Accommodations and Modifications: Help for Students with Dysgraphia

Many students struggle to produce neat, expressive written work, whether or not they have accompanying physical or cognitive difficulties. They may learn much less from an assignment because they must focus on writing mechanics instead of content. After spending more time on an assignment than their peers, these students understand the material less. Not surprisingly, belief in their ability to learn suffers. When the writing task is the primary barrier to learning or demonstrating knowledge, then accommodations, modifications, and remediation for these problems may be in order.

There are sound academic reasons for students to write extensively. Writing is a complex task that takes years of practice to develop. Effective writing helps people remember, organize, and process information. However, for some students writing is a laborious exercise in frustration that does none of those things. Two students can labor over the same assignment. One may labor with organizing the concepts and expressing them, learning a lot from the 'ordeal.' The other will force words together, perhaps with greater effort (perhaps less if the language and information has not been processed), with none of the benefits either to developing writing skills or organizing and expressing knowledge.

How can a teacher determine when and what accommodations are merited? The teacher should meet with the student and/or parent(s), to express concern about the student's writing and listen to the student's perspective. It is important to stress that the issue is not that the student can't learn the material or do the work, but that the writing problems may be interfering with learning instead of helping. Discuss how the student can make up for what writing doesn't seem to be providing -- are there other ways he can be sure to be learning? Are there ways to learn to write better? How can writing assignments be changed to help him learn the most from those assignments? From this discussion, everyone involved can build a plan of modifications, accommodations, and remediations that will engage the student in reaching his best potential.

What to do about Dysgraphia:

• Accommodate -- reduce the impact that writing has on learning or expressing knowledge -- without substantially changing the process or the product.

• Modify -- change the assignments or expectations to meet the student's individual needs for learning.

• Remediate - provide instruction and opportunity for improving handwriting

Accomodations for Dysgraphia:

When considering accommodating or modifying expectations to deal with dysgraphia, consider changes in:

• the rate of producing written work,

• the volume of the work to be produced,

• the complexity of the writing task, and

• the tools used to produce the written product, and

• the format of the product.

1. Change the demands of writing rate:

• Allow more time for written tasks including note-taking, copying, and tests

• Allow students to begin projects or assignments early

• Include time in the student's schedule for being a 'library assistant' or 'office assistant' that could also be used for catching up or getting ahead on written work, or doing alternative activities related to the material being learned.

• Encourage learning keyboarding skills to increase the speed and legibility of written work.

• Have the student prepare assignment papers in advance with required headings (Name, Date, etc.), possibly using the template described below under "changes in complexity."

2. Adjust the volume:

• Instead of having the student write a complete set of notes, provide a partially completed outline so the student can fill in the details under major headings (or provide the details and have the student provide the headings).

• Allow the student to dictate some assignments or tests (or parts of tests) a 'scribe'. Train the 'scribe' to write what the student says verbatim ("I'm going to be your secretary") and then allow the student to make changes, without assistance from the scribe.

• Remove 'neatness' or 'spelling' (or both) as grading criteria for some assignments, or design assignments to be evaluated on specific parts of the writing process.

• Allow abbreviations in some writing (such as b/c for because). Have the student develop a repertoire of abbreviations in a notebook. These will come in handy in future note-taking situations.

• Reduce copying aspects of work; for example, in Math, provide a worksheet with the problems already on it instead of having the student copy the problems.

3. Change the Complexity:

• Have a 'writing binder' option. This 3-ring binder could include:

  • a model of cursive or print letters on the inside cover (this is easier to refer to than one on the wall or blackboard). I

  • A laminated template of the required format for written work. Make a cut-out where the name, date, and assignment would go and model it next to the cutout. Three-hole punch it and put it into the binder on top of the student's writing paper. Then the student can set up his paper and copy the heading information in the holes, then flip the template out of the way to finish the assignment. He can do this with worksheets, too.

• Break writing into stages and teach students to do the same. Teach the stages of the writing process (brainstorming, drafting, editing, and proofreading, etc.). Consider grading these stages even on some 'one-sitting' written exercises, so that points are awarded on a short essay for brainstorming and a rough draft, as well as the final product. If writing is laborious, allow the student to make some editing marks rather than recopying the whole thing.
  On a computer, a student can make a rough draft, copy it, and then revise the copy, so that both the rough draft and final product can be evaluated without extra typing.

