Dr. Joyce Nash, psychologist and author discusses adult ADD, ADHD diagnosis, along with treatment and ADDult work and relationship issues.

David is the HealthyPlace.com moderator.

The people in blue are audience members.

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Conference Transcript

David: Good evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com.

Our topic tonight is "Adult Attention Deficit Disorder Issues." Psychologist, Joyce Nash, Ph.D. is our guest. Dr. Nash has a private practice in Menlo Park, California. She is the author of 7 self-help books, along with having a private practice. One of her specialties is treating Adults with ADD, ADHD (Attention Deficit Disorder, Attention Deficit Hyperactivity Disorder).

We'll be starting with the Adult ADD diagnosis and treatment issues, then moving on into adult relationship and work issues. And, of course, Dr. Nash will be taking questions from the audience.

Good evening Dr. Nash. Welcome to HealthyPlace.com. Thank you for being our guest tonight. Most of the attention on ADD has been on children and adolescents. Still, many adults with ADD are being overlooked, misunderstood, undiagnosed, and untreated. Why is that? Is it difficult to diagnose ADD-ADHD in adults?

Dr. Nash: Good evening. For a long time, mental health professionals have believed that ADHD disappeared at about age 12. We now know that isn't true, although some people still doubt the diagnosis. Making the diagnosis of ADHD in adults is difficult. There are no definitive tests that say "yes, you've got it." What we do is a combination of things to decide "by the weight of the evidence" if ADHD or ADD is present.

Let me pause for a moment and say that there are now two subtypes of ADHD (Attention Deficit Hyperactivity Disorder) that are recognized. One is the primarily Inattentive type and the other is the primarily Hyperactive-Impulsive type. It is possible for a person to have either or a combination of both. The way we go about diagnosing is through a combination of:

1. a clinical interview that takes into account childhood history;

2. use of paper-and-pencil self-report measures, such as the Connors;

3. watching what the person does in the interview, i.e., observation; and

4. seeing what changes happen as the result of treatment, specifically, ADD medication treatment.

David: There are medications, private therapy, support groups available to help adults with ADD. Which do you recommend as the first line of treatment and why?

Dr. Nash: Probably the best bet is to find a psychologist who is trained to assess ADD (Attention Deficit Disorder) and start there. He or she should then be able to refer for a medication evaluation to a psychiatrist if that seems appropriate. Many people who do appear to have ADD don't want to start with medication, however. Therapy that does not use medication can focus on how to cope with ADD symptoms. Support groups are great, especially CHADD, which has chapters all over and a website. It is a good place to get initial information.

David: Because of the difficulty in obtaining an ADD, ADHD diagnosis, would you recommend that a person get a second opinion if they aren't satisfied with the first diagnosis?

Dr. Nash: Getting a second opinion is okay. A problem is that many people have read the popular literature on ADD and have memorized the ADD symptoms. They, then, rattle these off to the interviewer, who may take them on face value. It is important that whomever the person sees for diagnosis be trained and understand Attention Deficit Disorder in adults.

David: Here are some audience questions, Dr. Nash

val1: I have ADHD, so do all 4 of my children. How common is this?

Dr. Nash: It is believed that between 2 and 5% of children have ADHD, but estimates vary depending on the study and the criteria used. Often an adult "discovers" that he or she has ADD when the child has been diagnosed. ADD does tend to run in families.

David: Does ADD start in childhood and progress into adulthood? Or can it arise in adulthood without appearing in childhood?

Dr. Nash: ADD never arises in adulthood. Some symptoms of Attention Deficit Hyperactivity Disorder are always present in childhood, usually before age 7. The ADHD symptoms in childhood may be overlooked, however, and become a problem progressively. The key is to understand what is age-appropriate behavior and distinguish that from behavior that is "not normal."

David: Here's an audience comment, then more questions:

Starsdancing: I've shown ADHD symptoms all of the 40 years of my life, even before most doctors knew what it was. Only after looking at the 3 of 5 of my kids that have it, was I able to find a doctor who would consider me to have ADHD.

Stacie: Why are so many doctors hesitant to start an adult on Ritalin, even when the signs point to ADHD?

Dr. Nash: Ritalin is a stimulant drug and as such is closely monitored by the government. In addition, there are side-effects that can cause problems. Usually, the first intervention with adults with ADD is an antidepressant. This is generally a good idea because by the time an adult with ADD is "of age", they are often depressed as well. If the antidepressant doesn't help (usually an SSRI like Prozac), then the doctor may move to a stimulant.

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chilly: I have consulted a psychiatrist about the possibility of ADD, and after only 15 minutes he concluded that I "absolutely do not have it" because I made good grades in school; even though I have many other traits and ADD symptoms. How do you feel about eliminating the diagnosis based solely on this fact?

Dr. Nash: I think 15 minutes and one criterion--good grades--is not a good basis on which to decide a diagnosis. Many ADD adults compensate in various ways. Some have uniformly good grades. Some have high marks in some subjects and low marks in others--usually, the ones they aren't interested in or that are BORING.

add_orable: I had "known" for some time I had ADD because it was there in my school report. I found a specialist, took his name to my doctor and asked for the referral. He didn't believe me until my mind started to wander and my talking became rapid. I informed him that ADD in women can be very different than it appears in males.

Dr. Nash: It might be a good idea to take some handouts with you to the doctor's office before seeking diagnosis or treatment, especially if you are seeing an MD. CHADD has lots of terrific handouts that spell out in easy to understand language, the different "faces" of ADD.

David: I'd like you to address the differences between the appearance of ADD in women and men. Does ADD appear differently in women than it does in men -- symptom-wise, I mean?

Dr. Nash: Men with ADD tend to show more "active" symptoms, like aggression, anger, irritability. Women with ADD tend to be dreamers and "spacey." Of course, it can go either way.

netboy: Is it true that most ADD children can become Bipolar Adults? If so, how can you differentiate between whether an adult has Attention Deficit Disorder or Bipolar?

Dr. Nash: ADD can co-occur with a number of disorders, including depression, obsessive-compulsive disorder, anxiety disorders, etc. I haven't heard that ADD leads to, or causes, Bipolar.

Attention Deficit Disorder is believed to be a neurological problem--a difference in the way the brain functions, especially the frontal lobes or the "executive system". Bipolar results from an imbalance in the chemistry in the body and brain, usually in a deficit of lithium salts. I don't see how ADD could cause Bipolar, but I don't think they are mutually exclusive.

The symptoms of ADD and Bipolar are quite different. ADD symptoms are more or less constant and don't vary-- i.e., they are not: there sometimes, and not there other times.

Bipolar, which is also known as manic depression, involves an alteration (for most people) between a "high" state of mania or hypomania ("high but not that high") and depression.

David: Dr. Nash is a psychologist, not a psychiatrist, and as such isn't an expert in medication issues, but maybe you could answer this question:

tink2: I've been taking Adderall for two years, and I am concerned about possible addiction. My doctor says that it is no more addictive than caffeine.

Dr. Nash: Stimulant drugs can be addictive, which is why the government watches it so carefully. In addition, they cause side-effects such as insomnia. I'd talk to my doctor again or seek a second opinion.

David: Here are a few audience comments regarding adult ADD diagnosis and treatment. Then we'll address Adult ADD and relationship issues:

Starsdancing: There are still many docs who believe you outgrow ADHD.

tink2: Since I've been on Adderall, I can better help my own children to organize themselves.

Stacie: CHADD is great for the support and they have been great in helping me get through the diagnosis stage.

add_orable: I'm seeing one of the top ADD adult specialists in Australia. It has come from my father's side. My doctor believes me now and is getting quite interested!

Dr. Nash: More and more psychiatrists are willing to consider the diagnosis of ADD, now that the research evidence is accumulating.

David: On the relationships front: Living with ADD can easily feel like an emotional roller coaster, both for the adult with ADD and also for the spouse or partner of the adult with ADD. What does the partner need to understand that would help the relationship go smoother?

Dr. Nash: ADHD can wreak havoc on relationships, especially if the non-ADD partner doesn't understand what is going on. I often see couples that involve one ADD and one non-ADD person. It is so important for the non-ADD spouse to get educated about what ADD is. Otherwise, she (or he) may take the behavior as a personal affront. It is possible to teach the non-ADD person how to be supportive of the ADD spouse. It is also important for the non-ADD person to learn to understand and deal better with her frustration and anger that result from the behavior she sees but doesn't understand.

David: When you say "wreak havoc" on a relationship, what are you referring to, and what ADD symptoms cause that to occur?

Dr. Nash: The non-ADD spouse is likely to take it personally when the ADD person forgets appointments, loses things, etc. Often she will say, "Why can't he just think!" She gets angry, which in turn can make him feel criticized, misunderstood, and angry.

Sometimes, it is the ADD person with the anger problem. When he gets frustrated with himself, he can take it out at home. So the ADD person needs to learn how to cope better with his situation so that anger is less likely or more manageable.

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netboy: How can a spouse help the ADD mate structure their day?

Dr. Nash: Often, an ADD person marries a spouse who is highly organized and detail-oriented. This is terrific for the ADD person, but the non-ADD detail-oriented spouse can become frustrated. Both spouses need to learn how to work together. An ADD person usually does much better when there is a structured environment. The ADD person should learn to use some type of organizing system, but the key is that it must be SIMPLE. Some day organizers are just too overwhelming. Some ADD persons like the Palmcorders, others don't.

The non-ADD spouse can be helpful by providing reminders and playing back up. However, she must be willing to do so and understand why it is necessary, and he (the ADD person) must be willing for her to play this role.

In couple's therapy, these are some of the issues we address. In addition, she (the non-ADD person) can help out in managing his impulsivity, if that is a problem. For example, she can send him "silent signals" when he is interrupting or talking too much. My husband is ADD and we use a signal system in social situations where I gently tug on my earlobe, and that is his signal to slow down, take a breath, stop talking, start listening.

cBYcc: How can coping skills be learned for the angry, ADD male?

Dr. Nash: The first thing is to understand the emotion of anger and that it is the body's hard-wired alarm system. Once we understand that anger is inevitable, especially in the presence of frustration or fear, then we can focus on what to do with the anger. Anger is not a behavior; aggression (shouting, yelling, cursing, throwing things, etc.) is a behavior that is usually, but not always, driven by anger.

Next, we learn to understand what triggers his anger. What are the situations that are "high risk" for anger. Usually, they are being tired, hungry, in pain, overwhelmed, or otherwise distressed. The coping skills needed depend on the situation. It may be necessary to take time out, leave the arena, and "catch your breath." Go for a walk, but don't rehearse angry thoughts while you are doing so. Leaving an upsetting situation is a behavioral strategy.

Another type of coping skill involves thinking--talking oneself down, so to speak, from being angry. Trying to see or understand the situation another way.

Dobby: Any suggestions for explaining your Attention Deficit Disorder to your children?

Dr. Nash: Children are naturally full of energy, at least most of them. Use simple concrete language to explain your ADD to your children. (If they, too, are ADD, keep it really simple.) Say something like, "You know how you can get so excited sometimes that you forget things, well Daddy can get that way too." Try to help them understand that everyone is different, but that doesn't mean bad. It just means that each of us has to learn different ways to "be good."

David: Here are a couple of audience comments on Adult ADD and relationship issues, then we'll go onto ADD work issues:

cBYcc: My husband and daughter have ADD, and I feel I am constantly trying to "smooth" things for them!

add_orable: My better half says he exists to pick up after me and find my keys and glasses. He says "how do you do it? (laughing)" I say, "it is just a talent," and his life has meaning!

tink2: I've found that exercise improves my ADD symptoms.

Dr. Nash: Exercise releases endorphins and provides a calming effect. Some ADD people develop a substance abuse problem because they try to medicate away their symptoms that way. Exercise is a much better solution.

David: One of the most common problems adults with ADD experience in their jobs or careers, centers around time management -- getting things done on time. What do you suggest for dealing with that?

Dr. Nash: As to work-related issues, I believe it is really important to learn to PLAY TO YOUR STRENGTHS. I once worked with an attorney who graduated at the bottom of his class but was hired into a firm even so. Then, he was fired from that job. He was convinced that he shouldn't be an attorney because he couldn't remember trial dates, when to submit briefs, etc. But he loved constructing and arguing a case in court. I convinced him to start his own firm and hire someone to do the details--remind him of court appearances, etc. At first, he argued that he "should" be able to do these things. He did hire someone finally (part-time), and now he has his own successful law firm with several attorneys working for him. ADD people are often better being their own boss.

But even if you do work in an organization, learn to delegate, delegate, delegate. Say "no" to jobs that are too detail-oriented or repetitive. It just isn't an ADD person's strengths. An ADD person is usually creative and a "big picture" thinker. Let someone else do the details.

There is a saying I like repeating to my ADD clients: "It is easier to ride the horse in the direction it is going." Play to your strengths and don't try to be what you aren't. Build a support system around you. You may have to tinker a bit to find what works for you. Keep trying.

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David: One of the hallmarks of Attention Deficit Hyperactivity Disorder is forgetting, losing things, not being organized. What can adults do to help them remember and keep track of things?

Dr. Nash: We used to have the problem (more so than now) at our house. We developed a system that works for my ADD husband. We have an "in" drawer and "out" drawer in the chest in the foyer. Everything in his pockets goes into the in drawer each night and goes into his pockets in the morning. In the morning he also takes anything in the out drawer with him. Periodically, we coordinate calendars, and I play back up. He emails me copies of every communication that relates to both of us. (It used to be that he would agree to a social invitation and forget to tell me). Now, he just forwards emails to me or he emails me anything that comes to his mind. We have a saying here: "If it isn't written, it's not real."

These are just some of the ways that spouses can work together to deal with ADD.

David: That's a good system. Here's a good suggestion from one of our audience members:

add_orable: Turbonote.com has a wonderful little program that is like a post-it note for your computer. You can set it to alarm if you like too. It is wonderful!

David: Another work difficulty centers on "paperwork"-- trying to keep up with the details. Do you have any suggestions for handling that?

Dr. Nash: My husband also uses turbonote! Each ADD person has his or her own presentation of ADD or specific set of symptoms. Managing paperwork can be a problem. This is where Obsessive Compulsive Disorder and ADD can overlap. Some OCD people are hoarders. They can't make a decision about where to put something, or they can't bear to part with it, so they pile it. Filing is boring. ADD persons abhor boring tasks.

Here again, delegating is a good idea, or finding a simple system of managing paperwork. But if you have paperwork strewn all over the place, piled on the floor, etc., and you have trouble getting rid of paper, consider consulting a professional about the possibility of OCD complicating your ADD (God forbid).

add_orable: How do you deal with housework. None of us are really any good at it. Hubby does it every now and then. I am hopeless and never get it finished. I am sure I have lost a few friends as it is embarrassing for them to come over to an untidy house.

Dr. Nash: ADD people don't do well with boring or repetitive tasks. If you can afford it, hire someone to clean your house. Create a simple system for organizing things. As usual, the advice is to delegate and create a structure that supports you.

