Childhood Depression

Childhood and Adolescent Depression

SHASHI K. BHATIA, M.D., and SUBHASH C. BHATIA, M.D., Creighton University, Department of Psychiatry, Omaha, Nebraska

(abstract)….Juvenile depression may manifest in different forms….children younger than seven years may not be able to describe their internal mood state and may express their distress through vague somatic symptoms or pain. Irritable mood may be the cause of angry, hostile behavior. Impaired attention, poor concentration, and anxiety may resemble attention-deficit/hyperactivity disorder, and substance abuse may be a means of self-medication for depression.

Diagnosis

Diagnosis of primary depressive mood disorders (Table 2) requires that physicians rule out depression from medical causes, such as endocrinopathies, malignancies, chronic diseases, infectious mononucleosis, anemia, and vitamin deficiency (especially folic acid),10 and from medications, such as isotretinoin (Accutane).13 If any of these causes are present, the condition is referred to as secondary depressive mood disorder or depressive mood disorder secondary to medical conditions. Lack of improvement following treatment or medication discontinuation warrants further evaluation and treatment.

Major depressive disorder is the most severe of the depressive mood disorders. The Diagnostic and Statistical Manual of Mental Disorders, 4th ed., criteria for diagnosing major depressive disorder in children and adolescents are similar to those for adults (Table 3).20-24

If substance abuse is present, an independent diagnosis of major depression requires the presence of depression before substance abuse or during periods of remission. Concurrent treatment of substance use disorder and depression is needed to improve outcomes for both.25

Adjustment disorder with depressed mood is the most common depressive mood disorder in children and adolescents. Symptoms start within three months of an identifiable stressor (e.g., loss of a relationship), with distress in excess of what would be expected and interference with social, occupational, or school functioning. Symptoms should not meet criteria for another psychiatric disorder, are not caused by bereavement, and do not last longer than six months after the stressor has stopped.

Dysthymic disorder is a chronic, milder form of depression characterized by a depressed or irritable mood (indicated subjectively or described by others) present for more days than not for at least one year (as opposed to two years for adults). Two of the following additional symptoms also are required: changes in appetite, sleep difficulty, fatigue, low self-esteem, poor concentration or difficulty with making decisions, and feelings of hopelessness.20 About 70 percent of children and adolescents with dysthymic disorder eventually develop major depression.26

Diagnosis of minor depression requires the presence of two out of the nine symptoms for major depression (Table 3), one being depressed mood or decreased interest, and a time course similar to that of major depression. If present between the episodes of major depression, minor depression can be a risk factor for relapse.20

Atypical depression is characterized by hypersomnia, increased appetite with carbohydrate craving, weight gain, interpersonal rejection sensitivity, feeling of heaviness in the arms and legs, and reactivity of mood.20 It is relatively common in children and adolescents.27

Presence of depressed mood, increased sleep, decreased appetite, and social isolation between October and February of two consecutive years suggests seasonal affective disorder.

Although less common, bipolar disorder is an important differential diagnosis. In 40 percent of children and adolescents with bipolar disorder, the illness begins with a major depressive episode.2 Risk factors for bipolar disorder are acute and early onset of depression, presence of psychotic symptoms (e.g., hallucinations), significant psychomotor slowing, family history of bipolar disorder, any mood disorder in three consecutive generations of family members, and antidepressant-induced mania.28 Physicians should maintain a higher level of surveillance in patients at greater risk of bipolar disorder.

In severe major depression with psychosis, auditory hallucinations (often criticizing the patient) rather than delusions (as occur in adults) are present. This age-related variability in psychotic symptoms may be a result of differences in cognitive maturation. Treatment of major depressive disorder with psychosis requires the combination of an antidepressant and an antipsychotic medication.29 Patients with this disorder are at a greater risk of suicide and often require inpatient psychiatric admission.

Suicide Risk Assessment

During the first visit, physicians should assess the suicide risk of patients with depression and decide on the most appropriate treatment venue. Depressive disorders are the most common diagnoses present in all suicides. Twenty percent of teenagers seriously contemplate suicide,30 and 8 percent attempt it.31 In 2001, there were 1,833 suicides in children and adolescents 10 to 18 years of age; and in 2000, suicide was the third leading cause of death among those 10 to 19 years of age.31

Suicidal communication in any form must be taken seriously. Documentation of suicide risk should include high-risk and protective factors for suicide (Table 4).1,30-36 Patients with multiple high-risk factors should be referred to a child and adolescent psychiatrist. However, patients with low-risk and protective factors (e.g., a close, warm, supportive family; religious beliefs against suicide; a positive future outlook) are less likely to harm themselves32 and may be treated as outpatients.

