Read More About Health

The 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*

Exercise recommendations vary greatly, depending on the degree of arthritis activity present in the joints. Before undertaking any exercise program, you should always review it with the physician or physical therapist who is familiar with your specific situation. The key to developing and following an effective rehabilitation and exercise program is to know your arthritis.

You may already appreciate that your arthritis can vary greatly over time. You may have experienced a severe flare-up of arthritis in the past after you overexerted yourself. If you know the pattern of your own arthritis, you will be the best judge of which exercises make you feel better and which ones only make you feel worse.

In describing model exercise programs in the rest of this chapter, we have for the sake of convenience divided RA into three different levels of activity: very inflamed, moderately inflamed, and controlled. We recognize that this is an artificial division, however, and that few people fit neatly into any one of these categories all the time. Individuals have different exercise needs. We’d like to stress once again that no one with RA should begin an exercise program without obtaining the advice of a health care professional who is familiar with that individual’s needs.

*73/209/5*

Beth was a bright, vivacious, almost five-year-old when she fell off of a see-saw and had a generalized seizure. A CT scan showed atrophy in the left hemisphere, but she had no neurological deficit. Shortly thereafter she began to have more seizures on the right side of her body. They did not respond to medication, and gradually she began to limp on the right leg and to have increasing difficulty with speech. Clearly something was continuing to happen to the left side of her brain. Another hospital diagnosed Rasmussen’s syndrome and said there was nothing they could do, that this viral-like process would continue to destroy her brain.

Six months later her seizures were occurring several times a day and her speech and right-sided paralysis had worsened. She was seen at Johns Hopkins, where we agreed that she had Rasmussen’s syndrome. We told the family that this condition would inevitably become worse, that children with it become retarded and severely handicapped. We said that this progression would occur over several years. We told them that the only treatment was to remove the left side of Beth’s brain.

Since at this time Beth was walking, talking, and had only slight intellectual deterioration, the family, quite understandably, was reluctant to subject their daughter to a risky operation that would leave her paralyzed on one side and might cause a problem with her ability to speak. They decided to wait.

Six months later, when Beth was clearly having more difficulty with her seizures, with the right side of her body, and with school, they decided to have the operation.

The operation was a success! After a stormy post-operative period, Beth has made a remarkable recovery. She is left-handed and uses her right hand only minimally. Her speech and reading are entirely normal. She has had no seizures since surgery and is on no medications. She is now in the regular third grade, doing well, keeping up with her classmates, telling “knock-knock” jokes, and learning how to play soccer. Clearly for Beth, half a brain is far better than a badly functioning whole brain.

The choice is not always between removing a small part of one side of the brain and removing an entire hemisphere. These are the two extremes. Large parts of one side of the brain can, when appropriate, be removed. The risks and benefits of these operations depend on the abnormality causing the seizures and the area of the brain to be removed.

*164\208\8*

Most people feel at times that they have been abused, neglected, and treated unfairly or even cruelly. The avenger invests enormous amounts of his energy seeking vengeance in one way or another. In this activity’s poisonous form, the avenger simply enjoys hurting other people, as if to lessen the pain he himself has experienced. Sometimes he chooses a career that can serve as an outlet for his vengeance. When he does his job well, someone else suffers in some way or is “brought to justice.” Or, the avenger may dwell on the misery of others as he futilely seeks satisfaction (nourishment) from other people’s misfortunes. He poisons himself further by a refusal to let go of past grievances. Any satisfaction he may receive is temporary, and ultimately the avenger is left empty again.

“I’LL OUTLAST YOU”

This is a frequent pattern in toxic marriages in which one or both partners are committed to a war to the finish. Having decided, for various reasons, that they can’t (i.e., won’t) dissolve the marriage, they engage in an ongoing campaign in which each seems interested in deliberately irritating the other. Their pattern is one of mutual frustration and vindictiveness.

While the toxic interaction is obvious, the endless battle to which each partner commits himself is also a virulent self-poisoning process. The winner also loses. The one who may succeed in literally burying the other has paid an enormous price in the neglect of his own nourishment and growth.

