Category: Anti Depressants-Sleeping Aid
PATIENTS’ RESPONSES TO BDD TREATMENT DAVID: A GOOD RESPONSE TO MEDICATION PLUS COGNITIVE-BEHAVIORAL THERAPY
PATIENTS’ RESPONSES TO BDD TREATMENT DAVID: A GOOD RESPONSE TO MEDICATION PLUS COGNITIVE-BEHAVIORAL THERAPYDavid was feeling desperate. A 32-year-old disc jockey, he was at the point of quitting his job. He couldn’t focus on his work because of his hair obsessions, and was often late because he couldn’t tear himself away from the mirror in the morning. Even the expensive new hairpiece he’d bought to hide his slightly receding hairline didn’t help him feel any better. “I don’t like going out in public, and I’ve given up on dating,” he said. “I don’t want to date because someone will run their fingers through my hair and know it’s a hairpiece. I can’t focus on conversations because I think people are looking at my hair. At times I stay in completely; I don’t even food shop.”In the week before he first saw me, David missed work three times and had considered going to an emergency room because he was so panicked about his hair. “I hate myself and how I look. I’m really down on myself. I’ve even had thoughts of ending my life. I can’t live the rest of my life like this. How can you live in your own body if you can’t stand it?”David started taking fluoxetine (Prozac) right away. He continued supportive psychotherapy (see description below) which had helped him cope a little better but didn’t diminish his BDD symptoms. As expected, the medication didn’t work immediately, and the first month of treatment was rocky. David and I considered hospitalization several times. But with the support of friends, family, and his therapist, he maintained his will to live. About a month after beginning treatment, David started to feel somewhat better. His hair preoccupation began to wane, and the thoughts were less painful. He was more willing to see his friends. He didn’t check mirrors all the time, and he sought reassurance less often. He was no longer considering suicide.He then started CBT while continuing the medication. His CBT therapist helped him stop mirror checking and reassurance seeking. He started going out more and seeing friends. Finally, he even gave up his hairpiece. He received many compliments on his new hair style, and his self-confidence greatly improved.*229\204\8*
MANAGEMENT OF SLEEPWALKINGMy approach to managing sleepwalking is usually one of benign neglect. Children almost always outgrow the problem between the ages of seven and fourteen, with no permanent psychological damage, while virtually any kind of treatment may be worse than the condition itself. Drugs are usually of little value and may produce unwanted side effects. Psychological counseling or behavior modification is a two-edged sword; such an approach may work in some children, while in others it may pro-Time and patience, however, are the best remedies. Some form of family counseling may also help reassure the parents that the child is not suffering from any serious disorder.In adult sleepwalkers there may be an element of emotional disturbance which does need to be addressed. If so, careful psychiatric evaluation is needed to determine which approach has the greatest chance of success. Benzodiazepine drugs such as diazepam and flurazepam may help, primarily due to the fact that they suppress Stages 3 and 4 sleep. Evidence of any benefit from a drug called imipramine, used in the treatment of endogenous depression and childhood bed-wetting, is still inconclusive. It’s also possible that hypnotism, conducted by a qualified professional, may produce some benefits, although many investigators feel it will not work.*179\226\8*
Being afraid is all right. Being hesitant is all right. Feeling vulnerable and defenceless is all right. They are all part of the ongoing development of our self. When we begin to work with it, we won’t know where we are, where we are going and what will happen to us along the way. This is all right too.
There is no exact blueprint on how to get to know our self, no external guide or map we can look at. The blueprint is our self. How to read the map means reading our self. The guide is our self and it will show us how to work through the various stages. From the first step to the last, it will be an individual journey. But what a journey!
As we let the process continue we begin to trust our self and we begin to trust the process. We begin to see familiar landmarks and we begin to see the bridges we need to cross. We get to know the rest stops on the way and we know with growing certainty that we are headed in the right direction.
It does mean changes, but all the resources necessary will be found in our self and we will find them waiting for us at each step. Not only will we find them waiting, we will find they have been there all along. There will be times of uncertainty when we turn back or stop along the way. When we are ready to begin again, we will find the resources are still there.
What does fear hold us back from? Being free. Self-expression. What do we want for ourselves in five years time? Who do we want to be? That person is not going to magically appear one morning. We must work towards being that person. It is a journey in ourselves to ourselves.
All the energy which has been used to suppress our self, can be freed for us to use in whatever way we wish. It is a gift of life which is waiting for all of us. The time will come again for change, far less dramatically, but come again it will and there will be new challenges to meet. This call for growth is part of the evolutionary development in all of us. It is a question of how honest we are being with ourselves, but this honesty is the way of self determination. Of individuation.
It is our choice.
I have often been told people can’t let an attack or the anxiety happen because other people may see it happening. So what if they do. Why are we giving our mental health away to everyone else? We can spend all day trying to hide our symptoms from employers, work colleagues, family and friends. The extraordinary energy and control we use to hide our symptoms only makes us more anxious and exhausted. The more anxious we become the more we have to hide it.
