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Patient Education Protocols ListADHDAdherence Using Meds SuccessfullyAlcohol & Low Risk DrinkingAnxiety & Coping with Panic AttacksAnxietyChronic PainDepression – PostpartumDepressionExercise & Physical ActivityGriefHeadachesHypertensionParenting ProtocolRelationship ProblemsRelationship Sexual ProblemsSleep & InsomniaSleep ApneaSleep Behavior Change & DiarySleep Class PacketStressSubstance Misuse & Maintaining Behavior ChangeWeight ManagementAttention-Deficit/Hyperactivity Disorder (ADHD)What is it?ADHD is an acronym for Attention-deficit/Hyperactivity Disorder. It is a neurological brain disorder that is marked by a continual pattern of inattention and/or hyperactivity-impulsivity that is more frequent and severe than what considered typical for someone of that age.Does it affect me?There are two main problems identified with ADHD: (1) Inattention and (2) Hyperactivity / Impulsivity. These problems are further broken down into individual symptoms.InattentionHyperactivity/ImpulsivityPoor attention to detail/carelessnessFidgetiness/squirminessDifficulty sustaining attentionDifficulty remaining in seatDoes not appear to listenRuns about or climbs excessivelyOften fails to complete tasksDifficulty with quiet activitiesDifficulty with organizationOften seems “on the go”Avoids/dislikes focused tasksTalks excessivelyLoses things easilyBlurts out answers or opinionsEasily distractedDifficulty waiting or taking turnsForgetful of daily activitiesInterrupts or intrudes on others* It is important to note how common and normal these symptoms are in children and adults, being mindful of the overlap they have with other mental and physical health problems. The symptoms listed above must be: Chronic: lasting at least six months consistentlyPresent from a young age: onset must be prior to age 7Observable and problematic across many settings: for example, at home, school, work, etc. How do you find out if you have ADHD?There is no one test for ADHD, but a comprehensive evaluation completed with a professional is needed to establish a diagnosis. The evaluation is long and requires sustained mental effort to complete. In addition to the testing, information related to current functioning and background information will be collected. Reports from several people are also helpful in establishing a diagnosis: (1) parents report about home functioning, (2) teachers report about school functioning, (3) co-workers report about work functioning, and (4) friends report about social functioning. Typically, the testing battery includes symptom checklists, rating scales to identify emotional and behavioral signs, intelligence testing, and achievement testing. How common is it? By definition, ADHD begins in childhood prior to age 7, and according to recent research, it can continue into adulthood. While some children “outgrow” ADHD, evidence suggests that up to 70% can continue to carry symptoms of inattention into adulthood, with hyperactivity typically diminishing with age. According to a 2003 Centers for Disease Control study, 7.8% of children between the ages of 4 and 17 have ever been diagnosed with ADHD. Research indicates that nearly 4% of adults in the U.S. continue to have ADHD. Is Adult ADHD any different from Childhood ADHD? Because ADHD is a neurological condition that starts during childhood, symptoms that adults experience are not new, but rather, have continued from childhood. Most adults who have continued symptoms may notice problems with difficulty paying attention to details, organization, talking fast, and difficulties focusing and concentrating. Adults with ADHD do not typically report problems with hyperactivity; either the symptoms have subsided or they have developed coping strategies for handling their increased activity level. There is no evidence that ADHD develops during adulthood. Concentration problems and distractibility in adults are often due to other problems such as depression, anxiety, stress in relationships, or occupational stress. Any of these and other mental health conditions can mimic the symptoms of ADHD, but they are not ADHD. Associated problems and consequences that often co-exist with adults who have continued symptoms of ADHD from childhood may include: Poor self controlEasily boredForgetfulnessLow self-esteemDifficulty focusing Substance abusePoor time managementDifficulty regulating emotions, arousal, and motivationRelationship problemsAnxiety/depressionPoor time perceptionMood swingsVariability in work performanceEmployment difficultiesChronic latenessRisk-taking behaviorsResources and Suggested ReadingsChildren Quinn & Stern (2001). Putting on the brakes: Young people’s guide to understanding Attention-deficit/Hyperactivity Disorder.Nadeau, Nixon, & Beyl (2004). Learning to slow down & pay attention: A book for kids about ADHD.AdolescentsZiegler Dendy, & Ziegler (2003) A Bird's-Eye View of Life with ADD and ADHD: Advice from Young Survivors.ParentsBarkley (2000). Taking charge of ADHD: The complete, authoritative guide for parents.Barkley & Benton (1998). Your defiant child: Eight steps to better behavior. AdultsKelly & Ramundo (1995). You mean I’m not lazy, stupid, or crazy: A self-help book for adults with attention deficit disorder. Hallowell & Ratey (1995). Driven to distraction: Recognizing and Coping with Attention Deficit Disorder from Childhood Through Adulthood. WebsitesChildren and Adults with Attention-deficit/Hyperactivity Disorder : Teens Health: teen/school_jobs/school/adhd.htmlTeens with ADHD by Chris Dendy: ADHD News: What are my treatment options? Treatment for ADHD is often “multimodal”—that is, it often involves any combination of education, skills training, behavioral interventions, and medication. Depending on your symptoms and response to these interventions, treatments will vary on a case-by-case basis. As with most illnesses, it is highly recommended to start with the least invasive options first.In treating ADHD, exhaustive attempts at behavioral interventions should initially be pursued before beginning a trial of medication. Behavioral InterventionsBehavioral Modification, or B-Mod, is typically the type of behavioral intervention that is used in the treatment of ADHD. B-Mod is a process where individuals learn specific skills and techniques designed to alter habits/problem areas and replace them with more adaptive, functional responses. As parents, if we can consistently alter the antecedents (how we make requests) or consequences (our reaction when the child obeys or disobeys), we can alter our child’s behaviors and shape a more functional way of responding. As an adult trying to shape your own behaviors, similar contingencies (“if…then” scenarios) are helpful in establishing a behavioral plan that encourages a desired behavior attached to a reward (e.g., if I complete X, then I can do Y). Common guidelines for implementing a B-Mod plan include:Start with goals that are small and attainableBe consistent—regardless of time of day, setting, and situationFollow through with the behavioral intervention over the long haulRemember that learning new skills takes time and is gradual—don’t give up!!Suggestions for Parents: Provide clear, concise expectations, directions, and limits—avoid ambiguityHouse rules and structure are a necessity—plan ahead and predict barriersSet up an effective discipline system based on rewards and consequencesChange the most problematic behaviors first—use charts/graphs to see progressHelp your child in social situations—promote cooperation and peer interactionTeach social skills and promote extracurricular activitiesIdentify & build on your child’s strengths—promote confidence, success, and esteemHave a “special time” for your child—TLC goes a long way in maintaining self-worthLearn to praise appropriate behaviors and ignore minor inappropriatenessPharmacological InterventionsStrong evidence supports the use of stimulant medication for the management of inattention, impulsivity, and hyperactivity in school children. Studies suggest that 70-80% of children with ADHD improve with the use of stimulant medication. Some changes include: academic improvement, increased focus and concentration, increased compliance and effort, and decreased activity level and impulsivity. Medical intervention often involves a trial of Ritalin, Concerta, Adderall, Dexedrine, or Strattera (an effective non-stimulant). The effects of these medications are typically felt within 30-60 minutes of taking the medication. Increasing, decreasing, or terminating medication is determined on a case-by-case basis to maximize functioning.Tips for Parents Tips to help parents identify common problem areas for childrenWriting/Language ProblemsStrategyChildren with ADHD often have poor handwriting, grammar, and spelling skills. Listening to information, processing it, and writing it down is challenging. Comprehension of instructions and expression of thoughts and ideas is often difficult.Parents need to be supportive; consider writing down answers given verbally by your child; encourage a language-rich environment and never shame your child for slow processing or misuse of words.Missing AssignmentsStrategyChildren with ADHD have difficulty keeping track of information, lose track of time, and often turn in assignments late. They have intentions of being compliant, but lack organizational skills.Develop a system and provide support at each stage of project completion; use checklists, labels, and color-coded binders/folders for all subjects; establish and keep a routine; prevent procrastination by using independence as a reward.DistractibilityStrategyADHD is marked by an inability to control what one pays attention to, and is not always a conscious decision. Children with ADHD are often unable to inhibit their responses to distractions, such as outside noises, movement, or their own thoughts.Establish a daily homework routine with scheduled breaks; create a comfortable, distraction-free environment to facilitate focus; communicate with teachers if your child seems to lack the skills needed to complete an assignment or if it takes an inordinately long time.Immature Social Behavior StrategyChildren with ADHD often have a hard time reading social cues, may misinterpret remarks, or miss the point of a conversation.Involve your child in activities such as music, sports, or other hobbies to identify strengths; role play everyday situations with your child and allow them to practice these skills in a “safe environment”; children with ADHD are often great playmates with younger children and can learn to foster positive caring traits without feeling threatened by same-age peers.Following InstructionsStrategyMulti-step directions are notoriously difficult for children with ADHD, as they often only hear bits and pieces of the request.Break down large tasks into multiple, smaller steps; create checklists and use reward systems when possible; use redirection and explanation rather than punishment for distraction.ImpulsivityStrategyChildren with ADHD are often labeled as unruly or aggressive because of their impulsive physical and social interactions. They often have difficulty controlling impulses, despite having caring & sensitive intentions.Natural consequences are important parts of discipline and expected to occur; provide immediate, positive feedback and attention for appropriate behaviors; the most successful discipline is specific, proactive, and directive; avoid ambiguity (“Be good”) and tell your child exactly what behavior is expected.Adapted from “Tips for Schools and Home”; Eli Lily & CoTips for Teachers Tips to help teachers address common problem areas for studentsWriting/Language ProblemsStrategyChildren with ADHD often have poor handwriting, grammar, and spelling skills. Listening to information, processing it, and writing it down is challenging. Comprehension of instructions and expression of thoughts and ideas is often difficult.Consider giving extra time or abbreviated assignments; offer corrections, but avoid taking off points on less important areas (e.g., spelling vs. completing the book report); make yourself available for additional questions and explanations.Missing AssignmentsStrategyChildren with ADHD have difficulty keeping track of information, lose track of time, and often turn in assignments late. They have intentions of being compliant, but lack organizational skills.Supervision and structure are critical; cues and reminders can be helpful, and ensure the child writes down assignments and stores paperwork in a homework folder; track progress periodically on long-term projects; use positive and instructive comments for corrections.DistractibilityStrategyADHD is marked by an inability to control what one pays attention to, and is not always a conscious decision. Children with ADHD are often unable to inhibit their responses to distractions, such as outside noises, movement, or their own thoughts.Have child sit close to teacher and away from doors and windows; use privacy dividers to limit distraction during individual study/work time; lessons should involve visual & auditory aids, and should be kept short; use a variety of pacing and gesturing to capture attention; use nonverbal cues (e.g., tapping) to refocus attention.Immature Social Behavior StrategyChildren with ADHD often have a hard time reading social cues, may misinterpret remarks, or miss the point of a conversation.Talk with teachers about your child’s social immaturity; teachers should use positive reinforcement, especially in front of peers, to help reduce the child’s use of inappropriate antics for attention; one-on-one social modeling followed by small group work can help children develop appropriate behaviors.Following InstructionsStrategyMulti-step directions are notoriously difficult for children with ADHD, as they often only hear bits and pieces of the request.Teachers should use specific, brief, and personal instructions whenever possible; written instructions are best so children can review assignments again later; consider recording classes if possible; have children repeat instructions back to you to ensure translation.ImpulsivityStrategyChildren with ADHD are often labeled as unruly or aggressive because of their impulsive physical and social interactions. They often have difficulty controlling impulses, despite having caring & sensitive intentions.Rules that are posted in the classroom make expectations clear and serve as written reminders to think before you act; tape targeted behavior cards to the child’s desk that encourage appropriate activity (e.g., raise hand to ask a question); give periodic warnings of pending transitions in activity to avoid a meltdown (e.g., “We have 5 more minutes before lunch”); anticipate problem situations.Adapted from “Tips for Schools and Home”; Eli Lily & CoUsing Medications SuccessfullyThe Cycle of DepressionPeople become depressed for many reasons. This booklet describes strategies for using medications successfully to alleviate symptoms of depression. Most often, depression is related to stressful life circumstances, such as marital problems, death of a loved one, loss of a job, or a child leaving home. Depression may also be related to physical problems such as chronic pain or medical illness. Depression Occurs In Three WaysThe Body Feels DepressedWhen the body is depressed, a person sleeps poorly, eats differently, has less energy, struggles with concentration, and has more aches and pains. Behavior Is DepressedWhen behavior is depressed, a person does much less than usual. She/he talks less, produces less, and socializes less. The Mind Is DepressedWhen the mind is depressed, thinking changes. A depressed person experiences more intensely negative and painful thoughts about the past and the future. A person’s body, behavior, and thoughts interact continuously. Once depression becomes a problem, this interaction may lead to a “downward spiral” in mood and hopefulness. Two courses of action help reverse the downward direction and create a “positive spiral.”Use of MedicationsMedications may help some people with symptoms of depression feel better, but they work slowly and do not appear to prevent you from having future episodes of depression. Therefore, it is best to use medications in combination with behavioral planning and use of coping strategies. If you decide to use medications and your doctor prescribes them, this booklet will help you use them well. Strategic Use of Coping StrategiesUse of active coping strategies helps you reverse the downward spiral of depression. When you address life problems with effective strategies, you have more opportunities to create positive conditions in your life context. Make a concerted effort to work with your health care provider in planning medication treatment and skillful use of coping strategies. You will soon be feeling better.Using Medications SuccessfullyThere are four important areas to attend to when considering the start of a medication, and this booklet will help you assess and prepare for success in each of these areas. Your Past Experiences with MedicationsTake a moment to recall your past experiences with use of medications for depression and anxiety.Have you ever used a medicine to help alleviate symptoms of depression or anxiety? FORMCHECKBOX Yes FORMCHECKBOX NoTry to recall the medication name, dosage, and length of treatment. NameDoseWhen? How long?Also, recall any side effects you had with this medication. How much did they trouble you?SideEffectBotheredA LittleBotheredA Lot FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX How much did you benefit from use of medication when you tried medication before? FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX NoneA LittleSomeQuite A LotVery MuchThis information will be helpful to you and your provider in making a decision about medication use and selection of a specific medication.If you did have a limited response to medication treatment or experienced bothersome side effects in the past, you may still be a candidate for medication treatment. You doctor may suggest that you try a new medication. Your Beliefs about MedicationsYour beliefs have a significant impact on your success in using antidepressant medications. Take stock of your beliefs right now. Mark an “X” by any of the following statements that you believe. FORMCHECKBOX I’ll be the one to get terrible side effects. FORMCHECKBOX I can’t afford these medicines. FORMCHECKBOX I’ll never remember to take them. FORMCHECKBOX I’ll get addicted. FORMCHECKBOX My family would not want me to use medications for this problem. FORMCHECKBOX These types of medications are overused. FORMCHECKBOX I should be able to get over my problems without taking medicine.If you believe any of these statements, discuss the belief with your health care provider. She/he may be able to provide you with additional information to help you re-evaluate beliefs which might make medication use more difficult for you. Your Knowledge about MedicationsYou are much more likely to succeed in antidepressant treatment when you have accurate information about all aspects of medication use. Please review the following details and discuss any questions you have with your health care providers. Starting medication . . .Start your medicine as soon as it is prescribed. The sooner you start, the sooner you will experience the desired benefits. Remembering to take medicine . . .Take your medicine at a certain time of day every day. During the first several weeks, you may want to leave yourself several reminder notes. Some people use a behavioral hygiene task, such as teeth brushing, as a cue to take their medication. Also, some people may want to leave an extra bottle of medication in a desk drawer at work in the event that they forget to take the medicine at home. Deciding how to take the medication . . .Some medications are best taken in one dose, while others are best divided into several doses during the day. Some medications cause drowsiness, while others are more activating. Medications with a sedative effect are taken at night, and activating medications are taken in the morning. Carrying on with other activities . . .If you do notice minor sedation or sleepiness in starting a medicine, avoid driving or carrying out hazardous activities. Sleepiness will usually diminish. If it does not, talk with your provider about a medication change. Compatibility of a new medicine with other medications . . .Talk with your provider about the compatibility of any new medicine with other medications you are taking. Taking antidepressant medications and consuming alcohol . . .Talk with your doctor about possible problems with consuming alcohol with prescription medications. Increasing medication dose . . .Talk with your doctor about the dose and if she or he plans to increase the dose.Continuing to take the medication . . .Take the medicine until you and your provider decide that you are ready to stop the medicine. Do not stop taking the medicine until you and your doctor have a plan for you to stop. Your Ability to Anticipate and Plan for Problems in Using MedicationsMost medicines have mild side effects. The side effects may be temporary and diminish or disappear shortly after start of treatment. If you experience side effects that are more severe, call your doctor. She/he will probably suggest one or more of the following strategies: change the time you take the medicine, change the dose, add a second medicine, change to a different medicine, or use a remedy for the side effect. The following table provides some examples of medication side effects and