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HOW TO TREAT BDD WITH AN SRIThe recommendations below are based on all of the research studies that have been published to date, as well as extensive experience treating patients with BDD. Keep in mind, though, that your treatment will need to be individually tailored to you, in consultation with your doctor.1. Use an SRI as a first-line medication for BDD, including delusional BDD: The studies I’ve reviewed, as well as my and other clinicians’ clinical experience, indicate that SRIs are effective for a majority of people with BDD. Importantly, the SRIs appear more effective than other types of medications, such as other antidepressants or neuroleptics (antipsychotics). They appear equally effective for “delusional” and “nondelusional” BDD (see Chapter 16 for a description of these forms of BDD).2. You can try any SRI: All of the SRIs appear effective for BDD, so you can use any of them. As you can see from Table 13, fluoxetine (Prozac), clomipramine (Anafranil), escitalopram (Lexapro), citalopram (Celexa), and fluvoxamine (Luvox) have been best studied, but clinical experience suggests that sertraline (Zoloft) and paroxetine (Paxil) are also effective. No scientifically rigorous studies have directly compared the effectiveness of any SRI to that of any other, so we don’t know with certainty whether one is more effective than another. Clomipramine would generally not be used first, however, because it’s a little more likely to cause side effects and can be toxic if a patient overdoses.In my escitalopram (Lexapro) and citalopram (Celexa) studies, a somewhat higher percentage of patients improved than in my other SRI studies. In addition, a higher percentage were “very much improved” (as opposed to only “much improved”). In addition, many patients responded earlier (within 2-6 weeks) than people usually respond to an SRI. While we can’t conclude from these preliminary observations that escitalopram (Lexapro) or citalopram (Celexa) are more effective for BDD than other SRIs, these observations are very encouraging.At this time, there’s no way to predict which SRI (or SRIs) will work (or work best) for you. The only way you’ll know is to try them. It’s best to discuss the options with your doctor.*254\204\8*
ALCOHOLISM TREATMENT AND EDUCATIONAL ACTIVITIESCounselors are often called upon to participate in public and professional education programs. The former might include presentations to high school students, or the church group, or being a panelist on a radio talk show. The latter might take the form of in-service training for other professionals, supervision of trainees or students, or workshops.Do’s. In any educational endeavor, plan ahead—don’t just “wing it.” An effective presentation takes some thought ahead of time. Find out from those organizing the program what they have in mind for a topic (you may wish to suggest an alternative), who will be in the audience and its size, how long you are expected to speak, and if there are others on the program. In choosing a topic consider what would be of interest, ask yourself what kinds of questions are likely to be on the audience’s minds. Do not be overly ambitious and try to cover everything you think someone ought to know about alcohol. If your audience goes away understanding three or four major points, you can consider yourself successful. Pick a subject about which you are more expert than your audience. A counselor might effectively talk about alcohol’s effects on the body to a group of fifth or sixth graders.Any counselor who would attempt to lecture a group of doctors about medical complications is asking for trouble. However, by sharing with physicians practical tips on how to interview an alcoholic or how to tell a patient about a suspected alcohol problem, you can make a big contribution. On that topic you are clearly the expert and able to provide them information they can use and do not already have. Leave time for questions and save some of your choice tidbits for a question-and-answer period.Feel free to develop several basic spiels. Use films or videotapes. A film can be an excellent vehicle for stimulating conversation, but be sure it is appropriate. Three questions for sparking a discussion afterward are the following: “What kind of response did you (the audience) have?” “What new information did you learn?” and “What surprised you?”Don’ts. Avoid crusading, “drunkalogs,” or horror stories. These approaches may titillate your audience; however, most audiences will not identify with what you are saying. The presentation will be unconnected to their experience and you are likely to leave them with a “Not me!” response. Clinical vignettes, too, are usually inappropriate with lay audiences. With professional audiences, if case material is used, great care must be taken to obscure identifying information. Avoid using jargon. Instead, look for everyday words to convey what you mean, or use examples.Professional training. Counselors have a special contribution to make in training of other professionals. A common complaint of many counselors is how ill-equipped other professional helpers may be to work with alcoholics. However, this situation is not likely to change unless and until the alcohol experts, such as counselors, begin to participate in the education of others. So we would urge you to consider this a priority activity.The general do’s and don’ts already listed apply. Here it is especially important to stick to your area of expertise. To our minds, your single unique skill is your ability to interact therapeutically with alcoholics. This is the thing you can share. Often this is most effectively communicated by example rather than by lecturing. However, one trap you should avoid is giving the impression that what you do and know is a mystery that others could never hope to learn. This can come across to your students in subtle ways, through statements such as “Well, I’ve been there so I know what it’s like,” or the offhanded comment that “If you really want to know what alcoholism’s all about, what you have to do is (1) spend 2 weeks working on an alcohol unit, (2) go to at least twenty AA meetings, (3) talk firsthand to recovering alcoholics, (4) and so on.” Any or all of these might be advisable and valuable educational experiences; however, you ought to be able also to explain in very concrete terms what this might