David: I know it's getting late. Thank you, Dr. Nash, for being our guest tonight and staying to answer everyone's questions. And thanks to everyone in the audience for coming and participating. I hope you found it helpful.

Dr. Nash: Thank you for the opportunity to be with you.

David: Good night everyone. and thank you again for being here tonight.

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We frequently hold topical mental health chat conferences. The schedule for upcoming conferences, and transcripts from previous chats, are here.

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Conference transcripts dealing with many aspects of ADHD in children and adults.

1. Adult ADHD Diagnosis - Conference Transcript
   Guest: Dr. Lenard Adler

2. Adult Attention Deficit Disorder Issues
   Guest: Dr. Joyce Nash

3. Advocating ADD/ADHD children
   Guest: Judy Bonnell

4. Alternative Thoughts About Attention Deficit Disorder
   Guest: Gabor Mate

5. Advice and Insights for Parents of Children with ADHD
   Guest: Brandi Valentine

6. Coaching, For Parents of ADD/ADHD Children
   Guest: Dr. Richfield

7. Coping Skills for Adults with ADD, ADHD
   Guest: Thom Hartmann

8. Mood Disorders in Children
   Guest: Trudy Carlson

9. Parenting Difficult Children
   Guest: Howard Glasser

10. Parents of ADHD Teens: School issues, social, and peer relationships
    Guests: Dr. Alan Graham, and Dr. Bill Benninger

11. Special Education Law
    Guests: Pete Wright and Pam Wright.

Conference transcripts on alternative therapies for psychological disorders, spirituality in the healing process and experiencing a Birthquake.

1. Alternative Therapies for Psychological Disorders
   Guest: Bill Dockett

2. BirthQuake: The Journey To Wholeness
   Guest: Tammy Fowles

3. Spirituality in the Healing Process
   Guest: Anil Coumar

4. Thought Field Therapy
   Guests: Dr. Frank Patton and Phyllis

 

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back to: Alternative Community Homepage ~ Other Conference Transcripts on Mental Health

Dr. Frank Patton is a psychologist who specializes in Thought Field Therapy (TFT). This technique reportedly eliminates emotional distress and gives immediate relief for PTSD, addictions, phobias, fears and anxieties.

Phyllis is our support group manager as well as a host for one of the anxiety disorders support groups on our site. She has been coping with moderate to severe anxiety for some time and has tried "Thought Field Therapy" with Dr. Patton.

David Roberts: HealthyPlace.com moderator.

The people in blue are audience members.

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Online Conference Transcript

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com.

Our topic tonight is "Thought Field Therapy." We have two guests - psychologist, Frank Patton, Psy.D. and Phyllis, who has tried "Thought Field Therapy" and will provide us with a first-hand account of her experience with it. Dr. Patton has a Doctor of Psychology degree from Baylor University. He is one of fourteen professionals worldwide trained in the use of TFT Voice Technology, the highest and most advanced level of TFT training. Dr. Patton also currently serves as a consultant nationwide to residential treatment programs for adolescents and their families.

Thought Field Therapy (TFT) is supposedly a safe and effective technique for the elimination of emotional distress. It reportedly gives immediate relief for PTSD, addictions, phobias, fears and anxieties by directly treating the blockage in the energy flow created by a disturbing thought pattern. It's proponents say it virtually eliminates any negative feeling previously associated with a thought.

Good evening, Dr. Patton, and welcome to HealthyPlace.com. Thank you for joining us tonight. Can you please tell us a bit more about yourself and how you got into "Thought Field Therapy?"

Dr. Patton: After trying all treatment modalities, thought field therapy has emerged as the most powerful and effective. Working with adolescents in a treatment facility, we were pressed to find effective methods of dealing with explosive behavior and also the many traumas in their lives. We were interested in finding an effective treatment that would help them to overcome their anger and out-of-control behavior, thus we found thought field therapy.

David: In layman's terms, can you explain how "Thought Field Therapy" works?

Dr. Patton: TFT is a gentle tapping method along the energy meridians of the body to eliminate negative emotions that are trapped in the thought field and can be released and then eliminate the root of the problem.

David: For the audience, here's a slightly more detailed explanation: The therapist asks a person to think about a situation or event and rate how uncomfortable they feel at the moment on a scale from one to ten; where ten is the worst you can feel and one is no trace of the problem. Then, at the direction of the therapist, the patient taps with two fingers on various acupressure points on the body. During this process, the patient rates how they feel. The tapping is done according to a prescribed recipe pattern (algorithm). The algorithm is based on the particular emotions elicited by the upset. After the series of tapping, which takes only five to six minutes, the treatment is complete and the distress is reportedly eliminated.

First of all, what types of disorders is TFT effective with?

Dr. Patton: Any negative emotions such as anger, depression, anxiety, fear, guilt, obsessive thinking - any emotional problem that has distress attached to it can be treated with TFT.

David: I know that TFT has only been around for about 20 years, a relatively short period of time compared to other forms of therapy. It sounds relatively easy and I'm wondering how effective it can be?

Dr. Patton: Success rates achieved with TFT are unprecedented. 75% to 80% success are achieved with TFT basic general formulas (algorithms). 95% success is obtained with causal diagnostic procedures, even with the most difficult cases.

David: I also know that a lot of people in the audience are shaking their heads right now, going "Right! I just think about what causes my problems, rate the severity on that problem on a scale of 1-10, and then I tap on some acupressure points on my body and 'poof,' I'm cured." Is it as simple as that, Dr. Patton?

Dr. Patton: Yes, it does seem remarkable. One owes it to themself to try this simple technique and then, by your personal experience, you will know if it works or not.

David: In just a few minutes, Phyllis will be joining us. She tried Thought Field Therapy with Dr. Patton and will be sharing her experiences with us.

My last question, and then we'll get to a couple of audience questions before Phyllis comes on -- How does one access a Thought Field therapist, how are the sessions conducted, and how much does it cost per session?

Dr. Patton: Do a web search on Yahoo or Altavista using the keywords thought field therapy and this will provide you with the names of some though field therapists. The cost is comparable to professional fees in the community. It is, however, structured differently. It is faster and more effective than traditional treatment and can be done by phone.

David: So are you saying that it costs about $75-100 per session?

Dr. Patton: That is fair to say. Therapists set their own individual fees. We do make sure that the individual receives the results they are seeking.

David: You mentioned TFT is used to treat anxiety, depression, OCD and other disorders. How many sessions before one would notice a significant improvement and approximately how many sessions until the treatment is concluded?

Dr. Patton: Simple problems can be taken care of in one session. More complex problems require more treatment time, up to 5 hours for the most complex.

David: Here's an audience question, Dr. Patton:

Italiana: How can this "therapy" help an agoraphobic?

Dr. Patton: First the fear and anxieties are cleared. The individual then is able move more freely without anxiety.

Italiana: And which type of professional is certified to teach this "method" or is it self-taught?

Dr. Patton: There are three levels of certification: algorithm, diagnostic and voice technology. The founder of Thought Field Therapy, Dr. Roger Callahan also has a book called Tapping the Healer Within that offers instructions on how to perform the basic treatments.

adultchile: Does insurance cover TFT?

Dr. Patton: In some instances, it would, if the treatment provider gives direct service (Person to Person). VT by phone is not covered by insurance, because the treatment has to be direct contact with the person. The person can check with their insurance carrier.

Hollyhock: How does this therapy help clinical depression? Especially if the depression is long standing? Is it effective?

Dr. Patton: We have found it effective with clinical depression which does require more treatment time due to its complexity.

David: Joining Dr. Patton is Phyllis. Phyllis is our support group manager as well as a host for one of the anxiety disorders support groups on our site. She has been coping with moderate to severe anxiety for some time and tried "Thought Field Therapy" with Dr. Patton recently.

Welcome Phyllis. Can you describe what you've been dealing with, for how long, and some of the symptoms, along with the severity of those symptoms?

Phyllis: Good evening David and Dr. Patton and all users. I have had anxiety in different forms for many years. For about 5 years I was agoraphobic and could not leave my home. The symptoms were very high. I would like to add here that I am now nearly 99% recovered and have been so for nearly 10 years.

David: And when you spoke with Dr. Patton by phone for your session, what issues were you dealing with specifically?

Phyllis: When I spoke with Dr. Patton I had issues of high stress and anxiety. He did not need to know exactly what these issues were, but I was to visualize them and rate them on a level of 1-10. I rated mine at a 10.

David: Just so we all know, what symptoms did the stress and anxiety produce in you?

Phyllis: The symptoms were lightheadedness, a feeling of agitation, depression to some degree, and a feeling of being slightly out of control.

David:So you had severe stress and anxiety. You rated these issues a 10 on a level of 1-10 with 10 being the highest. What happened next?

Phyllis: I had a session with Dr. Patton this week. I had to visualize the issue and rate it, as I said. I was given sentences to say and they were used to figure my own individual sequence of tapping. The sentences were:

1. I want to be healthy.
2. I want to be over this problem.
3. I WILL be over this problem.
4. I want to be COMPLETELY over this problem.

By using their Voice Technology, they figured out a sequence of tapping to unblock negative emotions.

David: Do you remember how the tapping sequence went?

Phyllis: They made up a sequence according to what my voice presented to them. There was a tapping sequence that involved part of the hand, along the eyes and under the eyes, under the arm, and the collarbones.

David: Now, when you decided to participate in this, what was your attitude? What were your feelings about TFT?

Phyllis: I was skeptical, as I am more used to the traditional "talking" therapy. However, I was willing to give this a try. I was also told to hum something with 5 notes, to count to 5 and to do most tapping 5 times.

Periodically Dr. Patton would assess my level of distress. The first time I went from a 10 to only about an 8, so we repeated the sequence. By the end my anxiety level was about a 2-3 -- much improved.

David: And was that something that was temporary in nature or do you feel that this is a permanent improvement?

Phyllis: I cannot honestly say, although it did continue all through the day, but with added issues it is going up and down. But I feel stronger about the issues now and really do feel better.

Dr. Patton talked also about toxins that are produced in the body. They can block some of the release of emotions. For me, we discovered it was laundry detergent in my shirt and also a smell of smoke.

David: It also seems, with the tapping and humming, that it was a form of relaxation therapy. Did you find that to be so, Phyllis?

Phyllis: The tapping and humming did seem to be a form of relaxation, but I was so busy trying to do it just perfect (my downfall) that it might have been better for me to have just relaxed and gone with it.

David: Here's an audience question, Phyllis:

Italiana: Since Phyllis is, as she states, "99%" cured for 10 years, I am thinking maybe this was easier for her. Is this true?

Phyllis: Italiana, yes, it may have been easier for me. But remember that I had a very high level of stress when I went into this. This had to be worked on all over again.

David: Dr. Patton, is TFT a form of relaxation or meditation therapy?

Dr. Patton: This works the same for everyone, no matter how long they have suffered.

No, relaxation is a benefit of the treatment.

David: I have a couple of site notes and then we'll continue with our discussion:

Here's the link to the HealthyPlace.com Anxiety Community. You can click on this link and sign up for the mail list at the top of the page so you can keep up with events like this.

Dr. Patton, I just want to make sure I understand. Are you saying this "Thought Field Therapy" is a complete solution to certain disorders. That a person wouldn't need additional therapy or medications after completing the sessions?

Dr. Patton: For some, this may be the case. However, additional treatment and medication are helpful for those who need it. I, personally, have worked with an individual who has stopped medication for over 15 months and also worked with an individual who has decreased their medication.

David: Well, this has been very interesting. Thank you, Dr. Patton, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com. You will always find people interacting with various sites.

Thank you, too, Phyllis, for being our guest tonight and sharing your experiences with TFT with us.

Dr. Patton: Thank you for your time. It has been a pleasure to be with you tonight. Thank you, David.

Phyllis: You are quite welcome, David.

David: Good night everyone and I hope the rest of your week goes well.

Anil Coumar, a psychotherapist specializing in integrating psychological and spiritual growth, discussed spirituality and spiritual thinking and incorporating spirituality and spiritual practice into your life -- improving your mental well-being. We talked about the practice of meditation, learning to self soothe and engaging in soothing activity to get in touch with your essential self. These are just some of the tools people can use to improve their mental health.

Mr. Coumar also addressed some audience members' concerns about their not feeling worthy of God's attention; that they were not good enough to talk with God. The conversation covered how to feel better about yourself and how we can learn to accept ourselves and find mental peace.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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Online Conference Transcript

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com.

Our topic tonight is "Spirituality in the Healing Process." Our guest is psychotherapist, Anil Coumar. Mr. Coumar graduated from medical school in India and later came to the United States, where he now works at the University of Washington mental health clinic and also has a private practice.

Good evening Mr. Coumar, and welcome to HealthyPlace.com. We appreciate you being our guest tonight.

Anil Coumar: Thank you for inviting me.

David: Can you please tell us a bit more about yourself?

Anil Coumar: I was born and raised in India, where I spent the first 25 years of my life. I completed medical school and my residency in psychiatry in India, then I came to England and started training to be a psychotherapist while working as a physician. I trained in Transactional Analysis psychotherapy, and in 1992, I moved to the US and completed a master's degree in psychology. I have been working at the University of Washington since 1994.

I have a deep interest in the role of spiritual practice in mental well being. I believe that sometimes psychotherapy can be a little pessimistic; incorporating spirituality enhances the work of the psychotherapist.

David: So we are all on the same page, can you please give us your definition of "spirituality?"

Anil Coumar: Spirituality is the experience of interconnectedness of all things... It is more than a belief.

David: Can you clarify that for us?

Anil Coumar: Normally we feel disconnected from ourselves and everything around us, and I believe this happens because of what is happening in our minds, the internal chatter. Once this internal chatter shuts down, then we can reach a place of silence. When you reach the place of silence, you feel love, connection, and interconnectedness.

David: Many people who come to HealthyPlace.com are suffering from depression, anxiety disorders, eating disorders and other mental health problems. How can they use spirituality to help themselves feel better?

Anil Coumar: Spirituality is not something we can use to change the reality. Spirituality is understanding things as they are. Now, when it comes to depression, we have always been trained to do one of two things:

We have been trained to either suppress it or to express it. The trouble with these 2 approaches is that they have a way of prolonging the depression. For example, if I suppress my anger it might come out as a physical symptom, such as an ulcer, or I may engage in passive-aggressive behavior. If I express my anger, I have to deal with the consequences. You might hurt somebody or hurt yourself, therefore prolonging the emotion. There is a 3rd approach, which is to stay with the emotion (depression) every time a problem arises.

We are always looking for solutions. That approach is sometimes useful, but if the problem keeps occurring, we need to look at the problem. The same way if we stay with an emotion, there is a great chance that we will come to a place of insight about our problem or situation.