ways to cope with them.Examples of Side Effects and Possible RemediesDry MouthDrink plenty of water. Chew sugarless gum. Use sugarless drops.ConstipationEat more fiber-rich foods. Take a stool softener.DrowsinessGet fresh air and take frequent walks. Try taking your medicine earlier in the evening, or if you’re taking your medicine in the day ask your doctor if you can take it at night.WakefulnessTake medications early in the day. Learn more about insomnia. Take a warm bath and have a light snack before bed. Avoid exercising vigorously late in the evening.Blurred VisionRemind yourself that this will be a temporary difficulty. Talk with your doctor if it persists.DizzinessStand up slowly. Drink plenty of fluids. If you are worried, call your doctor.Feeling Speeded UpTell yourself, “This will go away within three to five days.” If it does not, call your doctor or nurse.Sexual ProblemTalk with your doctor. A change in medications or a medication holiday may help.Nausea or Appetite LossTake the medicine with food. Prepare food so that it is appetizing and colorful. Eat small healthy meals. A Guide to Low-Risk DrinkingWhat is Low Risk Drinking?Low-risk drinking involves limiting alcohol use to amounts and patterns that are unlikely to cause harm to oneself or others. Scientific evidence indicates that the risk of harm increases significantly when people consume more than two drinks per day and more than five days per week. Because different types of alcoholic beverages contain different amounts of alcohol, it is important that you know what a standard drink is when you are cutting down or trying to stick to a limit. In the box below, you can see that standard drinks of different beverages are different sizes. But what they have in common, is that each of them contains about 10 grams of pure alcohol. The following can be used as a guide to help you keep track of your drinking. Remember, each is a standard drink.Light BeerFull Strength BeerWinePort/SherrySpirits1 glass-425ml1 glass-285ml1 glass-100ml1 glass-60ml1 nip 30ml2.9% alcohol4.9% alcohol12% alcohol20% alcohol40% alcoholMany individuals who would otherwise regard themselves as moderate drinkers, at times drink in ways that cause problems. For example, limiting alcohol use to two or fewer drinks a day may present risks in certain circumstances:When driving or operating machineryWhen pregnant or breast feedingWhen taking certain medicationsIf you have certain medical conditionsIf you cannot control your drinkingIf you have a personal history of drinking problemsIf you suffer from depression or anxietyIf you have been told not to drink for legal reasonsWhat is High-Risk Drinking?Some people may think that you have to drink heavily all of the time or be dependent on alcohol to have alcohol-related problems. This is not true. Some problems can come from simply being drunk every now and again. Other problems may come from regularly drinking too much even though you may hardly ever get drunk. You may be surprised that alcohol problems occur at what you consider to be moderate levels of drinking. You increase your risks of experiencing alcohol related problems if you drink to the point of intoxication (being drink), drink on a regular basis, or spend a lot of time drinking. Risks due to intoxication (that is, being drunk). You do not have to be “falling down drunk”, nor do you have to drink often to have these problems. Examples of intoxication related problems include drunken driving, falls, hangovers, unsafe sex, arguments, absenteeism, and embarrassment. The problems can range from being minor to being fatal.Risks due to regular use. Problems coming from drinking too much on a regular basis include: spending too much money on alcohol, concentration and memory difficulties, experiencing stomach and liver disorders, diabetes, poor sleeping habits, gaining weight, and conflict in your relationships.Risks due to dependence. Some people begin to devote more and more time to drinking and feel uncomfortable if they don’t drink. They may feel alcohol is beginning to take over their lives, and cutting down their drinking becomes harder. Dependence can mean anxiety, depression, withdrawal symptoms, losing interest in other activities and feelings of loss of control.Physical Effects of High Risk DrinkingIn addition to the above mentioned risks, individuals who drink more than two standard drinks are likely to experience a number of physiological effects from alcohol, some of which may lead to physical difficulties. The following diagram outlines the effects of high risk drinking. Indications of High-Risk DrinkingHigh-risk drinkers may have difficulty recognizing the problematic nature of their drinking. They may minimize the amount of alcohol they drink or simply ignore the fact that the amount of alcohol they drink is excessive. At times it may be helpful to consider looking for common signs of high-risk drinking. Some indications of high-risk drinking include:Drinking alone when you feel angry or sadBeing late or absent from work due to the effects of alcohol Friends or family have indicated they are concerned about your drinkingDrinking even after telling yourself you won’t Forgetting what you did while you were drinkingPeriods of headaches or a hang-over after drinkingPast failed attempts to decrease your alcohol useHow to Manage Your DrinkingReading about the risks associated with high-risk drinking has hopefully changed how you think about your own and others drinking habits. After reading this material you may want to change your drinking habits in some way, but are not exactly sure how. Many people change their behavior all on their own. Often, when they are asked what brought about the change, they say they just “thought about it,” meaning they evaluated the consequences of their current behavior and of changing before making a final decision. You can do the same thing by asking two simple questions: “What do I stand to lose and gain by continuing my current drinking pattern?” and “What do I stand to lose and gain by changing my drinking pattern?” To change, the scale needs to tip so the costs outweigh the benefits. This is called Decisional Balancing. Weighing the pros and cons of changing happens all the time. For example, when changing jobs or deciding to move or get married. At some point, you may have received real benefits from the behavior you want to change, such as relaxation, fun, or stress reduction. However, because you are reading this, you are considering both the benefits and the costs. Below is an example of a Decisional Balance Worksheet for someone wanting to change the amount of alcohol they drink.Decisional Balance Worksheet Benefits of ChangingNot Changing Increased control over my life Support from family and friends Decreased job problems Improved health & finances my problemsMore relaxedMore fun at partiesDon’t have to think about my problemsCosts ofIncreased stress/anxietyFeel more depressedIncreased boredomSleeping problemsDisapproval from friends/familyMoney problemsDamage close relationshipsIncreased health risksNow that you have seen an example of a Decisional Balance for someone else thinking about changing their drinking behaviors, consider what the personal costs and benefits of changing (and not changing) your drinking behaviors are to you. Write down the costs and benefits in the worksheet below:Decisional Balance Worksheet Benefits of ChangingNot Changing Costs ofDecision to Change Worksheet: Look over what you have written. What do you feel is the best choice for you? If you have made the decision to change your drinking behavior, it is often helpful to refer back to this worksheet to remind yourself why you made the decision to change. It is also a good idea to talk it over with the person you are closest to so that they can fully understand why you have chosen your goal. Then they will find it easier to be supportive of your attempts to change. All change can be uncomfortable at first, so it helps to get support from others. Research shows support from others will increase your chances for success.Identifying TriggersAlthough we sometimes do things that are not good for us, there are usually reasons why we behave in certain ways. An important step in trying to change a behavior is identifying why it occurs. Frequently behaviors are triggers by other things. Many circumstances can act as triggers, such as pleasant or unpleasant emotions, a particular setting, or just a routine situation. To help you identify possible triggers for your drinking consider the following questions:With whom do you typically drink?What do you hope will happen when you drink?Are you in any particular emotional state when you drink (e.g., angry, depressed, happy, sad)?What physical state are you in when you drink (e.g., relaxed, tense, tired, aroused)?What setting do you tend to drink in (e.g. work, party, ex-spouse’s house)?What activities are you involved with when drinking (e.g., work, playing sports, watching TV)My Triggers for DrinkingTake a few moments to note your common triggers for drinking. Finish each of the sentences below:The places where I most frequently drink alcohol are:The people I am usually with when I drink include:I usually drink when I am feeling:I frequently drink when doing the following activities:Situations where I typically do not drink are:Change PlanNow that you have identified some of your personal drinking triggers, you have determined those situations in which you might drink a lot. The next step is to figure out how to be in these situations and experience those feelings without a drink in your hand. Can you avoid the situation altogether? Or find a way of handling it without a drink? Or with only one drink instead of half a dozen? Rather than waiting until you are under pressure, work out some strategies for managing your drinking before you get into these situations. You’ll feel more in control if you have prepared for a difficult “triggering” situation. To help you accomplish this go through the steps outlined below.First, pick one of your “triggers”.Example: Going to the Club with friends Second, think of as many ways you can for handling that situation and write them all down. Be creative—try to put down some ideas you have never tried before, no matter how silly some of them seem.Example: Ask friends to keep me from drinking Don’t go to the clubGo someplace that doesn’t serve alcoholDon’t bring any extra moneyThird, review your list and consider how these strategies might not work. Then figure out ways to work around these obstacles. Determine if you need to alter the option in some way.Example: If I don’t bring any money, I will just ask a friend to spot me. Maybe I should ask them not to do this beforehand. Fourth, read your list carefully and pick the two ideas that seem the most practical and sensible for that situation.Example: Don’t bring extra money and ask friends not to loan me any money.Fifth, try out the most promising strategies and see if they work. If they don’t, go back to step 2 and think of other ideas. It is important to recognize that some of these ideas may not work, (e.g., it may be tempting fate to say you will go to the pub and only drink orange juice). Thus, it is important to establish realistic and achievable strategies. Use the next page to work out these steps. If you need help, your BHC can assist you. My Personal Change PlanStep 1Choose a trigger: Step 2Write down as many strategies for controlling your drinking in this setting:Step 3Think of how the strategies in Step 2 might fail, then consider ways to work around these obstacles:Step 4Look at what you have in Step 3, and choose the two that seem the most doable:1. 2. Step 5Test your strategies from Step 4 to see if they work. If not, start over at Step 2 to figure out new ways to make them work given what you have learned. Ask your BHC for help, if needed.Make as many copies of this worksheet as necessary until you find a successful strategy. Most people will fill one out for each of their triggering situations. The more worksheets you complete, the more thinking and planning you end up doing, which makes you more prepared to make a behavior change. Coping with Panic AttacksWhat is a panic attack? You may have had a panic attack if you experienced four or more of the symptoms listed below coming on abruptly and peaking in about 10 minutes.Panic SymptomsPounding heartSweatingTrembling or shakingShortness of breathFeeling of chokingChest painNausea or abdominal distressFeeling dizzy, unsteady, lightheaded, or faintFeelings of unreality or being detached from yourselfFear of losing control or going crazyFear of dyingNumbness or tinglingChills or hot flashesPanic attacks are sometimes accompanied by avoidance of certain places or situations. These are often situations that would be difficult to escape from or in which help might not be available. Examples might include crowded shopping malls, public transportation, restaurants, or driving.Why do panic attacks occur?Panic attacks are the body’s alarm system gone awry. All of us have a built-in alarm system, powered by adrenaline, which increases our heart rate, breathing, and blood flow in response to danger. Ordinarily, this ‘danger response system’ works well. In some people, however, the response is either out of proportion to whatever stress is going on, or may come out of the blue without any stress at all.For example, if you are walking in the woods and see a bear coming your way, a variety of changes occur in your body to prepare you to either fight the danger or flee from the situation. Your heart rate will increase to get more blood flow around your body, your breathing rate will quicken so that more oxygen is available, and your muscles will tighten in order to be ready to fight or run. You may feel nauseated as blood flow leaves your stomach area and moves into your limbs. These bodily changes are all essential to helping you survive the dangerous situation. After the danger has passed, your body functions will begin to go back to normal. This is because your body also has a system for “recovering” by bringing your body back down to a normal state when the danger is over.As you can see, the emergency response system is adaptive when there is, in fact, a “true” or “real” danger (e.g., bear). However, sometimes people find that their emergency response system is triggered in “everyday” situations where there really is no true physical danger (e.g., in a meeting, in the grocery store, while driving in normal traffic, etc.).What triggers a panic attack?Sometimes particularly stressful situations can trigger a panic attack. For example, an argument with your spouse or stressors at work can cause a stress response (activating the emergency response system) because you perceive it as threatening or overwhelming, even if there is no direct risk to your survival.Sometimes panic attacks don’t seem to be triggered by anything in particular – they may “come out of the blue.” Somehow, the natural “fight or flight” emergency response system has gotten activated when there is no real danger. Why does the body go into “emergency mode” when there is no real danger?Often, people with panic attacks are frightened or alarmed by the physical sensations of the emergency response system. First, unexpected physical sensations are experienced (tightness in your chest or some shortness of breath). This then leads to feeling fearful or alarmed by these symptoms (“Something’s wrong!”, “Am I having a heart attack?”, “Am I going to faint?”) The mind perceives that there is a danger even though no real danger exists. This, in turn, activates the emergency response system (“fight or flight”), leading to a “full blown” panic attack. In summary, panic attacks occur when we misinterpret physical symptoms as signs of impending death, craziness, loss of control, embarrassment, or fear of fear. Sometimes you may be aware of thoughts of danger that activate the emergency response system (for example, thinking “I’m having a heart attack” when you feel chest pressure or increased heart rate). At other times, however, you may not be aware of such thoughts. After several incidences of being afraid of physical sensations, anxiety and panic can occur in response to the initial sensations without conscious thoughts of danger. Instead, you just feel afraid or alarmed. In other words, the panic or fear may seem to occur “automatically” without you consciously telling yourself anything.After having had one or more panic attacks, you may also become more focused on what is going on inside your body. You may scan your body and be more vigilant about noticing any symptoms that might signal the start of a panic attack. This makes it easier for panic attacks to happen again because you pick up on sensations you might otherwise not have noticed, and misinterpret them as something dangerous. A panic attack may then result.How do I cope with panic attacks? An important part of overcoming panic attacks involves re-interpreting your body’s physical reactions and teaching yourself ways to decrease the physical arousal. This can be done through practicing the cognitive and behavioral interventions below. Behavioral Interventions1. Breathing RetrainingResearch has found that over half of people who have panic attacks show some signs of hyperventilation or over-breathing. This can produce initial sensations that alarm you and lead to a panic attack. Over-breathing can also develop as part of the panic attack and make the symptoms worse. When people hyperventilate, certain blood vessels in the body become narrower. In particular, the brain may get slightly less oxygen. This can lead to the symptoms of dizziness, confusion, and lightheadedness that often occur during panic attacks. Other parts of the body may also get a bit less oxygen, which may lead to numbness or tingling in the hands or feet or the sensation of cold, clammy hands. It also may lead the heart to pump harder. Although these symptoms may be frightening and feel unpleasant, it is important to remember that hyperventilating is not dangerous. However, you can help overcome the unpleasantness of over-breathing by practicing Breathing Retraining.Practice this basic technique three times a day, every day:Inhale. With your shoulders relaxed, inhale as slowly and deeply as you can while you count to six. If you can, use your diaphragm to fill your lungs with air. Hold. Keep the air in your lungs as you slowly count to four. Exhale. Slowly breath out as you count to six. Repeat. Do the inhale-hold-exhale cycle several times. Each time you do it, exhale for longer counts.Like any new skill, Breathing Retraining requires practice. Try practicing this skill twice a day for several minutes. Initially, do not try this technique in specific situations or when you become frightened or have a panic attack. Begin by practicing in a quiet environment to build up your skill level so that you can later use it in time of “emergency.”2. Decreasing AvoidanceRegardless of whether you can identify why you began having panic attacks or whether they seemed to come out of the blue, the places where you began having panic attacks often can become triggers themselves. It is not uncommon for individuals to begin to avoid the places where they have had panic attacks. Over time, the individual may begin to avoid more and more places, thereby decreasing their activities and often negatively impacting their quality of life. To break the cycle of avoidance, it is important to first identify the places or situations that are being avoided, and then to do some “relearning.” To begin this intervention, first create a list of locations or situations that you tend to avoid. Then choose an avoided location or situation that you would like to target first. Now develop an “exposure hierarchy” for this situation or location. An “exposure hierarchy” is a list of actions that make you feel anxious in this situation. Order these actions from least to most anxiety-producing. It is often helpful to have the first item on your hierarchy involve thinking or imagining part of the feared/avoided situation.Here is an example of an exposure hierarchy for decreasing avoidance of the grocery store. Note how it is ordered from the least amount of anxiety (at the top) to the most anxiety (at the bottom): Think about going to the grocery store alone.Go to the grocery store with a friend or family member.Go to the grocery store alone to pick up a few small items (5-10 minutes in the store).Shopping for 10-20 minutes in the store alone.Doing the shopping for the week by myself (20-30 minutes in the store). Your homework is to “expose” yourself to the lowest item on your hierarchy and use your breathing relaxation and coping statements (see below) to help you remain in the situation. Practice this several times during the upcoming week. Once you have mastered each item with minimal anxiety, move on to the next higher action on your list.Cognitive Interventions1. Identify your negative self-talkAnxious thoughts can increase anxiety symptoms and panic. The first step in changing anxious thinking is to identify your own negative, alarming self-talk. Some common alarming thoughts:I’m having a heart attack.I’m going to pass out.I must be going crazy.Oh no – here it comes.I think I’m dying.I can’t stand this.People will think I’m crazy.I’ve got to get out of here!2. Use positive coping statements Changing or disrupting a pattern of anxious thoughts by replacing them with more calming or supportive statements can help to divert a panic attack. Some common helpful coping statements:This is not an emergency.I don’t like feeling this way, but I can accept it.I can feel like this and still be okay.This has happened before, and I was okay. I’ll be okay this time, too.I can be anxious and still deal with this situation.Suggested ReadingsBarlow, D., & Craske, M. (2006). Mastery of your anxiety and panic workbook, 4th Edition. New York: Oxford University Press. Bourne, E. (2000). The Anxiety and phobia workbook, 3rd Edition. Oakland, CA: New Harbinger Publication.Anxiety Challenging Anxiety Anxiety affects approximately 19 MILLION adults in the United States alone. 