See also:  Uncovering the Myths of Childhood Depression

Childhood and Adolescent onset of BiPolar Disorder

Stephanie E. Meyer, Ph.D., and Gabrielle A. Carlson, M.D.

Correspondence: Address correspondence to Stephanie E. Meyer, Ph.D., Division of Child and Adolescent Psychiatry, Cedars-Sinai Medical Center, 8730 Alden Drive, Thalians W101, Los Angeles, CA 90048; e-mail: Stephanie.Meyer@cshs.org

….Distinguishing between mania and other conditions of childhood is complicated by overlapping symptoms and by the confounding influences of development itself. At the center of the debate regarding symptom overlap has been a focus on differentiating between symptoms of ADHD and mania (41, 42).

At this point, several studies have shown that these two conditions are distinct and separable (32, 43). However, in practice, mental health professionals may continue to struggle with the question of how to categorize certain behaviors. Indeed, a detailed history and symptom ascertainment are often required to distinguish between the disinhibited silliness of a child with ADHD and the euphoric mood associated with mania. Similarly, impulsivity can closely resemble the pleasure-seeking behaviors of mania, and resistance to bedtime must be distinguished from decreased need for sleep (see reference 4 for a review).

There is some question as to whether rage episodes may be diagnostic of bipolar disorder in youth (15). Although it is true that rages can occur in manic individuals of any age, as an isolated symptom explosive irritability (presumably the affect underlying rage episodes) is common in a variety of childhood conditions and thus has poor discriminatory power (32).

Therefore, although parents often refer to rages as “mood swings,” these should not be interpreted as sufficient evidence of a manic episode. Indeed, Mick et al. (16) found that although extreme explosiveness or “super” angry/grouchy/cranky irritability was common among children with mania, the majority of youth exhibiting these behaviors did not meet the full diagnostic criteria for a bipolar spectrum condition. Similarly, G. A. Carlson et al. (unpublished 2008 data) conducted a pilot study of children referred specifically to “rule out bipolar disorder” (N=33) and found that those youth with the most severe rage episodes (N=8) were a diagnostically heterogeneous group, with 25% meeting the criteria for mania with comorbid ADHD, 25% meeting the criteria for major depressive disorder with comorbid ADHD, 25% with pervasive developmental disorder not otherwise specified and ADHD, and 25% with pervasive developmental disorder not otherwise specified and major depressive disorder.

The issue of differential diagnosis of pediatric bipolar disorder is further complicated by the fact that affective and behavioral symptoms may be exacerbated by the emergence of new developmental demands and changing circumstances. Indeed, children with attention or learning challenges may begin to look increasingly dysregulated with the heightened demands of late elementary or middle school.

Similarly, irritability may intensify in conjunction with increasing environmental challenges, such as difficulties with family and peer relationships. Moreover, symptoms similar to pediatric mania have been found among maltreated children (reviewed in reference 4), and therefore clinicians may struggle to determine whether presenting behaviors are sequelae of the abuse, symptoms of an emerging bipolar disorder, or both. In adolescents with severe psychotic symptoms, schizophrenia and substance-induced psychosis must be considered.

Detailed information regarding history and longitudinal course of symptoms is necessary to distinguish such behavioral changes from the onset of a true mood disorder. In many instances, diagnostic clarity may only come with extended longitudinal follow-up.

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The DSM-IV-TR distinguishes among four bipolar phenotypes.

Bipolar I disorder is the most severe, requiring the presence of at least one manic or mixed episode. Depressive episodes are not required for a diagnosis of bipolar I disorder but are usually present.

Bipolar II disorder is defined by a history of one or more major depressive episodes and at least one hypomanic episode.

Cyclothymic disorder involves chronic and variable symptoms of hypomania and depression and is believed to represent a “temperamental predisposition” to more severe forms of bipolar disorder.

Bipolar disorder not otherwise specified is diagnosed when mood symptoms are insufficient in number and/or duration to meet full criteria. The DSM-IV-TR also provides a series of specifiers for making a diagnosis of bipolar disorder, which characterize the illness in terms of severity and chronicity, seasonal patterns, and rapid cycling.

Symptom patterns in youth with bipolar disorder often do not resemble the episodic nature of bipolar disorder in adults as it has been classically described (13). According to McClellan et al. (14), the most common presentation among youth with bipolar disorder in community settings is characterized by “outbursts of mood lability, irritability, reckless behavior, and aggression.” Shifts in mood state are short-lived (15), and irritability, rather than euphoria, tends to be the predominant and most impairing mood state (16).

