(Doctor Dale Guyer discusses alternative medicine in the treatment of depression)

Guest physician Dr. Dale Guyer combines traditional and alternative methods in the treatment of common health problems.

Editor's Note: In 1997, the Post featured a series of TV health shows exploring the growing field of complementary medicine. Response from TV viewers was overwhelming. We invited Dr. Guyer back to share his knowledge from clinical work in both the traditional and complementary fields of medicine.

Q. Could you please tell us about St. John's Wort?

A. St. John's Wort is an extract from a common plant that is used in hedgerows in Europe and seems to be useful in the treatment of depression and certain types of anxiety disorders. In some clinical studies, it has been shown to have potential as an immune-boosting agent that can be of help for patients in treating infections. Certain injectable extracts of the plant may have efficacy in treating HIV disease. Of course, this is a pure, pharmaceutical-grade extract of the plant, so it would not be something that a person could get the same results from by using homegrown herbal decoctions. The standardized herbal extracts that are used as prescription medicines in Europe for the treatment of depression are subject, to very high quality purification processes. You may not get the same physiological effect by taking an over-the-counter herbal preparation. They are very different substances.

Q. Is it called St. John's Wort in Germany?

A. Hypericum is another name that is often used. The concept of St. John's Wort often creates a lot of interest. The word "wort" in our culture has a different visual picture. It is actually an old word for "root."

Q. It's more popular right now in Europe than it is in the United States, is that right?

A. That's true. It relates to an interesting enigma. In our culture, the FDA gives us permission to use certain medications, but it has fairly stringent criteria for bringing a new drug to the marketplace. In Europe, particularly in Germany, there are separate regulatory agencies for natural compounds. Despite the fact that there exists a lot of data to support the use of St. John's Wort, most of it is published in Europe and oftentimes not in the English language, so a lot of the information tends to be unavailable to physicians who practice in this country. The unfortunate part is that this information gap puts physicians at a disadvantage because they just don't have the information or background to know how to prescribe the herb, nor do they have the confidence gained from clinical experience. An interesting observation I've noted is that oftentimes in our country, the medical consumer has a better source of information and education as it relates to natural products than do most physicians.

Q. Physicians would be concerned about the quality of the product.

A. True, product reliability is a major concern regarding many of the natural substances. There have been several studies where products are bought off the shelves, then assayed by an independent lab in order to determine how much of the active ingredient of a compound is actually in, for example, a capsule. The range is pretty dramatic to the point that certain herbal extracts might not even have the same herb that is advertised on the label; they might not have the same type of extract, or might not have the active components present. All these problems are improving. We have a lot of good companies and quality products out there. We also have many high-quality health- food stores. And many of the people who run these establishments are very well educated and can effectively direct a client or customer to the best-quality supplements.

Q. What should the consumer look for in buying St. John's Wort?

A. When you are looking at any herbal medicine like St. John's Wort, make sure it is a standardized extract. It will usually be stated on the label. For example, HyperiMed is a product made by PhytoPharmica. It clearly says on the label: St. John's Wort 300 mg, standardized to contain 0.3% hypericins, which is thought to be the active ingredient in the herbal product. It will have some sort of verification. In some cases, it will state that it is verified by a high-pressure liquid chromatography (HPLC), which is one way to standardize the active chemical constituents. There should also be an expiration date and some assurance of quality. For a consumer who might have questions, it is very reasonable to call a company and ask for verification that a product has been independently assayed: request the source of the extracts, and so forth. Any good, reputable company can supply that information. This way, you have a lot more assurance that you are getting a quality product.

Q. The reason that many people take St. John's Wort is that they are not afraid of its side effects, but they are afraid of the side effects of prescription drugs.

A. Side-effect profile is certainly an interesting concept. There is a book that I once read called Life Extension by Sandy Shaw and Durk Pearson. One of my favorite chapters in the book was titled, "Is there anything in the world that is absolutely safe?" The only word in the chapter was "No."

There is an assumption in the mind of the consumer that because something is natural, it is absolutely safe. Of course, we know that this is not quite accurate: many of the most toxic compounds in the world are natural compounds--arsenic, lead, mercury, etc. However, many natural substances tend to have, less propensity to have side effects than many of our standard prescription drugs. In my clinical experience, I have found that maybe 80 to 85 percent of the time, if not more, many of these very simple approaches work better and are better tolerated by most individuals than prescription medications. That is not to exclude the fact that we really need prescription medications in acute and crisis care. But three elements often missing from conventional medical care are an understanding of, information about, and experience in using some of the less-invasive therapies.

Q. If a patient comes to you who is mildly to moderately depressed, what are some other means you would use to treat this particular patient?

A. In that situation, there is often a reaction of opinion from the general medical provider's perspective. Here's a situation that has an emotional component, and I have eight minutes to spend with this patient, which is unfortunate. One way to effectively deal with this situation is to write a prescription for an antidepressant that might make someone feel better. But patients who have gone through this experience often tell me that they only feel better about feeling bad. They still feel bad.

Maybe a more effective route would be to look at what is contributing to the process. This culture keeps us so busy with so much stress that for a lot of people, it is often a situational issue. I think that you have to step back in a responsible way and look at the life experience of the individual and ask, What's going on and what could change here? Is there a light at the end of the tunnel when this process is going to shift? Then you look at simple things, as well. You ask if they are exercising. Exercise is such a big key. Our bodies are designed to be very physically active, and when they are not, it changes our perspective, our immune system, and many other parameters about living an optimal life. We then look at the social-support structure and at the emotional issue with a counselor. All these things have a bearing on the individual. There is often an assumption of looking for salvation in a pill. It doesn't occur. Salvation comes from our own responsibility. The pill can be a transitional piece that can certainly help with depression.

There are individuals with a genetic predisposition to possessing an altered genetic neurologic chemistry. Many of the people in this class might be looking at taking medication for a lifetime in order to more effectively cope with day-to-day existence. But they are not the majority of patients whom I or most other doctors see.

Q. What if a bipolar, or manic-depressive, patient came to you? They are on lithium but prefer something else, or maybe didn't get enough results from the lithium. Does St. John's Wort help with the depression period of a manic-depressive?

A. Lithium is a good step. It certainly has a lot of side effects, but it does offer effective therapy. That's a very reasonable approach. You have to look at what phase of the illness that person might be going through. If it is coupled with a lot of anxiety, you might look at another herbal medicine like kava or valerian root. Other types of approaches include biofeedback training, meditation, and exercise.

Q. Is valerian root available in health-food stores?

A. Yes. Valerian root used to be harvested and manufactured by pharmaceutical companies at the turn of the century. It was used as an effective treatment for insomnia, anxiety, and related disorders. You can buy it today in most health-food stores; even Sam's Club now has a fair supply of many of these natural compounds. You can always identify valerian root by its odor because the isovaleric acid--thought to be the active component--smells like dirty socks. Fortunately, it doesn't make the person smell like that, but the smell tends to decrease one's compliance with the medicine.

Q. What are some other pharmaceutical approaches to depression?

A. One of the compounds that I have found very useful in my own practice is a medicine that is approved by the FDA in this country for the treatment of Parkinson's disease. It is known as deprenyl, or Eldepryl. Another name for it is selegiline hydrochloride. It is used in Europe and elsewhere as a treatment for depression. It works by a different mechanism than more popular drugs like Prozac and Paxil, which work on the serotonin system in the bodies. Eldepryl works on dopamine. Dopamine is a neurotransmitter that regulates much of our behavior--motivation, memory, and so forth.

The most common side effects one sees with antidepressants, especially of the serotonin type, are the sexual side effects---difficulty in achieving orgasm, for example, and other sexual dysfunction. Deprenyl, on the other hand, tends to actually have a libido-enhancing property. It seems to be more noticeable for men, but in my clinical experience, I have noticed it occurs in both genders, which is a significant plus for a lot of people looking at a medicine that would help with managing depression.

Another thing about deprenyl that I find fascinating is that it seems also to improve memory significantly. There is a growing interest in what is called life-extension medicine, which I am sure will become a medical subspecialty. Deprenyl is one of those very interesting compounds that when given to laboratory animals seems to increase their maximum lifespan, which is a fascinating concept. If you extrapolate the data from animal models to human experience, it would suggest that we might all live to be 160 or 180 years old--a significant event.

