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DEALING WITH THE CAUSE OF INSOMNIA: HIDDEN DEPRESSION
As with anxiety, people don’t always know that they are depressed. They may feel constantly tired and lethargic; some people complain they can’t concentrate, or that their memory is going. Others may get physical aches and pains, particularly headaches and backaches, or lose their appetite for food or sex. In some, depression disguises itself as anxiety. So if you haven’t been able to fathom the cause of your insomnia, could you be concealing unhappiness from yourself?
Anti-DepressantIt took further tests and in-depth interviewing for her to begin to realize what she was really feeling: that for the first time in her life she felt increasingly useless. Her children had left home, some neighbours who had always leaned on her for support had moved, and she felt her life was over, with nothing left for her to do.
Tests in a sleep laboratory showed that she really was sleeping very poorly. She was given an anti-depressant sedative, which helped her to sleep, and with psychotherapy she explored ways of becoming useful again, finally becoming involved in voluntary work for a charity. Nine months later she was off all drugs and her sleep was greatly improved; objective measurements showed that it wasn’t perfect, but she was satisfied with the sleep she was getting, as well as with her daily life.
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DEALING WITH THE CAUSE OF INSOMNIA: LOOKING AFTER YOUR BODY
Anxiety, depression, and obsessive thinking all have a strong physical component, since they trigger the production of stress hormones which create further anxiety, depression and obsessive thinking. Breaking the cycle by looking after your body will have a positive feedback on your emotions.
Stress hormones are actually produced to gear us up for action. If you start taking regular exercise you will get rid of them healthily. You have to make a commitment, says my ’super-anxiety’ friend; part of her strategy was to go swimming every day. She had to force herself to go to the pool for the first few days, but it was worth it; feeling physically relaxed and well helped her to get back in control.
I’ll be going more fully into looking after the body in Parts 3 and 4, but meanwhile, remember that:
Caffeine can keep the mind churning, and in some people causes depression and anxiety.
Smoking also over-stimulates the nervous system.
Alcohol may lift your mood short-term; long-term it depletes the adrenal glands and can make you more anxious or depressed.
Anti-DepressantLearning to relax physically helps you to relax mentally. It’s quite hard to be relaxed and feel anxious or unhappy at the same time.
Check whether environmental stress is making you feel worse.
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Anti-DepressantThe BDDQ questions ask about the core definitional features of BDDЂ”what’s required for the diagnosis. But BDD has some features that, while not necessary for the diagnosis, can provide clues to its presence. These include frequent mirror checking, excessive grooming, face picking, reassurance seeking and other behaviors.
I’ve sometimes observed strangers doing things that have made me wonder if they have BDD. I once saw a young man in a parking lot who stood outside his car repeatedly checking his hair in a side-view mirror, frantically combing and recombing it. He wasn’t simply taking a quick glance, as some people mightЂ”instead, he seemed “stuck” there, and appeared extremely agitated and distressed over the state of his hair. I once drove behind a woman on a busy highway for about 20 miles who spent most of the time looking in her rearview mirror fixing her hair, rather than looking at the road. And what about the young woman I saw at a baseball game who seemed to have normal body hair everywhere except her arms, which had none? Had she removed it through excessive “grooming,” trying to improve “excessively” hairy arms? Did any of these people have BDD? Without talking with them, I couldn’t make the diagnosis. But their behaviors were clues to the diagnosis that made me wonder.
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STRESS AND MARRIAGE BREAKDOWN: COMMUNICATION PROBLEMS AND STAGE THREE BREAKDOWN
In stage three stress breakdown, the over-stressed person is no longer capable of not responding to things he learned to not respond to. Stage three symptoms also include a switching-off response to big problems and worries, while the person continues to respond normally to lesser problems. The result of these two symptoms is to produce a real communication problem. This is true enough if just one of the couple is suffering from stress symptoms, but if both are suffering, as is usually the case, communication becomes very difficult.