Taking the power back means we cannot let the fear of what other people think get in our way of full recovery. If our hands and legs shake, let them shake. If our face turns bright red, then our face turns bright red. If we feel faint, then sit down on a chair, on the floor, on the footpath, if need be. If we vomit or have an attack of diarrhoea, then we vomit or have an attack of diarrhoea. Let it happen. When we let it happen, we turn off the adrenalin and it will be over as quick as it starts. We will not have to waste all of our energy trying to keep it under control and thereby turning on more adrenalin. Our mental health needs to be more important than other peoples’ opinions. The feelings of embarrassment are created by our thoughts. We have to move from ‘what if to the all powerful attitude of ‘so what’. ‘So what’ if we have an attack, ‘so what’ if we are feeling anxious, ‘so what’ if people see. So what.
Depending on how high our anxiety level is, the anxiety may not disappear as quickly. Learning to manage the anxiety by being aware of our thoughts, letting them go and by letting the anxiety be there, is part of the recovery process. As we work through the process of recovery our anxiety level diminishes, until we are anxiety-free.
We will reach the point where we will have a choice in how we respond, either with fear or by letting it happen. This choice will always be there. After recovery in times of extreme stress we may experience further attacks. We can choose how we respond: either with fear, ‘what if, or by letting go and letting it happen. So what.
The working through process can at times be very frustrating, but the final result is worth every step. Everything which has been taken away from us by the disorder will be given back to us through the clarity of thought and freedom wbich recovery brings.
Live in rooms full of light
Avoid heavy foods
Be moderate in the drinking of wine
Take massage, baths, exercise and gymnastics
Fight insomnia with gentle rocking or
the sound of running water
Change surroundings and take long journeys
Strictly avoid frightening ideas
Indulge in cheerful conversation and amusements
Listen to music
advice to melancholics -A. Cornelius Celsus, 1ST century ad
It is typical for us humans to expect everything to fly into our mouths without work, art, effort, grief and suffering. But all of this is not God’s way; rather, it is His will that we should work hard for our food and that we should want to support both ourselves and those around us.
There is an old joke about a bookseller who is trying to sell a book to a student. ‘It will do half your work for you,’ he claims. ‘Great,’ says the student. ‘I’ll buy two copies.’ It is only human for us to want to have all our work done for us or all our problems solved by a simple remedy such as a pill. The bad news – and, of course, it is not really news at all – is that wondrous though a pill may be, St John’s Wort included, it will not cure all that ails you. The good news is that there are so many ways to help yourself, many of them quite painless and even pleasurable, as the advice of A. Cornelius Celsus above would suggest. Celsus was the doctor to the Emperor Tiberius, a cruel, powerful and frightening man, and the gentleness of Celsus’ advice was perhaps as much politic as it was wise. Paracelsus, an outspoken man, fearless and impolitic in the conduct of his own life, had no qualms about expressing himself frankly. If you want your life to be better, you need to exert some effort to make it so. In my own dealings with depressed people I have found many ways in which modifying elements of one’s life can contribute enormously to an anti-depressant lifestyle that works beautifully in conjunction with anti-depressant medications, including St John’s Wort. In this chapter we will consider some of the many ways that you can help take control of your life and conquer your own depression.
A general guideline is to allow an infant about five or six months old to establish her own sleep habits. By then, most children have the neurological maturity to sleep more soundly. When your child is between fur and six months old, begin to encourage the sleep association you value.
The following is a discussion of the sleep associations that most commonly cause problems.
Feeding. The child who is nursed or fed to sleep learns to need the calming that comes from eating, sucking, and being held. If she rouses during the night, she will call for more of the same. She may also wake seeming “rested” with a burp after 20 minutes, but she will not be establishing dependable routines.
As she loses that newborn drowsiness, begin to keep her awake during feedings (easier said than done for some babies) or purposely rouse her while laying her down so that she knows she is falling asleep in her own bed, not in your arms.
Sucking. Pacifiers help some children settle themselves to sleep. Be aware that their use after ‘about three or four months means that this habit will eventually need to be unlearned.
Rocking. Rocking is a pleasant, calming experience for both child and parent, but it can be a strong sleep association. One alternative is to rock a child to soothe and lull him, but not put him into a full sleep. Or rock until it ceases to be soothing—perhaps at four or five months with the sociable child, or later, as mobility increases, when she squirms to get down to play.
Children love to “nest”—that is, move around in bed until it feels just right. If we confine them by rocking, walking, or whatever, we deny them this winding down pleasure. If you are a “pillow fluffer” yourself, you will understand.
Loveys. Many children become attached to special blankets, stuffed anim or toys. “Loveys” make it easier to sleep without parents. To avoid the pai of a lost or forgotten lovey, make more than one available (buy matchi blankets) or make it so general that a replacement might not be noticed.
This “Readiness Factor” has more to do with the success of all of the methods than any other factor. This cannot be emphasized enough and should certainly not be scoffed at.
Too often parents will succumb to feelings of guilt or to pressure from other people. They try something—usually whatever has been “suggested” m often—and it fails. The list under “we-tried-that” only looks like proof t nothing will ever work.
