Tools for Behavioral Health Interventions

A public-private partnership Mountainview transforming primary care www.pcpci.org Consulting Group

Provided as part of Primary Care Behavioral Health (PCBH) Introduction and Foundations training provided by Mountainview Consulting Group through the Patient-Centered Primary Care Institute

October/November 2013

A library of editable documents included in this implementation kit is available by clicking here, or by visiting our website: www.pcpci.org.

Table of Contents

I. PCBH Bull’s Eye Plan

II. Using Medications Successfully

III. Beliefs About Medications

IV. Seven Ways to Cope

V. Love Work Play Health, Three T’s

VI. PCBH Patient Education Protocols

VII. Exam Room Posters

VIII. Spanish Materials

PCBH Bull’s Eye Plan Bulls Eye Plan

Value Area (Love, Work or Play) & Value Statement:

1 2 3 4 5 6 7

Not Slightly Somewhat Remarkably Very BULLS Consistent Consistent Consistent Consistent Consistent Consistent EYE!

Behavior Plan:

3. Guide for Using the Bulls Eye Plan

1. Ask the patient to choose Love, Work, or Play as a focus for a short discussion about values. Ask the patient to explain what is important to him or her in each area of life.

2. Listen closely, reflect what you heard and then write a statement on the Bulls Eye Plan using the words (global, abstract) the patient used in talking about the value.

3. Explain that the Bulls Eye on the target represents the patient’s hitting her / his value target on a daily basis (and explain for most of us fall far short of that on a day to day basis, but knowing the target helps us make choices, set goals, and implement plans).

4. Ask patient to chose a number to represent how close to the Bulls Eye value statement her/his behavior has come over the past 2 weeks.

5. Ask patient to plan 2 specific behavior experiments for the next 2 weeks that patient believes will make her / his behavior more value consistent (closer to the Bulls Eye target).

6. At follow-up, ask patient to re-rate and identify barriers to engaging in planned behaviors.

7. If time allows, rate the patient’s current functioning level in one core area on the CPAT. This will provide a baseline against which you can judge the impact of the Bulls Eye Plan and REAL Behavior Change techniques you use with the patient.

8. If time allows, chose one technique from the REAL Behavior Change Pocket Guide to use in the visit.

Using Medications Successfully

An ICP Booklet

CONTEXT PRESS Reno, Nevada

What is Depression? Depression is a response to problems in living. When we become exhausted in our efforts to cope with life, we begin to experience symptoms of depression. Following is a list of common symptoms of depression. Make a check in the box beside any symptom you have had almost daily for the past two weeks. 1. Anger or irritability 2. Sadness 3. Sleeping too much or too little 4. A lack of interest in others and in activities you usually enjoy 5. Guilt, self critical thoughts, feeling inadequate or worthless 6. Feeling tired most of the time 7. Concentration difficulties 8. Appetite change — eating significantly more or less 9. Feeling very “slowed down” or very “speeded up” 10. More aches and pain 11. Thoughts of suicide or death in general Total Symptoms:_____

The Cycle of Depression People become depressed for many reasons. This booklet describes strategies for using medications successfully to alleviate symptoms of depression. Most often, depression is related to stressful life circumstances, such as marital problems, death of a loved one, loss of a job, or a child leaving home. Depression may also be related to physical problems such as chronic pain or medical illness. Depression Occurs In Three Ways The Body Feels Depressed When the body is depressed, a person sleeps poorly, eats differently, has less energy, struggles with concentration, and has more aches and pains. Behavior Is Depressed When behavior is depressed, a person does much less than usual. She/he talks less, produces less, and socializes less. The Mind Is Depressed When the mind is depressed, thinking changes. A depressed person experiences more intensely negative and painful thoughts about the past, the present and the future.

A person’s body, behavior, and thoughts interact continuously. Once depression becomes a problem, this interaction may lead to a “downward spiral” in mood and hopefulness. Two courses of action help reverse the downward direction and create a “positive spiral.”

1. Use of Medications Medications may help you to feel better. Antidepressant medications restore the presence of neurotransmitter substances that become depleted by stress. Medications may work somewhat slowly. Therefore, it is best to use medications in combination with behavioral planning and use of coping strategies. This booklet will help you use medications successfully. Antidepressant therapy and behavioral health

planning are complementary treatments for depression and anxiety.

2. Strategic Use of Coping Strategies Use of active coping strategies helps you reverse the downward spiral of depression. When you address life problems with effective strategies, you have more opportunities to create positive conditions in your life context. Make a concerted effort to work with your health care provider in planning medication treatment and skillful use of coping strategies. You will soon be feeling better.

Using Medications Successfully There are four important areas to address in order to use medications successfully. They include: 1. Your Past Experiences with Medications 2. Your Beliefs about Medications 3. Your Knowledge about Medications 4. Your Ability to Anticipate and Plan for Problems in Using Medications This booklet will help you assess and prepare for success in each of these key areas.

Your Past Experiences with Medications Take a moment to recall your past experiences with use of medications for depression and anxiety. 1. Have you ever used a medicine to help alleviate symptoms of depression or anxiety? Yes No 2. Try to recall the medication name, dosage, and length of treatment.

Name Dose Length of Treatment

1. Also, recall any side effects you had with this medication. How much did they trouble you?

Side Bothered Bothered Effect A Little A Lot

4. How much did you benefit from use of medication when you tried medication before?

None A Little Some Quite A Very Much Lot

This information will be helpful to you and your provider in making a decision about medication use and selection of a specific medication. If you did have a limited response to medication treatment or experienced bothersome side effects in the past, you may still be a candidate for medication treatment. Several new types of antidepressant medications have become available in recent years. New medications are equally effective and have fewer side effects.

Your Beliefs about Medications Your beliefs have a significant impact on your success in using antidepressant medications. Take stock of your beliefs right now. Mark an “X” by any of the following statements that you believe. I’ll be the one to get terrible side effects. My family would not want me to use medications for depression and anxiety. These types of medications are overused. I should be able to get over my problems without taking medicine.

I’ll get addicted.

If you believe any of these statements, discuss the belief with your health care provider. She/he may be able to provide you with additional information to help you re-evaluate beliefs which might make medication use more difficult for you.

Your Knowledge about Medications You are much more likely to succeed in antidepressant treatment when you have accurate information about all aspects of medication use. Please review the following details and discuss any questions you have with your health care providers.

Starting medication . . . Start your medicine as soon as it is prescribed. The sooner you start, the sooner you will experience the desired benefits. Remembering to take medicine . . . Take your medicine at a certain time of day every day. During the first several weeks, you may want to leave yourself several reminder notes. Some people use a behavioral hygiene task, such as teeth brushing, as a cue to take their medication. Also, some people may want to leave an extra bottle of medication in a desk drawer at work in the event that they forget to take the medicine at home. Deciding how to take the medication . . . Some medications are best taken in one dose, while others are best divided into several doses during the day. Some medications cause drowsiness, while others are more activating. Medications with a sedative effect are taken at night, and activating medications are taken in the morning. Carrying on with other activities . . . You may continue with your normal activities while taking antidepressant medications. If you do notice minor sedation or sleepiness in starting a medicine, avoid driving or carrying out hazardous activities. Sleepiness will usually diminish. If it does not, talk with your provider about a medication change.

Taking antidepressants with other medications . . . You may take antidepressants with most other types of medications. However, do talk with your provider about the compatibility of antidepressant medications with other medications you are taking. Taking antidepressant medications and consuming alcohol . . . Do not drink alcohol while taking antidepressant medications. Increasing medication dose . . . Increase your medication dose according to the directions of your provider. In starting some antidepressant medications, you start with small doses initially and increase gradually. Do not worry that you are “taking too many pills.” Your provider is prescribing a slow increase in dose in order to help you avoid side effects. After you reach your “therapeutic dose,” your provider will probably prescribe tablets that are larger in dosage, which then allows you to take fewer tablets. Continuing to take the medication . . . Take the medicine until you and your provider decide that you are ready to stop the medicine. In most cases, your provider will ask you to take the medicine for at least four months after you reach a therapeutic dose. Do not stop taking the medicine because you feel better. Wait and plan how and when to stop with your provider.

Your Ability to Anticipate and Plan for Problems in Using Medications

Most antidepressant medications have mild side effects. The side effects are usually temporary and diminish or disappear during the first few weeks of treatment. If you experience side effects that are more severe, call your doctor. She/he will probably suggest one or more of the following strategies:

• Change the time that you take the medicine

• Change the dose of the medicine

• Use a remedy for the side effect

• Add a second medication

• Change to a different medication The following table summarizes common side effects and possible remedies or strategies for coping with side effects. Most medications have only one or two of the side effects listed in this table.

Common Side Effects and Remedies

Dry Mouth Drink plenty of water. Chew sugarless gum. Use sugarless gum drops.

Constipation Eat more fiber-rich foods. Take a stool softener.

Drowsiness Get fresh air and take frequent walks. Try taking your medicine earlier in the evening, or if you’re taking your medicine in the day ask your doctor if you can take it at night.

Wakefulness Take medications early in the day. Learn more about insomnia. Take a warm bath and have a light snack before bed. Avoid exercising vigorously late in the evening.

Blurred Vision Remind yourself that this will be a temporary difficulty. Talk with your doctor if it persists.

Dizziness Stand up slowly. Drink plenty of fluids. If you are worried, call your doctor.

Feeling Tell yourself, “This will go away within three to five Speeded Up days.” If it does not, call your doctor or nurse.

Sexual Talk with your doctor. A change in medications or Problem a medication holiday may help.

Nausea or Take the medicine with food. Prepare food so that Appetite Loss it is appetizing and colorful. Eat small healthy meals.

Remember to Ask for Help

Starting antidepressant treatment is not easy. Remember to ask for the support of your health care team. Take this booklet with you to your next visit with your health care provider. She/he is prepared to skillfully address your concerns about use of medications and plan successful treatment with you.

If you want more information on using behavioral strategies to alleviate depression and anxiety consider reading Living Life Well: New Strategies for Hard Times by Patricia Robinson, Ph.D.

Beliefs About Medications From Robinson, 1996. Living Life Well: New Strategies for Hard Times.

List of questions to explore with patients when the BHC is targeting medication use:

I’ll be the one to get terrible side effects. My family would not want me to use medications for depression and anxiety. These types of medications are overused. I should be able to get over my problems without taking medicine. I’ll get addicted.

Seven Ways to Cope

An ICP Booklet

CONTEXT PRESS Reno, Nevada

What is Depression?

Depression is a response to problems in living. When we become exhausted in our efforts to cope with life, we begin to experience symptoms of depression. Following is a list of common symptoms of depression. Make a check in the box beside any symptom you have had almost daily for the past two weeks.

1. Anger or irritability 2. Sadness 3. Sleeping too much or too little 4. A lack of interest in others and in activities you usually enjoy 5. Guilt, self critical thoughts, feeling inadequate or worthless 6. Feeling tired most of the time 7. Concentration difficulties 8. Appetite change — eating significantly more or less 9. Feeling very “slowed down” or very “speeded up” 10. More aches and pain 11. Thoughts of suicide or death in general Total Symptoms:_____

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 2

If you checked four or more symptoms, talk with your health care provider. Also, use this booklet to make a plan to address these symptoms.

This booklet describes seven coping strategies for addressing symptoms of depression, solving problems in living and creating the life you want.

The Cycle of Depression

People become depressed for many reasons. Most often, depression is related to stressful life circumstances, such as marital problems, death of a loved one, loss of a job, or a child leaving home. Depression may also be related to physical problems such as chronic pain or medical illness.

Depression Occurs In Three Ways

The Body Feels Depressed

When the body is depressed, a person sleeps poorly, eats differently, has less energy, struggles with concentration, and has more aches and pains.

Behavior Is Depressed

When behavior is depressed, a person does much less than usual. She/he talks less, produces less, and socializes less.

The Mind Is Depressed

When the mind is depressed, thinking changes. A depressed person experiences more intensely negative and painful thoughts about the past, the present and the future.

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 3

A person’s body, behavior, and mind interact continuously. Once depression becomes a problem, this interaction may lead to a “downward spiral” in mood, hopefulness and energy. Two courses of action help reverse the downward direction and create a “positive spiral.”

1. Strategic Use of Coping Strategies

Use of active coping strategies helps you reverse the downward spiral of depression. When you address life problems with effective strategies, you have more opportunities to create positive conditions in your life context. This booklet suggests seven coping strategies for you to use to restore your body, behavior and mind and to effectively address life problems. If you make a concerted effort to work with your health care provider in using these strategies, you can make significant and lasting changes to your lifestyle.

2. Use of Medications

Medications may also help you to feel better. Antidepressant medications help restore the presence of neurotransmitter substances that become depleted by stress. However, these medications work somewhat slowly. The impact of effective coping is more immediate. If you decide to use medications, use coping strategies as well. Coping strategies will complement the action of medications on the body’s neurochemistry.

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 4 The First Strategy:

Hoping…Planning…Doing

Hope is the foundation of a healthy life. Without hope, most people avoid constructive activity. Another way of stating this is that hopefulness is a good predictor of action. In turn, action is a good predictor of mood improvement.

Try this exercise to help you increase your sense of hopefulness.

Sit in a quiet place for a few minutes and ask yourself about your explanation of your current troubles. Are you blaming yourself? If so, stop. You are well- intentioned and worthy of self-respect. Decide upon an explanation for your current difficulties that reflects a sense of respect for who you are. You may be stressed or overwhelmed or simply lacking skills you need to overcome challenging circumstances. Write down your revised explanation of your present situation here.

______

Planning and doing are also important behavioral skills for coping with stress and depression.

With a little hope, you can make a “behavioral health plan” to address needed changes in your daily life. Read and respond to each of the following seven steps to make a behavioral health plan for this week.

1. Choose an area of life that you want to make better. Possible areas include: enjoying things alone or with others, accomplishing difficult and unpleasant tasks, talking to or “making connections” with others, contentment with your work, sensual experiencing, or imagining a better future. Write down your choice here.

2. Imagine yourself doing something different in the activity area you choose. Write down what you imagine.

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 5

3. Plan a specific time and place to engage in an activity that represents making an improvement to the area of life you want to make more satisfying. Activity: ______

Time: ______

Place: ______

4. During and after you conduct this “experiment in mood change,” watch what happens, inside you (your thoughts, feelings and behaviors) and outside of you (what others say and do). Write down your observations here. Inside you: ______

Outside of you: ______

5. Think about your findings or results.

6. Talk with others about your results and draw conclusions. Write down your conclusions here.

7. Plan your next “behavioral health plan.” Activity: ______

Time: ______

Place: ______

Try to make a behavioral health plan weekly for the next month. The positive impact of small changes in two or three areas of your life can become highly significant with three or four weeks of effort. Try to find a friend who will support your on-going use of this strategy.

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 6 The Second Strategy:

Building Acceptance and Making Value-Based Choices We often respond to a difficult circumstance, whether it is internal or external, with an action that moves us away from the source of unwanted distress. While we may avoid some external stresses, we cannot avoid painful internal events. Internal events include thoughts and feelings — positive and negative. Psychological acceptance is a strategy that involves actively embracing unwanted, painful thoughts and feelings.

When we use psychological acceptance strategies, we are more free to make decisions about our behavior. We can make choices to behave in accordance with our values. Our daily activities take on greater meaning when they reflect our values rather than our attempts to control unwanted thoughts and feelings. Try these exercises to improve your skills in using strategies of psychological acceptance and value-based behavioral planning.

1. Write down feelings (for example, fear, sadness, anxiety, depression, panic, anger) that you have difficulty tolerating.

2. Decide on a psychological acceptance procedure or method for observing unwanted feelings and thoughts.

Options include visualizing the feeling or seeing or listening to the words associated with the feeling. You may use the phrase, “I am having the sensation of: ______” or “I am having the thought that: ______.”

3. Follow this procedure during acceptance or self-observation practice periods. Take four deep breaths and move into “observation mode.”

Start to use your method of observation to help you stay in the “observation mode” (i.e., visualize your thoughts or use a phrase to prompt acceptance).

Practice daily for 5 to 10 minutes for a week. Record the number of minutes you practice each day. Day 1: _____ Day 2: _____ Day 3: _____

Day 4: _____ Day 5: _____ Day 6: _____

Day 7: _____

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 7

When you are ready, begin using the psychological acceptance procedure in daily situations that provoke painful thoughts and feelings. Record situations where you used your breathing and observation method and made a behavior choice that reflected your values.

______

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 8 The Third Strategy:

Appreciating Your Mind and Body

Using this strategy will help you become more aware of your body and more able to create sensations of physical well-being in your body. Basic body listening skills strengthen your ability to cope with physical and psychological health problems. Experiment with the following exercises.

Rest for a few minutes in a favorite “quiet” place. Take several deep breaths and recall or fantasize an image of a serene environment. Give yourself time to develop this image with many details, including sounds, smells, colors, etc. Practicing this image on a daily basis will help you learn to create the image and associated sensations of wellness efficiently during highly stressful moments of daily living.

II.

Cultivate playfulness, curiosity, and openness. These mental states are related to well-being. If you are overly serious, controlled, or “closed off,” make behavioral health plans to help you play and explore. For example, you may want to attend a comedy show, rekindle an old hobby, or go for a treasure hunt in a park. A good way to get started with use of these strategies is to watch young children, as most demonstrate these qualities very nicely.

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 9 The Fourth Strategy:

Solving Problems

Self-efficacy is a reflection of your confidence in solving the problems you encounter in life. Mastery of problem-solving skills improves your confidence and, hence, your self-efficacy. The following steps are prerequisites for effective problem solving.

• Identifying that something is a problem

• Accepting the possibility that something can be done about it

• Expressing a desire to change

• Being willing to make an effort to change

Use the following problem-solving exercise to review the critical steps in strategic problem- solving and address a current problem in your life.

1. Pinpoint a current problem. Write the problem down here. Define the problem so that it is a problem with a solution.

2. Brainstorm solutions. Generate at least 3 possible solutions.

3. Evaluate potential solutions. Describe advantages and disadvantages of each solution.

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 10

4. Identify the first step you will take to implement the solution you choose.

5. Anticipate and plan for obstacles to your implementing the solution you choose.

6. DO IT! Record here when you did it.

7. Evaluate the results and continue working toward the solution by simply determining and planning a next step or going through these seven steps again.

Results suggest that:

Next step:

Remember To Celebrate Your Efforts, As Well As Your Successes!

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 11 The Fifth Strategy:

Responding to Interpersonal Conflicts

Our patterns of responding to conflict may cost more than we want to pay. If we believe that we must avoid conflict, we may withhold information needed to have healthy relationships. We may passively punish a person who makes a hurtful statement by ceasing to talk to that person. We may sacrifice self-respect to maintain the status quo when we use these strategies to respond to interpersonal conflict.

Alternatively, we may seek power and control over others more directly. We may use verbal and non-verbal expressions to frighten others. When we approach conflict in these ways, we are likely to have few friends and we are vulnerable to a host of physical problems associated with excessive arousal or anger.

If you want to become more skillful in this area, try the following exercises:

1. Acknowledge yourself on a daily basis. You may simply say to yourself, “I allow myself to be,” or “I am okay as I am.” 2. Whenever you notice tension in your body, ask yourself, “How do I feel right now?” 3. Give yourself a choice about expressing or not expressing feelings and opinions. It is okay to keep your feelings private or share them. The following exercises are useful if you are currently in a close relationship and want to become more skillful in responding to conflict in this close relationship.

• Try scheduling a “problem solving” meeting. Allow 30 minutes.

• Set the agenda for your meeting. Keep it simple and make it agreeable to both of you.

• Convene your meetings when you are both rested and free from distraction.

• Positively and specifically define the problem you plan to address.

• Use “I” statements (e.g., “I want to have 20 minutes alone everyday” or “I feel upset about being without a job”). These statements help you responsibly express your feelings and make requests without blaming.

• Discuss only one problem at a time.

• Focus on solutions. Avoid trying to be “right.”

• Compromise. Select a solution that allows both of you to “win.”

• Set a time to “reconvene” and evaluate how your solution is working.

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 12 The Sixth Strategy:

Expressing Yourself

There are two important skills involved in the strategy of “expressing yourself.” The first is personal assertion and the second is creative expression. Both of these skills require “balancing.” Personal assertion requires on-going balancing of respect for yourself with respect for others. Creative expression involves balancing who you are with what you have to work with right now.

Personal assertion skills form the basis of your ability to make direct and honest statements and to stand up for your rights. Development of effective assertion skills may help you improve your mood, your sense of hopefulness, and your energy for enjoying life.

Creative expression is engaging in any activity for the sole purpose of expressing yourself. The possibilities for creative expression are many and change over the course of a lifetime. The loss of an avenue for creative expression may actually provoke symptoms of depression and anxiety. Try the following exercises to strengthen your skills in strategic self-expression.

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 13

Personal Assertion Exercise

Do you believe that you have the following rights? Make a check in the first box of any right you claim for yourself.

Does your day-to-day life indicate that you give yourself these rights? Make a check in the second box of any right that you “live” in your day-to-day behavior.

1. The right to say no without feeling guilty.

2. The right to be treated with respect.

3. The right to experience your feelings.

4. The right to change your mind.

5. The right to do less than you are capable of doing.

6. The right to make mistakes.

These are only a few basic assertive rights. If your beliefs are weak in any of the above areas or if your day-to-day life does not reflect your beliefs, you may want to develop a program to strengthen your beliefs in your assertive rights and your behavioral expression of these rights. You may want to read more about personal assertion and join a personal assertion class. Classes may be available within your health care system or in your community. Make a behavioral health plan to help you start a program of strengthening skills in this critical area.

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 14

Creative Expression

List five creative expression activities that you enjoy and that are consistent with your values. Indicate how many hours you have spent in each of these activities in the past week.

Creative Expression Activity # Hours in Past Week

1. 1. 2. 2. 3. 3. 4. 4. 5. 5.

If you had difficulty identifying activities, take time to evaluate your “gifts” or “interests” and available resources or materials in you life at the present moment. If you spent little time in identified activities, consider “scheduling” time for these important activities. Write down your findings here and make a behavioral health plan to engage in creative activities on a daily basis. Gifts: ______Interests: ______Resources: ______

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 15 The Seventh Strategy:

Balancing Your Thinking

When life is going well, we tend to have two positive thoughts to every negative thought. When we become depressed, the balance changes to two negative thoughts to every positive thought. “Realistic” thinking probably lies somewhere in between.

Shifting the balance in the direction of more positive thoughts is difficult to do, especially without someone to help you. Friends can help when you give them an opportunity and ask for their opinion on something. Knowing how to change the balance of your thoughts is important because it can help you catch yourself when you start to become depressed.

Use the following steps and suggested exercises to help you balance your thoughts.

• Identify a favorite saying or thought that inspires courage or optimism for you in difficult times.

• Try changing your perspective on something of little importance to you from an exaggerated negative perspective to a realistic or slightly positive point of view.

• Identify someone who tends to be a “realist” or “optimist” and contact this person. They can help you balance your thoughts.

Exercises to Help Balance Thinking

Write down favorite sayings and thoughts that inspire courage or optimism.

______

What positive thoughts do you want to keep in mind right now?

______

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 16

______

Who helps you balance your thinking on different issues?

______

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 17

Getting Started

Which of the seven strategies discussed in this booklet, if any, do you think will work best for you at present? Place an “X” in the box to indicate the extent to which each of the strategies might help you now. Use a rating scale where:

1 = Not Helpful and 4 = Very Helpful

Strategy 1 2 3 4

Hoping…Planning…Doing

Building Acceptance and Making Value-Based Choices

Appreciating Your Mind and Body

Solving Problems

Responding to Interpersonal Conflicts

Expressing Yourself

Balancing Your Thinking

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996 18

Are you ready to start trying the strategies that you think will be most helpful to you?

My level of readiness is:

Not Ready Unsure Ready

Can you identify friends, relatives or professionals who can help you make a plan to use one or more of the seven strategies suggested in this booklet and support you in staying with the plan over the next month? Yes No

Persons who will help and support: ______

______

Take this booklet with you when you visit your health care provider. She or he will want to look at your responses.

If you want to read more on the use of strategies suggested in this booklet, read the book, Living Life Well: New Strategies for Hard Times by Patricia Robinson, Ph.D.

Notes:

______

Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996

Love Work Play Health, Three T’s COMPLEX PATIENT ASSESSMENT TOOL

Love, Work, Play and Health

Where do you live? With whom? Love How long have you been there? Are things okay at your home? Do you have loving relationships with your family or friends? Do you work? Study? If yes, what is your work? Work Do you enjoy it? If not working, are you looking for work? If not working and not looking for a job, how do you support yourself? What do you do for fun? Play For relaxation? For connecting with people in your neighborhood or community? Do you use tobacco products, alcohol, illegal drugs? Do you exercise on a regular basis for your health? Do you eat well? Health Sleep well? (If patient has chronic disease) Do you find it difficult to manage your health problems? Do you have a doctor you like?

Three Ts and Workability

When did this start? How often does it happen? Time What happens before / after the problem? Why do you think it is a problem now?

Trigger Is there anything--a situation or a person--that seems to set it off?

What’s this problem been like over time? Trajectory Have there been times when it was less of a concern? More of a concern? And recently . . . getting worse, better? What have you tried (to address the problem)? Workability How has that worked in the short run? Question In the long run or in the sense of being consistent with what really matters to you?

Adapted from Robinson, Gould & Strosahl. Real Behavior Change in Primary Care: Improving Outcomes and Increasing Satisfaction, New Harbinger, 2007.

PCBH Patient Education Protocols Patient Education Protocols List

1. ADHD

2. Adherence Using Meds Successfully

3. Alcohol & Low Risk Drinking

4. Anxiety & Coping with Panic Attacks

5. Anxiety

6. Chronic Pain

7. Depression – Postpartum

8. Depression

9. Exercise & Physical Activity

10. Grief

11. Headaches

12. Hypertension

13. Parenting Protocol

14. Relationship Problems

15. Relationship Sexual Problems

16. Sleep & Insomnia

17. Sleep Apnea

18. Sleep Behavior Change & Diary

19. Sleep Class Packet

20. Stress

21. Substance Misuse & Maintaining Behavior Change

22. Weight Management

Attention-Deficit/Hyperactivity Disorder (ADHD)

What is it? ADHD is an acronym for Attention-deficit/Hyperactivity Disorder. It is a neurological brain disorder that is marked by a continual pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than what considered typical for someone of that age.

Does it affect me? There are two main problems identified with ADHD: (1) Inattention and (2) Hyperactivity / Impulsivity. These problems are further broken down into individual symptoms.

Inattention Hyperactivity/Impulsivity Poor attention to detail/carelessness Fidgetiness/squirminess Difficulty sustaining attention Difficulty remaining in seat Does not appear to listen Runs about or climbs excessively Often fails to complete tasks Difficulty with quiet activities Difficulty with organization Often seems “on the go” Avoids/dislikes focused tasks Talks excessively Loses things easily Blurts out answers or opinions Easily distracted Difficulty waiting or taking turns Forgetful of daily activities Interrupts or intrudes on others

* It is important to note how common and normal these symptoms are in children and adults, being mindful of the overlap they have with other mental and physical health problems.

The symptoms listed above must be: • Chronic: lasting at least six months consistently • Present from a young age: onset must be prior to age 7 • Observable and problematic across many settings: for example, at home, school, work, etc.

How do you find out if you have ADHD? There is no one test for ADHD, but a comprehensive evaluation completed with a professional is needed to establish a diagnosis. The evaluation is long and requires sustained mental effort to complete. In addition to the testing, information related to current functioning and background information will be collected. Reports from several people are also helpful in establishing a diagnosis: (1) parents report about home functioning, (2) teachers report about school functioning, (3) co-workers report about work functioning, and (4) friends report about social functioning. Typically, the testing battery includes symptom checklists, rating scales to identify emotional and behavioral signs, intelligence testing, and achievement testing.

How common is it? By definition, ADHD begins in childhood prior to age 7, and according to recent research, it can continue into adulthood. While some children “outgrow” ADHD, evidence suggests that up to 70% can continue to carry symptoms of inattention into adulthood, with hyperactivity typically diminishing with age. According to a 2003 Centers for Disease Control study, 7.8% of children between the ages of 4 and 17 have ever been diagnosed with ADHD. Research indicates that nearly 4% of adults in the U.S. continue to have ADHD.

Is Adult ADHD any different from Childhood ADHD? Because ADHD is a neurological condition that starts during childhood, symptoms that adults experience are not new, but rather, have continued from childhood. Most adults who have continued symptoms may notice problems with difficulty paying attention to details, organization, talking fast, and difficulties focusing and concentrating. Adults with ADHD do not typically report problems with hyperactivity; either the symptoms have subsided or they have developed coping strategies for handling their increased activity level. There is no evidence that ADHD develops during adulthood. Concentration problems and distractibility in adults are often due to other problems such as depression, anxiety, stress in relationships, or occupational stress. Any of these and other mental health conditions can mimic the symptoms of ADHD, but they are not ADHD.

Associated problems and consequences that often co-exist with adults who have continued symptoms of ADHD from childhood may include:

• Poor self control • Easily bored • Forgetfulness • Low self-esteem • Difficulty focusing • Substance abuse • Poor time management • Difficulty regulating emotions, arousal, and motivation • Relationship problems • Anxiety/depression • Poor time perception • Mood swings • Variability in work performance • Employment difficulties • Chronic lateness • Risk-taking behaviors

Resources and Suggested Readings

Children Quinn & Stern (2001). Putting on the brakes: Young people’s guide to understanding Attention- deficit/Hyperactivity Disorder. Nadeau, Nixon, & Beyl (2004). Learning to slow down & pay attention: A book for kids about ADHD.

Adolescents Ziegler Dendy, & Ziegler (2003) A Bird's-Eye View of Life with ADD and ADHD: Advice from Young Survivors.

Parents Barkley (2000). Taking charge of ADHD: The complete, authoritative guide for parents. Barkley & Benton (1998). Your defiant child: Eight steps to better behavior.

Adults Kelly & Ramundo (1995). You mean I’m not lazy, stupid, or crazy: A self-help book for adults with attention deficit disorder. Hallowell & Ratey (1995). Driven to distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood Through Adulthood.

Websites Children and Adults with Attention-deficit/Hyperactivity Disorder : www.chadd.org Teens Health: www.kidshealth.org/teen/school_jobs/school/adhd.html Teens with ADHD by Chris Dendy: www.chrisdendy.com ADHD News: www.adhdnews.com

What are my treatment options? Treatment for ADHD is often “multimodal”—that is, it often involves any combination of education, skills training, behavioral interventions, and medication. Depending on your symptoms and response to these interventions, treatments will vary on a case-by-case basis. As with most illnesses, it is highly recommended to start with the least invasive options first. In treating ADHD, exhaustive attempts at behavioral interventions should initially be pursued before beginning a trial of medication.

Behavioral Interventions Behavioral Modification, or B-Mod, is typically the type of behavioral intervention that is used in the treatment of ADHD. B-Mod is a process where individuals learn specific skills and techniques designed to alter habits/problem areas and replace them with more adaptive, functional responses. As parents, if we can consistently alter the antecedents (how we make requests) or consequences (our reaction when the child obeys or disobeys), we can alter our child’s behaviors and shape a more functional way of responding. As an adult trying to shape your own behaviors, similar contingencies (“if…then” scenarios) are helpful in establishing a behavioral plan that encourages a desired behavior attached to a reward (e.g., if I complete X, then I can do Y).

Common guidelines for implementing a B-Mod plan include: 1. Start with goals that are small and attainable 2. Be consistent—regardless of time of day, setting, and situation 3. Follow through with the behavioral intervention over the long haul 4. Remember that learning new skills takes time and is gradual—don’t give up!!

Suggestions for Parents: • Provide clear, concise expectations, directions, and limits—avoid ambiguity • House rules and structure are a necessity—plan ahead and predict barriers • Set up an effective discipline system based on rewards and consequences • Change the most problematic behaviors first—use charts/graphs to see progress • Help your child in social situations—promote cooperation and peer interaction • Teach social skills and promote extracurricular activities • Identify & build on your child’s strengths—promote confidence, success, and esteem • Have a “special time” for your child—TLC goes a long way in maintaining self-worth • Learn to praise appropriate behaviors and ignore minor inappropriateness Pharmacological Interventions Strong evidence supports the use of stimulant medication for the management of inattention, impulsivity, and hyperactivity in school children. Studies suggest that 70-80% of children with ADHD improve with the use of stimulant medication. Some changes include: academic improvement, increased focus and concentration, increased compliance and effort, and decreased activity level and impulsivity. Medical intervention often involves a trial of Ritalin, Concerta, Adderall, Dexedrine, or Strattera (an effective non-stimulant). The effects of these medications are typically felt within 30-60 minutes of taking the medication. Increasing, decreasing, or terminating medication is determined on a case-by-case basis to maximize functioning.

Tips for Parents Tips to help parents identify common problem areas for children Writing/Language Problems Strategy Children with ADHD often have poor Parents need to be supportive; consider writing down handwriting, grammar, and spelling skills. answers given verbally by your child; encourage a Listening to information, processing it, and language-rich environment and never shame your writing it down is challenging. child for slow processing or misuse of words. Comprehension of instructions and expression of thoughts and ideas is often difficult. Missing Assignments Strategy Children with ADHD have difficulty keeping Develop a system and provide support at each stage of track of information, lose track of time, and project completion; use checklists, labels, and color- often turn in assignments late. They have coded binders/folders for all subjects; establish and intentions of being compliant, but lack keep a routine; prevent procrastination by using organizational skills. independence as a reward. Distractibility Strategy ADHD is marked by an inability to control Establish a daily homework routine with scheduled what one pays attention to, and is not breaks; create a comfortable, distraction-free always a conscious decision. Children with environment to facilitate focus; communicate with ADHD are often unable to inhibit their teachers if your child seems to lack the skills needed to responses to distractions, such as outside complete an assignment or if it takes an inordinately noises, movement, or their own thoughts. long time. Immature Social Behavior Strategy Children with ADHD often have a hard time Involve your child in activities such as music, sports, or reading social cues, may misinterpret other hobbies to identify strengths; role play everyday remarks, or miss the point of a conversation. situations with your child and allow them to practice these skills in a “safe environment”; children with ADHD are often great playmates with younger children and can learn to foster positive caring traits without feeling threatened by same-age peers. Following Instructions Strategy Multi-step directions are notoriously difficult Break down large tasks into multiple, smaller steps; for children with ADHD, as they often only create checklists and use reward systems when hear bits and pieces of the request. possible; use redirection and explanation rather than punishment for distraction. Impulsivity Strategy Children with ADHD are often labeled as Natural consequences are important parts of discipline unruly or aggressive because of their and expected to occur; provide immediate, positive impulsive physical and social interactions. feedback and attention for appropriate behaviors; the They often have difficulty controlling most successful discipline is specific, proactive, and impulses, despite having caring & sensitive directive; avoid ambiguity (“Be good”) and tell your intentions. child exactly what behavior is expected. Adapted from www.adhd.com “Tips for Schools and Home”; Eli Lily & Co

Tips for Teachers

Tips to help teachers address common problem areas for students Writing/Language Problems Strategy Children with ADHD often have poor Consider giving extra time or abbreviated assignments; handwriting, grammar, and spelling skills. offer corrections, but avoid taking off points on less Listening to information, processing it, important areas (e.g., spelling vs. completing the book and writing it down is challenging. report); make yourself available for additional questions Comprehension of instructions and and explanations. expression of thoughts and ideas is often difficult. Missing Assignments Strategy Children with ADHD have difficulty Supervision and structure are critical; cues and reminders keeping track of information, lose track of can be helpful, and ensure the child writes down time, and often turn in assignments late. assignments and stores paperwork in a homework folder; They have intentions of being compliant, track progress periodically on long-term projects; use but lack organizational skills. positive and instructive comments for corrections. Distractibility Strategy ADHD is marked by an inability to control Have child sit close to teacher and away from doors and what one pays attention to, and is not windows; use privacy dividers to limit distraction during always a conscious decision. Children with individual study/work time; lessons should involve visual ADHD are often unable to inhibit their & auditory aids, and should be kept short; use a variety of responses to distractions, such as outside pacing and gesturing to capture attention; use nonverbal noises, movement, or their own thoughts. cues (e.g., tapping) to refocus attention. Immature Social Behavior Strategy Children with ADHD often have a hard Talk with teachers about your child’s social immaturity; time reading social cues, may teachers should use positive reinforcement, especially in misinterpret remarks, or miss the point of front of peers, to help reduce the child’s use of a conversation. inappropriate antics for attention; one-on-one social modeling followed by small group work can help children develop appropriate behaviors. Following Instructions Strategy Multi-step directions are notoriously Teachers should use specific, brief, and personal difficult for children with ADHD, as they instructions whenever possible; written instructions are often only hear bits and pieces of the best so children can review assignments again later; request. consider recording classes if possible; have children repeat instructions back to you to ensure translation. Impulsivity Strategy Children with ADHD are often labeled as Rules that are posted in the classroom make expectations unruly or aggressive because of their clear and serve as written reminders to think before you impulsive physical and social interactions. act; tape targeted behavior cards to the child’s desk that They often have difficulty controlling encourage appropriate activity (e.g., raise hand to ask a impulses, despite having caring & question); give periodic warnings of pending transitions in sensitive intentions. activity to avoid a meltdown (e.g., “We have 5 more minutes before lunch”); anticipate problem situations. Adapted from www.adhd.com “Tips for Schools and Home”; Eli Lily & Co

USING MEDICATIONS SUCCESSFULLY

The Cycle of Depression

People become depressed for many reasons. This booklet describes strategies for using medications successfully to alleviate symptoms of depression. Most often, depression is related to stressful life circumstances, such as marital problems, death of a loved one, loss of a job, or a child leaving home. Depression may also be related to physical problems such as chronic pain or medical illness.

