Archive for the ‘Stress Management’ Category

I have had chronic sleeping problems for 10 years. I am a 58 yo woman going through menopause. My mother is 90 and still on sleeping pills. Could my condition be hereditary? Which pill will give me 7 hours of sleep leaving me refreshed the next day?

See the Do’s and Don’ts of sleeping habits on my site:

Make sure you are doing all the cognitive and behavioral things you can do to optimize sleep. 

You are in a high risk group for insomnia.  Sleep problems are more common in women than men, increase with age, and are aggravated by menopause.  The onset of your insomnia coincides with perimenopause.

Estrogen has many more potential benefits than risks for most women – especially brain benefits.  Unfortunately, if you still have your uterus you have to take some progesterone.  There are options like long acting intrauterine forms of progesterone that can minimize side-effects.  I am totally opposed to oral estradiol such as Estrace.

  Premarin or synthetic Cenestin by mouth and or estradiol cream/gel or patch is the best form.  The WHE study 5 years ago scared a lot of women about estrogen replacement therapy but the women in the study were on average 10 years post menopause and never used estrogen – that puts women at greater risk and may apply to you especially if you smoke.

One milder option is prescription DHEA which in women mainly turns to testosterone (good for bone and muscle) but then in the brain is converted to estrogen – avoiding the increased risk of estrogen related breast cancer.  

There are occasional women who benefit from natural progesterone (Prometrium) at bedtime since it has a natural benzodiazepine like sedative effect.  I recommend that you don’t take synthetic progesterone like Provera.  

Any form of alcohol can contribute to sleep problems because it causes arousal as it wears off.  If you do drink alcohol make sure it is not within 3-4 hours of going to bed.

We are fortunate to have very effective sleep medications that provide normal sleep.  The mildest, shortest acting is Sonata, usually 10mg-20mg lasts 4-5 hours.  Benzodiazepines such as Xanax, Klonodine, Ativan, etc., shouldn’t be used at bedtime because they decrease stage 4 sleep (the most important type of sleep), but they can be used for early awakening with inability to get back to sleep – since we get all our deep sleep in the first three hours.

Lunesta (2-4mg is needed) for sleep but may cause a bad taste in 15-20% of people (less likely if taken with orange juice).

In general, Ambien CR is better than Ambien tablets because they frequently don’t last long enough.  The generic form is probably weaker.  The CR form is not as strong as the tablets for inducing sleep but lasts longer.  Some people have to combine CR with the short acting tablets to get to sleep.

All of these sleep medications work better on an empty stomach – combined with good sleep habits as I stated earlier.

Circadian rhythm problems can also contribute to the problem.  Morning bright light and or evening melatonin or prescription Rozerum may also help. 

Adding Tenex or Clonidine, or occasionally Prozosin can be helpful.  Trazodone, Seroquel, or low dose Doxepin may help.  Neurontin (up to 800mg) or Lyrica also induce normal sleep.

Chronic insomnia can be very resistant because of all the anxiety and conditioned negative expectations.  It is harder to treat initially and gets easier as fear of insomnia subsides.  When problems persist a sleep study can help identify problems such as restless legs, myoclonus, or sleep apnea.

When all else fails there is a medication that usually works, Xyrem.  It is highly regulated because of previous misuse of it as GHB.

Because good sleep is so essential you have to persist until you find what works for you.  Don’t give up until you find the right medication at the right dose.    

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Will I always need Lexapro and Klonopin if I successfully go through cognitive behavioral therapy?

It partly depends on what you’re taking the medications for.  Uncomplicated panic disorder without agoraphobia has the highest rate of complete remission.  Severe obsessive compulsive disorder, agoraphobia, or social anxiety disorder may require some long term medication to maintain remission.  Generalized anxiety without serious depression may respond fully to CBT.  A lot will depend on how good the CBT is and how hard you are willing to work on it.  For OCD I recommend Brainlock by Jeffrey Schwartz.  For panic disorder proper breathing is essential.  The following link has instructions for proper breathing.

For social anxiety stimulants are frequently helpful.

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Vitamins & Supplements: Are they really worth it?

  We have heard it since we were kids, but do we really need to take our vitamins? 

