The relaxation technique we developed while working with our patients is taken largely from a program devised by Dr. Edmond Jacobson, who calls his technique “progressive relaxation.” In practice, we combine this technique with the mental imagery process we describe later in this chapter. However, we have detailed the relaxation process separately here so that you will see its value for use anytime. We recommend to our patients that they complete the combined relaxation/mental imagery activity three times a day for ten to fifteen minutes each time. Most people feel relaxed the first time they use this technique. But since relaxation is something that can be learned and improved upon, you will find that you’ll enter into increasingly relaxed states as the process is repeated.

To make the relaxation/mental imagery process easier to learn, we provide our patients with a cassette tape of instructions. You may also find it helpful to have a friend read the following instructions to you or to make a tape recording of them. Allow plenty of time for completing each step in a comfortable, relaxed manner.

1. Go to a quiet room with soft lighting. Shut the door and sit in a comfortable chair, feet flat on the floor, eyes closed.

2. Become aware of your breathing.

3. Take in a few deep breaths, and as you let out each breath, mentally say the word, “relax.”

4. Concentrate on your face and feel any tension ifl your face and eyes. Make a mental picture of this tension—it might be a rope tied in a knot or a clenched fist—and then mentally picture it relaxing and becoming comfortable, like a limp rubber band.

5. Experience your face and eyes becoming relaxed. As they relax, feel a wave of relaxation spreading through your body.

6. Tense your eyes and face, squeezing tightly, then relax them and feel the relaxation spreading through’ out your body.

7. Apply the previous instructions to other parts of your body. Move slowly down your body—jaw, neck, shoulders, back, upper and lower arms, hands, chest, abdomen, thighs, calves, ankles, feet, toes— until every part of your body is relaxed. For each part of the body, mentally picture the tension, then picture the tension melting away; tense the area, then relax it.

8. When you have relaxed each part of the body, rest quietly in this comfortable state for two to five minutes.

9. Then let the muscles in your eyelids lighten up, become ready to open your eyes, and become aware of the room.

10. Now let your eyes open, and you are ready to go on with your usual activities.

If you have not already done so, we encourage you to g through this process before reading on. You can find the relaxation it produces pleasurable and energizing.

People sometimes experience difficulty picturing the mental image or keeping their minds from wandering the first few times they try the process. There’s no need to feel discouraged. It’s very natural and criticizing yourself will only increase your tension. At the end of this chapter, when you are more familiar with relaxation and visualization techniques, we will deal with a few of the common problems patients have with these procedures and suggest how to overcome them.

The next section provides instructions for moving directly from the relaxation process into the mental imagery process. Although the relaxation technique is valuable by itself, as we said earlier, we use it primarily as a prelude to mental imagery, because the physical relaxation reduces tension that could distract from concentrating on the mental imagery. The relaxation technique is also a prelude to mental imagery in another sense: Learning to use mental guidance to produce physical relaxation should help strengthen your belief that you can use your mind in support of your body.

*40\347\2*

The ovum is released by the mature follicle of the ovary. Very soon it is caught up in the waving fimbriated ends of the outer part of the oviducts, or Fallopian tubes. The microscopic egg (invisible to the naked eye) is carried into the expanded outer end of the oviduct, to begin its journey towards the uterus.

Its trip is assisted by the tiny hair-like structures projecting from the cells lining the tube. These are the cilia, and they set up currents that tend to sweep the egg towards the uterus. Also, waves of muscle contraction, called peristalsis take place in the walls of the tubes. These also push the egg onwards.

Along the tubal journey, one of two events will occur. Either the egg will encounter a male cell of reproduction, called a spermaxazoon (or sperm, for short); or it will not. In short, conception (and pregnancy) will take place, or it will not. Here is where its momentous decision occurs: midway along the tube—the tunnel of love.

If sexual intercourse has occurred within the previous 24 hours, the chances arc high that millions of sperms will be found actively swimming along the tube. Sperms are like tadpoles in microscopic appearance: they have an expanded, rounded head, and a long tail. Madly waggling, the tail propels them along, at an amazingly fast rate.

Although there may be millions of sperms present—at each ejaculation (climax) by the male, anywhere from 200 million to 500 million sperms may foe released into the vaginal canal – in the final count only one will pierce the outer wall and combine with the ovum.

*16\45\4*

The types and variety of foods you select make a difference to your heart and your overall health. You already know the importance of control ling fat, cholesterol, sodium, and calories. Too much sugar and alcohol also are not healthful. The following section provides specific suggestions for replacing less-healthful foods with more-healthful, tasty food choices.

