Better sleep, naturally

coffee
sleep_better

The world looks very different at 3 a.m. when you’re lying in bed staring at the ceiling or the clock. “How will I make it through tomorrow without any sleep?” you worry. If you regularly can’t get to sleep — or stay asleep — and it’s affecting you during the day, then you may have insomnia.

Prescription or over-the-counter sleep aids can help you drift off, but these drugs also have side effects. These include morning drowsiness, which can make activities like driving or using machinery dangerous, and an increased risk for falling. There are other ways to get a good night’s sleep than medications.

Two good lifestyles to start with include avoiding caffeine and sticking to a regular sleep schedule. If these steps don’t help, it’s worth a call to your doctor to see if a medical condition — such as thyroid problems, anemia, sleep apnea, menopausal hot flashes, heartburn, incontinence, or depression — is affecting the quality or the quantity of your sleep. Treating the health problem may take care of the sleep problem.

 

Your Daily Sleep Guide
This morning-to-evening, sleep-promoting schedule may help you get the rest you need.
Morning
7:00 a.m. Wake up at the same time each morning, even on weekends.
8:00 a.m. Limit yourself to just one cup of caffeinated coffee at breakfast, or drink decaf. Too much caffeine in the morning can stay with you until bedtime. (If you’re used to drinking several cups of coffee a day, wean yourself off it gradually over a few weeks.)
9:00 a.m. Get outside for a 30-minute walk. Both exercise and morning sunlight can help you sleep better.
Evening
6:00 p.m. Eat a light dinner. A heavy meal can lead to heartburn, which can keep you awake. Avoid caffeinated tea, coffee, and soda, as well as alcohol and chocolate.
9:15 p.m. Turn off your TV, computer, cell phone, and tablet at least 30 minutes before bed. They stimulate the brain. Read a book (not on a tablet), take a warm bath, or listen to soft music to help your body and mind unwind before bed.
9:45 p.m. Get your bedroom ready for sleep. Dim the lights, close the curtains, make sure the temperature is cool and comfortable, and cover your alarm clock so you can’t see the time if you do wake up in the middle of the night.
10:00 p.m. Use the bathroom.
10:15 p.m. Lights out. Try to go to bed at the same time every night. If you can’t fall asleep in 15 minutes, leave the bedroom. Sit somewhere quiet, like the couch, and read a book for 15-20 minutes or until you get sleepy. Then go back to bed.

The guide above can help you establish a sleep routine to promote restful nights.

Five Skills to Guarantee Your Career Success?

Have you ever wondered what it takes to have a successful career? Specifically, what skills would it be helpful to learn and master that could considerably enhance your career opportunities?

Well of course every career path is somewhat different. There will for instance be very specific skills that you must develop that come part of your job description. In other words, you need to have certain skills and knowledge that help you perform your job to a satisfactory level. These skills are of course vital and required for your chosen career path. However, there is also another set of skills that is well worth developing.

Specifically, there are five critical career skills that can dramatically enhance your value to your organization, while also enhancing your career prospects. These skills include:

  • Thinking
  • Memory
  • Reading
  • Writing
  • Speaking

On the surface there’s nothing special about these critical career skills. We are all able to think, to remember, to read, write and speak. So what’s the big deal, right? Well we have all of course mastered these skills at a very basic level. These skills help us to interact with the world around us and coexist with others. However, to truly thrive and move our careers forward, we need to take the time to develop each of these skills at a far deeper level of proficiency.

These five critical career skill areas in fact form the foundations that can help you thrive along just about any career path. For instance, can you think of a career path that wouldn’t benefit from understanding how to think more effectively? Or from being able to remember and recall information far more quickly? Or from having the ability to read and absorb information efficiently and rapidly? Or from being able to write clearly and concisely? Or from having the ability to speak persuasively and confidently?

Just about every career path you could probably think of would gain value from many of these soft skills. This is why these are the five critical career skills that will dramatically enhance your value to your organization. What’s more is that they are transferable to just about any career path you may choose to take. Given this, it’s certainly well worth taking the time to master each of these critical career skills at a high level of proficiency.

Let’s now explore each of these skill areas in a little detail to see how they can be of value for you as you move down your chosen career path.


Skill #1: Effective Thinking

To think effectively means having the ability to work through work related problems in optimal ways. It means having a deep understanding of what you’re doing and the awareness to know what needs improvement. This subsequently helps you develop action plans that allow you to work more efficiently and productively on work related tasks and activities throughout the day.

To think effectively requires having the ability to think logically, laterally and intuitively all at the same time.

First, when you’re thinking logically you use reason. You effectively assess the circumstances of your situation and outline logical paths or steps that can help you move forward in more optimal ways. Logical thinking also requires taking into consideration the consequences of your actions and the possible scenarios that may arise. Understanding these ramifications can help you make more effective decisionsthat allow you to improve your output and workflow.

Secondly, while thinking laterally you are using your creative capacity to think through your problems and circumstances in imaginative ways. This is what some people call out-of-the-box thinking.

To think creatively requires the use of analogies and metaphors that can help shift how you view work related activities and problems.

Thinking creatively is essentially about making perspective shifts that transform how you view a situation. These perspective shifts can help you to work through work-related issues in far more optimal ways.

Finally, while thinking intuitively you are essentially tuning into your inner feelings and thoughts about a situation. These intuitive hunches can help you to gather valuable insights that allow you to make more effective choices and decisions throughout the day.

To think effectively requires bridging together the logical, lateral and intuitive areas of your brain. Specifically this requires:

  • Understanding how to gather relevant facts, data and evidence.
  • Taking into account possible alternatives, various perspectives and sides of an issue.
  • Searching for new methods and processes for tackling work-related issues successfully.
  • Obtaining contributions from everyone involved in order to gather helpful insights that unlock new understandings.
  • Making decisions based on what makes logical sense in the moment, while at the same time taking into consideration intuitive thoughts and feelings.
  • Laying out a set of contingency plans for when things don’t work out as originally expected.

