On Bulimia

Bulimia Nervosa is a type of eating disorder and the primary features thereof are described in the Diagnostic and Statistical Manual of Mental Disorders 4^th ed. Text Revision, (DSM-IV-TR), as “binge eating and inappropriate compensatory methods to prevent weight gain. In addition, the self-evaluation of individuals with Bulimia Nervosa is excessively influenced by body shape and weight.”, p. 589. A binge episode is commonly described as one in which an individual consumes far more than most persons would under similar situations. The DSM-IV-TR regards a binge as, “eating in a discrete period of time an amount of food that is definitely larger than most individuals would eat under similar circumstances”, p. 589. Furthermore, individuals engaging in binge eating are often embarrassed of the episodes and usually perform them in secret. Bulimia Nervosa has two subtypes as noted on page 591 of the DSM-IV-TR:

“Purging Type. This subtype describes presentations in which the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas during the current episode.

Non purging Type. This subtype describes presentations in which the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas during the current episode.”

What causes bulimia?

There are multiple agents that contribute to the development of bulimia and bulimic symptoms. Therefore, as much as we would like to, we simply cannot reasonably attribute the majority of cases to any one construct, scenario, or event. When asked where they think it all started, some patients will suggest that they were teased about weight at a very early age, (whether or not they were actually over or under weight), others will report witnessing their mothers denigrate themselves in front of the mirror, when getting dressed, or even during mealtimes. Still, others will report that the onset of symptoms likely followed a traumatic event such as sexual assault. Despite the myriad of potential starting points, bulimia nervosa, and eating disorders in general, are not something an individual simply decides to start doing one day for fun; in other words, eating disorders do not come out of nowhere.

Why can't they just stop?

First, if it were this easy, don't you think the people afflicted with this disorder would just stop? As a result of an otherwise competent and successful outward image, many people fail to recognize that bulimia nervosa is a psychological disorder. Oftentimes the patient will have a job, a high grade point average, and may even volunteer or belong to clubs as well. Therefore, people often look at the individual and think, “Wow, he/she is doing so great, how could anything be going wrong”? Sadly, the patient is suffering from a great deal of pain inside. These could be a conglomeration of guilt, anger, sadness, worry, and other painful emotions that the individual is afraid to share with others. The person suffering from this dangerous disorder is trying to address this pain through his or her bulimic symptoms. While each person will have a somewhat different experience in the throws of the disorder, it is often reported that painful feelings become overwhelming and the person tries to stuff them down inside or cover them up by bingeing. The binge can sometimes be described as a violent episode of eating, not something that is slow and calculated, but rather wild and filled with rage, sadness, fear, and general emotional pain. Following the binge, the patient feels physically and emotionally exhausted, not to mention extremely uncomfortably full from the large intake of food rather quickly. A terrible sense of guilt sets in over not being able to control oneself and the self-loathing is thus reinforced during each cycle. The patient who engages in purge-type then engages in some compensatory behavior, such as vomiting, to rid him or her self of the food in order to alleviate the physical discomfort, as well as, in an attempt to atone for the binge, perceiving it as something morally wrong and disgusting. The patient who engages in a non-purge type will also utilize some compensatory mechanism in an attempt to obtain self-forgiveness or a perceived cleansing, but the mechanisms are different, as aforementioned. The patient, as previously stated, is usually very embarrassed about engaging in this pattern of behaviors and therefore tries to keep it hidden, allowing people on the outside to only see the accomplishments and accolades the individual strives to maintain.

How can I help my loved one?

Oftentimes, family members or friends may want to help, but don't know how. It can be difficult knowing what to say or do, as well as, what not to say or do. I would suggest first, remember that your loved one's struggles are real. This is not something he or she simply made up to get attention, be a brat, or any other asinine proposition. Eating disorders are real and the emotional pain and torment the afflicted individual suffers is real. Secondly, you cannot make this all better simply by being a better friend, parent, sibling, etcetera. Eating disorder treatment requires professional help. A team approach consisting of a therapist, nutritionist, and possibly a psychiatrist, is often a good start. Group therapy has been shown to be of immense value in overcoming an eating disorder. This is not something that is cured by once a week visits to a therapist with no experience in the treatment of eating disorders. Third, get some education about what eating disorders are. Read, attend support groups, and talk to therapists. Finally, I want to leave you with a basic list of concepts;

