Introducing Self-Comparisons Cognitive Therapy

All of us hanker for instant magic, a quick fix for our troubles. And that's what the simple-minded variety of get-happy self-help books promise, which explains why so many people buy them. But in the end there seldom is a one-stroke magical cure for a persons' depression.

The understanding of depression provided by cognitive therapy and Self-Comparisons Analysis is an exciting advance over the older ways of dealing with depression. But this new theory also shows that there is more to understanding depression than a single magical button. Instead, you must do some hard thinking about yourself. Whether you have the help of a psychotherapeutic counselor, or fight your depression by yourself, the battle takes effort and discipline.

Writing down and analyzing your depressed thoughts is a very important part of the cure. Some detailed suggestions are given below. Learning more about the nature of depression is worthwhile, too. I particularly recommend two excellent practical books, Feeling Good, by David Burns, and A New Guide to Rational Living, by Albert Ellis and Robert A. Harper, both of which are which are available in inexpensive paperback. Other works which have two or three stars in the reference list at the end of this book also are valuable for the depression sufferer; the more you read, the better your chances to find insights and methods which will fit your mind-set and your daily needs. When reading those books, you will quickly see how their general notion of negative thoughts can be translated into the more precise and useful notion of negative self-comparisons.

A bit later, this chapter discusses whether you should try to win the battle by yourself or seek a counselor's aid, and whether you can expect to sail into a permanent harbor of total untroubled bliss. First we must discuss the first requirements of almost any successful battle against depression.

Before proceeding further, here is a nice tidbit for you which -- even if it will not cure your depression by itself -- every depression specialist agrees is valuable therapy. Do some things which you enjoy. If you enjoy dancing, go out and dance tonight. If you like to read the funny papers before you start work for the day, read them. If you delight in a bubble bath, take one this evening. There are plenty of pleasures in this world that are not illegal, immoral, or fattening. Let it be the first step in your program to overcome depression to brighten up your days with some of these pleasures.

Pleasurable activities reduce the mental pain which causes sadness. And while you are enjoying pleasure you do not feel pain. The less pain and the more pleasure, the more value you find in living. This advice to find pleasure clearly is "just" common sense, and I do not know of any controlled scientific studies proving it is curative. But this shows how the core of the contemporary scientifically-proven cognitive theory is a return to the common-sense wisdom known for ages, though systematic modern research has made large advances with new theoretical understanding of the principles and practical development of the accompanying methods.

You Must Monitor and Analyze Your Thinking

The understanding of depression provided by cognitive therapy and Self-Comparisons Analysis is an exciting advance over the older ways of dealing with depression. But this new theory also shows that there is more to understanding depression than a single magical button. Instead, you must do some hard thinking about yourself. Whether you have the help of a psychotherapeutic counselor, or fight your depression by yourself, the battle takes effort and discipline.

Writing down and analyzing your depressed thoughts is a very important part of the cure.

Self-Comparisons Analysis teaches that your negative self- comparisons, together with a sense of helplessness, cause your sadness. Obviously, then, you will have to eliminate or reduce those negative self-comparisons in order to banish depression and achieve a joyful life. But with the possible exception of drug therapy or electroshock, every successful anti-depression tactic requires that you know which depressing thoughts you are thinking. Cognitive therapy also requires that you monitor your thinking in order to prevent those self-comparisons from entering and remaining in your mind.

So there it is. Fighting depression requires the work and discipline of observing your own thoughts. Watching over anything--watching over a child lest it get into the fireplace, or taking notes on what is said at a meeting, or listening to a travel guide give you directions to your destination--requires the effort of paying attention. And it requires the discipline of paying attention often enough and long enough. Many of us are sufficiently short of such discipline so that without a counselor to hold our hands we certainly will not do it, and even with a skilled counselor we may not be willing and able to do it. On the other hand, if you decide to do it--and making that decision to break out of depression, to give up its benefits and to do the necessary work is a key step -- if you decide to apply yourself to the task, you almost surely can do it.

The first step is every tactic we shall describe, then, will be to observe your thoughts closely when you are depressed, analyze which negative self-comparisons you are making, and write them down if you can make yourself do so. Later, when you have learned how to keep depression at bay, an important part of your continuing exercise will be to identify each negative self- comparison before it gets a firm foothold, and pitch it out of your mind with the devices we shall describe.

One useful trick is to watch your thoughts in a disengaged fashion, as if they were the thoughts of a stranger whom you were reading about in a book or hearing at the movies. You can then examine the thoughts and see how interesting they are, including the peculiar illogical tricks we all play with our thinking. Watching your thoughts in this way is like what happens in meditation, which is described in Chapter 15. Watching your thoughts at a distance desensitizes them; it removes the sting of neg-comps. You will be amazed at the fascinating stream-of- consciousness drama that goes on inside your head, how one thing leads to another in the most peculiar way, with astonishing emotional ups and downs within a minute or less sometimes. Try it. You'll probably like it.

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Learning to monitor your thoughts also is like the first crucial step in stopping smoking: You must first be aware of what you are doing before you can intervene to change the behavior. Confirmed smokers often pull out and light cigarettes without being fully aware of the process, and do not make a conscious decision to do so.

Other hard thinking also is necessary to overcome depression. You may have to straighten out some misapprehensions or confusions that customarily depress you. You may need to re- think your priorities. It may even help to search your memory for some childhood experiences. Perhaps hardest of all, you may have to study how you misuse language, and how you fall into linguistic traps. For example, your vocabulary probably makes you think that you must do some things which, upon inspection, you will conclude you have no obligation to do, and which may have dragged you into depression.

Conquering depression is not easy - rather, it is difficult. But difficult ...does not mean impossible. Of course you will find it hard to think and to act rationally in an irrational world. Of course you will have trouble reasoning your way out of circumstances which have unreasonably bogged you down for many years. All right, so you find it difficult. But it also proves difficult for a blind man to learn to read Braille, a victim of polio to use his muscles again, or a perfectly normal person to swing from a trapeze, learn ballet dancing, or play the piano well. Tough! But you still can do it.(1)

How To Observe Your Thoughts

You should -- I'd say "must" except that I don't want to add any must's to your life, and besides, there always are exceptions -- you should observe your thoughts with pencil and paper in hand, and write down the thoughts and their analysis. Better yet, because it makes writing easier, use a computer when you are near one.

Let's take this idea further. It is crucial that you actually take action to fight your depression. Writing down and analyzing your thoughts is one such action. But other actions are important, too, such as getting out and participating in pleasurable activities so that you will enjoy life more, or, arriving at meetings on time if you know that getting there late will start you thinking depressing thoughts. Certainly, all this takes effort. But cranking yourself up to carry through with the actions is often a crucial part of the cure of depression. More about this below.

Now back to your thoughts. Ask yourself, "What am I thinking right at this moment, as I am feeling so sad?" Record your thought in the format of Table 10-1. This table guides you from the raw "uninvited thought" ("automatic thought", some writers call it) which floats into your mind and causes you pain, into and through an analysis of that thought which pinpoints the problems and the opportunities to intervene so as to get rid of the painful negative self-comparison you are making.

Table 10-1

Let's follow through an example I have taken from Burns 1.1 so that a reader who uses his book can expand this method (developed over many years by Aaron Beck) with Self-comparisons Analysis. Let's call it the case of Ms. X, a woman who suddenly realizes that she is late for an important meeting. The thought then zips uninvited into her mind, "I never do anything right". Ms. X writes down this thought in column 1 of Table 10-1. She also writes down in column 2 the event that triggered the uninvited thought, being late for the meeting.

The thought in column 1 creates pain. Let's assume that X has a hopeless attitude, too. The uninvited thought then produces sadness.

The uninvited thought in column 1 translates logically into the negative self-comparison, "I do fewer things right than does the average person". So Ms. X writes down in column 3 this analysis of her uninvited thought. Now we may consider various aspects of this neg-comp. The methods for dealing with the various aspects of neg-comps are discussed in detail in the chapters to follow, but we shall now skim through the process briefly in order to focus on the process rather than upon the particular methods.

Look first at the numerator. Is the assessment of her actual situation correct? Is she "always" late, or even usually late? She asks this question, and writes it in column 4. Now X realizes that she is very seldom late. She had told herself, "I'm always late", and then "I never do anything right", because she has a typical cognitive-distortion habit of depressives, generalizing to "always" or "everything" bad from just a single bad instance. She specifies this self-fooling device in the last column of the table.

Ms. X now can see how she has created a painful neg-comp unnecessarily. If she has any sense of humor she can laugh at how her mind plays silly tricks on her -- but tricks that make her depressed -- because of habits built up through the years, for reasons that are long in her past.

Notice how the pain of depression is removed by examining present thoughts. It might be interesting and useful to know how and why X developed the habit of over-generalizing from a single bad instance, but it is usually not necessary to have that knowledge. (Freudian doctrine erred fundamentally in this matter.)

It is worth mentioning that if you are usually late for meetings, you should re-arrange your life so that you get there on time. Depressives often fail to do this because, even when they acknowledge that they could change the situation so as to remove the causal event, they say they are helpless to change. Often the effort to get things right seems worse than the pain and sadness that getting it wrong produces; as long as a person feels this way, the person will continue to be depressed.

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The analysis of X's actual-state numerator may be sufficient to demolish this painful neg-comp. But perhaps Ms. X is not easily convinced that she is playing the self-depressing mind game with her numerator that is shown in the table. People's capacity to fool themselves by using additional plausible- sounding distorted arguments is almost limitless. Therefore, let us go on to a second possible way to deal with this neg-comp, the denominator.

Ms. X agrees that her statement "I never do anything right" implies that others do better than she. Now she can ask herself, Do others really usually do things more right than I do? And is my benchmark comparison really appropriate? Hopefully she will see that this is not a correct assessment, and she is not on average a poor performer. Once more, she may come to see how her biased assessment of others is biased against herself, and hence will let go of the depressing neg-comp. And perhaps she will see the humor in this, too, which will help even more.

Table 10-1 shows still a third line of analysis. Is the dimension of Ms. X being late for meetings important and appropriate for her to rate herself upon? When she asks herself that question, she answers "No". Even if she is late for meetings, this does not mean that she is an incompetent person. And having realized this to be true, she can focus on other aspects of her life which are more important and on which she looks good to herself.

The analysis above provides three different tactics to deal with the neg-comp. Any one of these strategies may be appropriate and effective for a given circumstance for a given person. Sometimes, however, using more than one tactic increases your effectiveness in combating the neg-comp.

There are still other ways to address the problem Ms. X causes herself by telling herself "I never do anything right", and we will discuss them later. The important point emphasized now is writing down the analysis, as a way of forcing your thoughts out into the open so that you -- perhaps together with a therapist -- can analyze their logic and their factual support. The rest of this Part II of the book expands on this advice.

The moment just after awakening in the morning commonly is the bleakest, blackest of the day, depressives commonly say. Therefore, this moment is one of the most interesting to observe, just as it is one of the most challenging to deal with. It takes a bit of time, usually, to get one's morning thoughts directed onto a non-depressing path. This makes sense when you realize that when you first awake your thoughts have just been in the less-consciously-directed sleep state, which tends to be negatively-directed for depressives.

Can You Do It Alone?

Can you really conquer depression by your own efforts, or do you need the help of a professional counselor? Many of us can do it alone, and if you are able to, you will gain great satisfaction and renewed strength from doing so. And nowadays you can have the assistance of Kenneth Colby's computer program OVERCOMING DEPRESSION, which comes with this book and is based on the principles of Self-Comparisons Analysis set forth in this book; experimental research shows that computer-based cognitive therapy does as well as therapy with a counselor (Selmi et. al., 1990), and avoids several possible dangers touched on below.

In the example above, Ms. X can conduct the analysis in Table 10-1 by herself. And if she does so, she will gain considerable satisfaction from it. But a trained therapist can be helpful in helping X unravel her patterns of thought, and may help her discipline herself to proceed through the analysis.

Lest you doubt that a person can cure himself of depression without assistance from a physician or psychologist, keep in mind the millions of people who have done just that, in our times and in earlier times. Religion has often been the vehicle, though this is clearer in Eastern religion than in Western religion. The continued practice for 2500 years of Buddhism, which aims to reduce suffering, should itself be proof enough that at least some people can successfully combat depression without medical help. Granted, there do not exist scientifically-controlled experiments measuring whether just the passage of time would have induced as much improvement as such intercession, as we do have controlled experiments for cognitive therapy with the aid of a therapist (see Appendix A). But people's own experiments on themselves, sometimes using such depression-preventing methods and sometimes not, would seem to constitute rather reliable evidence.

People's power to radically change the course of their own lives has been quite underestimated in recent years, in large part because of the emphasis of Freudian psychology on childhood experience as determinants of the adult's psychological state. As Beck described the dominant view in psychotherapy prior to cognitive therapy: "The emotionally disturbed person is victimized by concealed forces over which he has no control."(2) In contrast, cognitive therapy has found that "Man has the key to understanding and solving his psychological disturbance within the scope of his own awareness."(3)

Even delinquency and drug addiction can be "kicked" by some people simply by deciding to do so. Alcoholics Anonymous provides massive evidence that it can be done. Another example is the Delancey Street Foundation of San Francisco: When a reporter asked its director about his "pioneering" new way of rehabilitation, he was told, with glee: "Yeah, you could say we have a 'new' way of fighting crime and drugs. It's a way that hasn't been tried lately. We tell 'em to stop."(4)

The simple fact is that all of us, all the time, make and carry out decisions about how our minds will act in the future. We decide to study a book, and we do so. We focus our attention on doing this or that, and we do it. We are not beyond our own control.

As interesting evidence that "ordinary" people can willfully alter their own thinking so as to make themselves happier at some times than at others, consider the example of Orthodox Jews on the Sabbath. Jews are enjoined not to think sad or anxious thoughts on the Sabbath (not even when in mourning). And for roughly twenty-six hours each Sabbath they do just that. How? The way a house-wife chases out cats when they come in--as if with a mental broom.

This raises the question: Why not perform the same simple trick all week long? The answer is that the world prevents it. A person cannot, for example, neglect thoughts of work all week; one must make a living, and the world of work inevitably implies strife as well as cooperation, losses as well as gains, failure as well as success.

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The operational question is whether you are better off attacking your depression on your own, or getting the help of a professional counselor. The appropriate answer is - a definite maybe.

The help of a counselor clearly can be valuable, as even such self-help advocates as Ellis and Harper agree:

One of the main advantages of intensive psycho- therapy lies in its repetitive, experimenting, revising, practicing nature. And no book, sermon, article, or series of lectures, no matter how clear, can fully give this. Consequently, we, the authors of this book, intend to continue doing individual and group therapy and to train other psychotherapists. Whether we like it or not, we cannot reasonably expect most people with serious problems to rid themselves of their needless anxiety and hostility without some amount of intensive, direct contact with a competent therapist. How nice if easier modes of treatment prevailed! But let us face it: they rarely do...

Our own position? People with personality disturbance usually have such deep-seated and long- standing problems that they often require persistent psychotherapeutic help. But this by no means always holds true.(5)

But a counselor will only help you if the counselor is well skilled, and has a point of view which fits your particular needs. The chances of finding such a skilled counselor are always uncertain. For one thing, therapists tend to be typecast by their training, and there have occurred "increasingly sharp disagreements among authorities regarding the nature and appropriate treatment."6 What you get depends on the accident of where the therapist studied and which "school" she therefore belongs to; too few are the therapists whose thinking is broad enough to give you what you need rather than what they have in stock. Additionally, many practicing therapists got their training before cognitive therapy had been shown to be clinically effective (as none of the earlier therapies had been).

There is real danger here. Two experienced therapists and teachers of therapists write: "Some people are hurt... by the wrong types of therapists for them...Most people really have no sound basis on which to choose...Most therapists are trained in and practice a particular type of therapy, and in general you will get what that person knows, which may not necessarily be what is best for you."7

Depression is a profoundly philosophical disease. A person's most basic values enter into depressive thinking. On the one hand, values can cause depression when they set up over- demanding and inappropriate goals, and therefore a troublesome denominator in a Rotten Mood Ratio. On the other hand, values can help overcome depression as part of Values Treatment, as discussed in Chapter 18. Helping you deal with such issues requires a depth of wisdom which is not learned in school, and which is too seldom in any of us. But without such wisdom, a therapist is useless or worse.

Depression is also a philosophical matter when it arises from disorder of logical thinking and misuse of linguistic. And starting in the 1980s, professional philosophers have begun to work with depressed people, with some apparent success (Ben-David, 1990). The participation of philosophers is quite reasonable given that cognitive therapy is seen by its creators as being "primarily educative", with the therapist being a "teacher/shaper", and the process as being a Socratic "problem-solving question-and-answer format" (Karasu, February, 1990, p. 139)

But a counselor will only help you if the counselor is well skilled, and has a point of view which fits your particular needs. concepts. The interesting dialogues in Ellis and Harper's A New Guide to Rational Living and in Burns's Feeling Good illustrate how a skilled therapist with a sound grasp of logic can help patients correct their thinking and thereby overcome depression. But few therapists -- or anyone else, for that matter -- have the necessary skill in manipulating logical concepts. All this makes it difficult to find a satisfactory therapist, and provides additional incentive for you to proceed without a therapist.

