Patients want to talk about sexual problems with physicians, but often fail to do so, thinking their physicians are too busy, the topic is too embarrassing, or there is no treatment available.⁽¹⁾Female sexual dysfunction (FSD) is a serious problem in the United States, and unfortunately often goes untreated. It is a difficult and complex problem to address in the medical setting, but it must not be neglected. Physicians must encourage patients to discuss FSD, and then aggressively treat the underlying disease or condition.

DEFINING SEXUAL DYSFUNCTION

Sexual dysfunction is defined as a disturbance in, or pain during, the sexual response. This problem is more difficult to diagnose and treat in women than it is in men because of the intricacy of the female sexual response. In 1998, the Sexual Function Health Council of the American Foundation of Urologic Disease revised preexisting definitions and classifications of FSD.⁽²⁾ Medical risk factors, etiologies, and psychological aspects were classified into four categories of FSD: desire, arousal, orgasmic disorders, and sexual pain disorders:

• Hypoactive sexual desire is the persistent or recurrent deficiency (or absence) of sexual fantasies or thoughts and/or the lack of receptivity to sexual activity.
• Sexual arousal disorder is the persistent or recurrent inability to achieve or maintain sufficient sexual excitement, expressed as a lack of excitement or a lack of genital or other somatic responses.
• Orgasmic disorder is the persistent or recurrent difficulty, delay, or absence of attaining orgasm after sufficient sexual stimulation and arousal.
• Sexual pain disorder includes dyspareunia (genital pain associated with sexual intercourse); vaginismus (involuntary spasm of the vaginal musculature that causes interference with vaginal penetration), and noncoital sexual pain disorder (genital pain induced by noncoital sexual stimulation).

Each of these definitions has three additional subtypes: lifelong versus acquired; generalized versus situational; and of organic, psychogenic, mixed, and unknown etiologic origin.

PREVALENCE

Approximately 40 million American women are affected by FSD.3 The National Health and Social Life Survey, a probability sample study of sexual behavior in a demographically representative cohort of US adults ages 18 to 59, found that sexual dysfunction is more prevalent in women (43%) than in men (31%), and decreases as women age.⁽⁴⁾ Married women have a lower risk of sexual dysfunction than unmarried women. Hispanic women consistently report lower rates of sexual problems, whereas African American women have higher rates of decreased sexual desire and pleasure than do Caucasian women. Sexual pain, however, is more likely to occur in Caucasians. This survey was limited by its cross-sectional design and age restrictions, since women more than 60 years old were excluded. Also, no adjustments were made for the effects of menopausal status or medical risk factors. Despite these limitations, the survey clearly indicates that sexual dysfunction affects many women.

PATHOPHYSIOLOGY

FSD has both physiologic and psychological components. It is important to first understand the normal female sexual response in order to understand sexual dysfunction.

Physiologically, sexual arousal begins in the medial preoptic, anterior hypothalamic, and limbic-hippocampal structures within the central nervous system. Electrical signals are then transmitted through the parasympathetic and sympathetic nervous systems.⁽³⁾

Physiologic and biochemical mediators that modulate vaginal and clitoral smooth-muscle tone and relaxation are currently under investigation. Neuropeptide Y, vasoactive intestinal polypeptide, nitric oxide synthase, cyclic guanosine monophosphate, and substance P have been found in vaginal-tissue nerve fibers. Nitric oxide is thought to mediate clitoral and labial engorgement, while vasoactive intestinal polypeptide, a nonadrenergic/noncholinergic neurotransmitter, may enhance vaginal blood flow, lubrication, and secretions.⁽⁵⁾

Many changes occur in the female genitalia during sexual arousal. Increased blood flow promotes vasocongestion of the genitalia. Secretions from uterine and Bartholin's glands lubricate the vaginal canal. Vaginal smooth muscle relaxation allows for lengthening and dilatation of the vagina. As the clitoris is stimulated, its length and diameter increase and engorgement occurs. In addition, the labia minora promote engorgement due to increased blood flow.

FSD is psychologically complex. The female sexual response cycle was first characterized by Masters and Johnson in 1966 and included four phases: excitement, plateau, orgasm, and resolution.⁽⁶⁾ In 1974, Kaplan modified this theory and characterized it as a three-phase model that included desire, arousal, and orgasm.⁽⁷⁾ Basson proposed a different theory for the female sexual response cycle,⁽⁸⁾ suggesting that the sexual response is driven by the desire to enhance intimacy (Figure 1). The cycle begins with sexual neutrality. As a woman seeks a sexual stimulus and responds to it, she becomes sexually aroused. Arousal leads to desire, thus stimulating a woman's willingness to receive or provide additional stimuli. Emotional and physical satisfaction are gained by an increase in sexual desire and arousal. Emotional intimacy is then ultimately achieved. Various biological and psychological factors can negatively affect this cycle, thus leading to FSD.

SIGNS AND SYMPTOMS

Sexual dysfunction presents in a variety of ways. It is important to elicit specific signs and symptoms since many women make generalizations about their sexual problems, describing the trouble as a decrease in libido or overall dissatisfaction. Other women may be more specific and recount pain with sexual stimulation or intercourse, anorgasmia, delayed orgasm, and decreased arousal. Postmenopausal women with estrogen deficiency and vaginal atrophy may also describe a decrease in vaginal lubrication.

DIAGNOSIS

History

An accurate diagnosis of FSD requires a thorough medical and sexual history. Issues such as sexual preference, domestic violence, fears of pregnancy, human immunodeficiency virus, and sexually transmitted diseases must be discussed. In addition, specific details of the actual dysfunction, identifying causes, medical or gynecologic conditions, and psychosocial information must be obtained.⁽⁹⁾ FSD is often multifactorial, and the presence of more than one dysfunction should be ascertained. Patients may be able to provide insight into the cause or causes of the problem; however, various tools are available to assist with obtaining a good sexual history. The Female Sexual Function Index (FSFI) is one such example.⁽¹⁰⁾ This questionnaire contains 19 questions and categorizes sexual dysfunction in the domains of desire, arousal, lubrication, orgasm, satisfaction, and pain. The FSFI and other similar questionnaires can be filled out before the appointment time in order to expedite the process.

FSD needs to be categorized according to the onset and duration of symptoms. It is also imperative to determine whether the symptoms are situational or global. Situational symptoms occur with a specific partner or in a particular setting, whereas global symptoms relate to an assortment of partners and circumstances.

A variety of medical problems can contribute to FSD (table 1).⁽¹¹⁾ Vascular disease, for example, may lead to decreased blood flow to the genitalia, causing decreased arousal and delayed orgasm. Diabetic neuropathy may also contribute to the problem. Arthritis may make intercourse uncomfortable and even painful. It is essential to aggressively treat these diseases and inform patients of how they can affect sexuality.