• Do not count spelling on rough drafts or one-sitting assignments.

• Encourage the student to use a spellchecker and to have someone else proofread his work, too. Speaking spellcheckers are recommended, especially if the student may not be able to recognize the correct word (headphones are usually included).

4. Change the tools:

• Allow the student to use cursive or manuscript, whichever is most legible

• Consider teaching cursive earlier than would be expected, as some students find cursive easier to manage, and this will allow the student more time to learn it.

• Encourage primary students to use paper with the raised lines to keep writing on the line.

• Allow older students to use the line width of their choice. Keep in mind that some students use small writing to disguise its messiness or spelling, though.

• Allow students to use paper or writing instruments of different colors.

• Allow student to use graph paper for math, or to turn lined paper sideways, to help with lining up columns of numbers.

• Allow the student to use the writing instrument that is most comfortable. Many students have difficulty writing with ballpoint pens, preferring pencils or pens which have more friction in contact with the paper. Mechanical pencils are very popular. Let the student find a 'favorite pen' or pencil (and then get more than one like that).

• Have some fun grips available for everybody, no matter what the grade. Sometimes high school kids will enjoy the novelty of pencil grips or even big "primary pencils."

• Word Processing should be an option for many reasons. Bear in mind that for many of these students, learning to use a word processor will be difficult for the same reasons that handwriting is difficult. There are some keyboarding instructional programs which address the needs of learning disabled students. Features may include teaching the keys alphabetically (instead of the "home row" sequence), or sensors to change the 'feel' of the D and K keys so that the student can find the right position kinesthetically.

• Consider whether use of speech recognition software will be helpful. As with word processing, the same issues which make writing difficult can make learning to use speech recognition software difficult, especially if the student has reading or speech challenges. However, if the student and teacher are willing to invest time and effort in 'training' the software to the student's voice and learning to use it, the student can be freed from the motor processes of writing or keyboarding.

Modifications for Dysgraphia:

For some students and situations, accommodations will be inadequate to remove the barriers that their writing problems pose. Here are some ways assignments can be modified without sacrificing learning.

1. Adjust the volume:

• Reduce the copying elements of assignments and tests. For example, if students are expected to 'answer in complete sentences that reflect the question,' have the student do this for three questions that you select, then answer the rest in phrases or words (or drawings). If students are expected to copy definitions, allow the student to shorten them or give him the definitions and have him highlight the important phrases and words or write an example or drawing of the word instead of copying the definition.

• Reduce the length requirements on written assignments -- stress quality over quantity.

2. Change the complexity:

• Grade different assignments on individual parts of the writing process, so that for some assignments "spelling doesn't count," for others, grammar.

• Develop cooperative writing projects where different students can take on roles such as the 'brainstormer,' 'organizer of information,' 'writer,' 'proofreader,' and 'illustrator.'

• Provide extra structure and intermittent deadlines for long-term assignments. Help the student arrange for someone to coach him through the stages so that he doesn't get behind. Discuss with the student and parents the possibility of enforcing the due dates by working after school with the teacher in the event a deadline arrives and the work is not up-to-date.

Change the format:

• Offer the student an alternative project such as an oral report or visual project. Establish a rubric to define what you want the student to include. For instance, if the original assignment was a 3-page description of one aspect of the Roaring Twenties (record-breaking feats, the Harlem Renaissance, Prohibition, etc) you may want the written assignment to include:

  • A general description of that 'aspect' (with at least two details)

  • Four important people and their accomplishments

  • Four important events - when, where, who and what

  • Three good things and three bad things about the Roaring Twenties

You can evaluate the student's visual or oral presentation of that same information, in the alternative format.

Remediation for Dysgraphia:

Consider these options:

• Build handwriting instruction into the student's schedule. The details and degree of independence will depend on the student's age and attitude, but many students would like to have better handwriting if they could.

• If the writing problem is severe enough, the student may benefit from occupational therapy or other special education services to provide intensive remediation.

• Keep in mind that handwriting habits are entrenched early. Before engaging in a battle over a student's grip or whether they should be writing in cursive or print, consider whether enforcing a change in habits will eventually make the writing task a lot easier for the student, or whether this is a chance for the student to make his or her own choices.