1 out of every 6 people will experience uncomfortable anxiety at some time during their lives (that is nearly 45 million people)! The body’s natural response to danger is to prepare for “fight” or “flight”. When the sympathetic nervous system activates to emergency situations, you may experience feelings and body sensations such as:Increased heart rateQuick, shallow breathsIncreased adrenalineImpending doomIncreased muscle tensionIncreased perspirationLight headednessChest painsThese physical responses usually occur as components of anxiety. It is important to recognize that these reactions are your body’s normal response to a perceived danger. However, with anxiety, your body is responding to situations in which you are not physically threatened. None of these physical reactions can harm you—they are designed to keep you safe.Anxiety begins in the cognitive (thinking) part of the brain. Physical symptoms ALWAYS begin as thoughts or perceptions based on your personal beliefs. You may experience the following kinds of thoughts:Uncontrollable worryFear, apprehensionFeelings of impending doomNegative thoughts you cannot stopNegative thoughts about yourself, the future, or past eventsThe thinking part of the brain can activate the physical “danger” response even when there is no immediate threat of danger. The physical and cognitive aspects of anxiety feed into each other to continue the negative cycle of worry and physical discomfort. Fortunately, there are several ways to alleviate the physical and cognitive discomfort of anxiety. Some typical behavioral exercises you can use to reduce physical symptoms of anxiety include:Relaxation breathingPhysical exerciseEngage in enjoyable/distracting activityNoticing and being curious about it negative or distorted thinkingIt will take practice to feel comfortable using these techniques, and to notice a decrease in your symptoms of anxiety. Remember, learning to feel anxious took time learning to feel more calm will take time. Soon, use of relaxation techniques and new ways of responding to anxious thoughts and sensations will become natural. Diaphragmatic Breathing ExerciseSit in a comfortable position, legs shoulder width apart, eyes closed, jaw relaxed, arms loose.Place one hand on your chest, one hand on your stomach.Try to breathe so that only your stomach rises and falls.Inhale: Concentrate on keeping your chest relatively still. Imagine you are trying to hold up a pair of pants that are slightly too big.Exhale: Allow your stomach to fall as if you are melting into your chair. Repeat the word “calm” to provide focus as you are practicing the exercise.Do not force the breath, let your body tell you when to take the next breath.Take several deep breaths moving only your stomach in and out with the breath.Practice 3-5 minutes 2-3 times. The more you practice, the faster your progress will be.Note: It is normal for this type of breathing to feel a bit awkward at first. With practice it will become more natural for you.Challenging Negative ThoughtsNegative thought cycles perpetuate the physical symptoms of anxiety. In addition to practicing diaphragmatic breathing it is important to learn new ways to respond to negative thought patterns to decrease the experience of anxiety.Examine your thoughts for key words:must, should, have to (unrealistic standards for yourself and others)never, always, every (“black and white” thinking)This kind of thinking does not allow room for alteration, compromise, or change. Using these words casts blame, and they are judgmental.awful, horrible, disaster (catastrophic thinking)This kind of thinking encourages the sense of despair and doom.jerk, slob, creep, stupid (negative labels)Changing your choice of words makes a big difference in the way a situation or person is perceived. The way we react to a situation is the determinant of our moods, not the situation itself. Our thoughts influence our moods, so by altering the way we respond to them we are able to alter our mood. Here are some simple ways to challenge your thoughts:Question the negative/worrisome thoughts you are having. Is the thought valid? provide evidence for and against the truth of the thoughtChallenge the likelihood that an event will occur.Challenge the need to “fix” all problems, do all chores, or take care of things immediately.Ask yourself, “What is the worst thing that will happen if …….. does not happen?”Change the negative thought into a positive self-statement.For example: Instead of, “I am never on time, I am such a loser”, say “Ok, so I am not always on time, but I am not always late either. Sometimes I am running behind schedule, but that does not mean I am a loser”.Play with the negative thought:Try saying the opposite of the thought. For example, “I am always on time, I am a complete winner”.Try saying the thought very slowly and then quickly, softly and then loudly.Try singing the song to the tune of happy birthday. Recommended Reading“The Mindfulness and Acceptance Workbook for Anxiety”, John Forseyth and George Eifort“Why Zebras Don’t Get Ulcers”, Robert Sapolsky“The Anxiety and Phobia Workbook” and “Coping with Anxiety”, Edmund J. BourneGate Control Theory of PainAccording to the gate control theory of pain, pain signals that originate in an area of injury or disease do not travel directly or automatically to the brain. Rather, there exists within the spinal cord a ‘gate mechanism’, which determines the degree to which pain signals are transmitted to the brain. When the gate is wide open, more pain signals get through than when it is closed. Generally, rather than being completely open or shut, the gate is open to varying degrees. Factors which:OPEN the pain gateCLOSE the pain gatePhysical-Extent of the injury -Readiness of the nervous system to send pain signals-Inappropriate activity level-Application of heat or cold -Massage-Relaxation skills (to lower readiness of the nervous system)-Appropriate activity levelEmotionalDepression WorryAnxietyTension AngerAvoiding excessive emotions Positive emotionsManaging stressMentalFocusing on the pain Boredom due to minimal involvement in life activities Non-adaptive attitudesDistraction away from pain Increased social activities Positive attitudesBehavioral-Withdrawal from positive life activities -Poor health habits-Increased positive life activities-Appropriate exercise -Healthy eating -Refraining from unhealthy habitsPacing YourselfWhen people first injure themselves, pain serves as a signal that harm has been caused to the body. The natural and healthy response is to stop doing whatever is causing the pain (e.g., walking on a sprained ankle, lifting with a strained back). In this case, harm is being done to the body and the body’s warning system (pain) is working properly. However with chronic pain, healing has usually occurred but pain remains. Thus, the body’s warning system is no longer working properly. In other words, the pain no longer indicates harm is being done to the body. Therefore, stopping the activity that causes the pain is often not indicated. People with chronic pain are often very inactive during episodes of severe pain; laying or sitting for extended periods. Through the course of the natural pain cycle, they eventually experience some pain relief. In response to this decreased pain, they often try and make up for all the things they were unable to do during the severe pain episode (i.e., they over do it). Since their body has lost strength and endurance during these extended periods of inactivity, even resumption of normal life activity can result in increased pain. As a result, a cyclical pattern of ‘under-doing’ it followed by ‘over-doing’ it is created. Pacing activity differently enables pain patients to break this cycle. How to paceStop or change an activity when your pain level goes two points (on a 10 point scale) above your normal pain level. Do something less active until your pain returns to your normal level. If this rule is followed throughout the day, then pain will be no worse at the end of the day then at the beginning. What to expect when pacingIt will be challenging to learn the right combinations of up and down times. You may find it works best to tackle small portions of your daily routine at a time rather than changing your entire day at once. Start with activities that are most important to you or that increased pain causes the greatest challenge to you. Avoiding over activity, which can result in severe pain episodes and longer downtimes, will increase your success at engaging in effective pacing. Expect to reassess your pacing plan on a regular basis (increasing uptime and decreasing downtime as appropriate). In the beginning of pacing you may find that your uptimes are shorter than you would like and your down times are longer than you would like. What you should find is that your uptimes gradually increase and your downtimes gradually decrease. Setting realistic goals for yourself may help keep you from getting frustrated and disappointed with the slow rate of improvement as you gradually recondition your body. By planning your activities in this way, you can accomplish more (and have more fun) in a day without significantly increasing your pain. The attached worksheet can be used to help you determine your ‘up’ and ‘down’ times.Setting Realistic Goals for Taking Control of Your LifeUnfortunately, being pain free is rarely a realistic goal. More realistic goals might include: reducing impact of pain on activities, learning to live with the pain, learning to enjoy life, regaining control of your life, increasing activity, etc. Talk with your doctor about what physical limitations you have and do not do those activities. Instead, focus on gradually resuming those that hurt but are not harmful. Setting realistic goals provides a focus for your energy and enables your goals to be achieved. Also, when you are devoting your time and energy to things you really want to do and can accomplish, there is less time to think about your pain. The less you think about your pain, the less you will suffer. Establishing Goals Is the Goal is Realistic? Is the goal statement realistic? Can the goal actually be achieved? Is it possible to achieve at your pain management skill level?Is there a Target Date for Completion? When will the goal be accomplished? It's a good idea to set a target date to act as a guideline and then re-set if needed.Is the Goal Measurable? Can you evaluate when the goal has been reached? Will the goal be measured in some way? For example:Minutes spent doing some activity such as exercise or relaxation.Specifics type and number of pleasurable activities to engage in each week.Is The Goal Broken Down Into Small, Realistic Parts? Remember to start at a point that you already know you can do, and build onto it from there. Program the steps for a sense of early success to help give you the boost and momentum to keep you going.Is the goal “I” centered? Are “you” the one engaging in the actions or behaviors to be measured?Once Accomplished, What Rewards Will You Use? Remember, actions that are rewarded are more likely to reoccur.Is the Goal Desirable or Personally Meaningful? Do you want the outcome enough to put forth the effort? You are much more likely to strive toward a goal that you care about.Is A Relapse Plan Clearly Established? What happens if you do not reach to goal as you originally planned? What will you do to get started again?Postpartum DepressionWhat is it?Postpartum depression (PPD) is sometimes called postpartum blues (“baby blues”) or puerperal psychosis. It affects 10-15% of women. Among adolescent mothers it may be more common. PPD is more likely to occur for women who have previously struggled with depression. In fact, there is little difference between postpartum depression and major depression. Women with relatives who have struggled with depression are also more likely to develop PPD.What is it NOT?PDD is not a disease or illness that can be blamed on the mother or on anyone else. It is not a chemical imbalance or simply a hormonal problem. It may occur due to environmental, biological, or behavioral factors. Frequently it is due to a combination of these. PDD is not incurable or permanent. It usually arises within 6 weeks of childbirth and may last between 3 and 14 months. PPD can lead to other difficulties with one’s spouse, family, social life, job, or health. If untreated PPD may also lead to behavioral and developmental problems in the children of the depressed mother. PDD is not uncontrollable. If targeted early it can be treated with simple behavioral strategies and skills which a mother can learn quickly and implement in a way that best suits her. There are also antidepressant medications which physicians may prescribe to help mothers feel better. PPD is not something to be ashamed of – it is pretty common. One out of three women who have a prior history of major depression will experience postpartum depression.How do I know if I have PPD?Recognizing PPD early not only makes it easier for the mother to address the symptoms of depression, but it also enables doctors, friends, spouses, and other family members to help. You may have one or more symptoms of PDD. Every woman’s experience of PDD is a little different. The severity of PDD varies. If you have difficulties identifying it, your doctor will be able to help you. Below are a few things to look for. Common symptoms of PPDmoodinessconfusionirritabilitylow of motivationanxietyfatiguefeeling unable to copecrying spellsWhat can I do to get better?Generally, the treatments that are successful in treating PDD are the same ones used to treat depression. However, the best treatment for PDD is PREVENTION! When we feel depressed, sometimes we do not feel the energy or interest to do things we typically enjoy. As a result, we stop spending time with others and/or doing fun activities. This leaves us with fewer opportunities to be happy and gain pleasure out of each day, which may make us feel even more depressed.1. Remain actively engaged in activitiesSchedule weekly activities that provide you a sense of pleasure and/or a feeling of accomplishment.Stick to this schedule! Even if initially you do not begin feeling better, the research shows that the more consistently people engage in such activities, the higher their mood becomes overtime.You may have to literally force yourself to maintain a schedule of activities, but this is where the momentum starts!2. Ensure you have a social network Ensure that you regularly spend time with family and friends – depressive feelings can often be helped by remaining connected to others.Seek support from others. Others you know may have also struggled with PDD. Talk to them - they may have some ideas to help you!Contact your friends, family, and doctor if you notice symptoms of depression getting worse.3. Use problem-solving skillsIf you have difficulties carrying out any of these behavioral routines use your resources to make sure they happen.Reschedule your activities around obligationsReorganize your own daily routineSpread out your other responsibilities over a longer period of time to provide yourself periods of time in which you can schedule activities for yourself.Ask for help from others4. Engage in some sort of physical exerciseEven if you walk on a treadmill at home while watching television. This does count as exercise! Studies show that regular exercise can increase one’s mood.Start with a manageable exercise routine – do not try to do too much initially.Begin slowly, and as your body adjusts to the level of activity, increase the duration or intensity of your workouts gradually.5. DO NOT GIVE UP!Sometimes when people begin to feel better, they stop doing the things that helped them feel better. This results in their mood declining all over again. If what you’re doing is helping, do not stop doing it!Reward yourself for keeping an exercise routine, activity schedule, and social schedule! It is okay to do things for yourself to maintain your motivation.Time is precious. If you are someone who feels guilty about taking time to yourself because this competes with other responsibilities, just remember: if you are not feeling well, your ability to care for others and carry out other responsibilities will decrease. Investing a little time for yourself daily or weekly to do the activities mentioned above, can give you the energy and motivation to address all the other responsibilities you may have. 6. Contact your doctor If you are interested in taking medication to treat these symptoms, there are a few options, even if you are breastfeeding.7. Stay informed about PPDBooks can be powerful tools to help people learn about depression or PPD. Information you may learn or ideas you may get from books may better help you manage your symptoms. Suggested books for coping with PPD“This Isn’t What I Expected: Overcoming Postpartum Depression” by Karen R. Kleiman, M.S.W. and Valerie D. Raskin, M.D.“Conquering Postpartum Depression: A Proven Plan for Recovery” by Rosenberg, Greening, and WindellDepression: Tips for CopingWhat is depression?There are several forms of depression. Depression can develop rapidly or come on slowly over weeks or months. In some cases, depression can develop into a chronic or episodic syndrome. Although many people associate depression only with sadness, there are other signs as well (for example, dropping enjoyable activities; feeling tired; feeling guilty or worthless; having problems with concentration, sleep or appetite). It is estimated that up to 25% of women and 12% of men will experience clinical depression at some point during their lifetime. Women are twice as likely as men to become depressed. What depression is notThere are a lot of myths and stigmas surrounding depression. Depression is not a “weakness;” nor is it “all in your head.” Clinical depression is not something that you can just “snap out of.” The good news is that help is available. Years of research have identified effective behavioral interventions for improving symptoms of depression. If you or someone you know is depressed, it’s very important that you seek help. Reading this pamphlet is a first step towards understanding depression and getting the help that you need. What causes us to feel down? Prolonged stress and major negative life events (e.g., the death of a loved one), and medical illness can all play a significant role in depression. Usually, depression is related to a combination of factors including the social environmental, biological factors, our thoughts and beliefs, our emotions, and our behavior. Each of these factors can affect the others, and often work together in a sort of “snowball effect” that may leads to more symptoms of depression. The depression spiral provides a helpful illustration of this:EnvironmentDEPRESSION SYMPTOMSThoughts and EmotionsBiologyBehaviorsIt is important to keep in mind that what initially causes the depression may not be the same as what maintains it, or causes it to persist over time. For example, the loss of a loved one or a job may lead to feelings of loss and result in increased stresses, including loneliness, financial problems, etc. Symptoms of depression may worsen in response to growing stress levels, but it our experience of failure in solving the problems triggered by initial stresses that get us “in the dumps”. Often, we “pull back” from life and then forget to re-engage. We drop our previously enjoyable activities, see others less, and often move into more sedentary or inactive lifestyles. How to cope with depressionThe good news about the depression spiral is that it is reversible----there are specific behavior change strategies that you can use to improve your life, starting TODAY. These strategies have been shown to lead to significant and enduring improvement among hundreds of thousands of other people. STEP ONE: GET MOVING!Our level of activity is often connected to the way we feel. You may notice that when you are depressed, you tend to be less active—you may cut down on social activities or on exercise. As a first step towards treating depression, it is often beneficial to increase activities—particularly those that you have found pleasurable in the past, those that lead you to feel that you have accomplished something (i.e., hobbies), or those that are aligned with your values (i.e., if you are a parent, spending quality time with your children). Aerobic exercise, in particular, is one of the best ways to improve your mood. When you exercise, your body releases endorphins, which are natural “feel good” chemicals. Research has shown that exercise is an effective treatment for depression. When you’re depressed, you will rarely feel motivated or excited about initiating an activity…but you’ll find that once you get started, the positive momentum will build and over time (over several weeks of increasing your activity level), most people experience increased energy and an elevation in mood. You will increase your chances of success if you plan, and schedule, specific activities (i.e., “tomorrow morning at 7am, I