Whenever I tell someone or ask someone to stay with the problem, they are often confused. How does one stay with the problem? This is where the practice of meditation comes in and is useful. In the kind of meditation I practice, one has to stay with the bodily or somatic sensations. The rationale behind it is that every time there is an emotion, it evokes a physiological change in the body which we can feel as a physical sensation. For example, when we are anxious, the heart beats faster, the hands trembles, or we feel butterflies in our stomach. Normally, when we get an unpleasant sensation, our impulse is to get rid of it. However, if we stay with the sensation we will learn about the nature of it.

David: Just to summarize for a moment, are you saying that too many times we run away from our problems or look for instant solutions when we really need to figure out what the problem is?

Anil Coumar: Correct, and when you use the term "figure out," it implies an intellectual approach. What I'm talking about goes beyond the intellect. It's an actual feeling remaining with the sensation.

David: Besides meditation, are there any other helpful tools that one can use to improve their mental health?

Anil Coumar: Understanding the nature of time is helpful. Time being past, present and future. Most of the time, we are worrying about the future or regretting the past. Both past and future are non-existent, meaning one cannot go into the past or future. This is important to understand, since most of our problems are caused by not being in the present. However, it is difficult, if not impossible, to force the mind to be in the present. What we can do is to understand the content of the mind. Other things apart from meditation that can help us to remain in the here and now are taking a walk, being in nature, listening to music, or whatever activities you like. Sometimes it's hard to remain in the moment when one is in acute pain. During those time, we can learn to self soothe. A person can think about a soothing activity for each sense organ. For example, if we take the eyes, we can look at the beautiful sunset or mountain or even watch TV mindfully. These things can be soothing. We need to be flexible to come up with an activity that is soothing to us because the same technique is not going to work each time.

David: Here's an audience comment I'd like you to respond to:

Montana: I feel that facing your fears, discussing them with a therapist, and understanding the feelings so you can let them go helps you get in touch with your essential self.

Anil Coumar: Montana, there is no fixed self. Each emotion that comes up is not going to be dealt with the same way.

sher36: What can we do to change the learned behavior of living in the past? I would like to do many things now, in the present, but therapy concentrates on dealing with the past. I would like to overcome this and live in the present. Any suggestions?

Anil Coumar: Sometimes talking about the past with a therapist can help us let go of the incessant rumination and thereby slowly clear the path, and it'd only be clearing the path, the mind can remain in the present.

David: Here's the link to the HealthyPlace.com Alternative Mental Health Community. You can click on this link and sign up for the mail list at the top of the page so you can keep up with events like this.

Here's the next question:

riverfish: Isn't worrying about the future sometimes healthy, like worrying about the material future, which makes us search for better a job that finally gives more then it takes?

Anil Coumar: I'm glad you asked that question; this is something people get confused about. Let's take the example of the student: If the student is sitting in front of his or her book and worrying about the outcome of his or her exam or what job he may find, he is not paying attention to the present. If he pays attention to the present, which is to learn the content of the book in front of him, he will take care of the future. Worrying about the future is not the same as planning for the future. Planning is good as long as we are flexible because the future is so unpredictable we need to be flexible. Plans never go the way we want them to go.

Nerak: I want so much to get my spirituality back. I think what is holding me back is that I don't think I have a right to talk with God ( as I have) and do Self Injury. Any suggestions about how to overcome this?

Anil Coumar: Could you tell me, Nerak, what you mean by getting your spirituality back, because you never lost it.

Nerak: Well, I feel I have lost it or lost touch with it.

David: Nerak, can you tell us what you mean by that? What has made you feel this way?

Nerak: I no longer talk with God as I used to.

Anil Coumar: I don't understand what you mean when you say you "talk to God."

David: Part of the problem, I think, Mr. Coumar, is that some people who engage in self injury or other destructive behaviors may feel that they aren't worthy of God's attention (or their higher power's attention).

Nerak: Thank you, that is it.

ErikCOBx: I feel the same way, Nerak.

Anil Coumar: I would really challenge that assumption, Nerak, and ask myself, " is it really true that I'm not worthy of God's attention?" How do you know that it's true? That is what you should ask yourself. See what happens and how it affects you when you believe that assumption is a fact. You begin to dislike yourself even more, so it is important to examine our assumptions.

David: Also, I think that many times when we feel unworthy of another's attention, whether it be a physical person or God or your higher power, it's not because they have said to us "you are unworthy". Rather, it's our own self-talk, the way we feel about ourselves, and we project it onto others as if they feel the same way about us.

Here are a few audience comments about this:

ErikCOBx: I feel as if I'm not good enough to talk to God, but he has been talking to me in my dreams. Though we lose our faith at times, God always remains faithful to us! :)

Nerak: I guess I don't, but that is how I feel.

Londa: Deep down inside, we know we are not worthy. It is something we can say we do not believe, but it is there, all the same.

Montana: I felt I had lost it, but it was just buried underneath my past, in my sacred territory. Once I worked through some of those issues, I began to get connected with my spirituality which helped me resolve much more, and I began to have love of self and live in the serene present.

Londa: I feel the same way, unworthy of Creator's attention. Like, I believe other people can talk and pray and get a response, but I am too ...unworthy.

David: So, maybe as we begin to heal and feel better about ourselves, we begin to feel more worthy and more connected.

Anil Coumar: Precisely.

Montana: That has been my experience.

Alohio: Define 'spirit' to us. Spirit as 'soul'?

Anil Coumar: First of all, it is something that is difficult to express through words. It's a deep felt oneness and the recognition that everything is connected. We are always looking outside for solutions. It's like we have a big flashlight which we are shining all around us... What happens when we shine the flashlight unto ourselves?

What I mean by that is to look at the source of the problem, which is the I. Most of our problems exist because we are ignorant to the true nature of ourselves, so it's important to ask, "What Am I?" When we first ask that question, we will begin by describing things about ourselves: our name, our relationships, our behavior; but behind that there is the entity that cannot be described.

In asking this question, "What Am I?," we come across a brick wall, and it's important to observe that state of silence.

David: Here are a few more audience comments about what's being said tonight:

Alohio: We all start off as children who need to learn. Therefore, wisdom comes from outside of us.

sher36: I believe that spirit is something inside of us, and unless you nurture this spirit, you can never heal. If you are true to yourself, you nurture your spirit and, in return, are happy with yourself. You feel better about yourself and will find yourself worthy of anything, including a high power.

ErikCOBx: I think in order to feel God's acceptance of us, we need to learn to accept ourselves. To me, we are not human beings experiencing a spiritual experience, we are spiritual beings experiencing a human experience.

Montana: Connection of mind, body, and spirit/wholeness/oneness.

species55: And one must integrate the past with the present if one is to move smoothly enough towards the future to integrate that future with the now 'present past.'

ErikCOBx: Hi, my name is Erik. I've been worrying about my health and feel my constant worrying is making me feel symptoms. Can your mind really make you believe you have symptoms?

Anil Coumar: Absolutely, Erik. There have been experiments conducted where a hypnotherapist put a coin on a subject's arm and told the subject under hypnosis that the coin is red hot, in reality, it was not hot but the subject's body reacted as if the coin was very hot. So because the subject believed that the coin was hot, his body produced a reaction as if there was a burn.

gigi: My therapist also has a prayer group. Do you think it is a good idea to see a therapist in more than one role?

Anil Coumar: It's hard to comment. Ideally, a therapist should have only 1 role. However, in small towns and communities, this may not be possible. It is important to find out if there is any pressure from the therapist to join the prayer group, gigi.

eveinaustralia: What happens if you can't remember the past and you have many troubled souls inside you, fighting so much for the present that you can hardly bear to open your eyes in the morning? What, then, of spirit?

Anil Coumar: The spirit can be felt only when the mind is somewhat clear of the pain that you are describing. I encourage you to go and talk to a professional so that you can have some mental peace to welcome the spirit.

David: If you haven't been on the main HealthyPlace.com site yet, I invite you to take a look. There are over 9000 pages of content.

Thank you, Mr. Coumar, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com. I invite you to stay and chat in any of the other rooms on the site. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others: http://www.healthyplace.com

Anil Coumar: It's been my pleasure and I thank you for this opportunity.

David: Good night everyone.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Tammy Fowles, the author of BirthQuake: The Journey to Wholeness, and site master at SagePlace, talked about BIRTHQUAKES, where everything in your life is rocked and shifted, where foundations crack, and treasures lie buried beneath the rubble. In the end, those who experience one are, in every case, ultimately transformed.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good evening everyone. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "BIRTHQUAKE: Transitioning Through A Crisis in Your Life". Our guest is Tammie Fowles, Ph.D., author of the book "BirthQuake: The Journey to Wholeness". Dr. Fowles' site, SagePlace is here at HealthyPlace.com. 

Good evening Dr. Fowles. Welcome to HealthyPlace.com. Thank you for being our guest tonight. What is a BirthQuake?

Dr. Fowles: Hi David. Glad to be here. A Birthquake essentially is a transformational process that gets triggered by a turning point or crisis, what I call a quake. Quakes occur for most of us when we are standing at a crossroad. They can be precipitated by a loss, a major lifestyle change, or even a new awareness.

David: When you say a "turning point" or "crisis," is this something of monumental proportions or simply a significant change in our life?

Dr. Fowles: Generally, they are of monumental proportions. Ultimately, however, a lifestyle change or even a single awareness can prompt one. Typically, they are painful experiences, but the pain holds promise because they trigger a healing process.

David: Can you give us an example of what you are referring to?

Dr. Fowles: Sure. A man who has worked his entire life for a major corporation loses his job, is devastated, depressed, but ultimately discovers that his life felt empty and enters another career that offers greater rewards.

David: On your site, you say one of the goals of writing "BirthQuake: The Journey to Wholeness" is to help people find meaning and purpose in their life. I think, and this is especially true here at HealthyPlace.com where our visitors deal with many types of psychological disorders and ask, "why did this happen to me?" how does one start on the journey to find meaning and purpose in their life?

Dr. Fowles: Well, the discovery of meaning and purpose is a unique journey for each of us. For myself, it was about no longer looking for the meaning of my life, but instead to do what I could to make my life more meaningful. To create meaning.

David: We have a few audience questions, Tammie, then we will continue:

BlackAngel: I have anorexia. The turning point in my life happened prior to this, and going through the process of anorexia is the transition part, the healing. Is that what you are saying?

Dr. Fowles: Yes, I am saying that the recovery process you are undergoing will lead to healing on a number of levels.

Dottie: About two years ago, I began working through child sexual abuse issues and I experienced what I described as an earthquake. The memories came flooding back, and I felt so alone through all of that. Is that a typical reaction or feeling?

Dr. Fowles: Absolutely, Dottie. In fact, I named my book BirthQuake because this process is initially very much like encountering an earthquake. This healing process, this uncovering treasures buried beneath the rubble, this rebuilding, can lead to rebirth. Jacob Needleman wrote, "When you're in the middle of an earthquake you begin to question what is it that I really need? What is my rock?" I can fully appreciate your feeling alone and overwhelmed. You will also discover your rock, your strength.

David: In essence, what you are saying is-- when going through a BirthQuake you are developing a "new you" and hopefully one finds themselves in a more emotionally and spiritually comforting position than even before the crisis happened.

Dr. Fowles: Yes, on some level you are developing a new you David, or rediscovering the real you. You are strengthened through this process. A Birthquake affects the entire person, affects us physically, emotionally, spiritually, and impacts our outer world in most cases.

David: Here are some more audience questions:

Pier: When we feel we can go no further, experience nothing worse, do you feel that part of the process of recovering from this is this earthquake of which you speak?

Dr. Fowles: Yes Pier I do, although we don't need to always get to that place.

David: Are there phases to a BirthQuake -- from the crisis to healing, finding the "new you"? If so, can you identify them for us?

Dr. Fowles: Certainly. The first phase of a Birthquake, I call the "exploration and integration phase." This phase is triggered by the quake or turning point. This phase generally involves a great deal on soul searching, questions, confusion, and uncertainty. It is during this phase that we begin to explore what we want/need/fear, etc. Tom Bender wrote that, "like a garden, our lives need to be weeded to produce a good crop," and that's what we start to do during this first phase. We look at where in our lives we need to weed, and where and what we need to plant and cultivate. Bender also wrote that in order for a person and a society to be healthy, there needs to exist a spiritual core and that the spiritual core involves honoring. An important question that we need to ask during this first phase is, "what do I really honor, and how, if at all, does my life style reflect what I truly honor?"

The next phase is the "movement phase." It is here that we begin to make changes. They are often small at first. For instance, we might change our diet or make an appointment to see a counselor.

The final phase is the "expansion phase." This phase is where our changes and growth not only impact our own lives, but touches other lives as well.

David: Dr. Fowles' website is called SagePlace. When you have some quiet time, I encourage you to sit down at your computer and read through this excellent site. Not only is there a lot of information, but it is presented in a very thoughtful manner. Here is the link to purchase Dr. Fowles' book: "BirthQuake: The Journey to Wholeness".

Here are a couple of audience comments on what's been said so far, then more audience questions:

flitecrew: I think my experience qualifies as a quake. I lost a cousin, three weeks later I lost my brother, seven months later my mother passed away in her sleep, four months later my sister was diagnosed with incurable pancreatic cancer and died one year later. I had given up my job to care for my sister and when it was done, I had no immediate family left or a job. But four years later, I am doing well, although it was a long and difficult journey.

Pier: We have all had our terrible experiences. We have all searched for answers. The answers lie only within ourselves. This is what I understand of healing.

Montana: I experienced several years of severe abreactions, which in reality, helped me get into the healing process and remove the pain and anguish. My question is how do you connect the mind, body and spirit to find balance after the BirthQuake?

Dr. Fowles: By attending to each of these sacred aspects of the self. It takes time, certainly, but they are clearly interconnected. Laurence J. Bennet observed that, "Healing is a process of reorganization and reintegration of things which have come apart." Step-by-step, as you make a conscious effort to integrate mind/body/spirit, this process takes place. There are some wonderful books that you might find helpful, Montana, such as Ken Pelletier's books -- "Mind as Healer, Mind as Slayer" and "Sound Mind, Sound Body." There are several more.

David: Here are two similar questions:

BlackAngel: What if instead of going through the entire process, you fail. Where does that leave you?

Keiki: What if the healing doesn't work, so you rip open wounds (literally) and never feel solace?

Dr. Fowles: Healing is a process. You may think you've failed when you've only stumbled. Ken Nerburn advises that, "You must ask yourself not if you will heal, but how you will heal." You may think you have reached the end, when you are actually simply at another turning point.

tjs53221: I was wondering if there is any way of quickening a new birth or birthquake. I have been divorced for three and a half years and can't seem to get over the pain and get on with my life. What can I do?

Dr. Fowles: I am wondering if you've sought counseling, if you've sought the support of a group. These are two helpful steps.

tjs53221: Yes. I have done both.