• DO NOT make the discussion about food; strange as it may seem at first, throughout the therapeutic process with your loved one you'll come to understand that eating disorders have pretty much nothing to do with food

• DO NOT be the food police; policing the food makes meal time very anxiety provoking, instead it should be a pleasant time. Furthermore, you are not the nutritionist, the therapist, the psychiatrist, etcetera, you are the loving family member or friend who is part of the support system; stick to your appropriate role.

• DO be consistent in your support; even if you're upset with your loved one, you can love and support him or her in recovery. Along this line, it is perfectly okay to talk about feelings; the therapist will likely guide you as to how best to communicate what you're feeling to your loved one as he or she goes through this struggle in recovery. There are no good or bad feelings, though there are helpful and unhelpful ways of showing those feelings.

• DO take care of yourself. Supporting a loved one in his or her recovery, whether from an eating disorder, chemical addiction, or any other psychological disorder, can be overwhelming. The best way you can be there for someone else is if you are in a healthy frame of mind; it is not uncommon and may actually be recommended that the friends and family of the patient also seek their own therapists.

I hope this has shed some light on the subject of bulimia nervosa and given you some things to think about. If you think you or someone you know might be experimenting with or engaged in an eating disorder, please speak with a psychologist or therapist who is experienced in the treatment of eating disorders. There is an extensive list of eating disorder treatment centers listed by state in the Gurze Books website: www.bulimia.com. Here's to wishing you Good Mental Health.

On Schizophrenia

Schizophrenia is a psychological disorder characterized by such symptoms as delusional thinking, hallucinations, disorganized speech, substantially inappropriate emotional responses, and considerable social dysfunction. However, the aforementioned list is not exhaustive, and persons with schizophrenia will not necessarily report the same symptoms. Not only can people experience different types of symptoms, but also varying amounts thereof. What do these terms really mean though? Let's take a quick look at some explanations of common indicators.

Delusions:

According to the Diagnostic and Statistical Manual of Mental Disorders, 4^th ed., Text Revision, (DSM-IV-TR), delusions can be described as, “...erroneous beliefs that usually involve a misinterpretation of perceptions or experiences. Their content may include a variety of themes (e.g., persecutory, referential, somatic, religious, or grandiose)”, p. 299. This misinterpretation does not mean that an individual failed to understand a joke or missed the hidden meaning in a movie. Rather, such distorted interpretations, as can be seen in this illness, would be something like believing that someone is plotting to steal money from you because you saw three green bicycles on the way to work today and in your mind the colour green represents money. These faulty interpretations, as previously mentioned, may also have some grandiosity to them. For example, as you pull your car toward the traffic light, it changes from red to green, but rather than just feeling fortunate, you take this to mean that you have innate supernatural abilities to alter the physical world around you without being in direct contact with it.

Hallucinations:

The website, www.dictionary.com, describes an hallucination as, “a sensory experience of something that does not exist outside the mind...”. While hallucinations are most commonly of the auditory type, it should be noted that they can be experienced in any of the five senses. For instance, it is uncommon even among those who experience hallucinations, but nonetheless possible for someone who is suffering from schizophrenia to encounter olfactory hallucinations. In other words, the individual will smell something that is not actually present. Bear in mind, this experience is different from recalling a scent, sound, sight, taste, or touch. Nearly everyone has the ability to recall sensory experiences. However, the person suffering from hallucinations may actually believe the encounters are present outside of his or her own mind at that moment. I recall a discussion with a patient who was afflicted with schizophrenia. The patient, in a much healthier and lucid state, was talking with me between group sessions. He described having occasional visual hallucinations while maintaining an awareness that the sensory experience was not really occurring outside of his mind. So, despite sometimes seeing blue trees in the middle of the group room, the patient was able to realize that his brain was merely formulating another hallucination.