am going to walk my dog around the neighborhood for 30 minutes”). The activities you select don’t have to be extravagant- they can be as simple as a 10-minute walk outside, taking a bath, gardening, reading a book, talking to a close friend, or listening to soothing music. Remember- everybody is different- it’s important to identify activities that are enjoyable or meaningful to YOU! (Note: if you are having a difficult time identifying activities, your PCB can provide you with a list of hundreds of potentially enjoyable activities to “spur” your brainstorming process.) Use the activity schedule on the last page of this pamphlet to schedule and track your activities for the next week. Tracking your activities can help you to see more clearly the relationship between them and your mood. Be sure to rate your level of enjoyment/mastery for each activity, and your average mood (using a 0-10 scale, with 0 representing “completely depressed” and 10 representing “not at all depressed”) for each day. After you’ve done this for one week, ask yourself the following questions: Did my activities affect my mood? How?Which activities helped me to feel better?Did any activities (or periods of inactivity) cause me to feel worse? Which activities had the greatest positive impact on my mood?Were there certain times of the day or week when I felt better or worse? Based on my answers to the previous questions, what activities can I plan in the coming weeks to maximize the chances that I will feel better? Use the information you’ve gained to guide activity plans for the upcoming weeks. Becoming “un-depressed” is a little bit like walking out of a big hole in the ground. It won’t happen all at once; rather, you’ll have to climb out one step at a time. The important thing is to keep the momentum in the positive direction. Don’t give up!!! If you need to, get your friends/family to help keep you on track with planning and committing to activities. STEP TWO: LOOK OUT FOR “STINKIN’ THINKIN’!”Depression is characterized by thought patterns that actually maintain the depressed mood. Individuals who are depressed experience negative thoughts about the self (self-criticism), the world (general negativity) and the future (hopelessness). It’s a little bit like wearing a pair of dark sunglasses—everything you see has a shadow cast over it. Our thoughts have a direct impact on our mood, on our interactions with others, and on our activity level (or lack thereof). It’s very important, therefore, that you pay attention to unhelpful thinking. Use intentional choice get you out the door and involved in meaningful and important life activities more often. It is possible to simply notice your “stinkin’ thinkin’” and take it with you to the park or the library. It is possible to smile at a neighbor even if you are feeling discouraged and thinking painful thoughts. Choosing is difficult, and worth it. It can open “new doors” for you. For example, you might start a new friendship if the neighbor smiles back. Whenever you experience a negative shift in mood, pay attention to what you were thinking at that moment. Pay attention to any thing that triggered it. Use an attitude of curious interest. Perhaps you can make a note of it on a piece of paper. Once you’ve identified your thoughts, ask yourself “is this type of thinking helping me or hurting me?” If you find that your thinking is making your depressed mood worse (as is usually the case for depressed individuals), here are some things you can do: “Examine the evidence” for and against the negative thought. Is it truly accurate? Where’s the proof? Are you blaming yourself for something over which you do not have complete control? Are you jumping to conclusions? Are you discounting your strengths, or positive attributes, in some way? Become your own scientific investigator and collect the facts.Explore the negative thought and look for other thoughts to appear (thoughts do “come and go”). Ask yourself, five years from now, if you look back at this situation, how might you look at it differently? Allow yourself to view a situation from more than one angle (how might your spouse, friend, or someone you admire view the same situation?) Use the “best friend” scenario. What would you tell your best friend if he or she was having these same thoughts? Would you criticize him or her as harshly as you criticize yourself?Most of us go through life on “autopilot,” unaware of much of our thoughts or on the impact that they have on our mood and our behavior. It can take awhile before you get to be skilled at identifying and working with negative thoughts. Over time, you’ll get better at this.Additional Resources (Self-help workbooks)“Get Out of Your Mind and Into Your Life” by Stephen Hayes, Ph.D.*“Living Life Well: New Strategies for Hard Times” by Patricia Robinson“The Mindfulness and Acceptance Workbook for Depression” by Kirk Strosahl &Patricia Robinson* *Winners of the ABCT Self-Help Book Merit AwardActivity Log – Dates:____________Grade each activity for sense of accomplishment “A” and pleasure “P” on a scale from 0-10 (10 being the highest)SundayAPMonday APTuesdayAPWednesdayAPThursdayAPFridayAPSaturdayAP6-88-1010-1212-22-44-66-88-1010-1212-6Day’sMood 0-10Exercise and Physical ActivityMost people have been told, “you need to exercise more” or “If you did some sort of physical activity, you would probably feel better”? Exercise and physical activity of any kind is healthy and can help increase positive mood and energy. It can also decrease weight, stress and blood pressure, increase alertness and motivation to accomplish other goals. This isn’t earth shattering news, as a matter of fact it is hard to find anyone who hasn’t heard these things before. Yet, it still isn’t enough to get people up and moving. So, if most people already know that physical activity and exercise have so many positive attributes, why is it that so many people don’t engage in these activities? (especially when experiencing anxiety, depression or significant life stress)When people feel down or depressed, stressed or nervous they tend to cut out healthy activities that normally bring value, meaning and enjoyment to their lives. Giving up healthy habits in the face of negative mood and life stress seems to be the path of least resistance for most, and the initiation of a cycle that is difficult to stop. Finding reasons not to exercise isn’t difficult, where most people get “stuck” is in problem solving and finding ways to overcome barriers to change. Sometimes, being able to weigh the reasons NOT to exercise against the reasons to DO exercise can help create the motivation and rationale to begin MOVING forward. Try using the scale below to “weigh” your options……REASONS TO EXERCISEImprove moodIncrease EnergyWeight ControlImprove SleepStress ReductionLower Blood PressureLower CholesterolIncrease Muscle ToneDecrease Chronic PainImprove ConcentrationIncrease MetabolismImprove Cardiovascular functioningEnhance Stamina for Daily ActivitiesREASONS NOT TO EXERCISEFeeling SadFeeling SickLow EnergyNo Social SupportExercise Goal is UnattainableDon’t Have Proper AttireToo BusyToo Tired Too Hot or ColdPainLow Level of InterestIntimidated by Gym PeopleList Top 3 Reasons to ExerciseMy short term exercise goal is: ______________________________________________My long term exercise goal is: ______________________________________________When I REALLY don’t feel like exercising I will: __________________________________I will look to: ________________________________for support in my effort to exercise.I will reward myself with: __________________________________________________*Post this list in a place where you will see it several times each day!GETTING STARTEDCheck with your doctor - It is always a good idea to check in with your doctor before beginning a new fitness program. This is particularly true if you're over 40, if you smoke, or if you have a family history of cardiovascular disease, high blood pressure, elevated cholesterol, diabetes, arthritis, or asthma. Have fun - Choose an activity you like or want to do. You're much more likely to stick with it. If you find your first choice doesn't suit you, switch to something else. Start slowly and progress gradually - You'll avoid becoming discouraged and reduce the risk of injury. Set goals - Maybe you want to lose a little weight, get in shape for a particular sport you enjoy, or reduce arthritis pain and increase joint mobility. Keep track - You may not notice that you're walking further in the same amount of time or that you're not as winded climbing the stairs. Keeping track helps you evaluate your progress and gives you a sense of accomplishment. Reward yourself - When you reach a goal, buy yourself a new T-shirt or tennis racket. Find a partner - It's more fun to share and you'll keep each other on track. Have a plan B - If it's raining, walk around an indoor mall or do an exercise video. Include variety - You're less likely to become bored if you cross train. Include the three basic forms of exercise in your fitness program: aerobics, strength training, and stretching. Or if you prefer, alternate your activities, basketball one day, yoga another, and stacking wood on the third. The thing to remember is that ANY activity will help you burn calories! Stick with it - You have to exercise regularly for your fitness to improve. Fifteen to thirty minutes a day is all that is required to see improvement and you'll enjoy the same benefits if you find it easier to fit two 15 minute or two to three 10 minute sessions into your day. Daily Exercise GoalDateType of ActivityLevel of Difficulty Low-Mod-DiffTotal Exercise TimeReward for Completion of GoalGrief, Bereavement, & MourningBereavement is the state of having lost a significant other to death.Grief is the personal response to the loss.Mourning is the public expression of that loss. What is “Normal” Grief?Grief reactions vary depending on who we are, who we lost, our relationship with that person, the circumstances around their passing, and how much their loss affects our day-to-day functioning. Different people may express grief differently and you may even have different grief responses between one loss and another. Reactions to grief and loss include not just emotional symptoms, but also behavioral and physical symptoms. These reactions can often change over time. All are normal for a short period of time.EmotionalBehavioralPhysicalShock, denial, numbnessCrying unexpectedlyExhaustion/FatigueSadness, anxiety, guilt, fearSleep changes (increase or decrease)Decreased energy Anger (at others or God),Not eating/Weight changesMemory problemsIrritability, frustrationWithdrawing from othersStomach and intestinal upsetRestlessness, difficulty concentrating, trouble making decisionsPain and headachesSymptoms that are not normal and may signal the need to talk to a professional include: Use of drugs, alcohol, violence, and thoughts of killing oneself.The duration of grief varies from person to person. Current research shows that the average recovery time is 18 to 24 months. Also, grief reactions can be stronger around anniversary or other significant dates, such as the anniversary of the person’s death, birthdays, and holidays.The Stages of GriefGrief therapists often describe stages of grief outlined by the research of Dr. Elizabeth Kubler-Ross. These stages do not always go in order. You may move back and forth among some of the stages and may even “skip” some of them. These stages are meant as a guide to help you understand your reactions and those of others who are grieving.Denial: Denial (not acknowledging the loss) can help contain the shock of loss. Denial can act as a “safety mechanism” to block out grief until we are ready to handle it.Sadness and depression: Deep, intense grief and mourning appear during this stage. When the full understanding of our loss comes, it can seem overwhelming. During this stage, you may cry often and unexpectedly. You may not want to be around people or to do things that you normally enjoy. During this stage, it is best to remain as active as possible and to seek supportive people who will allow you to say what you need to or to cry when you need to. It is important to allow yourself to work through your full range and experience of emotions.Anger: Rage and anger can be intense toward the person who died, toward friends and relatives, and even toward God. It is important to have an outlet to release anger through activities such as exercise, hobbies, or through therapy. Guilt, shame, and blame are feelings that need to be addressed, especially if it is toward you.Acceptance: This stage includes “coming to terms” with the loss. It does not mean that you have found the answers to your questions or that you stop thinking about the person who is gone. It does signify a reinvestment in life and a willingness to readjust to your new circumstances while carrying the memory of your loved one with you.How to Help YourselfGive yourself time to grieve. It is normal and important to express your grief and to work through the concerns that arise for you at this time. “Stuffing” your feelings may not be helpful and may delay or prolong your grief.Find supportive people to reach out to during your grief. This is the time when the support of others may be the most helpful. Don’t be afraid to tell them how they can best help, even if it means just listening. It is often very helpful to talk about your loss with people who will allow you to express your emotions.Take care of your health. Often after a loss, we stop doing the things we need to for health care, such as exercising, eating correctly, keeping Dr. appointments, or taking prescribed medications. If you are on a health care regimen, it is important to continue to adhere to your treatment.Postpone major life changes. Give yourself time to adjust to your loss before making plans to change jobs, move or sell your home, remarry, etc. Grief can sometimes cloud your judgment and ability to make decisions.Consider keeping a journal. It is often helpful to write or tell the story of your loss and what it means to you as a way to work through your feelings. Participate in activities. Staying active through exercise, enjoyable activities, outings with supportive others, or even starting new hobbies can help us get through tough times while providing opportunities for constructive development and use of energy.Find a way to memorialize your loved one. Planting a tree or garden in the name of your loved one, dedicating a work to their memory, contributing to a charity in their name, and other such activities can be helpful.Consider joining grief-support groups or contacting a grief counselor for additional support and help.Remember that depressive symptoms (feeling sad) are a fundamental part of normal bereavement. Staying active and finding support from others can help you to work through the grief process.ReferencesAartsen, MJ, Van Tilberg, T, Smits, CH, Comijs, HC, & Knipscheer, KC. (2005). Does widowhood affect memory performance of older persons? Psychological Medicine, 35(2), 217-226.Chen, JH, Gill, TM, & Prigerson, HG. (2005). Health behaviors associated with better quality of life for older bereaved persons. Journal of Palliative Medicine, 8(1), 96-106.Clark, A. (2004). Working with grieving adults. Advances in Psychiatric Treatment, 10, 164-170.Clements, PT, DeRanieri, JT, Vigil, GJ, & Benasutti, KM. (2004). Life after death: Greif therapy after the suddent traumatic death of a family member. Perspectives in Psychiatric Care, 40(4), 149-154.Fauri, DP, Ettner, B, & Kovacs, PJ. (2000). Bereavement services in acute care settings. Death Studies, 24, 51-64.Jacobs, S, & Prigerson, H. (2000). Psychotherapy of traumatic grief: A review of evidence for psychotherapeutic treatment. Death Studies, 24, 479-495.Servaty-Seib, HL. (2004). Connections between counseling theories and current theories of grief and mourning. Journal of Mental Health Counseling, 26(2), 125-145.HEADACHE: Types, Tips & Treatment SuggestionsHeadaches are one of the most common complaints patients present with in primary care settings. They are often correlated with stress, tension and a litany of existing medical conditions. Often, patients will live with headache pain for months or even years before seeking care. Over the counter remedies like aspirin, ibuprofen and acetimenophen are often used to reduce symptoms of pressure and pain prior to seeking medical advice. The following information is intended for patients that suffer from chronic headache pain and are looking for ways to better manage symptoms, increase function and improve quality of life.A headache is a headache is a headache…..Right?There are actually two main types of headache, primary and secondary, and they can differ greatly in intensity, frequency and duration. Primary headaches include, but are not limited to, tension-type and migraine headaches and are not caused by other underlying medical conditions. Over 90% of headaches are considered primary.Secondary headaches result from other medical conditions, such as infection or increased pressure in the skull due to tumor, disease, etc. These account for fewer than 10% of all headaches. Headache ClassificationTension-type HeadachesTension type headaches are the most common, affecting upwards of 75% of all headache sufferers.As many as 90% of adults have had tension-type headacheThese headaches are typically a steady ache rather than a throbbing one, and affect both sides of the headDistracting but usually not debilitatingPeople can get tension-type (and migraine) headaches in response to stressful events or a hectic dayThese headaches may also be chronic, occurring as frequently as every dayMigraine HeadachesLess common than tension-type headaches, migraines affect approximately 25 to 30 million people in the United States and cause considerably more disability, lost work days and lost revenue.As many as 6% of all men and up to 18% of all women (about 12% of the population as a whole) experience a migraine headache at some timeRoughly three out of four migraine sufferers are femaleAmong the most distinguishing features is the potential disability accompanying the headache pain of a migraineMigraines are felt on one side of the head by about 60% of migraine sufferers, and the pain is typically throbbing in natureNausea, with or without vomiting, as well as sensitivity to light and sound often accompanies migrainesAn aura?