In general, thinking effectively will help you to solve work-related problems far more quickly; will allow you to develop new systems and methods that will improve your work-flow, and will provide you with the assets you need to work more productively throughout the day. All this in combination will help increase your value to your organization.

Effective Thinking for Career Success


Skill #2: Enhanced Memory

Enhanced memory and recall can be quite valuable for career paths that require working with a large knowledge base of systems, processes and information. However, it can also be equally valuable for anyone learning on the job.

Those who are able to remember and recall information quickly and easily learn faster and are therefore able to put that knowledge into practice far more rapidly. This subsequently gives them an edge over other people who haven’t developed their memory to a high degree.

You can of course improve your memory by using associations, mnemonic devices, rhymes, and pegs. You can also improve your memory by organizing the information you are trying to learn clearly and logically. Use all five senses and build vivid stories around everything you are learning. Explore how to do all this by using effective memory techniques.

But of course having a good memory isn’t enough. Your memory is essentially only as good as your health, vitality, and ability to handle stressful situations. If for instance you’re feeling sluggish and struggle to handle stress, then your memory will suffer as a result. Likewise your memory will suffer if you’re unable to successfully manage work-related distractions.

Given this, it’s vital that you learn how to deal with stress, how to optimize your energy levels, and how to manage a plethora of work-related distractions that are likely to interfere with your work-flow.

Enhancing Memory for Career Success


Skill #3: Accelerated Reading

Accelerated reading is a critical career skill that is related to memory and learning. When you are able to read through information quickly this gives you a significant edge as you are able to work through written information far more rapidly than the average person. However, reading quickly doesn’t necessarily mean you are learning. Learning also requires comprehension.

Knowing how to read quickly is all well and good, however it’s of little value if you cannot make sense of the information you are reading. Accelerated reading is therefore more than just about speed. It’s rather also about comprehension and putting that information into practice in effective ways that can help you learn quickly on the job. But how do we do this? What’s the technique?

I’ve already written a comprehensive guide on how to accelerated your reading speed and boost your memory and comprehension. There are however several important things that are worth noting here.

Accelerated reading is first and foremost about being very selective. It’s about selecting what’s most important to read. Read what’s most important and then skim over the rest. Many times the key information you need is often contained within 20 percent of the document text. This 20 percent will often provide you with 80 percent of the actionable knowledge you need to know and understand.

Typically when people read, they read the words on the page one at a time. However, to accelerate your reading speed you must get into the habit of reading groups of words together in chunks. It’s very much akin to looking at a picture as a whole. You can either choose to view the entire image, or you can instead choose to explore the details. Yes, you will certainly know more about the image by exploring the details, but it will also take you longer, and potentially the details aren’t really that important. All you need is just a quick overview to give you an idea of what it’s all about. And that’s essentially how accelerated reading works.

While reading though, pay particular attention not to silently repeat words back to yourself. This will tend to slow you down. Moreover, don’t backtrack. Once you have read something, just keep moving forward, but be sure that you’re fully focused and concentrating on what you are reading. If you’re distracted or your mind starts to wander, then it will be difficult for you to gain value from the process of accelerated reading.

Finally, it can be helpful to take visual notes while reading. Yes, this will slow down the reading process, but visual notes can help improve your comprehension of the information you are reading. In the end, reading without remembering or understanding is not an effective use of your time. In such instances, you are far better off reading at normal speeds. At least then you will know and understand more at the end of your session.

As you develop your ability to read quickly, you will naturally save yourself time working through written information related to your job. You will conduct research far more quickly and effectively, and will grasp concepts and ideas far more readily. This will therefore provide you with a superior advantage over those who read and comprehend information at a normal speed.

Speed Reading for Career Success


Skill #4: Proficient Writing

Proficient writing is a critical career skill that isn’t necessarily needed along some career paths. However, it is nevertheless a vital skill that is highly valued within many industries.

Writing proficiently is of course of value when writing reports, preparing presentations, and any time we need to get our message across in an effective way. This of course includes the various methods of written communication such as email.

To write proficiently means communicating effectively and persuasively. It means getting your message across in the most efficient and optimal way that ensures you are being understood. Moreover, it’s all about results. Your written communication must get you optimal results. Those who are able to do this effectively are highly sought after and valued within their organization. But how to do this? What does it actually take to write proficiently?

To write proficiently means to write succinctly using short words, sentences and paragraphs. Your objective is to get to the point as quickly as possible without creating confusion. However, there must be smooth and logical transitions within your writing. The ideas you are trying to get across must flow naturally from one paragraph to the next. There must be no guesswork in understanding your intended message and objectives.

While writing, be sure to keep in mind the intended audience you are writing for. Use language that this audience understands and responds to. With this in mind, avoid using archaisms and cliches. Also, use an active voice over a passive voice. Using active verbs helps gets the reader more engaged with your writing.

Above all else, if you desire to climb the career ladder, then focus on learning how to write more persuasively.

Writing persuasively is your ticket to becoming more influential within your organization. It allows you to present your ideas in effective ways that move people to take action. And that’s essentially what it takes to become a force for positive change within your organization, and potentially win that next promotion.

Persuasive Writing for Career Success


Skill #5: Persuasive Speaking

The final critical career skill that will provide you with ample opportunity to move your career forward comes in the form of persuasive speaking.

You are of course very familiar with language and know how to express yourself and get your point across. However, when you speak, do you speak with purpose and conviction? In other words, do you speak just to say a few words, or is there a purposeful intention behind each and every one of your words?

Most of us probably don’t often think about how we come across while interacting with others. At least not at a deep enough level that forces us to question our words and communication style. We just assume that we are being understood, but the truth could actually be very different.

The words you speak, how you express yourself, your tone of voice — all coupled together with your body language — sends a very specific message that makes people feel a certain way about you and about your ideas. Being vigilant and aware of how you’re coming across while interacting with others is vital to your career success. It’s vital because moving up the career ladder is basically all about the relationships you develop with other people.