In our normal pattern of communicating our feelings and ideas, it is often what we avoid saying that is the real communication. For example, ‘She pointedly didn’t mention making out a new will’, might well mean that the lady in question is communicating to a relative whom she had previously blackmailed with the threat of exclusion from the estate, that all is forgiven. Not saying something when a person might be expected to say something could be a very significant communication in itself.
Meaningful pauses, facial expressions and tone of voice are very important in conveying meaning in spoken language. It is entirely possible to have someone deliver a whole speech on a particular topic and convey something totally different, just by altering the emphasis: overstating the case here, understating it there, etc.
Under conditions of breakdown the ability to respond to tonal communication and to communicate by significant restraint is lost. Many couples under stress complain of not being able to communicate with each other. This complaint is a common reason for referral to marriage counseling agencies. However, it is important to realize that two people who have been getting on well for years don’t just lose the ability to communicate without a particular reason. Stress breakdown is a major cause; it is very important to identify stress breakdown early because quite often, joint interviews aimed at improving communication between husband and wife might just put more stress on either or both, and worsen their already over-strained relationship.
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DEALING WITH THE CAUSE OF INSOMNIA: SOMEONE TO TALK TO
Whether you suffer from anxiety depression or some other form of unhappiness, there’s an awful lot you can do to help yourself, but that doesn’t mean that you have to do it all yourself. Bottling up your feelings inside keeps them on the churn. Just talking with someone who’s sympathetic but objective can release some of that bottled-up energy.
Friends and partners can be a great support, but sometimes people who know you well try to cheer you up or change the subject, when what you really want is a listening, receptive ear. Friends and relations can also feel uncomfortable when they hear you aren’t happy, and may tell you that of course you don’t really feel that way, and all you need to do is to pull yourself together. This is not helpful. Sometimes, of course, they are the cause of your problems, and you find it hard to tell them what’s on your mind.
Don’t be embarrassed about seeking help from a counsellor or psychotherapist, or feel there’s something shameful about needing such help. There really isn’t. After all, nobody feels embarrassed at consulting an expert about their finances or buying a new car. Why should you worry about seeing an expert on that priceless item, your emotional health? Getting help in order to help yourself is a much healthier option than staying miserable.
Many personal problems can be helped by short-term counselling. There are cases when psychotherapy can be helpful, when the person hasn’t got over traumatic childhood events, for instance. Some people feel that seeing a psychotherapist may be opening a whole can of worms, and they’d rather not, thank you. But if you are sitting on a can of worms, really it’s better out than in! Otherwise they simply go on niggling at you.
Psychotherapy doesn’t necessarily mean years of delving into the painful past. It’s true that how we deal with life and relate to other people is affected by our past. But the purpose of psychotherapy is to change our reactions in the present. (Some psychotherapists and natural practitioners use a technique called Voice Dialogue, which enables all those inner voices to be heard, which in itself can alter your perceptions of yourself, and is also fun.)
Nor will you be putting yourself in the hands of someone who’ll take over your life and tell you what to do. A good counsellor or therapist will accept you as you are, for who you are, and listen to you in a way that people who are involved with you may not be able to. Being really heard will help you to listen to yourself and understand yourself in a new way. As you begin to unburden your mind of problems, you can begin to find your own solutions.
That said, the field of psychotherapists and counsellors contains both good therapists and bad. I have heard complaints that some psychotherapists do keep their clients in a subservient role, putting them in the wrong or making them feel inadequate. If you start therapy with anyone like this, just leave. These people are also quite skilled at making you feel guilty when you announce you are leaving; don’t let them. It’s your life, and a therapist’s job is to make you feel more whole, not smaller.
How do you set about finding this kind of help? Here are some of the sources you could try:
Your doctor:
Some GPs are very aware of the value of counselling, and are good at it themselves when they have the time. Some are in touch with local counselling services to whom they can refer you. They can also refer you to psychiatrists or clinical psychologists within the National Health Service.
Other doctors, alas, are less clued up; you can still ask them to get you an appointment with your local hospital psychiatric or psychological medicine department.
Psychiatrists:
They have a medical training and can prescribe drugs if they feel it necessary, which isn’t always the case. To a normally anxious person, for example, some may recommend relaxation training, or meditation. Some may refer you on to a psychologist; some have themselves taken additional trainings in subjects like hypnotherapy or psychotherapy.