--a group of telltale neurological symptoms--sometimes occurs before the head pain begins. Typically, an aura involves a disturbance in vision that may consist of brightly colored or blinking lights in a pattern that moves across the field of visionAbout one in five migraine sufferers experiences an auraUsually, migraine attacks are occasional, or sometimes as often as once or twice a week, but not daily Headache TriggersMany things can cause a headache, thus it is important for you to become aware of the factors in your life that may contribute to your suffering, and, if possible, make changes to minimize the chances of continued suffering. Some examples of factors that can cause headache are outlined below:Emotional Factors: Stress (work, home, family), depression, anxiety, frustration, let down, even positive excitementDietary Factors: Alcohol, aspartame, cheese, chocolate, caffeine, monosodium glutamate (MSG), processed meats containing nitratesPhysical Factors: Getting too much or too little sleep, too much physical exertion, injuries, skipping mealsEnvironmental Factors: Glare from the sun or bright lights, changes in the weather, strong odors, smogHormonal Events: Menstruation, oral contraceptives, hormone replacement therapies, menopauseTreatment of HeadachesThere are a number of medications, such as muscle relaxants, analgesics (e.g., aspirin, percocet, fiorinol), or antihypertensives that can help with migraine and/or tension headaches. If you’re reading this, chances are they’re not working for you or you haven’t tried all available treatments yet. Taking medication isn’t the only thing you can do to alleviate your headache. Research has shown that numerous other methods, or behaviors, are also very effective in treating and managing recurrent headaches. Here are some examples of what you can do to increase your control over your headaches.Become educated about your specific headache type, visit websites, such as: The American Council for Headache Education ()The American Headache Society ()Engage in relaxation exercises to decrease stress and tension:Deep breathing & cue controlled relaxationProgressive muscle relaxationRelaxation by recallBiofeedbackCognitive-behavioral stress-management: Focuses on increasing your understanding of the role of cognitions (thoughts) in stress responses, and relationships between stress, coping, and headachesTalk with your PCP about anti-depressant medications:Combination of behavioral and medication therapies: For example, engaging in relaxation exercises and taking Zoloft at the same timeOptimizing TreatmentTo be better able to treat your headache, it is important to keep track of your triggers, symptoms and progress. Filling out a headache diary gives you, and your medical and behavioral health doctor, an accurate picture of the frequency and severity of your headache experience. It also provides a way to identify patterns, such as the association with certain foods or specific situations.Why Use a Headache Diary? Triggers: you may become more aware of your specific triggers as you monitor your headaches. Keeping a headache diary will help you determine whether factors such as food, change in weather, and/or mood have any relationship to your headache pattern.Track progress: diaries are also an excellent way to track your progress in treatment. DATESEVERITY1 = mild2 = moderate3 = severeTRIGGER/SRELIEF MEASURE/SDURATIONManaging HypertensionNormal blood pressure is below 120/80 mmHg. Prehypertension is the range of 120/80 to 139/89. This means that you don't have high blood pressure now but are likely to develop it in the future. You can take steps to prevent high blood pressure by adopting a healthy lifestyle. Hypertension or high blood pressure is a blood pressure reading of 140/90 or higher. Nearly one in three American adults has high blood pressure. Once high blood pressure develops, it usually lasts a lifetime. The good news is that it can be treated and controlled. Not all incidents of hypertension have a known cause, but some factors have been shown to increase blood pressure:OVERWEIGHTTOBACCOSODIUMSTRESSHigh blood pressure is sometimes called "the silent killer" because it usually has no symptoms. Some people may not find out they have it until they have trouble with their heart, brain, or kidneys. When high blood pressure is not found and treated, it can cause: The heart to enlarge, which can lead to heart failure. Small bulges (aneurysms) to form in blood vessels. Common locations are the main artery from the heart (aorta), arteries in the brain, legs, and intestines, and the artery leading to the spleen. Blood vessels in the kidney to narrow, which may cause kidney failure. Arteries throughout the body to "harden" faster, especially those in the heart, brain, kidneys, and legs. This can cause a heart attack, stroke, kidney failure, or amputation of part of the leg. Blood vessels in the eyes to burst or bleed, which may cause vision changes and can result in blindness. So, how can you manage hypertension?Fortunately, research has shown there are a number of things you can do to manage your hypertension and keep those blood pressure numbers down! ExerciseRegular exercise has been shown to significantly decrease blood pressure. If you don’t normally exercise, you can start with something as simple as walking and work your way up to a daily exercise routine that is right for you. Diet ModificationA number of studies have shown that a diet low in sodium, and rich in fruits, vegetables, lean meats and low-fat dairy foods is highly effective in lowering blood pressure. The American Heart Association and the National Institute of Health endorse a specific diet for individuals with high blood pressure, called the DASH (Dietary Approaches to Stop Hypertension) diet. The DASH diet is based on about 2,000 calories and 1,500 milligrams of sodium a day. For more details about the DASH diet, you can go to either of these websites: Or ask the Primary Care Behaviorist for a copy of the DASH eating plan.Weight LossMany studies have shown that being overweight is a very important risk factor for hypertension. Managing your weight through eating a balanced diet and engaging in regular exercise can help you maintain a healthy weight. Managing StressMedical studies have shown that the way we react to stress can greatly impact hypertension. You can learn to manage stress by engaging in relaxation techniques that help to reduce blood pressure. One great relaxation technique that is easy to do and takes very little time is diaphragmatic or deep breathing.Deep Breathing ExerciseSit in a comfortable position.Take 3 deep cleansing breaths.Place one hand on your stomach and the other on your chest.Try to breathe so that only your stomach rises and falls.As you inhale, concentrate on your chest remaining relatively still while your stomach rises. It may be helpful to imagine that your pants are too big and you need to push your stomach out to hold them up.When exhaling, allow your stomach to fall in and the air to fully escape.Take some deep breaths, concentrating on only moving your stomach. Return to regular breathing, continuing to breathe so that only your stomach moves. Focus on an easy, regular breathing pattern. Note: It is normal for this healthy breathing to feel a little awkward at first. With practice, it will become more natural to you.The CALM ReminderChest:Breathing slower and deeperArms:Shoulders sagLegs:Loose and flexibleMouth:Jaw dropProtocol for Parenting InterventionsPCPs refer parent(s) and children to the PCB when patients identify the following difficulties: developmental delays in a child, discipline problems or communication problems. In the initial PCB consultation, the PCB will provide routine initial health and behavior assessment services and determine the cause(s) of parenting problems (parent conflicts, parent-child conflicts, deficits in parenting skills) determine patient preferences concerning interventions (services from PCP and PCB team or participation in a parenting class in the community)determine need for services from specialty MHIf the patient(s) chooses to participate in a parenting class, the PCB will complete the appropriate referral form and schedule 1 follow-up with the patient(s) to (a) assess the impact of the initial plan and (b) to further refine the intervention for on-going support by the PCP. If the patient(s) choose to receive services only from the PCP and PCB team, the PCB will implement the Primary Care Parenting Protocol. This program can be adjusted to fit parent-child issues from age 2 to 18. The PCB will also provide on-going training, individually and in provider meeting presentations, on the Primary Care Parenting Protocol (PCPP) and provide related patient education handouts for PCPs. Primary Care Parenting ProtocolThis program includes 3 contacts (including the initial) with the PCB and an optional fourth visit. The PCB adjusts the curriculum to fit the needs of the patient(s).Initial Visit: Behavioral Health Plan will focus on interventions that may improve the parent-child relationship (Handout: Positive Parenting)Second Visit: Education and Behavioral Health Plan will focus on building skills for setting limits and using incentive programs (to help the child establish new behaviors) and consequences (to help the child change undesired behaviors). (Handout: Setting Limits and Using Incentives and Consequences)Third Visit: Education and Behavioral Health Plan will focus on building skills for ignoring and time out procedures. (Handout: Ignoring and Time-Out / A United Front)Optional Visit: The optional visit is for parents who are in conflict about parenting issues or who lack skills for taking a mindful stance in using behavioral parenting strategies. When these problems are observed, it is best to schedule the optional visit as the second visit. Education and Behavioral Health Planning will focus on helping the parents present a united front to the child(ren), model effective conflict resolution skills, and practice mindfulness strategies on a daily basis both in the context of parenting and during alone time. (Handout: Ignoring and Time Out / A United Front) PCPs will see patients at least once during or at the conclusion of participation in the Primary Care Parenting Protocol.PCPP content for items 1-3 above is consistent with empirically supported programs detailed in Schafer, C. E. & Briemeister, J. M. (1998). Handbook of Parent Training, NY: John Wiley & Sons. (See chapter by Webster-Stratton & Hancock, pp. 98-152).Positive ParentingWe are more successful disciplining our children when we have good relationships with them. To develop good relationships, parents need to know how to praise their children and to play with them. This is true from birth. The following tips will help you with a child of any age. Make an X by any that you want to discuss with your provider. When playing with children, Follow the child’s lead. Pace at the child’s level. Engage in role-play and make-believe with the child. Praise and encourage the child’s ideas and creativity. Use descriptive comments instead of asking questions. Be an attentive and appreciative audience. Curb the desire to give too much help; encourage the child’s problem solving. Don’t expect too much—give the child time to think and explore. Avoid too much competition with children. Don’t criticize. Reward quiet play times by giving your positive attention. Laugh and have fun. Important information about praising childrenDon’t worry about spoiling children with praise. Catch the child when he or she is being good—don’t save praise for perfect behavior. Make praise contingent on positive behavior. Praise immediately. Give labeled and specific praise. Praise with smiles, eye contact, and enthusiasm. Give pats, hugs, and kisses along with verbal praise.Praise in front of other people. Praise wholeheartedly, without qualifiers or sarcasm.Increase praise for difficult children. Model self-praise.Plan: Results: Setting Limits and Using Incentives and ConsequencesWe are more likely to succeed as parents if we have skills. Setting limits and using incentive programs and consequences are important tools for shaping a child’s behavior. About setting limits Be realistic in your expectations and use age-appropriate commands. Give one command at a time. Use commands that clearly specify the desired behavior.Make commands short and to the point. Use do commands and when-then commands. Make commands positive and polite. Give children options when possible. Give children ample opportunity to comply. Praise compliance or provide consequences for noncompliance. Give warnings and helpful reminders. Don’t use stop or don’t commands. Don’t give unnecessary commands. Don’t threaten children. Support your partner’s commands. Strike a balance between parent and child control. Important information about incentive programs Define the desired behavior clearly. Choose effective rewards (i.e., rewards the child will find sufficiently reinforcing). Set consistent limits concerning which behaviors will receive rewards. Make the program simple and fun. Make the steps small. Monitor the charts carefully. Follow through with the rewards immediately. Avoid mixing rewards with punishment. Gradually replace rewards with social approval. Revise the program as the behaviors and rewards change. Points to remember about consequencesMake consequence age-appropriateBe sure you can live with the consequences you have set up.Give the child a choice; specify consequences ahead of time. Involve the child whenever possible.Use consequences that are short and to the point. Make consequences immediate. Make consequences safe and nonpunitive. Plan: Results: Ignoring and Time Out / A United FrontIgnoring and Time out are important skills, and they work very well with certain behavior problems. While it is sometimes difficult, parents need to support each other in front of children and present a united front. Guidelines for ignoring Limit the number of behaviors to ignore. Choose specific behaviors to ignore and make sure you can ignore them. Be consistent. Physically move away from the child, but stay in the room if possible. Avoid eye contact and discussion while ignoring. Return attention to the child as soon as misbehavior stops. Be prepared for testing. When using time-out Carefully limit the number of behaviors for which time-out is used.Use time-out consistently for chosen misbehaviors. Be as polite and calm as possible in sending child to time-out. Give time-outs for one minute per year of child up to 10 minutes. Be prepared for testing. Use non-violent approaches, such as loss of privileges, as backup for not going to time out. Hold children responsible for messes in time-out. Support a partner’s use of time out. Don’t rely exclusively on time-out; combine with other techniques such as ignoring, logical consequence, and problem solving. Build up a “bank account”Presenting a united frontPresent a united front to reassure a child.Model conflict resolution at a level appropriate for the child. Make a plan about what to do when one parent is not at home and a discipline problem occurs. Use problem solving in a private meeting to solve differences in parenting style. Problem solving involves the following steps: (a) agree on an agenda, time and place, (b) come prepared, (c) define the problem, (d) brain-storm solutions and look at the pros and cons of each, (e) make a decision, (f) implement, (g) meet again and evaluate the results.Stepparents may have special ways of presenting a united front. Plan: Results: Common Relationship ProblemsPoor CommunicationThe way couples communicate with each other can lead to both increased stress and tension. Some examples of poor communication are when:One partner has a demanding communication style that leads the other partner to refuse to communicate in response.One partner tries to manipulate the other with negative emotions, such as anger and sadness. One Partner personally criticizes his/her partner, such as calling him/her ‘lazy’, rather than focusing on behaviors.Ways to enhance communication:Remove all distractions, such as television or radio noise, and arrange a time to talk that suits you both.Avoid interrupting your partner. Summarize back what you have heard for accuracy before replying.Avoid labeling. Focus on behaviors that are problematic, not your partner as an individual. Talk about the positive aspects of the relationship, as well as the problems.Poor Problem Solving SkillsProblem solving skills are vital to working out relationship difficulties when they arise.Some common barriers to problem solving are:Not identifying the true cause of the problem. For example, assuming your partner’s recent disinterest means he/she is losing feelings for you, when the actual reason is work stress.Choosing a solution before considering all options. Trying to solve the problem without your partner’s input. Ways to enhance problem solving skills:Separate big problems into smaller ones and deal with each individually in order of importance. Consider many possible options and strategies before choosing a solution. Work with your partner as a partner. Both of you need to have a sense of shared ownership in the process and the outcomes.Inadequate Partner SupportBoth partners need to give and receive adequate support for a relationship to survive and flourish.Some common problems with partner support are:Having unrealistic expectations and demands. Relying on your partner to meet all of your support needs likely places too much pressure on them. Not effectively communicating your needs can result in arguments. Ways to enhance partner support:Identify and be realistic about the support you need. Realize that your partner will not be able to meet all of your needs. Some of these needs will have to be met outside the municate your expectations clearly. Check if he/she can fulfill your expectations / understands your expectations for support.Lack of Quality Time TogetherSpending time together is not “quality” when you are tired and distracted, and end up arguing or failing to enjoy each other’s company. Quality time together involves:Jointly planning to spend quality time together. When planning, focus on positive things, unless you agree to do otherwise.Identifying shared interests that you can enjoy together and try to think of new ones that you can try.Personal Differences in the RelationshipAll couples will have differences in their relationships. The way you deal with these differences can either enhance or add stress to the relationship.Ways to deal with personal differences:People in successful relationships do not try to force the other to be exactly like them; they work to accept difference even when this difference is profound.Do not demand that a partner change to meet all your expectations. Work to accept the differences that you see between your ideal and the reality. Try to see things from the other's point of view. This doesn't mean that you must agree with one another, but rather that you can expect yourself and your partner to understand and respect your differences, your points of view and your separate needs.Golden rules for arguing constructivelyDO:Know why you are arguing before you start Devote some time to resolving the problem Sit down and make eye contact Speak personally about what you feel Acknowledge when the other person makes a valid point Agree to differ if you cannot agree Stick to the matter at hand Cease arguing and separate if there is any likelihood of violence DON’T:Behave aggressively or disrespectfully Argue deliberately to hurt the other person's feelings Generalize problems to entire relationshipBring up old unresolved disputes Walk away without deciding when discussion will be resumed (unless violence threatens) Bring other peoples' opinions into the argument Argue about something for more than an hour, late at night or after drinking alcoholSexual ProblemsWhat leads to sexual problems?Results of sexual problemsWhat reduces sexual problemsSide effects from certain medicationsRelationship difficulties Medical treatment (if problem is biological)Medical problemsFeeling distant Reduced performance demandsRelationship difficultiesAnxietySexual exercisesPsychological factorsGuiltRealistic expectationsPhysical environmentLow self-esteemIndividual/Couple therapyWhat Are Sexual Problems?Sexual problems are problems related to the sexual interactions between couples. Problems can occur during desire, arousal, or orgasm stages. Sexual problems are not rare. Approximately 20% of married couple and 30% of non-married couples have sexual contact than 10 times per yearApproximately 43% of women and 31% of men of all ages report having sexual problems1 in 3 women complain of a lack of sexual desire Inhibited sexual desire affects 15% of men and increases with ageSexual problems can have a powerful impact on relationships. Clinicians suggest that sexuality contributes to about 15-20% of a marital relationship. When sexual problems occur, they contribute up to 50-75%, which can be very draining to the marriage.What Leads to Sexual Problems?Many medications can affect your sexual desire, arousal, and orgasm: Antidepressantsalcoholsome allergymood stabilizersnarcoticshypertensionanxiolyticsoral contraceptivesglaucoma medicationschemotherapy drugshormonal therapiesanticonvulsantsCertain medical problems or surgeries can impact sexual functioning:Chronic painhypertensionemphysemainsomniathyroid conditionscancerdiabetesheart diseaseRecent surgeries that have impacted sexual organs:mastectomyprostatectomyhysterectomyorchiectomy, etc. for malesremoval of ovaries for femalesDifficulties within the relationship can lead to sexual problems:Dissatisfactionpoor communicationlack of emotional expressionresentmentdifferent value systemslack of physical affectionpower struggleslack of intimacydifferent sexual preferencesPersonal and Psychological Factors:Fatigueagepoor body imagestressperformance anxietynarrow or unrealistic standards for sexual interactionsdepressionnegative beliefs about sex or certain sexual practicesanxietylow self-esteemWhat’s a Normal Sexual Response Anyway?The way people respond sexually is variable. Most couples/partners don’t have the same response at the same time. Problems can occur when the arousal phase is not achieved, when the plateau period is extended, or when orgasm does not occur.Male Sexual Responses (example)Female Sexual Responses (example)OrgasmRefractory PeriodResolutionArousalPossible 2nd arousal and orgasmPlateauOrgasmArousalPossible 2nd arousal and orgasmResolutionPlateauCommon Female Sexual DysfunctionsInhibited sexual desire: low or no desire for sexual intercourse. Sexual desire involves positive anticipation and a sense of deserving pleasure.Nonorgasmic response during partner sex: inability to achieve orgasm during intercourse. This is a normal variation in the female sexual response cycle. Painful intercourse (dyspareunia): genital pain associated with sexual intercourse, commonly experienced during coitus, but may also occur before or after intercourse.Female arousal dysfunction: persistent or recurrent inability to attain or to maintain until completion of sexual activity, often not feeling “turned on” or not producing an appropriate amount of lubrication.Primary nonorgasmic response: persistent or recurrent delay or absence of an orgasm following sexual stimulationVaginismus: pain during intercourse associated with high anticipatory anxiety, dissatisfaction with their bodies, and intimidation by their partners’ sexual desire and mon Male Sexual DysfunctionEarly ejaculation: onset or orgasm and ejaculation with little sexual stimulation, or before, on, or shortly after penetration.Erectile dysfunction: inability to attain or maintain an adequate erection during sexual activity.Inhibited sexual desire: Lack of desire for sex. Often secondary to another problem such as erectile dysfunction or ejaculatory inhibition, and typically worsens over time due to a cycle of anticipatory anxiety.Ejaculatory inhibition: inability to ejaculate during intercourse. Men with this problem may be able to ejaculate through oral or manual stimulation, but not during intercourse.Treating Sexual ProblemsTreatment of sexual problems takes on a variety of forms due to the variety of problems.Realistic expectations must be understood by both partners. Anxiety plays a large role is sexual problems. Worries about performance only make performance worse.Important to see physician to ensure problem is not biological and to receive appropriate medical care if it is.Decreasing Sexual Problems with DesireBuild a sense of comfort with nudity and body imageTake turns initiatingIdentify characteristics each partner finds attractiveInitiate erotic touching on a weekly