There are many gynecologic causes of FSD, contributing to physical, psychological, and sexual difficulties (table2).⁽⁹⁾ Women who have undergone gynecologic surgeries, ie, hysterectomies and excisions of vulvar malignancies, may experience feelings of decreased sexuality because of alterations in or loss of psychological symbols of femininity. Women with vaginismus may find vaginal penetration painful and virtually impossible. Alterations in hormones during pregnancy or the postpartum period may lead to a decrease in sexual activity, desire, and satisfaction, which may be prolonged by lactation.⁽¹²⁾

Prescription and over-the-counter medications should be reviewed in order to identify any contributing agents (table 3).^(13,14) Consideration should be given to dosage adjustments, medication alterations, and even drug discontinuation, if possible. In addition, use of recreational drugs, alcohol, and alternative therapies should be discussed.

Psychosocial and psychological factors should also be identified. For example, a woman with a strict religious upbringing may have feelings of guilt that decrease sexual pleasure. A history of rape or sexual abuse may contribute to vaginismus. Financial struggles may preclude a woman's desire for intimacy.

Physical Examination

A thorough physical examination is required to identify disease. The entire body and genitalia should be examined. The genital examination can be utilized to reproduce and localize pain that is encountered during sexual activity and vaginal penetration.⁽¹⁵⁾ External genitalia should be inspected. Skin color, texture, thickness, turgor, and the amount and distribution of pubic hair should be assessed. Internal mucosa and anatomy should then be examined and cultures taken if indicated. Attention should be given to muscle tone, location of episiotomy scars and strictures, tissue atrophy, and the presence of discharge in the vaginal vault. Some women with vaginismus and severe dyspareunia may not endure a normal speculum and bimanual examination; a "monomanual" examination using one to two fingers may be better tolerated.⁽⁹⁾ The bimanual or monomanual examination can give information about rectal disease, uterine size and position, cervical motion tenderness, internal muscle tone, vaginal depth, prolapse, ovarian and adenexal size and location, and vaginismus.

Laboratory Tests

Although no specific laboratory tests are universally recommended for the diagnosis of FSD, routine Pap smears and stool guaiac tests should not be overlooked. Baseline hormone levels may be helpful when indicated, including thyroid-stimulating hormone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), total and free testosterone levels, sex hormone-binding globulin (SHBG), estradiol, and prolactin.

The diagnosis of primary and secondary hypogonadism can be assessed with FSH and LH. An elevation of FSH and LH may suggest primary gonadal failure, whereas lower levels suggest impairment of the hypothalamic-pituitary axis. Decreased estrogen levels can lead to decreased libido, vaginal dryness, and dyspareunia. Testosterone deficiencies can also cause FSD, including decreased libido, arousal, and sensation. SHBG levels increase with age but decrease with the use of exogenous estrogens.⁽¹⁶⁾ Hyperprolactinemia may also be associated with decreased libido.

Other Tests

Some medical centers have the capacity to perform additional testing, although many of these tests are still investigational. The genital blood flow test uses duplex Doppler ultrasonography to determine peak systolic and diastolic velocities of blood flow to the clitoris, labia, urethra, and vagina. Vaginal pH can serve as an indirect measurement of lubrication. Pressure-volume changes can identify dysfunction of vaginal tissue compliance and elasticity. Vibratory perception thresholds and temperature perception thresholds may offer information regarding genital sensation.⁽³⁾ Clitoral electromyography may also be beneficial in evaluating the autonomic innervation of the corpus clitoris.⁽¹⁷⁾ These tests may be helpful in guiding medical therapy.

THERAPY AND OUTCOMES

Once a diagnosis is made, suspected causes should be addressed. For example, diseases such as diabetes or hypothyroidism must be aggressively treated. Consideration should also be given to changes in medications or dosages.

Patients should be educated about sexual function and dysfunction. Information about basic anatomy and the physiologic changes associated with hormonal fluctuations may help a woman better understand the problem. There are many good books, videos, websites, and organizations available that can be recommended to patients (Table 4).

If no exact cause can be identified, basic treatment strategies should be applied. Patients should be encouraged to enhance stimulation and avoid a mundane routine. Specifically, the use of videos, books, and masturbation can help maximize pleasure. Patients should also be encouraged to make time for sexual activity and communicate with their partners about sexual needs. Pelvic muscle contraction during intercourse, background music, and the use of fantasy may help eliminate anxiety and increase relaxation. Noncoital behaviors, such as massage and oral or noncoital stimulation, should also be recommended, especially if the partner has erectile dysfunction. Vaginal lubricants and moisturizers, positional changes, and nonsteroidal anti-inflammatory drugs may reduce dyspareunia.⁽¹⁸⁾

Hypoactive Sexual Desire

Desire disorders are often multifactorial and may be difficult to treat effectively. For many women, lifestyle issues such as finances, careers, and family commitments may greatly contribute to the problem. In addition, medications or another type of sexual dysfunction, ie, pain, may contribute to the dysfunction. Individual or couple counseling may be of benefit, as there is no medical treatment geared toward this specific disorder.

Hormone replacement therapy can affect sexual desire. Estrogen may benefit menopausal or peri-menopausal women. It can enhance clitoral sensitivity, increase libido, improve vaginal atrophy, and decrease dyspareunia. In addition, estrogen can improve vasomotor symptoms, mood disorders, and symptoms of urinary frequency and urgency.⁽¹⁹⁾ Progesterone is necessary for women with intact uteri using estrogen; however, it may negatively affect mood and contribute to decreased sexual desire.

Testosterone appears to directly influence sexual desire, but data are controversial regarding its replacement in androgen-deficient premenopausal women. Indications for testosterone replacement include premature ovarian failure, symptomatic premenopausal testosterone deficiency, and symptomatic postmenopausal testosterone deficiency (includes natural, surgical, or chemotherapy-induced).⁽¹⁹⁾ Currently, however, there is no national guideline for testosterone replacement in women with sexual dysfunction. In addition, there is no consensus regarding what is considered normal or therapeutic levels of testosterone therapy for women.⁽¹⁵⁾

Before initiating therapy, potential side effects and risks of treatment should be discussed. Androgenic side effects can occur in 5% to 35% of women taking testosterone and include acne, weight gain, hirsutism, clitorimegaly, deepening of the voice, and lowering of high-density lipoprotein cholesterol.⁽²⁰⁾ Baseline levels of lipids, testosterone (free and total), and liver function enzymes should be obtained in addition to a mammogram and Pap smear if indicated.

Postmenopausal women may benefit from 0.25 to 2.5 mg of methyltestosterone (Android, Methitest, Testred, Virilon) or up to 10 mg of micronized oral testosterone. Doses are adjusted according to symptom control and side effects. Methyltestosterone is also available in combination with estrogen (Estratest, Estratest H.S.). Some women may benefit from topical methyltestosterone or testosterone propionate compounded with petroleum jelly in a 1% to 2% formula. This ointment can be applied up to three times per week.^(9,19) It is important to periodically monitor liver function, lipids, testosterone levels, and androgenic side effects during treatment.

There are various over-the-counter herbal products that advertise improvement in female sexual dysfunction and restoration of hormone levels. Although evidence is conflicting, many of these products lack sufficient scientific studies required to support the manufactures' claims of efficacy and safety.^(21,22) Patients should be cautioned about the potential for side effects and drug-to-drug interactions with these products.

