times daily, for appetite stimulation.
Cayenne pepper (Capsicum annuum) standardized extract, 400 mg three times daily, for digestive stimulation.
Milk thistle (Silybum marianum) seed standardized extract, 80 - 160 mg two to three times daily, for detoxification support.
Fermented wheat germ extract, 1 packet dissolved in favorite beverage once daily, for immune effects and muscle gain.

Massage and Physical Therapy

Massage appears to be a helpful component of treatment for anorexia nervosa. Individuals using massage report lower anxiety levels and improved body image.

Homeopathy

A professional homeopath can provide supportive care to address various aspects of anorexia. Discuss homeopathy and anorexia with your health care provider.

Mind-Body Medicine

Cognitive Behavioral Therapy

Cognitive behavioral therapy is reported to be one of the most effective therapies for anorexia. It is based on the assumption that anorexia develops in response to life stresses. Treatment is aimed at confronting the individual's fears and avoidance behaviors and cultivating new problem-solving skills. It also aims to increase awareness of negative thought processes and to change them. Cognitive techniques are used to encourage patients to evaluate and challenge their automatic thoughts, examine their underlying assumptions, and replace them with realistic beliefs and actions based on reasonable self-expectations.

Family Therapy

Family therapy is recommended for both children and adults, in addition to individual therapy for the person with anorexia. Parents and other family members often have intense feelings of guilt and anxiety that they need to address. Family therapy is aimed, in part, at helping the parents or partner (in the case of an adult) understand the medical gravity of this illness and the ways in which they may be inadvertently contributing to it.

Hypnosis

Hypnosis has been reported to be successful as part of an integrated treatment program for anorexia nervosa. Hypnosis reportedly strengthens both self-confidence and the ability to cope, which may result in healthier eating, improved body image, and greater self-esteem.

Biofeedback

Studies suggest that biofeedback may be helpful in reducing stress in people with anorexia.

Other Considerations

Pregnancy

Anorexia poses several potential problems for women who are pregnant or wishe to become pregnant:

Difficulty getting pregnant and carrying a pregnancy to term because of higher rates of infertility and spontaneous abortion
Increased risk of low birth weight babies and birth defects
Malnourishment (particularly calcium deficiency) as the fetus grows
Increased risk of medical complications
Increased risk of relapse being triggered from the stress of pregnancy or parenthood

Prognosis and Complications

Medical complications associated with anorexia include:

Irregular heartbeat and heart attack
Anemia, often related to lack of vitamin B12
Low potassium, calcium, magnesium, and phosphate levels (particularly with binge-purge types)
Increased cholesterol
Hormonal changes (can lead to absence of menstrual periods, infertility, bone loss, and stunted growth)
Osteoporosis
Seizures and numbness in hands and feet
Disorganized thinking
Death (suicide is responsible for 50% of fatalities associated with anorexia)

The outlook for individuals with anorexia is variable, with recovery taking between 4 - 7 years. There is also a high chance of disease recurrence even after recovery. Long-term studies show that 50 - 70% of people recover from anorexia nervosa. However, 25% do not fully recover. Many, even after they are considered "cured," continue to exhibit traits of anorexia, such as remaining very thin and striving for perfection.

Supporting Research

Birmingham CL, Goldner EM, Bakan R. Controlled trial of zinc supplementation in anorexia nervosa. Int J Eating Disord. 1994;15:251-255.

Biederman J, Herzog DB, Rivinus TM, et al. Amitriptyline in the treatment of anorexia nervosa: a double-blind, placebo-controlled study. J Clin Psychopharmacol. 1985;5(1):10-16.

Crisp AH, Lacey JH, Crutchfield M. Clomipramine and 'drive' in people with anorexia nervosa: an inpatient study. Br J Psychiatry. 1987;150:355-358.

Escolar DM, Buyse G, Henricson E, et al. CINRG randomized controlled trial of creatine and glutamine in Duchenne muscular dystrophy. Ann Neurol. 2005;58(1):151-5.

