LEARN TO SLEEP
Do we learn to sleep? The answer is yes. This is for the same reason as a little boy knows that when he feels the urge he should do it in the toilet and not in the sitting room. A learning process, popularly known as toilet training, is involved. The same is true of sleep. We learn to sleep at night and stay awake during the day, even if we sometimes feel sleepy during the day.
We are more familiar with other learning experiences, such as learning to drive a car, learning to ride a bicycle, and so on. We take for granted that we know how to sleep, but in fact we all had to learn to sleep.
Psychologically, there are three kinds of activities:
* Innate activities—no learning is required
* New activities—a lot of learning is involved, e.g. driving
* Modified innate activities, such as toilet training and sleeping
Innate activities are basic activities that require no learning, including breathing, crying, smiling, reaction to pain, and so on. These are biological activities that are built into our system.
At the other extreme, there are new activities and skills which require learning from scratch. We spend years in school to learn how to read and write. We attend many lessons to learn to drive, and we learn to ride a bicycle after many falls. In fact, we are learning all the time without knowing it. We are imitating, copying from others, and modifying ourselves all the time. Indeed, it is the acquisition and accumulation of new skills, created and handed down through previous generations, that makes the human race so superior.
‘Modified9 innate activities are innate activities that are modified by learning; this learning is seen to be essential if the person is to conform to the norms of society. The most well known example is toilet training. From birth, babies have no concept and respect of when and where to relieve themselves; hence they have to wear nappies. It is considered normal for babies to wet and dirty their nappies at any time of the day. When they reach the age of about three it is no longer considered normal for them to do it anywhere they wish. They learn to go to the toilet and to do it properly there. This learning is gradual, and the activities are modified to conform to the expectation of parents and the pressure of society.
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COMMON CAUSES OF ANXIETY: PROBLEMS OF THE OVERSEXED AND THE UNDERSEXED
It is unlikely that any two individuals will have exactly the same sexual appetite. In this respect the early steps of marriage are a period of adjustment for almost every couple. It is common for the man’s desire to be rather greater than that of his wife. He adjusts to a little less and she to rather more. However, sometimes there is a gross difference in sexual appetite which may remain throughout marriage and serve to keep both partners in a state of tension. In the less common situation in which the wife has the greater sexual appetite, her repeated demands may be particularly destructive to her husband because they psychologically threaten his masculinity.
If the adjustment of the partners one to the other is incomplete, the actual sexual experience itself may become a potent cause of tension. Thus if the sexual response of the husband is too rapid, his wife is left unsatisfied. If this pattern is constantly repeated the wife is likely to show signs of nervous tension and may develop any of the symptoms produced by anxiety.
Many introvert men are not as sexually active as their extrovert brothers. An attractive woman with four children was married to an introvert husband who was some years older than she was, and who no longer satisfied her feeling of sexual need. She was tense and irritable, and disturbed by sexual feelings. She had an affair with another man. This, through guilt and fear lest her husband should find out, only increased her anxiety, and she soon abandoned her lover.
A young couple who had been married five or six years consulted their local doctor because they were not getting on together. He referred them to me. The wife was an attractive girl, who covered up her tension very well. However, she openly admitted her irritability with her husband and the children. The husband was a big extrovert athlete, very much in love with his wife, and very willing to help in any way he could.
The wife eventually disclosed that she had come to dread going to bed. Her husband desired sex relations almost every night. Whatever her state of mind, she always created the illusion for her husband’s sake that her sexual desire was as strong as his. This she was able to do because of her control over her feelings. The situation had eventually become impossible and she had broken down with anxiety. All the time the husband was completely unaware of his wife’s
sacrifice, and he was simply astounded when it was explained to him. He promptly reacted by curtailing his sexual appetite and heaping gifts on his wife.
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HOW LONG AFTER STARTING ST JOHN’S WORT SHOULD I EXPECT IT TO TAKE BEFORE I SEE AN IMPROVEMENT?
Although some people may experience relief from the symptoms of depression within days of starting St John’s Wort, for others it may be as long as six weeks before there is a real sense of improvement. A informal survey of European psychiatrists who have treated hundreds of patients with St John’s Wort revealed that most believe that one should wait at least three weeks after a full dose (900 mg per day) of St John’s Wort has been started before judging whether it has been effective or not. In this regard, St John’s Wort is similar to other anti-depressants, most of which take between two and four weeks to produce their initial anti-depressant effects. The reason for this delay in response to anti-depressants has been the focus of considerable research, but at this time no one has really come up with a satisfactory explanation for it. If you detect no benefit after three weeks, you have the choice of increasing the dosage of St John’s Wort, switching to a conventional anti-depressant, or adding the anti-depressant to St John’s Wort.