Q. Are there side effects to deprenyl?

A. Everything has side effects. The most common ones that I have seen with deprenyl are stomachache, nausea, lightheadedness, and headaches. Those are infrequent, but not unusual. Deprenyl belongs to a class of medicines called MAO (monoamine oxidase) inhibitors. Some problems can occur when patients on MAO type A inhibitors consume cheese or other foods that contain an amino acid called tyramine. Deprenyl, however, belongs to a different class. It is an MAO type B selective inhibitor, so the tendency to have those side effects is not really present until one gets to a very high dose. For the doses required to treat as an antidepressant or as memory-enhancing medicine--life- extension medicine--doses are very low, but you always have to be cautious and attentive to what's going on.

Q. Any cheese or just aged cheese?

A. Mostly aged cheeses.

Q. The large population of senior citizens should be very interested in life extension. With the year 2000 approaching, many 80-year-olds will want to get there and beyond to see what happens.

A. Some people ask, "Why would I want to live to be 160 years old if I'm going to have all the associations of aging?" In the animal studies to date, they maintained a very active lifestyle. How you gauge that for a rat is a challenge, but you can say that they ran mazes as fast as the younger animals, didn't lose their hair, and remained sexually active until the day they died.

Q. Our readers will be very interested in life enhancement, including maintaining the libido. It's healthy to be active sexually.

A. Like exercise, sexuality has a lot of health benefits as well. Many compounds are thought to be members of that class of life-extension or cognition-enhancing medicines. There are medical organizations assembled to research and bring this information to the forefront. The American Academy of Anti-Aging Medicine is one. A newsletter called Smart Drug News, published by the Cognition Enhancement Research Institute in Menlo Park, California, focuses on research into cognition-enhancing medicines, often called "smart drugs." What we don't realize in this country is that elsewhere in the world, patients have access to many medical compounds and pharmaceuticals that can actually increase intelligence and cognitive capacity. Had I known about this when I was going through medical school, Gross Anatomy would have been much easier.

Q. My mother gave my brother okra, which for whatever reason was considered a brain food. When he was at home, she would cook okra soup. He did excel and was at the top of his class at Annapolis. What are some brain foods?

A. One example that I will mention is a compound called dimethylaminoethanol (DMAE). You have probably heard the story that eating sardines makes you more intelligent. There might be some truth to this observation. Sardines have a higher level of this DMAE. In the past, DMAE was a prescription medicine. It is now available over the counter. Many people notice that DMAE helps improve their memory, visual-spatial skills, cognitive awareness, verbal ability, and so forth.

Q. If readers wanted to know more about these subjects, how would they subscribe to the newsletter?

A. They do have a website [www.ceri.com/sdnews.htm]. The newsletter is called Smart Drug News.

Q. We were pretty excited about Evista, Eli Lilly Company's recently approved drug to prevent osteoporosis. It seemed to be a good alternative for women who can't take estrogen, yet want to make sure that they don't have a hip fracture before they are 80 years old. Osteoporosis is a major problem. Maybe how much calcium you took as a child is important in building a bank of calcium. How do you prevent osteoporosis and hip fractures?

A. Osteoporosis is, unfortunately, a big problem in this country. In addressing osteoporosis, you have to look at the individual. Dietary considerations are very important, as is the hormone status. It is less clear that estrogen contributes much to overall bone density, whereas we know that some hormones that have a more anabolic quality- -like progesterone, DHEA, testosterone, and growth hormone--will increase bone density. My first approach would be to give the patient a global endocrine evaluation: What are levels of all the hormones, not just estrogen?

But there is a common-sense element to approaching the disease as well. We can have all the hormones on board and the nutritional component-the calcium, magnesium, and so forth--in place, but if you don't have the physiologic drive to enhance bone density, you only get so far. The physiologic drive for bone is to have a load placed on it, which comes back to weight-bearing exercise. This is a tough sell for many women. When you tell them that they need to go to the gym and pump iron, some think that they will end up looking like Arnold Schwarzenegger, which really isn't the case. It's not so much that they are striving to compete in a powerlifting competition or even a bodybuilding competition. It's using the load-bearing exercise to put stress on the bone and connective tissue, and thereby increasing its strength and bone density.

Q. How do you motivate your patients to get out there and do the right kinds of exercises?

A. What I encourage them to do is to take one day at a time. Set one simple, attainable goal, such as going to the gym tomorrow and working out for ten minutes. As people make a habit of exercise, they find that the more they get involved and engaged in the exercises, the better they start to feel. They then begin to crave feeling better, as opposed to craving some of the bad habits.

Q. Do you have personal trainers who help people get on track?

A. If exercise of that capacity is a new experience, it's definitely a good idea to work with a personal trainer who can help set up a program that meets a person's individual needs.

Q. Could you tell us how you investigate a thyroid deficiency?

A. Thyroid dysfunction is very common. It is unfortunate that many patients have this problem, but it is not recognized. In my practice, I frequently see patients who say that they are cold all the time; gain weight easily; don't lose weight easily; have poor exercise tolerance, decreased libido, poor concentration, dry skin, brittle nails, etc.- -basically, a textbook description of low thyroid function.

Q. Thinning outside eyebrows?

A. Lateral margins of the eyebrows are among the observations that can sometimes be made, as is lower-extremity edema and slow heart rate. The fatigue seems to be a common issue that is associated with a deficiency of thyroid hormone. We have thyroid tests that can measure hormone levels. That would probably be an adequate screen for a majority of people. However, there are many individuals who seem to have a subclinical hypothyroid picture. Their lab tests are normal, yet they have all the symptoms that we just talked about. With these individuals, a thyroid-replacement therapy is something definitely worth trying. In my clinical experience, I find that this can change someone's life dramatically. This goes back to the issue of depression, too. There are studies now that are looking at thyroid-replacement therapy to treat depression. In many cases, it works very well. It's unfortunate that thyroid deficiency is something that is not very commonly recognized in conventional medicine.

Q. It is an underdiagnosed affliction.

A. Certainly underdiagnosed.

Q. A lot of people are now on low-salt diets, and noniodized salt is probably cheaper in restaurants and canneries than iodized salt. Are some people possibly not getting enough iodine in their diets?

A. That is a real possibility. I don't think it is as common as it used to be. Goiters and iodine deficiency used to be endemic in some areas of the country many years ago. However, there are situations in which individuals have a higher-than-usual metabolic need for certain nutrients, and there are tests that determine this. Iodine is no exception. Iodine supplementation, itself, can be a very effective treatment for fibrocystic breast disease, certain problems of ovarian function, and so forth. We tend to think of iodine as only functioning for the thyroid, but actually it is also used in many other areas of the body. The ovaries are a good example. If I remember my physiology correctly, ovaries are the second most prolific users of iodine, as far as organs, in our body.

Q. In men, the prostate uses zinc. Where is the zinc pump in women?

A. What we know is that prostate tissue tends to have a lot of zinc in it. Exactly what the role might be is a little less clear, but we do know that zinc is involved in the hormonal regulations of the male androgens. It is also involved with hormonal regulation in women. Like many of the other trace minerals, we don't know all of the activities and how zinc is used. There are so many trace minerals- -such as vanadium, strontium, boron, and so forth--whose activities are less well defined, partially because we need such small quantities of these nutrients to maintain normal health that it is very difficult to delineate where it is functioning in the body.

Q. There is a Purdue man who has good evidence that for some people, copper is able to help with their arthritis. A. Copper bracelets do help a lot of people with their arthritis. Using a copper supplement can be helpful for some people. There is some research that would suggest that antiinflammatory drugs commonly prescribed to treat the pain associated with arthritis only work as they bind to a copper ion in the body. Copper seems to play a big role in our bodies. We know that it is used as an enzymatic cofactor for cross-linking collagen, which adds structural integrity to our connective tissues, circulatory system, and any place collagen is used. Although copper has many benefits, we don't want to overdo it, either, because copper is thought to be one of those ions like iron that generates free radicals. It's an example of balance. Everything is best in balance. If you get too low, there are problems. If you get too high, there are potential side effects as well.

Q. I have always wondered why they didn't put copper in the soles of their shoes where it wouldn't show, instead of wearing copper bracelets around their wrists and letting their skin turn colors.

