IS IT RELATIVE OF BDD? SCHIZOPHRENIA: DIFFERENCES BETWEEN BDD AND SCHIZOPHRENIA AND PRACTICAL IMPLICATIONSImportantly, the delusional thinking that occurs in BDD usually isn’t bizarre, as it is in schizophrenia. In addition, other symptoms of schizophrenia (prominent hallucinations, disorganized speech, grossly disorganized behavior, and negative symptoms) are absent in BDD. Data on the cooccurrence of these disorders strongly refute a close relationship between them: in my series of patients with BDD, none were diagnosed with schizophrenia, nor have other researchers found coexisting schizophrenia in people with BDD. Similarly, schizophreniaTreatment response also differs. Antipsychotic medications (neuroleptics) are the mainstay of treatment for schizophrenia and are often effective. In contrast, SRIs seem most efficacious for BDD, whereas antipsychotics alone appear ineffective.Conclusions: Overall, BDD doesn’t appear to be a symptom of schizophrenia. Nor does BDD appear closely related to schizophrenia.Practical Implications: Even though BDD is misdiagnosed as schizophrenia less often than in the past, it still happens. It’s important to differentiate these disorders from each other, especially because effective treatments differ. If a person has both disorders, each disorder should each be diagnosed and targeted in treatment.*385\204\8*

COGNITIVE-BEHAVIORAL THERAPY FOR BDD:  SEVERAL THINGS TO KEEP IN MIND WHEN DESIGNING A GOOD BEHAVIORAL EXPERIMENT – SOME RECOMMENDATIONS FOR DOINGYou can do a behavioral experiment alone or with your therapist or a friend: It can be an advantage to take someone with you, because you can get someone else’s input as to whether the hypothesis was confirmed or not. It’s best, at least initially, to do experiments with your therapist, but whether this is feasible will depend on factors such as where your therapist’s office is located and whether there’s enough time during your session.Do lots of experiments: It takes lots of experiments and lots of practice to get the full benefit of behavioral experiments. It isn’t realistic to think that just a few experiments will get rid of your BDD.You can combine your behavioral experiments with cognitive restructuring: It can help to try to anticipate the negative thoughts you’ll have about your appearance during the experiment and to do some cognitive restructuring on a thought record form to help you prepare for the behavioral experiment. For example, Lorenzo could have filled out a thought record form for the thought “People will look at me with disgust because I look so bad” before he did his experiment.*314\204\8*

HOW TO SUCCESSFULLY TREAT BDD WITH MEDICATION:  WHAT IF AN SRI DOESN’T WORK WELL ENOUGH? YOU CAN “AUGMENT” AN SRI OR “SWITCH” TO ANOTHER SRI; IT ISN’T CLEAR WHICH STRATEGY IS BETTERUnfortunately, we don’t know whether it’s better to augment an inadequately effective SRI, or discontinue the SRI and switch to another SRI, because this question hasn’t been well studied. However, in my clinical practice, I found that among patients who hadn’t responded well to an adequate SRI trial, augmenting the first SRI was successful in 33% of cases, whereas switching to another SRI was successful in 44% of cases. This difference wasn’t significantly different statistically.However, I found something interesting when I considered whether the patient had had no response, versus a partial response, to the first SRI. Of those people who hadn’t responded to the first SRI (i.e., were not “much improved” or “very much improved”), only 18% responded when I added an augmenting medicine to the SRI. But among people who’d had a partial response to the SRI (i.e., were “much improved” or “very much improved”), 41% responded when I added an augmenting medicine. This difference was statistically significant. This finding suggests that you may be better off augmenting an SRI if you’ve partially responded to it, but it may be better to switch to another SRI if you haven’t responded to the first SRI. However, because this study was relatively small and not very scientifically rigorous (because it was based on my clinical practice), it’s best not to draw firm conclusions about which approach is more effective.There are other things you might want to consider when deciding whether to augment or switch. If you haven’t responded to numerous SRIs (for example, 3 of them) without any attempt at augmentation, it would make sense to try augmentation. Conversely, if you haven’t responded to several augmentation strategies with one SRI, it’s probably best to switch to another SRI.Another consideration is that the better you’ve responded to an SRI, the less appealing it is to discontinue it and try another one. For example, if you no longer feel suicidal, and your BDD and depression are a lot better (even if not completely better) on an SRI, it may be too risky to discontinue that SRI and try a new one. It’s possible that the second one won’t work or won’t work as well as the first one, and your symptoms could get worse again (although it’s possible that another SRI could work better). Continuing the SRI and adding another medicine allows you to maintain your partial response to the SRI, whereas if you stop the SRI you risk losing whatever response you had.So when deciding whether to augment or switch, there are several things to consider, including your individual situation and your and your doctor’s preference. The approach you take needs to be tailored to you. If the approach you choose doesn’t work, you can always try the other one.*264\204\8*

