sexual fantasies

Robert W. Birch, Ph.D. Sexologist & Adult Sexuality Educator

Have you ever given any thought to the differences between the sexual fantasies typically conjured up by man and women. Men tend to have more sexual fantasies than women and are more likely to pair them with masturbation. Men, being visual beings, are likely create a visual image of a woman's sexual body and imagine watching her or seducing her or, quite often, being seduced by her. Women, on the other hand, are typically less visual in their sexual fantasies, are usually less focused on genitals, and usually focus more on the emotional feelings of a romantic encounter. Women also tend to involve more olfactory and auditory memories... memories of smells and sounds.

Many women have difficulty imagining an explicit sexual encounter, but readily acknowledge the stirring of sexual feelings while engrossed in a romantic novel or movie. Erotic fantasies, PG-13 through the X rated ones, can serve several sexual functions. Fantasies can induce sexual desire, maintain sexual arousal, enhance the sexual experience, trigger an orgasm, and preserve a memory.

The desire to be sexual is not controlled by a switch that can be turned on following the eleven o'clock news. Many people, particularly as they age or as a relationship matures, find that the easy turn ons are less and less likely to occur, particularly late at night. At times when time is limited, fantasies can serve to focus attention on the anticipated erotic event and help induce a desire for sexual intimacy.

More than one person has told me, "I'm not able to get excited on a moment's notice - I need time to psych myself up." To induce desire, you can think ahead about what you would like to experience and what you wish to both give and receive. Imagine the sexual encounter is your very first, but without those initial anxieties, and let it be, in your mind, a new and exciting adventure. Recall the good sexual feelings you have experienced and mentally reminisce about memorable past encounters. Conjure up the memory of a partner's warmth, softness, and gentle touch. See your partner's face in your mind's eye and recall that person's sounds of pleasure and the aroma of their excitement.

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Desire can be induced mutually throughout the day, with, for example, a phone call to say, "I've been thinking of your wonderful body." The mid-day message, "You won't believe what I want to do to you tonight," can stir the imagination of both partners, spending the day thinking of the possibilities in store for that night.

For those without a partner, fantasies during the day can become the prelude for an episode of self-loving that evening. Self-stimulation, the normal, natural way of experiencing solitary pleasure, is a healthy outlet for many who are alone. Fantasy during the day can certainly prepare you for the quiet celebration of your own sexual response.

Most of us have had the experience of beginning a sexual encounter, only to find our minds wandering off to the worries of the day or the pressing issues of tomorrow. By pushing away the intrusive nonsexual thoughts, erotic fantasy can maintain arousal. When distractions hit, we need only focus on a pleasant sexual memory or project an exciting visual image on our mental movie screen. Fantasies can be of our current sexual partner, but often they will revolve around persons from the past, coworkers, movie stars, or attractive strangers. Bringing others into fantasies is normal and is justified if it serves the current relationship by eliminating distractions that would otherwise dampen or destroy the passion. Obviously, if someone feels guilty about including others in his or her fantasy script, they should be left out. Some people like a cast of thousands, while others want to focus exclusively on their current partner.

Many people worry about their fantasies being "kinky", but such fantasies are common. Unusual fantasies can help maintain arousal and are harmless if there is no compulsion to actually experience an act that would be emotionally or physically harmful to oneself or to others. Whereas honesty is usually the best policy, discretion must be used in the sharing of some unusual fantasies or fantasies involving other people. It is rare that a couple can share such private thoughts without, at best, a little discomfort. Too often the reaction to hearing a partner's most kinky fantasy is one of jealousy and distrust, if not anger and disgust.

One woman playfully imagined that her partner's penis was enormous, and reported how she would visualize engulfing this gigantic imaginary erection into her body... and she would privately marveled at her vagina's ability to swallow up this massive tool. She quickly acknowledged, however, that she had no desire to experience anything that large in real life, but she did enjoy embellishing her fantasy with the thoughts of dressing this impressive male member in doll's clothing and taking it for walks in the park. During her sexual encounters, this fantasy helped rivet her attention on the pleasure she was feeling from the very adequate reasonably-sized penis of her partner.

One night, this woman decided that it would be fun to share her fantasy with her partner. To her utter surprise, the man was devastated upon hearing her playful musings! He began worrying that she had been with men who had larger penises than his, fearing that these well-endowed men must have please her more than he could ever hope to. He erroneously assumed that she could not enjoy his average-sized penis, and began to feel totally inadequate as her lover. Fearing he could not satisfy this woman, he backed off sexually. When he did try, he felt self-conscious and, as a result, often failed to become erect. This, of course, led to more avoidance and self-degradation.

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In couples therapy, this man worked on understanding that his partner's fantasy had nothing to do with his genital size or sexual performance, but made their shared intimacy more exciting for her. In our last therapy session he began laughing and, when questioned, shared his own "pet" fantasy. He had for many years fantasized he was making love to a virgin and that her vagina was the town's tightest. Both agreed that they loved each other, loved the sexuality they shared, and would never again ask about the private fantasies each used to dispel the occasional intruding distractions. The also learned that virginity and penis size are immaterial when there is love.

The consequences of disclosure were more serious for another couple. The man fantasized about having sex with his wife's younger married sister. While he found the sister attractive, he had no illusions about her commitment to her husband and would never, in reality, make a pass at her. When he shared his fantasy, however, his wife expressed anger and disbelief. She became extremely uncomfortable whenever her sister was around and believed that she had to watch them both closely for any signs of subtle flirtation. Angry that she now felt distrusting, not only of her husband, but of her sister as well, she chose to end her marriage with the man rather than further damaging her relationship with her sister. The fantasy proved to be too close, too personal, and too threatening.

Many shared fantasies, however, enhance desire and maintain arousal. One night a man entered a singles bar, propped himself up on a bar stool and slowly rotated, carefully surveying the women around him. Apparently no one caught his eye, so he turned his back on the scene and sipped quietly on his drink. About fifteen minutes later, a woman walked in. As her eyes adjusted to the darkened room, she also scrutinized the crowd. She wandered around a bit, being careful not to make eye contact with any of the men scattered around the room. After a few minutes of aimless wandering, she moved up beside the man who was seemingly intent on nursing his drink. Sliding between him and the person sitting next to him, she leaned toward the bar to catch the bartender's attention. As she did, the man felt her breast brush lightly across his arm, but he did not look her way.

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After being served, the woman stepped back, drink in hand, and stood behind the man. Aware of her presence, the man turned and looked into her eyes. His unoriginal inquiry, "Do you come her very often?" was met with an abrupt, "No!" As he turned toward her, his leg came to rest against her thigh. She made no attempt to avoid the contact, but waited for him to continue his attempt to initiate conversation. Awkwardly he asked, "What do you do for fun?" Both grinned at her response, "I pick up strange men in singles bars." At this point the drink he had been nursing so patiently was gulped down in record time and he asked her to dance. She played at being reluctant, but allowed him to convince her. On the dance floor, they danced as though each was covered by porcupine quills and a large man on a Harley-Davidson could have driven between them. As they continued to dance, however, they moved closer until, from a distance, it looked as though their bodies had blended into one.

As they left together he asked, "Shall we take your car or mine?" Again giggling, they took his car to the nearest motel, where he produced a bottle of wine from an ice bucket on the back seat. Ralph and Mary, who had been married for three years, were acting out their shared fantasy. Once in the room, Mary enticed Ralph into seducing her slowly, pretending uncertainty "I really don't know if I should!" as he pretended clumsiness, fumbling to unbutton her blouse and acting bewildered by the complexities of the one-handed unsnapping of a push-up bra.

During their lovemaking, Mary intentionally cried out, "Oh Bill, you make me feel so good," and in the morning, Ralph pretended to have completely forgotten her name. It was a night not soon forgotten, providing the erotic content for many fantasies that followed.

Novelty can get lost in long-term relationships. When a couple becomes comfortable and familiar with each other sexually, they often forget to be romantic. The entire sexual scenario might become routine, taking place at the same time of the day and in the same location - and all too often hurried. While it might be impractical for most of us to make love on a beach, in fantasy we can imagine the sound of the ocean, the warmth of the sand beneath our body, and the excitement of making love under the stars. Perhaps yours will be a fantasy of making love in the woods, or in an old barn, or in the backseat of a car you had as a teenager.

Some fantasies can be acted out, e.g., a pick up in a grocery store. But most fantasies are just private thoughts that need not have a complex storyline, or a cast of hundreds. Working too hard at building a sexual fantasy can become a distraction, defeating one of its purposes. The best fantasies are often quite simple and tied in with pleasant memories. Often it is visual, creating a mental image of a part of the partner's body that is pleasing to look at, but impossible to see in the dark or in a particular position. At times words can be added to the fantasy while forming the mental image "I love your buns."

Special fantasies can be saved for those times when an orgasm is a bit elusive. These favorites can often add the final bit of excitement needed to trigger a powerful climax.

Fantasies serve many functions from getting started to getting finished. Remember, sexual fantasies before, during and after a sexual encounter are normal, natural and often helpful in changing a routine experience into a new and exciting event.

Robert W. Birch, Ph.D. is retired after 35 years of clinical experience, university teaching and public lecturing in the specialized area of relationships and sexuality. No longer a sex therapist, he now identifies himself as a sexologist and an adult sexuality educator, and lives and writes in rural Ohio with Susan and their four dogs. For much more on this topic, read Dr. Birch's illustrated book titled Male Sexual Endurance: A Man's Book About Ejaculatory Control. A shorter bare-bones outline of the start-start exercises are available in his manual titled Introduction To The Management Of Premature Ejaculation: A Short Book About Lasting Longer. For a short illustrated brochure on the use of vibrators, including their use during intercourse, read Dr. Birch's Your Vibrator: Using It, Enjoying It, and Sharing It. Men wanting to learn more about orally satisfying a woman should read the book written by Dr. Birch titled Oral Caress: A Loving Guide to Exciting a Woman. All these books and much more can be found on his website at http://www.oralcaress.com/.

next: Understanding Male and Female Sexual Fantasies

Excerpts from the Archives of the Narcissism List Part 23

1. Interview at Amazon UK
2. Vindictive Narcissists
3. Narcissistic Thoughts about Humanity
4. The Good Enough Mother
5. Vindicating One's Self-Loathing
6. The Narcissist as a Meaningful Other
7. On the Irrelevance of Labelling

1. Interview at Amazon UK

Amazon.co.uk talks to Sam Vaknin

Amazon.co.uk: Where are you from? How--if at all--has your sense of place coloured your writing?

S.V.: I was born in Israel to Jewish immigrants from Turkey and Morocco. We belonged to a socially and economically backward minority - which might explain what led to my interest in Narcissistic defence mechanisms. Israel is an aggressive, militaristic, power-driven, intolerant, religious and conservative society. Enclaves of liberal thinking do exist but they are outweighed and diluted by the general populace. It is an odd admixture of the Western indulgence of the individual (Lasch's narcissistic society) coupled with strong compensatory mechanisms employed in an effort to counter-balance a national inferiority complex and survival anxiety. This coalesces into the clinical picture known as "pathological narcissism" - which is the subject of my book.

Amazon.co.uk: When and why did you begin writing? When did you first consider yourself an author?

S.V.: I wrote all my life. It was my preferred venue of escape. I published short fiction, works of reference and columns in periodicals. Writing sits well with my personality disorder. It provides me with narcissistic supply. It is magical in that symbols lead to action. It provides the twin illusions of eternity and sagaciousness. I have never thought of myself as anything but an author.

Amazon.co.uk: Who or what has influenced your writing, and in what way? What books have most influenced your life?

S.V.: I have always been drawn to short fiction - although most of my published work (in Hebrew, Macedonian, other languages) is non-fiction. There is an essence in short fiction, distilled and aromatic which is missing in the homeopathic equivalent of the longer genres (such as the novel). I have thus found myself enamoured with A.A.Poe on one end of the spectrum - and Francoise Sagan on the other. The last two decades have been a revelation to me in that they provided me with legitimacy. My short fiction deals with amoral characters, making amoral decisions about emotionally harrowing (to them, emotionally neutral) situations. Post modernism liberated me and allowed me to pursue this line of writing.

Amazon.co.uk: What is the most romantic book you've ever read? The scariest? The funniest?

S.V.: I try to abstain from romantic literature and am pretty successful at doing so. The scariest book I ever read is the Amityville Horror. It took a whole sleepless night to wear off. The funniest book I read is "Three Men in a Boat" by Jerome K. Jerome. I love wry, marginally vicious humour.

Amazon.co.uk: What music, if any, most inspires you to write? What do you like to listen to while writing?

S.V.: I hate music. All types of music. It makes me intolerably sad. It osmotically infiltrates me, cell-level, and drowns me. Short of breath I barely make it to the gramophone (I prefer vinyl records) and turn it off.

Amazon.co.uk: What are you reading now? What CD is currently in your stereo?