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HOW COMMON ARE THE INDIVIDUAL CAUSES OF EPILEPSY?
Causes of epilepsy that could be defined, with a fair degree of confidence, in each of two studies. The way in which the subjects were selected was different in each study, but the final
figure—the proportion in which a cause for epilepsy could be defined—varied within narrow limits, between only 34.5 per cent and 39.0 per cent.
The fact that 61.0-65.5 per cent of people with epilepsy have no discernible cause for their seizures certainly does not mean that the remainder have ‘idiopathic’ epilepsy. Since the advent of magnetic resonance imaging we know that a large proportion of subjects with such ‘cryptogenic’ epilepsy (epilepsy of hidden cause), have minor structural changes in the
brain—very commonly zones of atrophy in one or other temporal lobe. More recent studies show that nearly 90 per cent of those with temporal lobe epilepsy, for example, will have abnormalities on magnetic resonance imaging, though these abnormalities may be very minor, and only detectable with careful measurements on the scan.
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WHAT DO THE PEOPLE SAY FOR ARTHRITIS: STORY 6
Mrs M.G., an accountant in California, writes: “My knees have always been a problem, ever since I got hit by a car when I was eight years old. They weren’t too bad at first. But when I reached 25 and put on a little weight, they kept getting worse every year. I’m only 38 now, but I’ve felt like an old lady for the past ten years.
“Now, I can’t believe I went dancing! I haven’t been able to do that in eight years. I was on my feet, jumping up and down, often on tiptoe, for THREE HOURS at the rock concert! In heels, yet! I haven’t been able to wear heels for six years. Unbelievable!
“I overdid it, of course, being out of shape and all. So I got sore muscles but that went away in a day. (You might caution people to take it slow at first. It’s so easy to go overboard without the pain.)
“I don’t know how to thank you enough for making me feel young again. Who would ever have believed a handful of capsules could do this for me. I swear it’s a miracle!” [Editor's note: Mrs M.G. took CMO in August of 1995 and has needed no further treatment of any kind.]
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INGROWN TOENAILS IN CHILDHOOD
Symptoms: swollen, red, and painful area near toenail; thin, watery pus from the infected area; raw, red tissue covering part of the nail.
Home care
- Soak the toe frequently in warm water.
- If possible, gently cut out the ingrown part of the nail.
- If the ingrown spur cannot be removed, soak the bandaged foot in a solution of Epsom salts and encase the foot, complete with bandage, in plastic wrap or a plastic bag.
- In the case of an infant, do not try to remove the ingrown nail, but wipe the toe several times daily with rubbing alcohol, then soak in warm water.
- Any time home treatment does not work, consult the doctor.
Precautions
- Be sure your child always wears well-fitting shoes; if the shoes are too small or too pointed they can cause ingrown toenails.
- Show your child how to trim the toenails correctly.
Sometimes the corners and edges of toenails break the skin surrounding the nail. Once the skin is broken, infection can set in. The infection causes the tissues to swell, forcing the corner of the nail further into the toe. This condition is known as ingrown toenail, and it cannot heal as long as the nail remains within the tissues.
The initial wound may be caused by injury to the toe as a result of being stepped on or being squeezed by ill-fitting shoes. Or the nail may have been trimmed to leave a sharp spur at the corner; this spur pierces the skin as the nail grows.
Most cases of ingrown toenails involve the big toes of older children; however, any toe can be involved, at any age. A baby can develop an ingrown toenail by digging bare toes into the crib mattress or into another surface onto which he or she has been placed face down.
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PREVENTIVE MEDECINE: FITS (CONVULSIONS)
What are they?
Sudden spasms of the muscles caused by an abnormal burst of activity in the brain. Convulsions are common in babies and young children. Epilepsy, which causes one kind of fit, is relatively rare, so you should not jump to the conclusion that your child’s fit is epileptic in origin.
What causes them?
• The most common cause of fits (in children) by far is a raised temperature. These so-called febrile convulsions occur most often between the age of 6 months and 3 years old. They are rare after the age of 5 years.
The most usual causes of such high fevers are tonsillitis, acute ear infections, urinary infections and measles. There is often a family history of febrile convulsions during infancy.
• Epilepsy. This is a condition in which a person has repeated losses of consciousness. There are more than 100 causes for such attacks but for the vast majority of people with epilepsy there is no known, provable cause as such. Epilepsy starts at any age but usually during infancy. Most epileptic children are normal mentally and physically when the attacks start and most lead happy and normal lives with the help of drugs.