A. That's a new marketing concept that could go over big.

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~ depression library articles
~ all articles on depression

When psychologist Kay Redfield Jamison, Ph.D., wrote An Unquiet Mind, an account of her struggles with manic depressive illness--which she has both experienced and studied--she expected modest sales, mostly to people who had been directly affected by the disorder. But the 1995 book was a surprise hit, spending five months on the New York Times best-seller list and selling more than 400,000 copies. Part of its appeal came from the fascinating contrast between Jamison's elegant prose and the extreme, often brutal experiences she recounted. In person, the incongruity is even more startling: Jamison is graceful and self-possessed, but speaks frankly about the harrowing realities of mental illness.

Seated in her office at the Johns Hopkins School of Medicine in Baltimore, Jamison reflects on the personal and professional price of that candor. Asked whether she would do it all again, she pauses for a long moment. "I think now, two years after the publication of the book, I'd say yes, it was worth it," she says at last. "But has it been costly? For sure." Jamison does acknowledge relief at being able to drop the "Brooks Brothers conservative" image she adopted to conceal her disorder, saying, "I hadn't realized the amount of time and energy I put into keeping this illness to myself. I am much more myself publicly than I was before." Her colleagues have been supportive, she says, and her status as a tenured professor made the disclosure less risky for her than for most people. "But you also have more to lose under those circumstances, because you've spent a long time building a certain reputation as a scientist," adds Jamison. "All of a sudden, your work is subject to questions: `What was her motivation? Was she objective?'"

It's not just her research that has undergone reappraisal. "As soon as somebody knows that you have a mental illness, they treat you differently," she says. "Particularly if you've written about being psychotic and delusional, people will question your judgment, your rationality." Jamison talks with resignation about the inevitable loss of privacy: "It would be disingenuous to write such a personal book and not expect people to respond." Perhaps more painful, though, was giving up her therapy practice. "I spent many years learning to be a clinician, and I loved doing it," she says. "But I've written a highly personal book. Patients have the right to walk into an office and deal with their own problems, not with what they construe their therapist's problems to be."

Despite her very public "coming out," Jamison still counsels caution to those considering revealing their illness to employers and others. Her emphasis is on encouraging people to acknowledge their mental disorders to themselves, and to get treatment. "There's no excuse in this day and age for seventeenth-century notions of mental illness," says Jamison, whose own manic-depression went untreated for years until it was brought under control by lithium "If you don't discuss it and don't seek treatment, you can die, and ruin a lot of lives around you."

Jamison saw some of those lives for herself while traveling the country to promote An Unquiet Mind. "At almost every talk I gave, somebody would come up to me with a photograph of a kid who had committed suicide," she relates. "The devastation was unbearable, all of that unnecessary pain and suffering. It just broke my heart." Jamison's next book, Night Falls Fast, will deal head-on with the topic of suicide, exploring the implications of recent neurological and psychological research. "It's been a relief to turn back to science," says Jamison. "You get into this business of talking about your own experiences and you forget why you went into science," " she continues, "which is that it's really interesting."

Also gratifying, she says, is her work on yet another book. Tentatively titled Beyond Dr. Doolittle, it's about medicine and science at the National Zoo. "The doctors there are confronted with an extraordinary range of medical problems," says Jamison. "Imagine treating 500 different species!" She pauses, then smiles. "Doctors around here have enough problems with just one."

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Postpartum anxiety disorders in new mothers are often missed. Read why. Also symtoms, strategies for managing postpartum anxiety.

Overcoming Postpartum Depression and Anxiety

To understand the various kinds of anxiety disorders that may accompany pregnancy and the postpartum period, it is helpful for you to first understand the kind of anxiety that nearly everyone experiences. People with anxiety disorders often report that others minimize, or brush off, their problems. This may occur because all people experience anxiety. Most people do not understand the difference between anxiety disorders and normal anxiety.

Anxiety is a part of our lives. It is a normal and protective response to events outside the range of everyday human experience. It helps us concentrate and focus on tasks. It helps us avoid dangerous situations. Anxiety also provides motivation to accomplish things that we may otherwise tend to put off. As you can see, anxiety is essential to our survival.

Anxiety is often described as a spectrum of feelings. Just about everyone experiences mild or moderate anxiety as we go about our work and play. When we have moderate anxiety, our heart rates increase minimally so that there is more oxygen available. We are alert so we can focus better on a task or problem. Our muscles are slightly tensed so we can move and work. Our production of hormones, such as adrenaline and insulin, is slightly elevated to help the body react. We can study for a test, prepare a report for work, give a speech, or hit the ball when we are up to bat. If we were completely relaxed, we could not concentrate or accomplish these tasks. Anxiety helps us meet the demands made on us.

relaxed/calm -- mild -- moderate -- severe -- panic

The subjective feeling we call anxiety is accompanied by a predictable pattern of bodily responses summarized in the continuum above. People with anxiety disorders have reactions, designed to help us escape danger, in situations that are not life threatening. The normal mechanism for initiating these responses goes awry for reasons we do not fully understand. When we have severe anxiety, we do not think well and cannot solve problems. Production of adrenaline is so high that it causes a sensation of a "pounding" heart, shortness of breath, and extremely tense muscles. We feel a sense of danger or dread. This fear may or may not have a focus. If we were facing a tiger, this level of anxiety would be helpful to us to fight or flee. However, if this level of anxiety occurs without a dangerous stimulus, this response is not helpful. Anxiety disorders differ from anxiety in general in that the experience or feelings are more intense and last longer. Anxiety disorders also interfere with the normal functioning of people at work, at play, and in relationships.

When we are faced with real or imagined threats, our brain signals the body that we are in danger. Hormones are released as part of this general alarm call. These hormones produce the following changes:

• the mind is more alert
• blood clotting ability increases, preparing for injury
• heart rate increases and blood pressure rises (there may be a sensation of the heart pounding and a tightness in the chest)
• sweating increases to help cool the body
• blood is diverted to the muscles to help prepare for action (this may lead to a light-headed feeling as well as a tingling in the hands)
• digestion slows down (this may lead to a heavy feeling like a "lump" in the stomach, as well as nausea)
• saliva production decreases (which leads to a dry mouth and a choking sensation)
• breathing rate increases (which may feel like shortness of breath)
• liver releases sugar to provide quick energy (which may feel like a "rush")
• sphincter muscles contract to close the opening of the bowel and bladder
• immune response decreases (useful in the short term to let the body respond to a threat, but over time harmful to our health)
• thinking speeds up
• there is a sensation of fear, a desire to move or take action, and an inability to sit still

Is Anxiety Normal for New Mothers?

All new mothers are somewhat anxious. Being a mother is a new role, a new job, with a new person in your life and new, responsibilities. Anxiety in response to this situation is very common. Pediatricians, obstetricians, and nurses are used to worries, concerns, and questions like yours.

However, for reasons we cannot explain, some mothers have excessive worries and experience a severe level of anxiety. Dori, a new mother, describes her anxiety:

I could not sit still or relax at all. My thoughts were racing, and I couldn't focus on anything at all. I worried constantly that something was wrong with the baby or that I would do something wrong. I had never felt this kind of anxiety before, but I didn't know if it was normal for new mothers.

As with Dori, mothers with severe anxiety have difficulty enjoying their new babies, and they are overly concerned about minor problems. They have unrealistic fears about doing something wrong to hurt the baby. Mothers with severe anxiety cannot relax when there is an opportunity to do so. Anxiety disorders are often missed in new mothers because of the belief that all new mothers are excessively anxious. If you find yourself meeting the criteria for any of the anxiety disorders described in this chapter, or if you are very uncomfortable for prolonged periods such as several hours, talk to your health care provider. Take this book with you and share your concerns, because not all health care providers are familiar with the criteria for anxiety disorders.

Why Anxiety Disorders and Panic for Some?

Although anxiety is a normal human response to stress, we are not sure why some people have severe anxiety or panic in response to everyday situations. As with depression, there are several theories about why these problems occur.

One theory proposes that some people have a biological tendency toward anxiety. Some people seem to be more sensitive to the effects of the hormones released during anxiety. There may be a genetic link in some disorders. Because the chemicals in the brain that are affected in anxiety are similar to the ones affected during depression, family history is important in determining what kind of disorder is present and what kind of treatment may help.

Another theory proposes that anxiety is a learned response to negative or fearful situations as we grow up. If you were around someone who was fearful, negative, and/or critical when you were a child, you may have developed a long-standing habit of assuming the worst is going to happen or reacting negatively to events. This theory also explains why trauma, an extremely upsetting event, may play a role in the development of anxiety. If you are in an accident, if you see someone die, or if you are attacked, you may have a reaction that marks the beginning of an anxiety disorder. Reactions to stress and loss may also be a factor.