Depression Occurs In Three Ways

The Body Feels Depressed

When the body is depressed, a person sleeps poorly, eats differently, has less energy, struggles with concentration, and has more aches and pains.

Behavior Is Depressed

When behavior is depressed, a person does much less than usual. She/he talks less, produces less, and socializes less.

The Mind Is Depressed

When the mind is depressed, thinking changes. A depressed person experiences more intensely negative and painful thoughts about the past and the future.

1. Use of Medications

Medications may help some people with symptoms of depression feel better, but they work slowly and do not appear to prevent you from having future episodes of depression. Therefore, it is best to use medications in combination with behavioral planning and use of coping strategies. If you decide to use medications and your doctor prescribes them, this booklet will help you use them well.

2. Strategic Use of Coping Strategies

Make a concerted effort to work with your health care provider in planning medication treatment and skillful use of coping strategies. You will soon be feeling better.

USING MEDICATIONS SUCCESSFULLY

There are four important areas to attend to when considering the start of a medication, and this booklet will help you assess and prepare for success in each of these areas.

I. YOUR PAST EXPERIENCES WITH MEDICATIONS Take a moment to recall your past experiences with use of medications for depression and anxiety.

Have you ever used a medicine to help alleviate symptoms of depression or anxiety?

Yes No

Try to recall the medication name, dosage, and length of treatment.

Name Dose When? How long?

Also, recall any side effects you had with this medication. How much did they trouble you?

Side Bothered Bothered Effect A Little A Lot

How much did you benefit from use of medication when you tried medication before?

None A Little Some Quite A Lot Very Much

This information will be helpful to you and your provider in making a decision about medication use and selection of a specific medication.

If you did have a limited response to medication treatment or experienced bothersome side effects in the past, you may still be a candidate for medication treatment. You doctor may suggest that you try a new medication.

II. YOUR BELIEFS ABOUT MEDICATIONS

Your beliefs have a significant impact on your success in using antidepressant medications. Take stock of your beliefs right now. Mark an “X” by any of the following statements that you believe.

I’ll be the one to get terrible side effects. I can’t afford these medicines. I’ll never remember to take them. I’ll get addicted. My family would not want me to use medications for this problem. These types of medications are overused. I should be able to get over my problems without taking medicine. If you believe any of these statements, discuss the belief with your health care provider. She/he may be able to provide you with additional information to help you re-evaluate beliefs which might make medication use more difficult for you.

III. Your Knowledge about Medications You are much more likely to succeed in antidepressant treatment when you have accurate information about all aspects of medication use. Please review the following details and discuss any questions you have with your health care providers. Starting medication . . . Start your medicine as soon as it is prescribed. The sooner you start, the sooner you will experience the desired benefits. Remembering to take medicine . . . Take your medicine at a certain time of day every day. During the first several weeks, you may want to leave yourself several reminder notes. Some people use a behavioral hygiene task, such as teeth brushing, as a cue to take their medication. Also, some people may want to leave an extra bottle of medication in a desk drawer at work in the event that they forget to take the medicine at home. Deciding how to take the medication . . . Some medications are best taken in one dose, while others are best divided into several doses during the day. Some medications cause drowsiness, while others are more activating. Medications with a sedative effect are taken at night, and activating medications are taken in the morning. Carrying on with other activities . . . If you do notice minor sedation or sleepiness in starting a medicine, avoid driving or carrying out hazardous activities. Sleepiness will usually diminish. If it does not, talk with your provider about a medication change. Compatibility of a new medicine with other medications . . . Talk with your provider about the compatibility of any new medicine with other medications you are taking.

Taking antidepressant medications and consuming alcohol . . .

Talk with your doctor about possible problems with consuming alcohol with prescription medications. Increasing medication dose . . . Talk with your doctor about the dose and if she or he plans to increase the dose. Continuing to take the medication . . . Take the medicine until you and your provider decide that you are ready to stop the medicine. Do not stop taking the medicine until you and your doctor have a plan for you to stop.

IV. YOUR ABILITY TO ANTICIPATE AND PLAN FOR PROBLEMS IN USING MEDICATIONS Most medicines have mild side effects. The side effects may be temporary and diminish or disappear shortly after start of treatment. If you experience side effects that are more severe, call your doctor. She/he will probably suggest one or more of the following strategies: change the time you take the medicine, change the dose, add a second medicine, change to a different medicine, or use a remedy for the side effect. The following table provides some examples of medication side effects and ways to cope with them.

Examples of Side Effects and Possible Remedies Dry Mouth Drink plenty of water. Chew sugarless gum. Use sugarless drops. Constipation Eat more fiber-rich foods. Take a stool softener. Drowsiness Get fresh air and take frequent walks. Try taking your medicine earlier in the evening, or if you’re taking your medicine in the day ask your doctor if you can take it at night. Wakefulness Take medications early in the day. Learn more about insomnia. Take a warm bath and have a light snack before bed. Avoid exercising vigorously late in the evening. Blurred Vision Remind yourself that this will be a temporary difficulty. Talk with your doctor if it persists. Dizziness Stand up slowly. Drink plenty of fluids. If you are worried, call your doctor. Feeling Speeded Up Tell yourself, “This will go away within three to five days.” If it does not, call your doctor or nurse. Sexual Problem Talk with your doctor. A change in medications or a medication holiday may help. Nausea or Appetite Loss Take the medicine with food. Prepare food so that it is appetizing and colorful. Eat small healthy meals.

A Guide to Low-Risk Drinking

What is Low Risk Drinking? Low-risk drinking involves limiting alcohol use to amounts and patterns that are unlikely to cause harm to oneself or others. Scientific evidence indicates that the risk of harm increases significantly when people consume more than two drinks per day and more than five days per week. Because different types of alcoholic beverages contain different amounts of alcohol, it is important that you know what a standard drink is when you are cutting down or trying to stick to a limit. In the box below, you can see that standard drinks of different beverages are different sizes. But what they have in common, is that each of them contains about 10 grams of pure alcohol. The following can be used as a guide to help you keep track of your drinking. Remember, each is a standard drink.

Full Strength Light Beer Wine Port/Sherry Spirits Beer 1 glass-425ml 1 glass-285ml 1 glass-100ml 1 glass-60ml 1 nip 30ml 2.9% alcohol 4.9% alcohol 12% alcohol 20% alcohol 40% alcohol

Many individuals who would otherwise regard themselves as moderate drinkers, at times drink in ways that cause problems. For example, limiting alcohol use to two or fewer drinks a day may present risks in certain circumstances:

• When driving or operating machinery • When pregnant or breast feeding • When taking certain medications • If you have certain medical conditions • If you cannot control your drinking • If you have a personal history of drinking problems • If you suffer from depression or • If you have been told not to drink for legal reasons anxiety

What is High-Risk Drinking? Some people may think that you have to drink heavily all of the time or be dependent on alcohol to have alcohol-related problems. This is not true. Some problems can come from simply being drunk every now and again. Other problems may come from regularly drinking too much even though you may hardly ever get drunk. You may be surprised that alcohol problems occur at what you consider to be moderate levels of drinking. You increase your risks of experiencing alcohol related problems if you drink to the point of intoxication (being drink), drink on a regular basis, or spend a lot of time drinking.

Risks due to intoxication (that is, being drunk). You do not have to be “falling down drunk”, nor do you have to drink often to have these problems. Examples of intoxication related problems include drunken driving, falls, hangovers, unsafe sex, arguments, absenteeism, and embarrassment. The problems can range from being minor to being fatal.

Risks due to regular use. Problems coming from drinking too much on a regular basis include: spending too much money on alcohol, concentration and memory difficulties, experiencing

stomach and liver disorders, diabetes, poor sleeping habits, gaining weight, and conflict in your relationships.

Risks due to dependence. Some people begin to devote more and more time to drinking and feel uncomfortable if they don’t drink. They may feel alcohol is beginning to take over their lives, and cutting down their drinking becomes harder. Dependence can mean anxiety, depression, withdrawal symptoms, losing interest in other activities and feelings of loss of control.

Physical Effects of High Risk Drinking In addition to the above mentioned risks, individuals who drink more than two standard drinks are likely to experience a number of physiological effects from alcohol, some of which may lead to physical difficulties. The following diagram outlines the effects of high risk drinking.

Indications of High-Risk Drinking High-risk drinkers may have difficulty recognizing the problematic nature of their drinking. They may minimize the amount of alcohol they drink or simply ignore the fact that the amount of alcohol they drink is excessive. At times it may be helpful to consider looking for common signs of high-risk drinking. Some indications of high-risk drinking include: • Drinking alone when you feel angry or sad • Being late or absent from work due to the effects of alcohol • Friends or family have indicated they are concerned about your drinking • Drinking even after telling yourself you won’t • Forgetting what you did while you were drinking • Periods of headaches or a hang-over after drinking • Past failed attempts to decrease your alcohol use

How to Manage Your Drinking Reading about the risks associated with high-risk drinking has hopefully changed how you think about your own and others drinking habits. After reading this material you may want to change your drinking habits in some way, but are not exactly sure how. Many people change their behavior all on their own. Often, when they are asked what brought about the change, they say they just “thought about it,” meaning they evaluated the consequences of their current behavior and of changing before making a final decision. You can do the same thing by asking two simple questions: “What do I stand to lose and gain by continuing my current drinking pattern?” and “What do I stand to lose and gain by changing my drinking pattern?” To change, the scale needs to tip so the costs outweigh the benefits. This is called Decisional Balancing. Weighing the pros and cons of changing happens all the time. For example, when changing jobs or deciding to move or get married. At some point, you may have received real benefits from the behavior you want to change, such as relaxation, fun, or stress reduction. However, because you are reading this, you are considering both the benefits and the costs. Below is an example of a Decisional Balance Worksheet for someone wanting to change the amount of alcohol they drink.

Decisional Balance Worksheet Changing Not Changing

• Increased control over my life • More relaxed • Support from family and friends • More fun at parties • Decreased job problems • Don’t have to think about my

Benefits of of Benefits • Improved health & finances my problems problems • Increased stress/anxiety • Disapproval from friends/family • Feel more depressed • Money problems • Increased boredom • Damage close relationships

Costs of • Sleeping problems • Increased health risks

Now that you have seen an example of a Decisional Balance for someone else thinking about changing their drinking behaviors, consider what the personal costs and benefits of changing (and not changing) your drinking behaviors are to you. Write down the costs and benefits in the worksheet below:

Decisional Balance Worksheet Changing Not Changing

Benefits of of Benefits

Costs of

Decision to Change Worksheet: Look over what you have written. What do you feel is the best choice for you? If you have made the decision to change your drinking behavior, it is often helpful to refer back to this worksheet to remind yourself why you made the decision to change. It is also a good idea to talk it over with the person you are closest to so that they can fully understand why you have chosen your goal. Then they will find it easier to be supportive of your attempts to change. All change can be uncomfortable at first, so it helps to get support from others. Research shows support from others will increase your chances for success.

Identifying Triggers Although we sometimes do things that are not good for us, there are usually reasons why we behave in certain ways. An important step in trying to change a behavior is identifying why it occurs. Frequently behaviors are triggers by other things. Many circumstances can act as triggers, such as pleasant or unpleasant emotions, a particular setting, or just a routine situation. To help you identify possible triggers for your drinking consider the following questions: • With whom do you typically drink? • What do you hope will happen when you drink? • Are you in any particular emotional state when you drink (e.g., angry, depressed, happy, sad)? • What physical state are you in when you drink (e.g., relaxed, tense, tired, aroused)? • What setting do you tend to drink in (e.g. work, party, ex-spouse’s house)? • What activities are you involved with when drinking (e.g., work, playing sports, watching TV)

My Triggers for Drinking Take a few moments to note your common triggers for drinking. Finish each of the sentences below: 1. The places where I most frequently drink alcohol are: 2. The people I am usually with when I drink include: 3. I usually drink when I am feeling: 4. I frequently drink when doing the following activities: 5. Situations where I typically do not drink are:

Change Plan Now that you have identified some of your personal drinking triggers, you have determined those situations in which you might drink a lot. The next step is to figure out how to be in these situations and experience those feelings without a drink in your hand. Can you avoid the situation altogether? Or find a way of handling it without a drink? Or with only one drink instead of half a dozen?

Rather than waiting until you are under pressure, work out some strategies for managing your drinking before you get into these situations. You’ll feel more in control if you have prepared for a difficult “triggering” situation. To help you accomplish this go through the steps outlined below.

First, pick one of your “triggers”. Example: Going to the Club with friends

Second, think of as many ways you can for handling that situation and write them all down. Be creative—try to put down some ideas you have never tried before, no matter how silly some of them seem. Example: 1. Ask friends to keep me from drinking 2. Don’t go to the club 3. Go someplace that doesn’t serve alcohol 4. Don’t bring any extra money

Third, review your list and consider how these strategies might not work. Then figure out ways to work around these obstacles. Determine if you need to alter the option in some way. Example: If I don’t bring any money, I will just ask a friend to spot me. Maybe I should ask them not to do this beforehand.

Fourth, read your list carefully and pick the two ideas that seem the most practical and sensible for that situation. Example: Don’t bring extra money and ask friends not to loan me any money.

Fifth, try out the most promising strategies and see if they work. If they don’t, go back to step 2 and think of other ideas. It is important to recognize that some of these ideas may not work,

(e.g., it may be tempting fate to say you will go to the pub and only drink orange juice). Thus, it is important to establish realistic and achievable strategies. Use the next page to work out these steps. If you need help, your BHC can assist you.

My Personal Change Plan

Step 1

Choose a trigger:

Step 2 Write down as many strategies for controlling your drinking in this setting:

Step 3 Think of how the strategies in Step 2 might fail, then consider ways to work around these obstacles:

Step 4 Look at what you have in Step 3, and choose the two that seem the most doable:

1. 2.

Step 5 Test your strategies from Step 4 to see if they work. If not, start over at Step 2 to figure out new ways to make them work given what you have learned. Ask your BHC for help, if needed.

Make as many copies of this worksheet as necessary until you find a successful strategy. Most people will fill one out for each of their triggering situations. The more worksheets you complete, the more thinking and planning you end up doing, which makes you more prepared to make a behavior change.

Coping with Panic Attacks

What is a panic attack? You may have had a panic attack if you experienced four or more of the symptoms listed below coming on abruptly and peaking in about 10 minutes.

Panic Symptoms • Pounding heart • Feeling dizzy, unsteady, lightheaded, or faint • Sweating • Feelings of unreality or being detached from yourself • Trembling or shaking • Fear of losing control or going crazy • Shortness of breath • Fear of dying • Feeling of choking • Numbness or tingling • Chest pain • Chills or hot flashes • Nausea or abdominal distress Panic attacks are sometimes accompanied by avoidance of certain places or situations. These are often situations that would be difficult to escape from or in which help might not be available. Examples might include crowded shopping malls, public transportation, restaurants, or driving.

Why do panic attacks occur? Panic attacks are the body’s alarm system gone awry. All of us have a built-in alarm system, powered by adrenaline, which increases our heart rate, breathing, and blood flow in response to danger. Ordinarily, this ‘danger response system’ works well. In some people, however, the response is either out of proportion to whatever stress is going on, or may come out of the blue without any stress at all.

For example, if you are walking in the woods and see a bear coming your way, a variety of changes occur in your body to prepare you to either fight the danger or flee from the situation. Your heart rate will increase to get more blood flow around your body, your breathing rate will quicken so that more oxygen is available, and your muscles will tighten in order to be ready to fight or run. You may feel nauseated as blood flow leaves your stomach area and moves into your limbs. These bodily changes are all essential to helping you survive the dangerous situation.

After the danger has passed, your body functions will begin to go back to normal. This is because your body also has a system for “recovering” by bringing your body back down to a normal state when the danger is over.

As you can see, the emergency response system is adaptive when there is, in fact, a “true” or “real” danger (e.g., bear). However, sometimes people find that their emergency response system is triggered in “everyday” situations where there really is no true physical danger (e.g., in a meeting, in the grocery store, while driving in normal traffic, etc.).

What triggers a panic attack? Sometimes particularly stressful situations can trigger a panic attack. For example, an argument with your spouse or stressors at work can cause a stress response (activating the emergency response system) because you perceive it as threatening or overwhelming, even if there is no direct risk to your survival.

Sometimes panic attacks don’t seem to be triggered by anything in particular – they may “come out of the blue.” Somehow, the natural “fight or flight” emergency response system has gotten activated when there is no real danger. Why does the body go into “emergency mode” when there is no real danger?

Often, people with panic attacks are frightened or alarmed by the physical sensations of the emergency response system. First, unexpected physical sensations are experienced (tightness in your chest or some shortness of breath). This then leads to feeling fearful or alarmed by these symptoms (“Something’s wrong!”, “Am I having a heart attack?”, “Am I going to faint?”) The mind perceives that there is a danger even though no real danger exists. This, in turn, activates the emergency response system (“fight or flight”), leading to a “full blown” panic attack. In summary, panic attacks occur when we misinterpret physical symptoms as signs of impending death, craziness, loss of control, embarrassment, or fear of fear. Sometimes you may be aware of thoughts of danger that activate the emergency response system (for example, thinking “I’m having a heart attack” when you feel chest pressure or increased heart rate). At other times, however, you may not be aware of such thoughts. After several incidences of being afraid of physical sensations, anxiety and panic can occur in response to the initial sensations without conscious thoughts of danger. Instead, you just feel afraid or alarmed. In other words, the panic or fear may seem to occur “automatically” without you consciously telling yourself anything.

After having had one or more panic attacks, you may also become more focused on what is going on inside your body. You may scan your body and be more vigilant about noticing any symptoms that might signal the start of a panic attack. This makes it easier for panic attacks to happen again because you pick up on sensations you might otherwise not have noticed, and misinterpret them as something dangerous. A panic attack may then result.

How do I cope with panic attacks? An important part of overcoming panic attacks involves re-interpreting your body’s physical reactions and teaching yourself ways to decrease the physical arousal. This can be done through practicing the cognitive and behavioral interventions below.

Behavioral Interventions

1. Breathing Retraining Research has found that over half of people who have panic attacks show some signs of hyperventilation or over-breathing. This can produce initial sensations that alarm you and lead to a panic attack. Over-breathing can also develop as part of the panic attack and make the symptoms worse. When people hyperventilate, certain blood vessels in the body become narrower. In particular, the brain may get slightly less oxygen. This can lead to the symptoms of dizziness, confusion, and lightheadedness that often occur during panic attacks. Other parts of the body may also get a bit less oxygen, which may lead to numbness or tingling in the hands or feet or the sensation of cold, clammy hands. It also may lead the heart to pump harder. Although these symptoms may be frightening and feel unpleasant, it is important to remember that hyperventilating is not dangerous. However, you can help overcome the unpleasantness of over-breathing by practicing Breathing Retraining.

Practice this basic technique three times a day, every day:

• Inhale. With your shoulders relaxed, inhale as slowly and deeply as you can while you count to six. If you can, use your diaphragm to fill your lungs with air. • Hold. Keep the air in your lungs as you slowly count to four. • Exhale. Slowly breath out as you count to six.

• Repeat. Do the inhale-hold-exhale cycle several times. Each time you do it, exhale for longer counts.

Like any new skill, Breathing Retraining requires practice. Try practicing this skill twice a day for several minutes. Initially, do not try this technique in specific situations or when you become frightened or have a panic attack. Begin by practicing in a quiet environment to build up your skill level so that you can later use it in time of “emergency.”

2. Decreasing Avoidance Regardless of whether you can identify why you began having panic attacks or whether they seemed to come out of the blue, the places where you began having panic attacks often can become triggers themselves. It is not uncommon for individuals to begin to avoid the places where they have had panic attacks. Over time, the individual may begin to avoid more and more places, thereby decreasing their activities and often negatively impacting their quality of life. To break the cycle of avoidance, it is important to first identify the places or situations that are being avoided, and then to do some “relearning.”

To begin this intervention, first create a list of locations or situations that you tend to avoid. Then choose an avoided location or situation that you would like to target first. Now develop an “exposure hierarchy” for this situation or location. An “exposure hierarchy” is a list of actions that make you feel anxious in this situation. Order these actions from least to most anxiety- producing. It is often helpful to have the first item on your hierarchy involve thinking or imagining part of the feared/avoided situation.

Here is an example of an exposure hierarchy for decreasing avoidance of the grocery store. Note how it is ordered from the least amount of anxiety (at the top) to the most anxiety (at the bottom): • Think about going to the grocery store alone. • Go to the grocery store with a friend or family member. • Go to the grocery store alone to pick up a few small items (5-10 minutes in the store). • Shopping for 10-20 minutes in the store alone. • Doing the shopping for the week by myself (20-30 minutes in the store). Your homework is to “expose” yourself to the lowest item on your hierarchy and use your breathing relaxation and coping statements (see below) to help you remain in the situation. Practice this several times during the upcoming week. Once you have mastered each item with minimal anxiety, move on to the next higher action on your list.

Cognitive Interventions

1. Identify your negative self-talk Anxious thoughts can increase anxiety symptoms and panic. The first step in changing anxious thinking is to identify your own negative, alarming self-talk. Some common alarming thoughts:

• I’m having a heart attack. • I’m going to pass out. • I must be going crazy. • Oh no – here it comes. • I think I’m dying. • I can’t stand this. • People will think I’m crazy. • I’ve got to get out of here!

2. Use positive coping statements Changing or disrupting a pattern of anxious thoughts by replacing them with more calming or supportive statements can help to divert a panic attack. Some common helpful coping statements:

• This is not an emergency. • I don’t like feeling this way, but I can accept it. • I can feel like this and still be okay. • This has happened before, and I was okay. I’ll be okay this time, too. • I can be anxious and still deal with this situation.

Suggested Readings • Barlow, D., & Craske, M. (2006). Mastery of your anxiety and panic workbook, 4th Edition. New York: Oxford University Press. • Bourne, E. (2000). The Anxiety and phobia workbook, 3rd Edition. Oakland, CA: New Harbinger Publication.

Anxiety

Challenging Anxiety Anxiety affects approximately 19 MILLION adults in the United States alone. 1 out of every 6 people will experience uncomfortable anxiety at some time during their lives (that is nearly 45 million people)! The body’s natural response to danger is to prepare for “fight” or “flight”. When the sympathetic nervous system activates to emergency situations, you may experience feelings and body sensations such as:

• Increased heart rate • Increased muscle tension • Quick, shallow breaths • Increased perspiration • Increased adrenaline • Light headedness • Impending doom • Chest pains

These physical responses usually occur as components of anxiety. It is important to recognize that these reactions are your body’s normal response to a perceived danger. However, with anxiety, your body is responding to situations in which you are not physically threatened. None of these physical reactions can harm you—they are designed to keep you safe.

Anxiety begins in the cognitive (thinking) part of the brain. Physical symptoms ALWAYS begin as thoughts or perceptions based on your personal beliefs. You may experience the following kinds of thoughts:

• Uncontrollable worry • Negative thoughts you cannot stop • Fear, apprehension • Negative thoughts about yourself, the • Feelings of impending doom future, or past events

The thinking part of the brain can activate the physical “danger” response even when there is no immediate threat of danger. The physical and cognitive aspects of anxiety feed into each other to continue the negative cycle of worry and physical discomfort. Fortunately, there are several ways to alleviate the physical and cognitive discomfort of anxiety. Some typical behavioral exercises you can use to reduce physical symptoms of anxiety include:

• Relaxation breathing • Physical exercise • Engage in enjoyable/distracting activity • Noticing and being curious about it negative or distorted thinking

It will take practice to feel comfortable using these techniques, and to notice a decrease in your symptoms of anxiety. Remember, learning to feel anxious took time learning to feel more calm will take time. Soon, use of relaxation techniques and new ways of responding to anxious thoughts and sensations will become natural.

Diaphragmatic Breathing Exercise 1. Sit in a comfortable position, legs shoulder width apart, eyes closed, jaw relaxed, arms loose. 2. Place one hand on your chest, one hand on your stomach. 3. Try to breathe so that only your stomach rises and falls.

Inhale: Concentrate on keeping your chest relatively still. Imagine you are trying to hold up a pair of pants that are slightly too big.

Exhale: Allow your stomach to fall as if you are melting into your chair. Repeat the word “calm” to provide focus as you are practicing the exercise.

Do not force the breath, let your body tell you when to take the next breath.

4. Take several deep breaths moving only your stomach in and out with the breath. 5. Practice 3-5 minutes 2-3 times. The more you practice, the faster your progress will be.

Note: It is normal for this type of breathing to feel a bit awkward at first. With practice it will become more natural for you.

Challenging Negative Thoughts Negative thought cycles perpetuate the physical symptoms of anxiety. In addition to practicing diaphragmatic breathing it is important to learn new ways to respond to negative thought patterns to decrease the experience of anxiety.

Examine your thoughts for key words: • must, should, have to (unrealistic standards for yourself and others) • never, always, every (“black and white” thinking) This kind of thinking does not allow room for alteration, compromise, or change. Using these words casts blame, and they are judgmental. • awful, horrible, disaster (catastrophic thinking) This kind of thinking encourages the sense of despair and doom. • jerk, slob, creep, stupid (negative labels)

Changing your choice of words makes a big difference in the way a situation or person is perceived. The way we react to a situation is the determinant of our moods, not the situation itself. Our thoughts influence our moods, so by altering the way we respond to them we are able to alter our mood.

Here are some simple ways to challenge your thoughts:

1. Question the negative/worrisome thoughts you are having. Is the thought valid? a) provide evidence for and against the truth of the thought b) Challenge the likelihood that an event will occur.

2. Challenge the need to “fix” all problems, do all chores, or take care of things immediately. Ask yourself, “What is the worst thing that will happen if …….. does not happen?”

3. Change the negative thought into a positive self-statement. For example: Instead of, “I am never on time, I am such a loser”, say “Ok, so I am not always on time, but I am not always late either. Sometimes I am running behind schedule, but that does not mean I am a loser”.

4. Play with the negative thought: a) Try saying the opposite of the thought. For example, “I am always on time, I am a complete winner”. b) Try saying the thought very slowly and then quickly, softly and then loudly. c) Try singing the song to the tune of happy birthday.

Recommended Reading

• “The Mindfulness and Acceptance Workbook for Anxiety”, John Forseyth and George Eifort • “Why Zebras Don’t Get Ulcers”, Robert Sapolsky • “The Anxiety and Phobia Workbook” and “Coping with Anxiety”, Edmund J. Bourne

Gate Control Theory of Pain

According to the gate control theory of pain, pain signals that originate in an area of injury or disease do not travel directly or automatically to the brain. Rather, there exists within the spinal cord a ‘gate mechanism’, which determines the degree to which pain signals are transmitted to the brain. When the gate is wide open, more pain signals get through than when it is closed. Generally, rather than being completely open or shut, the gate is open to varying degrees.

Factors OPEN the pain gate CLOSE the pain gate which: • -Extent of the injury • -Application of heat or cold

• -Readiness of the nervous system to • -Massage send pain signals • -Relaxation skills (to lower readiness

Physical • -Inappropriate activity level of the nervous system) • -Appropriate activity level

• Depression • Avoiding excessive emotions • Worry • Positive emotions • Anxiety • Managing stress • Tension Emotional • Anger • Focusing on the pain • Distraction away from pain • Boredom due to minimal • Increased social activities involvement in life activities • Positive attitudes

Mental • Non-adaptive attitudes

• -Withdrawal from positive life • -Increased positive life activities activities • -Appropriate exercise • -Poor health habits • -Healthy eating • -Refraining from unhealthy habits Behavioral

Pacing Yourself When people first injure themselves, pain serves as a signal that harm has been caused to the body. The natural and healthy response is to stop doing whatever is causing the pain (e.g., walking on a sprained ankle, lifting with a strained back). In this case, harm is being done to the body and the body’s warning system (pain) is working properly. However with chronic pain, healing has usually occurred but pain remains. Thus, the body’s warning system is no longer working properly. In other words, the pain no longer indicates harm is being done to the body. Therefore, stopping the activity that causes the pain is often not indicated.

People with chronic pain are often very inactive during episodes of severe pain; laying or sitting for extended periods. Through the course of the natural pain cycle, they eventually experience some pain relief. In response to this decreased pain, they often try and make up for all the things they were unable to do during the severe pain episode (i.e., they over do it). Since their body has lost strength and endurance during these extended periods of inactivity, even resumption of normal life activity can result in increased pain. As a result, a cyclical pattern of ‘under-doing’ it followed by ‘over-doing’ it is created. Pacing activity differently enables pain patients to break this cycle.

How to pace • Stop or change an activity when your pain level goes two points (on a 10 point scale) above your normal pain level. • Do something less active until your pain returns to your normal level. • If this rule is followed throughout the day, then pain will be no worse at the end of the day then at the beginning.

What to expect when pacing • It will be challenging to learn the right combinations of up and down times. You may find it works best to tackle small portions of your daily routine at a time rather than changing your entire day at once. Start with activities that are most important to you or that increased pain causes the greatest challenge to you. • Avoiding over activity, which can result in severe pain episodes and longer downtimes, will increase your success at engaging in effective pacing. • Expect to reassess your pacing plan on a regular basis (increasing uptime and decreasing downtime as appropriate). In the beginning of pacing you may find that your uptimes are shorter than you would like and your down times are longer than you would like. What you should find is that your uptimes gradually increase and your downtimes gradually decrease. • Setting realistic goals for yourself may help keep you from getting frustrated and disappointed with the slow rate of improvement as you gradually recondition your body. By planning your activities in this way, you can accomplish more (and have more fun) in a day without significantly increasing your pain. The attached worksheet can be used to help you determine your ‘up’ and ‘down’ times.

Setting Realistic Goals for Taking Control of Your Life Unfortunately, being pain free is rarely a realistic goal. More realistic goals might include: reducing impact of pain on activities, learning to live with the pain, learning to enjoy life, regaining control of your life, increasing activity, etc. Talk with your doctor about what physical limitations you have and do not do those activities. Instead, focus on gradually resuming those that hurt but are not harmful. Setting realistic goals provides a focus for your energy and enables your goals to be achieved. Also, when you are devoting your time and energy to things you really want to do and can accomplish, there is less time to think about your pain. The less you think about your pain, the less you will suffer.

Establishing Goals

1. Is the Goal is Realistic? Is the goal statement realistic? Can the goal actually be achieved? Is it possible to achieve at your pain management skill level?

2. Is there a Target Date for Completion? When will the goal be accomplished? It's a good idea to set a target date to act as a guideline and then re-set if needed.

3. Is the Goal Measurable? Can you evaluate when the goal has been reached? Will the goal be measured in some way?

For example: . Minutes spent doing some activity such as exercise or relaxation. . Specifics type and number of pleasurable activities to engage in each week.

4. Is The Goal Broken Down Into Small, Realistic Parts? Remember to start at a point that you already know you can do, and build onto it from there. Program the steps for a sense of early success to help give you the boost and momentum to keep you going.

5. Is the goal “I” centered? Are “you” the one engaging in the actions or behaviors to be measured?

6. Once Accomplished, What Rewards Will You Use? Remember, actions that are rewarded are more likely to reoccur.

7. Is the Goal Desirable or Personally Meaningful? Do you want the outcome enough to put forth the effort? You are much more likely to strive toward a goal that you care about.

8. Is A Relapse Plan Clearly Established? What happens if you do not reach to goal as you originally planned? What will you do to get started again?

Postpartum Depression

What is it? Postpartum depression (PPD) is sometimes called postpartum blues (“baby blues”) or puerperal psychosis. It affects 10-15% of women. Among adolescent mothers it may be more common.

PPD is more likely to occur for women who have previously struggled with depression. In fact, there is little difference between postpartum depression and major depression. Women with relatives who have struggled with depression are also more likely to develop PPD.

What is it NOT? PDD is not a disease or illness that can be blamed on the mother or on anyone else. It is not a chemical imbalance or simply a hormonal problem. It may occur due to environmental, biological, or behavioral factors. Frequently it is due to a combination of these.

PDD is not incurable or permanent. It usually arises within 6 weeks of childbirth and may last between 3 and 14 months. PPD can lead to other difficulties with one’s spouse, family, social life, job, or health. If untreated PPD may also lead to behavioral and developmental problems in the children of the depressed mother.

PDD is not uncontrollable. If targeted early it can be treated with simple behavioral strategies and skills which a mother can learn quickly and implement in a way that best suits her. There are also antidepressant medications which physicians may prescribe to help mothers feel better.

PPD is not something to be ashamed of – it is pretty common. One out of three women who have a prior history of major depression will experience postpartum depression.

How do I know if I have PPD? Recognizing PPD early not only makes it easier for the mother to address the symptoms of depression, but it also enables doctors, friends, spouses, and other family members to help. You may have one or more symptoms of PDD. Every woman’s experience of PDD is a little different. The severity of PDD varies. If you have difficulties identifying it, your doctor will be able to help you. Below are a few things to look for.

Common symptoms of PPD • moodiness • confusion • irritability • low of motivation • anxiety • fatigue • feeling unable to cope • crying spells

What can I do to get better? Generally, the treatments that are successful in treating PDD are the same ones used to treat depression. However, the best treatment for PDD is PREVENTION!

When we feel depressed, sometimes we do not feel the energy or interest to do things we typically enjoy. As a result, we stop spending time with others and/or doing fun activities. This leaves us with fewer opportunities to be happy and gain pleasure out of each day, which may make us feel even more depressed.

1. Remain actively engaged in activities Schedule weekly activities that provide you a sense of pleasure and/or a feeling of accomplishment.

Stick to this schedule! Even if initially you do not begin feeling better, the research shows that the more consistently people engage in such activities, the higher their mood becomes overtime.

You may have to literally force yourself to maintain a schedule of activities, but this is where the momentum starts!

2. Ensure you have a social network • Ensure that you regularly spend time with family and friends – depressive feelings can often be helped by remaining connected to others. • Seek support from others. Others you know may have also struggled with PDD. Talk to them - they may have some ideas to help you! • Contact your friends, family, and doctor if you notice symptoms of depression getting worse.