You will only succeed by winning people over through your communication style. You may very well have great knowledge, skill and understanding in key areas related to your career, however if you don’t have the right connections and relationships established, then you are very unlikely to succeed or win that next promotion. This is why it’s so important to stay very vigilant of you’re coming across while interacting with others.

Many people of course probably don’t have too much trouble communicating one-on-one or within small group settings. They do however struggle speaking in public. And this is of course where they miss their biggest opportunity.

Public speaking provides you with an opportunity to get your message across to many people at one time. It’s a platform you can use to influence, persuade and to share your ideas that help move people to action.

Often you will find that the most successful people within your organization are proficient public speakers and presenters. They just feel comfortable speaking to large groups of people, and this naturally puts them in a position of power and authority to win people over and influence their choices, decisions and actions. But how do we do this? How do we learn how to speak persuasively in public?

First and foremost, it’s important to overcome your nerves. When you feel nervous, it’s almost impossible to come across persuasively. With that in mind, learn to control your breath, focus on adjusting your physiology, and try visualizing your ideal outcome in advance. This will help you to feel more relaxed and at ease in front of your audience.

Now that you’re feeling more calm and collected, it’s important to begin focusing on the message that you would like to get across. An ideal structure for this message comes in three distinct parts:

  1. Introduction: Tell your audience what you will be talking about.
  2. Body: Talk about what you mentioned within your introduction.
  3. Conclusion: Summarize what you have told your audience and finish with a call-to-action.

This is the very basic structure of a solid speech that builds the foundations of your persuasive message. However, within the body of your speech you must also take into account the Rule of Three. This essentially means presenting your audience with three key points for them to remember and take action upon. Any more than three points, and your persuasive message will quickly lose its effect.

In addition to this, it’s important to back-up your three points with relevant evidence that includes facts, data, stats, visuals, charts and even feedback/testimonials from other people that your audience admires and respects. Also be sure to transition smoothly between each point and argument you make. Everything you say must make sense, and the meaning must be very clear in order to get your persuasive message across most effectively.

To learn more about how to speak more persuasively, please visit the Six Minutes website. There you will find a wide variety of articles on how to improve your public speaking and presentation skills.

Persuasive Speaking for Career Success


Identifying Additional Critical Career Skills

Having fully explored the five critical career skills, it’s important to also address the fact that along your current career path there may very well be other additional vital skills that might be worth developing.

Think for a moment about your current work and responsibilities. Consider also your future goals and how you might like to move your career forward in the coming years.

Now, reflect on the types of skills that would help improve your effectiveness and efficiency throughout the day. Or how about the skills that could enhance your career prospects and opportunities, while also helping boost your levels of productivity?

Here are some questions that can help you to better pinpoint the critical career skills that might be of most value:

What are the most important skills I can learn right now that can help move my career forward?

What skills would give me a competitive advantage over other people in my organization and industry?

How relevant are these skills to my career path and toward improving my career prospects?

How could these skills potentially help me to advance my career forward?

What are the specific advantages of mastering each of these skill areas?

 

 

cited in :

5 Critical Career Skills that will Guarantee Your Success

عصر ادارة المعلومات

هل أرهقتك غزارة المعلومات ..لقد مضى عصر الزراعة في عام 1750

و خلفه عصر الصناعة  في 1950

و نحن لسنا في عصر ثورة تكنولوجيا المعلومات فقد انتهت عام 2007 هذه الحقبة و هذا العهد

و لكننا الآن في عصر ادارة المعلومات و القصة ليست فقط ادارة المعلومات و لكنها ادارة مدير المعلومات  …ان ادارة المعلومات تحتاج الوقت و و المال و تحتاج الى أدوات و من أدواتها الابداع اللفظي و الرقمي و الحسي و التخيلي انه عصر الذكاء

احتاج كثير من الوقت لأدير كثير من المعلومات و المخ هو المدير و المدبر في هذه الادارة هو الذي يرعى و يستعين بكل هذه الأدوات لتنسيق و تذكر المعلومات المرتبه

ادارة و رعاية المعلومات هي متابعة بذكاء و تدبير  وادارة بذكاء

watch

كلمة مانجو عند طفل صغير ..المخ يكتبها و يرسمها و يشتهيها و يشم رائحتها و يربطها بالموسم و السعر و كأنه يتذوقها كل هذا في أقل من ثانية  ولكن لم يقل لك المخ ان الكلمة هي   م   ا    ن   ج   و  …هذا بطء متخلف و خطأ فاحش في التربية في عصر ادارة المعلومات .. كلمة كلمة عشان افهم .. واحدة واحدة عشان أستوعب أبدا اقرأ بسرعة تخيل أسرع حس و أربط بلمحة!!هكذا تكون ادارة المعلومات

child using laptop

الطفل يولد مبدعا ذكيا عنده القدره على ادارة أي كم من المعلومات  .. اعط لطفل ذو العامين ورقة بيضاء .. سيكرمشها يضعها في فمه و يخبط بها على الطولة ثم يخبط بها في الهواء  .. ماذا فعل ..انه الطفل العالم  و كل الأطفال علماء  انه افترض الفرض عن هذه الورقه.. ثم خضعها لبحث علمي  الخواص  ..خضعها للنظرية و التجربة و التطبيق ثم الاثبات أو النفي ..  ولو أعطيته ورقه ثانيه .. سيبدأ من حيث انتهى أو من حيث أحب ان ينتهي فقد عرف ما هي و كيف يمكن أن يتعامل معها  .. أنت أيضا طفل عالم تخيل العلام حولك و انت تحل مشاكلك أو تنظم وقتك

حينما يفعل طفلك خطأ ما لا تنهره أبدا فأنت تقتل المستكشف الذي بداخله …جميعنا أطفال

كيف يقرأ المخ اشارة المرور .. بمجرد تحولها للأخضر خرجت السيارة من بين عشرات السيارات للطريق و قد عرف المخ المشهد ووجد الثغرة  .. لم يقرأ متكاسلا دراجة ..سيارة زرقاء باص أحمر ..رجل يسير …الى آخر ما يحدث بالشارع  ولكنه صور المشهد و اتخذ قرار النفاذ في لحظة