S.V.: I am reading David Deutsch's "The Fabric of Reality". To me, it is a funeral. The death of science. When highly qualified physicists engage in metaphysics, even mysticism - both disciplines emerge the lesser for their efforts.

Amazon.co.uk: What are you working on?

S.V.: I have just finished writing my second book of short stories (in Hebrew) and submitted it. I am augmenting "Malignant Self Love - Narcissism Revisited" with additional chapter (available online and to the book purchasers via email). And I am columnizing ferociously on the Kosovo crisis. I used to live in Yugoslavia and Macedonia until 1998, so I know the area and its inhabitants first hand.

Amazon.co.uk: Use this space to write about whatever you wish.

S.V.: Malignant Self Love - Narcissism Re-Visited was written under extreme conditions of duress. It was composed in jail as I was trying to understand what had hit me. My nine years old marriage dissolved, my finances were in a shocking condition, my family estranged, my reputation ruined, my personal freedom severely curtailed. Slowly, the realization that it was all my fault, that I was sick and needed help penetrated the decades old defences that I erected around me. This book is the documentation of a road of self-discovery. It was a painful process, which led to nowhere. I am no different - and no healthier - today than I was when I wrote this book. My disorder is here to stay, the prognosis is poor and alarming.

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2. Vindictive Narcissists

Basically, there are only two ways of coping with such people:

(a) Frighten them

Narcissists live in a state of constant rage, repressed aggression, envy, and hatred. They firmly believe that everyone is like them. As a result, they are paranoid, suspicious, scared, and erratic. Frightening the narcissist is a powerful tool for the modification of his behaviour. If sufficiently deterred - the narcissist will promptly disengage, give up everything he was been fighting for and sometimes make amends.

To act effectively, one has to identify the vulnerabilities and susceptibilities of the narcissist and strike repeated, escalating blows at them - until the narcissist lets go and vanishes.

Example:

One should threaten a narcissist with public disclosure of misdeeds, misbehaviur, or unfavourable traits. One should drop cryptic hints that there are mysterious witnesses and recently revealed evidence. The narcissist has a very vivid imagination. Let his imagination do the rest.

If the narcissist has been involved in tax evasion, in malpractice, in child abuse, in infidelity - these are so many fields which offer a rich vein of attack. If done cleverly, noncommittally, gradually, in an escalating manner - the narcissist will crumble, disengage and disappear. He will lower his profile thoroughly in the hope of avoiding hurt and pain. Most narcissists have been known to disown and abandon a whole PNS (pathological narcissistic space) in response to a well focussed campaign by their victims. Thus, a narcissist may leave town, change a job, desert a field of professional interest, avoid friends and acquaintances - only to secure a cessation of the unrelenting pressure exerted on him by his victim.

I repeat: most of the drama takes place in the confined recesses of the paranoid mind of the narcissist. His imagination runs amok with him. He finds himself snarled by horrifying scenarios, pursued by the most vile "certainties". The narcissist is his own worst persecutor and prosecutor.

You don't have to do much except utter a vague reference, make an ominous allusion, delineate a possible turn of events. The narcissist will do the rest for you. He is like a little child in the dark, generating the very monsters that paralyse him with fear.

Needless to add that all these activities have to be pursued legally, preferably through the good services of law offices and in broad daylight.

Otherwise, if done privately and in the wrong way - it might constitute extortion, blackmail, harassment, and a host of other criminal offences.

(b) Lure them

The other way to neutralize a vindictive narcissist is to offer him continued narcissistic supply until the war is over and won by you. Dazzled by the drug of narcissistic supply - the narcissist will immediately become tamed, forget his vindictiveness and triumphantly take over his "property" and "territory". Under the influence of narcissistic supply, the narcissist is unable to tell when he is being manipulated. He is blind, dumb, and deaf to all but the song of the NS sirens. You can make a narcissist do ANYTHING by offering, withholding, or threatening to withhold narcissistic supply (adulation, admiration, attention, sex, awe, subservience, etc.).

3. Narcissistic Thoughts about Humanity

What is different today is the DEATH OF CURIOSITY.

Curiosity is the result of SCARCITY of information. It is like thirst - it is so much stronger when water is scarce. Or like hunger - it is so accentuated after a long fast.

But when there is a glut - too much of something - our hunger for it, our cravings, die.

There is too much information, data, knowledge. We have been desensitized. No one wants to know more than he ABSOLUTELY needs to know. This is the world of the absolute minimum. People are becoming more and more narrow minded, less open to the world, more isolated. The more TELEcommunication - the more the distance (=tele) between people. There is no more "professional pride" because people value their leisure more than their work, change workplaces and professions very often, and are flooded by superfluous information. So, no one knows anything about anything. What we fail to understand is that too much information results in insufficient knowledge and pervasive ignorance. People are dumbed down. Television, newspapers, books, films - I remember another era. Today, these are mass products for intellectually passive consumers. The education system disintegrated. Publishers refuse to publish books, or articles, with a vocabulary "too extensive". Collective idiocy replaced collective intelligence.

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For someone like me - this is an impossible world to live in. I am intelligent, forever curious to learn more about seemingly unnecessary things. I am intolerant of ignorance and stupidity in all its forms. While in the 1960's I could have survived somehow - today it is very difficult to even breathe. EVERYONE is stupid. University professors don't read books. Authors don't spell correctly. Freight forwarders know little about customs procedures.

Soldiers are too afraid to fight (hence "smart bombs" to replace soldiers). It is a total degeneration of all civilization.

Every time I come across a reminder of this - I MUCH PREFER my computer and books to ANY human. This is why I LOVED it in jail. Together with the army (another kind of jail) - it was the best period of my life. I didn't have to deal with humans.

4. The Good Enough Mother

The critical question is, of course, not whether she can be a good mother to her teen off-spring, but whether (to use Winnicott's phrase) she has been a "good enough mother" to her children when they were younger. Most theoreticians agree that the critical ages are 4 months to 6 years. It is then that most (not all, but most) of the long term damage is done.

She is crying for help the only way she knows how. She is playing on the fact that her father feels threatened by her exploding sexuality. She maximizes this threat by behaving promiscuously or by seeming to do so. It is her way of saying: "Daddy, I am hurting so terribly! Please help me!".

The FIRST thing he must do is VALIDATE this pain of hers. Ignoring it, denying it, belittling it, transforming, it, redirecting it, projecting it - is WRONG. It will (and does) have adverse effects.

The SOURCE of the pain, at least at this stage, is IMMATERIAL.

She must know that there is one place - ONE place - in this ominous, dangerous, capricious, arbitrary universe - one place where she is accepted and loved unconditionally AS SHE IS. One place where she DOES NOT have to play slut or gay or strip herself to gain attention, credence and an ear. She must be listened to and believed. She is in pain. If someone is bleeding - will a doctor postpone all treatment until he finds the instrument that wounded the patient?

5. Vindicating One's Self-Loathing

She is looking to victimize herself and thus validate the judgement instilled in her that she is worthless, lowly scum.

BUT

She is also testing the world to see: is it really as bad? Are all people vicious exploiters, devoid of conscience?

In psychological parlance: is everyone a "bad object"?

She is employing Projective Identification (PI) and Splitting (S).

These are two primitive defence mechanisms (defence against pain usually inflicted by a mother).

PI is when she tries to force people to conform to her view of them. If she thinks someone is a bad object she does her damnedest to provoke him, invoke anger, and a sense of threat and danger in him, motivate him to BE a bad object. Finally, when the inevitable reaction comes, she feels vindicated ("you see, I was right all along, everyone IS rotten, including my Daddy").

Splitting is the separation of the good aspects of an object (a person) from his bad aspects. If the person is seen as bad - the good aspects are tossed aside and often attributed to someone else (projection). Then the person remains "all bad".

She does not need things one can measure or count (time, money, possessions). She needs love, caring, sharing and support. Some of us are less gifted at giving these to others - because we never received them ourselves. This is the tragedy of mental disorders. Like some genetic curse, they are handed from one generation to the other, oblivious to all good intentions and fervent promises made.

6. The Narcissist as a Meaningful Other

The child modifies his behaviour in order to secure the Narcissist's continued love, so as not to be abandoned.

This is the root of the perniciousness of this phenomenon:

The narcissist IS a meaningful, crucially significant figure ("object") in the Inverted Narcissist's (IN) life.

This is the narcissist's leverage over the IN. And since the IN is usually very young when she makes the adaptation to the N - it all boils down to fear of abandonment and death in the absence of care and sustenance.

I don't think inverted narcissism is as much a wish to gratify one's narcissist (parent) - as the sheer terror of forever withholding gratification from one's self.

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7. On the Irrelevance of Labelling

Whether a poison is strychnine or cyanide is of very little consequence once one is poisoned.

It does not really matter whether he is a narcissist or not.

What matters is that loving this man and taking care of yourself are NOT COMPATIBLE goals. They are mutually exclusive behaviours. EITHER you are with him - OR you take good care of yourself.

A decision that only you can make, a matter of priorities. I don't know how long you have been together but I do not think that your husband is going to abandon you. This is because you accept him back. Not many women would - and he knows it.

Read FAQ 66

Think about his escapades as VACATIONS.

Perhaps you SHOULD establish a formal schedule of such "vacations" - or at least establish a procedure for your husband to take these vacations.

It will reduce your abandonment issues and provide him with the respite that he need. His escapes are obsessive-compulsive in nature, the result of mounting anxiety. There are many very effective cognitive-behavioural techniques to treat such behaviours. Did you try marital or couple therapy?

Accept that which you cannot change - formalize it, enshrine it, even encourage it.

Do not be afraid to lose him. The more freedom you allow him - the more attached to you he will become, knowing that such leeway is not to be found elsewhere.

The Persian poet Omar Al-Khayam wrote in the Rubaayat: "When you want the bird, set it free".

 

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next: Excerpts from the Archives of the Narcissism List Part 24

When I first came into contact with the word "Codependent" over a decade ago, I did not think that the word had anything to do with me personally. At that time I heard the word used only in reference to someone who was involved with an Alcoholic - and since I was a Recovering Alcoholic, I obviously could not be Codependent.

I paid only slightly more attention to the Adult Children of Alcoholics Syndrome, not because it applied to me personally - I was not from an Alcoholic family - but because many people whom I knew obviously fit the symptoms of that syndrome. It never occurred to me to wonder if the Adult Child Syndrome and Codependence were related.

As my Recovery from Alcoholism progressed, however, I began to realize that just being clean and sober was not enough. I started to look for some other answers. By that time the conception of the Adult Child Syndrome had expanded beyond just pertaining to Alcoholic families. I started to realize that, although my family of origin had not been Alcoholic, it had indeed been dysfunctional.

I had gone to work in the Alcoholism Recovery field by this time and was confronted daily with the symptoms of Codependence and Adult Child Syndrome. I recognized that the definition of Codependence was also expanding. As I continued my personal Recovery, and continued to be involved in helping others with their Recovery, I was constantly looking for new information. In reading the latest books and attending workshops, I could see a pattern emerging in the expansion of the terms "Codependent" and "Adult Child." I realized that these terms were describing the same phenomenon.

I was troubled, however, by the fact that every book I read, and every expert with whom I came into contact defined "Codependence" differently. I began to try to discover, for my own personal benefit, one all-encompassing definition.

This search led me to examine the phenomenon in an increasingly larger context. I began to look at the dysfunctional nature of society, and then expanded farther into looking at other societies. And finally to the human condition itself. The result of that examination is this book: Codependence: The Dance of Wounded Souls, A Cosmic Perspective on Codependence and the Human Condition.

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This book is based upon a talk that I have been giving for the last few years. I have edited and reorganized, expanded, added, and clarified information in adapting the talk to book form, but there is still the flavor and style of a talk throughout much of this book. I have not attempted to change this for several reasons, the main reason being that it works in conveying the multi-leveled message that I wish to communicate.

One of the reasons for the human dilemma, for the confusion that humans have felt about the meaning and purpose of life, is that more than one level of reality comes into play in the experience of being human. Trying to apply the Truth of one level to the experience of another has caused humans to become very confused and twisted in our perspective of the human experience. It is kind of like the difference between playing the one-dimensional chess that we are familiar with, and the three-dimensional chess played by the characters of Star Trek - they are two completely different games.

That is the human dilemma - we have been playing the game with the wrong set of rules. With rules that do not work. With rules that are dysfunctional.

I was terrified beyond description the first time I gave this talk in June of 1991. It seemed as if emotional memories of what it felt like to be stoned to death by an angry mob were assaulting my being. I went ahead with it anyway, because it is what I needed to do for myself. I needed to stand up in public and own my Truth. I needed to own the Truth that I had come to believe in, the Truth that worked for me to allow me to find some happiness, peace, and Joy in my life. I found that other people found Joy and peace in my message also.

