Tools for Behavioral Health Interventions

Transcripción

Tools for Behavioral
Health
Interventions
A public-private partnership
transforming primary care
www.pcpci.org
Mountainview
Consulting Group
Provided as part of Primary Care Behavioral Health (PCBH) Introduction and Foundations
training provided by Mountainview Consulting Group through the Patient-Centered Primary
Care Institute
October/November 2013
A library of editable documents included in this implementation kit is available by clicking
here, or by visiting our website: www.pcpci.org.
Table of Contents
I.
PCBH Bull’s Eye Plan
II.
Using Medications Successfully
III.
Beliefs About Medications
IV.
Seven Ways to Cope
V.
Love Work Play Health, Three T’s
VI.
PCBH Patient Education Protocols
VII.
Exam Room Posters
VIII.
Spanish Materials
PCBH Bull’s Eye Plan
Bulls Eye Plan
Value Area (Love, Work
or Play) & Value
Statement:
1
2
3
4
5
6
Not
Slightly Somewhat
Remarkably
Very
Consistent
Consistent Consistent Consistent
Consistent Consistent
Behavior Plan:
1.
2.
3.
7
BULLS
EYE!
Guide for Using the Bulls Eye Plan
1. Ask the patient to choose Love, Work, or Play as a focus for a short discussion about
values. Ask the patient to explain what is important to him or her in each area of life.
2. Listen closely, reflect what you heard and then write a statement on the Bulls Eye Plan
using the words (global, abstract) the patient used in talking about the value.
3. Explain that the Bulls Eye on the target represents the patient’s hitting her / his value
target on a daily basis (and explain for most of us fall far short of that on a day to day
basis, but knowing the target helps us make choices, set goals, and implement plans).
4. Ask patient to chose a number to represent how close to the Bulls Eye value statement
her/his behavior has come over the past 2 weeks.
5. Ask patient to plan 2 specific behavior experiments for the next 2 weeks that patient
believes will make her / his behavior more value consistent (closer to the Bulls Eye target).
6. At follow-up, ask patient to re-rate and identify barriers to engaging in planned behaviors.
7. If time allows, rate the patient’s current functioning level in one core area on the CPAT.
This will provide a baseline against which you can judge the impact of the Bulls Eye Plan
and REAL Behavior Change techniques you use with the patient.
8. If time allows, chose one technique from the REAL Behavior Change Pocket Guide to use in
the visit.
Using Medications
Successfully
Using Medications
Successfully
An ICP Booklet
CONTEXT PRESS
Reno, Nevada
What is Depression?
Depression is a response to problems in living. When we
become exhausted in our efforts to cope with life, we begin to
experience symptoms of depression. Following is a list of
common symptoms of depression. Make a check in the box
beside any symptom you have had almost daily for the past two
weeks.
1.
Anger or irritability
2.
Sadness
3.
Sleeping too much or too little
4.
A lack of interest in others and in activities you
usually enjoy
5.
Guilt, self critical thoughts, feeling inadequate or
worthless
6.
Feeling tired most of the time
7.
Concentration difficulties
8.
Appetite change — eating significantly more or less
9.
Feeling very “slowed down” or very “speeded up”
10.
More aches and pain
11.
Thoughts of suicide or death in general
Total Symptoms:_____
The Cycle of Depression
People become depressed for many reasons. This booklet
describes strategies for using medications successfully to
alleviate symptoms of depression. Most often, depression is
related to stressful life circumstances, such as marital
problems, death of a loved one, loss of a job, or a child leaving
home. Depression may also be related to physical problems
such as chronic pain or medical illness.
Depression Occurs In Three Ways
The Body Feels Depressed
When the body is depressed, a person sleeps poorly, eats
differently, has less energy, struggles with concentration, and
has more aches and pains.
Behavior Is Depressed
When behavior is depressed, a person does much less than
usual. She/he talks less, produces less, and socializes less.
The Mind Is Depressed
When the mind is depressed, thinking changes. A depressed
person experiences more intensely negative and painful
thoughts about the past, the present and the future.
A person’s body, behavior, and thoughts interact continuously.
Once depression becomes a problem, this interaction may lead
to a “downward spiral” in mood and hopefulness. Two courses
of action help reverse the downward direction and create a
“positive spiral.”
1.
Use of Medications
Medications may help you to feel better. Antidepressant
medications restore the presence of neurotransmitter
substances that become depleted by stress. Medications may
work somewhat slowly. Therefore, it is best to use medications
in combination with behavioral planning and use of coping
strategies. This booklet will help you use medications
successfully. Antidepressant therapy and behavioral health
planning are complementary treatments for depression and
anxiety.
2.
Strategic Use of Coping Strategies
Use of active coping strategies helps you reverse the downward
spiral of depression. When you address life problems with
effective strategies, you have more opportunities to create
positive conditions in your life context.
Make a concerted effort to work with your health care provider
in planning medication treatment and skillful use of coping
strategies. You will soon be feeling better.
Using Medications Successfully
There are four important areas to address in order to use
medications successfully. They include:
1.
Your Past Experiences with Medications
2.
Your Beliefs about Medications
3.
Your Knowledge about Medications
4.
Your Ability to Anticipate and Plan for Problems in Using
Medications
This booklet will help you assess and prepare for success in
each of these key areas.
Your Past Experiences with Medications
Take a moment to recall your past experiences with use of
medications for depression and anxiety.
1.
Have you ever used a medicine to help alleviate symptoms
Yes
No
of depression or anxiety?
2.
Try to recall the medication name, dosage, and length of
treatment.
Name
Dose
Length of Treatment
1.
Also, recall any side effects you had with this medication.
How much did they trouble you?
Side
Effect
Bothered
A Little
Bothered
A Lot
1.
2.
3.
4.
How much did you benefit from use of medication when
you tried medication before?
None
A Little
Some
Quite A
Lot
Very Much
This information will be helpful to you and your provider in
making a decision about medication use and selection of a
specific medication.
If you did have a limited response to medication treatment or
experienced bothersome side effects in the past, you may still
be a candidate for medication treatment. Several new types of
antidepressant medications have become available in recent
years. New medications are equally effective and have fewer
side effects.
Your beliefs have a significant impact on your success in using
antidepressant medications. Take stock of your beliefs right
now. Mark an “X” by any of the following statements that you
believe.
I’ll be the one to get terrible side effects.
My family would not want me to use medications for
depression and anxiety.
These types of medications are overused.
I should be able to get over my problems without taking
medicine.
I’ll get addicted.
If you believe any of these statements, discuss the belief with
your health care provider. She/he may be able to provide you
with additional information to help you re-evaluate beliefs
which might make medication use more difficult for you.
Your Knowledge about Medications
You are much more likely to succeed in antidepressant
treatment when you have accurate information about all
aspects of medication use. Please review the following details
and discuss any questions you have with your health care
providers.
Starting medication . . .
Start your medicine as soon as it is prescribed. The sooner you
start, the sooner you will experience the desired benefits.
Remembering to take medicine . . .
Take your medicine at a certain time of day every day. During
the first several weeks, you may want to leave yourself several
reminder notes. Some people use a behavioral hygiene task,
such as teeth brushing, as a cue to take their medication. Also,
some people may want to leave an extra bottle of medication
in a desk drawer at work in the event that they forget to take
the medicine at home.
Deciding how to take the medication . . .
Some medications are best taken in one dose, while others are
best divided into several doses during the day. Some
medications cause drowsiness, while others are more
activating. Medications with a sedative effect are taken at
night, and activating medications are taken in the morning.
Carrying on with other activities . . .
You may continue with your normal activities while taking
antidepressant medications. If you do notice minor sedation or
sleepiness in starting a medicine, avoid driving or carrying out
hazardous activities. Sleepiness will usually diminish. If it does
not, talk with your provider about a medication change.
Taking antidepressants with other medications . . .
You may take antidepressants with most other types of
medications. However, do talk with your provider about the
compatibility of antidepressant medications with other
medications you are taking.
Taking antidepressant medications and consuming alcohol . . .
Do not drink alcohol while taking antidepressant medications.
Increasing medication dose . . .
Increase your medication dose according to the directions of
your provider. In starting some antidepressant medications,
you start with small doses initially and increase gradually. Do
not worry that you are “taking too many pills.” Your provider is
prescribing a slow increase in dose in order to help you avoid
side effects. After you reach your “therapeutic dose,” your
provider will probably prescribe tablets that are larger in
dosage, which then allows you to take fewer tablets.
Continuing to take the medication . . .
Take the medicine until you and your provider decide that you
are ready to stop the medicine. In most cases, your provider
will ask you to take the medicine for at least four months after
you reach a therapeutic dose. Do not stop taking the medicine
because you feel better. Wait and plan how and when to stop
with your provider.
Your Ability to Anticipate and Plan for Problems in
Using Medications
Most antidepressant medications have mild side effects. The
side effects are usually temporary and diminish or disappear
during the first few weeks of treatment. If you experience side
effects that are more severe, call your doctor. She/he will
probably suggest one or more of the following strategies:
•
Change the time that you take the medicine
•
Change the dose of the medicine
•
Use a remedy for the side effect
•
Add a second medication
•
Change to a different medication
The following table summarizes common side effects and
possible remedies or strategies for coping with side effects.
Most medications have only one or two of the side effects
listed in this table.
Common Side Effects and Remedies
Dry Mouth
Drink plenty of water. Chew sugarless gum. Use
sugarless gum drops.
Constipation
Eat more fiber-rich foods. Take a stool softener.
Drowsiness
Get fresh air and take frequent walks. Try taking
your medicine earlier in the evening, or if you’re
taking your medicine in the day ask your doctor if
you can take it at night.
Wakefulness
Take medications early in the day. Learn more
about insomnia. Take a warm bath and have a
light snack before bed. Avoid exercising vigorously
late in the evening.
Blurred Vision
Remind yourself that this will be a temporary
difficulty. Talk with your doctor if it persists.
Dizziness
Stand up slowly. Drink plenty of fluids. If you are
worried, call your doctor.
Feeling
Speeded Up
Tell yourself, “This will go away within three to five
days.” If it does not, call your doctor or nurse.
Sexual
Problem
Talk with your doctor. A change in medications or
a medication holiday may help.
Nausea or
Appetite Loss
Take the medicine with food. Prepare food so that
it is appetizing and colorful. Eat small healthy
meals.
Remember to Ask for Help
Starting antidepressant treatment is not easy. Remember to
ask for the support of your health care team. Take this booklet
with you to your next visit with your health care provider.
She/he is prepared to skillfully address your concerns about use
of medications and plan successful treatment with you.
If you want more information on using behavioral
strategies to alleviate depression and anxiety
consider reading Living Life Well: New Strategies for
Hard Times by Patricia Robinson, Ph.D.
Beliefs About
Medications
From Robinson, 1996. Living Life Well: New Strategies for Hard Times.
List of questions to explore with patients when the BHC is targeting medication use:
Your beliefs have a significant impact on your success in using antidepressant
medications. Take stock of your beliefs right now. Mark an “X” by any of the following
statements that you believe.
My family would not want me to use medications for depression and anxiety.
I should be able to get over my problems without taking medicine.
If you believe any of these statements, discuss the belief with your health care provider.
She/he may be able to provide you with additional information to help you re-evaluate
beliefs which might make medication use more difficult for you.
Seven Ways to Cope
Seven Ways to Cope
An ICP Booklet
CONTEXT PRESS
Reno, Nevada
1
What is Depression?
Depression is a response to problems in living. When we become exhausted in our efforts to
cope with life, we begin to experience symptoms of depression. Following is a list of common
symptoms of depression. Make a check in the box beside any symptom you have had almost
daily for the past two weeks.
1.
Anger or irritability
2.
Sadness
3.
Sleeping too much or too little
4.
A lack of interest in others and in activities you
usually enjoy
5.
Guilt, self critical thoughts, feeling inadequate or
worthless
6.
Feeling tired most of the time
7.
Concentration difficulties
8.
Appetite change — eating significantly more or
9.
Feeling very “slowed down” or very “speeded up”
10.
More aches and pain
11.
Thoughts of suicide or death in general
less
Total Symptoms:_____
Treating Depression In Primary Care Robinson, Wischman, & Del Vento, 1996
2
If you checked four or more symptoms, talk with your health care provider. Also, use this
booklet to make a plan to address these symptoms.
This booklet describes seven coping strategies for addressing symptoms of depression, solving
problems in living and creating the life you want.
People become depressed for many reasons. Most often, depression is related to stressful life
circumstances, such as marital problems, death of a loved one, loss of a job, or a child leaving
home. Depression may also be related to physical problems such as chronic pain or medical
illness.
When the body is depressed, a person sleeps poorly, eats differently, has less energy, struggles
with concentration, and has more aches and pains.
When behavior is depressed, a person does much less than usual. She/he talks less, produces
less, and socializes less.
When the mind is depressed, thinking changes. A depressed person experiences more
intensely negative and painful thoughts about the past, the present and the future.
3
A person’s body, behavior, and mind interact continuously. Once depression becomes a
problem, this interaction may lead to a “downward spiral” in mood, hopefulness and energy.
Two courses of action help reverse the downward direction and create a “positive spiral.”
1. Strategic Use of Coping Strategies
Use of active coping strategies helps you reverse the downward spiral of depression. When you
address life problems with effective strategies, you have more opportunities to create positive
conditions in your life context. This booklet suggests seven coping strategies for you to use to
restore your body, behavior and mind and to effectively address life problems. If you make a
concerted effort to work with your health care provider in using these strategies, you can make
significant and lasting changes to your lifestyle.
2. Use of Medications
Medications may also help you to feel better. Antidepressant medications help restore the
presence of neurotransmitter substances that become depleted by stress. However, these
medications work somewhat slowly. The impact of effective coping is more immediate. If you
decide to use medications, use coping strategies as well. Coping strategies will complement the
action of medications on the body’s neurochemistry.
4
The First Strategy:
Hoping…Planning…Doing
Hope is the foundation of a healthy life. Without hope, most people avoid constructive activity.
Another way of stating this is that hopefulness is a good predictor of action. In turn, action is a
good predictor of mood improvement.
Try this exercise to help you increase your sense of hopefulness.
Sit in a quiet place for a few minutes and ask yourself about your explanation of
your current troubles. Are you blaming yourself? If so, stop. You are wellintentioned and worthy of self-respect. Decide upon an explanation for your
current difficulties that reflects a sense of respect for who you are. You may be
stressed or overwhelmed or simply lacking skills you need to overcome
challenging circumstances. Write down your revised explanation of your present
situation here.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Planning and doing are also important behavioral skills for coping with stress and depression.
With a little hope, you can make a “behavioral health plan” to address needed changes in your
daily life. Read and respond to each of the following seven steps to make a behavioral health
plan for this week.
1. Choose an area of life that you want to make better. Possible areas include: enjoying
things alone or with others, accomplishing difficult and unpleasant tasks, talking to or
“making connections” with others, contentment with your work, sensual experiencing,
or imagining a better future. Write down your choice here.
2. Imagine yourself doing something different in the activity area you choose. Write
down what you imagine.
5
3. Plan a specific time and place to engage in an activity that represents making an
improvement to the area of life you want to make more satisfying.
Activity: ___________________________________________________________
Time: ____________________________________________________________
Place: ____________________________________________________________
4. During and after you conduct this “experiment in mood change,” watch what happens,
inside you (your thoughts, feelings and behaviors) and outside of you (what others say
and do). Write down your observations here.
Inside you: _________________________________________________________
Outside of you: _____________________________________________________
5. Think about your findings or results.
6. Talk with others about your results and draw conclusions. Write down your conclusions
here.
7. Plan your next “behavioral health plan.”
Activity: ___________________________________________________________
Time: ____________________________________________________________
Place: ____________________________________________________________
Try to make a behavioral health plan weekly for the next month. The positive impact of small
changes in two or three areas of your life can become highly significant with three or four
weeks of effort. Try to find a friend who will support your on-going use of this strategy.
6
The Second Strategy:
Building Acceptance and
Making Value-Based Choices
We often respond to a difficult circumstance, whether it is internal or external, with an action
that moves us away from the source of unwanted distress. While we may avoid some external
stresses, we cannot avoid painful internal events. Internal events include thoughts and feelings
— positive and negative. Psychological acceptance is a strategy that involves actively
embracing unwanted, painful thoughts and feelings.
When we use psychological acceptance strategies, we are more free to make decisions about
our behavior. We can make choices to behave in accordance with our values. Our daily
activities take on greater meaning when they reflect our values rather than our attempts to
control unwanted thoughts and feelings. Try these exercises to improve your skills in using
strategies of psychological acceptance and value-based behavioral planning.
1. Write down feelings (for example, fear, sadness, anxiety, depression, panic, anger) that you
have difficulty tolerating.
2. Decide on a psychological acceptance procedure or method for observing unwanted feelings
and thoughts.
Options include visualizing the feeling or seeing or listening to the words associated with the
feeling. You may use the phrase, “I am having the sensation of:
_____________________________________________________________________”
or “I am having the thought that: ___________________________________________.”
3. Follow this procedure during acceptance or self-observation practice periods.
Take four deep breaths and move into “observation mode.”
Start to use your method of observation to help you stay in the “observation mode” (i.e.,
visualize your thoughts or use a phrase to prompt acceptance).
Practice daily for 5 to 10 minutes for a week. Record the number of minutes you practice each
day.
Day 1: _____
Day 2: _____
Day 3: _____
Day 4: _____
Day 5: _____
Day 6: _____
Day 7: _____
7
When you are ready, begin using the psychological acceptance procedure in daily situations
that provoke painful thoughts and feelings. Record situations where you used your breathing
and observation method and made a behavior choice that reflected your values.
______________________________________________________________________________
______________________________________________________________________________
8
The Third Strategy:
Appreciating Your Mind and Body
Using this strategy will help you become more aware of your body and more able to create
sensations of physical well-being in your body. Basic body listening skills strengthen your ability
to cope with physical and psychological health problems. Experiment with the following
exercises.
I.
Rest for a few minutes in a favorite “quiet” place. Take several deep breaths and recall or
fantasize an image of a serene environment. Give yourself time to develop this image with
many details, including sounds, smells, colors, etc. Practicing this image on a daily basis will
help you learn to create the image and associated sensations of wellness efficiently during
highly stressful moments of daily living.
II.
Cultivate playfulness, curiosity, and openness. These mental states are related to well-being. If
you are overly serious, controlled, or “closed off,” make behavioral health plans to help you
play and explore. For example, you may want to attend a comedy show, rekindle an old hobby,
or go for a treasure hunt in a park. A good way to get started with use of these strategies is to
watch young children, as most demonstrate these qualities very nicely.
9
The Fourth Strategy:
Solving Problems
Self-efficacy is a reflection of your confidence in solving the problems you encounter in life.
Mastery of problem-solving skills improves your confidence and, hence, your self-efficacy. The
following steps are prerequisites for effective problem solving.
•
Identifying that something is a problem
•
Accepting the possibility that something can be done about it
•
Expressing a desire to change
•
Being willing to make an effort to change
Use the following problem-solving exercise to review the critical steps in strategic problemsolving and address a current problem in your life.
1. Pinpoint a current problem. Write the problem down here. Define the problem so that it is a
problem with a solution.
2. Brainstorm solutions. Generate at least 3 possible solutions.
3. Evaluate potential solutions. Describe advantages and disadvantages of each solution.
10
4. Identify the first step you will take to implement the solution you choose.
5. Anticipate and plan for obstacles to your implementing the solution you choose.
6. DO IT! Record here when you did it.
7. Evaluate the results and continue working toward the solution by simply determining and
planning a next step or going through these seven steps again.
Results suggest that:
Next step:
Remember To Celebrate Your Efforts, As Well As Your Successes!
11
The Fifth Strategy:
Responding to Interpersonal Conflicts
Our patterns of responding to conflict may cost more than we want to pay. If we believe that
we must avoid conflict, we may withhold information needed to have healthy relationships.
We may passively punish a person who makes a hurtful statement by ceasing to talk to that
person. We may sacrifice self-respect to maintain the status quo when we use these strategies
to respond to interpersonal conflict.
Alternatively, we may seek power and control over others more directly. We may use verbal
and non-verbal expressions to frighten others. When we approach conflict in these ways, we
are likely to have few friends and we are vulnerable to a host of physical problems associated
with excessive arousal or anger.
If you want to become more skillful in this area, try the following exercises:
1. Acknowledge yourself on a daily basis. You may simply say to yourself, “I allow myself to
be,” or “I am okay as I am.”
2. Whenever you notice tension in your body, ask yourself, “How do I feel right now?”
3. Give yourself a choice about expressing or not expressing feelings and opinions. It is
okay to keep your feelings private or share them.
The following exercises are useful if you are currently in a close relationship and want to
become more skillful in responding to conflict in this close relationship.
•
Try scheduling a “problem solving” meeting. Allow 30 minutes.
•
Set the agenda for your meeting. Keep it simple and make it agreeable to both of you.
•
Convene your meetings when you are both rested and free from distraction.
•
Positively and specifically define the problem you plan to address.
•
Use “I” statements (e.g., “I want to have 20 minutes alone everyday” or “I feel upset
about being without a job”). These statements help you responsibly express your
feelings and make requests without blaming.
•
Discuss only one problem at a time.
•
Focus on solutions. Avoid trying to be “right.”
•
Compromise. Select a solution that allows both of you to “win.”
•
Set a time to “reconvene” and evaluate how your solution is working.
12
The Sixth Strategy:
Expressing Yourself
There are two important skills involved in the strategy of “expressing yourself.” The first is
personal assertion and the second is creative expression. Both of these skills require
“balancing.” Personal assertion requires on-going balancing of respect for yourself with respect
for others. Creative expression involves balancing who you are with what you have to work
with right now.
Personal assertion skills form the basis of your ability to make direct and honest statements
and to stand up for your rights. Development of effective assertion skills may help you improve
your mood, your sense of hopefulness, and your energy for enjoying life.
Creative expression is engaging in any activity for the sole purpose of expressing yourself. The
possibilities for creative expression are many and change over the course of a lifetime. The loss
of an avenue for creative expression may actually provoke symptoms of depression and
anxiety. Try the following exercises to strengthen your skills in strategic self-expression.
13
Personal Assertion Exercise
Do you believe that you have the following rights? Make a check in the first box of any right
you claim for yourself.
Does your day-to-day life indicate that you give yourself these rights? Make a check in the
second box of any right that you “live” in your day-to-day behavior.
1.
The right to say no without feeling guilty.
2.
The right to be treated with respect.
3.
The right to experience your feelings.
4.
The right to change your mind.
5.
The right to do less than you are capable of doing.
6.
The right to make mistakes.
These are only a few basic assertive rights. If your beliefs are weak in any of the above areas or
if your day-to-day life does not reflect your beliefs, you may want to develop a program to
strengthen your beliefs in your assertive rights and your behavioral expression of these rights.
You may want to read more about personal assertion and join a personal assertion class.
Classes may be available within your health care system or in your community. Make a
behavioral health plan to help you start a program of strengthening skills in this critical area.
14
Creative Expression
List five creative expression activities that you enjoy and that are consistent with your values.
Indicate how many hours you have spent in each of these activities in the past week.
Creative Expression Activity
# Hours in Past Week
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
If you had difficulty identifying activities, take time to evaluate your “gifts” or “interests” and
available resources or materials in you life at the present moment. If you spent little time in
identified activities, consider “scheduling” time for these important activities. Write down your
findings here and make a behavioral health plan to engage in creative activities on a daily basis.
Gifts: _________________________________________________________________________
______________________________________________________________________________
Interests: ______________________________________________________________________
______________________________________________________________________________
Resources: _____________________________________________________________________
______________________________________________________________________________
15
The Seventh Strategy:
Balancing Your Thinking
When life is going well, we tend to have two positive thoughts to every negative thought.
When we become depressed, the balance changes to two negative thoughts to every positive
thought. “Realistic” thinking probably lies somewhere in between.
Shifting the balance in the direction of more positive thoughts is difficult to do, especially
without someone to help you. Friends can help when you give them an opportunity and ask for
their opinion on something. Knowing how to change the balance of your thoughts is important
because it can help you catch yourself when you start to become depressed.
Use the following steps and suggested exercises to help you balance your thoughts.
•
Identify a favorite saying or thought that inspires courage or optimism for you in
difficult times.
•
Try changing your perspective on something of little importance to you from an
exaggerated negative perspective to a realistic or slightly positive point of view.
•
Identify someone who tends to be a “realist” or “optimist” and contact this person.
They can help you balance your thoughts.
Exercises to Help Balance Thinking
Write down favorite sayings and thoughts that inspire courage or optimism.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What positive thoughts do you want to keep in mind right now?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
16
______________________________________________________________________________
______________________________________________________________________________
Who helps you balance your thinking on different issues?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
17
Getting Started
Which of the seven strategies discussed in this booklet, if any, do you think will work best for
you at present? Place an “X” in the box to indicate the extent to which each of the strategies
might help you now. Use a rating scale where:
1 = Not Helpful and 4 = Very Helpful
Strategy
1
2
3
4
Hoping…Planning…Doing
Building Acceptance and Making Value-Based
Choices
Appreciating Your Mind and Body
Solving Problems
Responding to Interpersonal Conflicts
Expressing Yourself
Balancing Your Thinking
18
Are you ready to start trying the strategies that you think will be most helpful to you?
My level of readiness is:
Not Ready
Unsure
Ready
Can you identify friends, relatives or professionals who can help you make a plan to use one or
more of the seven strategies suggested in this booklet and support you in staying with the plan
over the next month?
Yes
No
Persons who will help and support: _________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Take this booklet with you when you visit your health care provider. She or he will want to look
at your responses.
If you want to read more on the use of strategies suggested in this booklet, read the book,
Living Life Well: New Strategies for Hard Times by Patricia Robinson, Ph.D.
Notes:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Love Work Play Health,
Three T’s
COMPLEX PATIENT ASSESSMENT TOOL
Love, Work, Play and Health
Love
Work
Play
Health
Where do you live?
With whom?
How long have you been there?
Are things okay at your home?
Do you have loving relationships with your family or friends?
Do you work? Study?
If yes, what is your work?
Do you enjoy it?
If not working, are you looking for work?
If not working and not looking for a job, how do you support yourself?
What do you do for fun?
For relaxation?
For connecting with people in your neighborhood or community?
Do you use tobacco products, alcohol, illegal drugs?
Do you exercise on a regular basis for your health?
Do you eat well?
Sleep well?
(If patient has chronic disease) Do you find it difficult to manage your health
problems?
Do you have a doctor you like?
Three Ts and Workability
Time
When did this start?
How often does it happen?
What happens before / after the problem?
Why do you think it is a problem now?
Trigger
Is there anything--a situation or a person--that seems to set it off?
Trajectory
Workability
Question
What’s this problem been like over time?
Have there been times when it was less of a concern? More of a concern?
And recently . . . getting worse, better?
What have you tried (to address the problem)?
How has that worked in the short run?
In the long run or in the sense of being consistent with what really matters to you?
Adapted from Robinson, Gould & Strosahl. Real Behavior Change in Primary Care: Improving Outcomes and
Increasing Satisfaction, New Harbinger, 2007.
PCBH Patient
Education Protocols
Patient Education Protocols List
1. ADHD
2. Adherence Using Meds Successfully
3. Alcohol & Low Risk Drinking
4. Anxiety & Coping with Panic Attacks
5. Anxiety
6. Chronic Pain
7. Depression – Postpartum
8. Depression
9. Exercise & Physical Activity
10. Grief
11. Headaches
12. Hypertension
13. Parenting Protocol
14. Relationship Problems
15. Relationship Sexual Problems
16. Sleep & Insomnia
17. Sleep Apnea
18. Sleep Behavior Change & Diary
19. Sleep Class Packet
20. Stress
21. Substance Misuse & Maintaining Behavior Change
22. Weight Management
Attention-Deficit/Hyperactivity Disorder (ADHD)
What is it?
ADHD is an acronym for Attention-deficit/Hyperactivity Disorder. It is a neurological brain
disorder that is marked by a continual pattern of inattention and/or hyperactivity-impulsivity
that is more frequent and severe than what considered typical for someone of that age.
Does it affect me?
There are two main problems identified with ADHD: (1) Inattention and (2) Hyperactivity /
Impulsivity. These problems are further broken down into individual symptoms.
Inattention
Hyperactivity/Impulsivity
Poor attention to detail/carelessness
Difficulty sustaining attention
Does not appear to listen
Often fails to complete tasks
Difficulty with organization
Avoids/dislikes focused tasks
Loses things easily
Easily distracted
Forgetful of daily activities
Fidgetiness/squirminess
Difficulty remaining in seat
Runs about or climbs excessively
Difficulty with quiet activities
Often seems “on the go”
Talks excessively
Blurts out answers or opinions
Difficulty waiting or taking turns
Interrupts or intrudes on others
* It is important to note how common and normal these symptoms are in children and adults,
being mindful of the overlap they have with other mental and physical health problems.
The symptoms listed above must be:
•
Chronic: lasting at least six months consistently
•
Present from a young age: onset must be prior to age 7
•
Observable and problematic across many settings: for example, at home, school, work, etc.
How do you find out if you have ADHD?
There is no one test for ADHD, but a comprehensive evaluation completed with a professional
is needed to establish a diagnosis. The evaluation is long and requires sustained mental effort
to complete. In addition to the testing, information related to current functioning and
background information will be collected. Reports from several people are also helpful in
establishing a diagnosis: (1) parents report about home functioning, (2) teachers report about
school functioning, (3) co-workers report about work functioning, and (4) friends report about
social functioning. Typically, the testing battery includes symptom checklists, rating scales to
identify emotional and behavioral signs, intelligence testing, and achievement testing.
How common is it?
By definition, ADHD begins in childhood prior to age 7, and according to recent research, it can
continue into adulthood. While some children “outgrow” ADHD, evidence suggests that up to
70% can continue to carry symptoms of inattention into adulthood, with hyperactivity typically
diminishing with age. According to a 2003 Centers for Disease Control study, 7.8% of children
between the ages of 4 and 17 have ever been diagnosed with ADHD. Research indicates that
nearly 4% of adults in the U.S. continue to have ADHD.
Is Adult ADHD any different from Childhood ADHD?
Because ADHD is a neurological condition that starts during childhood, symptoms that adults
experience are not new, but rather, have continued from childhood. Most adults who have
continued symptoms may notice problems with difficulty paying attention to details,
organization, talking fast, and difficulties focusing and concentrating. Adults with ADHD do not
typically report problems with hyperactivity; either the symptoms have subsided or they have
developed coping strategies for handling their increased activity level. There is no evidence
that ADHD develops during adulthood. Concentration problems and distractibility in adults are
often due to other problems such as depression, anxiety, stress in relationships, or occupational
stress. Any of these and other mental health conditions can mimic the symptoms of ADHD, but
they are not ADHD.
Associated problems and consequences that often co-exist with adults who have continued
symptoms of ADHD from childhood may include:
•
•
•
•
•
•
•
•
Poor self control
Forgetfulness
Difficulty focusing
Poor time management
Relationship problems
Poor time perception
Variability in work performance
Chronic lateness
•
•
•
•
•
•
•
•
Easily bored
Low self-esteem
Substance abuse
Difficulty regulating emotions, arousal, and motivation
Anxiety/depression
Mood swings
Employment difficulties
Risk-taking behaviors
Resources and Suggested Readings
Children
Quinn & Stern (2001). Putting on the brakes: Young people’s guide to understanding Attentiondeficit/Hyperactivity Disorder.
Nadeau, Nixon, & Beyl (2004). Learning to slow down & pay attention: A book for kids about
ADHD.
Adolescents
Ziegler Dendy, & Ziegler (2003) A Bird's-Eye View of Life with ADD and ADHD: Advice from
Young Survivors.
Parents
Barkley (2000). Taking charge of ADHD: The complete, authoritative guide for parents.
Barkley & Benton (1998). Your defiant child: Eight steps to better behavior.
Adults
Kelly & Ramundo (1995). You mean I’m not lazy, stupid, or crazy: A self-help book for adults
with attention deficit disorder.
Hallowell & Ratey (1995). Driven to distraction: Recognizing and Coping with Attention Deficit
Disorder from Childhood Through Adulthood.
Websites
Children and Adults with Attention-deficit/Hyperactivity Disorder : www.chadd.org
Teens Health: www.kidshealth.org/teen/school_jobs/school/adhd.html
Teens with ADHD by Chris Dendy: www.chrisdendy.com
ADHD News: www.adhdnews.com
What are my treatment options?
Treatment for ADHD is often “multimodal”—that is, it often involves any combination of
education, skills training, behavioral interventions, and medication. Depending on your
symptoms and response to these interventions, treatments will vary on a case-by-case basis.
As with most illnesses, it is highly recommended to start with the least invasive options first.
In treating ADHD, exhaustive attempts at behavioral interventions should initially be pursued
before beginning a trial of medication.
Behavioral Interventions
Behavioral Modification, or B-Mod, is typically the type of behavioral intervention that is used
in the treatment of ADHD. B-Mod is a process where individuals learn specific skills and
techniques designed to alter habits/problem areas and replace them with more adaptive,
functional responses. As parents, if we can consistently alter the antecedents (how we make
requests) or consequences (our reaction when the child obeys or disobeys), we can alter our
child’s behaviors and shape a more functional way of responding. As an adult trying to shape
your own behaviors, similar contingencies (“if…then” scenarios) are helpful in establishing a
behavioral plan that encourages a desired behavior attached to a reward (e.g., if I complete X,
then I can do Y).
Common guidelines for implementing a B-Mod plan include:
1. Start with goals that are small and attainable
2. Be consistent—regardless of time of day, setting, and situation
3. Follow through with the behavioral intervention over the long haul
4. Remember that learning new skills takes time and is gradual—don’t give up!!
Suggestions for Parents:
•
•
•
•
•
•
•
•
•
Provide clear, concise expectations, directions, and limits—avoid ambiguity
House rules and structure are a necessity—plan ahead and predict barriers
Set up an effective discipline system based on rewards and consequences
Change the most problematic behaviors first—use charts/graphs to see progress
Help your child in social situations—promote cooperation and peer interaction
Teach social skills and promote extracurricular activities
Identify & build on your child’s strengths—promote confidence, success, and esteem
Have a “special time” for your child—TLC goes a long way in maintaining self-worth
Learn to praise appropriate behaviors and ignore minor inappropriateness
Pharmacological Interventions
Strong evidence supports the use of stimulant medication for the management of inattention,
impulsivity, and hyperactivity in school children. Studies suggest that 70-80% of children with
ADHD improve with the use of stimulant medication. Some changes include: academic
improvement, increased focus and concentration, increased compliance and effort, and
decreased activity level and impulsivity. Medical intervention often involves a trial of Ritalin,
Concerta, Adderall, Dexedrine, or Strattera (an effective non-stimulant). The effects of these
medications are typically felt within 30-60 minutes of taking the medication. Increasing,
decreasing, or terminating medication is determined on a case-by-case basis to maximize
functioning.
Tips for Parents
Tips to help parents identify common problem areas for children
Writing/Language Problems
Children with ADHD often have poor
handwriting, grammar, and spelling skills.
Listening to information, processing it, and
writing it down is challenging.
Comprehension of instructions and
expression of thoughts and ideas is often
difficult.
Missing Assignments
Children with ADHD have difficulty keeping
track of information, lose track of time, and
often turn in assignments late. They have
intentions of being compliant, but lack
organizational skills.
Distractibility
ADHD is marked by an inability to control
what one pays attention to, and is not
always a conscious decision. Children with
ADHD are often unable to inhibit their
responses to distractions, such as outside
noises, movement, or their own thoughts.
Immature Social Behavior
Children with ADHD often have a hard time
reading social cues, may misinterpret
remarks, or miss the point of a conversation.
Strategy
Parents need to be supportive; consider writing down
answers given verbally by your child; encourage a
language-rich environment and never shame your
child for slow processing or misuse of words.
Strategy
Develop a system and provide support at each stage of
project completion; use checklists, labels, and colorcoded binders/folders for all subjects; establish and
keep a routine; prevent procrastination by using
independence as a reward.
Strategy
Establish a daily homework routine with scheduled
breaks; create a comfortable, distraction-free
environment to facilitate focus; communicate with
teachers if your child seems to lack the skills needed to
complete an assignment or if it takes an inordinately
long time.
Strategy
Involve your child in activities such as music, sports, or
other hobbies to identify strengths; role play everyday
situations with your child and allow them to practice
these skills in a “safe environment”; children with
ADHD are often great playmates with younger children
and can learn to foster positive caring traits without
feeling threatened by same-age peers.
Following Instructions
Strategy
Multi-step directions are notoriously difficult Break down large tasks into multiple, smaller steps;
create checklists and use reward systems when
for children with ADHD, as they often only
possible; use redirection and explanation rather than
hear bits and pieces of the request.
punishment for distraction.
Impulsivity
Strategy
Children with ADHD are often labeled as
Natural consequences are important parts of discipline
unruly or aggressive because of their
and expected to occur; provide immediate, positive
impulsive physical and social interactions.
feedback and attention for appropriate behaviors; the
They often have difficulty controlling
most successful discipline is specific, proactive, and
impulses, despite having caring & sensitive
directive; avoid ambiguity (“Be good”) and tell your
intentions.
child exactly what behavior is expected.
Adapted from www.adhd.com “Tips for Schools and Home”; Eli Lily & Co
Tips for Teachers
Tips to help teachers address common problem areas for students
Writing/Language Problems
Children with ADHD often have poor
handwriting, grammar, and spelling skills.
Listening to information, processing it,
and writing it down is challenging.
Comprehension of instructions and
expression of thoughts and ideas is often
difficult.
Missing Assignments
Children with ADHD have difficulty
keeping track of information, lose track of
time, and often turn in assignments late.