اذن فمدير ادارة المعلومات و هو المخ يستحضر المشهد كاملا

quran4

كيف تقرأ القرآن ..هل تستحضر المشهد و هل تراه أمامك وهل ترى تفسير ما يحاط بك أثناء القراءة ..هكذا يجب ان يعمل مدير ادارة المعلومات

الملكة الانسانية هي التخيل و التصور  فلا تقتل الخيال و تفنن في استحضار المشاهد المصورة

أما اللغة اللفظية فهي أداة التعبير عن الخيال و بالتالي فالخرائط العقلية و الانفوجراف و آلات وأدوات التصور و التصويرجميعها من سبل تطويع و فن ادارة المعلومات

فالابداع معكو بالرغم من تقدم العمر قد تنخفض الذاكرة و التذكر لكن لا ينخفض الخيال و التخيل و لذلك اذا سألتك أذكر في دقيقة عشرة استعمالات للدبوس

لو تخيلت كم فكرة ستأتي لك ???

ولو كتبت كم فكرة تستحضرها???

ولو تكلمت سردا بدون خيال هل ستأتي بشئ؟؟؟

Buzan_STUDY_SKILLS_handbook_Mind_Maps_Speed_Reading_Memory (1)

خريطة العقل و الذهن هي زهرة العقل و هي قوة الذكاء ..التفكير المشع هو الذكاء و الابداع .. وأدواتك هي ألوان العقل ..أكتب بالألوان و ضع مشكلتك في منتصف الصفحة و اجعل المعلومات تشع منها و حول النص المكتوب الى صورة ملونة ذكية ممتعة .. حينما تشتغل بالالوان توقظ ملايين الخلايا بالمخ ..هل ستكتب محاضراتك بالاوان و الرسوم و الخرابيش و اليقونات أم ستكتبها فقط باللون الأسود حتى لا تكون طفلا ..الطفل يتذكر أفضل و يبحث  ويبدع أكثر ..فلم لا تكون طفلا؟

mindbody

تحت يديك بنك و بنوك من العلومات  كتب ..يو تيوب..محاضرات.. أوراق .. تسجيلات  ..كيف ستدير المشهد بسرعة و بدقة و تجمع العناوين ثم تحتها عناوين ثم تحتها تفاصيل

لو تخيلت نفسك انك في قاعة محاضرات و أحد الحاضرين اعتذر و طلبوا منك ان تقف مكانه و لمدة نصف ساعة تتحدث عن نفسك بشكل جذاب يعني السيرة الذاتية لك

كيف سيكون أداءك…ان أهم ما في ادارة المعلومات هو القدرة على التخيل و القدرة على الربط  imagination and association

imagination_association

حلم مصري

لو سمحت .. لوسمحت … إنت إخوان لام العودة القريبة !

بقلم / أحمد رفاعى

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

انتخبت عبد المنعم أبو الفتوح فى الجولة الأولى, قبل أن أعض أصابع الندم لاحقاً … ثم ساندت الدكتور مرسي ضد شفيق و لم أكن وقتها مقتنعاً به , لكن انتخبته لا لشيء إلا لأنه ضد النظام القديم فقط …

بعد ترأس مرسي للجمهورية , ذاب جبل الجليد بيننا و استُبدل ببحر من الثقة و الإيمان بصدق هذا الرجل و لو كره الكارهون من الإعلاميين المضللين و أرباب العصر البائد من المنتفعين و الفاسدين !

إطلعت على مشروعاته للنهوض بالوطن ..و تابعت خطابه الذى رأيت فيه نهايته عندما أعلن على الملأ ان ميزانية العسكر ستدخل فى ميزانية الدولة .. بالاضافه إلى إعلانه عزم مصر على الإكتفاء بغذائها و سلاحها و دوائها .. و قلت وقتها : حفر قبره بايده !!!

تابعت تربص ( العسكر ) به و استخدامهم كل الطرق الغير مشروعة لذلك .. مستغلين ( تجهيلهم )أكثر من 60% من عامة الشعب على مدار ستين عام .. ثم إطلاقهم كلابهم المسعورة .. كل حسب ما وجه اليه .. فاستغلوا الأموال المنهوبة من أباطرة الحزب الوطنى لينفقوا ببذخ على تسيير مئات المظاهرات الفئوية و عشرات المليونيات , الغرض منها إفشال الرئيس مرسي فقط !

… ثم اختلقوا حركات ارهابية ممثلة فى جيش البلطجية الذى أنشأ فى عهد مبارك و الذى قارب المليون بلطجى يتبعون وزارة الداخلية بصورة مباشرة .. و جماعه البلاك بلوك … الذين ساحوا فى الارض ارهابا و فسادا .. إنتهاءاً بحركة تمرد التى مهدت للإنقلاب العسكري.

… ثم تنحت الشرطة عن دورها فى حفظ الأمن و اعلانهم (علاااانية ) أنهم فى أجازة مفتوحة لمدة أربع سنوات !!.

؟

…………………………………………………..

بنظرة بها الكثير من الشك , التفت لى و هو يقوم بإنهاء إجراءات التحويل البنكي , قائلاً :

: أوعى تكون من الإخوان يا دكتور أحمد !!

بابتسامة هادئة أجبته : و ايه اللى خلاك تقول كده يا أستاذ علاء ؟

: يعنى شايف حضرتك كده دايماً مبتسم .. و كلامك مؤدب .. و زي مانا عارفك يعني بتحب تساعد الناس !!

………

تكرر الموقف مرة أخرى , تقريباً كل يوم .. و لكن بصورة مختلفة .. حيث أتلقى العديد و العديد من الرسائل الخاصة على الإنبوكس .. يستفسرون فيها بارتياب ..عما إذا كنت – لا مؤاخذة – من الإخوان !! .. و عندما أسألهم لماذا ؟ .. يقولون نفس القول .. و لكن بصور أخرى !