So now I share this message with you, the reader of this book, in the hopes that it will help you to remember the Truth of who you are, and why you are here. This information is not meant to be absolute or the final word - it is meant as an alternative perspective for you to consider. A Cosmic Perspective that just might help to make life an easier, more enjoyable experience for you.

next: Links

Determining Your Sensitivity to Sugar and Eating Habits

Directions: If the statement applies to you, put the number of points (in the parenthesis) on the line. When you are done, add the points and look at the key below for what the total means.

(5) _____ I have a tendency to higher blood pressure.

(5) _____ I gain weight easily, especially around my waist and have difficulty losing it.

(5) _____ I often experience mental confusion.

(5) _____ I often experience fatigue and generalized weakness.

(10) ____ I have diabetic tendecies.

(4) _____ I get tired and/or hungry in the mid-afternoon.

(5) _____ About an hour or two after eating a full meal that includes dessert, I want more of the dessert.

(3) _____ It is harder for me to control my eating for the rest of the day if I have a breakfast containing carbohydrates, than it would be if I had only coffee or nothing at all.

(4) _____ When I want to lose weight, I find it easier not to eat for most of the day than to try to at several small diet meals.

(3) _____ Once I start eating sweets, starches, or snack foods, I often have a difficult time stopping.

(3) _____ I would rather have an ordinary meal that included dessert than a gourmet meal that did not include dessert.

(5) _____ After finishing a full meal, I sometimes feel as if I could go back and eat the whole meal again.

(3) _____ A meal of only meat and vegetables leaves me feeling unsatisfied.

(3) _____ If I'm feeling down, a snack of cake or cookies makes me feel better.

(3) _____ If potatoes, bread, pasta, or dessert are on the table, I will often skip eating vegetables or salad.

(4) _____ I get a sleepy, almost "drugged" feeling after eating a large meal containing bread or pasta or potatoes and dessert, whereas I feel more energetic after a meal of only meat or fish and salad.

(3) _____ I have a hard time going to sleep at times without a bedtime snack.

(3) _____ At times I wake in the middle of the night and can't go back to sleep unless I eat something.

(5) _____ I get irritable if I miss a meal or mealtime is delayed

(2) _____ At a restaurant, I almost always eat too much bread, even before the meal is served.

Total _______

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KEY:

A score of 20 or less indicates that you are a person who can do well on low fat / high complex carbohydrates diet, and might do well as a vegetarian, or on a Pritikin type or Ornish type diet. These diets are approx. 10% to 15% fat, 15% to 20% proteins, and 65% to 75% carbohydrates by calories. *

Those of you with scores of greater than 25 need diets lower in simple sugars, like sweets, alcohol and starches, but higher in protein and fats. * The higher your score, the more fastidious you should be regarding your protein to carbohydrate ratios at each meal and the more important the following tests. The "Zone Diet" of 40% complex carbohydrates, 30% protein and 30% fat is a good example of the diet you might follow. Indeed, the Zone Diet is also known as the 40-30-30 Diet.

Those with very high scores may do well to consider high protein, moderate fat, low carb strategies like the Atkin's Diet, Dr Eades Protein Power, and Crayhon's "Carnitine Miracle" Caveman Diet.

Regular exercise is also a vital component in any program to optimize blood sugar control.

The higher your score, the more at risk you are for the all too common dysglycemias: hypo-glycemia, Syndrome X**, and adult onset diabetes, a major disease of aging. Having your blood pressure, cholesterol, and triglycerides checked in a "cardiac risk profile" blood test is a good idea then, as high blood pressure and high blood lipids is a sign of Syndrome X. Having your doctor test your blood sugar and insulin level via a two hour post-prandial glucose challenge is indicated as well with the higher scores if middle aged or older.

Those with higher scores might do well to take the "Adrenal Stress Index" salivary hormone test by ZRT Labs. This is the Two Tube Test Kit to measure morning and evening cortisol and a Two Test Kit to measure progesterone and DHEA. See the RX Learning Channel article, "Stress, The Ultimate Ager" for more information. Abnormal patterns of DHEA to cortisol are common with dysglycemias. Correcting such a pattern first is a good place to start.

Important: Middle aged and older apple shaped females who carry fat in their upper torso and arms and score higher on the above insulinogenic scale, particularly women who suffer adult acne and facial hair, are showing strong signs of dysglycemias. Dysglycemias tend to shunt DHEA into testosterone over estrogen, resulting in a high testosterone to estrogen ratio, sometimes even leading to polycystic ovary syndrome. Therefore, the enhancing of the androgens, i.e., DHEA, androstenes and testosterone should be avoided until salivary tests show them not to be too high. 7-KetoDHEA (7-KetoLean) is the choice for weight loss in these cases. See the RxShopping Channel for more info.

To restore hormonal balance the following guidelines are offered:

1. Follow the basic instructions suggested in from Vol. 1, lesson 1 article, "How to Enhance the Effectiveness of Hgh". This includes good diet, exercise, supplementing with MultiWellness without Iron at six / day, and enhancing HGH w/ Hgh Plus if over 40.
2. Strongly consider low to low moderate carbohydrate diets and low glycemic diets like the Zone or 40-30--30 diet and the Atkin's diet. Links are in the RxResources Channel. Books are in the Wellness Community bookstore.
3. Use a low glycemic sweetener like Agave Nectar.
4. Measure your hormones via saliva tests as suggested above, that is the adrenal stress index, restoring hormone balance as in dictated by the results.
5. Have your doctor consider performing cardiac profile and post-prandial blood sugar and insulin tests.
   IF hyper-glycemia and or hyper-insulinemia are found, and or you score high on the Syndrome X Survey, consider supplementing with:
   • Insulin Wellness( Niacin, chromium, zinc, magnesium and vanadyl sulfate, AKG and ginseng),
   • EPA-DHA Complex (fish oils), ground flax seed, and
   • Alpha-Lipoic acid

   These products are intended to enhance insulin sensitively and/or provide the extra anti-oxidant activity necessitated by the dysglycemias.

6. 6 If diabetic, consider adding to the above Glucose Wellness. These are herbs and nutrients that greatly support a normal blood sugar. Glucose Wellness is so effective in restoring insulin sensitivity that you must be careful not to go into insulin shock if you take insulin! +++ Even though Glucose Wellness is a totally natural product, please inform your doctor of your plans before proceeding +++.

* These fats should consist of no more than 1/3 saturated fats. A variety of small amounts of ground or well-chewed nuts and seeds are the best source of fats, generally speaking, as are the cold water fish as well.

** Syndrome X signs includes HBP, high blood lipids with poor HDL/LDL ratio's, poor lean body mass, and hyper-insulinemia, or insulin resistance/insensitivity.

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Skullcap is an alternative mental health herbal remedy for anxiety, nervous tension and convulsions. Learn about the usage, dosage, side-effects of Skullcap.

Botanical Name:Scutellaria lateriflora
Common Names:Mad-dog skullcap, scullcap

• Overview
• Plant Description
• Parts Used
• Medicinal Uses and Indications
• Available Forms
• How to Take It
• Precautions
• Possible Interactions
• References

Overview

Skullcap (Scutellaria lateriflora) is native to North America, but is now widely cultivated in Europe and other areas of the world. It has been used for over two hundred years as a mild relaxant and has long been hailed as an effective therapy for anxiety, nervous tension, and convulsions. Because of its calming effects on the nervous and musculoskeletal system, it was also at one time considered to be a remedy for rabies, thus it's name "mad dog weed."

Plant Description

Scutellaria lateriflora is one species of skullcap that is used in herbal preparations. The plant derives its name from the caplike appearance of the outer whorl of its small blue flowers. Skullcap is a slender, heavily branched plant that grows to a height of two to four feet and blooms each July.

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Parts Used

The parts of the skullcap plant used for medicinal purposes are the leaves. These are harvested in June from a three- to four-year-old skullcap plant.

Medicinal Uses and Indications

While scientific studies have not been conducted on the medicinal properties of Scutellaria lateriflora, its current uses, based on traditional and clinical practice, include:

• Treatment of muscle spasms
• Calming of the nerves

It has also been used to treat symptoms associated with:

• Tension headache
• Anorexia nervosa
• Anxiety
• Fibromyalgia
• Restless leg syndrome and other causes of insomnia
• Mild Tourette's syndrome (a disorder characterized by multiple motor and vocal tics)
• Seizure disorders.

Chinese Skullcap
A closely related herb, Chinese skullcap (Scuterllaria baicalensis) has actually been the subject of a number of studies, including those on animals and people. It has anti-oxidative, anti-inflammatory, and antihistamine properties, which can help treat allergies such as hay fever (called allergic rhinitis), particularly when used with other herbs, including stinging nettle.

Cancer
Chinese skullcap is also used in Traditional Chinese Medicine to treat tumors. Early laboratory studies investigating this traditional use are emerging and showing preliminary promise for combating bladder, liver, and other types of cancers, at least in test tubes.

In terms of clinical studies on people, skullcap is also one of the eight herbs that make up PC-SPES, an alternative treatment for prostate cancer. (It is important to note, however, that the U.S. Food and Drug Administration [FDA] recently issued a warning to consumers that PC SPES may contain undeclared prescription drug ingredients that could cause dangerous side effects.)

Other
Chinese laboratory research has isolated an element present in skullcap that may prove useful in treating hepatitis B and has suggested that the antioxidant properties of Chinese skullcap may prove beneficial for preventing heart disease or limiting the damage following a heart attack. Much more research needs to be done in these areas before conclusions can be drawn.

Available Forms

Skullcap is available as a powder or liquid extract.

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How to Take It

Pediatric

Although not common, skullcap may be used for calmative purposes in children and administered as a mild tea. Use either prepackaged tea bags, letting it steep for approximately 2 minutes or add 1 tsp of dried leaves to 1 cup of boiling water and steep for 2 minutes. (Shorter steeping time makes for milder strength teas).

The tea should be dosed according to the child's age and weight as follows:

• Children 1 to 2 years (24 lb [11 kg] or less): ¼ cup one to three times per day
• Children 3 to 6 years (25 to 48 lb [11 to 22 kg]): ½ cup one to four times per day
• Children 7 to 11 years (49 to 95 lb [22 to 43 kg]): ¾ cup one to four times per day
• Children 12 and older (over 95 lb [43 kg]): 1 cup one to four times per day

Adult

The following are recommended adult doses for skullcap:

• Dried herb: 1 to 2 grams per day
• Tea: Pour 1 cup boiling water over 1 teaspoon of dried herb. Steep 20 to 30 minutes. Drink 2 to 3 cups per day.
• Fluid extract (1:1 in 25% alcohol): 2 to 4 mL (40 to 120 drops), three times daily
• Tincture (1:5 in 45% alcohol): 2 to 5 mL (40 to 150 drops), three times per day

Precautions

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, contain active substances that can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, herbs should be taken with care, under the supervision of a practitioner knowledgeable in the field of botanical medicine.

There are mixed opinions as to the safety of skullcap because it has, in the past, been contaminated with Teucrium species, a group of plants known to cause liver problems. It is therefore important that skullcap be obtained from a reliable source.

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Overdose of skullcap tincture produces giddiness, stupor, mental confusion, twitching, irregular heartbeat, and epileptic-like symptoms. Skullcap should not be used during pregnancy and breastfeeding.

Possible Interactions

While there are no reports in the scientific literature to suggest that skullcap interacts with any conventional medications, it does possess sedative properties. Therefore, skullcap should be used with caution, if at all, by those who are taking benzodiazepines (anti-anxiety medications) such as diazepam or alprazolam, barbiturates (medications often prescribed for sleep disorders or seizures) such as pentobarbital, or other sedative medications (including antihistamines).

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Supporting Research

Brinker F. Herb Contraindications and Drug Interactions. 2nd ed. Sandy, Ore: Eclectic Medical; 1998:163.

Cauffield JS, Forbes HJ. Dietary supplements used in the treatment of depression, anxiety, and sleep disorders. Lippincotts Prim Care Pract. 1999; 3(3):290-304.

Darzynkiewicz Z, Traganos F, Wu JM, Chen S. Chinese herbal mixture PC-SPES in treatment of prostate cancer (Review). Int J Oncol. 2000;17:729-736.

Fisher C. Nettles - an aid to the treatment of allergic rhinitis. European Journal of Herbal Medicine. 1997;3(2):34-35.

Foster S, Tyler VE. Tyler's Honest Herbal. New York, NY: The Haworth Herbal Press; 1999:349-351.

Gao Z, Huang K, Xu H. Protective effects of flavonoids in the roots of Scutellaria baicalensis Georgi against hydrogen peroxide-induced oxidative stress in HS-SY5Y cells. Pharmacol Res. 2001;43(2):173-178.

Gruenwald J, Brendler T, Christof J. PDR for Herbal Medicines. 2nd ed. Montvale, NJ: Medical Economics Company; 2000:678-679.