These recommendations for improving your diet for your heart’s sake are not a “prescription” diet. Eating healthfully is something your whole family can enjoy together. The principles of good nutrition are basically the same whether you are trying to maintain your health or whether you need to reduce your level-of blood cholesterol, lose weight, or control high blood pressure or diabetes. Your doctor or registered dietitian may suggest more specific changes in yotur diet to help you lose weight or customize the treatment of diabetes, high blood pressure, or high blood cholesterol.

The following six basic guidelines will make your diet more healthful. They start by suggesting you eat more—not less—of certain types of foods.

1. Eat five or more servings of various fruits and vegetables every day.

2. Eat six or more daily servings of grain products, preferably whole-grain breads, cereals, rice, and pasta.

3. Include two to three servings of low-fat or skim milk dairy products in your daily diet.

4. Eat no more than 5 to 7 ounces of meat a day. Occasionally substitute other high-protein, low-fat foods, such as eggs and dried beans, for meat.

5. Use fats sparingly—no more than 6 to 8 teaspoons of spreadable or pourable fat in your daily diet.

6. Eat fewer sweets and desserts and drink less alcohol.

Use these basic principles when you eat, shop for groceries, and plan meals, as well as when you eat out. You will most likely decrease fat and calories in your diet by eating more fruits, vegetables, and grains, and the temptation to eat higher-calorie processed foods that may be higher in fat and sodium will diminish.

The following pages discuss each guideline in more detail and provide specific suggestions for grocery shopping, reading labels, and cooking. With a few simple substitutions, you will be eating more healthfully.

*288\252\8*

I have one patient who had a bone density scan just after her fortieth birthday, a time when many doctors are still reluctant to send a patient for the test. Ruth had a lifetime of excellent diet and exercise habits, but was concerned because her mother had osteoporosis. Since she felt strongly about it, I wrote the referral. The scan revealed that she already had low bone density. And her real danger zone—menopause— was still years away!

With this knowledge, she stepped up her efforts to prevent further bone loss. She increased the amount of time she spent exercising, and began taking calcium and vitamin D supplements, along with a multivitamin-and-trace-minerals supplement, aiming to get herself back to the density of a healthy 30-year-old with peak bone mass.

Although encroaching osteoporosis in such a young woman is alarming, to me the truly scary part of this story is thinking about what would have happened if Ruth hadn’t had the bone scan. Without knowing she needed to take positive steps now, and staying on top of her progress, I fear she would have ended up with a fracture before long, possibly before menopause. She would have lost a great deal of height, found an ever-increasing forward curve in her upper back, perhaps suffered bone pain, and maybe would have had to curtail her many and varied activities. Not only did the bone density scan perhaps save Ruth’s life, it surely saved her lifestyle.

*36\228\2*

Wendy had her first complex partial seizure when she was 13. Her initial evaluation, including a CT scan and EEG, revealed no cause, and medication was prescribed. Phenobarbital made her sleepy, and phenytoin (Dilantin) only slightly reduced the frequency of her seizures, now occurring three to four times a week. Carbamazepine (Tegretol) was added, and the seizures became less frequent. However, Wendy’s school work began to suffer while she was taking several medications, and she became depressed. At sixteen she couldn’t drive and because of embarrassment she became less social and more isolated. When she was eighteen, valproic acid (Depakene) became available, but despite attempts to adjust medication, her physicians were unable to completely control her seizures. By this time, Wendy’s school work had suffered and she had been turned down by the colleges of her choice. She was about to enter the local junior college.

When we first saw Wendy, she was a highly motivated young lady, depressed about the seizures and about her future. She had received psychological counseling, which had helped some, but the seizures—suddenly stopping what she was doing, staring, then wandering about the room, picking at her clothes, and remaining in a confused state for ten to fifteen minutes—were still occurring several times each week despite good levels of medication.

Our evaluation suggested that the seizures came from the right temporal lobe. Surgery was discussed, but Wendy, now twenty-two, was afraid. We worked with her, long distance, to adjust the medications, but she either had problems with drug toxicity or with seizure control. Nevertheless, she finished college and began a masters program in psychology. Finally she decided she was willing to have the surgery. Repeat evaluation suggested that the focus was in the anterior right temporal lobe. This was removed surgically and revealed “mesial temporal sclerosis,” an old scar that had not been visible on the scans.

Wendy has had no seizures in the past five years, has finished her Ph.D. in psychology, and says that life and her work are both much easier now without seizures and without any medication. “I only wish that we had done the surgery much earlier,” she says. “It would have made growing up so much easier.”