………………………

حتى أريح حضراتكم .. أنا ( إنسان ) … أكره الظلم حتى كدت أن أفقد وظيفتى بسبب تضامنى مرة مع ممرضة مسيحية فلبينية ضد مسلم سنّى !! … و اتهمت بالخسة و النذالة عندما قمت بإنجاح طبيب هندوسي يستحق , على حساب طبيب مصري لم يستحق !! …

تأخذنى الجلالة , و أهيم فى عالم آخر عند سماعى القرآن الكريم بصوت الشيخ مصطفى اسماعيل .. و تطربنى أم كلثوم بآدائها فى ( يا ترى .. يا واحشنى .. بتفكر فى مين ) .. و يذهلنى أحمد رامي و هو يكتب ( طاوعت روحى على الهجران و انت هواك بيجرى فى دمي .. و فضلت أفكر فى النسيان لما بقى النسيان همى ) ! .. لا تعجبني كثيراً ألحان محمد عبد الوهاب , بينما تطير بي ألحان العملاق رياض السنباطي … فوق السحاب .

أهلاوى طحن … أتحول إلى مراهق , عندما يلعب الأهلى ( و إن كان هذا قد تغير الان بعد الانقلاب فلم أعد أتابعه الا فى مبارياته الأفريقية ) , لأجد نفسي أعانق السقف عندما يحرز هدفاً فى وقت قاتل !

أعشق مارادونا و أراه فلته الكرة التى لن تتكرر …أما أبو تريكة بالنسبة لى , فهو يفوق محمود الخطيب … بمواقفه الانسانية ..

أستمتع بموسيقى ( أندريه ريو ) .. و احتفظ بموسيقى ( عمر خيرت ) على سطح كمبيوتر مكتبي ….. اما فى سيارتى , فهناك تجميعة لأجمل أغانى الثمانينات و التسعينات .. الأجنبية !

أشاهد الافلام الأجنبية فقط .. و مشاهدتى للأفلام العربية توقفت عند حدود الأفلام الابيض و الاسود.. لا أتابع أى من القنوات المصرية التليفزيونية , حفاظاً على آدميتي … و لا أحب أى من الممثلين أو الممثلات المصريين و الحمد لله أكرههم جميعاً فى الله و أراهم سبب تدنى الذوق و الأخلاق فى مصر , و انحدار المثل و القيم النبيلة فى المجتمع !

أجالس الأدباء و الشعراء و المبدعين .. و أسعد أكثر بمجالسة البسطاء فى قريتي و تناول كوب من الشاى ( على الراكية ) تحت تكعيبة عنب عم (غمرى) فى قريتي عند زياراتى المتقطعة لها ..

لعبت الكرة قديماً و كنت مولعٌ بها .. لبست أغلى أحذية الكرة و أشهر ماركاتها .. لكنى لم أبدع إلا بحذاء (باتا ) القماشي ابو تلاتة جنيه و نص !

أكلت السمك فى مطعم السمبوك على ساحل الخليج العربي ب 1000 ريال .. لكنى لم أستطعم الا بوجبة السمك المقلى فى زيت ما اتغيرشي من شهرين , من عند عم حسن بتاع شارع بورسعيد فى كامب شيزار ب 75 قرش !

أعشق الكابتشينو فى ( ستاربكس ) .. و القهوة العربي فى ( باتيل ) .. , لكن متعتي الحقيقية فى شاى كشرى فى كباية قزاز على صينية ألومونيوم صدأه , غسلت بماء لم يجف بعد , فى قهوة بلدى , كراسيها من الخشب المتهالك , فى المنشية القديمة !!

الذى أطاح بكل أح

. ثم اطلاقهم بعد ذلك كلاب اعلامهم المسعورة لتنهش فى الرئيس مرسي و جماعته و ايهام الناس على اختلاف مستوياتهم بأن مصر كبيرة عليهم , و أنهم سبب خراب البلد على مدار الثمانين عاماً منذ نشأتهم

.. فأرسلوا توفيق عكاشة الى طبقة الفلاحين الغلابة … و الذين لا يعرفون القراءة و لا الكتابة , و ما أكثرهم , ممن يعتبرون أن ( التلافزيون ) هو فى نفس مكانة القرآن و الحديث !! … و يوسف الحسيني و جابر القرموطي الى طبقة المطبلاتية و الهتيفة و ما أكثرهم … و محمود سعد و منى الشاذلى الى الطبقة النصف مثقفة و ما أكثرهم .. و وائل الابراشي و عمرو أديب الى طبقة التلات اربع مثقفين و ما أكثرهم … و ابراهيم عيسي و باسم يوسف الى الطبقة المثقفة و ما أكثرهم … و مرتضى منصور و أحمد شوبير الى الطبقة السافلة و ما أقذرهم .. و أحمد موسي لوحده الى الطبقة المعفنة جداً و ما أكثرهم .. و شريف مدكور إلى الطبقة استغفر الله العظيم و ما أكثرهم … حتى تمكنوا من احتواء أكبر عدد من الشعب , ليأتى الدور على تسيير مظاهرات 30 يونيو برعاية خالد يوسف .. ليتم اخراج الحدث كما خططوا له .. لينتهى الأمر بإيداع أول رئيس مدنى مصري منتخب فى غيابات الظلم و السجن .. و ليتبوأوا ما خططوا له من السيطرة على كل مقدرات الوطن .. و ليبعد عنهم شبح من هددهم بسحب عزهم و جاههم و سلطانهم و ميزانيتهم .. ليتولى الأمر عنهم قضاه يصرخ الظلم من ظلمهم .. ليتكفلوا بإيصاله إلى .. حبل المشنقة !!!!

