SEROTONIN-REUPTAKE INHIBITORS (SRIS): FIRST-LINE MEDICATIONS FOR BDD- WHAT IS SEROTONIN? Serotonin is one of the brain’s natural chemicals that transmits signals between nerve cells. These chemicals (neurotransmitters) are the chemical messengers that make the brain’s nerve cells fire and function. Healthy functioning of serotonin is important in many bodily functions, including mood, sleep, and appetite.The SRIs increase the amount of serotonin at the junction between nerve cells by preventing its reuptake, or reabsorption, into the releasing nerve cell (neuron). As a result, less serotonin is broken down, and more is then available to act on neurons that are “downstream.” This increased amount of serotonin between nerve cells in turn influences the activity of brain neurons. It appears that the SRIs increase overall serotonin transmission in the brain. They probably work by increasing serotonin availability at key brain areas. However, the serotonin system in the brain is extremely complex, and the SRIs’ overall effect on this system needs to be better understood. In addition, because different neurotransmitter systems are highly interconnected, the SRIs also influence other neurotransmitters, such as dopamine. Furthermore, it’s possible that the SRIs’ effect on serotonin isn’t what actually leads to decreased symptoms. This effect may simply be one step in a complicated chain of events.*243\204\8*

OVERCOMING BARRIERS TO BDD TREATMENT: OVERCOMING STIGMA   To some extent, psychiatric disorders are still unfortunately associated with stigma, which may make people reluctant to seek psychiatric treatment. However, this view is changing. Increasingly, psychiatric problems are being recognized as medical problems that deserve treatment, thanks in good part to the advocacy of consumer groups.What To Do: Accept that BDD is a medical condition like diabetes or heart disease. It just happens to involve the brain, as many other medical conditions do too. You’d probably go to the doctor if you had bad chest pain, so why not go and get treatment if you’re obsessed and have time-consuming behaviors you feel compelled to do? Remember that stigma is decreasing, and isn’t something you need to buy into anyway. Would you feel stigmatized if you got treatment for a heart attack? Would you stigmatize someone else if they did? I hope not! BDD really isn’t any different. It just happens to involve the brain rather than the heart.*238\204\8*

A clock is bad for someone who is conscious of the number of hours they feel is necessary to sleep each night. A common experience for most people who wake up in the middle of the night is to look at the clock by their beds. Some will exclaim, ‘My goodness, it is now one in the morning. This is it, I will be unable to sleep again and will stay awake for the rest of the night’. The worry of what time it is in the middle of the night can give rise to tension and anxiety. Of course, this tension and anxiety will prevent the person from falling asleep again. Then when they look at the clock again after a while, they will panic and say to themselves, ‘It is now two, and there is only a few hours before morning’.

Marking the hours of the night. There is a self-fulfilling prophecy for some people. They believe that, once they wake up in the middle of the night, they will not sleep again. Their tension increases as they mark the hours through the night. This tension is in fact reducing their chances of sleep. So, as the night approaches, they already predict that they are going to wake up in the middle of the night and will not be able to fall asleep again. The night comes and they wake up in the middle of the night and immediately look at the clock to find out what time it is. Each time they look at the clock, they generate more anxiety within, which prevents them from sleeping. Each time they fail to sleep, they are convinced once more of their own prediction.

Anxiety is cumulative and their confidence to sleep is reduced with succeeding nights that they fail to sleep. Looking at the clock and marking the hours of the night is to be avoided completely, as this generates tension and reduces the confidence to sleep.

No clocks. A normal sleep pattern always consists of a few awakenings at night. The older we are, the more frequent we wake up in the night. However, it is common that we do not always remember these awakenings, and we fall back into sleep. Next time when you wake up in the middle of the night, tell yourself it is perfectly normal and healthy to do so. Do not bother to find out what time it is or try to work out how much time you have slept or how long it will be before daybreak. It is very tempting to look at the clock, but once you get used to putting the clock away you will surely sleep much better. Just lie back, do nothing, practice self-relaxation, and you will fall back into sleep.

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A twenty-seven-year-old man sought help to stop biting his nails. He said he had had the habit ever since he could remember. He was extraordinarily tense, and he said he did most of his

nail-biting when he was worried and on edge. He admitted that he was so tense that with little provocation he would flare up.

He did the exercises and when last seen about six weeks after his first visit claimed that he had mastered the habit, and as evidence showed me how his nails were beginning to grow normally.

Blushing-About two years ago an attractive nurse said she had been plagued with blushing for as long as she could remember. She often kept thinking about it and then she would blush. She blushed in the company of young men. She blushed in buses, and did not even like asking other nurses about patients on account of her blushing.

She learned the exercises, but I was not sure how much help she had gained until she came in a few weeks ago to ask advice about some other problem. When I asked her about the blushing she merely commented, “Oh, that’s all gone,” as if she had forgotten all about it.

It is interesting to note that some years previously I had seen a man with similar trouble about blushing. This was at the time before I had developed the idea of the patient doing the exercises himself. I treated this man with a number of sessions of hypnosis, and there was little improvement in his blushing.

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