RECOMMENDATIONS FOR TREATING BDD WITH AN SRI: SRIS USUALLY BEGIN TO WORK GRADUALLY AND YOU NEED TO TAKE THE MEDICINE EVERY DAY AS PRESCRIBEDSRIs usually begin to work gradually: Occasionally, the medication begins to work in a dramatic fashion. Sometimes people can pinpoint the day, or even the hour, that it starts working. But typically it starts working gradually. People say things like “I felt a little better three days ago and today, but not for very long, so I don’t know if it’s really working.” Don’t get discouraged if this happens, because it’s expected. These ups and downs—what I call a “sawtooth pattern” of improvement—gradually give way to more sustained periods of feeling better. Good hours gradually turn into good days, and good days transform into good weeks. With time, you’ll notice more and more improvement in many, if not all, of your symptoms.You need to take the medicine every day as prescribed: It’s very important to take the medication every day, exactly as prescribed. It usually takes a while to work, so you need to take it every day even if it doesn’t seem to be helping. If you take less than prescribed, or you take it sporadically, it may not work as well or at all. If you have trouble remembering to take it, try a pill box, which you can buy at a pharmacy. This can help you stay on track. If you don’t want to take the medicine as prescribed because of side effects or because you have concerns about it, it’s better to discuss your concerns with your doctor than to stop the medicine or not take it as prescribed. The whole point of taking it is to feel better, and you’re more likely to feel better if you actually take it and don’t miss any doses.*259\204\8*

SOCIOCULTURAL THEORIES ABOUT BDD CAUSE – TRIGGERS: COMMENTS, STRESS, AND OTHER POSSIBLE PRECIPITANTS”I started worrying about my skin when one of my friends in high school called me ‘pizza face,’ ” Patrick told me. “I know he was only kidding, but it stuck in my mind. I started feeling very self-conscious about my skin.” Scott started parents split up unexpectedly,” he said. “It was especially rough on me, because my father blamed me for the breakup. I remember in the middle of their divorce, when he was really angry about something, he said to me ‘You’re no longer my son.’ I looked in the mirror and I thought I looked different. My whole face seemed to be sagging. I’ve never looked the same since.”In some cases it seems that a chance remark about appearance may acutely trigger the onset of BDD symptoms. Examples in published case reports include “You certainly resemble your father,” “You look very nice but you have got a small mouth,” or “Why is your face half red and half white?” G. G. Hay, who wrote about BDD in the 1970s, reported that such a remark was at least partly responsible for the onset of BDD symptoms in” 9 of his 17 patients. Several other published case descriptions note the sudden onset of symptoms soon after a distressing event, such as a spouse’s affair or abandonment by a boyfriend.Negative comments about appearance or stressful life events seem to sometimes play a role in BDD’s onset. Eight percent of the people in my studies reported that a negative comment about their appearance triggered the onset of symptoms. In most of these cases, symptoms began abruptly and acutely, soon after the comment or stress occurred, as opposed to more gradually. However, such events probably act as a trigger or contributing factor, but not the only cause of BDD. In other words, they seem to have the potential to precipitate the onset of BDD in someone who is biologically and psychologically vulnerable to developing the disorder. This is sometimes referred to as the vulnerability-stress hypothesis. A high school teacher’s comment reflected this view: “My concern about my nose was triggered by a comment about it, in a context of extreme sensitivity and low self-esteem.”One reason to think that comments or stress may act as a precipitant, as opposed to the major or only cause of BDD, is that negative comments about appearance and stress are very common. Virtually everyone has experienced significant stress. Most of us have heard something negative about how we look. But most of us don’t develop BDD. In addition, most people with BDD can’t identify a trigger of their symptoms, so a trigger doesn’t appear necessary for BDD to occur.*197\204\8*

TYPES OF SUICIDE: SUCCEEDERS, ATTEMPTERS, AND THREATENERSAlcohol use and suicide go together. Recall from Chapter 1 that in 65% of all suicide attempts the individual had been drinking, and that 40% of all successful suicides are related to alcohol. The suicide rate in alcoholics is fifty-five times that of the general population. Before we all commit suicide ourselves over these statistics, we should consider why suicide and alcohol are related, and what we can do about it.For practical purposes, there are several different groups to be considered when examining suicide. First are the succeeders, those who succeed and intended to. Classically, these are lonely white men over 50 years of age or lonely teenagers. They use violent means such as a gun or hanging, and their methods are calculated and secretive. Second are those who succeed but did not intend to. These are the attempters. Classically they are white women, ages 20 to 40, often with interpersonal conflicts, whose “method” is pills, and whose action is an impulsive response. At tempters die by mistake or miscalculation. For example, they lose track of dosage, or something goes wrong with their plans for rescue. The attempter’s intent is not so much to die as to elicit response from the environment. Emergency-room psychology, which dismisses this client with a firm kick in the pants, is inappropriate. Someone who is trying to gain attention by attempting suicide is in reality quite sick and deserves care. Third are the threateners, who use suicide as a lethal weapon: “If you leave me, I’ll kill myself.” They are often involved in a pathological relationship. These people usually do not follow through, but are frightened and guilt-ridden. It is a good idea for the therapist to challenge the threat and quickly remove the deadlock it has created.*161\331\2*