معارضتى للإنقلاب و مساندتى للشرعية .. هى دفاع عن حقى فى الإختيار … إختيار رئيس .. و إختيار دستور …. و إختيار برلمان بصورة ديمقراطية … اختارهم معى أكثر من نصف الشعب .. ليقوم النصف الآخر الفاشل بالإستعانة بمن قامت عليهم الثورة .. ليتمكنوا بمنطق القوة .. و القوة فقط .. من ايداع الرئيس الذى انتخبته فى السجن .. و إلغاءالدستور الذى اخترته بمحض إرادتى .. و حل البرلمان الذى رأيته خير من يمثلنى !

دفاعى عن الإخوان المسلمين .. هو دفاع عن فصيل أراه أكثر من ضحى من أجل ثورة 25 يناير .. هو الفصيل الوحيد الذى ما زال يحمل مشعل الثورة على أرض الواقع و فى الشوارع حتى الآن , و ان خبت شعلتها كثيراً .. لكنها ما زالت مشتعلة .. فصيل أخطأ فى حساباته بحسن نيه مع من لا نية حسنة عندهم على الإطلاق … لكنهم وحدهم الذين دفعوا الثمن .. و ما زالوا يدفعونه حتى الآن .. فهم المطاردون المطرودون و المقتولون و المسجونون و المحاصرون و المشوهة سمعتهم و الممنوعون من السفر و الممنوعون من العودة الى ديارهم !

…………………………………

أنا عبارة عن حلم .. يسير على أرض الواقع .. قد يتأخر تحقيقه قليلاً .. لكن إيمانى به لم يتزحزح قيد أنملة … و حلمى هو وطن .. يتساوى فيه الرئيس مع الغفير .. و قانون الغنى هو قانون الفقير .. وطن لا يرى بعين واحدة .. لا يفرق بين أبنائه .. وطن تقام فيه دولة العدل … الظالم يُقتص منه .. و المظلوم يُفرج عنه .. و الحق يعود لأصحابه … و العدالة لا تعطى ظهرها لمن لا ظهر له … وطن يحتضن أبناءه .. يلم شتات المغتربين … و يطمئن فؤاد المواطنين .. بمستشفيات محترمة تداوي مرضاهم .. و مدارس محترمة تعلم أبناءهم .. و جامعات محترمة … تهيئهم لوظائف محترمة …. تضمن لهم مستقبل محترم .. بصورة محترمة… فى وطن محترم !

وطن , جيشه يحمى حدوده .. شرطته تحمى أمنه … قضاته يحكمون بما أنزل الله … علماؤه يتقدمون المسيره … يقيم أركانه كل أبنائه ..

حلمي هو وطن … كل

يعجبني التشيكين تيبانياكي فى ( المطعم ) الصيني .. و التشيز بلاتر مع السيزر سالاط فى ( بول ) … لكن يأسرنى فول و فلافل محمد أحمد فى اسكندرية , على ترابيزات مجلمطة مزيتة مش نضيفة ! 

أطير بأحلامى إلى ما فوق السحاب .. لكن يتدلى من جناحاي .. أحلام أخرى لا أستطع الطيران بعيداً عنها ! 

أعيش فى فيللا فى الاسكندرية .. لكن أجد متنفسي فى بيتي على النيل فى قريتي الصغيرة فى كفر الشيخ !!.

أصلى الفجر منذ نعومة أظافرى و ذلك لاستيقاظى الطبيعي فى مثل هذا الوقت من يوم ما اتولدت … و الحمد لله لا أترك فرضاً فرضه الله عليّ . 

أحب التصوير و أجده اللغة الأرقى بلا كلمات .. أما المصورون فهم أرقى من عرفت و صادقت !! 

أكتب القصص القصيرة .. و أرى يوسف إدريس معجزة لن تتكرر .. شاعرى المفضل هو أمل دنقل .. و فاروق جويدة كرهته .. و احمد فؤاد نجم إحتقرته … وهشام الجخ عبقري , خانته عبقريته .

لى الاف الأصدقاء على الفيسبوك أحبهم جميعاً و احترمهم .. و أعتبرهم جميعاً أصدقاءاً حقيقيين ..مش مجرد أصدقاء من عالم وهمي !

لى موقعى الخاص على الإنترنت به محاضراتى و قصصي و رسوماتى و أعمال من تصويري .. و الموقع مفتوح لكل من أراد أن يستزيد علمياً .. أو مزاجياً 

لى أصدقاء من كل الأطياف .. من الإخوان المسلمين … و من المسيحيين .. و من السنة .. و من الشيعة .. و من غير المسلمين أيضاً .. لكن يجمعنا جميعاً الإنسانية و حب الحق و كره الظلم …

أقوم بعمل بلوك فوراً لكل من يتجاوز حدود الأدب , فلا يشرفنى صديق , انحدرت كلماته .

أحب عملى كطبيب آشعه .. و أجد نفسي تماماً فى ساعات عملى , و استمتع جداً بالتواصل مع زملائى و تلاميذى من خلال القاء المحاضرات العلمية .. 

عايشت الثورة المجيدة فى 25 يناير .. و رأيت فيها الحلم الذى طالما حلمت به بعد سفرى خارج مصر .. نسجت الآمال و أعددت العدة لعودتى مرة أخرى الى بلدى بعد غربة قاربت الخمسة عشر عاما …لولا الإنقلاب المشئوم مواطنيه …. هم أهم ما فيه

 

mood dys-regulation disorder: Diagnosis and Management

Professor Dr. Heba El Shehawi,Professor of Child Psychiatry,,Institute of Psychiatry,Ain Shams University,Egypt. She is giving a full lecture about mood dysregulation disorders among children, diagnosis and management. Professor Heba has a full clinical experience in the field and she is running a daily child psychiatry clinic managing different disorder.

Evolution of the brain: Psychiatrist and Mind

Professor Ahmed Okasha, gives a full lecture about psychiatry, mind and the brain.
Evolution of the human brain from psychiatric point of view. Lecture is mostly in arabic for everyone working in the field of psychiatry, psychology , medicine and anthropology as well. It is a global view , comparative , analyzing and critical thinking.
Ahmed Okasha M.D., PhD, FRCP, FRCPsych, FACP(Hon.) is an Egyptian psychiatrist. He is a professor of psychiatry at Ain Shams University, Cairo, Egypt. He wrote many books and articles about psychiatry and mental disorders. He is the first Arab-Muslim to be president of World Psychiatric Association from 2002 to 2005.