Dr. Fowles: Perhaps, although you continue to be in pain, you are continuing to grow. Even your pain can be a pathway to possibility. Are you journaling? Have you looked for the lessons of this painful experience? What are you doing now to provide support and nurturance to yourself?

David: One of the things you talk about in your book is the myth of "happily ever after." We are led to believe that the spouse, the kids, the white picket fence and having money is the ideal. In reality, many people don't reach that point, ever! What does that mean?

Dr. Fowles: Frederick Edwards wrote of living on the "deferred payment plan," that's what we do when we hope that some event will lead to us being happily ever after. The truth is that there is no "happily ever after."

adultchile: How can you attend to these sacred aspects when you are doing all you can to just keep breathing and keep a roof over your head? How can you get your perspective back, when you don't feel safe?

Dr. Fowles: It doesn't come with the right partner, job, etc. That's a very good question, one that speaks to my heart. The priority first is to do what you need to do to feel safe. That comes first.

When you are living with anxiety and fear, it is difficult to have a positive outlook or a healthy perspective, so sometimes you have to "borrow" the perspective of others.

This helps you to keep your expectations of yourself modest, to take one step at a time, and trust to the very best of your ability that you'll make your way out of the darkness. Once you begin to feel safer, and that will require work on your part as well as reaching out, your perspective will shift.

David: I want to mention here that we have a very large journaling community, people who keep online diaries of their experiences. It is not only helpful to the journaler, but also to the visitors who come by and discover they are not alone in their feelings.

Dr. Fowles: I highly recommend journaling as well.

David: Here are a few more audience comments on what's been said so far:

Keiki: People don't ever reach "the white picket fence" because they hurt too much inside themselves.

Joyce1704: The truth is, you are as happy as you allow yourself to be. It comes from within. As I know, if you learn to love all the little pleasures, soon the larger problems melt away. In 1962, I suffered a near fatal auto accident resulting in total amnesia. I had to have the faith to start a whole new life. With faith in GOD and Divine intellegence, I built a new life. It wasn't easy.

Pier: We are not human beings trying to become spiritual, we are spiritual beings trying to become human.

Dr. Fowles: I absolutely agree with you Joyce and Pier.

Reenie274: What about the severe traumas we may have encountered in our lives, things that we have yet to resolve. Does this relate to them as well?

Dr. Fowles: Absolutely. Confronting those, very often leads to a Birthquake.

David: Another audience comment:

tjs53221: I journal sometimes. I guess I don't really nurture myself because I keep dwelling on the pain.

Montana: Healing and Growth takes practice, practice, practice and willingness, willingness, willingness!

Dr. Fowles: Absolutely, Montana. Edwin Louis Cole observed, "You don't drown by falling in the water, you drown by staying there." Dwelling on the pain might still be part of the process for you, but you need to move beyond this dear sister. Have you heard of dialoging as a journaling tool?

David: Can you briefly explain that?

Dr. Fowles: Well there are many forms of dialoging. But one that I often suggest is dialoging with our inner wisdom. Each of us contains an enormous storehouse of wisdom that we need only tap into. When we simply write to ourselves, we can get mired in our pain, anger, confusion. If we write to our inner wisdom and then allow that inner wisdom to answer, then we begin to make progress. There is an amazing amount we can learn from ourselves.

David: One thing I want to ask: Concretely, how do you move from beyond the pain to starting the transformation, to the "journey to wholeness" as you describe it?

Dr. Fowles: I think the first step is to ask yourself, "how do I grow from here?" There is no one specific action that each of us can take that works for all of us. I hate to be in pain. I hate to hurt. But when I'm hurting I've learned to ask myself what lessons live along with this pain. What do I need? What must I do? What must I change? etc. James Hillman once said, "Every major change involves a breakdown." What change is this breakdown calling for?

David: I want to thank Dr. Fowles for being our guest tonight and sharing her knowledge and experience with us. And thanks to everyone in the audience for coming and participating. I hope you found it helpful.

Dr. Fowles: I would like to thank you David for providing us with this opportunity to explore this area together. And thank each of you for being here. I sincerely hope you found this chat helpful. Goodnight.

David: Thanks again and good night everyone.

 

Bill Docket discusses herbal remedies and alternative therapies used for psychological disorders. Mr. Dockett studied Traditional Therapeutic Herbalism and is also a certified addictions counselor.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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Online Conference Transcript

David: Good evening everyone. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Alternative Remedies and Therapies for Psychological Disorders". Our guest, William Dockett, has over nine years of experience in the mental health field. He is a Traditional Therapeutic Herbalist and a certified addictions counselor.

I also want to run our usual disclaimer, that we are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Good evening, Bill, and welcome to HealthyPlace.com. Can you explain what traditional therapeutic herbalism is?

Bill: Hello, and thank you for inviting me. Traditional herbalism is the use of herbs for healing. The most common is Chinese Herbalism or TCM.

David: Do various herbal remedies work for mental health issues like depression, bipolar, ADD, etc.?

Bill: Yes, the most common ones are St. John's Wort, Valerian, and Chamomile, which is also used for folks sensitive to St. John's Wort.

David: Are there any mental health areas where herbs are ineffective in treating a psychological disorder?

Bill: Yes, schizophrenia and organic mental disorders.

David: Besides herbalism, are there any other remedies that are effective in treating psychological disorders?

Bill: Actually, yes. Acupuncture is very effective for stress disorders. Also, aromatherapy works well for stress and uplifting spirits in general.

David: I know you are an herbalist, so maybe this is an unfair question, but would you recommend that a person use herbal treatments rather than standard psychiatric medications? Are they, in your estimation, equally as effective?

Bill: Herbal treatments can be as effective as medications, but they take longer to be effective. For severe mental illness, I would default to medications, and as always, any treatment should be discussed with your doctor. I am not sure how psychiatrists, in general, feel about herbal medications, though. It might be hard to find one who will work with herbals.

David: So what type of specialist would you go to then? And how much longer do herbs take to be effective vs. standard medications?

Bill: The specialist really depends on the preferences of the main psychologist working with the client. Osteopaths are generally more holistically inclined. As far as effectiveness, herbal medications work with individual body chemistry and it usually takes at least two weeks for herbal treatments to show effects when treating depression.

David: We have a lot of audience questions, Bill. Let's get started:

Charbeaner: How much Same (Sam-e) will really help mild to moderate depression? Is there something better and should you take Same with Folic Acid and B12? I have heard 400 mg of Same will work, but then I have heard it must be much much more. I cannot take standard antidepressants, i.e. Prozac, etc., because they upset my colon. I have depression and I need help.

Bill: First, I would say that it is important to consult with your doctor or an herbal specialist who has your case history. However, Same and B12 would be a good combination. I can't really comment on dosage without your individual case history. An additional comment: try eating fresh or pickled ginger for an upset colon.

Ellen R: What herbal remedies are being used in the treatment of chemical dependency at this time?

Bill: Generally, I use a combination of gingko, chamomile and St. John's Wort. Gingko increases blood circulation and improves memory. Chamomile soothes anxiety and it also helps regulate sleep patterns. St. John's Wort, Same are for easing depression. I use these in conjunction with traditional addictions therapies, such as counseling.

kaymac: Are any of these herbs safe for children or teenagers with mild depression?

Bill: Yes, but proceed with extreme caution. I hesitate to give suggestions in this case, because it is so easy to overmedicate young children, as well as the elderly. Herbal treatments for these groups should definitely be done only under professional supervision.

reneeandjerry: Are there any long-term, strong sleep herbs, that help anxiety that I can take?

Bill: Valerian works well, in moderation. So does kava-kava. However, valerian sometimes causes headaches or a "hangover" effect. Furthermore, you should investigate the reasons behind your anxiety. The herbal treatments can only help the symptom and lack of sleep, they will not address the cause of your anxiety.

David: What about taking these herbs you're mentioning while at the same time taking prescription medications. Is there a concern about side-effects or toxicity here?

Bill: There is always a concern of toxicity or ill effects when mixing medications. Mixing medications is never a good idea unless you have the approval of a medical professional.

David: What kinds of side-effects from herbals can one expect?

Bill: On my website, there is a list of common drug interactions. Of the ones I mentioned, there are few side-effects from herbals. For example, I would not take ginko if I am taking any type of clotting medication.

David: Here are some more audience questions, Bill:

elizabetha2: If you have severe Bipolar Disorder, will these herbs help at all, or is this considered an organic brain problem?

Bill: For severe bipolar disorders, I would generally default to medication, but you could also use Same, and it will not interfere with most SSRI's. So a combination approach.

cassady: In Bipolar 1 cases, do you know of any instances where herbs have replaced anti-psychotic meds?

Bill: Not as a total treatment, initially, but I have known some individuals who made the transition to a mostly herbal regimen.

David: We have a lot of bipolar questions:

gremmy: What can Valerian Root do to help bipolar disorder, i.e., specifically the hypomanias, etc?

Bill: Valerian will definitely calm you down, but it is rather a strong herb. I would generally recommend kava kava, and chamomile to sedate instead. Valerian often causes too much drowsiness.

Ellen R: Are there herbal remedies, in addition to those for depression, that are used to treat irritability and explosive anger symptoms?

Bill: None specifically, that I am familiar with, for anger issues. For that, I would default to a counseling approach and self-concept issues.

whinavi: I am bipolar and am treated with 1750mg of Lithium and 2000mg of Epilum per day. Despite this, I still have manic episodes. What would you suggest as an alternative? By the way, I suffer from mania and not depression.

Bill: I am leery to make recommendations when Lithium is involved, due to it's finicky nature and long half-life.

David: Is it your experience that most people turn to herbs because of the side-effects of standard psychiatric medications? Or do you think herbs should be a first-line of treatment?

Bill: I have mostly seen the use of herbs as treatment for side-effects, and for frustration with traditional psychiatric medications, seldom as a first line defense. This is possibly due to lack of knowledge.

David: I'm getting some questions about brands and manufacturers and the best place to buy herbs. I think part of that stems from reports that "not all brands/manufacturers are the same." Can you shed some light on that?

Bill: This is true. Not all brands are the same, and herbs are not regulated by FDA. When looking for herbs in stores, you want to look for a complete herb and not just the active properties. This is because it is the complete herb that works, and most herbs in the stores contain only active properties. When you have only active properties, there is nothing to balance any side-effects caused by that property, which is where the inactive properties come into play. I believe GNC has a product called the herbal fingerprint line.

David: Is there something on the label, some "code words", that consumers should look for to indicate this is a complete herb?

Bill: Yes. Like I stated, "complete", "fingerprint", "full spectrum", and always try and find "organically grown."

reneeandjerry: Are there any herbs that, in combination, treat daytime fatigue?

Bill: Well, as an energy boost, there is always ginseng, I often tell clients Korean or American opposed to Siberian. Siberian tends to give only a short-term boost, that the the body quickly adapts to or builds a tolerance for.

pam: Am I correct in assuming that it is not recommended to take herbal supplements while on medications?

Bill: Not without first consulting your doctor.

David: I was just thinking, would you take herbs as a preventative measure? For instance, to prevent depression or anxiety, lets say.

Bill: Again herbs/medications only treat symptoms and not the underlying causes of your problems.

David: I also wanted to ask you are there herbs for ADD, ADHD.

Bill: I have seen the most dramatic results with a reduction in refined sugar, (sugar busters diet) and I believe the removal of yellow dye #5.

David: I know it's late now, so I want to thank Bill for being our guest tonight and sharing his knowledge and experience with us. And thanks to everyone in the audience for coming and participating. I hope you found it helpful.

Bill: Thank you and good night everybody.

David: Good night everyone.

Brand Name: Levemir
Generic Name: Insulin Detemir

Dosage Form: injection

Contents:

Description
Clinical Pharmacology
Clinical Studies
Indications and Usage
Contraindications
Warnings
Precautions
Adverse Reactions
Overdosage
Dosage and Administration
How Supplied

Levemir, insulin detemir (rDNA origin), patient information (in plain English)

Description

Levemir® (insulin detemir [rDNA origin] injection) is a sterile solution of insulin detemir for use as an injection. Insulin detemir is a long-acting basal insulin analog, with up to 24 hours duration of action, produced by a process that includes expression of recombinant DNA in Saccharomyces cerevisiae followed by chemical modification.

Insulin detemir differs from human insulin in that the amino acid threonine in position B30 has been omitted, and a C14 fatty acid chain has been attached to the amino acid B29. Insulin detemir has a molecular formula of C267H402O76N64S6 and a molecular weight of 5916.9. It has the following structure:

 

Levemir is a clear, colorless, aqueous, neutral sterile solution. Each milliliter of Levemir contains 100 U (14.2 mg/mL) insulin detemir. Each milliliter of Levemir 10 mL Vial contains the inactive ingredients 65.4 mcg zinc, 2.06 mg m-cresol, 30.0 mg mannitol, 1.80 mg phenol, 0.89 mg disodium phosphate dihydrate, 1.17 mg sodium chloride, and water for injection. Each milliliter of Levemir 3 mL PenFill® cartridge, FlexPen® and InnoLet® contains the inactive ingredients 65.4 mcg zinc, 2.06 mg m-cresol, 16.0 mg glycerol, 1.80 mg phenol, 0.89 mg disodium phosphate dihydrate, 1.17 mg sodium chloride, and water for injection. Hydrochloric acid and/or sodium hydroxide may be added to adjust pH. Levemir has a pH of approximately 7.4.

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Clinical Pharmacology

Mechanism of Action

The primary activity of insulin detemir is the regulation of glucose metabolism. Insulins, including insulin detemir, exert their specific action through binding to insulin receptors.

Receptor-bound insulin lowers blood glucose by facilitating cellular uptake of glucose into skeletal muscle and fat and by inhibiting the output of glucose from the liver. Insulin inhibits lipolysis in the adipocyte, inhibits proteolysis, and enhances protein synthesis.

Pharmacodynamics

Insulin detemir is a soluble, long-acting basal human insulin analog with a relatively flat action profile. The mean duration of action of insulin detemir ranged from 5.7 hours at the lowest dose to 23.2 hours at the highest dose (sampling period 24 hours).

The prolonged action of Levemir is mediated by the slow systemic absorption of insulin detemir molecules from the injection site due to strong self-association of the drug molecules and albumin binding. Insulin detemir is distributed more slowly to peripheral target tissues since insulin detemir in the bloodstream is highly bound to albumin.

Figure 1 shows glucose infusion rate results from a glucose clamp study in patients with type 1 diabetes.

Figure 1: Activity Profiles in Patients with Type 1 Diabetes in a 24-hour Glucose Clamp Study

Figure 2 shows glucose infusion rate results from a 16-hour glucose clamp study in patients with type 2 diabetes. The clamp study was terminated at 16 hours according to protocol.

Figure 2: Activity Profiles in Patients with Type 2 Diabetes in a 16-hour Glucose Clamp Study

For doses in the interval of 0.2 to 0.4 U/kg, Levemir exerts more than 50% of its maximum effect from 3 to 4 hours up to approximately 14 hours after dose administration.