PARANOIA

An important feature of paranoid thinking is its centrality: that the paranoid person perceives himself as central figures in an experienced scenario which may be either dangerous (persecutory) or self-exalting (grandiose) and interprets events which have no reference to them in reality as directed at or about them. 

Hypervigilance, hypersensitivity, suspiciousness, and guardedness of these patients can be quite muted, so that their role in the patients’ difficulties is not readily apparent. In many psychoanalyses of patients with unrelated character diagnoses, paranoid traits, especially fears centered on passivity, issues of narcissistic injury and rage, and masochistic and projective defenses, come to the surface. These traits are often subtle and muted but at times can be surprisingly intense. In paranoid personalities, ideas of reference may be present, but without the degree of delusional conviction found in psychotic paranoid patients.

Characteristically, patients with paranoid personalities have difficulty accepting responsibility for themselves, their lives, and the consequences of their behavior. They are quick to blame others, even fate or the gods, for their misfortune or unhappiness. Constant blaming is a typical paranoid posture. Their general guardedness is often reflected in keeping their ideas to themselves and communicating them reluctantly even under the best of circumstances. Consequently, although difficulties characteristically arise in more intimate contexts (e.g., marital relationships or work situations, particularly in relation to authority figures), their external impairment and maladaptation often escape notice or are rationalized as minor eccentricities.

Common Difficulties

Paranoid personality disorder is well established in the catalogue of personality disorders, but even so, the clinical literature, not to mention research, on its specific treatment is rather sparse. Most discussions of treatment of paranoid pathology deal more or less exclusively with psychotic conditions.

The dearth of careful study is striking but may be the result of a series of factors: 1) the personality disorder as such is rarely seen clinically; 2) the defensive organization is often ego-syntonic and does not give rise to symptoms or significant impairment – the impairment is more often interpersonal than intrapsychic and more disturbing or disruptive to those around the patients than to the patients themselves; 3) even when such individuals come to psychiatric attention, they often keep their emotional or interpersonal difficulties hidden because of their guardedness and mistrust; 4) for similar reasons, they are less likely to lend themselves to systematic investigation; 5) such patients tend to maintain a reasonably good level of functioning, coming to psychiatric attention only when their defenses have crumbled and they experience a regressive episode that may result in a more severe diagnostic evaluation; and finally, 6) often enough, the paranoid characteristics are mingled with other pathological personality features that allow the patient to be classified as narcissistic, borderline, antisocial, schizoid, or even depressed. The rigidity of paranoid defenses does not augur well for effective treatment, so that diagnosis should include assessment of the patient’s motivation and receptivity for psychotherapy as well as capacity to tolerate the therapeutic process.

The diagnosis of paranoid personality may be easy or difficult – easy when the paranoid characteristics can be identified but difficult when they cannot. The problem is that these traits are often not easily recognized. Even when recognition of traits is not complicated, mixed personality configurations and the potential overlap between paranoid personality characteristics and those of other personality disorders are persistent problems.

Paranoid Traits

The presence of paranoid traits may be muted and subtle. These “soft signs” of paranoia are continuous with a more normal range of personality characteristics and functioning and often are difficult to evaluate for this reason. They include the following:

• Centrality – Often these patients believe that they are somehow the center of other people’s interest or attention. This can reflect their sense of being passive recipients of external influences over which they may feel they have little or no control. In patients with personality disorder, this more commonly may take the form of ideas of reference, whereas in psychotic paranoid disorders, it takes a more extreme form, in which evil and often powerful external forces or influences are seen as directed against and threatening the patient.
• Self-sufficiency – Also characteristic is a facade of self-sufficiency, which may represent an attempt to defend against underlying narcissistic vulnerability. The self-sufficiency may involve a degree of grandiosity and isolation similar to that seen in patients with schizoid conditions.
• Concern over autonomy – A concern over autonomy is fragile and easily threatened. This can especially be a problem in therapy.
• Blaming – A tendency to blame others for any personal failures, shortcomings, or disappointments is often evident.
• Feelings of inadequacy – Patients’ feelings of inadequacy or deficiency may be reflected in concerns about being different or feeling like an outsider or often in a more diffuse concern with having values or beliefs different from those of associates.
• Concerns over power and powerlessness – Paranoid individuals typically have difficulty in relating to authority figures, taking orders, assuming appropriate responsibility, and generally fitting into preexisting social or group structures.

Foods commonly eaten in the United States:

All of the vegetables and fruits are raw, unless otherwise stated.

