Question and Answer Post

From a Reader named “Mary”

Please help me! I have been in a relationship with my live in boyfriend about 3 yrs. He is like having another child around. He does not help with things and expects me to take care of everything. He has a bad temper and although he has never hit me when he gets angry he breaks things. I want to end this relationship but when I tell him that he says he can’t live without me and will kill himself if I go. I’m scared! I don’t know what to do. I cry all the time and can’t sleep well at night.

Dr. Duffy’s response.

Mary, this is a tough situation and I can under why you feel scared. First let me tell you that unfortunately this situation is not that uncommon. Men who act like your boyfriend are often very dependent on the women they are with! They try to get what they want and need with threats of all kinds. Threatening to kill himself in order to keep you is emotional blackmail! So what to do…….

First and most important: you must be very sure you want to end this relationship. The worse thing you can do is make threats to leave in hopes that he will change his behavior. When you do this it only teaches him that you do not mean what you say. If these threats do get him to change, it is usually only for a very brief time and then the behavior starts again. So you must so some serious soul searching and make sure this is what you really want. Make sure you are really ready. Once you have done this you must put a plan in place to leave. Try not to do it on the spur of the moment or during a crisis unless you are being physically threatened!

Second: Make a plan: You must decide when you want to leave and where you will go. Many women want the man to leave the home. This is much harder to make happen (although not impossible) and the easier and safer thing to do would be to leave temporarily with the expectation that living arrangements will be settled later. Certainly who leaves the home may be dependent on who ownership. Leaving may also have some legal complications for those who are married and the advice of an attorney should be sought. If there are children involved it is more difficult but that is also all the more reason to go ahead with such a plan.

If you have already discussed your desire to leave you do not need to tell him that you are leaving until you are ready to go. In the process of leaving however YOU CANNOT COUNT ON HIM TO BE REASONABLE. Once the crisis is over and he is certain this is really the end, he may become more reasonable and able to negotiate things. Mediators are available in most areas to help separating people with just this type of issue.

Third: get the help of others. Many women are embarrassed by this type of situation and try to manage it alone. This is a mistake! Secrecy is one of the things that make blackmail effective! You must let people you trust know what is going on. Tell a friend, family members, your boyfriend’s family (he needs support too) and perhaps a professional. You do not need to reveal all the details just make sure they realize you are planning to leave and he is making threats to kill himself. A strategy that often works is to have someone he trusts with him when you actually leave. If you leave and he makes threats you may need to notify the police to check on him.

Fourth: take care of yourself. This is critical. I have a few questions here. Are you depressed? You mention crying and trouble sleeping. Now a certain amount of this is to be expected in this situation, but are you seriously depressed? This is an important distinction to make. Do you have trouble with concentration and memory? Are you anxious and feeling overwhelmed by the situation? Are you feeling hopeless, helpless and immobilized? Are you having trouble machine decisions? Are you eating? Is your energy level where it should be? Do you have a history of depression? These are some questions that might help you decide the level of your depression. Please review the symptoms of depression on the following page to help you decide if you are clinically depressed. If you are significantly depressed you may find it much harder if not impossible to leave while you feel this way. If you think this is the case you should consider having an evaluation by a mental health professional. If you are depressed there are medications and some herbs that may be of help to you. Once you feel better you will be more able to deal with this situation.

The other question I would have in this area is IS THIS A PATTERN FOR YOU? Do you have a history of getting involved in the same type of relationships? Do you seem to attract needy people (men and friends.)? Do you try and take care of everyone. Do you take care of yourself? Do you feel good about yourself? These are important questions to answer for your own emotional well being and to help with future choices.

You must remember no one is responsible for the life of another person. We all must take responsibility for our own lives. Just as you cannot cause someone to take their own life if they wish to live, you also cannot prevent it if they are determined to die. Suicide is not usually the result of a single loss, but the end of a long history of depression , problems and pain. Persons like this are in desperate need of professional help and sometimes staying with them to try and help may actually prevent them from getting the professional help they really need. GOOD LUCK!

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I am often asked what to say or do to comfort someone who is upset. My answer is always : make an empathic comment. In thinking about it however I decided to give some examples of what not to say.

1.”I know just how you feel, when this happened to me blah, blah, blah.”

2. “Everything will work out for the best.”

3. “It’s time to put it behind you”

4.”You will get through this.”

5. “Thinking about it will just make you more upset.”

6. Attempts to change the subject

7. “Let me get you something” (coffee, sandwich etc).

8. “Do you want me to call your therapist, priest” etc.

As you can see, offering clichés like the examples given above will not help the situation or the distressed person. In fact they often make things worse. The person crying will sense your discomfort, may think their feelings are ignored, downplayed, or devalued. They may even become angry at you, or totally shut down.