They have intentions of being compliant,
but lack organizational skills.
Distractibility
ADHD is marked by an inability to control
what one pays attention to, and is not
always a conscious decision. Children with
ADHD are often unable to inhibit their
responses to distractions, such as outside
noises, movement, or their own thoughts.
Immature Social Behavior
Children with ADHD often have a hard
time reading social cues, may
misinterpret remarks, or miss the point of
a conversation.
Following Instructions
Multi-step directions are notoriously
difficult for children with ADHD, as they
often only hear bits and pieces of the
request.
Impulsivity
Children with ADHD are often labeled as
unruly or aggressive because of their
impulsive physical and social interactions.
They often have difficulty controlling
impulses, despite having caring &
sensitive intentions.
Strategy
Consider giving extra time or abbreviated assignments;
offer corrections, but avoid taking off points on less
important areas (e.g., spelling vs. completing the book
report); make yourself available for additional questions
and explanations.
Strategy
Supervision and structure are critical; cues and reminders
can be helpful, and ensure the child writes down
assignments and stores paperwork in a homework folder;
track progress periodically on long-term projects; use
positive and instructive comments for corrections.
Strategy
Have child sit close to teacher and away from doors and
windows; use privacy dividers to limit distraction during
individual study/work time; lessons should involve visual
& auditory aids, and should be kept short; use a variety of
pacing and gesturing to capture attention; use nonverbal
cues (e.g., tapping) to refocus attention.
Strategy
Talk with teachers about your child’s social immaturity;
teachers should use positive reinforcement, especially in
front of peers, to help reduce the child’s use of
inappropriate antics for attention; one-on-one social
modeling followed by small group work can help children
develop appropriate behaviors.
Strategy
Teachers should use specific, brief, and personal
instructions whenever possible; written instructions are
best so children can review assignments again later;
consider recording classes if possible; have children repeat
instructions back to you to ensure translation.
Strategy
Rules that are posted in the classroom make expectations
clear and serve as written reminders to think before you
act; tape targeted behavior cards to the child’s desk that
encourage appropriate activity (e.g., raise hand to ask a
question); give periodic warnings of pending transitions in
activity to avoid a meltdown (e.g., “We have 5 more
minutes before lunch”); anticipate problem situations.
Adapted from www.adhd.com “Tips for Schools and Home”; Eli Lily & Co
USING MEDICATIONS SUCCESSFULLY
People become depressed for many reasons. This booklet describes strategies for using
medications successfully to alleviate symptoms of depression. Most often, depression is related
to stressful life circumstances, such as marital problems, death of a loved one, loss of a job, or a
child leaving home. Depression may also be related to physical problems such as chronic pain or
medical illness.
When the body is depressed, a person sleeps poorly, eats differently, has less energy, struggles
with concentration, and has more aches and pains.
When behavior is depressed, a person does much less than usual. She/he talks less, produces
less, and socializes less.
When the mind is depressed, thinking changes. A depressed person experiences more intensely
negative and painful thoughts about the past and the future.
A person’s body, behavior, and thoughts interact continuously. Once depression becomes a
problem, this interaction may lead to a “downward spiral” in mood and hopefulness. Two
courses of action help reverse the downward direction and create a “positive spiral.”
1. Use of Medications
Medications may help some people with symptoms of depression feel better, but they work slowly and
do not appear to prevent you from having future episodes of depression. Therefore, it is best to use
medications in combination with behavioral planning and use of coping strategies. If you decide to use
medications and your doctor prescribes them, this booklet will help you use them well.
2. Strategic Use of Coping Strategies
Use of active coping strategies helps you reverse the downward spiral of depression. When you address
life problems with effective strategies, you have more opportunities to create positive conditions in your
life context.
Make a concerted effort to work with your health care provider in planning medication treatment and
skillful use of coping strategies. You will soon be feeling better.
USING MEDICATIONS SUCCESSFULLY
There are four important areas to attend to when considering the start of a medication, and
this booklet will help you assess and prepare for success in each of these areas.
I. YOUR PAST EXPERIENCES WITH MEDICATIONS
Take a moment to recall your past experiences with use of medications for depression and
anxiety.
Have you ever used a medicine to help alleviate symptoms of depression or anxiety?
Yes
No
Try to recall the medication name, dosage, and length of treatment.
Name
Dose
When? How long?
Also, recall any side effects you had with this medication. How much did they trouble you?
Side
Effect
Bothered
A Little
Bothered
A Lot
How much did you benefit from use of medication when you tried medication before?
None
A Little
Some
Quite A Lot
Very Much
This information will be helpful to you and your provider in making a decision about medication use and
selection of a specific medication.
If you did have a limited response to medication treatment or experienced bothersome side effects in
the past, you may still be a candidate for medication treatment. You doctor may suggest that you try a
new medication.
II. YOUR BELIEFS ABOUT MEDICATIONS
Your beliefs have a significant impact on your success in using antidepressant medications. Take stock of
your beliefs right now. Mark an “X” by any of the following statements that you believe.
I can’t afford these medicines.
I’ll never remember to take them.
My family would not want me to use medications for this problem.
I should be able to get over my problems without taking medicine.
If you believe any of these statements, discuss the belief with your health care provider. She/he may be
able to provide you with additional information to help you re-evaluate beliefs which might make
medication use more difficult for you.
III. Your Knowledge about Medications
You are much more likely to succeed in antidepressant treatment when you have accurate information
about all aspects of medication use. Please review the following details and discuss any questions you
have with your health care providers.
Starting medication . . .
Start your medicine as soon as it is prescribed. The sooner you start, the sooner you will
experience the desired benefits.
Remembering to take medicine . . .
Take your medicine at a certain time of day every day. During the first several weeks, you may
want to leave yourself several reminder notes. Some people use a behavioral hygiene task, such
as teeth brushing, as a cue to take their medication. Also, some people may want to leave an
extra bottle of medication in a desk drawer at work in the event that they forget to take the
medicine at home.
Deciding how to take the medication . . .
Some medications are best taken in one dose, while others are best divided into several doses
during the day. Some medications cause drowsiness, while others are more activating.
Medications with a sedative effect are taken at night, and activating medications are taken in
the morning.
Carrying on with other activities . . .
If you do notice minor sedation or sleepiness in starting a medicine, avoid driving or carrying out
hazardous activities. Sleepiness will usually diminish. If it does not, talk with your provider about
a medication change.
Compatibility of a new medicine with other medications . . .
Talk with your provider about the compatibility of any new medicine with other medications you
are taking.
Taking antidepressant medications and consuming alcohol . . .
Talk with your doctor about possible problems with consuming alcohol with prescription
medications.
Increasing medication dose . . .
Talk with your doctor about the dose and if she or he plans to increase the dose.
Continuing to take the medication . . .
Take the medicine until you and your provider decide that you are ready to stop the medicine.
Do not stop taking the medicine until you and your doctor have a plan for you to stop.
IV. YOUR ABILITY TO ANTICIPATE AND PLAN FOR PROBLEMS IN USING MEDICATIONS
Most medicines have mild side effects. The side effects may be temporary and diminish or disappear
shortly after start of treatment. If you experience side effects that are more severe, call your doctor.
She/he will probably suggest one or more of the following strategies: change the time you take the
medicine, change the dose, add a second medicine, change to a different medicine, or use a remedy for
the side effect.
The following table provides some examples of medication side effects and ways to cope with them.
Examples of Side Effects and Possible Remedies
Dry Mouth
Drink plenty of water. Chew sugarless gum. Use sugarless drops.
Constipation
Eat more fiber-rich foods. Take a stool softener.
Drowsiness
Get fresh air and take frequent walks. Try taking your medicine earlier in
the evening, or if you’re taking your medicine in the day ask your doctor if
you can take it at night.
Wakefulness
Take medications early in the day. Learn more about insomnia. Take a warm
bath and have a light snack before bed. Avoid exercising vigorously late in
the evening.
Blurred Vision
Remind yourself that this will be a temporary difficulty. Talk with your
doctor if it persists.
Dizziness
Stand up slowly. Drink plenty of fluids. If you are worried, call your doctor.
Feeling Speeded Up
Tell yourself, “This will go away within three to five days.” If it does not, call
your doctor or nurse.
Sexual Problem
Talk with your doctor. A change in medications or a medication holiday may
help.
Nausea or Appetite Loss
Take the medicine with food. Prepare food so that it is appetizing and
colorful. Eat small healthy meals.
A Guide to Low-Risk Drinking
What is Low Risk Drinking?
Low-risk drinking involves limiting alcohol use to amounts and patterns that are unlikely to
cause harm to oneself or others. Scientific evidence indicates that the risk of harm increases
significantly when people consume more than two drinks per day and more than five days per
week. Because different types of alcoholic beverages contain different amounts of alcohol, it is
important that you know what a standard drink is when you are cutting down or trying to stick
to a limit. In the box below, you can see that standard drinks of different beverages are
different sizes. But what they have in common, is that each of them contains about 10 grams of
pure alcohol. The following can be used as a guide to help you keep track of your drinking.
Remember, each is a standard drink.
Wine
Port/Sherry
Spirits
1 glass-425ml
Full Strength
Beer
1 glass-285ml
1 glass-100ml
1 glass-60ml
1 nip 30ml
2.9% alcohol
4.9% alcohol
12% alcohol
20% alcohol
40% alcohol
Light Beer
Many individuals who would otherwise regard themselves as moderate drinkers, at times drink
in ways that cause problems. For example, limiting alcohol use to two or fewer drinks a day
may present risks in certain circumstances:
•
•
•
•
When driving or operating machinery
When taking certain medications
If you cannot control your drinking
If you suffer from depression or
anxiety
•
•
•
•
When pregnant or breast feeding
If you have certain medical conditions
If you have a personal history of drinking problems
If you have been told not to drink for legal reasons
What is High-Risk Drinking?
Some people may think that you have to drink heavily all of the time or be dependent on
alcohol to have alcohol-related problems. This is not true. Some problems can come from
simply being drunk every now and again. Other problems may come from regularly drinking
too much even though you may hardly ever get drunk. You may be surprised that alcohol
problems occur at what you consider to be moderate levels of drinking. You increase your risks
of experiencing alcohol related problems if you drink to the point of intoxication (being drink),
drink on a regular basis, or spend a lot of time drinking.
Risks due to intoxication (that is, being drunk). You do not have to be “falling down drunk”,
nor do you have to drink often to have these problems. Examples of intoxication related
problems include drunken driving, falls, hangovers, unsafe sex, arguments, absenteeism, and
embarrassment. The problems can range from being minor to being fatal.
Risks due to regular use. Problems coming from drinking too much on a regular basis include:
spending too much money on alcohol, concentration and memory difficulties, experiencing
stomach and liver disorders, diabetes, poor sleeping habits, gaining weight, and conflict in your
relationships.
Risks due to dependence. Some people begin to devote more and more time to drinking and
feel uncomfortable if they don’t drink. They may feel alcohol is beginning to take over their
lives, and cutting down their drinking becomes harder. Dependence can mean anxiety,
depression, withdrawal symptoms, losing interest in other activities and feelings of loss of
control.
Physical Effects of High Risk Drinking
In addition to the above mentioned risks, individuals who drink more than two standard drinks
are likely to experience a number of physiological effects from alcohol, some of which may lead
to physical difficulties. The following diagram outlines the effects of high risk drinking.
Indications of High-Risk Drinking
High-risk drinkers may have difficulty recognizing the problematic nature of their drinking.
They may minimize the amount of alcohol they drink or simply ignore the fact that the amount
of alcohol they drink is excessive. At times it may be helpful to consider looking for common
signs of high-risk drinking. Some indications of high-risk drinking include:
•
Drinking alone when you feel angry or sad
•
Being late or absent from work due to the effects of alcohol
•
Friends or family have indicated they are concerned about your drinking
•
Drinking even after telling yourself you won’t
•
Forgetting what you did while you were drinking
•
Periods of headaches or a hang-over after drinking
•
Past failed attempts to decrease your alcohol use
How to Manage Your Drinking
Reading about the risks associated with high-risk drinking has hopefully changed how you think
about your own and others drinking habits. After reading this material you may want to change
your drinking habits in some way, but are not exactly sure how. Many people change their
behavior all on their own. Often, when they are asked what brought about the change, they say
they just “thought about it,” meaning they evaluated the consequences of their current
behavior and of changing before making a final decision. You can do the same thing by asking
two simple questions: “What do I stand to lose and gain by continuing my current drinking
pattern?” and “What do I stand to lose and gain by changing my drinking pattern?” To change,
the scale needs to tip so the costs outweigh the benefits. This is called Decisional Balancing.
Weighing the pros and cons of changing happens all the time. For example, when changing jobs
or deciding to move or get married. At some point, you may have received real benefits from
the behavior you want to change, such as relaxation, fun, or stress reduction. However,
because you are reading this, you are considering both the benefits and the costs. Below is an
example of a Decisional Balance Worksheet for someone wanting to change the amount of
alcohol they drink.
Decisional Balance Worksheet
Costs of
Benefits of
Changing
•
•
•
•
•
•
•
•
Increased control over my life
Support from family and friends
Decreased job problems
•
•
•
More relaxed
•
•
•
•
Disapproval from friends/family
Improved health & finances my problems
Increased stress/anxiety
Feel more depressed
Increased boredom
Sleeping problems
Not Changing
More fun at parties
Don’t have to think about my
problems
Money problems
Damage close relationships
Increased health risks
Now that you have seen an example of a Decisional Balance for someone else thinking about
changing their drinking behaviors, consider what the personal costs and benefits of changing
(and not changing) your drinking behaviors are to you. Write down the costs and benefits in
the worksheet below:
Decisional Balance Worksheet
Not Changing
Costs of
Benefits of
Changing
Decision to Change Worksheet: Look over what you have written. What do you feel is the best
choice for you? If you have made the decision to change your drinking behavior, it is often
helpful to refer back to this worksheet to remind yourself why you made the decision to
change. It is also a good idea to talk it over with the person you are closest to so that they can
fully understand why you have chosen your goal. Then they will find it easier to be supportive
of your attempts to change. All change can be uncomfortable at first, so it helps to get support
from others. Research shows support from others will increase your chances for success.
Identifying Triggers
Although we sometimes do things that are not good for us, there are usually reasons why we
behave in certain ways. An important step in trying to change a behavior is identifying why it
occurs. Frequently behaviors are triggers by other things. Many circumstances can act as
triggers, such as pleasant or unpleasant emotions, a particular setting, or just a routine
situation. To help you identify possible triggers for your drinking consider the following
questions:
•
•
•
With whom do you typically drink?
•
•
•
What physical state are you in when you drink (e.g., relaxed, tense, tired, aroused)?
What do you hope will happen when you drink?
Are you in any particular emotional state when you drink
(e.g., angry, depressed, happy, sad)?
What setting do you tend to drink in (e.g. work, party, ex-spouse’s house)?
What activities are you involved with when drinking (e.g., work, playing sports,
watching TV)
My Triggers for Drinking
Take a few moments to note your common triggers for drinking. Finish each of the sentences
below:
1. The places where I most frequently drink alcohol are:
2. The people I am usually with when I drink include:
3. I usually drink when I am feeling:
4. I frequently drink when doing the following activities:
5. Situations where I typically do not drink are:
Change Plan
Now that you have identified some of your personal drinking triggers, you have determined
those situations in which you might drink a lot. The next step is to figure out how to be in these
situations and experience those feelings without a drink in your hand. Can you avoid the
situation altogether? Or find a way of handling it without a drink? Or with only one drink
instead of half a dozen?
Rather than waiting until you are under pressure, work out some strategies for managing your
drinking before you get into these situations. You’ll feel more in control if you have prepared
for a difficult “triggering” situation. To help you accomplish this go through the steps outlined
below.
First, pick one of your “triggers”.
Example: Going to the Club with friends
Second, think of as many ways you can for handling that situation and write them all down. Be
creative—try to put down some ideas you have never tried before, no matter how silly some of
them seem.
Example:
1. Ask friends to keep me from drinking
2. Don’t go to the club
3. Go someplace that doesn’t serve alcohol
4. Don’t bring any extra money
Third, review your list and consider how these strategies might not work. Then figure out ways
to work around these obstacles. Determine if you need to alter the option in some way.
Example: If I don’t bring any money, I will just ask a friend to spot me. Maybe I should
ask them not to do this beforehand.
Fourth, read your list carefully and pick the two ideas that seem the most practical and sensible
for that situation.
Example: Don’t bring extra money and ask friends not to loan me any money.
Fifth, try out the most promising strategies and see if they work. If they don’t, go back to step 2
and think of other ideas. It is important to recognize that some of these ideas may not work,
(e.g., it may be tempting fate to say you will go to the pub and only drink orange juice). Thus, it
is important to establish realistic and achievable strategies. Use the next page to work out
these steps. If you need help, your BHC can assist you.
My Personal Change Plan
Step 1
Choose a trigger:
Step 2
Write down as many strategies for controlling your drinking in this setting:
Step 3
Think of how the strategies in Step 2 might fail, then consider ways to work around these
obstacles:
Step 4
Look at what you have in Step 3, and choose the two that seem the most doable:
1.
2.
Step 5
Test your strategies from Step 4 to see if they work. If not, start over at Step 2 to figure out
new ways to make them work given what you have learned. Ask your BHC for help, if needed.
Make as many copies of this worksheet as necessary until you find a successful strategy. Most
people will fill one out for each of their triggering situations. The more worksheets you
complete, the more thinking and planning you end up doing, which makes you more prepared
to make a behavior change.
Coping with Panic Attacks
What is a panic attack?
You may have had a panic attack if you experienced four or more of the symptoms listed below
coming on abruptly and peaking in about 10 minutes.
Panic Symptoms
•
•
•
•
•
•
•
Pounding heart
Sweating
Trembling or shaking
Shortness of breath
Feeling of choking
Chest pain
•
•
•
•
•
•
Feeling dizzy, unsteady, lightheaded, or faint
Feelings of unreality or being detached from yourself
Fear of losing control or going crazy
Fear of dying
Numbness or tingling
Chills or hot flashes
Nausea or abdominal
distress
Panic attacks are sometimes accompanied by avoidance of certain places or situations. These
are often situations that would be difficult to escape from or in which help might not be
available. Examples might include crowded shopping malls, public transportation, restaurants,
or driving.
Why do panic attacks occur?
Panic attacks are the body’s alarm system gone awry. All of us have a built-in alarm system,
powered by adrenaline, which increases our heart rate, breathing, and blood flow in response
to danger. Ordinarily, this ‘danger response system’ works well. In some people, however, the
response is either out of proportion to whatever stress is going on, or may come out of the blue
without any stress at all.
For example, if you are walking in the woods and see a bear coming your way, a variety of
changes occur in your body to prepare you to either fight the danger or flee from the situation.
Your heart rate will increase to get more blood flow around your body, your breathing rate will
quicken so that more oxygen is available, and your muscles will tighten in order to be ready to
fight or run. You may feel nauseated as blood flow leaves your stomach area and moves into
your limbs. These bodily changes are all essential to helping you survive the dangerous
situation.
After the danger has passed, your body functions will begin to go back to normal. This is
because your body also has a system for “recovering” by bringing your body back down to a
normal state when the danger is over.
As you can see, the emergency response system is adaptive when there is, in fact, a “true” or
“real” danger (e.g., bear). However, sometimes people find that their emergency response
system is triggered in “everyday” situations where there really is no true physical danger (e.g.,
in a meeting, in the grocery store, while driving in normal traffic, etc.).
What triggers a panic attack?
Sometimes particularly stressful situations can trigger a panic attack. For example, an
argument with your spouse or stressors at work can cause a stress response (activating the
emergency response system) because you perceive it as threatening or overwhelming, even if
there is no direct risk to your survival.
Sometimes panic attacks don’t seem to be triggered by anything in particular – they may “come
out of the blue.” Somehow, the natural “fight or flight” emergency response system has gotten
activated when there is no real danger. Why does the body go into “emergency mode” when
there is no real danger?
Often, people with panic attacks are frightened or alarmed by the physical sensations of the
emergency response system. First, unexpected physical sensations are experienced (tightness
in your chest or some shortness of breath). This then leads to feeling fearful or alarmed by
these symptoms (“Something’s wrong!”, “Am I having a heart attack?”, “Am I going to faint?”)
The mind perceives that there is a danger even though no real danger exists. This, in turn,
activates the emergency response system (“fight or flight”), leading to a “full blown” panic
attack. In summary, panic attacks occur when we misinterpret physical symptoms as signs of
impending death, craziness, loss of control, embarrassment, or fear of fear. Sometimes you
may be aware of thoughts of danger that activate the emergency response system (for
example, thinking “I’m having a heart attack” when you feel chest pressure or increased heart
rate). At other times, however, you may not be aware of such thoughts. After several
incidences of being afraid of physical sensations, anxiety and panic can occur in response to the
initial sensations without conscious thoughts of danger. Instead, you just feel afraid or
alarmed. In other words, the panic or fear may seem to occur “automatically” without you
consciously telling yourself anything.
After having had one or more panic attacks, you may also become more focused on what is
going on inside your body. You may scan your body and be more vigilant about noticing any
symptoms that might signal the start of a panic attack. This makes it easier for panic attacks to
happen again because you pick up on sensations you might otherwise not have noticed, and
misinterpret them as something dangerous. A panic attack may then result.
How do I cope with panic attacks?
An important part of overcoming panic attacks involves re-interpreting your body’s physical
reactions and teaching yourself ways to decrease the physical arousal. This can be done
through practicing the cognitive and behavioral interventions below.
Behavioral Interventions
1. Breathing Retraining
Research has found that over half of people who have panic attacks show some signs of
hyperventilation or over-breathing. This can produce initial sensations that alarm you and lead
to a panic attack. Over-breathing can also develop as part of the panic attack and make the
symptoms worse. When people hyperventilate, certain blood vessels in the body become
narrower. In particular, the brain may get slightly less oxygen. This can lead to the symptoms of
dizziness, confusion, and lightheadedness that often occur during panic attacks. Other parts of
the body may also get a bit less oxygen, which may lead to numbness or tingling in the hands or
feet or the sensation of cold, clammy hands. It also may lead the heart to pump harder.
Although these symptoms may be frightening and feel unpleasant, it is important to remember
that hyperventilating is not dangerous. However, you can help overcome the unpleasantness of
over-breathing by practicing Breathing Retraining.
Practice this basic technique three times a day, every day:
•
Inhale. With your shoulders relaxed, inhale as slowly and deeply as you can while
you count to six. If you can, use your diaphragm to fill your lungs with air.
•
Hold. Keep the air in your lungs as you slowly count to four.
•
Exhale. Slowly breath out as you count to six.
•
Repeat. Do the inhale-hold-exhale cycle several times. Each time you do it, exhale
for longer counts.
Like any new skill, Breathing Retraining requires practice. Try practicing this skill twice a day for
several minutes. Initially, do not try this technique in specific situations or when you become
frightened or have a panic attack. Begin by practicing in a quiet environment to build up your
skill level so that you can later use it in time of “emergency.”
2. Decreasing Avoidance
Regardless of whether you can identify why you began having panic attacks or whether they
seemed to come out of the blue, the places where you began having panic attacks often can
become triggers themselves. It is not uncommon for individuals to begin to avoid the places
where they have had panic attacks. Over time, the individual may begin to avoid more and
more places, thereby decreasing their activities and often negatively impacting their quality of
life. To break the cycle of avoidance, it is important to first identify the places or situations that
are being avoided, and then to do some “relearning.”
To begin this intervention, first create a list of locations or situations that you tend to avoid.
Then choose an avoided location or situation that you would like to target first. Now develop an
“exposure hierarchy” for this situation or location. An “exposure hierarchy” is a list of actions
that make you feel anxious in this situation. Order these actions from least to most anxietyproducing. It is often helpful to have the first item on your hierarchy involve thinking or
imagining part of the feared/avoided situation.
Here is an example of an exposure hierarchy for decreasing avoidance of the grocery store.
Note how it is ordered from the least amount of anxiety (at the top) to the most anxiety (at the
bottom):
•
Think about going to the grocery store alone.
•
Go to the grocery store with a friend or family member.
•
Go to the grocery store alone to pick up a few small items (5-10 minutes in the store).
•
Shopping for 10-20 minutes in the store alone.
•
Doing the shopping for the week by myself (20-30 minutes in the store).
Your homework is to “expose” yourself to the lowest item on your hierarchy and use your
breathing relaxation and coping statements (see below) to help you remain in the situation.
Practice this several times during the upcoming week. Once you have mastered each item with
minimal anxiety, move on to the next higher action on your list.
Cognitive Interventions
1. Identify your negative self-talk
Anxious thoughts can increase anxiety symptoms and panic. The first step in changing anxious thinking
is to identify your own negative, alarming self-talk. Some common alarming thoughts:
•
•
•
•
I’m having a heart attack.
I must be going crazy.
I think I’m dying.
People will think I’m crazy.
•
•
•
•
I’m going to pass out.
Oh no – here it comes.
I can’t stand this.
I’ve got to get out of here!
2. Use positive coping statements
Changing or disrupting a pattern of anxious thoughts by replacing them with more calming or supportive
statements can help to divert a panic attack. Some common helpful coping statements:
•
•
•
•
•
This is not an emergency.
I don’t like feeling this way, but I can accept it.
I can feel like this and still be okay.
This has happened before, and I was okay. I’ll be okay this time, too.
I can be anxious and still deal with this situation.
Suggested Readings
•
Barlow, D., & Craske, M. (2006). Mastery of your anxiety and panic workbook, 4th
Edition. New York: Oxford University Press.
•
Bourne, E. (2000). The Anxiety and phobia workbook, 3rd Edition. Oakland, CA: New
Harbinger Publication.
Anxiety
Challenging Anxiety
Anxiety affects approximately 19 MILLION adults in the United States alone. 1 out of every 6
people will experience uncomfortable anxiety at some time during their lives (that is nearly 45
million people)! The body’s natural response to danger is to prepare for “fight” or “flight”.
When the sympathetic nervous system activates to emergency situations, you may experience
feelings and body sensations such as:
•
•
•
•
Increased heart rate
Quick, shallow breaths
Increased adrenaline
Impending doom
•
•
•
•
Increased muscle tension
Increased perspiration
Light headedness
Chest pains
These physical responses usually occur as components of anxiety. It is important to recognize
that these reactions are your body’s normal response to a perceived danger. However, with
anxiety, your body is responding to situations in which you are not physically threatened. None
of these physical reactions can harm you—they are designed to keep you safe.
Anxiety begins in the cognitive (thinking) part of the brain. Physical symptoms ALWAYS begin
as thoughts or perceptions based on your personal beliefs. You may experience the following
kinds of thoughts:
•
•
•
Uncontrollable worry
Fear, apprehension
•
•
Feelings of impending doom
Negative thoughts you cannot stop
Negative thoughts about yourself, the
future, or past events
The thinking part of the brain can activate the physical “danger” response even when there is
no immediate threat of danger. The physical and cognitive aspects of anxiety feed into each
other to continue the negative cycle of worry and physical discomfort. Fortunately, there are
several ways to alleviate the physical and cognitive discomfort of anxiety. Some typical
behavioral exercises you can use to reduce physical symptoms of anxiety include:
•
•
•
•
Relaxation breathing
Physical exercise
Engage in enjoyable/distracting activity
Noticing and being curious about it negative or distorted thinking
It will take practice to feel comfortable using these techniques, and to notice a decrease in your
symptoms of anxiety. Remember, learning to feel anxious took time learning to feel more calm
will take time. Soon, use of relaxation techniques and new ways of responding to anxious
thoughts and sensations will become natural.
Diaphragmatic Breathing Exercise
1. Sit in a comfortable position, legs shoulder width apart, eyes closed, jaw relaxed, arms
loose.
2. Place one hand on your chest, one hand on your stomach.
3. Try to breathe so that only your stomach rises and falls.
Inhale: Concentrate on keeping your chest relatively still. Imagine you are trying to hold
up a pair of pants that are slightly too big.
Exhale: Allow your stomach to fall as if you are melting into your chair. Repeat the word
“calm” to provide focus as you are practicing the exercise.
Do not force the breath, let your body tell you when to take the next breath.
4. Take several deep breaths moving only your stomach in and out with the breath.
5. Practice 3-5 minutes 2-3 times. The more you practice, the faster your progress will be.
Note: It is normal for this type of breathing to feel a bit awkward at first. With practice it
will become more natural for you.
Challenging Negative Thoughts
Negative thought cycles perpetuate the physical symptoms of anxiety. In addition to practicing
diaphragmatic breathing it is important to learn new ways to respond to negative thought
patterns to decrease the experience of anxiety.
Examine your thoughts for key words:
•
must, should, have to (unrealistic standards for yourself and others)
•
never, always, every (“black and white” thinking)
This kind of thinking does not allow room for alteration, compromise, or change. Using
these words casts blame, and they are judgmental.
•
awful, horrible, disaster (catastrophic thinking)
This kind of thinking encourages the sense of despair and doom.
•
jerk, slob, creep, stupid (negative labels)
Changing your choice of words makes a big difference in the way a situation or person is
perceived. The way we react to a situation is the determinant of our moods, not the situation
itself. Our thoughts influence our moods, so by altering the way we respond to them we are
able to alter our mood.
Here are some simple ways to challenge your thoughts:
1. Question the negative/worrisome thoughts you are having. Is the thought valid?
a) provide evidence for and against the truth of the thought
b) Challenge the likelihood that an event will occur.
2. Challenge the need to “fix” all problems, do all chores, or take care of things
immediately.
Ask yourself, “What is the worst thing that will happen if …….. does not happen?”
3. Change the negative thought into a positive self-statement.
For example: Instead of, “I am never on time, I am such a loser”, say “Ok, so I am not
always on time, but I am not always late either. Sometimes I am running behind
schedule, but that does not mean I am a loser”.
4. Play with the negative thought:
a) Try saying the opposite of the thought. For example, “I am always on time, I am a
complete winner”.
b) Try saying the thought very slowly and then quickly, softly and then loudly.
c) Try singing the song to the tune of happy birthday.
Recommended Reading
•
“The Mindfulness and Acceptance Workbook for Anxiety”, John Forseyth and George
Eifort
•
“Why Zebras Don’t Get Ulcers”, Robert Sapolsky
•
“The Anxiety and Phobia Workbook” and “Coping with Anxiety”, Edmund J. Bourne
Gate Control Theory of Pain
According to the gate control theory of pain, pain signals that originate in an area of injury or
disease do not travel directly or automatically to the brain. Rather, there exists within the
spinal cord a ‘gate mechanism’, which determines the degree to which pain signals are
transmitted to the brain. When the gate is wide open, more pain signals get through than
when it is closed. Generally, rather than being completely open or shut, the gate is open to
varying degrees.
Behavioral
Mental
Emotional
Physical
Factors
which:
OPEN the pain gate
•
•
•
-Extent of the injury
-Readiness of the nervous system to
send pain signals
-Inappropriate activity level
•
•
•
•
•
•
•
Depression
•
Non-adaptive attitudes
•
-Withdrawal from positive life
activities
•
Worry
Anxiety
CLOSE the pain gate
•
•
•
-Application of heat or cold
•
•
•
•
-Appropriate activity level
•
•
•
Distraction away from pain
•
•
•
•
-Increased positive life activities
-Massage
-Relaxation skills (to lower readiness
of the nervous system)
Avoiding excessive emotions
Positive emotions
Managing stress
Tension
Anger
Focusing on the pain
Boredom due to minimal
involvement in life activities
-Poor health habits
Increased social activities
Positive attitudes
-Appropriate exercise
-Healthy eating
-Refraining from unhealthy habits
Pacing Yourself
When people first injure themselves, pain serves as a signal that harm has been caused to the
body. The natural and healthy response is to stop doing whatever is causing the pain (e.g.,
walking on a sprained ankle, lifting with a strained back). In this case, harm is being done to the
body and the body’s warning system (pain) is working properly. However with chronic pain,
healing has usually occurred but pain remains. Thus, the body’s warning system is no longer
working properly. In other words, the pain no longer indicates harm is being done to the body.
Therefore, stopping the activity that causes the pain is often not indicated.
People with chronic pain are often very inactive during episodes of severe pain; laying or sitting
for extended periods. Through the course of the natural pain cycle, they eventually experience
some pain relief. In response to this decreased pain, they often try and make up for all the
things they were unable to do during the severe pain episode (i.e., they over do it). Since their
body has lost strength and endurance during these extended periods of inactivity, even
resumption of normal life activity can result in increased pain. As a result, a cyclical pattern of
‘under-doing’ it followed by ‘over-doing’ it is created. Pacing activity differently enables pain
patients to break this cycle.
How to pace
•
Stop or change an activity when your pain level goes two points (on a 10 point scale)
above your normal pain level.
•
Do something less active until your pain returns to your normal level.
•
If this rule is followed throughout the day, then pain will be no worse at the end of the
day then at the beginning.
What to expect when pacing
•
It will be challenging to learn the right combinations of up and down times. You may
find it works best to tackle small portions of your daily routine at a time rather than
changing your entire day at once. Start with activities that are most important to you or
that increased pain causes the greatest challenge to you.
•
Avoiding over activity, which can result in severe pain episodes and longer downtimes,
will increase your success at engaging in effective pacing.
•
Expect to reassess your pacing plan on a regular basis (increasing uptime and decreasing
downtime as appropriate). In the beginning of pacing you may find that your uptimes
are shorter than you would like and your down times are longer than you would like.
What you should find is that your uptimes gradually increase and your downtimes
gradually decrease.
•
Setting realistic goals for yourself may help keep you from getting frustrated and
disappointed with the slow rate of improvement as you gradually recondition your
body.
By planning your activities in this way, you can accomplish more (and have more fun) in a day
without significantly increasing your pain. The attached worksheet can be used to help you
determine your ‘up’ and ‘down’ times.
Setting Realistic Goals for Taking Control of Your Life
Unfortunately, being pain free is rarely a realistic goal. More realistic goals might include:
reducing impact of pain on activities, learning to live with the pain, learning to enjoy life,
regaining control of your life, increasing activity, etc. Talk with your doctor about what physical
limitations you have and do not do those activities. Instead, focus on gradually resuming those
that hurt but are not harmful. Setting realistic goals provides a focus for your energy and
enables your goals to be achieved. Also, when you are devoting your time and energy to things
you really want to do and can accomplish, there is less time to think about your pain. The less
you think about your pain, the less you will suffer.
Establishing Goals
1. Is the Goal is Realistic? Is the goal statement realistic? Can the goal actually be
achieved? Is it possible to achieve at your pain management skill level?
2. Is there a Target Date for Completion? When will the goal be accomplished? It's a
good idea to set a target date to act as a guideline and then re-set if needed.
3. Is the Goal Measurable? Can you evaluate when the goal has been reached? Will the
goal be measured in some way?
For example:
 Minutes spent doing some activity such as exercise or relaxation.

Specifics type and number of pleasurable activities to engage in each week.
4. Is The Goal Broken Down Into Small, Realistic Parts? Remember to start at a point that
you already know you can do, and build onto it from there. Program the steps for a
sense of early success to help give you the boost and momentum to keep you going.
5. Is the goal “I” centered? Are “you” the one engaging in the actions or behaviors to be
measured?
6. Once Accomplished, What Rewards Will You Use? Remember, actions that are
rewarded are more likely to reoccur.
7. Is the Goal Desirable or Personally Meaningful? Do you want the outcome enough to
put forth the effort? You are much more likely to strive toward a goal that you care
about.
8. Is A Relapse Plan Clearly Established? What happens if you do not reach to goal as you
originally planned? What will you do to get started again?
Postpartum Depression
What is it?
Postpartum depression (PPD) is sometimes called postpartum blues (“baby blues”) or puerperal
psychosis. It affects 10-15% of women. Among adolescent mothers it may be more common.
PPD is more likely to occur for women who have previously struggled with depression. In fact,
there is little difference between postpartum depression and major depression. Women with
relatives who have struggled with depression are also more likely to develop PPD.
What is it NOT?
PDD is not a disease or illness that can be blamed on the mother or on anyone else. It is not a
chemical imbalance or simply a hormonal problem. It may occur due to environmental,
biological, or behavioral factors. Frequently it is due to a combination of these.
PDD is not incurable or permanent. It usually arises within 6 weeks of childbirth and may last
between 3 and 14 months. PPD can lead to other difficulties with one’s spouse,
family, social life, job, or health. If untreated PPD may also lead to behavioral and
developmental problems in the children of the depressed mother.
PDD is not uncontrollable. If targeted early it can be treated with simple behavioral strategies
and skills which a mother can learn quickly and implement in a way that best suits
her. There are also antidepressant medications which physicians may prescribe to
help mothers feel better.
PPD is not something to be ashamed of – it is pretty common. One out of three women who
have a prior history of major depression will experience postpartum depression.
How do I know if I have PPD?
Recognizing PPD early not only makes it easier for the mother to address the symptoms of
depression, but it also enables doctors, friends, spouses, and other family members to help.
You may have one or more symptoms of PDD. Every woman’s experience of PDD is a little
different. The severity of PDD varies. If you have difficulties identifying it, your doctor will be
able to help you. Below are a few things to look for.
Common symptoms of PPD
•
•
•
•
moodiness
irritability
anxiety
feeling unable to cope
•
•
•
•
confusion
low of motivation
fatigue
crying spells
What can I do to get better?
Generally, the treatments that are successful in treating PDD are the same ones used to treat
depression. However, the best treatment for PDD is PREVENTION!
When we feel depressed, sometimes we do not feel the energy or interest to do things we
typically enjoy. As a result, we stop spending time with others and/or doing fun activities. This
leaves us with fewer opportunities to be happy and gain pleasure out of each day, which may
make us feel even more depressed.