provide, why it is valuable.A few words on supervision of trainees or students may be helpful. Do not be fooled by the notion that the arrival of a student or a trainee is going to ease your workload. It shouldn’t. Doing a good job of supervision requires a big investment of your time and energy. Whether the student is with you for a single day, several weeks, or a semester, you will need to give some hard thought to what can be provided to insure a valuable experience for the student. There are some basic questions you need to consider in planning a reasonable program. Do you want the trainee to acquire specific skills or just become “sensitized” to alcohol treatment techniques? What are the student’s goals? What will prove most useful to the student later on? What is the student’s background in terms of academic training and experience with alcoholism? The social worker trainee, the clergy member, the recovering alcoholic with 10 years of AA experience—each is starting from a different point. Each has different strengths and weaknesses, different things to learn and unlearn. In planning the educational program, consider how you will incorporate the trainee. In what activities will the trainee participate? Generally, you will want to have the student at least “sample” a broad range of agency activity but also have a more in-depth continuing involvement in selected areas.Probably the single most important thing is to allow the trainee ample time to discuss what goes on, either with you or with other staff. The idea is not to run a student ragged with a jam-packed schedule and no chance to sit down with anyone to talk about what has been observed. If a student is going to be joining you for an interview, be sure you set aside at least 10 to 15 minutes ahead of time as a preinterview briefing. Also at the conclusion spend some time to review the session, to respond to questions. Do not expect that what the student is to learn is obvious.Be sure to introduce or discuss with clients the presence of trainees. Clients do not need to be provided a student’s resume, or a brochure describing in complete detail the nature of the training program. However, they do need to be told who the trainees are and to be reassured that they are working with the staff in a trainee capacity. Clients have every right to be uncomfortable and apprehensive at the thought that either the merely curious are passing through to observe them or they are being used as guinea pigs. In our experience, most clients do not object to being involved with students if the situation is properly presented and if they recognize they have the right to say no.*179\331\2*
Sexual Causes of Tension-At the present time there is a tendency to lay great emphasis on sex, and the tensions of both young and old are often ascribed to some disharmony in their sex life without due consideration of other factors. This line of approach is particularly common with the amateur psychologist. In evaluating the situation it is well for us to realize that sexual conflicts are in fact a very important cause of anxiety, but that conflicts in other areas are also important, and that anxiety often results from a summation of stresses arising from various problems.
There is another factor which makes it difficult to assess the significance of sexual troubles as a cause of anxiety. People have a tendency to give socially acceptable explanations for things. A man is working hard at his office; there are many difficult problems, and he has to work late at night. He will readily tell you this is the cause of his anxiety, and in a way it is true enough; but he does not readily discuss the tension he feels as a result of his being involved with his secretary. The patient often gives these false explanations quite knowingly for the simple reason that he is too ashamed to admit the real cause to the doctor. In other cases, the patient is too ashamed to admit the true cause even to himself. In these circumstances he believes that he is speaking the truth when he gives the socially acceptable reason as the cause of his trouble.
Anxiety may have an effect on stuttering. The right side of the body is controlled by the left side of the brain and vice versa. In the right-handed person the left side of the brain is dominant over the right, and as a result the right hand is given preference over the left. In those who are left-handed the right side of the brain is dominant over the left. It is believed that stuttering often develops when the dominance of the leading side of the brain is incomplete, or when a potentially left-handed child is trained to function as a right-hander. We see then that stuttering results when the messages from the brain to the organ of speech are indecisive. This indecision may be further increased by the presence of anxiety. This is shown very clearly by the fact that many quite normal people show a hesitancy in their speaking or even a mild stutter when confronted with the task of speaking in some formal situation which produces anxiety.
On the other hand, some people stutter without showing or feeling much tension or anxiety at all. As a general rule these people who stutter in the absence of anxiety do not gain much help in their speech difficulty by practising relaxing mental exercises. However, the majority of stutterers experience considerable tension when they are speaking, and with them the reduction of the general level of anxiety by relaxing mental exercises is a great help toward establishing a pattern of easy normal speech.
James, a 50-year-old professional, wrote to me as follows:
I have had one form or another of depression for over 10 years. My depression has greatly affected my life in many ways. Most notably, my relationship with my wife has suffered and my relationship and reactions to daily work circumstances have been greatly and negatively affected. Many of my attempts to deal with my depression failed.
James describes how he first underwent six months of psychotherapy, which was of no help, followed by a course of Lustral, which helped his depression slightly but caused him chronic diarrhoea, a liability far greater than its minimal benefit in relieving his depression. After he broke his foot, this side-effect became even more inconvenient as he had difficulty getting to the toilet in time. He decided to discontinue the medication and his depression returned with full force.