*149\208\8*

There is no need to be. If you are aware of the risks, you can take preventive action before these conditions have a chance to develop. If you have regular check-ups, minor changes can be identified at a time when something can be done about them. This is one reason why it is important to keep your] appointments even if you feel well and your blood glucose levels are all right. Most people with diabetes are untroubled by complications, and even if you develop them, a great deal can be done to treat them.

•   Have regular health check-ups.

•   Tell your doctor at once if you have any trouble with your vision; notice any change in sensation in your limbs; have pain or burning on passing urine or need to urinate very often; have soreness or irritation between the legs; pain in your calves when you walk; pain in your chest; or any problems with your feet.

•   Do not smoke.

•   Watch your weight.

•   Eat a high fibre diet, without added salt, with reduced fat content, low in saturated and high in polyunsaturated fats.

•   Keep your blood glucose levels normal.

•   Take any pills prescribed by your doctor.

*40/102/5*

Anytime the presence of cancer is suspected, the person involved is likely to react with great anxiety, fear, and anger. Emotional distress is sometimes so intense that the person is unable to serve as his or her own best advocate in making critical health care decisions. If you find it difficult to know what to ask your doctor on a routine exam, imagine how hard it would be to discuss life or death options for yourself or a loved one. Having a list of important questions to ask when you appear at the doctor’s office may help tremendously. Remember, your health care provider should be your partner in making the best decisions for you. By actively challenging, questioning, and letting the physician know your wishes, difficult decisions may become easier.

If the diagnosis is cancer, you may want to ask these questions:

- What kind of cancer do I have? What stage is it in? Based on my age and stage, what type of prognosis do I have?

- What are my treatment choices? Which do you recommend? Why?

- What are the expected benefits of each kind of treatment?

- What are the long- and short-term risks and possible side effects?

- Would a clinical trial be appropriate for me? (Clinical trials are research studies designed to answer specific questions and to find better ways to prevent or treat cancer. Often new cancer-fighting treatments are used.)

If surgery is recommended, you may want to ask these questions:

- What kind of operation will it be, and how long will it take? What form of anesthesia will be used? How many similar procedures has this surgeon done in the past month? What is his or her success rate?

- How will I feel after surgery? If I have pain, how will you help me?

- Where will the scars be? What will they look like? Will they cause disability?

- Will I have any activity limitations after surgery? What kind of physical therapy, if any, will I have? When will I get back to normal activities?

If radiation is recommended, you may want to ask these questions:

- Why do you think this treatment is better than my other options?

- How long will I need to have treatments, and what will the side effects be in the short and long term? What body organs or systems may be damaged?

- What can I do to take care of myself during therapy? Are there services available to help me?

- What is the long-term prognosis for people of my age with my type of cancer who are using this treatment?

If chemotherapy is recommended, you may want to ask these questions:

- Why do you think this treatment is better than my other options?

- Which drug combinations pose the fewest risks and most benefits?

- What are the short- and long-term side effects on my body?

- What are my options?

Before beginning any form of cancer therapy, it is imperative that you be a vigilant and vocal consumer. Read and seek information from cancer support groups. Check the skills of your surgeon, your radiation therapist, and your doctor in terms of clinical work and interpersonal interactions. The time spent asking these questions and seeking information is well worth the effort.

*33/277/5*

Many people with BDD seek and receive unnecessary medical and surgical evaluation and treatment. Doctors often refuse to provide such treatment because the defect is so minimal they consider treatment unnecessary. Several men I’ve seen have even been turned down by hair clubs. But some people nonetheless persist in their search for a doctor who will give them what they want. Some receive treatment after treatment—even surgery after surgery—hoping that the next one will finally provide the relief they so desperately seek.

This behavior can take the place of living. Abby, who told me she’d seen just about every dermatologist in Chicago, described this behavior as “just about all I do. The doctors I saw said my skin wasn’t so terrible. Some of them thought I was crazy. So off I’d go to find another one. It’s how I spend my days—going to skin doctors.”

While most people who have cosmetic surgery are happy with the result, this doesn’t seem to be the case for people with BDD. Most are unhappy with the outcome and blame themselves or the doctor for having made a serious mistake. For some, preoccupation and suffering diminish temporarily, only to return. Or the bodily preoccupation may shift to another area.

Rarely, people with BDD who are dissatisfied with medical or surgical treatment are violent toward the doctor who provided it. There are several reported cases of violence, even murder or attempted murder, toward a physician who the patient thought had ruined his or her appearance. Occasionally, people with BDD sue, even though the treatment outcome appears acceptable to others. Large amounts of money may be spent seeking and receiving such treatments, to no avail. In some cases, life savings are depleted.