There is probably no one single reason why people develop anxiety disorders. Because we are limited in our understanding of how these disorders develop, it is probably not all that helpful to try to figure out how yours started or which family member "gave" you this problem. You will find it more productive to look at how you can respond differently to situations that make you anxious, to modify the physiological response to these situations, and to master your habit of negative thinking.

People with anxiety disorders are often known as "worriers" concerned about control and perfectionism. These can be good traits to have. But when the need for perfectionism or control interferes with your life, an anxiety disorder often develops.

If you find yourself fitting the criteria for a diagnosis of an anxiety disorder, it is important that the possible physical causes of these symptoms be eliminated. Several physical illnesses may cause symptoms similar to these disorders. A basic principle of mental health treatment is to first rule out any physical causes of symptoms. Some of these physical conditions or illnesses are hypoglycemia (low blood sugar), hyperthyroidism (an overactive thyroid), inner ear problems, mitral valve prolapse, hypertension, and some nutritional deficiencies. While the anxiety symptoms caused by these problems affect only a small percentage of people with the symptoms, it is important to first investigate all the possible causes of the symptoms.

What Anxiety Disorders are Common in the Postpartum Period?

Women with postpartum anxiety disorders experience a spectrum of problems that range in severity from adjustment disorder to generalized anxiety disorder (GAD) to obsessive-compulsive disorder to panic disorder. In this chapter, we'll review the symptoms of each disorder, according to the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders.

It's important to note, however, that these anxiety disorders are not unique to the postpartum period. In fact, anxiety disorders are one of the most common psychiatric problems seen by mental health and family practice professionals. Studies show that more women than men suffer anxiety disorders. About 10 percent of women in the United States will have an anxiety disorder sometime in their lives, while 5 percent of men will experience these problems.

Adjustment disorder is a reaction to an external stress beyond what is considered typical. It is usually time-limited and responds well to minimal intervention. Many people have difficulty accommodating to changes in their lives such as divorce, job loss, retirement, or other crises.

Twenty-nine-year-old Darla's story is typical of a problem called adjustment disorder. Although it is not specifically an anxiety disorder, adjustment disorder is included in this section because anxiety is such a common feature. However, symptoms of depression may be present also.

After my son was born, I felt "revved up" and could not sit down and relax for a minute. I felt like there was a motor inside that would not shut off. I just thought it was the excitement of having the baby we had wanted for so long. When I got home from the hospital, I couldn't sleep at all. I got so tired and irritable that when he cried I wanted to yell, "Shut up!" This only made me feel worse. I was worried I was not going to be able to handle being a mother. I found myself avoiding taking care of my baby. It took me almost two weeks before I could enjoy him.

Darla was referred to a therapist who helped her learn to relax and to not worry so much about minor problems like diaper rash. Darla tended to "catastrophize." Small events took on life-and-death proportions in her thinking. Darla learned to observe herself catastrophizing and to be more objective in her assessment of situations. After several sessions with the therapist, Darla was less anxious, was beginning to enjoy the baby, and was able to sleep when the baby slept.

Are You Having Any of These Symptoms?

• Are you so anxious that you cannot adquately care for your baby?
• Are you afraid of hurting yourself or the baby to the extent that you are not sure that you can stop yourself?
• Are your compulsive behaviors harmful to the baby?
• Are you so anxious that you cannot eat or sleep?

If so, consult a mental health professional and tell him/her that you require immediate attention.

Symptoms of Adjustment Disorder

• Emotional or behavioral symptoms develop in response to identifiable stressor(s), occurring within three months of the onset of the stressor(s).
• These symptoms or behaviors are shown by either marked distress in excess of what would normally be expected from exposure to the stressor or by significant impairment in social or occupational functions.
• The symptoms are not related to bereavement or grief.
• The symptoms last no more than six months once the stressor has stopped.

What Is Generalized Anxiety Disorder?

A more severe form of anxiety is generalized anxiety disorder (GAD). This illness is characterized by a persistent anxiety that affects most areas of a person's life. This disorder is accompanied by worries or fears that are out of proportion to the situation. Many people, men and women alike, have this kind of anxiety but never seek treatment. They are known to their friends and families as "worriers."

If a woman with GAD becomes pregnant, she may feel less anxiety during her pregnancy. But she is likely to experience anxiety again after delivery. Since anxiety continues during pregnancy for some women, it is difficult to predict who will experience anxiety during pregnancy. Jill's story is very typical of a new mother with GAD:

I have always been a "worrywart" and have been teased about my nervousness since I was a little girl. I felt pretty good during my pregnancy. But after the baby came, I got much worse. I couldn't sleep, and I was always calling the doctor because I thought something was wrong with the baby. I developed horrible muscle spasms in my neck. The pediatrician suggested I see a therapist about my anxiety. I didn't realize that what I had could be helped.

Jill meets the criteria for a diagnosis of GAD. She saw a therapist who used a cognitive therapy approach to help her become more aware of how her thinking increased her anxiety. Jill realized that she tended to think of things as either "black or white, right or wrong." She also tended to assume the worst in most situations. Jill learned to use relaxation techniques to help her remain calm. She also learned to change her habit of negative thinking. After a brief therapy process, Jill felt less anxious and enjoyed her baby more.

Generalized Anxiety Disorder Criteria

• Excessive anxiety and worry about a number of events or activities, occurring more days than not for at least six months.
• The person finds it difficult to control the worry.
• The anxiety and worry are associated with three or more of the following symptoms:
  - restlessness, feeling "keyed up," or "on edge"
  - being easily fatigued
  - difficulty concentrating or mind going blank
  - irritability
  - muscle tension
  - sleep disturbance (trouble going to sleep or staying asleep)

What Is Obsessive-Compulsive Disorder?

Obsessive-compulsive disorder (OCD) is an anxiety disorder that used to be considered rare. Now psychiatric clinicians recognize it is much more common than originally thought. Obsessive and compulsive are terms sometimes used to depict people who are perfectionistic, require a certain order, or have rigid routines. Although these characteristics may fit many people, these traits are parts of our personalities. The actual criteria for OCD diagnosis include many more serious symptoms. People with the disorder (rather than just the traits) lead disrupted lives.

This anxiety disorder has two components: thoughts and behavior. Obsessions are persistent thoughts that intrude upon the person's consciousness. These thoughts are unwelcome, but the affected person feels incapable of controlling them. Examples of obsessions are thoughts about a body part, saying a word over and over, and thoughts of hurting yourself or someone else. Among postpartum women, these obsessions are frequently about hurting the baby in some manner, like throwing it against a wall or by hitting or stabbing it. In her book, Shouldn't I Be Happy? Emotional Problems of Pregnant and Postpartum Women, Dr. Shaila Misri reports that in addition to the obsessive thought of hurting the baby, another obsession is frequent. She describes a theme of obsessing about previously having killed a baby, which may affect women who have terminated an earlier pregnancy. This theme may also be evident in women who have miscarried.

Compulsions are behaviors that are repetitive and ritualistic. Common compulsions are continuous cleaning, rearranging things such as items in kitchen cabinets, or washing hands. The urge to do these things continually is uncomfortable, but the person feels as if stopping is not possible. Common compulsive behaviors in postpartum women with OCD are frequent bathing of the baby or changing its clothes. Nola, a twenty-five-year-old mother, tells of her OCD episode:

After I was home for about two weeks, I began having fears about smothering the baby with her pillow. I could not stop the thoughts from happening.
I love my daughter so much, and I felt so ashamed of having these awful thoughts.
Finally, I called a crisis hotline. They told me I probably had an anxiety problem called OCD. I was so relieved, I cried for several hours. I was started on a medication, and the thoughts stopped. It was like a miracle!

Nola's story is very typical of persons with OCD. They recognize that their thinking and behavior is "not normal." Women describe a sense of shame and guilt about having these thoughts and behaviors. They often hide from their family and friends their ritualistic behaviors and obsessive thoughts. Nola reports:

I'd had obsessions since I was a child, but thought I could control them. I never told anyone because I was afraid they would send me to a psychiatric hospital. I realize now how much of my life I have spent hiding something that was easily treated. I wish I had gotten help earlier so I would not have had such a hard time when my daughter was born.