Huang RL, Chen CC, Huang HL, Chang CG, Chen CF, Chang C, Hsieh MT. Anti-hepatitis B virus effects of wogonin isolated from Scutellaria baicalensis. Planta Med. 2000;66(8):694-698.

Ikemoto S, Sugimura K, Yoshida N, et al. Antitumor effects of Scutellariae radix and its components baicalein, baicalin, and wogonin on bladder cancer cell lines. Urology. 2000;55(6):951-955.

Larrey D, Vial T, Pauwels A,et al. Hepatitis after germander (Teucrium chamaedrys) administration: another instance of herbal medicine toxicity. Ann Coll Physicians. 1992; 117: 129-132.

Miller LG, Murray WJ, eds. Herbal Medicinals: A Clinician's Guide. New York, NY: Pharmaceutical Products Press; 1998.

Newall C, Anderson L, Phillipson J. Herbal Medicines: A Guide for Health-care Professionals. London: Pharmaceutical Press; 1996: 239-240.

Shao ZH, Vanden Hoek TL, Qin Y, et al. Baicalein attenuates oxidant stress in cardiomyocytes. Am J Physiol Heart Circ Physiol. 2002;282(3):H999-H1006.

Watanabe S, Kitade Y, Maski T, Nishioba M, Satoh K, Nishino H. Effects of lycopene and Sho-saiko-to on hepatocarcinogenesis in a rat model of sponstaneous liver cancer. Nutr Cancer. 2001;39(1):96-101

White L, Mavor S. Kids, Herbs, Health. Loveland, Colo: Interweave Press; 1998:22, 40-41.

The publisher does not accept any responsibility for the accuracy of the information or the consequences arising from the application, use, or misuse of any of the information contained herein, including any injury and/or damage to any person or property as a matter of product liability, negligence, or otherwise. No warranty, expressed or implied, is made in regard to the contents of this material. No claims or endorsements are made for any drugs or compounds currently marketed or in investigative use. This material is not intended as a guide to self-medication. The reader is advised to discuss the information provided here with a doctor, pharmacist, nurse, or other authorized healthcare practitioner and to check product information (including package inserts) regarding dosage, precautions, warnings, interactions, and contraindications before administering any drug, herb, or supplement discussed herein.

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How Strattera and stimulants can be utilized in combination to extend duration of ADHD symptom relief without intolerable side effects.

Atomoxetine and Stimulants in Combination for Treatment of Attention Deficit Hyperactivity Disorder: Four Case Reports

Thomas E. Brown - Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut

Thomas E. Brown. Journal of Child and Adolescent Psychopharmacology. 2004, 14(1): 129-136. doi:10.1089/104454604773840571.

ABSTRACT

Atomoxetine and stimulants have both been demonstrated effective as single agents for treatment of attention deficit hyperactivity disorder in children, adolescents, and adults. However, attention deficit hyperactivity disorder symptoms in some patients do not respond adequately to single-agent treatment with these medications, each of which is presumed to impact dopaininergic and noradrenergic networks by alternative mechanisms in different ratios. Four cases are presented to illustrate how atomoxetine and stimulants can be utilized effectively in combination to extend duration of symptom relief without intolerable side effects or to alleviate a wider range of impairing symptoms than either agent alone. This combined pharmacotherapy appears effective for some patients who do not respond adequately to monotherapy, but because there is virtually no research to establish safety and effectiveness of such strategies, careful monitoring is needed.

INTRODUCTION

Atomoxetine (ATX), a specific noradrenergic reuptake inhibitor approved by the U.S. Food and Drug Administration in November 2002, is the first new medication approved for treatment of attention deficit hyperactivity disorder (ADHD) in many years. In clinical trials including 3,264 children and 471 adults (D. Michelson, personal communication, September 15, 2003). ATX has been demonstrated to be safe and effective as a monotherapy for treatment of ADHD.

This new compound is quite different from stimulants, the long-established mainstay for treatment of ADHD. It has shown minimal risk of abuse and is not a schedule II agent; therefore, it can be prescribed with refills and distributed by physicians in samples. Unlike the stimulants that act primarily on the brain's dopamine (DA) system, ATX exerts its action primarily through the noradrenergic system of the brain.

Evidence suggests that there is an important role for both norepinephrine (NE) and DA systems in the pathophysiology of ADHD (Pliszka 2001). It appears that cognitive management systems of the brain can become dysregulated by either insufficiency of DA and/or NE in synapses or by excessive synaptic release of DA and/or NE (Arnsten 2001). There Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut. is some consensus that DA and NE are centrally important in ADHD (Biederman and Spencer 1999), but relative importance of these two catecholamines in particular ADHD subtypes or in particular cases with or without specific comorbidities has not been established.

Although the stimulants methylphenidate (MPH) and amphetamine block reuptake of both NE and DA at their respective transporters, the primary mechanism of action of these stimulant medications widely used for ADHD is via the dopaminergic system of the brain (Grace 2001; Pliszka 2001; Solanto et al. 2001). Until ATX the primary noradrenergic medications for treatment of ADHD were the tricyclic antidepressants. These agents have been shown effective for treatment of ADHD, but risks of adverse cardiovascular effects have caused many clinicians to avoid theft use. Analysis of tricyclic antidepressant response profiles suggests that these agents more consistently improve behavioural symptoms of ADHD) than cognitive function as measured in neuropsychological testing (Biederman and Spencer 1999). In contrast, ATX has not shown elevated cardiovascular risks and has been shown effective for both inattentive and hyperactive-impulsive symptoms of ADHD (Michelson et al 2001. 2002, 2003), although relative efficacy of ATX and stimulants on the two symptom sets has not yet been established.

The mechanism of action for ATX is more specific than that of the tricyclic antidepressants. It inhibits reuptake by the presynaptic NE transporter with minimal affinity for other noradrenergic transporters or receptors (Gehlert et al. 1993; Wong et al. 1982). This pattern of affinity might suggest that its therapeutic benefits derive exclusively from action on noradrenergic circuits, but the process may not be that simple. Preclinical work by Bymaster et al. (2002) and Lanau et al. (1997) suggests that noradrenergic agents such as ATX may act indirectly but potently on the DA system in addition to their recognized impact on noradrenergic receptors. It may be that both stimulants and ATX impact both dopaminergic and noradrenergic circuits in the brain, albeit in different ratios or sequences.

Given the complexity of ADHD and of the mechanisms of action in agents used to treat the disorder, it is likely that ADHD symptoms of some patients with respond to one ratio of noradrenergic versus dopaminergic intervention better than to another. For many patients, ATX or stimulants are quite effective as single agents for alleviating ADHD symptoms, yet some who suffer from ADHD impairments continue to experience significant problematic symptoms when treated with either a stimulant or ATX alone.

In cases where response obtained from a single agent is insufficient, the possibility of utilizing ATX and stimulants in combination may be considered. This combined treatment strategy is similar to the combination of MPH with fluoxetine reported by Gammon and Brown (1993), although that study focused exclusively on ADHD with comorbid symptoms. This report is concerned with treatment of core symptoms of ADHD alone as well as with the more commonly found cases of ADHD complicated by various comorbid symptoms (Brown 2000).

The following case reports describe patients carefully diagnosed with ADHD who did not respond adequately to treatment with a stimulant or ATX as a single agent. In some cases, ATX was added to an existing regimen of a stimulant; in others, a stimulant was added to a regimen of ATX. Each brief vignette describes the problematic symptoms, the regimen tried, and the patient's response. Possible indications for such combined treatment are described, and risks and benefits to such treatment strategies are discussed.

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ATX ADDED TO STIMULANTS

Some patients with ADHD obtain a robust response from stimulants for most of their ADHD symptoms or for most of the day, but not for the full range of impairing symptoms or the full span of time needed.

Case I

Jimmy, an 8-year-old boy in second grade, had been diagnosed with ADHD-combined type while in kindergarten. He was doing well throughout the school day on OROS® MPH 27 mg q 7 a.m., but this dose wore off by 4p.m., leaving the boy restless, irritable, and severely oppositional for the ensuing 5 hours until his bedtime. During this time Jimmy was unable to focus on homework and often engaged in hostile interactions with playmates and family. He also was very irritable and oppositional every morning for about an hour until his OROS MPH had taken effect. In addition, Jimmy had chronic difficulty falling asleep, a longstanding problem that antedated his being on stimulant medication. Doses of 2.5, 5, and 7.5 mg immediate release MPH (MPH-IR) were tried at 3:30 p.m. to supplement the morning dose of OROS MPH. The 2.5- and 5-mg doses were ineffective; the 7.5-mg dose after school was helpful in alleviating Jimmy's irritability and oppositional behaviour after school and in the evening. This regimen had to be discontinued, however, because it left Jimmy with severely diminished appetite for afternoon and evening, a serious problem for this boy who was underweight. The 3:30 p.m. dose also exacerbated his chronic difficulty in falling asleep. Clonidine 0.1mg 1/2 tab q 3:30 p.m. and 1 tab hs was helpful in alleviating afternoon irritability and the difficulty failing asleep but did not help his impaired focus for homework or the serious problems with morning routine that were very stressful for the entire household.

Clonidine was discontinued, and a trial of ATX 18 mg qam was begun while continuing the OROS MPH. Jimmy's sleep problems improved markedly within a few days. His irritability and oppositionality improved slightly within a few days and significantly over the next 3 weeks after the dose of ATX had been increased to 36 mg at the end of the first week. In addition, after 3 weeks, parents reported that Jimmy was generally much less irritable upon awakening and much more cooperative with morning routines, even during the hour before his OROS MPH took effect. Patient has continued in this OROS MPH and ATX regimen for 4 months with continuing benefit and no adverse effects. Appetite is still somewhat problematic in the evening but much less so than during the treatment with an afternoon dose of MPH-IR.

This case highlights the usefulness of ATX for alleviating difficulties in falling asleep and for improving oppositional behaviour in late afternoon, early evening, and morning, times when the OROS MPH had either worn off or not yet taken effect. It was not clear whether ATX had enhanced positive effects of the MPH during daytime hours, but no negative effects were reported. The benefits of ATX were obtained without the adverse effects that accompanied the trials of MPH-IR administered after school.

Case 2

Jennifer, a 17-year-old high school junior had been diagnosed with ADFID, predominantly inattentive type, in ninth grade. She was treated initially with Adderall-XR® 20 mg administered q 6:30 a.m. as she left for school. Adderall-XR provided coverage only until about 4:30 p.m., which was sufficient for days when homework assignments were relatively light and could be done immediately after school.

At the outset of her junior year, Jennifer and her parents requested medication adjustments that would extend coverage into the evening. Because of part-time employment after school, Jennifer now had to do her homework in the evening. Also she was now driving herself to and from school, to and from her job, and to other activities. After she had a minor motor vehicle accident caused by her being inattentive, Jennifer and her parents decided it would be important for her to have medication coverage in the evening to help her with homework and to improve her attention when driving.

Jennifer's morning dose was maintained at 20 mg of Adderall-XR, and Adderall-IR 10 mg was added at 3:30 p.m. This provided coverage until about 10 p.m, but it caused Jennifer to feel extremely restless and anxious in late afternoon. These adverse effects were not alleviated by reducing the dose of Adderall-IR to 5 mg. Moreover, the lower dose of JR did not provide enough symptom control for Jennifer in the evening for homework, so she had to quit her after school job.

When ATX became available, Jennifer was started on ATX 18 mg qam for 1 week concurrent to the existing regimen of Adderall-XR 20 mg qam. After a couple of days of feeling somnolent on this combination, she reported no other adverse effects and some slight improvement in her ability to get homework done in the evening. ATX was increased to 40 mg qam. She experienced 2 days of somnolence on this increased dose, but this dissipated on the third day.

Over the next 3 weeks, Jennifer reported feeling calmer, more focused, and more alert throughout the day and into the evening until bedtime. For 5 months Jennifer and her parents have continued to report good control of her ADHD symptoms throughout the day and evening, with no adverse effects reported.

Jennifer was able to tolerate and benefit from the Adderall-XR given in the morning, but she did not respond well when a second dose of Adderall was given in the afternoon. The combination of Adderall-XR with Adderall-IR seemed to produce an accumulated level by late afternoon that caused her marked restlessness and anxiety The combination of Adderall-XR with ATX allowed better alleviation of ADHD symptoms throughout the day and into afternoon and evening. On this regimen, Jennifer did not feel anxious or restless and was able to do well during school, complete her homework in the evening, and resume her after school job. She also reported that she felt more focused when driving in the evening, at times when the stimulant would be expected to have lost effectiveness. Expanded duration of medication coverage, especially for evenings and weekends, for drivers with ADHD may provide important protection from elevated safety risks reported for drivers with this disorder (Barkley et al. 2002).

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STIMULANTS ADDED TO ATX

Some patients with ADHD gain a positive response from treatment with ATX alone but continue to suffer with additional impairments that are highly problematic.