Disorganized speech:

A person suffering from schizophrenia may exhibit disorganized speech. This can range from mild to severe in nature and presentation. Although it may appear oddly disturbing, just because someone exhibits disorganized speech does not necessarily mean he or she has schizophrenia. The disorganization exhibited may be frequent derailment, or jumping from one topic to another more than usual. Again, keep in mind that a person presenting this does not necessarily have schizophrenia, as this speech pattern may also be seen in the context of a manic episode or usage of a stimulant, such as cocaine. The presentation of disorganized patterns of speech may also be much more severe, as in the case of a word salad. This may sound something like the following:

So, there hotdog cantilevered and books on the blue shoe made right. President buttons can never tabletop a skateboard sandwich. Music likes water pitchers. 

 A word salad may also be present in conditions of traumatic brain injury or severe oxygen deprivation, resulting in expressive aphasia.

So, where does it come from? Well, with regards to its origin, we're just not 100% sure. However, it is believed that schizophrenia has a very strong genetic component. The DSM-IV-TR, reports, “The first-degree biological relatives of individuals with Schizophrenia have a risk for Schizophrenia that is about 10 times greater than that of the general population.”, p. 309. The text goes on to note, “Adoption studies have shown that biological relatives of individuals with Schizophrenia have a substantially increased risk for Schizophrenia, whereas adoptive relatives have no increased risk.”, p. 309.

Is it treatable? Many people suffering from schizophrenia have found immense help through a combination of psychiatric medication and psychotherapy. Many antipsychotic medications are available to treat the symptoms of schizophrenia and an individual should discuss his or her options with a psychiatrist. Furthermore, be advised that just like nearly everything else, the medicines that work for one patient may not work so well for another. Our bodies are like individual chemistry sets so expect that it may take a bit of trial and error, as well as, adjusting of dosage levels in order to get your exact fit; a psychiatrist will know best how to do this. Once on a stable and sufficient regimen of medication, psychotherapy can help one develop coping skills and self-awareness in order to prevent, manage, and alleviate the onset of possible psychotic episodes in the future. This is not going to be a one time fix, like painting over a scratch on your car's surface. Rather, this is going to be ongoing periodic maintenance, like changing the car's oil. However, simply because one suffers from schizophrenia does not mean one cannot lead a happy and fulfilling life. We will all encounter bumps, potholes, and sharp curves in our individual journeys, though we may have a different road map than someone else.

I hope this has offered you some enlightenment and awareness on the often misunderstood illness, schizophrenia. If you have encountered any of the aforementioned symptoms, or know someone who has, please speak with a physician, psychologist, or therapist about your experiences. Here's to wishing you Good Mental Health.

On Communication

Communication; simple enough, it's just talking, right?


While this might be a common term, there is so much more to real and effective communication than simply talking.  Whereas talking simply involves the oral production of words, communication delves deeper to convey an interchange of ideas, concepts, or experiences.  This involves not only talking, but listening, as well.  When two or more individuals are engaged in a discussion, debate, or other exchange of perspectives, it's unlikely that authentic communication will occur if everyone just talks.  Rather, when one individual talks, it is important that others actively listen, even if the listeners do not agree with the message the speaker is sending.  This seems very simple, so why do we often get it wrong?  The short answer is that nearly everyone wishes to be heard and this need can become so strong that we make the mistake of not taking the time to play the role of listener.  However, there is hope!


The first point is recognizing that each of us has something we deem worthy of saying and that we want someone else to take the time to really hear it.  It is true, however, that only one person can speak at a time if we are to have an effective discussion.  With that being said, there are a number of ways to initiate and maintain healthy discussions.  For instance, some have chosen an object to determine who's turn it is to speak.  This can be any object, a feather, a lavender scented sachet (possibly calming), an amulet, or any other non-threatening hand held item.  Participants in the discussion may also wish to set some ground rules before the communicating begins.  These can be simple rules for all to follow that will help guide us when we feel that emotions may cause the discussion to go awry.  The following is a list of a few simple rules that may aide in effectively communicating:


1. Only the person holding the chosen item, may speak.


2. The speaker has five minutes to say what he or she is experiencing.


3. The speaker must pass the hand-held item after the five minute period has ended.


4. The speaker may not use attacking, insulting, or threatening language toward any listener(s).


5. The listener(s) MUST refrain from interrupting the speaker; the listener may use a notepad to jot down ideas or thoughts he/she wishes to comment on during his/her turn speaking.