Just like Nola, many of these women suffer in silence because they feel so ashamed of having such thoughts. Often the new mother with OCD will go to great lengths to avoid being alone with her baby. Common strategies are to be gone from home all day to places like the library or shopping mall or out to visit friends. Developing complaints of illness to avoid taking care of the baby is also common.

Because OCD is not a psychotic illness, the mother is unlikely to act on her thoughts, so there is little risk to the infant. Nevertheless, the toll on the mother is tremendous. Some women whose children are now in their twenties with children of their own clearly remember the thoughts they had of possibly harming their babies. They still feel guilty decades later.

In order to meet the criteria for a diagnosis of obsessive-compulsive disorder, either compulsions or obsessions can be present. In addition, at some point, the person has recognized that the obsessions or compulsions are excessive or unreasonable. The obsessions or compulsions cause marked distress, are time-consuming, or significantly interfere with the person's normal routine, occupational functions, or usual social activities or relationships.

Symptoms of Obsessive-Compulsive Disorder

Obsessions are defined by:

• recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate and cause anxiety or distress
• thoughts, impulses, or images that are not simply excessive worries about real-life problems
• attempts to ignore or suppress such thoughts, impulses, or images
• awareness that the obsessional thoughts, impulses, or images are a product of his or her own mind

Compulsions are defined by:

• repetitive behaviors (hand washing, ordering, checking) or mental acts (praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
• behaviors or mental acts aimed at preventing or reducing distress or preventing some dreaded event or situation

If you recognize that you have obsessive-compulsive disorder, seek help. Far too many people live their lives hiding these problems and not getting the treatment that can make such a difference in the quality of their life.

What Is Panic Disorder?

Panic disorder, a more extreme form of anxiety, is marked by intense episodes of anxiety, usually accompanied by a fear of impending death. These episodes are called panic attacks. Once a person has a panic attack, he or she often has an overwhelming fear of future attacks and avoids many situations as a strategy to prevent them. Panic attacks are a painful and debilitating illness.

Ten days after I had my son, I had my first experience of thinking I was going to die. I was giving him a bath. Suddenly my heart started pounding. I became dizzy and short of breath. I was so afraid I would pass out that I got on the floor and crawled with the baby into the bedroom. I called my husband, and he came home.

I thought I was having a heart attack, so we went to the emergency room. I was crying and worrying about not seeing my baby grow up. They ran tests and told me it was anxiety. I didn't believe them. I called my own doctor, and he ran some more tests.

When I kept having panic attacks,, I started reading about panic. I went to a therapist who helped me manage my symptoms and my thinking. Now I can head panic off most of the time. I still can remember how scared I was. It is hard to believe that it is anxiety and that I am not dying.

Twenty-eight-year-old Melissa's description of her panic attack is very typical of first-time sufferers. Panic attacks are terrifying and are often mistaken for heart attacks or strokes.

Many people have experienced moments of panic in frightening situations such as accidents, but this is a normal response to a situation outside the range of typical human experience. Panic attacks occur even when the situation does not warrant the body responding in such a way.

Panic Attack Criteria

A panic attack is a discrete period of intense fear or discomfort, in which four or more of the following symptoms develop abruptly and reach a peak within ten minutes:

• palpitations (sensation of pounding heart) or faster heart rate
• sweating
• trembling or shaking
• shortness of breath or smothering sensations
• feeling of choking
• chest pain or discomfort
• nausea or abdominal distress
• feeling dizzy, unsteady, light-headed or faint
• a sensation that things are not real (derealization or a sensation of being detached from oneself)
• fear of losing control or going crazy
• fear of dying
• numbness or tingling in the hands or feet
• feeling chilled or having hot flashes

Often the panic attack is associated with a certain place or event. Avoiding situations that may precipitate a panic attack becomes a way of life that usually becomes more and more restrictive. For example, let's say you have a panic attack as you're driving and approach a red light. You begin to experience shortness of breath. Heart-pounding thoughts like, "What if I pass out?" or "What if I crash?" begin to race through your head. In the future, you will probably associate red lights with a panicky feeling. Soon you will begin to avoid stoplights and will take long detours to reach your destination. These avoidance strategies create major problems in the life of a person with panic disorder. All types of situations are seen as dangers to be avoided. Soon the world becomes smaller and smaller. Eventually, the person may not be able to leave the house, go into a public building, drive a car, or be around strangers. This creates a fear called agoraphobia, which often accompanies panic episodes.

Agoraphobia, translated literally is "fear of the marketplace." The condition has been known since the time of the ancient Greeks. Individuals with agoraphobia are usually terrified of leaving their homes alone. They may fear such things as being in public or among crowds, standing in a line, being on a bridge, or traveling in a bus or car. This avoidance of public places severely restricts the lives of those with this disorder. Often they will become depressed because they are so isolated. This sense of being alone in a terrifying world and unable to seek help is a very frightening experience.

Sandy, a twenty-two-year-old new mother, illustrates the emotional devastation that can result from agoraphobia and panic attacks:

I was driving to the grocery store with the baby for the first time. Six blocks from home, my heart started pounding. I was sweating. I thought I was going to faint. I went back home. I didn't tell anyone because I didn't want to worry them. Somehow I felt ashamed because I thought I should be able to do something as simple as go to the store.

I thought maybe I was still tired from the delivery or was anemic. But it kept happening when I drove, so I made up excuses not to drive. I refused to go out of the house for four months.

Finally my husband got impatient with me and made me go out. We got a sitter and went out. I had such a horrible time because I was so scared and wouldn't let go of his hand.

He made me go to see a counselor, and I found out I was having panic attacks. I never knew other people had the same thing. I was able to control my anxiety by breathing. I didn't need medication. I worry that I will have it again if I have another baby.

Sandy's story is tragic. Not only did she have a frightening experience, but she thought she was the only one affected with the problem. Her story also illustrates how people with anxiety may try to hide what is happening to them because they feel a sense of shame. Anxiety becomes a prison that keeps getting smaller and smaller.

If you or someone you know suffers from any of the anxiety disorders described in this chapter, seek help immediately. Like depression, anxiety is very responsive to treatment. Many people have these problems, so you are not alone.

Strategies for Managing Anxiety

In addition to medication and therapy, there are some strategies you can use to help lessen and eventually prevent anxiety episodes. The most common technique is relaxation breathing. Most of us breathe with only part of our lung capacity. We usually do not use our abdominal muscles. By deep breathing and using your abdominal muscles, you can tell your body and mind, "All is well, and you can relax."

Follow the instructions below to learn this breathing relaxation technique:

Relaxation Breathing Instruction

• Sit or lie comfortably. Close your eyes or gaze at a fixed spot in the room.
• Begin to focus on your breathing putting all other thoughts out of your mind. The only thing you have to do now is to practice relaxation breathing.
• Begin to pace your breathing by counting: "in-2-3-4, out-2-3-4." You can also pace your breathing with positive sayings like (breathing in) "I-am-more-relaxed-and-calm, I-am-more-relaxed-and-calm" (breathing out).
• Gradually take deeper and deeper breaths, consciously raising your abdomen when you breathe in and lowering your abdomen when you breathe out.
• Continue comfortably breathing for at least ten minutes.

Like any skill, this will take some practice. Do this for at least five minutes two or three times daily. Gradually, you will develop an automatic response to beginning this kind of breathing. You can use this breathing to help diminish your anxiety or even to prevent anxiety in situations that might create tenseness for you. This kind of behavior training is commonly used to help people lessen their reliance on medication.