Anti-DepressantThey work within the NHS and are not doctors, but are trained in helping with emotional problems. They may have a number of techniques to offer, from practical advice to psychotherapy. A popular form of therapy these days is cognitive therapy, aimed at helping people to change a negative self-image by identifying and changing the ways you talk to yourself (along the lines suggested in the previous chapters).
Unfortunately, there are not too many clinical psychologists around; there are only some 1800-2000 in the country. Whether you can get a speedy appointment depends on their availability in your part of the country; in some areas there is a one-year waiting list. But it’s worth trying.
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YOUR SLEEP AND OTHER PEOPLE: PARTNERSHIP PROBLEMS
Most marriages and partnerships go through bad patches; feeling resentful towards your partner can be a major source of sleeplessness. Do try to resolve your problems, or at least start to, during the day or early evening: don’t leave it until bedtime to have rows. And don’t lie in bed brooding over your partner’s faults and telling yourself that if only he or she were different you would be quite happy.
You cannot change other people; what you can do is to tell them how you feel Ђ” they may have no idea. And give them the opportunity to tell you how they feel. People often make totally false assumptions about what’s going on in someone else’s head, even their nearest and dearest. Talking openly and honestly, and listening to the other person’s point of view as well as expressing your own, can clear the air remarkably at times.
Women often have difficulty in acknowledging that they are angry at all; we are still brought up with the idea that anger isn’t very nice. Some women repress their own wants and needs in order to be perfect wives and mothers; they don’t realize that underneath they are quite angry at constantly giving out to others. This kind of situation can trigger insomnia. If you are constantly giving out to others, make sure that you get your own needs met as well.
It has been found helpful for couples to have a regular weekly date and time for expressing their grievances in turn, and listening to each other without interruption while they are expressed. End the session by telling your partner what you appreciate about them; couples often neglect this. You hear people say, ‘I don’t have to tell my wife/husband I love her/him, she/he knows without me telling her/him.’ I think that’s an awful pity. It doesn’t matter whether we know or not, it’s always heartwarming to be told.
When you live with someone else it can be a good idea to have a spare bed ready made up, or a sofa, to which one of you can retire when you both need space. (Don’t retire to it forever, though, if you want to keep the relationship going.)
In some of the books and articles I’ve read about insomnia, the writers remark gaily that sex is the one activity it’s good to indulge in before bedtime, the assumption being that you then drop off, happy and relaxed.
Anti-DepressantIf you have a good relationship and goodwill on both sides, and if your partner agrees, ask your doctor to put you in touch with a sex therapist (unfortunately they’re not easily available on the NHS), or get in touch with a marriage guidance counsellor. If there’s no real goodwill, of course, you need to ask yourself why you are staying in this marriage. Again, it can be helpful to see a marriage guidance or some other kind of counsellor, to help you to clarify the confused feelings that are keeping you awake.
Even in a good relationship, there’s usually room for improvement. Many men don’t realize that physical contact doesn’t have to lead to sex, and studiously ignore their partners if they don’t feel like performing. Meanwhile, the woman may be longing for a friendly cuddle. Learning to touch each other in non-sexual ways, perhaps by taking a massage course together, can do a lot for your relationship and your sleep.
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TOWARDS GOOD SLEEP: RELAXATION AND PAIN
Relaxation is one of the techniques employed in pain relief clinics, and research into its benefits has been carried out in London hospitals. Properly taught, it has been found to reduce not only anxiety but the amount of painkillers required after operations.
There are two possible ways of dealing with pain: to accept it and relax into it, or to focus your mind on something completely different. Although these two methods might seem contradictory, what they have in common is that both remove the resistance to pain. Resisting pain always makes it worse; tensing up against it tightens muscles and restricts the flow of blood. Mentally resisting also makes it worse. So, some alternatives are:
Anti-DepressantUse imagery while you relax, perhaps visualizing the pain as a blob of colour which slowly melts, running out of the body through your fingers or toes.