This involves the understanding and practice of the various ideas which we have discussed. Remember that this is not difficult, but it requires a little time and a little perseverance. Remember that many patients whom I have told these things verbally have succeeded. The only difference with you is that I am telling you by writing it down instead of saying it in words; and actually by writing it down I am able to explain it much more fully.

We have spoken of six general principles in the self-management of pain. If you were with me in my consulting room, I would repeat them to you in order to impress them on your mind. So I shall do the same now.

1. Reduce your general level of anxiety by understanding the nature of pain, by facing and resolving conflicts which cause anxiety, and by using the relaxing mental exercises to reduce anxiety.

2. Guard against the reactions that make pain worse. Do not allow distress, guilt, or fear to take over.

3. Use the reactions that reduce pain. Deny it and distract yourself from it when you can. Relax deeply and practice autosuggestion. When you can, use dissociation.

4. Practise the relaxing mental exercises.

5. Increase your pain threshold by conditioning yourself with the exercises in discomfort and pain.

6. Learn to experience and accept pain in pure form, which does not hurt.

We have discussed the means of fulfilling each of these principles, and we have seen that each step in itself is not difficult, as one follows the other in ordered gradation.

I always warn my patients of three things: Do not expect too much too quickly. Expect a few ups and downs, good days and bad days in the process of mastering the self-management. Do not get cross with yourself if at first you cannot do just what I ask.

I could relate many examples of patients I have had who have been successful in learning how to control their pain.

A man with cancer of the prostate suffered severe pain from secondary growths in the bones of his pelvis. He learned to relax and control the pain reasonably well, so that the last weeks of his life were actually spent in a clear mind and relative comfort.

A woman in her sixties complained of continuous severe pain in the legs, the vagina, and the area of the bladder. An operation on her back had shown a cystic degeneration of the nerve roots. So there was no doubt about the organic origin of her pain.

At first she found it hard to accept the idea that a psychological approach could help pain of this nature. She kept saying, “But the nerves have this degeneration.” I asked her to stick some pins into my forearm. She was reluctant, but she eventually did so, and was obviously surprised that it did not seem to hurt me. I then had her relax, and I did the same to her. When she opened her eyes she was astounded to find a couple of pins well embedded in her skin. From then on she was most enthusiastic about the exercises. She lost all the pain in her legs, and most of it, but not all, in her vagina and bladder. She later stated that she had developed a real peace of mind, and she volunteered that she was sleeping better than she had for eight or nine years.

I well remember one of my first experiments in helping people with organically determined pain. A woman in her sixties suffered chronic pain in her back from a degenerative condition of her backbone. She said that she had to fly from Melbourne to London and back, and she was terrified of the pain from having to remain in one position in her seat for so long. This was before the advent of the jets.

I taught her to relax and wished her luck. A few weeks later she came in to thank me, saying that she had made the trip without discomfort.

Just a year ago I saw a retired doctor, aged seventy-six years, who had had an extremely painful condition of his foot for nine years. He kept describing it as feeling as if someone were screwing up his foot in a vice. One surgeon had cut the main nerve, another surgeon had dissected the little nerves that lead to the toes, and later the artery had been freed of its nerves. But nothing had any effect on the pain. Another psychiatrist had tried hypnosis, but this was also unsuccessful.

In spite of his age he learned to do the relaxing mental exercises, and soon found he could control the pain.

A few days ago I received a note from his wife saying that he had died, and thanking me for the relief he had had in this last year of his life.

*146\57\2*

There are quite different forms of meditation in which the brain functions in quite different ways. I have abundant evidence to show that the form of meditation which I am about to describe is much more effective than other forms in restoring the harmonious brain function that relieves stress.

In classical meditation as in yoga, in Zen Buddhist meditation, and in the meditation as practiced by the early Christian mystics, the thought processes of the mind are helped by will power concentrating on some object or spiritual concept. The mind is active, striving to attain and maintain this ideal. In the meditation that I would advise you to practice there is no striving, no activity of brain function, just quietness, a stillness of effortless tranquility.