Case 3

Frank, a 14-year-old ninth grader, had been diagnosed with ADHD-combined type in seventh grade. He was tried on MPH at that time but did not respond well to doses of 10 or 15 mg tid. When the dose was increased to 20 mg tid, he experienced marked improvement in symptoms of both inattention and hyperactivity/impulsivity, but he refused to continue because this higher dose caused severe blunting of affect and anorexia. Subsequently he was tried on mixed salts of amphetamine and on OROS MPH. With all of these stimulants, the dose required to produce significant alleviation of ADHD symptoms caused the same intolerable side effects.

Frank was then tried on nortriptyline (NT) up to 80 mg hs. On this regimen his hyperactive and impulsive symptoms were markedly alleviated, but his inattention symptoms continued to be problematic. and he disliked the regimen because it caused him to feel that he had lost his "sparkle," a less severe blunting of affect than on stimulants, but still uncomfortable enough to make him reluctant to take the medication. Over 2 years, he had several episodes of interrupting his treatment with NT to avoid side effects, being frustrated by declining grades and behaviour problems, and then unhappily resuming treatment on the NT regimen.

Frank requested a trial of ATX immediately after it became available. His NT was discontinued, and he was started on 25 mg qam for 1 week, after which the dose was increased to 50 mg and then, 1 week later, to 80 mg qam. After minor gastrointestinal complaints and some somnolence in the first week, no adverse effects were reported. Frank initially reported no benefit, but after 3 weeks he noticed that he felt more calm throughout the day. His parents and teachers reported improved behaviour throughout the day, but they and Frank noted that he continued to show much difficulty in sustaining concentration for academic tasks.

In week 6, Frank's regimen of ATX 80 mg qam was divided into 40 mg bid and then augmented with OROS MPH 18 mg qam. He reported that this slightly improved his ability to remember what he had read and to focus on his schoolwork. At his request, the dose was increased to OROS MPH 27 mg qam with the ATX 40 mg bid. Frank has continued on this regimen for 4 months with no adverse effects.

He reports that on this regimen he feels "like my regular self," and his grades have improved in all subjects. Frank's intermittent disruption of his treatment with NT illustrates an important problem that commonly occurs, especially with adolescent patients. Uncomfortable side effects such as blunting of affect can significantly interfere with treatment compliance, even when the regimen significantly improves target symptoms. The combination of ATX and OROS MPH alleviated this problem that had threatened to totally disrupt Frank's treatment. This combined regimen developed in collaboration with Frank also resulted in better control of the wider range symptoms targeted for treatment.

Case 4

Six-year-old George was diagnosed with ADHD-combined type and oppositional defiant disorder after 3 months in full-day kindergarten. His teacher complained that George refused to follow directions and was unable to sustain attention to tasks. George's parents reported that over several years he had been increasingly oppositional at home, so much that they were unable to get any babysitter to return for a second time. He often fought with neighbourhood children and was argumentative and disrespectful to his parents and other adults. Parents also reported that since early childhood George had experienced chronic difficulty in falling asleep. Despite their efforts to calm him, he was unable to settle into sleep until 10 to 11:30 p.m.

George was started on ATX 18 mg qam. Initially he complained of stomach-ache, but this dissipated within a few days. Dose was increased to 36 mg qam after 1 week. After 2 weeks, parents reported that George had begun to settle down more easily in the evening and was falling asleep without much difficulty by 8:30 p.m. They also noted improvement in his compliance with morning routines and getting off to school. After 3 weeks, the teacher reported that George was more cooperative in following directions and had a better attitude with other children but noted that he still had much difficulty in sustaining attention to stories, play, or reading exercises.

In that the recommended ATX dosing limit for George's weight had been reached, a trial of Adderall-XR 5 mg qam was added to the ATX regimen. This improved George's behaviour further and increased his ability to sustain attention in school, but it also caused increased difficulty in falling asleep. The ATX dose was then split so that George received 18 mg ATX with the morning dose of stimulant and 18 mg ATX at dinnertime. This recaptured the improvement in sleep. George has continued on this regimen for 3 months, with marked improvement at home and school and no adverse effects. ATX was chosen as an initial intervention for George because it offered the possibility of addressing his severe problems in sleep as well as his very problematic oppositional behaviour and inattention using a single agent with relatively smooth coverage throughout the day.

ATX was quite helpful for George, but the teacher's reports of continuing inattention symptoms that were interfering with leaning highlighted the need for further intervention. A higher dose of ATX was not tried because a dose response study of ATX (Michelson et a!. 2001) did not show added benefit to doses above 1.2 mg/kg/day. At this point, the combination of ATX and stimulant every morning was tried. Splitting the dose of ATX provided a way to retain benefits of the stimulant while sustaining improved sleep.

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RISKS OF COMBINING STIMULANTS WITH ATX

Stimulants and ATX have been subjected to extensive clinical testing that has demonstrated safety and efficacy in their use as single agents for treatment of ADHD. An enormous quantity of research and clinical experience has been accumulated with stimulants over the past 30 years. Most of this has been with elementary school children, but there is a sizable body of research on stimulants with adolescents and with adults as well. Greenhill et al. (1999) summarized studies including 5,899 individuals that have shown stimulants to be safe and effective for treatment of ADHD. ATX has not yet been tested for long in the wider population of patients treated outside the protective restrictions of clinical trials, but it has been demonstrated safe and effective in clinical trials involving over 3,700 individuals, a much larger sample than for other nonstimulant medications tried for ADHD. However, the substantial evidence of safety and effectiveness of ATX and stimulants as single agents does not establish satisfactory evidence of safety and benefits of using these agents together.

The combination of stimulants with ATX described in these cases has thus far been quite helpful in alleviating patients' ADHD symptoms without any recognized adverse effects. At present, however, there are virtually no research data to demonstrate the safety and effectiveness of such combined treatments. The manufacturer of ATX has reported that tests of combined administration of MPH and ATX did not result in increased blood pressure, but not much more has been published about the use of these two medications together.

When more than two medications are used together, the potential for adverse effects is further increased. We had one 18-year-old high school student in whom a combination of three medications produced significant although transient adverse effects. This student's severe ADHD symptoms and moderate dysthymia had responded only partially to 1 year of treatment with OROS MPH 72 mg qam with fluoxetine 20 mg qam. When his continuing difficulties with inattention symptoms jeopardized his graduating from high school; ATX 80 mg was added to the existing regimen. After this regimen had been working well for 6 weeks, a taper down was begun to discontinue the fluoxetine. Before the taper down was completed, the boy reported an acute episode of headache and dizziness in school The school nurse found his blood pressure to be 149/100 mm Hg; previous baseline was consistently 110 / 70 mm Hg. All medications were discontinued until his pressure was restabilized for 2 weeks, at which time ATX was restarted followed by the OROS MPH a week later. The hypertensive episode apparently resulted from effects of the fluoxetine on metabolism of the ATX. This is evidence to support the warning from manufacturers of ATX that caution must be used when strong CYP2D6 inhibitors such as fluoxetine are used concurrent to ATX. The combination of ATX and OROS MPH was helpful and well tolerated by this patient after the fluoxetine had been fully washed out, a step that should have been taken prior to adding the ATX.

Lack of systematic research on use of ADHL) medications in combination is an example of a broader problem in psychopharmacology, particularly in child and adolescent psychopharmacological treatment. The practice of using medications in combination is increasingly widespread. Safer et al. (2003) recently reviewed clinical research and practice literature from 1996-2002 to assess frequency of concomitant psychotropics for youths- They reported that during 1997-1998 almost 25% of the representative physician office visits for youths in which a stimulant prescription was written were also associated with use of concomitant psychotropic medication. This was a fivefold increase over the rate in 1993-1994. Elevated rates for use of alternative combinations of medications to treat other psychiatric disorders in children were also found, usually to treat aggressive behaviour, insomnia, tics, depression, or bipolar disorder. Apparently, combined pharmacotherapy with children is increasing despite the lack of adequate research on the safety of such combinations.

Some might question why clinicians utilize a combined pharmacotherapy treatment before it has been fully evaluated in controlled trials. Usually the rationale is that apparent risks for a particular patient appear significantly less harmful than the likely risks of not providing such treatment and that there is potential of substantial benefit for a patient suffering significant impairment. The major problem with this approach is the dearth of adequate research to guide estimates of possible risks and benefits in the use of combined medication treatment. Similar uncertainties exist in many fields of medicine.

The cases described in this report reflect various problems that were not life threatening but were significantly impairing the learning, school achievement, family life, and/or social relationships of these patients in ways that had substantial negative impact on functioning and quality of life for the children and their families. Each derived some benefit from treatment with a single agent, but significant ADHD symptoms or related impairments persisted on the monotherapy regimen- In these cases, neither parents nor clinicians were engaged in a quixotic search for perfection; these children and families were suffering significantly from impairing symptoms inadequately alleviated by single-agent treatment.

In such cases, clinicians need to weigh carefully potential advantages and risks of accepting limited benefits obtained 1mm monotherapy versus the potential risks and benefits of utilizing combined agents. As Greenhill (2002) observed, "The individual practitioner must make key decisions when treating an individual patient, often without an authoritative answer or direction from the research literature." Greenhill added that even when relevant research literature is available, it yields "averaged group data to evaluate medication effects, possibly missing important subgroup differences in treatment response" (chapter 9, pp. 19-20). The clinician's task is to tailor treatment interventions utilizing understanding of the relevant science together with sensitive understanding of the particular patient.

In the four cases presented here; the combination of ATX with stimulants has apparently been safe and effective. We have obtained similar results thus far in 21 other cases with no significant adverse effects. Such anecdotal reports, however, especially over short time frames, are not sufficient to establish safety In~ the absence of adequate research, decisions to utilize this combination of ATX and stimulants should be made on a case-by-case basis, with full disclosure of the limited research base given to the patient or parents and with ongoing monitoring for effectiveness and possible adverse effects.

NOTE: This study has been printed here with the very kind permission of Thomas E. Brown, Ph.D.

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REFERENCES

Arnsten AFT: Dopaminergic and noradrenergic influences on cognitive functions. In: Stimulant Drugs and ADHD: Basic and Clinical Neuroscience Edited by Solanto MV, Arnsten AFT, Castellanos FX New York, Oxford University Press, 2001, pp 185-208.
Barkley RA, Murphy KR, DuPaul GI, Bush T: Driving in young adults with attention deficit hyperactivity disorder: Knowledge, performances adverse outcomes, and the roleof executive functioning . J. Neuropsychol Soc 8: 655-672. 2002.
Biederman J, Spencer T: Attention- deficit/hyperactivity disorder (ADHD) as a noradrenergic disorder. Biol Psychiatry 46:1234-1242, 1999.
Brown TE: Emerging understandings of attention deficit disorders and comorbidities. In: Attention Deficit Disorders and Comorbidities in Children, Adolescents and Adults. Edited by Brown TE. Washington (DC), American Psychiatric Press, 2000, pp 3-55.
Bymaster FP, Katner JS, Nelson DL, HemrickLuecke 5K, Threlkeld PC, Heiligenstein JH, Morin SM, Gehlert DR, Perry KW: Atomoxetine increases extracellular levels of norepinephrine and doparnine in prefrontal cortex of rat: A potential mechanism for efficacy in attention deficit/hyperactivity disorder Neuropsychopharmacology 27:699-711, 2002.
Gammon GD, Brown TE: Fluoxetine and methylphenidate in combination for treatment of attention deficit disorder and comorbid depressive disorder. J Child Adolesc Psychopharrnacol 3:1-10, 1993.
Gehlert DR. Gackenheimer SL, Robinson DW: Localization of rat brain binding sites for [3H]tomoxetine, an enantiomerically pure ligand for norepinephrine reuptake sites. Neurosci Lett157:203-206, 1993
Grace AA: Psychostimulant actions on dopamine and limnbic system function: Relevance to the pathophysiology and treatment of ADHD. In: Stimulant Drugs and ADHD: Basic and Clinical Neuroscience. Edited by Solanto MV, Arnsten AFT, Castellanos FX. New York, Oxford University Press, 2001, pp 134-157.
Greenhill L: Stimulant medication treatment of children with attention deficit hyperactivity disorder. In: Attention Deficit Hyperactivity Disorder: State of the Science, Best Pracfices Edited by Jensen PS, Cooper JR. Kingston (New Jersey), Civic Research Institute, 2002, pp 1-27.
Greenhill L, Halperin JM, Abikoff H: Stimulant medications. J Am Acad Child Adolesc Psychiatry 38:503-512, 1999.
Lanau F, Zenner M, Civelli O, Hartmann D: Epinephrine and norepinephrine act as potent agonists at the recombinant human dopamine D4 receptor J Neurochem 68:804-812, 1997.
Michelson D, Adler L, Spencer T, Reimherr FW, West SA, Allen AJ, Kelsey D, Wernicke I, DietrichA, Milton D: Atomoxetine in adults with ADHD: Two randomized, placebo-controlled studies. Biol Psychiatry 53:112-120, 2003.
Michelson D. Allen AJ, Busner J. Casat C, Dunn D, Kratochvil C, Newcom J, Sallee FR, Sangal RB, Saylor K, West SA, Kelsey D, Wernicke J, Trapp NJ, Harder D: Once-daily atomoxetine for children and adolescents with attention deficit hyperactivity disorder: A randomized, placebo-controlled study. AmJ Psychiatry 159:1896-1901,2002
Michelson D, Faries D, Wernicke J, Kelsey D, Kendrick K, Sallee FR, Spencer T; Atomoxetine ADHD Study Group: Atomoxetine in the treatment of children and adolescents with attention-deficit/hyperactivity disorder: A randomized, placebo-controlled, dose-response study. Pediatrics 108:E83, 2001
Pliszka SR: Comparing the effects of stimulant and non-stimulant agents on catecholamn~e function: Implications for theories of ADHD. In: Stimulant Drugs and ADHD: Basic and Clinical Neuxoscjence Edited by Solanto MV, Arnsten AFT, Castellanos FX. New York, Oxford University Press, 2001, pp 332-352.
Safer DJ, Zito JM, Doskeis 5: Concomitant psychotropic medication for youths. Am J Psychiatry 160:438-449,2003.
Solanto MV, Arnsten AFT, Castellanos FX: Neuroscience of stimulant drug action in ADHD. In; Stimulant Drugs and ADHD: Basic and Clinical Neuroscience. Edited by Solanto MV ArnstenAFT, Castellanos FX. New York, Oxford University Press, 2001, pp 355-379.
Wong DT, Threlkeld It, Best KL, Bymaster FP: A new inhibitor of norepinephrine uptake devoid of affinity for receptors in rat brain. J Pharmacol Exp Ther 222:61-65, 1982.