3. Use problem-solving skills If you have difficulties carrying out any of these behavioral routines use your resources to make sure they happen. • Reschedule your activities around obligations • Reorganize your own daily routine • Spread out your other responsibilities over a longer period of time to provide yourself periods of time in which you can schedule activities for yourself. • Ask for help from others 4. Engage in some sort of physical exercise • Even if you walk on a treadmill at home while watching television. This does count as exercise! Studies show that regular exercise can increase one’s mood. • Start with a manageable exercise routine – do not try to do too much initially.

• Begin slowly, and as your body adjusts to the level of activity, increase the duration or intensity of your workouts gradually.

5. DO NOT GIVE UP! • Sometimes when people begin to feel better, they stop doing the things that helped them feel better. This results in their mood declining all over again. If what you’re doing is helping, do not stop doing it! • Reward yourself for keeping an exercise routine, activity schedule, and social schedule! It is okay to do things for yourself to maintain your motivation. • Time is precious. If you are someone who feels guilty about taking time to yourself because this competes with other responsibilities, just remember: if you are not feeling well, your ability to care for others and carry out other responsibilities will decrease. • Investing a little time for yourself daily or weekly to do the activities mentioned above, can give you the energy and motivation to address all the other responsibilities you may have.

6. Contact your doctor If you are interested in taking medication to treat these symptoms, there are a few options, even if you are breastfeeding.

7. Stay informed about PPD Books can be powerful tools to help people learn about depression or PPD. Information you may learn or ideas you may get from books may better help you manage your symptoms.

Suggested books for coping with PPD

• “This Isn’t What I Expected: Overcoming Postpartum Depression” by Karen R. Kleiman, M.S.W. and Valerie D. Raskin, M.D. • “Conquering Postpartum Depression: A Proven Plan for Recovery” by Rosenberg, Greening, and Windell

Depression: Tips for Coping

What is depression? There are several forms of depression. Depression can develop rapidly or come on slowly over weeks or months. In some cases, depression can develop into a chronic or episodic syndrome. Although many people associate depression only with sadness, there are other signs as well (for example, dropping enjoyable activities; feeling tired; feeling guilty or worthless; having problems with concentration, sleep or appetite). It is estimated that up to 25% of women and 12% of men will experience clinical depression at some point during their lifetime. Women are twice as likely as men to become depressed.

What depression is not There are a lot of myths and stigmas surrounding depression. Depression is not a “weakness;” nor is it “all in your head.” Clinical depression is not something that you can just “snap out of.” The good news is that help is available. Years of research have identified effective behavioral interventions for improving symptoms of depression. If you or someone you know is depressed, it’s very important that you seek help. Reading this pamphlet is a first step towards understanding depression and getting the help that you need.

What causes us to feel down? Prolonged stress and major negative life events (e.g., the death of a loved one), and medical illness can all play a significant role in depression. Usually, depression is related to a combination of factors including the social environmental, biological factors, our thoughts and beliefs, our emotions, and our behavior. Each of these factors can affect the others, and often work together in a sort of “snowball effect” that may leads to more symptoms of depression. The depression spiral provides a helpful illustration of this:

Environmen

DEPRESSIO Thoughts Biology N and Emotions

Behaviors

It is important to keep in mind that what initially causes the depression may not be the same as what maintains it, or causes it to persist over time. For example, the loss of a loved one or a job may lead to feelings of loss and result in increased stresses, including loneliness, financial problems, etc. Symptoms of depression may worsen in response to growing stress levels, but it our experience of failure in solving the problems triggered by initial stresses that get us “in the dumps”. Often, we “pull back” from life and then forget to re-engage. We drop our previously enjoyable activities, see others less, and often move into more sedentary or inactive lifestyles.

How to cope with depression The good news about the depression spiral is that it is reversible----there are specific behavior change strategies that you can use to improve your life, starting TODAY. These strategies have been shown to lead to significant and enduring improvement among hundreds of thousands of other people.

STEP ONE: GET MOVING! Our level of activity is often connected to the way we feel. You may notice that when you are depressed, you tend to be less active—you may cut down on social activities or on exercise. As a first step towards treating depression, it is often beneficial to increase activities—particularly those that you have found pleasurable in the past, those that lead you to feel that you have accomplished something (i.e., hobbies), or those that are aligned with your values (i.e., if you are a parent, spending quality time with your children).

Aerobic exercise, in particular, is one of the best ways to improve your mood. When you exercise, your body releases endorphins, which are natural “feel good” chemicals. Research has shown that exercise is an effective treatment for depression.

When you’re depressed, you will rarely feel motivated or excited about initiating an activity…but you’ll find that once you get started, the positive momentum will build and over time (over several weeks of increasing your activity level), most people experience increased energy and an elevation in mood.

You will increase your chances of success if you plan, and schedule, specific activities (i.e., “tomorrow morning at 7am, I am going to walk my dog around the neighborhood for 30 minutes”). The activities you select don’t have to be extravagant- they can be as simple as a 10- minute walk outside, taking a bath, gardening, reading a book, talking to a close friend, or listening to soothing music. Remember- everybody is different- it’s important to identify activities that are enjoyable or meaningful to YOU! (Note: if you are having a difficult time identifying activities, your PCB can provide you with a list of hundreds of potentially enjoyable activities to “spur” your brainstorming process.)

Use the activity schedule on the last page of this pamphlet to schedule and track your activities for the next week. Tracking your activities can help you to see more clearly the relationship between them and your mood. Be sure to rate your level of enjoyment/mastery for each activity, and your average mood (using a 0-10 scale, with 0 representing “completely depressed” and 10 representing “not at all depressed”) for each day. After you’ve done this for one week, ask yourself the following questions:

• Did my activities affect my mood? How? • Which activities helped me to feel better? • Did any activities (or periods of inactivity) cause me to feel worse? • Which activities had the greatest positive impact on my mood? • Were there certain times of the day or week when I felt better or worse? • Based on my answers to the previous questions, what activities can I plan in the coming weeks to maximize the chances that I will feel better?

Use the information you’ve gained to guide activity plans for the upcoming weeks. Becoming “un-depressed” is a little bit like walking out of a big hole in the ground. It won’t happen all at once; rather, you’ll have to climb out one step at a time. The important thing is to keep the momentum in the positive direction. Don’t give up!!! If you need to, get your friends/family to help keep you on track with planning and committing to activities.

STEP TWO: LOOK OUT FOR “STINKIN’ THINKIN’!” Depression is characterized by thought patterns that actually maintain the depressed mood. Individuals who are depressed experience negative thoughts about the self (self-criticism), the world (general negativity) and the future (hopelessness). It’s a little bit like wearing a pair of dark sunglasses—everything you see has a shadow cast over it. Our thoughts have a direct impact on our mood, on our interactions with others, and on our activity level (or lack thereof). It’s very important, therefore, that you pay attention to unhelpful thinking.

Use intentional choice get you out the door and involved in meaningful and important life activities more often. It is possible to simply notice your “stinkin’ thinkin’” and take it with you to the park or the library. It is possible to smile at a neighbor even if you are feeling discouraged and thinking painful thoughts. Choosing is difficult, and worth it. It can open “new doors” for you. For example, you might start a new friendship if the neighbor smiles back.

Whenever you experience a negative shift in mood, pay attention to what you were thinking at that moment. Pay attention to any thing that triggered it. Use an attitude of curious interest. Perhaps you can make a note of it on a piece of paper. Once you’ve identified your thoughts, ask yourself “is this type of thinking helping me or hurting me?” If you find that your thinking is making your depressed mood worse (as is usually the case for depressed individuals), here are some things you can do:

• “Examine the evidence” for and against the negative thought. Is it truly accurate? Where’s the proof? Are you blaming yourself for something over which you do not have complete control? Are you jumping to conclusions? Are you discounting your strengths, or positive attributes, in some way? Become your own scientific investigator and collect the facts.

• Explore the negative thought and look for other thoughts to appear (thoughts do “come and go”). Ask yourself, five years from now, if you look back at this situation, how might you look at it differently? Allow yourself to view a situation from more than

one angle (how might your spouse, friend, or someone you admire view the same situation?)

• Use the “best friend” scenario. What would you tell your best friend if he or she was having these same thoughts? Would you criticize him or her as harshly as you criticize yourself?

Most of us go through life on “autopilot,” unaware of much of our thoughts or on the impact that they have on our mood and our behavior. It can take awhile before you get to be skilled at identifying and working with negative thoughts. Over time, you’ll get better at this.

Additional Resources (Self-help workbooks)

• “Get Out of Your Mind and Into Your Life” by Stephen Hayes, Ph.D.* • “Living Life Well: New Strategies for Hard Times” by Patricia Robinson • “The Mindfulness and Acceptance Workbook for Depression” by Kirk Strosahl &Patricia Robinson*

*Winners of the ABCT Self-Help Book Merit Award

Activity Log – Dates:______

Grade each activity for sense of accomplishment “A” and pleasure “P” on a scale from 0-10 (10 being the highest)

Sun A P Mon A P Tues A P Wednes A P Thurs A P Friday A P Satur A P day day day day day day

6-8

8-10

10-12

12-2

2-4

4-6

6-8

8-10

10-12

12-6 Day’s Mood 0-10

Exercise and Physical Activity

Most people have been told, “you need to exercise more” or “If you did some sort of physical activity, you would probably feel better”? Exercise and physical activity of any kind is healthy and can help increase positive mood and energy. It can also decrease weight, stress and blood pressure, increase alertness and motivation to accomplish other goals. This isn’t earth shattering news, as a matter of fact it is hard to find anyone who hasn’t heard these things before. Yet, it still isn’t enough to get people up and moving. So, if most people already know that physical activity and exercise have so many positive attributes, why is it that so many people don’t engage in these activities? (especially when experiencing anxiety, depression or significant life stress)

When people feel down or depressed, stressed or nervous they tend to cut out healthy activities that normally bring value, meaning and enjoyment to their lives. Giving up healthy habits in the face of negative mood and life stress seems to be the path of least resistance for most, and the initiation of a cycle that is difficult to stop.

Finding reasons not to exercise isn’t difficult, where most people get “stuck” is in problem solving and finding ways to overcome barriers to change. Sometimes, being able to weigh the reasons NOT to exercise against the reasons to DO exercise can help create the motivation and rationale to begin MOVING forward. Try using the scale below to “weigh” your options……

REASONS TO EXERCISE

REASONS NOT TO EXERCISE • Improve mood

Increase Energy • Feeling Sad • Feeling Sick • • Low Energy • No Social Support • Weight Control • Exercise Goal is • Don’t Have Proper • Improve Sleep Unattainable Attire • Stress Reduction

Too Busy Too Tired Lower Blood Pressure • • • • Too Hot or Cold • Pain • Lower Cholesterol • Low Level of • Intimidated by Gym • Increase Muscle Tone • Decrease Chronic Pain

• Improve Concentration • Increase Metabolism • Improve Cardiovascular functioning • E h St i f D il

List Top 3 Reasons to Exercise

• My short term exercise goal is: ______• My long term exercise goal is: ______• When I REALLY don’t feel like exercising I will: ______• I will look to: ______for support in my effort to exercise. • I will reward myself with: ______

*Post this list in a place where you will see it several times each day!

GETTING STARTED

• Check with your doctor - It is always a good idea to check in with your doctor before beginning a new fitness program. This is particularly true if you're over 40, if you smoke, or if you have a family history of cardiovascular disease, high blood pressure, elevated cholesterol, diabetes, arthritis, or asthma. • Have fun - Choose an activity you like or want to do. You're much more likely to stick with it. If you find your first choice doesn't suit you, switch to something else. • Start slowly and progress gradually - You'll avoid becoming discouraged and reduce the risk of injury. • Set goals - Maybe you want to lose a little weight, get in shape for a particular sport you enjoy, or reduce arthritis pain and increase joint mobility. • Keep track - You may not notice that you're walking further in the same amount of time or that you're not as winded climbing the stairs. Keeping track helps you evaluate your progress and gives you a sense of accomplishment. • Reward yourself - When you reach a goal, buy yourself a new T-shirt or tennis racket. • Find a partner - It's more fun to share and you'll keep each other on track.

• Have a plan B - If it's raining, walk around an indoor mall or do an exercise video. • Include variety - You're less likely to become bored if you cross train. Include the three basic forms of exercise in your fitness program: aerobics, strength training, and stretching. Or if you prefer, alternate your activities, basketball one day, yoga another, and stacking wood on the third. The thing to remember is that ANY activity will help you burn calories! • Stick with it - You have to exercise regularly for your fitness to improve. Fifteen to thirty minutes a day is all that is required to see improvement and you'll enjoy the same benefits if you find it easier to fit two 15 minute or two to three 10 minute sessions into your day.

Daily Level of Total Reward for Type of Exercise Date Difficulty Exercise Completion of Activity Goal Low-Mod-Diff Time Goal

Grief, Bereavement, & Mourning

Bereavement is the state of having lost a significant other to death. Grief is the personal response to the loss. Mourning is the public expression of that loss.

What is “Normal” Grief? Grief reactions vary depending on who we are, who we lost, our relationship with that person, the circumstances around their passing, and how much their loss affects our day-to-day functioning. Different people may express grief differently and you may even have different grief responses between one loss and another.

Reactions to grief and loss include not just emotional symptoms, but also behavioral and physical symptoms. These reactions can often change over time. All are normal for a short period of time.

Emotional Behavioral Physical Shock, denial, numbness Crying unexpectedly Exhaustion/Fatigue

Sadness, anxiety, guilt, fear Sleep changes (increase or decrease) Decreased energy

Anger (at others or God), Not eating/Weight changes Memory problems

Irritability, frustration Withdrawing from others Stomach and intestinal upset

Restlessness, difficulty Pain and headaches concentrating, trouble making decisions

Symptoms that are not normal and may signal the need to talk to a professional include: Use of drugs, alcohol, violence, and thoughts of killing oneself.

The duration of grief varies from person to person. Current research shows that the average recovery time is 18 to 24 months. Also, grief reactions can be stronger around anniversary or other significant dates, such as the anniversary of the person’s death, birthdays, and holidays.

The Stages of Grief Grief therapists often describe stages of grief outlined by the research of Dr. Elizabeth Kubler-Ross. These stages do not always go in order. You may move back and forth among some of the stages and may even “skip” some of them. These stages are meant as a guide to help you understand your reactions and those of others who are grieving. • Denial: Denial (not acknowledging the loss) can help contain the shock of loss. Denial can act as a “safety mechanism” to block out grief until we are ready to handle it. • Sadness and depression: Deep, intense grief and mourning appear during this stage. When the full understanding of our loss comes, it can seem overwhelming. During this stage, you may cry often and unexpectedly. You may not want to be around people or to do things that you normally enjoy. During this stage, it is best to remain as active as possible and to seek supportive people who will allow you to say what you need to or to cry when you need to. It is important to allow yourself to work through your full range and experience of emotions. • Anger: Rage and anger can be intense toward the person who died, toward friends and relatives, and even toward God. It is important to have an outlet to release anger through activities such as exercise, hobbies, or through therapy. Guilt, shame, and blame are feelings that need to be addressed, especially if it is toward you. • Acceptance: This stage includes “coming to terms” with the loss. It does not mean that you have found the answers to your questions or that you stop thinking about the person who is gone. It does signify a reinvestment in life and a willingness to readjust to your new circumstances while carrying the memory of your loved one with you.

How to Help Yourself 1. Give yourself time to grieve. It is normal and important to express your grief and to work through the concerns that arise for you at this time. “Stuffing” your feelings may not be helpful and may delay or prolong your grief. 2. Find supportive people to reach out to during your grief. This is the time when the support of others may be the most helpful. Don’t be afraid to tell them how they can best help, even if it means just listening. It is often very helpful to talk about your loss with people who will allow you to express your emotions. 3. Take care of your health. Often after a loss, we stop doing the things we need to for health care, such as exercising, eating correctly, keeping Dr. appointments, or taking prescribed medications. If you are on a health care regimen, it is important to continue to adhere to your treatment. 4. Postpone major life changes. Give yourself time to adjust to your loss before making plans to change jobs, move or sell your home, remarry, etc. Grief can sometimes cloud your judgment and ability to make decisions. 5. Consider keeping a journal. It is often helpful to write or tell the story of your loss and what it means to you as a way to work through your feelings. 6. Participate in activities. Staying active through exercise, enjoyable activities, outings with supportive others, or even starting new hobbies can help us get through tough times while providing opportunities for constructive development and use of energy.

7. Find a way to memorialize your loved one. Planting a tree or garden in the name of your loved one, dedicating a work to their memory, contributing to a charity in their name, and other such activities can be helpful. 8. Consider joining grief-support groups or contacting a grief counselor for additional support and help.

Remember that depressive symptoms (feeling sad) are a fundamental part of normal bereavement. Staying active and finding support from others can help you to work through the grief process.

References Aartsen, MJ, Van Tilberg, T, Smits, CH, Comijs, HC, & Knipscheer, KC. (2005). Does widowhood affect memory performance of older persons? Psychological Medicine, 35(2), 217-226.

Chen, JH, Gill, TM, & Prigerson, HG. (2005). Health behaviors associated with better quality of life for older bereaved persons. Journal of Palliative Medicine, 8(1), 96-106.

Clark, A. (2004). Working with grieving adults. Advances in Psychiatric Treatment, 10, 164- 170.

Clements, PT, DeRanieri, JT, Vigil, GJ, & Benasutti, KM. (2004). Life after death: Greif therapy after the suddent traumatic death of a family member. Perspectives in Psychiatric Care, 40(4), 149-154.

Fauri, DP, Ettner, B, & Kovacs, PJ. (2000). Bereavement services in acute care settings. Death Studies, 24, 51-64.

Jacobs, S, & Prigerson, H. (2000). Psychotherapy of traumatic grief: A review of evidence for psychotherapeutic treatment. Death Studies, 24, 479-495.

Servaty-Seib, HL. (2004). Connections between counseling theories and current theories of grief and mourning. Journal of Mental Health Counseling, 26(2), 125-145.

HEADACHE: Types, Tips & Treatment Suggestions

Headaches are one of the most common complaints patients present with in primary care settings. They are often correlated with stress, tension and a litany of existing medical conditions. Often, patients will live with headache pain for months or even years before seeking care. Over the counter remedies like aspirin, ibuprofen and acetimenophen are often used to reduce symptoms of pressure and pain prior to seeking medical advice. The following information is intended for patients that suffer from chronic headache pain and are looking for ways to better manage symptoms, increase function and improve quality of life.

A headache is a headache is a headache…..Right?

There are actually two main types of headache, primary and secondary, and they can differ greatly in intensity, frequency and duration.

Primary headaches include, but are not limited to, tension-type and migraine headaches and are not caused by other underlying medical conditions. Over 90% of headaches are considered primary.

Secondary headaches result from other medical conditions, such as infection or increased pressure in the skull due to tumor, disease, etc. These account for fewer than 10% of all headaches.

Headache Classification

Tension-type Headaches Tension type headaches are the most common, affecting upwards of 75% of all headache sufferers. • As many as 90% of adults have had tension-type headache • These headaches are typically a steady ache rather than a throbbing one, and affect both sides of the head • Distracting but usually not debilitating • People can get tension-type (and migraine) headaches in response to stressful events or a hectic day • These headaches may also be chronic, occurring as frequently as every day

Migraine Headaches Less common than tension-type headaches, migraines affect approximately 25 to 30 million people in the United States and cause considerably more disability, lost work days and lost revenue.

• As many as 6% of all men and up to 18% of all women (about 12% of the population as a whole) experience a migraine headache at some time • Roughly three out of four migraine sufferers are female • Among the most distinguishing features is the potential disability accompanying the headache pain of a migraine • Migraines are felt on one side of the head by about 60% of migraine sufferers, and the pain is typically throbbing in nature • Nausea, with or without vomiting, as well as sensitivity to light and sound often accompanies migraines • An aura --a group of telltale neurological symptoms--sometimes occurs before the head pain begins. Typically, an aura involves a disturbance in vision that may consist of brightly colored or blinking lights in a pattern that moves across the field of vision • About one in five migraine sufferers experiences an aura • Usually, migraine attacks are occasional, or sometimes as often as once or twice a week, but not daily

Headache Triggers Many things can cause a headache, thus it is important for you to become aware of the factors in your life that may contribute to your suffering, and, if possible, make changes to minimize the chances of continued suffering. Some examples of factors that can cause headache are outlined below:

• Emotional Factors: Stress (work, home, family), depression, anxiety, frustration, let down, even positive excitement • Dietary Factors: Alcohol, aspartame, cheese, chocolate, caffeine, monosodium glutamate (MSG), processed meats containing nitrates • Physical Factors: Getting too much or too little sleep, too much physical exertion, injuries, skipping meals • Environmental Factors: Glare from the sun or bright lights, changes in the weather, strong odors, smog • Hormonal Events: Menstruation, oral contraceptives, hormone replacement therapies, menopause

Treatment of Headaches There are a number of medications, such as muscle relaxants, analgesics (e.g., aspirin, percocet, fiorinol), or antihypertensives that can help with migraine and/or tension headaches. If you’re reading this, chances are they’re not working for you or you haven’t tried all available treatments yet. Taking medication isn’t the only thing you can do to alleviate your headache. Research has shown that numerous other methods, or behaviors, are also very effective in treating and managing recurrent headaches. Here are some examples of what you can do to increase your control over your headaches.

• Become educated about your specific headache type, visit websites, such as: • The American Council for Headache Education (http://www.achenet.org/) • The American Headache Society (http://www.ahsnet.org/) • Engage in relaxation exercises to decrease stress and tension: • Deep breathing & cue controlled relaxation • Progressive muscle relaxation • Relaxation by recall • Biofeedback • Cognitive-behavioral stress-management: Focuses on increasing your understanding of the role of cognitions (thoughts) in stress responses, and relationships between stress, coping, and headaches • Talk with your PCP about anti-depressant medications: • Combination of behavioral and medication therapies: For example, engaging in relaxation exercises and taking Zoloft at the same time

Optimizing Treatment To be better able to treat your headache, it is important to keep track of your triggers, symptoms and progress. Filling out a headache diary gives you, and your medical and behavioral health doctor, an accurate picture of the frequency and severity of your headache experience. It also provides a way to identify patterns, such as the association with certain foods or specific situations.

Why Use a Headache Diary? 1 • Triggers: you may become more aware of your specific triggers as you monitor your headaches. Keeping a headache diary will help you determine whether factors such as food, change in weather, and/or mood have any relationship to your headache pattern. • Track progress: diaries are also an excellent way to track your progress in treatment.

1 Sources: The International Headache Society, The American Council for Headache Education, The American Headache Society, WHMC Clinical Health Psychology Dept, Neurology, The Clinical Psychologist, Journal of Consulting and Clinical Psychology, Behavior Therapy.

DATE SEVERITY TRIGGER/S RELIEF MEASURE/S DURATION 1 = mild 2 = moderate 3 = severe

Managing Hypertension

• Normal blood pressure is below 120/80 mmHg. • Prehypertension is the range of 120/80 to 139/89. This means that you don't have high blood pressure now but are likely to develop it in the future. You can take steps to prevent high blood pressure by adopting a healthy lifestyle. • Hypertension or high blood pressure is a blood pressure reading of 140/90 or higher. Nearly one in three American adults has high blood pressure. Once high blood pressure develops, it usually lasts a lifetime. The good news is that it can be treated and controlled.

Not all incidents of hypertension have a known cause, but some factors have been shown to increase blood pressure:

STRESS SODIUM TOBACCO OVERWEIGHT

High blood pressure is sometimes called "the silent killer" because it usually has no symptoms. Some people may not find out they have it until they have trouble with their heart, brain, or kidneys. When high blood pressure is not found and treated, it can cause:

1. The heart to enlarge, which can lead to heart failure. 2. Small bulges (aneurysms) to form in blood vessels. Common locations are the main artery from the heart (aorta), arteries in the brain, legs, and intestines, and the artery leading to the spleen. 3. Blood vessels in the kidney to narrow, which may cause kidney failure. 4. Arteries throughout the body to "harden" faster, especially those in the heart, brain, kidneys, and legs. This can cause a heart attack, stroke, kidney failure, or amputation of part of the leg. 5. Blood vessels in the eyes to burst or bleed, which may cause vision changes and can result in blindness.

So, how can you manage hypertension? Fortunately, research has shown there are a number of things you can do to manage your hypertension and keep those blood pressure numbers down!

Exercise Regular exercise has been shown to significantly decrease blood pressure. If you don’t normally exercise, you can start with something as simple as walking and work your way up to a daily exercise routine that is right for you.

Diet Modification A number of studies have shown that a diet low in sodium, and rich in fruits, vegetables, lean meats and low-fat dairy foods is highly effective in lowering blood pressure. The American Heart Association and the National Institute of Health endorse a specific diet for individuals with high blood pressure, called the DASH (Dietary Approaches to Stop Hypertension) diet. The DASH diet is based on about 2,000 calories and 1,500 milligrams of sodium a day. For more details about the DASH diet, you can go to either of these websites:

• http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/ • http://www.dashforhealth.com/ • Or ask the Primary Care Behaviorist for a copy of the DASH eating plan. Weight Loss Many studies have shown that being overweight is a very important risk factor for hypertension. Managing your weight through eating a balanced diet and engaging in regular exercise can help you maintain a healthy weight.

Managing Stress Medical studies have shown that the way we react to stress can greatly impact hypertension. You can learn to manage stress by engaging in relaxation techniques that help to reduce blood pressure. One great relaxation technique that is easy to do and takes very little time is diaphragmatic or deep breathing.

Deep Breathing Exercise 1. Sit in a comfortable position. 2. Take 3 deep cleansing breaths. 3. Place one hand on your stomach and the other on your chest. 4. Try to breathe so that only your stomach rises and falls. a) As you inhale, concentrate on your chest remaining relatively still while your stomach rises. It may be helpful to imagine that your pants are too big and you need to push your stomach out to hold them up. b) When exhaling, allow your stomach to fall in and the air to fully escape. 5. Take some deep breaths, concentrating on only moving your stomach. 6. Return to regular breathing, continuing to breathe so that only your stomach moves. Focus on an easy, regular breathing pattern.

Note: It is normal for this healthy breathing to feel a little awkward at first. With practice, it will become more natural to you.

The CALM Reminder

Chest: Breathing slower and deeper Arms: Shoulders sag Legs: Loose and flexible Mouth: Jaw drop

Protocol for Parenting Interventions

1. PCPs refer parent(s) and children to the PCB when patients identify the following difficulties: developmental delays in a child, discipline problems or communication problems. 2. In the initial PCB consultation, the PCB will provide routine initial health and behavior assessment services and a. determine the cause(s) of parenting problems (parent conflicts, parent-child conflicts, deficits in parenting skills) b. determine patient preferences concerning interventions (services from PCP and PCB team or participation in a parenting class in the community) c. determine need for services from specialty MH 3. If the patient(s) chooses to participate in a parenting class, the PCB will complete the appropriate referral form and schedule 1 follow-up with the patient(s) to (a) assess the impact of the initial plan and (b) to further refine the intervention for on-going support by the PCP. 4. If the patient(s) choose to receive services only from the PCP and PCB team, the PCB will implement the Primary Care Parenting Protocol. This program can be adjusted to fit parent-child issues from age 2 to 18. 5. The PCB will also provide on-going training, individually and in provider meeting presentations, on the Primary Care Parenting Protocol (PCPP) and provide related patient education handouts for PCPs.

Primary Care Parenting Protocol

This program includes 3 contacts (including the initial) with the PCB and an optional fourth visit. The PCB adjusts the curriculum to fit the needs of the patient(s).

1. Initial Visit: Behavioral Health Plan will focus on interventions that may improve the parent-child relationship (Handout: Positive Parenting) 2. Second Visit: Education and Behavioral Health Plan will focus on building skills for setting limits and using incentive programs (to help the child establish new behaviors) and consequences (to help the child change undesired behaviors). (Handout: Setting Limits and Using Incentives and Consequences) 3. Third Visit: Education and Behavioral Health Plan will focus on building skills for ignoring and time out procedures. (Handout: Ignoring and Time-Out / A United Front) 4. Optional Visit: The optional visit is for parents who are in conflict about parenting issues or who lack skills for taking a mindful stance in using behavioral parenting strategies. When these problems are observed, it is best to schedule the optional visit as the second visit. Education and Behavioral Health Planning will focus on helping the parents present a united front to the child(ren), model effective conflict resolution skills, and practice mindfulness strategies on a daily basis both in the context of parenting and during alone time. (Handout: Ignoring and Time Out / A United Front) 5. PCPs will see patients at least once during or at the conclusion of participation in the Primary Care Parenting Protocol.

PCPP content for items 1-3 above is consistent with empirically supported programs detailed in Schafer, C. E. & Briemeister, J. M. (1998). Handbook of Parent Training, NY: John Wiley & Sons. (See chapter by Webster-Stratton & Hancock, pp. 98-152).

Positive Parenting

We are more successful disciplining our children when we have good relationships with them. To develop good relationships, parents need to know how to praise their children and to play with them. This is true from birth. The following tips will help you with a child of any age. Make an X by any that you want to discuss with your provider.

When playing with children, 1. Follow the child’s lead. 2. Pace at the child’s level. 3. Engage in role-play and make-believe with the child. 4. Praise and encourage the child’s ideas and creativity. 5. Use descriptive comments instead of asking questions. 6. Be an attentive and appreciative audience. 7. Curb the desire to give too much help; encourage the child’s problem solving. 8. Don’t expect too much—give the child time to think and explore. 9. Avoid too much competition with children. 10. Don’t criticize. 11. Reward quiet play times by giving your positive attention. 12. Laugh and have fun.

Important information about praising children 1. Don’t worry about spoiling children with praise. 2. Catch the child when he or she is being good—don’t save praise for perfect behavior. 3. Make praise contingent on positive behavior. 4. Praise immediately. 5. Give labeled and specific praise. 6. Praise with smiles, eye contact, and enthusiasm. 7. Give pats, hugs, and kisses along with verbal praise. 8. Praise in front of other people. 9. Praise wholeheartedly, without qualifiers or sarcasm. 10. Increase praise for difficult children. 11. Model self-praise.

Plan:

Results:

Setting Limits and Using Incentives and Consequences

We are more likely to succeed as parents if we have skills. Setting limits and using incentive programs and consequences are important tools for shaping a child’s behavior.

About setting limits 1. Be realistic in your expectations and use age-appropriate commands. 2. Give one command at a time. 3. Use commands that clearly specify the desired behavior. 4. Make commands short and to the point. 5. Use do commands and when-then commands. 6. Make commands positive and polite. 7. Give children options when possible. 8. Give children ample opportunity to comply. 9. Praise compliance or provide consequences for noncompliance. 10. Give warnings and helpful reminders. 11. Don’t use stop or don’t commands. 12. Don’t give unnecessary commands. 13. Don’t threaten children. 14. Support your partner’s commands. 15. Strike a balance between parent and child control.

Important information about incentive programs 16. Define the desired behavior clearly. 17. Choose effective rewards (i.e., rewards the child will find sufficiently reinforcing). 18. Set consistent limits concerning which behaviors will receive rewards. 19. Make the program simple and fun. 20. Make the steps small. 21. Monitor the charts carefully. 22. Follow through with the rewards immediately. 23. Avoid mixing rewards with punishment. 24. Gradually replace rewards with social approval. 25. Revise the program as the behaviors and rewards change.

Points to remember about consequences 26. Make consequence age-appropriate 27. Be sure you can live with the consequences you have set up. 28. Give the child a choice; specify consequences ahead of time. 29. Involve the child whenever possible. 30. Use consequences that are short and to the point. 31. Make consequences immediate. 32. Make consequences safe and nonpunitive.

Plan:

Results:

Ignoring and Time Out / A United Front

Ignoring and Time out are important skills, and they work very well with certain behavior problems. While it is sometimes difficult, parents need to support each other in front of children and present a united front.

Guidelines for ignoring 1. Limit the number of behaviors to ignore. 2. Choose specific behaviors to ignore and make sure you can ignore them. 3. Be consistent. 4. Physically move away from the child, but stay in the room if possible. 5. Avoid eye contact and discussion while ignoring. 6. Return attention to the child as soon as misbehavior stops. 7. Be prepared for testing.

When using time-out 1. Carefully limit the number of behaviors for which time-out is used. 2. Use time-out consistently for chosen misbehaviors. 3. Be as polite and calm as possible in sending child to time-out. 4. Give time-outs for one minute per year of child up to 10 minutes. 5. Be prepared for testing. 6. Use non-violent approaches, such as loss of privileges, as backup for not going to time out. 7. Hold children responsible for messes in time-out. 8. Support a partner’s use of time out. 9. Don’t rely exclusively on time-out; combine with other techniques such as ignoring, logical consequence, and problem solving. 10. Build up a “bank account”

Presenting a united front 1. Present a united front to reassure a child. 2. Model conflict resolution at a level appropriate for the child. 3. Make a plan about what to do when one parent is not at home and a discipline problem occurs. 4. Use problem solving in a private meeting to solve differences in parenting style. Problem solving involves the following steps: (a) agree on an agenda, time and place, (b) come prepared, (c) define the problem, (d) brain-storm solutions and look at the pros and cons of each, (e) make a decision, (f) implement, (g) meet again and evaluate the results. 5. Stepparents may have special ways of presenting a united front.

Plan:

Results:

Common Relationship Problems

Poor Communication The way couples communicate with each other can lead to both increased stress and tension.

Some examples of poor communication are when: • One partner has a demanding communication style that leads the other partner to refuse to communicate in response. • One partner tries to manipulate the other with negative emotions, such as anger and sadness. • One Partner personally criticizes his/her partner, such as calling him/her ‘lazy’, rather than focusing on behaviors.

Ways to enhance communication: • Remove all distractions, such as television or radio noise, and arrange a time to talk that suits you both. • Avoid interrupting your partner. Summarize back what you have heard for accuracy before replying. • Avoid labeling. Focus on behaviors that are problematic, not your partner as an individual. • Talk about the positive aspects of the relationship, as well as the problems.

Poor Problem Solving Skills Problem solving skills are vital to working out relationship difficulties when they arise.

Some common barriers to problem solving are: • Not identifying the true cause of the problem. For example, assuming your partner’s recent disinterest means he/she is losing feelings for you, when the actual reason is work stress. • Choosing a solution before considering all options. • Trying to solve the problem without your partner’s input.

Ways to enhance problem solving skills: • Separate big problems into smaller ones and deal with each individually in order of importance. • Consider many possible options and strategies before choosing a solution. • Work with your partner as a partner. Both of you need to have a sense of shared ownership in the process and the outcomes.

Inadequate Partner Support Both partners need to give and receive adequate support for a relationship to survive and flourish.

Some common problems with partner support are: • Having unrealistic expectations and demands. • Relying on your partner to meet all of your support needs likely places too much pressure on them. • Not effectively communicating your needs can result in arguments. Ways to enhance partner support: • Identify and be realistic about the support you need. • Realize that your partner will not be able to meet all of your needs. Some of these needs will have to be met outside the relationship. • Communicate your expectations clearly. Check if he/she can fulfill your expectations / understands your expectations for support.

Lack of Quality Time Together Spending time together is not “quality” when you are tired and distracted, and end up arguing or failing to enjoy each other’s company.

Quality time together involves: • Jointly planning to spend quality time together. When planning, focus on positive things, unless you agree to do otherwise. • Identifying shared interests that you can enjoy together and try to think of new ones that you can try.

Personal Differences in the Relationship All couples will have differences in their relationships. The way you deal with these differences can either enhance or add stress to the relationship.