basisEstablish a trust/vulnerability positionStop any uncomfortable sexual experience (especially true for those who have survived sexual trauma)Decreasing Sexual Problems with PainPartner’s need to be actively engaged in the process and couples need to function as an intimate unitGain knowledge and comfort with genitaliaUse of relaxation strategiesUse of lubricationControlling the type and pacing of sexual activityActivities that can decrease sexual problemsSelf-exploration and stimulation. This can help you increase awareness of your own body and make it easier to communicate likes and dislikes to your partner.Changing negative thoughts and assumptions about what sex should be with more positive and realistic thoughts about what feels good and right for you. Challenging negative thoughts about your partner by focusing on what is attractive and positive about them.Physical exercise: Increases blood flow, reduces tension, enhances body image, and can improve other conditions that hinder sexual functioningRebuild or establish emotional intimacy: Schedule time together when you simply talk to each other. Use the time to share feelings and get reacquainted with what is attractive and unique about your partner.Share leisure activities Add small expressions of affection back into your daily routine if this is lacking (i.e. an affectionate note, phone call, or e-mail; hugs or hand-holding, etc.)Increase communicationDiscuss sexual interests, desires, needs, and difficulties when you are NOT engaged in sexual activity. Talk about what is going well and what you would like to be different in the relationship overall, then work together to come up with do-able solutions. Add something new to sexual encounters (e.g., place, position, clothing, technique, erotica)Allow more time for foreplay and provide more partner-guided stimulation.During sexual encounters focus on sensations rather than thoughts, performance, expectations, and appearances. Recommended ReadingSchnarch, David (1997). Passionate marriage: Keeping love & intimacy alive in committed relationships.Weiner-Davis, Michele (2003). The sex-starved marriage: A couple’s guide to boosting their marriage libido.InsomniaResults of InsomniaWhat Leads to InsomniaWhat maintains insomnia?Physiological arousalWorrisome thinkingAnxietyDepressionFamily conflictWork problemsLoss of motivationAcute stressPersonal loss (death, separation, divorce, etc)Medical problemsWork problemsFamily problemsIrregular sleep scheduleInaccurate thoughts about sleepSleeping pillsMyths about duration of sleepDaytime nappingExcess time in bedPerformance anxietyMedications for health problems How can I improve my sleep? Change your sleep behavior.Go To Bed Only When You Are SleepyThere is no reason to go to bed if you are not sleepy. When you go to bed too early, it only gives you more time to become frustrated. Individuals often ponder the events of the day, plan the next day’s schedule, or worry about their inability to fall to sleep. These behaviors are incompatible with sleep, and tend to perpetuate insomnia. You should therefore delay your bedtime until you are sleepy. This may mean that you go to bed later than your scheduled bedtime. However, stick to your scheduled rising time regardless of the time you go to bed.Get Out of Bed when You Can’t Fall Asleep or Cannot Go Back to Sleep in 15 Min When you recognize that you’ve become a clockwatcher, get out of bed. If you wake up during your sleep and you’ve tried falling back to sleep for 15 minutes and can’t, get out of bed. Remember, the goal is to fall to sleep quickly. Return to bed only when you are sleepy (i.e., yawning, head bobbing, eyes closing, concentration decreasing). The goal is for you to reconnect your bed with sleeping rather than frustration. You will have to repeat this step as often as necessary.Use Your Bed or Bedroom for Sleep and Sex OnlyThe purpose of this guideline is to associate your bedroom with sleep rather than wakefulness. Just as you may associate the kitchen with hunger, this guideline will help you associate sleep and pleasure with your bedroom. Follow this rule both during the day and at night. DO NOT watch TV, listen to the radio, eat or read in bed. You may have to temporarily move the t.v. or radio from your bedroom to help you regain a stable sleep cycle. Sleep Hygiene Guidelines to Improve your Sleep BehaviorNO CAFFEINE: No caffeine 6-8 hours before bedtimeYep, its true caffeine disturbs sleep; even for people who do not think they experience a stimulation effect. Individuals with insomnia are often more sensitive to mild stimulants than normal sleepers. Caffeine is found in items such as coffee, tea, soda, chocolate, and many over-the-counter medications (e.g., Excedrin). AVOID NICOTINE: Avoid nicotine before bedtimeNicotine is a stimulant. It is a myth that smoking helps you “relax.” As nicotine builds in the system it produces an effect similar to caffeine. DO NOT smoke to get yourself back to sleep.AVOID ALCOHOL: Avoid alcohol after dinnerAlcohol often promotes the onset of sleep, but as alcohol is metabolized sleep becomes disturbed and fragmented. Thus, a large amount of alcohol is a poor sleep aid and should not be used as such. Limit alcohol use to small quantities to moderate quantities.NO SLEEPING PILLS: Sleep medications are effective only temporarilyScientists have shown that sleep medications lose their effectiveness in about 2 - 4 weeks when taken regularly. Over time, sleeping pills actually make sleep problems worse. When sleeping pills have been used for a long period, withdrawal from the medication can lead to an insomnia rebound. Thus, after long-term use, many individuals incorrectly conclude that they “need” sleeping pills in order to sleep normally. REGULAR EXERCISE: Preferably 40 minutes each dayExercise in the late afternoon or early evening can aid sleep, although the positive effect often takes several weeks to become noticeable. Do not exercise within 2 hours of bedtime because it may elevate your nervous system activity and interfere with falling asleep. BEDROOM ENVIRONMENT: Moderate temperature, quiet, dark and comfortableExtremes of heat or cold can disrupt sleep. Noises can be masked with background white noise (such as the noise of a fan) or with earplugs. Bedrooms may be darkened with black-out shades or sleep masks can be worn. Position clocks out-of-sight since clock-watching can increase worry about the effects of lack of sleep. Be sure your mattress is not too soft or too firm and that your pillow is the right height and firmness.EATINGYou should avoid the following foods at bedtime: anything caffeinated like chocolate, peanuts, beans, most raw fruits and vegetables (they may cause gas), and high-fat foods such as potato chips or corn chips. Be especially careful to avoid heavy meals and spices in the evening. Do not go to bed too hungry or too full. Avoid snacks in the middle of the night because awakening may become associated with hunger. A light bedtime snack, such a glass of warm milk, cheese, or a bowl of cereal can promote sleep.AVOID NAPSThe sleep you obtain during the day takes away from your sleep needed at night resulting in lighter, more restless sleep, difficulty falling asleep or early morning awakening. If you must nap, keep it brief, and try to schedule it before 3:00 pm. It is best to set an alarm to ensure you don’t sleep more than 15-30 minutes.UNWINDAllow yourself at least an hour before bedtime to wind down. The brain is not a light switch that you can instantly cut on and off. Most of us cannot expect to go full speed till 10:00 pm then fall peacefully to sleep at 10:30 pm. Take a hot bath, read a novel, watch some TV, or have a pleasant talk with your spouse or kids. Find what works for you and make it your routine before bed. Be sure not to struggle with a problem, get into an argument before bed or anything else that increases your body’s arousal.REGULAR SLEEP SCHEDULESpending excessive time in bed has two unfortunate consequences - (1) you begin to associate your bedroom with arousal and frustration and (2) your sleep actually becomes shallow. Surprisingly, it is very important that you cut down your sleep time in order to improve sleep! Set the alarm clock and get out of bed at the same time each morning, weekdays and weekends, regardless of your bedtime or the amount of sleep you obtained on the previous night. You probably will be tempted to stay in bed if you did not sleep well, but try to maintain your new schedule. This guideline is designed to regulate your internal biological clock and reset your sleep-wake rhythm.It usually takes 2-3 months for a sleep problem to get totally better, but most people see improvements within 2-3 weeks if they consistently follow the guidelines.Obstructive Sleep ApneaWhat it is and How it is TreatedObstructive sleep apnea (OSA) is defined as a periodic reduction or cessation of breathing due to narrowing of the upper airways during sleep. This condition affects approximately 2% of women and 4% of men in the U.S. However, about 95% of all cases go undiagnosed and untreated, which is alarming considering that untreated obstructive sleep apnea poses several major health risks.Studies show that patients with sleep apnea have increased baseline heart rates, increased blood pressure, and lower levels of blood oxygen, which may put them at increased risk for cardiovascular problems such as hypertension, stroke, and heart failure. Often, patients present to their primary care manager (PCM) complaining of persistent daytime fatigue, regardless of how much sleep they have had the night before. The good news for patients who have been diagnosed with OSA is that with proper treatment and lifestyle change, full recovery can be achieved and the health risks mon SymptomsRisk FactorsSnoringDaytime sleepiness or fatigueSleep fragmentation or recurrent night awakeningsUnrestful sleepIncreased irritabilityMorning headachesDecreased memoryDifficulty concentratingNocturia (awakening from sleep to urinate)Falling asleep while drivingFirst degree relative diagnosed with sleep apneaObesity HypertensionMale genderAge (greater than 40)Neck circumferencePostmenopausal women (higher risk than premenopausal)How is sleep apnea diagnosed?A nocturnal polysomnogram (sleep study) is conducted by sleep specialists to diagnose obstructive sleep apnea. During this assessment information regarding chest wall effort, airflow, body positioning, snoring, and oxyhemoglobin saturation is recorded. As you may have guessed, the sleep specialists literally observe you sleeping while monitoring your brain / sleep patterns. Often times, patients report their sleep duration as being longer or shorter than it actually is. This assessment can identify exact sleep onset time, wake after sleep onset episodes and the depth and quality of your sleep.TreatmentsA variety of treatments for sleep apnea exist and the use of each treatment is determined by the severity of the disturbance in breathing during sleep. A combination of the following treatments provided by a multidisciplinary team is ideal and can include: a behavioral medicine specialist, a nutritionsist, an exercise specialist, a respiratory therapist and a pulmonary doctor that has specialty training in sleep disorders. Below is a description of the types of treatments that are currently available for OSA. Behavioral Weight loss –as little as a10% decrease in body weight has been found to have significant improvement in obstructive breathing problems. Avoidance of alcohol and sedativesAvoidance of sleep deprivationPositioning – Laying on side rather than backMedicalCPAP Mask – Positive pressure through a maskOral Appliance – Recommended for patients with mild to moderate sleep apneaSurgical Sometimes used when patients are unable to tolerate positive airway pressure and for those that find other treatments ineffective. However, sometimes surgeries do not entirely eliminate the obstruction. Treatment GoalsEstablish normal nocturnal oxygenation and ventilationEliminate snoringEliminate disruption of sleepContinuous Positive Airway Pressure (CPAP)Nasal continuous positive airway pressure (CPAP) is the most common treatment for moderate to severe obstructive sleep apnea. Research finds that this method is also highly effective when used for more than 4.5 hours a night on a consistent basis. Studies have also shown that adequate CPAP use can decrease the risk of cardiovascular diseases in patients with sleep apnea. A CPAP unit provides immediate effects and complications with CPAP treatment are rare. However, use of the CPAP masks may result in some level of discomfort. The following table shows effective corrections for negative side effects from CPAP masks. However, if symptoms persist, contact your physician.Problems associated with CPAP MasksCauseAdjustmentNasal congestionDry nose and/or throatDry airTry nasal saline spray before bedtime or upon awakening.Add heated humidification.Try antihistamines or topical corticosteroids.Dry mouthSleeping with mouth openTry a chin strap and if it is not helpful consider a full-face mask. Add heated humidification.Sore, dry, irritated or swollen eyesMask leaksMask too tightTry readjusting the mask on face. Readjust headgear straps. Inspect mask for breaks.Use eye patch.Runny nose Dry airTry saline nasal spray before bedtime.Try topical nasal steroid preparation before bedtime.Add heated humidification.Hay feverIrritants drawn in with room air through machinePut unit away from dust or animal hairs.Some units can have special filters added.Add heated humidification.Air leaks Strap is loose or tight.Incorrect mask size.Worn-out mask.Dirty maskReadjust headgear straps. The mask should be loose but still create a seal. Nasal pillows may improve fit. Consider full face mask that covers nose and mouth. Inspect mask for leaks or cracks.Wash mask daily.Chest discomfortSensation of too much pressure.Difficulty exhalingPressure requirement may be lower at beginning of sleep periodTry pressure ramp at beginning of sleep period.Reduce pressure with bilevel positive airway pressure.Feelings of claustrophobiaInitial adjustment periodConsider changing mask (nasal mask, full face, nasal prongs)CPAP machine too noisyBlocked air intakeToo close to sleep areaCheck if filter is clean and not blocked by item.Place unit farther away. May need to add to length of hose.Bed partner intoleranceNoise, anxietyAttend patient support group (such as, A.W.A.K.E Network of the American Sleep Apnea Association)Non-ComplianceThe most common form of treatment for sleep apnea is with continuous positive airway pressure (CPAP). However, as many as 50% of patients stop CPAP therapy during the first 2-4 weeks of treatment because of the negative side effects. Did you know that research has found that……CPAP refusers are more likely to be female and current smokers.Non-compliance is related to high BMI (>30 kg/m2) and CPAP pressure >12.Acceptance of CPAP treatment is not predicted by severity of sleep apnea or degree of sleepiness.Adequate compliance = >4.5 hours of CPAP use per night on a regular basis.Patient education is especially important first month of treatment.Follow-up with physician is important at least once after initiation of treatment and annually thereafter. Noncompliance is classified in terms of tolerance problems, psychological factors, and lack of education, support and adequate follow-up care.Improving Sleep through Behavior ChangeStimulus Control ProceduresGo to Bed only when You are Sleepy There is no reason to go to bed if you are not sleepy. When you go to bed too early, it only gives you more time to become frustrated. Individuals often ponder the events of the day, plan the next day’s schedule, or worry about their inability to fall to sleep. These behaviors are incompatible with sleep, and tend to perpetuate insomnia. You should therefore delay your bedtime until you are sleepy. This may mean that you go to bed later than your scheduled bedtime. Remember to stick to your scheduled arising time regardless of the time you go to bed.Get Out Of Bed When You Can’t Fall Asleep Or Go Back To Sleep In About 15 Minutes. Return to Bed Only When You Are Sleepy. Repeat This Step As Often As Necessary.Although we don’t want you to be a clockwatcher, get out of bed if you don’t fall to sleep fairly soon. Remember, the goal is for you to fall to sleep quickly. Return to bed only when you are sleepy. When you feel sleepy (i.e., yawning, head bobbing, eyes closing, concentration decreasing), then return to bed. The object is for you to reconnect your bed with sleeping rather than frustration. It will be demanding to follow this instruction, but many people from all walks of life have found ways to adhere to this guideline.Use the Bed or Bedroom for Sleep and Sex Only; Do Not Watch TV, Listen to the Radio, Eat, or Read in Your Bedroom. The purpose of this guideline is to associate your bedroom with sleep rather than wakefulness. Just as you may associate the kitchen with hunger, this guideline will help you associate sleep with your bedroom. Follow this rule both during the day and at night. You may have to temporarily move the TV or radio from your bedroom to help you during treatment. Sleep Hygiene GuidelinesGood dental hygiene is important in determining the health of your teeth and gums. We all know we are supposed to brush and floss regularly. Those who do so are more likely to have strong, healthy gums and less cavities. Similarly good sleep hygiene is important in determining the quality and quantity of your sleep. Below are guidelines for good sleep hygiene practices. Review these guidelines and evaluate how well you practice good sleep hygiene.Caffeine: Avoid Caffeine 6-8 Hours before BedtimeCaffeine disturbs sleep, even in people who do not think they experience a stimulation effect. Individuals with insomnia are often more sensitive to mild stimulants than are normal sleepers. Caffeine is found in items such as coffee, tea, soda, chocolate, and many over-the-counter medications (e.g., Excedrin). Thus, drinking caffeinated beverages should be avoided near bedtime and during the night. You might consider a trial period of no caffeine if you tend to be sensitive to its effects.Nicotine: Avoid Nicotine before BedtimeAlthough some smokers claim that smoking helps them relax, but nicotine is a stimulant. The initial relaxing effects occur with the initial entry of the nicotine, but as the nicotine builds in the system it produces an effect similar to caffeine. Thus, smoking, dipping, or chewing tobacco should be avoided near bedtime and during the night. Don’t smoke to get yourself back to sleep.Alcohol: Avoid Alcohol after DinnerAlcohol often promotes the onset of sleep, but as alcohol is metabolized sleep becomes disturbed and fragmented. Thus, a large amount of alcohol is a poor sleep aid and should not be used as such. Limit alcohol use to small quantities to moderate quantities.Sleeping Pills: Sleep Medications are Effective Only TemporarilyScientists have shown that sleep medications lose their effectiveness in about 2 - 4 weeks when taken regularly. Despite advertisements to the contrary, over-the-counter sleeping aids have little impact on sleep beyond the placebo effect. Over time, sleeping pills actually can make sleep problems worse. When sleeping pills have been used for a long period, withdrawal from the medication can lead to an insomnia rebound. Thus, after long-term use, many individuals incorrectly conclude that they “need” sleeping pills in order to sleep normally. Keep use of sleep pills infrequent, but don’t worry if you need t use one on an occasional basis.Regular ExerciseGet regular exercise, preferably 40 minutes each day of an activity that causes sweating. . Exercise in the late afternoon or early evening seems to aid sleep, although the positive effect often takes several weeks to become noticeable. Exercising sporadically is not likely to improve sleep, and exercise within 2 hours of bedtime may elevate nervous system activity and interfere with sleep onset. Bedroom Environment: Moderate Temperature, Quiet, and DarkExtremes of heat or cold can disrupt sleep. A quiet environment is more sleep promoting than a noisy one. Noises can be masked with background white noise (such as the noise of a fan) or with earplugs. Bedrooms may be darkened with black-out shades or sleep masks can be worn. Position clocks out-of-sight since clock-watching can increase worry about the effects of lack of sleep. Be sure your mattress is not too soft or too firm and that your pillow is the right height and firmness.EatingA light bedtime snack, such a glass of warm milk, cheese, or a bowl of cereal can promote sleep. You should avoid the following foods at bedtime: any caffeinated foods (e.g., chocolate), peanuts, beans, most raw fruits and vegetables (since they may cause gas), and high-fat foods such as potato chips or corn chips. Avoid snacks in the middle of the nights since awakening may become associated with hunger. If you have trouble with regurgitation, be especially careful to avid heavy meals and spices in the evening. Do not go to bed too hungry or too full. It may help to elevate you head with some pillows.Avoid NapsAvoid naps, the sleep you obtain during the day takes away from you sleep need that night resulting in lighter, more restless sleep, difficulty falling asleep or early morning awakening. If you must nap, keep it brief, and try to schedule it before 3:00 pm. It is best to set an alarm to ensure you don’t sleep more than 15-30 minutes.Allow Yourself At Least an Hour before Bedtime to UnwindThe brain is not a light switch that