The answer is yes. 
Most Americans don’t get the nutrition they need simply from the foods they eat, and supplements insure that our body meets its nutrient “quota” enabling our body to function optimally at the cellular level.  However, the vitamin and supplement industry is not regulated by the FDA, so there is no guarantee that products bought from grocery and health food stores are effective or contain the stated ingredients.    
Cooper Complete Vitamins are backed by Science.
That is one reason we decided to make them available to our patients. Reputable physician Kenneth Cooper created the Cooper Institute, a non-profit organization that manufactures, researches and publishes studies on Cooper Complete vitamins. He ensures regular testing to measure efficacy, potency and absorption of Cooper supplements.  Not only does Dr. Jones promote these vitamins, but he takes them himself and he furnishes them to his staff at no charge to promote wellness among staff members.  To encourage patients to take these supplements over other store bought brands, Dr. Jones decided to make these supplements available to his patients at a discounted price, so we offer the Cooper Complete© line of products for less than you can get them at most grocery stores and even less than the price from ordering them directly from his website. 
If you are interested in ordering supplements or would like more information about the supplements, please feel free to contact our office or e-mail us your request to  

Studies published in the American College of Nutrition and
the American Journal of Medicine found Cooper Complete multi-vitamin lowered: 
· Oxidation rates of LDL Cholesterol by 14%

· Homocysteine levels by 17%

· C-reactive Protein Levels by 32%

High levels of these values are all associated with increased cardiovascular disease risk.

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Habit 3: First Things First

You have to take care of your biological needs first. This includes a good diet plus basic vitamins and supplements. It also includes good sleep, ideally 7-8 hours of quality sleep every night and blood pressure in the normal range. Hormones like thyroid, estrogen, testosterone, and blood sugar, cholesterol, triglycerides, iron, and B12 are important. To be ideally healthy you have to be physically fit. “First be a good animal.”

According to Ken Cooper (aerobics) this requires a minimum of 30 minutes of vigorous physical activity three times per week for cardiovascular health. To help with depression or to control weight you need to exercise 6-7 days per week. The effort level required is equal to a brisk walk (2 miles in 30 minutes).

A lot of my patients say, “I hate to exercise.” That’s okay. Don’t call it exercise. Call it work. Vigorously vacuum, mop and clean house, or wash the car – an effort that gets your heart rate up to at least 120 to 144. Or you can call it play. Go dancing, play basketball.

But whatever you do make sure to get off your butt and get fit. It’s a lot easier when you find something that you enjoy doing and for many people it’s easier to do with a friend or loved one. One of the easiest ways to stay fit is to have a treadmill, elliptical trainer, or stationery bike in front of a TV where you can exercise while watching the news, sports, or a favorite show. Don’t put it off – you have to do it!

One thing I do is keep a log of my workouts in my day timer. I convert all exercise to miles and I keep a weekly total and an ongoing total. By running competitively at least once or twice a year I keep myself motivated to work out even on days that I don’t feel like it. To feel good and to be optimally productive you have to be fit! You have to take care of your body, and the most important part of your body is your brain!

Being physically healthy obviously means not smoking – that includes second hand smoke. It means not drinking excessively or abusing drugs or medication. It means being smart and wearing your seat belt.

Although not as essential as physical fitness, a good sex life enhances quality of life. Since stress inhibits sex drive and can interfere with sexual functioning and since we live in a high stress world, a lot of people have a sex life that they are not completely happy with. Thankfully we now have many effective treatments for sexual problems and you need to be able to discuss this openly with your doctor. I will discuss all the specifics of sexual dysfunction in men and women and all the current treatments in a future article.

In addition to your physical well being you have to address your spiritual, emotional, and intellectual needs.

What’s next? Your basic biological needs are being met and you are not in any acute danger. Should we focus more on love (relationships) or work (productivity)?

Actually you can go either way. By focusing on education, training, and work you become independent and self sufficient. That enables you to be in relationships interdependently. You are not needy and you are not manipulative. There is give and take. You can focus on relationships first, especially if you had a healthy family and had “good enough” nurturing. This means you feel good about yourself and your uniqueness. Having a lot of emotional/social support can make it easier to build your career and become self sufficient. Most people alternate between these two major needs.

Stephen Covey describes these levels in Maslow’s hierarchy as “to live, to love, and to learn.” The highest level then is “to leave a legacy,” or what he now refers to as the 8th habit – “find your voice and help others to find theirs.” Your deepest most personal, most passionate driving force or motivation is somewhere inside of you. You may or may not know what it is – you may need help in being able to understand what it is or how you can fulfill it. For me, writing this is expressing my voice and if I can help one person to find theirs my life will have meaning. Find your voice!

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Happy Holidays … The Best of Times and The Worst of Times

They are the best of times and the worst of times, to borrow a phrase from Dickens. Parties, presents, family – and parties, presents and family.