The numbers are the grams of available carbohydrate
(that is, carbohydrate minus dietary fiber)
in 100 grams of the portion of the food):

Alfalfa seeds, sprouted 1.28
Arugula 2.05
Asparagus, cooked 2.63
Bamboo shoots, cooked 0.92
Beans, green, cooked 4.69
Beans, snap, green, cooked 4.68
Beet greens, cooked 2.56
Broccoli, cooked 2.16
Brussels sprouts, cooked 4.5
Cabbage, cooked 2.16
Cauliflower, cooked 1.41
Celeriac (celery root), cooked 4.7
Celery 1.95
Chard, swiss, cooked 2.04
Collards, cooked 2.1
Cucumber 1.8
Dandelion greens, cooked 3.5
Eggplant, cooked 4.14
Endive 0.25
Fennel, bulb 4.19
Hearts of palm, canned 2.22
Jicama 3.92
Kale, cooked 3.63
Lettuce, butterhead 1.32
Lettuce, cos or romaine 0.67
Lettuce, iceberg 0.69
Mustard greens, cooked 0.1
Mushrooms 2.94-3.57 (except shitake)
Nopales, cooked 1.27
Olives, canned ripe 3.06
Okra, cooked 4.71
Olives, canned ripe 3.06
Parsley 3.03
Peppers, serano 3.00
Peppers, jalapeno 3.11
Peppers, sweet green 4.63
Peppers, sweet red 4.43
Pumpkin, cooked 3.80
Purslane 3.43
Radicchio 3.58
Radishes 1.99
Rhubarb 2.74
Sauerkraut 1.78
Scallions (green onions) 4.74
Spinach, cooked 1.35
Squash, summer, cooked 2.91
Squash, zucchini, cooked 2.53
Tomatillos 3.93
Tomatoes 3.54
Tomato juice 3.83
Turnips, cooked 2.9
Turnip greens, cooked 0.86
Watercress 0.79
 

FRUIT:

Avocados 2.39
Chayote (christophene) 2.20
Raspberries 4.77
Strawberries 4.72

NUTS:

Macademia Nuts 4.83
Pecans 4.26

MEAT AND FISH:

All meat and fin fish 0.00
Caviar 4.00
Crab 0.95
Lobster 1.28
Shrimp 0.00

EGGS AND DAIRY:

Butter 0.06
Buttermilk, lowfat 4.79
Cheese, cheddar 1.28
Cheese, Edam 1.43
Cheese, Gouda 2.22
Cheese, Swiss 3.38
Cream cheese, 2.66
Cottage cheese, 2% milkfat 3.63
Eggs 1.22
Half and Half 4.30
Heavy Cream 2.79
Goat milk 4.45
Mayonnaise 2.70
Milk, 1% milkfat, added solids 4.97
Milk, 3.25% milkfat 4.66
Ricotta cheese, whole milk 3.04
Soy milk, 0.51
Yogurt, plain, whole milk 4.66

DIETARY FIBER:

Soluble and insoluble fiber (a part of other foods) 0.00

BEVERAGES:

Coffee (without cream or sugar) 0.00
Diet Soda 0.00
Tea (without milk or sugar) 0.00
Water 0.00

SWEETENERS:

Aspartame (NutraSweet) 0.001
Saccharin (Sweet’N Low) 0.001
Stevia 0.00
Sucralose (Splenda) 0.001

Over 100 Super Foods for a Super You

These foods benefit your body in so many ways. They power your brain, and correctly and efficiently fuel your body. Super foods fight infection, enhance your immune system, and protect against diseases such as osteoporosis, heart disease, certain cancers, diabetes, and respiratory infections.

These foods are not only healthy, but they’re also affordable, familiar, and readily available at regular grocery stores and farmers markets. With so many choices, you’ll discover just how easy it is to eat super healthy every day…even when on a tight budget.

This is an all-inclusive list, but some foods might not be right for your tastes, preferences or health goals. Remember that no single food can provide everything you need to be healthy. That’s why it’s important to choose a variety of super foods from each category to meet your daily nutrition needs.

Vegetables

Asparagus
Avocados
Beets
Bell peppers
Broccoli
Brussels sprouts
Cabbage
Carrots
Cauliflower
Collard greens
Crimini mushrooms
Cucumbers
Eggplant
Garlic
Green beans
Kale
Mustard greens
Onions
Peas
Portobello mushrooms
Potatoes
Rainbow chard
Romaine lettuce
Shiitake mushrooms
Spinach
Summer squash
Sweet potatoes
Swiss chard
Tomatoes
Turnip greens
Winter squash
Yams

Calcium-Rich Foods

Almond milk
Cheese, low fat
Cottage cheese, low fat
Milk, skim or 1%
Orange juice with calcium
Rice milk
Soy milk
Yogurt with active cultures, low fat