Furthermore, the computer is not subject to some failings of human therapists: The computer never wears out from fatigue late in the day, and becomes inattentive and therefore useless. The computer never burns out from emotional overload, as is not uncommon with human therapists - because they are human. The computer never becomes involved with the client in a troubling sexual relationship - as occurs in a surprisingly large number of cases, recent reports indicate. And you never feel that the computer is exploiting you financially, which bothers some clients whether or not there is a real basis for the feeling. These are additional reasons to at least give computer therapy a try before seeking a human therapist.

The ill-effects of getting involved with a counselor who is unsympathetic to your particular needs, or does not understand how to deal with your particular mentality, or is temporarily ineffectual or worse, can be great. The encounter can discourage you further, and drive you further into depression, compounded by the pain of having paid your good money in return for being made worse off. Given all this, it would at least make sense to try to work on yourself for a while before seeking out professional help. And even if you do eventually seek out a counselor, you will be better prepared to find one you like, and to work with that person, if you have studied your own psychology and the nature of depression beforehand.

Can You Reach Permanent Bliss?

You can hope to get rid of your depression, and by your own efforts. You can hope to remain depression-free most of your life. But if your depression is more than a passing episode you should not expect that after learning to fight and overcome deep depression you will have the same psychological make-up as nondepressives.

Just as alcoholics who have stopped drinking are forever different from other people with respect to alcohol (though recently there has been some scientific question raised about this), depressives who pull out of deep depression often are different than other people. They must constantly reinforce the dikes and guard against the first incursions of depression in order to keep a trickle from becoming a flood. Consider John Bunyan and Leo Tolstoy. Bunyan wrote as follows: "I found myself in a miry bog...and was as there left by God and Christ, and the Spirit, and all good things...I was both a burthen and a terror to myself...weary of my life, and yet afraid to die."(8) Tolstoy's relevant description of his depression is in Chapter 3.

James wrote as follows about the lives of Bunyan and Tolstoy after their depressions:

Neither Bunyan nor Tolstoy could become what we have called healthy-minded. They had drunk too deeply of the cup of bitterness ever to forget its taste, and their redemption is into a universe two stories deep. Each of them realized a good which broke the effective edge of his sadness; yet the sadness was preserved as a minor ingredient in the heart of the faith by which it was overcome. The fact of interest for us is that as a matter of fact they could and did find something welling up in the inner reaches of their consciousness, by which such extreme sadness could be overcome. Tolstoy does well to talk of it as that by which men live; for that is exactly what it is, a stimulus, an excitement, a faith, a force that reinfuses the positive willingness to live, even in full presence of the evil perceptions that ere- while made life seem unbearable.(8)

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Depressives less exceptional than Tolstoy and Bunyan share this condition:

You rarely ever completely win the battle against sustained psychological pain. When you feel unhappy because of some silly idea and you analyze and eradicate this idea, it rarely stays away forever, but often recurs from time to time. So you have to keep reanalyzing and subduing repeatedly. You may acquire the ridiculous notion, for instance, that you cannot live without some friend's approval and may keep making yourself immensely miserable because you believe this rot. Then, after much hard thinking, you may finally give up this notion and believe it quite possible for you to live satisfactorily without your friend's approbation. Eventually, however, you will probably discover that you, quite spontaneously, from time to time revive the groundless notion that your life has no value without the approval of this--or some other--friend. And once again you feel you'd better work at beating this self-defeating idea out of your skull.(9)

But this does not mean that you are doomed to a constant and unrelenting struggle. As you learn more about yourself and your depression, and as you build habits to keep negative self- comparisons at bay, it gets easier and easier.

Let us hasten to add that you will usually find the task of depropagandizing yourself from your own self- defeating beliefs easier and easier as you persist. If you consistently seek out and dispute your mistaken philosophies of life, you will find that their influence weakens. Eventually, some of them almost entirely lose their power to harass you. Almost.(10)

Furthermore, one often develops a commitment to remaining free of depression, just as a person who has stopped smoking has an investment in keeping a "clean record" and sustaining his or her success. One then feels a justifiable pride that helps keep you on the rails and away from sustained depression.

One Stroke For All?

Self-comparisons Analysis makes clear that many sorts of influences, perhaps in combination with each other, can produce persistent sadness. From this it follows that many sorts of interventions may be of help to a depression sufferer. That is, different causes--and there are many different causes, as most psychiatrists have finally concluded, call for different therapeutic interventions. Furthermore, there may be several sorts of intervention that can help any particular depression. Yet all these interventions may be traced to the "common pathway" of negative self-comparisons.

In short, different strokes for different folks. In contrast, however, each of the various schools of psychological therapy--psychoanalytic, behavioral, religious, and so on--does its own thing no matter what the cause of the person's depression, on the assumption that all depressions are caused in the same way. Furthermore, each school of thought insists that its way is the only true therapy.

Self-comparisons Analysis points a depression sufferer toward whichever is the most promising tactic to banish the depression. It focuses on understanding why you make negative self-comparisons, and then develops ways of preventing the neg- comps, rather than focusing on merely understanding and reliving the past, or on simply changing contemporary habits. With this understanding you can choose how best to fight your own depression and achieve happiness.

In a capsule: Your thoughts about yourself cause your depression, though of course your thoughts may be prompted by conditions outside you. To overcome your depression, you must think about yourself in ways different than your habitual patterns. Self-comparisons Analysis systematically suggests many possible kinds of change.

There are also some unsystematic tactics that sometimes effectively change your thinking about yourself. One of these is humor -- jokes about your situation, as well as humorous songs. (Albert Ellis is big on these).(11) The switch in perspective that is the heart of much humor causes you to view your situation less seriously, and in that fashion takes the sting out of the negative self-comparisons that the humor makes fun of.

Viktor Frankl uses a method he calls "paradoxical intention" which radically switches a person's perspective in a fashion akin to humor. Often this is akin to the Values Treatment discussed in Chapter 18. Consider this case of Frankl's:

A young physician consulted me because of his fear of perspiring. Whenever he expected an outbreak of perspiration, this anticipatory anxiety was enough to precipitate excessive sweating. In order to cut this circle formation I advised the patient, in the event that sweating should recur, to resolve deliberately to show people how much he could sweat. A week later he returned to report that whenever he met anyone who triggered his anticipatory anxiety, he said to himself, "I only sweated out a quart before, but now I'm going to pour at least ten quarts!" The result was that, after suffering from his phobia for four years, he was able, after a single session, to free himself permanently of it within one week.(12) Frankl's procedure can be understood in terms of altering negative self-comparisons. Frankl asks the patient (who must have some power of imagination for the method to work) to imagine that his actual state of affairs is different than what it is. Then he leads the person to compare the actual with that imagined state, and to see that the actual state is preferable to the imagined state. This produces a positive self-comparison in place of the former negative self-comparison, and hence removes sadness and depression.

Are the Best Things In Life Free?

"The best things in life are free," says the song. In money terms, that may be true. But the real best things in life--such as true happiness, and the end to prolonged sadness--are not free in terms of effort. Not to recognize this can be disastrous.

The failure of all popular remedies for depression arises from their unwillingness to recognize that every anti-depression tactic has its cost. As with a farmer, giving up the struggle to plant and raise a crop means not having a harvest and not making a living. To avoid going to parties or business meetings that lead to negative self-comparisons is to forego the pleasures or profits that may also be present there. Another misleading example is the popular recommendation to "accept yourself as you are."

Accepting yourself certainly can have its benefits. But there is also a drawback with simply accepting--either "accepting yourself," in the popular sense, or making no comparisons, as in Eastern meditative practices. If one wants to change one's habits or personality in order to improve or remedy a difficulty, one cannot avoid making comparisons. You cannot conduct any program of self-improvement without comparing and evaluating various modes of behavior.

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An example: Wanda L. did not get much affection or respect from people in her work or personal life, other than from her husband and children. There were no obvious objective facts to explain this; she is a productive and talented worker, a very decent person, and not personally unpleasant. But a wide variety of aspects of her personality and behavior apparently combine to lead others to distrust her or not seek her out or to choose her for positions of responsibility.

Wanda can accept the situation as it is, not dwell on it in her thinking, and hence reduce the amounts of negative self- comparisons and sadness. But if she does that, she will not be able to study and analyze herself to change her behavior so as to improve her relationships.

Which should Wanda choose to do? The decision is like that of a business investor who must guess at the chances that the investment will pay off. So there is a price for Wanda to "accept" herself as she is. The price is foregoing the chance of changing her life. Which is the better choice in this trade-off? That is a tough decision--and a choice that is ignored in the usual self-help books. And this makes those simplistic books, and their promises of quick and free miracles, unrealistic and ultimately disappointing.

Whereas this book focuses mostly on changes in how you think, this example focuses on changing the actual state of affairs so as to produce a more Rosy Ratio. But the underlying principle is exactly the same: reduce the negative self- comparisons.

Table 10-1

Column 1 Column 2 Column 3 Uninvited thought Causal Event Self-Comparison "I never do anything Late for a I do fewer things right right." meeting than do most people. Column 4 Column 5 Analysis Response Numerator: Are you usually late for meetings? Almost never. Denominator: Do most other people do most things more "right" than you do? Not really. Dimension: Is your timeliness at meetings an important aspect of your life? Of course not. Column 6 Behavior you wish to change Inappropriately generalizing from a single instance to your entire life. Biased assessment of what other people are like, making you look bad. Focusing on a dimension which a) you need not attribute importance to, and b) does not reflect well upon you.

Summary

This chapter begins the section of the book that discusses ways to overcome depression and the sadness-creating mechanisms that the earlier chapters discussed. The understanding of depression provided by cognitive therapy and Self-Comparisons Analysis is an exciting advance over the older ways of dealing with depression. But this new theory also shows that there is more to understanding depression than a single magical button. Instead, you must do some hard thinking about yourself. Whether you have the help of a psychotherapeutic counselor, or fight your depression by yourself, the battle takes effort and discipline.

Self-Comparisons Analysis teaches that your negative self- comparisons, together with a sense of helplessness, cause your sadness. Obviously, then, you will have to eliminate or reduce those negative self-comparisons in order to banish depression and achieve a joyful life. But with the possible exception of drug therapy or electroshock, every successful anti-depression tactic requires that you know which depressing thoughts you are thinking. Cognitive therapy also requires that you monitor your thinking in order to prevent those self-comparisons from entering and remaining in your mind. Writing down and analyzing your depressed thoughts is a very important part of the cure.

The first step in every tactic is to observe your thoughts closely when you are depressed, analyze which negative self- comparisons you are making, and write them down if you can make yourself do so. Later, when you have learned how to keep depression at bay, an important part of your continuing exercise will be to identify each negative self-comparison before it gets a firm foothold, and pitch it out of your mind.

You may have to straighten out some misapprehensions or confusions that customarily depress you. You may need to re- think your priorities. It may even help to search your memory for some childhood experiences. Perhaps hardest of all, you may have to study how you misuse language, and how you fall into linguistic traps.

One may seek the help of a counselor or choose to tackle depression by yourself. Self-cure certainly is feasible. The simple fact is that all of us, all the time, make and carry out decisions about how our minds will act in the future. We decide to study a book, and we do so. We focus our attention on doing this or that, and we do it. We are not beyond our own control.

The help of a counselor clearly can be valuable. But finding a counselor who meets your needs is not easy. Depression is a profoundly philosophical disease. A person's most basic values enter into depressive thinking. On the one hand, values can cause depression when they set up over-demanding and inappropriate goals, and therefore a troublesome denominator in a Rotten Mood Ratio. On the other hand, values can help overcome depression. Helping you deal with such issues requires a depth of wisdom which is not learned in school, and which is too seldom in any of us. But without such wisdom, a therapist is useless or worse

Depression is also a philosophical matter when it arises from disorder of logical thinking and misuse of linguistic

Self-comparisons Analysis makes clear that many sorts of influences, perhaps in combination with each other, can produce persistent sadness. From this it follows that many sorts of interventions may be of help to a depression sufferer. That is, different causes--and there are many different causes, as most psychiatrists have finally concluded, call for different therapeutic interventions. Furthermore, there may be several sorts of intervention that can help any particular depression. Yet all these interventions may be traced to the "common pathway" of negative self-comparisons.

Self-comparisons Analysis points a depression sufferer toward whichever is the most promising tactic to banish the depression. It focuses on understanding why you make negative self-comparisons, and then develops ways of preventing the neg- comps, rather than focusing on merely understanding and reliving the past, or on simply changing contemporary habits. With this understanding you can choose how best to fight your own depression and achieve happiness.

next: Good Mood: The New Psychology of Overcoming Depression Chapter 18
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Body-Image Negativism Poses Physical, Mental Threats to Many Women

Stand in line at the supermarket, and you're bombarded by tabloids and women's magazines."Lose 20 pounds in two weeks," screams one cover headline. Meanwhile, the cover photo is a four-layer chocolate cake offering "desserts to die for."

The tension between these two priorities - being thin and enjoying good food - has created an epidemic of eating disorders. Psychologist Stacey Nye, who specializes in treating those disorders, explains that "even though we're more educated about eating disorders now, it hasn't helped us protect ourselves from developing them, because we're seeing them in younger and younger children."

An additional conflict between Jewish culture, in which food plays a central role, and the general culture, which advocates the ideal of thinness, creates a compounded vulnerability for Jewish women, according to Nye. To explore these issues, Nye attended "Food, Body Image and Judaism - A Conference on Disorders and Resources for Change." The conference, held earlier this year in Philadelphia, was sponsored by the KOLOT Center for Jewish Women and Gender Studies at the Reconstructionist Rabbinical College and the Renfew Center, a women's psychiatric hospital in Philadelphia. It was sponsored in part by the Jewish Federation of Greater Philadelphia with support from the Germantown Jewish Center.

"I specialize in eating disorders and body image," explains Nye. "Being a Jewish woman myself, I wanted to learn more about what particular struggles (exist) for Jewish women. Jewish women have particular cultural vulnerabilities that make them more at risk."

Conference workshops included "Zaftig Women in a Barbie Doll Culture," "Chopped Liver and Chicken Soup: Soothing Food for the Traumatized Soul" and "Bagel Politics: Jewish Women, American Culture and Jewish Culture."

"If we want to follow our tradition, we have to revolve our lives around food," says Nye. "But if we want to assimilate, we have to look different."

Catherine Steiner-Adair, director of education, prevention and treatment at the Harvard Eating Disorders Center, points out that basic hereditary and physiological factors make it almost impossible for most women, including Jewish women, to conform to the Barbie-doll ideal.

"One percent of our population is genetically predisposed to be really tall, really thin and busty. And it's not us - it's the Scandinavians," says Steiner-Adair.

But experts note that societal and psychological influences make women strive to emulate unrealistic prototypes in terms of appearance.

"It's really hard not to buy into the general culture," admits Nye. "Girls are bombarded by messages that tell them appearance defines their identity. We have 8-year-old girls on diets. Body image dissatisfaction and distortion are rampant in our culture."

Steiner-Adair estimates that "every morning 80 percent of women wake up with body loathing. Eighty percent of the women in America don't relate to their bodies in a healthy, respectful, loving way."

"Stop worrying, and meet at the water cooler"

She says that combining this general obsession with "weightism" and anti-Semitic stereotypes results in a greater vulnerability to all types of eating disorders among Jewish women.

"If you have a Jewish girl who's feeling wobbly about herself and who feels a lot of pressure on her to assimilate, to achieve, it's very easy for a girl to say, 'I can't be all those things. I know what I'll be good at: I'll be thin,' " Steiner-Adair says.

Nye specializes in helping people accept their bodies and stop dieting.

"I help people to normalize their eating, not by dieting." She encourages her clients to eat normal, healthy food and to stop eating when they're full.

"I practice gentle nutrition, staying away from a dieting mentality." Nye also encourages increased activity rather than exercise, which she says has "a bad reputation with some people" - almost like medicine.

"I help people expand their identities. To explore what there is to feel good about," Nye adds.

Nye frequently speaks in schools to educate young people about accepting their own body image and that of others. "They're getting bombarded about looking a certain way. The reality is that not everyone is meant to be thin. Weight falls in a normal curve like anything else. Some people are intelligent, others are less intelligent. You can't make yourself taller."

She says one aspect in Jewish culture that is helpful is the emphasis on knowledge and excelling in scholastic settings, rather than on the athletic field.

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Family plays a role A Los Angeles-based psychotherapist who specializes in addictive behaviors, Judith Hodor finds, "more likely than not," that her patients with eating disorders come from Jewish homes. There often is an "enmeshment" in the Jewish family, she says, where one member, usually a child, feels pressured to be a reflection of the others.