All methods of addressing sleep problems are difficult even when begun with the utmost determination. To begin before you are ready is to yourself—and your child—up for failure. That sense of failure usually la longer than if you had waited until you were fully ready.
How do you know when you are “ready?” It is a balance of be exhausted, frustrated, and prepared.
Developing a plan that feels personalized to your situation will give you more confidence to begin. Deciding what does and doesn’t feel right about current situation helps you define the problem for yourself. Trouble-shooting “glitches” before you encounter them gives you more ammunition. Work with your partner ahead of time builds a stronger, united front. Find supports before you need them means they will be there when you Examining the range of emotions and thoughts you have on the whole issue v help you give yourself permission to begin. You need to reach the conclusion that it is important to make some changes.
At five months I thought she was too young to sleep better. At seven months; was learning to crawl—and was so frustrated. At a year she wouldn’t leave side. Now she’s two and teething miserably again. Before I know it she’ll be college—1 guess then it’s okay to stay up all night!
Is it too late? “She climbs out of her crib,” “He can cry for hours,” “She still nurses every two hours,” “He has a baby brother now,” the reasons to take or not to take action are many.
It is never too late—you only have more information to take into account. Maybe it would have been easier yesterday, but chances are it will be easier today than tomorrow.
Identifying problem areas and your motivation for making changes are the f steps in problem solving. You also need solid information about children sleep.
At different times we all experience nervous tension of some degree, and we are all familiar with the more obvious signs of anxiety. However, there is a multitude of ways in which anxiety may manifest itself, and some of these are of such a nature that they often mislead both patient and doctor into the belief that the trouble is due to some organic cause rather than to the disordered function of our mind.
I have seen quite a number of patients who had suffered from long-standing anxiety and nervous tension, and who had become so accustomed to their tensed-up state that they had grown to accept it as normal. Each of these consulted me on account of some bodily symptom, and when I commented on their general state of tension, they denied that they felt tense; and it was only after treatment that they realized that an easier and more relaxed way of life was possible for them. Strangely enough, one of these patients is a well-known surgeon.
The surgeon was referred to me by another doctor in the hope that I might be able to help him with a long-standing difficulty with his speech. I could see that he was a tense person, but when I asked him about it, he strongly denied that he was in any way tense, and added that everyone who knew him regarded him as particularly relaxed. His wife was with him at the time, so I asked her to lift up my arm and let it go suddenly. It flopped down with its dead weight on to the arm of my chair. I then asked her to do the same thing with the patient. When she let his arm go it remained stuck up in the air for a moment, held there by the tension in the patient’s muscles. Try as he might, he could not let his arm fall naturally and relaxed.
One day after two or three sessions of the relaxing exercises, he smiled, and said, “I never really knew that I was tense like that.”
Although it has not been completely cured, his speech is much improved, and he has achieved an ease in his ordinary way of life which he had not thought possible.
The signs of anxiety are elusive and may well escape even the physician who does not specialize in this aspect of medicine.
Refer to the definition of sleep problem: When a child’s sleep habits cause recurring or continuing problems for him or for his family, then there is a sleep problem.
The best way to identify a possible problem is to listen to the parents— yourselves. Listen to how you describe the experience of parenting. How quickly, or how often, does the subject of sleep come up? How much energy do you spend thinking, worrying, or complaining about sleep? Are your feelings about your child being colored by your frustration and exhaustion? If there were just one thing you could change about your child or your life, would it be sleep?
EXERCISE 1-1: Types Of Problems
The following checklist will help clarify the type or types of problem your child is having. Mark each sentence that generally describes your child. Use a check mark for those that fit at some times. Circle that check mark if it is a current issue.
1. She wakes during the night and can’t find her pacifier.
2. The only way I can get him back to sleep is to feed him.
3. He sleeps in late and won’t take a nap.
4. She hops out of bed defiantly.
5. He wants several drinks of water and goodnight kisses.
6. She comes to our bed during the night.
7. I can’t wake him in the morning.
8. He won’t be alone in his room because of the “monsters and snakes.”
9. She comes to our room scared and crying.
10. He needs to have all the lights on at bedtime but will look at books forever if I let him.
11. She screams and thrashes around.
12. My husband can’t put her to bed—she only wants Mom.
13. We are ready for bed, but he is not!
14. He calls out during the night wanting juice.
15. She wakes up several times with no particular pattern.
16. He seems to wake about every few hours.
17. He is reluctant to go to sleep at bedtime because he’s afraid of bad dreams.
18. Note any uncircled check marks; these indicate changes—possibly improvements. Fit your answers into the following key to see possible types of problems your child shows. There may be some overlap because the same symptom can be an indicator of several types of problems.
Frequent waken 1, 6, 9, 14, 15, 16 Nightmares and sleep terrors: 8, 9, 11, 17
Night feeder: 2, 14 Difficulty getting to sleep: 4, 5, 8, 10, 12, 13, 17
Unusual sleep cycle: 3, 7, 10, 13, 15