Fruits

Apples
Apricots
Bananas
Black olives
Blackberries
Blueberries
Cantaloupe
Cherries
Cranberries
Figs
Grapefruit
Grapes
Honeydew melon
Kiwifruit
Lemons
Limes
Nectarines
Oranges
Papaya
Peaches
Pears
Pineapple
Plums
Prunes
Raisins
Raspberries
Strawberries
Watermelon

Grains

Amaranth
Arborio rice
Barley
Brown rice
Buckwheat
Bulgur
Corn
Jasmine rice
Millet
Oats
Quinoa
Rye
Spelt
Triticale
Wheat berries
Whole grain breads, cereal, pasta
Whole wheat breads, cereal, pasta
Wild Rice

Proteins

Almonds
Beef, lean
Black beans
Cashews
Chicken, skinless
Chickpeas
Egg whites
Eggs
Fish, unbreaded
Flaxseed
Garbanzo beans
Hemp seeds
Hummus
Kidney beans
Lima beans
Lentils
Miso
Navy beans
Nuts
Peanut butter, natural
Peanuts
Pinto beans
Pork, lean
Pumpkin seeds
Salmon, canned or fresh
Seafood, unbreaded
Sesame seeds
Soybeans
Sunflower seeds
Tahini
Tempeh
Tofu
Tuna, canned or fresh
Turkey, skinless
Veggie burgers
Walnuts
Wild game, skinless

Miscellaneous

Canola oil
Dark chocolate
Green tea
Olive oil

Are You In An Abusive Relationship:  12  Signs It’s Time to Leave

By Norine Dworkin-McDaniel, Special to Lifescript

Published October 18, 2009

Earlier this year, Chris Brown was arrested for assaulting his girlfriend, singer Rihanna, and is now doing community service for his crime. Just last week, “So You Think You Can Dance” judge Mary Murphy revealed that she was in an abusive marriage for years. Are you? In recognition of Domestic Violence Month, read on for 12 signs you’re being abused. Plus, take our quiz to see if you’re in an abusive relationship…

Celebrity abuse scandals make one thing clear: No matter how rich, how successful, how beautiful a woman is, she is not immune to physical abuse.

Even if he never raises a hand, you could be hit with emotional or verbal smackdowns that are equally damaging.

Yet, “women tend to overlook these signs because we’re trying to be understanding, or because we can’t believe that our man would do anything like that,” says Michele Sugg, MSW, a therapist in Branford, Conn.

The number of women who don’t make headlines or get personal pleas from Oprah is staggering: Each year, two million are battered and 1,200 are killed by their partners, according to the Centers for Disease Control and Prevention.

Even more live in fear of violence or face emotional abuse every day.

Check out these 12 signs of abuse, which can help you avoid becoming another statistic:

Signs of Abuse

1.  He makes snide jokes at your expense.

Although boorish and rude, the occasional zinger isn’t an automatic ticket to the Abusers Hall of Fame.

But aiming poison barbs in your direction and then brushing it off – like “Can’t you take a joke?” – shows a lack of respect. “It’s a sign of emotional distancing, which can very quickly turn into abuse,” says Gilda Carle, Ph.D., (aka Dr. Gilda), an advice columnist on Match.com and author of He’s Not All That (Collins).

Emotional abuse can become physical with very little notice. Just ask Aimee, 41, of San Francisco, who was in an abusive relationship for eight years – while working at a battered women’s shelter!

It was so subtle, says Aimee (whose name was changed to protect her privacy).

“It went from unhealthy to pathological in such tiny increments that I accepted every little increment completely.”

By the time it crossed over into physical abuse, “I couldn’t name it. I was in absolute denial,” she says.

2. The relationship is on the fast track.

He’s infatuated with you and is already talking commitment. But slow down.

A light-speed lothario often has something to hide, says relationship therapist Joyce Morley-Ball, Ed.D. (aka Dr. Joyce).

If he’s quick to say “I love you” and soon makes plans for moving in, getting married and having a baby, he may be trying to lock up the relationship before you can see what he’s really about.

He knows you’re less likely to leave him after you get involved, she says. 

3. Nothing is ever his fault.

That speeding ticket?  The cop had it in for him.  The job he lost?  The boss had a grudge against him.  The promotion he didn’t get?  The woman who did must have been sleeping with the boss. Maybe your guy has the worst luck ever. Or consider this: The man who never takes responsibility for any of his actions may be quick to blame you when he ultimately loses control of his temper – and his fists. “If you hadn’t done _____, I wouldn’t have hit you.”

If he can get you to believe it’s your fault, he’s off the hook in his mind. So take notice of his blame list – you could be next.