Ways to deal with personal differences: • People in successful relationships do not try to force the other to be exactly like them; they work to accept difference even when this difference is profound. • Do not demand that a partner change to meet all your expectations. Work to accept the differences that you see between your ideal and the reality. • Try to see things from the other's point of view. This doesn't mean that you must agree with one another, but rather that you can expect yourself and your partner to understand and respect your differences, your points of view and your separate needs.

Golden rules for arguing constructively

DON’T: DO: • Behave aggressively or disrespectfully • Know why you are arguing before you start • Argue deliberately to hurt the other • Devote some time to resolving the problem person's feelings Sit down and make eye contact • • Generalize problems to entire relationship • Speak personally about what you feel • Bring up old unresolved disputes • Acknowledge when the other person makes • Walk away without deciding when a valid point discussion will be resumed (unless violence

• Agree to differ if you cannot agree threatens) • Stick to the matter at hand • Bring other peoples' opinions into the • Cease arguing and separate if there is any argument likelihood of violence • Argue about something for more than an hour, late at night or after drinking alcohol

Sexual Problems

What leads to sexual What reduces sexual Results of sexual problems problems? problems • Side effects from • Relationship • Medical treatment certain medications difficulties (if problem is biological) • Medical problems • Feeling distant • Reduced performance demands • Relationship • Anxiety • Sexual exercises difficulties • Psychological • Guilt • Realistic factors expectations • Physical • Low self-esteem • Individual/Couple environment therapy

What Are Sexual Problems? Sexual problems are problems related to the sexual interactions between couples. Problems can occur during desire, arousal, or orgasm stages. Sexual problems are not rare. • Approximately 20% of married couple and 30% of non-married couples have sexual contact than 10 times per year • Approximately 43% of women and 31% of men of all ages report having sexual problems • 1 in 3 women complain of a lack of sexual desire • Inhibited sexual desire affects 15% of men and increases with age

Sexual problems can have a powerful impact on relationships. Clinicians suggest that sexuality contributes to about 15-20% of a marital relationship. When sexual problems occur, they contribute up to 50-75%, which can be very draining to the marriage.

What Leads to Sexual Problems?

Many medications can affect your sexual desire, arousal, and orgasm:

• Antidepressants • alcohol • some allergy • mood stabilizers • narcotics • hypertension • anxiolytics • oral contraceptives • glaucoma medications • chemotherapy drugs • hormonal therapies • anticonvulsants

Certain medical problems or surgeries can impact sexual functioning:

• Chronic pain • hypertension • emphysema • insomnia • thyroid conditions • cancer • diabetes • heart disease

Recent surgeries that have impacted sexual organs:

• mastectomy • prostatectomy • hysterectomy • orchiectomy, etc. for males • removal of ovaries for females

Difficulties within the relationship can lead to sexual problems:

• Dissatisfaction • poor communication • lack of emotional expression • resentment • different value systems • lack of physical affection • power struggles • lack of intimacy • different sexual preferences

Personal and Psychological Factors:

• Fatigue • age • poor body image • stress • performance anxiety • narrow or unrealistic • depression • negative beliefs about sex or standards for sexual certain sexual practices interactions • anxiety • low self-esteem

What’s a Normal Sexual Response Anyway? The way people respond sexually is variable. Most couples/partners don’t have the same response at the same time. Problems can occur when the arousal phase is not achieved, when the plateau period is extended, or when orgasm does not occur.

Male Sexual Responses (example) Female Sexual Responses (example)

Orgasm Refractor Possible Orgasm Possible y Period 2nd arousal 2nd arousal and and

Plateau Arousa

Arousal

Resolutio Plateau Resolutio

Common Female Sexual Dysfunctions • Inhibited sexual desire: low or no desire for sexual intercourse. Sexual desire involves positive anticipation and a sense of deserving pleasure. • Nonorgasmic response during partner sex: inability to achieve orgasm during intercourse. This is a normal variation in the female sexual response cycle. • Painful intercourse (dyspareunia): genital pain associated with sexual intercourse, commonly experienced during coitus, but may also occur before or after intercourse. • Female arousal dysfunction: persistent or recurrent inability to attain or to maintain until completion of sexual activity, often not feeling “turned on” or not producing an appropriate amount of lubrication. • Primary nonorgasmic response: persistent or recurrent delay or absence of an orgasm following sexual stimulation • Vaginismus: pain during intercourse associated with high anticipatory anxiety, dissatisfaction with their bodies, and intimidation by their partners’ sexual desire and arousal.

Common Male Sexual Dysfunction • Early ejaculation: onset or orgasm and ejaculation with little sexual stimulation, or before, on, or shortly after penetration. • Erectile dysfunction: inability to attain or maintain an adequate erection during sexual activity. • Inhibited sexual desire: Lack of desire for sex. Often secondary to another problem such as erectile dysfunction or ejaculatory inhibition, and typically worsens over time due to a cycle of anticipatory anxiety. • Ejaculatory inhibition: inability to ejaculate during intercourse. Men with this problem may be able to ejaculate through oral or manual stimulation, but not during intercourse.

Treating Sexual Problems • Treatment of sexual problems takes on a variety of forms due to the variety of problems. • Realistic expectations must be understood by both partners. Anxiety plays a large role is sexual problems. Worries about performance only make performance worse. • Important to see physician to ensure problem is not biological and to receive appropriate medical care if it is.

Decreasing Sexual Problems with Desire • Build a sense of comfort with nudity and body image • Take turns initiating • Identify characteristics each partner finds attractive • Initiate erotic touching on a weekly basis • Establish a trust/vulnerability position • Stop any uncomfortable sexual experience (especially true for those who have survived sexual trauma)

Decreasing Sexual Problems with Pain • Partner’s need to be actively engaged in the process and couples need to function as an intimate unit • Gain knowledge and comfort with genitalia • Use of relaxation strategies • Use of lubrication • Controlling the type and pacing of sexual activity

Activities that can decrease sexual problems • Self-exploration and stimulation. This can help you increase awareness of your own body and make it easier to communicate likes and dislikes to your partner. • Changing negative thoughts and assumptions about what sex should be with more positive and realistic thoughts about what feels good and right for you. • Challenging negative thoughts about your partner by focusing on what is attractive and positive about them. • Physical exercise: Increases blood flow, reduces tension, enhances body image, and can improve other conditions that hinder sexual functioning • Rebuild or establish emotional intimacy: o Schedule time together when you simply talk to each other. Use the time to share feelings and get reacquainted with what is attractive and unique about your partner. o Share leisure activities o Add small expressions of affection back into your daily routine if this is lacking (i.e. an affectionate note, phone call, or e-mail; hugs or hand-holding, etc.) • Increase communication

o Discuss sexual interests, desires, needs, and difficulties when you are NOT engaged in sexual activity. o Talk about what is going well and what you would like to be different in the relationship overall, then work together to come up with do-able solutions. • Add something new to sexual encounters (e.g., place, position, clothing, technique, erotica) • Allow more time for foreplay and provide more partner-guided stimulation. • During sexual encounters focus on sensations rather than thoughts, performance, expectations, and appearances.

Recommended Reading • Schnarch, David (1997). Passionate marriage: Keeping love & intimacy alive in committed relationships. • Weiner-Davis, Michele (2003). The sex-starved marriage: A couple’s guide to boosting their marriage libido.

Insomnia

Results of Insomnia What Leads to Insomnia What maintains insomnia? • Physiological arousal • Acute stress • Inaccurate thoughts about sleep • Worrisome thinking • Personal loss (death, separation, divorce, etc) • Sleeping pills • Anxiety • Medical problems • Myths about duration of sleep • Depression • Work problems • Daytime napping • Family conflict • Family problems • Excess time in bed • Work problems • Irregular sleep schedule • Performance anxiety • Loss of motivation • Medications for health problems

How can I improve my sleep? Change your sleep behavior.

Go To Bed Only When You Are Sleepy There is no reason to go to bed if you are not sleepy. When you go to bed too early, it only gives you more time to become frustrated. Individuals often ponder the events of the day, plan the next day’s schedule, or worry about their inability to fall to sleep. These behaviors are incompatible with sleep, and tend to perpetuate insomnia. You should therefore delay your bedtime until you are sleepy. This may mean that you go to bed later than your scheduled bedtime. However, stick to your scheduled rising time regardless of the time you go to bed.

Get Out of Bed when You Can’t Fall Asleep or Cannot Go Back to Sleep in 15 Min When you recognize that you’ve become a clockwatcher, get out of bed. If you wake up during your sleep and you’ve tried falling back to sleep for 15 minutes and can’t, get out of bed. Remember, the goal is to fall to sleep quickly. Return to bed only when you are sleepy (i.e., yawning, head bobbing, eyes closing, concentration decreasing). The goal is for you to reconnect your bed with sleeping rather than frustration. You will have to repeat this step as often as necessary.

Use Your Bed or Bedroom for Sleep and Sex Only The purpose of this guideline is to associate your bedroom with sleep rather than wakefulness. Just as you may associate the kitchen with hunger, this guideline will help you associate sleep and pleasure with your bedroom. Follow this rule both during the day and at night. DO NOT watch TV, listen to the radio, eat or read in bed. You may have to temporarily move the t.v. or radio from your bedroom to help you regain a stable sleep cycle.

Sleep Hygiene Guidelines to Improve your Sleep Behavior

1. NO CAFFEINE: No caffeine 6-8 hours before bedtime Yep, its true caffeine disturbs sleep; even for people who do not think they experience a stimulation effect. Individuals with insomnia are often more sensitive to mild stimulants than normal sleepers. Caffeine is found in items such as coffee, tea, soda, chocolate, and many over-the-counter medications (e.g., Excedrin).

2. AVOID NICOTINE: Avoid nicotine before bedtime Nicotine is a stimulant. It is a myth that smoking helps you “relax.” As nicotine builds in the system it produces an effect similar to caffeine. DO NOT smoke to get yourself back to sleep.

3. AVOID ALCOHOL: Avoid alcohol after dinner Alcohol often promotes the onset of sleep, but as alcohol is metabolized sleep becomes disturbed and fragmented. Thus, a large amount of alcohol is a poor sleep aid and should not be used as such. Limit alcohol use to small quantities to moderate quantities.

4. NO SLEEPING PILLS: Sleep medications are effective only temporarily Scientists have shown that sleep medications lose their effectiveness in about 2 - 4 weeks when taken regularly. Over time, sleeping pills actually make sleep problems worse. When sleeping pills have been used for a long period, withdrawal from the medication can lead to an insomnia rebound. Thus, after long-term use, many individuals incorrectly conclude that they “need” sleeping pills in order to sleep normally.

5. REGULAR EXERCISE: Preferably 40 minutes each day Exercise in the late afternoon or early evening can aid sleep, although the positive effect often takes several weeks to become noticeable. Do not exercise within 2 hours of bedtime because it may elevate your nervous system activity and interfere with falling asleep.

6. BEDROOM ENVIRONMENT: Moderate temperature, quiet, dark and comfortable Extremes of heat or cold can disrupt sleep. Noises can be masked with background white noise (such as the noise of a fan) or with earplugs. Bedrooms may be darkened with black- out shades or sleep masks can be worn. Position clocks out-of-sight since clock-watching can increase worry about the effects of lack of sleep. Be sure your mattress is not too soft or too firm and that your pillow is the right height and firmness.

7. EATING You should avoid the following foods at bedtime: anything caffeinated like chocolate, peanuts, beans, most raw fruits and vegetables (they may cause gas), and high-fat foods such as potato chips or corn chips. Be especially careful to avoid heavy meals and spices in the evening. Do not go to bed too hungry or too full. Avoid snacks in the middle of the night because awakening may become associated with hunger. A light bedtime snack, such a glass of warm milk, cheese, or a bowl of cereal can promote sleep.

8. AVOID NAPS The sleep you obtain during the day takes away from your sleep needed at night resulting in lighter, more restless sleep, difficulty falling asleep or early morning awakening. If you must nap, keep it brief, and try to schedule it before 3:00 pm. It is best to set an alarm to ensure you don’t sleep more than 15-30 minutes.

9. UNWIND Allow yourself at least an hour before bedtime to wind down. The brain is not a light switch that you can instantly cut on and off. Most of us cannot expect to go full speed till 10:00 pm then fall peacefully to sleep at 10:30 pm. Take a hot bath, read a novel, watch some TV, or have a pleasant talk with your spouse or kids. Find what works for you and make it your routine before bed. Be sure not to struggle with a problem, get into an argument before bed or anything else that increases your body’s arousal.

10. REGULAR SLEEP SCHEDULE Spending excessive time in bed has two unfortunate consequences - (1) you begin to associate your bedroom with arousal and frustration and (2) your sleep actually becomes shallow. Surprisingly, it is very important that you cut down your sleep time in order to improve sleep! Set the alarm clock and get out of bed at the same time each morning, weekdays and weekends, regardless of your bedtime or the amount of sleep you obtained on the previous night. You probably will be tempted to stay in bed if you did not sleep well, but try to maintain your new schedule. This guideline is designed to regulate your internal biological clock and reset your sleep-wake rhythm.

It usually takes 2-3 months for a sleep problem to get totally better, but most people see improvements within 2-3 weeks if they consistently follow the guidelines.

Obstructive Sleep Apnea What it is and How it is Treated

Obstructive sleep apnea (OSA) is defined as a periodic reduction or cessation of breathing due to narrowing of the upper airways during sleep. This condition affects approximately 2% of women and 4% of men in the U.S. However, about 95% of all cases go undiagnosed and untreated, which is alarming considering that untreated obstructive sleep apnea poses several major health risks.

Studies show that patients with sleep apnea have increased baseline heart rates, increased blood pressure, and lower levels of blood oxygen, which may put them at increased risk for cardiovascular problems such as hypertension, stroke, and heart failure. Often, patients present to their primary care manager (PCM) complaining of persistent daytime fatigue, regardless of how much sleep they have had the night before. The good news for patients who have been diagnosed with OSA is that with proper treatment and lifestyle change, full recovery can be achieved and the health risks reversed.

Common Symptoms Risk Factors • Snoring • First degree relative diagnosed with • Daytime sleepiness or fatigue sleep apnea • Sleep fragmentation or recurrent night • Obesity awakenings • Hypertension • Unrestful sleep • Male gender • Increased irritability • Age (greater than 40) • Morning headaches • Neck circumference • Decreased memory • Postmenopausal women (higher risk • Difficulty concentrating than premenopausal) • Nocturia (awakening from sleep to urinate) • Falling asleep while driving

How is sleep apnea diagnosed? A nocturnal polysomnogram (sleep study) is conducted by sleep specialists to diagnose obstructive sleep apnea. During this assessment information regarding chest wall effort, airflow, body positioning, snoring, and oxyhemoglobin saturation is recorded. As you may have guessed, the sleep specialists literally observe you sleeping while monitoring your brain / sleep patterns. Often times, patients report their sleep duration as being longer or shorter than it actually is. This assessment can identify exact sleep onset time, wake after sleep onset episodes and the depth and quality of your sleep.

Treatments A variety of treatments for sleep apnea exist and the use of each treatment is determined by the severity of the disturbance in breathing during sleep. A combination of the following treatments provided by a multidisciplinary team is ideal and can include: a behavioral medicine specialist, a nutritionsist, an exercise specialist, a respiratory therapist and a pulmonary doctor that has specialty training in sleep disorders. Below is a description of the types of treatments that are currently available for OSA.

Behavioral • Weight loss –as little as a10% decrease in body weight has been found to have significant improvement in obstructive breathing problems. • Avoidance of alcohol and sedatives • Avoidance of sleep deprivation • Positioning – Laying on side rather than back Medical • CPAP Mask – Positive pressure through a mask • Oral Appliance – Recommended for patients with mild to moderate sleep apnea Surgical Sometimes used when patients are unable to tolerate positive airway pressure and for those that find other treatments ineffective. However, sometimes surgeries do not entirely eliminate the obstruction.

Treatment Goals • Establish normal nocturnal oxygenation and ventilation • Eliminate snoring • Eliminate disruption of sleep

Continuous Positive Airway Pressure (CPAP) Nasal continuous positive airway pressure (CPAP) is the most common treatment for moderate to severe obstructive sleep apnea. Research finds that this method is also highly effective when used for more than 4.5 hours a night on a consistent basis. Studies have also shown that adequate CPAP use can decrease the risk of cardiovascular diseases in patients with sleep apnea. A CPAP unit provides immediate effects and complications with CPAP treatment are rare. However, use of the CPAP masks may result in some level of discomfort. The following table shows effective corrections for negative side effects from CPAP masks. However, if symptoms persist, contact your physician.

Problems associated Cause Adjustment with CPAP Masks Nasal congestion Dry air Try nasal saline spray before bedtime or upon Dry nose and/or throat awakening. Add heated humidification. Try antihistamines or topical corticosteroids.

Dry mouth Sleeping with mouth Try a chin strap and if it is not helpful consider a open full-face mask. Add heated humidification.

Sore, dry, irritated or swollen Mask leaks Try readjusting the mask on face. Readjust eyes Mask too tight headgear straps. Inspect mask for breaks. Use eye patch. Runny nose Dry air Try saline nasal spray before bedtime. Try topical nasal steroid preparation before bedtime. Add heated humidification. Hay fever Irritants drawn in Put unit away from dust or animal hairs. with room air Some units can have special filters added. through machine Add heated humidification. Air leaks Strap is loose or Readjust headgear straps. The mask should be tight. loose but still create a seal. Incorrect mask size. Nasal pillows may improve fit. Worn-out mask. Consider full face mask that covers nose and Dirty mask mouth. Inspect mask for leaks or cracks. Wash mask daily. Chest discomfort Pressure Try pressure ramp at beginning of sleep period. Sensation of too much requirement may be Reduce pressure with bilevel positive airway pressure. lower at beginning of pressure. Difficulty exhaling sleep period Feelings of claustrophobia Initial adjustment Consider changing mask (nasal mask, full face, period nasal prongs)

CPAP machine too noisy Blocked air intake Check if filter is clean and not blocked by item. Too close to sleep Place unit farther away. May need to add to area length of hose.

Bed partner intolerance Noise, anxiety Attend patient support group (such as, A.W.A.K.E Network of the American Sleep Apnea Association)

Non -Compliance The most common form of treatment for sleep apnea is with continuous positive airway pressure (CPAP). However, as many as 50% of patients stop CPAP therapy during the first 2-4 weeks of treatment because of the negative side effects.

Did you know that research has found that…… • CPAP refusers are more likely to be female and current smokers. • Non-compliance is related to high BMI (>30 kg/m2) and CPAP pressure >12. • Acceptance of CPAP treatment is not predicted by severity of sleep apnea or degree of sleepiness. • Adequate compliance = >4.5 hours of CPAP use per night on a regular basis. • Patient education is especially important first month of treatment. • Follow-up with physician is important at least once after initiation of treatment and annually thereafter. • Noncompliance is classified in terms of tolerance problems, psychological factors, and lack of education, support and adequate follow-up care.

Improving Sleep through Behavior Change

Stimulus Control Procedures

Go to Bed only when You are Sleepy There is no reason to go to bed if you are not sleepy. When you go to bed too early, it only gives you more time to become frustrated. Individuals often ponder the events of the day, plan the next day’s schedule, or worry about their inability to fall to sleep. These behaviors are incompatible with sleep, and tend to perpetuate insomnia. You should therefore delay your bedtime until you are sleepy. This may mean that you go to bed later than your scheduled bedtime. Remember to stick to your scheduled arising time regardless of the time you go to bed.

Get Out Of Bed When You Can’t Fall Asleep Or Go Back To Sleep In About 15 Minutes. Return to Bed Only When You Are Sleepy. Repeat This Step As Often As Necessary. Although we don’t want you to be a clockwatcher, get out of bed if you don’t fall to sleep fairly soon. Remember, the goal is for you to fall to sleep quickly. Return to bed only when you are sleepy. When you feel sleepy (i.e., yawning, head bobbing, eyes closing, concentration decreasing), then return to bed. The object is for you to reconnect your bed with sleeping rather than frustration. It will be demanding to follow this instruction, but many people from all walks of life have found ways to adhere to this guideline.

Use the Bed or Bedroom for Sleep and Sex Only; Do Not Watch TV, Listen to the Radio, Eat, or Read in Your Bedroom. The purpose of this guideline is to associate your bedroom with sleep rather than wakefulness. Just as you may associate the kitchen with hunger, this guideline will help you associate sleep with your bedroom. Follow this rule both during the day and at night. You may have to temporarily move the TV or radio from your bedroom to help you during treatment.

Sleep Hygiene Guidelines Good dental hygiene is important in determining the health of your teeth and gums. We all know we are supposed to brush and floss regularly. Those who do so are more likely to have strong, healthy gums and less cavities. Similarly good sleep hygiene is important in determining the quality and quantity of your sleep. Below are guidelines for good sleep hygiene practices. Review these guidelines and evaluate how well you practice good sleep hygiene.

Caffeine: Avoid Caffeine 6-8 Hours before Bedtime Caffeine disturbs sleep, even in people who do not think they experience a stimulation effect. Individuals with insomnia are often more sensitive to mild stimulants than are normal sleepers. Caffeine is found in items such as coffee, tea, soda, chocolate, and many over-the-counter medications (e.g., Excedrin). Thus, drinking caffeinated beverages should be avoided near bedtime and during the night. You might consider a trial period of no caffeine if you tend to be sensitive to its effects.

Nicotine: Avoid Nicotine before Bedtime Although some smokers claim that smoking helps them relax, but nicotine is a stimulant. The initial relaxing effects occur with the initial entry of the nicotine, but as the nicotine builds in the system it produces an effect similar to caffeine. Thus, smoking, dipping, or chewing tobacco should be avoided near bedtime and during the night. Don’t smoke to get yourself back to sleep.

Alcohol: Avoid Alcohol after Dinner Alcohol often promotes the onset of sleep, but as alcohol is metabolized sleep becomes disturbed and fragmented. Thus, a large amount of alcohol is a poor sleep aid and should not be used as such. Limit alcohol use to small quantities to moderate quantities.

Sleeping Pills: Sleep Medications are Effective Only Temporarily Scientists have shown that sleep medications lose their effectiveness in about 2 - 4 weeks when taken regularly. Despite advertisements to the contrary, over-the-counter sleeping aids have little impact on sleep beyond the placebo effect. Over time, sleeping pills actually can make sleep problems worse. When sleeping pills have been used for a long period, withdrawal from the medication can lead to an insomnia rebound. Thus, after long-term use, many individuals incorrectly conclude that they “need” sleeping pills in order to sleep normally. Keep use of sleep pills infrequent, but don’t worry if you need t use one on an occasional basis.

Regular Exercise Get regular exercise, preferably 40 minutes each day of an activity that causes sweating. . Exercise in the late afternoon or early evening seems to aid sleep, although the positive effect often takes several weeks to become noticeable. Exercising sporadically is not likely to improve sleep, and exercise within 2 hours of bedtime may elevate nervous system activity and interfere with sleep onset.

Bedroom Environment: Moderate Temperature, Quiet, and Dark Extremes of heat or cold can disrupt sleep. A quiet environment is more sleep promoting than a noisy one. Noises can be masked with background white noise (such as the noise of a fan) or with earplugs. Bedrooms may be darkened with black-out shades or sleep masks can be worn. Position clocks out-of-sight since clock-watching can increase worry about the effects of lack of sleep. Be sure your mattress is not too soft or too firm and that your pillow is the right height and firmness.

Eating A light bedtime snack, such a glass of warm milk, cheese, or a bowl of cereal can promote sleep. You should avoid the following foods at bedtime: any caffeinated foods (e.g., chocolate), peanuts, beans, most raw fruits and vegetables (since they may cause gas), and high-fat foods such as potato chips or corn chips. Avoid snacks in the middle of the nights since awakening may become associated with hunger. If you have trouble with regurgitation, be especially careful to avid heavy meals and spices in the evening. Do not go to bed too hungry or too full. It may help to elevate you head with some pillows.

Avoid Naps Avoid naps, the sleep you obtain during the day takes away from you sleep need that night resulting in lighter, more restless sleep, difficulty falling asleep or early morning awakening. If you must nap, keep it brief, and try to schedule it before 3:00 pm. It is best to set an alarm to ensure you don’t sleep more than 15-30 minutes.

Allow Yourself At Least an Hour before Bedtime to Unwind The brain is not a light switch that you can instantly cut on and off. Most of us cannot expect to go full speed till 10:00 pm then fall peacefully to sleep at 10:30 pm. Take a hot bath, read a novel, watch some TV, or have a pleasant talk with your spouse or kids. Find what works for you. Be sure not to struggle with a problem, get into an argument before bed or anything else that might increase your body’s arousal.

Regular Sleep Schedule Keep a regular time each day, 7 days a week, to get out of bed. Keeping a regular awaking time helps set your circadian rhythm set so that your body learns to sleep at the desired time.

Set A Reasonable Bedtime and Arising Time and Stick to Them. Spending excessive time in bed has two unfortunate consequences - (1) you begin to associate your bedroom with arousal and frustration and (2) your sleep actually becomes more shallow. Surprisingly, it is very important that you cut down your sleep time in order to improve sleep! Set the alarm clock and get out of bed at the same time each morning, weekdays and weekends, regardless of your bedtime or the amount of sleep you obtained on the previous night. You probably will be tempted to stay in bed in the morning if you did not sleep well, but try to maintain your new schedule. This guideline is designed to regulate your internal biological clock and reset your sleep-wake rhythm.

Sticking to the Changes You Make

It can be difficult to stick to a self-management program. However, it is important to remind yourself that the sleep guidelines have been extensively researched and represent the best science has to offer for conquering a long-term insomnia problem. Literally, thousands of individuals have improved their sleep through following the guidelines. The following points may help you to stick to the guidelines.

1. Find activities to engage in when out of bed during the night. • Plan activities to engage in when you are not in bed at night because you can’t fall asleep. These activities should be non-stimulating. • Prepare any materials needed to get out of bed (e.g., robe, book, etc.) ready prior to bedtime.

2. Identify cues to determine sleepiness and time to return to bed. • Examples of “Sleepy Behavior” include yawning, heavy eyelids, nodding off, etc. • Remember that the longer you stay up and the sleepier you are, the quicker you will fall to sleep.

3. Use alarm clock to maintain regular arising time. • You may also want to plan social, work or family commitments soon after waking to increase motivation to adhere to arising time.

4. Find competing activities to fight the urge to take a nap before your bedtime. • These activities should be physical (e.g., housework, walking) rather than cognitive (e.g., reading) or passive (e.g., watching TV). • Examples include: taking a walk, having someone visit in the evening, talking on the phone to a friend, working a puzzle, drawing, etc.

5. Secure support from your spouse/significant others. • Typically your bed partner will be deeply asleep and will not notice you getting out of bed. • Have friends/family members help you adhere to the sleep guidelines. For example, a family member could play a game with you to help you stay awake until bedtime.

6. Remember the time-limited nature of following these procedures. • It usually takes 2-3 months for a sleep problem to get totally better but most people see improvements within 2-3 weeks if the consistently follow the guidelines. Isn’t sticking to the guidelines for this short period worth it if your sleep ultimately improves?

Sleep Diary Instructions In order to better understand your sleep problem and to assess your progress during treatment, we’d like you to collect some important information about your sleep habits. • Before you go to sleep at night, please answer Questions 1 - 6. • After you get up in the morning, please answer the remaining questions, Questions 7 - 13. It is very important that you complete the diary every evening and morning!!! Please don’t attempt to complete the diary later. If you have any difficulties completing the diary, please contact one of the BHP staff members at (210) 670-5968 and we’ll be glad to assist you.

It’s often difficult to estimate how long you take to fall asleep or how long you’re awake at night. Keep in mind that we simply want your best estimates.

If any unusual events occur on a given night (e.g., emergencies, phone calls) please make a note of it on the diary (at the bottom of the sheet).

Below are some guidelines to help you complete the Sleep Diary.

1. Napping: Please include all times you slept during the day, even if you didn’t intend to fall asleep. For example, if you fell asleep for 10 minutes during a movie, please write this down. Remember to specify a.m. or p.m., or use military time.

2. Sleep Medication: Include both prescribed and over-the-counter medications. Only include medications used as a sleep aid.

3. Alcohol as a sleep aid: Only include alcohol that you used as a sleep aid.

4. Bedtime: This is the time you physically got into bed, with the intention of going to sleep. For example, if you went to bed at 10:45 p.m. but turned the lights off to go to sleep at 11:15 p.m., write down 10:45 p.m.

5. Lights-Out Time: This is the time you actually turned the lights out to go to sleep.

6. Time Planned to Awaken: This is the time you plan to get up the following morning.

7. Sleep-Onset Latency: Provide your best estimate of how long it took you to fall asleep after you turned the lights off to go to sleep.

8. Number of Awakenings: This is the number of times you remember waking up during the night.

9. Duration of Awakenings: Please estimate how many minutes you spent awake for each awakening. If this proves impossible, then estimate the number of minutes you spent awake for all awakenings combined. Don’t include your very last awakening in the morning, as this will be logged in number 10.

10. Morning Awakening: This is the very last time you woke up in the morning. If you woke up at 4:00 a.m. and never went back to sleep, this is the time you write down. However, if you woke up at 4:00 a.m. but went back to sleep for a brief time (for example, from 5:00 a.m. to 5:15 a.m.), then your last awakening would be 5:15 a.m.

11. Out-of-Bed Time: This is the time you actually got out of bed for the day.

12. Restedness upon Arising: Rate your restedness using the scale on the diary sheet.

13. Sleep Quality: Rate the quality of your sleep using the scale on the diary sheet.

Sleep Diary Name: ______

Week:______to ______(Beginning date) (Ending date)

Example: Fill in the Day of the Week above each column

Mon. 1. I napped from to (note times of all naps). 2:00 to 2:45 pm 2. I took mg of sleep medication as a sleep aid. ProSom 1 mg 3. I took oz. of alcohol as a sleep aid. Beer 12 oz. 4. I went to bed at o’clock. 10:30 5. I turned the lights out at o’clock. 11:15 6. I plan to awaken at o’clock. 6:15 7. After turning the lights out, I fell asleep in minutes. 45 8. My sleep was interrupted times (specify number of 3 nighttime awakenings). 9. My sleep was interrupted for minutes (specify 20 duration of each awakening). 30 15 10. I woke up at o’clock (note time of last awakening). 6:15 11. I got out of bed at o’clock (specify the time). 6:40 12. When I got up this morning I felt . 2 (1 = Exhausted, 2 = Tired, 3 = Average, 4 = Rather Refreshed, 5 = Very Refreshed) 13. Overall, my sleep last night was . 1 (1 = Very Restless, 2 = Restless, 3 = Average, 4 = Sound, 5 = Very Sound)

NOTES:

Sleep Checklist

Question Yes No Do you avoid caffeine 4 - 6 hours before bedtime? Recommendation:

Do you avoid nicotine before bedtime? Recommendation:

Do you avoid alcohol after dinner? Recommendation:

Do you avoid vigorous exercise within 2 hours of bedtime? Recommendation:

Do you have a “wind-down” ritual at least an hour before bed? Recommendation:

Do you nap during the day? Recommendation:

Is your bedroom comfortable (good temperature, quiet, and dark)? Recommendation:

Do you wake-up at about the same time each morning? Recommendation:

Do you go to bed only when you are sleepy? Recommendation: If you wake in the middle of the night or early morning, do you lie in bed for more than 15-20 minutes? Recommendation:

Do you watch TV, listen to the radio, eat, or read in your bedroom? Recommendation:

Facts about Sleep

Prevalence of Insomnia Insomnia is a widespread problem affecting essentially everyone at one period in their lifetime. It is perhaps the most frequent health complaint after pain. A Gallup survey conducted in 1991 found that 36% of Americans suffer from some type of sleep problem, with 27% reporting occasional insomnia and 9% reporting chronic insomnia. Surveys of physicians indicate that 19% of medical outpatients complain of insomnia.

Factors Which Make You Vulnerable to Insomnia • Increased Physiological Arousal • Worrisome Thinking Style • Models of Poor Sleep Habits • Anxiety • Aging • Depression Factors Which May Initially Cause Insomnia • Acute Stress • Personal Loss (e.g., death, divorce separation) • Family Conflict • Work Problems • Jet Lag • Medical Problems • Hospital Stay • Chronic Low-level Stress • Changes in Schedules (work, etc.) • Pain Factors Which Maintain Insomnia • Poor Sleep Habits • Extreme Worry or Concern about Getting to Sleep • Sleeping Pills • Medications • Irregular Sleep Schedule • Daytime Napping • Anxious Thinking • Excessive Time Spent in Bed when Not Sleeping • Activity that “Keys-up” the Body Before Bed • Misinformation about the Effects of Sleep • Misinformation about “Normal” Sleep Problems Aging and Sleep As individuals age, they often have more interrupted sleep. Instead of having one consolidated sleep period at night, they may sleep in two to four sleep episodes. As we age, total time in bed increases, but total sleep time decreases. Generally, as people grow older, there is an increase in light sleep and a decrease in deep sleep. However, aging alone does not account for all the sleep problems seniors experience and behavioral insomnia treatment has been found to be effective for seniors.

Alcohol and Sleep Although alcohol may help you to go to sleep faster, alcohol actually causes sleep to be less deep and more fragmented.

Sleep Needs Sleep needs vary considerably among individuals. Sleep needs range from 3 to 10 hours of sleep. Some people may get by on 4-5 hours, others feel good after 9 hours. Each individual’s

sleep needs varies somewhat day-to-day; some days 6 hours will be okay while other days 8 hours will be optimal.

Health Consequences There is no evidence that anyone has died from lack of sleep. Excessive worrying about insomnia may be more detrimental to health than sleep loss itself.

Daytime Consequences Scientists have found that performance impairments as a result of poor sleep are fairly limited as long as you get from 4-5 hours of sleep on most nights. Excessive worrying or concern about insomnia appears to have more affect on our functioning than sleep loss itself.

Resting; Is it Better than Nothing? Actually, staying in bed to rest when you are not sleeping can make an insomnia problem worse. When you stay in bed awake for too long, you begin to associate your sleep surroundings with frustration and arousal rather than sleep. The harder you try to sleep, the less likely you are to succeed.

Behavioral Treatment for Insomnia

Behavioral procedures for insomnia have been extensively tested throughout the world and have been shown to be effective with other patients suffering insomnia problems. About 75% of chronic insomniacs benefit from this intervention, with an average improvement rate of 50- 60% in the reduction time it takes to fall asleep and/or time awake after going to sleep. Following the highly structured guidelines requires time, patience, and effort. To achieve your goals of falling asleep quickly at bedtime and of reducing the time spent awake in the middle of the night, it is important that you follow all the guidelines. You cannot choose only those that seem least painful.

It is likely that in about 4 weeks you will experience substantial improvement in your sleep. However, it sometimes takes 2-3 weeks to start noticing improvement. Therefore, it is important guard against discouragement in the early stages of treatment. Further, during the first week of practice some people report that they feel worse. It is only after about three to four weeks of consistent practice that people start to experience significant benefits. The benefits of these highly effective procedures are related to how closely and consistently one follows the guidelines.

For the first few nights you may be getting up many times before you fall asleep. You are likely to be sleepy the next day. You may become discouraged and even think about discontinuing behavioral treatment. You will think of many reasons why you can’t or shouldn’t follow the guidelines. Remind yourself that for most individuals the worsening of sleep is only temporary and is the path to a future of better sleep. You will see gradual and long-term improvement in your sleep. People tell us that regaining control of their sleep was definitely worth the temporary disruption caused by following the guidelines. So, don’t talk yourself out of gaining control of your sleep!

Sleep Guidelines

Good dental hygiene is important in determining the health of your teeth and gums. We all know we are supposed to brush and floss regularly. Those who do so are more likely to have strong, healthy gums and fewer cavities. Similarly good sleep hygiene is important in determining the quality and quantity of your sleep. Below are guidelines for good sleep hygiene practices. Review these guidelines and evaluate how well you practice good sleep hygiene.