• Teach alternative handwriting methods such as "Handwriting Without Tears."

• Even if the student employs accommodations for writing, and uses a word processor for most work, it is still important to develop and maintain legible writing. Consider balancing accommodations and modifications in content area work with continued work on handwriting or other written language skills. For example, a student for whom you are not going to grade spelling or neatness on certain assignments may be required to add a page of spelling or handwriting practice to his portfolio.

Books on Dysgraphia and Handwriting Problems

Richards, Regina G. The Writing Dilemma: Understanding Dysgraphia. RET Center Press, 1998. This booklet defines and outlines the stages of writing, the effects of different pencil grips on writing, and dysgraphia symptoms. Guidelines are provided to identify students with dysgraphia and specific helps and compensations are provided.

Levine, Melvin. Educational Care: A System for Understanding and Helping Children with Learning Problems at Home and in School. Cambridge, MA: Educators Publishing Service, 1994. Concise, well organized descriptions of specific learning tasks, variations in the ways students process information, and concrete techniques that teachers and parents can use to bypass areas of difficulty.

Olsen, Jan Z Handwriting Without Tears.

Shannon, Molly, OTR/L Dysgraphia Defined: The Who, What, When, Where and Why of Dysgraphia - conference presentation, 10/10/98. web4246@charweb.org

When Writing's a Problem: A Description of Dysgraphia - by Regina Richards, a great starting place.

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Related articles:

LD OnLine In Depth: Writing (Many articles about writing and learning disabilities)

Keyboarding Programs for Students with Special Needs - part of LD OnLine's listing of Assistive Technology Resources for Students with Learning Disabilities.

Making Technology Work in the Inclusive Classroom: A Spell-Checking Strategy for Students with Learning Disabilities - 1998 - Dr. Tamarah Ashton, Ph.D. This strategy helps the student with learning disabilities get the most out of spell checking software.

From Illegible to Understandable: How Word Prediction and Speech Synthesis Can Help - 1998 - Charles A. MacArthur, Ph.D. New software helps writers by predicting the word the student wants to type and reading what s/he has written. How, and how much, does this help with student writing and spelling?

Speech Recognition Software - Daniel J. Rozmiarek, University of Delaware, February 1998 - A review of the new continuous speech recognition software now available.

A Manual For Implementing Dragon Dictate - 1998 - John Lubert and Scott Campbell. A step-by-step manual for helping students with learning disabilities "train" Dragon Dictate to recognize their speech.

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NIH consensus panel statement validates existence of ADHD but cites inconsistencies in care for children with ADHD.

NIH Consensus Statement on ADHD in Children

In November 1998, the National Institutes of Health held a three-and-a-half-day conference of non-advocate, non-federal experts with the goal of establishing a professional consensus on a number of questions surrounding ADHD, including:

• What is the scientific evidence to support ADHD as a disorder?
• What is the impact of ADHD on individuals, families, and society?
• What are the effective treatments for ADHD?
• What are the risks of the use of stimulant medication and other treatments?
• What are the existing diagnostic and treatment practices, and what are the barriers to appropriate identification, evaluation, and intervention?
• What are the directions for future research?

Over the course of two days, thirty-one experts presented their research findings before the consensus panel and an audience of over 1,000. Then the consensus panel, which consisted of 13 experts representing the fields of psychology, psychiatry, neurology, pediatrics, epidemiology, biostatistics, education, and the public, wrote and presented a draft of a consensus statement for discussion and refinement. Despite some criticism of the consensus process, the final version remains the most comprehensive and unbiased evaluation of ADHD and its treatments to date.

Conclusions of the Consensus Panel

"Attention deficit hyperactivity disorder or ADHD is a commonly diagnosed behavioral disorder of childhood that represents a costly major public health problem. Children with ADHD have pronounced impairments and can experience long-term adverse effects on academic performance, vocational success, and social-emotional development which have a profound impact on individuals, families, schools, and society. Despite progress in the assessment, diagnosis, and treatment of ADHD, this disorder and its treatment have remained controversial, especially the use of psychostimulants for both short- and long-term treatment.

Although an independent diagnostic test for ADHD does not exist, there is evidence supporting the validity of the disorder. Further research is needed on the dimensional aspects of ADHD, as well as the comorbid (coexisting) conditions present in both childhood and adult forms.