After doing some research on the herb, James decided to take St John’s Wort on his own; within six weeks of starting to take 300 mg three times a day, his feelings of depression began to subside. ‘My depression is now manageable and I would have to say almost non-existent,’ he concludes. T hope St John’s Wort remains available without a prescription and that the … medical professionals do not attempt to “prescriptionize” it… I hope my short personal history regarding my depression and travels towards St John’s Wort will help to keep it available to the general public’
An infant may need to be six months old before gaining the neurological maturity necessary to settle into an 8-10 hour nighttime stretch of sleep (although many do it sooner). Older children tend to wake periodically due to illness, dreams, or while learning a new developmental task. Very often the cause is undetermined.
Waking for Feeding
After three or four months, a healthy, full-term infant no longer needs night feedings for nutritional reasons. Early risers may wake up hungry.
Separation issues peak at times of developmental disequilibrium (leaps or regression). Typical times: four to six months, nine to twelve months, one and a half to two years, and subsequent half-year stages. Fears are strong for toddlers and preschoolers. Older preschoolers tend to fall asleep quickly once settled.
An infant may have his “days and nights mixed up”—this can be adjusted. Up to and including nine months, an infant may take a third nap around dinner time, so a late bedtime is not inappropriate. Typical bedtime for a toddler/preschooler is between 7:30 and 9:00 pm.
Infants appear to “dream” (or to be affected by dreaming) at around 9 months. Children continue to gain the language to express dreams and fears beginning at age two. This may peak during preschool years.
These are probably experienced by infants, occur most commonly around age four, and decrease by school age.
Children are individuals. Each one brings to the issue of sleep his ñ needs, personality, and physical functioning. This does not mean that you need to accept your child’s sleep patterns as “the way it is.” Your goal as pare is to help your child fit smoothly into your family—and into his world. You can recognize his uniqueness, while teaching him skills to make his life easier.
Commonly, after the sleep issue is resolved, parents notice real difference. The child is more easy-going, less frustrated, happier, and more predictable Parents wonder why they didn’t do something sooner. Parents, too, feel m content and self-confident.
In the long-run, the child’s sense of independence and self-esteem enhanced. When he masters sleep problems, he has mastered an important p of life. (He knows it is important by the significance you—and the rest of world—have placed on it.) Sleep and nighttime can be frightening; child need to know that Mom and Dad are in charge.
A child who continually disrupts his parents’ sleep forms an unhealthy vi of life. He learns that his needs are the only important ones. This is a far from what parents intend.
Perhaps this is the message you would like to send: / love you and I want you to grow up to be a happy person. Sleeping is part life. The way you are sleeping now doesn’t fit with the rest of our family. It becoming a problem for us all. Let’s work on it together.
It is important to remember that there have been no head-to-head trials comparing St John’s Wort with the SSRIs in the treatment of depression. All reports of comparisons between the herbal and synthetic anti-depressants are therefore anecdotal. Nevertheless, there are lessons to be learned from anecdotes and one conclusion I have reached, based on many stories that there are certain people who do better on St John’s Wort than on the SSRIs. When both types of antidepressants are used in their conventional dosages, St John’s Wort appears to be superior to the SSRIs with respect to side-effects. Particularly, it appears to cause fewer sexual side-effects, less weight gain and fewer feelings of dullness in thinking or feeling. When used in their conventional dosages it is possible that the SSRIs may be more potent and I have encountered cases where they have reversed depressive symptoms that did not respond to St John’s Wort alone. In the currently planned multi-centre research study sponsored by the US National Institute of Mental Health, St John’s Wort and the SSRI Lustral are to be compared for the first time; It will be fascinating to see how they stack up against each other. In the meanwhile each depressed person will have to choose the type of anti-depressant – herbal or synthetic -best suited to his or her needs based on the information available and his or her own personal preferences.
A cognitive behavioural therapist will normally work with various types of exposure methods pertaining to our particular anxiety disorder. When wc begin to work with our avoidance behaviour we will probably feel anxious and the ‘what ifs’ may return. In only a few seconds the ‘what ifs’ can create a mountain of fear and anxiety which seems insurmountable. We may forget any management strategies we have learnt, and become caught up in the automatic cycle of thinking.
It is most important to realise that we will feel anxious and frightened when working with a CBT program. By accepting this we can work with it, not against it.
As an example, part of our CBT program may include doing the shopping alone. This can be broken down into easy steps. To begin with, we can go to the shop early in the morning. We will feel more comfortable in letting the anxiety and attack happen if the shop is not too crowded. As we become more confident in letting it happen, we can begin to shop at different times of the day.
If part of our program means going to dinner or the theatre, we can ask to be seated by an aisle or an exit, or both-not so much for a quick getaway, but to help break down the feeling of being trapped. The aisle or exit is there if we do need to leave quickly. If we work with our thinking and let the anxiety and attack happen, we will find we won’t have to leave.