4. You’re always making excuses for his behavior.

He’s tired. He had a hard week. He’s under a lot of pressure. He’s only like that when he’s had too much to drink.

Sure, these excuses may explain the rare social gaffe and could, in fact, be true.

But if you’re regularly trying to explain away rude, violent or disrespectful behavior, you could be emotionally abused.

“There’s this wall of denial that we put up when we’re in a relationship, and we all do it to some extent,” Sugg says. “But you shouldn’t have to explain away someone else’s behavior.”

It’s just like a slap in the face, she says. “How many of those slaps would you take?”

5. You bend over backward so he doesn’t get upset.

Are you walking on eggshells because of his hair-trigger temper that erupts for everything big (a blown business deal) to small (his warm beer)?

But you can’t keep the peace by being perfect because you can’t control his emotions, Dr. Joyce says. “His anger has nothing to do with you and everything to do with him.”

Chances are, no matter how hard you try t make things “perfect” –there’s no such thing, by the way –he’ll still find something that’ll set him off. 

“If you’re living in fear of upsetting him because he’ll blow up in your face, undertand that eventually he’ll blow up on your face,”  Dr. Gilda says. 

6. He controls the money.

It’s one thing if your man is the designated bill-payer (as mutually agreed upon). It’s a different story if you have no access to your personal money, no credit cards in your name and you get only a small allowance. Maybe he even runs up your credit cards, then tanks your credit score.

This is financial abuse, says Brian Namey, spokesman for the National Network to End Domestic Violence (www.nnedv.org). It’s meant to keep you dependent on him.

(To learn more about financial independence, check out the joint venture between NNEDV and AllState Foundation at www.clicktoempower.org.)

7. He doesn’t like your family or friends.

Maybe your mom is a piece of work and your best friend is a teensy bit shallow. But isolating you from people you love and trust until there’s no one left in your life except your guy?

That’s Rule No. 1 in the Abusers Handbook.

When you have no one else to turn to, then he really has you under his thumb. 

8.  He keeps tabs on what you wear, where you go, who you call…

At first, this may seem loving. If you’re used to emotionally distant guys, the attention he pays will seem wonderful – until you start to suffocate.

All that attention is a way to reel you in so you become dependent on his approval and fear losing it.

“It’s about power and control,” not love, Namey says. 

9. He gets in your face when you fight.

All couples fight. But if he comes closer to you during an argument or follows you when you’re trying to walk away, “That’s a sign that he’s so frustrated, he could hit you at any moment,” Dr. Gilda says.

10. He raises his hand (or fist) in anger.

Even if he catches himself before he slaps you, who knows if next time he’ll have such self control?

Denise, 42, of Cleveland, recalls a heated argument with an ex-boyfriend. “It was a stupid discussion about a movie,” says Denise, who requested that her name be changed to protect her privacy.

“All of a sudden his arm flew back,” she says, “and I could see the supreme effort it took him not to smack me. Right then, I knew there’d be a point when he wouldn’t be able to stop himself. I broke up with him the next day.” Pushing, shoving, pinching, hair pulling or other rough treatment is physical abuse. Don’t blow it off. 

11. He’s gotten physical – even once. 

“Domestic violence is incremental.  It escalates,” Dr. Joyce says.  “The woman who loses her life probably started with name-calling, a push, a sove, hair pulling or something lke that.” 

12. He threatens to kill you.

Believe him and leave. Even if he’s never kept his word before, you don’t want to be there when he decides to follow through.

“When a person is brash enough to make threats, we need to take it at face value,” Dr. Joyce says. “The reality is, if he said it, he probably meant it.”

There are no statistics about how often threats translate into homicide, but Namey says the following situations increase the odds that an abused woman will be killed by her partner:

• He has a weapon and has threatened you with it before.
• He’s threatened your children.
• He’s unemployed.
• He’s forced you to have sex.
• He’s jealous and controls most of your daily activities.
• He says if he can’t have you, nobody can.
• He’s threatened or attempted suicide.
• You believe he could kill you.

If any of these signs describe your relationship, what’s your next step?

Start by talking to someone you trust, like your girlfriends or family. They have the distance to see red flags in your relationship that you may not. 

“If you’re hearing from people that you’re not being treated very well, listen to them and think about that,” Sugg says. 

You can even talk about it at your next gynecology visit. In fact, if you feel unsafe in your relationship, ob-gyns hope you’ll talk with them.

“When a woman feels she’s in danger, we can bring her into the hospital, provide a safe zone and help her figure out ways to get out of the relationship,” says ob-gyn Rakhi Dimino, M.D., of Woman’s Hospital of Texas in Houston.