Tibolone is a synthetic steroid with tissue-specific estrogenic, progestogenic and androgenic properties. It has been used in Europe for the past 20 years in the prevention of postmenopausal osteoporosis and in the treatment of menopausal symptoms, including sexual dysfunction. It is not yet available in the United States, but is actively being studied.⁽²³⁾

Sexual Arousal Disorder

Inadequate stimulation, anxiety, and urogenital atrophy may contribute to arousal disorder. A pilot study of 48 women with arousal disorder showed that sildenafil (Viagra) significantly improved subjective and physiologic parameters of the female sexual response.⁽²⁴⁾ Other treatment options for arousal disorder include lubricants, vitamin E and mineral oils, increased foreplay, relaxation, and distraction techniques. Estrogen replacement may benefit postmenopausal women, as urogenital atrophy is one of the most common causes of arousal disorder in this age group.

Orgasmic Disorder

Women with orgasmic disorders often respond well to therapy. Sex therapists encourage women to enhance stimulation and minimize inhibition. Pelvic muscle exercises can improve muscle control and sexual tension, while the use of masturbation and vibrators can increase stimulation. The use of distraction, ie, background music, fantasy, and so forth, can also help minimize inhibition.⁽⁹⁾

Sexual Pain Disorder

Sexual pain can be classified as superficial, vaginal, or deep. Superficial pain is often due to vaginismus, anatomic abnormalities or irritative conditions of the vaginal mucosa. Vaginal pain can be caused by friction due to inadequate lubrication. Deep pain can be muscular in nature or associated with pelvic disease.⁽¹⁵⁾ The type(s) of pain a woman experiences can dictate therapy, thus making an aggressive approach to an accurate diagnosis imperative. The use of lubricants, vaginal estrogens, topical lidocaine, moist heat to the genital area, NSAIDs, physical therapy and positional changes may help to minimize discomfort during intercourse. Sex therapy may benefit women with vaginismus, as it is often triggered by a history of sexual abuse or trauma.

CONCLUSION

The complexity of sexual dysfunction in women makes the diagnosis and treatment very difficult. Disorders of desire, for example, are difficult to treat, while other disorders, such as vaginismus and orgasmic dysfunction, easily respond to therapy. Numerous women suffer from FSD; however, it is unknown how many women are successfully treated.

Until recently, there has been limited clinical or scientific research in the field of FSD. Although some progress has been made, additional research is needed to assess treatment efficacy and establish national treatment guidelines.

next: How to Bring Up Sexual Problems with Your Doctor

Sources:

1. Marwick C. Survey says patients expect little physician help on sex. JAMA. 1999;281:2173-2174.
2. Basson R, Berman JR, Burnett A, et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol. 2000;163:888-893.
3. Berman JR, Berman L, Goldstein I. Female sexual dysfunction: incidence, pathophysiology, evaluation, and treatment options. Urology. 1999;54:385-391.
4. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281:537-544.
5. Park K, Moreland RB, Goldstein I, et al. Sildenafil inhibits phosphodiesterase type 5 in human clitoral corpus cavernosum smooth muscle. Biochem Biophys Res Commun. 1998;249:612-617.
6. Masters EH, Johnson VE. Human Sexual Response. Boston, Little, Brown, 1966.
7. Kaplan HS. The New Sex Therapy: Active Treatment of Sexual Disorders. London, Bailliere Tindall, 1974.
8. Basson R. Human sex-response cycles. J Sex Marital Ther. 2001;27:33-43.
9. Phillips NA. The clinical evaluation of dyspareunia. Int J Impot Res. 1998;10(Suppl 2):S117-S120.
10. Rosen R. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000; 26:191-208.
11. Bachman GA, Phillips NA. Sexual dysfunction. In: Steege JF, Metzger DA, Levy BS, eds. Chronic Pelvic Pain: an integrated approach. Philadelphia: WB Saunders, 1998:77-90.
12. Byrd JE, Hyde JS, DeLamater JD, Plant EA. Sexuality during pregnancy and the year postpartum. J Fam Pract. 1998;47:305-308.
13. Drugs that cause sexual dysfunction: an update. Med Lett Drugs Ther. 1992;34:73-78.
14. Finger WW, Lund M, Slagle MA. Medications that may contribute to sexual disorders. A guide to assessment and treatment in family practice. J Fam Pract. 1997;44:33-43.
15. Phillips NA. Female sexual dysfunction: evaluation and treatment. Am Fam Physician. 2000;62:127-136, 142-142.
16. Messinger-Rapport BJ, Thacker HL. Prevention for the older woman. A practical guide to hormone replacement therapy and urogynecologic health. Geriatrics. 2001;56:32-34, 37-38, 40-42.
17. Yilmaz U, Soylu A, Ozcan C, Caliskan O. Clitoral electromyography. J Urol. 2002;167:616-20.
18. Striar S, Bartlik B. Stimulation of the libido: the use of erotica in sex therapy. Psychiatr Ann. 1999;29:60-62.
19. Berman JR, Goldstein I. Female sexual dysfunction. Urol Clin North Am. 2001;28:405-416.

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20. Slayden SM. Risks of menopausal androgen supplementation. Semin Reprod Endocrinol. 1998;16:145-152.
21. Aschenbrenner D. Avlimil taken for female sexual dysfunction. A J Nurs. 2004;104:27-9.
22. Kang BJ, Lee SJ, Kim MD, Cho MJ. A placebo-controlled, double-blind trial of Ginkgo biloba for antidepressant-induced sexual dysfunction. Human Psychopharmacology. 2002;17:279-84.
23. Modelska K, Cummings S. Female sexual dysfunction in postmenopausal women: systematic review of placebo-controlled trials. Am J Obstet Gynecol. 2003;188:286-93.
24. Berman JR, Berman LA, Lin A, et al. Effect of sildenafil on subjective and physiologic parameters of the female sexual response in women with sexual arousal disorder. J Sex Marital Ther. 2001;27:411-420.

next: How to Bring Up Sexual Problems with Your Doctor

Dear Colleagues,

You have asked me to discuss the treatment of Bulimia. I must confess that initially, I was somewhat daunted by the task. Where do I begin? First of all, I suggest that we review what we know or have been told about the Bulimic individual. According to Christopher Fairburn, her average age is 23.5 years; her attitudes toward her shape and weight are considered to be grossly abnormal; her eating habits are markedly disturbed and have been for several years, although her weight remains within the normal range.

Her most prominent feature is said to be affective in nature; she is almost always depressed. She tends to be plagued with pathological guilt and might tell you that "worry" is her middle name. She has difficulty concentrating, tends to obsess, and plagues herself with endless "should's" and "should not's." She is anxious, she is tired, and she doesn't really like herself much. She is also often irritable, although like a "nice" girl, she generally tries to hide those aspects of herself that one might consider unpleasant. It is not uncommon for young women with her diagnoses to experience panic attacks. After all, the world can be a very frightening place when you're in hiding. She often feels hopeless and alone. And that's just the tip of the proverbial iceberg. And like the tip - there is so much more submerged beneath the surface.