"There is a tendency," she says, for parents to try to create a perfect existence as a positive reflection of themselves. This "demand for perfection" creates huge pressure on a child, who might try to starve herself as a "means of escape." This is one area, she explains, where the child can actually be in control.

Hodor cites an instance during a session in her office when the patient, a teenager, "actually was fading in and out due to lack of food" and the mother ran out to purchase milk, bananas and other edibles. "When she returned," Hodor recalls, "she looked at her daughter with tears in her eyes and said, 'You have to stop this. You are my reason for living.' "

"If I was anyone's reason for living, I might well want to disappear too," Hodor notes ruefully.

Within the context of the Jewish home, Hodor finds, there is an emphasis on intellectualism - and food. In other groups she tends to find "more aloofness, which, in a sense, protects family members from each other." But then again, she notes, they often have their own "isms, such as alcoholism" with which to deal.

Common to many cultures Taking issue with the premise that eating disorders are more prevalent within Judaism, Phoenix psychiatrist Jill Zweig reports that a significant percentage of her patients who suffer from anorexia or bulimia are not Jewish.

"These ailments are pervasive in all cultures and all socio-economic levels," she finds. "Food plays an important role in the traditions of many cultures," she points out.

"Adolescence is a time of turmoil," Zweig says, "a time of seeking individuality and separation. This typically creates some conflict within the family and this is normal, expected - and to some extent, healthy."

But, she warns, those with eating disorders tend to internalize and distort suggestions that might be as innocuous as "cut down on junk food." Determining "what actually goes into the mouth" is one way that someone can be in total control. This can lead to such inappropriate thought and pattern behaviors as, for example, cutting out all junk food, all meat, all fats - "and then they are down to three rice cakes a day," Zweig says.

Individuals suffering from anorexia and bulimia constantly are thinking about food, Zweig says, and with both there is focus on body image as a source of self-esteem.

"The difference is how the individual goes about obtaining control. The anorexic constantly restricts food intake; the bulimic may binge, regularly or periodically, and then purge."

Parents who fear that their children may be prone to, or suffering from, an eating disorder should be alert to significant changes in their children's eating patterns, such as eliminating certain foods from their diet, skipping meals, finding excuses not to eat with the family; also, hair and/or weight loss, and cessation of menstruation are signals. Warning signs of purging include locking themselves in the bathroom after meals, along with the odor of vomit.

Patients prone to eating disorders are influenced by media-created images portraying the ideal woman along the lines of Ally McBeal, Zweig says, adding: "Dissatisfaction with their bodies comes down to a comparison with image. They look in the mirror and see their own body distorted. That is the illness part of it. They don't see what others see."

The challenge for parents, Zweig suggests, is to work on effective communication, "to go for realistic goal-setting."

To that end, she emphasizes the importance of tension-free family meals and the need to teach youngsters to make appropriate food choices.

"Fat-free items don't necessarily fall into that category," she says. "Rethink what has been drummed into us regarding the craze for fat-free foods," she proposes.

"The truth is that fat is necessary in moderation. The healthiest diets include some fat."

Both Hodor and Zweig advocate a team approach in their work with patients who have eating disorders. When appropriate, they confer and collaborate with dietitians, family physicians, gynecologists, family members and friends.

next: Eating Disorders Minority Women: The Untold Story
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Depression always goes hand-in-hand with an eating disorder. Together the two rob a person of their happiness and self-worth, and easily wreak havoc on innocent lives. Unfortunately, we are living in a "pill society" and, more often than not, therapists tend to treat depression alone with drugs instead of with a more psychological basis and along with the eating disorder. It's amazing to look at the statistics and discover the multitudes of people who suffer from depression while this, just as with eating disorders, still appears to be an enigma to understanding. Hopefully the information contained here will help clear some of the fogginess of sadness away...

overview

Depression is not biased - it affects anyone at any race and age and economical standing. It can strike at any moment; it doesn't need a tragic incident to trigger onset. Over 19 million over age 18 are considered to be clinically depressed, or 1 out of 5 people in general society. Depression is so common that it is second only to heart disease in causing lost work days. More frighteningly so, untreated, depression is the number ONE cause of suicide (appx. 13,000 people died from suicide in '96 alone).

the.many.forms.of.depression

There are indeed three different kinds of depression - normal, mild, and then severe. I have found personally that those with eating disorders tend to range between having mild and severe depression.

normal.depression - This is a natural reaction to the loss of a loved one, one which has caused sadness, lethargy, and in serious cases, grief to the point of loss of appetite, insomnia, anger, obsessive thoughts about the lost person, and never ending guilt. What is different about normal depression from mild and severe cases is that most people eventually recover and return to their typical moods after encountering normal depression. When the moods of a person do not lift and instead continue, then mild depression is setting in.

mild.depression - When a person is chronically depressed, possesses low self-esteem, and has some symptoms of severe depression, then they are considered to have mild depression. With mild depression the person can still function through their daily life, but it is very hard for them and they are known as having "the blues." Many times the mildly depressed person has nothing to hold accountable for their change of moods. Doctors and therapists should carefully watch over a person with mild depression because often times the mild depression will start out this way, but eventually progress into severe depression.

I am the voice inside your head and I control you
I am the hate you try to hide and I control you
I am denial guilt and fear and I control you
I am the lie that you believe and I control you
I am the high you can't sustain and I control you
I am the truth from which you run and I control you
I take you where you want to go
I give you all you need to know
I drag you down, I use you up
Mr. Self Destruct-NIN

severe.depression - The person with this feels utterly hopeless and feels such great despair that they lose all interest in life, causing the person to be incapable of feeling pleasure. Sometimes the person will be unable to eat for days or be incapable to get out of bed. Trying to do these activities when severely depressed, the person feels anxious, irritable, agitated, and chronic indecisiveness. Sleep disturbances such as insomnia are not uncommon. Just as with mild depression, severe depression often does not set in after a traumatic incident or the loss of a loved one. However, the intense feelings of grief, guilt, and unworthiness are experienced just the same. Untreated, an estimated 25% of sufferers try to kill themselves after suffering for 5 years with this horrible mood disorder.

why.does.this.happen?

Often trying to figure out which triggered what (Did the eating disorder trigger the depression, or the other way around?) ends up being a game of whether the chicken or the egg came first, so I don't even bother. What's more important to me is finding the main trigger to the depression currently. Obviously the helplessness and hopelessness that comes from anorexia and bulimia is plenty enough to aggravate someone's moods. The person with the eating disorder feels helpless - they feel out of control, while desperately searching for control by starvation and/or purging. At the same time, they feel like failures for not losing enough weight and not doing it fast enough (making a twisted accomplishment). The current state of the medical community also doesn't host many rays of light, as it isn't uncommon for a severe case to be called "hopeless" and "incurable," or for a mis-understanding and mis-educated doctor to call someone with an eating disorder "selfish" and "manipulative." It's extremely hard to "think positively" and to "just read a few self-help books" and then magically, POOF, be ok. Depression doesn't work that way, and inevitably it is aggravated and made worse. The person may occasionally able to have a once in a blue moon GENUINE happy moment, but for the majority, they are down in the dumps (often believing they deserve to be there).

Along with an eating disorder triggering and aggravating depression, biological problems also affect mood disorders such as this. Studies on seratonin, also known as the "feel good" neurotransmitter, have caused some interesting findings to come up - some showing that you can be born with messed up levels and that alone can cause a 4 year old to be diagnosed as clinically depressed. The basics of seratonin are if it falls too low, depression and other complications occur, and starving and/or purging always messes up this chemical. Usually when someone with anorexia is in what is known as "starvation mode" (occurs generally when the weight has fallen below 98 pounds and the body just goes completely bonkers and manic), depression is almost solely biological. Some therapists even require that a patient's weight be raised up past 98 pounds before they will treat them for the eating disorder and/or depression because it is too hard to have the person think clearly at such a weight and condition that the body is in.

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depression treatment

Just as with any additional disorder, depression MUST be treated along with the eating disorder. Often depression treatment includes Cognitive Behavioral Therapy (CBT) which identifies the ten forms of distorted thinking found in depression (see below). Besides CBT, there are many anti-depressants that are used. These include the famous Prozac, Zoloft, and Paxil. It is true that generally after a person is taken away cold turkey from their anti-depressant that they relapse back into old thinking patterns and the depression re-surfaces, however, when treated along with Cognitive Behavioral Therapy, most are able to be "weened" off of the anti-depressants without many problems. The key is to learn better rationalization techniques along with using the drug as just a little "booster," so that in the end you have learned how to rationalize and use logic for your problems well enough that you no longer need anti-depressants.

the.nine.forms.of.distorted.thinking

1. All-or-Nothing Thinking :
   This is the black or white thinking pattern. If the person is not perfect they are nothing and a total failure. If the victim gets an A- on a test it's the end of the world
2. Labeling :
   The person makes a mistake and instead of thinking that hey they made a mistake no big deal they label themselves names such as a failure or pathetic. Another example of this is having a parent yell at you for forgetting to do a chore. Instead of thinking that you'll remember next time you may label yourself totally worthless and because of that your parents don't love you now.
3. Over-generalization :
   This is when a person makes a slight blunder and believes they will never get it right. ("I relapsed again; I wont ever be able to recover.")
4. Mental Filtering :
   ED victims tend to do this quite a lot. Say a friend commented on a piece of art work but then added that one of the colors was a little off. Instead of remembering that 99% of the art work is great looking the person dwells on the negative part of what the friend said and filters out any positive remarks. Many times the ED victim will say that they are good for nothing and that no one gives them any positive remarks but they do not realize that any positive remarks that they have been given they have immediately dismissed.
5. Discounting the Positive :
   This thinking is when you do something well such as cooking a good meal and then when given positive remarks on it you immediately think things like "Well, anyone could have done it," or, "It wasn't that great..."
6. Jumping to Conclusions :
   You assume the worst based on no evidence. You decide that another person is reacting negatively to you. ("I know she didn't really mean it when she said I wasn't fat; she's lying just to be nice.")
7. Magnification:
   This is the exaggeration of importance of problems and minor annoyances. An example of this would be an eating disorder victim not exercising for a full hour and thinking that what he did before was worth nothing.
8. Emotional Reasoning :
   Ever confuse your emotions for reality? This is when the thoughts of 'I feel fat so therefore I am fat' come up. The self-demanding tip-off's include 'must', 'ought to', and 'have to'.
9. Personalizing the Blame :
   These thoughts are another very common trait among eating disorder victims. The person believes that things beyond his or her control are the victim's fault. ("I ate yesterday and that's why the plane crashed," or, "If I had gotten an A+ instead of an A then my mom wouldn't have a migraine today.")

Personally, I have found that a major key in helping rid depression is realizing that we all have limits and faults, but that that is OK, and that there are better ways of dealing with things than self-destruction. One particular quote has been especially helpful, and it goes a lil' something like this: Most depression or anxiety-producing events are not inherently awful. What makes them feel distressing is the way we react to them.

next: Eating Disorder Relapses: What to Do and How to Prevent Them
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(sildenafil citrate) Tablets

Description
Pharmacology
Indications and Usage
Contraindications
Warnings
Precautions
Drug Interactions
Adverse Reactions
Overdose
Dosage
Supplied

DESCRIPTION

VIAGRA®, an oral therapy for erectile dysfunction, is the citrate salt of sildenafil, a selective inhibitor of cyclic guanosine monophosphate (cGMP)-specific phosphodiesterase type 5 (PDE5).

Sildenafil citrate is designated chemically as 1-[[3-(6,7-dihydro-1-methyl-7-oxo-3-propyl-1Hpyrazolo[ 4,3-d]pyrimidin-5-yl)-4-ethoxyphenyl]sulfonyl]-4-methylpiperazine citrate and has the following structural formula:

Sildenafil citrate is a white to off-white crystalline powder with a solubility of 3.5 mg/mL in water and a molecular weight of 666.7. VIAGRA (sildenafil citrate) is formulated as blue, film-coated rounded-diamond-shaped tablets equivalent to 25 mg, 50 mg and 100 mg of sildenafil for oral administration. In addition to the active ingredient, sildenafil citrate, each tablet contains the following inactive ingredients: microcrystalline cellulose, anhydrous dibasic calcium phosphate, croscarmellose sodium, magnesium stearate, hypromellose, titanium dioxide, lactose, triacetin, and FD & C Blue #2 aluminum lake.

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CLINICAL PHARMACOLOGY

Mechanism of Action

The physiologic mechanism of erection of the penis involves release of nitric oxide (NO) in the corpus cavernosum during sexual stimulation. NO then activates the enzyme guanylate cyclase, which results in increased levels of cyclic guanosine monophosphate (cGMP), producing smooth muscle relaxation in the corpus cavernosum and allowing inflow of blood. Sildenafil has no direct relaxant effect on isolated human corpus cavernosum, but enhances the effect of nitric oxide (NO) by inhibiting phosphodiesterase type 5 (PDE5), which is responsible for degradation of cGMP in the corpus cavernosum. When sexual stimulation causes local release of NO, inhibition of PDE5 by sildenafil causes increased levels of cGMP in the corpus cavernosum, resulting in smooth muscle relaxation and inflow of blood to the corpus cavernosum. Sildenafil at recommended doses has no effect in the absence of sexual stimulation.

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Studies in vitro have shown that sildenafil is selective for PDE5. Its effect is more potent on PDE5 than on other known phosphodiesterases (10-fold for PDE6, >80-fold for PDE1, >700-fold for PDE2, PDE3, PDE4, PDE7, PDE8, PDE9, PDE10, and PDE11). The approximately 4,000-fold selectivity for PDE5 versus PDE3 is important because PDE3 is involved in control of cardiac contractility. Sildenafil is only about 10-fold as potent for PDE5 compared to PDE6, an enzyme found in the retina which is involved in the phototransduction pathway of the retina. This lower selectivity is thought to be the basis for abnormalities related to color vision observed with higher doses or plasma levels (see Pharmacodynamics).

In addition to human corpus cavernosum smooth muscle, PDE5 is also found in lower concentrations in other tissues including platelets, vascular and visceral smooth muscle, and skeletal muscle. The inhibition of PDE5 in these tissues by sildenafil may be the basis for the enhanced platelet antiaggregatory activity of nitric oxide observed in vitro, an inhibition of platelet thrombus formation in vivo and peripheral arterial-venous dilatation in vivo.

Pharmacokinetics and Metabolism

VIAGRA is rapidly absorbed after oral administration, with absolute bioavailability of about 40%. Its pharmacokinetics are dose-proportional over the recommended dose range. It is eliminated predominantly by hepatic metabolism (mainly cytochrome P450 3A4) and is converted to an active metabolite with properties similar to the parent, sildenafil. The concomitant use of potent cytochrome P450 3A4 inhibitors (e.g., erythromycin, ketoconazole, itraconazole) as well as the nonspecific CYP inhibitor, cimetidine, is associated with increased plasma levels of sildenafil (see DOSAGE AND ADMINISTRATION). Both sildenafil and the metabolite have terminal half lives of about 4 hours.

Mean sildenafil plasma concentrations measured after the administration of a single oral dose of 100 mg to healthy male volunteers is depicted below:

Figure 1: Mean Sildenafil Plasma Concentrations in Healthy Male Volunteers.

Absorption and Distribution: VIAGRA is rapidly absorbed. Maximum observed plasma concentrations are reached within 30 to 120 minutes (median 60 minutes) of oral dosing in the fasted state. When VIAGRA is taken with a high fat meal, the rate of absorption is reduced, with a mean delay in Tmax of 60 minutes and a mean reduction in Cmax of 29%. The mean steady state volume of distribution (Vss) for sildenafil is 105 L, indicating distribution into the tissues. Sildenafil and its major circulating N-desmethyl metabolite are both approximately 96% bound to plasma proteins. Protein binding is independent of total drug concentrations.

Based upon measurements of sildenafil in semen of healthy volunteers 90 minutes after dosing, less than 0.001% of the administered dose may appear in the semen of patients.

Metabolism and Excretion: Sildenafil is cleared predominantly by the CYP3A4 (major route) and CYP2C9 (minor route) hepatic microsomal isoenzymes. The major circulating metabolite results from N-desmethylation of sildenafil, and is itself further metabolized. This metabolite has a PDE selectivity profile similar to sildenafil and an in vitro potency for PDE5 approximately 50% of the parent drug. Plasma concentrations of this metabolite are approximately 40% of those seen for sildenafil, so that the metabolite accounts for about 20% of sildenafil's pharmacologic effects.

After either oral or intravenous administration, sildenafil is excreted as metabolites predominantly in the feces (approximately 80% of administered oral dose) and to a lesser extent in the urine (approximately 13% of the administered oral dose). Similar values for pharmacokinetic parameters were seen in normal volunteers and in the patient population, using a population pharmacokinetic approach.

Pharmacokinetics in Special Populations

Geriatrics: Healthy elderly volunteers (65 years or over) had a reduced clearance of sildenafil, with free plasma concentrations approximately 40% greater than those seen in healthy younger volunteers (18-45 years).

