Some people with BDD compulsively seek, buy, and read any information they can find about their perceived defect. Men with genital concerns may frequent bookstores and libraries, perusing every book and magazine they can uncover, searching for information about genital size. Is theirs really small? Or is it okay? Some people with hair concerns read voraciously about hair growth. How quickly does it grow? Once it’s lost, can it be regained? They search medical textbooks and the internet, seeking information about agents purported to increase or speed hair growth.Men and women with body size concerns may spend hours a day reading fashion magazines, weight-lifting magazines, and books on dieting or exercise. They compare themselves with the models, hoping to reassure themselves. Or they search for tips about how to look bigger or smaller, hoping to discover the magical diet or exercise regimen that will finally make them look the way they’d like.*114\204\8*

The person experiencing excessive stress who fails to heed t warning of anxiety symptoms, may cross over the first threshold and experience the symptoms of stage two.
In stage two there are two extra symptoms added on to the anxiety symptoms of stage one.
These are the symptoms of failure of emotional control, and failure of self motivation.
Whenever I lecture on the topic of stress breakdown, aft discussing the symptoms of stage one, I often ask the members of the audience if they can identify the symptoms of stage two. usually put this question: Suppose you were working with friend who you knew had been under a great deal of stress and train, and had been having trouble sleeping, and had been complaining to you about feeling tense and jumpy. One day something happens which leads you to say to your friend, ‘Look, I think you’d better take the rest of the day off – go home and have a rest. I’ll finish up here. Don’t you worry about talking to the boss – I’ll fix that up – you go home and take it easy!’ … What was it that happened?
The response from the audience usually includes answers such as:
-    Suddenly burst into tears for no apparent reason.
-    Suddenly lost his or her temper over only a little thing.
-    Became inefficient, couldn’t do the work.
-    Was laughing one minute and crying the next.
-    Was just sitting   there looking at the work, not doing anything.
-    Couldn’t get moving.
I have found that members of an adult audience usually have о difficulty identifying with the question, and they tend to give remarkably consistent answers. Not only can people generally recognize the symptoms of second-stage stress break-down, but they usually recognize these symptoms as serious.
Furthermore, it seems that caring people instinctively know that the person in stage two stress breakdown has already lost the ability to go to the boss, arrange time off, close down the shop, and so on. It is as though we recognize loss of emotional control as a signal of serious disturbance, and that the person needs to be rescued. That is, we seem to know that the person who has lost emotional control will have simultaneously lost the ability to initiate adaptive changes in behaviour. Although caring people may well recognize these changes as temporary, we generally regard them as serious enough for us to insist on taking some of the load off the stressed person, often in spite of his insistence that he is perfectly capable of carrying out his duties.

*15/129/5*

Sleep is a fascinating biological function which we all experience. In fact, one-third of our lives is spent in sleep. Most of us take it for granted that we fall asleep at night and wake up the next morning. We do this night after night, and we do this from the day we enter this earth to the day we depart. However, have you stopped and asked what sleep actually is and why we need to sleep at all? Sleep is something we have no control over. We cannot close our eyes and give the magic word sleep, as sleep may not follow. In studies of how people fall asleep, it is observed that we are not folly awake one second and asleep the next. We all go through a very brief hypnotic state, which is called the Transitional Hypnotic State or THS.

We have all experienced the fact that after a good night’s sleep we are refreshed and appear to function better than after a restless night. The exact nature of this is not fully understood. Sleep is not unique to man. Nearly all species of the Animal Kingdom sleep. But the amount of sleep in animals varies a great deal between different species. Gorillas sleep 14 hours a day, elephants only 2. We will explain the possible reasons why we sleep under the following headings:

* Evolution theory

* Chemical theory

* Biological theory

* Dream theory

* Neurone theory

*2\174\4*

Self-stimulation of the sexual parts is a common cause of anxiety in both men and women. The habit is almost universal in boys and young men before marriage, so much so that most

authorities assume it to be a normal practice, one that causes harm only when done with excessive frequency—several times a day—or when it is associated with guilt from the warnings of overzealous parents. When there is a certain feeling of guilt, as there often is, the nervous tension may be extremely severe. The unfortunate youth is so ashamed that he tends to suffer his distress rather than seek help; and his fears may become so acute that he comes to think the habit will lead him to the insane asylum, or at least ruin any chance of happy marriage. Such people are greatly relieved by the simple and truthful explanation that a certain amount of

self-stimulation seems to be a natural part of the ordinary process of growing up and leads to no harm of either body or mind.