She could be your daughter, your grandchild, your sister, or your wife. She might have big blue eyes and golden hair. She might love music, draw beautifully, and have missed just about every ball that has ever been thrown her way. Perhaps you see her every day and have not yet recognized her.

Her family background varies, although it's generally characterized as enmeshed, overprotective, appearance-conscious, triangulated, and rigid. Her father is often moody and self-depreciating while her mother tends to be described as anxious and depressed. There tends to be a family history of obesity and often the family encounters a high amount of stress.

When she arrives in your office for the first time, you can be assured that her arrival was a long time coming. She often arrives under duress, bowing to the demands of significant others. Rarely does she come to you of her own volition. She is anxious and ashamed. She is also ambivalent. While she knows that her bingeing and purging is harmful, she fears her weight spiraling out of control even more. Her illness is not without its benefits, and the thought of surrendering them leaves her cold.

No matter how gentle your smile, how warm your welcome, you remain a threat to her. She desperately hopes that you can save her, and yet her potential savior is also her enemy. She wonders how you can possibly understand her, and doubts your ability to care about her even more. Will you attempt to seize her already tenuous hold on her life? Can she trust you? How would you feel about her if you were to discover her darkest secrets? Will you betray her? Abandon her? Despise her? How can you possibly help her with the emptiness and pain that she has experienced, it seems, her entire life?

What will you see when you encounter this young woman? Will you see her in the morning when you are relatively refreshed and alert? Or will she find herself sitting in your office at the end of the day, when you are feeling depleted, perhaps bored, and eager to go home? Will you feel excited by the prospect of learning and assisting this stranger before you? Or will you be at a place in your life where you feel discouraged, disheartened, inadequate, or burned out?

While unspoken for the most part, her demands of you will be tremendous. There is much she will need to learn from you and you from her. She will require your support, your understanding, your full attention, your genuine concern and most of all - your patience.

You will need to earn her trust. It won't be given. She has learned all too well to recognize insincerity and will recognize it in you, perhaps even before you do yourself. You will need to soothe her pain and anxiety, while at the same time teaching her how to manage it herself. You will need to demonstrate that you not only recognize and appreciate her fear of gaining weight, but that you expect her to be afraid. You must help her to believe that you understand that asking her to give up bingeing and purging is, as Alan Goodsitt contends, "like asking someone who can't swim to let go of the life preserver and try swimming."

Her healing will often be turbulent and frightening. Metaphorically speaking, while you can't rescue her from the raging waters necessary to complete the journey, you'll need to teach her how to whitewater raft.

You must encourage her to talk about her distress around eating, around abandoning a life long pursuit of the perfect diet, and around so many other issues that have created pain in her life. While she must consistently hear that you expect her to do the very things she most fears, she must also know that you want to hear about that fear; that you won't reject it or her. She must also come to recognize that it is only she who can make the difficult changes which are necessary, most of which must occur not without, but in spite of, her fear.

A major therapeutic task will be to help her become aware of, and accepting of, her true feelings, both negative and positive. She must also come to recognize her needs, particularly those related to independence and dependency, needs which she has probably come to despise within herself.

She must begin the process of determining her own value system and recognize that some of the very values she has failed to adhere to may never have truly been her own, but instead, were inflicted upon her. You must point out that she is capable of creating her own guidelines for living, and that because they are her own, she will be much more able to follow them. She must determine what her own goals are, and differentiate between those which spring from her own true desires, and those that come from some other source. She will need to recognize that we seldom pursue the objectives of another as successfully and as earnestly as we pursue our own. And in regards to treatment goals, it is she who ultimately must determine them. You can only guide her. What does she want to be different about her life? What is she hoping for? In the end, it is she who will determine the destination, while you assist her in charting the course.

When encountering unknown persons in your office, I ask you to remember that he or she is seldom comfortable, and almost always uncertain as to how they will be received. Will you be disinterested, judgmental, detached, or bored? Or will they find you responsive, accepting, and warm? There is much that is out of your control about this first encounter. And yet, it is critical that you are able to provide reassurance to the stranger who has bravely entered this unknown land (your land), that they have truly found a safe place.

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Avid outdoorsman, Robert Lane, on his Birthquake experience - examining and struggling with the spiritual, creative and passive side of me.

A terrible feeling enveloped me as I realized the canoe was going over and I was going into that cold, dark water. I remember a golden color up at the surface as I sank beneath it. It was cold, so cold that I went into shock. From somewhere came the where-with-all to grab the bright red life jacket that waited two feet above my head. There was silence on the top. All of my gear was drifting away from me in a circle of paddles, back pack and rod cases. It felt like I was being abandoned. My head ached from the cold and I felt very heavy.

The bottom of the canoe and the submerged engine looked ominous. It was the thing that had put me into the water and the gloomy situation that I was now in. I reached for it and it rolled away from like a porpoise that was trying to escape danger. The life jacket slipped down to my wrist and I sunk beneath the surface again. There was no golden glow this time when I looked up from beneath the water. It took several, strong, almost futile kicks to get back up onto the life jacket. I was heavy now. Very heavy. I thought of a tired, old bull moose trying to get his legs under him for the last time in the middle of a bog.

The canoe was very touchy and wouldn't stay upright or let me get back in her. I felt like I had done something bad and that I shouldn't have been out there in the first place. My mind was slowing down and my heart was racing. Anxiety and sweeping depression circled inside of me like gray storm clouds. Deep in the recesses of my consciousness I was in a dark foreboding arena. The knowledge that I would soon die seeped up from my subconcience.

I thought of my father at home in Millinocket this Mother's day Eve. He'd be sitting in his easy chair watching television before taking my mother to church. Then he'd probably taking a ride up into the country surrounding Mt. Katahdin after he dropped her off. It was something that he and I shared together each time I went north to visit my family.

I had called my mother that morning to wish her a happy Mother's Day and to tell that I was going fishing for the weekend up in the big mountain country of Western Maine. Neither of them would have a clue of my demise for several days. My father would take it hard. I felt bad about that as I climbed onto the overturned canoe and tried to keep it steady so I could rest while the rain fell and the fog closed in.

I though about my family and friends as I pondered taking my boots and pants off for an attempt at the one-half mile swim to shore, where a camp with smoke billowing from the chimney stood among a stand of fir trees.

For the past eighteen months, I had been thinking about what I was going to do with the rest of my life. I had been examining and struggling with the spiritual, creative and passive side of me. I had all of these ideas in my head for my book, a hundred short stories and six or seven up-tempo blues songs but was doing nothing with them. If only I had it to do over again was my recurring thought. Counter to this self-absorbing rationalization was my own conscious awareness that each day that I got up and stood vertical was a new beginning. I had no excuses to shy away from a "Birthquake" that was continually making sizable movements in my heart and psyche after a "top of the Richter scale" burst six years ago. Surrounding the fragmented chunks of what I once was professionally and personally, was an ever intruding and clearer sense of who I really was diametrically opposed to the slick, cocky, shining star bureaucrat that I had molded myself into for a "spirit of the times" identity. Creativity, spiritualism, and a strong belief in the power and process of the subconscience along with a belief in a creative deity make for strange bedfellows within a soul gilded in the realm of a bored, been there done it bureaucrat. As with two subterranean continental plates, the result is an emotional and psychological upheaval of volcanic proportions. Here I was in the middle of these forces, unhappy with the false Identity that I had molded for myself in order to compensate for the pain stemming the loss my true self during my adolescent years. On the surface, it was a case of the "shoulds". I should do this because this is what I had been taught and had subscribed to as well having falsely embraced and embellished them. The consequence of which was a much more painful collision of these two opposing forces than I could possibly hope to endure alone.