Renal Insufficiency: In volunteers with mild (CLcr=50-80 mL/min) and moderate (CLcr=30-49 mL/min) renal impairment, the pharmacokinetics of a single oral dose of VIAGRA (50 mg) were not altered. In volunteers with severe (CLcr=<30 mL/min) renal impairment, sildenafil clearance was reduced, resulting in approximately doubling of AUC and Cmax compared to age-matched volunteers with no renal impairment.

Hepatic Insufficiency: In volunteers with hepatic cirrhosis (Child-Pugh A and B), sildenafil clearance was reduced, resulting in increases in AUC (84%) and Cmax (47%) compared to age-matched volunteers with no hepatic impairment.

Therefore, age >65, hepatic impairment and severe renal impairment are associated with increased plasma levels of sildenafil. A starting oral dose of 25 mg should be considered in those patients (see DOSAGE AND ADMINISTRATION).

Pharmacodynamics

Effects of VIAGRA on Erectile Response: In eight double-blind, placebo-controlled crossover studies of patients with either organic or psychogenic erectile dysfunction, sexual stimulation resulted in improved erections, as assessed by an objective measurement of hardness and duration of erections (RigiScan®), after VIAGRA administration compared with placebo. Most studies assessed the efficacy of VIAGRA approximately 60 minutes post dose. The erectile response, as assessed by RigiScan®, generally increased with increasing sildenafil dose and plasma concentration. The time course of effect was examined in one study, showing an effect for up to 4 hours but the response was diminished compared to 2 hours.

Effects of VIAGRA on Blood Pressure: Single oral doses of sildenafil (100 mg) administered to healthy volunteers produced decreases in supine blood pressure (mean maximum decrease in systolic/diastolic blood pressure of 8.4/5.5 mmHg). The decrease in blood pressure was most notable approximately 1-2 hours after dosing, and was not different than placebo at 8 hours. Similar effects on blood pressure were noted with 25 mg, 50 mg and 100 mg of VIAGRA, therefore the effects are not related to dose or plasma levels within this dosage range. Larger effects were recorded among patients receiving concomitant nitrates (see CONTRAINDICATIONS).

Figure 2: Mean Change from Baseline in Sitting Systolic Blood Pressure, Healthy Volunteers.

Effects of VIAGRA on Cardiac Parameters: Single oral doses of sildenafil up to 100 mg produced no clinically relevant changes in the ECGs of normal male volunteers.

Studies have produced relevant data on the effects of VIAGRA on cardiac output. In one small, open-label, uncontrolled, pilot study, eight patients with stable ischemic heart disease underwent Swan-Ganz catheterization. A total dose of 40 mg sildenafil was administered by four intravenous infusions.

The results from this pilot study are shown in Table 1; the mean resting systolic and diastolic blood pressures decreased by 7% and 10% compared to baseline in these patients. Mean resting values for right atrial pressure, pulmonary artery pressure, pulmonary artery occluded pressure and cardiac output decreased by 28%, 28%, 20% and 7% respectively. Even though this total dosage produced plasma sildenafil concentrations which were approximately 2 to 5 times higher than the mean maximum plasma concentrations following a single oral dose of 100 mg in healthy male volunteers, the hemodynamic response to exercise was preserved in these patients.

TABLE 1. HEMODYNAMIC DATA IN PATIENTS WITH STABLE ISCHEMIC HEART DISEASE AFTER IV ADMINISTRATION OF 40 MG SILDENAFIL

Means ± SD	At rest				After 4 minutes of exercise
	n	Baseline (B2)	n	Sildenafil (D1)	n	Baseline	n	Sildenafil
PAOP (mmHg)	8	8.1 ± 5.1	8	6.5 ± 4.3	8	36.0 ± 13.7	8	27.8 ± 15.3
Mean PAP (mmHg)	8	16.7 ± 4	8	12.1 ± 3.9	8	39.4 ± 12.9	8	31.7 ± 13.2
Mean RAP (mmHg)	7	5.7 ± 3.7	8	4.1 ± 3.7	-	-	-	-
Systolic SAP (mmHg)	8	150.4 ± 12.4	8	140.6 ± 16.5	8	199.5 ± 37.4	8	187.8 ± 30.0
Diastolic SAP (mmHg)	8	73.6 ± 7.8	8	65.9 ± 10	8	84.6 ± 9.7	8	79.5 ± 9.4
Cardiac output (L/min)	8	5.6 ± 0.9	8	5.2 ± 1.1	8	11.5 ± 2.4	8	10.2 ± 3.5
Heart rate (bpm)	8	67 ± 11.1	8	66.9 ± 12	8	101.9 ± 11.6	8	99.0 ± 20.4

 

In a double-blind study, 144 patients with erectile dysfunction and chronic stable angina limited by exercise, not receiving chronic oral nitrates, were randomized to a single dose of placebo or VIAGRA 100 mg 1 hour prior to exercise testing. The primary endpoint was time to limiting angina in the evaluable cohort. The mean times (adjusted for baseline) to onset of limiting angina were 423.6 and 403.7 seconds for sildenafil (N=70) and placebo, respectively. These results demonstrated that the effect of VIAGRA on the primary endpoint was statistically non-inferior to placebo.

Effects of VIAGRA on Vision: At single oral doses of 100 mg and 200 mg, transient dose-related impairment of color discrimination (blue/green) was detected using the Farnsworth-Munsell 100-hue test, with peak effects near the time of peak plasma levels. This finding is consistent with the inhibition of PDE6, which is involved in phototransduction in the retina. An evaluation of visual function at doses up to twice the maximum recommended dose revealed no effects of VIAGRA on visual acuity, intraocular pressure, or pupillometry.

Clinical Studies

In clinical studies, VIAGRA was assessed for its effect on the ability of men with erectile dysfunction (ED) to engage in sexual activity and in many cases specifically on the ability to achieve and maintain an erection sufficient for satisfactory sexual activity. VIAGRA was evaluated primarily at doses of 25 mg, 50 mg and 100 mg in 21 randomized, double-blind, placebo-controlled trials of up to 6 months in duration, using a variety of study designs (fixed dose, titration, parallel, crossover). VIAGRA was administered to more than 3,000 patients aged 19 to 87 years, with ED of various etiologies (organic, psychogenic, mixed) with a mean duration of 5 years. VIAGRA demonstrated statistically significant improvement compared to placebo in all 21 studies. The studies that established benefit demonstrated improvements in success rates for sexual intercourse compared with placebo.

The effectiveness of VIAGRA was evaluated in most studies using several assessment instruments. The primary measure in the principal studies was a sexual function questionnaire (the International Index of Erectile Function - IIEF) administered during a 4-week treatment-free run-in period, at baseline, at follow-up visits, and at the end of double-blind, placebo-controlled, at-home treatment. Two of the questions from the IIEF served as primary study endpoints; categorical responses were elicited to questions about (1) the ability to achieve erections sufficient for sexual intercourse and (2) the maintenance of erections after penetration. The patient addressed both questions at the final visit for the last 4 weeks of the study. The possible categorical responses to these questions were (0) no attempted intercourse, (1) never or almost never, (2) a few times, (3) sometimes, (4) most times, and (5) almost always or always. Also collected as part of the IIEF was information about other aspects of sexual function, including information on erectile function, orgasm, desire, satisfaction with intercourse, and overall sexual satisfaction. Sexual function data were also recorded by patients in a daily diary. In addition, patients were asked a global efficacy question and an optional partner questionnaire was administered.

The effect on one of the major end points, maintenance of erections after penetration, is shown in Figure 3, for the pooled results of 5 fixed-dose, dose-response studies of greater than one month duration, showing response according to baseline function. Results with all doses have been pooled, but scores showed greater improvement at the 50 and 100 mg doses than at 25 mg. The pattern of responses was similar for the other principal question, the ability to achieve an erection sufficient for intercourse. The titration studies, in which most patients received 100 mg, showed similar results. Figure 3 shows that regardless of the baseline levels of function, subsequent function in patients treated with VIAGRA was better than that seen in patients treated with placebo. At the same time, on-treatment function was better in treated patients who were less impaired at baseline.

 

Figure 3. Effect of VIAGRA and Placebo on
Maintenance of Erection by Baseline Score.

The frequency of patients reporting improvement of erections in response to a global question in four of the randomized, double-blind, parallel, placebo-controlled fixed dose studies (1797 patients) of 12 to 24 weeks duration is shown in Figure 4. These patients had erectile dysfunction at baseline that was characterized by median categorical scores of 2 (a few times) on principal IIEF questions. Erectile dysfunction was attributed to organic (58%; generally not characterized, but including diabetes and excluding spinal cord injury), psychogenic (17%), or mixed (24%) etiologies. Sixty-three percent, 74%, and 82% of the patients on 25 mg, 50 mg and 100 mg of VIAGRA, respectively, reported an improvement in their erections, compared to 24% on placebo. In the titration studies (n=644) (with most patients eventually receiving 100 mg), results were similar.

Figure 4. Percentage of Patients Reporting an Improvement in Erections.

The patients in studies had varying degrees of ED. One-third to one-half of the subjects in these studies reported successful intercourse at least once during a 4-week, treatment-free run-in period.

In many of the studies, of both fixed dose and titration designs, daily diaries were kept by patients. In these studies, involving about 1600 patients, analyses of patient diaries showed no effect of VIAGRA on rates of attempted intercourse (about 2 per week), but there was clear treatment-related improvement in sexual function: per patient weekly success rates averaged 1.3 on 50-100 mg of VIAGRA vs 0.4 on placebo; similarly, group mean success rates (total successes divided by total attempts) were about 66% on VIAGRA vs about 20% on placebo.

During 3 to 6 months of double-blind treatment or longer-term (1 year), open-label studies, few patients withdrew from active treatment for any reason, including lack of effectiveness. At the end of the long-term study, 88% of patients reported that VIAGRA improved their erections.

Men with untreated ED had relatively low baseline scores for all aspects of sexual function measured (again using a 5-point scale) in the IIEF. VIAGRA improved these aspects of sexual function: frequency, firmness and maintenance of erections; frequency of orgasm; frequency and level of desire; frequency, satisfaction and enjoyment of intercourse; and overall relationship satisfaction.

One randomized, double-blind, flexible-dose, placebo-controlled study included only patients with erectile dysfunction attributed to complications of diabetes mellitus (n=268). As in the other titration studies, patients were started on 50 mg and allowed to adjust the dose up to 100 mg or down to 25 mg of VIAGRA; all patients, however, were receiving 50 mg or 100 mg at the end of the study. There were highly statistically significant improvements on the two principal IIEF questions (frequency of successful penetration during sexual activity and maintenance of erections after penetration) on VIAGRA compared to placebo. On a global improvement question, 57% of VIAGRA patients reported improved erections versus 10% on placebo. Diary data indicated that on VIAGRA, 48% of intercourse attempts were successful versus 12% on placebo.

One randomized, double-blind, placebo-controlled, crossover, flexible-dose (up to 100 mg) study of patients with erectile dysfunction resulting from spinal cord injury (n=178) was conducted. The changes from baseline in scoring on the two end point questions (frequency of successful penetration during sexual activity and maintenance of erections after penetration) were highly statistically significantly in favor of VIAGRA. On a global improvement question, 83% of patients reported improved erections on VIAGRA versus 12% on placebo. Diary data indicated that on VIAGRA, 59% of attempts at sexual intercourse were successful compared to 13% on placebo.

Across all trials, VIAGRA improved the erections of 43% of radical prostatectomy patients compared to 15% on placebo.

Subgroup analyses of responses to a global improvement question in patients with psychogenic etiology in two fixed-dose studies (total n=179) and two titration studies (total n=149) showed 84% of VIAGRA patients reported improvement in erections compared with 26% of placebo. The changes from baseline in scoring on the two end point questions (frequency of successful penetration during sexual activity and maintenance of erections after penetration) were highly statistically significantly in favor of VIAGRA. Diary data in two of the studies (n=178) showed rates of successful intercourse per attempt of 70% for VIAGRA and 29% for placebo.

A review of population subgroups demonstrated efficacy regardless of baseline severity, etiology, race and age. VIAGRA was effective in a broad range of ED patients, including those with a history of coronary artery disease, hypertension, other cardiac disease, peripheral vascular disease, diabetes mellitus, depression, coronary artery bypass graft (CABG), radical prostatectomy, transurethral resection of the prostate (TURP) and spinal cord injury, and in patients taking antidepressants/antipsychotics and antihypertensives/diuretics.

Analysis of the safety database showed no apparent difference in the side effect profile in patients taking VIAGRA with and without antihypertensive medication. This analysis was performed retrospectively, and was not powered to detect any pre-specified difference in adverse reactions.

INDICATION AND USAGE

VIAGRA is indicated for the treatment of erectile dysfunction.

CONTRAINDICATIONS

Consistent with its known effects on the nitric oxide/cGMP pathway (see CLINICAL PHARMACOLOGY), VIAGRA was shown to potentiate the hypotensive effects of nitrates, and its administration to patients who are using organic nitrates, either regularly and/or intermittently, in any form is therefore contraindicated.

After patients have taken VIAGRA, it is unknown when nitrates, if necessary, can be safely administered. Based on the pharmacokinetic profile of a single 100 mg oral dose given to healthy normal volunteers, the plasma levels of sildenafil at 24 hours post dose are approximately 2 ng/mL (compared to peak plasma levels of approximately 440 ng/mL) (see CLINICAL PHARMACOLOGY: Pharmacokinetics and Metabolism). In the following patients: age >65, hepatic impairment (e.g., cirrhosis), severe renal impairment (e.g., creatinine clearance <30 mL/min), and concomitant use of potent cytochrome P450 3A4 inhibitors (erythromycin), plasma levels of sildenafil at 24 hours post dose have been found to be 3 to 8 times higher than those seen in healthy volunteers. Although plasma levels of sildenafil at 24 hours post dose are much lower than at peak concentration, it is unknown whether nitrates can be safely coadministered at this time point.

VIAGRA is contraindicated in patients with a known hypersensitivity to any component of the tablet.

WARNINGS

There is a potential for cardiac risk of sexual activity in patients with preexisting cardiovascular disease. Therefore, treatments for erectile dysfunction, including VIAGRA, should not be generally used in men for whom sexual activity is inadvisable because of their underlying cardiovascular status.

VIAGRA has systemic vasodilatory properties that resulted in transient decreases in supine blood pressure in healthy volunteers (mean maximum decrease of 8.4/5.5 mmHg), (see CLINICAL PHARMACOLOGY: Pharmacodynamics). While this normally would be expected to be of little consequence in most patients, prior to prescribing VIAGRA, physicians should carefully consider whether their patients with underlying cardiovascular disease could be affected adversely by such vasodilatory effects, especially in combination with sexual activity.

Patients with the following underlying conditions can be particularly sensitive to the actions of vasodilators including VIAGRA - those with left ventricular outflow obstruction (e.g. aortic stenosis, idiopathic hypertrophic subaortic stenosis) and those with severely impaired autonomic control of blood pressure.

There is no controlled clinical data on the safety or efficacy of VIAGRA in the following groups; if prescribed, this should be done with caution.

• Patients who have suffered a myocardial infarction, stroke, or life-threatening arrhythmia within the last 6 months;
• Patients with resting hypotension (BP 170/110);
• Patients with cardiac failure or coronary artery disease causing unstable angina;
• Patients with retinitis pigmentosa (a minority of these patients have genetic disorders of retinal phosphodiesterases).

Prolonged erection greater than 4 hours and priapism (painful erections greater than 6 hours in duration) have been reported infrequently since market approval of VIAGRA. In the event of an erection that persists longer than 4 hours, the patient should seek immediate medical assistance. If priapism is not treated immediately, penile tissue damage and permanent loss of potency could result.

The concomitant administration of the protease inhibitor ritonavir substantially increases serum concentrations of sildenafil (11-fold increase in AUC). If VIAGRA is prescribed to patients taking ritonavir, caution should be used. Data from subjects exposed to high systemic levels of sildenafil are limited. Visual disturbances occurred more commonly at higher levels of sildenafil exposure. Decreased blood pressure, syncope, and prolonged erection were reported in some healthy volunteers exposed to high doses of sildenafil (200-800 mg). To decrease the chance of adverse events in patients taking ritonavir, a decrease in sildenafil dosage is recommended (see Drug Interactions, ADVERSE REACTIONS and DOSAGE AND ADMINISTRATION).

PRECAUTIONS

General

The evaluation of erectile dysfunction should include a determination of potential underlying causes and the identification of appropriate treatment following a complete medical assessment.

Before prescribing VIAGRA, it is important to note the following:

Patients on multiple antihypertensive medications were included in the pivotal clinical trials for VIAGRA. In a separate drug interaction study, when amlodipine, 5 mg or 10 mg, and VIAGRA, 100 mg were orally administered concomitantly to hypertensive patients mean additional blood pressure reduction of 8 mmHg systolic and 7 mmHg diastolic were noted (see Drug Interactions).