Field T. Massage therapy effects. Am Psychol. 1998;53:1270-1281.

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.

Gross HA, Ebert MH, Faden VB, Goldberg SC, Nee LE, Kaye WH. A double-blind controlled trial of lithium carbonate primary anorexia nervosa. J Clin Psychopharmacol. 1981;1(6);376-381.

Halmi KA, Eckert E, LaDu TJ, Cohen J. Anorexia nervosa. Treatment efficacy of Cyproheptadine and amitriptyline. Arch Gen Psychiatry. 1986;43(2):177-181.

Holman RT, Adams CE, Nelson RA, et al. Patients with anorexia nervosa demonstrate deficiencies of selected essential fatty acids, compensatory changes in nonessential fatty acids and decreased fluidity of plasma lipids. J Nutr 1995;125:901-907.

Humphries L, Vivian B, Stuart M, McClain CJ. Zinc deficiency and eating disorders. J Clin Psychiatry. 1989;50:456-459.

Kennedy SH. Melatonin disturbances in anorexia nervosa and bulimia nervosa. Int J Eating Disord. 1994;16:257-265.

Kleifield EI, Wagner S, Halmi KA. Cognitive-behavioral treatment of anorexia nervosa. Psychiatric Clin N Am. 1996;19:715-737.

LaValle JB, Krinsky DL, Hawkins EB, et al. Natural Therapeutics Pocket Guide. Hudson, OH:LexiComp; 2000: 387-388.

McClain CJ, Stuart M, Vivian B, et al. Zinc status before and after zinc supplementation of eating disorder patients. J Am Col Nutr. 1992;11:694-700.

McNulty. Prevalence and contributing factors of eating disorder behaviors in active duty Navy men. Mil Med. 1997;162(11):753-758.

Moyano D, Sierra C, Brandi N, et al. Antioxidant status in anorexia nervosa. Int J Eating Disord. 1999;25:99-103.

Pop-Jordanova N. Psychological characteristics and biofeedback mitigation in preadolescents with eating disorders. Ped Int. 2000;42:76-81.

Rock CL, Vasantharajan S. Vitamin status of eating disorder patients: Relationship to clinical indices and effect of treatment. Int J Eating Disord. 1995;18:257-262.

Rotsein OD. Oxidants and antioxidant therapy. Crit Care Clin. 2001;17(1):239-47.

Safai-Kutti S. Oral zinc supplementation in anorexia nervosa. Acta Psychiatr Scand Suppl. 1990;361(82):14-17.

Shay NF, Manigan HF. Neurobiology of zinc-influenced eating behavior. J Nutr. 2000;130:1493S-1499S.

Simopoulos AP. Omega-3 fatty acids in inflammation and autoimmune diseases. J Am Coll Nutr. 2002;21(6):495-505.

Vandereycken W, Pierloot R. Pimozide combined with behavior therapy in the short-term treatment of anorexia nervosa. A double-blind placebo-controlled cross-over study. Acta Psychiatr Scand. 1982;66(6):445-450.

Wang HK. The therapeutic potential of flavonoids. Expert Opin Investig Drugs. 2000;9(9):2103-19.

Wheatland R. Alternative treatment considerations in anorexia nervosa. Med Hypotheses. 2002;59(6):710-5.

Wiseman CV, Harris WA, Halmi KA. Eating disorders. Medical Clin N Am. 1998;82:145-159.

Wolfe BE, Metzger ED, Jimerson DC. Research update on serotonin function in bulimia nervosa and anorexia nervosa. Psychopharmacol Bull. 1997;33:345-354.

Yoon JH, Baek SJ. Molecular targets of dietary polyphenols with anti-inflammatory properties. Yonsei Med J. 2005;46(5):585-96.

Young D. The use of hypnotherapy in the treatment of eating disorders. Contemporary Hypnosis. 1995;12:148-153.

Review Date:
10/19/2006
Reviewed By:
Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources; and Steven D. Ehrlich, N.M.D., private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

adam.com