DOES BDD INVOLVE A SENSORY-PERCEPTUAL ABNORMALITY? “GORILLA MASK”A young woman told me that within several days of responding to fluoxetine (Prozac), the “gorilla mask” disappeared from her face. “It’s gone?” I asked her, amazed that her supposedly excessive and dark facial hair had disappeared. “Yes, I don’t see it anymore. It isn’t there,” she replied. “Where do you think it went?” I asked, very pleased with the change but also wondering how the hair could have suddenly disappeared. “How could your face have changed so quickly?” “I don’t know,” she replied. “But it’s gone.” “Is it still there and looks the same, but you no longer think it’s ugly, or does it actually look different to you—you actually don’t see it anymore?” I asked her. “It’s gone,” she replied. “I know what I see. It’s not there anymore.” When she decreased ,her dose of Prozac, the hair reappeared.Some people, like this woman, whose defects disappeared when they took a serotonin-reuptake inhibitor saw the defects again when they lowered their dose or discontinued the medication. One person told me that the holes in his teeth disappeared every time we increased his clomipramine (Anafranil) dose. He didn’t see them anymore. When we decreased the dose slightly to avoid side effects, the holes came back. This cycle repeated itself many times. He, too, insisted that his teeth changed visually. It wasn’t that the holes were still there but he decided they weren’t so ugly or that he could tolerate them better. They actually closed up. One possible explanation for these experiences is that serotonin appears to influence vision. It may protect people from overreacting to unimportant visual input, such as minimal flaws in appearance.*214\204\8*

ALCOHOL PROBLEMS AND PSYCHIATRIC ILLNESS: ATTENTION DEFICIT DISORDERSIt has been recognized that some children are unable to remain attentive in situations where it is socially necessary to do so. This is often most apparent in school, but also in the home. In the past these conditions were termed hyperactivity or minimal brain dysfunction; they are now known as attention deficit disorders (ADD). Follow-up studies of children with ADD have noted a tendency for the development of alcoholism in adulthood. The examination of alcoholics’ childhoods also shows a higher incidence of ADD. A hypothesis exists that a subgroup of alcohol abusers began to drink in order to stabilize areas of the brain that are “irritable” due to damage earlier in life. For them alcohol can be considered a self-medication. Alcohol may improve performance on cognitive tasks, allow better concentration, and offer a subjective sense of stability. Such a response to alcohol would be highly reinforcing and thereby increase the risk of addiction. With adults, it is very difficult to sort out the cognitive impairment caused by alcohol from a preexisting, underlying deficit. Prolonged abstinence is once more desirable. On the other hand, these clients may be unable to achieve and maintain sobriety.When confronted with an individual who has been through treatment several times and never been able to establish sobriety, take a careful childhood history. If there is evidence of difficulties in school, or other problems suggesting ADD, further evaluation and treatment with medication may be warranted. The medication prescribed in such cases belongs to the stimulant class; however, for such clients it has a paradoxical “calming” effect. In addition, the above data suggest it would be useful to discuss, with parents of children currently diagnosed as having ADD, steps that might be taken to reduce future risk of alcohol problems.*171\331\2*

But there is something else, something much more elusive, something much more significant. I have experienced it. I also know that others have experienced it, although they have rarely told me so.

You may easily think to yourself, “Well, how does he know?” I know in the same way as you will know when it comes to you.

When I was asking him about the nature of meditation, the yogi saint of Katmandu told me, “You can show a child a banana, but you cannot tell him how it tastes.” Taste the flavour of your relaxing mental exercises. Taste it deeply. And you will know what I mean. This that is greater than all the rest.

I have tried to write as if I were talking with you in my consulting room. If you were here with me, I would ask you to drop me a note just to let me know how things have gone with you.

As a doctor I want to know the result of my treatment. If the treatment is not quite orthodox, it is all the more important that we know the result. Please, if you have had help from this let me know. What was your trouble? How long had you had it? Then these ideas can be put to others with the additional weight of your own experience.

*149\57\2*

Stress is the disparity between the problem and the person’s ability to cope with it. So for some women an unfaithful husband is no stress at all; whilst for others it is a devastating stress.