Keep in mind that this is not an exhaustive list, but merely a starting point and can be altered by the members, (before the discussion begins), in order to facilitate communication.


Another important piece of healthy communication is to utilize what are called I statements, instead of YOU statements.  The reason being, is that we all tend to get defensive when someone starts out with, "Well, if YOU had just.....".  Rather than hear what the speaker is trying to convey, we put up a wall of defensiveness.  Remember though, we cannot hug each other through walls.  When a speaker uses an I statement, he or she is merely stating his or her truth.  For example, "I get angry when I am compared to your ex-girlfriend".  When we look closely at this statement, the speaker is merely stating her own feelings and this comes across to the listener as far less accusatory or threatening than, "You make me angry when you compare me to your ex-girlfriend".  In the first statement, the speaker is taking ownership and responsibility for her own feelings, whereas in the second statement, she is placing responsibility for her feelings on the listener. 


 We all have emotional experiences and our emotions are our own property; no one can make them for us and no one can take them away from us! 


 When the listener hears the first statement, he is unlikely to feel blamed for the speaker's distress, though he will still understand his involvement in the situation.  The listener is likely to respond to the first statement with something like, "Sometimes I see behaviors that remind me of my ex-girlfriend and that frightens me; so it's like this alarm goes off in my head and I react by making the comparison between you and her.  I guess it's to try and get some distance or protect myself somehow from that bad experience I had in the past".  In this statement, the person who is now speaking, is acknowledging his own internal feelings and fears of repeating a very bad relationship from the past.  He is not accusing, blaming, or threatening the listener.  He is taking ownership for his feelings and his behaviors.


It may well feel odd the first few times you engage in this new way of communicating.  However, just like everything else, it takes some practice.  You are not likely to become a perfectly effective communicator in one sitting, but do not get discouraged, because you are indeed making good progress!  Consider the following differences in the previous discussion when using I and YOU statements between our imaginary couple; we'll call them Alexis and Michael.


YOU statements:
A: "You make me angry when you compare me to your ex-girlfriend". 
M: "Well, if you wouldn't act so damn crazy like her then maybe I wouldn't have to call you out on it!" 
A: "I am NOT YOUR EX-GIRLFRIEND!" 
M: "There you go again, freaking out just like her. You're all the same".


I statements:
A: "I get angry when I am compared to your ex-girlfriend".  
M: "Sometimes I see behaviors that remind me of my ex-girlfriend and that frightens me; so it's like this alarm goes off in my head and I react by making the comparison between you and her.  I guess it's to try and get some distance or protect myself somehow from that bad experience I had in the past". 
A: "Well, I know she was a nut-case and really messed with your head, but I love you and I want this relationship to work.  It's okay to let me know when you're feeling freaked out or something, we can work through it together." 
M: "Yeah, I would really like that.  I want this relationship too, I really love you and I appreciate how good you are to me.  It's just new because no one has ever done this for me before".

From the two examples above we see how dramatically different the outcome can be when we substitute I statements for YOU statements.  When we take the time to really listen to what someone is saying underneath all that anger, pain, and frustration we see things from a different perspective and then we don't feel so threatened or hurt.  It can also help to think of healthy communication like playing a game of catch.  When we play a game of catch we throw the ball or disc TO one another, not AT one another!  Given we want the relationship to work, it is very important to always keep in mind, we're on the same team.

Well, I sincerely hope this has been enlightening and enjoyable.  I would recommend trying some of the aforementioned techniques together with some very lighthearted subjects at first, as to avoid any immediate catastrophes.  If you feel you need help with communication in your family or partnership, I encourage you to consult a therapist or psychologist for couples or family therapy.  If you feel you might be in a dangerous or abusive relationship, please consider building a plan to ensure the safety of yourself and any children or dependents, contact your local authorities, domestic violence shelters, and/or a trauma therapist for help.  Here's to wishing you Good Mental Health.