1. Remain actively engaged in activities
Schedule weekly activities that provide you a sense of pleasure and/or a feeling of
accomplishment.
Stick to this schedule! Even if initially you do not begin feeling better, the research shows
that the more consistently people engage in such activities, the higher their mood becomes
overtime.
You may have to literally force yourself to maintain a schedule of activities, but this is where
the momentum starts!
2. Ensure you have a social network
•
Ensure that you regularly spend time with family and friends – depressive feelings
can often be helped by remaining connected to others.
•
Seek support from others. Others you know may have also struggled with PDD. Talk
to them - they may have some ideas to help you!
•
Contact your friends, family, and doctor if you notice symptoms of depression
getting worse.
3. Use problem-solving skills
If you have difficulties carrying out any of these behavioral routines use your resources to
make sure they happen.
•
Reschedule your activities around obligations
•
Reorganize your own daily routine
•
Spread out your other responsibilities over a longer period of time to provide
yourself periods of time in which you can schedule activities for yourself.
•
Ask for help from others
4. Engage in some sort of physical exercise
•
Even if you walk on a treadmill at home while watching television. This does count as
exercise! Studies show that regular exercise can increase one’s mood.
•
Start with a manageable exercise routine – do not try to do too much initially.
•
Begin slowly, and as your body adjusts to the level of activity, increase the duration
or intensity of your workouts gradually.
5. DO NOT GIVE UP!
•
Sometimes when people begin to feel better, they stop doing the things that helped
them feel better. This results in their mood declining all over again. If what you’re
doing is helping, do not stop doing it!
•
Reward yourself for keeping an exercise routine, activity schedule, and social
schedule! It is okay to do things for yourself to maintain your motivation.
•
Time is precious. If you are someone who feels guilty about taking time to yourself
because this competes with other responsibilities, just remember: if you are not
feeling well, your ability to care for others and carry out other responsibilities will
decrease.
•
Investing a little time for yourself daily or weekly to do the activities mentioned
above, can give you the energy and motivation to address all the other
responsibilities you may have.
6. Contact your doctor
If you are interested in taking medication to treat these symptoms, there are a few options,
even if you are breastfeeding.
7. Stay informed about PPD
Books can be powerful tools to help people learn about depression or PPD. Information you
may learn or ideas you may get from books may better help you manage your symptoms.
Suggested books for coping with PPD
•
“This Isn’t What I Expected: Overcoming Postpartum Depression” by Karen R.
Kleiman, M.S.W. and Valerie D. Raskin, M.D.
•
“Conquering Postpartum Depression: A Proven Plan for Recovery” by Rosenberg,
Greening, and Windell
Depression: Tips for Coping
What is depression?
There are several forms of depression. Depression can develop rapidly or come on slowly over
weeks or months. In some cases, depression can develop into a chronic or episodic syndrome.
Although many people associate depression only with sadness, there are other signs as well (for
example, dropping enjoyable activities; feeling tired; feeling guilty or worthless; having
problems with concentration, sleep or appetite). It is estimated that up to 25% of women and
12% of men will experience clinical depression at some point during their lifetime. Women are
twice as likely as men to become depressed.
What depression is not
There are a lot of myths and stigmas surrounding depression. Depression is not a “weakness;”
nor is it “all in your head.” Clinical depression is not something that you can just “snap out of.”
The good news is that help is available. Years of research have identified effective behavioral
interventions for improving symptoms of depression. If you or someone you know is
depressed, it’s very important that you seek help. Reading this pamphlet is a first step towards
understanding depression and getting the help that you need.
What causes us to feel down?
Prolonged stress and major negative life events (e.g., the death of a loved one), and medical
illness can all play a significant role in depression. Usually, depression is related to a
combination of factors including the social environmental, biological factors, our thoughts and
beliefs, our emotions, and our behavior. Each of these factors can affect the others, and often
work together in a sort of “snowball effect” that may leads to more symptoms of depression.
The depression spiral provides a helpful illustration of this:
Environmen
Biology
DEPRESSIO
N
Behaviors
Thoughts
and
Emotions
It is important to keep in mind that what initially causes the depression may not be the same
as what maintains it, or causes it to persist over time. For example, the loss of a loved one or
a job may lead to feelings of loss and result in increased stresses, including loneliness, financial
problems, etc. Symptoms of depression may worsen in response to growing stress levels, but it
our experience of failure in solving the problems triggered by initial stresses that get us “in the
dumps”. Often, we “pull back” from life and then forget to re-engage. We drop our previously
enjoyable activities, see others less, and often move into more sedentary or inactive lifestyles.
How to cope with depression
The good news about the depression spiral is that it is reversible----there are specific behavior
change strategies that you can use to improve your life, starting TODAY. These strategies have
been shown to lead to significant and enduring improvement among hundreds of thousands of
other people.
STEP ONE: GET MOVING!
Our level of activity is often connected to the way we feel. You may notice that when you are
depressed, you tend to be less active—you may cut down on social activities or on exercise. As
a first step towards treating depression, it is often beneficial to increase activities—particularly
those that you have found pleasurable in the past, those that lead you to feel that you have
accomplished something (i.e., hobbies), or those that are aligned with your values (i.e., if you
are a parent, spending quality time with your children).
Aerobic exercise, in particular, is one of the best ways to improve your mood. When you
exercise, your body releases endorphins, which are natural “feel good” chemicals. Research
has shown that exercise is an effective treatment for depression.
When you’re depressed, you will rarely feel motivated or excited about initiating an
activity…but you’ll find that once you get started, the positive momentum will build and over
time (over several weeks of increasing your activity level), most people experience increased
energy and an elevation in mood.
You will increase your chances of success if you plan, and schedule, specific activities (i.e.,
“tomorrow morning at 7am, I am going to walk my dog around the neighborhood for 30
minutes”). The activities you select don’t have to be extravagant- they can be as simple as a 10minute walk outside, taking a bath, gardening, reading a book, talking to a close friend, or
listening to soothing music. Remember- everybody is different- it’s important to identify
activities that are enjoyable or meaningful to YOU! (Note: if you are having a difficult time
identifying activities, your PCB can provide you with a list of hundreds of potentially enjoyable
activities to “spur” your brainstorming process.)
Use the activity schedule on the last page of this pamphlet to schedule and track your activities
for the next week. Tracking your activities can help you to see more clearly the relationship
between them and your mood. Be sure to rate your level of enjoyment/mastery for each
activity, and your average mood (using a 0-10 scale, with 0 representing “completely
depressed” and 10 representing “not at all depressed”) for each day. After you’ve done this for
one week, ask yourself the following questions:
•
•
•
•
•
•
Did my activities affect my mood? How?
Which activities helped me to feel better?
Did any activities (or periods of inactivity) cause me to feel worse?
Which activities had the greatest positive impact on my mood?
Were there certain times of the day or week when I felt better or worse?
Based on my answers to the previous questions, what activities can I plan in the coming
weeks to maximize the chances that I will feel better?
Use the information you’ve gained to guide activity plans for the upcoming weeks. Becoming
“un-depressed” is a little bit like walking out of a big hole in the ground. It won’t happen all at
once; rather, you’ll have to climb out one step at a time. The important thing is to keep the
momentum in the positive direction. Don’t give up!!! If you need to, get your friends/family to
help keep you on track with planning and committing to activities.
STEP TWO: LOOK OUT FOR “STINKIN’ THINKIN’!”
Depression is characterized by thought patterns that actually maintain the depressed mood.
Individuals who are depressed experience negative thoughts about the self (self-criticism), the
world (general negativity) and the future (hopelessness). It’s a little bit like wearing a pair of
dark sunglasses—everything you see has a shadow cast over it. Our thoughts have a direct
impact on our mood, on our interactions with others, and on our activity level (or lack thereof).
It’s very important, therefore, that you pay attention to unhelpful thinking.
Use intentional choice get you out the door and involved in meaningful and important life
activities more often. It is possible to simply notice your “stinkin’ thinkin’” and take it with you
to the park or the library. It is possible to smile at a neighbor even if you are feeling discouraged
and thinking painful thoughts. Choosing is difficult, and worth it. It can open “new doors” for
you. For example, you might start a new friendship if the neighbor smiles back.
Whenever you experience a negative shift in mood, pay attention to what you were thinking at
that moment. Pay attention to any thing that triggered it. Use an attitude of curious interest.
Perhaps you can make a note of it on a piece of paper. Once you’ve identified your thoughts,
ask yourself “is this type of thinking helping me or hurting me?” If you find that your thinking is
making your depressed mood worse (as is usually the case for depressed individuals), here are
some things you can do:
•
“Examine the evidence” for and against the negative thought. Is it truly accurate?
Where’s the proof? Are you blaming yourself for something over which you do not have
complete control? Are you jumping to conclusions? Are you discounting your
strengths, or positive attributes, in some way? Become your own scientific investigator
and collect the facts.
•
Explore the negative thought and look for other thoughts to appear (thoughts do
“come and go”). Ask yourself, five years from now, if you look back at this situation,
how might you look at it differently? Allow yourself to view a situation from more than
one angle (how might your spouse, friend, or someone you admire view the same
situation?)
•
Use the “best friend” scenario. What would you tell your best friend if he or she was
having these same thoughts? Would you criticize him or her as harshly as you criticize
yourself?
Most of us go through life on “autopilot,” unaware of much of our thoughts or on the impact
that they have on our mood and our behavior. It can take awhile before you get to be skilled at
identifying and working with negative thoughts. Over time, you’ll get better at this.
Additional Resources (Self-help workbooks)
•
“Get Out of Your Mind and Into Your Life” by Stephen Hayes, Ph.D.*
•
“Living Life Well: New Strategies for Hard Times” by Patricia Robinson
•
“The Mindfulness and Acceptance Workbook for Depression” by Kirk Strosahl &Patricia
Robinson*
*Winners of the ABCT Self-Help Book Merit Award
Activity Log – Dates:____________
Grade each activity for sense of accomplishment “A” and pleasure “P” on a scale from 0-10
(10 being the highest)
Sun A P Mon
day
day
6-8
8-10
10-12
12-2
2-4
4-6
6-8
8-10
10-12
12-6
Day’s
Mood
0-10
A P Tues
day
A
P
Wednes
day
A P Thurs
day
A
P
Friday
A P Satur
day
A
P
Exercise and Physical Activity
Most people have been told, “you need to exercise more” or “If you did some sort of physical
activity, you would probably feel better”? Exercise and physical activity of any kind is healthy
and can help increase positive mood and energy. It can also decrease weight, stress and blood
pressure, increase alertness and motivation to accomplish other goals. This isn’t earth
shattering news, as a matter of fact it is hard to find anyone who hasn’t heard these things
before. Yet, it still isn’t enough to get people up and moving. So, if most people already know
that physical activity and exercise have so many positive attributes, why is it that so many
people don’t engage in these activities? (especially when experiencing anxiety, depression or
significant life stress)
When people feel down or depressed, stressed or nervous they tend to cut out healthy
activities that normally bring value, meaning and enjoyment to their lives. Giving up healthy
habits in the face of negative mood and life stress seems to be the path of least resistance for
most, and the initiation of a cycle that is difficult to stop.
Finding reasons not to exercise isn’t difficult, where most people get “stuck” is in problem
solving and finding ways to overcome barriers to change. Sometimes, being able to weigh the
reasons NOT to exercise against the reasons to DO exercise can help create the motivation and
rationale to begin MOVING forward. Try using the scale below to “weigh” your options……
REASONS TO EXERCISE
REASONS NOT TO EXERCISE
•
•
•
Feeling Sad
•
•
•
Too Busy
Low Energy
Exercise Goal is
Unattainable
Too Hot or Cold
Low Level of
•
•
•
Feeling Sick
•
•
•
Too Tired
No Social Support
Don’t Have Proper
Attire
Pain
Intimidated by Gym
•
•
•
•
•
•
•
•
•
•
•
•
Improve mood
•
E h
Increase Energy
Weight Control
Improve Sleep
Stress Reduction
Lower Blood Pressure
Lower Cholesterol
Increase Muscle Tone
Decrease Chronic Pain
Improve Concentration
Increase Metabolism
Improve Cardiovascular
functioning
St
i
f
D il
List Top 3 Reasons to Exercise
1.
2.
3.
•
My short term exercise goal is: ______________________________________________
•
My long term exercise goal is: ______________________________________________
•
When I REALLY don’t feel like exercising I will: __________________________________
•
I will look to: ________________________________for support in my effort to
exercise.
•
I will reward myself with: __________________________________________________
*Post this list in a place where you will see it several times each day!
GETTING STARTED
•
Check with your doctor - It is always a good idea to check in with your doctor before
beginning a new fitness program. This is particularly true if you're over 40, if you smoke,
or if you have a family history of cardiovascular disease, high blood pressure, elevated
cholesterol, diabetes, arthritis, or asthma.
•
Have fun - Choose an activity you like or want to do. You're much more likely to stick
with it. If you find your first choice doesn't suit you, switch to something else.
•
Start slowly and progress gradually - You'll avoid becoming discouraged and reduce the
risk of injury.
•
Set goals - Maybe you want to lose a little weight, get in shape for a particular sport you
enjoy, or reduce arthritis pain and increase joint mobility.
•
Keep track - You may not notice that you're walking further in the same amount of time
or that you're not as winded climbing the stairs. Keeping track helps you evaluate your
progress and gives you a sense of accomplishment.
•
•
Reward yourself - When you reach a goal, buy yourself a new T-shirt or tennis racket.
Find a partner - It's more fun to share and you'll keep each other on track.
•
•
Have a plan B - If it's raining, walk around an indoor mall or do an exercise video.
•
Stick with it - You have to exercise regularly for your fitness to improve. Fifteen to thirty
minutes a day is all that is required to see improvement and you'll enjoy the same
benefits if you find it easier to fit two 15 minute or two to three 10 minute sessions into
your day.
Include variety - You're less likely to become bored if you cross train. Include the three
basic forms of exercise in your fitness program: aerobics, strength training, and
stretching. Or if you prefer, alternate your activities, basketball one day, yoga another,
and stacking wood on the third. The thing to remember is that ANY activity will help you
burn calories!
Daily
Exercise
Goal
Date
Type of
Activity
Level of
Difficulty
Low-Mod-Diff
Total
Exercise
Time
Reward for
Completion of
Goal
Grief, Bereavement, & Mourning
Bereavement is the state of having lost a significant other to death.
Grief is the personal response to the loss.
Mourning is the public expression of that loss.
What is “Normal” Grief?
Grief reactions vary depending on who we are, who we lost, our relationship with that person,
the circumstances around their passing, and how much their loss affects our day-to-day
functioning. Different people may express grief differently and you may even have different
grief responses between one loss and another.
Reactions to grief and loss include not just emotional symptoms, but also behavioral and
physical symptoms. These reactions can often change over time. All are normal for a short
period of time.
Emotional
Behavioral
Physical
Shock, denial, numbness
Crying unexpectedly
Exhaustion/Fatigue
Sadness, anxiety, guilt, fear
Sleep changes (increase or decrease) Decreased energy
Anger (at others or God),
Not eating/Weight changes
Memory problems
Irritability, frustration
Withdrawing from others
Stomach and intestinal upset
Restlessness, difficulty
concentrating, trouble making
decisions
Pain and headaches
Symptoms that are not normal and may signal the need to talk to a professional include: Use of
drugs, alcohol, violence, and thoughts of killing oneself.
The duration of grief varies from person to person. Current research shows that the average
recovery time is 18 to 24 months. Also, grief reactions can be stronger around anniversary or
other significant dates, such as the anniversary of the person’s death, birthdays, and holidays.
The Stages of Grief
Grief therapists often describe stages of grief outlined by the research of Dr. Elizabeth Kubler-Ross.
These stages do not always go in order. You may move back and forth among some of the stages and
may even “skip” some of them. These stages are meant as a guide to help you understand your
reactions and those of others who are grieving.
•
Denial: Denial (not acknowledging the loss) can help contain the shock of loss. Denial
can act as a “safety mechanism” to block out grief until we are ready to handle it.
•
Sadness and depression: Deep, intense grief and mourning appear during this stage.
When the full understanding of our loss comes, it can seem overwhelming. During this
stage, you may cry often and unexpectedly. You may not want to be around people or
to do things that you normally enjoy. During this stage, it is best to remain as active as
possible and to seek supportive people who will allow you to say what you need to or to
cry when you need to. It is important to allow yourself to work through your full range
and experience of emotions.
•
Anger: Rage and anger can be intense toward the person who died, toward friends and
relatives, and even toward God. It is important to have an outlet to release anger
through activities such as exercise, hobbies, or through therapy. Guilt, shame, and
blame are feelings that need to be addressed, especially if it is toward you.
•
Acceptance: This stage includes “coming to terms” with the loss. It does not mean that
you have found the answers to your questions or that you stop thinking about the
person who is gone. It does signify a reinvestment in life and a willingness to readjust to
your new circumstances while carrying the memory of your loved one with you.
How to Help Yourself
1. Give yourself time to grieve. It is normal and important to express your grief and to
work through the concerns that arise for you at this time. “Stuffing” your feelings may
not be helpful and may delay or prolong your grief.
2. Find supportive people to reach out to during your grief. This is the time when the
support of others may be the most helpful. Don’t be afraid to tell them how they can
best help, even if it means just listening. It is often very helpful to talk about your loss
with people who will allow you to express your emotions.
3. Take care of your health. Often after a loss, we stop doing the things we need to for
health care, such as exercising, eating correctly, keeping Dr. appointments, or taking
prescribed medications. If you are on a health care regimen, it is important to continue
to adhere to your treatment.
4. Postpone major life changes. Give yourself time to adjust to your loss before making
plans to change jobs, move or sell your home, remarry, etc. Grief can sometimes cloud
your judgment and ability to make decisions.
5. Consider keeping a journal. It is often helpful to write or tell the story of your loss and
what it means to you as a way to work through your feelings.
6. Participate in activities. Staying active through exercise, enjoyable activities, outings
with supportive others, or even starting new hobbies can help us get through tough
times while providing opportunities for constructive development and use of energy.
7. Find a way to memorialize your loved one. Planting a tree or garden in the name of
your loved one, dedicating a work to their memory, contributing to a charity in their
name, and other such activities can be helpful.
8. Consider joining grief-support groups or contacting a grief counselor for additional
support and help.
Remember that depressive symptoms (feeling sad) are a fundamental part of normal
bereavement. Staying active and finding support from others can help you to work through the
grief process.
References
Aartsen, MJ, Van Tilberg, T, Smits, CH, Comijs, HC, & Knipscheer, KC. (2005). Does
widowhood affect memory performance of older persons? Psychological Medicine, 35(2),
217-226.
Chen, JH, Gill, TM, & Prigerson, HG. (2005). Health behaviors associated with better quality
of life for older bereaved persons. Journal of Palliative Medicine, 8(1), 96-106.
Clark, A. (2004). Working with grieving adults. Advances in Psychiatric Treatment, 10, 164170.
Clements, PT, DeRanieri, JT, Vigil, GJ, & Benasutti, KM. (2004). Life after death: Greif
therapy after the suddent traumatic death of a family member. Perspectives in Psychiatric
Care, 40(4), 149-154.
Fauri, DP, Ettner, B, & Kovacs, PJ. (2000). Bereavement services in acute care settings.
Death Studies, 24, 51-64.
Jacobs, S, & Prigerson, H. (2000). Psychotherapy of traumatic grief: A review of evidence
for psychotherapeutic treatment. Death Studies, 24, 479-495.
Servaty-Seib, HL. (2004). Connections between counseling theories and current theories of
grief and mourning. Journal of Mental Health Counseling, 26(2), 125-145.
HEADACHE: Types, Tips & Treatment Suggestions
Headaches are one of the most common complaints patients present with in primary care
settings. They are often correlated with stress, tension and a litany of existing medical
conditions. Often, patients will live with headache pain for months or even years before
seeking care. Over the counter remedies like aspirin, ibuprofen and acetimenophen are often
used to reduce symptoms of pressure and pain prior to seeking medical advice. The following
information is intended for patients that suffer from chronic headache pain and are looking for
ways to better manage symptoms, increase function and improve quality of life.
A headache is a headache is a headache…..Right?
There are actually two main types of headache, primary and secondary, and they can differ
greatly in intensity, frequency and duration.
Primary headaches include, but are not limited to, tension-type and migraine headaches
and are not caused by other underlying medical conditions. Over 90% of
headaches are considered primary.
Secondary headaches result from other medical conditions, such as infection or
increased pressure in the skull due to tumor, disease, etc. These account for
fewer than 10% of all headaches.
Headache Classification
Tension-type Headaches
Tension type headaches are the most common, affecting upwards of 75% of all headache
sufferers.
•
As many as 90% of adults have had tension-type headache
•
These headaches are typically a steady ache rather than a throbbing one, and affect
both sides of the head
•
Distracting but usually not debilitating
•
People can get tension-type (and migraine) headaches in response to stressful events or
a hectic day
•
These headaches may also be chronic, occurring as frequently as every day
Migraine Headaches
Less common than tension-type headaches, migraines affect approximately 25 to 30 million
people in the United States and cause considerably more disability, lost work days and lost
revenue.
•
As many as 6% of all men and up to 18% of all women (about 12% of the population as a
whole) experience a migraine headache at some time
•
Roughly three out of four migraine sufferers are female
•
Among the most distinguishing features is the potential disability accompanying the
headache pain of a migraine
•
Migraines are felt on one side of the head by about 60% of migraine sufferers, and the
pain is typically throbbing in nature
•
Nausea, with or without vomiting, as well as sensitivity to light and sound often
accompanies migraines
•
An aura --a group of telltale neurological symptoms--sometimes occurs before the head
pain begins. Typically, an aura involves a disturbance in vision that may consist of
brightly colored or blinking lights in a pattern that moves across the field of vision
•
About one in five migraine sufferers experiences an aura
•
Usually, migraine attacks are occasional, or sometimes as often as once or twice a week,
but not daily
Headache Triggers
Many things can cause a headache, thus it is important for you to become aware of the factors
in your life that may contribute to your suffering, and, if possible, make changes to minimize
the chances of continued suffering. Some examples of factors that can cause headache are
outlined below:
•
Emotional Factors: Stress (work, home, family), depression, anxiety, frustration, let
down, even positive excitement
•
Dietary Factors: Alcohol, aspartame, cheese, chocolate, caffeine, monosodium
glutamate (MSG), processed meats containing nitrates
•
Physical Factors: Getting too much or too little sleep, too much physical exertion,
injuries, skipping meals
•
Environmental Factors: Glare from the sun or bright lights, changes in the weather,
strong odors, smog
•
Hormonal Events: Menstruation, oral contraceptives, hormone replacement therapies,
menopause
Treatment of Headaches
There are a number of medications, such as muscle relaxants, analgesics (e.g., aspirin, percocet,
fiorinol), or antihypertensives that can help with migraine and/or tension headaches. If you’re
reading this, chances are they’re not working for you or you haven’t tried all available
treatments yet. Taking medication isn’t the only thing you can do to alleviate your headache.
Research has shown that numerous other methods, or behaviors, are also very effective in
treating and managing recurrent headaches. Here are some examples of what you can do to
increase your control over your headaches.
•
Become educated about your specific headache type, visit websites, such as:
•
•
•
The American Council for Headache Education (http://www.achenet.org/)
The American Headache Society (http://www.ahsnet.org/)
Engage in relaxation exercises to decrease stress and tension:
•
•
•
•
Deep breathing & cue controlled relaxation
Progressive muscle relaxation
Relaxation by recall
Biofeedback
•
Cognitive-behavioral stress-management: Focuses on increasing your understanding of
the role of cognitions (thoughts) in stress responses, and relationships between stress,
coping, and headaches
•
•
Talk with your PCP about anti-depressant medications:
Combination of behavioral and medication therapies: For example, engaging in
relaxation exercises and taking Zoloft at the same time
Optimizing Treatment
To be better able to treat your headache, it is important to keep track of your triggers,
symptoms and progress. Filling out a headache diary gives you, and your medical and
behavioral health doctor, an accurate picture of the frequency and severity of your headache
experience. It also provides a way to identify patterns, such as the association with certain
foods or specific situations.
Why Use a Headache Diary? 1
•
Triggers: you may become more aware of your specific triggers as you monitor your
headaches. Keeping a headache diary will help you determine whether factors such as
food, change in weather, and/or mood have any relationship to your headache pattern.
•
Track progress: diaries are also an excellent way to track your progress in treatment.
Sources: The International Headache Society, The American Council for Headache Education, The American
Headache Society, WHMC Clinical Health Psychology Dept, Neurology, The Clinical Psychologist, Journal of
Consulting and Clinical Psychology, Behavior Therapy.
1
DATE
SEVERITY
1 = mild
2 = moderate
3 = severe
TRIGGER/S
RELIEF MEASURE/S
DURATION
Managing Hypertension
•
Normal blood pressure is below 120/80 mmHg.
•
Prehypertension is the range of 120/80 to 139/89. This means that you don't have high
blood pressure now but are likely to develop it in the future. You can take steps to
prevent high blood pressure by adopting a healthy lifestyle.
•
Hypertension or high blood pressure is a blood pressure reading of 140/90 or higher.
Nearly one in three American adults has high blood pressure. Once high blood pressure
develops, it usually lasts a lifetime. The good news is that it can be treated and
controlled.
Not all incidents of hypertension have a known cause, but some factors have been shown to
increase blood pressure:
STRESS
SODIUM
TOBACCO
OVERWEIGHT
High blood pressure is sometimes called "the silent killer" because it usually has no symptoms.
Some people may not find out they have it until they have trouble with their heart, brain, or
kidneys. When high blood pressure is not found and treated, it can cause:
1. The heart to enlarge, which can lead to heart failure.
2. Small bulges (aneurysms) to form in blood vessels. Common locations are the main
artery from the heart (aorta), arteries in the brain, legs, and intestines, and the artery
leading to the spleen.
3. Blood vessels in the kidney to narrow, which may cause kidney failure.
4. Arteries throughout the body to "harden" faster, especially those in the heart, brain,
kidneys, and legs. This can cause a heart attack, stroke, kidney failure, or amputation
of part of the leg.
5. Blood vessels in the eyes to burst or bleed, which may cause vision changes and can
result in blindness.
So, how can you manage hypertension?
Fortunately, research has shown there are a number of things you can do to manage your
hypertension and keep those blood pressure numbers down!
Exercise
Regular exercise has been shown to significantly decrease blood pressure. If you don’t normally
exercise, you can start with something as simple as walking and work your way up to a daily
exercise routine that is right for you.
Diet Modification
A number of studies have shown that a diet low in sodium, and rich in fruits, vegetables, lean
meats and low-fat dairy foods is highly effective in lowering blood pressure. The American
Heart Association and the National Institute of Health endorse a specific diet for individuals
with high blood pressure, called the DASH (Dietary Approaches to Stop Hypertension) diet.
The DASH diet is based on about 2,000 calories and 1,500 milligrams of sodium a day. For more
details about the DASH diet, you can go to either of these websites:
•
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/
•
http://www.dashforhealth.com/
•
Or ask the Primary Care Behaviorist for a copy of the DASH eating plan.
Weight Loss
Many studies have shown that being overweight is a very important risk factor for
hypertension. Managing your weight through eating a balanced diet and engaging in regular
exercise can help you maintain a healthy weight.
Managing Stress
Medical studies have shown that the way we react to stress can greatly impact hypertension.
You can learn to manage stress by engaging in relaxation techniques that help to reduce blood
pressure. One great relaxation technique that is easy to do and takes very little time is
diaphragmatic or deep breathing.
Deep Breathing Exercise
1. Sit in a comfortable position.
2. Take 3 deep cleansing breaths.
3. Place one hand on your stomach and the other on your chest.
a) As you inhale, concentrate on your chest remaining relatively still while your
stomach rises. It may be helpful to imagine that your pants are too big and you
need to push your stomach out to hold them up.
b) When exhaling, allow your stomach to fall in and the air to fully escape.
5. Take some deep breaths, concentrating on only moving your stomach.
6. Return to regular breathing, continuing to breathe so that only your stomach moves.
Focus on an easy, regular breathing pattern.
Note: It is normal for this healthy breathing to feel a little awkward at first. With practice, it will
become more natural to you.
The CALM Reminder
Chest:
Breathing slower and deeper
Arms:
Shoulders sag
Legs:
Loose and flexible
Mouth:
Jaw drop
Protocol for Parenting Interventions
1. PCPs refer parent(s) and children to the PCB when patients identify the following difficulties:
developmental delays in a child, discipline problems or communication problems.
2. In the initial PCB consultation, the PCB will provide routine initial health and behavior
assessment services and
a. determine the cause(s) of parenting problems (parent conflicts, parent-child conflicts,
deficits in parenting skills)
b. determine patient preferences concerning interventions (services from PCP and PCB
team or participation in a parenting class in the community)
c. determine need for services from specialty MH
3. If the patient(s) chooses to participate in a parenting class, the PCB will complete the
appropriate referral form and schedule 1 follow-up with the patient(s) to (a) assess the impact
of the initial plan and (b) to further refine the intervention for on-going support by the PCP.
4. If the patient(s) choose to receive services only from the PCP and PCB team, the PCB will
implement the Primary Care Parenting Protocol. This program can be adjusted to fit parent-child
issues from age 2 to 18.
5. The PCB will also provide on-going training, individually and in provider meeting presentations,
on the Primary Care Parenting Protocol (PCPP) and provide related patient education handouts
for PCPs.
Primary Care Parenting Protocol
This program includes 3 contacts (including the initial) with the PCB and an optional fourth visit. The PCB
adjusts the curriculum to fit the needs of the patient(s).
1. Initial Visit: Behavioral Health Plan will focus on interventions that may improve the parent-child
relationship (Handout: Positive Parenting)
2. Second Visit: Education and Behavioral Health Plan will focus on building skills for setting limits
and using incentive programs (to help the child establish new behaviors) and consequences (to
help the child change undesired behaviors). (Handout: Setting Limits and Using Incentives and
Consequences)
3. Third Visit: Education and Behavioral Health Plan will focus on building skills for ignoring and
time out procedures. (Handout: Ignoring and Time-Out / A United Front)
4. Optional Visit: The optional visit is for parents who are in conflict about parenting issues or who
lack skills for taking a mindful stance in using behavioral parenting strategies. When these
problems are observed, it is best to schedule the optional visit as the second visit. Education and
Behavioral Health Planning will focus on helping the parents present a united front to the
child(ren), model effective conflict resolution skills, and practice mindfulness strategies on a
daily basis both in the context of parenting and during alone time. (Handout: Ignoring and Time
Out / A United Front)
5. PCPs will see patients at least once during or at the conclusion of participation in the Primary
Care Parenting Protocol.
PCPP content for items 1-3 above is consistent with empirically supported programs detailed in Schafer, C. E. &
Briemeister, J. M. (1998). Handbook of Parent Training, NY: John Wiley & Sons. (See chapter by Webster-Stratton &
Hancock, pp. 98-152).
Positive Parenting
We are more successful disciplining our children when we have good relationships with them. To
develop good relationships, parents need to know how to praise their children and to play with
them. This is true from birth. The following tips will help you with a child of any age. Make an X by
any that you want to discuss with your provider.
When playing with children,
1. Follow the child’s lead.
2. Pace at the child’s level.
3. Engage in role-play and make-believe with the child.
4. Praise and encourage the child’s ideas and creativity.
5. Use descriptive comments instead of asking questions.
6. Be an attentive and appreciative audience.
7. Curb the desire to give too much help; encourage the child’s problem solving.
8. Don’t expect too much—give the child time to think and explore.
9. Avoid too much competition with children.
10. Don’t criticize.
11. Reward quiet play times by giving your positive attention.
12. Laugh and have fun.
Important information about praising children
1. Don’t worry about spoiling children with praise.
2. Catch the child when he or she is being good—don’t save praise for perfect
behavior.
3. Make praise contingent on positive behavior.
4. Praise immediately.
5. Give labeled and specific praise.
6. Praise with smiles, eye contact, and enthusiasm.
7. Give pats, hugs, and kisses along with verbal praise.
8. Praise in front of other people.
9. Praise wholeheartedly, without qualifiers or sarcasm.
10. Increase praise for difficult children.
11. Model self-praise.
Plan:
Results:
Setting Limits and Using Incentives and Consequences
We are more likely to succeed as parents if we have skills. Setting limits and using incentive
programs and consequences are important tools for shaping a child’s behavior.
About setting limits
1. Be realistic in your expectations and use age-appropriate commands.
2. Give one command at a time.
3. Use commands that clearly specify the desired behavior.
4. Make commands short and to the point.
5. Use do commands and when-then commands.
6. Make commands positive and polite.
7. Give children options when possible.
8. Give children ample opportunity to comply.
9. Praise compliance or provide consequences for noncompliance.
10. Give warnings and helpful reminders.
11. Don’t use stop or don’t commands.
12. Don’t give unnecessary commands.
13. Don’t threaten children.
14. Support your partner’s commands.
15. Strike a balance between parent and child control.
Important information about incentive programs
16. Define the desired behavior clearly.
17. Choose effective rewards (i.e., rewards the child will find sufficiently reinforcing).
18. Set consistent limits concerning which behaviors will receive rewards.
19. Make the program simple and fun.
20. Make the steps small.
21. Monitor the charts carefully.
22. Follow through with the rewards immediately.
23. Avoid mixing rewards with punishment.
24. Gradually replace rewards with social approval.
25. Revise the program as the behaviors and rewards change.
Points to remember about consequences
26. Make consequence age-appropriate
27. Be sure you can live with the consequences you have set up.
28. Give the child a choice; specify consequences ahead of time.
29. Involve the child whenever possible.
30. Use consequences that are short and to the point.
31. Make consequences immediate.
32. Make consequences safe and nonpunitive.
Plan:
Results:
Ignoring and Time Out / A United Front
Ignoring and Time out are important skills, and they work very well with certain behavior problems.
While it is sometimes difficult, parents need to support each other in front of children and present a
united front.
Guidelines for ignoring
1. Limit the number of behaviors to ignore.
2. Choose specific behaviors to ignore and make sure you can ignore them.
3. Be consistent.
4. Physically move away from the child, but stay in the room if possible.
5. Avoid eye contact and discussion while ignoring.
6. Return attention to the child as soon as misbehavior stops.
7. Be prepared for testing.
When using time-out
1. Carefully limit the number of behaviors for which time-out is used.
2. Use time-out consistently for chosen misbehaviors.
3. Be as polite and calm as possible in sending child to time-out.
4. Give time-outs for one minute per year of child up to 10 minutes.
5. Be prepared for testing.
6. Use non-violent approaches, such as loss of privileges, as backup for not going to time
out.
7. Hold children responsible for messes in time-out.
8. Support a partner’s use of time out.
9. Don’t rely exclusively on time-out; combine with other techniques such as ignoring,
logical consequence, and problem solving.
10. Build up a “bank account”
Presenting a united front
1. Present a united front to reassure a child.
2. Model conflict resolution at a level appropriate for the child.
3. Make a plan about what to do when one parent is not at home and a discipline problem
occurs.
4. Use problem solving in a private meeting to solve differences in parenting style. Problem
solving involves the following steps: (a) agree on an agenda, time and place, (b) come
prepared, (c) define the problem, (d) brain-storm solutions and look at the pros and cons
of each, (e) make a decision, (f) implement, (g) meet again and evaluate the results.
5. Stepparents may have special ways of presenting a united front.
Plan:
Results:
Common Relationship Problems
Poor Communication
The way couples communicate with each other can lead to both increased stress and tension.
Some examples of poor communication are when:
•
One partner has a demanding communication style that leads the other partner to
refuse to communicate in response.
•
One partner tries to manipulate the other with negative emotions, such as anger and
sadness.
•
One Partner personally criticizes his/her partner, such as calling him/her ‘lazy’, rather
than focusing on behaviors.
Ways to enhance communication:
•
Remove all distractions, such as television or radio noise, and arrange a time to talk that
suits you both.
•
Avoid interrupting your partner. Summarize back what you have heard for accuracy
before replying.
•
Avoid labeling. Focus on behaviors that are problematic, not your partner as an
individual.
•
Talk about the positive aspects of the relationship, as well as the problems.
Poor Problem Solving Skills
Problem solving skills are vital to working out relationship difficulties when they arise.
Some common barriers to problem solving are:
•
Not identifying the true cause of the problem. For example, assuming your partner’s
recent disinterest means he/she is losing feelings for you, when the actual reason is
work stress.
•
Choosing a solution before considering all options.
•
Trying to solve the problem without your partner’s input.
Ways to enhance problem solving skills:
•
Separate big problems into smaller ones and deal with each individually in order of
importance.
•
Consider many possible options and strategies before choosing a solution.
•
Work with your partner as a partner. Both of you need to have a sense of shared
ownership in the process and the outcomes.
Inadequate Partner Support
Both partners need to give and receive adequate support for a relationship to survive and
flourish.
Some common problems with partner support are:
•
Having unrealistic expectations and demands.
•
Relying on your partner to meet all of your support needs likely places too much
pressure on them.
•
Not effectively communicating your needs can result in arguments.
Ways to enhance partner support:
•
Identify and be realistic about the support you need.
•
Realize that your partner will not be able to meet all of your needs. Some of these needs
will have to be met outside the relationship.
•
Communicate your expectations clearly. Check if he/she can fulfill your expectations /
understands your expectations for support.
Lack of Quality Time Together
Spending time together is not “quality” when you are tired and distracted, and end up arguing
or failing to enjoy each other’s company.
Quality time together involves:
•
Jointly planning to spend quality time together. When planning, focus on positive
things, unless you agree to do otherwise.
•
Identifying shared interests that you can enjoy together and try to think of new ones
that you can try.
Personal Differences in the Relationship
All couples will have differences in their relationships. The way you deal with these differences
can either enhance or add stress to the relationship.