This is not the tranquility of drowsy somnolence. The mind is clear but still. At first, until the meditator has learned the art of letting his mind run in this way, there will be moments of stillness, but these are soon interrupted by the intrusion of thoughts. Do not try to dispel the thoughts by actively driving them from the mind. Just let them be, and they will fizzle out, cease, and stillness will come again. Then thoughts will recur. And again, if they are let alone, stillness will supervene. And gradually the space between the thoughts, the stillness that we want, will become longer and longer.

At the start this process will come and go, very much like the natural rhythms that are all about us, night and day, the tides, our very heartbeat. There may be a tendency for the beginner to get cross with himself with the recurring thoughts. This, of course, brings the meditative process to a halt.

Another error, which may befall the beginner, is a tendency to examine the situation. ‘How am I going? Am I doing it properly?’ Of course, any enquiry of this nature involves activity of the mind, which is exactly what we are trying to avoid. At the start it is best just to let ourselves experience a sense of being. Just being. Not even being in the room. Not even being alive. Just being. This state of mental activity, or rather inactivity, is a step towards the real stillness of mind experienced in full meditation.

*86/98/5*

This basic neurological state of affairs is aggravated by the sense of frustration that stress brings. We don’t like being under stress. It means we have failed somewhere. We feel hostile about it. Hostile to ourselves and this is easily transferred to others in the form of aggression.

If we let fly our aggression, it means that the over-alert brain cells discharge, and there comes to us a period of relative tranquility. This is a common experience. We get angry. Blow off our aggression, and then quieting down. Some people get into this inferior way of coping with stress. They do not do it consciously. It is just something that happens. They feel tensed up with stress. Then with some trivial irritation they blow up, and their tension from their stress is relieved. With some people this becomes a habitual reaction and, of course destroys, not only the quality of their own life, but also that of those around them, particularly husband or wife, whichever the case may be.

In this respect it is worthwhile noting that different fashions appear in clinical psychology and psychiatry. For the last ten years or so there has been a foolish vogue of encouraging patients to learn to blow off their aggression rather than bottle it up. What should be done, of course, is to show the patient how to let his mind run smoothly so that his aggression does not build up.

*79/98/5*

Palpitations

“The tests were all normal. That does not mean anything.

They often miss things. If you feel your heart banging away, that’s evidence enough that something is wrong. Real evidence. I feel I am going to have a heart attack. I know I am. Father died of a coronary when he was forty. Life is too precious. Don’t want to do that. But they don’t do a thing for me. Gave me some tranquillizers! I’m sick of it. I tell you I am frightened. Who wouldn’t be? It’s going now. Thump. Thump. Thump. Put your hand on my chest and you can feel it. Worse if I get fussed or upset. Even coming here makes it worse. What can I do to stop a heart attack? I keep thinking that this might be the start of it coming on now.”

Palpitation, the abnormal awareness of the action of our heart, is one of the commonest bodily symptoms of stress.

When we are in good physical and mental health, we are not aware of the action of our heart except for brief periods following strenuous physical exercise. This in itself is rather remarkable, as the action of our heart involves quite considerable movement within our chest. But in normal circumstances, information about this movement is not transmitted by our nervous system to our brain with sufficient intensity to reach the threshold of consciousness.

When we are under stress, two factors may operate to produce palpitation. The over-activity of nerve cells produces anxiety. The basic physiological purpose of anxiety is to prepare us for danger. There is more adrenalin in our blood. It increases our heart action, and puts up our blood pressure so that we are better able to cope with physical danger either by fighting or running away. This, of course, is a very primitive reaction which was evolved in times past, in the early days of our race, to help cope with the physical dangers of primitive life. However, the danger that we perceive as a result of stress is not a physical danger, but a mental one for which this old, primitive, outworn reaction is quite inappropriate and no help to us at all.

The second factor in stress, which contributes to palpitation, is our increased awareness due to the over-alertness of our brain cells. As a result of this we become aware of movements of our heart in a way that would not normally come to our consciousness.

The important matter for those who suffer palpitation is to be reassured that the cause of the palpitation is nervous, and is not due to any disease of the heart itself. Those who suffer palpitation often accept this reassurance, but still feel that the frequent experience of palpitation must, in the long term, have some deleterious effect on the heart. This is not so, as the normal heart has a great capacity to increase its activity, as in strenuous exercise, without any harm coming of it.

*41/98/5*