you can instantly cut on and off. Most of us cannot expect to go full speed till 10:00 pm then fall peacefully to sleep at 10:30 pm. Take a hot bath, read a novel, watch some TV, or have a pleasant talk with your spouse or kids. Find what works for you. Be sure not to struggle with a problem, get into an argument before bed or anything else that might increase your body’s arousal.Regular Sleep ScheduleKeep a regular time each day, 7 days a week, to get out of bed. Keeping a regular awaking time helps set your circadian rhythm set so that your body learns to sleep at the desired time.Set A Reasonable Bedtime and Arising Time and Stick to Them.Spending excessive time in bed has two unfortunate consequences - (1) you begin to associate your bedroom with arousal and frustration and (2) your sleep actually becomes more shallow. Surprisingly, it is very important that you cut down your sleep time in order to improve sleep! Set the alarm clock and get out of bed at the same time each morning, weekdays and weekends, regardless of your bedtime or the amount of sleep you obtained on the previous night. You probably will be tempted to stay in bed in the morning if you did not sleep well, but try to maintain your new schedule. This guideline is designed to regulate your internal biological clock and reset your sleep-wake rhythm.Sticking to the Changes You MakeIt can be difficult to stick to a self-management program. However, it is important to remind yourself that the sleep guidelines have been extensively researched and represent the best science has to offer for conquering a long-term insomnia problem. Literally, thousands of individuals have improved their sleep through following the guidelines. The following points may help you to stick to the guidelines.1. Find activities to engage in when out of bed during the night.Plan activities to engage in when you are not in bed at night because you can’t fall asleep. These activities should be non-stimulating.Prepare any materials needed to get out of bed (e.g., robe, book, etc.) ready prior to bedtime.2. Identify cues to determine sleepiness and time to return to bed.Examples of “Sleepy Behavior” include yawning, heavy eyelids, nodding off, etc.Remember that the longer you stay up and the sleepier you are, the quicker you will fall to sleep.3. Use alarm clock to maintain regular arising time.You may also want to plan social, work or family commitments soon after waking to increase motivation to adhere to arising time.4. Find competing activities to fight the urge to take a nap before your bedtime.These activities should be physical (e.g., housework, walking) rather than cognitive (e.g., reading) or passive (e.g., watching TV).Examples include: taking a walk, having someone visit in the evening, talking on the phone to a friend, working a puzzle, drawing, etc.5. Secure support from your spouse/significant others.Typically your bed partner will be deeply asleep and will not notice you getting out of bed.Have friends/family members help you adhere to the sleep guidelines. For example, a family member could play a game with you to help you stay awake until bedtime.6. Remember the time-limited nature of following these procedures.It usually takes 2-3 months for a sleep problem to get totally better but most people see improvements within 2-3 weeks if the consistently follow the guidelines. Isn’t sticking to the guidelines for this short period worth it if your sleep ultimately improves?Sleep Diary InstructionsIn order to better understand your sleep problem and to assess your progress during treatment, we’d like you to collect some important information about your sleep habits.Before you go to sleep at night, please answer Questions 1 - 6. After you get up in the morning, please answer the remaining questions, Questions 7 - 13. It is very important that you complete the diary every evening and morning!!! Please don’t attempt to complete the diary later. If you have any difficulties completing the diary, please contact one of the BHP staff members at (210) 670-5968 and we’ll be glad to assist you. It’s often difficult to estimate how long you take to fall asleep or how long you’re awake at night. Keep in mind that we simply want your best estimates. If any unusual events occur on a given night (e.g., emergencies, phone calls) please make a note of it on the diary (at the bottom of the sheet). Below are some guidelines to help you complete the Sleep Diary.Napping: Please include all times you slept during the day, even if you didn’t intend to fall asleep. For example, if you fell asleep for 10 minutes during a movie, please write this down. Remember to specify a.m. or p.m., or use military time.Sleep Medication: Include both prescribed and over-the-counter medications. Only include medications used as a sleep aid.Alcohol as a sleep aid: Only include alcohol that you used as a sleep aid.Bedtime: This is the time you physically got into bed, with the intention of going to sleep. For example, if you went to bed at 10:45 p.m. but turned the lights off to go to sleep at 11:15 p.m., write down 10:45 p.m.Lights-Out Time: This is the time you actually turned the lights out to go to sleep.Time Planned to Awaken: This is the time you plan to get up the following morning.Sleep-Onset Latency: Provide your best estimate of how long it took you to fall asleep after you turned the lights off to go to sleep.Number of Awakenings: This is the number of times you remember waking up during the night.Duration of Awakenings: Please estimate how many minutes you spent awake for each awakening. If this proves impossible, then estimate the number of minutes you spent awake for all awakenings combined. Don’t include your very last awakening in the morning, as this will be logged in number 10.Morning Awakening: This is the very last time you woke up in the morning. If you woke up at 4:00 a.m. and never went back to sleep, this is the time you write down. However, if you woke up at 4:00 a.m. but went back to sleep for a brief time (for example, from 5:00 a.m. to 5:15 a.m.), then your last awakening would be 5:15 a.m.Out-of-Bed Time: This is the time you actually got out of bed for the day.Restedness upon Arising: Rate your restedness using the scale on the diary sheet.Sleep Quality: Rate the quality of your sleep using the scale on the diary sheet.Sleep DiaryName: _____________________________Week:_______________ to ______________ (Beginning date) (Ending date)Example: Fill in the Day of the Week above each column Mon. 1. I napped from to (note times of all naps).2:00 to2:45 pm2. I took mg of sleep medication as a sleep aid.ProSom1 mg3. I took oz. of alcohol as a sleep aid.Beer12 oz.4. I went to bed at o’clock. 10:305. I turned the lights out at o’clock.11:156. I plan to awaken at o’clock.6:157. After turning the lights out, I fell asleep in minutes.458. My sleep was interrupted times (specify number of nighttime awakenings).39. My sleep was interrupted for minutes (specify duration of each awakening).20301510. I woke up at o’clock (note time of last awakening).6:1511. I got out of bed at o’clock (specify the time).6:4012. When I got up this morning I felt .(1 = Exhausted, 2 = Tired, 3 = Average, 4 = Rather Refreshed, 5 = Very Refreshed)213. Overall, my sleep last night was .(1 = Very Restless, 2 = Restless, 3 = Average, 4 = Sound, 5 = Very Sound)1NOTES:Sleep ChecklistQuestionYesNoDo you avoid caffeine 4 - 6 hours before bedtime? Recommendation:Do you avoid nicotine before bedtime?Recommendation:Do you avoid alcohol after dinner?Recommendation:Do you avoid vigorous exercise within 2 hours of bedtime? Recommendation:Do you have a “wind-down” ritual at least an hour before bed?Recommendation:Do you nap during the day?Recommendation:Is your bedroom comfortable (good temperature, quiet, and dark)?Recommendation:Do you wake-up at about the same time each morning?Recommendation:Do you go to bed only when you are sleepy?Recommendation:If you wake in the middle of the night or early morning, do you lie in bed for more than 15-20 minutes?Recommendation:Do you watch TV, listen to the radio, eat, or read in your bedroom?Recommendation:Facts about SleepPrevalence of InsomniaInsomnia is a widespread problem affecting essentially everyone at one period in their lifetime. It is perhaps the most frequent health complaint after pain. A Gallup survey conducted in 1991 found that 36% of Americans suffer from some type of sleep problem, with 27% reporting occasional insomnia and 9% reporting chronic insomnia. Surveys of physicians indicate that 19% of medical outpatients complain of insomnia.Factors Which Make You Vulnerable to InsomniaIncreased Physiological ArousalWorrisome Thinking StyleModels of Poor Sleep HabitsAnxietyAgingDepressionFactors Which May Initially Cause InsomniaAcute StressPersonal Loss (e.g., death, divorce separation)Family ConflictWork ProblemsJet LagMedical ProblemsHospital StayChronic Low-level StressChanges in Schedules (work, etc.)PainFactors Which Maintain InsomniaPoor Sleep HabitsExtreme Worry or Concern about Getting to SleepSleeping PillsMedicationsIrregular Sleep ScheduleDaytime NappingAnxious ThinkingExcessive Time Spent in Bed when Not SleepingActivity that “Keys-up” the Body Before BedMisinformation about the Effects of Sleep ProblemsMisinformation about “Normal” SleepAging and SleepAs individuals age, they often have more interrupted sleep. Instead of having one consolidated sleep period at night, they may sleep in two to four sleep episodes. As we age, total time in bed increases, but total sleep time decreases. Generally, as people grow older, there is an increase in light sleep and a decrease in deep sleep. However, aging alone does not account for all the sleep problems seniors experience and behavioral insomnia treatment has been found to be effective for seniors.Alcohol and SleepAlthough alcohol may help you to go to sleep faster, alcohol actually causes sleep to be less deep and more fragmented.Sleep NeedsSleep needs vary considerably among individuals. Sleep needs range from 3 to 10 hours of sleep. Some people may get by on 4-5 hours, others feel good after 9 hours. Each individual’s sleep needs varies somewhat day-to-day; some days 6 hours will be okay while other days 8 hours will be optimal.Health ConsequencesThere is no evidence that anyone has died from lack of sleep. Excessive worrying about insomnia may be more detrimental to health than sleep loss itself.Daytime ConsequencesScientists have found that performance impairments as a result of poor sleep are fairly limited as long as you get from 4-5 hours of sleep on most nights. Excessive worrying or concern about insomnia appears to have more affect on our functioning than sleep loss itself.Resting; Is it Better than Nothing?Actually, staying in bed to rest when you are not sleeping can make an insomnia problem worse. When you stay in bed awake for too long, you begin to associate your sleep surroundings with frustration and arousal rather than sleep. The harder you try to sleep, the less likely you are to succeed.Behavioral Treatment for InsomniaBehavioral procedures for insomnia have been extensively tested throughout the world and have been shown to be effective with other patients suffering insomnia problems. About 75% of chronic insomniacs benefit from this intervention, with an average improvement rate of 50-60% in the reduction time it takes to fall asleep and/or time awake after going to sleep. Following the highly structured guidelines requires time, patience, and effort. To achieve your goals of falling asleep quickly at bedtime and of reducing the time spent awake in the middle of the night, it is important that you follow all the guidelines. You cannot choose only those that seem least painful. It is likely that in about 4 weeks you will experience substantial improvement in your sleep. However, it sometimes takes 2-3 weeks to start noticing improvement. Therefore, it is important guard against discouragement in the early stages of treatment. Further, during the first week of practice some people report that they feel worse. It is only after about three to four weeks of consistent practice that people start to experience significant benefits. The benefits of these highly effective procedures are related to how closely and consistently one follows the guidelines.For the first few nights you may be getting up many times before you fall asleep. You are likely to be sleepy the next day. You may become discouraged and even think about discontinuing behavioral treatment. You will think of many reasons why you can’t or shouldn’t follow the guidelines. Remind yourself that for most individuals the worsening of sleep is only temporary and is the path to a future of better sleep. You will see gradual and long-term improvement in your sleep. People tell us that regaining control of their sleep was definitely worth the temporary disruption caused by following the guidelines. So, don’t talk yourself out of gaining control of your sleep! Sleep GuidelinesGood dental hygiene is important in determining the health of your teeth and gums. We all know we are supposed to brush and floss regularly. Those who do so are more likely to have strong, healthy gums and fewer cavities. Similarly good sleep hygiene is important in determining the quality and quantity of your sleep. Below are guidelines for good sleep hygiene practices. Review these guidelines and evaluate how well you practice good sleep hygiene.Caffeine: Avoid Caffeine 6-8 Hours Before BedtimeCaffeine disturbs sleep, even in people who do not think they experience a stimulation effect. Individuals with insomnia are often more sensitive to mild stimulants than are normal sleepers. Caffeine is found in items such as coffee, tea, soda, chocolate, and many over-the-counter medications (e.g., Excedrin). Thus, drinking caffeinated beverages should be avoided near bedtime and during the night. You might consider a trial period of no caffeine if you tend to be sensitive to its effects.Nicotine: Avoid Nicotine Before BedtimeAlthough some smokers claim that smoking helps them relax, but nicotine is a stimulant. The initial relaxing effects occur with the initial entry of the nicotine, but as the nicotine builds in the system it produces an effect similar to caffeine. Thus, smoking, dipping, or chewing tobacco should be avoided near bedtime and during the night. Don’t smoke to get yourself back to sleep.Alcohol: Avoid Alcohol After DinnerAlcohol often promotes the onset of sleep, but as alcohol is metabolized sleep becomes disturbed and fragmented. Thus, alcohol is a poor sleep aid and will lead to less restful sleep. Sleeping Pills: Sleep Medications are Effective Only TemporarilyScientists have shown that sleep medications lose their effectiveness in about 2 - 4 weeks when taken regularly. Despite advertisements to the contrary, over-the-counter sleeping aids have little impact on sleep beyond the placebo effect. Over time, sleeping pills actually can make sleep problems worse. When sleeping pills have been used for a long period, withdrawal from the medication can lead to an insomnia rebound. Thus, after long-term use, many individuals incorrectly conclude that they “need” sleeping pills in order to sleep normally. Keep use of sleep pills infrequent, but don’t worry if you need to use one on an occasional basis.Regular ExerciseGet regular exercise, preferably 30 minutes each day of an activity that causes sweating. . Exercise in the late afternoon or early evening seems to aid sleep, although the positive effect often takes several weeks to become noticeable. Exercising occasionally is not likely to improve sleep, and exercise within 2 hours of bedtime is likely to interfere with sleep onset. Bedroom Environment: Moderate Temperature, Quiet, and DarkExtremes of heat or cold can disrupt sleep. A quiet environment is more sleep promoting than a noisy one. Noises can be masked with background white noise (such as the noise of a fan) or with earplugs. Bedrooms may be darkened with black-out shades or sleep masks can be worn. Position clocks out-of-sight since clock-watching can increase worry about the effects of lack of sleep. Be sure your mattress is not too soft or too firm and that your pillow is the right height and firmness.EatingA light bedtime snack, such a glass of warm milk, cheese, or a bowl of cereal can promote sleep. You should avoid the following foods at bedtime: any caffeinated foods (e.g., chocolate), peanuts, beans, most raw fruits and vegetables (since they may cause gas), and high-fat foods such as potato chips or corn chips. Avoid snacks in the middle of the nights since awakening may become associated with hunger. If you have trouble with regurgitation, be especially careful to avoid heavy meals and spices in the evening. Do not go to bed too hungry or too full. It may help to elevate you head with some pillows.Avoid NapsAvoid naps, the sleep you obtain during the day takes away from you sleep need that night resulting in lighter, more restless sleep, difficulty falling asleep or early morning awakening. If you must nap, keep it brief, and try to schedule it before 3:00 pm. It is best to set an alarm to be sure you don’t sleep more than 15-30 minutes.Allow Yourself At Least an Hour before Bedtime to UnwindThe brain is not a light switch that you can instantly cut on and off. Most of us cannot expect to go full speed till 10:00 pm then fall peacefully to sleep at 10:30 pm. Take a hot bath, read a novel, watch some TV, or have a pleasant talk with your spouse or kids. Find what works for you. Be sure not to struggle with a problem, get into an argument before bed or anything else that might increase your body’s arousal.Set A Reasonable Arising Time and Stick to ThemSpending excessive time in bed has two unfortunate consequences - (1) you begin to associate your bedroom with arousal and frustration and (2) your sleep actually becomes shallower. Surprisingly, it is very important that you cut down your sleep time in order to improve sleep! Set the alarm clock and get out of bed at the same time each morning, weekdays and weekends, regardless of your bedtime or the amount of sleep you obtained on the previous night. Keeping a regular awaking time helps set your circadian rhythm set so that your body learns to sleep at the desired time. You probably will be tempted to stay in bed in the morning if you did not sleep well, but try to maintain your new schedule. This guideline is designed to regulate your internal biological clock and reset your sleep-wake rhythm.Go To Bed Only When You Are SleepyThere is no reason to go to bed if you are not sleepy. When you go to bed too early, it only gives you more time to become frustrated. Individuals often ponder the events of the day, plan the next day’s schedule, or worry about their inability to fall to sleep. These behaviors are incompatible with sleep, and tend to perpetuate insomnia. You should therefore delay your bedtime until you are sleepy. Sleepiness is different from feeling tired. Examples of sleepiness include yawning, head bobbing, eyes closing, and concentration decreasing. This may mean that you go to bed later than your scheduled bedtime. Remember to stick to your scheduled arising time regardless of the time you go to bed.Get Out of Bed When You Can’t Fall Asleep or Go Back to Sleep in about 15 Minutes. Return to Bed Only When You Are Sleepy. Repeat This Step as Often as Necessary.Although we don’t want you to be a clock watcher, get out of bed if you don’t fall to sleep fairly soon. Remember, the goal is for you to fall to sleep quickly in your bed. Return to bed only when you are sleepy. The object is for you to reconnect your bed with sleeping rather than frustration. It will be demanding to follow this instruction, but many people from all walks of life have found ways to adhere to this guideline.Use the Bed or Bedroom for Sleep and Sex Only; Do Not Watch TV, Listen to The Radio, Eat, or Read in Your Bedroom. The purpose of this guideline is to associate your bedroom with sleep rather than wakefulness. Just as you may associate the kitchen with hunger, this guideline will help you associate sleep with your bedroom. Follow this rule both during the day and at night. You may have to temporarily move the TV or radio from your bedroom to help you while you work to improve insomnia.It will take time for your sleep to improve once you begin your sleep change plan. Are 1-2 months of work worth a lifetime of good sleep?Sticking To the GuidelinesIt can be difficult to stick to a self-management program. However, it is important to remind yourself that the sleep guidelines have been extensively researched and represent the best science has to offer for conquering a long-term insomnia problem. Literally, thousands of individuals have improved their sleep through following the guidelines. The following points may help you to stick to the guidelines.Find activities to engage in when out of bed during the night.Plan activities to engage in when you are not in bed at night because you can’t fall asleep. These activities should be non-stimulating.Prepare any materials needed to get out of bed (e.g., robe, book, etc.) ready prior to bedtime.Identify cues to determine sleepiness and time to return to bed.Examples of “Sleepy Behavior” include yawning, heavy eyelids, nodding off, etc.Remember that the longer you stay up and the sleepier you are, the quicker you will fall to sleep.Use alarm clock to maintain regular arising time.You may also want to plan social, work or family commitments soon after waking to increase motivation to adhere to arising time.Find competing activities to fight the urge