Ways to deal with personal differences:
•
People in successful relationships do not try to force the other to be exactly like them;
they work to accept difference even when this difference is profound.
•
Do not demand that a partner change to meet all your expectations. Work to accept the
differences that you see between your ideal and the reality.
•
Try to see things from the other's point of view. This doesn't mean that you must agree
with one another, but rather that you can expect yourself and your partner to
understand and respect your differences, your points of view and your separate needs.
Golden rules for arguing constructively
DO:
DON’T:
•
•
Behave aggressively or disrespectfully
•
•
•
Generalize problems to entire relationship
Stick to the matter at hand
•
Cease arguing and separate if there is any
likelihood of violence
Bring other peoples' opinions into the
argument
•
Argue about something for more than an
hour, late at night or after drinking alcohol
•
•
•
•
•
Know why you are arguing before you start
Devote some time to resolving the problem
•
•
•
Agree to differ if you cannot agree
Sit down and make eye contact
Speak personally about what you feel
Acknowledge when the other person makes
a valid point
Argue deliberately to hurt the other
person's feelings
Bring up old unresolved disputes
Walk away without deciding when
discussion will be resumed (unless violence
threatens)
Sexual Problems
What leads to sexual
problems?
Results of sexual problems
What reduces sexual
problems
•
Side effects from
certain medications
•
Relationship
difficulties
•
Medical treatment
(if problem is
biological)
•
Medical problems
•
Feeling distant
•
Reduced
performance
demands
•
Relationship
difficulties
•
Anxiety
•
Sexual exercises
•
Psychological
factors
•
Guilt
•
Realistic
expectations
•
Physical
environment
•
Low self-esteem
•
Individual/Couple
therapy
What Are Sexual Problems?
Sexual problems are problems related to the sexual interactions between couples. Problems
can occur during desire, arousal, or orgasm stages. Sexual problems are not rare.
•
Approximately 20% of married couple and 30% of non-married couples have sexual
contact than 10 times per year
•
•
•
Approximately 43% of women and 31% of men of all ages report having sexual problems
1 in 3 women complain of a lack of sexual desire
Inhibited sexual desire affects 15% of men and increases with age
Sexual problems can have a powerful impact on relationships. Clinicians suggest that sexuality
contributes to about 15-20% of a marital relationship. When sexual problems occur, they
contribute up to 50-75%, which can be very draining to the marriage.
What Leads to Sexual Problems?
Many medications can affect your sexual desire, arousal, and orgasm:
• Antidepressants
• mood stabilizers
• anxiolytics
• chemotherapy drugs
• alcohol
• narcotics
• oral contraceptives
• hormonal therapies
• some allergy
• hypertension
• glaucoma medications
• anticonvulsants
Certain medical problems or surgeries can impact sexual functioning:
• Chronic pain
• insomnia
• diabetes
• hypertension
• thyroid conditions
• heart disease
• emphysema
• cancer
Recent surgeries that have impacted sexual organs:
• mastectomy
• hysterectomy
• removal of ovaries for females
• prostatectomy
• orchiectomy, etc. for males
Difficulties within the relationship can lead to sexual problems:
• Dissatisfaction
• resentment
• power struggles
• poor communication
• different value systems
• lack of intimacy
• lack of emotional expression
• lack of physical affection
• different sexual preferences
Personal and Psychological Factors:
• Fatigue
• stress
• depression
• age
• performance anxiety
• negative beliefs about sex or
• anxiety
• low self-esteem
• poor body image
• narrow or unrealistic
standards for sexual
interactions
certain sexual practices
What’s a Normal Sexual Response Anyway?
The way people respond sexually is variable. Most couples/partners don’t have the same
response at the same time. Problems can occur when the arousal phase is not achieved, when
the plateau period is extended, or when orgasm does not occur.
Possible
2nd arousal
and
Orgasm
Plateau
Resolutio
Plateau
Refractor
y Period
Resolutio
Arousa
Orgasm
Female Sexual Responses (example)
Arousal
Male Sexual Responses (example)
Possible
2nd arousal
and
Common Female Sexual Dysfunctions
•
Inhibited sexual desire: low or no desire for sexual intercourse. Sexual desire involves
positive anticipation and a sense of deserving pleasure.
•
Nonorgasmic response during partner sex: inability to achieve orgasm during
intercourse. This is a normal variation in the female sexual response cycle.
•
Painful intercourse (dyspareunia): genital pain associated with sexual intercourse,
commonly experienced during coitus, but may also occur before or after intercourse.
•
Female arousal dysfunction: persistent or recurrent inability to attain or to maintain
until completion of sexual activity, often not feeling “turned on” or not producing an
appropriate amount of lubrication.
•
Primary nonorgasmic response: persistent or recurrent delay or absence of an orgasm
following sexual stimulation
•
Vaginismus: pain during intercourse associated with high anticipatory anxiety,
dissatisfaction with their bodies, and intimidation by their partners’ sexual desire and
arousal.
Common Male Sexual Dysfunction
•
Early ejaculation: onset or orgasm and ejaculation with little sexual stimulation, or
before, on, or shortly after penetration.
•
Erectile dysfunction: inability to attain or maintain an adequate erection during sexual
activity.
•
Inhibited sexual desire: Lack of desire for sex. Often secondary to another problem such
as erectile dysfunction or ejaculatory inhibition, and typically worsens over time due to
a cycle of anticipatory anxiety.
•
Ejaculatory inhibition: inability to ejaculate during intercourse. Men with this problem
may be able to ejaculate through oral or manual stimulation, but not during intercourse.
Treating Sexual Problems
•
Treatment of sexual problems takes on a variety of forms due to the variety of
problems.
•
Realistic expectations must be understood by both partners. Anxiety plays a large role is
sexual problems. Worries about performance only make performance worse.
•
Important to see physician to ensure problem is not biological and to receive
appropriate medical care if it is.
Decreasing Sexual Problems with Desire
•
Build a sense of comfort with nudity and body image
•
Take turns initiating
•
Identify characteristics each partner finds attractive
•
Initiate erotic touching on a weekly basis
•
Establish a trust/vulnerability position
•
Stop any uncomfortable sexual experience (especially true for those who have survived
sexual trauma)
Decreasing Sexual Problems with Pain
•
Partner’s need to be actively engaged in the process and couples need to function as an
intimate unit
•
Gain knowledge and comfort with genitalia
•
Use of relaxation strategies
•
Use of lubrication
•
Controlling the type and pacing of sexual activity
Activities that can decrease sexual problems
•
Self-exploration and stimulation. This can help you increase awareness of your own
body and make it easier to communicate likes and dislikes to your partner.
•
Changing negative thoughts and assumptions about what sex should be with more
positive and realistic thoughts about what feels good and right for you.
•
Challenging negative thoughts about your partner by focusing on what is attractive and
positive about them.
•
Physical exercise: Increases blood flow, reduces tension, enhances body image, and can
improve other conditions that hinder sexual functioning
•
Rebuild or establish emotional intimacy:
•
o
Schedule time together when you simply talk to each other. Use the time to
share feelings and get reacquainted with what is attractive and unique about
your partner.
o
o
Share leisure activities
Add small expressions of affection back into your daily routine if this is lacking
(i.e. an affectionate note, phone call, or e-mail; hugs or hand-holding, etc.)
Increase communication
o
Discuss sexual interests, desires, needs, and difficulties when you are NOT
engaged in sexual activity.
o
Talk about what is going well and what you would like to be different in the
relationship overall, then work together to come up with do-able solutions.
•
Add something new to sexual encounters (e.g., place, position, clothing, technique,
erotica)
•
Allow more time for foreplay and provide more partner-guided stimulation.
•
During sexual encounters focus on sensations rather than thoughts, performance,
expectations, and appearances.
Recommended Reading
•
Schnarch, David (1997). Passionate marriage: Keeping love & intimacy alive in
committed relationships.
•
Weiner-Davis, Michele (2003). The sex-starved marriage: A couple’s guide to boosting
their marriage libido.
Insomnia
Results of Insomnia
What Leads to Insomnia
What maintains insomnia?
•
Physiological arousal
•
Acute stress
•
•
Worrisome thinking
•
•
Anxiety
Personal loss (death,
separation, divorce, etc)
Inaccurate thoughts about
sleep
•
Sleeping pills
•
Depression
•
Medical problems
•
Myths about duration of sleep
•
Family conflict
•
Work problems
•
Daytime napping
•
Work problems
•
Family problems
•
Excess time in bed
•
Loss of motivation
•
Irregular sleep schedule
•
Performance anxiety
•
Medications for health
problems
How can I improve my sleep? Change your sleep behavior.
Go To Bed Only When You Are Sleepy
There is no reason to go to bed if you are not sleepy. When you go to bed too early, it only
gives you more time to become frustrated. Individuals often ponder the events of the day, plan
the next day’s schedule, or worry about their inability to fall to sleep. These behaviors are
incompatible with sleep, and tend to perpetuate insomnia. You should therefore delay your
bedtime until you are sleepy. This may mean that you go to bed later than your scheduled
bedtime. However, stick to your scheduled rising time regardless of the time you go to bed.
Get Out of Bed when You Can’t Fall Asleep or Cannot Go Back to Sleep in 15 Min
When you recognize that you’ve become a clockwatcher, get out of bed. If you wake up during
your sleep and you’ve tried falling back to sleep for 15 minutes and can’t, get out of bed.
Remember, the goal is to fall to sleep quickly. Return to bed only when you are sleepy (i.e.,
yawning, head bobbing, eyes closing, concentration decreasing). The goal is for you to
reconnect your bed with sleeping rather than frustration. You will have to repeat this step as
often as necessary.
Use Your Bed or Bedroom for Sleep and Sex Only
The purpose of this guideline is to associate your bedroom with sleep rather than wakefulness.
Just as you may associate the kitchen with hunger, this guideline will help you associate sleep
and pleasure with your bedroom. Follow this rule both during the day and at night. DO NOT
watch TV, listen to the radio, eat or read in bed. You may have to temporarily move the t.v. or
radio from your bedroom to help you regain a stable sleep cycle.
Sleep Hygiene Guidelines to Improve your Sleep Behavior
1. NO CAFFEINE: No caffeine 6-8 hours before bedtime
Yep, its true caffeine disturbs sleep; even for people who do not think they experience a
stimulation effect. Individuals with insomnia are often more sensitive to mild stimulants
than normal sleepers. Caffeine is found in items such as coffee, tea, soda, chocolate, and
many over-the-counter medications (e.g., Excedrin).
2. AVOID NICOTINE: Avoid nicotine before bedtime
Nicotine is a stimulant. It is a myth that smoking helps you “relax.” As nicotine builds in
the system it produces an effect similar to caffeine. DO NOT smoke to get yourself back to
sleep.
3. AVOID ALCOHOL: Avoid alcohol after dinner
Alcohol often promotes the onset of sleep, but as alcohol is metabolized sleep becomes
disturbed and fragmented. Thus, a large amount of alcohol is a poor sleep aid and should
not be used as such. Limit alcohol use to small quantities to moderate quantities.
4. NO SLEEPING PILLS: Sleep medications are effective only temporarily
Scientists have shown that sleep medications lose their effectiveness in about 2 - 4 weeks
when taken regularly. Over time, sleeping pills actually make sleep problems worse.
When sleeping pills have been used for a long period, withdrawal from the medication can
lead to an insomnia rebound. Thus, after long-term use, many individuals incorrectly
conclude that they “need” sleeping pills in order to sleep normally.
5. REGULAR EXERCISE: Preferably 40 minutes each day
Exercise in the late afternoon or early evening can aid sleep, although the positive effect
often takes several weeks to become noticeable. Do not exercise within 2 hours of
bedtime because it may elevate your nervous system activity and interfere with falling
asleep.
6. BEDROOM ENVIRONMENT: Moderate temperature, quiet, dark and
comfortable
Extremes of heat or cold can disrupt sleep. Noises can be masked with background white
noise (such as the noise of a fan) or with earplugs. Bedrooms may be darkened with blackout shades or sleep masks can be worn. Position clocks out-of-sight since clock-watching
can increase worry about the effects of lack of sleep. Be sure your mattress is not too soft
or too firm and that your pillow is the right height and firmness.
7. EATING
You should avoid the following foods at bedtime: anything caffeinated like chocolate,
peanuts, beans, most raw fruits and vegetables (they may cause gas), and high-fat foods
such as potato chips or corn chips. Be especially careful to avoid heavy meals and spices in
the evening. Do not go to bed too hungry or too full. Avoid snacks in the middle of the
night because awakening may become associated with hunger. A light bedtime snack,
such a glass of warm milk, cheese, or a bowl of cereal can promote sleep.
8. AVOID NAPS
The sleep you obtain during the day takes away from your sleep needed at night resulting
in lighter, more restless sleep, difficulty falling asleep or early morning awakening. If you
must nap, keep it brief, and try to schedule it before 3:00 pm. It is best to set an alarm to
ensure you don’t sleep more than 15-30 minutes.
9. UNWIND
Allow yourself at least an hour before bedtime to wind down. The brain is not a light
switch that you can instantly cut on and off. Most of us cannot expect to go full speed till
10:00 pm then fall peacefully to sleep at 10:30 pm. Take a hot bath, read a novel, watch
some TV, or have a pleasant talk with your spouse or kids. Find what works for you and
make it your routine before bed. Be sure not to struggle with a problem, get into an
argument before bed or anything else that increases your body’s arousal.
10. REGULAR SLEEP SCHEDULE
Spending excessive time in bed has two unfortunate consequences - (1) you begin to
associate your bedroom with arousal and frustration and (2) your sleep actually becomes
shallow. Surprisingly, it is very important that you cut down your sleep time in order to
improve sleep! Set the alarm clock and get out of bed at the same time each morning,
weekdays and weekends, regardless of your bedtime or the amount of sleep you obtained
on the previous night. You probably will be tempted to stay in bed if you did not sleep
well, but try to maintain your new schedule. This guideline is designed to regulate your
internal biological clock and reset your sleep-wake rhythm.
It usually takes 2-3 months for a sleep problem to get totally better, but most people see
improvements within 2-3 weeks if they consistently follow the guidelines.
Obstructive Sleep Apnea
What it is and How it is Treated
Obstructive sleep apnea (OSA) is defined as a periodic reduction or cessation of breathing due
to narrowing of the upper airways during sleep. This condition affects approximately 2% of
women and 4% of men in the U.S. However, about 95% of all cases go undiagnosed and
untreated, which is alarming considering that untreated obstructive sleep apnea poses several
major health risks.
Studies show that patients with sleep apnea have increased baseline heart rates, increased
blood pressure, and lower levels of blood oxygen, which may put them at increased risk for
cardiovascular problems such as hypertension, stroke, and heart failure. Often, patients
present to their primary care manager (PCM) complaining of persistent daytime fatigue,
regardless of how much sleep they have had the night before. The good news for patients who
have been diagnosed with OSA is that with proper treatment and lifestyle change, full recovery
can be achieved and the health risks reversed.
Common Symptoms
•
•
•
Snoring
•
•
•
•
•
•
•
Unrestful sleep
Daytime sleepiness or fatigue
Sleep fragmentation or recurrent night
awakenings
Increased irritability
Morning headaches
Decreased memory
Difficulty concentrating
Risk Factors
•
First degree relative diagnosed with
sleep apnea
•
•
•
•
•
•
Obesity
Hypertension
Male gender
Age (greater than 40)
Neck circumference
Postmenopausal women (higher risk
than premenopausal)
Nocturia (awakening from sleep to urinate)
Falling asleep while driving
How is sleep apnea diagnosed?
A nocturnal polysomnogram (sleep study) is conducted by sleep specialists to diagnose
obstructive sleep apnea. During this assessment information regarding chest wall effort,
airflow, body positioning, snoring, and oxyhemoglobin saturation is recorded. As you may have
guessed, the sleep specialists literally observe you sleeping while monitoring your brain / sleep
patterns. Often times, patients report their sleep duration as being longer or shorter than it
actually is. This assessment can identify exact sleep onset time, wake after sleep onset
episodes and the depth and quality of your sleep.
Treatments
A variety of treatments for sleep apnea exist and the use of each treatment is determined by
the severity of the disturbance in breathing during sleep. A combination of the following
treatments provided by a multidisciplinary team is ideal and can include: a behavioral medicine
specialist, a nutritionsist, an exercise specialist, a respiratory therapist and a pulmonary doctor
that has specialty training in sleep disorders. Below is a description of the types of treatments
that are currently available for OSA.
Behavioral
•
Weight loss –as little as a10% decrease in body weight has been found to have
significant improvement in obstructive breathing problems.
•
Avoidance of alcohol and sedatives
•
Avoidance of sleep deprivation
•
Positioning – Laying on side rather than back
Medical
•
CPAP Mask – Positive pressure through a mask
•
Oral Appliance – Recommended for patients with mild to moderate sleep apnea
Surgical
Sometimes used when patients are unable to tolerate positive airway pressure and for
those that find other treatments ineffective. However, sometimes surgeries do not
entirely eliminate the obstruction.
Treatment Goals
•
Establish normal nocturnal oxygenation and ventilation
•
Eliminate snoring
•
Eliminate disruption of sleep
Continuous Positive Airway Pressure (CPAP)
Nasal continuous positive airway pressure (CPAP) is the most common treatment for moderate
to severe obstructive sleep apnea. Research finds that this method is also highly effective when
used for more than 4.5 hours a night on a consistent basis. Studies have also shown that
adequate CPAP use can decrease the risk of cardiovascular diseases in patients with sleep
apnea. A CPAP unit provides immediate effects and complications with CPAP treatment are
rare. However, use of the CPAP masks may result in some level of discomfort. The following
table shows effective corrections for negative side effects from CPAP masks. However, if
symptoms persist, contact your physician.
Problems associated
with CPAP Masks
Cause
Adjustment
Nasal congestion
Dry nose and/or throat
Dry air
Try nasal saline spray before bedtime or upon
awakening.
Add heated humidification.
Try antihistamines or topical corticosteroids.
Dry mouth
Sleeping with mouth
open
Try a chin strap and if it is not helpful consider a
full-face mask. Add heated humidification.
Sore, dry, irritated or swollen
eyes
Mask leaks
Mask too tight
Try readjusting the mask on face. Readjust
headgear straps.
Inspect mask for breaks.
Use eye patch.
Runny nose
Dry air
Try saline nasal spray before bedtime.
Try topical nasal steroid preparation before
bedtime.
Hay fever
Irritants drawn in
with room air
through machine
Put unit away from dust or animal hairs.
Some units can have special filters added.
Air leaks
Strap is loose or
tight.
Incorrect mask size.
Worn-out mask.
Dirty mask
Chest discomfort
Sensation of too much
pressure.
Difficulty exhaling
Pressure
requirement may be
lower at beginning of
sleep period
Readjust headgear straps. The mask should be
loose but still create a seal.
Nasal pillows may improve fit.
Consider full face mask that covers nose and
mouth.
Inspect mask for leaks or cracks.
Wash mask daily.
Try pressure ramp at beginning of sleep period.
Reduce pressure with bilevel positive airway
pressure.
Feelings of claustrophobia
Initial adjustment
period
Consider changing mask (nasal mask, full face,
nasal prongs)
CPAP machine too noisy
Blocked air intake
Too close to sleep
area
Check if filter is clean and not blocked by item.
Place unit farther away. May need to add to
length of hose.
Bed partner intolerance
Noise, anxiety
Attend patient support group (such as,
A.W.A.K.E Network of the American Sleep Apnea
Association)
Non-Compliance
The most common form of treatment for sleep apnea is with continuous positive airway
pressure (CPAP). However, as many as 50% of patients stop CPAP therapy during the first 2-4
weeks of treatment because of the negative side effects.
Did you know that research has found that……
•
CPAP refusers are more likely to be female and current smokers.
•
Non-compliance is related to high BMI (>30 kg/m2) and CPAP pressure >12.
•
Acceptance of CPAP treatment is not predicted by severity of sleep apnea or degree of
sleepiness.
•
Adequate compliance = >4.5 hours of CPAP use per night on a regular basis.
•
Patient education is especially important first month of treatment.
•
Follow-up with physician is important at least once after initiation of treatment and
annually thereafter.
•
Noncompliance is classified in terms of tolerance problems, psychological factors, and
lack of education, support and adequate follow-up care.
Improving Sleep through Behavior Change
Stimulus Control Procedures
Go to Bed only when You are Sleepy
bedtime until you are sleepy. This may mean that you go to bed later than your scheduled
bedtime. Remember to stick to your scheduled arising time regardless of the time you go to
bed.
Get Out Of Bed When You Can’t Fall Asleep Or Go Back To Sleep In About 15
Minutes. Return to Bed Only When You Are Sleepy. Repeat This Step As Often
As Necessary.
Although we don’t want you to be a clockwatcher, get out of bed if you don’t fall to sleep fairly
soon. Remember, the goal is for you to fall to sleep quickly. Return to bed only when you are
sleepy. When you feel sleepy (i.e., yawning, head bobbing, eyes closing, concentration
decreasing), then return to bed. The object is for you to reconnect your bed with sleeping
rather than frustration. It will be demanding to follow this instruction, but many people from
all walks of life have found ways to adhere to this guideline.
Use the Bed or Bedroom for Sleep and Sex Only; Do Not Watch TV, Listen to the
Radio, Eat, or Read in Your Bedroom.
with your bedroom. Follow this rule both during the day and at night. You may have to
temporarily move the TV or radio from your bedroom to help you during treatment.
Sleep Hygiene Guidelines
Good dental hygiene is important in determining the health of your teeth and gums. We all
know we are supposed to brush and floss regularly. Those who do so are more likely to have
strong, healthy gums and less cavities. Similarly good sleep hygiene is important in determining
the quality and quantity of your sleep. Below are guidelines for good sleep hygiene practices.
Review these guidelines and evaluate how well you practice good sleep hygiene.
Caffeine: Avoid Caffeine 6-8 Hours before Bedtime
Caffeine disturbs sleep, even in people who do not think they experience a stimulation effect.
Individuals with insomnia are often more sensitive to mild stimulants than are normal sleepers.
Caffeine is found in items such as coffee, tea, soda, chocolate, and many over-the-counter
medications (e.g., Excedrin). Thus, drinking caffeinated beverages should be avoided near
bedtime and during the night. You might consider a trial period of no caffeine if you tend to be
sensitive to its effects.
Nicotine: Avoid Nicotine before Bedtime
Although some smokers claim that smoking helps them relax, but nicotine is a stimulant. The
initial relaxing effects occur with the initial entry of the nicotine, but as the nicotine builds in
the system it produces an effect similar to caffeine. Thus, smoking, dipping, or chewing tobacco
should be avoided near bedtime and during the night. Don’t smoke to get yourself back to
sleep.
Alcohol: Avoid Alcohol after Dinner
disturbed and fragmented. Thus, a large amount of alcohol is a poor sleep aid and should not
be used as such. Limit alcohol use to small quantities to moderate quantities.
Sleeping Pills: Sleep Medications are Effective Only Temporarily
Scientists have shown that sleep medications lose their effectiveness in about 2 - 4 weeks when
taken regularly. Despite advertisements to the contrary, over-the-counter sleeping aids have
little impact on sleep beyond the placebo effect. Over time, sleeping pills actually can make
sleep problems worse. When sleeping pills have been used for a long period, withdrawal from
the medication can lead to an insomnia rebound. Thus, after long-term use, many individuals
incorrectly conclude that they “need” sleeping pills in order to sleep normally. Keep use of
sleep pills infrequent, but don’t worry if you need t use one on an occasional basis.
Regular Exercise
Get regular exercise, preferably 40 minutes each day of an activity that causes sweating. .
Exercise in the late afternoon or early evening seems to aid sleep, although the positive effect
often takes several weeks to become noticeable. Exercising sporadically is not likely to improve
sleep, and exercise within 2 hours of bedtime may elevate nervous system activity and interfere
with sleep onset.
Bedroom Environment: Moderate Temperature, Quiet, and Dark
Extremes of heat or cold can disrupt sleep. A quiet environment is more sleep promoting than
a noisy one. Noises can be masked with background white noise (such as the noise of a fan) or
with earplugs. Bedrooms may be darkened with black-out shades or sleep masks can be worn.
Position clocks out-of-sight since clock-watching can increase worry about the effects of lack of
sleep. Be sure your mattress is not too soft or too firm and that your pillow is the right height
and firmness.
Eating
A light bedtime snack, such a glass of warm milk, cheese, or a bowl of cereal can promote sleep.
You should avoid the following foods at bedtime: any caffeinated foods (e.g., chocolate),
peanuts, beans, most raw fruits and vegetables (since they may cause gas), and high-fat foods
such as potato chips or corn chips. Avoid snacks in the middle of the nights since awakening
may become associated with hunger.
If you have trouble with regurgitation, be especially careful to avid heavy meals and spices in
the evening. Do not go to bed too hungry or too full. It may help to elevate you head with
some pillows.
Avoid Naps
Avoid naps, the sleep you obtain during the day takes away from you sleep need that night
resulting in lighter, more restless sleep, difficulty falling asleep or early morning awakening. If
you must nap, keep it brief, and try to schedule it before 3:00 pm. It is best to set an alarm to
ensure you don’t sleep more than 15-30 minutes.
Allow Yourself At Least an Hour before Bedtime to Unwind
The brain is not a light switch that you can instantly cut on and off. Most of us cannot expect to
go full speed till 10:00 pm then fall peacefully to sleep at 10:30 pm. Take a hot bath, read a
novel, watch some TV, or have a pleasant talk with your spouse or kids. Find what works for
you. Be sure not to struggle with a problem, get into an argument before bed or anything else
that might increase your body’s arousal.
Regular Sleep Schedule
Keep a regular time each day, 7 days a week, to get out of bed. Keeping a regular awaking time
helps set your circadian rhythm set so that your body learns to sleep at the desired time.
Set A Reasonable Bedtime and Arising Time and Stick to Them.
Spending excessive time in bed has two unfortunate consequences - (1) you begin to associate
your bedroom with arousal and frustration and (2) your sleep actually becomes more shallow.
Surprisingly, it is very important that you cut down your sleep time in order to improve sleep!
Set the alarm clock and get out of bed at the same time each morning, weekdays and
weekends, regardless of your bedtime or the amount of sleep you obtained on the previous
night. You probably will be tempted to stay in bed in the morning if you did not sleep well, but
try to maintain your new schedule. This guideline is designed to regulate your internal
biological clock and reset your sleep-wake rhythm.
Sticking to the Changes You Make
It can be difficult to stick to a self-management program. However, it is important to remind
yourself that the sleep guidelines have been extensively researched and represent the best
science has to offer for conquering a long-term insomnia problem. Literally, thousands of
individuals have improved their sleep through following the guidelines. The following points
may help you to stick to the guidelines.
1. Find activities to engage in when out of bed during the night.
•
Plan activities to engage in when you are not in bed at night because you can’t fall
asleep. These activities should be non-stimulating.
•
Prepare any materials needed to get out of bed (e.g., robe, book, etc.) ready prior to
bedtime.
2. Identify cues to determine sleepiness and time to return to bed.
•
•
Examples of “Sleepy Behavior” include yawning, heavy eyelids, nodding off, etc.
Remember that the longer you stay up and the sleepier you are, the quicker you will fall
to sleep.
3. Use alarm clock to maintain regular arising time.
•
You may also want to plan social, work or family commitments soon after waking to
increase motivation to adhere to arising time.
4. Find competing activities to fight the urge to take a nap before your bedtime.
•
These activities should be physical (e.g., housework, walking) rather than cognitive (e.g.,
reading) or passive (e.g., watching TV).
•
Examples include: taking a walk, having someone visit in the evening, talking on the
phone to a friend, working a puzzle, drawing, etc.
5. Secure support from your spouse/significant others.
•
Typically your bed partner will be deeply asleep and will not notice you getting out of
bed.
•
Have friends/family members help you adhere to the sleep guidelines. For example, a
family member could play a game with you to help you stay awake until bedtime.
6. Remember the time-limited nature of following these procedures.
•
It usually takes 2-3 months for a sleep problem to get totally better but most people see
improvements within 2-3 weeks if the consistently follow the guidelines. Isn’t sticking to
the guidelines for this short period worth it if your sleep ultimately improves?
Sleep Diary Instructions
In order to better understand your sleep problem and to assess your progress during
treatment, we’d like you to collect some important information about your sleep habits.
•
Before you go to sleep at night, please answer Questions 1 - 6.
•
After you get up in the morning, please answer the remaining questions, Questions 7 13.
It is very important that you complete the diary every evening and morning!!! Please don’t
attempt to complete the diary later. If you have any difficulties completing the diary, please
contact one of the BHP staff members at (210) 670-5968 and we’ll be glad to assist you.
It’s often difficult to estimate how long you take to fall asleep or how long you’re awake at
night. Keep in mind that we simply want your best estimates.
If any unusual events occur on a given night (e.g., emergencies, phone calls) please make a note
of it on the diary (at the bottom of the sheet).
Below are some guidelines to help you complete the Sleep Diary.
1. Napping: Please include all times you slept during the day, even if you didn’t intend to
fall asleep. For example, if you fell asleep for 10 minutes during a movie, please write
this down. Remember to specify a.m. or p.m., or use military time.
2. Sleep Medication: Include both prescribed and over-the-counter medications. Only
include medications used as a sleep aid.
3. Alcohol as a sleep aid: Only include alcohol that you used as a sleep aid.
4. Bedtime: This is the time you physically got into bed, with the intention of going to
sleep. For example, if you went to bed at 10:45 p.m. but turned the lights off to go to
sleep at 11:15 p.m., write down 10:45 p.m.
5. Lights-Out Time: This is the time you actually turned the lights out to go to sleep.
6. Time Planned to Awaken: This is the time you plan to get up the following morning.
7. Sleep-Onset Latency: Provide your best estimate of how long it took you to fall asleep
after you turned the lights off to go to sleep.
8. Number of Awakenings: This is the number of times you remember waking up during
the night.
9. Duration of Awakenings: Please estimate how many minutes you spent awake for each
awakening. If this proves impossible, then estimate the number of minutes you spent
awake for all awakenings combined. Don’t include your very last awakening in the
morning, as this will be logged in number 10.
10. Morning Awakening: This is the very last time you woke up in the morning. If you woke
up at 4:00 a.m. and never went back to sleep, this is the time you write down. However,
if you woke up at 4:00 a.m. but went back to sleep for a brief time (for example, from
5:00 a.m. to 5:15 a.m.), then your last awakening would be 5:15 a.m.
11. Out-of-Bed Time: This is the time you actually got out of bed for the day.
12. Restedness upon Arising: Rate your restedness using the scale on the diary sheet.
13. Sleep Quality: Rate the quality of your sleep using the scale on the diary sheet.
Sleep Diary
Name: _____________________________
Week:_______________ to ______________
(Beginning date)
(Ending date)
Example: Fill in the Day of the Week above each column
1. I napped from
to
(note times of all naps).
2. I took
mg of sleep medication as a sleep aid.
3. I took
oz. of alcohol as a sleep aid.
4. I went to bed at
o’clock.
5. I turned the lights out at
o’clock.
6. I plan to awaken at
o’clock.
7. After turning the lights out, I fell asleep in
minutes.
8. My sleep was interrupted
times (specify number of
nighttime awakenings).
9. My sleep was interrupted for
minutes (specify
duration of each awakening).
10. I woke up at
o’clock (note time of last awakening).
11. I got out of bed at
o’clock (specify the time).
12. When I got up this morning I felt
.
(1 = Exhausted, 2 = Tired, 3 = Average, 4 = Rather
Refreshed, 5 = Very Refreshed)
13. Overall, my sleep last night was
.
(1 = Very Restless, 2 = Restless, 3 = Average, 4 = Sound, 5 =
Very Sound)
NOTES:
Mon.
2:00 to
2:45 pm
ProSom
1 mg
Beer
12 oz.
10:30
11:15
6:15
45
3
20
30
15
6:15
6:40
2
1
Sleep Checklist
Question
Do you avoid caffeine 4 - 6 hours before bedtime?
Recommendation:
Do you avoid nicotine before bedtime?
Recommendation:
Do you avoid alcohol after dinner?
Recommendation:
Do you avoid vigorous exercise within 2 hours of bedtime?
Recommendation:
Do you have a “wind-down” ritual at least an hour before bed?
Recommendation:
Do you nap during the day?
Recommendation:
Is your bedroom comfortable (good temperature, quiet, and dark)?
Recommendation:
Do you wake-up at about the same time each morning?
Recommendation:
Do you go to bed only when you are sleepy?
Recommendation:
If you wake in the middle of the night or early morning, do you lie in
bed for more than 15-20 minutes?
Recommendation:
Do you watch TV, listen to the radio, eat, or read in your bedroom?
Recommendation:
Yes
No
Facts about Sleep
Prevalence of Insomnia
Insomnia is a widespread problem affecting essentially everyone at one period in their lifetime.
It is perhaps the most frequent health complaint after pain. A Gallup survey conducted in 1991
found that 36% of Americans suffer from some type of sleep problem, with 27% reporting
occasional insomnia and 9% reporting chronic insomnia. Surveys of physicians indicate that
19% of medical outpatients complain of insomnia.
Factors Which Make You Vulnerable to Insomnia
•
•
•
Increased Physiological Arousal
Models of Poor Sleep Habits
Aging
•
•
•
Worrisome Thinking Style
Anxiety
Depression
Factors Which May Initially Cause Insomnia
•
•
•
•
•
Acute Stress
Family Conflict
Jet Lag
Hospital Stay
Changes in Schedules (work, etc.)
•
•
•
•
•
Personal Loss (e.g., death, divorce separation)
•
•
•
•
•
Extreme Worry or Concern about Getting to Sleep
Work Problems
Medical Problems
Chronic Low-level Stress
Pain
Factors Which Maintain Insomnia
•
•
•
•
•
•
Poor Sleep Habits
Sleeping Pills
Irregular Sleep Schedule
Anxious Thinking
Activity that “Keys-up” the Body Before Bed
Misinformation about “Normal” Sleep
Medications
Daytime Napping
Excessive Time Spent in Bed when Not Sleeping
Misinformation about the Effects of Sleep
Problems
Aging and Sleep
As individuals age, they often have more interrupted sleep. Instead of having one consolidated
sleep period at night, they may sleep in two to four sleep episodes. As we age, total time in bed
increases, but total sleep time decreases. Generally, as people grow older, there is an increase
in light sleep and a decrease in deep sleep. However, aging alone does not account for all the
sleep problems seniors experience and behavioral insomnia treatment has been found to be
effective for seniors.
Alcohol and Sleep
Although alcohol may help you to go to sleep faster, alcohol actually causes sleep to be less
deep and more fragmented.
Sleep Needs
Sleep needs vary considerably among individuals. Sleep needs range from 3 to 10 hours of
sleep. Some people may get by on 4-5 hours, others feel good after 9 hours. Each individual’s
sleep needs varies somewhat day-to-day; some days 6 hours will be okay while other days 8
hours will be optimal.
Health Consequences
There is no evidence that anyone has died from lack of sleep. Excessive worrying about
insomnia may be more detrimental to health than sleep loss itself.
Daytime Consequences
Scientists have found that performance impairments as a result of poor sleep are fairly limited
as long as you get from 4-5 hours of sleep on most nights. Excessive worrying or concern about
insomnia appears to have more affect on our functioning than sleep loss itself.
Resting; Is it Better than Nothing?
Actually, staying in bed to rest when you are not sleeping can make an insomnia problem
worse. When you stay in bed awake for too long, you begin to associate your sleep
surroundings with frustration and arousal rather than sleep. The harder you try to sleep, the
less likely you are to succeed.
Behavioral Treatment for Insomnia
Behavioral procedures for insomnia have been extensively tested throughout the world and
have been shown to be effective with other patients suffering insomnia problems. About 75%
of chronic insomniacs benefit from this intervention, with an average improvement rate of 5060% in the reduction time it takes to fall asleep and/or time awake after going to sleep.
Following the highly structured guidelines requires time, patience, and effort. To achieve your
goals of falling asleep quickly at bedtime and of reducing the time spent awake in the middle of
the night, it is important that you follow all the guidelines. You cannot choose only those that
seem least painful.
It is likely that in about 4 weeks you will experience substantial improvement in your sleep.
However, it sometimes takes 2-3 weeks to start noticing improvement. Therefore, it is
important guard against discouragement in the early stages of treatment. Further, during the
first week of practice some people report that they feel worse. It is only after about three to
four weeks of consistent practice that people start to experience significant benefits. The
benefits of these highly effective procedures are related to how closely and consistently one
follows the guidelines.
For the first few nights you may be getting up many times before you fall asleep. You are likely
to be sleepy the next day. You may become discouraged and even think about discontinuing
behavioral treatment. You will think of many reasons why you can’t or shouldn’t follow the
guidelines. Remind yourself that for most individuals the worsening of sleep is only temporary
and is the path to a future of better sleep. You will see gradual and long-term improvement in
your sleep. People tell us that regaining control of their sleep was definitely worth the
temporary disruption caused by following the guidelines. So, don’t talk yourself out of gaining
control of your sleep!
Sleep Guidelines
Good dental hygiene is important in determining the health of your teeth and gums. We all
know we are supposed to brush and floss regularly. Those who do so are more likely to have
strong, healthy gums and fewer cavities. Similarly good sleep hygiene is important in
determining the quality and quantity of your sleep. Below are guidelines for good sleep
hygiene practices. Review these guidelines and evaluate how well you practice good sleep
hygiene.
Caffeine: Avoid Caffeine 6-8 Hours Before Bedtime
Caffeine disturbs sleep, even in people who do not think they experience a stimulation effect.
Individuals with insomnia are often more sensitive to mild stimulants than are normal sleepers.