Most of the comments listed signify the discomfort of the person trying to help. Becoming comfortable with someone who is crying, allowing the expression of feelings, and using the powerful tool of empathy are your best bets; silence also works.

At all costs, avoid clichés. Remember the power of empathy!

I realize I am a little late posting on this story, but I have been struggling with what to say. I decided to tell my own experience around this issue. I read the story on Harvard MDs and drug company money with a mixture of guilty pleasure (I was right!!!) and disgust.  The guilty pleasure comes from the I told you so feeling that I couldn’t help.  I had been complaining about the Harvard view for a long time (but nobody had listened.)

As a psychiaric nurse practitioner I have been prescribing medication for years. I can tell you  that MOST NPs  have a different perspective from MOST physicians.  I don’t see every psychological problem as a diagnosis or a disease to be treated or cured. I see many problems as social, enviornmental and learned. I firmly believe they shouldn’t be given a label or diagnosis ( did you know insurance companies require a diagnosis in order to make payment) and can’t be fixed with pills .

 Having said that, I also know that clinical depression, and other legitimate mental illnesses often MUST be treated with medication. The problem is often figuring out which is which. It seems that many people who really need medications don’t get them, and so many who don’t need them are taking them ( and thus the medicine “doesn’t help”.)

 Any way, back to the “I told you so” part. As a concientious prescriber I have always feel it is critical to keep up on the latest in medication information. To do this for a number of years I went to what I thought was the “best”, Harvard .I attended quite a few of Harvard’s well known and respected psychopharmacology conferences. More then once I listened to the physicians who are now identified as not reporting their drug company income. After a few times I got tired of the same old message: more medications, higher doses, polypharmacy and  a drug for each symptom. I stopped going.

I have to say many of the physicians in the audience seemed to be swallowing these ideas whole. This is in part because of the traditional viewpoint taught in medical schools, the “disease and cure model”.  

Now comes the  hard part. We all need to take some responsibility for fostering this as this is ALSO the public expectation of medical care That is, we expect providers to be able to “fix it”, no matter what it is.  We often want, no insist on a pill. This is a big part of the reason for the overuse of antibiotics.

Dr. Biederman’s push for the diagnosis of Bi-Polar disorder in kids was particularly disturbing to me. Of course if we give them this diagnosis, it will naturally follow that we can give them a drug (or two) and FIX them. Few seem willing/able to look at social or environmental facts. Or if they do, they realize how difficult it is to change these things; pills are so much easier!  By the way pills are all most insurance companies will pay for (with higher and higher copays of course) and pills are what many of the public wants instead of dealing with all the other factors.

In order to make things better there are many pieces that need to be looked at. The first is regulation, but also I recommend the following:

• Patients need to stop expecting doctors to know everything and fix everything, and ask more questions. Even when they are afraid of the answers! If they don’t get their questions answered in a way they understand (not necessarily like),  they should  get a second opinion.
• Doctors and all health care providers start excepting there own limitations and the limitations of our medical knowledge
• We also need more self oversite by medical professionals. This is not a closed private club, its a public trust. Persons who break that trust should be given fair treatment but severe consequences.
• The broken health care system in this country needs to be seriously overhauled.

Ok lets get to work.

Be Prepared

We have all been reading about the floods in the midwest, the tornados and the wild fires in California. While we feel for those affected there is always relief that it did not happen to us or someone we love. While this is understandable, don’t put your head in the sand, or use denial.  Perhaps its time to review the things you need to do  to deal with a weather  emergency. Remember the first thing is to take a deep breath, try to remain calm and get your list of things to gather or do. Use the skills you have learned at this site to remain calm and help others stay calm.

You can print this off this page and keep it handy. Collect the suggested items (and any others you think you need)  and put them in all one place.

  Remain Calm by talking to yourself, slowing your breathing, and forcing yourself to speak and move deliberately. This will help you think clearer. Next assess the situation and make a plan. Avoid minimizing and denial. Better to overreact then underreact.

Know what the signs of a approaching storm are, keep a radio( a weather radio may be worth buying in certain parts of the country)  on and listen for alerts. Have a fire escape plan from every room.

Plans should be made ahead of time and every family member should have a task to do and should know what it is and how to do it. Make them practice even if they roll their eyes. A meeting place is critical incase you get separated.