Studies (primarily short term, approximately 3 months), including randomized clinical trials, have established the efficacy of stimulants and psychosocial treatments for alleviating the symptoms of ADHD and associated aggressiveness and have indicated that stimulants are more effective than psychosocial therapies in treating these symptoms. Because of the lack of consistent improvement beyond the core symptoms and the paucity of long-term studies (beyond 14 months), there is a need for longer term studies with drugs and behavioral modalities and their combination. Although trials are under way, conclusive recommendations concerning treatment for the long term cannot be made presently.

There are wide variations in the use of psychostimulants across communities and physicians, suggesting no consensus regarding which ADHD patients should be treated with psychostimulants. These problems point to the need for improved assessment, treatment, and followup of patients with ADHD. A more consistent set of diagnostic procedures and practice guidelines is of utmost importance. Furthermore, the lack of insurance coverage preventing the appropriate diagnosis and treatment of ADHD and the lack of integration with educational services are substantial barriers and represent considerable long-term costs for society.

Finally, after years of clinical research and experience with ADHD, our knowledge about the cause or causes of ADHD remains largely speculative. Consequently, we have no documented strategies for the prevention of ADHD."

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According to a report published in August of 1996 by the public health watch dog group, Public Citizen Health Research Group, the number of all doctors disciplined for sexual misconduct doubled from 1990 to 1994. Of the total disciplinary actions taken against doctors, 5.1% were for sexual abuse of patients or other sexual misconduct. The American Psychiatric Association, a professional organization for psychiatrists which enforces its own code of ethics suspends or expels an average of 12 members per year for various forms of patient exploitation, most of them sexual. The Association of State and Provincial Psychology Boards estimates 100 Psychologists lose their licenses annually for sexual misconduct. In addition, The American Psychological Association, a professional organization for Psychologists, estimates 10 members are expelled annually for sexual misconduct.

Psychiatrists
Are You Being Exploited?

The American Psychiatric Association's committee on Ethics offers these suggestions to help you tell if your therapist may be stepping over the ethical line. You should be wary if your therapist:

* Begins to disclose personal problems or begins to discuss his or her personal life, including sexual experience, in detail;

* Offers not to charge for sessions or greatly reduces the fee, even when payment is not a hardship;

* Offers to socialize with you outside the office or outside office hours;

* Begins to touch you in seemingly "comforting" ways, such as hugging, putting an arm around you during therapy, holding your hand or caressing you;

* Begins to regularly extend therapy sessions significantly beyond the normal session-by ten to fifteen minutes or more;

* Suggests a relationship beyond that of therapist and patient - offering you the opportunity to participate in business deals, for instance, or soliciting stock market advice.

If you feel a psychiatrist has sexually exploited you, there are three courses of action open to you . You may:

• File a written ethical complaint with the District branch of the American Psychiatric Association in your area, or with APA directly. The APA has no statute of limitations on such complaints;

• * File a written complaint with the appropriate professional licensing board in your state (depending on your state, psychiatrists, psychologists and psychiatric social workers may have different licensing bodies). Most states have statutes of limitation on such complaints, so it is best to file a complaint as near to the time of the alleged abuse as possible.

• Begin a civil or, depending on where you live, criminal action. States having either civil or criminal laws against therapist/patient sexual contact include California, Colorado, Florida, Georgia, Illinois, Iowa, Maine, Minnesota, New Mexico, North Dakota, South Dakota and Wisconsin.

NOTE: The American Medical Association advises those with complaints to contact their state or county medical association.

Psychologists

The ethical code of the American Psychological Association as well as most professional organizations specifically prohibits sexual contact between therapists and their clients. Bringing sex into therapy is believed to destroy trust and objectivity. While clients often feel love and even sexual attraction toward their therapists, it is considered a "bad idea" to end therapy in order to start a personal relationship. Sexual contact includes a wide range of behaviors besides intercourse, and these behaviors aim to arouse sexual feelings. They range from suggestive verbal remarks, to erotic hugging and kissing, to manual or oral genital contact. If anything makes you uncomfortable in therapy, talk to your therapist about it . An ethical therapist will want to discuss your feelings and try to understand them. It is possible that you may be misunderstanding your therapist's intentions. However, if you are still uncomfortable after the discussion and the therapist persists in his or her actions, you should consider taking additional steps such as talking to another therapist or changing your therapist.