Focus on something other than the pain, so long as it’s something pleasant: imagine yourself in beautiful surroundings, or remember a place where you have felt particularly happy and peaceful.
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DEALING WITH THE CAUSE OF INSOMNIA: DEALING WITH SPECIFIC PROBLEMS
If you’re being kept awake by specific problems, learn to deal with them during the day, so that you don’t take unfinished business to bed with you.
Find some time during the day or early evening to write a list of the worries or anxieties that are keeping you awake. A friend of mine who did this realized she had one ’super-anxiety’, around which revolved a set of sub-anxieties. Once she’d taken steps to deal with the super-anxiety, many of the sub-anxieties were automatically cleared up, and the rest became much less important.
Having identified the super-anxiety, write down what you can do about it. If you’re worried about a job interview, what steps can you take to prepare yourself for it? If getting a job interview is difficult, what can you do about it? Are there any alternatives to the kind of action you’ve been taking so far?
Once you’ve decided on your course of action, close your eyes for a few minutes and see yourself taking it. If you are anxious about a forthcoming event, or finally doing that thing you’ve been nervous about, picture yourself dealing with it calmly and efficiently; don’t imagine all the difficulties in the way, but see the successful end-product. Set the scene very clearly: see yourself with your problem solved or having achieved the thing you fear doing. Imagine telling someone about it, and hearing their congratulations. Don’t worry if you can’t visualize clearly; imagine how you’ll feel Ђ” relieved, pleased with yourself, no longer anxious. In this way you are priming your brain with the fact that solutions are possible; anxiety or hesitation are not the only options.
Anti-DepressantThen, having identified what action to take, do it! It’s amazing how anxiety and fear disappear and depression lifts when you actually get going on a project. The mind can’t focus on two things at once. Actors who suffer from stagefright lose it when they walk on the stage and begin concentrating on their roles. If you are really involved in and concentrated on an activity, there isn’t room for negative feelings.
Supposing, for some reason, there is no direct action you can take to deal with the problem itself? What you can do right now is to take physical action to deal with your state of anxiety, depression or lethargy.
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Anti-DepressantBDD isn’t rare. In fact, the numbers shown on the next page indicate it’s fairly common. Research studies have found that about 1% of adults in the general population in the U.S. and Italy have BDD. These studies used DSM criteria and diagnosed BDD with face-to-face interviews, so the percentages may be fairly accurate. Studies of students have found far higher rates of BDDЂ”from more than 2% of high school students to as many as 13% of college students. Some of the student studies used self-report questionnaires rather than face-to-face interviews to diagnose BDD, so they may have overdiagnosed it to some extent. We need much larger and more scientifically rigorous studies to more precisely determine how common BDD is in the general population and in students. But in the meantime, these study results indicate that millions of people in the U.S. alone have BDD.
Studies in clinical settings also suggest that BDD is fairly common. A study of 122 people in Minnesota who were hospitalized on a psychiatric inpatient unit found that a surprisingly high percentage (13%) had BDD. BDD was more common than schizophrenia, obsessive compulsive disorder, social phobia, eating disorders, and many other disorders. Rates of BDD among people receiving mental health treatment as an outpatient have found varying but often high rates, depending on the group being assessed. A study of patients with anorexia nervosa, for example, found that 39% also had BDD. Several studies of depressed outpatients found that BDD is more common than a host of other psychiatric disorders in people with depression .
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WHY BDD IS UNDERDIAGNOSED: LACK OF FAMILIARITY WITH BDD AND BDD CAN BE TRIVIALIZED
Lack of Familiarity with BDD
Anti-DepressantBDD Can Be Trivialized
BDD can be easily trivialized. Why should he care so much about a few pimples? How could she be so worried about her face when she’s so pretty? The fact that BDD sufferers generally look fine, combined with the fact that appearance concerns are so common in the general population, contribute to its trivialization. BDD can be mistaken for vanity. But anyone who knows someone like Jennifer or Jane is only too aware of how seriousЂ”even life-threateningЂ”the disorder can be.