When the alpha blocker doxazosin (4 mg) and VIAGRA (25 mg) were administered simultaneously to patients with benign prostatic hyperplasia (BPH), mean additional reductions of supine blood pressure of 7 mmHg systolic and 7 mmHg diastolic were observed. When higher doses of VIAGRA and doxazosin (4 mg) were administered simultaneously, there were infrequent reports of patients who experienced symptomatic postural hypotension within 1 to 4 hours of dosing. Simultaneous administration of VIAGRA to patients taking alpha-blocker therapy may lead to symptomatic hypotension in some patients. Therefore, VIAGRA doses above 25 mg should not be taken within 4 hours of taking an alpha-blocker

The safety of VIAGRA is unknown in patients with bleeding disorders and patients with active peptic ulceration.

VIAGRA should be used with caution in patients with anatomical deformation of the penis (such as angulation, cavernosal fibrosis or Peyronie's disease), or in patients who have conditions which may predispose them to priapism (such as sickle cell anemia, multiple myeloma, or leukemia).

The safety and efficacy of combinations of VIAGRA with other treatments for erectile dysfunction have not been studied. Therefore, the use of such combinations is not recommended.

In humans, VIAGRA has no effect on bleeding time when taken alone or with aspirin. In vitro studies with human platelets indicate that sildenafil potentiates the antiaggregatory effect of sodium nitroprusside (a nitric oxide donor). The combination of heparin and VIAGRA had an additive effect on bleeding time in the anesthetized rabbit, but this interaction has not been studied in humans.

Information for Patients

Physicians should discuss with patients the contraindication of VIAGRA with regular and/or intermittent use of organic nitrates.

Physicians should discuss with patients the potential cardiac risk of sexual activity in patients with preexisting cardiovascular risk factors. Patients who experience symptoms (e.g., angina pectoris, dizziness, nausea) upon initiation of sexual activity should be advised to refrain from further activity and should discuss the episode with their physician.

Physicians should advise patients to stop use of all PDE5 inhibitors, including VIAGRA, and seek medical attention in the event of a sudden loss of vision in one or both eyes. Such an event may be a sign of non-arteritic anterior ischemic optic neuropathy (NAION), a cause of decreased vision including permanent loss of vision, that has been reported rarely post-marketing in temporal association with the use of all PDE5 inhibitors. It is not possible to determine whether these events are related directly to the use of PDE5 inhibitors or to other factors. Physicians should also discuss with patients the increased risk of NAION in individuals who have already experienced NAION in one eye, including whether such individuals could be adversely affected by use of vasodilators, such as PDE5 inhibitors (see POSTMARKETING EXPERIENCE/Special Senses).

Physicians should warn patients that prolonged erections greater than 4 hours and priapism (painful erections greater than 6 hours in duration) have been reported infrequently since market approval of VIAGRA. In the event of an erection that persists longer than 4 hours, the patient should seek immediate medical assistance. If priapism is not treated immediately, penile tissue damage and permanent loss of potency may result.

Physicians should advise patients that simultaneous administration of VIAGRA doses above 25 mg and an alpha-blocker may lead to symptomatic hypotension in some patients. Therefore, VIAGRA doses above 25 mg should not be taken within four hours of taking an alpha-blocker.

The use of VIAGRA offers no protection against sexually transmitted diseases. Counseling of patients about the protective measures necessary to guard against sexually transmitted diseases, including the Human Immunodeficiency Virus (HIV), may be considered.

Drug Interactions

Effects of Other Drugs on VIAGRA

In vitro studies: Sildenafil metabolism is principally mediated by the cytochrome P450 (CYP) isoforms 3A4 (major route) and 2C9 (minor route). Therefore, inhibitors of these isoenzymes may reduce sildenafil clearance.

In vivo studies: Cimetidine (800 mg), a nonspecific CYP inhibitor, caused a 56% increase in plasma sildenafil concentrations when coadministered with VIAGRA (50 mg) to healthy volunteers.

When a single 100 mg dose of VIAGRA was administered with erythromycin, a specific CYP3A4 inhibitor, at steady state (500 mg bid for 5 days), there was a 182% increase in sildenafil systemic exposure (AUC). In addition, in a study performed in healthy male volunteers, coadministration of the HIV protease inhibitor saquinavir, also a CYP3A4 inhibitor, at steady state (1200 mg tid) with VIAGRA (100 mg single dose) resulted in a 140% increase in sildenafil Cmax and a 210% increase in sildenafil AUC. VIAGRA had no effect on saquinavir pharmacokinetics. Stronger CYP3A4 inhibitors such as ketoconazole or itraconazole would be expected to have still greater effects, and population data from patients in clinical trials did indicate a reduction in sildenafil clearance when it was coadministered with CYP3A4 inhibitors (such as ketoconazole, erythromycin, or cimetidine) (see DOSAGE AND ADMINISTRATION).

In another study in healthy male volunteers, coadministration with the HIV protease inhibitor ritonavir, which is a highly potent P450 inhibitor, at steady state (500 mg bid) with VIAGRA (100 mg single dose) resulted in a 300% (4-fold) increase in sildenafil Cmax and a 1000% (11-fold) increase in sildenafil plasma AUC. At 24 hours the plasma levels of sildenafil were still approximately 200 ng/mL, compared to approximately 5 ng/mL when sildenafil was dosed alone. This is consistent with ritonavir's marked effects on a broad range of P450 substrates. VIAGRA had no effect on ritonavir pharmacokinetics (see DOSAGE AND ADMINISTRATION).

Although the interaction between other protease inhibitors and sildenafil has not been studied, their concomitant use is expected to increase sildenafil levels.

It can be expected that concomitant administration of CYP3A4 inducers, such as rifampin, will decrease plasma levels of sildenafil.

Single doses of antacid (magnesium hydroxide/aluminum hydroxide) did not affect the bioavailability of VIAGRA.

Pharmacokinetic data from patients in clinical trials showed no effect on sildenafil pharmacokinetics of CYP2C9 inhibitors (such as tolbutamide, warfarin), CYP2D6 inhibitors (such as selective serotonin reuptake inhibitors, tricyclic antidepressants), thiazide and related diuretics, ACE inhibitors, and calcium channel blockers. The AUC of the active metabolite, N-desmethyl sildenafil, was increased 62% by loop and potassium-sparing diuretics and 102% by nonspecific beta-blockers. These effects on the metabolite are not expected to be of clinical consequence.

Effects of VIAGRA on Other Drugs

In vitro studies: Sildenafil is a weak inhibitor of the cytochrome P450 isoforms 1A2, 2C9, 2C19, 2D6, 2E1 and 3A4 (IC50 >150 mM). Given sildenafil peak plasma concentrations of approximately 1 mM after recommended doses, it is unlikely that VIAGRA will alter the clearance of substrates of these isoenzymes.

In vivo studies: When VIAGRA 100 mg oral was coadministered with amlodipine, 5 mg or 10 mg oral, to hypertensive patients, the mean additional reduction on supine blood pressure was 8 mmHg systolic and 7 mmHg diastolic.

No significant interactions were shown with tolbutamide (250 mg) or warfarin (40 mg), both of which are metabolized by CYP2C9.

VIAGRA (50 mg) did not potentiate the increase in bleeding time caused by aspirin (150 mg).

VIAGRA (50 mg) did not potentiate the hypotensive effect of alcohol in healthy volunteers with mean maximum blood alcohol levels of 0.08%.

In a study of healthy male volunteers, sildenafil (100 mg) did not affect the steady state pharmacokinetics of the HIV protease inhibitors, saquinavir and ritonavir, both of which are CYP3A4 substrates.

Carcinogenesis, Mutagenesis, Impairment of Fertility

Sildenafil was not carcinogenic when administered to rats for 24 months at a dose resulting in total systemic drug exposure (AUCs) for unbound sildenafil and its major metabolite of 29- and 42-times, for male and female rats, respectively, the exposures observed in human males given the Maximum Recommended Human Dose (MRHD) of 100 mg. Sildenafil was not carcinogenic when administered to mice for 18-21 months at dosages up to the Maximum Tolerated Dose (MTD) of 10 mg/kg/day, approximately 0.6 times the MRHD on a mg/m2 basis.

Sildenafil was negative in in vitro bacterial and Chinese hamster ovary cell assays to detect mutagenicity, and in vitro human lymphocytes and in vivo mouse micronucleus assays to detect clastogenicity.

There was no impairment of fertility in rats given sildenafil up to 60 mg/kg/day for 36 days to females and 102 days to males, a dose producing an AUC value of more than 25 times the human male AUC.

There was no effect on sperm motility or morphology after single 100 mg oral doses of VIAGRA in healthy volunteers.

Pregnancy, Nursing Mothers and Pediatric Use

VIAGRA is not indicated for use in newborns, children, or women.

Pregnancy Category B. No evidence of teratogenicity, embryotoxicity or fetotoxicity was observed in rats and rabbits which received up to 200 mg/kg/day during organogenesis. These doses represent, respectively, about 20 and 40 times the MRHD on a mg/m2 basis in a 50 kg subject. In the rat pre- and postnatal development study, the no observed adverse effect dose was 30 mg/kg/day given for 36 days. In the nonpregnant rat the AUC at this dose was about 20 times human AUC. There are no adequate and well-controlled studies of sildenafil in pregnant women.

Geriatric Use: Healthy elderly volunteers (65 years or over) had a reduced clearance of sildenafil (see CLINICAL PHARMACOLOGY: Pharmacokinetics in Special Populations). Since higher plasma levels may increase both the efficacy and incidence of adverse events, a starting dose of 25 mg should be considered (see DOSAGE AND ADMINISTRATION).

ADVERSE REACTIONS

PRE-MARKETING EXPERIENCE:

VIAGRA was administered to over 3700 patients (aged 19-87 years) during clinical trials worldwide. Over 550 patients were treated for longer than one year.

In placebo-controlled clinical studies, the discontinuation rate due to adverse events for VIAGRA (2.5%) was not significantly different from placebo (2.3%). The adverse events were generally transient and mild to moderate in nature.

In trials of all designs, adverse events reported by patients receiving VIAGRA were generally similar. In fixed-dose studies, the incidence of some adverse events increased with dose. The nature of the adverse events in flexible-dose studies, which more closely reflect the recommended dosage regimen, was similar to that for fixed-dose studies.

When VIAGRA was taken as recommended (on an as-needed basis) in flexible-dose, placebo-controlled clinical trials, the following adverse events were reported:

TABLE 2. ADVERSE EVENTS REPORTED BY ³2% OF PATIENTS TREATED WITH VIAGRA AND MORE FREQUENT ON DRUG THAN PLACEBO IN PRN FLEXIBLE-DOSE PHASE II/III STUDIES

Adverse Event	Percentage of Patients Reporting Event
	VIAGRA	PLACEBO
	N=734	N=725
Headache	16%	4%
Flushing	10%	1%
Dyspepsia	7%	2%
Nasal Congestion	4%	2%
Urinary Tract Infection *	3%	2%
Abnormal Vision	3%	0%
Diarrhea	3%	1%
Dizziness	2%	1%
Rash	2%	1%

* Abnormal Vision: Mild and transient, predominantly color tinge to vision, but also increased sensitivity to light or blurred vision. In these studies, only one patient discontinued due to abnormal vision.

Other adverse reactions occurred at a rate of >2%, but equally common on placebo: respiratory tract infection, back pain, flu syndrome, and arthralgia.

In fixed-dose studies, dyspepsia (17%) and abnormal vision (11%) were more common at 100 mg than at lower doses. At doses above the recommended dose range, adverse events were similar to those detailed above but generally were reported more frequently.

The following events occurred in <2% of patients in controlled clinical trials; a causal relationship to VIAGRA is uncertain. Reported events include those with a plausible relation to drug use; omitted are minor events and reports too imprecise to be meaningful:

Body as a whole: face edema, photosensitivity reaction, shock, asthenia, pain, chills, accidental fall, abdominal pain, allergic reaction, chest pain, accidental injury.

Cardiovascular: angina pectoris, AV block, migraine, syncope, tachycardia, palpitation, hypotension, postural hypotension, myocardial ischemia, cerebral thrombosis, cardiac arrest, heart failure, abnormal electrocardiogram, cardiomyopathy.

Digestive: vomiting, glossitis, colitis, dysphagia, gastritis, gastroenteritis, esophagitis, stomatitis, dry mouth, liver function tests abnormal, rectal hemorrhage, gingivitis.

Hemic and Lymphatic: anemia and leukopenia.

Metabolic and Nutritional: thirst, edema, gout, unstable diabetes, hyperglycemia, peripheral edema, hyperuricemia, hypoglycemic reaction, hypernatremia.

Musculoskeletal: arthritis, arthrosis, myalgia, tendon rupture, tenosynovitis, bone pain, myasthenia, synovitis.

Nervous: ataxia, hypertonia, neuralgia, neuropathy, paresthesia, tremor, vertigo, depression, insomnia, somnolence, abnormal dreams, reflexes decreased, hypesthesia.

Respiratory: asthma, dyspnea, laryngitis, pharyngitis, sinusitis, bronchitis, sputum increased, cough increased.

Skin and Appendages: urticaria, herpes simplex, pruritus, sweating, skin ulcer, contact dermatitis, exfoliative dermatitis.

Special Senses: mydriasis, conjunctivitis, photophobia, tinnitus, eye pain, deafness, ear pain, eye hemorrhage, cataract, dry eyes.

Urogenital: cystitis, nocturia, urinary frequency, breast enlargement, urinary incontinence, abnormal ejaculation, genital edema and anorgasmia.

POST-MARKETING EXPERIENCE:

Cardiovascular and cerebrovascular

Serious cardiovascular, cerebrovascular, and vascular events, including myocardial infarction, sudden cardiac death, ventricular arrhythmia, cerebrovascular hemorrhage, transient ischemic attack, hypertension, subarachnoid and intracerebral hemorrhages, and pulmonary hemorrhage have been reported post-marketing in temporal association with the use of VIAGRA. Most, but not all, of these patients had preexisting cardiovascular risk factors. Many of these events were reported to occur during or shortly after sexual activity, and a few were reported to occur shortly after the use of VIAGRA without sexual activity. Others were reported to have occurred hours to days after the use of VIAGRA and sexual activity. It is not possible to determine whether these events are related directly to VIAGRA, to sexual activity, to the patient's underlying cardiovascular disease, to a combination of these factors, or to other factors (see WARNINGS for further important cardiovascular information).

Other events

Other events reported post-marketing to have been observed in temporal association with VIAGRA and not listed in the pre-marketing adverse reactions section above include:

Nervous: seizure and anxiety.

Urogenital: prolonged erection, priapism (see WARNINGS) and hematuria.

Special Senses: diplopia, temporary vision loss/decreased vision, ocular redness or bloodshot appearance, ocular burning, ocular swelling/pressure, increased intraocular pressure, retinal vascular disease or bleeding, vitreous detachment/traction, paramacular edema and epistaxis.

Non-arteritic anterior ischemic optic neuropathy (NAION), a cause of decreased vision including permanent loss of vision, has been reported rarely post-marketing in temporal association with the use of phosphodiesterase type 5 (PDE5) inhibitors, including VIAGRA. Most, but not all, of these patients had underlying anatomic or vascular risk factors for developing NAION, including but not necessarily limited to: low cup to disc ratio ("crowded disc"age over 50, diabetes, hypertension, coronary artery disease, hyperlipidemia and smoking. It is not possible to determine whether these events are related directly to the use of PDE5 inhibitors, to the patient's underlying vascular risk factors or anatomical defects, to a combination of these factors, or to other factors (see PRECAUTIONS/Information for Patients).

OVERDOSAGE

In studies with healthy volunteers of single doses up to 800 mg, adverse events were similar to those seen at lower doses but incidence rates were increased.

In cases of overdose, standard supportive measures should be adopted as required. Renal dialysis is not expected to accelerate clearance as sildenafil is highly bound to plasma proteins and it is not eliminated in the urine.

DOSAGE AND ADMINISTRATION

For most patients, the recommended dose is 50 mg taken, as needed, approximately 1 hour before sexual activity. However, VIAGRA may be taken anywhere from 4 hours to 0.5 hour before sexual activity. Based on effectiveness and toleration, the dose may be increased to a maximum recommended dose of 100 mg or decreased to 25 mg. The maximum recommended dosing frequency is once per day.

The following factors are associated with increased plasma levels of sildenafil: age >65 (40% increase in AUC), hepatic impairment (e.g., cirrhosis, 80%), severe renal impairment (creatinine clearance <30 mL/min, 100%), and concomitant use of potent cytochrome P450 3A4 inhibitors [ketoconazole, itraconazole, erythromycin (182%), saquinavir (210%)]. Since higher plasma levels may increase both the efficacy and incidence of adverse events, a starting dose of 25 mg should be considered in these patients.

Ritonavir greatly increased the systemic level of sildenafil in a study of healthy, non-HIV infected volunteers (11-fold increase in AUC, see Drug Interactions.) Based on these pharmacokinetic data, it is recommended not to exceed a maximum single dose of 25 mg of VIAGRA in a 48 hour period.