Sustinance:

• 3 days of supplies & food
•  Water / hydration   minimum 1gal per day per person
• 2 gal collapsible water containers
• Water purification tabs or water purification system, or make your own pure water with an eyedropper and iodine or chlorine bleach.  Iodine works, doesn’t taste so good, 20 gtts per gallon of clear water, 40 gtts for cloudy water. 5 % chlorine bleach (usual strength of household bleach use plain bleach unsented)- Add 2 drops of bleach/ gallon of water
• Food 2000 cal. per day per person  
• Can opener 

Shelter / Protection

•  Blankets / pillow
•  Toilet paper
• Non-cotton clothing (fast drying synthetics or wool)
•  Duct tape
• Emergency thermal blankets
•  Leather gloves / rubber gloves
• Rain Poncho
•  Face mask / N-95 respirator
• Moist Towelettes                       
•  1 roll plastic sheeting
• Garbage bags 
• Hand sanitizer
• 12 hour light sticks / flashlights/wind up flashlight
• Extra batteries

Communication

•  Cell phone & charger 
•  Whistle  
• Important papers
•  Wind- up radio

Other important items

•  Multi-function tool 
•  Cash / change / travelers checks
• Prescription medication / other meds 
• Bleach
• Pet food / extra water for pet 
• Pet meds
• Waterproof container 1 large 1 small
• Paper and pencil 
• First Aid Kit & Book
• Entertainment (cards, small games (many games come in travel size, pick up sticks, dominos, etc)
• Favorite Book, religious/ spiritual books that you use

Being prepared will help you feel in control, calmer and improve your decision making under stress. Here’s hoping you never need to test your preparedness.

I would like to thank my financial advisor Jay Cappon of Rochester NY who is the author of this article. It is one of the many good and practical things he does to help people manage their money. Check out his web site at www.capvestfinancial.com 

We all know that a stress-filled existence is responsible for nail biting and dark circles under the eyes. But we may not realize the heavy toll it can extract from our bank account. Chronic stress, the kind you experience when the demands of life exceed your ability to cope, increases your risk of developing ailments ranging from the common cold and gum disease to obesity and heart diseases. This, in turn, will cause you to pay more for medical treatments, insurance and dental work. If you need more incentive to do something about your stressful lifestyle, consider these potential costs:

• Pills�

  The list of symptoms linked to stress is long: headache, back pain, insomnia and heartburn are major ones. The lineup of nonprescription drugs used to treat these ailments can easily run several hundred dollars annually.

• Bills
  
  While health-care costs for an average adult run about $2,800. Annually, one who suffers from sever stress can easily rack up twice this amount, according to a recent survey by benefits provider Hewitt Associates. Part of the reason is that stress weakens the immune system, which can worsen chronic conditions such as arthritis, asthma and lupus. Stressed workers are also more prone to job-related injuries.
• Higher Premiums�

  High levels of stress hormones are commonly linked to weight gain, which in turn raises your risk of heart disease, stroke and Type 2 diabetes. Loose some excess pounds and you could get lower life insurance premium, upwards to 50% or more.

• Costlier Dental Problems�

  Stress also increases the risk of gum disease. Teeth grinding and eating sugary foods lead to cavities and gradual tooth enamel erosion.

• Missed Career Opportunities
  
  In the same survey by Hewitt Associates, half of all workers who call in sick do so because of a stress-related illness. Workers suffering from severe stress are away from their desks an average of 23 working days, according to the Bureau of Labor Statistics. All of these missed meetings and blown deadlines can wreak havoc on your career, resulting in tens of thousands of dollars off what you might earn over your employment lifetime.

  What to do?

There is some good news: reducing stress can be as simple and inexpensive as stretching out on the sofa and breathing deeply for 10 minutes. Daily exercise is another powerful weapon. While breaking a sweat with weights  is ideal, just taking a walk around the block will help. Nutrition-wise, cut back on coffee and other caffeine-containing beverages, as this aggravates the symptoms of chronic stress. Refrain from alcohol and smoking. Doing this will not only have immediate financial savings in the short-run, but even greater benefits on your quality of life over the long-run.

Check out my blog for more stress reduction techniques.

There is a terrific article in the NY Times today that is a must read for everyone who will eventually die (that’s you & me). It talks about the “you must fight” attitude many of us think we should have and expect of other people when they are very ill.  Is this the best for them and us?

The usual statement ” I am going to fight and beat this” is the politically correct thing to do, especially in public. However, many people believe that this is the way we must react to illness; keep a stiff upper lip and fight!  This is what some people (not the writer) think is a positive attitude. The truth is that no one can be strong all the time, especially when your life is threatened. Moments of feeling weak and frightened do not mean you are going to give up. Expectations that are unrealistic make people think: What is wrong with me? Why can’t I be more like him?  I must be weak. I am ashamed of myself. I am feeling sorry for myself.