In a glucose clamp study, the overall glucodynamic effect (AUCGIR 0-24h) [mean mg/kg ± SD (CV)] of four separate subcutaneous injections in the thigh was 1702.6 ± 489 mg/kg (29%) in the Levemir group and 1922.8 ± 765 mg/kg (40%) for NPH. The clinical significance of this difference has not been established.

Pharmacokinetics

Absorption

After subcutaneous injection of insulin detemir in healthy subjects and in patients with diabetes, insulin detemir serum concentrations indicated a slower, more prolonged absorption over 24 hours in comparison to NPH human insulin.

Maximum serum concentration (Cmax) is reached between 6 and 8 hours after administration.

The absolute bioavailability of insulin detemir is approximately 60%.

Distribution and Elimination

More than 98% insulin detemir in the bloodstream is bound to albumin. Levemir has a small apparent volume of distribution of approximately 0.1 L/kg. Levemir, after subcutaneous administration, has a terminal half-life of 5 to7 hours depending on dose.

Special Populations

Children and Adolescents- The pharmacokinetic properties of Levemir were investigated in children (6 to 12 years) and adolescents (13 to 17 years) and adults with type 1 diabetes. Similar to NPH human insulin, slightly higher plasma Area Under the Curve (AUC) and Cmax were observed in children by 10% and 24%, respectively, compared to adolescents and adults. There was no difference in pharmacokinetics between adolescents and adults.

Geriatrics- In a clinical trial investigating differences in pharmacokinetics of a single subcutaneous dose of Levemir in young (25 to 35 years) versus elderly (≥68 years) healthy subjects, higher insulin AUC levels (up to 35%) were found in elderly subjects due to a reduced clearance. As with other insulin preparations, Levemir should always be titrated according to individual requirements.

Gender- In controlled clinical trials, no clinically relevant difference between genders is seen in pharmacokinetic parameters based on subgroup analyses.

Race- In two trials in healthy Japanese and Caucasian subjects, there were no clinically relevant differences seen in pharmacokinetic parameters. Pharmacokinetics and pharmacodynamics of Levemir were investigated in a clamp trial comparing patients with type 2 diabetes of Caucasian, African-American, and Latino origin. Dose-response relationships were comparable for Levemir in these three populations.

Renal impairment- Individuals with renal impairment showed no difference in pharmacokinetic parameters as compared to healthy volunteers. However, literature reports have shown that clearance of human insulin is decreased in renally impaired patients. Careful glucose monitoring and dose adjustments of insulin, including Levemir, may be necessary in patients with renal dysfunction (see PRECAUTIONS, Renal Impairment).

Hepatic impairment- Individuals with severe hepatic dysfunction, without diabetes, were observed to have lower AUCs as compared to healthy volunteers. Careful glucose monitoring and dose adjustments of insulin, including Levemir, may be necessary in patients with hepatic dysfunction (see PRECAUTIONS, Hepatic Impairment).

Pregnancy- The effect of pregnancy on the pharmacokinetics and pharmacodynamics of Levemir has not been studied (see PRECAUTIONS, Pregnancy ).

Smoking- The effect of smoking on the pharmacokinetics and pharmacodynamics of Levemir has not been studies.

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Clinical Studies

The efficacy and safety of Levemir given once-daily at bedtime or twice-daily (before breakfast and at bedtime, before breakfast and with the evening meal, or at 12-hour intervals) was compared to that of once-daily or twice-daily NPH human insulin or once-daily insulin glargine in non-blinded, randomized, parallel studies of 6004 patients with diabetes (3724 with type 1, and 2280 with type 2). In general, patients treated with Levemir achieved levels of glycemic control similar to those treated with NPH human insulin or insulin glargine, as measured by glycosylated hemoglobin (HbA1c).

Type 1 Diabetes - Adult

In one non-blinded clinical study (Study A, n=409), adult patients with type 1 diabetes were randomized to treatment with either Levemir at 12-hour intervals, Levemir morning and bedtime or NPH human insulin morning and bedtime. Insulin aspart was also administered before each meal. At 16 weeks of treatment, the combined Levemir-treated patients had similar HbA1c and fasting plasma glucose (FPG) reductions to NPH-treated patients (Table 1). Differences in timing of Levemir administration (or flexible dosing) had no effect on HbA1c, FPG, body weight, or risk of having hypoglycemic episodes.

Overall glycemic control achieved with Levemir was compared to that achieved with insulin glargine in a randomized, non-blinded, clinical study (Study B, n=320) in which patients with type 1 diabetes were treated for 26 weeks with either twice-daily (morning and bedtime) Levemir or once-daily (bedtime) insulin glargine. Insulin aspart was administered before each meal. Levemir-treated patients had a decrease in HbA1c similar to that of insulin glargine-treated patients.

In a randomized, controlled clinical study (Study C, n=749), patients with type 1 diabetes were treated with once-daily (bedtime) Levemir or NPH human insulin, both in combination with human soluble insulin before each meal for 6 months. Levemir and NPH human insulin had a similar effect on HbA1c.

Table 1: Efficacy and Insulin Dosage in Type 1 Diabetes Mellitus - Adult

	Study A
Treatment duration	16 weeks
Treatment in combination with	NovoLog® (insulin aspart)
	Levemir	NPH
Number of subjects treated	276	133
HbA1c (%)
Baseline	8.64	8.51
End of study adjusted mean	7.76	7.94
Mean change from baseline	-0.82	-0.60
Fasting Plasma Glucose (mg/dL)
End of study adjusted mean	168	202
Mean change from baseline	-42.48	-10.80
Daily Basal Insulin Dose (U/kg)
Prestudy mean	0.36	0.39
End of study mean	0.49	0.45
Daily Bolus Insulin Dose (U/kg)
Prestudy mean	0.40	0.40
End of study mean	0.38	0.38
Baseline values were included as covariates in an ANCOVA analysis.

Type 1 Diabetes - Pediatric

In a non-blinded, randomized, controlled clinical study (Study D, n=347), pediatric patients (age range 6 to 17) with type 1 diabetes were treated for 26 weeks with a basal-bolus insulin regimen. Levemir and NPH human insulin were administered once- or twice-daily (bedtime or morning and bedtime) according to pretrial dose regimen. Bolus insulin aspart was administered before each meal. Levemir-treated patients had a decrease in HbA1c similar to that of NPH human insulin.

Table 2: Efficacy and Insulin Dosage in Type 1 Diabetes Mellitus - Pediatric

	Study D
Treatment duration	26 weeks
Treatment in combination with	NovoLog® (insulin aspart)
	Levemir	NPH
Number of subjects treated	232	115
HbA1c (%)
Baseline	8.75	8.77
End of study adjusted mean	8.02	7.93
Mean change from baseline	-0.72	-0.80
Fasting Plasma Glucose (mg/dL)
End of study adjusted mean	151.92	172.44
Mean change from baseline	-45.00	-19.98
Daily Basal Insulin Dose (U/kg)
Prestudy mean	0.48	0.49
End of study mean	0.67	0.64
Daily Bolus Insulin Dose (U/kg)
Prestudy mean	0.52	0.47
End of study mean	0.52	0.51

Type 2 Diabetes - Adult

In a 24-week, non-blinded, randomized, clinical study (Study E, n=476), Levemir administered twice-daily (before breakfast and evening) was compared to a similar regimen of NPH human insulin as part of a regimen of combination therapy with one or two of the following oral antidiabetes agents (metformin, insulin secretagogue, or α-glucosidase inhibitor). Levemir and NPH similarly lowered HbA1c from baseline (Table 3).

Table 3: Efficacy and Insulin Dosage in Type 2 Diabetes Mellitus

	Study E
Treatment duration	24 weeks
Treatment in combination with	OAD
	Levemir	NPH
Number of subjects treated	237	239
HbA1c (%)
Baseline	8.61	8.51
End of study adjusted mean	6.58	6.46
Mean change from baseline	-1.84	-1.90
Proportion achieving HbA1c ≤ 7%	70%	74%
Fasting Plasma Glucose (mg/dL)
End of study adjusted mean	119.16	113.40
Mean change from baseline	-75.96	-74.34
Daily Insulin Dose (U/kg)
End of study mean	0.77	0.52

In a 22-week, non-blinded, randomized, clinical study (Study F, n=395) in adults with Type 2 diabetes, Levemir and NPH human insulin were given once- or twice-daily as part of a basal-bolus regimen. As measured by HbA1c or FPG, Levemir had efficacy similar to NPH human insulin.

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Indications and Usage

Levemir is indicated for once- or twice-daily subcutaneous administration for the treatment of adult and pediatric patients with type 1 diabetes mellitus or adult patients with type 2 diabetes mellitus who require basal (long acting) insulin for the control of hyperglycemia.

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Contraindications

Levemir is contraindicated in patients hypersensitive to insulin detemir or one of its excipients.

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Warnings

Hypoglycemia is the most common adverse effect of insulin therapy, including Levemir. As with all insulins, the timing of hypoglycemia may differ among various insulin formulations.

Glucose monitoring is recommended for all patients with diabetes.

Levemir is not to be used in insulin infusion pumps.

Any change of insulin dose should be made cautiously and only under medical supervision. Changes in insulin strength, timing of dosing, manufacturer, type (e.g., regular, NPH, or insulin analogs), species (animal, human), or method of manufacture (rDNA versus animal-source insulin) may result in the need for a change in dosage.

Concomitant oral antidiabetic treatment may need to be adjusted.

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Precautions

General

Inadequate dosing or discontinuation of treatment may lead to hyperglycemia and, in patients with type 1 diabetes, diabetic ketoacidosis. The first symptoms of hyperglycemia usually occur gradually over a period of hours or days. They include nausea, vomiting, drowsiness, flushed dry skin, dry mouth, increased urination, thirst and loss of appetite as well as acetone breath. Untreated hyperglycemic events are potentially fatal.

Levemir is not intended for intravenous or intramuscular administration. The prolonged duration of activity of insulin detemir is dependent on injection into subcutaneous tissue. Intravenous administration of the usual subcutaneous dose could result in severe hypoglycemia. Absorption after intramuscular administration is both faster and more extensive than absorption after subcutaneous administration.

Levemir should not be diluted or mixed with any other insulin preparations (see PRECAUTIONS, Mixing of Insulins).

Insulin may cause sodium retention and edema, particularly if previously poor metabolic control is improved by intensified insulin therapy.

Lipodystrophy and hypersensitivity are among potential clinical adverse effects associated with the use of all insulins.

As with all insulin preparations, the time course of Levemir action may vary in different individuals or at different times in the same individual and is dependent on site of injection, blood supply, temperature, and physical activity.

Adjustment of dosage of any insulin may be necessary if patients change their physical activity or their usual meal plan.

Hypoglycemia

As with all insulin preparations, hypoglycemic reactions may be associated with the administration of Levemir. Hypoglycemia is the most common adverse effect of insulins. Early warning symptoms of hypoglycemia may be different or less pronounced under certain conditions, such as long duration of diabetes, diabetic nerve disease, use of medications such as beta-blockers, or intensified diabetes control (see PRECAUTIONS, Drug Interactions). Such situations may result in severe hypoglycemia (and, possibly, loss of consciousness) prior to patients' awareness of hypoglycemia.

The time of occurrence of hypoglycemia depends on the action profile of the insulins used and may, therefore, change when the treatment regimen or timing of dosing is changed. In patients being switched from other intermediate or long-acting insulin preparations to once- or twice-daily Levemir, dosages can be prescribed on a unit-to-unit basis; however, as with all insulin preparations, dose and timing of administration may need to be adjusted to reduce the risk of hypoglycemia (see DOSAGE AND ADMINISTRATION, Changeover to Levemir).

Renal Impairment

As with other insulins, the requirements for Levemir may need to be adjusted in patients with renal impairment (see CLINICAL PHARMACOLOGY, Pharmacokinetics).

Hepatic Impairment

As with other insulins, the requirements for Levemir may need to be adjusted in patients with hepatic impairment (see CLINICAL PHARMACOLOGY, Pharmacokinetics).

Injection Site and Allergic Reactions

As with any insulin therapy, lipodistrophy may occur at the injection site and delay insulin absorption. Other injection site reactions with insulin therapy may include redness, pain, itching, hives, swelling, and inflammation. Continuous rotation of the injection site within a given area may help to reduce or prevent these reactions. Reactions usually resolve in a few days to a few weeks. On rare occasions, injection site reactions may require discontinuation of Levemir.

In some instances, these reactions may be related to factors other than insulin, such as irritants in a skin cleansing agent or poor injection technique.

Systemic allergy: Generalized allergy to insulin, which is less common but potentially more serious, may cause rash (including pruritus) over the whole body, shortness of breath, wheezing, reduction in blood pressure, rapid pulse, or sweating. Severe cases of generalized allergy, including anaphylactic reaction, may be life-threatening.

Intercurrent Conditions

Insulin requirements may be altered during intercurrent conditions such as illness, emotional disturbances, or other stresses.

Information for Patients

Levemir must only be used if the solution appears clear and colorless with no visible particles (see DOSAGE AND ADMINISTRATION, Preparation and Handling). Patients should be informed about potential risks and advantages of Levemir therapy, including the possible side effects. Patients should be offered continued education and advice on insulin therapies, injection technique, life-style management, regular glucose monitoring, periodic glycosylated hemoglobin testing, recognition and management of hypo- and hyperglycemia, adherence to meal planning, complications of insulin therapy, timing of dosage, instruction for use of injection devices and proper storage of insulin. Patients should be informed that frequent, patient-performed blood glucose measurements are needed to achieve effective glycemic control to avoid both hyperglycemia and hypoglycemia. Patients must be instructed on handling of special situations such as intercurrent conditions (illness, stress, or emotional disturbances), an inadequate or skipped insulin dose, inadvertent administration of an increased insulin dose, inadequate food intake, or skipped meals. Refer patients to the Levemir "Patient Information" circular for additional information.

As with all patients who have diabetes, the ability to concentrate and/or react may be impaired as a result of hypoglycemia or hyperglycemia.

Patients with diabetes should be advised to inform their health care professional if they are pregnant or are contemplating pregnancy (see PRECAUTIONS, Pregnancy ).

Laboratory Tests

As with all insulin therapy, the therapeutic response to Levemir should be monitored by periodic blood glucose tests. Periodic measurement of HbA1c is recommended for the monitoring of long-term glycemic control.

Drug Interactions

A number of substances affect glucose metabolism and may require insulin dose adjustment and particularly close monitoring.

The following are examples of substances that may reduce the blood-glucose-lowering effect of insulin: corticosteroids, danazol, diuretics, sympathomimetic agents (e.g., epinephrine, albuterol, terbutaline), isoniazid, phenothiazine derivatives, somatropin, thyroid hormones, estrogens, progestogens (e.g., in oral contraceptives).