* Non-REM sleep: brain is relaxed, but body is active

* REM sleep: brain is actively dreaming, but body is relaxed

Dreams erection

During REM sleep, a lot is going on besides dreaming, and rapid eye movement is only the tip of the iceberg. In a man, although he is completely relaxed and unable to move even one muscle, î part of his body, the penis, is moving, becoming hard and ere This is one of the most important discoveries made in the sleep laboratory, and has led to a very rapidly progressing field in t treatment of impotence.

It has been confirmed again and again in sleep laboratories f men have erections in the dream state during REM sleep. Hence they have several erections a night, corresponding with the seven episodes of REM sleep. This is called dream erection and completely automatic; furthermore, most of the time the dreamer is not aware of the erection. Most men will tell you that t experience a morning erection when they are just waking up from a dream.

Why do men have these dream erections? Do they serve a purpose? No one has so far been able to give a good reason; however I am going to explore the possibilities and îoffer my own explanation of this strange phenomenon.

Sexual dreams

According to Sigmund Freud, the father of psychoanalysis, dreams which appear to be asexual are in fact symbolic of so sexual nature. In the days of Freud there were no sleep laboratories

and no one knew anything about REM sleep and dream erections. However, it is common knowledge among men that they have erections in the morning. Now we know, of course, that this is because they wake up in the morning in the midst of one of these recurring dream erections. Freud could have also observed that whenever he was dreaming he had an erection. This could have influenced his theory put forth in The Interpretation of Dreams. He maintained that sexual drive was the primary motivation of most dreams, and he even had a list of sex symbols to go along with his theory. Freud, if alive today, would say that dream erections are caused by the sexual nature of dreams, even if the dreams appear to be asexual to the dreamer. Freud placed a great emphasis on sex in all his dream interpretations. Could this be because of his observations of his own erections associated with every dream? But are there other explanations?

*16/23/6*

Most of us wake from our dreams in the morning and still have our dreams fresh in the mind. However, when activities of the real world set in, the dream details disappear. As the day continues, you normally cease to think of your dreams—your mind is occupied with real tasks and real problems. Hence forgetting our dreams is normal and healthy.

Once, on waking in the morning, my wife Patricia tried to tell me about an interesting dream. However, by the time we were having breakfast and discussing the day’s work ahead of us, she had totally forgotten the contents of the dream. Patricia manages my clinic and is also a registered nursing sister. Unless we make a conscious effort to remember a dream, such as writing it down, it vanishes from memory. Just stop for a moment and think. Can you remember the dream you had the night before?

I now want to propose another theory of the function of dreams. While we are dreaming we act out and experience some of our unconscious wishes and desires. Some of these desires may be very wicked and sometimes even immoral, and some of these desires may be too ambitious or even against the law and can never be fulfilled in real life. The dreams seem to satisfy our wishes and desires and let us experience them as if they are real and as if our dreams have come true.