 The fear and anger that we hold inside eventually will take its toll. It will cost you and those around you. I believe the stress of hiding true feelings will make it more difficult for you to heal. The inability or unwillingness to cry or get mad can be a costly trait.

 We are very death phobic in this country and life at any cost seems to be our mantra.  Don’t get me wrong, many people fight long and hard to live, and survive against all odds. That is right for them. But even these folks have moments of feeling like giving up. That is normal, these moments pass, but the feelings should be acknowledged or they will only become more powerful. Then there are others who perhaps don’t fight as hard to live for lots of reasons; and that is ok too.

 As someone who worked for many years with people who were ill and often dying, I know there are as many ways of dying as of living. But everyone has moments (days, weeks) of fear, sadness, and anger. We do not need to share all of feelings of fear and anger with everyone at all times, but you must allow them. Hopefully  you can share them with someone who will listen.

  When I had my heart attack a few years ago, lying in the ER I thought, “Well this might be it”.  I remember being sad about leaving those I loved. I cried a little. I then turned over and peacefully went to sleep. Well as you can see, I woke up. I had three new 3 stents in my heart and more time. I am trying to enjoy that time to the max and build a legacy to leave when my time does come.

 My thoughts are with Senator Kennedy, Patrick Swayze and all those struggling for life. For them and all of us I say, enjoy live as best you can at the moment and go easy on yourself!

PTSD Diagnosis up 50 % in Iraq Troups in 2007 according to an associated press article.

Is anyone  really suprised that acute stress reactions are very high in troups in Iraq?  I would think not. But the issue of  a PTSD diagnoses  is another matter altogether.   In my opinion PTSD  is a diagnosis in vogue these days that is overused (similar to  Bi-Polar disorder) .  I do not believe you do  justice to a person returning from combat by  labeling (and burdening) them with a diagnosis too quickly.

Persons returning from War need time to heal. They need a  few months of reduced stress and expectations,  a place to  talk if they want, information on  how to deal with common problems,  help with reestablishing relationships (with very stressed family) and contact with others who have some idea of  what they are going through.   Lets give them the support and the time they need.  This is what  VA and communities should provide, not just another label. Ongoing support will provide prevention for PTSD, allow healing and time to identify those who are not doing so well.

When looking at the criteria to make a PTSD diagnosis having experienced a major stressor is only one criteria needed for the diagnosis to be made. 

Any life-threatening event

• Combat
• Natural disasters
• Accidents
• Assault

 Most survivors of trauma return to normal given a little time. Some will have stress reactions that linger or  even get worse over time. These individuals may develop PTSD.

Signs and Symptoms that last over a month ( this seems unrealistically brief to me.)

• Reliving the trauma (thinking about it with full emotional reactions)
• Becoming angry or upset  with a  thought or reminder of the trauma
• Avoiding places or people that bring memories of the trauma,
• Spending lots of time alone avoiding others.
• Lack of feelings or complaints of feeling numb.
• Feelings of being on guard (hypervigalent),  irritable, and being easily startled.

Question and Answer

I am a new nurse on a psychiatric inpatient unit. I was told that I was allowing a patient to “split.”  The person who said this to me seemed annoyed. Can you tell me what it means? What did I do wrong? I didn’t want to ask her.

 You may have heard the expression “splitting” as a description of the way that persons with personality disorders  relate to others.  Splitting is a coping mechanism (also called a defense mechanism) that is used by both persons with and without Borderline Personality Disorder.  It is a mechanism that is considered immature and is an unhealthy way to deal with disappointment in relationships.

• How does Splitting Work?  

  Splitting is defined as the inability to reconcile the presence of both positive and negative aspects in another. Splitting allows the person who uses it  to see others as either all good or all bad. Of course no human being is either “all good or all bad” but a combination of strengths and weakness. Splitting and Relationships  Although being the “all good” person may initially feel flattering, be aware that it will not last! When the person who is seen as all good disappoints (which of course is inevitable when expectations are unrealistic) they quickly become “all bad”. It is often this change in perception that will make someone struggling with BPD enraged. Persons who use splitting have unrealistic and unobtainable expectations of others, chaotic relationships, and are inevitably disappointed.

• Splitting and Relationships.
  
  Although being the “all good” person may initially feel flattering, be aware that it will not last! When the person who is seen as all good disappoints (which of course is inevitable when expectations are unrealistic) they quickly become “all bad”. It is often this change in perception that will make someone struggling with BPD enraged. Persons who use splitting have unrealistic and unobtainable expectations of others, chaotic relationships, and are inevitably disappointed. In order to grow and heal, a person who uses splitting as a way of  coping must somehow come to terms with the limitations of other human beings (and of themselves).
  