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TREATMENT OF STRESS BREAKDOWN
When we come to discuss the treatment of stress breakdown, the first point to make is that correct diagnosis is essential before attempting any treatment, because treatment appropriate for stress breakdown will be of no use for the other conditions which may resemble stress breakdown. Moreover, wrongly giving a patient who in fact is suffering from stress breakdown a treatment designed for some other disorder, may well make the over-stressed patient worse.
Therefore we need to understand stress breakdown before we can treat it properly.
Understanding stress breakdown is the key to successful treatment, and the best treatment is prevention.
Firstly, I need to say that the best, most effective treatment always for stress breakdown is prevention. Stress breakdown is much more difficult to treat than to prevent, because the fact of having broken down becomes a stress in itself; further, treatment for stress breakdown may have to include the mending of hurts and strained relationships caused by the symptoms of the stress breakdown.
Secondly, before discussing treatment for stress breakdown I need to clarify exactly where the anxiety equation fits in with stage one. I don’t want to give the impression that all conditions which cause anxiety can progress on to cause further stress-breakdown symptoms.
The anxiety equation suggests that there can be a number of reasons why a person will experience anxiety. One of them is excessive overload of the nervous system. Others, for example, low blood-glucose levels and sedative drug withdrawal, might produce anxiety when the nervous system is not unduly overloaded. However, these conditions in themselves need not lead on to stage two breakdown.
The necessary precondition for stage one stress symptoms to progress to stage two is the use of will-power mechanisms to ignore the anxiety symptoms and to stay in the stressful situation.
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Other names: Eldepryl
DEALING WITH THE CAUSE OF INSOMNIA: THE UNFULFILLED MIND
Anti-Depressant
Parkinson And AlzheimerThere can be physical reasons for light, broken sleep, particularly lack of exercise, so a good start to dealing with malsomnia is to ensure that you take regular, physically tiring exercise. But broken sleep may also be a message that you need to do something about your daytime life. Dr Lambley suggests that sufferers are anxious, nervous people who are afraid of taking risks; over-protective of themselves, they avoid confrontations and challenges. They may be people who try very hard to be ‘good’, avoiding conflict and therefore only partly living. They can also be people who have retired from work that made life meaningful, and instead of enjoying the rest that they looked forward to, feel bored and unfulfilled.
Like the rushers-round, they are not really working towards what they really want, and they are also depriving themselves of the conflicts and challenges that generate REM sleep and dreaming. The inner voices here may be connected with over-protective or over-critical parents. Many people have found it difficult to reach their full potential because a mother or father dealt them the double message: ‘It’s really important to be a success Ђ” but of course, you are not good enough!’ Which is enough to immobilize some people for a long time.
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STAGE THREE OF STRESS BREAKDOWN: LOSS OF ABILITY TO HOLD PREVIOUSLY STRONGLY-HELD VIEWS
We may hold views on politics, morals and religion which may not be held by others but which will be stoutly defended against arguments to the contrary.
In order to hold strong views which differ from those of another person, we need to play down the importance of those things which the other person regards as paramount, and vice versa. Thus our ability to hold strongly differing views relies to some extent on our ability to diminish the importance of what the other person holds dear. This requires psychic energy to negate the value of the other person’s principles. In stage three stress breakdown, a person has begun to lose the ability to negate the other person’s view; the over-stressed person may not be able to resist being talked out of his views where they differ significantly from those of another.
In the third stage of stress breakdown, people have begun to lose the ability to use their will-power to negate a truth held by someone who differs from their own views. Hence it becomes very difficult to resist being talked out of holding views that required the person to ignore the value of an opposing truth.
Commonly used ‘brain-washing’ techniques aim to produce stage three stress breakdown in the victim, who is then no longer able to resist the arguments of the interrogator.
Most brain-washing techniques will aim at getting the person into stage three stress breakdown, often through lack of sleep, torture, and deprivation of various kinds, sufficient to produce severe stress. If severe life-threatening stress is teamed up with measures designed to lower the efficiency of the brain’s processing capacity, as well as encouraging the victim to oppose his interrogators with his will-power, then the appropriate conditions are present for rapid stress breakdown. The victim rapidly develops stage three stress breakdown symptoms, in which state he is no longer capable of resisting the arguments of his enemies.