VIAGRA was shown to potentiate the hypotensive effects of nitrates and its administration in patients who use nitric oxide donors or nitrates in any form is therefore contraindicated.

Simultaneous administration of VIAGRA doses above 25 mg and an alpha-blocker may lead to symptomatic hypotension in some patients. Doses of 50 mg or 100 mg of VIAGRA should not be taken within 4 hours of alpha-blocker administration. A 25 mg dose of VIAGRA may be taken at any time.

HOW SUPPLIED

VIAGRA® (sildenafil citrate) is supplied as blue, film-coated, rounded-diamond-shaped tablets containing sildenafil citrate equivalent to the nominally indicated amount of sildenafil as follows:

	25 mg	50 mg	100 mg
Obverse	VGR25	VGR50	VGR100
Reverse	PFIZER	PFIZER	PFIZER
Bottle of 30	NDC-0069-4200-30	NDC-0069-4210-30	NDC-0069-4220-30
Bottle of 100	N/A	NDC-0069-4210-66	NDC-0069-4220-66

Recommended Storage: Store at 25°C (77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature].

Rx only

© 2005 PFIZER INC

21 Distributed by LAB-0221-4.0 Revised July 2005 Pfizer Labs Division of Pfizer Inc, NY, NY 10017

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Suggestions for dealing with various aspects of living with and relating to someone who has bipolar disorder or another mental illness.

Supporting Someone with Bipolar - For Family and Friends

Don't criticize
People struggling with any sort of mental illness are very vulnerable, and cannot defend themselves against direct personal attack. Try to be supportive, and keep negative or nagging remarks to an absolute minimum. If there is one single standard to work for in your relationship with a mentally ill person, it is to respect, and protect, their shattered self-esteem.

Don't press, don't fight, don't punish
"With this disease there is no fighting. You may not fight. You just have to take it and take it calmly. And remember to keep your voice down. Also punishment doesn't work with this disease. Now that I have lived with a person with schizophrenia, it makes me very upset when I see mental health workers try to correct their clients' adverse behavior by punishment, because I know it doesn't work." - Joe Talbot, quoted in The Family Face of Schizophrenia by Patricia Backlar

If you want to influence behavior effectively, the best thing to do is ignore negative behavior as much as you can, and praise positive behavior every chance you get
Study after study shows that if you "accentuate the positive" people will want to perform the behaviors that earn them recognition and approval. Many reliable studies indicate that criticism, conflict and emotional pressure are most highly related to relapse.

Learn to recognize and accept the primary symptoms, and the residual symptoms, of a person's brain disorder
Don't try to "jump start" someone in a depression, or "shoot down" a person with mania, or argue with schizophrenic delusions. Help them learn which of their behaviors are caused by their illness. Tell them it's not their fault if they cannot get out of depression, that they are not "terrible" for the things they did when they were manic, etc. This kind of support relieves a lot of guilt and anxiety, even when someone is still in denial.

Don't buy into the stigma all around you

People with mental illness are not "bad," or ill because of some failure of character. Our family member is not willfully trying to disgrace us, frustrate us and embarrass us. Their behavior is not a reflection on our relationship, or our parenting. They are not dedicated to undermining our dignity, or ruining our prestige and standing in the community. They are simply ill. Stigma ia awfully hard for us to bear in mental illness, but we certainly don't have to go along with it!

Lessen your demand for support from your ill relative
People with mental illness become very "self involved" when so much of their identity and self-respect is at stake. They often cannot fulfill normal family roles. We are all well advised to seek additional sources of emotional support for ourselves when there is mental illness in the family. Then our loved ones can be who they are, and they will feel less guilty for letting us down.

Having made these necessary allowances, treat people with mental illness, day-to-day, just like anybody else
Expect the "basics" we all require to get along together, and set the same limits and expectations for reasonable order that would exist if they were well. It is very reassuring to people with mental illness when we make a clear distinction between them as a person, and them as someone who has a problem with disordered behavior. All persons require rules of conduct and cooperative standards to live by.

It is important to encourage independent behavior
Ask your ill family member what they feel they are ready to do. Plan for progress in small steps that have a better chance for success. Make short-term plans and goals and be prepared for changes in directions, and retreats. Progress in mental illness requires flexibility; it means giving up our zeal for progress measured by normal standards. There is lots more danger in pushing than there is in waiting. When they are ready, they move.

It doesn't help us to cling to the past, or dwell on "what might have been"
The best gift we can offer is to accept that mental illness is a fact in the life of someone we love, and look ahead with hope to the future. It is important to tell our family members that mental illness makes life difficult, but not impossible. This is the only way it is now; things can be better. People come out of these illnesses; people get better. Family members can help keep the future alive; most people with mental illness do struggle on and rebuild their lives.

Every time our relatives "get better" and show improvement, for them it means that they are moving back into a risk position
Being well signals that they might be required to participate in the real world, and this is a frightening prospect for the "shaky self." So, it is important for us to be very patient in wellness, just as we are in illness. People recovering from mental illness still have the awesome task of accepting what has happened to them, finding new meaning in life, and constructing a way of living that protects them from becoming ill again.

Empathy must also extend to each of us who struggle to understand and encourage those we love who have mental illness. Remember, we can only try to do our best. We cannot do any better than that. Some illness processes get "stuck" no matter what we do to help. Brain disorders go through hard, intractable periods where helping those who suffer them is often very difficult to do. We can hope, we can assist, we can keep on trying, but we can't produce miracles.

Families tell us that the most important "grace" one learns is the process of caring for people with mental illness is forbearance, synonymous with tolerance, charity, endurance and self-restraint
Do not criticize yourself if you sometimes cannot muster up these graces when you are feeling frightened or frustrated. For all of us, coming to terms with changed life circumstances in serious illness is a huge adjustment. We do know that empathetic understanding will deepen and enrich our relationships with our relative suffering from a mental illness.

next: Help for Surviving Your Spouse's Mental Illness
~ bipolar disorder library
~ all bipolar disorder articles

An innovative new level of Inner Child Healing - a healing paradigm that includes tools, techniques, and perspectives for achieving spiritual integration and emotional balance.

• Feeling the Feelings

• Grief, Love, and Fear of Intimacy

• Grief Process Techniques

• Inner Child Healing Techniques

• Internal Boundaries

• Learning to Love Our Self

• Positive Affirmations

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next: Feeling the Feelings

Problems ADHD teens may have with different types of relationships and how to handle them.

ADHD can have a marked effect on relationships in the teenage years - with friends, parents, siblings, other family members and partners.

Impact of ADHD  on Friendships

• Teens with ADHD may feel 'different' from their peers and feel socially isolated.
• Friends' parents may think they're troublemakers.
• They may not notice how friends are feeling, especially if focused on something else.
• They may clash with friends because they speak before they think.

Ways to tackle

• Encourage friendships.
• Let your teen invite people home as often as possible.
• Have a discreet word with the parents of friends. Talk about the problems and encourage them to view your child in a more positive light.
• Teach your teen social skills such as how to read people's body language. This will help him see when he's at odds with friends and why.
• Teach your teen to take a deep breath before he says or does something. Ask him to think about how he'd feel if someone said or did that to him.

ADHD's Effect on Relationship with Parents

• Most teenagers think they're old enough to do something, whereas their parents feel the opposite.
• For teens with ADHD, the situation's even harder because the ADHD means they tend to react as if they're two or three years younger than they are. This means parents find it difficult to give them more freedom.
• There may also be conflict between parents as to the best way to handle the teen.

Ways to tackle

• Work as a partnership - parents and teenager need to be on the same team and respect each other.
• Discuss the issues and work out possible solutions together. This way, you'll end up with a set of house rules that everyone can work with.
• Include consequences of what happens if your teen doesn't stick to the rules, and follow through.
• Expect your teen to be responsible and treat him as if he'll do well. If you expect him to fail or behave badly and treat him as if he's going to go wrong, he probably will.
• Listen to each other and keep communication going.
• Keep calm - if you lose control, you'll lose your authority.

Effect of ADHD  Teen on Siblings and Other Family Members

• Siblings may feel that the child with ADHD gets all the attention and resent them having a different set of rules.
• Teens with ADHD might not respect their siblings' space.
• They may squabble more.
• They may not be able to 'put the brakes on'.
  Their behaviour may cut short family trips.
• Outside your home, other family members may be critical of your ADHD child or refuse to accept the condition exists.

Ways to tackle

• Make non-negotiable rules about siblings' space and property. This includes no disturbing homework, and any damage to belongings is paid for out of pocket money.
• Explain to your other children why there are different rules.
• Separate squabblers to give them time to calm down.
• Try to share time between your children. For example, the child without ADHD gets one parent to see school plays or sporting events.
• Explain the situation to other family members. If they can't accept it, that's their problem.

Impact of ADHD on Personal Relationships

• Teens with ADHD will be more forgetful than ones without ADHD, and may hurt their partner's feelings. They may have shifts in energy and their boyfriend or girlfriend may find it hard to keep up.
• Teenagers with ADHD may find it harder to manage a relationship at times of stress such as exams. Those with poor impulse control may come on too strong.
• First dates can be very tricky - the teen with ADHD may be so excited that he talks too much or find himself unable to follow the conversation. He may also misread social cues.

Ways to tackle

• First dates are never easy, but the following tips may help your teen.
• If talking too much is likely to be a problem, use a signal as a reminder to stop, eg a vibrating mobile phone alarm.
• Think of a couple of questions to ask your date to show interest in them.
• If you're not sure if it's OK to hold hands or kiss, ask first. Let your date set the pace so you don't come on too strong.

In the long-term, if your teen is finding the relationship hard to manage, he should talk to his girlfriend or boyfriend and explain how he feels. They are likely to understand and may even be able to help him through stressful times.

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If your child is taking an ADHD stimulant medication and you're considering switching to non-stimulant Strattera, here are some things to keep in mind.

Many parents were excited when Strattera was introduced, especially if they didn't like the idea of giving their child a stimulant or if they were not doing well with their ADHD medicine.

There were several things that kept some kids from being switched over right away though. As a new medicine, some people were hesitant to try it in case it caused as many or more side effects as a stimulant. Others didn't like the idea of waiting the two to four weeks that Strattera takes to be effective.

Of course, if your child's current medication, whether it is Adderall XR, Concerta, or Ritalin LA, etc., is controlling his ADHD symptoms and is not causing significant side effects, like a poor appetite, poor weight gain, or insomnia, than you likely still don't want to change.

Summertime Switch

For a child who was doing well at school, making a big change and taking the risk of interfering with that success is another big reason parents stick with their child's regular medicine.

That makes summer a good time to make a switch if you or your pediatrician have been considering it. Over the summer, you will likely have more time to deal with side effects of Strattera, adjust the dosage of Strattera that your child takes, and give it time to work. And you will have plenty of time before school starts back up again to change back to his old ADHD medicine or switch to a different one if it doesn't work.

Switching to Strattera at Other Times

Waiting until summer is not always practical though. If your child is losing a lot of weight, becomes too irritable when taking a stimulant, or if they just don't seem to work, you may want to try Strattera even if it is right in the middle of the school year.

If your child with ADHD is very hyperactive, aggressive, and impulsive, and gets in trouble a lot, the idea of sending him to school without any symptom control likely doesn't sound like a good idea. In situations like this, while waiting for the Strattera to take effect, many doctors also prescribe the child's stimulant medicine to take at the same time for a few weeks. They then later stop the stimulant, continue the Strattera, and see how well it is working.

Making Strattera Work

Many people have been concerned that Strattera doesn't seem to work as well as stimulants do. Part of the reason has been that most Pediatricians were only switching their children who weren't doing well on a stimulant. Expecting these children who weren't easy to treat with a stimulant to all of a sudden do great with just Strattera likely isn't fair.

Many Pediatricians also don't have a lot of experience with Strattera yet, so they may not know to increase the dose if it isn't working, give the dose at night if it is making the child too sleepy, or change to a twice a day dose if it is causing stomachaches.

Parents and teachers also often have unrealistic expectations of a child that goes from a stimulant to Strattera. They may expect the medicine to work right away or to work in exactly the same way as a stimulant. With Strattera, although they may pay attention well and not be easily distracted, it doesn't always seem to control symptoms of hyperactivity as well as a stimulant might.

Why should you accept less symptom control when changing your child's medicine?

Well, you shouldn't if your child was doing well on a stimulant and it wasn't causing side effects. But if your child was not tolerating a stimulant, then you may have to accept the way Strattera works for your child, especially if they are getting their work done at school and aren't getting in trouble.

For many other kids with ADHD, Strattera does seem to offer symptom control that compares to a stimulant. In fact, the American Academy of Child and Adolescent Psychiatry recently introduced new ADHD treatment guidelines that listed Strattera as being a first-line treatment option.

Strattera Suicide Warning

Although infrequent, the FDA has warned about an increased risk of suicidal thinking in children and adolescents being treated with Strattera. Specifically, like many other psychiatric medications, the FDA states that Strattera 'may increase thoughts of suicide or suicide attempts in children and teens,' and that parents should call their child's doctor if their child has:

• new or increased thoughts of suicide
• changes in mood or behavior including becoming irritable or anxious

This warning doesn't mean that your child can't be prescribed Strattera or that he should stop taking Strattera if it is doing a good job managing his ADHD symptoms and not causing side effects. Instead, the benefit of taking Strattera should be weighed against the possible risks of the drug. And children taking Strattera should be 'observed closely for clinical worsening, suicidal thinking or behaviors, or unusual changes in behavior,' especially in the first few months of starting treatment or when the dosage is changed.

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next: Which ADHD Medication is Right for Your Child
~ adhd library articles
~ all add/adhd articles

Assessing The Situation

Once it is suspected that someone has an eating disorder, there are several ways of assessing the situation further, from a personal as well as a professional level. This chapter will review assessment techniques that can be used by loved ones and significant others, in addition to those used in professional settings. Advances in our understanding and treatment for anorexia nervosa and bulimia nervosa have resulted in improvements in assessment tools and techniques for these disorders. Standard assessments for binge eating disorder are still being developed because less is known about the clinical features involved in this disorder. An overall assessment should ultimately include three general areas: behavioral, psychological, and medical. A thorough assessment should provide information on the following: history of body weight, history of dieting, all weight loss - related behaviors, body image perception and dissatisfaction, current and past psychological, family, social, and vocational functioning, and past or present stressors.

ASSESSING THE SITUATION IF YOU ARE A SIGNIFICANT OTHER

If you suspect that a friend, relative, student, or colleague has an eating disorder and you want to help, first you need to gather information in order to substantiate your concerns. You can use the following checklist as a guide.

CHECKLIST OF OBSERVABLE AND NONOBSERVABLE SIGNS OF AN EATING DISORDER

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• Does anything to avoid hunger and avoids eating even when hungry
• Is terrified about being overweight or gaining weight
• Obsessive and preoccupied with food
• Eats large quantities of food secretly
• Counts calories in all foods eaten
• Disappears into the bathroom after eating
• Vomits and either tries to hide it or is not concerned about it
• Feels guilty after eating
• Is preoccupied with a desire to lose weight
• Must earn food through exercising
• Uses exercise as punishment for overeating
• Is preoccupied with fat in food and on the body
• Increasingly avoids more and more food groups
• Eats only nonfat or "diet" foods
• Becomes a vegetarian (in some cases will not eat beans, cheese, nuts, and other vegetarian protein)
• Displays rigid control around food: in the type, quantity, and timing of food eaten (food may be missing later)
• Complains of being pressured by others to eat more or eat less
• Weighs obsessively and panics without a scale available
• Complains of being too fat even when normal weight or thin, and at times isolates socially because of this
• Always eats when upset
• Goes on and off diets (often gains more weight each time)
• Forgoes nutritious food on a regular basis for sweets or alcohol
• Complains about specific body parts and asks for constant reassurance regarding appearance
• Constantly checks the fitting of belt, ring, and "thin" clothes to see if any fit too tightly
• Checks the circumference of thighs particularly when sitting and space between thighs when standing

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Is found using substances that could affect or control weight such as:

• Laxatives
• Diuretics
• Diet pills
• Caffeine pills or large amounts of caffeine
• Other amphetamines or stimulants
• Herbs or herbal teas with diuretic, stimulant, or laxative effects
• Enemas
• Ipecac syrup (household item that induces vomiting for poison control)
• Other

If the person you care about displays even a few of the behaviors on the checklist, you have reason to be concerned. After you have assessed the situation and are reasonably sure there is a problem, you will need help deciding what to do next.

ASSESSING THE SITUATION IF YOU ARE A PROFESSIONAL

Assessment is the first important step in the treatment process. After a thorough assessment, a treatment plan can be formulated. Since the treatment for eating disorders takes place on three simultaneous levels, the assessment process must take all three into consideration:

• Physical correction of any medical problem.
• Resolving underlying psychological, family, and social problems.
• Normalizing weight and establishing healthy eating and exercise habits.