Caffeine: Avoid Caffeine 6-8 Hours Before Bedtime Caffeine disturbs sleep, even in people who do not think they experience a stimulation effect. Individuals with insomnia are often more sensitive to mild stimulants than are normal sleepers. Caffeine is found in items such as coffee, tea, soda, chocolate, and many over-the-counter medications (e.g., Excedrin). Thus, drinking caffeinated beverages should be avoided near bedtime and during the night. You might consider a trial period of no caffeine if you tend to be sensitive to its effects.

Nicotine: Avoid Nicotine Before Bedtime Although some smokers claim that smoking helps them relax, but nicotine is a stimulant. The initial relaxing effects occur with the initial entry of the nicotine, but as the nicotine builds in the system it produces an effect similar to caffeine. Thus, smoking, dipping, or chewing tobacco should be avoided near bedtime and during the night. Don’t smoke to get yourself back to sleep.

Alcohol: Avoid Alcohol After Dinner Alcohol often promotes the onset of sleep, but as alcohol is metabolized sleep becomes disturbed and fragmented. Thus, alcohol is a poor sleep aid and will lead to less restful sleep.

Regular Exercise Get regular exercise, preferably 30 minutes each day of an activity that causes sweating. . Exercise in the late afternoon or early evening seems to aid sleep, although the positive effect often takes several weeks to become noticeable. Exercising occasionally is not likely to improve sleep, and exercise within 2 hours of bedtime is likely to interfere with sleep onset.

If you have trouble with regurgitation, be especially careful to avoid heavy meals and spices in the evening. Do not go to bed too hungry or too full. It may help to elevate you head with some pillows.

Set A Reasonable Arising Time and Stick to Them Spending excessive time in bed has two unfortunate consequences - (1) you begin to associate your bedroom with arousal and frustration and (2) your sleep actually becomes shallower. Surprisingly, it is very important that you cut down your sleep time in order to improve sleep! Set the alarm clock and get out of bed at the same time each morning, weekdays and weekends, regardless of your bedtime or the amount of sleep you obtained on the previous night. Keeping a regular awaking time helps set your circadian rhythm set so that your body learns to sleep at the desired time. You probably will be tempted to stay in bed in the morning if you did not sleep well, but try to maintain your new schedule. This guideline is designed to regulate your internal biological clock and reset your sleep-wake rhythm.

Go To Bed Only When You Are Sleepy There is no reason to go to bed if you are not sleepy. When you go to bed too early, it only gives you more time to become frustrated. Individuals often ponder the events of the day, plan the next day’s schedule, or worry about their inability to fall to sleep. These behaviors are incompatible with sleep, and tend to perpetuate insomnia. You should therefore delay your bedtime until you are sleepy. Sleepiness is different from feeling tired. Examples of sleepiness include yawning, head bobbing, eyes closing, and concentration decreasing. This may mean

that you go to bed later than your scheduled bedtime. Remember to stick to your scheduled arising time regardless of the time you go to bed.

Get Out of Bed When You Can’t Fall Asleep or Go Back to Sleep in about 15 Minutes. Return to Bed Only When You Are Sleepy. Repeat This Step as Often as Necessary. Although we don’t want you to be a clock watcher, get out of bed if you don’t fall to sleep fairly soon. Remember, the goal is for you to fall to sleep quickly in your bed. Return to bed only when you are sleepy. The object is for you to reconnect your bed with sleeping rather than frustration. It will be demanding to follow this instruction, but many people from all walks of life have found ways to adhere to this guideline.

Use the Bed or Bedroom for Sleep and Sex Only; Do Not Watch TV, Listen to The Radio, Eat, or Read in Your Bedroom. The purpose of this guideline is to associate your bedroom with sleep rather than wakefulness. Just as you may associate the kitchen with hunger, this guideline will help you associate sleep with your bedroom. Follow this rule both during the day and at night. You may have to temporarily move the TV or radio from your bedroom to help you while you work to improve insomnia.

It will take time for your sleep to improve once you begin your sleep change plan.

Are 1-2 months of work worth a lifetime of good sleep?

Sticking To the Guidelines It can be difficult to stick to a self-management program. However, it is important to remind yourself that the sleep guidelines have been extensively researched and represent the best science has to offer for conquering a long-term insomnia problem. Literally, thousands of individuals have improved their sleep through following the guidelines. The following points may help you to stick to the guidelines.

Find activities to engage in when out of bed during the night. Plan activities to engage in when you are not in bed at night because you can’t fall asleep. These activities should be non-stimulating.

Prepare any materials needed to get out of bed (e.g., robe, book, etc.) ready prior to bedtime.

Identify cues to determine sleepiness and time to return to bed. Examples of “Sleepy Behavior” include yawning, heavy eyelids, nodding off, etc.

Remember that the longer you stay up and the sleepier you are, the quicker you will fall to sleep.

Use alarm clock to maintain regular arising time. You may also want to plan social, work or family commitments soon after waking to increase motivation to adhere to arising time.

Find competing activities to fight the urge to take a nap before your bedtime. These activities should be physical (e.g., housework, walking) rather than cognitive (e.g., reading) or passive (e.g., watching TV).

Examples include: taking a walk, having someone visit in the evening, talking on the phone to a friend, working a puzzle, drawing, etc.

Secure support from your spouse/significant others. Typically your bed partner will be deeply asleep and will not notice you getting out of bed.

Have friends/family members help you adhere to the sleep guidelines. For example, a family member could play a game with you to help you stay awake until bedtime.

Remember the time-limited nature of following these procedures. It usually takes 2-3 months for a sleep problem to get totally better but most people see improvements within 2-3 weeks if the consistently follow the guidelines. Isn’t sticking to the guidelines for this short period worth it if your sleep ultimately improves?

Stress and Stress Reduction

The stress reactions below are presented in categories so that they may be more easily recognized and understood. There is no magic number of the symptoms that suggest difficulty in coping. Rather it is the extent to which the noted reaction is a change (different from a person's normal condition) that makes a reaction potentially important. Further, it is the combined presence of symptoms that determines the degree of the problem. Indicators may be isolated reactions or combinations among the three categories listed below. Finally, it is their duration (how long the symptoms have been present/how long they last), the frequency of such incidents (how often they happen) and the intensity (strength) with which they are present that suggests the severity of the difficulty in coping.

Indicators of Difficulty in Coping

Emotional Behavioral Physical Apathy Withdrawal (smoking avoidance) Preoccupation with illness The "blahs" Social isolation (intolerant of/dwelling on minor Recreation no longer Work related withdrawal ailments) pleasurable Reluctance to accept Sad responsibilities Frequent illness (actually sick) Neglecting responsibilities Anxiety Use of self medication Restless Acting Out Agitated Alcohol abuse Physical exhaustion Insecure Gambling Feeling of worthlessness Spending spree Immune system suppression Promiscuity Irritability Somatic (Body) Indicators Overly sensitive Desperate Acting Out Headache Defensive (getting attention-cry for help) Insomnia Arrogant/argumentative Initial insomnia Insubordinate/hostile Administrative Infractions Recurrent awakening Tardy to work Early morning rising Mental Fatigue Poor appearance Change in Appetite Preoccupied Poor personal hygiene Weight gain Difficulty concentrating Accident prone Weight loss (more serious) Inflexible Indigestion Legal Infractions Nausea Overcompensation (denial) Indebtedness Vomiting Exaggerate/Grandiose Shoplifting Diarrhea Overworks to exhaustion Traffic tickets Constipation Denies Problems/Symptoms Fights Sexual difficulties Suspicious/Paranoid Child/spouse abuse

Deep Breathing Exercise

1. Sit in a comfortable position. 2. Take 3 deep cleansing breaths. 3. Place one hand on your stomach and the other on your chest. 4. Try to breathe so that only your stomach rises and falls. a. As you inhale, concentrate on your chest remaining relatively still while your stomach rises. It may be helpful to imagine that your pants are too big and you need to push your stomach out to hold them up. b. When exhaling, allow your stomach to fall in and the air to fully escape. 5. Take some deep breaths, concentrating on only moving your stomach. 6. Return to regular breathing, continuing to breathe so that only your stomach moves. Focus on an easy, regular breathing pattern.

Note: It is normal for this healthy breathing to feel a little awkward at first. With practice, it will become more natural to you.

The CALM Reminder

Chest: Breathing slower and deeper Arms: Shoulders sag Legs: Loose and flexible Mouth: Jaw drop

Cue -Controlled Relaxation Cue-controlled relaxation is a very quick and easy relaxation technique. Set up a cue to remind you to relax.

1. There are two different types of cues (reminders):

External Cue (reminder) (e.g., when your watch alarm sounds; when you see a note on your desk; at traffic lights, etc.) Internal Cue (reminder) (e.g., when your muscles reach a certain tension level, when you feel a headache coming on)

Note: It’s very important that once you set up a cue, that you actually do the relaxation exercise when the cue comes up. Eventually it will become a healthy habit! 2. Relax by doing the following a. Take a deep, easy breath b. Exhale s l o w l y.... c. Say a word to yourself as you exhale (e.g., “relax” or “calm”) d. As you exhale, focus on letting your muscles relax. As an option (if it’s convenient), you can close your eyes too

Disputation: Challenging Upsetting Thinking

Examine your thoughts for key words: 1. must, need, got to, have to, should (unrealistic standards) 2. never, always, completely, totally, all everything, everyone (predictions / labeling) 3. awful, terrible, horrible, unbearable, disaster, worst ever (labeling / predictions) 4. jerk, slob, creep, hypocrite, bully, stupid (labels)

Dispute or question the accuracy of the questionable thoughts. 1. Am I upsetting myself unnecessarily? How can I see this another way? 2. Is my thinking working for or against me? How could I view this in a less upsetting way? 3. What am I demanding must happen? What do I want or prefer, rather than need? 4. Am I making something too terrible? Is it really that awful? What would be so terrible about that? 5. Am I labeling a person? What is the action that I don’t like? 6. What’s untrue about my thoughts? How can I stick to the facts? What’s the proof for what I am thinking or believing about this? 7. Am I using extreme, black-and-white language? What less extreme words might be more accurate?

8. Am I fortune telling or mind reading in a way that gets me upset or unhappy? What are the odds (percent chance -- e.g., there is a 5% chance...) that it will really turn out the way I’m thinking or imagining? 9. What are my options in this situation? How would I like to respond? 10. Create more moderate, helpful, or realistic statements to replace the upsetting ones. 11. Have I had any experiences that show that this thought might not be completely true? 12. If my best friend or someone I loved had this thought, what would I tell them? 13. If my best friend or someone I loved knew I was thinking this thought, what would they say to me? What evidence would they point out to me that would suggest that my thought is not completely true? 14. Are there strengths in me or positives in the situation that I am ignoring? Am I underestimating my ability to cope with unfortunate circumstances? 15. When I am not feeling this way, do I think about this situation any differently? How? 16. Have I been in this type of situation before? What happened? What have I learned from prior experiences that could help me now? 17. Five years from now, if I look back on this situation, will I look at it any differently? Will I focus on any different part of my experience? 18. Am I blaming myself for something over which I do not have complete control?

Maintaining Behavior Change

Maintaining the progress you have been making is one of the greatest challenges you will face as you complete this program. There are two keys to maintaining the gains you have made and continuing to make progress.

Prevent "Slips" from Occurring Control how You Respond to Slips

A slip is a: • mistake • lapse • deviation from the plan • error

It is usually the first instance of backsliding. It is a brief experience and does not signal an inevitable downward spiral.

Example: You miss your workout for one or two days; you consume more calories than you planned during a special meal, etc.; you had a cigarette; you used an illegal substance

Preventing Slips • Identify high-risk situations: These are situations in which you expect to have difficulty continuing with your newly developed skills. • Learn from the past. You can identify many of these from past experience. Think back and identify situations in which you remember having a particularly difficult time coping. • Plan in advance. When you know similar situations are coming, start planning for how to deal with them in advance. If you wait until you are in the midst of the situation, you are not likely to come up with effective solutions. Use the information from past struggles to guide your planning and identify past hurtles that will need to be overcome. The attached form will help you develop your own relapse prevention plan.

Controlling Response to Slips Even though many slips are preventable, you cannot prevent them all (e.g., some high-risk situations are not predictable or were not known to be high risk). You will always have some periods when you are not doing as well as you would like.

In other words, you will have slips.

The most important thing is to respond to these slips in a manner that gets you back on track as quickly as possible.

How you think about the slip is the most important factor. If you view the slip as a total return to old habits you are more likely to give up. Therefore, it is important to distinguish between a slip (a.k.a., a lapse), a relapse and a collapse.

A SLIP (as discussed above) is a mistake, a first instance of backsliding. A RELAPSE occurs when slips string together and you return to your former behaviors. Since a relapse is made up of multiple slips, there are many opportunities to stop it and turn it back around before it reaches the relapse stage. However, even once it reaches this stage, you can still turn it around again (that’s what you did originally).

At any point along this relapse line, you need to: • Identify that you have slipped, • Recall what you were doing that had been helping, and • Resume it. These actions will get you moving back in the right direction. The measure of success is not whether there are dips in your line of progress, but whether over all you are progressing upwards in spite of occasional dips. If you find you have relapsed, get out the education materials you used to help you learn more effective coping skills and remind yourself what you can do to get back on track and/or return to the clinic to see your primary care provider for support.

When a relapse is complete and there is little hope of reversing the negative trend, COLLAPSE has occurred. If you find yourself in a collapse, the best solution is to seek help from your healthcare provider.

R E M E M B E R A LAPSE = A RELAPSE

Personalized Relapse Prevention Plan

I. What situations are you likely to relapse in?

______

II. What do you plan to do in these situations to avoid relapse? What specifically will you do in these situations? What will you tell people to help you? How will you alter the situation so you won’t fall back into your hold maladaptive habits?

1. 5. 2. 6. 3. 7. 4. 8.

III. What are some of the negative thoughts or “mental gremlins” that you are likely to experience in these relapse situations? ______

______

IV. What truthful and realistic things will you say to yourself to counteract negative thoughts and help you connect with values in these high-risk situations? ______

______

Weight Management

Effective weight management involves behavior modification which is a lifelong commitment and includes at least two components: 1. Healthy eating in accordance with the Dietary Guidelines for Americans, emphasizing a reduction in total calories, lowered fat consumption, and an increase in vegetables, fruits and whole grains. 2. Increased frequency of regular physical activity of at least moderate intensity.

1. Eating Healthy

Caloric intake Losing weight requires burning more calories than the body takes in, by either reducing caloric intake or increasing caloric expenditure, or preferably, both.

Estimated Calorie Requirements (in Kilocalories) for Each Gender and Age Group at Three Levels of Physical Activity Activity Level b, c, d Gender Age (years) Sedentaryb Moderately Activec Actived Child 2-3 1,000 1,000-1,400 1,000-1,400 Female 4-8 1,200 1,400-1,600 1,400-1,800 9-13 1,600 1,600-2,000 1,800-2,200 14-18 1,800 2,000 2,400 19-30 2,000 2,000-2,200 2,400 31-50 1,800 2,000 2,200 51+ 1,600 1,800 2,000-2,200 Male 4-8 1,400 1,400-1,600 1,600-2,000 9-13 1,800 1,800-2,200 2,000-2,600 14-18 2,200 2,400-2,800 2,800-3,200 19-30 2,400 2,600-2,800 3,000 31-50 2,200 2,400-2,600 2,800-3,000 51+ 2,000 2,200-2,400 2,400-2,800 Source: HHS/USDA Dietary Guidelines for Americans, 2005

Sedentary = less than 30 minutes a day of moderate physical activity in addition to daily activities. Moderately Active = at least 30 minutes up to 60 minutes a day of moderate physical activity in addition to daily activities. Active = 60 or more minutes a day of moderate physical activity in addition to daily activities.

Healthy Food Choices Individualized food plan according to 2005 USDA Dietary Guidelines: http://www.mypyramid.gov/mypyramid/index.aspx

Four key recommendations of the 2005 Dietary Guidelines for food groups to encourage are: 1. Consume a sufficient amount of fruits and vegetables while staying within energy needs. Two cups of fruit and 2-1/2 cups of vegetables per day are recommended for a reference 2,000-calorie intake, with higher or lower amounts depending on the calorie level. 2. Choose a variety of fruits and vegetables each day. Eat fresh, frozen, canned, or dried fruit, rather than drinking fruit juice, for most of your fruit choices. Select from all five vegetable subgroups several times a week. Examples of vegetables from these subgroups include: • DARK GREEN VEGETABLES -- Broccoli, spinach, most greens such as spinach, collards, turnip greens, kale, beet and mustard greens, green leaf lettuce, and romaine lettuce • ORANGE VEGETABLES -- Carrots, sweet potatoes, winter squash, pumpkin • LEGUMES (DRY BEANS) -- Dry beans, chickpeas • STARCHY VEGETABLES -- Corn, white potatoes, green peas • OTHER VEGETABLES -- Tomatoes, cabbage, celery, cucumber, lettuce, onions, peppers, green beans, cauliflower, mushrooms, summer squash

3. Consume 3 or more one-ounce equivalents of whole-grain products per day, with the rest of the recommended grains coming from enriched or whole-grain products. In general, at least half the grains should come from whole grains. Examples of whole- grains commonly consumed in the United States include: • whole wheat • whole rye • bulgur (cracked wheat) • brown rice • whole • whole-grain barley • millet • tritacale oats/oatmeal • whole-grain corn • wild rice • quinoa

4. Consume 3 cups per day of fat-free or low-fat milk or equivalent milk products. If you don't or can't consume milk, choose lactose-free milk products and/or calcium-fortified foods and beverages.

For more information, visit: http://lancaster.unl.edu/food/ftfeb05.htm.

Food log By keeping track of food and drink consumption you will stay mindful of your eating habits. Do you eat when bored? Do you eat unhealthy foods when in a hurry? Are you eating something that seems nutritious and healthy, but really isn’t? You can calculate calories consumed to determine weight loss/maintenance goals and assess progress. Keeping a food log allows you to be accountable and mindful of calories consumed and you will become aware of the nutrient value of the foods/drinks you are using.

An on-line calorie counter is available at http://www.my-calorie-counter.com. This site lets you count calories for free (extra features cost $35/year).

Portion Size Another common problem leading to overeating is taking portions that are too big. Most of us overestimate the size of a healthy portion, especially when we eat at restaurants and want to get a “good value” for our money. Listed below are the recommended portion sizes for a variety of foods. How do your typical portions compare?

3 oz. meat: size of a deck of cards or bar of soap (the recommended portion for a meal) • 8 oz. meat: size of a thin paperback book • 3 oz. fish: size of a checkbook • 1 oz. cheese: size of 4 dice • Medium potato: size of a computer mouse • 1/2 cup pasta: size of a tennis ball • Average bagel: size of a hockey puck. • 1 cup chopped raw vegetables or fruit: baseball size • 1/4 cup dried fruit (raisins, apricots, mango): a small handful

For more information, visit http://www.cancer.org/docroot/PED/content/PED_3_2x_Portion_Control.asp

2. Exercise Exercise is an important piece of weight loss and overall health. For example, 30 minutes of moderate intensity physical activity above your normal daily routine reduces the risk of chronic disease in adulthood. To manage body weight and prevent gradual, unhealthy body weight gain in adulthood, increase your exercise to approximately 60 minutes of moderate to vigorous intensity activity on most days of the week. To sustain weight loss, increase your exercise to 60 - 90 minutes per day of moderate intensity physical activity while not exceeding caloric intake requirements.

Another way to track physical activity is to use a pedometer to keep track of the number of steps you take. For example, 2000-2500 average steps is approximately one mile, which equates to around 100 expended calories.

3. Simple Strategies to Manage Your Eating

How often have you over-eaten or eaten unhealthy foods due to eating effortlessly in an unaware and mindless manner? Have you ever noticed that when you’re done eating, you feel sick because you ate too much? This happens when we do not pay attention to eating, typically because we are doing something else at the same time like watching television, talking with others, or working. If you increase your awareness—or mindfulness—of eating, however, you can reduce your caloric intake and not feel so sick. Mindfulness is a way of observing your experiences and being in touch with your actions, thoughts and feelings. Mindful eating teaches you to pay attention to your bodies’ signals that you are full and about what foods to eat. The goal of mindful eating is to understand your hunger and your body and mind’s reaction to food and the process of eating. Try this activity:

Mindful eating To start, move through the meal slowly. Take your time performing every action and notice what your experience is as you go through it. When you lift a fork or cut your meat, note what that is like for you. As you place a bite of food in your mouth and chew it, place your fork on the table and think about the flavors and the texture of the food. Is it enjoyable or repulsive? Don’t get hung up in judging it. Just notice it. Do you find that particular thoughts or feelings come up during the course of the meal? If so, simply note those as well.

For more information about mindful eating consider reading these books: 1. Albers, S. (2003). Eating Mindfully. Oakland: New Harbinger Publications, Inc. 2. Hayes, S.C. (2005). Get Out of Your Mind and Into Your Life. Oakland: New Harbinger Publications.

4. Developing Weight Goals Setting SMART goals for your weight loss is the first, and most important, step for managing your weight. Good goals have several qualities: • Specific: Goals should not be too general or vague, since this makes it hard for us to know when we have accomplished them. For example, “I want to lose 20 pounds” is a better goal than “I want to lose weight.” • Measurable: Goals should be set in a way that can easily and meaningfully measured. For example, “I want to look better” is not easily measured, but “I want a 34-inch waist” is easily measured. • Attainable: Goals should be something you are motivated to achieve. For example, if improving your PT score is more important to you than your overall weight, then your goal should not be to lose weight. • Realistic: Goals should be something you are able to accomplish. For example, setting a goal to run a marathon next month when you struggle to run 2 miles now is not a realistic goal. • Timely: Goals should have a time frame built into them to hold you accountable. You’re more likely to work towards a goal if you give yourself a deadline.

Body Mass Index (BMI) & Waist Size BMI uses a mathematical formula that takes into account both a person's height and weight. BMI equals a person's weight in kilograms divided by height in meters squared. (BMI=kg/m2). It is the measurement of choice for many physicians and researchers studying obesity, because it is a more accurate indicator of overall health than just weight alone. Setting a BMI goal, instead of simply a weight loss goal, is a better weight management strategy for many people, especially those with medical conditions such as diabetes, COPD, heart diseases, hypertension, and more. To calculate your BMI, visit this website: http://www.consumer.gov/weightloss/bmi.htm.

Risk of Associated Disease According to BMI and Waist Size Waist less than or equal to Waist greater than BMI 40 in. (men) or 40 in. (men) or 35 in. (women) 35 in. (women)

18.5 or less Underweight -- N/A

18.5 - 24.9 Normal -- N/A

25.0 - 29.9 Overweight Increased High

30.0 - 34.9 Obese High Very High

35.0 - 39.9 Obese Very High Very High

40 or greater Extremely Obese Extremely High Extremely High

Setting a SMART Weight Management Goal Specific: Where will you do it? With whom will you do it? How often will you do it? Measureable: How much? How many? Attainable: What is most important to you? What do you hope to accomplish? Realistic: Are you able to do it? What can you do right now? How easy will this be to maintain? Timely: When do you want to accomplish this? Do you have a deadline?

Now that you have considered the necessary components for a SMART goal, write down your weight management goal below:

Other tips for accomplishing this goal:

1. Hang this goal up where you can see it regularly so you can remind yourself what you’re working towards. 2. Tell others about it. Ask them to help you stay accountable and support you. 3. Ask your doctor for advice or tips on reaching this goal. 4. Try this goal out for two weeks. At the end of two weeks, see if it’s a goal that will work for you. If not, change it so it will work better. 5. Once you have accomplished this goal, set another SMART goal right away. 6. Remember to pace yourself. Change will not happen all at once, but will slowly build up over time. Be patient.

Exam Room Posters

Motherhood is a process that begins with conception

and results in new life for you and your family.

If you are experiencing any of the following, please ask your provider or the technician about the OB/GYN clinic’s BHOP program:  Uncertainty  Stress  Frustration  Sadness/feeling “blah”  Increased difficulties with your significant other  Moodiness  Nervousness  Irritability  Communication problems with your significant other  Previous depression, baby blues, or postpartum depression

The BHOP program is intended to provide you with extra resources and support so that your transition into motherhood unfolds as smoothly as possible for you.

New Year’s RESOLUTION: Lose Weight

New Year’s SOLUTION: Tell your PCM you’d like a weight management consultation from a behavioral health consultant

On XXXX, the XXXX Clinic will begin offering a consultation service to help you succeed with this Resolution.

Ask your PCM or Nurse about this new service and they can sign you up today!!

Is Your New Year’s Resolution to

QUIT SMOKING?

On XXXX the XXXX Clinic will began offering a consultation service to help you keep this Resolution.

Ask your PCM about this new service and they can sign you up today!!

Spanish Materials

Spanish Materials List

1. 15 Sugerencias para Conflicto Constructivo / 15 Tips for Constructive Conflict 2. Enfrentando el Dolor / Confronting Chronic Pain Handout 3. Discusión: Desafiando el Pensamiento Angustioso / Cognitive Restructuring 4. Cuestionario de la Salud del Paciente (PHQ-9) / Patient Health Questionnaire 5. Hechos Acerca del Sueño / Practical Strategies for Managing Sleep 6. Nuevos Hábitos Saludables de la Salud del Sueño / Sleep Hygeine Strategies 7. Ayuda para los que están de luto / Tips for Dealing with Grief 8. Teniendo éxito con los Medicamentos Antidepresivos / Using Medications Successfully

9. Una Técnica de Relajación: Respiración con el Diafragma / Diafragmatic Breathing

10. Terapia Cognitiva del Comportamiento (TCC) / Cognitive Behavioral Therapy 11. Acuerdo para la Administración de Medicamentos / Agreement for the Administration of Medications

12. Depresión: ¿Qué es y cómo obtener ayuda? / What is Depression? 13. Lo que Debemos Saber sobre la Ansiedad y el Pánico / What you Should Know about Anxiety and Panic

14. Como Funciona la Ansiedad / The Psychology of Anxiety 15. Plan de Valores Para Los Pacientes De Cuidados Primarios / Behavior Change Prescription Pad

16. Plan de Cuidado Para la Despresion / Depression Self-Management Plan 17. Ciclo de Letargo / Lethargy Cycle

15 Sugerencias para Conflicto Constructivo

Cuando algo sucede para comenzar un pleito entre la pareja matrimonial, es importante mantener los desacuerdos lo más constructivo posible para evitar patrones de comunicación perjudicial.

1. Sea especifico al quejarse. 2. No nomás se queje; aunque sea especifico; pida un cambio razonable que elimine la queja. 3. Pida y dé sugerencias hacia el punto principal, para asegurar que lo escuchan y para asegurar a su pareja que usted entiende lo que él o ella quiere. 4. Enfoque en un problema a la vez, porque de otro modo y sin ayuda profesional, puede usted darle vuelta al asunto y evadir los problemas más difíciles. 5. No hable demasiado y no sea intolerante. Préstese a sus propios sentimientos y preste lugar a los de su pareja. 6. Siempre considere un acuerdo. Recuerde que el punto de vista de su pareja puede ser tan real para él o ella como para usted. Aunque sean diferentes. No existe realidad totalmente objetiva. 7. No permita que las exigencias en contra se presenten hasta que se hayan aclarado claramente las exigencias originales y la respuesta a ellas ha sido precisa y clara. 8. Nunca asuma saber lo que su pareja piensa hasta que lo haya aclarado en palabras ni asuma o prediga como reaccionará o lo que aceptará o rechazará. Entre parejas no se puede uno atener a la bolita de cristal. 9. No atropelle el pensar de su pareja. No le corrija cuando le exprese sus sentimientos. No le diga a su pareja lo que debe saber o sentir. 10. Nunca clasifique a su pareja ni le diga que su vecino es cobarde, neurótico o niño. Si en verdad creyera que él o ella sufre de alguna incompetencia o defecto básico, es más probable que no estuviera usted ya con él o ella. No juzgue o califique sus sentimientos, especialmente el que sí es, o no, real o importante. 11. El sarcasmo es pleito sucio. 12. Olvídese del pasado y plántese en el aquí y hoy. Lo que cualquiera de los dos hizo el año o el mes pasado o esta mañana no es tan importante como lo que están haciendo y sintiendo ahora. Y no es posible cambiar lo que ya paso. Las heridas, las quejas y lo que le irrita se deben de sacar a la luz lo mas pronto posible o la pareja tiene el derecho de sospechar que se han guardado cuidadosamente como armas. 13. No abrume a su pareja con quejas. Al hacerlo la hará sentirse incapaz y sospechará que tal vez usted ha estado amontonando las quejas o no ha definido lo que en verdad le molesta. 14. Medite. Tome tiempo para consultar sus los pensamientos y sentimientos verdaderos antes de hablar. Su reacción superficial puede servir de mascara para ocultar algo mas profundo e importante. No tenga miedo de serrar los ojos y pensar. 15. Recuerde que nunca hay un solo ganador en un pleito intimo y honesto. Ambos o ganan o pierden aun más intimidad.

INDAGACIÓN: ¿Hay alguna otro sugerencia la cual agregaría usted a la lista? ¿Cuál de las 15 sugerencias piensa usted que son mas criticas para un pleito constructivo?

RECURSOS: Exhorto de G.R. Bach y R.M. Deutsch (1974)

CONTRIBUTORS: Nancy Wexler & Laura Heesaker, United Community Health Center, Green Valley, AZ. Enfrentando el Dolor

Varias veces, cuando los pacientes con dolor piensan en las experiencias dolorosas, estas se amontonan causando experiencias agobiadoras. Sin embargo, el separar el dolor en sus componentes nos facilita a sobrellevarlo. Al separar el dolor en trozos, podemos enfrentarlo y manejarlo en partes separadas.

Dolor vs. Sufrimiento

Es muy importante distinguir entre el dolor y el sufrimiento que se apodera como respuesta al mismo. Muy seguido, los pacientes con dolor los agrupan juntos. Cuando ellos piensan o platican acerca del dolor que sienten, no solo están platicando de la sensación física en donde sienten el dolor. También están pensando en el impacto múltiple que este dolor acarrea a sus vidas. El no poder hacer las cosas. La angustia emocional. La tensión en la familia. El impacto potencial en su estabilidad financiera. Todas estas cosas se agrupan bajo la etiqueta “dolor”. Sin embargo, el dolor y el sufrimiento asociado al dolor son en efecto muy distintos. Es mas, lo severo del dolor tiene relación mínima comparado al impacto severo en la vida del paciente con dolor. Otros pacientes pueden sufrir dolor moderado, pero pueden sentir impactos significativos. La razón por lo que estos dos no se relacionan es porque son controlados por cosas diferentes.

El dolor es una sensación física que resulta de las reacciones biológicas que ocurren por medio de la vía de transmisión del dolor. Mientras puede ser afectada la percepción de la experiencia dolorosa por factores psicológicos (consultar la sección de Teoría del Puertón de Control en la primera sesión), el dolor no se encuentra directamente bajo el control de la persona.

Alternativamente, el sufrimiento, como respuesta a la experiencia física del dolor, es controlado por factores que no son físicos, tales como los pensamientos, sentimientos, la conducta, y factores en el medio ambiente. Como seres humanos, nosotros podemos controlar, o aprender a controlar estos factores.

Siendo así, es importante distinguir entre el “dolor” y el “sufrimiento” cuando nos enfrentamos al dolor. Ya que uno identifica de donde viene el “sufrimiento”, puede uno comenzar a buscar la manera de reducirlo. Las destrezas que usted ha estado aprendiendo en este programa le ayudaran a hacerlo. Además, como ya sabemos que algunos de estos factores influyen en el “puertón del dolor”, al reducir el sufrimiento, es más seguro que la percepción de dolor se vea impactada.

Etapas de Dolor

Los episodios de dolor también se pueden dividir en cuatro etapas. El pensar en el dolor como etapas e identificando la manera para manejar cada etapa ayuda a que el dolor sea una experiencia más llevadera. Esto ayudará mucho mas en episodios más severos.

En realidad, la primera etapa es antes del episodio de dolor. Durante este estado, usted se encuentra anticipando o preparándose para el episodio de dolor. Esta es la etapa durante la cual usted necesita pensar como va a llevar el dolor. Es muy importante planear esto por adelantado porque durante el dolor severo no podrá pensar claramente y, es mas, será más fácil volver a las viejas costumbres si no hay un plan en pie. Le ayudará escribir su plan para que no tenga que recordarlo durante un nivel fuerte de dolor. Además, debe de tener planes múltiples. A veces el primer plan no funciona y es bueno tener otras opciones que tomar. Esta es una de las razones por la cual enseñamos métodos múltiples para sobrellevar el dolor. Diferentes técnicas funcionan para diferentes ocasiones pero no todo el tiempo ayuda una sola técnica. En fin, el plan debe de ser muy especifico. En vez de escribir simplemente “relajamiento”, mejor explique específicamente que hará para relajarse; en vez de escribir simplemente “llamaré una amiga”, escriba el nombre y el numero de teléfono de la persona a quien llamará.

La segunda etapa tiene que ver con encarar el dolor cuando primero comienza a empeorar. La meta ahora es empezar a usar algunas de las técnicas para llevar el dolor. Esta etapa es particularmente importante porque la manera en que usted responde inicialmente al aumento de dolor predice como usted responderá al resto del episodio. Si usted entra enfocándose en el manejo e implementando el plan de la primer etapa, es más posible que le sea efectivo. Si usted inicia de una manera mal adaptada, será más difícil volver al grano.

Usualmente, el dolor llegará a lo máximo y luego bajará. La tercer etapa se enfoca en como llevar el dolor ya que llegue a lo máximo. Es posible que sé de cuenta de que la misma estrategia que funciono bien al principio del episodio ya no funcione tan bien. Intente usar otras técnicas (tal como los planes alternativos en la primer etapa) Mantenga en mente que el dolor máximo siempre bajará. Su meta durante esta etapa es el sobrevivir el dolor máximo. Durante el dolor severo, las técnicas que se pueden hacer, ya sea parado o sentado, y para las que no se necesita un proceso de pensamiento complicado (tales como el conteo, respiración, fijar la vista en algo) a veces funcionan mejor.

Al comenzar a bajar el dolor, comienza la cuarta etapa. Durante esta etapa, será útil repasar los resultados de los planes. Considere lo que funcionó bien. Esas cosas que funcionaron bien mas seguido se deben de incluir en el plan primario de abastecimiento. Luego piense en lo que no funcionó bien. Considere como puede cambiar el plan para que la próxima vez sea más efectivo. Tenga en mente que el manejar el dolor se aprende con experiencia. Usted tendrá que luchar con varios episodios donde no maneje el dolor tan efectivamente como quisiera para poder llegar a la meta deseada de manejo del dolor.

En la siguiente hoja encontrará usted una lista que le sugiere los pensamientos y las acciones para tomar en cada etapa.

______El animo del hombre lo sostiene en su enfermedad; pero perdido el animo, ¿quién lo levantará? Proverbios 18:14

CONTRIBUTORS: Nancy Wexler & Laura Heesaker, United Community Health Center, Green Valley, AZ.

Etapas de Dolor: Pensamientos y Conducta Saludable

Anticipando /Preparándose para un Episodio de Dolor: Acciones: Implemente un plan A, B y C para cuando pegue el dolor. Sea especifico. Use respiración diafragmática.

Pensamientos: El sentarse y preocuparse por el dolor no le ayudará. Que más puedo hacer que podría ayudar. Lo haré ahora. Ya no me duele tanto. El pensar o hacer otras cosas, puedo hacer que el bienestar dure más tiempo. No tengo que asustarme así misma por el dolor. Sobrellevare el siguiente episodio cuando sea que llegue. Me alegra que ya no sea intenso. Si incrementa y disminuye, así es que me permitiré tener un plan para cuando este llegue.