Needless to say, I did survive this collision between the inner and outer armies of my spirit. The process did not start and end with one monumental purging of layers and layers of fortified false existence. As experienced in one of my dreams, a twisted pile of metal, which was the furnace of my home, ended up outside of the door of my house. It was smoldering and was wrapped in several strands of barbed wire. Jagged pieces of scorched steel and wire stuck out from all sides of what a later analysis of this dream revealed to be my very own soul. The inside of my house was still covered with a visible layer of soot and grime even though the beast within me had been purged. The point of this poignant, yet unsettling dream was to inform me that although I had done the good work of facing the monster that held my self in the chambers of its own learned darkness, the soot that was left on the new white walls of me that emerged still needed to be cleaned.

The cleaning that followed my primary, calamitous quake took me several years to accomplish before the walls of my inner house took on the bright white sheen of my lost, creative childhood self. Synchronicity soon abounded. I found that what little creative work I was putting forth was being received exceptionally well by my peers and teachers. Satisfied that I realized and recovered what the focal point of a long, lost self, I became flooded with emotionally sparked creativity. The problem was that I was spending more time dreaming about them than acting on them. The results were depressing as I struggled between planning and doing. "I'll do it" became a common theme in my head. Low self esteem and anxiety took hold as I saw other artists whom I thought possessed no greater talent than I did, were accomplishing more than I was. I was working piece-meal on a novel and a portfolio of short stories that were not emerging much farther when I started two years ago.

As I lay in my bed that night in a little Hotel in Rangeley, Maine, I became acutely aware of how alive I was. Al of my senses seemed to have been fine-tuned. I felt my legs standing on the floor, I kept telling myself over and over again that I was alive, and the meal that I had eaten that in the cabin of my rescuers was still vivid in my memory. The following morning on the way back to my new found friends' cabin I kept looking out at the mountains and the vast wilderness of the Western Maine woods, I inhaled every second of everything within my vision and my immediate, and my distant off physical space.

I was alive both spiritually and physically. As a spiritual message, I took my experience very seriously. Something was telling me that I was supposed to be around for a while longer. Precisely what for I did not know, but I knew that I was not at the end of my cameo appearance in this universe just yet. A musician friend said that maybe God wanted me around to play some more blues. I took it to mean it that way too, as well as a good kick in the ass to get going on these other projects that hold some degree of promise for me if no one else.

I have yet to create a masterpiece of any great magnitude. I do, however, have a better appreciation of the masterpiece of the mystery of life and fully appreciate that every day one is alive the universe is telling you that the world is yours and you can do as you wish with it. In a more profound sense, the universe gives us all subtle clues about what it is one is here for and that to read these clues, one must stop and listen to them ever so intently as they are not found in the chaotic everyday lives that we all have succumbed to, but come from deep within the soul and the psyche.

About the author: Bob Lane lives in the Augusta, Maine. He holds a Bachelor of Arts in Psychology from the University of Maine at Farmington and an Associate Degree in Music from the University of Maine at Augusta. Following completion of his music program at UMA, he spent six months traveling across the United States in a van and making his living as a skydiving instructor. Landing in Perris Valley California, Lane lived in the fuselage of a wrecked Twin Beech aircraft and worked as an instructor at Perris Valley Skydiving Center for a year.

Bob Lane returned to Augusta, Maine where he currently lives after a year in Los Angeles. Bob is an avid outdoorsman and licensed Master Maine Guide, specializing in two person and couples canoe and photography trips. In addition to his "real" job as a Planner for the Maine Department of Labor, he is a well-known photographer in the Kennebec Valley area. A member of the Maine Professional Photographers Association and the Kennebec Valley Art Association, Bob Lane is also a fledgling writer with his first novel in progress and is an experienced Chicago- style blues guitar player.

next:Essays, Stories: Take My Heart Along...

• Depression is a common, serious and costly illness that affects 1 in 10 adults in the U.S. each year, costs the Nation between $30 - $44 billion annually, and causes impairment, suffering, and disruption of personal, family, and work life.
• Though 80 percent of depressed people can be effectively treated, nearly two out of three of those suffering from this illness do not seek or receive appropriate treatment. Effective treatments include both medication and psychotherapy, which are sometimes used in combination.

Depression Co-occurs With Stroke

• Of particular significance, depression often co-occurs with stroke. When this happens, the presence of the additional illness, depression, is frequently unrecognized, leading to serious and unnecessary consequences for patients and families.
• Though depressed feelings can be a common reaction to a stroke, clinical depression is not the expected reaction. For this reason, when present, specific treatment should be considered for clinical depression even in the presence of a stroke.
• Appropriate diagnosis and treatment of depression may bring substantial benefits to the patient through improved medical status, enhanced quality of life, a reduction in the degree of pain and disability, and improved treatment compliance and cooperation.

More Facts

The association between depression and stroke has long been recognized for its negative impact on an individual's rehabilitation, family relationships, and quality of life. Appropriate diagnosis and treatment of depression can shorten the rehabilitation process and lead to more rapid recovery and resumption of routine. It can also save health care costs (e.g., eliminate nursing home expenses).

• Of the 600,000 Americans who experience a first or recurrent stroke each year, an estimated 10-27 percent experience major depression. An additional 15-40 percent experience depressive symptomatology (not major depression) within two months following the stroke.
• Three-fourths of strokes occur in people 65 years of age and over. With stroke a leading cause of disability in older persons, proper recognition and treatment of depression in this population is particularly important.
• The mean duration of major depression in stroke patients has been shown to be just under a year.
• Among the factors that effect the likelihood and severity of depression following a stroke are the location of the brain lesion, previous or family history of depression, and pre-stroke social functioning
• Post-stroke patients who are also depressed, particularly those with major depressive disorder, are less compliant with rehabilitation, more irritable and demanding, and may experience personality change.

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People share experiences about NAET (Nambudripad's Allergy Elimination Techniques) as an alternative to Ritalin and other ADHD drugs.

NAET (Nambudripad's Allergy Elimination Techniques)

We received the following information about this:
"My son has ADHD. He also has allergies. When we had his allergies treated by the NAET (Nambudripad's Allergy Elimination Techniques), he needed less ADHD medication. It really helped. There are web sites regarding this. I do not know if it is available in the UK though. There is one site listed as http://www.naet.com/ that may help with information."

NAET (Nambudripad's Allergy Elimination Techniques)

Mary writes......

"I muscle test my son to see what supplements he needs. He does call for Pedi Active in spurts. He says it helps him concentrate and it does seem to help.

We will continue to use it.