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Making the right contacts in business is extremely important to your success.

The truth is, no one really has cornered the market on networking as a contact sport. Networking is too big a sport for anyone to ever get a corner on it. For those of you who are successful, however, it's more than a favorite pastime. It's a way of life.

Most successful business women that I know are active networkers. Women excel in networking. Ask me, I know. I know a professional networker when I see one. I have built my professional speaking and publishing career by networking.

Meeting people is a must. It's not only "who you know," it's "who knows you." Meeting the people who count has to be a top priority. Meeting the right people gets you noticed and gets you places. If you have a desire to work smart, networking is one way to effectively do that.

Successful women in networking are not shy. Nancy Siegel, owner of Nancy Siegel Insurance Agency, Inc., says, "Don't be afraid to be the first one to speak to a stranger. Most people feel as uncomfortable as yourself and are usually glad to have someone to talk with after the ice is broken."

It has been my experience that women seem to have a special knack for networking. Perhaps it is inbred in our culture. Women always seem to intuitively understand where to go or who to contact for just about anything they need or want to know. There are many men who are very successful at networking, however, when it comes to being creative with contact talents, women get "thumbs up" from me.

Let's put networking in the right perspective. For the purpose of this discussion, let's work with a definition of networking that has served me well.

Networking is. . . using your creative talents to help others achieve their goals as you cultivate a network of people strategically positioned to support you in your goals. . . expecting nothing in return! - Larry James

Now, lets take a moment to think about that. Is that a belief system you could buy into? Read it again.

It is estimated that 65 - 75% of those people who are actively engaged in networking are women. People who network keep score by how many business leads they give others, not by how many leads they receive.

Kathy Holt, owner of Forget-Me-Not Gift Baskets, Inc., says, "If you really network right, with a commitment to only helping others, you will get back twice as much and make lifetime friendships." She should know. Kathy experienced a 38.6% increase in business in five months after she joined The Tulsa Business Connection, a group I founded in 1985. She also recommends joining and getting involved with the Chamber of Commerce.

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You won't find people who take the easy way out actively participating in networking groups. Experienced networkers can spot someone who is only in it for themselves a mile away. People who want something for nothing do not succeed at networking. They fade in and drop out.

We erroneously call these people losers. They are not losers, they have yet to understand that to be successful you must first have integrity and second, commitment. They seldom stay with a project until its completion. Therefore they don't do well when networking because networking demands both integrity and commitment. People who know the truth behind my definition of networking know that when you help others get what they want, you ultimately get what you want.

High achievers consistently are looking for a way to better themselves and to assist others in the process. They know that by participating in someone else's success, they become more successful. You can't be afraid of hard work and effectively network.

Networking works. And you must consistently work it. Rose Mary Winget, sales manager at McCaw Communications once told me, "Don't say you don't have time. You don't have time not to network." Her entire sales staff is actively involved in networking groups. She also hired me to present my networking seminar, Networking: Making the Right Connections, to her group.

Rose Mary's experience has taught her that networking gets quicker results than prospecting. When you prospect, you are looking for potential customers and clients. When you network, you capitalize on the alliances you have developed with others in your network; they do your prospecting for you.

It makes sense. You can multiply your own personal effectiveness by the number of people you know, who believe in you, like you, trust you and are committed to refer business leads to you. Isn't it a better use of your time to develop close personal and business relationships with people who are on your side and will help you succeed?

Many salespeople never get down to business. Their only interest is "busy-ness." I don't know about you, but busy-ness has never made me any money. To be successful, you must do what counts. Focus on what matters. Networking is building supportive personal and busines relationships; it's meeting new people and making new friends; it's helping others help themselves.

Marilyn Minter, a former Tulsa real estate agent started her own networking group, "Tulsans Networking Tulsa" (TNT) in March, 1991. Marilyn says, "Networking has given me the opportunity to make contact with literally hundreds of people. I never would have met those people without networking. The heart of my real estate business came from the personal referrals acquired while networking." Her advice to women who are considering networking, "Get started. Be patient. Believe in yourself and never quit."

Within the concept of networking is a blueprint for change. With change comes new ways of thinking. If you always do what you've always done, you will always get what you've always gotten.

There is only one way to keep your career growing. YOU must keep growing. Ask the women who network about the personal growth they have experienced. Ask them about how much better they feel about themselves now that they are doing more of what the pros do.

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In meetings that are specifically designated for networking, each person is asked to give their "30 Second Connection" as a way of introducing themselves and their business to the group. After her first networking meeting, Vicky Olsen, who was visiting the group to fill the banker slot, confided in me that standing up to give her "30 second connection" to the group was very scary and she wasn't sure she would return.

I asked her what her goals were for her advancement at the bank. She told me. I then explained that if she ever expected to achieve her goals, one of the most important elements of her success would be networking. To overcome her fear, I suggested that she take the Dale Carnegie Course. She did and later became one of their top "graduate assistants."

I also told her that as far as presenting her "30 second connection" was concerned, if she followed the guidelines, she couldn't get it wrong because no one in the audience knew what she was going to say anyway. I also suggested that she take an active part in the leadership of the group.

Less than a year later, she was the Treasurer of the group and served two one-year terms. Each week she stood unafraid to give the Treasurer's report. And now the good news: Vicky was promoted to Vice President of the bank.

It takes courage to network; do put yourself "out there;" to consistently move toward something better; to become the someone you look up to. The more you network, the more courage you receive. Be courageous and you will discover more courage!

Unless you are committed to doing more than you've done before, you will feel some discomfort when becoming involved in networking. This is natural. You will be in the presence of doers. You, who are not doing, may be confronted by this. Thus, you may feel uncomfortable.

People who do more get results! They are actively engaged in activities that feed their enthusiasm for their calling. For them, backward in not an option. They are on "fast forward." They get things done. They make every minute count when they are networking. They are aware of the "net" result. They know that what you put out to the universe, always comes back to you. They are dedicated to doing good for others.

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How many successful people do you know? Network to get to know more. The energy they dedicate to helping others is infectious. Listen to their success stories. Listen for the opportunity that a fresh perspective presents. For me, it's a lesson in inspiration; inspiring me to be the best I can be.

For a horse, one inch farther often wins the race. In networking, you never know when the next contact you make may be the one inch that puts you in the winner's circle.

I met Gregory J.P. Godek -- America's Romance Coach -- while networking. Greg is the best-selling author of 1001 Ways to Be Romantic. We sat at the same lunch table at a National Speakers Association meeing many years ago. He referred me to his book distributor. Five days later, I had a three year contract for them to distribute my relationship books to all the major book stores. This was a big break for me. We have since become great friends. He mentions my work in the relationship area in his books; I mention his work for the "romantically impaired" in my books.

Networkers play too! When they play, they have fun. They know that the time they devote to social and recreational activities with family and friends pays off with a sense of having recharged their batteries. After 11 years of networking, Nancy Siegel advises: "Know when to stop and recharge. Learn how to say "no" to please yourself instead of "yes" to please others. when you network, network! Whey you play, play!"

Remember too, the energy level of successful people operates above average because they love who they are and what they do.

Above average people network for above average results. They know a good thing when they see one. They stick with it. They are the above average women who have discovered a wonderful contact sport called "networking" and are still making new and exciting personal and business contacts after "all these years."

Click on a book cover or book title link to place an order

The First Book of Life Skills: 10 Ways to Maximize Your Personal and Professional Potential - Larry James - This book will teach you how excell in business networking. It is a book devoted to the process of developing close personal and business relationships that work. It is a book committed to personal development and career management. Adapted from Larry's popular seminar, "The 10 Commitments of Networking!"

Power Networking: 59 Secrets for Personal & Professional Success - Donna Fisher & Sandy Vilas - Packed with 59 proven networking methods for achieving success in all areas of your life, this inspiring book helps you to discover key networking skills to show you how to make the requests that get the results you want.

Larry's Review: The importance of making important business connections cannot be understated. Donna offers sound advice and encourages you to give up your shyness and offer to assist others as you build a network of support; one that increases your visibility, expands your network and marks you as someone who is willing to do whatever it takes to succeed.

The Essential Network: Success Through Personal Connections - John L. Bennett - This book is about establishing, maintaining, and reaping the benefits of connections. It incorporates many personal stories to illustrate the productive results that can occur from building connections. These include people who have found life-partners, avoided personal and financial disasters, made career changes, built businesses, and met famous people.

Larry's Review: The principles of business networking in an easy-read and understandable format. Highly recommended!

next: An Affirmation for Letting Go

The facts on the abuse of alcohol are sobering. According to the National Institute on Alcohol Abuse and Alcoholism alcohol consumption affect men and women differently, however some effects are the same in both genders.

Here is a look at how the body of a man reacts:

• Higher incidence of alcoholism.
• Higher rate of drunk-driving accidents. Male drivers who die in auto accidents are almost twice as likely to be legally drunk as women.
• Impotence (Now that's a good reason to quit!)

Here are some alcohol reactions specific to women:

• Gets sicker easier because of lower levels of enzyme that metabolizes alcohol.
• More likely to have interactions with medications.
• Drinking while pregnant can cause learning disabilities and low birth weight in babies.

In both sexes you are likely to find the same reactions:

• Alcohol affects neurotransmitters, affecting balance, speech and judgment.
• Over long periods, alcohol can damage liver cells and lead to potentially deadly cirrhosis.
• Alcohol can lead to dehydration.
• Evidence is growing that limited alcohol intake can decrease the risk of heart desease, however long-term alcoholics may suffer from a degeneration of the heart muscle.
• Alcohol can raise blood pressure, meaning it's not good for people with hypertension.
• Too much alcohol and you may pass out. In extreme cases. . . a person may never wake up. (Another good reason to quit!)
• Excessive alcohol can destroy a relationship!

Here is an easy way to tell if you are drinking too much. Truthfully answer these questions:

1 - Do you drink alone when you feel angry or sad?

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2 - Does your drinking ever make you late for work?

3 - Does your drinking worry your family or partner?

4 - Do you ever drink after telling yourself you won't?

5 - Do you ever forget what you did while you were drinking?

6 - Do you get headaches or have a hangover after you've been drinking?

Any answer of "Yes" signals a potential problem.

Here are some tips to help you cut back or stop drinking:

• Don't keep alcohol at home.
• Drink slowly, with an hour between drinks. Drink something else between alcoholic drinks.
• Try not to drink one or two days a week, then for a full week.
• Learn to say no.
• Stay ACTIVE, doing something other than drinking.
• Watch out for temptations. Avoid people, places or times that make you drink.

Excessive drinking causes more than 100,000 deaths a year in the United States. Nearly one-forth are attributable to drunken driving. One in five deaths results from alcohol-related homicide or suicide.

In an article in "Alcohol Health and Research World," Robert Swift and Dena Davidson say if you are determined to drink, stick with vodka or gin (unless you are allergic to juniper berries in gin), avoiding brandy, whiskey or red wine. Beer was not mentioned.