Enfrentando el Comienzo de Episodio de Dolor: Acciones: Comience a usar las destrezas que puede hacer para manejar el dolor mientras continua con su día. Intente la respiración diafragmática en medio de sus actividades. Luche activamente por mantener la atención enfocada en las tareas en las que se encuentra involucrada. Vigile los pensamientos alarmantes y sustitúyalos con pensamientos tranquilizadores.

Pensamientos: Bien, siento tensión. Esto me recuerda el respirar despacio, profundamente y relajarme. No me ofuscare. Lo tomare paso por paso. No sirve de nada permanecer acostado con este dolor. Me involucraré en algo. Aquí esta el episodio. Será como los otros y disminuirá gradualmente. No es necesario que me alarme.

Encarando el Dolor en su Máximo Acciones: Use el plan A (y B y C sí es necesario) Intente convenir las estrategias del manejo del dolor. Intente el uso de las técnicas más intensas como el PMR8. Use recursos mentales sencillos para intentar, y mantener, la atención enfocada lejos del dolor.

Pensamientos: El episodio está pasando tal y como yo lo esperaba. Puedo sobrevivir esto. Se disminuirá antes de que me dé cuenta, especialmente si me puedo concentrar en algo más. No quiero yo empeorar esto. Seguiré mi plan – cambiaré mis actividades. No caeré en pánico. Ya he sobrevivido esto antes.

Reflexiones al Ir Disminuyendo el Dolor: Acciones: Reflexione lo bien que funcionó su plan. Se da crédito a usted mismo donde lo merece, y cambie planes si así lo merita.

Pensamientos: Bien, lo hice. A la otra lograré manejarlo aun mejor. Ya logro con mas éxito colocar el dolor al fondo de mi mente; puedo utilizar mi atención y mis pensamientos para mi logro. No me riendo desesperado o incapaz con esto. Puedo limitar el efecto que el dolor causa en mi vida.

Discusión: Desafiando el Pensamiento Angustioso

Examine sus pensamientos buscando las palabras clave:

1. Debe, necesito, tiene que, debería (con frecuencia estas palabras están asociadas con normas).

2. Nunca, siempre, completamente, totalmente, todo, todos (frecuentemente estas palabras están asociadas con Predicciones o Categorías).

3. Feo, terrible, horrible, insoportable, desastre, peor que nunca (con frecuencia estas palabras están asociadas con Categorías o Predicciones).

4. Pelmazo, patán, desgraciado, hipócrita, estúpido, idiota, ¡¡¡***!!! (frecuentemente estas palabras están asociadas con Categorías).

Discuta o pregúntese que tan ciertos son sus pensamientos usando las siguientes preguntas:

1. ¿Me estoy angustiando innecesariamente? ¿Cómo puedo ver esto de otra manera menos angustiante? ¿Qué otras maneras hay de ver la situación?

2. ¿Mi pensamiento está trabajando para mi bien, o en contra mía? ¿Cómo puedo ver esto para que me sea de más ayuda?

3. ¿Qué estoy exigiendo que debe suceder? ¿Qué es lo que quiero o prefiero, no tanto lo que necesito?

4. ¿Estoy haciendo algo tan terrible? ¿Es realmente tan malo? ¿Qué sería tan terrible de esto? Aunque fuera tan terrible como imagino ¿Hay todavía algo que puedo hacer?

5. ¿Estoy etiquetando a una persona de forma extrema? ¿Cuál es la acción o comportamiento que no me gusta?

6. ¿Qué no es verdad en mis pensamientos? ¿Cómo me puedo apegar a los hechos? ¿Qué prueba hay de lo que estoy pensando o creyendo sobre esto?

7. ¿Estoy usando lenguaje extremo, en blanco y negro? ¿Qué palabras menos extremas serían más exactas?

8. ¿Soy un adivinador de la fortuna (prediciendo el futuro) o leo la mente (haciendo suposiciones sobre lo que están pensando los demás) de manera que me molesta o me hace infeliz? ¿Qué tan posible es que las cosas de verdad sucedan como las pienso o me las imagino? ¿Realmente sé lo que la otra persona está pensando?

9. ¿Cuáles son mis opciones en esta situación? ¿Cómo me gustaría responder? ¿Cómo debería cambiar mi pensamiento para responder de la manera que quiero? CUESTIONARIO DE LA SALUD DEL PACIENTE (PHQ-9)

NOMBRE:______FECHA:______

1) Durante las ultimas dos semana, con que frecuencia se ha visto afectado por los siguientes problemas? (marque su respuesta con “√”).

Nunca Varios Mas Casi dias de la todos mitad los dias 0 1 2 3 a. Tiene poco interés o encuentra poco placer en hacer las cosas. b. Se siente desanimado, deprimido o sin esperanza. c. Tiene problemas con dormir o mantenerse dormido o duerme demasiado. d. Se siente cansado o tiene poca energía. e. Tiene poco apetito o come en exceso. f. Siente falta de amor propio o que es un fracaso o que se ha decepcionado a sí mismo o a su familia. g. Encuentra dificultad en concentrarse, por ejemplo, al leer el periódico o ver televisión. h. Se mueve o habla tan léntamente que la gente lo puede haber notado, o de lo contrario, está tan agitado o inquieto que se mueve mucho más de lo acostumbrado. i. Tiene pensamientos de que sería mejor estar muerto o de que quiere hacerse algún daño.

Suma de las columnas:

2) Si usted se identificó con cualquiera de estos problemas, que dificultad le han ocasionado estos problemas al hacer su trabajo, ocuparse de las casa o llevarse bien con los demás.

Ninguna dificultad Algo de dificultad Mucha Dificultad Extrema Dificultad 0 1 2 3

Hechos Acerca del Sueño

1. Mito: Todos necesitas 8 horas de sueño

Hecho: Ocho horas es solo el promedio. Las necesidades del sueño varían entre 3 y más de 10 horas. Recuerde antes que desarrollara insomnio. Cuánto necesitaba dormir para sentirse revitalizado y renovado en ese entonces (ponga la cantidad aquí ______horas)? Esta cantidad será aproximadamente la cantidad de sueño que necesitará.

2. Mito: La falta de sueño podrá tener consecuencias serias en su salud.

Hecho: No hay evidencia que alguien haya muerto por falta de sueño. La preocupación excesiva acerca del insomnio puede ser más perjudicial para su salud que la falta de sueño.

3. Mito: Cuando tengo problemas para dormir debo quedarme en la cama y seguir tratando.

Hecho: Cuanto más trata de producir sueño voluntariamente, tiene menos posibilidades de tener éxito.

4. Mito: Las pastillas para dormir son una manera efectiva de manejar sus problemas de sueño de largo plazo.

Hecho: Las pastillas para dormir pueden actualmente perpetuar los problemas del sueño.

5. Mito: Las necesidades y calidad del sueño permanecen igual durante toda la vida.

Hecho: A medida que envejecemos, el tiempo que permanecemos en la cama aumenta pero el tiempo que dormimos disminuye. Con la edad el despertar durante el sueño aumenta. El sueño profundo disminuye y el sueño ligero incrementa con la edad. Muchas personas mayores duermen 2 o 4 episodios de una hora en lugar de un periodo de sueño consolidado. Los problemas de sueño en las personas mayores están generalmente relacionados con otros problemas de salud o medicamentos usados para estos problemas. De todas maneras, la calidad del sueño de los adultos puede a menudo ser mejorado con tratamiento.

6. Mito: El insomnio es un problema poco común.

Hecho: El insomnio es un problema ampliamente diseminado que afecta a casi todos en algún momento determinado de sus vidas. Es quizás es la queja más común después del dolor. Nueve a diez por ciento de la población reporta insomnio crónico.

Nuevos Hábitos Saludables de la Salud del Sueño

1. Limite la cantidad de tiempo que pasa en la cama a la cantidad que actualmente pasa durmiendo: ______horas. 2. Vaya a la cama sólo cuando tiene sueño. 3. Levántese de la cama si no puede dormir o volver a dormir entre 10 y 15 minutos; regrese a la cama solamente cuanto tenga sueño. Repita este paso tan seguido como sea necesario durante la noche. 4. Mantenga un horario regular para levantarse en las mañanas. 5. Use la cama/ su cuarto para dormir y tener relaciones sexuales solamente, no para mirar la televisión, escuchar la radio, comer, o leer en la cama. 6. No duerma durante el día.

Ayuda para los que están de Luto

A seguir, hay muchas ideas para ayudar a quién están de luto sobre un ser querido. Diversas clases de pérdidas dictan diversas respuestas, así es que no todas de estas ideas satisfacen a cada persona. Al mismo tiempo, todos somos individuales y necesitamos algo que funcionará para cada uno. Esta lista es una de sugerencias que han ayudado a várias personas con éxito. Quizás les vaya a ayudar también. El énfasis aquí está en ideas específicas y prácticas.

1. Hable regularmente con un amigo. El hablar con otro sobre lo qué usted piensa y sus sentimientos es una de las mejores cosas que usted puede hacer para sentirse mejor. Ayuda a que no sienta tanta presión. Puede darle un sentido de perspectiva, y le mantiene en contacto con otros. Busque a alguien que le escuche y quién tenga compasión. Entonces hable lo que está en su mente y dentro su corazón. Si esto se siente como que se esta aprovechando de la persona, deje que ese sentimiento continúe durante este tiempo porque usted lo necesita. A lo mejor la otra persona encontrará solaz en nomás escuchando y el tiempo vendrá cuando usted tendrá la ocasión de ser un buen oyente para alguna otra persona. Usted entonces será un oyente mejor, si deja que ahora la otra persona lo sea. 2. Caminata. Vaya para las caminatas afuera cada día si usted puede. No exagere, pero camina energéticamente para que se sienta vigorizo. A veces camine lentamente para que usted pueda fijarse en su alrededor. Observe la naturaleza y que tiene para ofrecerle, qué puede enseñarle. Goce tanto como usted pueda a la vista y los sonidos que le llegan. Si gusta, camine con otra persona. 3. Lleve o use un objeto que se liga. Lleve algo en su bolsillo o el monedero que le recuerda de la persona quién murió – algo que le dio quizás, u objeto pequeño que la persona llevó o que utilizó una vez o un recuerdo que usted selecciono para ese propósito. Puede ser que use un pedazo de su joyería de la misma manera. Siempre que usted desee, mire este objeto y recuerde lo que significa. 4. Visite el sepulcro. No toda la gente prefiere hacer esto, pero dependiendo de cómo se siente, puede hacerlo. No deje que otros le convenzan que esta es una cosa morbosa. Pase cualquier tiempo que siente que nesecite. Siéntese o párese en el lugar y haga lo que le viene naturalmente: sea silencioso o hablando, respirando profundamente, gritando, recordando, o rogando. Puede ser que usted quiera decorar el sepulcro, enderezándolo, limpiándolo, o poniéndole las pequeñas muestras de su amor. 5. Cree un libro de memoria. Junte las fotografías, que documentan la vida de su ser querido. Arréglelos en una cierta clase de orden así que cuentan una historia. Agregue otros elementos si usted desea: diplomas, recortes del periódico, realizaciones, y recuerdos de acontecimientos significativos. Ponga todo esto en un libro especial y guárdelo para que pueda verlo cuando lo desea. Úselo para recordar los tiempos mejores que tuvo con la persona y para conmemorar su vida. 6. Recuerde sus sueños. Sus sueños contienen información importante sobre sus emociones y sobre su relación con la persona quién murió. Sus sueños pueden ser asustadizos o tristes, especialmente después de la perdida. Los sueños pueden parecer extraños o locos. Usted podrá encontrar que la persona le aparezca en sus sueños. Acepte sus sueños por lo que son y vea lo que usted puede aprender de él. Nadie lo sabe mejor que usted. 7. Dígale a la gente qué le ayuda y qué no lo hace. Gente a su alrededor no puede entender lo que usted necesita. Dígales. Si le ayuda oír el nombre de la persona que ha fallecido, dígales que lo hagan. Si usted necesita más tiempo en a solas, o ayuda con tareas o trabajo que usted no puede terminar, o un abrazo ocasional, sea honesto(a). La gente no puede leer su mente, así que usted tendrá que decírselo. 8. Anote las cosas. La mayoría de la gente que está lamentando la perdida de alguien, generalmente se hace más olvidadiza. Escriba las cosas que le están ayudando a pasar por este tiempo. Esto puede incluir anotar cosas que usted desea preservar de la persona que ha muerto. 9. Pida una copia del servicio conmemorativo. Si la liturgia fúnebre o el servicio conmemorativo tienen significado especial para usted debido a lo qué fue dicho o leído, pida las palabras. Quienquiera participó en que el ritual se sentirá alagado que lo qué él/ella preparó fue apreciado. Convierta a estas palabras en lo que usted desee. Algunas personas han notado que estos pensamientos le ayudan aún más semanas y meses después del servicio. 10. Recuerde el rezo de la serenidad. Este rezo se atribuye al teólogo Reinhold Niebuhr, pero es realmente un rezo alemán antiguo. Ha traído comodidad y ayuda a muchos que han sufrido varias clases de aflicciones. 11. Haga una área de memoria en su hogar. En un espacio que sienta apropiado, arregle una pequeña mesa que honra a la persona: unas fotografías, quizás una estimada posesión o concesión o algo que crearon o algo que amaron. Esto puede ser colocado en una mesa pequeña, una chimenea o un escritorio. Alguna gente tiene gusto de utilizar un grupo de velas, representando no solo a la persona que murió, pero a otras que han muerto también. En ese caso una variedad de velas se puede arreglar cada una representada por una vida especial. 12. Beba agua. La gente que tiene alguien que fallece, puede fácilmente deshidratarse. Llorando naturalmente lo causa. Y con sus rutinas normales interrumpidas, usted podrá olvidarse de que necesita tomar agua como lo hizo antes. Que esto sea una manera que usted se cuida. 13. Use sus manos. A veces es importante hacer cosas repetitivas con sus manos, algo que usted no tiene que pensar porque es natural hacerlas. Cociendo, puede ser un ejemplo; la carpintería, solucionando un rompecabezas, pintando, haciendo trenzas, lavando y otras actividades parecidas. 14. Tome tiempos de descanso. El pasar por este tiempo difícil, no significa que uno siempre tiene que sentirse triste o desesperado(a). Es importante que conscientemente decida que usted pensará en otra cosa por un rato, o que haga algo que le gusta hacer. Algunas veces esto sucede naturalmente y es solamente más adelante usted realiza que su tristeza ya no es tan fuerte. Deje que esto pase. No indica que usted quiera la persona menos o que se esta olvidando de ella. Es una muestra que usted es normal y que necesita alivio de la presión y tristeza. Puede también ser una muestra sana que usted está mejorando emocionalmente. 15. Vea a un consejero. Si usted se preocupa sobre cómo se siente o como se está adaptando, haga una cita con un(a) consejero(a) que se especializa en esta área. Usted aprenderá lo que necesita saber sobre sus reacciones y las cosas saludables que ya esta haciendo. Haga preguntas al consejero antes de que usted empiece la conserjería. ¿Qué entrenamiento específico tiene él o ella? ¿Cuáles son sus calificaciones? La persona que es un terapeuta de la familia o psicólogo no necesariamente entiende las necesidades especificas para una persona que ha perdido a un ser querido. 16. Comience su día con su ser querido. Si la muerte es reciente, usted probablemente despertará pensando en esa persona de todos modos. Decida que usted la incluirá desde el comienzo del día. Enfoque este tiempo de una manera positiva. Traiga a su mente memorias buenas. Recuerde las cosas que esta persona le enseñó, los regalos que él o ella le dio. Piense de cómo usted puede pasar su día de la manera que le sería agradable a esa persona. Entonces lleve esa meta acabo durante el día. 17. Invite alguien que sea su compañero(a) por teléfono. Si su tristeza se le hace especialmente difícil, y siente que no puede hablar con alguien, pregunte que alguien de confianza sea su compañero(a) por teléfono. Pídale permiso de llamarle siempre que usted sienta que ya no puede. Entonces guarde su número y llame si usted lo(a) necesita. No abuse del privilegio, por supuesto. Prométales que un día será tiempo de reembolso - usted se hará algún día disponible para ayudar alguna otra persona de la misma manera que le han ayudado. Eso ayudara a que acepte el cuidado que está recibiendo. 18. Evite cierta gente si lo necesita. A nadie le gusta ser antipático o desagradable. Pero si hay gente en su vida que la hace muy difícil para que usted pase por este tiempo entonces haga lo que pueda para no tener contacto con ellos. 19. Done las posesiones significativas. Encárguese de donar las cosas personales de la persona que ha fallecido a personas quienes sacarán el mayor beneficio, sean conocidos o no. Miembros de la familia o amigos pueden disfrutar en recibir los recuerdos. Ellos u otros pueden merecer las herramientas, utensilios, libros o equipo deportivo. Las organizaciones filantrópicas pueden poner la ropa al buen uso. Hay gente que desea hacer esto inmediatamente después de la muerte, mientras otros desean esperar un rato. 20. Done en el otro nombre. Honre la memoria de la persona dando un regalo o varios regalos a una causa que a la persona le gustaría. ¿Una caridad preferida? ¿Un proyecto de edificio? 21. Cree o ponga en servicio un edredón de la memoria. Cosa o invite a otros que cosan con usted, o emplee a alguien para coser para usted. Haga un edredón o una cobija que recuerda los eventos importantes de la vida de la persona que murió. Tome su tiempo para hacer esto. Que sea un labor de su amor. 22. Tome una clase de yoga. Gente de casi cualquier edad puede hacer yoga. Hace más que condicionar su cuerpo, le ayuda a relajar y a fortalecer su mente. Puede ser que lo use junto con la práctica de la meditación. Es un arte apacible en su vida cuando usted merece ternura y tranquilidad a su alrededor. 23. Conecte en el Internet. Si sabe usar la computadora, busque el Internet. Encontrara muchos recursos para la gente que esta pasando por situaciones similares y se podrá comunicar con ellos. Usted puede hacer esto sin salir de su hogar. También encontrará más para ampliar sus horizontes como una persona quien esta creciendo. 24. Hable a una persona espiritual. Si usted está buscando respuestas más grandes; las preguntas sobre vida y muerte, la religión y la espiritualidad, considere la ayuda de un representante de su fe, o la fe de otra persona. Use ese tiempo espiritual con la otra persona para exploración personal. 25. Lea cómo otros han respondido a la muerte. Usted puede sentir que su propio dolor es todo lo que puede aguantar. Pero si usted quisiera mirar las maneras que otros lo han hecho, lea libros que otros han escrito sobre sus experiencias con la pérdida de un ser querido. Vaya a su biblioteca. 26. Aprenda con otros sobre la persona que murió. Escuche las historias que otros pueden contarle, tanto las historias que usted conoce como las que nunca ha oído. Pase el tiempo con sus amigos, compañeros de clase o colegas. Invítelos a su hogar. Pídales que escriban las memorias y guárdelas. Hay que celebrar el tiempo que tuvieron juntos. 27. Tome una vacación. Cuando usted siente que puede, tome una vacación de un día. Haga lo que usted desea, o no haga nada. Viaje a algún lugar, o quédese dentro de la casa solo(a). Sea muy activo o no haga nada. Nomás tenga un día para usted; y eso puede significar lo que usted quiera. 28. Invite que alguien le de su opinión de su progreso. Seleccione una persona en quien usted confía, preferiblemente alguien familiarizado(a) con la perdida y la muerte para dar su opinión del progreso que usted tiene. Si desea comprobar que usted está pensando claramente, cómo está recordando exactamente, cómo usted está manejando la situación, vaya a ésa persona. Haga sus preguntas, después escuche las respuestas. Lo que usted elige hacer con esa información será su responsabilidad. 29. Suelte su enojo en lugar de guardar todo adentro. Se sentirá extraño el sentir el enojo cuando acaba de morir una persona, pero esos sentimientos son una reacción normal. Aunque se siente avergonzado(a) cuando lo siente, encuentre maneras saludables de expresarlo. Grite, aunque sea solo(a) en la casa, llore, péguele a una almohada, aviente huevos, limpie la casa, y resista la tentación de guardarlo adentro. 30. Agradezca cada día. No le hace lo que le ha sucedido, usted todavía tiene cosas que agradecer. Quizás sean sus memorias, su familia, su ayuda, su trabajo; la salud - todas clases de cosas. Dirija su atención a esas partes de la vida que tienen valor y agradézcalas. 31. Fíjese en síntomas de la dependencia. Aunque sea normal llegar a ser más dependiente en otros por un tiempo inmediatamente después de una muerte, no será provechoso continuar haciendo eso a largo plazo. Fíjese en síntomas que está prolongando su necesidad de ayuda. Felicítese cuando usted hace las cosas para si mismo(a).

CONTRIBUTOR: Bill Rosenfeld MA, Mountain Park Health Center, Phoenix, AZ.

Teniendo éxito con los Medicamentos Antidepresivos

El cuerpo, el comportamiento y los pensamientos de una persona interactúan continuamente. Una vez que la depresión se ha convertido en un problema, esta interacción la puede llevar a un “espiral hacia abajo” tanto en el estado de ánimo como en esperanza. Existen dos maneras que lo pueden ayudar a cambiar la dirección hacia abajo y crear un “espiral positivo”.

1. Uso de medicamentos. Los medicamentos lo pueden ayudar a sentirse mejor. Los medicamentos antidepresivos reponen substancias necesarias para el cerebro que disminuyen con el stress. Los medicamentos pueden trabajar de manera lenta. Por lo tanto, es mejor usar los medicamentos en combinación con algunos planes de acción y el uso de estrategias para enfrentar el problema..

2. Tácticas para enfrentar la depresión. El uso de estrategias activas para enfrentar la depresión, puede ayudar a cambiar el espiral descendente de la depresión. Cuando usted trata los problemas de la vida con estrategias efectivas, usted tiene más oportunidades de crear condiciones positivas en su vida. Haga un esfuerzo, de acuerdo con su médico, para planear el uso adecuado de las estrategias para enfrentar la depresión.

Es probable que usted tenga más éxito con el tratamiento antidepresivo cuando haya obtenido información precisa sobre todos los aspectos del uso del medicamento. Por favor revise los siguientes detalles y discuta con su médico cualquier pregunta que tenga.

1. Inicio de la medicación Inicie su medicación tan pronto como le haya sido recetada. Entre más pronto empiece, más pronto experimentará los beneficios deseados. a. Tenga en mente, que generalmente toma de 2 a 3 semanas antes de que empiece a notar reducción en los síntomas y de 4-8 semanas para que los síntomas se calmen totalmente.. b. Lo primero que experimenta la mayoría de la gente es mejoría en el sueño, disminución de la fatiga y alguna mejoría en el control emocional. c. Los antidepresivos tienen mayor efecto en los síntomas físicos de la depresión. Otros síntomas, como ánimo deprimido y bajo sentido de auto-estima, pueden responder al tratamiento sólo de manera parcial. En otras palabras, los antidepresivos no son “tabletas de felicidad”, no eliminan totalmente los sentimientos de tristeza o vacío. 2. Recuerde tomar su medicamento. Tome su medicamento a determinada hora cada día. Durante las primeras semanas, hágase notas para que no se le olvide. Algunas personas usan algún hábito de higiene, como lavarse los dientes, para acordarse de tomar su medicamento. También habrá personas que quieran tener un frasco extra de medicamento en el cajón de su escritorio en el trabajo, por si olvidaran tomar su medicina en casa.

3. Llevar a cabo otras actividades. Usted puede continuar con sus actividades normales cuando esté tomando medicamentos antidepresivos. Si usted nota que se siente un poco sedado o con sueño al empezar a tomar la medicina, evite manejar o llevar a cabo actividades riesgosas. Normalmente el sueño disminuirá, de no ser así, hable con su médico sobre un cambio del medicamento. 4. Tomar antidepresivos junto con otros medicamentos. Usted puede tomar antidepresivos con casi todos los tipos de medicamentos. Sin embargo, hable con su médico para saber si puede tomar los medicamentos antidepresivos con otros medicamentos que usted esté tomando. 5. Tomar antidepresivos y consumo del alcohol. No tome alcohol mientras esté tomando medicamentos antidepresivos. El alcohol puede bloquear los efectos del medicamento. 6. ¿Adicción? Los antidepresivos no crean adicción. 7. Aumento en la dosis del medicamento. Aumente la dosis del medicamento de acuerdo con las indicaciones de su médico. Al inicio del tratamiento con medicamentos antidepresivos, usted empezará con dosis bajas se le irán aumentando poco a poco. No se preocupe porque está “tomando muchas pastillas”. Su médico le está aumentando lentamente la dosis para ayudarlo a eliminar los efectos secundarios. Cuando haya llegado a su “dosis terapéutica”, probablemente le recetarán tabletas con una dosis más alta, que le permitirán tomar menos pastillas. 8. Continúe con el medicamento. Tome el medicamento hasta que usted y su médico decidan que ya está listo para suspenderlo. En la mayoría de los casos, su médico le pedirá que tome la medicina por lo menos durante 6 meses después de que haya llegado a su dosis terapéutica. No deje de tomar la medicina porque ya se siente mejor. Use este período en el que ya se siente major para trabajar en el desarrollo de habilidades que lo ayudarán a prevenir una recaída. El promedio de recaídas cuando la gente deja de tomar muy pronto sus medicamentos es tan alta como 80%. Espere y planee con su médico cómo y cuándo dejará de tomarlos.

Manejando los Efectos Secundarios

La mayoría de los medicamentos antidepresivos tienen efectos secundarios leves. Los efectos secundarios normalmente son temporales y disminuyen o desaparecen durante las primeras semanas de tratamiento. Si usted experimenta efectos secundarios que sean más severos, llame a su médico. Probablemente él/ella le sugerirán una o más de las siguientes estrategias:

Cambiar la hora en la que toma el medicamento Cambiar la dosis del medicamento Usar algo para los efectos secundarios Cambiar a un medicamento diferente

La siguiente tabla resume los efectos secundarios más comunes y las posibles estrategias para enfrentar los efectos secundarios. La mayoría de los medicamentos tienen solamente uno o dos de los efectos secundarios enlistados en esta tabla.

Efectos Secundarios Comunes Remedios Boca Seca Tome mucha agua. Mastique goma de mascar sin azúcar. Coma gomitas sin azúcar. Estreñimiento Coma más alimentos ricos en fibra. Tome un laxante suave. Adormilado Tome aire fresco y camine con frecuencia. Trate de tomar más temprano su medicina de la noche, o si toma la medicina en el día pregunte a su doctor si puede tomarla en la noche. Insomnio Tome sus medicamentos en el día. Trate de informarse sobre el insomnio. Tome un baño caliente y una cena ligera antes de acostarse. No haga ejercicio pesado en la noche. Visión borrosa Recuerde que esta será una dificultad temporal. Hable con su doctor en caso de que continúe este problema. Mareo Levántese lentamente. Tome muchos líquidos, Si esto le preocupa, llame a su doctor. Sentirse acelerado Dígase a usted mismo, “Esto pasará en tres o cinco días.” Si no es así, llame a su doctor o enfermera. Problemas Sexuales Hable con su doctor. Tal vez podría ayudarle un cambio de medicamento o toma unas “vacaciones del medicamento.” Náuseas o Pérdida del Apetito Tome la medicina con alimento. Prepare la comida de tal manera que sea apetecible y colorida. Tome pequeñas porciones de comidas sanas.

Source: Using Medications Successfully. An ICP Booklet. Reno: Context Press. Preston, J. & Johnson, J. (2000) Clinical Psychopharmacology Made Ridiculously Simple, Edition 4. Miami: Medmaster.

Una Técnica de Relajación: Respiración con el Diafragma

¿Cómo Trabajan las Técnicas de Relajación? Antes de entrenarlo en la técnica, queremos que entienda cómo trabajan las técnicas de relajación. Los beneficios que traen las técnicas de relajación se pasan en la manera en que está diseñado su cuerpo. Su cuerpo tiene una respuesta biológica llamada “la respuesta de huída o lucha” o la respuesta al stress. La respuesta al stress ocurre como respuesta a los eventos o a pensamientos que producen stress (Ej. Preocuparse por el pasado, el presente o el futuro). Durante la respuesta al stress, su corazón late más rápido y más fuerte, usted respira más rápido y menos profundamente, sus músculos se tensan, usted suda más, su estómago produce más ácido, su digestión se vuelve lenta, y se le bajan las defensas. Es fácil entender entonces de qué manera la respuesta al stress afecta diferentes condiciones médicas. Afortunadamente, su cuerpo también tiene una respuesta que llamaremos la “respuesta de relajación”. En la respuesta de relajación su corazón late más lento y más suavemente, usted respira más lenta y profundamente, sus músculos se relajan, suda menos, su estómago vuelve a su funcionamiento normal, y su sistema de defensa regresa a la normalidad. La respuesta de relajación también ayuda a poder dormir.

Con frecuencia iniciamos esta respuesta de relajación haciendo una actividad donde nos relajamos, por ejemplo, ejercicio, lectura, escuchar música, pasatiempos, dar un paseo, ver televisión, pescar, etc. Aunque estos métodos para iniciar la relajación con frecuencia son útiles, están limitados por el hecho de que normalmente necesitan de equipo especial (Ej. televisión, una caña de pescar, un libro, etc.), mucho tiempo (Ej. tarde para pescar, una hora para ver un programa de television), o un escenario especial (Ej. cuarto donde se encuentra la televisión, un lago para pescar). Como resultado, en muchas situaciones en las que una persona se ve ansiosa, no hay manera de que haga la cosas que normalmente haría para relajarse. Por ejemplo, si usted se relaja leyendo un libro y usted se encuentra a la mitad de una junta, es muy poco probable que usted pueda tomar un libro y empezar a leer para relajarse.

Lo que se necesita es un método para iniciar la respuesta de relajación que pueda ser usado en cualquier momento, en cualquier lugar y sin la necesidad de equipo especial. Las técnicas de relajación le dan esta habilidad. Para entender cómo hacer esto, volvamos a la biología del stress y las respuestas de relajación. Ya que estas respuestas son sistemas, si podemos tomar una parte del sistema para que actué como en la respuesta de relajación, eso serviría para empezar la respuesta completa. De todos los cambios físicos que ocurren en las respuestas del stress y relajación, solamente tenemos control directo sobre dos de ellas: los pulmones y los músculos. Como consecuencia, si durante la respuesta del stress hacemos que nuestros pulmones respiren más lento y más profundamente y/o hacemos que nuestros músculos se relajen, con práctica podremos ser capaces de iniciar la respuesta de relajación.

Dejando libres a los Músculos para que se Relajen El primer paso es asegurarnos de que nuestro cuerpo está en posición para dejar libres a los músculos para que se relajen. Muchas veces pensamos que al sentarnos en una silla estamos en una posición relajada. Sin embargo, debido a que sus músculos están tensos para poder soportar el peso de su cuerpo, muchos músculos no están libres para relajarse. El objetivo es que su cuerpo esté sosteniendo por otra cosa que no sean sus músculos. Por ejemplo, al hacer las técnicas mientras está acostado en la cama, hace que la cama sostenga su cuerpo, permitiendo que sus músculos se relajen fácilmente. Un sillón reclinable puede funcionar de manera similar a la cama ya que soporta el peso de su cuerpo. Sin embargo, como queremos relajarnos en cualquier momento, en cualquier lugar, usted necesita ser capaz de dejar libre sus músculos para que se relajen, sin la necesidad de una cama o un sillón reclinable. Para hacer esto, usted usa su esqueleto para sostener el peso de su cuerpo. La siguiente lista describe en qué posición debe poner su cuerpo para permitir que sea sostenido por su esqueleto.

Posiciones para la Relajación

1. Pies y Piernas Rodillas y tobillos sin cruzar y doblados a 90 grados. Los pies planos sobre el piso.

2. Espalda La espina perpendicular al piso, derecha pero no rígida. Omóplatos y glúteos tocando el respaldo de la silla. 3. Brazos Doblados a nivel de los codos unos 120 grados con las muñecas descansando en los muslos. 4. Manos Descansando en las rodillas, con las palmas hacia arriba o hacia abajo. Los dedos ligeramente doblados. 5. Hombros Colgando sueltos y flácidos.

6. Cuello y Garganta Es ideal que la cabeza esté apoyada en la pared o en una silla, si no es así, la cabeza balanceada con el cuello. La garganta quieta y tranquila.

7. Parte Baja de la Cara Con la mandíbula colgando flácida. Los dientes separados aproximadamente el ancho de un dedo. Los labios ligeramente abiertos. 8. Parte Alta de la Cara Los ojos ligeramente cerrados. La frente y las cejas relajadas.

Usando su Respiración para Iniciar la Respuesta de Relajación Otro factor importante para relajarse es su respiración. Durante la respuesta del stress, la gente tiende a respirar más rápido y menos profundamente (Ej. Respiraciones pequeñas y rápidas). En cambio, durante la respuesta de relajación la gente tiende a respirar despacio y profundamente. Ya que usted tiene control sobre su respiración, usted puede usar esta forma de respiración como para hacer, que su cuerpo esté tenso o relajado. Respirar lenta y profundamente ayuda al cuerpo a iniciar la respuesta natural de relajación. Por ejemplo, ¿Alguna vez ha respirado profundamente para tratar de calmarse?. En muchos casos esa respiración profunda probablemente lo ayudó a sentirse un poco más calmado. Sin embargo, esas respiraciones profundas que la gente hace, con frecuencia no son tan efectivas como deberían ser, por varias razones. Primero, aunque una respiración profunda con el pecho es más profunda que la típica respiración, muchas veces la gente inhala y exhala muy rápido. Segundo, una respiración profunda con el pecho (de la manera típica en que la gente respira profundamente) no es tan profunda como una respiración total con el diafragma. Tercero, la gente no practica la respiración profunda antes de una situación de stress. Pero ya que la relajación es una habilidad, es necesario desarrollarla para que sea efectiva y eso necesita práctica.

Para poder relajarse de manera efectiva, usted necesitará combinar la postura de su cuerpo que discutimos antes con respiración lenta con el diafragma. Si alguna vez ha tomado clases de canto habrá aprendido a respirar con su diafragma. Esto es usado para relajarse y para cantar, porque le permite ensanchar más sus pulmones y como consecuencia respirar más lenta y profundamente.

La respiración con el diafragma, en realidad, es la manera más natural de respirar. Todos nacemos respirando así. Tome un momento e imagine a un niño pequeño acostado sobre su espalda. ¿Qué es lo que sube y baja mientras el niño respira? Correcto, su estómago. Sin embargo, con el tiempo aprendemos a respirar con el pecho. Por ejemplo, usamos ropa que está apretada en nuestra cintura (limitando nuestra capacidad para respirar con el diafragma) y nos enseñan a pararnos derechos, sacando el pecho y metiendo el estómago. Esto resulta en que aprendemos a respirar con el pecho.

Tome un momento y haga la prueba para ver como respira usted. Siéntese derecho y coloque una mano en su pecho y otra mano en su estómago. Observe qué mano se mueve más. Si se mueve la mano en su pecho, entonces usted está respirando con su pecho. Si se mueve la que está en su estómago, entonces está respirando con su diafragma.

Respirar con el pecho no es un problema para respirar normalmente. Tenemos bastante aire con esta forma de respirar. Sin embargo, cuando el objetivo es relajarse, necesitamos respirar más profunda y lentamente de lo que hacemos cuando respiramos con el pecho. La razón para esto es nuestras costillas. Cuando usted respira con su pecho, las costillas no dejan que sus pulmones se ensanchen completamente. Es como inflar un globo dentro de una botella. El globo solamente se podrá expandir el tamaño de la botella. La respiración con el diafragma permite a los pulmones que se expandan por debajo de las costillas. En la respiración diafragmática el diafragma jala hacia abajo, empujando el estómago hacia fuera, permitiendo que tanto la parte baja como alta de sus pulmones se llenen de aire. Es como inflar un globo dentro de una botella que tiene cortado el fondo. Como una mayor parte de los pulmones se encuentra llena de aire, usted puede respirar más lentamente.