The victim is then easily persuaded out of previously-held beliefs and will be unable to hold back information which he has been trying not to reveal.
On the basis of my reading, I am sure the evidence is that it is only possible to brainwash someone out of believing some doctrine when it required some form of psychic negation of an opposite view to develop or accept that doctrine in the first place.
Within relationships, this inability to hold to previously strongly-held views may result in what appears to be a change in moral values, work ethic and role differences in families.
The complaint most frequently expressed by married couples experiencing this symptom of stress breakdown is one of unexplained failure of communication. People complain of sudden changes in the value systems of their spouses. The relatively less-stressed person finds the over-stressed person difficult to understand. ‘My wife doesn’t understand me, doctor. I just can’t seem to get through to her. I say one thing and she just hears something else. We can’t seem to communicate.’ Or, ‘I just can’t make him out any more, doctor. He’s definitely not the man I married. I think he must be going through one of these change of life crises or something. I think he’s definitely developing a split personality!’
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Anti-DepressantThe purpose of criterion (the preoccupation isn’t better accounted for by another disorder) is to ascertain that people with anorexia nervosa and certain other psychiatric disorders don’t get misdiagnosed with BDD. Anorexia nervosa is a disorder in which peopleЂ”usually young womenЂ”think they’re fat and lose excessive amounts of weight to avoid being fat; in reality, they’re terribly underweight. Sometimes they become skeletal but still fear they are, or will become, fat. According to DSM-IV definitions, someone whose only concern is that she’s too fat and who is significantly (about 15% or more) underweight (and who meets certain other criteria for anorexia) should be diagnosed with anorexia nervosa, not BDD.
But the relationship between BDD and anorexia gets complicated when we consider the following: some researchers suggest that the core disturbance in anorexia nervosa isn’t a problem with eating or food, but with body image. Indeed, people with anorexia fulfill criterion 1 for BDD in that they’re preoccupied with a defect in their appearance (being fat) that others don’t perceive. This view raises the very interesting and even heretical question of whether anorexia might be a form of BDD. If so, we would need to delete BDD’s criterion. The interesting relationship between eating disorders and BDD is one that I’ll return to in Chapter 16. For the time being, however, if a person’s only significant appearance concern is that she’s too fat, and she otherwise meets all diagnostic criteria for an eating disorder, she should be diagnosed with an eating disorder, not BDD. However, a person can have both an eating disorder and BDD. A woman who thinks she’s too fat and her nose is too bumpy has both disorders. In fact, many women with an eating disorder also have BDD. In other words, they have additional problematic body image concerns unrelated to being fat or overweight.
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PSYCHOSOMATIC DISORDERS IN STAGE THREE BREAKDOWN
I just want to mention here how psychosomatic symptoms occur in stage three stress breakdown because of malfunction in conditioned reflexes.
A lot of the housekeeping of the body is done automatically; seeing we didn’t have to learn things like how to sneeze or coordinate stomach secretion of gastric juice with bowel movements, we can’t really forget how to co-ordinate them either. These built-in nervous system reflexes are not affected by stress breakdown.
Instead, it is those reflexes which have been learned through experience which are affected by the switching-off protective responses of the brain in stress breakdown. Thus the reflexes affected in third stage breakdown are those where we have learned, to some extent, to control body functions. These will primarily affect three areas of function.
1. Reflexes concerned with preparing for the ingestion of food.
2. Reflexes concerned with inhibiting large bowel elimination of faeces.
3. Reflexes concerned with the contraction of the bladder when it is filled.
When we imagine food, or visualize food before a meal, saliva is produced in anticipation of eating, and the stomach prepares to receive food by secreting gastric juice in anticipation. The preparation for receiving food into the digestive system also includes a readiness of the gall bladder to secrete bile into the small bowel, and a readiness of the pancreas to respond by excreting enzymes into the small bowel and to secrete insulin into the blood stream.