Muscle testing is a form of kineseology that can be life saving. You test each vitamin by holding it close to your body and asking whether you need it or not. Your body will answer the questions you ask. It sounds really weird. But my son and I lived in a toxic house and were VERY ill. I was taught this method of testing vitamins and it pulled me off the death bed. THE most important technique I ever learned.

I live in USA. I think that everyone needs to learn this technique. I wrote down all the supplements that you had in alternative treatments and tested them on my son. Found out that he needs Nutri-kids School Aid, Gotu Kola and NAET.

Fortunately I know how to do NAET, so we will continue using it. So I am adding the Nutri-kids school Aid and Gotu Kola to his daily muscle testing vitamins. I test my own vitamins at least three times a day as I am still dealing with mercury toxicity. I want to thank you for you web page. I am on my way there next to find out where to get the Nutrikids.

Again, I can not tell you how important the muscle testing techniques is. I know several people who use it. There are a few methods of doing it."

Jean-Michel Belin, manager NAET for Europe wrote to us saying....

"Good afternoon,

Just to let you know that NAET (Nambudripad's Allergy Elimination Techniques) exists in Europe where it is growing rapidly.

I have heard from you through Lori Lite who writes children's relaxation books (which books we distribute in Europe, as well as all NAET books).

We have now trained 160 health practitioners in the NAET technique in 12 different countries in Europe, many of whom have already treated ADD/ADHD kids with great success. We still conduct training seminars for professionals on a regular basis (taught in English with translation into French).

For more information on NAET, please visit our european website at http://www.naeteurope.com/.

We also have available Dr Devi Nambudripad's special book on ADD/ADHD named "Say Goodbye to ADD and ADHD".

Here is the endorsement that Lori Lite gave us in order to relate her work with the NAET world, that you might want to use as info on your site:

"I have spent 9 years trying traditional treatments and various holistic approaches for my child's ear infections, sinus infections, hyperactivity and mood swings. NAET proved to be the answer we've been looking for. NAET has allowed us to end 4 years of rotation and avoidance diets. My child can now enjoy a normal diet without having symptoms. My child is calm, balanced and healthy. NAET has been our best alternative to Ritalin and other drugs. My whole family has experienced the benefits of NAET. I recommend NAET to anyone searching for wellness on any level."

Lori Lite is the mother of 3 and the author of 4 children's relaxation books.

We would very much appreciate to find some synergy with you in Europe in order to help all the families touched by ADD and ADHD or allergy-related Autism conditions."

Ed. Note:Please remember, we do not endorse any treatments and strongly advise you to check with your doctor before using, stopping or changing any treatment

next: Good Things About Being ADHD
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There are many places to get help for depression or help for an emotional problem. We have a list here.

If unsure where to go for help, check the Yellow Pages under "mental health," "health," "social services," "suicide prevention," "crisis intervention services," "hotlines," "hospitals," or "physicians" for phone numbers and addresses. In times of crisis, the emergency room doctor at a hospital may be able to provide temporary help for an emotional problem, and will be able to tell you where and how to get further help.

Listed below are the types of people and places that will make a referral to, or provide, diagnostic and treatment services.

• Family doctors
• Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors
• Health maintenance organizations
• Community mental health centers
• Hospital psychiatry departments and outpatient clinics
• University- or medical school-affiliated programs
• State hospital outpatient clinics
• Family service/social agencies
• Private clinics and facilities
• Employee assistance programs
• Local medical and/or psychiatric societies

NAMI-National Alliance on Mental Illness
3803 N. Fairfax Dr., Ste. 100
Arlington, VA 22203
1-703-524-7600; 1-800-950-NAMI
Website: http://www.nami.org

National Depressive and Manic Depressive Association
730 N. Franklin, Suite 501
Chicago, IL 60601
1-312- 642-0049; 1-800-826-3632
Website: http://www.ndmda.org

National Foundation for Depressive Illness, Inc.
P.O. Box 2257
New York, NY 10016
1-212-268-4260; 1-800-239-1265
Website: http://www.depression.org

National Mental Health Association
1021 Prince Street
Alexandria, VA 22314-2971
(703) 684-7722; 1-800-969-6642
FAX: 1-703-684-5968
TTY: 1-800-433-5959
Website: http://www.nmha.org

next: Study: Depression From Job Loss Is Long Lasting
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Having weighed in on the antidepressant medication issue, here are some comments I have about getting therapy.

• There's no "magic bullet" in your past which you can uncover and then suddenly be free of depression. Only in Hollywood do people have those kinds of momentous "breakthroughs." More commonly, you will simply figure out more-and-more things over time. It will have a slow, cumulative effect on your life. Progress may seem slow and fitful at times, but eventually it all "flattens out," so that what seemed to be of no help becomes important later.

• Therapy is not just telling a therapist what you think. If that were all it was, it'd be useless. It's a give-and-take, an analytical process. You will go over things thoroughly and spend much of your time looking for ways to change your behavior and/or thinking that could have led to the depression. That is what therapy is all about--making changes.

• As much as you may dread the prospect, yes, therapy can force you to face uncomfortable things about yourself. It's not as bad as you think though, and I know of no decent therapist who will judge you because of anything you've done or that's happened to you. In the end, you'll be glad you talked about uncomfortable subjects. Believe me.

• Therapy has a stigma attached to it, just as with antidepressant medications--perhaps more so. Don't be ashamed of having to see a therapist. From what I've seen, there are lots of mentally-healthy people who'd nevertheless benefit from a little therapy, themselves!

• Both individual and group therapy have their advantages and drawbacks. Individual therapy focuses on you, but offers only one person's (that is, the therapist's) input. Group therapy offers many voices, but time is divided among patients. There may be times when one or the other is best for you. Don't assume that only one or the other will work for you. Things just aren't that cut-and-dried.

next: If You Know Someone Who's Depressed
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Resources on alcoholism, drug addiction and substance abuse treatment.

General inquiries: NIDA Public Information Office, 301-443-1124

Inquiries about NIDA's treatment research activities: Division of Treatment Research and Development (301) 443-6173 (for questions regarding behavioral therapies and medications) or Division of Epidemiology, Services and Prevention Research (301) 443-4060 (for questions regarding access to treatment, organization, management, financing, effectiveness and cost-effectiveness).

Website: http://www.nida.nih.gov/

Center for Substance Abuse Treatment (CSAT)

CSAT, a part of the Substance Abuse and Mental Health Services Administration, is responsible for supporting treatment services through block grants and developing knowledge about effective drug treatment, disseminating the findings to the field, and promoting their adoption. CSAT also operates the National Treatment Referral 24-hour Hotline (1-800-662-HELP) which offers informa-tion and referral to people seeking treatment programs and other assistance. CSAT publications are available through the National Clearinghouse on Alcohol and Drug Information (1-800-729-6686). Additional information about CSAT can be found on their website at http://csat.samhsa.gov/.

Selected NIDA Educational Resources on Drug Addiction Treatment

The following are available from the National Clearinghouse on Alcohol and Drug Information (NCADI), the National Technical Information Service (NTIS), or the Government Printing Office (GPO). To order, refer to the NCADI (1-800-729-6686), NTIS (1-800-553-6847), or GPO (202-512-1800) number provided with the resource description.