You can also call the National Domestic Violence hotline (available 24/7 in every state) at (800) 799-SAFE (7233) or at (800) 787-3244 for the hearing impaired.

Contrary to its name, it’s not only for physical abuse victims. For emotionally abused women, phone counselors can offer crisis intervention and referrals to other agencies.

Are You in an Abusive Relationship?

An abusive relationship saps your energy, strips away your dignity and can be physically dangerous to you and your family. Are you the victim of abuse? Find out in this abusive relationship quiz.

Check out Health Bistro for more healthy food for thought. See what Lifescript editors are talking about and get the skinny on latest news. Share it with your friends (it’s free to sign up!), and bookmark it so you don’t miss a single juicy post!

SIX REASONS YOU CAN’T LEAVE HIM

You know he’s not Mr. Right. He’s not even Mr. Right Now. So why can’t a smart woman like you ditch the loser?  Read on to find out. Plus, rate your relationship with our quiz…

I was in college when an older man asked me out. We went to a concert (nice), then back to his place (predictable). By morning, I knew the relationship was a non-starter.

But his attention was flattering and I was between boyfriends. Before I knew it, my one-night stand turned into a year-long relationship. He even talked of marriage.

Right then, I should have cut and run. But I’d grown used to his loud, obnoxious behavior. And at least I had a date on Saturday nights.

I didn’t get my complacent butt out of there until he raised his hand to smack me during a disagreement. Though his hand never connected, that near-slap was just the push I needed.

Any sign of abuse (physical or emotional) is an obvious relationship deal-breaker. And the same goes for addictions of any stripe (drugs, alcohol, sex, gambling). But even without such problems, we often find ourselves spinning our wheels in dead-end relationships. Why do smart women make such foolish choices?

According to relationship experts, here are the 6 most common reasons we stay with men we’re just not that into:

1. My family made me do it.

“What happens in the family shapes how we see ourselves in the world, our core beliefs and our behaviors,” says life/relationship coach Lauren Mackler, author of Solemate: Master the Art of Aloneness and Transform Your Life (Hay House). “Then we take those behavior patterns into adulthood.”

So a girl who grew up thinking I don’t deserve love is subconsciously attracted to men who can’t meet her emotional needs.

“It doesn’t make her happy, but it’s comfortable because it’s familiar,” Mackler says.

It’s the emotional equivalent of the hamster wheel: You never get the guy, no matter how hard you work. But the thought that you might if you just hang on a little longer keeps you in the game.

“Women are willing to deal with long stretches of crap for that momentary approval or affection,” explains clinical psychologist Dennis P. Sugrue, Ph.D., co-author of Sex Matters for Women (Guilford Press). “When it comes – and it’s not often – the attention is almost like oxygen. It means everything.”

2. I won’t find anyone better.
So he’s boorish and overly critical. Breaks dates. Doesn’t call. Plays head games. Forgets your birthday. But he’s all yours. Would it be any different with anyone else?

Hello?!? Someone’s self-esteem needs a transfusion.

Blame this one, too, on a dysfunctional family dynamic.

When a woman is in a relationship with a clear loser, there’s a symbolic agenda playing out. It’s “usually not getting the love and affection of a parent,” Sugrue says. “So when things don’t go well, it becomes easier for her to rationalize it and take the blame for it.”

This pattern is one of the most destructive ways women sabotage themselves in work and relationships, says clinical psychotherapist Pat Pearson, author of Stop Self-Sabotage: Get Out of Your Own Way to Earn More Money, Improve Your Relationships and Find the Success You Deserve (McGraw Hill). We think, Well, it’s better than nothing.

“If we don’t believe we deserve to have a good relationship, we settle for less than what we could have or truly want,” she says. “We compromise our own integrity.”

3. I don’t want to be alone.

Then there’s the fear that you’ll end up a lonely spinster, so you hang on longer than you should out of a misguided sense of self-preservation. 

Chalk this one up to family issues again, especially if the message you internalized growing up was, “You need a man to take care of you.”

“Fear of being alone is a huge factor that keeps people in bad relationships,” says Mackler, the life/relationship coach. “The underlying message is that you’re not able to take care of yourself.”

So you get into relationships with Mr. Wrong.

4. He’ll change.

Uh-huh. Tell it to the Tooth Fairy. Women have been deluding themselves with this particular fairy tale since cave gals sat around the fire pit, grousing that their men were such Neanderthals.

Don’t bet the farm on him changing in any substantial way. Improving hair and wardrobe is about the best you can do. (Though you might make some headway with the toilet-seat-down thing.) But serious character flaws? Figure on living with ’em… or leaving him.