*135\204\8*

Productive cough, shortness of breath, and fever are symptoms of tuberculosis and pneumonia caused by certain common types of bacteria; these symptoms may also be caused by PCP, certain viruses, Kaposi’s sarcoma in the lung, and several other unusual conditions.

Tuberculosis (TB)-The most common symptoms of TB are cough, bloody sputum, shortness of breath, fever, weight loss, chest pain with breathing, and night sweats. As with PCP, the tempo of tuberculosis is generally slow, usually progressing over a period of weeks or months. During this time the person is usually fatigued, has night sweats, and loses weight. TB can occur in the lung, but it can spread to almost any part of the body. People with HIV infection often have TB relatively early in the course of the infection, when the CD4 count is fairly high: TB

apparently has enough clout that it does not require a severely weakened immune system to cause disease.

TB, which is caused by a bacterium called Mycobacterium tuberculosis, can be active or inactive. When it is active, the bacterium is reproducing and the person has symptoms of TB. When it is inactive, Mycobacterium tuberculosis is dormant in the lung, much the way

Pneumocystis carinii is dormant in the lung. People with inactive TB have no symptoms, and all cultures for Mycobacterium tuberculosis are negative.

The only way to find out whether a person has been infected with Mycobacterium tuberculosis is the skin test most people are familiar with, done on the forearm. The skin test is a shallow injection of a protein called a purified protein derivative, or PPD, made from Mycobacterium tuberculosis. If the area around the injection become red and thickened two or three days later, the person’s immune system has already responded to the bacterium. In other words, a positive skin test means that Mycobacterium tuberculosis is in the body and the person has TB, either active or inactive. The only other evidence of infection might be a chest x-ray showing the scars of previous infections with TB that the person may be unaware of. Most, though not all, people with active TB have had inactive TB for several years previously.

If the skin test is positive, it is followed by sputum tests for TB and x-rays. If the sputum test is also positive, if symptoms are ascribed to TB, or if the x-ray shows new changes, the person has active TB. Otherwise, the TB is inactive.

It is especially important for people with HIV infection to have a skin test. Inactive TB can be treated with a drug, isoniazid (INH), that will prevent active TB. Active TB is treated more aggressively, with three or more drugs.

Mycobacterium tuberculosis must be distinguished from a related microbe called Mycobacterium avium-intracellulare, or MAI. MAI causes infections in many organs throughout the body. This distinction between Mycobacterium tuberculosis and MAI is important, not only for deciding what the treatment should be, but also for preventing transmission. Mycobacterium tuberculosis, the only contagious mycobacterial infection, can be transmitted from one person to another by close contact over a period of several months. For this reason, the people most likely to be infected are those who live with the infected person. But an infected person who has been treated with drugs against TB for several days is unlikely to transmit the infection to others. This means that once treatment has started, the likelihood that it will be spread to others is reduced or nil. The standard recommendation for testing those people who have been exposed to TB for long periods is to do the skin test, and if it is positive, to follow it with chest x-rays.

*107\191\2*

Seborrhoeic dermatitis

This condition occurs in approximately twenty per cent of the population and produces a red, scaly rash, usually around the nose, eyebrows, ears and scalp margin. It is caused by excessive oil production rather than dry skin, the oil causing an irritant skin reaction.

Many people think seborrhoeic dermatitis is due to dry skin and so apply moisturizers. Moisturizers, however, only make the condition worse. The body is actually trying to reject the inflamed skin, causing the redness and peeling, so by applying moisturizers you are ‘gluing’ on this unwanted skin.

Seborrhoeic dermatitis is largely hereditary, but is made worse by stress and alcohol. It is very easily and safely treated using a combination of topical cortisone and anti-fungal creams as well as tar-based shampoos such as Ionil T, Polytar and T/Gel.

Discoid dermatitis

As the name suggests, this condition produces dermatitis in rings, but is really just a form of eczema. It is often confused with ringworm and treated with various anti-fungal creams. These make the condition dramatically worse. Discoid dermatitis is treated in much the same way as endogenous dermatitis in adults.

Asteatotic dermatitis

With age, the skin becomes drier, gradually losing its protective coating. It therefore becomes more prone to irritation, especially if it is washed excessively or is exposed to excessive heat. Asteatotic or dry skin dermatitis is very simply avoided. All people over the age of sixty should use moisturizing bath oil in the shower or bath. Soaps should be kept to minimum and only moisturizing soaps used. After bathing a moisturizing cream should be applied. Harsh antiseptics and cleansers should also be avoided in elderly skin.

*50/150/5*