There are several avenues the professional can use for assessing an individual with disordered eating, including face-to-face interviews, inventories, detailed history questionnaires, and mental measurement testing. The following is a list of specific topics that should be explored.

ASSESSMENT TOPICS

• Eating behaviors and attitudes
• History of dieting
• Depression
• Cognitions (thought patterns)
• Self-esteem
• Hopelessness and suicidality
• Anxiety
• Interpersonal skills
• Body image, shape, and weight concerns
• Sexual or other trauma
• Perfectionism and obsessive-compulsive behavior
• General personality
• Family history and family symptoms
• Relationship patterns
• Other behaviors (e.g., drug or alcohol abuse)

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ASSESSMENT STRATEGIES AND GUIDELINES

It is important to get necessary information from clients while at the same time establishing rapport and creating a trusting, supportive environment. If less information is gathered in the first interview because of this, that is acceptable, as long as the information is eventually obtained. It is of primary importance that the client knows that you are there to help and that you understand what she is going through. The following guidelines for gathering information will help:

• Data: Gather the most important identifying data - age, name, phone, address, occupation, spouse, and so on. Presentation: How does the client look, act, and present herself?
• Reason for seeking eating disorder treatment: What is her reason for coming for help? Don't assume that you know. Some bulimics are coming because they want to be better anorexics. Some clients are coming for their depression or relationship problems. Some come because they think you have a magic answer or a magic diet to help them lose weight. Find out from the client's own words!
• Family information: Find out information about the parents and/or any other family members. Find out this information from the client and, if possible, from the family members, too. How do they get along? How do they see the problem? How have they, or do they, attempt to deal with the client and the problem?
• Support systems: Who does the client usually go to for help? From whom does the client get her normal support (not necessarily regarding the eating disorder)? With whom does she feel comfortable sharing things? Who does she feel really cares? It is helpful to have a support system in recovery other than the treating professionals. The support system can be the family or a romantic partner but doesn't have to be. It may turn out that members of a therapy or eating disorders support group and/or a teacher, friend, or coach provide the needed support. I have found that clients with a good support system recover much faster and more thoroughly than those without.
• Personal goals: What are the client's goals regarding recovery? It is important to determine these, as they may be different from those of the clinician. To the client, recovery may mean being able to stay 95 pounds, or gaining 20 pounds because "my parents won't buy me a car unless I weigh 100 pounds." The client may want to learn how to lose more weight without throwing up, even though only weighing 105 at a height of 5'8". You must try to find out the client's true goals, but don't be surprised if she really doesn't have any. It may be that the only reason some clients come for treatment is that they were forced to be there or they are trying to get everyone to stop nagging them. However, usually underneath, all clients want to stop hurting, stop torturing themselves, stop feeling trapped. If they don't have any goals, suggest some - ask them if they wouldn't like to be less obsessed and, even if they want to be thin, wouldn't they also like to be healthy. Even if clients suggest an unrealistic weight, try not to argue with them about it. This does no good and scares them into thinking you are going to try to make them fat. You might respond that the client's weight goal is an unhealthy one or that she would have to be sick to reach or maintain it, but at this point it is important to establish understanding without judgment. It is fine to tell clients the truth but is important that they know the choice for how to deal with that truth is theirs. As an example, when Sheila first came in weighing 85 pounds, she was still on a losing weight pattern. There was no way I could have asked her to start gaining weight for me or for herself; that would have been premature and would have ruined our relationship. So, instead, I got her to agree to remain at 85 pounds and not lose any more weight and to explore with me how much she could eat and still stay that weight. I had to show her, help her to do that. Only after time was I able to gain her trust and alleviate her anxiety in order for her to gain weight. Clients, whether anorexic, bulimic, or binge eaters, don't have any idea what they can eat just to maintain their weight. Later, when they trust the therapist and are feeling safer, another weight goal can be established.

• Chief complaint: You want to know what's wrong from the client's perspective. This will depend on whether they were forced to get treatment, or came in voluntarily, but either way the chief complaint usually changes the safer the client feels with the clinician. Ask the client, "What are you doing with food that you would like to stop doing?" "What can't you do with food that you would like to be able to do?" "What do others want you to do or stop doing?" Ask what physical symptoms the client has and what thoughts or feelings get in her way.
• Interference: Find out how much the disordered eating, body image, or weight control behaviors are interfering with the client's life. For example: Do they skip school because they feel sick or fat? Do they avoid people? Are they spending a lot of money on their habits? Are they having a hard time concentrating? How much time do they spend weighing themselves? How much time do they spend buying food, thinking about food, or cooking food? How much time do they spend exercising, purging, buying laxatives, reading about weight loss, or worrying about their bodies?

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• Psychiatric history: Has the client ever had any other mental problems or disorders? Have any family members or relatives had any mental disorders? The clinician needs to know if the client has other psychiatric conditions, such as obsessive- compulsive disorder or depression, that would complicate treatment or indicate a different form of treatment (e.g., signs of depression and a family history of depression that might warrant antidepressant medication sooner than later in the course of treatment). Symptoms of depression are common in eating disorders. It is important to explore this and see how persistent or bad the symptoms are. Many times clients are depressed because of the eating disorder and their unsuccessful attempts to deal with it, thus increasing low self-esteem. Clients also get depressed because their relationships often fall apart over the eating disorder. Furthermore, depression can be caused by nutritional inadequacies. However, depression may exist in the family history and in the client before the onset of the eating disorder. Sometimes these details are hard to sort out. The same is often true for other conditions such as obsessive-compulsive disorder. A psychiatrist experienced in eating disorders can provide a thorough psychiatric evaluation and recommendation regarding these issues. It is important to note that antidepressant medication has been shown to be effective in bulimia nervosa even if the individual does not have symptoms of depression.
• Medical history: The clinician (other than a physician) doesn't have to go into great specifics here because one can get all the details from the physician (see chapter 15, "Medical Management of Anorexia Nervosa and Bulimia Nervosa"). However, it is important to ask questions in this area to get an overall picture and because clients don't always tell their doctors everything. In fact, many individuals do not tell their doctors about their eating disorder. It is valuable to know if the client is often sickly or has some current or past problems that could have affected or have been related to their eating behaviors. For example, ask if the client has regular menstrual cycles, or if she is cold all the time, or constipated. It is also important to distinguish between true anorexia (loss of appetite) and anorexia nervosa. It is important to determine if a person is genetically obese with fairly normal food intake or is a binge eater. It is critical to discover if vomiting is spontaneous and not willed or self-induced. Food refusal can have other meanings than those found in the clinical eating disorders. An eight-year-old was brought in because she had been gagging on food and refusing it and had therefore been diagnosed with anorexia nervosa. During my assessment I discovered she was afraid of gagging due to sexual abuse. She had no fear of weight gain or body image disturbance and had been inappropriately diagnosed.
• Family patterns of health, food, weight, and exercise: This may have a great bearing on the cause of the eating disorder and/or the forces that sustain it. For example, clients with overweight parents who have struggled with their own weight unsuccessfully over the years may provoke their children into early weight loss regimens, causing in them a fierce determination not to follow the same pattern. Eating disorder behaviors may have become the only successful diet plan. Also, if a parent pushes exercise, some children may develop unrealistic expectations of themselves and become compulsive and perfectionistic exercisers. If there is no nutrition or exercise knowledge in the family or there is misinformation, the clinician may be up against unhealthy but long-held family patterns. I'll never forget the time I told the parents of a sixteen-year-old binge eater that she was eating too many hamburgers, french fries, burritos, hot dogs, and malts. She had expressed to me that she wanted to have family meals and not be sent for fast food all the time. Her parents didn't supply anything nutritious in the house, and my client wanted help and wanted me to talk to them. When I approached the subject, the father got upset with me because he owned a fast-food drive-through stand where the whole family worked and ate. It was good enough for him and his wife and it was good enough for his daughter, too. These parents had their daughter working there and eating there all day, providing no other alternative. They had brought her into treatment when she had tried to kill herself because she was "miserable and fat" and they wanted me to "fix" her weight problem.
• Weight, eating, diet history: A physician or dietitian on the team can get detailed information in these areas, but it is important for the therapist to have this information as well. In cases where there is no physician or dietitian, it becomes even more important for the therapist to explore these areas in detail. Get a detailed history of all weight issues and concerns. How often does the client weigh herself? How has the client's weight changed over the years? What was her weight and eating like when she was little? Ask clients what was the most they ever weighed and the least? How did they feel about their weight then? When did they first start feeling bad about their weight? What kind of eater were they? When did they first diet? How did they try to diet? Did they take pills, when, how long, what happened? What different diets have they tried? What are all the ways they tried to lose weight, and why do they think these ways haven't worked? What, if anything, has worked? These questions will reveal healthy or unhealthy weight loss, and they also tell how chronic the problem is. Find out about each client's current dieting practices: What kind of diet are they on? Do they binge, throw up, take laxatives, enemas, diet pills, or diuretics? Are they currently taking any drugs? Find out how much of these things they take and how often. How well do they eat now, and how much do they know about nutrition? What is an example of what they consider a good day of eating and a bad one? I may even give them a mini - Å“nutrition quiz to see how much they really know and to "open their eyes" a little bit if they are misinformed. However, a thorough dietary assessment should be performed by a registered dietitian who specializes in eating disorders.

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• Substance abuse: Often, these clients, especially bulimics, abuse other substances besides food and diet-related pills or items. Be careful when asking about these matters so clients do not think you are categorizing them or just deciding they are hopeless addicts. They often see no connection between their eating disorders and their use or abuse of alcohol, marijuana, cocaine, and so on. Sometimes they do see a connection; for example, "I snorted coke because it made me lose my appetite. I wouldn't eat so I lost weight, but now I really like the coke all the time and I eat anyway." Clinicians need to know about other substance abuse that will complicate treatment and may give further clues into the client's personality (e.g., that they are a more addictive personality type or the type of person who needs some form of escape or relaxation, or they are destructive to themselves for an unconscious or subconscious reason, and so on).

• Any other physical or mental symptoms: Make sure you explore this area fully, not just as it pertains to the eating disorder. For example, eating disorder clients often suffer from insomnia. They often do not connect this to their eating disorders and neglect to mention it. To varying degrees, insomnia has an effect on the eating disorder behavior. Another example is that some anorexics, when questioned often report a history of past obsessive-compulsive behavior such as having to have their clothes in the closet arranged perfectly and according to colors or they had to have their socks on a certain way every day, or they may pull out leg hairs one by one. Clients may not have any idea that these types of behaviors are important to divulge or will shed any light on their eating disorder. Any physical or mental symptom is important to know. Keep in your mind, and let the client know as well, that you are treating the whole person and not just the eating disorder behaviors.
• Sexual or physical abuse or neglect: Clients need to be asked for specific information about their sexual history and about any kind of abuse or neglect. You will need to ask specific questions about the ways they were disciplined as children; you will need to ask if they were ever hit to a degree that left marks or bruises. Questions about being left alone or being fed properly are also important, as is information such as their age the first time they had intercourse, whether their first intercourse was consensual, and if they were touched inappropriately or in a way that made them uncomfortable. Clients often do not feel comfortable revealing this kind of information, especially at the beginning of treatment, so it is important to ask if the client felt safe as a child, who the client felt safe with, and why. Come back to these questions and issues after treatment has been under way for a while and the client has developed more trust.
• Insight: How aware is the client about her problem? How deeply does the client understand what is going on both symptomatically and psychologically? How aware is she of needing help and of being out of control? Does the client have any understanding of the underlying causes of her disorder?
• Motivation: How motivated and/or committed is the client to get treatment and to get well?

These are all things that the clinician needs to assess during the early stages of eating disorders treatment. It may take a few sessions or even longer to get information in each of these areas. In some sense, assessment actually continues to take place throughout therapy. It may actually take months of therapy for a client to divulge certain information and for the clinician to get a clear picture of all the issues outlined above and to sort them out as they relate to the eating disorder. Assessment and treatment are ongoing processes tied together.

STANDARDIZED TESTS

A variety of questionnaires for mental measurement have been devised to help professionals assess behaviors and underlying issues commonly involved in eating disorders. A brief review of a few of these assessments follows.

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EAT (EATING ATTITUDES TEST)

One assessment tool is the Eating Attitudes Test (EAT). EAT is a rating scale that is designed to distinguish patients with anorexia nervosa from weight-preoccupied, but otherwise healthy, female college students, which these days is a formidable task. The twenty-six item questionnaire is broken down into three subscales: dieting, bulimia and food preoccupation, and oral control.

The EAT can be useful in measuring pathology in underweight girls but caution is required when interpreting the EAT results of average weight or overweight girls. The EAT also shows a high false-positive rate in distinguishing eating disorders from disturbed eating behaviors in college women. The EAT has a child version, which researchers have already used to gather data. It has shown that almost 7 percent of eight- to thirteen-year-old children score in the anorexic category, a percentage that closely matches that found among adolescents and young adults.

There are advantages to the self-report format of the EAT, but there are also limitations. Subjects, particularly those with anorexia nervosa, are not always honest or accurate when self-reporting. However, the EAT has been shown to be useful in detecting cases of anorexia nervosa, and the assessor can use whatever information is gained from this assessment combined with other assessment procedures to make a diagnosis.

EDI (EATING DISORDER INVENTORY)

The most popular and influential of the available assessment tools is the Eating Disorder Inventory, or EDI, developed by David Garner and colleagues. The EDI is a self-report measure of symptoms. Although the intent of the EDI was originally more limited, it is being used to assess the thinking patterns and behavioral characteristics of anorexia nervosa and bulimia nervosa. The EDI is easy to administer and provides standardized subscale scores on several dimensions that are clinically relevant to eating disorders. Originally there were eight subscales. Three of the subscales assess attitudes and behaviors concerning eating, weight, and shape. These are drive for thinness, bulimia, and body dissatisfaction. Five of the scales measure more general psychological traits relevant to eating disorders. These are ineffectiveness, perfectionism, interpersonal distrust, awareness of internal stimuli, and maturity fears. The EDI 2 is a follow-up to the original EDI and includes three new subscales: asceticism, impulse control, and social insecurity.

The EDI can provide information to clinicians that is helpful in understanding the unique experience of each patient and in guiding treatment planning. The easy-to-interpret graphed profiles can be compared to norms and to other eating disordered patients and can be used to track progress of the patient during the course of treatment. The EAT and the EDI were developed to assess the female population who most likely have or are susceptible to developing an eating disorder. However, both of these assessment tools have been used with males with eating problems or compulsive exercise behaviors.

In nonclinical settings the EDI provides a means of identifying individuals who have eating problems or those at risk for developing eating disorders. The body dissatisfaction scale has been successfully used to predict the emergence of eating disorders in high-risk populations.

There is a twenty-eight-item, multiple-choice, self-report measure for bulimia nervosa known as BULIT-R that was based on the DSM III-R criteria for bulimia nervosa and is a mental measurement tool to assess the severity of this disorder.

BODY IMAGE ASSESSMENTS

Body image disturbance has been found to be a dominant characteristic of eating disordered individuals, a significant predictor of who might develop an eating disorder and an indicator of those individuals having received or still receiving treatment who might relapse. As Hilda Bruch, a pioneer in eating disorder research and treatment, pointed out, "Body image disturbance distinguishes the eating disorders, anorexia nervosa and bulimia nervosa, from other psychological conditions that involve weight loss and eating abnormalities and its reversal is essential to recovery." This being true, it is important to assess body image disturbance in those with disordered eating. One way to measure body image disturbance is the Body Dissatisfaction subscale of the EDI mentioned above. Another assessment method is the PBIS, Perceived Body Image Scale, developed at British Columbia's Children's Hospital.

The PBIS provides an evaluation of body image dissatisfaction and distortion in eating disordered patients. The PBIS is a visual rating scale consisting of eleven cards containing figure drawings of bodies ranging from emaciated to obese. Subjects are given the cards and asked four different questions that represent different aspects of body image. Subjects are asked to pick which of the figure cards best represents their answers to the following four questions:

• Which body best represents the way you think you look?
• Which body best represents the way you feel you are?
• Which body best represents the way you see yourself in the mirror?
• Which body best represents the way you would like to look?

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The PBIS was developed for easy and rapid administration to determine which components of body image are disturbed and to what degree. The PBIS is useful not only as an assessment tool but also as an interactive experience facilitating the therapy.

There are other assessment tools available. In assessing body image it is important to keep in mind that body image is a multifaceted phenomenon with three main components: perception, attitude, and behavior. Each of these components needs to be considered.

Other assessments can be done to gather information in the various domains, such as the "Beck Depression Inventory" to assess depression, or assessments designed specifically for dissociation or obsessive-compulsive behavior. A thorough psychosocial evaluation should be done to gather information on family, job, work, relationships, and any trauma or abuse history. Additionally, other professionals can perform assessments as part of a treatment team approach. A dietitian can do a nutrition assessment and a psychiatrist can perform a psychiatric evaluation. Integrating the results of various assessments allows the clinician, patient, and treatment team to develop an appropriate, individualized treatment plan. One of the most important assessments of all that needs to be obtained and maintained is the one performed by a medical doctor to evaluate the individual's medical status.