*75\350\8*

There are two key preventive strategies to consider: breastfeeding and soy formula. The longer a child is breast-fed, the lower her chance of developing breast cancer; at the same time the mother lowers her own risk. Breast-fed infants have a 15 to 30 percent lower chance of developing breast cancer both before and after menopause. Breast-feeding also unloads from the breast chemical estrogens into breast milk. This is a risk-free and smart strategy to get your daughter off on the right foot and to drop your own risk of breast cancer. Breast-feeding also completes the maturation of the mothers breast so that it becomes less vulnerable to radiation, secondhand smoke, and other environmental hazards as well as estrogen. The American Academy of Pediatrics now strongly recommends breastfeeding for a full twelve months, with infants taking no other drink or solids for the first six months. This protects babies from a variety of ailments and protects their mothers against premenopausal breast cancer and ovarian cancer. American women who breast-feed for a total of two years decrease their risk 20 to 30 percent.

Infants drinking a soy formula have circulating blood levels of weak estrogens that are 13,000 to 20,000 times higher than their own estrogen production. This makes the use of these formulas controversial. They are having a biological effect, but is it strongly protective or harmful? That amount is six to eleven times more than is required to lengthen the menstrual cycle in premenopausal women — in other words a very powerful dose. In rats, this has proved very helpful. “We’ve been able to show that injections of genistein given to rats during either the neonatal or prepubertal periods results in about a 50 percent decrease of mammary tumors in adults,” says Coral Lamartiniere. Soy formulas have been used now for 30 years without reports of adverse circumstances. Of U.S. babies, 29 percent consume soy formulas. Growth charts do not show growth retardation from soy, nor is bone development different. However, recent concern about potential adverse consequences has caused enough alarm in the United Kingdom and Australia for soy formula consumption to drop by half.

Recommendation

Consider breast-feeding to decrease your risk and that of your child. Consider soy only after careful discussion with your pediatrician.

*61\239\2*

Strong history of heart disease in the family makes a person predisposed to coronary problems in his life. This cannot be changed. But one must remember that food habits, exercise habits and stress pattern are the three main causes of heart disease and are probably responsible for about 90 to 95% of the causes of heart disease.

Thus it is obvious that those who have a disadvantage from the heredity point of view should be more careful about their food habits, exercise, stress reduction and control of other coronary risk factors are concerned.

Most of the heredity effects among these persons come through excessive production of cholesterol and triglycerides in the liver. Liver makes these two elements little more than the body’s requirement. Thus these people, even if they restrict their diet, may still have high cholesterol/triglycerides. Obviously, their chances of having a heart disease will multiply if they do not restrict the fat intake in food.

*20/283/5*

For many pre-menopausal women the impact on, or total loss of fertility, often results in feelings of betrayal, loss, and depression. This is most extreme in women who have no child and had a desire to mother, or with women whose plans for a large family will now be unfulfilled. Most gynecological cancer specialists are very conscious of this and do all they can to preserve at least one ovary (to delay the onset of early menopause) or harvest the eggs prior to surgery. All doctors should discuss with you (and your partner) the range of options you have in preserving eggs pre-surgery, adoption, surrogacy and other child options. For some, however, this is not an option and a profound sense of loss is normal. Counseling may be helpful to help you readjust your earlier dreams, and explore other possibilities. Good counseling will help channel your energies and talents into other areas that will help achieve satisfaction and fulfillment. Partners and carers, however, should be sensitive to the grieving process, which may take time to work through, but is critical for the resumption of a fulfilling life. Most women at this time with this reaction can become quite self-absorbed and need to be mindful that the loss is just as great for their partner. Again, open communication is essential in working through this phase.

I was newly married when I was diagnosed with cervical cancer, and totally devastated that our dreams for a large family were shattered.

Children were not a consideration for me at all immediately after the diagnosis and treatment. At that point I was just happy to be alive, just wanting to get the first year over and done with. We now have our beautiful and greatly loved (adopted) daughter.

Marie

I was devastated at age 28 that a hysterectomy would remove my option to have a child. My doctor told us of surrogacy in the USA. It was this rather ‘unconventional’ information that kept me sane.