The amount of sensory input into these readiness reflexes determines the response of the system. Therefore, if the food is on the table in front of the person and the sight and smell of the food is increasing the level of input, then the law of strength of the nervous system would normally be in operation. That is, the more intense the input stimuli, the more preparation the digestive system responds with. By the time the food is in the mouth, there has already been some secretion of gastric juice and some increase in stomach movements in preparation.
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DEALING WITH THE CAUSE OF INSOMNIA: THE CHURNING MIND
Probably the most common complaint among poor sleepers is difficulty in getting off to sleep. It’s almost always related to a mind that won’t switch itself off. Your thoughts go round and round, you toss and turn, and an hour later you’re tired, twitchy, and wide awake.
The churning mind may be caused by anxiety about something specific Ђ” an exam, a job interview, a work project, a partner’s illness, or the state of your finances. It is possibly caused even more often by resentment or anger, brooding over unpleasant events, sometimes from the recent past, sometimes from way back. You relive the scenes, inventing scenarios in which you find just the right words to put down that person who insulted you yesterday, or even years ago. Or you may be feeling depressed and lonely, wishing your life were different, blaming yourself or others because it isn’t, and replaying past regrets, missed opportunities, or lost happiness.
A great deal of night-time churning is connected with unfinished business, something that computer in your head can’t stand. It chugs away looking for solutions, and won’t shut up. Or it allows you to get to sleep, and then wakes you up with a bad dream to remind you of a problem, or to tell you, ‘Hey, we really must do some worrying about this!’
Anti-DepressantSome people aren’t particularly worried about anything, but just have very active minds. Many of them accept this, often creative people who come up with creative ideas as they lie awake. But if your thoughts are unpleasant, sad or anxious, they are crying out to be dealt with.
Bed is not the place to deal with them.
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THE LAW OF STRENGTH OF THE NERVOUS SYSTEM
If I tap my patellar tendon just below the kneecap when my leg is flexed at the knee, the leg will extend. This is the knee-jerk reflex. If I tap it harder, the reflex is more brisk and the response is stronger. Within limits, there is a simple law operating in the nervous system with regard to reflexes that a weak input stimulus will produce a weak response, and a stronger input stimulus will produce a stronger response.
Not only does this law of strength hold true for the reflexes in my body which are automatic and which I did not have to learn, but it also holds true for reflexes which I have learned during my life experiences.
We have all experienced how learned skills become automatic after a while, as we become conditioned to respond in this way. Take driving a car, or riding a motorcycle, for example. The clutch- gearshift co-ordination movements become so automatic that we don’t even have to think about them after a while. These reflexes are called conditioned reflexes.
(I once rode an Ariel 500cc motorcycle while I was studying first year medicine in 1962, in Townsville. After I had become reasonably adept at riding this motorcycle, I discovered something strange. Whenever I checked, while riding along, to see which gear the bike was in by touching the gear lever with my foot, the bike slowed down, unexpectedly and for no apparent reason.
I then discovered that I had become so conditioned to cutting back the throttle with my right hand when I depressed the gear lever in changing gear that simply touching the gear lever with my toe was automatically producing the wrist rotation which was causing the inadvertent throttling back. The two actions had been coordinated into a conditioned reflex which did not require me to be conscious of it.)
The law of strength applies to these conditioned reflexes, as well as to the unlearned, built-in reflexes such as the knee-jerk reflex. That is, the conditioned response will be stronger if the input stimulus that triggers it is stronger. However, when the input is too strong, the response will be diminished because of the operation of circuit breaker mechanisms.
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WHY BDD IS UNDERDIAGNOSED: CLUES TO THE PRESENCE OF BDD
1. Do you often check your appearance in mirrors or other reflecting surfaces, such as windows? Or do you frequently check your appearance without using a mirror, by looking directly at the disliked body part?
2. Do you avoid mirrors because you dislike how you look?
3. Do you frequently compare yourself to others and ofjen think that you look worse than they do?
4. Do you often askЂ”or want to askЂ”others whether you look okay, or whether you look as good as other people?
5. Do you try to convince other people that there’s something wrong with how you look, but they consider the problem nonexistent or minimal?