Physiologically, stress is the disharmony of brain function which arises when more impulses are arriving in our brain from our problems than can be properly integrated.

The disharmony of brain function produces an over-alertness of nerve cells which is manifested as anxiety.

Anxiety produces nervous tension with various psychoneurotic and psychosomatic symptoms.

Obvious conditions are palpitations, butterflies in the stomach, shakiness, sweating and stiffness in muscles.

Less obvious conditions are asthma, ulcers and many cases of high blood pressure.

Stress is often fired off by some major problem. But the major problem always operates on a background of minor and incidental problems.

So a woman who has been able to cope with a sick child all day may suffer stress if her husband comes home and blows up because he has had a bad day at work. The two things together may be too much for her coping ability. On the other hand, if he gives his wife some help, all is well.

Then, of course, there are many long-acting problems— a child, not sick, but always wanting to avoid school; the children having friends who are taking drugs; poor communication in the marriage. Not big things in themselves, but they can add up and so cause stress.

The disturbing nervous impulses from different problems are cumulative, so that a reduction of nervous impulses from one problem may mean that the impulses from the major problem do not reach sufficient intensity to produce stress.

Most of our problems cannot be avoided or ameliorated. So how do we avoid stress?

We can make a second-class journey through life on tranquillizers. Tranquillizers work by dulling the activity of nerve cells; reducing our alertness, ability to think, and perception of the full beauty around us.

Or we can also avoid stress by trying to minimize our tasks and problems. Avoid trouble. Get an easy job. Avoid responsibility. Avoid active competition. Retreat from the active hurly-burly of life. Become a vegetable.

*89/98/5*

No. I don’t think so. I know it’s a common belief amongst many people, and even amongst many psychiatrists, that some stress is good for us; but stress is not good for us, because it is essentially a disordered function of the mind.

We want to be careful what we mean by stress. Different people have different ideas about what stress is. Some people just regard it as the problem, or the hurdle, or the difficulty that the person is confronted with. However, this is only one side of stress. I see it as the disparity between the problem and the person’s ability to cope with it: it is the gap between something difficult, or even frightening, and our ability to grapple with it. So one person faced with a problem may be under stress, while another person faced with the same problem may be under no stress at all.

If we are living really well, if we are well adjusted to life, we are coping with difficult situations without stress: the quality of life is good, and we deal with problems without anxiety, apprehension, or depression.

Quality of life – what is it?

‘Quality of life’ has become a catch-phrase. It sounds well from psychologists, it gets a few votes for politicians, and it is used by all manner of do-gooders.

But what is the Quality of Life?

Some years ago I had a large room with sixty comfortable chairs, which I called the Quiet Place because it was there that I showed people how to meditate. It was there, too, in the Quiet Place, that I held a series of public meetings to discuss the quality of life.

Now, what is the quality of life? People brought up all sorts of ideas. Is it a highbrow conversation? Is it looking at modern works of art? Is it a reasonable standard of living? Or is it nothing to worry about? Is it simply enjoying nature? Does it have something to do with God?

For many years I have felt that an important part of quality of life is inner peace of mind and the absence of tension, anxiety and stress. Life is better if we are free of tensions, and the quality of life is enhanced. However, I am not suggesting that ease of mind is quality of life in itself, but I do think that the development of ease of mind is a large step towards quality of life. And the important thing is this: it is a step that is within our grasp.

*82/98/5*

We have just discussed the way in which longstanding stress may cause chronic constipation. At first it may seem strange that stress is also the cause of nervous diarrhea. It comes about like this. Stress activates the sympathetic nervous system which inhibits movement of the bowel so that we will be free for action. But all these reactions are governed by self-regulating mechanisms. The self-regulating mechanism may overreact. This is what happens in nervous diarrhea. The parasympathetic nervous system has the opposite effect of the sympathetic. It increases movement of the bowel. In order to neutralize too great sympathetic activity, the self-regulating mechanism may activate the antagonistic, parasympathetic system. The result is an increase in the contractions of the bowel which results in diarrhea.

Nervous diarrhea of this nature can be relieved by reducing the level of stress by simple meditation. The object is to reduce the severity of stress in life as a whole, and not wait for the advent of some demanding situation.

*44/98/5*