Once these desires are satisfied, they are meant to be forgotten, so that the mind will no longer be disturbed by these desires and we can get on with our normal daily lives. In this theory about dreams, we are not encouraged to remember dreams or to analyse them. Dreams are perhaps a psychological filter and are used to dispose of our accumulated unconscious desires that may disturb our normal daily activities. After all, nature has designed dreams in such a way that most dreams are forgotten the next morning. Dreams are used to balance out our inner psychic life.

*13/23/6*

Sleep cycles

When a person falls asleep, he goes into NREM sleep, first entering the short-lived stage 1 sleep and then passing into stage 2 sleep. Stage 2 is the main stage and occupies about 50 per cent of the time spent in NREM sleep. He then goes into stages 3 and 4 of slow wave sleep. After 90 minutes from the onset of sleep he goes back to stage 2 sleep and enters the first REM sleep. The time up to the beginning of the first REM sleep is called the first sleep cycle .

The second sleep cycle starts with the first REM sleep, continues through the four stages of. NREM sleep, and ends at the beginning of the next REM sleep. Hence each sleep cycle consists of some REM sleep and some NREM sleep, except for the first sleep cycle which has little or no REM sleep.

Each sleep cycle lasts about 90 minutes and, as the night progresses, each REM period, and consequently each dream experience, lasts longer and longer, with the last REM stage in the morning perhaps lasting over an hour. This is why, when we wake up in the morning, we are very often in the middle of a dream. A normal sleep pattern will have four or five sleep cycles a night.

The 90 minute sleep cycle

In 1963 Kleitman postulated that the rhythmic recurrence of REM sleep is only a part of a biological rhythm which is continuous in both sleep and wakefulness. He called this the basic rest activity cycle (BRAC). In 1967 Franz Halberg, a scientist working in the USA, named such cycles the ultradian rhythm, which is also known as the 90 minute cycle or the REM/NREM cycle.

The hypothesis concerning the 90 minute cycle is as follows. We know that each sleep cycle consists of REM and NREM stages and that each sleep cycle lasts about 90 minutes. This is believed to be a basic biological rhythm innate in our state of awareness. The 90 minute cycles go right round the 24 hour clock. Every 90 minutes there is a window of a few minutes duration during which a person feels sleepy and can fall asleep. This is why some insomniacs, if they .miss the sleep window, may find it hard to fall asleep until the arrival of the next window 90 minutes later. This 90 minute cycle appears to be REM-stage related, and, during the window, other REM-related phenomena may be noted, such as day dreaming, penile erection, or just poor concentration.

Much research was conducted to demonstrate the existence of the ultradian rhythm. Extensive work was carried out on cats and monkeys to chart the activities of these animals in relation to their EEG recordings. It was found that, during the awake state, fluctuations in their activities correspond with the stage in the REM/NREM cycle.

However, the most convincing experiments were carried out by Lavie and Scheson in 1981. They tested human subjects in the sleep laboratory. The subjects were instructed to close their eyes and to fall asleep if they could during a 5 minute period of darkness occurring every 15 minutes over 12 hours. It was demonstrated that EEG recordings of stage 1 sleep were evident every 90 minutes but not at other times during the experiments. It was also demonstrated that, when these subjects were sleep-deprived and were very sleepy, their ultradian rhythm disappeared. In other words, when one is very sleepy, one- can fall asleep at any time irrespective of the 90 minute window of the ultradian rhythm. It is also now apparent that this 90 minute cycle is not exactly 90 minutes but can vary from 60 minutes to 130 minutes, with a mean of 90 minutes.

The present controversy over this 90 minute cycle is, when a person falls asleep, how are the cycles relating with each other between the awake state and the sleeping state? Most researchers favour the suggestion that, when a person falls asleep, the first period of NREM sleep or the first sleep cycle appears to reset the 90 minute cycle for the rest of the 24 hours. Also there seems to be a phase reversal after this first NREM sleep. After falling asleep, the brain activity of each REM stage is highly aroused with dream experience. However, during the awake state the 90 minute windows which are REM-related are of low arousal.