Para la mayoría de la gente la respiración con el diafragma es fácil de aprender, sin embargo toma un tiempo para que uno lo haga de manera natural y cómoda. Otros necesitarán algo de práctica para poder lograrlo. La mejor manera de aprender es usar nuevamente sus manos. Coloque sus manos en su pecho y su estómago, como lo hizo antes. Ahora observe sus manos y trate de respirar para que sea la mano en su estómago la que se mueva hacia arriba y hacia abajo y la mano en su pecho se quede medio quieta. Algo que puede ayudarlo es imaginar que sus pantalones son muy grandes y necesita sacar el estómago para detenerlos. ¿Podría hacerlo? Si no puede, probablemente necesitará un poco más de práctica. Siga tratando. Una vez que tenga una idea de como se siente, regrese a la posición anterior y practique de nuevo con sus manos.

Si después de algo de práctica todavía tiene problemas, puede tratar acostado en el piso sobre su espalda con un libro de tamaño mediano (no demasiado pesado) sobre su estómago. Ahora, mientras respira trate de hacer que el libro se mueva hacia arriba y hacia abajo. De manera alternada, puede acostarse sobre su estómago con sus manos sobre su cabeza. En esta posición, el peso de su cuerpo estará sobre su pecho y usted se verá forzado a respirar con su diafragma. Una vez que note la diferencia, regrese a la posición anterior y vuelva a tratar con sus manos.

Su ritmo de respiración también es muy importante. Inhale lentamente. Aguante la respiración por un segundo. Después exhale lentamente. No empuje el aire hacia fuera, simplemente deje que la presión natural de su cuerpo lo mueva hacia fuera. A veces sirve abrir un poco la boca, como cuando silba. Esto hace que baje la velocidad del aire que está saliendo. Un buena señal para saber si está respirando muy rápido es el sonido de su exhalación. Si apenas puede escuchar el sonido de su exhalación, usted está respirando lo suficientemente lento. Si lo puede escuchar bien, entonces respire más despacio. Un buen ritmo es alrededor de 5-6 respiraciones por minuto.

El Papel de su Mente en la Relajación Está bien, hemos cubierto la posición de su cuerpo y su respiración, pero existe otro factor importante del que necesitamos hablar antes de tratar de que se relaje. Es su mente. Su mente y su cuerpo están conectados. En otras palabras, la mente tiene influencia sobre el cuerpo y el cuerpo tiene influencia sobre la mente. Suponga que tiene una buena posición de su cuerpo y respira con su diafragma, pero está pensando en lo que tiene que hacer al día siguiente, o los problemas en casa, ¿Qué pasaría? Correcto, usted no se relajaría. Mientras que el cuerpo trata de relajarse, su mente continuará mandando la respuesta al stress.

Lo que haga con su cuerpo es importante mientras está tratando de relajarse. La clave es evitar pensar en cosas estresantes. Mucha gente simplemente tratará de poner su mente en blanco. Si alguna vez ha tratado de hacer esto, sabrá que no funciona. La mente quiere estar pensando en algo. Si trata de poner la mente en blanco, de manera natural tratará de encontrar algo por que preocuparse. Usted tiene que pensar en algo, pero debe ser otra cosa y no pensamientos que le den stress. Puede pensar en cosas neutrales (el viejo método de contar borreguitos es un ejemplo de este método) o puede pensar en cosas agradables. Usted elige. Por ejemplo, a los individuos con buena imaginación, les resulta bien el imaginar cosas agradables, pero no cosas neutrales, como contar. Por otro lado, los individuos con una imaginación pobre pueden frustrarse al tratar de imaginar cosas y con frecuencia encontrar que las ideas neutrales les son de más ayuda. Lo que usted piensa le llamamos el “aparato mental” porque es un aparato para ayudar a controlar la tendencia de la mente a pensar acerca de cosas estresantes.

Si usted quiere tratar con imágenes agradables existen dos formas que lo ayudarán a tener más éxito. La primera es imaginar la escena como si la estuviera viendo con sus ojos. Específicamente, si se está imaginando a usted mismo en las montañas, no se imagine sentando bajo un árbol, más bien imagine lo que vería a su alrededor si estuviera sentado bajo el árbol. (Ej. Solamente vería su cuerpo si volteara hacia abajo). Segundo, trate de usar los cinco sentidos. En otras palabras, no solamente imagine cómo se ve. Imagine los sonidos, olores, la sensación en su cuerpo/pies y también cualquier sabor en el aire (o imagínese comiendo algo). Usar los cinco sentidos ayuda a que la imagen en su mente sea más vívida, permitiéndole enfocarse de major manera en su imagen. Finalmente, escoja como escena un lugar relajante para usted. No tiene que ser un lugar donde en realidad ha estado, sino que puede ser un lugar al que ha querido ir o que simplemente ha visto en una fotografía.

Si usted piensa que los pensamientos neutrales trabajarán de mejor manera para usted, permítame sugerirle una idea (pero siéntase en libertad para crear sus propios pensamientos, usando éste como guía). Cuando inhale, diga el número “uno” (en su mente). Después con la siguiente inhalación diga el número “dos”, y así sucesivamente hasta llegar a 10. Cuando llegue a 10, vuelva a empezar con uno. Volviendo a empezar en uno, cada vez que llegue a 10 lo ayudará a mantenerse mejor enfocado en el ejercicio. Cuando exhale, diga una palabra como “calma” o “relax” para recordar lo que está tratando de lograr. Sería algo así: (inhale) “uno” (exhale) “relax” (inhale) “dos” (exhale) “relax” (inhale) “tres” (exhale) “relax” (inhale) “cuatro”...

El último punto relacionado con su mente involucra su actitud. Contrario a la mayoría de las habilidades donde entre más se esfuerza uno por su objetivo más posibilidades tiene de obtenerlo, el objetivo de la relajación requiere de una actitud pasiva para obtenerlo. ¿Qué pasaría si yo estuviera tratando de relajarme, pero pensando, “Bien, me voy a relajar. Ahora, Relájate. ¡Relájate! ¡RELAJATE!? Claro, que estaría más tenso. Y lo más probable es que entre más problemas tenga para relajarme ( Ej. fallar en conseguir mi objetivo) más me frustraría con esta técnica. Entonces se convertiría en una técnica estresante en lugar de una técnica de relajación. Necesita tener una actitud pasiva. En otras palabras, en lugar de enfocarse en relajarse, enfóquese en hacer el ejercicio como se le indicó y deje que la respuesta de relajación de su cuerpo ocurra de manera natural.

Practicando la Técnica Cuando apenas esté aprendiendo a relajarse, también lo ayudará practicar en un ambiente tranquilo. En otras palabras, si practica las habilidades mientras ve televisión, o mientras los niños están corriendo alrededor, no se sorprenda si no tiene éxito. Sin embargo, una vez que haya desarrollado la habilidad de relajación, con frecuencia podrá ser usada en medio de situaciones estresantes o en ambientes ruidosos. Usted lo hará simplemente haciendo una o dos respiraciones con el diafragma y usando su aparato mental. No se relajará tanto como cuando lo practica por varios minutos en un ambiente tranquilo, pero estará mucho más relajado de lo que pudo haber estado en medio de una situación estresante.

Bien, ahora pongamos todo junto y hagamos el intento. En un ambiente relajante, coloque su cuerpo como se le indicó y empiece a respirar con su diafragma. Recuerde mantener un ritmo lento, pero no tan lento que sea incómodo. Si empieza a sentirse mareado o con la cabeza débil, aumente un poco la velocidad de su respiración. Enfoque su mente en cualquier aparato mental que haya seleccionado. Su mente tratará de buscar preocupaciones y angustias, solo deje pasar esos pensamientos y vuelva a enfocarse en el ejercicio. Aún cuando obtenga una buena habilidad, su mente seguirá vagando. Las personas que son buenas para relajarse es por que pronto se dan cuenta y no dejan que les pase tanto. A veces, también ayuda el cerrar los ojos, pero si prefiere los puede dejar abiertos y simplemente enfocar su vista en algún objeto en la habitación. Recuerde, no trate de forzarse a relajarse. Simplemente enfóquese en el ejercicio y permita que la respuesta de relajación ocurra naturalmente. Yo recomiendo que practique durante 5 minutos, pero no vea el reloj. Sólo calcule que hayan pasado 5 minutos. También puede poner una alarma si quiere estar seguro de no pasarse de 5 minutos.

Yo recomiendo que practique 2 veces al día, 5 minutos cada vez. Si hace esto de manera consistente por 2-4 semanas probablemente esta técnica se volverá efectiva. Después puede empezar a usar esta habilidad cuando la necesite.

Una vez que desarrolle la habilidad, ésta se volverá más efectiva cuando sea usada con frecuencia en respuesta a las primeras señales de stress. Por lo tanto, usted necesita empezar a poner atención a sus primeras señales de stress. Busque señales físicas de su cuerpo, reacciones emocionales, o cosas que usted acostumbra hacer cuando está estresado. Y cuando los identifique, haga una o dos respiraciones profundas con el diafragma usando su aparato mental. Entre más aprenda a hacer esto con frecuencia, sus niveles de tensión se mantendrán más bajos. Ya que ésta es una técnica muy breve, el beneficio más grande viene al detectar el stress cuando empiece, evitando que llegue a niveles altos. Terapia Cognitiva del Comportamiento (TCC)

(Terapia emotiva racional, terapia racional del comportamiento, terapia del vivir racional, terapia del comportamiento dialéctico, terapia enfocada en esquema)

por Karen Schroeder Kassel, MS, RD, Med

English Version

Definición

La terapia cognitiva del comportamiento (TCC) es una forma de terapia de conversación. Esto significa que usted discute sus pensamientos, sentimientos, y comportamientos con un profesional en salud mental. La TCC se enfoca en la manera en la que su pensamiento afecta la forma en la que se siente y actúa.

Por ejemplo, una misma situación puede ser percibida de manera positiva por una persona, mejorando su bienestar, pero de manera negativa por otra, lo cual contribuye a experimentar sentimientos de tristeza o ansiedad. Su terapeuta le ayuda a identificar pensamientos negativos y evalúa qué tan realistas son estos pensamientos. Entonces, él le enseña a "desaprender" patrones negativos de pensamiento y "aprender" unos nuevos y útiles.

La TCC es un método de solución de problemas. Aunque usted no puede controlar a otras personas o a situaciones, puede controlar la manera en la que percibe y reacciona ante una situación en particular. La TCC le enseña las habilidades para cambiar su manera de pensar y controlar sus reacciones ante personas y situaciones estresantes.

Razones para realizar el procedimiento

La terapia cognitiva conductual se usa para tratar muchas preocupaciones de salud. Éstos incluyen:

• Trastorno de depresión mayor y cambios en el estado de ánimo • Trastornos de ansiedad, incluyendo trastorno de ansiedad social y trastorno de ansiedad generalizada, que incluye sensaciones de tristeza extrema y/o preocupación excesiva • Controlar el estrés • Trastornos de pánico • Fobias • Trastorno de estrés postraumático (PTSD) • Trastornos depresivos y de ansiedad infantiles • Trastorno obsesivo compulsivo (OCD) • Los trastornos alimenticios incluyen anorexia, bulimia nerviosa y obesidad • Insomnio y otros trastornos del sueño • Abuso de sustancias o dependencia de sustancias • Estilos de mala adaptación de relacionarse con otras personas, incluyendo permisión, agresión pasiva, o • co-dependencia • Dolor crónico • Dificultad con las relaciones • Baja autoestima • Malas habilidades para sobrellevar las cosas • Ira incontrolada

Cómo controlar problemas de salud mental

Muchos problemas de salud mental se originan por una combinación de desencadenantes fisiológicos y emocionales. La TCC puede ayudar a los pacientes a lidiar con la enfermedad, ya que disminuye los efectos de los desencadenantes emocionales.

Factores de riesgo de complicaciones durante el procedimiento

La TCC puede no ser apropiada para personas con algunas condiciones:

• Aquellas personas que son psicóticas • Aquellas personas sin tratar o sin controlar su trastorno bipolar • Aquellas personas que carecen de colocación estable de vivienda • Aquellas personas con una variedad de problemas de salud inestables

Qué esperar

Antes del procedimiento

No hay preparación específica para TCC. Se le puede pedir que llene un cuestionario sobre sus sensaciones.

Descripción del procedimiento

Usted puede recibir TCC en sesiones terapéuticas individualmente o en un formato grupal. Se puede dividir a la TCC en dos partes: análisis funcional y entrenamiento de habilidades. En el análisis funcional, usted y su terapeuta identifican situaciones estresantes. Usted también determina los pensamientos que conllevan o empeoran estas situaciones. Estos pensamientos se analizan para ver si son realistas y apropiados. Por ejemplo, su terapeuta le puede señalar patrones de pensamientos negativos, como "no puedo manejar esto" o "la gente se está burlando de mí".

Page 2 of 5 Copyright © 2010 EBSCO Publishing. All rights reserved. Después, mediante entrenamiento de habilidades, su terapeuta lo guía para reducir maneras poco saludables de pensamiento, y para aprender maneras más saludables. En vez de pensar "no puedo controlar esto", se le enseñará cómo recurrir a sus propias fuerzas: "Fui capaz de controlar situaciones difíciles anteriormente, entonces ahora puedo controlar esto".

Usted también aprenderá a hacer más preguntas sobre usted mismo antes de hacer una conclusión. Por ejemplo, "¿Esas personas podrían estarse burlando de otra cosa y no de mí" El objetivo es reemplazar patrones irracionales de pensamiento con unos más apropiados y racionales.

El entrenamiento de habilidades requiere mucha práctica, la cual frecuentemente se deja "de tarea". Usted podría practicar ejercicios de respiración profunda o representaciones sobre cómo actuar en algunas situaciones sociales. Una persona que lidia con abuso de sustancias podría practicar maneras para negarse a beber alcohol.

La tarea en casa es vital para el éxito de TCC. Usted debe practicar nuevas respuestas racionales hasta que reemplace sus respuestas anteriores poco saludables. La tarea también le permite intentar nuevas habilidades y darle retroalimentación a su terapeuta acerca de lo que funciona mejor para usted.

Después del procedimiento

Usted puede recibir tarea entre sesiones. Necesitará practicar las estrategias que usted y su terapeuta han discutido.

¿Cuánto durará?

La duración de cada sesión individual por lo general es de 50-100 minutos. Las sesiones grupales pueden tardar más tiempo. Las sesiones de tratamiento se pueden llevar a cabo de 1 a 2 veces por semana durante 12-16 semanas. Este es un lineamiento general y dependiendo de su situación, el tratamiento puede durar más o menos tiempo.

Tenga en mente que puede tomar varios intentos para desaprender malos hábitos y para aprender unos más saludables.

Posibles complicaciones

No se conocen complicaciones para los pacientes de TCC.

Hospitalización promedio

Por lo general, la TCC se realiza a pacientes ambulatorios. Esto se puede hacer en un consultorio médico o en un centro de salud comunitaria.

Cuidado Postoperatorio

Algunos terapeutas aconsejan que regrese para una revisión aproximadamente a los 3, 6, y 12 meses después que ha terminado la terapia. Además, puede llamar a su terapeuta cada vez que surja la necesidad de hacerlo.

Resultado El objetivo de la TCC es cambiar su proceso de pensamiento y sus patrones de pensamiento poco saludables para aprender respuestas saludables y realistas ante situaciones difíciles. Muchos pacientes notan una mejoría en los síntomas en un lapso de 3 a 4 semanas después de comenzar la TCC y hacer su "tarea en casa".

Si los pensamientos, sensaciones, u otras dificultades que conllevan a que busque terapia están regresando o empeorando, llame a su médico. Si usted tiene pensamientos de herirse a sí mismo o a otras personas, llame a su médico o al 911 inmediatamente.

RESOURCES:

American Psychological Association http://www.apa.org

The Beck Institute for Cognitive Therapy and Research http://www.beckinstitute.org

National Association of Cognitive—Behavioral Therapists http://www.nacbt.org/index.htm

CANADIAN RESOURCES:

BC Health Guide, British Columbia Ministry of Health http://www.bchealthguide.org

Canadian Psychiatric Association http://www.cpa-apc.org

REFERENCES:

About cognitive therapy. The Beck Institute for Cognitive Therapy and Research website. Available at: http://www.beckins... Accessed June 10, 2007.

About cognitive therapy. The Beck Institute for Cognitive Therapy and Research website. Available at: http://www.beckins... . Accessed November 30, 2005.

Bush JW. The CBT website. Available at: http://www.cognitivetherapy.com/index.html . Accessed November 29, 2005.

Butler AC, Chapman JE, Forman EM, et al. The empirical status of cognitive-behavioral therapy: a review of meta-analyses [abstract]. Clin Psychol Rev . 2005.

A cognitive-behavioral approach: treating cocaine addiction. National Institute on Drug Abuse website. Available at: http://www.nida.nih.gov/TXManuals/CBT/CBT1.html . Accessed November 22, 2005.

Cognitive-behavioral therapy. National Association of Cognitive-Behavioral Therapists website. Available at: http://www.nacbt.org/whatiscbt.htm . Accessed November 22, 2005.

Morris N, Raabe B. Some legal implications of CBT stress counselling in the workplace. British Journal of Guidance & Counselling . 2002 Feb;30(1):55-62.

Ultima revisión November 2008 por Rosalyn Carson-DeWitt, MD Last Updated: 11/17/08

Se provee esta información como complemento a la atención proporcionada por su medico. Dicha información no

Page 4 of 5 Copyright © 2010 EBSCO Publishing. All rights reserved. tiene el propósito o la presunción de substituir el consejo medico profesional. Procure siempre el consejo de su medico o de otro profesional de la salud competente antes de iniciar cualquier tratamiento nuevo o para aclarar cualquier duda que usted pueda tener con relación a un problema de salud.

PATIENT IDENTIFICATION

[Your CLINIC Name]

Sitio ______

Proveedor______

Acuerdo para la Administración de Medicamentos

Diagnóstico:

*************************************************************************** *****************

Se efectúa este acuerdo para evitar un malentendido con respecto a ciertos medicamentos que estará tomando para alivio de dolor. Esto nos ayudará a brindarle servicios médicos de calidad y seguir las leyes con respecto a estas medicinas controladas.

Sus iniciales Yo comprendo que este acuerdo es necesario para la confianza e importante para la relación entre el doctor y el paciente. Yo estoy consciente que el doctor me atenderá basándose en este acuerdo. Yo mantendré al tanto a mi doctor acerca de mi dolor. Yo le explicaré el tipo de dolor que siento y que intenso es. Yo le contaré como el dolor afecta a mi vida. También avisare lo bien que me está funcionando la medicina. Yo no usaré sustancias ilegales controladas incluyendo la marihuana, la cocaína, etc. Yo no venderé, compartiré, o cambiaré mi medicina a/con nadie. Yo no intentaré obtener medicinas controladas de otro proveedor sin una buena indicación clínica. Otras medicinas controladas incluyen medicinas narcóticas, estimulantes controlados, o sedantes. Yo les avisaré a todos los doctores que me estén atendiendo que estoy tomando este medicamento para alivio de dolor. Yo comprendo que las medicinas ni las recetas podrán ser repuestas si se pierden o son robadas. Yo estoy de acuerdo utilizar la medicina al paso que sea recetada. Si utilizo la medicina a un paso más rápido de lo recetado, me quedaré sin medicina por un tiempo. Yo comprendo que mis medicinas sólo se surtirán al tiempo de visita o durante las horas de oficina. Incluso, no faltaré a mis citas con mi proveedor de costumbre. También estoy consciente que mis medicinas se surtirán siguiendo un calendario. No me podrán surtir las medicinas por la noche o durante los fines de semana. Estoy de acuerdo llamar a la farmacia 3 días antes de la fecha indicada en el frasco para pedir que me vuelan a surtir la medicina. Si la medicina requiere una receta médica, yo llamaré a la clínica y pediré una receta médica por escrito 3 días antes que la necesite (pero no antes). Yo estoy de acuerdo llamar a la clínica no más de una vez por receta médica para averiguar cuanto tiempo se tarda para surtir mi medicina. Yo llevaré mis medicinas a cada cita. Estoy de acuerdo surtir mis recetas médicas en esta farmacia______localizada ______en ______solamente. Si surge una emergencia o soy hospitalizado y otro doctor necesita recetarme esta medicina, yo avisaré a La Clínica de Campesinos del Valle de Yakima lo antes posible. Si está disponible una clase ”Pain” (Dolor) o “Quality of Life” (Calidad de Vida) en la clínica donde me atienden, yo asistiré cada mes como parte del plan de tratamiento. Yo recibiré mi receta médica para mi medicina después de terminar la clase cada mes. Yo comprendo que si no cumplo con el acuerdo, mi doctor puede dejar de recetar estas medicinas y recomendar un programa contra la dependencia de drogas. También comprendo que si no cumplo con este contrato, me pueden pedir no volver a solicitar servicios de esta clínica (después de una evaluación apropiada). Yo autorizo a que mi doctor solicite y obtenga informes escritos/verbales de otras farmacias con respecto a las medicinas que estoy surtiendo (llenando) en esas farmacias. Yo autorizo a mi doctor a que proporcione una copia de este formulario a mi farmacia. Yo autorizo a mi doctor y a mi farmacia a cooperar en la investigación de posible abuso, venta u otro uso de la medicina. Cualquier departamento de seguridad de la ciudad, del estado, o federal o la Mesa de farmacia del estado de ______puede realizar tal investigación. Yo estoy de acuerdo a renunciar a cualquier inmunidad y al derecho de privacidad y confidencialidad con respecto a estas autorizaciones. Yo autorizo a mi doctor a proporcionar una copia de este formulario a otras organizaciones de salud que incluyen hospitales, clínicas, y otros proveedores que me estén atendiendo. Yo estoy de acuerdo someterme a una prueba de orina o de sangre si el doctor me lo pide. La prueba se realizaría para ver si estoy siguiendo las reglas del programa. Estoy de acuerdo participar en eI programa Three Strikes (tres faltas) si llega a ser necesario. Si recibo 3 faltas en menos de 2 meses, mi doctor puede dejar de recetarme medicinas narcóticas para el dolor. Puedo recibir una falta por: • Ausencia de una medicina en una prueba de orina o un análisis de sangre. • No llamar, someterme a una prueba de orina ni acudir a una cita con mi doctor o consejero de salud mental. • Intentar conseguir medicinas de otro doctor • Intentar surtir mi medicina en una farmacia que no sea la que está nombrada arriba. Yo estoy de acuerdo seguir cada condición de este acuerdo. Me han explicado cada condición con todo detalle. Yo tenía estas preguntas y dudas acerca del tratamiento: ______. ______(nombre de doctor) me ha clarificado todo. o . . . Yo no tuve preguntas o dudas con respecto al tratamiento.

Yo recibí una copia del acuerdo. Yo comprendo que, si deseo, me proporcionarán un resumen en español de este contrato sin costo alguno.

MEDICINAS INCLUIDAS EN ESTE ACUERDO:

Medicina Dosis Instrucciones Cantidad por mes ______

Mi firma abajo indica que yo estoy de acuerdo seguir todo los puntos de este acuerdo.

Formulario firmado el ______, 200___. Hora ______

FIRMA PACIENTE ______

FIRMA DOCTOR ______

ATESTIGUADO POR ______

PATIENT IDENTIFICATION Depresión: ¿Qué es y cómo obtener ayuda?

? ¿Qué es la depresión?

El sentirse triste o “bajoneado” de cuando en cuando es normal, pero no es lo mismo que la depresión. Cuando los doctores hablan de la depresión, ellos hablan de la enfermedad médica llamada depresión mayor. Alquien con una depresión mayor tiene la mayoría o todos los síntomas mencionados en el cuandro de abajo casi todos los dias, todo el día, por un periodo de dos semanas o más. También hay una forma más leve o “menor” de depresión con síntomas menos severos. La depresión menor tiene las mismas causas y tratamiento que la depresión mayor.

Síntomas de la Depresión . Falta de interés o placer en cosas que usted solía disfrutar. . Se siente triste o adormecido . Llora facilmente y sin razón aparente . Se siente lento o cansado e irritable . Se siente inútil o culpable . Cambio en el apetito, cambio de peso . Problemas para recordar, concentrarse o tomar desiciones . Dolores de cabeza, espalda o problemas digestivos . Problemas para dormir, o quiere dormir todo el tiempo . Se siente cansado/a todo el tiempo . Pensamientos sobre la muerte o suicidio

? ¿Qué causa la depresión?

Su cerebro posee substancias químicas que ayudan a controlar su estado de ánimo o humor. Cuando no tiene la suficiente cantidad de estas substancias químicas o su cerebro no responde a los mismos apropiadamente, puede volverse deprimido. La depresión puede ser genética (lo que significa que puede estar en la familia). La depresión también puede estar relacionada con eventos en su vida, como ser la muerte de un ser querido, divorcio o pérdida de un trabajo. La consumisión de ciertas medicinas, el abuso de las

drogas o el alcohol, o el padecimiento de otras enfermedades, también pueden conducir a la depresión. La depresión no es causada por debilidad personal.

¿Cómo es diagnosticada la ? depresión?

Si está teniendo síntomas de depresión, asegúrese de decírcelo a su doctor para recibir ayuda. El o Ella le podrá hacer algunas preguntas sobre sus síntomas, su salud y su historia familiar de problemas de salud. Su doctor también le puede hacer un exámen físico y algunas evaluaciones.

? ¿Cómo es tratada la depresión?

La depresión puede ser tratada con medicina o consejería o terapia, o ambos. Estos tratamiento son muy efectivos. La medicina puede ser particularmente importante en los casos de depresión severa. Háblele a su doctor acerca del tratemiento adecuado para usted.

? ¿Cuáles son las medicinas usadas para la depresión?

Las medicinas usadas para la depresión son llamadas antidepresivos. Corrigen el desbalance químico en su cerebro. Los antidepresivos pueden causar efectos secundarios cuando los empieza a tomar, pero los mismos usalmente desaparecen con el tiempo.

¿Por cuánto tiempo los tengo que tomar usualmente? ? La medicina puede empezar a actuar de inmediato, pero puede que no vea sus efectos en su totalidad hasta luego de unas 6 a 8 semanas. El tiempo que necesite tomar la medicina dependerá de su depresión. Usualmente lo mejor es tomar la medicina por unos 6 meses por lo menos. No suspenda o deje de tomar la medicina sin consultar con su doctor primero.

¿Qué hay del suicidio? ? La gente que sufre de depresión aveces piensa en el suicidio. Este pensamiento es una parte común de la depresión. Si tiene pensamientos de lastimarse a sí mismo/a, dígaselo a su doctor, amigos o familiares de inmediato, o llame al número local de emergencia para el suicidio (listados en el directorio telefónico). Los pensamientos de suicidio desaparecen luego de que la depresión es tratada.

¿Cómo puedo aprender más? ? Para más información contacte a las siguientes organizaciones:

National Depressive and Manic-Depressive Association 800-826-3632 www.admda.org

National Institute of Mentah Health Information Resources and Inquuiries Branch 800-421-4211 www.nimh.nih.gov

American Psychiatric Association 800-35-PSYCH www.psych.org

National Alliance for the Mentally Ill 800-950-NAMI www.nami.org

National Mental Health Association 800-969-NMHA www.nmha.org

Lo que Debemos Saber sobre la Ansiedad y el Pánico

La ansiedad es probablemente la emoción más básica de todas. No solamente es experimentada por los humanos, pues las respuestas de ansiedad han sido encontradas en todas las especies animales hasta el fondo del mar. Las experiencias de ansiedad varían tremendamente en su severidad, desde un ligero desasosiego hasta terror y pánico extremos. También pueden variar tremendamente en su duración, desde un instante breve, casi fugaz, hasta un problema constante durante todo el día. Aunque la ansiedad, por su naturaleza y definición, es una sensación desagradable, no es peligrosa en lo más mínimo. Este último punto es la base es este folleto. El objetivo de las siguientes páginas es instruirlo sobre los componentes de la ansiedad (físicos y mentales) para que (1) usted se dé cuenta de que muchos de los sentimientos que usted experimenta son el resultado de la ansiedad y (2) que usted aprenda que estos sentimientos no son dañinos ni peligrosos.

Definición de Ansiedad

Aunque es muy difícil proporcionar una definición real que cubra todos los aspectos de la ansiedad, (se han escrito libros enteros sobre este tema), todos conocemos el sentimiento que llamamos ansiedad. No hay una sola persona que no haya experimentado algún grado de ansiedad, ya se el sentimiento al entrar al salón de clases antes de un examen, o cuando uno se despierta a media noche, seguro de que oyó algún ruido extraño. Sin embargo, lo que es menos conocido, es que algunas sensaciones como mareo extremo, manchas u ojos borrosos, entumecimiento y hormigueo, músculos rígidos casi paralizados, y falta de aire casi asfixiante también pueden ser parte de la ansiedad. Cuando ocurren estas sensaciones y la gente no entiende por qué suceden, la ansiedad puede elevarse a niveles de pánico pues la gente imagina que debe tener alguna enfermedad.

La Respuesta de Huída o Lucha

La ansiedad es una respuesta ante un peligro o amenaza. Está científicamente probado, que la ansiedad inmediata o en un período corto de tiempo es catalogada como respuesta de huída/lucha. Es llamada así porque todos sus efectos están encaminados ya sea a luchar o a huir del peligro. Así que el propósito número uno de la ansiedad es proteger el organismo. Cuando nuestros ancestros vivían en cuevas, era vital que cuando enfrentaban algún peligro, se presentara alguna respuesta automática que hiciera que tomaran una acción inmediata (atacar o correr). Ese mecanismo es necesario, aún en el mundo agitado en el que vivimos actualmente. Nada más imagine al cruzar una calle, que de pronto apareciera un carro que viniera rápidamente hacia usted tocando el claxon. Si usted no experimentara ansiedad, lo mataría. Sin embargo, lo más probable es que aparezca su respuesta de huída/lucha y usted correría fuera del camino para ponerse a salvo. La moraleja de esta historia es simple – el propósito de la ansiedad es proteger el organismo, no dañarlo. Sería ridículo que la naturaleza desarrollara un mecanismo cuyo propósito es proteger un organismo, y al hacer esto, lo dañara.

Sistemas de la Ansiedad

La mejor manera de pensar en todos los sistemas de respuesta huída/lucha (ansiedad) es recordar que todos están encaminados a que el organismo se prepare para una acción inmediata y que su propósito es proteger al organismo.

Sistema Nervioso y Efectos Químicos

Cuando se percibe o anticipa algún tipo de peligro, el cerebro manda mensajes a una sección de nuestros nervios llamada el sistema nervioso autónomo. El sistema nervioso autónomo tiene dos sub-secciones o ramas llamadas sistema nervioso simpático y sistema nervioso parasimpático. Son estas dos ramas del sistema nervioso las que están directamente involucradas en el control de los niveles de energía del cuerpo y la preparación para la acción. Puesto de manera muy simple, el sistema nervioso simpatico es el sistema huída/lucha que libera la energía y hace que el cuerpo “se prepare” para la acción mientras que el sistema nervioso parasimpático es el sistema restaurador que regresa el cuerpo a su estado normal.

Un punto importante es que el sistema nervioso simpático tiende a ser en su mayor parte un sistema de todo o nada. Esto significa que, cuando se activa, todas sus partes responden. En otras palabras, se experimentan todos los síntomas o que no se experimenta ninguno; raramente ocurren los cambios solamente en una parte del cuerpo. Esto explica por qué la mayoría de los ataques de pánico involucran muchos síntomas y no solamente uno o dos.

Uno de los principales efectos del sistema nervioso simpático es la liberación de dos químicos de las glándulas suprarrenales en los riñones, llamados adrenalina y noradrenalina. Estos químicos son usados por el sistema nervioso simpático como mensajeros para continuar la actividad, por lo que una vez que la actividad inicia en el sistema nerviosos simpático, con frecuencia continúa y aumenta por algún tiempo. Sin embargo, es muy importante notar que la actividad del sistema nervioso simpático se detiene de dos maneras. Primero, los mensajeros químicos, adrenalina y noradrenalina son eventualmente destruidos por otros químicos del cuerpo. Segundo, el sistema nervioso parasimpático (que generalmente tiene efectos opuestos al sistema nervioso simpático) se activa y restaura con una sensación relajante. Es muy importante darse cuenta de que eventualmente el cuerpo “tendrá suficiente” de la respuesta huída/lucha y activará el sistema nervioso parasimpático para que restaure con una sensación relajante. En otras palabras, la ansiedad no puede continuar para siempre, ni aumentar hasta llegar a niveles posiblemente peligrosos. El sistema nervioso parasimpático es un protector interno que detiene al sistema nervioso simpático antes de que se exalte. Otro punto importante es que los mensajeros químicos, adrenalina y noradrenalina tardan un tiempo antes de ser destruidos. Así que, aún cuando el peligro haya pasado y su sistema nervioso simpatico haya dejado de responder, usted todavía podría sentirse inquieto o aprehensivo durante algún tiempo, debido a que los químicos todavía están flotando en su sistema. Usted debe recordar que esto es perfectamente natural y no hace ningún daño. De hecho, ésta es una función de adaptación, porque en los salvajes, con frecuencia el peligro tiene el hábito de regresar y es útil para que el organismo esté preparado para activar la respuesta huída/lucha.

Efectos en el Corazón y el Torrente Sanguíneo

La actividad en el sistema nervioso simpático produce un aumento en el ritmo cardiac y en la fuerza de los latidos del corazón. Esto es vital para prepararse para la actividad, ya que ayuda a elevar el torrente sanguíneo, y de esa manera mejora la oxigenación de los tejidos y la eliminación de los desechos de los tejidos. Por eso, un corazón acelerado es típico cuando se experimentan períodos de mucha ansiedad o pánico. Además del aumento en la actividad del corazón, también hay un cambio en el torrente sanguíneo. Básicamente, la sangre es redirigida fuera de los lugares donde no es necesitada (cerrando los vasos sanguíneos). Por ejemplo, la sangre es retirada de la piel, los dedos de las manos y de los pies. Esto es útil porque si el organismo es atacado y cortado de alguna manera, es menos probable que sangre hasta la muerte. De aquí que durante la ansiedad la piel se ve pálida y los dedos de las manos y los pies están fríos y algunas veces se experimenta entumecimiento y parálisis. Además, la sangre es llevada a los músculos mayores como los muslos o los bíceps que preparan el cuerpo para la acción.

Efectos de la Respiración

La respuesta huída/lucha está asociada con el aumento en la velocidad y disminución en la profundidad de la respiración. Esto tiene una importancia que es obvia para la defense del organismo, ya que los tejidos necesitan tener más oxígeno para poder prepararse para la acción. Sin embargo, las sensaciones producidas por este aumento en la respiración, pueden incluir sensaciones de falta de aire y asfixia, e inclusive dolores o tensión en el pecho. Algo importante es un efecto secundario del aumento en la respiración, especialmente si en realidad no ocurrió ninguna acción, esto es que se presenta una disminución en la sangre suministrada a la cabeza. Aunque se trata solamente de una pequeña parte y no es nada peligroso, sí produce una serie de síntomas desagradables (pero no dañinos) que incluyen mareos, visión borrosa, confusión, pérdida de la realidad y brotes de calor.

Efectos de las Glándulas Sudoríparas

La activación de la respuesta huída/lucha produce un aumento en la sudoración. Esto tiene importantes funciones de adaptación como son piel más resbalosa para que sea más difícil que un depredador lo pueda atacar, y enfriamiento del cuerpo para detener el sobrecalentamiento.