Improve Your Ability to Focus

 

There are a few core skills that, if you can improve them, can multiply your efforts in almost everything else you do.

Not all skills are like this. Being able to play the flute might be nice, but it isn’t going to help much with helping you lose weight or getting a promotion.

Core skills, like goal-setting, being organized or communicating well, can have enormous spillovers. When you get a little better at that one skill it can be applied to many different areas of life.

Being able to focus is one of these core skills. In this email, I’m going to share an unusual way of thinking about focus that can help you get better at it.

Should You Take an Outside or Inside View?

There’s two ways to approach improving your ability to focus. One is what I call the “outside view”. This is to try to improve your focus by constraining your environment. Eliminate distractions, turn off the phone, block the internet with apps like LeechBlock or better yet, don’t use a computer at all.

Another example of an “outside” strategy is the Pomodoro Technique. That’s where you decide to only focus for twenty minutes before taking a break, and you set a timer to tell you when to stop. The timer forms a constraint on your environment, so it’s easier to commit to focusing.

These strategies are all work. But they’re also probably the advice you’ve heard thousands of times before, so I wanted to share an alternative set of focusing tactics you may not have tried. These work in conjunction with “outside” strategies, so the best approach is to use both.

What are “Inside View” Tactics?

The “inside view” isn’t focused on changing your environment or external constraints. Instead it’s about paying attention to the subtle conversation you hold in your head while you’re focusing. By paying attention to this, and changing the script, you can extract more focus from your limited time.

This approach is very similar to what Buddhist monks often use when meditating. Meditation is a mental state very similar to focusing, however the object of focus usually isn’t a task, but your breathing, thoughts or consciousness.

One of the challenges of meditation is constantly being distracted by your own thoughts or impulses. It can feel almost like an itchy feeling where you constantly want to divert your attention onto some stream of thinking, worry or daydream.

This feeling, unsurprisingly, is very similar to what it feels like to be distracted when trying to focus on work. Although, occasionally, the impulse to move away from task at hand is caused by the environment—a ringing phone, a car siren in the distance—more often the distraction comes from within. It’s our own itchy feeling to escape whatever we’re doing and check Facebook, text a friend or pop open our email that pulls us away.

This problem also explains why, for many people, they can’t focus even when they pick a distraction-free work environment. Because the distractions are coming from inside your mind.

Tools for Combatting the Mental Itch to Distract Yourself

The first step to solving a problem is to properly understand it. So what actually happens, inside your head, when you lose focus?

If you’re anything like me, usually your focus slips without you realizing it. You notice your eyes have been moving but you haven’t actually been paying attention to the book you’re reading. You start thinking about some other issue in your life and realize you’re not actually working.

At some point, sometimes only a few seconds into your distraction, you catch yourself being distracted. This often comes with a wave of guilt over feeling like you should be working hard, but you’re not. Other times, the object of the distraction itself, seems to immediately demand you take action—“I should really check if so-and-so messaged me…”

I’ve often found, when you catch your attention slipping, there is a strong urge to stop with the task you’re focused on. You may feel guilty or frustrated. This may spin into a feeling that now isn’t the best time to work, that you really need a break or that it isn’t worth working on anyways.

How do you overcome this urge?

I’ve found that one of the best strategies is to copy what meditators do. Recognize that getting distracted is normal, and instead of getting mad at yourself, just allow your focus to drift back to what you’re doing.

It sounds simple, but amazingly, it often works quite well. By expecting that you’re going to get distracted, and simply allowing yourself to drift your focus back, you can often break the spell of a momentary distraction.

But what if that still doesn’t work, and twenty seconds later, you’re still itching to quit?

I’ve found there’s a good multi-stage self-talk habit I’ve created which helps me deal with it.

Stage 1: Drift back your focus naturally, no pressure to get work done

The first impulse I get to quit, I just remind myself what I’m doing and lazily return my focus back to the task. How you treat yourself here is important. If you chastise yourself or get angry, like a boss yelling at his employee to quit daydreaming, you’ll only exacerbate the frustrated or guilty feeling you have for not working hard.

On the other hand, if you treat your attention like a lost child who gently needs to be guided back to the task at hand, you’ll feel much better and focus can resume shortly.

Stage 2: Negotiate a future break

Sometimes the gentle prodding isn’t enough. Your mind keeps flitting away from what you’re doing and you can’t help but get frustrated.

Here, what you can do is negotiate a future break with yourself. Glance at a clock or timer and tell yourself that if you’re still unable to focus and it’s after some period of time in the future (say 5-10 minutes), you’ll allow yourself a short break. This can often reduce the feeling of being trapped in this semi-frustrated, distracted state of mind.

Stage 3: Take a smart break

Very often, ten minutes will pass and you’ll be back in the flow of working and you won’t need the break right at that moment.

But, if the time does pass and you still find yourself itching to quit, a good solution is to take a “smart” break. Smart breaks are activities that are relaxing, but unlikely to suck you into themselves. Going on the internet isn’t a smart break, because it’s very easy to get pulled in and find it hard to switch back to work when you need to.

Good smart break ideas include: going for a short walk, getting a glass of water, sitting with your eyes closed or doing pushups.

Summary

Training your ability to focus isn’t easy. However, sometimes just applying outside-view tactics isn’t enough because they don’t tackle the real problem—distractions coming from inside your own mind.

Making yourself feel guilty or frustrated often only make things worse. Better is to gently guide your mind back on task. If that still doesn’t work, negotiate a future break time. If the time elapses and you still can’t focus, take a smart break, rather than one prone to distraction.