Caffeine is found in items such as coffee, tea, soda, chocolate, and many over-the-counter
medications (e.g., Excedrin). Thus, drinking caffeinated beverages should be avoided near
bedtime and during the night. You might consider a trial period of no caffeine if you tend to be
sensitive to its effects.
Nicotine: Avoid Nicotine Before Bedtime
Although some smokers claim that smoking helps them relax, but nicotine is a stimulant. The
initial relaxing effects occur with the initial entry of the nicotine, but as the nicotine builds in
the system it produces an effect similar to caffeine. Thus, smoking, dipping, or chewing tobacco
should be avoided near bedtime and during the night. Don’t smoke to get yourself back to
sleep.
Alcohol: Avoid Alcohol After Dinner
disturbed and fragmented. Thus, alcohol is a poor sleep aid and will lead to less restful sleep.
Sleeping Pills: Sleep Medications are Effective Only Temporarily
Scientists have shown that sleep medications lose their effectiveness in about 2 - 4 weeks when
taken regularly. Despite advertisements to the contrary, over-the-counter sleeping aids have
little impact on sleep beyond the placebo effect. Over time, sleeping pills actually can make
sleep problems worse. When sleeping pills have been used for a long period, withdrawal from
the medication can lead to an insomnia rebound. Thus, after long-term use, many individuals
incorrectly conclude that they “need” sleeping pills in order to sleep normally. Keep use of
sleep pills infrequent, but don’t worry if you need to use one on an occasional basis.
Regular Exercise
Get regular exercise, preferably 30 minutes each day of an activity that causes sweating. .
Exercise in the late afternoon or early evening seems to aid sleep, although the positive effect
often takes several weeks to become noticeable. Exercising occasionally is not likely to improve
sleep, and exercise within 2 hours of bedtime is likely to interfere with sleep onset.
Bedroom Environment: Moderate Temperature, Quiet, and Dark
Extremes of heat or cold can disrupt sleep. A quiet environment is more sleep promoting than
a noisy one. Noises can be masked with background white noise (such as the noise of a fan) or
with earplugs. Bedrooms may be darkened with black-out shades or sleep masks can be worn.
Position clocks out-of-sight since clock-watching can increase worry about the effects of lack of
sleep. Be sure your mattress is not too soft or too firm and that your pillow is the right height
and firmness.
Eating
A light bedtime snack, such a glass of warm milk, cheese, or a bowl of cereal can promote sleep.
You should avoid the following foods at bedtime: any caffeinated foods (e.g., chocolate),
peanuts, beans, most raw fruits and vegetables (since they may cause gas), and high-fat foods
such as potato chips or corn chips. Avoid snacks in the middle of the nights since awakening
may become associated with hunger.
If you have trouble with regurgitation, be especially careful to avoid heavy meals and spices in
the evening. Do not go to bed too hungry or too full. It may help to elevate you head with
some pillows.
Avoid Naps
Avoid naps, the sleep you obtain during the day takes away from you sleep need that night
resulting in lighter, more restless sleep, difficulty falling asleep or early morning awakening. If
you must nap, keep it brief, and try to schedule it before 3:00 pm. It is best to set an alarm to
be sure you don’t sleep more than 15-30 minutes.
Allow Yourself At Least an Hour before Bedtime to Unwind
The brain is not a light switch that you can instantly cut on and off. Most of us cannot expect to
go full speed till 10:00 pm then fall peacefully to sleep at 10:30 pm. Take a hot bath, read a
novel, watch some TV, or have a pleasant talk with your spouse or kids. Find what works for
you. Be sure not to struggle with a problem, get into an argument before bed or anything else
that might increase your body’s arousal.
Set A Reasonable Arising Time and Stick to Them
Spending excessive time in bed has two unfortunate consequences - (1) you begin to associate
your bedroom with arousal and frustration and (2) your sleep actually becomes shallower.
Surprisingly, it is very important that you cut down your sleep time in order to improve sleep!
Set the alarm clock and get out of bed at the same time each morning, weekdays and
weekends, regardless of your bedtime or the amount of sleep you obtained on the previous
night. Keeping a regular awaking time helps set your circadian rhythm set so that your body
learns to sleep at the desired time. You probably will be tempted to stay in bed in the morning
if you did not sleep well, but try to maintain your new schedule. This guideline is designed to
regulate your internal biological clock and reset your sleep-wake rhythm.
Go To Bed Only When You Are Sleepy
bedtime until you are sleepy. Sleepiness is different from feeling tired. Examples of sleepiness
include yawning, head bobbing, eyes closing, and concentration decreasing. This may mean
that you go to bed later than your scheduled bedtime. Remember to stick to your scheduled
arising time regardless of the time you go to bed.
Get Out of Bed When You Can’t Fall Asleep or Go Back to Sleep in about 15
Minutes. Return to Bed Only When You Are Sleepy. Repeat This Step as Often
as Necessary.
Although we don’t want you to be a clock watcher, get out of bed if you don’t fall to sleep fairly
soon. Remember, the goal is for you to fall to sleep quickly in your bed. Return to bed only
when you are sleepy. The object is for you to reconnect your bed with sleeping rather than
frustration. It will be demanding to follow this instruction, but many people from all walks of
life have found ways to adhere to this guideline.
Use the Bed or Bedroom for Sleep and Sex Only; Do Not Watch TV, Listen to The
Radio, Eat, or Read in Your Bedroom.
with your bedroom. Follow this rule both during the day and at night. You may have to
temporarily move the TV or radio from your bedroom to help you while you work to improve
insomnia.
It will take time for your sleep to improve once you begin your sleep change plan.
Are 1-2 months of work worth a lifetime of good sleep?
Sticking To the Guidelines
It can be difficult to stick to a self-management program. However, it is important to remind
yourself that the sleep guidelines have been extensively researched and represent the best
science has to offer for conquering a long-term insomnia problem. Literally, thousands of
individuals have improved their sleep through following the guidelines. The following points
may help you to stick to the guidelines.
Find activities to engage in when out of bed during the night.
Plan activities to engage in when you are not in bed at night because you can’t fall asleep.
These activities should be non-stimulating.
Prepare any materials needed to get out of bed (e.g., robe, book, etc.) ready prior to bedtime.
Identify cues to determine sleepiness and time to return to bed.
Examples of “Sleepy Behavior” include yawning, heavy eyelids, nodding off, etc.
Remember that the longer you stay up and the sleepier you are, the quicker you will fall to
sleep.
Use alarm clock to maintain regular arising time.
You may also want to plan social, work or family commitments soon after waking to increase
motivation to adhere to arising time.
Find competing activities to fight the urge to take a nap before your bedtime.
These activities should be physical (e.g., housework, walking) rather than cognitive (e.g.,
reading) or passive (e.g., watching TV).
Examples include: taking a walk, having someone visit in the evening, talking on the phone to a
friend, working a puzzle, drawing, etc.
Secure support from your spouse/significant others.
Typically your bed partner will be deeply asleep and will not notice you getting out of bed.
Have friends/family members help you adhere to the sleep guidelines. For example, a family
member could play a game with you to help you stay awake until bedtime.
Remember the time-limited nature of following these procedures.
It usually takes 2-3 months for a sleep problem to get totally better but most people see
improvements within 2-3 weeks if the consistently follow the guidelines. Isn’t sticking to the
guidelines for this short period worth it if your sleep ultimately improves?
Stress and Stress Reduction
The stress reactions below are presented in categories so that they may be more easily
recognized and understood. There is no magic number of the symptoms that suggest difficulty
in coping. Rather it is the extent to which the noted reaction is a change (different from a
person's normal condition) that makes a reaction potentially important. Further, it is the
combined presence of symptoms that determines the degree of the problem. Indicators may
be isolated reactions or combinations among the three categories listed below. Finally, it is
their duration (how long the symptoms have been present/how long they last), the frequency
of such incidents (how often they happen) and the intensity (strength) with which they are
present that suggests the severity of the difficulty in coping.
Indicators of Difficulty in Coping
Emotional
Apathy
The "blahs"
Recreation no longer
pleasurable
Sad
Anxiety
Restless
Agitated
Insecure
Feeling of worthlessness
Irritability
Overly sensitive
Defensive
Arrogant/argumentative
Insubordinate/hostile
Mental Fatigue
Preoccupied
Difficulty concentrating
Inflexible
Overcompensation (denial)
Exaggerate/Grandiose
Overworks to exhaustion
Denies Problems/Symptoms
Suspicious/Paranoid
Behavioral
Physical
Withdrawal (smoking avoidance)
Social isolation
Work related withdrawal
Reluctance to accept
responsibilities
Neglecting responsibilities
Preoccupation with illness
(intolerant of/dwelling on minor
ailments)
Acting Out
Alcohol abuse
Gambling
Spending spree
Promiscuity
Desperate Acting Out
(getting attention-cry for help)
Administrative Infractions
Tardy to work
Poor appearance
Poor personal hygiene
Accident prone
Legal Infractions
Indebtedness
Shoplifting
Traffic tickets
Fights
Child/spouse abuse
Frequent illness (actually sick)
Use of self medication
Physical exhaustion
Immune system suppression
Somatic (Body) Indicators
Headache
Insomnia
Initial insomnia
Recurrent awakening
Early morning rising
Change in Appetite
Weight gain
Weight loss (more serious)
Indigestion
Nausea
Vomiting
Diarrhea
Constipation
Sexual difficulties
Deep Breathing Exercise
1. Sit in a comfortable position.
2. Take 3 deep cleansing breaths.
3. Place one hand on your stomach and the other on your chest.
a. As you inhale, concentrate on your chest remaining relatively still while your
stomach rises. It may be helpful to imagine that your pants are too big and you
need to push your stomach out to hold them up.
b. When exhaling, allow your stomach to fall in and the air to fully escape.
5. Take some deep breaths, concentrating on only moving your stomach.
6. Return to regular breathing, continuing to breathe so that only your stomach moves.
Focus on an easy, regular breathing pattern.
Note: It is normal for this healthy breathing to feel a little awkward at first. With practice, it will
become more natural to you.
The CALM Reminder
Chest:
Breathing slower and deeper
Arms:
Shoulders sag
Legs:
Loose and flexible
Mouth:
Jaw drop
Cue-Controlled Relaxation
Cue-controlled relaxation is a very quick and easy relaxation technique. Set up a cue to remind
you to relax.
1.
There are two different types of cues (reminders):
External Cue (reminder) (e.g., when your watch alarm sounds; when you see a note on
your desk; at traffic lights, etc.)
Internal Cue (reminder) (e.g., when your muscles reach a certain tension level, when
you feel a headache coming on)
Note: It’s very important that once you set up a cue, that you actually do the relaxation
exercise when the cue comes up. Eventually it will become a healthy habit!
2.
Relax by doing the following
a. Take a deep, easy breath
b. Exhale s l o w l y....
c. Say a word to yourself as you exhale (e.g., “relax” or “calm”)
d. As you exhale, focus on letting your muscles relax. As an option (if it’s
convenient), you can close your eyes too
Disputation: Challenging Upsetting Thinking
Examine your thoughts for key words:
1.
must, need, got to, have to, should (unrealistic standards)
2.
never, always, completely, totally, all everything, everyone (predictions / labeling)
3.
awful, terrible, horrible, unbearable, disaster, worst ever (labeling / predictions)
4.
jerk, slob, creep, hypocrite, bully, stupid (labels)
Dispute or question the accuracy of the questionable thoughts.
1.
Am I upsetting myself unnecessarily? How can I see this another way?
2.
Is my thinking working for or against me? How could I view this in a less upsetting
way?
3.
What am I demanding must happen? What do I want or prefer, rather than need?
4.
Am I making something too terrible? Is it really that awful? What would be so terrible
about that?
5.
Am I labeling a person? What is the action that I don’t like?
6.
What’s untrue about my thoughts? How can I stick to the facts? What’s the proof for
what I am thinking or believing about this?
7.
Am I using extreme, black-and-white language? What less extreme words might be
more accurate?
8.
Am I fortune telling or mind reading in a way that gets me upset or unhappy? What are
the odds (percent chance -- e.g., there is a 5% chance...) that it will really turn out the
way I’m thinking or imagining?
9.
What are my options in this situation? How would I like to respond?
10. Create more moderate, helpful, or realistic statements to replace the upsetting ones.
11. Have I had any experiences that show that this thought might not be completely true?
12. If my best friend or someone I loved had this thought, what would I tell them?
13. If my best friend or someone I loved knew I was thinking this thought, what would they
say to me? What evidence would they point out to me that would suggest that my
thought is not completely true?
14. Are there strengths in me or positives in the situation that I am ignoring? Am I
underestimating my ability to cope with unfortunate circumstances?
15. When I am not feeling this way, do I think about this situation any differently? How?
16. Have I been in this type of situation before? What happened? What have I learned
from prior experiences that could help me now?
17. Five years from now, if I look back on this situation, will I look at it any differently? Will
I focus on any different part of my experience?
18. Am I blaming myself for something over which I do not have complete control?
Maintaining Behavior Change
Maintaining the progress you have been making is one of the greatest challenges you will face
as you complete this program. There are two keys to maintaining the gains you have made and
continuing to make progress.
Prevent "Slips" from Occurring
Control how You Respond to Slips
A slip is a:
•
•
•
•
mistake
lapse
deviation from the plan
error
It is usually the first instance of backsliding. It is a brief experience and does not signal an
inevitable downward spiral.
Example: You miss your workout for one or two days; you consume more calories than you
planned during a special meal, etc.; you had a cigarette; you used an illegal substance
Preventing Slips
•
Identify high-risk situations:
These are situations in which you expect to have difficulty continuing with your newly
developed skills.
•
Learn from the past.
You can identify many of these from past experience. Think back and identify situations
in which you remember having a particularly difficult time coping.
•
Plan in advance.
When you know similar situations are coming, start planning for how to deal with them
in advance. If you wait until you are in the midst of the situation, you are not likely to
come up with effective solutions. Use the information from past struggles to guide your
planning and identify past hurtles that will need to be overcome. The attached form will
help you develop your own relapse prevention plan.
Controlling Response to Slips
Even though many slips are preventable, you cannot prevent them all (e.g., some high-risk
situations are not predictable or were not known to be high risk). You will always have some
periods when you are not doing as well as you would like.
In other words, you will have slips.
The most important thing is to respond to these slips in a manner that gets you back on track as
quickly as possible.
How you think about the slip is the most important factor. If you view the slip as a total return
to old habits you are more likely to give up. Therefore, it is important to distinguish between a
slip (a.k.a., a lapse), a relapse and a collapse.
A SLIP (as discussed above) is a mistake, a first instance of backsliding. A RELAPSE occurs when
slips string together and you return to your former behaviors. Since a relapse is made up of
multiple slips, there are many opportunities to stop it and turn it back around before it reaches
the relapse stage. However, even once it reaches this stage, you can still turn it around again
(that’s what you did originally).
At any point along this relapse line, you need to:
•
Identify that you have slipped,
•
Recall what you were doing that had been helping, and
•
Resume it.
These actions will get you moving back in the right direction. The measure of success is not
whether there are dips in your line of progress, but whether over all you are progressing
upwards in spite of occasional dips. If you find you have relapsed, get out the education
materials you used to help you learn more effective coping skills and remind yourself what you
can do to get back on track and/or return to the clinic to see your primary care provider for
support.
When a relapse is complete and there is little hope of reversing the negative trend, COLLAPSE
has occurred. If you find yourself in a collapse, the best solution is to seek help from your
healthcare provider.
REMEMBER
A LAPSE = A RELAPSE
Personalized Relapse Prevention Plan
I.
What situations are you likely to relapse in?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
II.
What do you plan to do in these situations to avoid relapse?
What specifically will you do in these situations? What will you tell people to help you? How
will you alter the situation so you won’t fall back into your hold maladaptive habits?
1.
5.
2.
6.
3.
7.
4.
8.
III.
What are some of the negative thoughts or “mental gremlins” that you
are likely to experience in these relapse situations?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
IV.
What truthful and realistic things will you say to yourself to counteract
negative thoughts and help you connect with values in these high-risk
situations?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Weight Management
Effective weight management involves behavior modification which is a lifelong commitment
and includes at least two components:
1. Healthy eating in accordance with the Dietary Guidelines for Americans, emphasizing a
reduction in total calories, lowered fat consumption, and an increase in vegetables,
fruits and whole grains.
2. Increased frequency of regular physical activity of at least moderate intensity.
1. Eating Healthy
Caloric intake
Losing weight requires burning more calories than the body takes in, by either reducing caloric
intake or increasing caloric expenditure, or preferably, both.
Estimated Calorie Requirements (in Kilocalories) for Each Gender and Age Group
at Three Levels of Physical Activity
Activity Level b, c, d
Gender
Child
Female
Male
Age (years)
2-3
4-8
9-13
14-18
19-30
31-50
51+
4-8
9-13
14-18
19-30
31-50
51+
Sedentaryb
Moderately Activec
Actived
1,000
1,000-1,400
1,000-1,400
1,200
1,400-1,600
1,400-1,800
1,600
1,600-2,000
1,800-2,200
1,800
2,000
2,400
2,000
2,000-2,200
2,400
1,800
2,000
2,200
1,600
1,800
2,000-2,200
1,400
1,400-1,600
1,600-2,000
1,800
1,800-2,200
2,000-2,600
2,200
2,400-2,800
2,800-3,200
2,400
2,600-2,800
3,000
2,200
2,400-2,600
2,800-3,000
2,000
2,200-2,400
2,400-2,800
Source: HHS/USDA Dietary Guidelines for Americans, 2005
Sedentary = less than 30 minutes a day of moderate physical activity in addition to daily
activities.
Moderately Active = at least 30 minutes up to 60 minutes a day of moderate physical activity in
addition to daily activities.
Active = 60 or more minutes a day of moderate physical activity in addition to daily activities.
Healthy Food Choices
Individualized food plan according to 2005 USDA Dietary Guidelines:
http://www.mypyramid.gov/mypyramid/index.aspx
Four key recommendations of the 2005 Dietary Guidelines for food groups to encourage are:
1. Consume a sufficient amount of fruits and vegetables while staying within energy needs.
Two cups of fruit and 2-1/2 cups of vegetables per day are recommended for a
reference 2,000-calorie intake, with higher or lower amounts depending on the calorie
level.
2. Choose a variety of fruits and vegetables each day. Eat fresh, frozen, canned, or dried
fruit, rather than drinking fruit juice, for most of your fruit choices.
Select from all five vegetable subgroups several times a week. Examples of vegetables from
these subgroups include:
•
DARK GREEN VEGETABLES -- Broccoli, spinach, most greens such as spinach, collards,
turnip greens, kale, beet and mustard greens, green leaf lettuce, and romaine lettuce
•
ORANGE VEGETABLES -- Carrots, sweet potatoes, winter squash, pumpkin
•
LEGUMES (DRY BEANS) -- Dry beans, chickpeas
•
STARCHY VEGETABLES -- Corn, white potatoes, green peas
•
OTHER VEGETABLES -- Tomatoes, cabbage, celery, cucumber, lettuce, onions, peppers,
green beans, cauliflower, mushrooms, summer squash
3. Consume 3 or more one-ounce equivalents of whole-grain products per day, with the
rest of the recommended grains coming from enriched or whole-grain products. In
general, at least half the grains should come from whole grains. Examples of wholegrains commonly consumed in the United States include:
•
•
whole wheat
•
whole-grain corn
whole
oats/oatmeal
•
•
whole rye
bulgur (cracked wheat)
whole-grain barley
•
•
•
wild rice
•
quinoa
millet
•
•
brown rice
tritacale
4. Consume 3 cups per day of fat-free or low-fat milk or equivalent milk products. If you
don't or can't consume milk, choose lactose-free milk products and/or calcium-fortified
foods and beverages.
For more information, visit: http://lancaster.unl.edu/food/ftfeb05.htm.
Food log
By keeping track of food and drink consumption you will stay mindful of your eating habits. Do
you eat when bored? Do you eat unhealthy foods when in a hurry? Are you eating something
that seems nutritious and healthy, but really isn’t? You can calculate calories consumed to
determine weight loss/maintenance goals and assess progress. Keeping a food log allows you
to be accountable and mindful of calories consumed and you will become aware of the nutrient
value of the foods/drinks you are using.
An on-line calorie counter is available at http://www.my-calorie-counter.com. This site lets you
count calories for free (extra features cost $35/year).
Portion Size
Another common problem leading to overeating is taking portions that are too big. Most of us
overestimate the size of a healthy portion, especially when we eat at restaurants and want to
get a “good value” for our money. Listed below are the recommended portion sizes for a
variety of foods. How do your typical portions compare?
3 oz. meat: size of a deck of cards or bar of soap (the recommended portion for a meal)
•
8 oz. meat: size of a thin paperback book
•
3 oz. fish: size of a checkbook
•
1 oz. cheese: size of 4 dice
•
Medium potato: size of a computer mouse
•
1/2 cup pasta: size of a tennis ball
•
Average bagel: size of a hockey puck.
•
1 cup chopped raw vegetables or fruit: baseball size
•
1/4 cup dried fruit (raisins, apricots, mango): a small handful
For more information, visit
http://www.cancer.org/docroot/PED/content/PED_3_2x_Portion_Control.asp
2. Exercise
Exercise is an important piece of weight loss and overall health. For example, 30 minutes of
moderate intensity physical activity above your normal daily routine reduces the risk of chronic
disease in adulthood. To manage body weight and prevent gradual, unhealthy body weight
gain in adulthood, increase your exercise to approximately 60 minutes of moderate to vigorous
intensity activity on most days of the week. To sustain weight loss, increase your exercise to 60
- 90 minutes per day of moderate intensity physical activity while not exceeding caloric intake
requirements.
Another way to track physical activity is to use a pedometer to keep track of the number of
steps you take. For example, 2000-2500 average steps is approximately one mile, which
equates to around 100 expended calories.
3. Simple Strategies to Manage Your Eating
How often have you over-eaten or eaten unhealthy foods due to eating effortlessly in an
unaware and mindless manner? Have you ever noticed that when you’re done eating, you feel
sick because you ate too much? This happens when we do not pay attention to eating, typically
because we are doing something else at the same time like watching television, talking with
others, or working. If you increase your awareness—or mindfulness—of eating, however, you
can reduce your caloric intake and not feel so sick. Mindfulness is a way of observing your
experiences and being in touch with your actions, thoughts and feelings. Mindful eating
teaches you to pay attention to your bodies’ signals that you are full and about what foods to
eat. The goal of mindful eating is to understand your hunger and your body and mind’s
reaction to food and the process of eating. Try this activity:
Mindful eating
To start, move through the meal slowly. Take your time performing every action and notice
what your experience is as you go through it. When you lift a fork or cut your meat, note what
that is like for you. As you place a bite of food in your mouth and chew it, place your fork on
the table and think about the flavors and the texture of the food. Is it enjoyable or repulsive?
Don’t get hung up in judging it. Just notice it. Do you find that particular thoughts or feelings
come up during the course of the meal? If so, simply note those as well.
For more information about mindful eating consider reading these books:
1. Albers, S. (2003). Eating Mindfully. Oakland: New Harbinger Publications, Inc.
2. Hayes, S.C. (2005). Get Out of Your Mind and Into Your Life. Oakland: New Harbinger
Publications.
4. Developing Weight Goals
Setting SMART goals for your weight loss is the first, and most important, step for managing
your weight. Good goals have several qualities:
•
Specific: Goals should not be too general or vague, since this makes it hard for us to
know when we have accomplished them. For example, “I want to lose 20 pounds” is a
better goal than “I want to lose weight.”
•
Measurable: Goals should be set in a way that can easily and meaningfully measured.
For example, “I want to look better” is not easily measured, but “I want a 34-inch waist”
is easily measured.
•
Attainable: Goals should be something you are motivated to achieve. For example, if
improving your PT score is more important to you than your overall weight, then your
goal should not be to lose weight.
•
Realistic: Goals should be something you are able to accomplish. For example, setting a
goal to run a marathon next month when you struggle to run 2 miles now is not a
realistic goal.
•
Timely: Goals should have a time frame built into them to hold you accountable.
You’re more likely to work towards a goal if you give yourself a deadline.
Body Mass Index (BMI) & Waist Size
BMI uses a mathematical formula that takes into account both a person's height and weight.
BMI equals a person's weight in kilograms divided by height in meters squared. (BMI=kg/m2). It
is the measurement of choice for many physicians and researchers studying obesity, because it
is a more accurate indicator of overall health than just weight alone. Setting a BMI goal, instead
of simply a weight loss goal, is a better weight management strategy for many people,
especially those with medical conditions such as diabetes, COPD, heart diseases, hypertension,
and more. To calculate your BMI, visit this website:
http://www.consumer.gov/weightloss/bmi.htm.
Risk of Associated Disease According to BMI and Waist Size
BMI
Waist less than or equal to
40 in. (men) or
35 in. (women)
Waist greater than
40 in. (men) or
35 in. (women)
18.5 or less
Underweight
--
N/A
18.5 - 24.9
Normal
--
N/A
25.0 - 29.9
Overweight
Increased
High
30.0 - 34.9
Obese
High
Very High
35.0 - 39.9
Obese
Very High
Very High
40 or greater
Extremely Obese
Extremely High
Extremely High
Setting a SMART Weight Management Goal
Specific:
Where will you do it?
With whom will you do it?
How often will you do it?
Measureable:
How much?
How many?
Attainable:
What is most important to you?
What do you hope to accomplish?
Realistic:
Are you able to do it?
What can you do right now?
How easy will this be to maintain?
Timely:
When do you want to accomplish this?
Do you have a deadline?
Now that you have considered the necessary components for a SMART goal, write down your
weight management goal below:
Other tips for accomplishing this goal:
1. Hang this goal up where you can see it regularly so you can remind yourself what you’re
working towards.
2. Tell others about it. Ask them to help you stay accountable and support you.
3. Ask your doctor for advice or tips on reaching this goal.
4. Try this goal out for two weeks. At the end of two weeks, see if it’s a goal that will work
for you. If not, change it so it will work better.
5. Once you have accomplished this goal, set another SMART goal right away.
6. Remember to pace yourself. Change will not happen all at once, but will slowly build up
over time. Be patient.
Exam Room Posters
M
otherhood is a process that begins with conception
and results in new life for you and your family.
If you are experiencing any of the following, please ask your provider or the technician
about the OB/GYN clinic’s BHOP program:










Uncertainty
Stress
Frustration
Sadness/feeling “blah”
Increased difficulties with your significant other
Moodiness
Nervousness
Irritability
Communication problems with your significant other
Previous depression, baby blues, or postpartum depression
The BHOP program is intended to provide you with extra resources and support so that
your transition into motherhood unfolds as smoothly as possible for you.
New Year’s RESOLUTION: Lose Weight
New Year’s SOLUTION: Tell your PCM
you’d like a weight management
consultation from a behavioral health
consultant
On XXXX, the XXXX Clinic will begin
offering a consultation service to help you
succeed with this Resolution.
Ask your PCM or Nurse about this new
service and they can sign you up today!!
Is Your New Year’s Resolution to
QUIT SMOKING?
On XXXX the XXXX Clinic will began
offering a consultation service to help you
keep this Resolution.
Ask your PCM about this new service and
they can sign you up today!!
Spanish Materials
Spanish Materials List
1. 15 Sugerencias para Conflicto Constructivo / 15 Tips for Constructive Conflict
2. Enfrentando el Dolor / Confronting Chronic Pain Handout
3. Discusión: Desafiando el Pensamiento Angustioso / Cognitive Restructuring
4. Cuestionario de la Salud del Paciente (PHQ-9) / Patient Health Questionnaire
5. Hechos Acerca del Sueño / Practical Strategies for Managing Sleep
6. Nuevos Hábitos Saludables de la Salud del Sueño / Sleep Hygeine Strategies
7. Ayuda para los que están de luto / Tips for Dealing with Grief
8. Teniendo éxito con los Medicamentos Antidepresivos / Using Medications
Successfully
9. Una Técnica de Relajación: Respiración con el Diafragma / Diafragmatic Breathing
10. Terapia Cognitiva del Comportamiento (TCC) / Cognitive Behavioral Therapy
11. Acuerdo para la Administración de Medicamentos / Agreement for the
Administration of Medications
12. Depresión: ¿Qué es y cómo obtener ayuda? / What is Depression?
13. Lo que Debemos Saber sobre la Ansiedad y el Pánico / What you Should Know about
Anxiety and Panic
14. Como Funciona la Ansiedad / The Psychology of Anxiety
15. Plan de Valores Para Los Pacientes De Cuidados Primarios / Behavior Change
Prescription Pad
16. Plan de Cuidado Para la Despresion / Depression Self-Management Plan
17. Ciclo de Letargo / Lethargy Cycle
15 Sugerencias para Conflicto Constructivo
Cuando algo sucede para comenzar un pleito entre la pareja matrimonial, es importante mantener
los desacuerdos lo más constructivo posible para evitar patrones de comunicación perjudicial.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Sea especifico al quejarse.
No nomás se queje; aunque sea especifico; pida un cambio razonable que elimine la
queja.
Pida y dé sugerencias hacia el punto principal, para asegurar que lo escuchan y para
asegurar a su pareja que usted entiende lo que él o ella quiere.
Enfoque en un problema a la vez, porque de otro modo y sin ayuda profesional, puede
usted darle vuelta al asunto y evadir los problemas más difíciles.
No hable demasiado y no sea intolerante. Préstese a sus propios sentimientos y preste
lugar a los de su pareja.
Siempre considere un acuerdo. Recuerde que el punto de vista de su pareja puede ser tan
real para él o ella como para usted. Aunque sean diferentes. No existe realidad
totalmente objetiva.
No permita que las exigencias en contra se presenten hasta que se hayan aclarado
claramente las exigencias originales y la respuesta a ellas ha sido precisa y clara.
Nunca asuma saber lo que su pareja piensa hasta que lo haya aclarado en palabras ni
asuma o prediga como reaccionará o lo que aceptará o rechazará. Entre parejas no se
puede uno atener a la bolita de cristal.
No atropelle el pensar de su pareja. No le corrija cuando le exprese sus sentimientos. No
le diga a su pareja lo que debe saber o sentir.
Nunca clasifique a su pareja ni le diga que su vecino es cobarde, neurótico o niño. Si en
verdad creyera que él o ella sufre de alguna incompetencia o defecto básico, es más
probable que no estuviera usted ya con él o ella. No juzgue o califique sus sentimientos,
especialmente el que sí es, o no, real o importante.
El sarcasmo es pleito sucio.
Olvídese del pasado y plántese en el aquí y hoy. Lo que cualquiera de los dos hizo el año
o el mes pasado o esta mañana no es tan importante como lo que están haciendo y
sintiendo ahora. Y no es posible cambiar lo que ya paso. Las heridas, las quejas y lo que
le irrita se deben de sacar a la luz lo mas pronto posible o la pareja tiene el derecho de
sospechar que se han guardado cuidadosamente como armas.
No abrume a su pareja con quejas. Al hacerlo la hará sentirse incapaz y sospechará que
tal vez usted ha estado amontonando las quejas o no ha definido lo que en verdad le
molesta.
Medite. Tome tiempo para consultar sus los pensamientos y sentimientos verdaderos
antes de hablar. Su reacción superficial puede servir de mascara para ocultar algo mas
profundo e importante. No tenga miedo de serrar los ojos y pensar.
Recuerde que nunca hay un solo ganador en un pleito intimo y honesto. Ambos o ganan
o pierden aun más intimidad.
INDAGACIÓN: ¿Hay alguna otro sugerencia la cual agregaría usted a la lista? ¿Cuál de las 15
sugerencias piensa usted que son mas criticas para un pleito constructivo?
RECURSOS: Exhorto de G.R. Bach y R.M. Deutsch (1974)
CONTRIBUTORS: Nancy Wexler & Laura Heesaker, United Community Health Center, Green
Valley, AZ.
Enfrentando el Dolor
Varias veces, cuando los pacientes con dolor piensan en las experiencias dolorosas,
estas se amontonan causando experiencias agobiadoras. Sin embargo, el separar el dolor en
sus componentes nos facilita a sobrellevarlo. Al separar el dolor en trozos, podemos
enfrentarlo y manejarlo en partes separadas.
Dolor vs. Sufrimiento
Es muy importante distinguir entre el dolor y el sufrimiento que se apodera como
respuesta al mismo. Muy seguido, los pacientes con dolor los agrupan juntos. Cuando ellos
piensan o platican acerca del dolor que sienten, no solo están platicando de la sensación física
en donde sienten el dolor. También están pensando en el impacto múltiple que este dolor
acarrea a sus vidas. El no poder hacer las cosas. La angustia emocional. La tensión en la
familia. El impacto potencial en su estabilidad financiera. Todas estas cosas se agrupan bajo
la etiqueta “dolor”. Sin embargo, el dolor y el sufrimiento asociado al dolor son en efecto
muy distintos. Es mas, lo severo del dolor tiene relación mínima comparado al impacto
severo en la vida del paciente con dolor. Otros pacientes pueden sufrir dolor moderado, pero
pueden sentir impactos significativos. La razón por lo que estos dos no se relacionan es
porque son controlados por cosas diferentes.
El dolor es una sensación física que resulta de las reacciones biológicas que ocurren
por medio de la vía de transmisión del dolor. Mientras puede ser afectada la percepción de la
experiencia dolorosa por factores psicológicos (consultar la sección de Teoría del Puertón de
Control en la primera sesión), el dolor no se encuentra directamente bajo el control de la
persona.
Alternativamente, el sufrimiento, como respuesta a la experiencia física del dolor, es
controlado por factores que no son físicos, tales como los pensamientos, sentimientos, la
conducta, y factores en el medio ambiente. Como seres humanos, nosotros podemos
controlar, o aprender a controlar estos factores.
Siendo así, es importante distinguir entre el “dolor” y el “sufrimiento” cuando nos
enfrentamos al dolor. Ya que uno identifica de donde viene el “sufrimiento”, puede uno
comenzar a buscar la manera de reducirlo. Las destrezas que usted ha estado aprendiendo en
este programa le ayudaran a hacerlo. Además, como ya sabemos que algunos de estos
factores influyen en el “puertón del dolor”, al reducir el sufrimiento, es más seguro que la
percepción de dolor se vea impactada.
Etapas de Dolor
Los episodios de dolor también se pueden dividir en cuatro etapas. El pensar en el
dolor como etapas e identificando la manera para manejar cada etapa ayuda a que el dolor sea
una experiencia más llevadera. Esto ayudará mucho mas en episodios más severos.
En realidad, la primera etapa es antes del episodio de dolor. Durante este estado,
usted se encuentra anticipando o preparándose para el episodio de dolor. Esta es la etapa
durante la cual usted necesita pensar como va a llevar el dolor. Es muy importante planear
esto por adelantado porque durante el dolor severo no podrá pensar claramente y, es mas,
será más fácil volver a las viejas costumbres si no hay un plan en pie. Le ayudará escribir su
plan para que no tenga que recordarlo durante un nivel fuerte de dolor. Además, debe de
tener planes múltiples. A veces el primer plan no funciona y es bueno tener otras opciones
que tomar. Esta es una de las razones por la cual enseñamos métodos múltiples para
sobrellevar el dolor. Diferentes técnicas funcionan para diferentes ocasiones pero no todo el
tiempo ayuda una sola técnica. En fin, el plan debe de ser muy especifico. En vez de escribir
simplemente “relajamiento”, mejor explique específicamente que hará para relajarse; en vez
de escribir simplemente “llamaré una amiga”, escriba el nombre y el numero de teléfono de
la persona a quien llamará.
La segunda etapa tiene que ver con encarar el dolor cuando primero comienza a
empeorar. La meta ahora es empezar a usar algunas de las técnicas para llevar el dolor. Esta
etapa es particularmente importante porque la manera en que usted responde inicialmente al
aumento de dolor predice como usted responderá al resto del episodio. Si usted entra
enfocándose en el manejo e implementando el plan de la primer etapa, es más posible que le
sea efectivo. Si usted inicia de una manera mal adaptada, será más difícil volver al grano.
Usualmente, el dolor llegará a lo máximo y luego bajará. La tercer etapa se enfoca
en como llevar el dolor ya que llegue a lo máximo. Es posible que sé de cuenta de que la
misma estrategia que funciono bien al principio del episodio ya no funcione tan bien. Intente
usar otras técnicas (tal como los planes alternativos en la primer etapa) Mantenga en mente
que el dolor máximo siempre bajará. Su meta durante esta etapa es el sobrevivir el dolor
máximo. Durante el dolor severo, las técnicas que se pueden hacer, ya sea parado o sentado,
y para las que no se necesita un proceso de pensamiento complicado (tales como el conteo,
respiración, fijar la vista en algo) a veces funcionan mejor.
Al comenzar a bajar el dolor, comienza la cuarta etapa. Durante esta etapa, será útil
repasar los resultados de los planes. Considere lo que funcionó bien. Esas cosas que
funcionaron bien mas seguido se deben de incluir en el plan primario de abastecimiento.
Luego piense en lo que no funcionó bien. Considere como puede cambiar el plan para que la
próxima vez sea más efectivo. Tenga en mente que el manejar el dolor se aprende con
experiencia. Usted tendrá que luchar con varios episodios donde no maneje el dolor tan
efectivamente como quisiera para poder llegar a la meta deseada de manejo del dolor.
En la siguiente hoja encontrará usted una lista que le sugiere los pensamientos y las
acciones para tomar en cada etapa.
________________________________________________________________________
El animo del hombre lo sostiene en su enfermedad;
pero perdido el animo, ¿quién lo levantará?
Proverbios 18:14
CONTRIBUTORS: Nancy Wexler & Laura Heesaker, United Community Health
Center, Green Valley, AZ.