Why do so many people feel so much stress this time of year? Parties are fun to go to – mostly, but then there’s the pressure to make small talk, the gossip, the time, and if you’re giving the party – the planning, shopping, cost and clean up. For many people who have social anxiety, they are especially difficult.

Then there’s the gift buying – what to buy – how much to spend. Thank God for plastic – until you get the bills. There’s the traffic, crowds, and an overwhelming amount of crap, frequently on sale and still usually overpriced. But the main stress of the holidays for many people is the family. Every day in my office I hear some horror story about some blow-out at a family function. In a recent interview, Donald Trump said "Friends are great; family is greater" – or not, I might add.

Why does there seem to be much more resentment between family members than between friends? What exactly does "blood is thicker than water" mean? It is certainly messier when it’s spilled all over the place.

The greater risk of hostility occurring in families has multiple causes. First, there’s a greater likelihood that we will get together with people we don’t particularly like when we are related to them. Many people avoid confrontation or open discussion of conflicts. In family, this may result in smoldering hurts and resentments, sometimes for decades.

Second are many opportunities for envy or jealousy. Third are feelings of entitlement that inevitably lead to disappointment. Fourth is a greater likelihood of indulging ourselves with a temper tantrum or tirade that would be fatal to a typical friendship but are usually tolerated in the context of the family. Throw in alcohol and the added stress of rug rats running around everywhere and you have the recipe for potential disaster.

What can we do to protect ourselves – or at least lessen the risks?

There’s no such thing as an unexpressed feeling. If not expressed or dealt with openly, it will come out indirectly in some neurotic or passive aggressive communication or will be internalized as a somatic or physical symptom.

But feelings don’t have to be expressed immediately. It’s OK to wait until a suitable time and place. The holidays aren’t the ideal time to try and resolve ongoing conflicts. Anticipating an awkward situation and getting together ahead of time to clear the air is preferable, if circumstances allow. But if not, it may be helpful to let the person know that you’re aware of the problem and that you would like to get together soon and talk (set a specific time if possible).

When you have a "serious talk," set your goals realistically. It takes two people to have a positive personal dialogue. It also takes two people to have a nasty fight – Either one can usually stop a bad exchange. Sometimes the best you can do is acknowledge that you understand how the other person feels and why. You don’t have to agree. You can’t make them understand how you’re feeling, but you have a better chance once they know you have heard their position. Covey says in Habit 5, "Seek first to understand, then to be understood."

The pain of lost loved ones is frequently most intense during the holidays. It helps to share feelings and memories with people you are close to. Don’t just share how much you miss them and how it’s not the same without them. Recall the happy or especially funny incidents. Be thankful you have loving memories.

Listen with your "third ear," to paraphrase Theodore Reik. Read body language and tone of voice so that you might prevent gradual escalation to an emotional uproar. When appropriate, use active listening. Point out the feeling that you sense (i.e. "You seem quiet or down or upset or stressed."). This invites the other person to share. If sincere, be supportive, but other options include getting an agreement that prevents an increase in tension. Be caring, playful or straightforward. Do not be critical, controlling or sarcastic.

Try to avoid feeling sorry for yourself, even if you inherited a screwed up family. Don’t be a rescuer and try to fix everything. We can observe a lot by watching according to Yogi Berra. And Einstein said, "Insanity is doing the same thing over and over and expecting a different result." Do something different.

For the fortunate, the holidays are the best time of year. We get to see our families, participate in traditional activities and laugh a lot. If you are not so fortunate, don’t be part of the problem. Be part of the solution. You can start a new tradition this year.

Good luck!

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Destressing: Pay Now or Pay Later

I like the word "stress", and I find that patients accept the word and the concept. It helps answer the question, "why am I so screwed up?" It certainly beats words like "schizophrenia", "manic depressive" and "neurosis." "Borderline personality" never sold well.

Change starts with awareness. Only when you know what the problem is can you make a decision to change. If you don’t pay now with good stress management, you will pay later with "wear and tear." The process of change is really a lifetime commitment to take responsibility and maintain balance. Of course it helps to be lucky.

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Many studies show that stress symptoms and disorders are increasing. Not only are more people becoming clinically depressed, but it’s starting at an earlier age. Suicide is second only to accidents in cause of death in teenagers. The average adult weighs 30 pounds more than in 1970. Stress is a major contributor to complaints of fatigue, headaches, anxiety, insomnia, poor concentration, lack of interest in sex, digestive problems, and high blood pressure. The list goes on and on.