“What you see is what you’re going to get,” Sugrue says. “If there is change, consider that to be a gift from heaven. But don’t count on it.”

5. He needs me.

If ever there was a big enough ball to keep you chained to a loser, it’s this one. We love being needed. We eat that up like a chocolate chip hot fudge sundae with a cherry on top.

“Women tend to over-give to people who don’t give as much back,” says Pearson, the clinical psychologist. “We’ve all been taught that we shouldn’t be selfish and to keep on giving even if we don’t get it back.”

We tell ourselves we’re indispensable. Or maybe you do have legitimate worries that if you split, he’d gamble, drink, slide into depression or kill himself.

But what you call “love,” therapists label as “co-dependency,” “enabling” or “emotional extortion.”

We’re then sucked into unhealthy relationships because serving in their lives makes us feel good about ourselves, explains Michele Sugg, a certified sex therapist in Branford, Conn. “It can be tough to move past the guilt and believe that he’ll make it, that you’re not his only lifeline.”

6. The sex is phenomenal.

That hormonal surge of oxytocin that courses through your brain when you have mind-blowing sex is designed to bond you to your partner. It’s emotional super-glue. But this neurochemistry can backfire when we bond with the wrong guy.

“Just because it was the best sex you ever had doesn’t mean that this is the best partner for you,” says certified sex therapist and psychologist Stephanie Buehler, Psy.D, of the Buehler Institute for sex therapy in Irvine, Calif.

And if you feel embarrassment or shame about becoming sexual too quickly, you might be tempted “to make a relationship out of the encounter,” Buehler says.

Should You Stay or Go?

These steps can get you thinking – honestly – about the state of your union.

1.Search your soul.

 Ask yourself these questions, Sugrue says:

•  Do I really care about this person or has the relationship become habit?
•  Is it easier to stay than make the effort to leave?
•  Do I feel  like he really cares for me? Or am I doing all the heavy lifting?
• Would I be tempted to leave If someone else I’m attracted to was suddenly available and I could get out of my current relationship with no negative consequences, embarrassment, shame or explanations? If you’re thinking maybe, “that should tell you something,” Sugrue says.

2. Make a list. Works with Christmas gifts and relationships.Figure out what works (and doesn’t) in your relationship, Sugg says. “That can help you determine what needs to change for the relationship to feel healthier for you.”

So make like Santa and check your list twice. And talk it over with your guy. Maybe he didn’t realize that openly flirting with other women gets on your nerves. It’s unlikely, but at least you’ve done due diligence before you walk out.

3. Get online.

If you just don’t think you can do any better, click through some online dating sites. You don’t even need to post a profile. Just punch in your zip code and take a look at who’s around. Nice guys! Near you!

It’s the relationship equivalent of window-shopping. Not all these dudes will pony up to ride into the sunset with you. But even if you’re convinced the sea is empty, you’ll see there are plenty of fish out there.

4. Take a break.

Absence can make the heart grow fonder… or show you that you’re doing just fine without him. Either way, you get some perspective, Buehler says.

5. Hold off on hooking up.

No judgment here. Casual, no-strings-attached sex definitely has its place. However, “it’s important to look at what you’re trying to get when you’re hooking up,” Sugg says.

If you want to meet your dream man and live happily ever after, hooking up is “not the way you’re going to form lasting relationships,” Sugg says.

6. Do a reality check.

If you worry that ditching an unsatisfying relationship will leave you alone forever or possibly even destitute, take a deep breath and step back from the ledge.

Therapists call this “awfulizing” or “catastrophizing.” Mackler says you’re playing the Gloom and Doom Movie by imagining the absolute worst-case scenario, and it’s spinning in your mind as reality. So take stock

“Look at the core beliefs you have about yourself that’s driving this fear,” she says.

Do you really believe you’ll die without someone to take care of you? What about those friends and family who love you? And don’t you have your own money to pay those bills?

Looks like an apartment with only cats for company isn’t your destiny after all.  And you’re doing pretty well fending for yourself.  Soon you’ll get your brain around the idea that you can jump ship if you want to – and land on your feet.

Then you can start thinking about what your new movie will look like, Mackler says. Perhaps the screen will show that you can be happy without a relationship. Or that the next guy you date will appreciate and respect you.

Roll tape…

Are You Just Not That Into Him?

Many people stay in relationships because they are convenient or comfortable. Take this quiz and find out whether you’re into him or not.

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Blaming your issues on Mom, Dad, your siblings or the dog can get a little tired. But persistently picking Mr. Wrong does have a lot to do with your upbringing, therapists say.