Etapas de Dolor: Pensamientos y Conducta Saludable
Anticipando /Preparándose para un Episodio de Dolor:
Acciones:
Implemente un plan A, B y C para cuando pegue el dolor. Sea especifico. Use respiración
diafragmática.
Pensamientos:
El sentarse y preocuparse por el dolor no le ayudará. Que más puedo hacer que podría
ayudar. Lo haré ahora.
Ya no me duele tanto. El pensar o hacer otras cosas, puedo hacer que el bienestar dure
más tiempo.
No tengo que asustarme así misma por el dolor. Sobrellevare el siguiente episodio cuando
sea que llegue. Me alegra que ya no sea intenso. Si incrementa y disminuye, así es que me
permitiré tener un plan para cuando este llegue.
Enfrentando el Comienzo de Episodio de Dolor:
Acciones:
Comience a usar las destrezas que puede hacer para manejar el dolor mientras continua con
su día.
Intente la respiración diafragmática en medio de sus actividades.
Luche activamente por mantener la atención enfocada en las tareas en las que se encuentra
involucrada.
Vigile los pensamientos alarmantes y sustitúyalos con pensamientos tranquilizadores.
Pensamientos:
Bien, siento tensión. Esto me recuerda el respirar despacio, profundamente y relajarme.
No me ofuscare. Lo tomare paso por paso.
No sirve de nada permanecer acostado con este dolor. Me involucraré en algo.
Aquí esta el episodio. Será como los otros y disminuirá gradualmente. No es necesario que
me alarme.
Encarando el Dolor en su Máximo
Acciones:
Use el plan A (y B y C sí es necesario)
Intente convenir las estrategias del manejo del dolor.
Intente el uso de las técnicas más intensas como el PMR8.
Use recursos mentales sencillos para intentar, y mantener, la atención enfocada lejos del
dolor.
Pensamientos:
El episodio está pasando tal y como yo lo esperaba. Puedo sobrevivir esto.
Se disminuirá antes de que me dé cuenta, especialmente si me puedo concentrar en algo más.
No quiero yo empeorar esto. Seguiré mi plan – cambiaré mis actividades.
No caeré en pánico. Ya he sobrevivido esto antes.
Reflexiones al Ir Disminuyendo el Dolor:
Acciones:
Reflexione lo bien que funcionó su plan.
Se da crédito a usted mismo donde lo merece, y cambie planes si así lo merita.
Pensamientos:
Bien, lo hice. A la otra lograré manejarlo aun mejor.
Ya logro con mas éxito colocar el dolor al fondo de mi mente; puedo utilizar mi atención y
mis pensamientos para mi logro.
No me riendo desesperado o incapaz con esto. Puedo limitar el efecto que el dolor causa en
mi vida.
Discusión: Desafiando el Pensamiento Angustioso
Examine sus pensamientos buscando las palabras clave:
1. Debe, necesito, tiene que, debería (con frecuencia estas palabras están asociadas
con normas).
2. Nunca, siempre, completamente, totalmente, todo, todos (frecuentemente estas
palabras están asociadas con Predicciones o Categorías).
3. Feo, terrible, horrible, insoportable, desastre, peor que nunca (con frecuencia estas
palabras están asociadas con Categorías o Predicciones).
4. Pelmazo, patán, desgraciado, hipócrita, estúpido, idiota, ¡¡¡***!!! (frecuentemente
estas palabras están asociadas con Categorías).
Discuta o pregúntese que tan ciertos son sus pensamientos usando las siguientes
preguntas:
1. ¿Me estoy angustiando innecesariamente? ¿Cómo puedo ver esto de otra manera
menos angustiante? ¿Qué otras maneras hay de ver la situación?
2. ¿Mi pensamiento está trabajando para mi bien, o en contra mía? ¿Cómo puedo ver
esto para que me sea de más ayuda?
3. ¿Qué estoy exigiendo que debe suceder? ¿Qué es lo que quiero o prefiero, no tanto
lo que necesito?
4. ¿Estoy haciendo algo tan terrible? ¿Es realmente tan malo? ¿Qué sería tan terrible
de esto? Aunque fuera tan terrible como imagino ¿Hay todavía algo que
puedo hacer?
5. ¿Estoy etiquetando a una persona de forma extrema? ¿Cuál es la acción o
comportamiento que no me gusta?
6. ¿Qué no es verdad en mis pensamientos? ¿Cómo me puedo apegar a los hechos?
¿Qué prueba hay de lo que estoy pensando o creyendo sobre esto?
7. ¿Estoy usando lenguaje extremo, en blanco y negro? ¿Qué palabras menos
extremas serían más exactas?
8. ¿Soy un adivinador de la fortuna (prediciendo el futuro) o leo la mente (haciendo
suposiciones sobre lo que están pensando los demás) de manera que me molesta o
me hace infeliz? ¿Qué tan posible es que las cosas de verdad sucedan como las
pienso o me las imagino? ¿Realmente sé lo que la otra persona está pensando?
9. ¿Cuáles son mis opciones en esta situación? ¿Cómo me gustaría responder?
¿Cómo debería cambiar mi pensamiento para responder de la manera que quiero?
CUESTIONARIO DE LA SALUD DEL PACIENTE (PHQ-9)
NOMBRE:__________________________________________ FECHA:___________
1) Durante las ultimas dos semana, con que frecuencia se ha visto afectado por los
siguientes problemas? (marque su respuesta con “√”).
Nunca
Varios
dias
Mas
de la
mitad
0
1
2
Casi
todos
los
dias
3
a. Tiene poco interés o encuentra poco placer en
hacer las cosas.
b. Se siente desanimado, deprimido o sin esperanza.
c. Tiene problemas con dormir o mantenerse
dormido o duerme demasiado.
d. Se siente cansado o tiene poca energía.
e. Tiene poco apetito o come en exceso.
f. Siente falta de amor propio o que es un fracaso o
que se ha decepcionado a sí mismo o a su familia.
g. Encuentra dificultad en concentrarse, por
ejemplo, al leer el periódico o ver televisión.
h. Se mueve o habla tan léntamente que la gente lo
puede haber notado, o de lo contrario, está tan
agitado o inquieto que se mueve mucho más de lo
acostumbrado.
i. Tiene pensamientos de que sería mejor estar
muerto o de que quiere hacerse algún daño.
Suma de las columnas:
2) Si usted se identificó con cualquiera de estos problemas, que dificultad le han
ocasionado estos problemas al hacer su trabajo, ocuparse de las casa o llevarse bien con
los demás.
Ninguna dificultad
0
Algo de dificultad
1
Mucha Dificultad
2
Extrema Dificultad
3
Hechos Acerca del Sueño
1. Mito: Todos necesitas 8 horas de sueño
Hecho: Ocho horas es solo el promedio. Las necesidades del sueño varían entre 3 y más de
10 horas. Recuerde antes que desarrollara insomnio. Cuánto necesitaba dormir para sentirse
revitalizado y renovado en ese entonces (ponga la cantidad aquí _________ horas)? Esta
cantidad será aproximadamente la cantidad de sueño que necesitará.
2. Mito: La falta de sueño podrá tener consecuencias serias en su salud.
Hecho: No hay evidencia que alguien haya muerto por falta de sueño. La preocupación
excesiva acerca del insomnio puede ser más perjudicial para su salud que la falta de sueño.
3. Mito: Cuando tengo problemas para dormir debo quedarme en la cama y seguir tratando.
Hecho: Cuanto más trata de producir sueño voluntariamente, tiene menos posibilidades de
tener éxito.
4. Mito: Las pastillas para dormir son una manera efectiva de manejar sus problemas de
sueño de largo plazo.
Hecho: Las pastillas para dormir pueden actualmente perpetuar los problemas del sueño.
5. Mito: Las necesidades y calidad del sueño permanecen igual durante toda la vida.
Hecho: A medida que envejecemos, el tiempo que permanecemos en la cama aumenta pero
el tiempo que dormimos disminuye. Con la edad el despertar durante el sueño aumenta. El
sueño profundo disminuye y el sueño ligero incrementa con la edad. Muchas personas
mayores duermen 2 o 4 episodios de una hora en lugar de un periodo de sueño consolidado.
Los problemas de sueño en las personas mayores están generalmente relacionados con otros
problemas de salud o medicamentos usados para estos problemas. De todas maneras, la
calidad del sueño de los adultos puede a menudo ser mejorado con tratamiento.
6. Mito: El insomnio es un problema poco común.
Hecho: El insomnio es un problema ampliamente diseminado que afecta a casi todos en
algún momento determinado de sus vidas. Es quizás es la queja más común después del
dolor. Nueve a diez por ciento de la población reporta insomnio crónico.
Nuevos Hábitos Saludables de la Salud del Sueño
1. Limite la cantidad de tiempo que pasa en la cama a la cantidad que
actualmente pasa durmiendo: ________ horas.
2. Vaya a la cama sólo cuando tiene sueño.
3. Levántese de la cama si no puede dormir o volver a dormir entre 10 y 15
minutos; regrese a la cama solamente cuanto tenga sueño. Repita este paso
tan seguido como sea necesario durante la noche.
4. Mantenga un horario regular para levantarse en las mañanas.
5. Use la cama/ su cuarto para dormir y tener relaciones sexuales solamente, no
para mirar la televisión, escuchar la radio, comer, o leer en la cama.
6. No duerma durante el día.
Ayuda para los que están de Luto
A seguir, hay muchas ideas para ayudar a quién están de luto sobre un ser querido. Diversas clases de
pérdidas dictan diversas respuestas, así es que no todas de estas ideas satisfacen a cada persona. Al
mismo tiempo, todos somos individuales y necesitamos algo que funcionará para cada uno. Esta lista
es una de sugerencias que han ayudado a várias personas con éxito. Quizás les vaya a ayudar también.
El énfasis aquí está en ideas específicas y prácticas.
1. Hable regularmente con un amigo. El hablar con otro sobre lo qué usted piensa y sus
sentimientos es una de las mejores cosas que usted puede hacer para sentirse mejor. Ayuda a que
no sienta tanta presión. Puede darle un sentido de perspectiva, y le mantiene en contacto con
otros. Busque a alguien que le escuche y quién tenga compasión. Entonces hable lo que está en su
mente y dentro su corazón. Si esto se siente como que se esta aprovechando de la persona, deje
que ese sentimiento continúe durante este tiempo porque usted lo necesita. A lo mejor la otra
persona encontrará solaz en nomás escuchando y el tiempo vendrá cuando usted tendrá la ocasión
de ser un buen oyente para alguna otra persona. Usted entonces será un oyente mejor, si deja que
ahora la otra persona lo sea.
2. Caminata. Vaya para las caminatas afuera cada día si usted puede. No exagere, pero camina
energéticamente para que se sienta vigorizo. A veces camine lentamente para que usted pueda
fijarse en su alrededor. Observe la naturaleza y que tiene para ofrecerle, qué puede enseñarle.
Goce tanto como usted pueda a la vista y los sonidos que le llegan. Si gusta, camine con otra
persona.
3. Lleve o use un objeto que se liga. Lleve algo en su bolsillo o el monedero que le recuerda de la
persona quién murió – algo que le dio quizás, u objeto pequeño que la persona llevó o que utilizó
una vez o un recuerdo que usted selecciono para ese propósito. Puede ser que use un pedazo de su
joyería de la misma manera. Siempre que usted desee, mire este objeto y recuerde lo que
significa.
4. Visite el sepulcro. No toda la gente prefiere hacer esto, pero dependiendo de cómo se siente,
puede hacerlo. No deje que otros le convenzan que esta es una cosa morbosa. Pase cualquier
tiempo que siente que nesecite. Siéntese o párese en el lugar y haga lo que le viene naturalmente:
sea silencioso o hablando, respirando profundamente, gritando, recordando, o rogando. Puede ser
que usted quiera decorar el sepulcro, enderezándolo, limpiándolo, o poniéndole las pequeñas
muestras de su amor.
5. Cree un libro de memoria. Junte las fotografías, que documentan la vida de su ser querido.
Arréglelos en una cierta clase de orden así que cuentan una historia. Agregue otros elementos si
usted desea: diplomas, recortes del periódico, realizaciones, y recuerdos de acontecimientos
significativos. Ponga todo esto en un libro especial y guárdelo para que pueda verlo cuando lo
desea. Úselo para recordar los tiempos mejores que tuvo con la persona y para conmemorar su
vida.
6. Recuerde sus sueños. Sus sueños contienen información importante sobre sus emociones y sobre
su relación con la persona quién murió. Sus sueños pueden ser asustadizos o tristes,
especialmente después de la perdida. Los sueños pueden parecer extraños o locos. Usted podrá
encontrar que la persona le aparezca en sus sueños. Acepte sus sueños por lo que son y vea lo que
usted puede aprender de él. Nadie lo sabe mejor que usted.
7. Dígale a la gente qué le ayuda y qué no lo hace. Gente a su alrededor no puede entender lo que
usted necesita. Dígales. Si le ayuda oír el nombre de la persona que ha fallecido, dígales que lo
hagan. Si usted necesita más tiempo en a solas, o ayuda con tareas o trabajo que usted no puede
terminar, o un abrazo ocasional, sea honesto(a). La gente no puede leer su mente, así que usted
tendrá que decírselo.
8. Anote las cosas. La mayoría de la gente que está lamentando la perdida de alguien, generalmente
se hace más olvidadiza. Escriba las cosas que le están ayudando a pasar por este tiempo. Esto
puede incluir anotar cosas que usted desea preservar de la persona que ha muerto.
9. Pida una copia del servicio conmemorativo. Si la liturgia fúnebre o el servicio conmemorativo
tienen significado especial para usted debido a lo qué fue dicho o leído, pida las palabras.
Quienquiera participó en que el ritual se sentirá alagado que lo qué él/ella preparó fue apreciado.
Convierta a estas palabras en lo que usted desee. Algunas personas han notado que estos
pensamientos le ayudan aún más semanas y meses después del servicio.
10. Recuerde el rezo de la serenidad. Este rezo se atribuye al teólogo Reinhold Niebuhr, pero es
realmente un rezo alemán antiguo. Ha traído comodidad y ayuda a muchos que han sufrido varias
clases de aflicciones.
11. Haga una área de memoria en su hogar. En un espacio que sienta apropiado, arregle una
pequeña mesa que honra a la persona: unas fotografías, quizás una estimada posesión o concesión
o algo que crearon o algo que amaron. Esto puede ser colocado en una mesa pequeña, una
chimenea o un escritorio. Alguna gente tiene gusto de utilizar un grupo de velas, representando
no solo a la persona que murió, pero a otras que han muerto también. En ese caso una variedad de
velas se puede arreglar cada una representada por una vida especial.
12. Beba agua. La gente que tiene alguien que fallece, puede fácilmente deshidratarse. Llorando
naturalmente lo causa. Y con sus rutinas normales interrumpidas, usted podrá olvidarse de que
necesita tomar agua como lo hizo antes. Que esto sea una manera que usted se cuida.
13. Use sus manos. A veces es importante hacer cosas repetitivas con sus manos, algo que usted no
tiene que pensar porque es natural hacerlas. Cociendo, puede ser un ejemplo; la carpintería,
solucionando un rompecabezas, pintando, haciendo trenzas, lavando y otras actividades
parecidas.
14. Tome tiempos de descanso. El pasar por este tiempo difícil, no significa que uno siempre tiene
que sentirse triste o desesperado(a). Es importante que conscientemente decida que usted pensará
en otra cosa por un rato, o que haga algo que le gusta hacer. Algunas veces esto sucede
naturalmente y es solamente más adelante usted realiza que su tristeza ya no es tan fuerte. Deje
que esto pase. No indica que usted quiera la persona menos o que se esta olvidando de ella. Es
una muestra que usted es normal y que necesita alivio de la presión y tristeza. Puede también ser
una muestra sana que usted está mejorando emocionalmente.
15. Vea a un consejero. Si usted se preocupa sobre cómo se siente o como se está adaptando, haga
una cita con un(a) consejero(a) que se especializa en esta área. Usted aprenderá lo que necesita
saber sobre sus reacciones y las cosas saludables que ya esta haciendo. Haga preguntas al
consejero antes de que usted empiece la conserjería. ¿Qué entrenamiento específico tiene él o
ella? ¿Cuáles son sus calificaciones? La persona que es un terapeuta de la familia o psicólogo no
necesariamente entiende las necesidades especificas para una persona que ha perdido a un ser
querido.
16. Comience su día con su ser querido. Si la muerte es reciente, usted probablemente despertará
pensando en esa persona de todos modos. Decida que usted la incluirá desde el comienzo del día.
Enfoque este tiempo de una manera positiva. Traiga a su mente memorias buenas. Recuerde las
cosas que esta persona le enseñó, los regalos que él o ella le dio. Piense de cómo usted puede
pasar su día de la manera que le sería agradable a esa persona. Entonces lleve esa meta acabo
durante el día.
17. Invite alguien que sea su compañero(a) por teléfono. Si su tristeza se le hace especialmente
difícil, y siente que no puede hablar con alguien, pregunte que alguien de confianza sea su
compañero(a) por teléfono. Pídale permiso de llamarle siempre que usted sienta que ya no puede.
Entonces guarde su número y llame si usted lo(a) necesita. No abuse del privilegio, por supuesto.
Prométales que un día será tiempo de reembolso - usted se hará algún día disponible para ayudar
alguna otra persona de la misma manera que le han ayudado. Eso ayudara a que acepte el cuidado
que está recibiendo.
18. Evite cierta gente si lo necesita. A nadie le gusta ser antipático o desagradable. Pero si hay
gente en su vida que la hace muy difícil para que usted pase por este tiempo entonces haga lo que
pueda para no tener contacto con ellos.
19. Done las posesiones significativas. Encárguese de donar las cosas personales de la persona que
ha fallecido a personas quienes sacarán el mayor beneficio, sean conocidos o no. Miembros de la
familia o amigos pueden disfrutar en recibir los recuerdos. Ellos u otros pueden merecer las
herramientas, utensilios, libros o equipo deportivo. Las organizaciones filantrópicas pueden poner
la ropa al buen uso. Hay gente que desea hacer esto inmediatamente después de la muerte,
mientras otros desean esperar un rato.
20. Done en el otro nombre. Honre la memoria de la persona dando un regalo o varios regalos a una
causa que a la persona le gustaría. ¿Una caridad preferida? ¿Un proyecto de edificio?
21. Cree o ponga en servicio un edredón de la memoria. Cosa o invite a otros que cosan con
usted, o emplee a alguien para coser para usted. Haga un edredón o una cobija que recuerda los
eventos importantes de la vida de la persona que murió. Tome su tiempo para hacer esto. Que sea
un labor de su amor.
22. Tome una clase de yoga. Gente de casi cualquier edad puede hacer yoga. Hace más que
condicionar su cuerpo, le ayuda a relajar y a fortalecer su mente. Puede ser que lo use junto con la
práctica de la meditación. Es un arte apacible en su vida cuando usted merece ternura y
tranquilidad a su alrededor.
23. Conecte en el Internet. Si sabe usar la computadora, busque el Internet. Encontrara muchos
recursos para la gente que esta pasando por situaciones similares y se podrá comunicar con ellos.
Usted puede hacer esto sin salir de su hogar. También encontrará más para ampliar sus horizontes
como una persona quien esta creciendo.
24. Hable a una persona espiritual. Si usted está buscando respuestas más grandes; las preguntas
sobre vida y muerte, la religión y la espiritualidad, considere la ayuda de un representante de su
fe, o la fe de otra persona. Use ese tiempo espiritual con la otra persona para exploración
personal.
25. Lea cómo otros han respondido a la muerte. Usted puede sentir que su propio dolor es todo lo
que puede aguantar. Pero si usted quisiera mirar las maneras que otros lo han hecho, lea libros
que otros han escrito sobre sus experiencias con la pérdida de un ser querido. Vaya a su
biblioteca.
26. Aprenda con otros sobre la persona que murió. Escuche las historias que otros pueden
contarle, tanto las historias que usted conoce como las que nunca ha oído. Pase el tiempo con sus
amigos, compañeros de clase o colegas. Invítelos a su hogar. Pídales que escriban las memorias y
guárdelas. Hay que celebrar el tiempo que tuvieron juntos.
27. Tome una vacación. Cuando usted siente que puede, tome una vacación de un día. Haga lo que
usted desea, o no haga nada. Viaje a algún lugar, o quédese dentro de la casa solo(a). Sea muy
activo o no haga nada. Nomás tenga un día para usted; y eso puede significar lo que usted quiera.
28. Invite que alguien le de su opinión de su progreso. Seleccione una persona en quien usted
confía, preferiblemente alguien familiarizado(a) con la perdida y la muerte para dar su opinión
del progreso que usted tiene. Si desea comprobar que usted está pensando claramente, cómo está
recordando exactamente, cómo usted está manejando la situación, vaya a ésa persona. Haga sus
preguntas, después escuche las respuestas. Lo que usted elige hacer con esa información será su
responsabilidad.
29. Suelte su enojo en lugar de guardar todo adentro. Se sentirá extraño el sentir el enojo cuando
acaba de morir una persona, pero esos sentimientos son una reacción normal. Aunque se siente
avergonzado(a) cuando lo siente, encuentre maneras saludables de expresarlo. Grite, aunque sea
solo(a) en la casa, llore, péguele a una almohada, aviente huevos, limpie la casa, y resista la
tentación de guardarlo adentro.
30. Agradezca cada día. No le hace lo que le ha sucedido, usted todavía tiene cosas que agradecer.
Quizás sean sus memorias, su familia, su ayuda, su trabajo; la salud - todas clases de cosas. Dirija
su atención a esas partes de la vida que tienen valor y agradézcalas.
31. Fíjese en síntomas de la dependencia. Aunque sea normal llegar a ser más dependiente en otros
por un tiempo inmediatamente después de una muerte, no será provechoso continuar haciendo eso
a largo plazo. Fíjese en síntomas que está prolongando su necesidad de ayuda. Felicítese cuando
usted hace las cosas para si mismo(a).
CONTRIBUTOR: Bill Rosenfeld MA, Mountain Park Health Center, Phoenix, AZ.
Teniendo éxito con los Medicamentos Antidepresivos
El cuerpo, el comportamiento y los pensamientos de una persona interactúan
continuamente. Una vez que la depresión se ha convertido en un problema, esta interacción la
puede llevar a un “espiral hacia abajo” tanto en el estado de ánimo como en esperanza.
Existen dos maneras que lo pueden ayudar a cambiar la dirección hacia abajo y crear un
“espiral positivo”.
1. Uso de medicamentos. Los medicamentos lo pueden ayudar a sentirse mejor. Los
medicamentos antidepresivos reponen substancias necesarias para el cerebro que disminuyen
con el stress. Los medicamentos pueden trabajar de manera lenta. Por lo tanto, es mejor usar
los medicamentos en combinación con algunos planes de acción y el uso de estrategias para
enfrentar el problema..
2. Tácticas para enfrentar la depresión. El uso de estrategias activas para enfrentar la
depresión, puede ayudar a cambiar el espiral descendente de la depresión. Cuando usted trata
los problemas de la vida con estrategias efectivas, usted tiene más oportunidades de crear
condiciones positivas en su vida. Haga un esfuerzo, de acuerdo con su médico, para planear
el uso adecuado de las estrategias para enfrentar la depresión.
Es probable que usted tenga más éxito con el tratamiento antidepresivo cuando haya
obtenido información precisa sobre todos los aspectos del uso del medicamento. Por favor
revise los siguientes detalles y discuta con su médico cualquier pregunta que tenga.
1. Inicio de la medicación Inicie su medicación tan pronto como le haya sido recetada. Entre
más pronto empiece, más pronto experimentará los beneficios deseados.
a. Tenga en mente, que generalmente toma de 2 a 3 semanas antes de que empiece a
notar reducción en los síntomas y de 4-8 semanas para que los síntomas se calmen
totalmente..
b. Lo primero que experimenta la mayoría de la gente es mejoría en el sueño,
disminución de la fatiga y alguna mejoría en el control emocional.
c. Los antidepresivos tienen mayor efecto en los síntomas físicos de la depresión. Otros
síntomas, como ánimo deprimido y bajo sentido de auto-estima, pueden responder al
tratamiento sólo de manera parcial. En otras palabras, los antidepresivos no son
“tabletas de felicidad”, no eliminan totalmente los sentimientos de tristeza o vacío.
2. Recuerde tomar su medicamento. Tome su medicamento a determinada hora cada día.
Durante las primeras semanas, hágase notas para que no se le olvide. Algunas personas usan
algún hábito de higiene, como lavarse los dientes, para acordarse de tomar su medicamento.
También habrá personas que quieran tener un frasco extra de medicamento en el cajón de su
escritorio en el trabajo, por si olvidaran tomar su medicina en casa.
3. Llevar a cabo otras actividades. Usted puede continuar con sus actividades normales
cuando esté tomando medicamentos antidepresivos. Si usted nota que se siente un poco
sedado o con sueño al empezar a tomar la medicina, evite manejar o llevar a cabo actividades
riesgosas. Normalmente el sueño disminuirá, de no ser así, hable con su médico sobre un
cambio del medicamento.
4. Tomar antidepresivos junto con otros medicamentos. Usted puede tomar antidepresivos
con casi todos los tipos de medicamentos. Sin embargo, hable con su médico para saber si
puede tomar los medicamentos antidepresivos con otros medicamentos que usted esté
tomando.
5. Tomar antidepresivos y consumo del alcohol. No tome alcohol mientras esté tomando
medicamentos antidepresivos. El alcohol puede bloquear los efectos del medicamento.
6. ¿Adicción? Los antidepresivos no crean adicción.
7. Aumento en la dosis del medicamento. Aumente la dosis del medicamento de acuerdo
con las indicaciones de su médico. Al inicio del tratamiento con medicamentos
antidepresivos, usted empezará con dosis bajas se le irán aumentando poco a poco. No se
preocupe porque está “tomando muchas pastillas”. Su médico le está aumentando lentamente
la dosis para ayudarlo a eliminar los efectos secundarios. Cuando haya llegado a su “dosis
terapéutica”, probablemente le recetarán tabletas con una dosis más alta, que le permitirán
tomar menos pastillas.
8. Continúe con el medicamento. Tome el medicamento hasta que usted y su médico decidan
que ya está listo para suspenderlo. En la mayoría de los casos, su médico le pedirá que tome
la medicina por lo menos durante 6 meses después de que haya llegado a su dosis terapéutica.
No deje de tomar la medicina porque ya se siente mejor. Use este período en el que ya se
siente major para trabajar en el desarrollo de habilidades que lo ayudarán a prevenir una
recaída. El promedio de recaídas cuando la gente deja de tomar muy pronto sus
medicamentos es tan alta como 80%. Espere y planee con su médico cómo y cuándo dejará
de tomarlos.
Manejando los Efectos Secundarios
La mayoría de los medicamentos antidepresivos tienen efectos secundarios leves. Los
efectos secundarios normalmente son temporales y disminuyen o desaparecen durante las
primeras semanas de tratamiento. Si usted experimenta efectos secundarios que sean más
severos, llame a su médico. Probablemente él/ella le sugerirán una o más de las siguientes
estrategias:
Cambiar la hora en la que toma el medicamento
Cambiar la dosis del medicamento
Usar algo para los efectos secundarios
Cambiar a un medicamento diferente
La siguiente tabla resume los efectos secundarios más comunes y las posibles
estrategias para enfrentar los efectos secundarios. La mayoría de los medicamentos tienen
solamente uno o dos de los efectos secundarios enlistados en esta tabla.
Efectos Secundarios Comunes
Boca Seca
Estreñimiento
Adormilado
Insomnio
Visión borrosa
Mareo
Sentirse acelerado
Problemas Sexuales
Náuseas o Pérdida del Apetito
Remedios
Tome mucha agua. Mastique goma de mascar sin azúcar.
Coma gomitas sin azúcar.
Coma más alimentos ricos en fibra. Tome un laxante suave.
Tome aire fresco y camine con frecuencia. Trate de tomar
más temprano su medicina de la noche, o si toma la medicina
en el día pregunte a su doctor si puede tomarla en la noche.
Tome sus medicamentos en el día. Trate de informarse sobre
el insomnio. Tome un baño caliente y una cena ligera antes
de acostarse. No haga
ejercicio pesado en la noche.
Recuerde que esta será una dificultad temporal. Hable con su
doctor en caso de que continúe este problema.
Levántese lentamente. Tome muchos líquidos, Si esto le
preocupa, llame a su doctor.
Dígase a usted mismo, “Esto pasará en tres o cinco días.” Si
no es así, llame a su doctor o enfermera.
Hable con su doctor. Tal vez podría ayudarle un cambio de
medicamento o toma unas “vacaciones del medicamento.”
Tome la medicina con alimento. Prepare la comida de tal
manera que sea apetecible y colorida. Tome pequeñas
porciones de comidas sanas.
Source: Using Medications Successfully. An ICP Booklet. Reno: Context Press.
Preston, J. & Johnson, J. (2000) Clinical Psychopharmacology Made Ridiculously Simple, Edition 4. Miami:
Medmaster.
Una Técnica de Relajación: Respiración con el Diafragma
¿Cómo Trabajan las Técnicas de Relajación?
Antes de entrenarlo en la técnica, queremos que entienda cómo trabajan las técnicas
de relajación. Los beneficios que traen las técnicas de relajación se pasan en la manera en
que está diseñado su cuerpo. Su cuerpo tiene una respuesta biológica llamada “la respuesta
de huída o lucha” o la respuesta al stress. La respuesta al stress ocurre como respuesta a los
eventos o a pensamientos que producen stress (Ej. Preocuparse por el pasado, el presente o el
futuro). Durante la respuesta al stress, su corazón late más rápido y más fuerte, usted respira
más rápido y menos profundamente, sus músculos se tensan, usted suda más, su estómago
produce más ácido, su digestión se vuelve lenta, y se le bajan las defensas. Es fácil entender
entonces de qué manera la respuesta al stress afecta diferentes condiciones médicas.
Afortunadamente, su cuerpo también tiene una respuesta que llamaremos la “respuesta de
relajación”. En la respuesta de relajación su corazón late más lento y más suavemente, usted
respira más lenta y profundamente, sus músculos se relajan, suda menos, su estómago vuelve
a su funcionamiento normal, y su sistema de defensa regresa a la normalidad. La respuesta de
relajación también ayuda a poder
dormir.
Con frecuencia iniciamos esta respuesta de relajación haciendo una actividad donde
nos relajamos, por ejemplo, ejercicio, lectura, escuchar música, pasatiempos, dar un paseo,
ver televisión, pescar, etc. Aunque estos métodos para iniciar la relajación con frecuencia son
útiles, están limitados por el hecho de que normalmente necesitan de equipo especial (Ej.
televisión, una caña de pescar, un libro, etc.), mucho tiempo (Ej. tarde para pescar, una hora
para ver un programa de television), o un escenario especial (Ej. cuarto donde se encuentra la
televisión, un lago para pescar). Como resultado, en muchas situaciones en las que una
persona se ve ansiosa, no hay manera de que haga la cosas que normalmente haría para
relajarse. Por ejemplo, si usted se relaja leyendo un libro y usted se encuentra a la mitad de
una junta, es muy poco probable que usted pueda tomar un libro y empezar a leer para
relajarse.
Lo que se necesita es un método para iniciar la respuesta de relajación que pueda ser
usado en cualquier momento, en cualquier lugar y sin la necesidad de equipo especial. Las
técnicas de relajación le dan esta habilidad. Para entender cómo hacer esto, volvamos a la
biología del stress y las respuestas de relajación. Ya que estas respuestas son sistemas, si
podemos tomar una parte del sistema para que actué como en la respuesta de relajación, eso
serviría para empezar la respuesta completa. De todos los cambios físicos que ocurren en las
respuestas del stress y relajación, solamente tenemos control directo sobre dos de ellas: los
pulmones y los músculos. Como consecuencia, si durante la respuesta del stress hacemos que
nuestros pulmones respiren más lento y más profundamente y/o hacemos que nuestros
músculos se relajen, con práctica podremos ser capaces de iniciar la respuesta de relajación.
Dejando libres a los Músculos para que se Relajen
El primer paso es asegurarnos de que nuestro cuerpo está en posición para dejar libres
a los músculos para que se relajen. Muchas veces pensamos que al sentarnos en una silla
estamos en una posición relajada. Sin embargo, debido a que sus músculos están tensos para
poder soportar el peso de su cuerpo, muchos músculos no están libres para relajarse. El
objetivo es que su cuerpo esté sosteniendo por otra cosa que no sean sus músculos. Por
ejemplo, al hacer las técnicas mientras está acostado en la cama, hace que la cama sostenga
su cuerpo, permitiendo que sus músculos se relajen fácilmente. Un sillón reclinable puede
funcionar de manera similar a la cama ya que soporta el peso de su cuerpo. Sin embargo,
como queremos relajarnos en cualquier momento, en cualquier lugar, usted necesita ser capaz
de dejar libre sus músculos para que se relajen, sin la necesidad de una cama o un sillón
reclinable. Para hacer esto, usted usa su esqueleto para sostener el peso de su cuerpo. La
siguiente lista describe en qué posición debe poner su cuerpo para permitir que sea sostenido
por su esqueleto.
Posiciones para la Relajación
1. Pies y Piernas
Rodillas y tobillos sin cruzar y doblados a 90 grados. Los pies
planos sobre el piso.
2. Espalda
La espina perpendicular al piso, derecha pero no rígida.
Omóplatos y glúteos tocando el respaldo de la silla.
3. Brazos
Doblados a nivel de los codos unos 120 grados con las
muñecas descansando en los muslos.
4. Manos
Descansando en las rodillas, con las palmas hacia arriba o
hacia abajo. Los dedos ligeramente doblados.
5. Hombros
Colgando sueltos y flácidos.
6. Cuello y Garganta
Es ideal que la cabeza esté apoyada en la pared o en una silla,
si no es así, la cabeza balanceada con el cuello. La garganta
quieta y tranquila.
7. Parte Baja de la Cara
Con la mandíbula colgando flácida. Los dientes separados
aproximadamente el ancho de un dedo. Los labios ligeramente
abiertos.
8. Parte Alta de la Cara
Los ojos ligeramente cerrados. La frente y las cejas relajadas.
Usando su Respiración para Iniciar la Respuesta de Relajación
Otro factor importante para relajarse es su respiración. Durante la respuesta del stress,
la gente tiende a respirar más rápido y menos profundamente (Ej. Respiraciones pequeñas y
rápidas). En cambio, durante la respuesta de relajación la gente tiende a respirar despacio y
profundamente. Ya que usted tiene control sobre su respiración, usted puede usar esta forma
de respiración como para hacer, que su cuerpo esté tenso o relajado. Respirar lenta y
profundamente ayuda al cuerpo a iniciar la respuesta natural de relajación. Por ejemplo,
¿Alguna vez ha respirado profundamente para tratar de calmarse?. En muchos casos esa
respiración profunda probablemente lo ayudó a sentirse un poco más calmado. Sin embargo,
esas respiraciones profundas que la gente hace, con frecuencia no son tan efectivas como
deberían ser, por varias razones. Primero, aunque una respiración profunda con el pecho es
más profunda que la típica respiración, muchas veces la gente inhala y exhala muy rápido.
Segundo, una respiración profunda con el pecho (de la manera típica en que la gente respira
profundamente) no es tan profunda como una respiración total con el diafragma. Tercero, la
gente no practica la respiración
profunda antes de una situación de stress. Pero ya que la relajación es una habilidad, es
necesario desarrollarla para que sea efectiva y eso necesita práctica.
Para poder relajarse de manera efectiva, usted necesitará combinar la postura de su
cuerpo que discutimos antes con respiración lenta con el diafragma. Si alguna vez ha tomado
clases de canto habrá aprendido a respirar con su diafragma. Esto es usado para relajarse y
para cantar, porque le permite ensanchar más sus pulmones y como consecuencia respirar
más lenta y profundamente.
La respiración con el diafragma, en realidad, es la manera más natural de respirar.
Todos nacemos respirando así. Tome un momento e imagine a un niño pequeño acostado
sobre su espalda. ¿Qué es lo que sube y baja mientras el niño respira? Correcto, su estómago.
Sin embargo, con el tiempo aprendemos a respirar con el pecho. Por ejemplo, usamos ropa
que está apretada en nuestra cintura (limitando nuestra capacidad para respirar con el
diafragma) y nos enseñan a pararnos derechos, sacando el pecho y metiendo el estómago.
Esto resulta en que aprendemos a respirar con el pecho.
Tome un momento y haga la prueba para ver como respira usted. Siéntese derecho y
coloque una mano en su pecho y otra mano en su estómago. Observe qué mano se mueve
más. Si se mueve la mano en su pecho, entonces usted está respirando con su pecho. Si se
mueve la que está en su estómago, entonces está respirando con su diafragma.
Respirar con el pecho no es un problema para respirar normalmente. Tenemos
bastante aire con esta forma de respirar. Sin embargo, cuando el objetivo es relajarse,
necesitamos respirar más profunda y lentamente de lo que hacemos cuando respiramos con el
pecho. La razón para esto es nuestras costillas. Cuando usted respira con su pecho, las
costillas no dejan que sus pulmones se ensanchen completamente. Es como inflar un globo
dentro de una botella. El globo solamente se podrá expandir el tamaño de la botella. La
respiración con el diafragma permite a los pulmones que se expandan por debajo de las
costillas. En la respiración diafragmática el diafragma jala hacia abajo, empujando el
estómago hacia fuera, permitiendo que tanto la parte baja como alta de sus pulmones se
llenen de aire. Es como inflar un globo dentro de una botella que tiene cortado el fondo.
Como una mayor parte de los pulmones se encuentra llena de aire, usted puede respirar más
lentamente.