If you think the therapist's behavior is inappropriate:

• Report the therapist's actions to a supervisor or agency director if the therapist is employed in an agency, to a state licensing board if the therapist is licensed and you think his or her behavior is unprofessional or illegal, to a state professional association or to a national professional association.

• If you think the therapist's behavior has harmed you or is illegal, it may be appropriate to file a civil lawsuit or a criminal complaint against the therapist.

The American Psychiatric Association recommends these organizations which exist specifically to support people who have been abused by their therapists:

Boston Association to Stop Treatment Abuse 528 Franklin St. Cambridge, MA 02139 (617) 661-4667

California Consumers for Responsible Therapy P.O. Box 2711 Fullerton, CA 92633 (714) 870-8864

Center for the Prevention of Sexual and Domestic Violence 1914 N 34th St., Suite 105 Seattle, WA 98103 (206) 634-1903

In Motion- People Abused in Counseling and Therapy 323 S. Pearl St. Denver, CO 80209 (303) 979-8073

Therapy Exploitation Link Line P.O. Box 115 Waban, MA 02168 (617) 964-8355

Professional Organizations

American Association for Marriage and Family Therapy 1133 15th Street, NW, Suite 300 Washington, DC 20005-2710 (202) 452-0109

American Psychiatric Association 1400 K Street, N.W. Washington, D.C. 20005 (202) 682-6000

American Psychological Association 750 First Street, NE Washington, DC 20002-4242 (202) 336-5700

Reference Materials

Books:

Sex in the Forbidden Zone. Peter Ritter, M.D., Ballantine Books Edition, 1991

Psychotherapists sexual involvement with clients: Intervention and Prevention. Gary Schoener., Walk in Counselor Center Breach of Trust., John Gonsiorek., Sage 1994

You Must be Dreaming. Kitty Waterson., Barbra Noel., Doubleday, 1992

Sexual Abuse by Professionals: A legal guide. Steven Bisbing, Linda Jorgenson, Pamela Sutherland, Michie Company, 1996

Videotapes:

"Ethical Concerns about Sexual Involvement Between Psychiatrists and Patients: Videotaped Vignettes for Discussion." Prepared by the American Psychiatric Association Subcommittee on Education of Psychiatrists on Ethical Issues, for sale through American Psychiatric Press, Inc., 1400 K St., NW, Washington, DC 20005, 800-368-5777

HOW CLOSE IS TOO CLOSE IN THERAPY

According to the National Institute of Mental Health, more than 30 million Americans need help dealing with situations that seem out of their control. Choosing to work with mental health professionals such as psychiatrists, psychologists or marriage and family therapists is considered one approach to resolving such problems. Psychiatrists and psychologists are trained professionals who specialize in psychotherapy and other forms of treatment to prevent, diagnose and treat human behavior. Psychiatrists are medical doctors who graduate from accredited medical schools and are licensed by their state licensing board. Psychologists are not medical doctors, but have varying degrees of education depending on state licensing and accreditation requirements.

The Association of State and Provincial Psychology Boards is the alliance of state, territorial and provincial agencies, however regulatory authority exists at the state level. Psychiatrists are licensed (medical) at the state level and state licensing boards handle any regulatory issues regarding a physician's medical license. Psychiatrists who are board certified by the American Board of Medical Specialties (ABMS) in Psychiatry and Neurology do so on a voluntary basis and have additional training and certification requirements considered by the American Medical Association to be a "Good Housekeeping Seal of Approval." For information about a physician's certification status call 800- 776-CERT.

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It was a time in my life when I was searching for a career that would fulfill me. I was doing a lot of writing at that time trying to sort out what I really wanted to do. I have been a graphic designer and artist for over 15 years. I loved the work but I also had a driving passion for personal and spiritual growth. I felt torn between art and spirit. I couldn't decide which field I wanted to pursue more.

"The circle of spirit and creation."

One day I was reading a book called "Your Life Purpose." The author stated that mandalas were a great way of seeing how balanced or out of balance your life was in all it's myriad of forms. Not having any idea what a mandala was, I looked up the word in the dictionary. The term was not in there. (I must have a crappy dictionary or maybe I was suppose to create a meaningful definition for myself.)

