RECOMMENDATIONS FOR TREATING BDD WITH AN SRI: DON’T GIVE UP ON AN SRI UNTIL YOU’VE TRIED IT FOR 12 TO 16 WEEKS, WHILE REACHING A HIGH ENOUGH DOSEIt’s also important to try the SRI for a long enough time. Taking the SRI for 12 to 16 weeks, and reaching a high dose (unless a lower dose works for you) for at least 3 of those weeks is called an “adequate” trial. If you don’t take a high enough dose, or if you don’t try it for long enough, the SRI trial is considered “inadequate.” In other words, it may not be sufficient to successfully treat BDD.In most published BDD studies and in my clinical practice, people needed to take an SRI, on average, for 6 to 9 weeks before BDD symptoms substantially improved. In my fluoxetine (Prozac) study, two thirds of people substantially improved (i.e., “responded”) between the 4th and 11th week of treatment. In my fluvoxamine (Luvox) study, two thirds improved between the 3rd and 10th week of treatment. However, in my citalopram (Celexa) and escitalopram (Lexapro) studies, people responded to the medicine, on average, after only 4 to 5 weeks (two thirds responded between weeks 1-2 and 7-8). So some people respond to an SRI within several weeks, whereas others have to try it for as long as 12 weeks—or occasionally even 16 weeks—before they respond. This means you’ll need to be patient and wait for the medicine to work. But don’t get discouraged: it often does work!It’s worth emphasizing that these numbers and recommendations are based on studies that increased the SRI dose, and reached the high end of the dosing range, fairly quickly (see the examples above). If you raise your SRI dose more slowlv (i.e.. if vou take more than 9 weeks or so to reach the maximum recommended dose), you may need more than 12 to 16 weeks to get better. If you haven’t gotten to a high enough dose by week 12 to 16, it’s usually advisable to try to raise your dose at that point to see if a higher dose works better than a lower dose. But if you’ve already reached the highest dose recommended by the pharmaceutical company, or the highest dose you can tolerate, by 12 to 16 weeks—and if you’ve been on that highest dose for at least 3 weeks—then it’s probably best to make a change by switching to another SRI or adding another medicine to the SRI. I often see patients who’ve tried lots of SRIs without getting better. A common problem is that they tried the SRI for too brief a time (e.g., only 4 to 8 weeks). In my fluoxetine study, nearly half of the people who eventually responded to the medication still hadn’t responded by the 8th week of treatment. This was the case for one third of the people in my fluvoxamine study. These people generally responded between weeks 8 and 12 of treatment. In addition, many people I’ve seen who didn’t respond to a past SRI never reached a high enough dose. Often such patients have been diagnosed with depression while their BDD was missed. Because their BDD wasn’t recognized or diagnosed, it wasn’t effectively treated. For many, depression didn’t improve either.*258\204\8*

Practising good sleep hygiene is an important alternative to taking sleeping pills.

People who do not work or take any exercise during the day will have too much time on their hands. They will tend to have frequent naps during the day and will not need as much sleep at night. For them there is not much difference between the activities during the day and those at night. These people do not accept the fact that they have already had too much sleep in the day and do not need much more sleep at night. They believe they are suffering from insomnia. A good day is normally a busy active day, so that in the evening you feel tired, as if you have achieved a lot and have earned a good night’s rest Regular exercise will keep your body healthy, keep your muscles strong, your heart and circulation in good shape, and also let off any tension that has accumulated in your body. It has been shown that exercise increases the amount of NREM sleep. However, if strenuous exercise is undertaken too close to sleep time, it may delay sleep onset. Exercise should be finished at least three hours before bedtime. Exercise and activities like aerobics, jogging, tennis, swimming, golf, gardening, and fishing are all very good for health. After all, sleeping well is a sign of good health, and good health starts with good hygiene.

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A seventeen-year-old schoolboy had this condition in quite advanced form so that his head was held twisted to one side with his chin over his shoulder. When for a moment he was able to bring his head to the front, there would be a sudden spasm of the muscles, and his head would be jerked to the side again.

I believe that this strange symptom had an unconscious symbolic meaning for the patient; and in fact it seemed that this lad was turning away from his father and the principles for which he stood,

I taught him to relax the rest of his body and to experience this relaxation in his mind. In doing this we had to ignore the spasm of the muscles in his neck. Then when he had mastered the exercises he was gradually able to bring his neck muscles to relax for a few moments, then for longer periods; until after several weeks of practice the condition completely cleared.

An interesting point was that the muscles on one side of his neck had grown to an unusual thickness as a result of the spasm. Some weeks after the spasm was relieved these returned to normal size.

His mother wrote, “I wish to take this opportunity of thanking you for the treatment you gave . . . earlier in the year. Without your help, I am quite sure he would not have recovered as he has done, and we are all very grateful to you. So far as … himself is concerned, he seems to be completely recovered, and his approach to life and its problems has, generally speaking, become much calmer and more reasonable than it was for some time past.” At Christmas the boy sent a card, “It is wonderful to be able to do things normally again.”

The mother spoke of the treatment I gave him. But remember that I merely showed him how to do it himself, just in the same way that I have set down here.

I have been a little doubtful of the wisdom of including these two cases—the writer’s cramp and the wryneck—because it is so easy for people to say to themselves, “It is impossible that such a simple approach could cure such difficult conditions.” Please do not be put off by the

simplicity of this approach. Remember that the regression is an essential factor,

I have just recently seen a man with a wryneck condition, and I think I could have helped him. But he rejected the idea: “How could this help me, when all the other treatment has done me no good.” The simplicity of the treatment is indeed its greatest difficulty.

Furthermore, please do not let the apparent diversity of all these conditions confuse

you—nail-biting, blushing, writer’s cramp, wryneck and even smoking. There is no diversity. They are all motivated by the one factor, anxiety. Our exercises reduce our anxiety and so allow the symptoms to subside.

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The experience of an uncued attack is the central feature of panic disorder. An uncued panic attack is an attack that occurs spontaneously, irrespective of what the person may be doing at the time. It is not triggered by situations and places. People who

experience this type of attack may also experience them at night while asleep.

‘Cued’ panic attacks

Unlike the experience of a spontaneous attack, the cued attack does relate to and is triggered by specific situations or places. The cued attack is one of the components of post traumatic stress disorder, obsessive compulsive disorder and social phobia. It is unusual for people with panic disorder to experience this type of attack.

‘Situationally predisposed panic attacks’

Some people may be predisposed to having panic attacks in some situations and/or places. The attack is not necessarily triggered by the particular situation and/or place and may happen on some occasions and not on others. People with spontaneous panic attacks may go on to develop this type of attack.

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Central to the anxiety disorders are the experience of panic attacks. Until the introduction in 1994 of three separate and distinct types of panic attacks (APA 1994), all panic attacks were considered one and the same. The introduction of these three categories is a major step forward in the understanding of the subjective experience of these attacks.

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