Para la mayoría de la gente la respiración con el diafragma es fácil de aprender, sin
embargo toma un tiempo para que uno lo haga de manera natural y cómoda. Otros
necesitarán algo de práctica para poder lograrlo. La mejor manera de aprender es usar
nuevamente sus manos. Coloque sus manos en su pecho y su estómago, como lo hizo antes.
Ahora observe sus manos y trate de respirar para que sea la mano en su estómago la que se
mueva hacia arriba y hacia abajo y la mano en su pecho se quede medio quieta. Algo que
puede ayudarlo es imaginar que sus pantalones son muy grandes y necesita sacar el estómago
para detenerlos. ¿Podría hacerlo? Si no puede, probablemente necesitará un poco más de
práctica. Siga tratando. Una vez que tenga una idea de como se siente, regrese a la posición
anterior y practique de nuevo con sus manos.
Si después de algo de práctica todavía tiene problemas, puede tratar acostado en el
piso sobre su espalda con un libro de tamaño mediano (no demasiado pesado) sobre su
estómago. Ahora, mientras respira trate de hacer que el libro se mueva hacia arriba y hacia
abajo. De manera alternada, puede acostarse sobre su estómago con sus manos sobre su
cabeza. En esta posición, el peso de su cuerpo estará sobre su pecho y usted se verá forzado a
respirar con su diafragma. Una vez que note la diferencia, regrese a la posición anterior y
vuelva a tratar con sus manos.
Su ritmo de respiración también es muy importante. Inhale lentamente. Aguante la
respiración por un segundo. Después exhale lentamente. No empuje el aire hacia fuera,
simplemente deje que la presión natural de su cuerpo lo mueva hacia fuera. A veces sirve
abrir un poco la boca, como cuando silba. Esto hace que baje la velocidad del aire que está
saliendo. Un buena señal para saber si está respirando muy rápido es el sonido de su
exhalación. Si apenas puede escuchar el sonido de su exhalación, usted está respirando lo
suficientemente lento. Si lo puede escuchar bien, entonces respire más despacio. Un buen
ritmo es alrededor de 5-6 respiraciones por minuto.
El Papel de su Mente en la Relajación
Está bien, hemos cubierto la posición de su cuerpo y su respiración, pero existe otro
factor importante del que necesitamos hablar antes de tratar de que se relaje. Es su mente. Su
mente y su cuerpo están conectados. En otras palabras, la mente tiene influencia sobre el
cuerpo y el cuerpo tiene influencia sobre la mente. Suponga que tiene una buena posición de
su cuerpo y respira con su diafragma, pero está pensando en lo que tiene que hacer al día
siguiente, o los problemas en casa, ¿Qué pasaría? Correcto, usted no se relajaría. Mientras
que el cuerpo trata de relajarse, su mente continuará mandando la respuesta al stress.
Lo que haga con su cuerpo es importante mientras está tratando de relajarse. La clave
es evitar pensar en cosas estresantes. Mucha gente simplemente tratará de poner su mente en
blanco. Si alguna vez ha tratado de hacer esto, sabrá que no funciona. La mente quiere estar
pensando en algo. Si trata de poner la mente en blanco, de manera natural tratará de encontrar
algo por que preocuparse. Usted tiene que pensar en algo, pero debe ser otra cosa y no
pensamientos que le den stress. Puede pensar en cosas neutrales (el viejo método de contar
borreguitos es un ejemplo de este método) o puede pensar en cosas agradables. Usted elige.
Por ejemplo, a los individuos con buena imaginación, les resulta bien el imaginar cosas
agradables, pero no cosas neutrales, como contar. Por otro lado, los individuos con una
imaginación pobre pueden frustrarse al tratar de imaginar cosas y con frecuencia encontrar
que las ideas neutrales les son de más ayuda. Lo que usted piensa le llamamos el “aparato
mental” porque es un aparato para ayudar a controlar la tendencia de la mente a pensar acerca
de cosas estresantes.
Si usted quiere tratar con imágenes agradables existen dos formas que lo ayudarán a
tener más éxito. La primera es imaginar la escena como si la estuviera viendo con sus ojos.
Específicamente, si se está imaginando a usted mismo en las montañas, no se imagine
sentando bajo un árbol, más bien imagine lo que vería a su alrededor si estuviera sentado
bajo el árbol. (Ej. Solamente vería su cuerpo si volteara hacia abajo). Segundo, trate de usar
los cinco sentidos. En otras palabras, no solamente imagine cómo se ve. Imagine los sonidos,
olores, la sensación en su cuerpo/pies y también cualquier sabor en el aire (o imagínese
comiendo algo). Usar los cinco sentidos ayuda a que la imagen en su mente sea más vívida,
permitiéndole enfocarse de major manera en su imagen. Finalmente, escoja como escena un
lugar relajante para usted. No tiene que ser un lugar donde en realidad ha estado, sino que
puede ser un lugar al que ha querido ir o que simplemente ha visto en una fotografía.
Si usted piensa que los pensamientos neutrales trabajarán de mejor manera para usted,
permítame sugerirle una idea (pero siéntase en libertad para crear sus propios pensamientos,
usando éste como guía). Cuando inhale, diga el número “uno” (en su mente). Después con la
siguiente inhalación diga el número “dos”, y así sucesivamente hasta llegar a 10. Cuando
llegue a 10, vuelva a empezar con uno. Volviendo a empezar en uno, cada vez que llegue a
10 lo ayudará a mantenerse mejor enfocado en el ejercicio. Cuando exhale, diga una palabra
como “calma” o “relax” para recordar lo que está tratando de lograr. Sería algo así: (inhale)
“uno” (exhale) “relax” (inhale) “dos” (exhale) “relax” (inhale) “tres” (exhale) “relax”
(inhale) “cuatro”...
El último punto relacionado con su mente involucra su actitud. Contrario a la mayoría
de las habilidades donde entre más se esfuerza uno por su objetivo más posibilidades tiene de
obtenerlo, el objetivo de la relajación requiere de una actitud pasiva para obtenerlo. ¿Qué
pasaría si yo estuviera tratando de relajarme, pero pensando, “Bien, me voy a relajar. Ahora,
Relájate. ¡Relájate! ¡RELAJATE!? Claro, que estaría más tenso. Y lo más probable es que
entre más problemas tenga para relajarme ( Ej. fallar en conseguir mi objetivo) más me
frustraría con esta técnica. Entonces se convertiría en una técnica estresante en lugar de una
técnica de relajación. Necesita tener una actitud pasiva. En otras palabras, en lugar de
enfocarse en relajarse, enfóquese en hacer el ejercicio como se le indicó y deje que la
respuesta de relajación de su cuerpo ocurra de manera natural.
Practicando la Técnica
Cuando apenas esté aprendiendo a relajarse, también lo ayudará practicar en un
ambiente tranquilo. En otras palabras, si practica las habilidades mientras ve televisión, o
mientras los niños están corriendo alrededor, no se sorprenda si no tiene éxito. Sin embargo,
una vez que haya desarrollado la habilidad de relajación, con frecuencia podrá ser usada en
medio de situaciones estresantes o en ambientes ruidosos. Usted lo hará simplemente
haciendo una o dos respiraciones con el diafragma y usando su aparato mental. No se relajará
tanto como cuando lo practica por varios minutos en un ambiente tranquilo, pero estará
mucho más relajado de lo que pudo haber estado en medio de una situación estresante.
Bien, ahora pongamos todo junto y hagamos el intento. En un ambiente relajante,
coloque su cuerpo como se le indicó y empiece a respirar con su diafragma. Recuerde
mantener un ritmo lento, pero no tan lento que sea incómodo. Si empieza a sentirse mareado
o con la cabeza débil, aumente un poco la velocidad de su respiración. Enfoque su mente en
cualquier aparato mental que haya seleccionado. Su mente tratará de buscar preocupaciones y
angustias, solo deje pasar esos pensamientos y vuelva a enfocarse en el ejercicio. Aún cuando
obtenga una buena habilidad, su mente seguirá vagando. Las personas que son buenas para
relajarse es por que pronto se dan cuenta y no dejan que les pase tanto. A veces, también
ayuda el cerrar los ojos, pero si prefiere los puede dejar abiertos y simplemente enfocar su
vista en algún objeto en la habitación. Recuerde, no trate de forzarse a relajarse. Simplemente
enfóquese en el ejercicio y permita que la respuesta de relajación ocurra naturalmente. Yo
recomiendo que practique durante 5 minutos, pero no vea el reloj. Sólo calcule que hayan
pasado 5 minutos. También puede poner una alarma si quiere estar seguro de no pasarse de 5
minutos.
Yo recomiendo que practique 2 veces al día, 5 minutos cada vez. Si hace esto de
manera consistente por 2-4 semanas probablemente esta técnica se volverá efectiva. Después
puede empezar a usar esta habilidad cuando la necesite.
Una vez que desarrolle la habilidad, ésta se volverá más efectiva cuando sea usada
con frecuencia en respuesta a las primeras señales de stress. Por lo tanto, usted necesita
empezar a poner atención a sus primeras señales de stress. Busque señales físicas de su
cuerpo, reacciones emocionales, o cosas que usted acostumbra hacer cuando está estresado.
Y cuando los identifique, haga una o dos respiraciones profundas con el diafragma usando su
aparato mental. Entre más aprenda a hacer esto con frecuencia, sus niveles de tensión se
mantendrán más bajos. Ya que ésta es una técnica muy breve, el beneficio más grande viene
al detectar el stress cuando empiece, evitando que llegue a niveles altos.
Terapia Cognitiva del Comportamiento (TCC)
(Terapia emotiva racional, terapia racional del comportamiento, terapia del vivir
racional, terapia del comportamiento dialéctico, terapia enfocada en esquema)
por Karen Schroeder Kassel, MS, RD, Med
English Version
Definición
La terapia cognitiva del comportamiento (TCC) es una forma de terapia de conversación. Esto
significa que usted discute sus pensamientos, sentimientos, y comportamientos con un profesional en
salud mental. La TCC se enfoca en la manera en la que su pensamiento afecta la forma en la que se
siente y actúa.
Por ejemplo, una misma situación puede ser percibida de manera positiva por una persona, mejorando
su bienestar, pero de manera negativa por otra, lo cual contribuye a experimentar sentimientos de
tristeza o ansiedad. Su terapeuta le ayuda a identificar pensamientos negativos y evalúa qué tan
realistas son estos pensamientos. Entonces, él le enseña a "desaprender" patrones negativos de
pensamiento y "aprender" unos nuevos y útiles.
La TCC es un método de solución de problemas. Aunque usted no puede controlar a otras personas o
a situaciones, puede controlar la manera en la que percibe y reacciona ante una situación en
particular. La TCC le enseña las habilidades para cambiar su manera de pensar y controlar sus
reacciones ante personas y situaciones estresantes.
Razones para realizar el procedimiento
La terapia cognitiva conductual se usa para tratar muchas preocupaciones de salud. Éstos incluyen:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Trastorno de depresión mayor y cambios en el estado de ánimo
Trastornos de ansiedad, incluyendo trastorno de ansiedad social y trastorno de ansiedad
generalizada, que incluye sensaciones de tristeza extrema y/o preocupación excesiva
Controlar el estrés
Trastornos de pánico
Fobias
Trastorno de estrés postraumático (PTSD)
Trastornos depresivos y de ansiedad infantiles
Trastorno obsesivo compulsivo (OCD)
Los trastornos alimenticios incluyen anorexia, bulimia nerviosa y obesidad
Insomnio y otros trastornos del sueño
Abuso de sustancias o dependencia de sustancias
Estilos de mala adaptación de relacionarse con otras personas, incluyendo permisión,
agresión pasiva, o
co-dependencia
Dolor crónico
Dificultad con las relaciones
Baja autoestima
Malas habilidades para sobrellevar las cosas
Ira incontrolada
Cómo controlar problemas de salud mental
Page 1 of 5
Copyright © 2010 EBSCO Publishing. All rights reserved.
Muchos problemas de salud mental se originan por una combinación de desencadenantes fisiológicos
y emocionales. La TCC puede ayudar a los pacientes a lidiar con la enfermedad, ya que disminuye los
efectos de los desencadenantes emocionales.
© 2009 Nucleus Medical Art, Inc.
Factores de riesgo de complicaciones durante el procedimiento
La TCC puede no ser apropiada para personas con algunas condiciones:
•
•
•
•
Aquellas personas que son psicóticas
Aquellas personas sin tratar o sin controlar su trastorno bipolar
Aquellas personas que carecen de colocación estable de vivienda
Aquellas personas con una variedad de problemas de salud inestables
Qué esperar
Antes del procedimiento
No hay preparación específica para TCC. Se le puede pedir que llene un cuestionario sobre sus
sensaciones.
Descripción del procedimiento
Usted puede recibir TCC en sesiones terapéuticas individualmente o en un formato grupal.
Se puede dividir a la TCC en dos partes: análisis funcional y entrenamiento de habilidades.
En el análisis funcional, usted y su terapeuta identifican situaciones estresantes. Usted también
determina los pensamientos que conllevan o empeoran estas situaciones. Estos pensamientos se
analizan para ver si son realistas y apropiados. Por ejemplo, su terapeuta le puede señalar patrones de
pensamientos negativos, como "no puedo manejar esto" o "la gente se está burlando de mí".
Page 2 of 5
Después, mediante entrenamiento de habilidades, su terapeuta lo guía para reducir maneras poco
saludables de pensamiento, y para aprender maneras más saludables. En vez de pensar "no puedo
controlar esto", se le enseñará cómo recurrir a sus propias fuerzas: "Fui capaz de controlar situaciones
difíciles anteriormente, entonces ahora puedo controlar esto".
Usted también aprenderá a hacer más preguntas sobre usted mismo antes de hacer una conclusión.
Por ejemplo, "¿Esas personas podrían estarse burlando de otra cosa y no de mí" El objetivo es
reemplazar patrones irracionales de pensamiento con unos más apropiados y racionales.
El entrenamiento de habilidades requiere mucha práctica, la cual frecuentemente se deja "de tarea".
Usted podría practicar ejercicios de respiración profunda o representaciones sobre cómo actuar en
algunas situaciones sociales. Una persona que lidia con abuso de sustancias podría practicar maneras
para negarse a beber alcohol.
La tarea en casa es vital para el éxito de TCC. Usted debe practicar nuevas respuestas racionales hasta
que reemplace sus respuestas anteriores poco saludables. La tarea también le permite intentar nuevas
habilidades y darle retroalimentación a su terapeuta acerca de lo que funciona mejor para usted.
Después del procedimiento
Usted puede recibir tarea entre sesiones. Necesitará practicar las estrategias que usted y su terapeuta
han discutido.
¿Cuánto durará?
La duración de cada sesión individual por lo general es de 50-100 minutos. Las sesiones grupales
pueden tardar más tiempo. Las sesiones de tratamiento se pueden llevar a cabo de 1 a 2 veces por
semana durante 12-16 semanas. Este es un lineamiento general y dependiendo de su situación, el
tratamiento puede durar más o menos tiempo.
Tenga en mente que puede tomar varios intentos para desaprender malos hábitos y para aprender unos
más saludables.
Posibles complicaciones
No se conocen complicaciones para los pacientes de TCC.
Hospitalización promedio
Por lo general, la TCC se realiza a pacientes ambulatorios. Esto se puede hacer en un consultorio
médico o en un centro de salud comunitaria.
Cuidado Postoperatorio
Algunos terapeutas aconsejan que regrese para una revisión aproximadamente a los 3, 6, y 12 meses
después que ha terminado la terapia. Además, puede llamar a su terapeuta cada vez que surja la
necesidad de hacerlo.
Resultado
El objetivo de la TCC es cambiar su proceso de pensamiento y sus patrones de pensamiento poco
saludables para aprender respuestas saludables y realistas ante situaciones difíciles. Muchos pacientes
notan una mejoría en los síntomas en un lapso de 3 a 4 semanas después de comenzar la TCC y hacer
su "tarea en casa".
Page 3 of 5
Llame a su médico si ocurre lo siguiente
Si los pensamientos, sensaciones, u otras dificultades que conllevan a que busque terapia están
regresando o empeorando, llame a su médico. Si usted tiene pensamientos de herirse a sí mismo o a
otras personas, llame a su médico o al 911 inmediatamente.
RESOURCES:
American Psychological Association
http://www.apa.org
The Beck Institute for Cognitive Therapy and Research
http://www.beckinstitute.org
National Association of Cognitive—Behavioral Therapists
http://www.nacbt.org/index.htm
CANADIAN RESOURCES:
BC Health Guide, British Columbia Ministry of Health
http://www.bchealthguide.org
Canadian Psychiatric Association
http://www.cpa-apc.org
REFERENCES:
About cognitive therapy. The Beck Institute for Cognitive Therapy and Research website. Available
at: http://www.beckins... Accessed June 10, 2007.
About cognitive therapy. The Beck Institute for Cognitive Therapy and Research website. Available
at: http://www.beckins... . Accessed November 30, 2005.
Bush JW. The CBT website. Available at: http://www.cognitivetherapy.com/index.html . Accessed
November 29, 2005.
Butler AC, Chapman JE, Forman EM, et al. The empirical status of cognitive-behavioral therapy: a
review of meta-analyses [abstract]. Clin Psychol Rev . 2005.
A cognitive-behavioral approach: treating cocaine addiction. National Institute on Drug Abuse
website. Available at: http://www.nida.nih.gov/TXManuals/CBT/CBT1.html . Accessed November
22, 2005.
Cognitive-behavioral therapy. National Association of Cognitive-Behavioral Therapists website.
Available at: http://www.nacbt.org/whatiscbt.htm . Accessed November 22, 2005.
Morris N, Raabe B. Some legal implications of CBT stress counselling in the workplace. British
Journal of Guidance & Counselling . 2002 Feb;30(1):55-62.
Ultima revisión November 2008 por Rosalyn Carson-DeWitt, MD
Last Updated: 11/17/08
Se provee esta información como complemento a la atención proporcionada por su medico. Dicha
información no
Page 4 of 5
tiene el propósito o la presunción de substituir el consejo medico profesional. Procure siempre el
consejo de su medico o de otro profesional de la salud competente antes de iniciar cualquier
tratamiento nuevo o para aclarar cualquier duda que usted pueda tener con relación a un problema de
salud.
Page 5 of 5
PATIENT IDENTIFICATION
[Your CLINIC Name]
Sitio _______________________
Proveedor_________________________
Acuerdo para la Administración de Medicamentos
Diagnóstico:
***************************************************************************
*****************
Se efectúa este acuerdo para evitar un malentendido con respecto a ciertos medicamentos que
estará tomando para alivio de dolor. Esto nos ayudará a brindarle servicios médicos de
calidad y seguir las leyes con respecto a estas medicinas controladas.
Sus iniciales
Yo comprendo que este acuerdo es necesario para la confianza e importante para la
relación entre el doctor y el paciente. Yo estoy consciente que el doctor me atenderá
basándose en este acuerdo.
Yo mantendré al tanto a mi doctor acerca de mi dolor. Yo le explicaré el tipo de dolor
que siento y que intenso es. Yo le contaré como el dolor afecta a mi vida. También
avisare lo bien que me está funcionando la medicina.
Yo no usaré sustancias ilegales controladas incluyendo la marihuana, la cocaína, etc.
Yo no venderé, compartiré, o cambiaré mi medicina a/con nadie.
Yo no intentaré obtener medicinas controladas de otro proveedor sin una buena
indicación clínica. Otras medicinas controladas incluyen medicinas narcóticas,
estimulantes controlados, o sedantes. Yo les avisaré a todos los doctores que me estén
atendiendo que estoy tomando este medicamento para alivio de dolor.
Yo comprendo que las medicinas ni las recetas podrán ser repuestas si se pierden o son
robadas.
Yo estoy de acuerdo utilizar la medicina al paso que sea recetada. Si utilizo la medicina
a un paso más rápido de lo recetado, me quedaré sin medicina por un tiempo.
Yo comprendo que mis medicinas sólo se surtirán al tiempo de visita o durante las horas
de oficina. Incluso, no faltaré a mis citas con mi proveedor de costumbre. También
estoy consciente que mis medicinas se surtirán siguiendo un calendario. No me podrán
surtir las medicinas por la noche o durante los fines de semana.
Estoy de acuerdo llamar a la farmacia 3 días antes de la fecha indicada en el frasco para
pedir que me vuelan a surtir la medicina. Si la medicina requiere una receta médica, yo
llamaré a la clínica y pediré una receta médica por escrito 3 días antes que la necesite
(pero no antes). Yo estoy de acuerdo llamar a la clínica no más de una vez por receta
médica para averiguar cuanto tiempo se tarda para surtir mi medicina.
Yo llevaré mis medicinas a cada cita.
Estoy
de
acuerdo
surtir
mis
recetas
médicas
en
esta
farmacia______________________________localizada _____________________ en
____________________________ solamente.
Si surge una emergencia o soy hospitalizado y otro doctor necesita recetarme esta
medicina, yo avisaré a La Clínica de Campesinos del Valle de Yakima lo antes posible.
Si está disponible una clase ”Pain” (Dolor) o “Quality of Life” (Calidad de Vida) en la
clínica donde me atienden, yo asistiré cada mes como parte del plan de tratamiento. Yo
recibiré mi receta médica para mi medicina después de terminar la clase cada mes.
Yo comprendo que si no cumplo con el acuerdo, mi doctor puede dejar de recetar estas
medicinas y recomendar un programa contra la dependencia de drogas. También
comprendo que si no cumplo con este contrato, me pueden pedir no volver a solicitar
servicios de esta clínica (después de una evaluación apropiada).
Yo autorizo a que mi doctor solicite y obtenga informes escritos/verbales de otras
farmacias con respecto a las medicinas que estoy surtiendo (llenando) en esas farmacias.
Yo autorizo a mi doctor a que proporcione una copia de este formulario a mi farmacia.
Yo autorizo a mi doctor y a mi farmacia a cooperar en la investigación de posible
abuso, venta u otro uso de la medicina. Cualquier departamento de seguridad de la
ciudad, del estado, o
federal o la Mesa de farmacia del estado de
_______________puede realizar tal investigación. Yo estoy de acuerdo a renunciar a
cualquier inmunidad y al derecho de privacidad y confidencialidad con respecto a estas
autorizaciones.
Yo autorizo a mi doctor a proporcionar una copia de este formulario a otras
organizaciones de salud que incluyen hospitales, clínicas, y otros proveedores que me
estén atendiendo.
Yo estoy de acuerdo someterme a una prueba de orina o de sangre si el doctor me lo
pide. La prueba se realizaría para ver si estoy siguiendo las reglas del programa.
Estoy de acuerdo participar en eI programa Three Strikes (tres faltas) si llega a ser
necesario. Si recibo 3 faltas en menos de 2 meses, mi doctor puede dejar de recetarme
medicinas narcóticas para el dolor. Puedo recibir una falta por:
• Ausencia de una medicina en una prueba de orina o un análisis de sangre.
• No llamar, someterme a una prueba de orina ni acudir a una cita con mi doctor o
consejero de salud mental.
•
•
Intentar conseguir medicinas de otro doctor
Intentar surtir mi medicina en una farmacia que no sea la que está nombrada
arriba.
Yo estoy de acuerdo seguir cada condición de este acuerdo. Me han explicado cada
condición con todo detalle.
Yo tenía estas preguntas y dudas acerca del tratamiento:
______________________________________________________________________
______________________________________________________________________
_________________________________________________________.
_____________________________ (nombre de doctor) me ha clarificado todo.
o...
Yo no tuve preguntas o dudas con respecto al tratamiento.
Yo recibí una copia del acuerdo. Yo comprendo que, si deseo, me proporcionarán un
resumen en español de este contrato sin costo alguno.
MEDICINAS INCLUIDAS EN ESTE ACUERDO:
Medicina
______________________
______________________
______________________
______________________
______________________
______________________
______________________
Dosis
___________
___________
___________
___________
___________
___________
___________
Instrucciones
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
Cantidad por mes
_______________
_______________
_______________
_______________
_______________
_______________
_______________
Mi firma abajo indica que yo estoy de acuerdo seguir todo los puntos de este acuerdo.
Formulario firmado el ________________, 200___. Hora ________________
FIRMA PACIENTE ___________________________________________________
FIRMA DOCTOR ____________________________________________________
ATESTIGUADO POR __________________________________________________
PATIENT IDENTIFICATION
Depresión:
¿Qué es y cómo obtener ayuda?
?
¿Qué es la depresión?
El sentirse triste o “bajoneado” de cuando en cuando es normal, pero no es lo mismo que la
depresión. Cuando los doctores hablan de la depresión, ellos hablan de la enfermedad
médica llamada depresión mayor.
Alquien con una depresión mayor tiene la mayoría o todos los síntomas mencionados en el
cuandro de abajo casi todos los dias, todo el día, por un periodo de dos semanas o más.
También hay una forma más leve o “menor” de depresión con síntomas menos severos. La
depresión menor tiene las mismas causas y tratamiento que la depresión mayor.
Síntomas de la Depresión
. Falta de interés o placer en cosas que
usted solía disfrutar.
. Se siente triste o adormecido
. Llora facilmente y sin razón aparente
. Se siente lento o cansado e irritable
. Se siente inútil o culpable
. Cambio en el apetito, cambio de peso
. Problemas para recordar, concentrarse o
tomar desiciones
. Dolores de cabeza, espalda o problemas
digestivos
. Problemas para dormir, o quiere dormir
todo el tiempo
. Se siente cansado/a todo el tiempo
. Pensamientos sobre la muerte o suicidio
?
¿Qué causa la depresión?
Su cerebro posee substancias químicas que ayudan a controlar su estado de ánimo o humor.
Cuando no tiene la suficiente cantidad de estas substancias químicas o su cerebro no
responde a los mismos apropiadamente, puede volverse deprimido. La depresión puede ser
genética (lo que significa que puede estar en la familia). La depresión también puede estar
relacionada con eventos en su vida, como ser la muerte de un ser querido, divorcio o pérdida
de un trabajo. La consumisión de ciertas medicinas, el abuso de las
drogas o el alcohol, o el padecimiento de otras enfermedades, también pueden conducir a la
depresión. La depresión no es causada por debilidad personal.
?
¿Cómo es diagnosticada la
depresión?
Si está teniendo síntomas de depresión, asegúrese de decírcelo a su doctor para recibir ayuda.
El o Ella le podrá hacer algunas preguntas sobre sus síntomas, su salud y su historia familiar
de problemas de salud. Su doctor también le puede hacer un exámen físico y algunas
evaluaciones.
?
¿Cómo es tratada la depresión?
La depresión puede ser tratada con medicina o consejería o terapia, o ambos. Estos
tratamiento son muy efectivos. La medicina puede ser particularmente importante en los
casos de depresión severa. Háblele a su doctor acerca del tratemiento adecuado para usted.
?
¿Cuáles son las medicinas usadas para la depresión?
Las medicinas usadas para la depresión son llamadas antidepresivos. Corrigen el desbalance
químico en su cerebro. Los antidepresivos pueden causar efectos secundarios cuando los
empieza a tomar, pero los mismos usalmente desaparecen con el tiempo.
?
¿Por cuánto tiempo los tengo que tomar usualmente?
La medicina puede empezar a actuar de inmediato, pero puede que no vea sus efectos en su
totalidad hasta luego de unas 6 a 8 semanas. El tiempo que necesite tomar la medicina
dependerá de su depresión. Usualmente lo mejor es tomar la medicina por unos 6 meses por
lo menos. No suspenda o deje de tomar la medicina sin consultar con su doctor primero.
?
¿Qué hay del suicidio?
La gente que sufre de depresión aveces piensa en el suicidio. Este pensamiento es una parte
común de la depresión. Si tiene pensamientos de lastimarse a sí mismo/a, dígaselo a su
doctor, amigos o familiares de inmediato, o llame al número local de emergencia para el
suicidio (listados en el directorio telefónico). Los pensamientos de suicidio desaparecen
luego de que la depresión es tratada.
?
¿Cómo puedo aprender más?
Para más información contacte a las siguientes organizaciones:
National Depressive and Manic-Depressive Association
800-826-3632
www.admda.org
National Institute of Mentah Health Information Resources and Inquuiries Branch
800-421-4211
www.nimh.nih.gov
American Psychiatric Association
800-35-PSYCH
www.psych.org
National Alliance for the Mentally Ill
800-950-NAMI
www.nami.org
National Mental Health Association
800-969-NMHA
www.nmha.org
Lo que Debemos Saber sobre la Ansiedad y el Pánico
La ansiedad es probablemente la emoción más básica de todas. No solamente es
experimentada por los humanos, pues las respuestas de ansiedad han sido encontradas en
todas las especies animales hasta el fondo del mar. Las experiencias de ansiedad varían
tremendamente en su severidad, desde un ligero desasosiego hasta terror y pánico
extremos. También pueden variar tremendamente en su duración, desde un instante breve,
casi fugaz, hasta un problema constante durante todo el día. Aunque la ansiedad, por su
naturaleza y definición, es una sensación desagradable, no es peligrosa en lo más mínimo.
Este último punto es la base es este folleto. El objetivo de las siguientes páginas es instruirlo
sobre los componentes de la ansiedad (físicos y mentales) para que (1) usted se dé cuenta de
que muchos de los sentimientos que usted experimenta son el resultado de la ansiedad y (2)
que usted aprenda que estos sentimientos no son dañinos ni peligrosos.
Definición de Ansiedad
Aunque es muy difícil proporcionar una definición real que cubra todos los aspectos
de la ansiedad, (se han escrito libros enteros sobre este tema), todos conocemos el
sentimiento que llamamos ansiedad. No hay una sola persona que no haya experimentado
algún grado de ansiedad, ya se el sentimiento al entrar al salón de clases antes de un examen,
o cuando uno se despierta a media noche, seguro de que oyó algún ruido extraño. Sin
embargo, lo que es menos conocido, es que algunas sensaciones como mareo extremo,
manchas u ojos borrosos, entumecimiento y hormigueo, músculos rígidos casi paralizados, y
falta de aire casi asfixiante también pueden ser parte de la ansiedad. Cuando ocurren estas
sensaciones y la gente no entiende por qué suceden, la ansiedad puede elevarse a niveles de
pánico pues la gente imagina que debe tener alguna enfermedad.
La Respuesta de Huída o Lucha
La ansiedad es una respuesta ante un peligro o amenaza. Está científicamente
probado, que la ansiedad inmediata o en un período corto de tiempo es catalogada como
respuesta de huída/lucha. Es llamada así porque todos sus efectos están encaminados ya sea a
luchar o a huir del peligro. Así que el propósito número uno de la ansiedad es proteger el
organismo. Cuando nuestros ancestros vivían en cuevas, era vital que cuando
enfrentaban algún peligro, se presentara alguna respuesta automática que hiciera que
tomaran una acción inmediata (atacar o correr). Ese mecanismo es necesario, aún en el
mundo agitado en el que vivimos actualmente. Nada más imagine al cruzar una calle, que
de pronto apareciera un carro que viniera rápidamente hacia usted tocando el claxon. Si
usted no experimentara ansiedad, lo mataría. Sin embargo, lo más probable es que
aparezca su respuesta de huída/lucha y usted correría fuera del camino para ponerse a
salvo. La moraleja de esta historia es simple – el propósito de la ansiedad es proteger el
organismo, no dañarlo. Sería ridículo que la naturaleza desarrollara un mecanismo cuyo
propósito es proteger un organismo, y al hacer esto, lo dañara.
Sistemas de la Ansiedad
La mejor manera de pensar en todos los sistemas de respuesta huída/lucha (ansiedad)
es recordar que todos están encaminados a que el organismo se prepare para una acción
inmediata y que su propósito es proteger al organismo.
Sistema Nervioso y Efectos Químicos
Cuando se percibe o anticipa algún tipo de peligro, el cerebro manda mensajes a una
sección de nuestros nervios llamada el sistema nervioso autónomo. El sistema nervioso
autónomo tiene dos sub-secciones o ramas llamadas sistema nervioso simpático y sistema
nervioso parasimpático. Son estas dos ramas del sistema nervioso las que están
directamente involucradas en el control de los niveles de energía del cuerpo y la
preparación para la acción. Puesto de manera muy simple, el sistema nervioso simpatico
es el sistema huída/lucha que libera la energía y hace que el cuerpo “se prepare” para la
acción mientras que el sistema nervioso parasimpático es el sistema restaurador que
regresa el cuerpo a su estado normal.
Un punto importante es que el sistema nervioso simpático tiende a ser en su mayor
parte un sistema de todo o nada. Esto significa que, cuando se activa, todas sus partes
responden. En otras palabras, se experimentan todos los síntomas o que no se
experimenta ninguno; raramente ocurren los cambios solamente en una parte del cuerpo.
Esto explica por qué la mayoría de los ataques de pánico involucran muchos síntomas y
no solamente uno o dos.
Uno de los principales efectos del sistema nervioso simpático es la liberación de dos
químicos de las glándulas suprarrenales en los riñones, llamados adrenalina y
noradrenalina. Estos químicos son usados por el sistema nervioso simpático como
mensajeros para continuar la actividad, por lo que una vez que la actividad inicia en el
sistema nerviosos simpático, con frecuencia continúa y aumenta por algún tiempo. Sin
embargo, es muy importante notar que la actividad del sistema nervioso simpático se
detiene de dos maneras. Primero, los mensajeros químicos, adrenalina y noradrenalina son
eventualmente destruidos por otros químicos del cuerpo. Segundo, el sistema nervioso
parasimpático (que generalmente tiene efectos opuestos al sistema nervioso simpático) se
activa y restaura con una sensación relajante. Es muy importante darse cuenta de que
eventualmente el cuerpo “tendrá suficiente” de la respuesta huída/lucha y activará el sistema
nervioso parasimpático para que restaure con una sensación relajante. En otras palabras, la
ansiedad no puede continuar para siempre, ni aumentar hasta llegar a niveles posiblemente
peligrosos. El sistema nervioso parasimpático es un protector interno que detiene al sistema
nervioso simpático antes de que se exalte. Otro punto importante es que los mensajeros
químicos, adrenalina y noradrenalina tardan un tiempo antes de ser destruidos. Así que, aún
cuando el peligro haya pasado y su sistema nervioso simpatico haya dejado de responder,
usted todavía podría sentirse inquieto o aprehensivo durante algún tiempo, debido a que los
químicos todavía están flotando en su sistema. Usted debe recordar que esto es perfectamente
natural y no hace ningún daño. De hecho, ésta es una función de adaptación, porque en los
salvajes, con frecuencia el peligro tiene el hábito de regresar y es útil para que el organismo
esté preparado para activar la respuesta huída/lucha.
Efectos en el Corazón y el Torrente Sanguíneo
La actividad en el sistema nervioso simpático produce un aumento en el ritmo cardiac
y en la fuerza de los latidos del corazón. Esto es vital para prepararse para la actividad, ya
que ayuda a elevar el torrente sanguíneo, y de esa manera mejora la oxigenación de los
tejidos y la eliminación de los desechos de los tejidos. Por eso, un corazón acelerado es típico
cuando se experimentan períodos de mucha ansiedad o pánico. Además del aumento en la
actividad del corazón, también hay un cambio en el torrente sanguíneo. Básicamente, la
sangre es redirigida fuera de los lugares donde no es necesitada (cerrando los vasos
sanguíneos). Por ejemplo, la sangre es retirada de la piel, los dedos de las manos y de los
pies. Esto es útil porque si el organismo es atacado y cortado de alguna manera, es menos
probable que sangre hasta la muerte. De aquí que durante la ansiedad la piel se ve pálida y
los dedos de las manos y los pies están fríos y algunas veces se experimenta entumecimiento
y parálisis. Además, la sangre es llevada a los músculos mayores como los muslos o los
bíceps que preparan el cuerpo para la acción.
Efectos de la Respiración
La respuesta huída/lucha está asociada con el aumento en la velocidad y disminución
en la profundidad de la respiración. Esto tiene una importancia que es obvia para la defense
del organismo, ya que los tejidos necesitan tener más oxígeno para poder prepararse para la
acción. Sin embargo, las sensaciones producidas por este aumento en la respiración, pueden
incluir sensaciones de falta de aire y asfixia, e inclusive dolores o tensión en el pecho. Algo
importante es un efecto secundario del aumento en la respiración, especialmente si en
realidad no ocurrió ninguna acción, esto es que se presenta una disminución en la sangre
suministrada a la cabeza. Aunque se trata solamente de una pequeña parte y no es nada
peligroso, sí produce una serie de síntomas desagradables (pero no dañinos) que incluyen
mareos, visión borrosa, confusión, pérdida de la realidad y brotes de calor.
Efectos de las Glándulas Sudoríparas
La activación de la respuesta huída/lucha produce un aumento en la sudoración. Esto
tiene importantes funciones de adaptación como son piel más resbalosa para que sea más
difícil que un depredador lo pueda atacar, y enfriamiento del cuerpo para detener el
sobrecalentamiento.
Otros Efectos Físicos
Un número de otros efectos físicos son producidos por la activación del sistema
nervioso simpático, de las cuales ninguna es dañina. Por ejemplo, las pupilas se abren
para dejar entrar más luz, lo cual puede resultar en visión borrosa, manchas en la vista, etc.
Hay una disminución en la salivación lo cual resulta en boca seca. Se presenta una
disminución en la actividad del sistema digestivo, lo cual con frecuencia produce náuseas,
sensación de pesadez en el estómago e inclusive estreñimiento. Finalmente, muchos de los
grupos de músculos se tensan como preparación para volar o luchar y esto resulta en
sensaciones de tensión, algunas veces llegando inclusive a dolores y molestias así como
temblor y estremecimiento.
En términos generales, la respuesta huída/lucha resulta en una activación general de
todo el metabolismo del cuerpo. Por eso, muchas veces uno se siente acalorado y, como este
proceso roba mucha energía, posteriormente la persona generalmente se siente
cansada, rendida, y disminuida.
