HOW TO SUCCESSFULLY TREAT BDD WITH MEDICATION: WHAT GETS BETTER WITH AN SRI? CONCERN WITH MORE NOTICEABLE APPEARANCE PROBLEMS Sometimes the SRIs decrease an obsessional preoccupation with a noticeable aspect of appearance, such as obesity. Some people whose appearance problem wouldn’t qualify for BDD (because the defect is obvious) may become less preoccupied with and less upset by these problems when treated with an SRI. For example, some people who are quite overweight become less consumed by their weight obsessions—they’re still not happy with their weight, but they’re no longer obsessed with it. Both their BDD-related concern and their concern with a more noticeable appearance problem diminish.*Insight was assessed with the Brown Assessment of Beliefs Scale (BABS), a scale developed by Dr. Jane Eisen of Brown Medical School, myself, and Drs. Doug Beer, Katherine Atala, Steven Rasmussen, and Lee Baer. This scale has been shown to be a reliable and valid measure of insight (degree of delusionality).In a way, this observation makes sense. The medication can’t distinguish between a slight appearance problem (i.e., BDD) and one that’s more noticeable. The medication doesn’t have eyes! The SRIs probably work by decreasing excessive, obsessional thinking, regardless of what someone actually looks like. This issue requires more research and goes beyond BDD. It raises the question of whether accident victims or people with congenital deformities who are overly preoccupied with and distressed by very noticeable defects might benefit from SRI treatment. Might they become less consumed by their concern—less preoccupied, less distressed, and better able to function? It’s possible.*253\204\8*

HOW TO SUCCESSFULLY TREAT BDD WITH MEDICATION: WHAT GETS BETTER WITH AN SRI? DAILY FUNCTIONING Functioning also often improves. It becomes easier to go to work or school and to concentrate. It’s not as hard to be around other people or leave the house. BDD sufferers may repair wounded relationships, start socializing more, or begin dating. “Our social life improved dramatically every time my wife took Prozac,” an engineer told me. “Every time she stopped it, our social life stopped too.”Several of the SRI studies I’ve described specifically evaluated whether people were able to function better in their daily life when treated with an SRI. All of them found that with SRI treatment, functioning improved in numerous areas: work and school functioning, household functioning, interpersonal relationships, and recreational activities. These changes can occur rapidly and may be dramatic. A woman I treated started school again within several weeks of responding to fluvoxamine, a change she’d wanted to make for 10 years but which her symptoms had made impossible. But other people change more slowly and make smaller gains. Habits can become very ingrained; it isn’t always easy to effect major changes. But most people who respond to an SRI do make some progress toward functioning the way they would like.*It’s fascinating to consider that animal research shows that enhancement of serotonin with medications like Prozac leads to more “social” behavior—decreased avoidance, vigilance, and social solitude. Animals with extreme depletion of serotonin show significantly less “social” interaction than other animals.*248\204\8*

Ultradian rhythm. This is the 90 minute cycle that goes on round the 24 hour clock. There is some practical significance of this rhythm to those who have sleeping problems.

There is a brief period of low arousal about every 90 minutes, and it is during this period, the 90 minute window, that we feel sleepy and fall asleep quite easily. If for any reason we miss this window, for example, because we are watching television and waiting until a program finishes, we may find it difficult to sleep. We have to wait until the next window, which is 90 minutes later. Hence if you feel sleepy at night, do not wait, go to sleep immediately, or else you may have to wait until the arrival of the next window. It does not follow that if we feel sleepy, say, at 10 p.m. we will feel even more sleepy at 10.30 p.m. In fact, for some people, having passed their 90 minute window at 10 p.m., they will feel wide awake at 10.30 p.m.

Some sleep experts suggest that if you miss the 90 minute window and feel distressed in bed and not sleepy, it may be a good idea to do something relaxing in another room and come back to bed once you feel sleepy again. Remember, the 90 minutes is an average of cycles varying from 60 minutes to 130 minutes.

If you are really very sleepy, you will fall asleep at any time, irrespective of the 90 minute window. This is because, in sleep deprived individuals, the ultradian rhythm disappears.

*72\174\4*

A thirty-two-year-old single woman had a very good and highly paid job managing a large office. Over a period of two years she had developed writer’s cramp. The condition had progressed to such an extent that writing was virtually impossible. She had been trying without much success to learn to write with her left hand. It was obvious that she was going to lose her job. She consulted her local doctor, who referred her to a leading neurologist. He wrote back to the local doctor, “As you know, this condition is somewhat a mystery and seldom responds to either medical or psychiatric treatment.” However, he suggested that it might be worth her while seeing

I showed her how to relax, and while she was still relaxed, I gave her a large crayon, and asked her to make wavy lines. She did this, and was soon able to write with the crayon in a bold flowing hand. She practised the relaxation, and in a few weeks was writing normally. I sent some specimens of her writing to the neurologist. He wrote back, “I do congratulate you, because writer’s cramp in the past has been thought to be unmanageable.”

But let us be clear about this. I did nothing to her beyond showing her how to relax in the way that is set out here.

*94\57\2*