Manuals and Clinical Reports

Measuring and Improving Cost, Cost-Effectiveness, and Cost-Benefit for Substance Abuse Treatment Programs (1999). Offers substance abuse treatment program managers tools with which to calculate the costs of their programs and investigate the relationship between those costs and treatment outcomes. NCADI # BKD340. Available online at http://www.nida.nih.gov/IMPCOST/IMPCOSTIndex.html.

A Cognitive-Behavioral Approach: Treating Cocaine Addiction (1998). This is the first in NIDA's "Therapy Manuals for Drug Addiction" series. Describes cognitive-behavioral therapy, a short-term focused approach to helping cocaine-addicted individuals become abstinent from cocaine and other drugs. NCADI # BKD254. Available online at http://www.nida.nih.gov/TXManuals/CBT/CBT1.html.

A Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction (1998). This is the second in NIDA's "Therapy Manuals for Drug Addiction" series. This treatment integrates a community reinforcement approach with an incentive program that uses vouchers. NCADI # BKD255. Available online at http://www.nida.nih.gov/TXManuals/CRA/CRA1.html.

An Individual Drug Counseling Approach to Treat Cocaine Addiction: The Collaborative Cocaine Treatment Study Model (1999). This is the third in NIDA's "Therapy Manuals for Drug Addiction" series. Describes specific cognitive-behavioral models that can be implemented in a wide range of differing drug abuse treatment settings. NCADI # BKD337. Available online at http://www.nida.nih.gov/TXManuals/IDCA/IDCA1.html.

Mental Health Assessment and Diagnosis of Substance Abusers: Clinical Report Series (1994). Provides detailed descriptions of psychiatric disorders that can occur among drug-abusing clients. NCADI # BKD148.

Relapse Prevention: Clinical Report Series (1994). Discusses several major issues to relapse prevention. Provides an overview of factors and experiences that can lead to relapse. Reviews general strategies for preventing relapses, and describes four specific approaches in detail. Outlines administrative issues related to implementing a relapse prevention program. NCADI # BKD147.

Addiction Severity Index Package (1993). Provides a structured clinical interview designed to collect information about substance use and functioning in life areas from adult clients seeking drug abuse treatment. Includes a handbook for program administrators, a resource manual, two videotapes, and a training facilitator's manual. NTIS # AVA19615VNB2KUS. $150.

Program Evaluation Package (1993). A practical resource for treatment program administrators and key staff. Includes an overview and case study manual, a guide for evaluation, a resource guide, and a pamphlet. NTIS # 95-167268/BDL. $86.50.

Relapse Prevention Package (1993). Examines two effective relapse prevention models, the Recovery Training and Self-Help (RTSH) program and the Cue Extinction model. NTIS # 95-167250/BDL. $189; GPO # 017-024-01555-5. $57. (Sold by GPO as a set of 7 books)

Research Monographs

Beyond the Therapeutic Alliance: Keeping the Drug-Dependent Individual in Treatment (Research Monograph 165) (1997). Reviews current treatment research on the best ways to retain patients in drug abuse treatment. NTIS # 97-181606. $47; GPO # 017-024-01608-0. $17. Available online at http://www.nida.nih.gov/pdf/monographs/monograph165/download165.html.

Treatment of Drug-Exposed Women and Children: Advances in Research Methodology (Research Monograph 166) (1997). Presents experiences, products, and procedures of NIDA-supported Treatment Research Demonstration Program projects. NCADI # M166; NTIS # 96-179106. $75; GPO # 017-01592-0. $13. Available online at http://www.nida.nih.gov/pdf/monographs/monograph166/download.html.

Treatment of Drug-Dependent Individuals With Comorbid Mental Disorders (Research Monograph 172) (1997). Promotes effective treatment by reporting state-of-the-art treatment research on individuals with comorbid mental and addictive disorders and research on HIV-related issues among people with comorbid conditions. NCADI # M172; NTIS # 97-181580. $41; GPO # 017-024-01605. $10. Available online at http://www.nida.nih.gov/pdf/monographs/monograph172/download172.html

Medications Development for the Treatment of Cocaine Dependence: Issues in Clinical Efficacy Trials (Research Monograph 175) (1998). A state-of-the-art handbook for clinical investigators, pharmaceutical scientists, and treatment researchers. NCADI # M175. Available online at http://www.nida.nih.gov/pdf/monographs/monograph175/download175.html

Videos

Adolescent Treatment Approaches (1991). Emphasizes the importance of pinpointing and addressing individual problem areas, such as sexual abuse, peer pressure, and family involvement in treatment. Running time: 25 min. NCADI # VHS40. $12.50.

NIDA Technology Transfer Series: Assessment (1991). Shows how to use a number of diagnostic instruments as well as how to assess the implementation and effectiveness of the plan during various phases of the patient's treatment. Running time: 22 min. NCADI # VHS38. $12.50.

Drug Abuse Treatment in Prison: A New Way Out (1995). Portrays two comprehensive drug abuse treatment approaches that have been effective with men and women in State and Federal Prisons. Running time: 23 min. NCADI # VHS72. $12.50.

Dual Diagnosis (1993). Focuses on the problem of mental illness in drug-abusing and drug-addicted populations, and examines various approaches useful for treating dual-diagnosed clients. Running time: 27 min. NCADI # VHS58. $12.50.

LAAM: Another Option for Maintenance Treatment of Opiate Addiction (1995). Shows how LAAM can be used to meet the opiate treatment needs of individual clients from the provider and patient perspectives. Running time: 16 min. NCADI # VHS73. $12.50.

Methadone: Where We Are (1993). Examines issues such as the use and effectiveness of methadone as a treatment, biological effects of methadone, the role of the counselor in treatment, and societal attitudes toward methadone treatment and patients. Running time: 24 min. NCADI # VHS59. $12.50.

Relapse Prevention (1991). Helps practitioners understand the common phenomenon of relapse to drug use among patients in treatment. Running time: 24 min. NCADI # VHS37. $12.50.

Treatment Issues for Women (1991). Assists treatment counselors help female patients to explore relationships with their children, with men, and with other women. Running time: 22 min. NCADI # VHS39. $12.50.

Treatment Solutions (1999). Describes the latest developments in treatment research and emphasizes the benefits of drug abuse treatment, not only to the patient, but also to the greater community. Running time: 19 min. NCADI # DD110. $12.50.

Program Evaluation Package (1993). A practical resource for treatment program administrators and key staff. Includes an overview and case study manual, a guide for evaluation, a resource guide, and a pamphlet. NTIS # 95-167268/BDL. $86.50.

Relapse Prevention Package (1993). Examines two effective relapse prevention models, the Recovery Training and Self-Help (RTSH) program and the Cue Extinction model. NTIS # 95-167250. $189; GPO # 017-024-01555-5. $57. (Sold by GPO as a set of 7 books)

Other Federal Resources

The National Clearinghouse for Alcohol and Drug Information (NCADI). NIDA publications and treatment materials along with publications from other Federal agencies are available from this information source. Staff provide assistance in English and Spanish, and have TDD capability. Phone: 1-800-729-6686. Website: http://ncadi.samhsa.gov/.