The following are examples of substances that may increase the blood-glucose-lowering effect of insulin and susceptibility to hypoglycemia: oral antidiabetic drugs, ACE inhibitors, disopyramide, fibrates, fluoxetine, MAO inhibitors, propoxyphene, salicylates, somatostatin analog (e.g., octreotide), and sulfonamide antibiotics.

Beta-blockers, clonidine, lithium salts, and alcohol may either potentiate or weaken the blood-glucose-lowering effect of insulin. Pentamidine may cause hypoglycemia, which may sometimes be followed by hyperglycemia. In addition, under the influence of sympatholytic medicinal products such as beta-blockers, clonidine, guanethidine, and reserpine, the signs of hypoglycemia may be reduced or absent.

The results of in-vitro and in-vivo protein binding studies demonstrate that there is no clinically relevant interaction between insulin detemir and fatty acids or other protein bound drugs.

Mixing of Insulins

If Levemir is mixed with other insulin preparations, the profile of action of one or both individual components may change. Mixing Levemir with insulin aspart, a rapid acting insulin analog, resulted in about 40% reduction in AUC(0-2h) and Cmax for insulin aspart compared to separate injections when the ratio of insulin aspart to Levemir was less than 50%.

Levemir should NOT be mixed or diluted with any other insulin preparations.

Carcinogenesis, Mutagenesis, Impairment of Fertility

Standard 2-year carcinogenicity studies in animals have not been performed. Insulin detemir tested negative for genotoxic potential in the in-vitro reverse mutation study in bacteria, human peripheral blood lymphocyte chromosome aberration test, and the in-vivo mouse micronucleus test.

Pregnancy

Pregnancy Category C

Teratogenic effects

In a fertility and embryonic development study, insulin detemir was administered to female rats before mating, during mating, and throughout pregnancy at doses up to 300 nmol/kg/day (3 times the recommended human dose, based on plasma Area Under the Curve (AUC) ratio). Doses of 150 and 300 nmol/kg/day produced numbers of litters with visceral anomalies. Doses up to 900 nmol/kg/day (approximately 135 times the recommended human dose based on AUC ratio) were given to rabbits during organogenesis. Drug-dose related increases in the incidence of fetuses with gall bladder abnormalities such as small, bilobed, bifurcated and missing gall bladders were observed at a dose of 900 nmol/kg/day. The rat and rabbit embryofetal development studies that included concurrent human insulin control groups indicated that insulin detemir and human insulin had similar effects regarding embryotoxicity and teratogenicity.

Nursing mothers

It is unknown whether Levemir is excreted in significant amounts in human milk. For this reason, caution should be exercised when Levemir is administered to a nursing mother. Patients with diabetes who are lactating may require adjustments in insulin dose, meal plan, or both.

Pediatric use

In a controlled clinical study, HbA1c concentrations and rates of hypoglycemia were similar among patients treated with Levemir and patients treated with NPH human insulin.

Geriatric use

Of the total number of subjects in intermediate and long-term clinical studies of Levemir, 85 (type 1 studies) and 363 (type 2 studies) were 65 years and older. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. In elderly patients with diabetes, the initial dosing, dose increments, and maintenance dosage should be conservative to avoid hypoglycemic reactions. Hypoglycemia may be difficult to recognize in the elderly.

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Adverse Reactions

Adverse events commonly associated with human insulin therapy include the following:

Body as Whole: allergic reactions (see PRECAUTIONS, Allergy).

Skin and Appendages: lipodystrophy, pruritus, rash. Mild injection site reactions occurred more frequently with Levemir than with NPH human insulin and usually resolved in a few days to a few weeks (see PRECAUTIONS, Allergy).

Other:

Hypoglycemia: (see WARNINGS and PRECAUTIONS).

In trials of up to 6 months duration in patients with type 1 and type 2 diabetes, the incidence of severe hypoglycemia with Levemir was comparable to the incidence with NPH, and, as expected, greater overall in patients with type 1 diabetes (Table 4).

Weight gain:

In trials of up to 6 months duration in patients with type 1 and type 2 diabetes, Levemir was associated with somewhat less weight gain than NPH (Table 4). Whether these observed differences represent true differences in the effects of Levemir and NPH insulin is not known, since these trials were not blinded and the protocols (e.g., diet and exercise instructions and monitoring) were not specifically directed at exploring hypotheses related to weight effects of the treatments compared. The clinical significance of the observed differences has not been established.

Table 4: Safety Information on Clinical Studies*

* See CLINICAL STUDIES section for description of individual studies † Major = requires assistance of another individual because of neurologic impairment c Minor = plasma glucose
			Weight (kg)		Hypoglycemia (events/subject/month)
	Treatment	# of subjects	Baseline	End of treatment	Majorâ€	Minorc
Type 1
Study A	Levemir	N=276	75.0	75.1	0.045	2.184
	NPH	N=133	75.7	76.4	0.035	3.063
Study C	Levemir	N=492	76.5	76.3	0.029	2.397
	NPH	N=257	76.1	76.5	0.027	2.564
Study D Pediatric	Levemir	N=232	N/A	N/A	0.076	2.677
	NPH	N=115	N/A	N/A	0.083	3.203
Type 2
Study E	Levemir	N=237	82.7	83.7	0.001	0.306
	NPH	N=239	82.4	85.2	0.006	0.595
Study F	Levemir	N=195	81.8	82.3	0.003	0.193
	NPH	N=200	79.6	80.9	0.006	0.235

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Overdosage

Hypoglycemia may occur as a result of an excess of insulin relative to food intake, energy expenditure, or both. Mild episodes of hypoglycemia usually can be treated with oral glucose. Adjustments in drug dosage, meal patterns, or exercise may be needed. More severe episodes with coma, seizure, or neurologic impairment may be treated with intramuscular/subcutaneous glucagon or concentrated intravenous glucose. After apparent clinical recovery from hypoglycemia, continued observation and additional carbohydrate intake may be necessary to avoid reoccurrence of hypoglycemia.

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Dosage and Administration

Levemir can be administered once- or twice-daily. The dose of Levemir should be adjusted according to blood glucose measurements. The dosage of Levemir should be individualized based on the physician's advice, in accordance with the needs of the patient.

• For patients treated with Levemir once-daily, the dose should be administered with the evening meal or at bedtime.
• For patients who require twice-daily dosing for effective blood glucose control, the evening dose can be administered either with the evening meal, at bedtime, or 12 hours after the morning dose.

Levemir should be administered by subcutaneous injection in the thigh, abdominal wall, or upper arm. Injection sites should be rotated within the same region. As with all insulins, the duration of action will vary according to the dose, injection site, blood flow, temperature, and level of physical activity.

Dose Determination for Levemir

• For patients with type 1 or type 2 diabetes on basal-bolus treatment, changing the basal insulin to Levemir can be done on a unit-to-unit basis. The dose of Levemir should then be adjusted to achieve glycemic targets. In some patients with type 2 diabetes, more Levemir may be required than NPH insulin. In a clinical study, the mean dose at end of treatment was 0.77 U/kg for Levemir and 0.52 IU/kg for NPH human insulin (see Table 3).
• For patients currently receiving only basal insulin, changing the basal insulin to Levemir can be done on a unit-to-unit basis.
• For insulin-naïve patients with type 2 diabetes who are inadequately controlled on oral antidiabetic drugs, Levemir should be started at a dose of 0.1 to 0.2 U/kg once-daily in the evening or 10 units once- or twice-daily, and the dose adjusted to achieve glycemic targets.
• As with all insulins, close glucose monitoring is recommended during the transition and in the initial weeks thereafter. Dose and timing of concurrent short-acting insulins or other concomitant antidiabetic treatment may need to be adjusted.

Preparation and Handling

Levemir should be inspected visually prior to administration and should only be used if the solution appears clear and colorless.

Levemir should not be mixed or diluted with any other insulin preparations.

After each injection, patients must remove the needle without recapping and dispose of it in a puncture-resistant container. Used syringes, needles, or lancets should be placed in "sharps" containers (such as red biohazard containers), hard plastic containers (such as detergent bottles), or metal containers (such as an empty coffee can). Such containers should be sealed and disposed of properly.

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How Supplied

Levemir is available in the following package sizes: each presentation containing 100 Units of insulin detemir per mL (U-100).

10 mL vial	NDC 0169-3687-12
3 mL PenFill® cartridges*	NDC 0169-3305-11
3 mL InnoLet®	NDC 0169-2312-11
3 mL FlexPen®	NDC 0169-6439-10

*Levemir PenFill® cartridges are for use with Novo Nordisk 3 mL PenFill® cartridge compatible insulin delivery devices and NovoFine® disposable needles.

Last Updated 05/2007

Levemir, insulin detemir (rDNA origin), patient information (in plain English)

Detailed Info on Signs, Symptoms, Causes, Treatments of Diabetes

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The information in this monograph is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects. This information is generalized and is not intended as specific medical advice. If you have questions about the medicines you are taking or would like more information, check with your doctor, pharmacist, or nurse.

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During this exclusive HealthyPlace.com chat conference, Ms. Liu discusses her personal experiences with anorexia, the underlying causesof eating disorders and what getting "real" treatment for an eating disorder means. Maybe, more importantly, Ms. Liu shares what she found out through interviewing the top eating disorders researchers and treatment professionals in the world. What she has to say could very well help you or your loved one.

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Natalie: Good Evening. I'm Natalie, the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Tonight, we're addressing the underlying causes of eating disorders and what getting "real" treatment for an eating disorder means.

Our guest is Aimee Liu, author of: "GAINING: The Truth About Life After Eating Disorders".

Aimee was suffering from anorexia during her high school and college years and thought she had recovered when she was in her twenties. That's when she wrote her first book on the subject entitled "Solitaire." 20-years later, during a tumultuous period in her life, she quit eating altogether. She now considers herself "fully recovered."

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Aimee Liu: Hi Natalie!

Natalie: So our audience members understand, Aimee - when you were 19, how did you get to the point in your mind where you said "I really need help."

Aimee Liu: In 1973, I reached what psychologist Sheila Reindl calls the "limit of distress." That summer, following my sophomore year at Yale, I had designed my life to accommodate the demands of anorexia. I'd broken up with my boyfriend, pushed my friends and family away. As a painting major, I argued that I needed the summer to be alone and paint.

I earned money working in a room by myself, matting prints for the Yale Art gallery. I house sat for vacationing faculty. And I painted in the otherwise empty undergraduate art studio. I ate less than minimally and walked miles back and forth to the studio every day.

One very hot evening in August, I reached the center of campus and noticed that I was all alone. Everyone else in the university, it seemed, was away on vacation. The whole city seemed to have emptied to escape the heat. I felt a crippling wave of loneliness, and it dawned on me that I had done this to myself, that the compulsion to avoid food and keep losing weight was making me unbearably miserable.

Although I didn't consciously connect the dots, emotionally I sensed that what I was avoiding was not really food but human contact; what I was so desperately afraid of was not weight but the risk of exposing myself to others - and yet what I most craved was human contact and intimacy. So I was denying myself what I most desperately wanted and needed.

It was a very, very distinct sensation and a very particular moment in my memory, and I've since learned that most people who recover can recall a specific turning point like this when they DECIDE they have to change. What's critical to understand, though, is that this turning point is only the beginning of a very long and variable process of recovery. (treatment for anorexia)

Natalie: What kind of help did you initially get for the eating disorder?

Aimee Liu: In 1973, I had never heard of anorexia or eating disorders, even though I'd been watching many of my classmates starving, bingeing, and purging since junior high school.

One of my high school classmates had been hospitalized -- but she'd returned with her face bloated from drugs, and no one ever mentioned what was wrong with her or what had been done to her in treatment. Another girl in a class behind me died from anorexia while I was in college. Still, no one named the problem, and when I did approach the doctors at the university, they ran me through a battery of tests and informed me that I "should gain a little weight." And although I'd daydreamed in high school about talking to a therapist, my family would not hear of this. So when I reached my turning point, it did not occur to me to seek professional help. Instead, I tried to think of the happiest, healthiest people I knew who would not judge or reject me for seeking their company.

Over the next two years, I watched these "normal" friends eat and party and talk, and I tried to imitate them, spending less time by myself, seeking out people who made me feel good and accepted. Two months after that summer turning point, I fell in love with a grad student who was so exuberant, so joyful, that I learned what it means to revel in life. He eventually broke my heart and I crashed hard, but in the meantime I'd learned enough from him to avoid sinking all the way back into anorexia. Instead, I became bulimic for several years. I wrote Solitaire as I was phasing out of bulimia - still on my own, with no therapy.

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Natalie: And at that time, we're talking about the early 1980's, did you feel confident that you had beat this thing?

Aimee Liu: When Solitaire was published in 1979, I was 25, and I did think I was cured. As many people I've interviewed have found, it is enormously therapeutic to write out one's entire life story, to tell the whole truth in one's own words, and to see the connections between things that others have done to us and the behaviors that so often crop up in response, as well as the choices we make to excuse or cover up those events and behaviors.

But as important as it is to make sense of one's past, the bigger challenge is to adjust one's present choices and to develop the strength of identity and the skills to move forward. I'm talking about genuine self-awareness. And what I couldn't admit at the end of Solitaire was that this level of self-awareness still eluded me. I was still faking a lot of my confidence, still trying on and throwing off different roles and jobs and relationships in an attempt to find one that would tell me who I was. What I did not realize until many years later, when I wrote GAINING, was that I was still restricting, binge eating, and purging - but I was doing it with sex, work, friends, alcohol, and exercise, instead of with food.

This persistent tendency to punish oneself and inflict suffering on one's body for feeling imperfect in life; his is what I now call the half-life of eating disorders.

Natalie: I'm wondering, after you felt that you had recovered, was there an underlying worry that "the anorexia was hiding around the corner just waiting" or was it something that you didn't think about much, if at all?

Aimee Liu: Because I defined anorexia purely in terms of self-starvation and the confusion of hyper-thinness with identity, I really did think I was done with it. However, I remained a vegetarian well into my thirties, when I became so weak that I consulted a nutritionist who insisted I eat red meat (and when I did, I felt dramatically better overnight).

Into my forties, I still habitually tallied the calories of everything I ate (even when I wasn't restricting). For many years, I ran compulsively, especially during periods of emotional stress, and did more damage to my body through exercise than I had through anorexia. But I didn't see that all of these self-punishing compulsions were vestiges of my eating disorder.

Natalie: Aimee, you reach your 40s, and bam!, here comes the anorexia again. Was getting to the point of saying "I need help" harder this time around than the first time? If so, why? Or why not?

Aimee Liu: I do not think it's an accident that anorexia struck again when I separated from my husband after 20 years together. It did not strike when our marital struggles began a year earlier. It did not strike when we began therapy. It struck when I found myself alone with myself and realized I still had no idea who I was!

This, I've since learned, is exceedingly common among people with only partially resolved histories of eating disorders - who have been leaning on a spouse or partner to supply or prop up their sense of self. What was crucially different for me this time around was the therapist my husband and I were already seeing. He was not an eating disorder specialist, but he was a tremendously empathic and wise individual who refused to indulge me when I joked about the "benefits of the divorce diet."