Otros Efectos Físicos

Un número de otros efectos físicos son producidos por la activación del sistema nervioso simpático, de las cuales ninguna es dañina. Por ejemplo, las pupilas se abren para dejar entrar más luz, lo cual puede resultar en visión borrosa, manchas en la vista, etc. Hay una disminución en la salivación lo cual resulta en boca seca. Se presenta una disminución en la actividad del sistema digestivo, lo cual con frecuencia produce náuseas, sensación de pesadez en el estómago e inclusive estreñimiento. Finalmente, muchos de los grupos de músculos se tensan como preparación para volar o luchar y esto resulta en sensaciones de tensión, algunas veces llegando inclusive a dolores y molestias así como temblor y estremecimiento.

En términos generales, la respuesta huída/lucha resulta en una activación general de todo el metabolismo del cuerpo. Por eso, muchas veces uno se siente acalorado y, como este proceso roba mucha energía, posteriormente la persona generalmente se siente cansada, rendida, y disminuida.

Sistema de Comportamiento

Como se mencionó anteriormente, la respuesta huída/lucha resulta en una activación general de todo el cuerpo como preparación para la acción – ya sea atacar o correr. Por eso no es de sorprender que los impulsos sobrecogedores asociados con esta respuesta son de agresión y deseo de escapar donde sea que usted se encuentre. Cuando esto no es posible (debido a limitaciones sociales), con frecuencia los impulses serán demostrados por medio de algunos comportamientos como son, golpear con los pies, caminar de un lado a otro, tratar a la gente con brusquedad. Sobretodo, las sensaciones producidas son aquellas de sentirse atrapado y con necesidad de escapar.

Sistema Mental

El efecto número uno de la respuesta de huída/lucha es alertar al organismo sobre la existencia de un posible peligro. Por lo que uno de los principales efectos es una cambio inmediato y automático en la atención para buscar en los alrededores una posible amenaza. En otras palabras, es muy difícil concentrarse en las labores diarias cuando uno está ansioso. Por lo tanto, las personas que están ansiosas con frecuencia se quejan de que se distraen fácilmente de sus rutinas diarias, que no se pueden concentrar, y que tienen problemas con su memoria. Esta es una parte normal e importante de la respuesta huída/lucha, ya que su propósito es detenerlo de seguir atendiendo sus actividades y permitirle buscar en los alrededores el posible peligro. Algunas veces, no se puede encontrar una amenaza obvia. Desafortunadamente, mucha gente no puede aceptar el no tener explicación para algo. Por lo tanto, en muchos casos, cuando la gente no encuentra explicación a sus sensaciones, empiezan a buscar dentro de ellos mismo. En otras palabras, “si nada en el exterior me hace sentir ansioso, debe haber algo mal conmigo”. En este caso, el cerebro inventa una explicación como, “debo estar muriendo, perdiendo el control o volviéndome loco”. Como hemos visto hasta ahora, nada puede estar más allá de la verdad, ya que el propósito de la respuesta huída/lucha es proteger al organismo y no dañarlo. De todas maneras, eso pensamientos son comprensibles.

Ataques de Pánico

Hasta ahora, hemos visto las características y componentes de la ansiedad en general o la respuesta huída/lucha. Sin embargo, usted puede estarse preguntando ¿De qué manera aplica todo esto a los ataques de pánico?. Después de todo, ¿Por qué debería ser activada la respuesta huída/lucha durante los ataques de pánico, si aparentemente no existe ninguna razón para estar asustado?

De acuerdo con extensas investigaciones, aparentemente la gente con ataques de pánico están temerosas (esto es, lo que causa el pánico) de las sensaciones físicas reales de la respuesta huída/lucha. Por lo tanto, los ataques de pánico pueden ser vistos como un grupo de síntomas físicos inesperados y una respuesta de pánico o temor a esos síntomas. La segunda parte de este modelo es fácil de entender. Como lo discutimos anteriormente, la respuesta huída/lucha (de la cual son parte los síntomas físicos) causa que el cerebro busque el peligro. Cuando el cerebro no puede encontrar un peligro obvio, cambia su búsqueda hacia uno mismo e inventa un peligro como “Estoy muriendo, perdiendo el control, etc.”. Como este tipo de interpretaciones de los síntomas físicos son aterradoras,

es comprensible que resulten en temor y pánico. Además el temor y el pánico producen más síntomas físicos, y por lo tanto, se produce un ciclo de síntomas, temor, síntomas, temor y así sucesivamente. La primera parte del modelo es más difícil de entender. ¿Por qué está usted experimentando los síntomas físicos de la respuesta huída/lucha, si para empezar usted no está asustado? Existen muchas maneras en las que estos síntomas pueden ser producidos, no solamente por miedo. Por ejemplo, puede ser que usted esté generalmente estresado por alguna razón en su vida y este stress resulta en un aumento de adrenalina y otros químicos que de vez en cuando producen síntomas. Este aumento de adrenalina pudiera ser mantenido de manera química en el cuerpo, incluso después de que la razón del stress haya desaparecido. Otra posibilidad es que usted tienda a respirar muy rápido (hiperventilación) debido a un hábito aprendido y esto también podría producir los síntomas. Debido a que la sobre respiración es muy leve, usted se acostumbró fácilmente a este nivel de respiración y no se dio cuenta de que usted padece hiperventilación. Una tercera posibilidad es que usted esté experimentando cambios normales en su cuerpo (todos las experimentamos pero la mayoría de nosotros no nos damos cuenta) y como usted está constantemente monitoreando y verificando el funcionamiento de su cuerpo, usted percibe estas sensaciones más que otras personas. Otra razón se debe al fenómeno llamado condicionamiento interoceptivo. En otras palabras, los síntomas físicos han sido asociados con el trauma de pánico, y por lo tanto para usted han llegado a ser señales de amenaza y peligro. Como resultado, es muy probable que usted sea altamente sensible a estos síntomas y que reaccione con temor simplemente por las experiencias anteriores de pánico con las que han sido asociados. Como consecuencia de este tipo de asociación condicionada, es posible que los síntomas que son producidos por las actividades regulares también lo puedan llevar a sentir pánico. Por ejemplo, las sensación de falta de aire y sudoración provocadas por el ejercicio físico, la sensación de agitación por tomar café, o el calor producido en tiendas llenas de gente, pueden llevarlo a sentir pánico.

Aunque no sean exactamente correctas todas las razones por las que se experimentan los síntomas iniciales, le podemos asegurar que son parte de la respuesta huída/lucha y por lo tanto son inofensivas. Entonces, una vez que usted crea (100%) que las sensaciones físicas no son peligrosas, es obvio que el miedo y el pánico no volverán a ocurrir y que eventualmente usted no volverá a experimentar ataques de pánico. Por supuesto, cuando usted ha tenido un número de ataques de pánico y ha malinterpretado los síntomas, muchas veces, esta mala interpretación se vuelve automática y se hace muy difícil durante un ataque de pánico, convencerse a uno mismo, de manera consciente, que los síntomas son inofensivos.

Resumen

En resumen, la ansiedad es científicamente conocida como respuesta de huída/lucha ya que su propósito inicial es activar el organismo y protegerlo del peligro. Una serie de cambios físicos, mentales y de comportamiento están asociados con esta respuesta. Es importante hacer notar que una vez que el peligro se ha ido, muchos de estos síntomas (especialmente los físicos) pueden continuar, casi como si tuvieran mente propia, debido al aprendizaje y otros cambios del cuerpo a largo plazo. Cuando ocurren síntomas físicos sin que exista una explicación obvia, con frecuencia la gente malinterpreta los síntomas normales de huída/lucha creyendo que indican un problema físico o mental serio. En este caso, las mismas sensaciones se pueden volverse amenazantes y pueden volver a iniciar la respuesta huída/lucha. Mucha gente cree que se está “volviendo loca”, cuando experimenta los síntomas de la respuesta huída/lucha. Dentro de esta creencia, lo mas posible es que se refieran a un desorden mental severo

conocido como esquizofrenia. Analicemos la esquizofrenia para ver qué tanto parecido existe.

Mal interpretaciones más Comunes

Volverse Loco

La esquizofrenia es un desorden importante caracterizado por síntomas severos, como son pensamientos y lenguaje desarticulado, algunas veces llegando a balbuceos, o creencias extrañas (por ejemplo, que están recibiendo mensajes del espacio exterior), y alucinaciones (por ejemplo, que hay voces en su cabeza). Además, la esquizofrenia parece ser en gran parte un desorden genético, que se encuentra fuertemente en las familias. Generalmente la esquizofrenia empieza de manera gradual y no intempestiva (como durante un ataque de pánico). Además, debido a que está en las familias, solamente una determinada porción de la gente puede volverse esquizofrénica y, en otras personas, ninguna cantidad de stress puede llegar a causar este desorden. El tercer punto importante es que la gente que se vuelve esquizofrénica siempre habrá mostrado ligeros síntomas durante gran parte de su vida (como pensamientos inusuales, lenguaje florido, etc.). Así que si esto todavía no ha sido notado en usted, entonces las probabilidades son que usted no se volverá esquizofrénico. Esto es especialmente cierto si usted tiene más de 25 años, pues la esquizofrenia generalmente aparece en los últimos años de la adolescencia y los primeros veintes. Finalmente, si usted ha tenido entrevistas con psicólogos y psiquiatras, entonces puede estar bastante seguro de que ellos hubieran sabido si usted podría volverse esquizofrénico.

Perdiendo el Control

Mucha gente cree que “perderá el control” cuando sufre un ataque de pánico. Presumiblemente, lo que ellos quieren decir es que se paralizarán totalmente y correrán salvajemente o gritarán obscenidades y se pondrán en vergüenza. Además, no sabrán qué esperar sino que simplemente experimentarán una sensación sobrecogedora de “condena inminente”. Por nuestra discusión anterior, ahora sabemos de dónde viene esa sensación. Durante la ansiedad, todo el cuerpo se prepara para la acción y viene un deseo excesivo por escapar. Sin embargo, la respuesta huída/lucha no está destinada a lastimar a otras personas (quienes no son una amenaza) y no producirá parálisis. Lo que es más, la respuesta entera simplemente está destinada a hacer que el organismo escape. Además, nunca se ha registrado un caso donde alguien se “haya vuelto salvaje” durante un ataque depánico. Aunque la respuesta huída/lucha lo haga sentir algo confundido, irreal y distraído, usted todavía puede pensar y funcionar normalmente. Simplemente piense con qué frecuencia las otras personas se han dado cuenta de que usted está teniendo un ataque de pánico.

Colapso Nervioso

Mucha gente tiene miedo de lo que les podría pasar como resultado de estos síntomas, tal vez por la creencia de que sus nervios podrían estar exhaustos y colapsarse. Como discutimos anteriormente, la respuesta huída/lucha es producida principalmente a través de la actividad del sistema nervioso simpático el cual es contrarrestado por el sistema nervioso parasimpático. El sistema nervioso parasimpático es, de alguna manera, unguardia de seguridad que lo protege de la posibilidad de que el sistema nervioso simpatico se “desgaste”. Los nervios no son como los cables de electricidad y la ansiedad no puede desgastar, dañar o acabarse los nervios. Lo peor que puede pasar durante un ataque de pánico es que el individuo pierda el conocimiento, en cuyo caso el sistema nervioso simpático detendría su actividad y la persona recobraría el conocimiento en unos cuantos segundos. Sin embargo, perder el conocimiento como parte de la respuesta huída/lucha es extremadamente raro, y si llegara a suceder, es una adaptación, ya que es una manera de que el sistema nervioso simpático no “se salga de control”.

Ataques al Corazón

Mucha gente malinterpreta los síntomas de la respuesta huída/lucha y creen que han de estar muriendo de un ataque al corazón. Esto se debe probablemente a que la gente no tiene suficientes conocimientos acerca de los ataques al corazón. Veamos los factores de un ataque al corazón y de qué manera difieren con los ataques de pánico. Los principales síntomas de una enfermedad del corazón son falta de aire y dolor en el pecho así como palpitaciones y desmayos ocasionales. Los síntomas de las enfermedades del corazón generalmente están directamente relacionadas con el esfuerzo. Esto es, entre más duro el ejercicio, los síntomas serán peores y entre menos ejercicio haga, se sentirá mejor. Normalmente los síntomas desaparecerán rápidamente al descansar. Esto es muy diferente a los síntomas asociados con los ataques de pánico, los cuales generalmente ocurren al descansar y parecen tener mente propia. Es cierto que los síntomas de pánico pueden ocurrir durante el ejercicio o pueden empeorar con el ejercicio, pero son diferentes a los síntomas de un ataque al corazón ya que también pueden ocurrir al descansar. Lo más importantes es que las enfermedades del corazón casi siempre producirán cambios eléctricos importantes en el corazón, los cuales son detectados muy fácilmente por un ECG. En los ataques de pánico, el único cambio que aparece en un ECG es un ligero aumento en el ritmo cardíaco. Por lo tanto, si le han tomado un ECG y el doctor le ha dicho que todo está bien, usted puede estar seguro de que no padece una enfermedad del corazón. También, si sus síntomas ocurren en cualquier momento y no solamente durante el ejercicio, esta es una evidencia adicional contra un ataque al corazón.

This handout was adapted from Craske, M.G. & Barlow, D.H. (1993). Panic disorder and agoraphobia. In D.H. Barlow (Ed.), Clinical Handbook of Psychological Disorders, 2nd Edition. New York: The Guilford Press.

Como Funciona la Ansiedad

Cuando usted percibe peligro, su cerebro activa su sistema nervioso autónomo. Las dos ramas de su sistema nervioso autónomo son, el simpático y el parasimpático, que controlan el nivel de energía de su cuerpo para prepararlo para la acción. El sistema nervioso simpático controla su respuesta de lucha o huída y libera la energía para prepararlo para la acción. El sistema nervioso parasimpático es el sistema de relajación/recuperación de su cuerpo: regresa su cuerpo a su estado normal cuando el peligro ha pasado.

El sistema nervioso simpático es el sistema todo-o-nada . Eso quiere decir que cuando es activado rápidamente pone en acción todos sus componentes (que es una muy buena manera para que opere un sistema de respuesta de emergencia.):

Latido del Corazón Acelerado, Respiración Acelerada: La reacción de alarma aumenta el latido del corazón y el ritmo de respiración para que estemos alertas y nuestros músculos estén listos para la acción. Estos cambios también ayudan a asegurar que los músculos y el cerebro tendrán suficiente oxigeno y energía para defenderse. Al mismo tiempo, la sangre que va hacia la piel disminuye, lo cual previene la pérdida de gran cantidad de sangre en caso de ser herido.

El Sudor: El sudor ayuda a enfriar el cuerpo durante el esfuerzo, haciéndolo más eficiente. El “sudor frío” es lo que alguna gente siente cuando se suda al mismo tiempo que la sangre que va hacia la piel disminuye.

Opresión en el Pecho, Hormigueo, Entumecimiento, Oleadas de Calor, Temblor: La hiperventilación ocurre cuando estamos respirando rápidamente pero no gastamos esa energía con la acción de los músculos. Como echar andar un carro con el freno puesto. Esto puede traer sensaciones de hormigueo y entumecimiento, oleadas de calor y aumento en la sudoración. Cuando ocurren al mismo tiempo la respiración rápida y la tensión de los músculos, la gente siente dolor en el pecho, falta de aliento y asfixia.

Malestar Estomacal, Diarrea: Durante los momentos de peligro la digestión no es necesaria por lo que el sistema nervioso simpático la bloquea, ocasionando boca seca y malestar estomacal. Ya que en los momentos precisos de peligro no se necesita el peso excesivo, el cuerpo puede eliminar el trayecto digestivo bajo, causando diarrea.

Visión Borrosa, Sensaciones de Irrealidad: Es común que nuestras pupilas se dilaten durante los momentos de peligro. Aunque esto mejora la visión nocturna, el incremento en la cantidad de luz que puede entrar a los ojos, puede ocasionar vision borrosa o más brillante durante el día. Cuando estos cambios en la percepción visual son combinados con otras sensaciones físicas poco usuales como las mencionadas anteriormente, se puede tener sensaciones de irrealidad, de las cosas y de ti mismo.

Sin embargo, como con cualquier sistema de emergencia, esto no continuará para siempre. El sistema nervioso parasimpático es un sistema de recuperación que detiene

al sistema nervioso simpático para que no se acabe. Está conectado a los mismos lugares que el sistema nervioso simpático, pero es precavido: llega más lentamente en caso de que el peligro regrese.

Todo esto significa que los síntomas físicos que siente cuando está ansioso (o cuando tiene un ataque de pánico) son parte de un sistema diseñado para mantenerlo a salvo – no le puede hacer daño. El único problema es que pueden pasar sin motivo alguno, o en respuesta a situaciones en las que usted está amenazado físicamente.

Aquí tiene un breve resumen:

Sistema de Respuesta de Sistema de Recuperación Área del Cuerpo Emergencia (Sistema (Sistema Nervioso Nervioso Simpático) Parasimpático) Corazón late más fuerte y más rápido late más lento y normalmente respira más rápido, menos Pulmones respira más despacio y profundo profundo Músculos rígidos, más tensos más flácidos y relajados Estómago disminuye la digestión aumenta la digestión Glándulas Sudoríparas aumenta la transpiración disminuye la transpiración Glándulas Suprarrenales aumento de adrenalina disminución de adrenalina Sistema Inmunológico se suprime funciona normalmente

Plan de Valores Para Los Pacientes De Cuidados Primarios

Área de la Vida Intención Barreras Plan

1. Familia y Amigos

2. Pareja

3. Trabajo

4. Diversión

5. Espíritu

6. Cuerpo

Fecha de Inicio del Plan: ______Patient Information Sticker Here

Plan de Cuidado Para la Depresión

Es fácil sentirse abatido(a) cuando se está deprimido(a). Puede ser difícil lidiar con las tareas diarias (incluso las más simples) cuando se siente triste, tiene poca energía, y no piensa claramente. Trate de desglosar o descomponer las cosas en pequeños pasos y desarrolle hábitos más saludables. En una escala del 0 al 5, donde 0 es 0% alcanzado de la meta, y 5 es 100% alcanzado de la meta, por favor defina sus metas personalizadas. Dése crédito por sus logros. Recuerde: ¡La Depresión es Tratable!

Por favor escoja las metas en las que está dispuesto(a) a trabajar Logros Seguimiento para mejorar el manejo de su depresión En escala del 0-5 En escala del 0-5 Meta 1: Me mantendré físicamente activo(a). Voy a ______(algún tipo de actividad) por 30 minutos ______días a la semana. Si siento dolor de pecho, falta de aire

o presión en el pecho, buscaré atención médica.

Meta 2: Comeré una dieta nutritiva y balanceada diariamente.

Meta 3: Reduciré la consumición de cafeína; evitaré la cafeína 4 horas antes de ir a la cama.

Meta 4: Me haré de tiempo para realizar actividades placenteras de modo a reducir el estrés.

Meta 5: Pasaré tiempo con mis amigos y familiares.

Meta 6: Dejaré de fumar.

Meta 7: Practicaré técnicas de relajación para reducir la ansiedad y el estrés. Meta 8: Limitaré la consumición de alcohol y evitaré el uso de drogas sin receta o prescripción médica.

Meta 9:

Tomaré pasos pequeños y simples cuando establezco

metas para resolver problemas o tomar decisiones.

Nombre del Paciente: ______MR#: ______Firma del Paciente: ______Fecha: ______

Ciclo de Letargo

Pensamientos Contraproducentes -No tiene caso hacer nada -No tengo la energía -No tengo ganas -Es probable que falle

-Necesito descansar más -Lo haré más tarde

Emociones Contraproducentes Acciones Contraproducentes -Cansado/Abrumado -Aburrido -Quedarse en Cama -Culpable/Odio a sí Mismo -Evitar a la Gente -Que no Vale Nada - Evitar las Actividades Divertidas -Apático/Descorazonado - Evitar el Trabajo -Culpable -Deprimido

Consecuencias del Ciclo de Letargo -Aislado de amigos y familia -Convencido de que es un perdedor -Sumido cada vez más profundamente en un estado de parálisis -El no hacer casi nada lo convence de que es un inútil

YVFWC PC/BHI Project 1/16/2014

Figure 3. FORM B: FOR ADMINISTRATION TO THE RESPONDENT BY AN INTERVIEWER (revised 1-99) DUKE HEALTH PROFILE (THE DUKE) Copyright  1989-2002 by the Department of Community and Family Medicine, Duke University Medical Center, Durham, N.C., U.S.A.

Patient label here

Femenino____Masculino____ Dia de Visita:____/____/_____

Entrevistador: dé estas instrucciones: “Le haré unas preguntas acerca de su salud y sus sentimientos. Por favor escuche cada pregunta cuidadosamente y déme una respuesta. Conteste las preguntas a su manera. No hay respuestas correctas ni incorrectas”. Entrevistador: Lea cada pregunta palabra por Sí, me Me No, no me palabra y marque el número apropiado según la describe describe describe de respuesta que le dé el/la entrevistado/a. exactamente más o ninguna menos manera ¿Qué bien lo/la describen las siguientes frases? 1. Me gusta la persona que soy...... 1 2 1 0 1 2. No es fácil llevarme bien con otras personas 2 0 1 2 2 3. Soy una persona saludable...... 3 2 1 0 3 4. Me doy por vencido/a fácilmente...... 4 0 1 2 4 5. Me resulta difícil concentrarme...... 5 0 1 2 5 6. Yo estoy contento(a) con mis relaciones familiares 6 2 1 0 6 7. Me siento cómodo(a) alrededor de otras personas. . 7 2 1 0 7

¿Tendría hoy algún problema físico o dificultad: Ninguna Alguna Mucha 8. para subir un tramo de escaleras?...... 8 2 1 0 8 9. para correr la distancia de un campo de fútbol 9 2 1 0 9 americano? ......

Durante la ÚLTIMA SEMANA: No Algo Mucho 10. tuvo dificultades para dormir...... 10 2 1 0 10 11. le dolió alguna parte del cuerpo...... 11 2 1 0 11 12. se cansó fácilmente...... 12 2 1 0 12 13. se sintió deprimido/a o triste...... 13 2 1 0 13 14. tuvo nerviosismo...... 14 2 1 0 14

Durante la ÚLTIMA SEMANA: ¿con qué frecuencia: Ninguna Alguna Mucha 15. Pasó tiempo con otras personas (hablando, 15 15 visitando amigos o parientes)?...... 0 1 2 16. omó parte en actividades sociales, religiosas, o 16 16 recreativa (reuniones, iglesia, cine, deportes, fiestas)? 0 1 2

Durante la ÚLTIMA SEMANA: ¿con qué frecuencia: Ninguna 1-4 Días 5-7 Días 17. se quedó en su casa, hogar de ancianos, u hospital 17 17 por una enfermedad, lesión, o cualquier otro problema de salud?...... 2 1 0

Hora que terminó: (Entrevistador: )

Created by YVFWC Translation Services 9/03 1/16/2014 YVFWC Planning & Development

X-Plain™ Trastornos del sueño Sumario

Los trastornos del sueño son 1. etapa 1 - somnolencia despertar a una persona un problema muy común que 2. etapa 2 - sueño ligero durante las etapas 3 y 4, que tiene solución. 3. etapa 3 - sueño profundo juntas forman lo que 4. etapa 4 - sueño profundo llamamos el sueño profundo. Es esencial entender la de ondas lentas Durante estas etapas no hay importancia del sueño y 5. etapa 5 - movimientos movimiento en los ojos ni cuáles son los factores que oculares rápidos, o MOR. actividad muscular. lo afectan. Cuando la gente se Pasamos casi el 50% del despierta durante el sueño Este sumario le informará tiempo total que dormimos profundo no se ajusta de sobre el sueño, los en la etapa 2, cerca de un inmediato y a menudo se trastornos del sueño y su 20% en la etapa MOR y el siente atontada y tratamiento. 30% restante en las otras desorientada por unos etapas. Sin embargo, minutos hasta que se El sueño durante la infancia, pasamos despierte por completo. Al dormir, el cuerpo está casi la mitad del tiempo total Durante la etapa de sueño inactivo pero el cerebro se que dormimos en la etapa de profundo algunos niños mantiene muy activo. Sólo MOR. mojan la cama, recientemente, los experimentan terrores investigadores han Durante la etapa 1, o sueño nocturnos o sonambulismo. empezado a entender cómo ligero, dormitamos y nos el sueño afecta a las despertamos con facilidad. Durante la etapa de MOR, la funciones diarias y a la salud Los ojos se mueven muy respiración se vuelve más física y mental. lentamente y la actividad rápida, irregular y superficial. muscular disminuye. Una Los ojos se mueven sensación de sentirse en rápidamente en varias caída a menudo precede a direcciones y los músculos las contracciones de las extremidades se musculares llamadas paralizan temporalmente. El mioclonía hípnica. En la latido del corazón se acelera, etapa 2 del sueño, el la tensión arterial sube, y los movimiento de los ojos se varones experimentan para y las señales del erecciones. Cuando las cerebro disminuyen. personas se despiertan Las personas tienen 5 En las etapas 3 y 4, las durante la etapa MOR, a etapas cíclicas de sueño: ondas cerebrales son muy menudo describen sueños lentas. Es muy difícil

Este documento es un resumen de lo que aparece en las pantallas de X-Plain. Este documento es para uso informativo y no se debe usar como sustituto de consejo de un médico o proveedor de salud profesional o como recomendación para cualquier plan de tratamiento particular. Como cualquier material impreso, puede volverse inexacto con el tiempo. Es importante que usted dependa del consejo de un médico o proveedor de salud profesional para el tratamiento de su condición particular.

1 extraños y que no tienen aunque algunas personas desempeñan tan mal o peor lógica. pudiesen necesitar que las personas en estado solamente 5 horas al día y de embriaguez. Un ciclo completo de sueño otras hasta 10 horas al día. dura entre 90 y 110 minutos. La falta de sueño también Los primeros ciclos de sueño Una persona necesita más empeora los efectos del de la noche comprenden horas de sueño si no ha alcohol. Cuando una períodos cortos de MOR y dormido lo suficiente durante persona cansada bebe, sus períodos largos de sueño los días anteriores. La falta funciones se afectan más profundo. A medida que de sueño crea una “deuda que las de una persona que avanza la noche, el sueño de sueño” que es como estar ha descansado bien. MOR aumenta en duración sobregirado en el banco. ¡Al Según la Administración mientras que el sueño final, el cuerpo pide que se Nacional de Seguridad de profundo disminuye. Por la pague la deuda! Tráfico en Autopistas, la mañana, casi todo el tiempo somnolencia al volante es de sueño se pasa en las Las personas no logran responsable de cerca de etapas 1, 2 y MOR. acostumbrarse a dormir 100.000 accidentes de menos de lo necesario. tráfico y 1.500 muertes cada Si el sueño de la etapa MOR Aunque algunas personas año. se interrumpe, nuestro pueden acostumbrarse a un cuerpo no sigue el ciclo horario que les reduzca las Beneficios normal de sueño cuando nos horas de sueño, esto Aunque los científicos dormimos de nuevo. En incapacita su juicio, tiempo continúan investigando las cambio, vamos directamente de reacción y otras razones por las que las a la etapa de MOR y funciones. personas necesitan dormir, pasamos a través de largos los estudios demuestran que períodos de MOR hasta que el sueño es necesario para “nos ponemos al día” con sobrevivir. Por ejemplo, las esta etapa de sueño. ratas normalmente viven de 2 a 3 años, pero en estudios Las necesidades de sueño en los que se les ha privado En cada persona la cantidad del sueño de MOR de horas de sueño depende sobreviven solamente 5 de muchos factores, semanas. Cuando se les incluyendo la edad. Los priva de todas las etapas de bebés generalmente sueño las ratas viven necesitan cerca de 16 horas Muchos estudios solamente 3 semanas. al día, mientras que los demuestran que la falta de adolescentes necesitan sueño es peligrosa. Las La privación del sueño tiene cerca de 9 horas al día. personas con falta de sueño efectos perjudiciales en el Para la mayoría de los sometidas a exámenes con sistema inmunológico. adultos, 7 u 8 horas por un simulador de guiar autos Asimismo, el sueño es noche parece ser la mejor o a pruebas de coordinación necesario para el cantidad de horas de sueño, manual y ocular se

2 funcionamiento adecuado y en las actividades sociales ayuda a las personas a del sistema nervioso. de una persona. dormirse, también evita que estas personas lleguen a las Cuando no dormimos lo Los trastornos del sueño son etapas de MOR y sueño suficiente, nos sentimos responsables por 16 mil profundo. somnolientos e incapaces de millones de dólares en concentrarnos. Esto puede gastos médicos anuales, provocar problemas de la además de gastos memoria, torpeza y dificultad adicionales debidos a en realizar cálculos ausencias durante las horas matemáticos. Si de trabajo y otros factores. continuamos privándonos de Existen más de 70 tipos de sueño, empezamos a sufrir trastornos del sueño. alucinaciones y cambios de Muchos de éstos se pueden humor. controlar satisfactoriamente, una vez que se hayan El sueño profundo en niños y diagnosticado. adultos está relacionado a la Los tipos más comunes de secreción de hormonas de trastornos de sueño son: crecimiento que son • insomnio esenciales. Muchas de las • apnea del sueño A menudo las personas que células del cuerpo se • síndrome de piernas fuman mucho tienen un regeneran cuando inquietas sueño ligero y menos sueño dormimos. Estas crecen y • narcolepsia de MOR. También suelen reparan los daños causados despertarse al cabo de 3 ó 4 por el estrés y los rayos Insomnio horas debido a la abstinencia ultravioletas. Por esta razón Muchas personas padecen de la nicotina. el sueño profundo puede ser de insomnio a corto plazo de El insomnio leve se puede realmente un “sueño de vez en cuando. evitar o curar con buenos belleza”. hábitos de sueño. Los

Para el insomnio a corto investigadores están Trastornos del sueño plazo, los médicos a veces realizando experimentos con Al menos 40 millones de recetan pastillas para dormir. terapia de luz y otros estadounidenses sufren de La mayoría de estas pastillas tratamientos para casos más trastornos crónicos del dejan de funcionar después graves de insomnio. sueño cada año, y 20 de tomarlas por varias millones más tienen semanas y su uso problemas para dormir La apnea del sueño prolongado puede afectar el Aproximadamente 18 ocasionalmente. Los sueño. millones de estadounidenses trastornos del sueño y por padecen apnea del sueño. consiguiente la privación del Muchas personas que sufren Sin embargo, sólo se ha sueño interfieren en el de insomnio intentan diagnosticado en algunos trabajo, al conducir vehículos resolver el problema con pocos. alcohol. Aunque el alcohol

La apnea del sueño consiste tales como irritabilidad y Una polisomnografía graba en una interrupción de la depresión. las ondas cerebrales, los respiración mientras latidos del corazón y la dormimos. Está relacionada La apnea del sueño causa respiración durante una con la obesidad y la que a las personas les falte noche completa de sueño. disminución del tono oxígeno, lo que puede Si se diagnostica la apnea muscular por causa de la producir: del sueño, se pueden edad. Estas condiciones • dolores de cabeza por la realizar varios tratamientos. permiten que la tráquea se mañana cierre cuando los músculos • falta de interés en la La apnea del sueño leve se se relajan durante el sueño. actividad sexual puede resolver adelgazando. Este problema, llamado • disminución de las El paciente debe también apnea del sueño obstructiva funciones mentales evitar dormir boca arriba. suele causar fuertes • hipertensión arterial Además, se pueden usar ronquidos. • latidos del corazón mecanismos especiales o irregulares cirugía para corregir las Durante un episodio de • mayor riesgo de sufrir obstrucciones causadas por apnea obstructiva, el ataques al corazón o la apnea del sueño. esfuerzo para inhalar aire derrames cerebrales crea una succión que cierra Las personas con apnea del la tráquea. La circulación de Los pacientes con apnea del sueño nunca deben tomar aire puede verse bloqueada sueño grave que no han sido sedantes o pastillas para de 10 a 60 segundos tratados tienen de 2 a 3 dormir porque éstas pueden mientras la persona dormida veces más posibilidades de evitar que se despierten lo trata de respirar. tener un accidente de suficiente para poder automóvil que las personas respirar. Cuando el nivel de oxígeno que no sufren de la apnea en la sangre de una persona del sueño. A veces, la El síndrome de piernas disminuye, el cerebro apnea del sueño puede inquietas responde despertándole de provocar una muerte manera que contrae los repentina debido a un paro músculos de las vías aéreas respiratorio durante el y abra la tráquea. La sueño. persona puede roncar o respirar entrecortadamente, Los pacientes que padecen y luego volver a roncar. Este síntomas típicos de apnea ciclo se puede repetir unas del sueño, tales como 100 veces cada noche. ronquidos fuertes, obesidad y somnolencia excesiva Al despertarse tantas veces, durante el día deben El síndrome de piernas los pacientes de apnea consultar con un especialista siempre tienen sueño e inquietas es un trastorno para hacerse una prueba hereditario que provoca una incluso pueden tener llamada polisomnografía. cambios en la personalidad, sensación como si algo se arrastrara sobre el cuerpo, o

4 una sensación de hormigueo personas con narcolepsia aun durante los fines de o pinchazos en las piernas y tienen episodios de sueño semana y los días feriados. pies. El paciente siente la varias veces al día, aun De ser posible, duerma necesidad de mover las cuando han dormido lo hasta que salga el sol. De lo piernas y los pies para suficiente durante la noche. contrario, utilice luces bien aliviarlos. El síndrome de Un episodio de sueño es un brillantes por la mañana. piernas inquietas se está período repentino de sueño convirtiendo en uno de los mientras se está despierto. El ejercicio diario puede trastornos del sueño más ayudar a los patrones de comunes. Los episodios de sueño sueño, especialmente si se duran de varios segundos hace ejercicio de 5 a 6 horas El síndrome de piernas hasta 30 minutos. Las antes de ir a la cama. inquietas que afecta a cerca personas con narcolepsia de 12 millones de también pueden sufrir de: Relájese antes de ir a estadounidenses, provoca • cataplejía - pérdida del dormir. Leer, ver televisión, un movimiento constante de control muscular durante rezar y meditar son buenas las piernas durante el día e una situación emocional maneras de relajarse. Evite insomnio durante la noche. • alucinaciones la cafeína, la nicotina y el El síndrome de piernas • sueño nocturno alcohol. inquietas severo es más interrumpido común en personas • parálisis temporal al ancianas, aunque los despertar síntomas pueden aparecer a cualquier edad. En algunos La narcolepsia se suele casos el síndrome de heredar, pero a veces está piernas inquietas puede asociada a lesiones estar relacionado con otras cerebrales provocadas por condiciones tales como la un traumatismo cerebral o anemia, el embarazo o la una enfermedad neurológica. diabetes. Los medicamentos tales Existen terapias de como los estimulantes o los medicamentos disponibles antidepresivos pueden para aliviar el síndrome de controlar los síntomas de la piernas inquietas. Conocer narcolepsia. Tomar siestas No se quede acostado en la las causas de este síndrome durante el día puede reducir cama si no puede dormir. puede ayudar al desarrollo la somnolencia excesiva. En vez de eso, haga algo de mejores terapias en el como leer o mirar la futuro. Duerma bien televisión. La frustración de Lo mejor es seguir un no poder dormir hace que el La narcolepsia horario fijo para irse a dormir insomnio sea peor. La narcolepsia afecta a y para despertarse. Es Asimismo, mantener el cerca de 250.000 preferible ir a la cama y dormitorio a una temperatura estadounidenses. Las despertarse a la misma hora,

5 confortable puede reducir la interrupción del sueño.

Consiga atención médica si sigue teniendo problemas para dormir. ¡Existe un sinnúmero de técnicas y medicamentos disponibles para ayudarle a dormir mejor!

Resumen Los problemas del sueño son comunes y pueden tener graves consecuencias. Sin embargo, se pueden tratar.

Si padece de problemas con el sueño, mejore sus hábitos de dormir y consulte a su médico. Así podrá obtener un buen descanso por la noche.