• Dealing with Splitting.

  In order to grow and heal, a person who uses splitting as a way of  coping must somehow come to terms with the limitations of other human beings (and of themselves). On an inpatient unit the best way to deal with splitting is not to engage in conversations about other staff with patients. Refer them to the person themselves or if necessay the nurse leader.  It is critical that all  staff are clear and in agreement  about the treatment and approaches to be used with the patient . This is also the same way to deal with difficult people in work or social groups who try to get people to take sides on an issue. an open discussion with everyone involved is the best strategy to avoid splitting. 

   

   

Did you know that there are at at least four major relaxation techniques to reduce stress. Most people have a particular favorite. I often think that when people tell me they have not had success with relaxation techniques it is because they have not found the one that is right for them! We all respond differently to suggestion.

I personally have tried all 4 before I decided which one is best for me. Let me tell you about them.

First they all begin with getting in a comfortable quiet position and paying attention to your breathing. After that you may choose from one of the following types. Some people use recordings to help them, others just do it in with their imaginations.

• Progressive relaxation

With this relaxation technique you start at the top of your head and tense and relax your muscle groups, one group at a time. For instance start with your scalp, tense tightly and hold for a few sessions, and then let go and relax. You do this moving down you body working with each muscle group. A lot of people like this because it is more active. It is not my favorite.

• Meditation

There are a number of different types of meditation. TM (transcendental meditation) is a popular one. In TM, you use a personal “mantra”.  This type of meditation can be done by picking a word known only you. You concentrate on this word saying it over and over in their mind. The word you pick really doesn’t matter. Pick a word that has special meaning for you.

• Autogenic Training

This is repeated concentration and suggestions of sensations of heaviness and warmth in the body. Like progressive relaxation you focus on one section of the body at a time and think of it and feel it as heavy and warm. You do this over you entire body. I enjoy this type of relaxation technique.

• Visualization

This is my favorite and there are many different forms of this. I like to use a CD as I don’t have a great imagination. You can do this yourself by concentrating on a favorite place, the sounds, the smells the view etc. There are some great recorded ones that will take you on a journey in your mind. You can find them to all your favorite places, the forest, the beach the mountains.

Try them all and see what works best for you. I am making an MP3 recording with general instructions and 5 minute examples of each for only $4.99. This is a great way of tasting all of the types without spending $15.00 on each CD. This is coming soon, get on my opt in list so you will be notified as soon as it is available.

Alcohol Use and Abuse:

It is not always easy to recognize when alcohol is becoming a problem for someone we love. First we do not want to see it and second the person is usually trying to hide it. Here are some clues to look for. Intoxication is usually easy to see. The signs of chronic use are more difficult to detect. Remember alcohol can become a problem for all ages. Older adults who live alone may be at high risk, as are adolescents. Here are some things to look for.

Sure Signs of Alcohol Intoxication

• Odor on the breath
• Difficulty focusing: glazed appearance of the eyes
• Irritability
• Excessive laughter
• Loud rapid, talking
• Sleepyness or stuporous in the later stages
• Inflammation in whites of eyes; pupils unlikely to be dilated

Changes Seen in Ongoing Alcohol Abuse

• Change in usual behavior
• Secrecy
• Decrease interest in appearance and hygiene.
• Decrease function in work or school
• Missing or tardiness at work or school. This often happens after time off.
• Increase in accidents
• Irritability
• Flushed skin
• Loss of memory (blackouts)
• Alcohol becomes the focus of activities.
• Loss of friends or different friends and associates
• Trouble in relationships, becoming secretive
• Forgetfulness in conversation
• Depression
• Physical illness, bruises

Marijuana Use and Abuse

Marijuana users are difficult to recognize unless the person is under the influence of the drug at the time. Casual users may show none of the general symptoms. Marijuana does have a distinct odor and may be the same color or a bit greener than tobacco.

Signs of the Influence of Marijuana

• Marijuana has a distinct odor, once you smell it you will recognize it. It smells similar to burnt rope on clothing or breath.
• Persons who are under the influence “high” tend to drive slowly, often below the speed limit.
• Persons under the influence tend to overestimate time intervals.

Signs of the Abuse of Marijuana

• Use or possession of paraphernalia including roach clip, packs of rolling papers, pipes or bongs.
• Financial difficulties (with long term use)
• Loss of interest in other activities with increased use
• Loss of motivation
• Increased sleep or time lying around
• Loss of job
• Loss of relationships except with other users
• Despondency, I don’t care attitude.

To learn to deal with someone under the influence of substances check out my book,

Behavioral First Aid: Managing Emotions During Emergencies