A similar technique often used in conjunction with relaxation breathing is muscle relaxation. This is usually a guided relaxation exercise; it can be on tape or read to you by someone. You can tape record the steps yourself, but you may find it more helpful to have someone read the steps to you slowly, allowing you to concentrate on the breathing and relaxation:

Progressive Relaxation Routine

• Sit or lie comfortably. Close your eyes or gaze at a spot in the room. Gradually focus your mind on your breathing.
• Begin to take deeper breaths, raising your abdomen as you breathe in and lower your abdomen as your breathe out.
• Feel your body relax and become warmer and heavier as you continue the deep breathing.
• Curl your toes under on both feet and hold for a count of 1-2-3-4. Relax your toes and take two deep breaths.
• Curl your toes under again for a count of 1-2-3-4-5-6. Relax and breathe deeply, being sure your abdomen rises as you breathe in and falls as you breathe out.
• Now tighten your calf muscles for a count of 1-2-3-4.
• Relax and take two deep breaths.
• Tighten your calf muscles again for a count of 1-2-3-4-5-6.
• Let go and breathe deeply, making sure your abdomen rises as you breathe in and falls as you breathe out. Continue this tightening-release-tightening longer-release pattern with your thigh muscles squeezed together, then your buttock muscles, then your abdomen.
• Then continue pattern by clenching your hands into fists, then bending your forearms to the biceps, then shrugging your shoulders.
• Finish with the facial muscles by squinting your eyes, then opening your mouth as far as possible.
• Be sure to deep breathe after tensing each muscle group and count in a gentle rhythmic manner, tensing with the second tensing longer than the first.
• Notice how much more relaxed you feel. You feel calm, relaxed, and peaceful. Tell yourself you have just given your body and mind a treat. It feels good.
• Open your eyes when ready.

  

You can tape someone reading this for you, or you can tape it yourself, being sure to pace the reading so that you don't rush through it. As with relaxation breathing, consistent practice on a daily basis will develop your capacity to relax in stressful situations.

"Copyright © 1998 by Linda Sebastian. From Overcoming Postpartum Depression and Anxiety, by arrangement with Addicus Books."

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What's the best treatment of anxiety disorders during pregnancy? Can anxiety harm the baby? Read about treating anxiety symptoms during pregnancy.

(July 2002) This question appeared on the Mass. General Hospital Center for Women's Mental Health site and was answered by Ruta M. Nonacs, MD PhD.

A. Given the limited information on the reproductive safety of certain medications, it is common for women to discontinue anti-anxiety medications during pregnancy. However, many women experience worsening of their anxiety symptoms during pregnancy, and it seems that the first trimester may be particularly difficult. Cognitive-behavioral therapy and relaxation techniques may be very useful for treating anxiety symptoms during pregnancy and may reduce the need for medication.

Some women, however, may not be able to remain symptom-free during pregnancy without medication and may instead elect to continue treatment with anti-anxiety medications. When choosing a medication for use during pregnancy, it is important to choose an effective treatment with a good safety profile. We have the most information on the reproductive safety of Prozac (fluoxetine) and the tricyclic antidepressants. These medications are effective for the treatment of anxiety disorders, and research indicates that there is no increase in risk of major congenital malformation in infants exposed to these medications in utero. Nor is there any consistent evidence that these medications are associated with any serious complications during pregnancy. There is also one report on the safety of Celexa (citalopram), indicating no increased risk of major malformation in exposed children. We have less information available on the safety of other serotonin reuptake inhibitors (SSRIs), including paroxetine, sertraline, and fluvoxamine.

How anxiety in the mother may affect the pregnancy has been a topic of recent research, and several studies indicate that women who experience clinically significant anxiety symptoms during pregnancy are more likely to have preterm labor and low birthweight infants, as well as other complications, including pre-eclampsia. Thus it is crucial that women with anxiety disorders be monitored carefully during pregnancy, such that appropriate treatment may be administered should anxiety symptoms emerge during pregnancy.

Ruta M. Nonacs, MD PhD

Kulin NA. Pastuszak A. Sage SR. Schick-Boschetto B. Spivey G. Feldkamp M. Ormond K. Matsui D. Stein-Schechman AK. Cook L. Brochu J. Rieder M. Koren G. Pregnancy outcome following maternal use of the new selective serotonin reuptake inhibitors: a prospective controlled multicenter study. JAMA. 279(8):609-10, 1998.

Glover V. O'Connor TG. Effects of antenatal stress and anxiety: Implications for development and psychiatry. British Journal of Psychiatry. 180:389-91, 2002.

DISCLAIMER: As it is not possible or good clinical practice to make a diagnosis without a thorough exam, this site will not dispense any specific medical advice.

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A former Macon psychologist pleaded guilty Tuesday to criminal charges of having sex with a patient, a woman who was suffering from a multiple personality disorder (MPD).

Robert Douglas Smith, 62, received a three-year sentence on the felony charge, but he received probation under the terms of a plea agreement.

Bibb County Superior Court Judge Walker P. Johnson, however, ordered a post-sentence investigation. Johnson indicated that he might invoke sex-offender probation rules on Smith.

Georgia law provides 20 such conditions, although the judge may choose which ones to impose. An offender can be required to register with the sheriff of the county where he lives, for instance, or to live up to a year in a "diversion center," a kind of halfway house.

Johnson will impose the final terms of the probation sometime in the new year.

Smith, a slight man with flowing white hair and a short white beard, spoke briefly at the hearing. He apologized to the victim, who also was in the courtroom, and he acknowledged, "My behavior was inexcusable. It was wrong for me to do. I feel a deep sense of shame and guilt over the emotional pain I have caused her and those around her."

Then he added, "I think there is some good I can do. I had 20 good years helping people in this community, and I ruined it all through my mistake."

The victim also spoke, reading from a prepared statement describing the "utter anguish, torment and suffering I endured as a result of his vile transgressions."

The woman had gone to Smith to seek treatment for a multiple personality condition and anorexia nervosa, an eating disorder. Under the pretext of treating her condition through therapy, Smith fondled her sexually, caused her to turn away from her family and eventually seduced her, having intercourse with her repeatedly over the course of several months while she was his patient, said Graham Thorpe, the prosecutor in the case.

She relapsed into anorexia and was at the point of suicide before another psychologist intervened, Thorpe said.

"There is such an imbalance of power between therapist and patient that there can be no such thing as consent," Thorpe told the judge. "She placed her trust in this man, and he abused her. He damaged her rather than helping."

Defense attorney O. Hale Almand acknowledged the injury to the victim, but he said Smith also has suffered, surrendering his license to practice as a psychologist, losing his career and undergoing a divorce.

"More importantly than that, he lost his professional reputation," Almand said. "There's no way he'll ever gain that back. He is now a pariah in the psychological-psychotherapy community."

Indeed, Donald Meck was incredulous on hearing that Smith had received a sentence of probation. Meck, a Warner Robins psychologist who serves on the State Board of Examiners of Psychologists, said, "I can't believe he got off. The evidence we looked at, at the board, was awfully strong, and it is amazing to me that he is going to walk the street."

While Tuesday's plea hearing focused on the charges involving a single victim, the licensing board also had received complaints from two other women who alleged that Smith made improper sexual advances toward them.

Even after he relinquished his psychology license in 1995, Smith continued to see patients under a rule that allowed him to practice under the supervision of a licensed psychologist. As a result of the Smith case, the licensing board tightened its regulations to prevent that.

© Copyright 1997 The Macon Telegraph

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Why do pregnant women suffer anxiety about childbirth? One reason is the lack of trust in the obstetrical staff. Read this abstract for more reasons.

Abstract

Center for Women and Children's Health, Department of Obstetrics and Gynecology,Karolinska Hospital,Stockholm, Sweden

The aims were to document conscious reasons for anxiety about childbirth. Pregnant women (n=100), consecutively referred from antenatal centers to a psychosomatic outpatient clinic because of extreme fear of childbirth, were interviewed.

Three subgroups are described: primiparae (n=36), women with a normal previous delivery (n=18) and women with a previous complicated delivery (n=46).

Anxiety over the delivery was related to lack of trust in the obstetrical staff (73%), fear of own incompetence (65%), fear of death of mother, infant or both (55%), intolerable pain (44%) or loss of control (43%).

In the description of the anxiety, more than one focus could be described. A previous complicated delivery predisposed for fear of death (p<0.001). In other aspects, the subgroups were similar. Fear of death in a previous labor was associated with this fear regarding the impending delivery (100%, 21%, p<0.001) and with fear of loss of control (61%, 18% p<0.01).

Many women (37%) had partners who admitted anxiety over the delivery. Anxiety over childbirth is related to fundamental human feelings: lack of trust, fear of female incompetence and fear of death. Fear of pain is important but not predominant. The results are discussed with regard to stress, theoretical and psychodynamic points of view.