An email support group introduced me to a wonderful lady, who was to become our surrogate.

We are now the proud parents of a beautiful daughter.

Grace

Post-menopausal women, and women who have no desire to mother are often more pragmatic about removal of the womb and loss of fertility, although some may see it as a loss of their ‘femaleness’. Resumption of other life activities takes priority.

Regardless of our state of fertility, our ability to love, to nurture, to make a meaningful contribution to our world can still be achieved. We acknowledge that in the early stages of loss, the process of grieving is essential but distorts this thinking. In time, most women come to terms with the loss and put their energies into other pursuits.

*41/144/5*

The narrowing of the bronchi in a child can be detected early enough by measuring the rate of air flow or the peak-flow of the breath with the help of small, portable devices called peak flow meters. These can detect changes in the bronchi before any apparent symptoms of breathlessness, or the detection of wheeze through the stethoscope. The test is itself quite simple, the instrument not very expensive and the child can perform the test independently.

Peak Expiratory Flow Monitor or Meter measures the force of expiratory breath. The child after a full inspiration, exhales forcefully into the tube of the monitor which has an indicator and a scale attached to it. The force of expiration is indicated by the push of the indicator along a scale and is read as Peak Expiratory Flow Rate (PEFR). Usually with the onset of asthma there is a narrowing of the airways and the force of expiration decreases.

Although many asthmatics have normal lung volume, their obstructed bronchial tubes prevent air from being exhaled at the normal speed. If the first set of breathing tests show abnormal results, the child is asked to inhale a bronchodilator drug and repeat the test. Testing the amount of air that can be forcefully exhaled in one second (FEV1, forced expiratory volume in one second) is the most important test in asthma. If the second set of tests shows more than a 15 to 20 per cent improvement in the FEV the diagnosis of asthma is almost certain.

A peak flow meter can be compared to a thermometer. Sometimes a child may feel hot or feverish but the thermometer may show normal body temperature. Similarly a child may sometimes complain of a tightness or heaviness in the chest, but may still have normal lung function. The peak flow meter helps in determining whether the tightness of the chest is really an airway obstruction. It is light and simple and can be used at home, office or in a doctor’s clinic.

Measuring and Interpreting PEFR

1. Move the indicator to the base or the bottom of the numbered scale.

2. Stand up.

3. Take a deep breath.

4. Place the monitor in the mouth and grip the mouth piece with the lips.

5. Blow out as hard and as fast as possible. The indicator will move up.

6. Write down the achieved measurement or value.

7. Record the highest of the three measurements achieved.

*54\260\8*

Initial treatment of primary peritonitis is often empiric, since the Gram stain is frequently (60% to 80% of the time) negative. Broad antimicrobial coverage should be started until the results of culture and susceptibilities are available. The combination of ampicillin plus an aminoglycoside has generally gone out of favor for patients with cirrhosis, given the potential for nephrotoxicity in this group. Third-generation cephalosporins are often recommended, but many other agents, including carbapenems (particularly, imipenem) and beta-lactam/beta-lactamase-inhibitor combinations (e.g., ampicillin-sulbactam) are alternative options. Anaerobic coverage (metronidazole or clindamycin) should be added, unless a beta-lactam/beta-lactamase inhibitor combination is used. If cultures remain sterile but there is a strong clinical suspicion of primary peritonitis (CNNA), antibiotics should be continued. Treatment is usually continued for 10 to 14 days, although a shorter course of therapy for 5 days has been found to be effective in patients, who are clinically well with a declining ascitic fluid leukocyte count and negative cultures after this period of therapy. Clinical improvement as well as a decline in the ascitic fluid white blood cell count should occur by 48 hours of treatment if the diagnosis is correct; otherwise, further evaluation to rule out other pathologic conditions should be done.

While treatment is successful in more than 50% of cirrhotic patients, the overall mortality rate of SBP is high, between 57% and 70%, primarily because of the underlying disease. Patients with the poorest prognosis include patients with renal insufficiency, hypothermia, hyperbilirubinemia, and hypoalbuminemia.

*90/348/5*

Counselors 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*