At his insistence, I stepped back and learned to observe what I was doing without judging or denying it. I learned to be interested in my actions and feelings instead of running from them. Fortunately, I had not lost a great deal of weight and was nowhere near a dangerously low weight, so my brain was in good shape to cooperate with my mind in this process. I was in psychological but not physical distress, and that made it much, much easier to commit to therapy. I realized just how much of my life had been short-changed by my failure to enter therapy when I was in my teens. Better late than never!

Natalie: What, specifically, were the differences between the treatment you received after the eating disorder relapse compared to the first time in your 20s?

Aimee Liu: There was no comparison because there was no treatment when I was in my 20s! But in the course of writing GAINING, I've learned of many exciting new therapies and therapeutic practices - DBT, equine therapy, cognitive behavior therapy, and mindful awareness- which did not exist and certainly were not widely respected until recently. Mindful awareness has dramatically changed my life today. As the genetic research proceeds, there will also doubtless be more effective medications that should help some people.

(Ed. Note:Mindful Awareness is the moment-by-moment process of actively and openly observing one's physical, mental and emotional experiences. Mindful awareness has scientific support as a means to reduce stress, improve attention, boost the immune system, reduce emotional reactivity, and promote a general sense of health and well-being.)

Natalie: From your own personal experience and from interviewing researchers and treatment specialists for your book, can you summarize for us what it really takes to recover from an eating disorder?

Aimee Liu: Everyone is different, of course. Eating disorders overlap with so many other conditions - OCD, anxiety disorders, PTSD, personality disorders, depression - that there can be no "one size fits all" treatment. It does seem to me, however, that all eating disorders serve as distress signals. I believe these signals come through the body from regions of the brain that are not fully conscious, and so the goal in treatment has to be to "read the signal" and identify the true source of distress, then develop effective coping strategies to resolve, minimize, or learn to tolerate the real distress.

Sometimes these strategies involve medication, sometimes mindful awareness training, sometimes cognitive or behavioral therapy. Almost always, full recovery requires the development of a strong and trusting relationship with a compassionate and insightful therapist. I have to emphasize that eating well does not constitute a cure for eating disorders, however vital a first step it may be.

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Natalie: Just so we're all on the same page, how are you defining "recovery" from an eating disorder?

Aimee Liu: I call my book GAINING because I really do think that the ability - eagerness, even - to "gain" in all areas of life is a good definition of eating disorder recovery. Note that I say gaining in "life" because I think that eating disorders are seated in core anxieties over what it means to be alive. Someone who is fully recovered embraces genuine (as opposed to superficial) gains in confidence, trust, intimacy, personal power, perspective, insight, faith, joy, nourishment, health, peace, love, and pleasures of the body and mind. Crucially, she makes choices in life out of desire, passion, compassion, and love instead of fear. She does not confuse perfection with suffering, nor does she feel she must measure up to some external standard of perfection.

Natalie: Since the mind can play tricks on you, how does one know if they've truly recovered?

Aimee Liu: There are so many signs!

• Can you sit quietly with yourself and be at peace?
• Can you face a significant problem or decision or experience stress without obsessing about your body or what you've just eaten or are planning to eat?
• Do you exercise because you honestly enjoy the activity - and not because you'll feel "guilty" if you don't?
• Can you look at your body with appreciation for all that it does, and not berate yourself for how it looks?
• Can you be open and intimate with those you love, without worrying about how they'll judge you?
• Can you enter an argument without feeling that you either have to dominate or disappear?
• Are you able to joke about your human failings and your flaws without secretly feeling ashamed of them?

The list can go on-and-on. The bottom line is that a person who is fully recovered feels comfortable enough in her body and compassionate enough toward herself that she can extend - offer -- that feeling of comfort to others.

Natalie: Let's start with the audience questions now.

chelseam1989: Aimee, I'm currently struggling with a severe Eating Disorder and have been for two-and-a-half years. I've been in therapy for eating disorders 2 years and I seem to be going nowhere. I feel hopeless. Do you have any suggestions? I'm only 17.

Aimee Liu: This is a huge question, and there is no "right" answer. But to start, I'd want to know if you have connected with the therapist, if there's trust -- and insight there. I believe that the ability to connect with another person -- to accept their wisdom -- and to grow with it is key. This is scientific. Because in most cases, something has gone wrong in the neural wiring that affects the capacity to love -- and that's underneath the eating disorder. Most of the people I know who have recovered, have managed to heal this connection with the help of a great therapist or lover or serious friend.

Beyond this, I use some simple questions...every day, throughout the day... we need to train ourselves to step back and ask why we make the choices we do. Are we acting out of fear... or curiosity? Shame... or love? Anger... or compassion?

I'm talking the simplest choices... making a phone call, taking a walk, signing up for a class. To get healthy, we have to retrain ourselves to make choices because we really want to, not because we're afraid NOT to. This is at the foundation of the new therapies I mentioned earlier... and it might help you to look into these -- DBT, mindful awareness, etc. I'm sorry I can't help more without knowing more about your specific situation. As I said, everyone is so different.

Natalie: One audience member asked this question Aimee: Many of us are told that recovery is an "ongoing process" that never ends. Yet, you speak about having fully recovered as "being cured." Do you see it that way?

Aimee Liu: What never ends are the temperament traits that make us vulnerable to eating disorders. Scientists liken an eating disorder to a gun.

1. Genetics, which account for around 60% of one's vulnerability, manufacture the gun;
2. Environment, which includes family dynamics, fashion magazines, social and cultural attitudes, loads the gun; and
3. The personal experience of unbearable distress pulls the trigger.

Genetics combine with family dynamics to create the personality types that are most at risk. We have these personalities as long as we live, but once we learn to re-direct our core traits -- perfectionism, hyper-sensitivity, persistence -- to goals and values that have genuine meaning TO US... then we become protected against the eating disorder.

Many of us start to relapse instinctively under intense stress, but if we know this tendency is there -- and that it's a natural attempt to cope -- we can redirect the instinct . It helps to develop an arsenal of positive, constructive coping mechanisms -- true friends, passions, interests, music, etc -- that can help us through the bad times. These are "life skills" that will help anyone; we just need to work harder to learn them!

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Natalie: You interviewed 40 people, women and men, who you knew from your youth. One of the things that really struck me, was the common theme of "shame" that each felt. Shame that they had an eating disorder. Shame that they shied away from intimacy or had a compulsion to be perfect. Could you talk about that?

Aimee Liu: In general, I've found, an eating disorder is a response to shame. In other words, the shame comes first. The shame is in the body and mind before the eating becomes disordered. So the shame that may develop about the eating disorder is usually an extension of distress that runs much deeper. People need to understand that an eating disorder is a coping mechanism. No one chooses to become anorexic or bulimic. It's that experience of unbearable distress that triggers the obsession with body and food as an escape or distraction or attempt to reconcile pressures that cannot be reconciled. Usually that unbearable distress involves shame.

Several of the people I interviewed had, like me, been molested as children. Others had been sent to fat farms as children and told by their parents that no one would love them if they didn't lose weight. Others had struggled since childhood with shame over their sexuality. Some had been shamed by parents because they did not sufficiently mirror the parents' values or appearance.

The persistence of an eating disorder is a signal that the underlying shame is still driving one's thoughts and behavior. And of course, because this group is perfectionistic, any residual problems are seen as imperfections and thus a source of further shame! That cycle can be broken, however, if we treat eating disorders as natural signals, instead of as character flaws.

Natalie: Here's a comment from the audience, then a question.

Erika_EDSA: Aimee, I'm happy to see that you've brought up that people can recover from eating disorders because the many people I work with just don't believe that. I tell people that no one wakes up one day and says, "Gee, I think I want to be anorexic or bulimic, etc."

khodem: Do you believe God played a role in your recovery?

Aimee Liu: Ah... that's tricky because I'm not a religious person... my definition of God is nature -- science... not some outside force that can pull my strings or command my choices. I believe I am accountable for my own choices and for my health. HOWEVER, seeing the unity in all things and developing a capacity for self-transcendence has been critical.

We need to learn how to move our minds to connect with others and with the natural world, to realize FULLY that we are not alone or isolated, and that we are all connected. So spirituality has been critical, but not necessarily "God".

Natalie: To got back to the subject of "shame" for a moment, I'm assuming you, too, were ashamed of turning to weight loss as a form of comfort, having an eating disorder, and some of the personality traits that go along with that. I think it would be helpful to many in our audience, and those who read the transcript, to know how you came to deal with that shame?

Aimee Liu: I actually don't feel that shame. I have tremendous respect for the mechanisms within my body and mind that cobbled together this "solution" to my unspeakable need as a child to tell the world that I felt empty, hollow, and unseen. I turned my body into a metaphor for the feelings I could not articulate any other way. And I did so again in my 40s.

I certainly do regret that no one was on hand in my early life who could read my body's code. And I am eternally grateful to the therapist who was able to read the code in mid-life and, just as crucially, to translate it for my husband.

I absolutely regret the nearly three decades I spent in the half-life of eating disorders before my relapse. But shame is just not the right word, nor is it an appropriate response to eating disorders at any stage or phase. The same goes for the personality traits that are involved.

Perfectionism is not shameful. It can be incredibly useful if one is an artist, or architect, or writer. The trick is to learn to direct one's innate traits toward creative goals that bring pleasure and meaning to one's life, instead of allowing them to cause unnecessary suffering. Self-awareness is a vital element of recovery, and self-awareness cannot develop unless we free ourselves from the kind of judgment and criticism that generates shame.

flchick7626: Is there anyway a person can get fully better without eating disorders treatment or therapy? If so, how?

Aimee Liu: Well, yes! The researchers estimate that only about a third of people with eating disorder symptoms ever even get diagnosed. And almost all of the women -- and men -- I interviewed got better without treatment (because there was none when we were seriously sick). But we got better by falling in love, or developing a passion for creative work, or animals -- we found sources of nourishment that did not involve food. HOWEVER, if you are seriously compromising your body by starving it or bingeing and purging, good specialized therapy is critical to save your health and support your brain as it starts to recover. Also, I believe good therapy is essential for us to move beyond the "half-life" of eating disorders and develop the capacity to live truly full lives.

Natalie: Aimee, we have parents, family members, husbands and other loved ones here tonight. They want to know how to offer support to someone they care about who has an eating disorder like anorexia or bulimia. Can you touch on that and the importance of it?

Aimee Liu: First, move the conversation away from body and food (especially if the person's physical condition is stable). Second, avoid the impulse to criticize and judge -- maintain a tone of compassion and openness at all times! Third, accept your own role in the problem -- especially if there is a family history of eating disorders or weight fixation. Recognize that EDs are largely genetic -- and the family has contributed to the problem in ways that are seen and unseen. This helps lift the burden of blame and shame from everyone.

The hardest part is to figure out what's causing the real distress... and that probably takes professional help. If the person is young and still living at home, the treatment with the best track record is the Maudsley Method. If the person is older, treatment will depend a lot on what kind of eating disorder it is and what the person's history is like. But for parents and friends... the important thing is to keep the lines of communication and connection and concern open -- and to treat the problem as an illness not a shameful choice or a problem the merits blame.

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Natalie: From guests we interview during our monthly chats, it's not uncommon to hear "don't give up hope. There's a reason for hope." When it comes to having anorexia or bulimia, why should anyone believe that?

Aimee Liu: The best evidence comes from neuroscience, and it's not remotely trite. The brain has an almost miraculous ability to change, and researchers are finding that we hold the keys to that change within our minds. I have met many, many gifted therapists who have helped people who have been sick for decades. Therapies such as dialectic behavior training (DBT), equine therapy, the Maudsley Method, and mindful awareness practices are showing tremendously promising results.

But the brain cannot rewire itself over night or, in most cases, without a good therapist. And no one can "cure" someone who is unwilling to change. An eating disorder masquerades as an identity and it offers a compelling illusion of escape and comfort. You have to be willing to give up that illusion and take the risk of developing a healthy identity - as long as that takes. One of the obstacles to eating disorder recovery I hear over and over is the notion that there is a moment when one is "recovered." Recovery is not a grade, or a state, or a status to be attained - it is an ongoing process that begins from the turning point when you decide you have simply had enough.

A young woman who wrote to me recently described this process best: "We have trained ourselves to empower our minds/bodies to restrict the foods, now we have to use that same power to re-feed ourselves. In other words, the reason we develop these disorders in most cases is to have power, and what we need to do instead of complaining or saying we can't, is just training the power to be used in a different way." That way leads to life instead of loss, love instead of isolation, self-direction instead of self-denial, and hope instead of shame. It's all part of the process not just of recovery but of being fully human.

Natalie: Our time is up tonight. Thank you, Aimee, for being our guest, for sharing your personal experiences with anorexia and recovery and for answering audience questions. We appreciate you being here and for donating the books for our book contest. Here are the links to purchase Aimee Liu's books: GAINING: The Truth About Life After Eating Disorders and Solitaire. You can visit Aimee's website here http://www.aimeeliu.net.

Aimee Liu: Thanks so much Natalie -- and all of you.

Natalie: Thank you, everybody, for coming and participating.

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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How To Deal With Deep Feelings of Anger and Explosive Rage

Our guest, Dr. George F. Rhoades, specializes in anger management. We discussed the effects that anger and rage can have on relationships, parenting, and work. We talked about different types of anger: deep feelings of anger and resentment, unresolved anger, chronic anger, uncontrollable anger (anger that is out of control), explosive anger and explosive rage. Dr. Rhoades suggested techniques to manage anger, for anger control, and ways to release anger in a healthy way, along with methods to deal with rage. And finally, we talked about forgiveness and closure (different than "forgive and forget"), as a meaningful way to significantly reduce high levels of anger.

David Roberts:HealthyPlace.com moderator.

The people in blue are audience members.

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Beginning of Chat Transcript

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Anger Management." Our guest is psychotherapist and author, George Rhoades, Ph.D.

Do you have anger that is all-consuming? Do you harbor deep feelings of anger or resentment? Does your anger control you and your relationships? Dr. Rhoades is the Director of Ola Hou Clinic in Pearl City, Hawaii. He is also the author of the book: "Controlling The Volcano Within: Anger Management Training."

Good evening, Dr. Rhoades and welcome to HealthyPlace.com. We appreciate you being our guest tonight. I'd like to start off by asking you what is the difference, in psychological terms, between normal anger and anger that is out of control, either in terms of the level of anger or how long it lasts?

Dr. Rhoades: We typically look at anger that is chronic, or that adversely affects our lives as being harmful. We also look at when anger becomes a problem, i.e. lasts too long, too intense, too frequent. Anger is also a problem when it affects our relationships with those we love or at work. We ask the question for each of us, how much has anger cost us in the past and are we still willing to pay that cost? Thus anger and when it is a problem will vary for each person, but we also try to point out that anger can be a normal part of all our lives.