Not to be discouraged I got on the Internet and did a search on the word "mandala". That keyword didn't produce many results. From the few web pages I did find, a mandala appeared to be a "pretty, colorful circle." None of the pages addressed the origin of the word or what to do with it, so I dropped the subject.

A couple weeks later I was reading a different book called "The Artist's Way" and she too started talking about mandalas! I got excited and frustrated at the same time. What the heck was the significance of these mandalas?!?

For 37 years I had never heard the term and now, in a two-week period, the word had popped up in two books I just happened to be reading. I felt it must mean something if it kept being pushed into my awareness.

As in the first book, she didn't go into much explanation about the history or purpose of mandalas, but spoke of its spiritual nature and the use of them in initiating change and clarity. I still had no idea what I was suppose to do with these "pretty circles." It felt like I was being sent a message but the communication was garbled and unclear. It was as if I was receiving Morse code, but I don't know how to read Morse code! I really wanted to understand but not knowing what to do next, I dropped the subject.

The following month I attended a week-long program called "Led By Spirit". The program was about learning how to turn up the volume on our "small, still voice within," and on trusting our own inner knowing. Most of us learn early in life that the safest way to live is by trusting the opinions of others more than we trust ourselves. We become experts at acquiring approval, direction, and confirmation of our choices, by referencing those around us.

continue story below

Somehow I knew the answers to my career questions would come from inside me and no other. I had hoped the program would help me to better hear my own wisdom on the subject.

On Friday morning, the last day of the program, I was sitting on the balcony of my hotel room enjoying the view of the ocean and writing in my journal. I asked myself, yet again, "What is the significance of the mandala for me?" I hypothesized several possible answers but none of them felt "right". It was time for class so I finished up my last remaining thoughts and went down stairs.

The participants were sitting a circle and getting settled in when the workshop leader pulled out a big coffee table type book and said, "today we' re going to talk about mandalas." I threw my pen up into the air both in disgust and disbelief. "NOT THIS MANDALA STUFF AGAIN!!," I said to myself. "Jeez, what is going on here?!?!" I wanted to jump right out of my chair, grab the teacher, and make her tell me the meaning of these mandalas. The instructor saw my reaction and looked at me questioningly. I waved her off and told her to continue.

I tried to focus on what she was saying but my mind was still reeling from this truly bizarre coincidence. It felt like someone was tapping me on the shoulder but every time I turned around, no one was there. The exercise we did that day with mandalas was interesting but I left the program still not knowing its significance in my life.

One sunny, quiet morning a couple of weeks later I was sitting outside enjoying the beauty of our back yard. The sun was sparkling diamonds on the water. I looked in wonder at the different shades, intensity, and textures of greens in the grass and foliage. Everything was so amazingly beautiful, intricate, complex, and varied. I felt such a deep sense of appreciate and awe for God the Artist. I started thinking about how she is one of the most amazing artists I have ever known. Then it hit me.

The mandala message is so obvious to me now I don't know how I ever missed it. For the last four years I've been trying to decide whether I wanted to continue pursuing my love for art or follow my passion for spiritual growth. They both felt like very strong desires.

The circle represents the wholeness and eternity of spirit. The painting or drawing of the circle is the act of creation (art). The mandala represents a marriage of both Art and Spirit into one. Personal growth has always been a spiritual act for me. In my mind, they are indistinguishable. Figuring out who I am is figuring out God.

My work would be Spirit expressed THROUGH Art. My art would be FOR spiritual work. I don't have to pick one career over the other, I can do both of them!. I can combine both my loves into one career! Both contained within the circle.

Since that experience I have quit my job and have been designing web sites and promotional material for organizations and people who focus on personal and spiritual growth. The perks have been enormous. I get to use my creativity in art while at the same time be involved in the process of helping people create themselves anew. AND, I get to work with people who feel as passionate about the work as I do. I've even created my own web site (this one) where I share what I have come to know. It has been absolutely wonderful.

I'm not sure how to describe how I know this is the significance of the mandala for me. All I can say is something clicked into place when the idea of combining art and spirit first came to me. Much like it feels when you find the right jigsaw puzzle piece and it snaps into place. It feels "right." It feels significant and important. It feels like clarity. It feels directional.

Thank you God for being so patient and persistent with me!

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(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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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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