MEDICAL ASSESSMENT

The information on the following pages is an overall summary of what is needed in a medical assessment. For a more detailed and thorough discussion of medical assessment and treatment, see chapter 15, "Medical Management of Anorexia Nervosa and Bulimia Nervosa."

Eating disorders are often referred to as psychosomatic disorders, not because the physical symptoms associated with them are "all in the person's head," but because they are illnesses where a disturbed psyche directly contributes to a disturbed soma (body). Aside from the social stigma and psychological turmoil that an eating disorder causes in an individual's life, the medical complications are numerous, ranging all the way from dry skin to cardiac arrest. In fact, anorexia nervosa and bulimia nervosa are two of the most life-threatening of all psychiatric illnesses. The following is a summary of the various sources from which complications arise.

SOURCES OF MEDICAL SYMPTOMS IN PATIENTS WITH EATING DISORDERS

• Self-starvation
• Self-induced vomiting
• Laxative abuse
• Diuretic abuse
• Ipecac abuse
• Compulsive exercise
• Binge eating
• Exacerbation of preexisting diseases (e.g., insulin-dependent diabetes mellitus)
• Treatment effects of nutritional rehabilitation and psychopharmacological agents (drugs prescribed to alter mental functioning)

A THOROUGH MEDICAL ASSESSMENT INCLUDES

• A physical exam
• Laboratory and other diagnostic tests
• A nutritional assessment/evaluation
• A written or oral interview of weight, dieting, and eating behavior
• Continued monitoring by a physician. The physician must treat any medical or biochemical cause for the eating disorder, treat the medical symptoms that arise as a result of the eating disorder, and must rule out any other possible explanations for symptoms such as malabsorption states, primary thyroid disease, or severe depression resulting in loss of appetite. Additionally, medical complications may arise as consequences of the treatment itself; for example, refeeding edema (swelling that results from the starved body's reaction to eating again - see chapter 15) or complications from mind-altering medications prescribed
• Assessment and treatment of any needed psychotropic medication (most often referred to a psychiatrist)

A normal lab report is not a guarantee of good health, and physicians need to explain this to their patients. In some cases at the discretion of the physician, more invasive tests like an MRI for brain atrophy or bone marrow test may have to be performed to show abnormality. If lab tests are even slightly abnormal, the physician should discuss these with the eating disordered patient and show concern. Physicians are unaccustomed to discussing abnormal lab values unless they are extremely out of range, but with eating disorder patients this may be a very useful treatment tool.

Once it is determined or likely that an individual has a problem that needs attention, it is important to get help not only for the person with the disorder but for those significant others who are also affected. Significant others not only need assistance in understanding eating disorders and in getting their loved ones help but in getting help for themselves as well.

Those who have tried to help know all too well how easy it is to say the wrong thing, feel like they are getting nowhere, lose patience and hope, and become increasingly frustrated, angry, and depressed themselves. For these reasons and more, the following chapter offers guidelines for family members and significant others of individuals with eating disorders

By Carolyn Costin, MA, M.Ed., MFCC - Medical Reference from "The Eating Disorders Sourcebook"

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In this editorial, Dr. Billy Levin denounces corporal punishment and says children who misbehave need help, not punishment; especially children with ADHD.

Corporal punishment is degrading, embarrassing, painful, abusive and harmful to children and has no benefits other than relieving frustration in an inadequate and ignorant adult bullying perpetrator.

"Science does not prove that G..D is right. G..D proves that science is right". ("Genesis and the Big Bang" by Gerald Schroeder, a pious Jew with a double doctorate in science.) As a very religious person, he has no difficulty writing a book to resolve the age old conflict between science and religion. In fact, he states there is no conflict!

Whenever man has accepted the wisdom of G..D humbly and unconditionally because of his faith in a "higher being", man has never been disappointed nor let down. Eventually, sooner or later, science has proved the custom or law to be correct and valuable in every aspect. These are a few examples:-

In the Jewish faith, one is not allowed to have milk for a set period of time after having eaten meat. Milk reduces the effect of the gastric juices in digesting meat. There are also laws governing when and how and what meat may be eaten, that were known from Biblical times. Today these laws would be seen as very scientific and medically correct.

Jewish woman, who follow the faith strictly, will attend a communal bath (the Mikva) after their menstrual period has ceased. There is also a requirement not to have sex until the 14th day after the start of the menstrual period. This coincides with ovulation time thus insuring maximum fertility for conception. I am very certain the ancients did not know about the Physiology of conception. Devine intervention?

Bathing in (washing) running water as a means of reducing the spread of infection was practiced in Mose's times, yet surgeons only recognised this as a means of reducing infection at the end of the 18th century.

The age of bar mitzvah for a Jewish boy is 13. The bat mitzva for a girl is at 12 years of age. Girls are more mature. It is recognised that at approximately this age there is a distinct maturing from a cognitive point of view that would make the person more responsible for his actions. The very word "Bar mitzvah" has this very significant meaning.

Once again in the Jewish faith, the ritual circumcision (Brit Mila), is done 8 days after birth. Circumcision done at this age results in a dramatic reduction in cancer of cervix in that person's future wife. But even more significant, is the fact that Prothrombin and Vitamin K, both needed for clotting of blood the prevent serious haemorrhage and so discourage infection is at an optimum at 8 days after birth. Moreover the baby has all his maternal antibodies to assist him to overcome any infection that might result from this circumcision. At a later stage in his life his mother's antibodies that he still has in his own circulation as an infant(8 days old) would decrease to nearly zero. The child would not have had enough time to have been exposed to the various germs and developed his own antibodies yet. Thus there would be a greater risk of infection if the circumcision was done at a later stage. Who new of Vitamin K and Prothrombin in those days. Clearly Devine intervention.

All these are examples of strict ancient religious requirements having a very good scientific explanation when viewed with our modern knowledge of today.

Therefore, if science proves corporal punishment is harmful for children, G..D must have known about this harm long before man researched it. Therefore "PROVERBS 13, 24 (spare the rod and spoil the child), written by King Solomon must have been interpreted by man incorrectly. The learned sages warn that some of King Solomon's writings are notorious for being misunderstood. The bible is always right, man may make mistakes. Unless of course, science is incorrect!

Proverbs are attributed to King Solomon who was renown for his wisdom. He was a very aggressive and violent king, although many would use the words "harsh" and "strict". If he used the rod on his children it certainly bred much aggression in his son, ........ who succeeded him. Solomon's son on his succession to the thrown is quoted as saying "If my father lashed the people with lashes, I will lash them with scorpions" Aggression breeds aggression. History tells us that this King brought about the downfall of the Hebrew kingdom and the splitting of the nation with his ruthless rule. The people were eventually forced to rebel against his tyranny. What Solomon had built up he broke down. His aggression and harsh rule brought ruination . Therefore the wisdom of Solomon is instantly challenged, or perhaps more correctly the interpretation of his writings. In the case of the two mothers fighting about whose baby it was, did Solomon have the wisdom to know the real mother would not want her child divided in half, or was it Solomon's callous disregard for life, to get rid of two nagging women. If it was a callous suggestion, then it was G..D's wisdom that saved the child and Solomon saw the wisdom of G..D. Solomon, after all strayed from the Lord by praying to idols with his many heathen wives. He also married out of the faith which should be questioned. That he was harsh and cruel is well documented. It was this harsh, cruel and straying King who wrote the proverbs including Proverbs 13,24. Because of his tendency to use aggression during his rule, he might well have also used hash aggression and punishment on his own children and produced an even harsher and crueller ruler to follow him, who ruined the nation and provoked then into rebellion. Was this not the same situation with apartheid in South Africa resulting in the overthrowing of the government's tyranny, but the legacy of aggression lingers on. Corporal punishment in schools would certainly breed aggression long after it was banned in schools.

On the Festival of the Passover, it is obligatory to retell the story of the exodus of the Israelites from Egypt to your children every year lest they forget. To the traditional "four sons", each with a different capacity for learning ranging from good to possibly very poor, there is not mention of corporal punishment even for the one who cannot learn. Only repetition.

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During the hard times in the Sinai desert, when there was a shortage of water the Israelites complained to Moses, who asked G..d for help. Help was forth coming via the famous Rock. In frustration and desperation Moses is alleged to have struck the "Rock" with his cane instead of speaking to it as instructed by G..d.. Who can blame him? On a previous occasion,( 40 years previously,) just after the crossing of the Red sea, Moses was instructed to strike the rock to provide water. If one considers the Israelites would be more impressed with the striking of the rock as they were used to physical force and punishment as slaves for 400 years. But 40 years later they were learning to be a free people with no need to have aggression shown to them or used to teach their children. Hence the change in modis operandi. "Talk to the rock!" Yet there was a severe punishment metered out by G..d. to Moses for having struck the rock. Moses would never enter the land of Canaan. How much more should the punishment be if innocent children and even perhaps sometimes not so innocent children are struck with a cane? Do parents and teachers get punished for hurting children? Yes, instead of the pleasure and pride of well-adjusted children, they have to grieve and suffer aggravation for their misdirected efforts. If G..d does not want the cane to be used even on an inanimate object like a rock, how much more so in the case of children. The important question is am I interpreting the situation correctly? But in Psalm 23, King David says " Thy rod and Thy staff shall comfort me". This does not sound like a weapon of destruction. G..d's rod and staff is certainly not intended to inflict pain, and neither should ours. It is for our comfort, guidance and protection.

Misinterpreting the Bible Regarding Corporal Punishment

Has man misinterpreted the bible before? The answer is emphatically, yes, on occasion but not always. Man with his limited knowledge and lack of insight has misinterpreted the bible before, on occasions. Like the broken telephone game played by children each interpretation could be even further from the original intended truth. Man is fallible. However the Torah (given at Sinai) and rewritten in exactly the same way and wording by expert scribes over more than three thousands years, has not changed. ( to an accuracy of 99.9% ) This in itself is considered a miracle. With the discovery of the Dead Sea scrolls in the 20th century, untouched for two thousands years, it was possible to compare them with a modern recently written scroll to prove this point. How correctly has man understood and interpreted the book of Genesis and the story of the Creation? Here are a few examples of possible misinterpretation:-

The interpretation of the Hebrew words "Vayehi Orr ", is "And there was light" ( Genesis ) The planet was cooling down from an astronomical "black hole", that did not even allow particles as small as a photon to escape it's gravitational force, to a molten fiery planet that glowed with light.. "And there was light". G..D did not create light, it was there. In Genesis we read about the creations .The sun was only placed in the heavens as a sign of the time on the fourth day(Genesis ). G..d knew we would use the sun's path as a calendar even then already.(Genesis ) So we may conclude the light referred to here was not from the sun, but a glowing planet busy cooling down to allow man to inhabit it many millions of years later.

In the Bible we read about the cherubs that were placed on the sides of the Tabernacle ( Exodus) . Just so we should read that Eve was placed at the side of Adam.(Genesis ), and not created from his side. She was intended to be a life long partner. In Yiddish, a Jewish dialect of the German language, one would say "she walked from his side", meaning she walked at his side. " At the side"' referring to the cherubs was the same wording that referred to Eve at Adam's side. "At the side" not from his side. If Eve was created from Adams side (ribs), she would have the "x' any "y' chromosomes that men have. She only has the "x" chromosome that woman have. At the end of each day of creation there is a statement made :- "And there was evening and there was morning"( Genesis ). This statement is made from the start of creation. On the third day of creation the sun was placed in the heavens. Thus the phrase, "and there was evening and there was morning" could not have referred to our understanding of morning and evening. It certainly could have implied that before creation there was chaos and disorganisation. After the specific creation was completed, there was order and organisation. The ancient Hebrew wording for chaos suggests "darkness", and when someone sheds some light on the chaos there was, not morning, but order.

At the start of creation G..d commenced his miracles on a certain day when the world was ready . The Hebrew words "Yom echad", meaning "On a day (on a certain day) (Genesis ) are used to signify the commencement of creation. .It did not mean "On day one", which would be in Hebrew "Yom Rishon". The creation was not intended to convey a message that it took only one day, but rather on a certain day G..d started creation.

An "eye for an eye and a tooth for a tooth"( Leviticus ) certainly does not mean we should poke out a criminal's eyes or punch out his teeth in violent and aggressive retaliation. It is intended to convey the message that the punishment should fit the crime, measure for measure when compensation is considered.

We should not misinterpret the word "Rod" or "staff' (cane). A shepherds crook is used to guide sheep, not hurt them. The "flock " was often used to indicate, the people, who should be led, not beaten with a shepherd's crook. To use a "crook' to guide your children somehow does not seem correct. The word "crook' has sinister connotations. A rod or staff is more acceptable. The rod is meant to guide and not inflict pain upon innocent children. A pastoral staff forms part of the regalia in certain churches. Once again the reference to leading the Pastor's flock with a guiding staff, and not inflicting pain. The reference is to a staff in the media of the then spoken word. I am not sure when the word "crook" came into the English language, but it was certainly not used in biblical times. A crooked staff with a bend in it was used to catch the sheep's legs, not to choke it by the neck.

Understanding Effective Discipline of Children

Children were not intended to be beaten in submission or bullied into retaliative aggression but rather to be guided gently as with a Shepard's crook. Children with a neurological dysfunction (Attentional Deficit Hyperactivity Disorder) do not yield to this type of discipline and even to aggressive beatings. They require sympathetic medical, educational and sometimes psychological help. These dysfunctional children form the vast majority of severe behaviour problems encountered among children and they are largely misunderstood, neglected and abused by ignorant well meaning ,and sometimes not so well meaning adults and teachers. Children who do not have a neurological dysfunctions may some times stray off the beaten track but they are self correcting with a minimum of guidance. These children respond very well to discipline. They do not need punishment. Discipline and punishment are totally different situations and should not be confused with each other. They are totally different.

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Discipline is the loving way of TEACHING children, at the right time, in the right way, at the right place and at the right age. It should be used frequently and repeatedly and lovingly."

"Punishment is the unpleasant task of having to UNREWARD a child for having done wrong despite adequate discipline. It should be used seldom, sparingly, forgivingly and judiciously."

Corporal punishment is never an option! Both these definitions, which I formulated about 20 years ago, assume the child does not have a neurological dysfunction such as Attentional Deficit Hyperactivity Disorder (ADHD). In this case the medical treatment is of paramount importance and a first priority to make the child more teachable. "You cannot teach a child if you cannot reach him. You cannot reach the child if he cannot concentrate and pay attention. He cannot concentrate without the benefit of stimulant medication if he has ADHD. Here medication is not the be-all or end-all, but rather the first step onto a long ladder that the team (parents, teacher, child etc.) has to climb to succeed.

As far back As 1985, Professor Holdstoch wrote a book entitled "BEAT THE CANE". He was professor of Psychology at the University of the Witwatersrand and founded a parent support group called "Education without fear." This was a case for the abolition of corporal punishment in schools in South Africa. In America, England and most of Europe this had already been achieved, in some countries in the previous century! Ten years later Professor Kiebel (professor of paediatrics) wrote in the South African Medical Journal( February 1995) about his disgust that corporal punishment still existed in schools. He was criticised in the journal by colleagues(July 1995) When I supported his opinion with a letter to the same journal (October 1995), there was a stony silence from his critics. It still took a few years after this, for corporal punishment to be banned in South Africa schools. Some religious (pious?) organisations even went to court to have the law banned! South Africa was one of the last of the so called first world countries to prevent hurting children officially in schools.

As clear as the evidence suggests that corporal punishment is detrimental (and not with standing the law banning corporal punishment in schools a T. V. program recently, "The Big Question" took a studio and viewing audience vote on the matter, agreeing it was acceptable to hit children. Did the presenters or the audience know they were voting in favour of an illegal, dangerous and banned practice. Ignorance is not bliss. It is dangerous. These dangers were well demonstrated in the media, about the many violent and aggressive practices in cultural initiation schools for blacks resulting in tragic deaths of young children from beatings in July 2002.

It would be fitting to conclude with the phrase "Ye who amongst us, who is without sin, should cast the first stone". I would also like to include to those who doubt what I have suggested, "Seek and ye shall find". Both these very wise comments are attributed to Jesus of Nazareth. Solomon was quoted as having said "a wise man has his eyes in his head." I cannot remember where the eyes were in a fool! He is also quoted as having said "it is far better to be chastised by a wise man than to listen to the song of a fool!" (Ecclesiastes)

Some years ago, when a Professor Garry Meyers and I both spoke at an international symposium on ADHD, he related a story of the state of Alabama instituting a law that a misbehaving child could only be punished twice. Thereafter, an automatic referral for a Neurological evaluation. Misbehaving children need help not punishment. There should be no confusion between discipline and punishment. Children are "people" too.

About the author: Dr. Levin is a pedaetrician with nearly 30 years of experience and specializes in working with ADHD children. He has published many articles on the subject and is our "ask-the-expert."

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