However, in spite of the knowledge that a certain amount of self-stimulation is almost universal and quite harmless, it is my experience that some boys and young men still remain very disturbed by this practice.

This is an example of knowing a matter to be true with one’s intellect and at the same time inwardly doubting it because the intellectual knowledge is not really integrated with the emotional life of the individual.

There are two categories of youths who consistently remain disturbed by their masturbation. There are those who are very rigid and fixed in their attitudes, who lack the normal flexibility of mind to change their view according to available evidence. They are often rather perfectionistic, and are technically known in psychiatry as obsessives. The other group consists of young men who are taught by their church that masturbation is sinful, and I do not believe that it is in the province of the psychiatrist to challenge a patient’s religious beliefs except under very exceptional circumstances. Accordingly, these two groups—the very rigid and those motivated by religion—are unable to adjust themselves to occasional masturbation, and as a result they must stop it altogether.

A twenty-year-old student was in great distress of mind, worrying about his masturbation, which he seemed quite unable to control.

Religious convictions were not involved here. The young man was extremely rigid and inflexible in his personality, so much so that in ordinary conversation he would talk obsessively about some particular topic. I showed him how to do the relaxing mental exercises. His nervous tension was greatly reduced. Now that he is calmer, he is able to use his will power with real determination, and has found that he has been able to abandon the habit which had caused him so much distress.

*28\57\2*

For a description of St John’s Wort, the plant, also known as Hypericum perforatum, I can do no better than to quote Dr O Phelps Brown, who wrote in 1885: This is a beautiful shrub, and is a great adornment to our meadows. It has a hard and woody root, which abides in the ground many years, shooting anew every year. The stalks run up about two feet high, spreading many branches, having deep-green, ovate, obtuse and opposite leaves, which are full of small holes, which are plainly seen when the leaf is held up to the light. At the tops of the stalks and branches stand yellow flowers of five leaves apiece with many yellow threads in the middle, which, being bruised, yield a reddish juice, like blood, after which come small round heads, wherein is contained small blackish seed, smelling like resin.

This description comes from a book called The Complete Herbalist; or the People Their Own Physicians by the use of Nature’s Remedies; describing the Great Curative Properties Found in the Herbal Kingdom. Over 100 years ago, it seems, people were intrigued by the same possibilities that we are revisiting nowadays – of using Nature’s apothecary as a source of remedies and of healing oneself instead of always seeking out the assistance of a medical practitioner.

The pores in the leaves of St John’s Wort, which look like perforations and give the plant half of its botanical name (perforatum), are thought to contain the plant’s pharmacologically active substances, as do the black spots on the petals. It is these black spots which, when rubbed, yield a reddish liquid that was used for dyeing clothes in earlier times.

*80\75\2*

Because Prozac is metabolized principally by the liver, depressed or alcoholic patients with liver disfunction should be given either a lower dose of Prozac (or any other SSRI antidepressant) or none at all. A liver that is already overtaxed will take significantly more time to metabolize the drug. Regular monitoring of liver funtioning is necessary. Researchers have discovered that patients with normal livers require no more than three days before the amount of Prozac in the body diminishes to one-half, while patients with cirrhosis of the liver need over a week—7.6 days—to reach the same point. In addition, the study found that Prozac’s metabolite, norfluoxetine, also took several days longer to be flushed out of the system when liver disease was present.

What about marijuana, cocaine, LSD, or other similar drugs? These illegally obtained mood-altering drugs are all completely contraindicated for patients taking Prozac—and this would be true even if they were legal. Taken with or without Prozac, these drugs can cause uncontrolled highs, severe depression, and psychotic states in some people. For patients already prone to these reactions, the risk is high if an antidepressant drug like Prozac is added.

*115\22\4*

Prozac is especially helpful for patients with major depression, dysthymia (the milder version of major depression), and obsessive-compulsive disorder, as well as for patients who lack energy, feel listless, and chronically function below par, symptoms typically seen in subclinical depression. In addition, psychiatrists who have read individual claims of Prozac’s usefulness in treating bulimia and other disorders can probably feel safe prescribing Prozac to individual patients with these symptoms.