*9/23/6*

Kleitman and Dement observed that, when a person is sleeping, there is rapid eye movement in both eyes and this recurs periodically about four to five times each night. If these people are awakened during one of these periods of rapid eye movement, 95 per cent report that they are dreaming, compared with 7 per cent at other times of awakening. The duration of the dreams they recall appear to correlate with the length of the period of the rapid eye movement. This rapid eye movement sleep is now abbreviated to REM sleep. REM is pronounced like the word ‘gem’.

During REM sleep, the person is dreaming, his mind is active, and his eyes are moving rapidly back and forth under closed eyelids. The EEG recording is very similar to that of the awake state, like a very irregular saw tooth, and nothing like that of the four stages of sleep described previously. Contrary to what we expect, when the person is dreaming his body is not moving at all, but is in complete relaxation—paralysed. Some people call this REM sleep the paradoxical sleep. This is because the mind is active and dreaming, but, paradoxically, the body is totally inactive and motionless. It is thought that this complete body rest during REM sleep is essential for the refreshing feeling the person feels in the morning. This is because no matter how tense a person is, during REM sleep his muscles are all relaxed. It is also thought that this complete body paralysis during dreaming prevents the dreamer from acting out his dream physically when he is asleep. It looks like there is some form of jamming mechanism that disconnects the brain activity from the muscular system of the body.

Michael Long, in a 1985 edition of National Geographic, reported that, in Minneapolis, at the Hennepin County Medical Centre, a Dr Mahowald and a Dr Schenck interviewed over 30 people who somehow bypassed this jamming mechanism during REM sleep and acted out their dreams. This is of course extremely dangerous, but fortunately also extremely rare. During dreaming all sorts of fantasies, angers, and frustrations are acted out. Those people with no jamming mechanism can endanger not only themselves but also those sleeping beside them. It was reported that some of these violent dreamers beat their wives up repeatedly, smashed windows, punched holes in the walls, and displayed remarkable strength and agility. Fortunately most of us have this jamming mechanism which prevents us from acting out our dreams; otherwise our beds would look very different, with restraining belts to lock our bodies and limbs to the bed, to prevent us from running wild destroying things in the house when we are having a nightmare.

*6/23/6*

We take for granted that we know how to sleep, but in fact we all had to learn to sleep.

Psychologically, there are three kinds of activities:

* Innate activities—no learning is required

* New activities—a lot of learning is involved, e.g. driving

* Modified innate activities, such as toilet training and sleeping

Innate activities are basic activities that require no learning, including breathing, crying, smiling, reaction to pain, and so on. These are biological activities that are built into our system.

At the other extreme, there are new activities and skills which require learning from scratch. We spend years in school to learn how to read and write. We attend many lessons to learn to drive, and we learn to ride a bicycle after many falls. In fact, we are learning all the time without knowing it. We are imitating, copying from others, and modifying ourselves all the time. Indeed, it is the acquisition and accumulation of new skills, created and handed down through previous generations, that makes the human race so superior.

‘Modified’ innate activities are innate activities that are modified by learning; this learning is seen to be essential if the person is to conform to the norms of society. The most well known example

is toilet training. From birth, babies have no concept and respect of when and where to relieve themselves; hence they have to wear nappies. It is considered normal for babies to wet and dirty their nappies at any time of the day. When they reach the age of about three it is no longer considered normal for them to do it anywhere they wish. They learn to go to the toilet and to do it properly there. This learning is gradual, and the activities are modified to conform to the expectation of parents and the pressure of society.