Sistema de Comportamiento
Como se mencionó anteriormente, la respuesta huída/lucha resulta en una activación
general de todo el cuerpo como preparación para la acción – ya sea atacar o correr. Por eso
no es de sorprender que los impulsos sobrecogedores asociados con esta respuesta son de
agresión y deseo de escapar donde sea que usted se encuentre. Cuando esto no es posible
(debido a limitaciones sociales), con frecuencia los impulses serán demostrados por medio de
algunos comportamientos como son, golpear con los pies, caminar de un lado a otro, tratar a
la gente con brusquedad. Sobretodo, las sensaciones producidas son aquellas de sentirse
atrapado y con necesidad de escapar.
Sistema Mental
El efecto número uno de la respuesta de huída/lucha es alertar al organismo sobre la
existencia de un posible peligro. Por lo que uno de los principales efectos es una cambio
inmediato y automático en la atención para buscar en los alrededores una posible amenaza.
En otras palabras, es muy difícil concentrarse en las labores diarias cuando uno está ansioso.
Por lo tanto, las personas que están ansiosas con frecuencia se quejan de que se distraen
fácilmente de sus rutinas diarias, que no se pueden concentrar, y que tienen
problemas con su memoria. Esta es una parte normal e importante de la respuesta
huída/lucha, ya que su propósito es detenerlo de seguir atendiendo sus actividades y
permitirle buscar en los alrededores el posible peligro. Algunas veces, no se puede
encontrar una amenaza obvia. Desafortunadamente, mucha gente no puede aceptar el no
tener explicación para algo. Por lo tanto, en muchos casos, cuando la gente no encuentra
explicación a sus sensaciones, empiezan a buscar dentro de ellos mismo. En otras
palabras, “si nada en el exterior me hace sentir ansioso, debe haber algo mal conmigo”. En
este caso, el cerebro inventa una explicación como, “debo estar muriendo, perdiendo el
control o volviéndome loco”. Como hemos visto hasta ahora, nada puede estar más allá de la
verdad, ya que el propósito de la respuesta huída/lucha es proteger al organismo y no
dañarlo. De todas maneras, eso pensamientos son comprensibles.
Ataques de Pánico
Hasta ahora, hemos visto las características y componentes de la ansiedad en general
o la respuesta huída/lucha. Sin embargo, usted puede estarse preguntando ¿De qué manera
aplica todo esto a los ataques de pánico?. Después de todo, ¿Por qué debería ser activada la
respuesta huída/lucha durante los ataques de pánico, si aparentemente no existe ninguna
razón para estar asustado?
De acuerdo con extensas investigaciones, aparentemente la gente con ataques de
pánico están temerosas (esto es, lo que causa el pánico) de las sensaciones físicas reales de la
respuesta huída/lucha. Por lo tanto, los ataques de pánico pueden ser vistos como un
grupo de síntomas físicos inesperados y una respuesta de pánico o temor a esos síntomas.
La segunda parte de este modelo es fácil de entender. Como lo discutimos anteriormente,
la respuesta huída/lucha (de la cual son parte los síntomas físicos) causa que el cerebro
busque el peligro. Cuando el cerebro no puede encontrar un peligro obvio, cambia su
búsqueda hacia uno mismo e inventa un peligro como “Estoy muriendo, perdiendo el
control, etc.”. Como este tipo de interpretaciones de los síntomas físicos son aterradoras,
es comprensible que resulten en temor y pánico. Además el temor y el pánico producen
más síntomas físicos, y por lo tanto, se produce un ciclo de síntomas, temor, síntomas,
temor y así sucesivamente. La primera parte del modelo es más difícil de entender. ¿Por
qué está usted experimentando los síntomas físicos de la respuesta huída/lucha, si para
empezar usted no está asustado? Existen muchas maneras en las que estos síntomas
pueden ser producidos, no solamente por miedo. Por ejemplo, puede ser que usted esté
generalmente estresado por alguna razón en su vida y este stress resulta en un aumento de
adrenalina y otros químicos que de vez en cuando producen síntomas. Este aumento de
adrenalina pudiera ser mantenido de manera química en el cuerpo, incluso después de que
la razón del stress haya desaparecido. Otra posibilidad es que usted tienda a respirar muy
rápido (hiperventilación) debido a un hábito aprendido y esto también podría producir los
síntomas. Debido a que la sobre respiración es muy leve, usted se acostumbró fácilmente
a este nivel de respiración y no se dio cuenta de que usted padece hiperventilación. Una
tercera posibilidad es que usted esté experimentando cambios normales en su cuerpo
(todos las experimentamos pero la mayoría de nosotros no nos damos cuenta) y como
usted está constantemente monitoreando y verificando el funcionamiento de su cuerpo, usted
percibe estas sensaciones más que otras personas. Otra razón se debe al fenómeno
llamado condicionamiento interoceptivo. En otras palabras, los síntomas físicos han sido
asociados con el trauma de pánico, y por lo tanto para usted han llegado a ser señales de
amenaza y peligro. Como resultado, es muy probable que usted sea altamente sensible a
estos síntomas y que reaccione con temor simplemente por las experiencias anteriores de
pánico con las que han sido asociados. Como consecuencia de este tipo de asociación
condicionada, es posible que los síntomas que son producidos por las actividades
regulares también lo puedan llevar a sentir pánico. Por ejemplo, las sensación de falta de
aire y sudoración provocadas por el ejercicio físico, la sensación de agitación por tomar
café, o el calor producido en tiendas llenas de gente, pueden llevarlo a sentir pánico.
Aunque no sean exactamente correctas todas las razones por las que se experimentan
los síntomas iniciales, le podemos asegurar que son parte de la respuesta huída/lucha y por lo
tanto son inofensivas.
Entonces, una vez que usted crea (100%) que las sensaciones físicas no son
peligrosas, es obvio que el miedo y el pánico no volverán a ocurrir y que eventualmente
usted no volverá a experimentar ataques de pánico. Por supuesto, cuando usted ha tenido un
número de ataques de pánico y ha malinterpretado los síntomas, muchas veces, esta mala
interpretación se vuelve automática y se hace muy difícil durante un ataque de pánico,
convencerse a uno mismo, de manera consciente, que los síntomas son inofensivos.
Resumen
En resumen, la ansiedad es científicamente conocida como respuesta de huída/lucha
ya que su propósito inicial es activar el organismo y protegerlo del peligro. Una serie de
cambios físicos, mentales y de comportamiento están asociados con esta respuesta. Es
importante hacer notar que una vez que el peligro se ha ido, muchos de estos síntomas
(especialmente los físicos) pueden continuar, casi como si tuvieran mente propia, debido al
aprendizaje y otros cambios del cuerpo a largo plazo. Cuando ocurren síntomas físicos sin
que exista una explicación obvia, con frecuencia la gente malinterpreta los síntomas
normales de huída/lucha creyendo que indican un problema físico o mental serio. En este
caso, las mismas sensaciones se pueden volverse amenazantes y pueden volver a iniciar la
respuesta huída/lucha. Mucha gente cree que se está “volviendo loca”, cuando experimenta
los síntomas de la respuesta huída/lucha. Dentro de esta creencia, lo mas posible es que se
refieran a un desorden mental severo
conocido como esquizofrenia. Analicemos la esquizofrenia para ver qué tanto parecido
existe.
Mal interpretaciones más Comunes
Volverse Loco
La esquizofrenia es un desorden importante caracterizado por síntomas severos, como
son pensamientos y lenguaje desarticulado, algunas veces llegando a balbuceos, o creencias
extrañas (por ejemplo, que están recibiendo mensajes del espacio exterior), y alucinaciones
(por ejemplo, que hay voces en su cabeza). Además, la esquizofrenia parece ser en gran parte
un desorden genético, que se encuentra fuertemente en las familias.
Generalmente la esquizofrenia empieza de manera gradual y no intempestiva (como
durante un ataque de pánico). Además, debido a que está en las familias, solamente una
determinada porción de la gente puede volverse esquizofrénica y, en otras personas, ninguna
cantidad de stress puede llegar a causar este desorden. El tercer punto importante es que la
gente que se vuelve esquizofrénica siempre habrá mostrado ligeros síntomas durante gran
parte de su vida (como pensamientos inusuales, lenguaje florido, etc.). Así que si esto todavía
no ha sido notado en usted, entonces las probabilidades son que usted no se volverá
esquizofrénico. Esto es especialmente cierto si usted tiene más de 25 años, pues la
esquizofrenia generalmente aparece en los últimos años de la adolescencia y los primeros
veintes. Finalmente, si usted ha tenido entrevistas con psicólogos y psiquiatras, entonces
puede estar bastante seguro de que ellos hubieran sabido si usted podría volverse
esquizofrénico.
Perdiendo el Control
Mucha gente cree que “perderá el control” cuando sufre un ataque de pánico.
Presumiblemente, lo que ellos quieren decir es que se paralizarán totalmente y correrán
salvajemente o gritarán obscenidades y se pondrán en vergüenza. Además, no sabrán qué
esperar sino que simplemente experimentarán una sensación sobrecogedora de “condena
inminente”.
Por nuestra discusión anterior, ahora sabemos de dónde viene esa sensación. Durante
la ansiedad, todo el cuerpo se prepara para la acción y viene un deseo excesivo por escapar.
Sin embargo, la respuesta huída/lucha no está destinada a lastimar a otras
personas (quienes no son una amenaza) y no producirá parálisis. Lo que es más, la
respuesta entera simplemente está destinada a hacer que el organismo escape. Además,
nunca se ha registrado un caso donde alguien se “haya vuelto salvaje” durante un ataque
depánico. Aunque la respuesta huída/lucha lo haga sentir algo confundido, irreal y distraído,
usted todavía puede pensar y funcionar normalmente. Simplemente piense con qué
frecuencia las otras personas se han dado cuenta de que usted está teniendo un ataque de
pánico.
Colapso Nervioso
Mucha gente tiene miedo de lo que les podría pasar como resultado de estos síntomas,
tal vez por la creencia de que sus nervios podrían estar exhaustos y colapsarse. Como
discutimos anteriormente, la respuesta huída/lucha es producida principalmente a través de la
actividad del sistema nervioso simpático el cual es contrarrestado por el sistema nervioso
parasimpático. El sistema nervioso parasimpático es, de alguna manera, unguardia de
seguridad que lo protege de la posibilidad de que el sistema nervioso
simpatico se “desgaste”. Los nervios no son como los cables de electricidad y la ansiedad no
puede desgastar, dañar o acabarse los nervios. Lo peor que puede pasar durante un ataque de
pánico es que el individuo pierda el conocimiento, en cuyo caso el sistema nervioso
simpático detendría su actividad y la persona recobraría el conocimiento en unos cuantos
segundos. Sin embargo, perder el conocimiento como parte de la respuesta huída/lucha es
extremadamente raro, y si llegara a suceder, es una adaptación, ya que es una manera de que
el sistema nervioso simpático no “se salga de control”.
Ataques al Corazón
Mucha gente malinterpreta los síntomas de la respuesta huída/lucha y creen que han
de estar muriendo de un ataque al corazón. Esto se debe probablemente a que la gente no
tiene suficientes conocimientos acerca de los ataques al corazón. Veamos los factores de un
ataque al corazón y de qué manera difieren con los ataques de pánico.
Los principales síntomas de una enfermedad del corazón son falta de aire y dolor en
el pecho así como palpitaciones y desmayos ocasionales. Los síntomas de las enfermedades
del corazón generalmente están directamente relacionadas con el esfuerzo. Esto es, entre más
duro el ejercicio, los síntomas serán peores y entre menos ejercicio haga, se sentirá mejor.
Normalmente los síntomas desaparecerán rápidamente al descansar. Esto es muy diferente a
los síntomas asociados con los ataques de pánico, los cuales generalmente ocurren al
descansar y parecen tener mente propia. Es cierto que los síntomas de pánico pueden ocurrir
durante el ejercicio o pueden empeorar con el ejercicio, pero son diferentes a los síntomas de
un ataque al corazón ya que también pueden ocurrir al descansar. Lo más importantes es que
las enfermedades del corazón casi siempre producirán cambios eléctricos importantes en el
corazón, los cuales son detectados muy fácilmente por un ECG. En los ataques de pánico, el
único cambio que aparece en un ECG es un ligero aumento en el ritmo cardíaco. Por lo tanto,
si le han tomado un ECG y el doctor le ha dicho que todo está bien, usted puede estar seguro
de que no padece una enfermedad del corazón. También, si sus síntomas ocurren en cualquier
momento y no solamente durante el ejercicio, esta es una evidencia adicional contra un
ataque al corazón.
This handout was adapted from Craske, M.G. & Barlow, D.H. (1993). Panic disorder
and agoraphobia. In D.H. Barlow (Ed.), Clinical Handbook of Psychological Disorders,
2nd Edition. New York: The Guilford Press.
Como Funciona la Ansiedad
Cuando usted percibe peligro, su cerebro activa su sistema nervioso autónomo. Las dos
ramas de su sistema nervioso autónomo son, el simpático y el parasimpático, que controlan el
nivel de energía de su cuerpo para prepararlo para la acción. El sistema
nervioso simpático controla su respuesta de lucha o huída y libera la energía para prepararlo
para la acción. El sistema nervioso parasimpático es el sistema de relajación/recuperación
de su cuerpo: regresa su cuerpo a su estado normal cuando el peligro ha pasado.
El sistema nervioso simpático es el sistema todo-o-nada . Eso quiere decir que cuando es
activado rápidamente pone en acción todos sus componentes (que es una muy buena manera
para que opere un sistema de respuesta de emergencia.):
Latido del Corazón Acelerado, Respiración Acelerada: La reacción de alarma aumenta el
latido del corazón y el ritmo de respiración para que estemos alertas y nuestros músculos
estén listos para la acción. Estos cambios también ayudan a
asegurar que los músculos y el cerebro tendrán suficiente oxigeno y energía para defenderse.
Al mismo tiempo, la sangre que va hacia la piel disminuye, lo cual previene la pérdida de
gran cantidad de sangre en caso de ser herido.
El Sudor: El sudor ayuda a enfriar el cuerpo durante el esfuerzo, haciéndolo más eficiente.
El “sudor frío” es lo que alguna gente siente cuando se suda al mismo tiempo que la sangre
que va hacia la piel disminuye.
Opresión en el Pecho, Hormigueo, Entumecimiento, Oleadas de Calor, Temblor: La
hiperventilación ocurre cuando estamos respirando rápidamente pero no gastamos esa
energía con la acción de los músculos. Como echar andar un carro con el freno
puesto. Esto puede traer sensaciones de hormigueo y entumecimiento, oleadas de calor y
aumento en la sudoración. Cuando ocurren al mismo tiempo la respiración rápida y la tensión
de los músculos, la gente siente dolor en el pecho, falta de aliento y asfixia.
Malestar Estomacal, Diarrea: Durante los momentos de peligro la digestión no es necesaria
por lo que el sistema nervioso simpático la bloquea, ocasionando boca seca y malestar
estomacal. Ya que en los momentos precisos de peligro no se
necesita el peso excesivo, el cuerpo puede eliminar el trayecto digestivo bajo, causando
diarrea.
Visión Borrosa, Sensaciones de Irrealidad: Es común que nuestras pupilas se dilaten
durante los momentos de peligro. Aunque esto mejora la visión nocturna, el incremento en la
cantidad de luz que puede entrar a los ojos, puede ocasionar vision borrosa o más brillante
durante el día. Cuando estos cambios en la percepción visual son combinados con otras
sensaciones físicas poco usuales como las mencionadas anteriormente, se puede tener
sensaciones de irrealidad, de las cosas y de ti mismo.
Sin embargo, como con cualquier sistema de emergencia, esto no continuará para siempre. El
sistema nervioso parasimpático es un sistema de recuperación que detiene
al sistema nervioso simpático para que no se acabe. Está conectado a los mismos lugares que
el sistema nervioso simpático, pero es precavido: llega más lentamente en caso de que el
peligro regrese.
Todo esto significa que los síntomas físicos que siente cuando está ansioso (o cuando tiene
un ataque de pánico) son parte de un sistema diseñado para mantenerlo a salvo – no le
puede hacer daño. El único problema es que pueden pasar sin motivo alguno, o en respuesta a
situaciones en las que usted está amenazado físicamente.
Aquí tiene un breve resumen:
Área del Cuerpo
Corazón
Pulmones
Músculos
Estómago
Glándulas Sudoríparas
Glándulas Suprarrenales
Sistema Inmunológico
Sistema de Respuesta de
Emergencia (Sistema
Nervioso Simpático)
late más fuerte y más rápido
respira más rápido, menos
profundo
rígidos, más tensos
disminuye la digestión
aumenta la transpiración
aumento de adrenalina
se suprime
Sistema de Recuperación
(Sistema Nervioso
Parasimpático)
late más lento y normalmente
respira más despacio y profundo
más flácidos y relajados
aumenta la digestión
disminuye la transpiración
disminución de adrenalina
funciona normalmente
Plan de Valores Para Los Pacientes De Cuidados Primarios
Área de la Vida
Intención
Barreras
Plan
1. Familia y Amigos
2. Pareja
3. Trabajo
4. Diversión
5. Espíritu
6. Cuerpo
Fecha de Inicio del Plan: ____________________________ Patient Information Sticker Here
Plan de Cuidado Para la Depresión
Es fácil sentirse abatido(a) cuando se está deprimido(a). Puede ser difícil lidiar con las
tareas diarias (incluso las más simples) cuando se siente triste, tiene poca energía, y no
piensa claramente. Trate de desglosar o descomponer las cosas en pequeños pasos y
desarrolle hábitos más saludables. En una escala del 0 al 5, donde 0 es 0% alcanzado de
la meta, y 5 es 100% alcanzado de la meta, por favor defina sus metas personalizadas.
Dése crédito por sus logros. Recuerde: ¡La Depresión es Tratable!
Por favor escoja las metas en las que está dispuesto(a) a trabajar
para mejorar el manejo de su depresión
Meta 1:
Me mantendré físicamente activo(a). Voy a _________
(algún tipo de actividad) por 30 minutos __________
días a la semana. Si siento dolor de pecho, falta de aire
o presión en el pecho, buscaré atención médica.
Logros
En escala del 0-5
Seguimiento
En escala del 0-5
Meta 2:
Comeré una dieta nutritiva y balanceada diariamente.
Meta 3:
Reduciré la consumición de cafeína; evitaré la cafeína 4
horas antes de ir a la cama.
Meta 4:
Me haré de tiempo para realizar actividades placenteras
de modo a reducir el estrés.
Meta 5:
Pasaré tiempo con mis amigos y familiares.
Meta 6:
Dejaré de fumar.
Meta 7:
Practicaré técnicas de relajación para reducir la
ansiedad y el estrés.
Meta 8:
Limitaré la consumición de alcohol y evitaré el uso de
drogas sin receta o prescripción médica.
Meta 9:
Tomaré pasos pequeños y simples cuando establezco
metas para resolver problemas o tomar decisiones.
Nombre del Paciente: _________________________________
MR#: _________________
Firma del Paciente: ___________________________________
Fecha: __________________
Ciclo de Letargo
Pensamientos Contraproducentes
-No tiene caso hacer nada
-No tengo la energía
-No tengo ganas
-Es probable que falle
-Necesito descansar más
-Lo haré más tarde
Emociones Contraproducentes
-Cansado/Abrumado
-Aburrido
-Culpable/Odio a sí Mismo
-Que no Vale Nada
-Apático/Descorazonado
-Culpable
-Deprimido
Acciones Contraproducentes
-Quedarse en Cama
-Evitar a la Gente
- Evitar las Actividades Divertidas
- Evitar el Trabajo
Consecuencias del Ciclo de Letargo
-Aislado de amigos y familia
-Convencido de que es un perdedor
-Sumido cada vez más profundamente en
un estado de parálisis
-El no hacer casi nada lo convence de que
es un inútil
YVFWC PC/BHI Project 1/16/2014
Figure 3. FORM B: FOR ADMINISTRATION TO THE RESPONDENT BY AN INTERVIEWER (revised 1-99)
DUKE HEALTH PROFILE (THE DUKE)
Copyright  1989-2002 by the Department of Community and Family Medicine,
Duke University Medical Center, Durham, N.C., U.S.A.
Patient label here
Femenino____Masculino____
Dia de Visita:____/____/_____
Entrevistador: dé estas instrucciones: “Le haré unas preguntas acerca de su salud y sus sentimientos. Por
favor escuche cada pregunta cuidadosamente y déme una respuesta. Conteste las preguntas a su manera. No
hay respuestas correctas ni incorrectas”.
Entrevistador: Lea cada pregunta palabra por
palabra y marque el número apropiado según la
respuesta que le dé el/la entrevistado/a.
¿Qué bien lo/la describen las siguientes frases?
1. Me gusta la persona que soy. . . . . . . . . . . . . .
2. No es fácil llevarme bien con otras personas
3. Soy una persona saludable. . . . . . . . . . . . . . .
4. Me doy por vencido/a fácilmente. . . . . . . . . . .
5. Me resulta difícil concentrarme. . . . . . . . . . . .
6. Yo estoy contento(a) con mis relaciones familiares
7. Me siento cómodo(a) alrededor de otras personas. .
Sí, me
Me
describe
describe
exactamente más o
menos
No, no me
describe de
ninguna
manera
1
2
3
4
5
6
7
2
0
2
0
0
2
2
1
1
1
1
1
1
1
0
2
0
2
2
0
0
1
2
3
4
5
6
7
8
9
Ninguna
2
2
Alguna
1
1
Mucha
0
0
8
9
10
11
12
13
14
No
2
2
2
2
2
Algo
1
1
1
1
1
Mucho
0
0
0
0
0
10
11
12
13
14
Ninguna
Alguna
Mucha
0
1
2
0
1
2
Ninguna
1-4 Días
5-7 Días
¿Tendría hoy algún problema físico o dificultad:
8. para subir un tramo de escaleras?. .. . . . . . . .
9. para correr la distancia de un campo de fútbol
americano? .. . . . . . . . .. . . . . . . . .. . . . . . . . .. . . . . . . .
Durante la ÚLTIMA SEMANA:
10.
11.
12.
13.
14.
tuvo dificultades para dormir. . . . . . . . . . . . . .
le dolió alguna parte del cuerpo. . . . . . . . . . .
se cansó fácilmente. . . . . . . . . . . . . . . . . . . .
se sintió deprimido/a o triste. . . . . . . . . . . . . .
tuvo nerviosismo. .. . . . . . . . . . . . . . . . . . . . . .
Durante la ÚLTIMA SEMANA: ¿con qué frecuencia:
15. Pasó tiempo con otras personas (hablando,
visitando amigos o parientes)?. . . . . . . . . . . .
16. omó parte en actividades sociales, religiosas, o
recreativa (reuniones, iglesia, cine, deportes, fiestas)?
15
15
16
16
Durante la ÚLTIMA SEMANA: ¿con qué frecuencia:
17. se quedó en su casa, hogar de ancianos, u hospital
por una enfermedad, lesión, o cualquier otro problema
de salud?. . . . . . . . .
17
Hora que terminó:
(Entrevistador:
Created by YVFWC Translation Services 9/03
1/16/2014
YVFWC Planning & Development
17
2
1
0
)
X-Plain™
Trastornos del sueño
Sumario
Los trastornos del sueño son
un problema muy común que
tiene solución.
Es esencial entender la
importancia del sueño y
cuáles son los factores que
lo afectan.
Este sumario le informará
sobre el sueño, los
trastornos del sueño y su
tratamiento.
El sueño
Al dormir, el cuerpo está
inactivo pero el cerebro se
mantiene muy activo. Sólo
recientemente, los
investigadores han
empezado a entender cómo
el sueño afecta a las
funciones diarias y a la salud
física y mental.
Las personas tienen 5
etapas cíclicas de sueño:
1.
2.
3.
4.
etapa 1 - somnolencia
etapa 2 - sueño ligero
etapa 3 - sueño profundo
etapa 4 - sueño profundo
de ondas lentas
5. etapa 5 - movimientos
oculares rápidos, o MOR.
Pasamos casi el 50% del
tiempo total que dormimos
en la etapa 2, cerca de un
20% en la etapa MOR y el
30% restante en las otras
etapas. Sin embargo,
durante la infancia, pasamos
casi la mitad del tiempo total
que dormimos en la etapa de
MOR.
Durante la etapa 1, o sueño
ligero, dormitamos y nos
despertamos con facilidad.
Los ojos se mueven muy
lentamente y la actividad
muscular disminuye. Una
sensación de sentirse en
caída a menudo precede a
las contracciones
musculares llamadas
mioclonía hípnica. En la
etapa 2 del sueño, el
movimiento de los ojos se
para y las señales del
cerebro disminuyen.
En las etapas 3 y 4, las
ondas cerebrales son muy
lentas. Es muy difícil
despertar a una persona
durante las etapas 3 y 4, que
juntas forman lo que
llamamos el sueño profundo.
Durante estas etapas no hay
movimiento en los ojos ni
actividad muscular.
Cuando la gente se
despierta durante el sueño
profundo no se ajusta de
inmediato y a menudo se
siente atontada y
desorientada por unos
minutos hasta que se
despierte por completo.
Durante la etapa de sueño
profundo algunos niños
mojan la cama,
experimentan terrores
nocturnos o sonambulismo.
Durante la etapa de MOR, la
respiración se vuelve más
rápida, irregular y superficial.
Los ojos se mueven
rápidamente en varias
direcciones y los músculos
de las extremidades se
paralizan temporalmente. El
latido del corazón se acelera,
la tensión arterial sube, y los
varones experimentan
erecciones. Cuando las
personas se despiertan
durante la etapa MOR, a
menudo describen sueños
Este documento es un resumen de lo que aparece en las pantallas de X-Plain. Este documento es para uso informativo y no se debe usar como
sustituto de consejo de un médico o proveedor de salud profesional o como recomendación para cualquier plan de tratamiento particular. Como
cualquier material impreso, puede volverse inexacto con el tiempo. Es importante que usted dependa del consejo de un médico o proveedor de salud
profesional para el tratamiento de su condición particular.
©1995-2002, The Patient Education Institute, Inc. [www.X-Plain.com]
nr2401s1
1
extraños y que no tienen
lógica.
Un ciclo completo de sueño
dura entre 90 y 110 minutos.
Los primeros ciclos de sueño
de la noche comprenden
períodos cortos de MOR y
períodos largos de sueño
profundo. A medida que
avanza la noche, el sueño
MOR aumenta en duración
mientras que el sueño
profundo disminuye. Por la
mañana, casi todo el tiempo
de sueño se pasa en las
etapas 1, 2 y MOR.
Si el sueño de la etapa MOR
se interrumpe, nuestro
cuerpo no sigue el ciclo
normal de sueño cuando nos
dormimos de nuevo. En
cambio, vamos directamente
a la etapa de MOR y
pasamos a través de largos
períodos de MOR hasta que
“nos ponemos al día” con
esta etapa de sueño.
Las necesidades de sueño
En cada persona la cantidad
de horas de sueño depende
de muchos factores,
incluyendo la edad. Los
bebés generalmente
necesitan cerca de 16 horas
al día, mientras que los
adolescentes necesitan
cerca de 9 horas al día.
Para la mayoría de los
adultos, 7 u 8 horas por
noche parece ser la mejor
cantidad de horas de sueño,
aunque algunas personas
pudiesen necesitar
solamente 5 horas al día y
otras hasta 10 horas al día.
Una persona necesita más
horas de sueño si no ha
dormido lo suficiente durante
los días anteriores. La falta
de sueño crea una “deuda
de sueño” que es como estar
sobregirado en el banco. ¡Al
final, el cuerpo pide que se
pague la deuda!
Las personas no logran
acostumbrarse a dormir
menos de lo necesario.
Aunque algunas personas
pueden acostumbrarse a un
horario que les reduzca las
horas de sueño, esto
incapacita su juicio, tiempo
de reacción y otras
funciones.
Muchos estudios
demuestran que la falta de
sueño es peligrosa. Las
personas con falta de sueño
sometidas a exámenes con
un simulador de guiar autos
o a pruebas de coordinación
manual y ocular se
desempeñan tan mal o peor
que las personas en estado
de embriaguez.
La falta de sueño también
empeora los efectos del
alcohol. Cuando una
persona cansada bebe, sus
funciones se afectan más
que las de una persona que
ha descansado bien.
Según la Administración
Nacional de Seguridad de
Tráfico en Autopistas, la
somnolencia al volante es
responsable de cerca de
100.000 accidentes de
tráfico y 1.500 muertes cada
año.
Beneficios
Aunque los científicos
continúan investigando las
razones por las que las
personas necesitan dormir,
los estudios demuestran que
el sueño es necesario para
sobrevivir. Por ejemplo, las
ratas normalmente viven de
2 a 3 años, pero en estudios
en los que se les ha privado
del sueño de MOR
sobreviven solamente 5
semanas. Cuando se les
priva de todas las etapas de
sueño las ratas viven
solamente 3 semanas.
La privación del sueño tiene
efectos perjudiciales en el
sistema inmunológico.
Asimismo, el sueño es
necesario para el
nr2401s1
2
funcionamiento adecuado
del sistema nervioso.
y en las actividades sociales
de una persona.
Cuando no dormimos lo
suficiente, nos sentimos
somnolientos e incapaces de
concentrarnos. Esto puede
provocar problemas de la
memoria, torpeza y dificultad
en realizar cálculos
matemáticos. Si
continuamos privándonos de
sueño, empezamos a sufrir
alucinaciones y cambios de
humor.
Los trastornos del sueño son
responsables por 16 mil
millones de dólares en
gastos médicos anuales,
además de gastos
adicionales debidos a
ausencias durante las horas
de trabajo y otros factores.
Existen más de 70 tipos de
trastornos del sueño.
Muchos de éstos se pueden
controlar satisfactoriamente,
una vez que se hayan
diagnosticado.
Los tipos más comunes de
trastornos de sueño son:
• insomnio
• apnea del sueño
• síndrome de piernas
inquietas
• narcolepsia
El sueño profundo en niños y
adultos está relacionado a la
secreción de hormonas de
crecimiento que son
esenciales. Muchas de las
células del cuerpo se
regeneran cuando
dormimos. Estas crecen y
reparan los daños causados
por el estrés y los rayos
ultravioletas. Por esta razón
el sueño profundo puede ser
realmente un “sueño de
belleza”.
Trastornos del sueño
Al menos 40 millones de
estadounidenses sufren de
trastornos crónicos del
sueño cada año, y 20
millones más tienen
problemas para dormir
ocasionalmente. Los
trastornos del sueño y por
consiguiente la privación del
sueño interfieren en el
trabajo, al conducir vehículos
Insomnio
Muchas personas padecen
de insomnio a corto plazo de
vez en cuando.
Para el insomnio a corto
plazo, los médicos a veces
recetan pastillas para dormir.
La mayoría de estas pastillas
dejan de funcionar después
de tomarlas por varias
semanas y su uso
prolongado puede afectar el
sueño.
Muchas personas que sufren
de insomnio intentan
resolver el problema con
alcohol. Aunque el alcohol
ayuda a las personas a
dormirse, también evita que
estas personas lleguen a las
etapas de MOR y sueño
profundo.
A menudo las personas que
fuman mucho tienen un
sueño ligero y menos sueño
de MOR. También suelen
despertarse al cabo de 3 ó 4
horas debido a la abstinencia
de la nicotina.
El insomnio leve se puede
evitar o curar con buenos
hábitos de sueño. Los
investigadores están
realizando experimentos con
terapia de luz y otros
tratamientos para casos más
graves de insomnio.
La apnea del sueño
Aproximadamente 18
millones de estadounidenses
padecen apnea del sueño.
Sin embargo, sólo se ha
diagnosticado en algunos
pocos.
nr2401s1
3
La apnea del sueño consiste
en una interrupción de la
respiración mientras
dormimos. Está relacionada
con la obesidad y la
disminución del tono
muscular por causa de la
edad. Estas condiciones
permiten que la tráquea se
cierre cuando los músculos
se relajan durante el sueño.
Este problema, llamado
apnea del sueño obstructiva
suele causar fuertes
ronquidos.
Durante un episodio de
apnea obstructiva, el
esfuerzo para inhalar aire
crea una succión que cierra
la tráquea. La circulación de
aire puede verse bloqueada
de 10 a 60 segundos
mientras la persona dormida
trata de respirar.
Cuando el nivel de oxígeno
en la sangre de una persona
disminuye, el cerebro
responde despertándole de
manera que contrae los
músculos de las vías aéreas
y abra la tráquea. La
persona puede roncar o
respirar entrecortadamente,
y luego volver a roncar. Este
ciclo se puede repetir unas
100 veces cada noche.
Al despertarse tantas veces,
los pacientes de apnea
siempre tienen sueño e
incluso pueden tener
cambios en la personalidad,
tales como irritabilidad y
depresión.
La apnea del sueño causa
que a las personas les falte
oxígeno, lo que puede
producir:
• dolores de cabeza por la
mañana
• falta de interés en la
actividad sexual
• disminución de las
funciones mentales
• hipertensión arterial
• latidos del corazón
irregulares
• mayor riesgo de sufrir
ataques al corazón o
derrames cerebrales
Los pacientes con apnea del
sueño grave que no han sido
tratados tienen de 2 a 3
veces más posibilidades de
tener un accidente de
automóvil que las personas
que no sufren de la apnea
del sueño. A veces, la
apnea del sueño puede
provocar una muerte
repentina debido a un paro
respiratorio durante el
sueño.
Los pacientes que padecen
síntomas típicos de apnea
del sueño, tales como
ronquidos fuertes, obesidad
y somnolencia excesiva
durante el día deben
consultar con un especialista
para hacerse una prueba
llamada polisomnografía.
Una polisomnografía graba
las ondas cerebrales, los
latidos del corazón y la
respiración durante una
noche completa de sueño.
Si se diagnostica la apnea
del sueño, se pueden
realizar varios tratamientos.
La apnea del sueño leve se
puede resolver adelgazando.
El paciente debe también
evitar dormir boca arriba.
Además, se pueden usar
mecanismos especiales o
cirugía para corregir las
obstrucciones causadas por
la apnea del sueño.
Las personas con apnea del
sueño nunca deben tomar
sedantes o pastillas para
dormir porque éstas pueden
evitar que se despierten lo
suficiente para poder
respirar.
El síndrome de piernas
inquietas
inquietas es un trastorno
hereditario que provoca una
sensación como si algo se
arrastrara sobre el cuerpo, o
nr2401s1
4
una sensación de hormigueo
o pinchazos en las piernas y
pies. El paciente siente la
necesidad de mover las
piernas y los pies para
aliviarlos. El síndrome de
piernas inquietas se está
convirtiendo en uno de los
trastornos del sueño más
comunes.
inquietas que afecta a cerca
de 12 millones de
estadounidenses, provoca
un movimiento constante de
las piernas durante el día e
insomnio durante la noche.
inquietas severo es más
común en personas
ancianas, aunque los
síntomas pueden aparecer a
cualquier edad. En algunos
casos el síndrome de
piernas inquietas puede
estar relacionado con otras
condiciones tales como la
anemia, el embarazo o la
diabetes.
Existen terapias de
medicamentos disponibles
para aliviar el síndrome de
piernas inquietas. Conocer
las causas de este síndrome
puede ayudar al desarrollo
de mejores terapias en el
futuro.
La narcolepsia
La narcolepsia afecta a
cerca de 250.000
estadounidenses. Las
personas con narcolepsia
tienen episodios de sueño
varias veces al día, aun
cuando han dormido lo
suficiente durante la noche.
Un episodio de sueño es un
período repentino de sueño
mientras se está despierto.
Los episodios de sueño
duran de varios segundos
hasta 30 minutos. Las
personas con narcolepsia
también pueden sufrir de:
• cataplejía - pérdida del
control muscular durante
una situación emocional
• alucinaciones
• sueño nocturno
interrumpido
• parálisis temporal al
despertar
aun durante los fines de
semana y los días feriados.
De ser posible, duerma
hasta que salga el sol. De lo
contrario, utilice luces bien
brillantes por la mañana.
El ejercicio diario puede
ayudar a los patrones de
sueño, especialmente si se
hace ejercicio de 5 a 6 horas
antes de ir a la cama.
Relájese antes de ir a
dormir. Leer, ver televisión,
rezar y meditar son buenas
maneras de relajarse. Evite
la cafeína, la nicotina y el
alcohol.
La narcolepsia se suele
heredar, pero a veces está
asociada a lesiones
cerebrales provocadas por
un traumatismo cerebral o
una enfermedad neurológica.
Los medicamentos tales
como los estimulantes o los
antidepresivos pueden
controlar los síntomas de la
narcolepsia. Tomar siestas
durante el día puede reducir
la somnolencia excesiva.
Duerma bien
Lo mejor es seguir un
horario fijo para irse a dormir
y para despertarse. Es
preferible ir a la cama y
despertarse a la misma hora,
No se quede acostado en la
cama si no puede dormir.
En vez de eso, haga algo
como leer o mirar la
televisión. La frustración de
no poder dormir hace que el
insomnio sea peor.
Asimismo, mantener el
dormitorio a una temperatura
nr2401s1
5
confortable puede reducir la
interrupción del sueño.
Consiga atención médica si
sigue teniendo problemas
para dormir. ¡Existe un
sinnúmero de técnicas y
medicamentos disponibles
para ayudarle a dormir
mejor!
Resumen
Los problemas del sueño
son comunes y pueden tener
graves consecuencias. Sin
embargo, se pueden tratar.
Si padece de problemas con
el sueño, mejore sus hábitos
de dormir y consulte a su
médico. Así podrá obtener
un buen descanso por la
noche.
nr2401s1
6

Tools for Behavioral Health Interventions

Transcripción

Documentos relacionados