David: Is long-lasting anger primarily the result of simply an unresolved situation or does it stem from the person having a serious psychological problem?

Dr. Rhoades: Long-lasting anger can be from both. Unresolved anger often leads to a lack of closure and bitterness. Psychological problems can also manifest in anger, a deep depression may have anger at its foundation. Anger can be expressed in a psychotic episode, either with schizophrenia and in a manic state (what is bipolar disorder and what is manic episode). It is important though to realize that anger that is not addressed tends to cause us a number of physical, psychological and relational problems.

David: What are some signs that let you know that your anger is out of control?

Dr. Rhoades: One clear sign is when you toss and turn at night, but the person that has angered you sleeps soundly. Anger often manifests itself in the ways expressed above, lasting too long, etc. This tells us that anger is extracting a heavy price in our lives.

I once knew a soldier that held his anger inside and he developed ulcers in his stomach, all the way to his mouth. The soldier could not express his anger, and it was, literally, eating him up alive. Anger is a problem when its function in your life are mainly negative, not positive. The negative aspects of anger include it disrupting your thinking, leading to aggression, defending yourself and being seen as an angry man or woman.

David: I'm sure you've heard the phrase: "he's an angry person." That generally means the person is angry all the time. Is that a personality or character flaw?

Dr. Rhoades: Any mother that has had more than one child will testify that each child is different from birth. The children tend to have different personalities from birth, different feeding patterns, different expressions of emotions, including anger. A child that tends to have a more irritable personality may thus be prone to anger and if not guided as a child, may not know how to deal with it in a healthy manner. An angry child becomes an angry teen, becomes an angry adult.

A character flaw would be hard to judge. I believe that we all can be helped with our anger and as such, there is hope for each of us with an anger problem. The issue is that we need first to admit that we have an anger problem, as "the first step in breaking a habit is knowing that you have a habit." The issue of untreatable anger is rare, usually due to a medical problem such as a tumor, or medication reactions. The latter can be helped and the other area would need to be addressed medically and then assessed further in anger management and anger assessment. So there is hope, even with seemingly chronic anger.

David: What are some proven techniques to better cope with chronic anger?

Dr. Rhoades: The anger management program that I have developed utilizes ten techniques that have been shown to be effective. These techniques involve the areas of our thinking, our emotions and our behaviors. The cognitive or thinking coping skills include understanding your own anger, through an anger assessment and journaling. It is also important to look at understanding the anger of others, through empathy. The third way to deal cognitively with our anger is to look at our thinking or self-talk. The emotional area requires that we learn how to relax and to use time-out procedures effectively. We also need to learn how to have humor in our lives. The behavioral area requires that we learn how to communicate our feelings, be assertive and to problem-solve. The most powerful technique to control or to manage anger is that of closure, closing doors on the past and/or forgiveness.

David:I want to get to that last one about closure, but first, we have a lot of audience questions, Dr. Rhoades, so let's get started. Here's the first one:

Ticket33: I have a problem with letting things go for too long and then getting to the point that I am so angry that I start crying. What do you suggest for that?

Dr. Rhoades: Here, in Hawaii, it is very common for us to not address issues directly, but this usually comes back to haunt us as you have noted. The issue is that if we hold on to our anger, we suffer as the energy of the anger effects our health and emotions. Anger that is held in often can lead to health problems in the weak or vulnerable areas of our lives. You may wish to journal your feelings rather than hold them in or allowing things to continue. If you are unable to address the issue directly, you may wish to talk it out with a friend or trusted counselor. It would be important to watch how your body reacts to anger situations and when you notice that you are getting angry, try to address the issues sooner.

flyier: How does one learn to release anger in a healthy way instead of turning it inwards?

Dr. Rhoades: Good question. We used to think that the expression of anger was the best way to get it out. The expression of anger was perhaps yelling in a group format, hitting pillows or even using a rubber bat to "beat out one's anger." In reality, this only lead people to link anger with hitting or yelling behavior, rather than actual anger management. We want to encourage individuals to get to the root of the anger, which produces that anger and thus have a more long-lasting solution. We do, of course, sometimes have a person hit a pillow. This may be in a situation wherein the patient has never been in touch with his/her anger and the pillow hitting is an intermediate step in the healing process. We would want the patient to quickly move to more of a resolution of the issues leading to the anger in the first place. The healthy expression of anger involves using the energy of anger to do constructive things, to problem-solve, take charge of a situation and to communicate their feelings.

bellissima: How do you control your temper with your children when you need to get them to be responsible? I harbor deep feelings of anger and resentment.

Dr. Rhoades: Children are a special test of our ability to control our anger. One of our challenges as parents (I have three children) is to continually guide them toward responsibility while realizing that they are still children. We often need to set clear expectations that are age appropriate and then have to stand firm with love in training our children. It is important for all parents to have ways to lower your stress and to regain control of ourselves when we are stressed out at work or even at home with our children and/or our spouses. No easy answers, but discipline that is applied consistently and fairly will eventually produce results with our children. We often need support and relief so that we can maintain our consistency in parenting.

David: Just a couple of site notes here and then we'll continue with the questions. We have many things going on at HealthyPlace.com. If you'd like to know what's happening, register for our weekly email newsletter.

queenofmyuniverse: How is the best way to deal with a child that has ADHD and an anger problem?

Dr. Rhoades: The ADHD child can have anger and frustration, as it is difficult for that child to focus and it is frustrating for us also to help our children with ADHD. It is critical to provide structure and to help the child to better organize his/her world. Medication is often helpful, although as a parent I have long resisted using medication for ADHD children. I used to create incredibly complex programs for parents and teachers to help the ADHD child. I watched as the parents and teachers became more frustrated and learned that medication can be helpful for the child to focus at school, a critical time for he or she to develop better self-esteem. It is also important for the parent to be disciplined as well. It is common for one of the parents to also have ADHD. The parents can work with the entire family to develop better structure and to help the child learn to safely and respectfully express their anger. I believe that all children need to learn how to express their anger in the home, and with respect for siblings and parents. We don't want to make the mistake of trying to stop the expression of anger, as this may lead the child then to express it inappropriately outside of the home.

David: We have several similar questions on explosive anger or rage:

tender ice: I get so angry that I want to punch a wall or throw the phone across the room. I can't do this because others are here and that would freak them out, so I just shove it in and my insides feel like exploding. How do I deal with that and learn to let go?

Dr. Rhoades: It would be important to better identify the triggers or what leads to the explosive anger inside. As you learn the triggers, you can then develop better ways to deal or to cope with the triggers that may lead to rage. You do need a way to lower the rage inside. This may be done through journaling, talking to a non-involved party or even vigorous exercise. It is important though to eventually address the causes of the triggers in your life. You may do relaxation, journaling, exercise and things like this to be able to take the energy or edge off the rage, but then you need to address the reasons for the rage. You are wise to not express the anger as rage, however, you may want to take a period of time to cool down and then revisit the issue. The issues that led to rage are still important. The problem with rage or explosive anger is that others may see you as out of control and thus minimize the reasons that you got angry, even if they were legitimate.

pmncmn2ooo: How come when I get the slightest bit angry it automatically turns to rage?

Dr. Rhoades: This would probably be due to your past link with anger---> rage or more violent anger. The issue is what you think about before you get angry. Those thoughts typically lead to the rage or actions when you are then angry. We think about what we want to do and then when we are angry we go into automatic mode. It would be important to give yourself time between your anger and rage, perhaps a time-out. One helpful technique is to talk with those important to you to establish that when you are getting angry, that you will give an agreed upon signal and then you will take a time-out. If you utilize time-out, let the other person know that you will return to address the issue in a specified period of time. This way the other person will not try to hold you back to "deal with the situation."

C.U.: How do mood swings affect anger? It seems like just about most things trigger me off. Why would things that are not normally triggered off by a calm person trigger me off in an instant, but the next day it might not trigger my anger?

Dr. Rhoades: Mood swings are going to affect the level of tension within us and thus the energy behind the emotions that we express. You can have intense joy and anger due to mood swings.

Hannah Cohen: I have been programmed to not show any emotion without negative consequences. I still don't show anger, but Dr. Rhoades my hubby and I have 5 children and each is allowed to express their anger as long as they don' t hurt themselves or anyone else. I, on the other hand, most of the time, feel numb. This is not good for me either, I don't think. However, I have been numb so long that I don't know where to begin to feel anything. Any suggestions?

Dr. Rhoades: It is good that your family is able to express their emotions and not harm themselves or each other. I hope that you will start to give yourself the same privilege of expressing your anger. A helpful way to start would be to journal how you are feeling, perhaps what you would like to say if you were not numb. You may have been taught as a young child to not express your anger, as an adult it is hard, but you will be able to learn how to express it without damaging yourself or others.

cranky: How would you handle the person who makes you angry all the time, doesn't care and doesn't think he has a problem? I don't live with him but he is my father so he likes to play the control game. In fact, he has made it clear that if I don't play he will never do anything for me again... and I mean anything.

Dr. Rhoades: You have to count the cost in abusive relationships. It usually isn't true that a parent or sibling will forever cut you off, even if they threaten you that they will do so. The very fact that he has to threaten you implies that he lacks control of you and has to threaten you to maintain that control. I would tend to encourage you to give honor to your father, but not to allow him to hurt you as he has in the past. It would be important to set more healthy boundaries with your father and others that would tend to harm you. You may need to let your dad know that you want a relationship with him, but one that is mutually beneficial, not damaging.

MissPeabody: Yes that's the kind of person I want to know about. Is it uncontrollable rage when a person who is sick and twisted gets off on toying with you and no matter how you address it, they act like you are the problem?

Dr. Rhoades: It is typically a person that does not like to take personal responsibility for problems in their lives and/or the problems that they cause in other's lives. Anger is often used as a shield to cover fear underneath. Show me an angry person and you will often show me a fearful person. The anger is used as a shield to keep people at a distance. If I let you in too close, you will see my insecurities and weaknesses. It does not take a strong person to control others with anger, but a fearful person that uses anger to manipulate others. This is not always the case, but I have seen it quite often. The challenge is to not allow the angry controlling person pushes us to react in similar ways, leading us to react in similar manners.

Zippity: Is there another alternative to the previously mentioned methods to deal with the rage when those have been already tried, and it still doesn't decrease the level of rage? I've been taking time-outs from my anger all my life, and that has led to increased rage. So how do time-outs ultimately help? Is it possible this way doesn't work for everyone?

Dr. Rhoades: You may need to find other ways to decrease the energy of your rages or anger so that you can think more clearly. Rage often overwhelms us to the point that we say and do things that we later regret. Some have used tranquilizers to lower their tension levels to help control anger. I see this as only a temporary solution. You may need to find the areas in your life that increase tension and then work on lowering tension to gain more self-control. Anger is seen as bodily tension plus a view of the world as either frustrating, irritating, insulting, assaulting and/or unfair. Should our lives be stress-filled, we are already primed for anger. When this is apparent, we need to lower the stress in our lives.

David: Here are a few audience comments about what's been said tonight, then I want to address the issue of forgiveness and closure.

bellissima: I have a boss who is trying to manipulate me and controlling me so I don't express my ideas or opinions to her boss. I am tired of her games and I want people to hear my ideas because they are good, she is afraid I will take her job.

nkr: I have always handled myself well until my husband and I get into such a rage. I just want to die.

Chunky: I let things build up too long, then when I try to approach problem-solving, I am afraid of "losing control".

suncletewoof: At times, I feel like I'll explode and kill everyone around me, though I've kept my rage intact. I have explosive rage that never comes out except when I am in the hospital.

David: Earlier, Dr. Rhoades, you said that forgiveness and closure were key to resolving or lowering your anger level. If only it were that easy to "forgive and forget." I'd like to know how do you get to that point?

Dr. Rhoades: "Forgive and forget" is a popular phrase, but we humans don't typically forget. The issues can fade though when we have done our parts to find closure on issues. The steps to forgive are about five and are a mirror image of saying that we are sorry as well. It is important to first note that forgiveness does not mean that what the other person did was okay. Forgiveness or closure is a letting go of or not allowing the situation or the person to hurt us any longer. Forgiveness also does not imply that we have the same level of trust with the person that harmed us. Forgiveness happens one moment in time, trust has to be earned. Thus closure or forgiveness involves a letting go that basically benefits the giver of the forgiveness. The steps for forgiveness are:

1. Determine what hurt you.
2. Determine what you need to close the door or to let go of the anger and hurt.
3. A confrontation with the situation or person that hurt you. It is important though to look at the costs and benefits of a confrontation. Sometimes a confrontation may not be beneficial as the person may deny the hurt or even re-abuse us. You may want to write out your confrontation, mail it, not mail it, burn it, but get it out of yourself. Another way perhaps is to talk it out with another trusted person, should the actual person of the hurt be too risky.
4. Determine to forgive or let go of the situation.
5. Maintain the decision to let go of the hurt and anger. Relationships are made or broken on the ability to forgive and to say that we are sorry. This is why forgiveness or closure is so important to those relationships that we want to maintain.

David: I'm getting a lot of audience responses about forgiveness, essentially saying they keep forgiving because the offending person keeps offending. But what you said above was forgiveness or closure doesn't mean you have to KEEP ALLOWING the other person to keep hurting you.

megan s: You can only say and hear you're sorry so many times through. The person keeps doing it and I keep letting them even though I tell my husband over-and-over again not to. I tell him that it hurts me when he does this or that and so I should leave-- but I have four kids and have been a stay at home mother for 10 years. I confront my husband on it all and he continues his behavior. You make it sound so easy but it's not when there are children involved.

Dr. Rhoades: That is correct, to forgive is to not say their behavior was okay or that you trust them. You may need to do what is necessary for your safety and that of others dependent on you. What we are addressing is a letting go so that you are not trapped by your own hurt and anger. Sometimes we hold on to our anger as we are so hurt by the other's actions. We have to be careful that in holding on to our anger, we may, in fact, be further harming ourselves and our children. I am not trying to imply that it is easy, but it is necessary to not be trapped by the past. The issue is to address the issues that we can, and at some point, we need to move on and not be trapped by the past. This does not mean that person that harmed us should have no consequences. You may still choose to not be around an abusive person, but don't allow that abusive person to still control you long distance, though held one-to anger within us for past hurts.

Zippity: Does that include breaking relations permanently with those who have harmed us, if that is the only way to achieve closure?

Dr. Rhoades: I would never recommend that a person break off a relationship permanently. That would be the individual choice of persons involved. It is important to personally look at what cost or consequences of maintaining the relationship will have on you and your loved ones.

David: Thank you, Dr. Rhoades, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com.

Thank you, again, Dr. Rhoades for coming and staying late tonight. We appreciate it.

Dr. Rhoades: Good night to all the participants in the chat on anger management. I enjoyed interacting with all of you. Aloha from Hawaii!

Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.