The National Institute of Justice (NIJ). As the research agency of the Department of Justice, NIJ supports research, evaluation, and demonstration programs relating to drug abuse in the contexts of crime and the criminal justice system. For information, including a wealth of publications, contact the National Criminal Justice Reference Service by telephone (1-800-851-3420 or 1-301-519-5500) or on the World Wide Web (http://www.ojp.usdoj.gov/nij).

Source: National Institute of Drug Abuse, "Principles of Drug Addiction Treatment: A Research Based Guide."

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• Watch the video on Transformations of Aggression

Prone to magical thinking, the narcissist is deeply convinced of the transcendental meaning of his life. He fervently believes in his own uniqueness and "mission". He constantly searches for clues regarding the hidden - though inevitable - meaning of his personal life. The narcissist is forever a "public persona", even when alone, in the confines of his bedroom. His every move, his every act, his every decision and every scribbling is of momentous consequence. The narcissist often documents his life with vigil, for the benefit of future biographers. His every utterance and shred of correspondence are carefully orchestrated as befitting a historical figure of import.

This grandiose background leads to an exaggerated sense of entitlement. The narcissist feels that he is worthy of special and immediate treatment by the most qualified. His time is too precious to be wasted by bureaucratic trifles, misunderstandings, underlings, and social conventions. His mission is urgent. Other people are expected both to share the narcissist's self-assessment - and to behave accordingly: to accommodate his needs, instantly comply with his wishes, and succumb to his whims.

But the world does not always accommodate, comply, and succumb. It often resists the wishes of the narcissist, mocks his comportment, or, worst of all, ignores him. The narcissist reacts to this with a cycle of frustration and aggression.

Still, it is not always possible to express naked aggression. It may be dangerous, or counterproductive, or plain silly. Even the narcissist cannot attack his boss, or a policeman, or the neighbourhood bully with impunity. So, the narcissist's aggression wears many forms. The narcissist suddenly becomes brutally "honest", or bitingly "humorous", or smotheringly "helpful", or sexually "experimental", or socially "reclusive", or behaviourally "different", or find yet another way to express his scathing and repressed hostility.

The narcissist's favourite sadistic cocktail is brutal honesty coupled with "helpful advice" and "concern" for the welfare of the person attacked. The narcissist blurts out - often unprovoked - hurtful observations. These statements are invariably couched in a socially impeccable context..

For instance, "Do you know you have a bad breath? You will be much more popular if you treated it", "You are really too fat, you should take care of yourself, you are not young, you know, who knows what this is doing to your heart", "These clothes do not complement you. Let me give you the name of my tailor...", "You are behaving very strangely lately, I think that talk therapy combined with medication may do wonders", and so on.

The misanthropic and schizoid narcissist at once becomes sociable and friendly when he spots an opportunity to hurt or to avenge. He then resorts to humour - black, thwarted, poignant, biting, sharpened and agonizing. Thinly disguises barbs follow thinly disguised threats cloaked in "jokes" or "humorous anecdotes".

Another favourite trick is to harp on the insecurities, fears, weaknesses, and deficiencies of the target of aggression. If married to a jealous spouse, the narcissist emphasizes his newfound promiscuity and need to experiment sexually. If his business partner has been traumatized by a previous insolvency, the narcissist berates him for being too cautious or insufficiently entrepreneurial while forcing the partnership to assume outlandish and speculative business risks. If co-habiting with a gregarious mate, the narcissist acts the recluse, the hermit, the social misfit, or the misunderstood visionary - thus forcing the partner to give up her social life.

The narcissist is seething with enmity and venom. He is a receptacle of unbridled hatred, animosity, and hostility. When he can, the narcissist often turns to physical violence. But the non-physical manifestations of his pent-up bile are even more terrifying, more all-pervasive, and more lasting. Beware of narcissists bearing gifts. They are bound to explode in your faces, or poison you. The narcissist hates you wholeheartedly and thoroughly simply because you are. Remembering this has a survival value.

next: Chronos and Narcissus

Narcissists are accustomed to loss. Their obnoxious personality and intolerable behaviours makes them lose friends and spouses, mates and colleagues, jobs and family. Their peripatetic nature, their constant mobility and instability causes them to lose everything else: their place of residence, their property, their businesses, their country, and their language.

There is always a locus of loss in the narcissist's life. He may be faithful to his wife and a model family man - but then he is likely to change jobs frequently and renege on his financial and social obligations. Or, he may be a brilliant achiever - scientist, doctor, CEO, actor, pastor, politician, journalist - with a steady, long term and successful career - but a lousy homemaker, thrice divorced, unfaithful, unstable, always on the lookout for better narcissistic supply.

The narcissist is aware of his propensity to lose everything that could have been of value, meaning, and significance in his life. If he is inclined to magical thinking and alloplastic defences, he blames life, or fate, or country, or his boss, or his nearest and dearest for his uninterrupted string of losses. Otherwise, he attributes it to people's inability to cope with his outstanding talents, towering intellect, or rare abilities. His losses, he convinces himself, are the outcomes of pettiness, pusillanimity, envy, malice, and ignorance. It would have turned out the same way even had he behaved differently, he consoles himself.

In time, the narcissist develops defence mechanisms against the inevitable pain and hurt he incurs with every loss and defeat. He ensconces himself in an ever thicker skin, an impenetrable shell, a make belief environment in which his sense of in-bred superiority and entitlement is preserved. He appears indifferent to the most harrowing and agonizing experiences, not human in his unperturbed composure, emotionally detached and cold, inaccessible, and invulnerable. Deep inside, he, indeed, feels nothing.

Four years ago, I had to surrender my collections to my creditors (who then proceeded to loot them egregiously). Over ten years, I have painstakingly recorded thousands of movies, purchased thousands of books, vinyl records, CD's and CD-ROM's. The only copies of many of my manuscripts - hundreds of finished articles, five completed textbooks, poems - were lost as were all my press clippings. It was a great labour of love. But, when I gave all that away, I felt relief. I dream about my lost universe of culture and creativity from time to time. But that is it.

Losing my wife - with whom I spent nine years of my life - was devastating. I felt denuded and annulled. But once the divorce was over, I forgot about her completely. I deleted her memory so thoroughly that I very rarely think and never dream about her. I am never sad. I never stop to think "what if", to derive lessons, to obtain closure. I am not pretending, nor am I putting effort into this selective amnesia. It happened serendipitously, like a valve shut tight. I feel proud of this ability of mine to un-be.

The narcissist cruises through his life as a tourist would through an exotic island. He observes events and people, his own experiences and loved ones - as a spectator would a movie that at times is mildly exciting and at others mildly boring. He is never fully there, entirely present, irreversibly committed. He is constantly with one hand on his emotional escape hatch, ready to bail out, to absent himself, to re-invent his life in another place, with other people. The narcissist is a coward, terrified of his true self and protective of the deceit that is his new existence. He feels no pain. He feels no love. He feels no life.

next: Transformations of Aggression