For your own sake and that of others. . . NEVER DRINK AND DRIVE. Don't kid yourself. A one-once cocktail can stay in your system for as much as 8 hours. If you are stopped by the police, arrested and convicted, a DUI can drastically affect your life for years to come, e.g., drivers license suspension, heavy fines, the humiliation of jail time, higher insurance rates (IF you can get insurance!), attorney fees and more. It could cost "at least" $3,200 after a drunk-driving arrest. The risk is not worth it. Always have a designated driver or take a cab.

To decrease the intensity of a hangover, eat fruit or drink fruit juices. Bland foods with complex carbohydrates such as toast or crackers make help. Drink plenty of water, and get some sleep.

As for medications, take antacids, asprin, ibuprofen or napozin. According to Swift and Davidson, DO NOT use acetaminophen, because alcohol metabolism can enhance that drug's toxicity to the liver.

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So. . . what is the "sure cure for a hangover?"

- Don't drink in the first place! -

Alcohol abuse is involved in at least one traffic fatality every half-hour in the United States.

If you DO drink, remember: A cab ride home is much cheaper than a DUI.

Here is one man's sobering story.

The following form calculates an individual's blood alcohol content based on the quantity of beverages consumed, the alcohol percentage in each drink, the person's weight, and the time spent consuming the drink. Use numbers only (not % or oz., etc.). All results are close approximates.

• Fluid Ounces Consumed
  (Beer = 12 oz. - Wine Glass = 4 oz. - 1 Shot = 1.5 oz)
• Your Weight (Lbs)
• Alcohol Percentate in Beverage
  (Beer = 4 or 4.5% Wine = 15 or 20% 1 Shot = 30 to 50%)
• Hours Consuming Drink

Ways for Teens to Say "No!" When Offered a Drink
Source: Arizona Students Against Destructive Decisions (Formerly Students Against Drunk Driving)

• I'd rather OD on pizza.
• I become so witty no one can stand me.
• I don't need any more hair on my chest. (This line is especially effective for women).
• My weekends are made for something else.
• It doesn't bring out my best.
• Chocolate and alcohol don't mix.
• I might forget where I parked my mind.
• The last time I had a drink I wanted to attack a chicken.
• It makes me look stupider.
• I don't look good in a lampshade.

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• If I want the high life, I'd rather go sky diving.
• I'm performing neurosurgery in the morning.
• It sloshes too much when I jog.
• Things are polluted enough already.
• I like me just the way I am.
• I'm saving my brain cells for science.
• I might forget all the witty things you're going to say tonight.
• If I'm going to blow my diet, I'll do it on junk food.
• My life is weird enough as it is.
• I think; therefore, I will not drink.
• I'm driving.

To purchase the following book, click on the book title link or book cover!

Responsible Drinking: A Moderation Management Approach for Problem Drinkers - Frederick Rotgers, Psy.D., Marc F. Kern, Ph.D., & Rudy Hoeltzel - The scientifically based program that shows you how to build a plan for a healthy, balanced approach to drinking. Researched-based techniques halp you to discover the the extent of your problem and learn key strategies for controlling your behavior, identifying your triggers and special needs, and developing a healthier, more moderate lifestyle.

Larry's Review: If you are truly intent on moderation or abstinence for the benefit of your health and your family, you will find an awesome collection of ideas and suggestions for taking responsibility for and being accountable for your drinking.

next: Networking: A Woman's Contact Sport

Introduction

In discussions about the theories, common problems, and treatment of repeat dieters or those dealing with issues of weight preoccupation, obesity and dieting are often interrelated. There are physical, psychological and social aspects to the problems of obesity. This is why the social work profession is ideally suited to understanding the problems and provide effective intervention.

Some controversy surrounds whether obesity is considered an "eating disorder." Stunkard (1994) has defined Night Eating Syndrome and Binge Eating Disorder as eating disorders that contribute to obesity. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV ™) (American Psychiatric Association, 1994) characterizes eating disorders as severe disturbances in eating behavior. It does not include simple obesity as an eating disorder because it is not consistently associated with a psychological or behavioral syndrome. Labeling obesity as an eating disorder that needs to be "cured" implies a focus on physical or psychological processes and does not include recognition of the social factors that may also have a contributive impact. Weight preoccupation and dieting behaviors will certainly have some aspects of an eating disorder and eating disorders psychological implications such as inappropriate eating behaviors or disturbances in body perception. In this paper, neither obesity or weight preoccupation are considered to be eating disorders. Labeling these as eating disorders does not provide any useful clinical or functional purpose and only serves to further stigmatize the obese and weight-preoccupied.

What is Obesity?

It is difficult to find an adequate or clear definition of obesity. Many sources discuss obesity in terms of percentage above normal weight using weight and height as parameters. Sources vary in their definitions as to what is considered "normal" or "ideal" versus "overweight" or "obese." Sources range in defining a person who is 10% above ideal as obese to 100% above ideal as obese (Bouchard, 1991; Vague, 1991). Even ideal weight is difficult to define. Certainly not all people of a certain height should be expected to weigh the same. Determining obesity by poundage alone is not always indicative of a weight problem.

Bailey (1991) has suggested that the use of measuring tools such as fat calipers or water submersion techniques where the percentage of fat is determined and considered within acceptable or non-acceptable standards is a better indicator of obesity. Waist-hip ratio measurements are also considered to be a better determination of risk factors due to obesity. The waist-hip ratio takes into account the distribution of fat on the body. If fat distribution is mainly concentrated at the stomach or abdomen (visceral obesity), the health risks for heart disease, high blood pressure, and diabetes increase. If fat distribution is concentrated at the hips (femoral or saggital obesity), there is considered to be somewhat less of a physical health risk (Vague, 1991).

Currently, the most common measurement of obesity is through the use of the Body Mass Index (BMI) scale. The BMI is based on the ratio of weight over height squared (kg/MxM). The BMI gives a broader range of weight that may be appropriate for a specific height. A BMI of 20 to 25 is considered to be within ideal body weight range. A BMI between 25 to 27 is somewhat at a health risk and a BMI above 30 is considered at significant health risk due to obesity. Most medical sources define a BMI of 27 or higher to be "obese." Although the BMI scale does not take into account musculature or fat distribution, it is the most convenient and presently most widely understood measure of obesity risk (Vague, 1991). For the purposes of this study, a BMI of 27 and above is considered to be obese. The terms obese or overweight are used interchangeably throughout this thesis and refer to those with a BMI of 27 or higher.

Obesity and Dieting Demographics

Berg (1994) reported that the most recent National Health and Nutrition Examination Survey (NHANES III) revealed that the average body mass index of American adults has risen from 25.3 to 26.3. This would indicate an almost 8 pound increase in the average weight of adults over the past 10 years. These statistics indicate that 35 percent of all women and 31 percent of men have BMIs over 27. The gains extend across all ethnic, age, and gender groups. Canadian statistics indicate that obesity is prevalent in the Canadian adult population. The Canadian Heart Health Survey (Macdonald, Reeder, Chen, & Depres, 1994) showed that 38% of adult males and 80% of adult females had BMIs of 27 or higher. This statistic has remained relatively unchanged over the past 15 years. Therefore, it clearly indicates that in North America, approximately one-third of the adult population is considered to be obese.

The NHANES III study reviewed the possible causes of the pervasiveness of obesity and took into consideration such issues as an increasing American sedentary lifestyle and the prevalence of eating food outside the home. It is interesting to note that in an era in which dieting has become almost the norm and profits from the diet industry are high, overall weight is increasing! This could this lend some credibility to the notion that dieting behaviors lead to increased weight gain.

In the Canadian survey, approximately 40% of men and 60% of women who were obese stated that they were trying to lose weight. It was estimated that 50% of all women are dieting at any one time and Wooley and Wooley (1984) estimated that 72% of adolescents and young adults were dieting. In Canada, it was striking to note that one third of women who had a healthy BMI (20-24) were trying to lose weight. It was disturbing to note that 23% of women in the lowest weight category (BMI under 20) wanted to further reduce their weight.

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Physical Risks of Obesity and Dieting

There is evidence that suggests obesity is linked to increased sickness and death rates. The physical risks to the obese have been described in terms of increased risks of hypertension, gall bladder disease, certain cancers, elevated levels of cholesterol, diabetes, heart disease and stroke, and some associative risks with conditions such as arthritis, gout, abnormal pulmonary function, and sleep apnea (Servier Canada, Inc.,1991; Berg, 1993). However, increasingly there have been conflicting opinions about the health risks of being overweight. Vague (1991) suggests that the health risks of being overweight may be more determined by genetic factors, fat location, and chronic dieting. Obesity may not be a major risk factor in heart disease or premature death in those who do not have pre-existing risks. In fact, there are some indications that moderate obesity (about 30 pounds overweight) may be healthier than thinness (Waaler, 1984).

It has been hypothesized that it is not the weight that causes the physical health symptoms found in the obese. Ciliska (1993a) and Bovey (1994) suggest the physical risks manifested in the obese are a result of the stress, isolation and prejudice that are experienced from living in a fat-phobic society. In support for this contention, Wing, Adams-Campbell, Ukoli, Janney, and Nwankwo (1994) studied and compared African cultures which exhibited increased acceptance of higher levels of fat distribution. She found that there were no significant increases in health risks where obesity was an accepted part of the cultural composition.

The health risks of obesity are usually well known to the general public. The public is often less well informed about the health risks of dieting and other weight loss strategies such as liposuction or gastroplasty. Dieters have been known to experience a wide variety of health complications including cardiac disorders, gallbladder damage, and death (Berg, 1993). Diet-induced obesity has been considered a direct result of weight cycling due to the body regaining more and more weight after each diet attempt such that there is a resultant net gain (Ciliska, 1990). Therefore, the physical risks of obesity may be attributed to the repetitive pattern of dieting that created the obesity through a gradual net gain of weight after each diet attempt. It is believed that the physical health risk in people who repeatedly go through weight losses followed by weight gains is likely greater than if they were to stay the same weight "above" ideal (Ciliska, 1993b)

Causes of Obesity

The underlying causes of obesity are largely unknown (National Institute of Health [NIH], 1992). The medical community and general public hold the strongly entrenched belief that most obesities are caused by an excessive amount of caloric intake with low energy expenditure. Most treatment models assume the obese eat considerably more than the non-obese and that daily food intake must be restricted in order to ensure weight loss. This belief is directly opposed by Stunkard, Cool, Lindquist, and Meyers (1980), and Garner and Wooley (1991) who contend that most obese people do NOT eat more than the general population. There is often no difference in the amount of food consumed, speed of eating, bite size or total calories consumed between obese people and the general population. There is a great deal of controversy to these beliefs. On the one hand, overweight people often state that they do not eat more than their thin friends. However, many overweight people will self report that they do eat considerably more than they need. For many of the obese, dieting behaviors may have created a dysfunctional relationship with food such that they may have learned to turn to food increasingly to meet many of their emotional needs. (Bloom & Kogel, 1994).

It is not entirely clear whether normal weight people who are not weight preoccupied are able to tolerate or adapt to varying amounts of food in a more efficient fashion or whether the obese who have attempted calorie restricted diets may indeed have a food intake that is too high for their daily needs (Garner & Wooley, 1991). Through repeated dieting, dieters may be unable to read their own satiety signals and therefore will eat more than others (Polivy & Herman, 1983). The very act of dieting results in binge eating behaviors. It is known that the onset of binge behaviors occurs only after the experience of dieting. It is believed that dieting creates binge eating behavior that is difficult to stop even when the person is no longer on a diet (NIH, 1992).

Therefore, the evidence would suggest that obesity is caused by a multitude of factors that are difficult to determine. There may be genetic, physiologic, biochemical, environmental, cultural, socioeconomic, and psychological conditions. It is important to recognize that being overweight is not simply a problem of will power as it is commonly assumed (NIH, 1992).

Physiological Aspects of Dieting and Obesity

Physiological explanations of obesity look to such areas as genetic predispositions to weight gain, set point theory, different ranges of metabolism and the issue of "diet induced obesity." Some physiological evidence may indicate that obesity is more a physical rather than psychological issue. Mouse studies undertaken by Zhang, Proenca, Maffei, Barone, Leopold, and Freidman (1994) and twin studies conducted by Bouchard (1994) indicate that there may indeed be a genetic predisposition for obesity and fat distribution.

Metabolic rates are determined by genetic inheritance and have often been discussed in relation to obesity. It has been hypothesized that overweight people may alter their metabolism and weight through caloric restriction. At the onset of a calorie reduced diet the body loses weight. However, slowly, the body recognizes it is in "famine" conditions. Metabolism slows down considerably so that the body is able to maintains itself on fewer calories. In evolution, this was a survival technique that ensured a population, particularly the females, could survive in times of famine. Today, the ability for one's metabolism to slow with dieting means that weight loss efforts through dieting will usually not be effective (Ciliska, 1990).