6. Do you spend a lot of time groomingЂ”for example, combing or arranging your hair, tweezing or cutting your hair, applying makeup, or shaving? Do you spend too much time getting ready in the morning, or do you groom yourself frequently during the day? Do others complain that you spend too much time in the bathroom?
7. Do you pick your skin, popping pimples or trying to get rid of blackheads or blemishes, because you’re trying to make it look better?
8. Do you try to cover or hide parts of your body with a hat, clothing, makeup, sunglasses, your hair, your hand, or other things? Is it hard to be around other people when you haven’t done these things?
9. Do you often change your clothes, trying to find an outfit that covers or improves disliked aspects of your appearance? Do you take a long time selecting your outfit for the day, trying to find one that makes you look better?
10. Do you try to hide certain aspects of your appearance by maintaining a certain body positionЂ”for example, turning your face away from others? Do you feel uncomfortable if you can’t be in your preferred positions?
11. Do you think that other people take special notice of you in a negative way because of how you look? For example, when you walk down the street, do you think others are noticing what’s unattractive about you?
12. Do you think that other people are thinking negative thoughts about you or making fun of you because of how you look? Are you “paranoid” because of this?
13. It is hard for you to leave your house, or have you actually been
housebound, because of how you look?
14. Do you frequently measure parts of your body, hoping to find they’re
as small as, as large as, or as symmetrical as you’d like?
15. Do you spend a lot of time looking for information or reading about
your appearance problems in the hope that you’ll reassure yourself
about how you look or find a solution to your problem?
16. Have you wanted to get cosmetic surgery, dermatologic treatment,
or other medical treatment to fix your appearance when other peo-
ple (for example, friends or doctors) have told you such treatment
isn’t necessary? Have surgeons been reluctant to do cosmetic sur-
gery, saying the defect is too minor or they’re afraid you won’t be
pleased with the results?
17. Have you had cosmetic surgery or dermatologic treatment and been
disappointed with the results? Or have you had multiple surgeries,
hoping that with the next procedure your appearance problems will
finally be fixed?
18. Do you work out excessively to improve your appearance?
19. Do you diet, even though others tell you it isn’t necessary?
20. Do you avoid having your picture taken because you think you look so bad?
21. Are you late for things because you worry you don’t look okay or because you’re trying to fix an appearance problem?
22. Do you get depressed or anxious because of how you look?
23. Have you felt that life wasn’t worth living because of your appearance?
24. Do you get very frustrated or angry because of how you look?
Anti-Depressant26. Do you feel more comfortable going out at night, or sitting in a dark part of a room, because your defects will be less visible?
27. Do you have panic attacks or get very anxious when you look in the mirror because of how you look?
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WHY BDD IS UNDERDIAGNOSED: SECRECY AND SHAME
BDD is often a secret disorder. The BDD sufferer doesn’t reveal their appearance concerns, and the health professional doesn’t ask. Many people I’ve seen have never mentioned their appearance concerns to others. Many who’ve been in treatment with a mental health professional have never discussed their BDD symptoms, even though they were a serious problem. In the Minnesota inpatient study, all of the patients with BDD wanted their doctor to know about it but said they wouldn’t raise it with their doctor unless they were specifically asked, because they felt too ashamed. In a study of patients with anorexia nervosa, of whom 39% also had BDD, all of those who also had BDD said they wouldn’t reveal their BDD to their treater unless they were specifically asked because they were too ashamed. It takes courage to mention the concerns and discuss them. If they aren’t asked about, they may not be revealed. Reasons for secrecy and shame include the following:
Anti-DepressantЂў Worry that once the perceived defect is mentioned, others will notice it and focus on it more, causing even more embarrassment and shame;
Ђў Fear that disclosure of the worry will be met with reassurance that the BDD sufferer looks fine. Many people with BDD interpret this response, although honest and well-meaning, to mean that they were foolish to have mentioned it, or that their emotional pain isn’t being taken seriously or understood. If they get this response, they may not mention it again.
*33/204/8*