Source: Journal of Psychosomatic Obstetrics and Gynecology, Volume 18 issue 4, December 1997

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Running down the concrete hill from the crowded school bus to home, I would fly down the street feeling free to finally follow my tomboy ways. It was the discoveries awaiting me in the woods behind our house that propelled me through the air with such excited fervor. After quickly changing out of my school uniform and grabbing my fishing pole, I'd head down to the lake. It was my haven of peace. My own, private playground. As I made my way through the woods, I wondered if I would hook that big bass I had spotted slowly gliding under the water's edge the day before. Maybe I'd catch a frog or some bluegill to fry up in a pan of butter for an after-school snack. You never knew what you were going to get down by the lake. That was the thrill.

"A walk down memory boulevard"

How many little girls do you know who take their brother's boy scout equipment out into the woods alone pretending they're frontiersmen, living off the land? Or cook soup over an open fire they built themselves, shoot BB guns, or actually WANT to catch and hold frogs? Girls don't like being alone. They don't like getting dirty. Right? Well I did. It wasn't that I didn't like playing with dolls or giggling with my friends, I just had other interests as well. By all anatomical appearances I was a girl, but my interests and behavior said all-boy.

The little women in my neighborhood didn't enjoy foraging in the woods, swinging from vines, fishing, or going on imaginary hunting expeditions. Boys played too rough, took more risks than I was comfortable with, and liked killing things. So I spent a lot of time alone in my childhood, even though I lived on a street brimming with children.

I wasn't lonely sitting by that lake. I actually didn't want anyone else around. Girls seemed to bore quickly in the quietness and boys made too much noise, scaring the wildlife away. I enjoyed being there by myself, sitting still for hours, watching the sounds and sights of nature move around me in its business of being. I'd watch the geese land skidding onto the lake or be mesmerized by my bobber as it lay on the water. I'd try to imagine what world lived under the mirrored liquid.

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One day as I was making my lure hop and dance over the wet muddy bank, a big Ole bullfrog dove for and latched itself onto my hook. I felt the exhilaration of connection. As I held his slick body in my hand I realized he had swallowed the hook. After several attempts to dislodge it, panic set in. One singular, but powerful thought consumed me. This frog may die, but he will NOT suffer because of me. My mind whirled as I tried to think of the quickest, least painful way to end his life.

Fish die quickly with one sure blow to the forehead. For some reason that seemed too brutal for this animal. This creature hopped, made sounds, could look at you and had soft fleshy skin. Somehow that made him different from fish. He was too much like me.

I ran back up to the house. My eyes darted over the garage shelves looking for anything toxic. As I sprayed this helpless creature with every imaginable household cleaner and spray paint I could find, my face was red and wet from tears of anguish. It wasn't working. He was still alive, but now bright orange from the spray paint. I finally relented and took away his misery with multiple blows of a shovel. With my eyes squeezed tightly shut, I struck at him, wanting to squeeze out my own suffering as well as his.

Upon reflection I can see the outrageousness and perhaps even the humor in the frantic actions of a child who wanted to do the right thing. One who didn't know toxic doesn't mean immediate death. When I think back to that day, I remember the feelings of a desperate child and feel compassion for both the little girl and her dilemma.

As I ventured into my teen years, my awareness of the differences in thought, word and deed between myself and other women, heightened. My un-feminine ways continued. I played sports, and worse yet, I was good at them. Being six feet tall attracted the interest of many coaches with dreams of transforming my young, gangly frame and awkwardness into a coordinated winning machine. With this special attention and added practice, I started my sports career and became known as a jock.

I enjoyed nothing better than playing a game of one-on-one basketball with the boys on the weekend, but something about that didn't feel right. I was suppose to be dating these guys, not trying to block their jump shots. I remember the body contact held a certain unique, tingly sensation that was fun. Maybe I partially enjoyed those games because they gave us a reason to be groping each other.

My masculine and feminine qualities were often at odds. I was competitive, but wouldn't risk relationships to win. I liked my fully-developed, female body, but resented men for their muscles and strength which put me at a competitive disadvantage. I taught myself to accept losing, but felt less worthy afterwards. Without that "win at any price," competitive drive, I didn't go on to be a college-star athlete. Not being fully female, I wasn't the picture perfect beauty queen of gentility, charm and grace, either. I didn't fit a stereotype. Many times I wish I had. Teenage years are confusing enough without having to go through a gender crisis. I struggled with accepting my oddities, while society told me I wasn't behaving "normally" for a woman. I was sure there was something wrong with me.

As I matured, I learned to act like a woman. I learned to suppress my strength once I realized men wanted to protect me, not compete with me. When my confidence intimidated them, I turned myself into a giggly, ditzy blonde. I knew I couldn't maintain a facade like that my whole life, so I assumed I would never find a man strong enough to enjoy my dualities. Eventually, I found a man who appreciated my independence and unique combination of qualities. I was a full grown woman, and married, but I still carried the Tomboy inside.

Other women held close guarded secrets about how to fulfill their roles as women and wives. They innately knew how to decorate and make a house look pretty. They knew about flowers and plants. They knew how and what to cook. They were, in some ways, better equipped as women for the "business of life." Although I was passionate about my career, I didn't fit in with the power-driven, brief-case-carrying career women. And although I loved writing and painting, I didn't fit in with the Sunday bake-offs and crafts groups, either. Maybe that was the problem. I was unclassifiable. I couldn't find a niche I could slide into.

It felt like no matter how hard I tried, I would never have the innate talents other women possessed. I would copy and fake my way through it, unnaturally, not like a real woman. So I didn't decorate, garden, cook, or fiddle with domesticity. To make myself feel better about this apparent inadequacy, I chalked all those qualities and interests up as being trivial, simple minded and certainly beneath me.

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Not only couldn't I seem to do "women things" but I also couldn't muster up the desire to have children. I didn't want to have babies. Was I low on estrogen or missing some crucial mommy gene? I must have misplaced my maternal instinct because it was unfathomable to women that I didn't find babies cute or want to hold them. I felt awkward when someone shoved a little human at me. Whatever the case, I chose to raise kittens instead of conceiving.

It wasn't until last year when my husband and I left Cincinnati, Ohio, that those beliefs about being "womanly challenged" were put to the test. Our real estate agent told us we'd get more money for the house if it looked more like a model home. I kinda, sorta knew what she meant but I didn't have a clue what to do. Too cheap to hire a decorator, I sat down and started looking through interior decorating magazines. Then it hit me. I didn't know how to decorate because I had never paid attention to how it was done! Since I assumed it was an innate womanly quality that I didn't have, I never even tried to learn. I studied those magazines and got busy totally redecorating the house.

When our agent returned, she was very pleased and surprised to find the place looking so "architectural-digest-like". More importantly, I was pleased! With that, I had a type of paradigm shift. I realized that I had been making choices about my life based on beliefs of inadequacy. I figured I might be able to change all those areas in which I had doubted myself, by simply paying attention to how others did them. Then, do them myself. I didn't know if I would enjoy these traditionally female interests, but I wanted to find out.

After we had moved into our new home on the Gulf Coast of Mississippi, I began decorating. I taught myself to cook. I designed a landscaping layout and planted shrubs and ground covers. I even tried my hand at flowering bulbs. Perennials of course. I'm not a masochist.

I had always dreamed of having a garden. It seemed so earthy. So I planted a vegetable garden. In typical type A personality, I planted almost every seed I could find. Corn, green beans, strawberries, tomatoes, potatoes, onions, and green and hot peppers became my laboratory subjects.

My biggest tomato was the size of a Ping-Pong ball and the entire garden was eventually massacred by deer, squirrels and raccoons, but that's not the point. The point is, I did it. I created something from nothing. Maybe it was the "living off the land" idea coming back to me from my childhood. The garden required me to pull both the Ying and yang aspects of myself to the forefront. I used my pioneering spirit, independence, and leaderships skills, which are traditionally male, as well as my sensitivity, nurturing and mother-earth type qualities, which are generally associated with women.

So began my blossoming into a woman. Or did I just blossom more into who I am? A more authentic me with fewer fears and self doubts. By experimenting, I was able to discover what I truly enjoyed. Having faced my own beliefs about what it means to be a woman, I now know my choices are based in freedom, and not in fear or feelings of inadequacy.

So what is a tomboy, anyway? Doesn't the term or label imply that our gender requires certain characteristics and behavior? It seems a sweeping generality to me, but perhaps all generalities hold some vestige of truth in them. But don't we limit ourselves when we demand our children to think and act a certain way, based entirely on gender? Where is the strengthening of natural tendencies?