Set point theory also relates to issues of metabolism. If one's metabolic rate is reduced to ensure survival, fewer calories are needed. The "set point" is lowered. Therefore, one will gain more weight when the diet stops ensuring a subsequent weight gain on fewer calories. This phenomena is often found in women who have endured a very low calorie liquid protein diet (VLCD) that consists of 500 calories per day. Weight is lost initially, stabilizes and when calories are increased to just 800 per day, weight is GAINED. It is believed that the set point is lowered and a resultant net gain occurs (College of Physicians and Surgeons of Alberta, 1994).

There has been discussion that the process of prolonged and repeated dieting puts the body at physical risk. Yo-yo dieting or weight cycling is the repeated loss and regain of weight. Brownell, Greenwood, Stellar, and Shrager (1986) suggested that repeat dieting will result in increased food efficiency that makes weight loss harder and weight regain easier. The National Task Force on the Prevention and Treatment of Obesity (1994) concluded that the long term health effects of weight cycling were largely inconclusive. It recommended that the obese should continue to be encouraged to lose weight and that there were considerable health benefits in remaining at a stable weight. This is an ironic suggestion in that most dieters do not intentionally try to regain weight once it has been lost.

Garner and Wooley (1991) have discussed how the prevalence of high fat foods in western society has challenged the adaptive capacity of the gene pool such that there is an increasing amount of obesity found in western populations. The belief that it is only the obese who overeat is sustained by stereotypical assumptions that non-obese individuals eat less. Normal weight individuals who eat a great deal will usually attract little or no attention to themselves. As Louderback (1970) wrote, "A fat person munching on a single stalk of celery looks gluttonous, while a skinny person wolfing down a twelve-course meal simply looks hungry."

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Psychological Aspects of Dieting and Obesity

While stating that the physical consequences of weight cycling were unclear but likely not as serious as some would assume, the National Task Force on the Prevention and Treatment of Obesity (1994) stated that the psychological impact of weight cycling was in need of further investigation. The study did not address the devastating emotional impact that repeat dieters universally experience when they repeatedly attempt diets that result in failure. The psychological damage that has been attributed to dieting include depression, diminishment of self esteem, and the onset of binge eating and eating disorders (Berg, 1993).

People may overeat compulsively due to psychological reasons that may include sexual abuse, alcoholism, a dysfunctional relationship with food, or genuine eating disorders such as bulimia (Bass & Davis, 1992). Such individuals are believed to use food to cope with other issues or feelings in their lives. Bertrando, Fiocco, Fascarini, Palvarinis, and Pereria (1990) discuss the "message" that the overweight person may be trying to send. The fat may be a symptom or signal representative of the need for protection or a hiding place. It has been suggested that overweight family members are often found having family therapy issues as well. Dysfunctional family relationships have been known to be manifested in such areas as parent-child struggles involving eating disorders. I believe that similar issues can also be recognized in families where there are family members who are perceived to be overweight regardless as to the accuracy of this perception.

Self Esteem and Body Image

Studies suggest that obese women will have significantly lower self esteem and negative body image than normal weight women (Campbell, 1977; Overdahl, 1987). When individuals fail to lose weight, issues of low self esteem, repeated failures, and the feeling that they "didn't try hard enough" come into play. Embarking on a diet that ultimately results in failure or even a higher rebound weight will have a significant negative impact on self esteem and body image. Contempt of oneself and disturbance of body image are often seen in those that struggle with weight control issues (Rosenberg, 1981). Wooley and Wooley (1984) have stated that concern over weight leads to "a virtual collapse" of self esteem.

Body image is the picture a person has of her body, what it looks like to her and what she thinks it looks like to others. This can be accurate or inaccurate and is often subject to change. The relationship between body image and self esteem is complicated. Often dual feelings that "I am fat" and "therefore I am worthless" go hand in hand (Sanford & Donovan, 1993). Both body image and self esteem are perceptions that are actually independent of physical realities. Improving body image involves changing the way one thinks about one's body rather than undergoing physical change (Freedman, 1990). To improve body image and therefore improve self esteem, it is important for women to learn to like themselves and to take care of themselves through healthy lifestyle choices that do not emphasize weight loss as the only measure of good health.

Relationship With Food

Repeat dieters often learn to use food to cope with their emotions. Women's experiences with emotional eating have often been neglected, trivialized and misunderstood (Zimberg, 1993). Polivy and Herman (1987) contend that dieting often results in distinctive personality traits such as "passivity, anxiety and emotionality." It is interesting to note that these are characteristics often used to describe women in stereotypical ways.

Food is often used to feed or nurture oneself for both physical and psychological hunger. Food is used to literally swallow emotions. I believe that when people become weight or diet preoccupied, it is often "safer" to focus on food and eating than on underlying emotional issues. It is important for people to look closely at their relationship with food. Through repeated experiences of dieting, people will develop a skewed relationship with food. Food should not be a moral judgment as to whether or not you have been "good" or "bad" depending on what has been consumed. Similarly, a person's self worth should not be measured on the bathroom scale.

There is often the belief that if one can make "peace" with food, then the logical result will be that weight will then be lost (Roth, 1992). While it is important to look at one's relationship with food and have it become a less powerful influence in life, this will not necessarily lead to weight loss. Studies that have utilized a non-dieting approach resulting in food disempowerment have shown that weight remained approximately stable (Ciliska, 1990). It may be considered a positive result for a person to be able to resolve a distorted relationship with food and then be able to maintain a stable weight without the gains and losses that repeat dieters often undergo.

I believe that when people become weight or diet preoccupied, it is often "safer" to focus on food and eating than on emotional issues. That is, for some people it may be easier to focus on their weight than to focus on the overwhelming feelings that they have learned to cope with through eating behaviors. People use food to nurture themselves or to literally "swallow" their emotions. Food is often used to cope with emotions such as grief, sadness, boredom, and even happiness. If food loses its power to aid in distracting or avoiding difficult situations, it may be quite overwhelming to confront the issues that were previously avoided through weight preoccupation or abnormal eating. Additionally, the excessive focus on concerns about body weight and dieting may also serve as a functional distraction to other overwhelming life issues.

Social Impact of Dieting and Obesity

From a young age, a woman is often given the message that she must be beautiful to be worthy. Attractive people are not only seen as more attractive, they are seen as smarter, more compassionate and morally superior. Cultural ideals of beauty are often transient, unhealthy and impossible for most women to live up to. Women are encouraged to be delicate, frail or "waif-like." There is a very narrow range of what is considered to be "acceptable" body size. Shapes that are not within this range are met with discrimination and prejudice (Stunkard & Sorensen, 1993). Women are taught early in life to be wary of what they eat and to fear getting fat. Trusting one's body often evokes tremendous fear for most women. Our society teaches women that eating is wrong (Friedman, 1993). Young women have long been taught to control their bodies and appetites, both sexually and with food (Zimberg, 1993). Women are expected to constrain their appetites and pleasures (Schroff, 1993).

We live in an age where women are seeking equality and empowerment, yet are starving themselves through diet and weight preoccupation while assuming that they can keep up with their better fed (male) counterparts. The strong social pressure to be thin began after World-War II (Seid, 1994). Magazines began showing thinner images of models as both pornography and the women's movement increased (Wooley, 1994). Faludi (1991) states that when society makes women conform to such a thin standard, it becomes a form of oppression towards women and a way of ensuring their inability to compete on equal grounds. The emphasis on thinness in our culture not only oppresses women, it also serves as a form of social control (Sanford & Donovan, 1993).

The stereotypical view of the overweight held by society is that they are unfeminine, antisocial, out of control, asexual, hostile and aggressive (Sanford & Donovan, 1993). Zimberg (1993) questions whether weight preoccupation would be a problem for women if it did not exist alongside society's clear prejudice against fat people. "Public derision and condemnation of fat people is one of the few remaining social prejudices... allowed against any group based solely on appearance" (Garner & Wooley, 1991). It is assumed that the obese willingly bring their condition on themselves through lack of will power and self control. The discriminatory implications of being overweight are well known and are often accepted as "truths" in western society. Fat oppression, the fear and hatred of fat is so commonplace in Western cultures that it is rendered invisible (MacInnis, 1993). Obesity is seen as a danger sign in moralistic terms that may imply personality faults, weak wills and laziness.

The obese face discriminatory practices such as having lower acceptance rates in high ranking colleges, a reduced likelihood of being hired for jobs and a lower possibility of movement to a higher social class through marriage. These effects are more severe for women than men. Obese women are not a strong social force and are likely to be of lower status in income and occupation (Canning & Mayer,1966; Larkin & Pines, 1979). "Prejudice, discrimination, contempt, stigmatization and rejection are not only sadistic, fascist and intensely painful for fat people. These things have a serious effect on physical, mental and emotional health; an effect which is real, and must not be trivialized." (Bovey, 1994)

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Juliet's husband, Greg, frankly discusses the emotional pain, exhaustion and helplessness that comes with being a spouse of someone with bipolar disorder.

Personal Stories on Living with Bipolar Disorder

People with Bipolar Disorder affect family dynamics in all sorts of ways. There are times when things can get really intense. Patience is crucial when a loved one has Bipolar Disorder. Support is critical to someone who has the illness however, this may be extremely demanding and exhausting at times depending on the severity of the episode. Some people may not be able to adapt to a person's Bipolar Illness. There are many consequences of this illness and it can take it's toll on family members and friends. Bipolars may lose a loved one. My husband Greg feels this illness is not the person's fault, nor the family member or friend's fault. You must love and care for he or she as if they had any other illness' such as diabetes, heart disease or cancer. I am one of the lucky people to have such a supportive back bone in my court! I have asked Greg to tell you how my illness affects him.

Greg on Juliet's Bipolar Disorder

It ain't easy! I have known my wife for nearly 24 years and still cannot predict her behavior from day-to-day. Her rapid cycling can have her changing moods from hour to hour on some days. I can leave the house with her in a somewhat "balanced" mood and return only to find her crying and laying in bed or so energized she can't stay off the computer while talking in rapid succession mixing words and sentences. Sometimes I can't follow what she's talking about because she's not making any sense. It seems impossible for her to slow down. We've suffered financial set backs due to her overspending on different occasions. When these mood changes occur, she may get very angry and sometimes violent. These anger outbursts are cutting and brutal. It's difficult to deal with the person you love most in the world being so angry at you with the ability to cut you to the bone in a matter of seconds. Her fury is often over things that are small, however she seems to magnify the issue in her mind. I have learned over time that her illness is often the cause of this type of behavior. Her cycles have changed over the years and she has drifted from straight manic episodes and depression to rapid cycling and mixed states with severe depressions in the interim.

Her severe depressions are the worst. I can see how bad she feels yet I am helpless to pull her out of it. When she gets seriously depressed, she doesn't cook, clean, groom, answer the phone, pay bills, go outside, or do any of her usual things. She's in bed most of the time. I'm afraid to leave her alone and am on edge constantly. I fear she will suicide as she has attempted before. I take her medications with me when I have to leave the house, and I hide or lock them up when I'm home. I study my home carefully looking at things she might try to kill herself with. I take all the knives and anything else I can think of out of our house. When she reaches this point, it's time for the hospital and I have to get her admitted. It's a very painful thing to see. The stress can sometimes be unbearable.

I used to blame myself in the early days that something I did was causing her outbursts. When she was "high" she was the life of the party and I didn't realize something was wrong. We were so young. After we were married her patterns began to change and her outbursts began as "happy" but quickly turned spiteful and outrageous. I was always in the line of fire. I have now learned and have come to the conclusion that it's not my fault and it's something she can't control. There is no magic pill to make it all go away. Yes, her illness is "controlled" by medication and it is treatable, however it does not just go away. I firmly believe that a spouse and other family members should participate as much as possible in the treatment process. I have learned so much by being my wife's supporter in all of this. We are a team. I understand her medications and the importance of compliance. I go to each and every meeting with her psychiatrist so that we can both "take notes" as sometimes she can't recall what was said in the meeting. When she asks me to go to her therapist's appointment, I do. I want to understand everything I can about Bipolar Illness so I can help my wife with the battle.

My best advice to those of you who have a Bipolar family member or friend is to be kind, supportive, loving (even if you are gritting your teeth) and participate in the treatment. I know it is exhausting at times! I have been there believe me! If you are not comfortable with the doctor or therapist, get a second opinion. We have been down that road too! Speak up, ask questions, and get answers. Learn coping skills as that is a major key for any family member or friend to be able to deal with someone who has Bipolar Disorder! Educate yourself about this disorder, read, read, read! I sometimes ask her doc or therapist for things I might do to help myself when she's having difficulties. Sometimes when she's feeling okay, Juliet and I chat about situations and what we should do when they occur.

Remember, when things look there absolute worst, try to remember that this is a treatable illness with proper care and medication. It can be controlled. You are not to blame nor is your family member. We have seen light at the end of the tunnel and are able to enjoy things at times. The illness is a part of who my wife is and I married the whole person!

Take care,
Greg

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