• Epilepsy can be triggered by late nights, too much alcohol, a high fever, flashing lights, and many other things. It can now be controlled in the vast majority of both adults and children.
• Hypoglycemia.
• Infections of the brain such as encephalitis, rabies and tetanus.
• Shortage of vitamin B6 in children.
• Certain poisons and intoxications, including lead, arsenic and alcohol poisoning.
• Head injuries.
• Hysteria. Some hysterical people (usually women) have convulsions but only in front of an audience-they never occur when they are alone.
Prevention
The preventive measures that can be taken against the above causes are obvious and some, such as hysteria, cannot be prevented. The two main causes of convulsions-fevers in children and certain precipitating factors in epilepsy-can, however, be prevented.
• If a child has a high fever the parent is in a difficult dilemma because there is no doubt that the fever is valuable in killing the bacteria or virus that caused it in the first place. It used to be thought that fevers should be lowered by using aspirin or similar drugs but this is now disputed. A substance called endogenous pyrogen produced during fevers enhances the body’s immunity to disease. Once this pyrogen is produced it circulates in the blood to the brain and stimulates the body’s thermostat to produce substances called prostaglandins which set the body’s temperature to normal. Endogenous pyrogen increases the mobility of white blood cells and stimulates the production of proteins to fight infection. Antibiotics, it appears, also work better at high temperatures.
However, high fevers have damaging effects too, especially over about 104° or 105°F. The secret then is to start lowering the child’s temperature before it gets this high-say at 102°, or earlier if the baby or child is irritable. Take all the clothes off the child and lay him or her on a waterproof sheet on the bed. Cool his or her face, trunk and limbs with tepid (just warm) water so as to make the surface blood vessels dilate and lose heat. Cold water makes them contract and conserves heat. Wrap cloths soaked in tepid water around the child’s groin and neck, and check his or her temperature every 10 minutes until it is normal. Don’t give aspirin unless the fever is very high (over 103°F/39.4°C). Give the child plenty of drinks (preferably water or dilute fruit juice).
The above procedure will prevent the vast majority of feverish fits. If ever your child has a fit, don’t panic but do tell the doctor.
Prevention of epileptic fits is far more difficult because the cause is rarely found. If you find that tiredness, alcohol, flashing lights or TV bring them on, you will have to avoid these things. You can avoid the TV problem by watching in a light room and not going near the set to switch it off or to adjust it. Most photosensitive people can overcome their problem by covering one eye with the palm of their hand. The effects of flashing lights on water can be reduced by wearing polarized spectacles. Sometimes psychological treatments can prevent attacks. The majority of preventive measures for true epilepsy centre around adequate drug control.
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PRIVATE CARE FOR PATIENTS WITH BREAST CANCER: ADMISSION TO HOSPITAL.
PREPARING FOR OPERATION
Admission to hospital
When you arrive at the hospital, the receptionist will contact the admissions department, and a ward receptionist will come to collect you. If you are paying for your stay in hospital yourself, you will probably be asked to pay your bill in advance at this stage if you have not already done so. Otherwise, you will be asked for your completed insurance form. The ward receptionist will take you to your room – probably a single or double room -and show you the facilities available there. You are likely to have a private bathroom, a television, and a telephone by your bed. The ward receptionist will explain hospital procedures to you, and will leave you to settle in.
The main difference you are likely to notice if you have been treated in an NHS hospital before, is that this time there is much less waiting for all the routine hospital procedures to be dealt with. The nurse to patient ratio is higher in private hospitals and so someone is usually available to deal with the pre-operative procedures quite quickly.
Your consultant will deal with your medical care throughout your stay, will visit you before the operation, perform the operation (with the assistance of the anesthetist and the operating staff), and visit you again when you are back in your own room. Trainees – whether doctors or nurses – do not work in private hospitals. The consultants are responsible for their own patients and supervise their care themselves. Most private hospitals now have resident medical officers – fully qualified, registered doctors who are available 24 hours a day to deal with any emergencies which may arise.
Preparing for your operation
When the time for your operation approaches, a porter and nurse will take you from your room to the anesthetic room. In many private hospitals, you will not be moved from your bed onto a trolley until you have been anaesthetized; the bed itself will be wheeled from your room. Similarly, you will be transferred back from the trolley to your own bed in the recovery room while you are still asleep. You therefore go to sleep and wake up in your own hospital bed.
When you are fully awake, you will be taken back to your room to rest.
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SURGICAL TREATMENTS OF ENDOMETRIOSIS: ABOUT LAPAROTOMY.