I no longer buy into society's beliefs about how someone with breasts is suppose to behave. We limit ourselves when we set up such tight parameters in which men and women can operate. Life is all about feeling free to follow our desires and wants. It's about choices. Maybe that's what I got from being a tomboy, considerably more choices then the little girls who had no interest in "boy things".

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Kenora Enterprise
July 20, 1997
By Jim Mosher

Psychiatrist and author Peter Breggin says shock treatment is little more than an electrical lobotomy. Breggin says electroconvulsive therapy (ECT) causes brain damage - and, he says, most psychiatrists know it.

"It's barbaric," Breggin said during a recent telephone interview from his summer home in West Virginia. "It causes brain damage. That was the argument used when it was first introduced in 1938. It was held as an electrical lobotomy."

Breggin has written more than a dozen popular books about modern psychiatry, including Toxic Psychiatry and Talking Back to Prozac. In Toxic Psychiatry, he makes the claim that ECT is bad medicine, and worse when it's combined with drugs.

He says claims that ECT is safer now than when it was first introduced are typical of the siege mentality of psychiatric associations, which he claims always go to bat for whatever technique is in fashion.

"They claim that it is safe, but there have never been any follow-up studies," he said. "If you claim a technique is safe, you have to show that with animal studies."

"To say that things are safer and better now is not true," he continued. "They said that in the '50s about lobotomies."

(Frontal lobotomies were a standard treatment in the 1950s. A portion of the frontal lobe of the brain was removed, usually by drawing it out through an eye socket. At the time, psychiatrists cited the witnessed 'improvement' in previously combative patients. Neurological studies later showed that the improvement resulted after some essential brain functions were literally eliminated after the removal of the frontal lobe. The practice has since been discontinued.)

Shock treatment is often combined with drug therapy. That's hardly surprising to Breggin. "It shows you how inadequate ECT is - they load you up with drugs," he said.

Professional psychiatric organizations have come out squarely behind ECT as a necessary and safe treatment for acute depressive disorders.

The Canadian Psychiatric Association's most recent position paper on the treatment notes that ECT remains "an important part of the therapeutic armentarium in contemporary psychiatric practice."

The CPA says ECT is a suitable treatment for single episode or recurrent major depression, bipolar disorder and chronic schizophrenia.

"For these disorders, there is either overwhelming evidence in the literature attesting to the efficacy of ECT or a consensus among experienced Psychiatrists as to its position paper.

But the use of ECT to treat other disorders should only be undertaken in "exceptional circumstances" because "compelling evidence of the effectiveness of ECT' (in these circumstances) is lacking."

Breggin remains uncowed. He's convinced of the barbarity of ECT. He says it takes away one's identity. It's hardly surprising that ECT patients are more pliant and cooperative, he says. That witnessed improvement is due, he claims, to brain damage.

In Toxic Psychiatry, he cites cases where ECT was used to make a previously combative and disputative wife into a docile and submissive 'perfect wife'. Breggin says there is reason to fear this 'social engineering'.

He says few psychiatrists are willing to speak out against ECT. "It's simply not true that all psychiatrists agree with this treatment," he said. "But I've been one of the few who has been willing to take a stand."

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Therapist called 'predator' who 'brainwashed' his victims

A once-prominent psychologist has been sentenced to two years in prison for "brainwashing" two of his former patients into having sex with him.

Both vulnerable victims "suffered substantial mental harm" at the hands of George Matheson, Mr. Justice George Ferguson said yesterday.

The former chief of psychology at Etobicoke General Hospital controlled, manipulated and mentally dominated the two women, the Ontario Court, general division judge said.

"I hope it sends a message to other doctors," one of the victims said of the sentencing.

"I'm glad it's over," the second victim said of the ordeal of having to testify in open court.

Prosecutor James Ramsay called Matheson a sexual "predator" who had violated the special trust between a therapist and his patients.

The charges specified the two victims submitted to him sexually or did not resist him because of "the exercise of (his) authority" as their therapist.

The judge quoted an expert witness in the case as saying that "when a psychologist has sex with a patient, therapy goes out the window."

Ferguson said people such as Matheson occupy a privileged position in society and must exercise the enormous power and authority they have only for their patients' benefit.

Matheson, who often helped various police forces by hypnotizing witnesses, has since lost his license to practise and now helps his girlfriend run a bed and breakfast house in Victoria,B.C.

The judge said that even though Matheson apologized for his conduct, he "continues to (wrongly) believe that he did not breach the (criminal) law" and is only guilty of professioonal misconduct.

Both victims testifed they had been sexually abused as children and were suffering from extreme depression when they became patients of Matheson.

One said her husband, in effect, paid Matheson approximately $5,000 - the fee for therapy - for Matheson to have sex with her, although he eventually returned the money.

The other testified Matheson told her he had fallen in love with her and he constantly phoned her, wrote her passionate letters and sent her gifts.

When he was out of town, he left her his cologne so she could smell him, and some of his clothes so she could hug them, the second victim told the court.

She said Matheson's wife caught them in bed together.

Toronto ex-therapist jailed for sex assaults - Patients abused in 'blatant' breach of trust.

BY DONN DOWNEY
THE GLOBE AND MAIL, May 13,1997

TORONTO- A once prominent Toronto psychologist who "brainwashed" two female patients and then sexually assaulted them was sentenced to two years in penitentiary yesterday.

In March, George Clifford Matheson, 48, was found guilty on two counts of sexual assault for a series of incidents involving two women over several years. Although they had consented to the encounters, the Crown took the position that they had submitted to sexual intercourse because of Dr. Matheson's authority over them.

Yesterday, he was seated for the first time in the prisoner's box, but earlier in the trial he was allowed to sit at the side of his lawyer, Alan Gold. He had asked Mr. Justice George Ferguson of the Ontario Court's General Division for a suspended or conditional sentence, but Judge Ferguson made it clear from the outset that Dr. Matheson would be going to jail.

Dr. Matheson was released on bail, pending appeal.

Judge Ferguson described Dr. Matheson as a predator who practiced mind control over two extremely vulnerable women in what "amounts to brainwashing."

He "continues to believe he did not breach the law" and shows no remorse for his criminal act although he voluntarily surrendered his professional certificate, acknowledging that he had violated the ethics of his profession.

He sentenced the psychologist to one year on each count, the sentences to be served consecutively.

If he had been sentenced to a day less, he would have gone to a provincial reformatory, but a two-year sentence must be served in a federal penitentiary, which generally houses the nation's most hardened criminals.

One of his victims was assaulted over five months in 1992 and the other was assaulted over two years beginning in 1987. The relationships amounted to "blatant long-term breach of trust," Judge Ferguson said. "He had the power to pressure and manipulate and he did so."

The victims, now 39 and 56, desperately needed therapy when they went to Dr. Matheson and made themselves vulnerable by revealing intimate details concerning their personal problems. They did not want sex, they wanted therapy, Judge Ferguson said.

One victim testified that Dr. Matheson told her that she would not get better unless she got rid of her husband.

Dr. Matheson is well known in legal circles, having served as an expert witness in the field of hypnosis. He also has aided police investigations by enhancing the memories of potential Crown witnesses.

He has three failed marriages and has two sons. Before he was sentenced, he was living with a female psychologist in Victoria, where they ran a bed-and-breakfast business.

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The Times
BY JEREMY LAURANCE, HEALTH CORRESPONDENT

A WOMAN has undergone the longest continuous course of electric shock treatment for depression.

Since 1989 the unnamed patient has received more than 430 treatments, in which a pulse of electricity is passed through her brain, triggering convulsions. For the first four years she had treatment twice a week but it was then cut to once a fortnight.

The regular shocks were effective in warding off her despair, which was accompanied by feelings of guilt, and did not cause progressive mental damage, as doctors had feared. The depression returned when the shocks were administered less than once a fortnight.

The woman had been treated for depression from the age of 43 with regular stays in hospital. Before the course of treatment began she had spent most of the previous five years in hospital. Since 1989, she has lived in a residential home and has been virtually free of symptoms. She is now 74, and understands fully the nature of her treatment.

Electric shock treatment, also known as electro-convulsive therapy, has a controversial history and was once described as barbaric. Today it is widely accepted by psychiatrists as a last-resort treatment for severe depression, although concern remains about its long-term effect on intellectual function.

The case is described by David Anderson, consultant psychogeriatrician at Rathbone Hospital, Liverpool, in the Journal of the Royal College of Psychiatrists.

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