You can think of stress symptoms as being like debts in your STRESS ECONOMY. IF your deposits (stress management) are less than your withdrawals (stress), this creates stress overload. Sometimes symptoms are caused by too many concurrent pressures (changes) but other times by a decrease in stress management.

A man came to me complaining of recent onset of panic attacks. He seemed to have everything going for him. He was in good general health, was financially well off, and had a great marriage. BUT, he did have a high volume business in a competitive market.

My assessment of why he suddenly started having symptoms is that he had stopped his daily thirty minute jog. He had fallen while working on a home improvement project and was a walking cast. Many people who don’t have any symptoms are susceptible to one sudden change or loss pushing them over the line and out of balance.

Selye defined stress as “the wear and tear of life” or, more specifically, that which increases your Cortisol (stress hormone).

If I had to put one word between life’s stresses and illness it would be Cortisol. Cortisol is essential for life. In a crisis Cortisol “marshals your troops to the front line” – BUT at the expense of longer term concerns like your immune system and less essential functions in an emergency, like digestion and sexual functioning. Chronic stress overload suppresses your immune system. This means not only increase in susceptibility to infection but can ultimately cause cancer that may not become symptomatic and diagnosed until years later. A study of dental students found that wounds took 40% longer to heal before exams than before the semester started and that their immune function before exams was reduced by 2/3’s. Stressors can be obvious. Travel is more difficult since 9-11. We all have some level of concern about the dangers associated with terrorism. But there’s the more mundane – traffic, deadlines, tests, conflicts, health insurance – an almost endless list of external issues that are far more complex than ever in history. There are also internal stressors – attitudes and expectations that we have. We put pressure on ourselves, and we sometimes dwell on past mistakes or worry excessively about the future.

More important than stressors themselves is how much control we have. When mice were experimentally shocked until they pressed a certain lever, and this was repeated over and over, they did not show much elevation in Cortisol. But when these mice are connected to a 2nd group of mice, who don’t have the levers but get exactly the same amount of shock as the 1st group, the 2nd group (without the levers) become agitated initially, but then give up and become passive. Their Cortisol levels are extremely elevated. Being helpless is more stressing than being shocked. It also shows that chronic stress eventually leads to exhaustion and fatigue. If the 2nd group of mice is given access to levers after they have reached this last stage, they don’t even try to use them. This has been called “learned helplessness” by Seligman. In today’s highly complex society, we have much less control than our ancestors. I remember a tax law change that lowered the value of the office condo I owned by 80%. Seventeen years later, it’s still worth only 1/2 of what I paid for it. Stress!

Another factor that alters the the effect of a stressor is predictability. Studies done with primates by Coplan dramatically demonstrate this. New mothers were put in one of 3 situations relative to getting food for themselves and their babies.

Food was either easily available, or required hard work and looking, or it varied between the two conditions. The mothers in the unpredictable situation became highly stressed. Importantly, so did their babies. Most importantly, these babies grew up to become adults who had permanent vulnerability to stress.

This study has also documented the effects on the brain of the stress syndrome. They had much lower survival rates of new brain cells, especially those in rapid access memory part of the brain.

There are other factors that influence how we react to stress.

  • Genetics – animals can be bred to be overreactive to stress or to be highly resilient and less than average in their stress responses.
  • Gender (sex) – women between puberty and menopause are more reactive to stress than men. When asked to dwell on the worst experience of their life, women had 8x’s more activity in the areas of emotional processing in the brain as men doing the same exercise. After 9-11, men were angry and increased their physical activity. Women were more emotional, worried about their loved ones, and had more symptoms.

One of the most important determinants of stress reactivity is early life experience. Even in utero, the fetus is impacted by the mothers stress symptoms. Clinical depression during pregnancy increases stress vulnerability in the infant and this effect is long lasting. One of the most controllable factors in stress reactivity is clinical depression itself. Stress reactivity, more than stress itself, determines response. Early recognition and adequate treatment to full remission is protective.

Just as physical exercise can make you stronger, manageable stress makes you more resilient. Animal studies show that brief separations of babies from their mothers followed by nurturing led to resistance to adversity. This has been called “Stress Inoculation”.

The following will also help reduce stress symptoms:

1.  Get rid of unnecessary stresses

2.  Resolve ongoing disputes

3.  Be proactive

4.  Attend church or have a spiritual life

5.  Have strong relationships and social support

6.  Have a good sex life

7.  Be physically active

8.  Get at least 7 hours of quality sleep per night

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