A laparotomy is a major operation involving a cut in the abdomen. Both conservative laparotomy and hysterectomy are performed as part of a laparotomy. This section describes what will happen before, during and after a laparotomy.
Things to think about before a laparotomy
Before your operation it is important that you make sure that you and your gynaecologist agree on the purpose and nature of your surgery and that you have resolved any questions or concerns that you may have. If necessary you should make a special visit to discuss these issues. Ideally, the preparation for your surgery should involve preparing yourself physically and emotionally for the operation itself as well as planning for your recuperation period afterwards.
The healthier you are before surgery the more quickly you are likely to recover afterwards. It might be worthwhile taking a few steps to improve your general health if necessary.
If you are a smoker it would be advisable for you to quit smoking at least one to two days before your operation to reduce the likelihood of anaesthetic complications. If you are taking the oral contraceptive pill it may be best to stop taking it for a month or so before your surgery to reduce the risk of complications, particularly thrombosis. If you are overweight, losing some weight will help reduce the risk of complications.
You should also make sure that you are completely happy with your decision to have the surgery. Do not hesitate to seek the advice and support of others if necessary.
Before you go into hospital you should arrange to have some help with household tasks such as cooking, laundry and cleaning when you return home.
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COGNITIVE-BEHAVIORAL TREATMENT FOR BULIMIA: STAGE TWO AND STAGE THREE
Stage two
During the second phase, we continue to work on developing regular eating habits. We also begin to change the makeup of her diet.
As we have seen, people with eating disorders often adopt rigid rules about what can and can’t be eaten. They create a list of “forbidden foods”-fattening or sweet foods they want but won’t allow themselves to have. Avoiding these foods makes them feel in control. However, these are often the very foods they run to when they lose control and binge.
It’s a quirk of human nature: Whatever is forbidden becomes the thing we most desire. When a bulimic decides certain foods are “off limits,” she creates an overwhelming temptation. In Stage Two, we work to reduce her feeling that she is completely helpless in the presence of forbidden foods. The goal is to take the power away from food and return it to the patient.
One method is to rank these foods in order of “danger level” and then gradually reintroduce them into the diet, starting with the least “dangerous” food. When she learns she can eat a few French fries, for example, and not feel driven to binge, she starts to feel in control. Success breeds success. Regaining a little bit of control reduces fear and gives her encouragement to keep trying. She may need a lot of coaching from her therapist and from others in her family to reach this point.
The best way to handle a phobia is to gradually increase exposure to the thing you fear. When the patient learns how to manage forbidden foods, she conquers some of her fears. Sometimes, for example, a patient tells me she will only eat something if she knows its calorie content. As an exercise, then, we work on eating foods whose calories are unknown. Or she may dread eating in restaurants or at parties. We find ways to expose her to those situations and build up her tolerance. Doing so takes her out of the “danger zone.”
One method to help with purging is technically known as exposure plus response prevention. We expose the patient to the problem-feeling full after eating-and prevent her usual response to it-vomiting. If the patient is in the hospital, we ask her to sit with a staff member for an hour or so after a meal. Eventually she gets used to the feeling of having food in her stomach. She learns that she needn’t respond to the feeling by giving in to her urge to purge. This strategy works especially well when the patient vomits often, or when eating anything at all triggers purging. If needed, we can use the method with outpatients as well.
During the second stage, the patient does better if she reduces her “magical thinking” about food. She also needs to learn new ways of thinking about, and solving, her problems. As I’ll explain shortly, cognitive therapy helps her achieve these goals.
In many cases, at the end of the second stage the patient has stopped bingeing completely, or binges only once in a while. Her attitudes about weight, body shape, and herself are much healthier.
Stage Three
During the third phase, we continue to build on successes during the previous stages – continuing regular eating and relaxing the patient’s need to control her diet. But now we shift our focus and prepare the patient to leave therapy and strike out on her own.
Many patients notice that their normal feelings of hunger and fullness have returned. This in itself makes it easier to control eating. We still work with the food diary, which will indicate whether there’s a problem that we still need to work on.
In fact, slipping back gives us a chance to address a key issue: the risk of relapse. Patients are always in danger of slipping back into old habits. Perfectionism is hard to shake; many patients believe that once they regain control, all will be well forever. Not so. Better to face the reality that relapse is possible, especially during times of stress.
The message is that a little slip does not mean total, crushing defeat. Instead, I urge the patient to remember how far she has come, and that she has learned a lot about how to deal with her illness. Through her diary, she knows how to look at her situation and discover what may have triggered her binge. Eventually she will learn how to avoid these triggers.
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