to take a nap before your bedtime.These activities should be physical (e.g., housework, walking) rather than cognitive (e.g., reading) or passive (e.g., watching TV).Examples include: taking a walk, having someone visit in the evening, talking on the phone to a friend, working a puzzle, drawing, etc.Secure support from your spouse/significant others.Typically your bed partner will be deeply asleep and will not notice you getting out of bed.Have friends/family members help you adhere to the sleep guidelines. For example, a family member could play a game with you to help you stay awake until bedtime.Remember the time-limited nature of following these procedures.It usually takes 2-3 months for a sleep problem to get totally better but most people see improvements within 2-3 weeks if the consistently follow the guidelines. Isn’t sticking to the guidelines for this short period worth it if your sleep ultimately improves?Stress and Stress ReductionThe stress reactions below are presented in categories so that they may be more easily recognized and understood. There is no magic number of the symptoms that suggest difficulty in coping. Rather it is the extent to which the noted reaction is a change (different from a person's normal condition) that makes a reaction potentially important. Further, it is the combined presence of symptoms that determines the degree of the problem. Indicators may be isolated reactions or combinations among the three categories listed below. Finally, it is their duration (how long the symptoms have been present/how long they last), the frequency of such incidents (how often they happen) and the intensity (strength) with which they are present that suggests the severity of the difficulty in coping.Indicators of Difficulty in CopingEmotionalBehavioralPhysicalApathyThe "blahs"Recreation no longer pleasurableSadAnxietyRestlessAgitatedInsecureFeeling of worthlessnessIrritabilityOverly sensitiveDefensiveArrogant/argumentativeInsubordinate/hostileMental FatiguePreoccupiedDifficulty concentratingInflexibleOvercompensation (denial)Exaggerate/GrandioseOverworks to exhaustionDenies Problems/SymptomsSuspicious/ParanoidWithdrawal (smoking avoidance)Social isolationWork related withdrawalReluctance to accept responsibilitiesNeglecting responsibilitiesActing OutAlcohol abuseGamblingSpending spreePromiscuityDesperate Acting Out(getting attention-cry for help)Administrative InfractionsTardy to workPoor appearancePoor personal hygieneAccident proneLegal InfractionsIndebtednessShopliftingTraffic tickets FightsChild/spouse abusePreoccupation with illness(intolerant of/dwelling on minor ailments)Frequent illness (actually sick)Use of self medication Physical exhaustionImmune system suppressionSomatic (Body) IndicatorsHeadacheInsomniaInitial insomniaRecurrent awakeningEarly morning risingChange in AppetiteWeight gainWeight loss (more serious)IndigestionNauseaVomitingDiarrheaConstipationSexual difficultiesDeep Breathing ExerciseSit in a comfortable position.Take 3 deep cleansing breaths.Place one hand on your stomach and the other on your chest.Try to breathe so that only your stomach rises and falls.As you inhale, concentrate on your chest remaining relatively still while your stomach rises. It may be helpful to imagine that your pants are too big and you need to push your stomach out to hold them up.When exhaling, allow your stomach to fall in and the air to fully escape.Take some deep breaths, concentrating on only moving your stomach. Return to regular breathing, continuing to breathe so that only your stomach moves. Focus on an easy, regular breathing pattern.Note: It is normal for this healthy breathing to feel a little awkward at first. With practice, it will become more natural to you.The CALM ReminderChest:Breathing slower and deeperArms:Shoulders sagLegs:Loose and flexibleMouth:Jaw dropCue-Controlled RelaxationCue-controlled relaxation is a very quick and easy relaxation technique. Set up a cue to remind you to relax. There are two different types of cues (reminders):External Cue (reminder) (e.g., when your watch alarm sounds; when you see a note on your desk; at traffic lights, etc.)Internal Cue (reminder) (e.g., when your muscles reach a certain tension level, when you feel a headache coming on)Note: It’s very important that once you set up a cue, that you actually do the relaxation exercise when the cue comes up. Eventually it will become a healthy habit!Relax by doing the followingTake a deep, easy breathExhale s l o w l y....Say a word to yourself as you exhale (e.g., “relax” or “calm”)As you exhale, focus on letting your muscles relax. As an option (if it’s convenient), you can close your eyes tooDisputation: Challenging Upsetting ThinkingExamine your thoughts for key words:must, need, got to, have to, should (unrealistic standards)never, always, completely, totally, all everything, everyone (predictions / labeling)awful, terrible, horrible, unbearable, disaster, worst ever (labeling / predictions)jerk, slob, creep, hypocrite, bully, stupid (labels)Dispute or question the accuracy of the questionable thoughts.Am I upsetting myself unnecessarily? How can I see this another way?Is my thinking working for or against me? How could I view this in a less upsetting way?What am I demanding must happen? What do I want or prefer, rather than need?Am I making something too terrible? Is it really that awful? What would be so terrible about that?Am I labeling a person? What is the action that I don’t like?What’s untrue about my thoughts? How can I stick to the facts? What’s the proof for what I am thinking or believing about this?Am I using extreme, black-and-white language? What less extreme words might be more accurate?Am I fortune telling or mind reading in a way that gets me upset or unhappy? What are the odds (percent chance -- e.g., there is a 5% chance...) that it will really turn out the way I’m thinking or imagining?What are my options in this situation? How would I like to respond?Create more moderate, helpful, or realistic statements to replace the upsetting ones.Have I had any experiences that show that this thought might not be completely true?If my best friend or someone I loved had this thought, what would I tell them?If my best friend or someone I loved knew I was thinking this thought, what would they say to me? What evidence would they point out to me that would suggest that my thought is not completely true?Are there strengths in me or positives in the situation that I am ignoring? Am I underestimating my ability to cope with unfortunate circumstances?When I am not feeling this way, do I think about this situation any differently? How?Have I been in this type of situation before? What happened? What have I learned from prior experiences that could help me now?Five years from now, if I look back on this situation, will I look at it any differently? Will I focus on any different part of my experience?Am I blaming myself for something over which I do not have complete control?Maintaining Behavior ChangeMaintaining the progress you have been making is one of the greatest challenges you will face as you complete this program. There are two keys to maintaining the gains you have made and continuing to make progress.Prevent "Slips" from Occurring Control how You Respond to SlipsA slip is a: mistakelapsedeviation from the planerrorIt is usually the first instance of backsliding. It is a brief experience and does not signal an inevitable downward spiral.Example: You miss your workout for one or two days; you consume more calories than you planned during a special meal, etc.; you had a cigarette; you used an illegal substancePreventing SlipsIdentify high-risk situations: These are situations in which you expect to have difficulty continuing with your newly developed skills.Learn from the past. You can identify many of these from past experience. Think back and identify situations in which you remember having a particularly difficult time coping.Plan in advance. When you know similar situations are coming, start planning for how to deal with them in advance. If you wait until you are in the midst of the situation, you are not likely to come up with effective solutions. Use the information from past struggles to guide your planning and identify past hurtles that will need to be overcome. The attached form will help you develop your own relapse prevention plan.Controlling Response to SlipsEven though many slips are preventable, you cannot prevent them all (e.g., some high-risk situations are not predictable or were not known to be high risk). You will always have some periods when you are not doing as well as you would like. In other words, you will have slips.The most important thing is to respond to these slips in a manner that gets you back on track as quickly as possible. How you think about the slip is the most important factor. If you view the slip as a total return to old habits you are more likely to give up. Therefore, it is important to distinguish between a slip (a.k.a., a lapse), a relapse and a collapse.A SLIP (as discussed above) is a mistake, a first instance of backsliding. A RELAPSE occurs when slips string together and you return to your former behaviors. Since a relapse is made up of multiple slips, there are many opportunities to stop it and turn it back around before it reaches the relapse stage. However, even once it reaches this stage, you can still turn it around again (that’s what you did originally). At any point along this relapse line, you need to:Identify that you have slipped, Recall what you were doing that had been helping, andResume it. These actions will get you moving back in the right direction. The measure of success is not whether there are dips in your line of progress, but whether over all you are progressing upwards in spite of occasional dips. If you find you have relapsed, get out the education materials you used to help you learn more effective coping skills and remind yourself what you can do to get back on track and/or return to the clinic to see your primary care provider for support.When a relapse is complete and there is little hope of reversing the negative trend, COLLAPSE has occurred. If you find yourself in a collapse, the best solution is to seek help from your healthcare provider.A LAPSE = A RELAPSER E M E M B E RPersonalized Relapse Prevention PlanWhat situations are you likely to relapse in?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What do you plan to do in these situations to avoid relapse? What specifically will you do in these situations? What will you tell people to help you? How will you alter the situation so you won’t fall back into your hold maladaptive habits?1.5.2.6.3.7.4.8.What are some of the negative thoughts or “mental gremlins” that you are likely to experience in these relapse situations? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________What truthful and realistic things will you say to yourself to counteract negative thoughts and help you connect with values in these high-risk situations? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________Weight ManagementEffective weight management involves behavior modification which is a lifelong commitment and includes at least two components: Healthy eating in accordance with the Dietary Guidelines for Americans, emphasizing a reduction in total calories, lowered fat consumption, and an increase in vegetables, fruits and whole grains. Increased frequency of regular physical activity of at least moderate intensity. 1. Eating HealthyCaloric intakeLosing weight requires burning more calories than the body takes in, by either reducing caloric intake or increasing caloric expenditure, or preferably, both.Estimated Calorie Requirements (in Kilocalories) for Each Gender and Age Group at Three Levels of Physical ActivityActivity Level b, c, dGenderAge (years)SedentarybModerately ActivecActivedChild2-31,0001,000-1,4001,000-1,400Female4-81,2001,400-1,6001,400-1,8009-131,6001,600-2,0001,800-2,20014-181,8002,0002,40019-302,0002,000-2,2002,40031-501,8002,0002,20051+1,6001,8002,000-2,200Male4-81,4001,400-1,6001,600-2,0009-131,8001,800-2,2002,000-2,60014-182,2002,400-2,8002,800-3,20019-302,4002,600-2,8003,00031-502,2002,400-2,6002,800-3,00051+2,0002,200-2,4002,400-2,800Source: HHS/USDA Dietary Guidelines for Americans, 2005Sedentary = less than 30 minutes a day of moderate physical activity in addition to daily activities.Moderately Active = at least 30 minutes up to 60 minutes a day of moderate physical activity in addition to daily activities.Active = 60 or more minutes a day of moderate physical activity in addition to daily activities.Healthy Food ChoicesIndividualized food plan according to 2005 USDA Dietary Guidelines: key recommendations of the 2005 Dietary Guidelines for food groups to encourage are: Consume a sufficient amount of fruits and vegetables while staying within energy needs. Two cups of fruit and 2-1/2 cups of vegetables per day are recommended for a reference 2,000-calorie intake, with higher or lower amounts depending on the calorie level.Choose a variety of fruits and vegetables each day. Eat fresh, frozen, canned, or dried fruit, rather than drinking fruit juice, for most of your fruit choices. Select from all five vegetable subgroups several times a week. Examples of vegetables from these subgroups include: DARK GREEN VEGETABLES -- Broccoli, spinach, most greens such as spinach, collards, turnip greens, kale, beet and mustard greens, green leaf lettuce, and romaine lettuce ORANGE VEGETABLES -- Carrots, sweet potatoes, winter squash, pumpkinLEGUMES (DRY BEANS) -- Dry beans, chickpeas STARCHY VEGETABLES -- Corn, white potatoes, green peas OTHER VEGETABLES -- Tomatoes, cabbage, celery, cucumber, lettuce, onions, peppers, green beans, cauliflower, mushrooms, summer squashConsume 3 or more one-ounce equivalents of whole-grain products per day, with the rest of the recommended grains coming from enriched or whole-grain products. In general, at least half the grains should come from whole grains. Examples of whole-grains commonly consumed in the United States include: whole wheatwhole ryebulgur (cracked wheat)brown ricewhole oats/oatmealwhole-grain barleymillettritacalewhole-grain cornwild ricequinoaConsume 3 cups per day of fat-free or low-fat milk or equivalent milk products. If you don't or can't consume milk, choose lactose-free milk products and/or calcium-fortified foods and beverages. For more information, visit: log By keeping track of food and drink consumption you will stay mindful of your eating habits. Do you eat when bored? Do you eat unhealthy foods when in a hurry? Are you eating something that seems nutritious and healthy, but really isn’t? You can calculate calories consumed to determine weight loss/maintenance goals and assess progress. Keeping a food log allows you to be accountable and mindful of calories consumed and you will become aware of the nutrient value of the foods/drinks you are using.An on-line calorie counter is available at . This site lets you count calories for free (extra features cost $35/year).Portion SizeAnother common problem leading to overeating is taking portions that are too big. Most of us overestimate the size of a healthy portion, especially when we eat at restaurants and want to get a “good value” for our money. Listed below are the recommended portion sizes for a variety of foods. How do your typical portions compare?3 oz. meat: size of a deck of cards or bar of soap (the recommended portion for a meal)8 oz. meat: size of a thin paperback book 3 oz. fish: size of a checkbook 1 oz. cheese: size of 4 dice Medium potato: size of a computer mouse 1/2 cup pasta: size of a tennis ball Average bagel: size of a hockey puck. 1 cup chopped raw vegetables or fruit: baseball size 1/4 cup dried fruit (raisins, apricots, mango): a small handful For more information, visit . ExerciseExercise is an important piece of weight loss and overall health. For example, 30 minutes of moderate intensity physical activity above your normal daily routine reduces the risk of chronic disease in adulthood. To manage body weight and prevent gradual, unhealthy body weight gain in adulthood, increase your exercise to approximately 60 minutes of moderate to vigorous intensity activity on most days of the week. To sustain weight loss, increase your exercise to 60 - 90 minutes per day of moderate intensity physical activity while not exceeding caloric intake requirements.Another way to track physical activity is to use a pedometer to keep track of the number of steps you take. For example, 2000-2500 average steps is approximately one mile, which equates to around 100 expended calories.3. Simple Strategies to Manage Your Eating How often have you over-eaten or eaten unhealthy foods due to eating effortlessly in an unaware and mindless manner? Have you ever noticed that when you’re done eating, you feel sick because you ate too much? This happens when we do not pay attention to eating, typically because we are doing something else at the same time like watching television, talking with others, or working. If you increase your awareness—or mindfulness—of eating, however, you can reduce your caloric intake and not feel so sick. Mindfulness is a way of observing your experiences and being in touch with your actions, thoughts and feelings. Mindful eating teaches you to pay attention to your bodies’ signals that you are full and about what foods to eat. The goal of mindful eating is to understand your hunger and your body and mind’s reaction to food and the process of eating. Try this activity:Mindful eatingTo start, move through the meal slowly. Take your time performing every action and notice what your experience is as you go through it. When you lift a fork or cut your meat, note what that is like for you. As you place a bite of food in your mouth and chew it, place your fork on the table and think about the flavors and the texture of the food. Is it enjoyable or repulsive? Don’t get hung up in judging it. Just notice it. Do you find that particular thoughts or feelings come up during the course of the meal? If so, simply note those as well. For more information about mindful eating consider reading these books: Albers, S. (2003). Eating Mindfully. Oakland: New Harbinger Publications, Inc.Hayes, S.C. (2005). Get Out of Your Mind and Into Your Life. Oakland: New Harbinger Publications.4. Developing Weight GoalsSetting SMART goals for your weight loss is the first, and most important, step for managing your weight. Good goals have several qualities:Specific: Goals should not be too general or vague, since this makes it hard for us to know when we have accomplished them. For example, “I want to lose 20 pounds” is a better goal than “I want to lose weight.”Measurable: Goals should be set in a way that can easily and meaningfully measured. For example, “I want to look better” is not easily measured, but “I want a 34-inch waist” is easily measured.Attainable: Goals should be something you are motivated to achieve. For example, if improving your PT score is more important to you than your overall weight, then your goal should not be to lose weight.Realistic: Goals should be something you are able to accomplish. For example, setting a goal to run a marathon next month when you struggle to run 2 miles now is not a realistic goal.Timely: Goals should have a time frame built into them to hold you accountable. You’re more likely to work towards a goal if you give yourself a deadline.Body Mass Index (BMI) & Waist SizeBMI uses a mathematical formula that takes into account both a person's height and weight. BMI equals a person's weight in kilograms divided by height in meters squared. (BMI=kg/m2). It is the measurement of choice for many physicians and researchers studying obesity, because it is a more accurate indicator of overall health than just weight alone. Setting a BMI goal, instead of simply a weight loss goal, is a better weight management strategy for many people, especially those with medical conditions such as diabetes, COPD, heart diseases, hypertension, and more. To calculate your BMI, visit this website: . Risk of Associated Disease According to BMI and Waist SizeBMIWaist less than or equal to40 in. (men) or35 in. (women)Waist greater than40 in. (men) or35 in. (women)18.5 or lessUnderweight--N/A18.5 - 24.9Normal--N/A25.0 - 29.9OverweightIncreasedHigh30.0 - 34.9ObeseHighVery High35.0 - 39.9ObeseVery HighVery High40 or greaterExtremely ObeseExtremely HighExtremely HighSetting a SMART Weight Management GoalSpecific: Where will you do it?With whom will you do it?How often will you do it?Measureable:How much?How many?Attainable:What is most important to you?What do you hope to accomplish?Realistic:Are you able to do it?What can you do right now?How easy will this be to maintain?Timely:When do you want to accomplish this?Do you have a deadline?Now that you have considered the necessary components for a SMART goal, write down your weight management goal below:Other tips for accomplishing this goal:Hang this goal up where you can see it regularly so you can remind yourself what you’re working towards.Tell others about it. Ask them to help you stay accountable and support you.Ask your doctor for advice or tips on reaching this goal.Try this goal out for two weeks. At the end of two weeks, see if it’s a goal that will work for you. If not, change it so it will work better.Once you have accomplished this goal, set another SMART goal right away.Remember to pace yourself. Change will not happen all at once, but will slowly build up over time. Be patient. ................
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