The FDA has completed some of its evaluations, and Prozac is now approved for major depression, obsessive-compulsive disorder, and bulimia. Despite its popularity, Prozac should be prescribed with care and not simply handed out to anyone who wants it.

What are the effects of Prozac on kidney function? Because the kidneys are responsible for the elimination of Prozac, an impaired and hence less efficient kidney may cause the drug to accumulate in the body. For this reason, patients with renal disease, as evidenced by high BUN or serum creatinine, including those undergoing hemodialysis, should take smaller than normal doses of Prozac. (Again, the same recommendation holds for patients with kidney disease who are receiving other SSRIs for their depression. Regular monitoring is required and nephrologists should be consulted.)

Can diabetics safely use Prozac if depressed? The use of Prozac in diabetic patients may alter the blood sugar control. Hypoglycemia, an abnormally low amount of glucose in the blood, has been reported in diabetic patients taking Prozac, and discontinuing therapy has occasionally produced hyperglycemia, an abnormally high concentration of sugar in the blood.

There is insufficient data to prove that Prozac alone can cause all of these changes in blood sugar, and so most diabetic patients may be treated safely with Prozac. However, when initiating therapy with Prozac and later when discontinuing its use, it is important to keep a close watch on blood glucose levels and adjusts insulin three to four times a day accordingly. My depressed diabetic patients have done extremely well on long-term Prozac.

*96\22\4*

No. Monoamine oxidase inhibitors (MAOIs) and Prozac just don’t mix. A few patients who have taken both drugs simultaneously have fed severe reactions mat include confusion, sweating, shivering, muscle spasms, tremors, and restlessness, as well as symptoms of rigidity, hyperthermia, rapid fluctuations of pulse and blood pressure, extreme agitation, delirium, coma, and in eight cases, death. Even patients who stopped taking Prozac and then immediately started up on an MAOI have had these reactions.

A patient who wants to switch to Prozac from an MAOI must allow fourteen days to elapse after discontinuing MAOI treatment before the MAOI is completely out of the system. Only then can Prozac be safely tried.

A patient who wants to go in the other direction, ceasing treatment with Prozac and beginning treatment with an MAOI, must wait even longer. Because Prozac and its major breakdown product, norfluoxetine, remain in the body for a long time, a minimum of five weeks is needed after discontinuing Prozac before MAOI treatment can commence.

*75\22\4*

Prozac is a member of a new class of antidepressants with a different mechanism of action than previous antidepressant drugs. Although equal to past antidepressants in effectiveness, it is uniquely not lethal in overdose, nor is it toxic to the cardiovascular system compared to the older drugs. It is also easier to take, since its side effects are so much milder.

A lot of patients walk in asking for Prozac, whether they need it or not Prozac has received more publicity than any other previously used psychiatric drug in America and abroad, and this unprecedented media attention has helped catapult Prozac to its current level of popularity. Seldom in the past did anyone I met at a dinner party question me about Tofranil or Nardil (although they did ask many times about lithium when its effectiveness as a treatment for manic depression first became known to the media). Now people ask about Prozac. Unlike other drugs, many of which are equally effective, Prozac has become a well-known, frequently requested remedy. Just as the most medically untutored know that a headache can be cured with aspirin, people who feel a little down today or want a personality “lift” are quick to discover that friends, family and the local GP have a single recommendation: Prozac. Sad to say, the media have oversold Prozac to the general public and to psychiatrists and other doctors. In my experience and in the experience of many of America’s leading psychopharmacologists, the myth of Prozac’s ability to cause a total personality metamorphosis has, more often than not, led to disappointment

*54\22\4*

Many patients who stop taking Prozac on their own do so because they find the side effects of slight nausea and insomnia unbearable or are too impatient to wait for early side effects to recede. Patients who are prone to hysterical reactions or those who are phobic about taking pills are often doomed to discontinue Prozac or any other medication from the outset.

The main complaints that cause patients to discontinue treatment are, in order of frequency, nausea, nervousness, insomnia, anxiety, tremor, headache, drowsiness, diarrhea, dizziness, sweating, and dry mouth.

The numbers and percentages for each of these categories are small. Nausea, the most common adverse reaction associated with stopping treatment, caused between 3% and 4% of the people tested to stop taking the drug. Nervousness and insomnia influenced another 2% to 3% to discontinue treatment. Not one of the other side effects involved in ending treatment affected more than 2% of those tested.

*34\22\4*