Multiphasic pattern

Sleep is a modified innate activity. Young babies sleep for about 16 hours a day, waking up about five to six times in the 24 hours for feeding. This multiphasic sleep pattern may be the innate pattern of sleep. Gradually, as we become older, we learn to sleep more at night and to stay awake more in the day. At about one year of age, we wake up only once or twice at night, but stay awake most of the day. When we reach school age, we go to bed at about 8 p.m. and wake up at about 7 a.m. the next day. When we are adults, most of us sleep for seven to eight hours each night at one stretch. Hence, through learning, we change from a multiphasic pattern to a monophasic pattern of sleep. In some countries there is a sleep in the afternoon called the siesta or midday nap. Sleeping at two different times in the 24 hours is known as a biphasic sleep pattern and is more natural and refreshing than a monophasic pattern since it more closely resembles the innate pattern of multiphasic sleep.

Hence learning a sleep pattern is like toilet training. We learn to sleep at certain times of the night. Our parents expect us to sleep at night, and our teachers expect us to stay awake in class. We are modifying the innate ability to sleep in order to fit in with society, the majority of which shows a monophasic sleep pattern.

Nowadays, with the help of the sleep laboratory, we can demonstrate that there is a recurrent 90 minute sleep cycle, discussed in detail in chapter 5 on Two Kinds of Sleep. Every 90 minutes throughout the 24 hours there is a few minutes of sleepiness which has been called the 90 minute window. During this window we can fall asleep easily if we want to. Can this be a vestige of the innate multiphasic sleep pattern?

Since sleep is a modified activity and we learn to sleep when we are very young, various problems are created. We learn a lot of bad sleeping habits. Bad habits are certain behaviours we pick up and incorporate into our routine. In chapter on Sleep Hygiene I mention that we watch television in bed, we eat in bed, we stay up late at night, and wake up at all sorts of hours in the morning. Yet we expect to be able to sleep well whenever we want to. If we want to have better sleep, these bad habits have to be unlearned and eliminated.

Distress of Insomnia

It is a common experience that we feel distressed when we cannot sleep at night. Now why do we feel distressed? Occasionally we close our eyes and want to sleep but cannot. We feel frustrated and impatient; the night is too long without a proper sleep. People label themselves as suffering from insomnia when they do not have a good sleep for one or two nights.

Sleep is a learned activity. Learning involves a lot of reward and punishment or approval and disapproval from people we respect, such as parents and teachers. Somehow we incorporate these values of judgement into the depth of our mind while we are learning. We feel distressed when we do not perform to the expectation of parents and teachers. Gradually these expectations of parents and teachers become our own expectations. Hence, in later life, even in the absence of parents and teachers, we still feel bad if we do not perform to our expectation. We are expected to sleep at night and, if we fail, we feel distressed.

The strange thing is that the more we feel bad about not sleeping and the more we want to sleep, the more we cannot. This is the law of reverse effect. The more you concentrate on the word ‘sleep’, the more you cannot go to sleep. The law of reverse effect applies to other activities also. Say to yourself now, ‘My nose is not itchy, and I do not need to scratch my nose. My nose is fine, there is no reason to feel so itchy, and I do not want to scratch my nose at all’. Repeating this a few times to yourself, the majority of you will have to scratch your nose to relieve the itch. The more you think of the word ‘itch’, the more you want to scratch your nose. Words that have a lot of emotion and feeling attached will always carry much more weight in your mind than other words. For those who do not fall asleep easily, the word sleep carries a lot of emotion and worry. The mere mention of the word sleep will arouse them and prevent sleep onset.

Another reason for feeling distress when not sleeping at night is the worry that, if you do not have a good sleep, the next day you will not be functioning well. This usually adds anxiety, and anxiety is one of the main causes of insomnia. For those who have a problem sleeping, you have to relearn how to sleep. This is because facts and knowledge about sleep are important to allay fear, myth, misunderstanding, and misconception about sleep. Confronting such questions as how much sleep do you need, can you die from not sleeping, are dreams reflecting good sleep or bad sleep, and so on will help you to take the myth and the fear away from not sleeping. Some poor sleepers, after acquiring this correct information about sleep, sleep much better.

*2/23/6*