On Psychotherapy

I have been asked several times, what I do as a psychotherapist.  It oftentimes seems that people are not sure what to expect when seeking help from a mental health practitioner.  Most people can recall a movie in which a group of zombie-like patients sit in a sterile, dimly lit room decorated with large pictures akin to Rorschach ink blots lining the walls.  Meanwhile, in this same Hollywood version, an emotionally detached clinician sits quietly scribbling notes onto a pad while giving accusatory glances and inquisitions, as if to shame someone for their internal struggles or, worse yet, as if fighting to convince the patient that he or she is mentally incompetent and unable to differentiate reality from non-reality.  On the other hand, we may see a more comedic approach to therapy, albeit, again from a movie or television program, in which the therapist comes across as goofy and out of touch; pretending to live in harmony with all life forces while we in the audience are wondering how much grasp he or she has on reality.  Seeing images like these over and over, it's no wonder people are uncertain of therapists.  We are portrayed as either out to get you, or as living precariously on the fringe of society's accepted boundaries of normal behavior.


What are therapists really like?  We're generally like anybody else.  We shop for groceries, we mail in the car payment every month, we might have pets, we like Italian food, we watch movies, we play sports, we laugh at jokes, we check our email.  So, if we are regular people, then what is therapy really like?  Therapists have varying styles of therapy; after all, we're individuals with our own personalities.  However, when describing therapy to someone, I generally explain that the therapist and patient take some time to get to know one another and develop a therapist/patient relationship.  In the very beginning some therapists may ask about a person's daily routine, whether anyone in the patient's family was addicted to drugs/alcohol, if the patient ever witnessed or personally experienced abuse, or bring up other questions that may seem somewhat uncomfortable.  Once again, each therapist will have his or her own style, but the reason for such initial questions may be to determine how to shape that style to match whatever issues or struggles the patient is bringing in.  Furthermore, keep in mind that not every therapist is capable of handling every type of psychological problem.  Therapists may be trained in different specialties, as are physicians, and this will limit the scope of treatment a therapist can or will provide.  Therefore, it's perfectly acceptable for the patient to ask the therapist questions too, especially if this is the individual's first time in therapy and he or she doesn't really know what to expect.  However, it can save the patient a lot of time and running around if he or she will ask questions prior to setting up the first session, therefore, one can eliminate therapists who may not be able to help.  Remember that you the patient are also looking for a good match, so it's alright to see a couple of therapists and then decide where you feel most comfortable.  Therapy, regardless of the issues discussed, is likely something that will take awhile.  I've never met a person who said one session was all that was needed; (this, however, does not mean that you must remain in therapy for decades).  It's not uncommon for someone to spend several months in weekly therapy, but you can arrange with your therapist how often you would like to meet.  During the course of therapy, there will be sessions that seem very productive and sessions that seem kind of bland.  A patient and his or her therapist will develop a relationship of trust and consistency.  Therapy is sometimes the very first place that some patients ever feel truly safe.  A patient should never feel afraid of his or her therapist.  Initial nervousness is normal, but if you've been meeting with your therapist for months and you feel afraid being harmed by the therapist, then something is definitely wrong.  In such a scenario, it is important that the patient let someone know, maybe another therapist or even the police.  Beyond such extremes though, therapy is not magic, it is work and sometimes that work is difficult and uncomfortable.  It can be of great value for a patient to step back and take a look at how he or she has been thinking or behaving and whether those things have served the patient well.  Patients can use their therapists as non-judgmental sounding boards when a quandary arises, or patients can share with their therapists things they've never told anyone.  We're not allowed to go blabbing it to everyone in town, it's actually illegal given that whole patient/therapist confidentiality thing.  However, even that has limitations, so be sure to ask about the limits of confidentiality during that initial session.  Furthermore, at the risk of sounding like a cliche, therapy is certainly a journey and not a destination.  It's my sincerest hope that you'll enjoy those travels.


Well, I hope this has offered a little more insight into what psychotherapists do and what psychotherapy is like.  Generally, one's world should feel comfortable, safe, and reasonably consistent.  If it does not, you may consider speaking with a therapist.  Here's to wishing you Good Mental Health.