Above all, practice this skill. New meditators can only sustain the posture for several minutes, while experienced practitioners can meditate for many hours at a time. So it is with focusing, you need to build your ability over time. If you try these methods and can’t go very long yet, don’t worry. With more practice you can stretch it longer and longer.

Understanding and treating an irritable bowel : Psychiatric Aspects

Irritable bowel syndrome significantly disrupts life for the women who have it. The good news is that we’re finding better ways to control it.

Irritable bowel syndrome (IBS) affects an estimated 24 million people in the United States. Experts aren’t sure why, but 70% of sufferers are women.

IBS causes recurrent episodes of constipation or diarrhea (or alternating bouts of each) along with cramps, bloating, and gas. For many, “irritable” vastly understates the impact of IBS. Symptoms often interfere with work and other activities. Some women hesitate to leave their homes because they’re embarrassed or don’t want to be very far from a bathroom.

Diagnosing an irritable bowel

There is no test for IBS. A clinician familiar with this condition can usually make a diagnosis just by talking with you and performing a physical exam. She or he will look for specific symptoms (see “Criteria for diagnosing IBS”) and may order routine blood and stool tests and check for lactose intolerance. She or he will also try to rule out other causes such as a thyroid disorder, endometriosis, and other bowel diseases. In some cases, clinicians may recommend a sigmoidoscopy or colonoscopy to examine the colon.

Criteria for diagnosing IBS

IBS is a functional bowel disorder — that is, there is no known disease or structural abnormality behind its symptoms. An IBS diagnosis requires the presence of abdominal pain or discomfort for 12 or more weeks (not necessarily consecutive) in the past 12 months, accompanied by at least two of the following:

  • relief of abdominal discomfort with defecation
  • a change in the frequency of bowel movements
  • a change in stool appearance or form.

These symptoms also suggest IBS:

  • abnormal stool frequency (more than three times per day or less than three times per week)
  • abnormal stool form or consistency
  • abnormal stool passage (straining, urgency, feeling of incomplete evacuation)
  • passage of mucus
  • bloating or a feeling of abdominal distention.

What causes the symptoms?

 

Some experts suspect disturbances in the nerves or muscles in the gut cause IBS. Others believe that abnormal processing of gut sensations in the brain may be responsible. For example, well-known research indicates that people with IBS have an unusually heightened awareness of bowel sensations. Some patients may have irregularities in the muscle activity of the colon. And research suggests that a bout with an intestinal virus may set off IBS, particularly when a stressful event follows the illness.

An emerging theory focuses on the neurotransmitter serotonin. Neurotransmitters are chemicals that transmit messages between nerve cells. Most of us have heard about the relationship between depression and serotonin in the brain, but the gut also produces serotonin, which in turn acts on nerves in the digestive tract. Some research suggests that IBS patients who suffer mainly from diarrhea may have increased serotonin levels in the gut, while those with constipation-predominant IBS have decreased amounts.

Emotional factors also play a role. For example, stress often worsens symptoms, and studies suggest that cognitive behavioral therapy, relaxation therapy, and hypnotherapy can help relieve pain and symptoms. Stress management, diet, and exercise have also proven useful.

 

Treating constipation, diarrhea, and gas

Because there is no cure for IBS, the goal of treatment is to control symptoms.

Constipation. Bulking agents (fiber, bran, and psyllium laxatives) help by moving waste through the intestines; however, they may not be useful for pain or diarrhea, and can cause gas and bloating. When using bulking agents, start slowly and gradually increase your intake. Be sure to drink plenty of fluids.

While there are no good data, most doctors think laxatives can be safe and effective when used judiciously. Stimulant laxatives (bisacodyl and glycerol) may cause abdominal cramping. Laxative herbal teas are also available; start with a weak brew and work up to the strength that works for you.

Diarrhea. Loperamide reduces intestinal muscle contractions and fluid secretion in the gut. Studies show that it helps relieve diarrhea, but not pain. It may not be a good choice for women whose symptoms fluctuate between constipation and diarrhea. A lower-dose form of loperamide is sold over the counter as Imodium. Lomotil (diphenoxylate and atropine) is a prescription drug also used to treat IBS-related diarrhea.

Gas and bloating. Simethicone-based products (Gas-X, Maalox), charcoal, and alpha-galactosidase (Beano) aren’t very effective, and no prescription drugs have proven useful. The best approach is to avoid the foods that trigger gas and bloating. Common offenders include beans, pretzels, bananas, dairy products, carbonated beverages, and raw fruits and vegetables (particularly cabbage, cauliflower, and broccoli). Fructose (a common sweetener) and sorbitol (an artificial sweetener) can also cause bloating and diarrhea.

Treating abdominal pain

Antispasmodics relax the muscle of the stomach and intestines. These drugs help relieve abdominal pain, but their benefits for constipation and diarrhea are uncertain. Antispasmodics available in the United States include dicyclomine (Bentyl) and hyoscyamine (Anaspaz, Cystospaz, others). Side effects include dry mouth, sweating, blurred vision, dizziness, constipation, bloating, urinary problems, headaches, and palpitations. Some women find peppermint oil helpful as an antispasmodic, but it can cause heartburn because it also relaxes the band of muscle that helps keep stomach contents from backing up into the esophagus.

Prokinetic agents increase smooth muscle activity and so may help relieve bloating or constipation. Metoclopramide (Reglan) and newer drugs such as tegaserod (Zelnorm) have prokinetic action.

Low doses of tricyclic antidepressants such as amitriptyline (Elavil) or nortriptyline (Aventyl, Pamelor) taken at bedtime appear to alleviate abdominal pain. Some studies suggest that these drugs are most helpful for diarrhea-predominant IBS. Side effects include fatigue, sleepiness, dry mouth, and constipation, which can be severe. It isn’t clear exactly how tricyclics help, but they may reduce nerve sensitivity. Selective serotonin reuptake inhibitor antidepressants have fewer side effects, but haven’t proved useful in IBS. However, they may be beneficial when depression or a mood disorder accompanies IBS.

The pros and cons of probiotics

Probiotics are live bacteria taken in capsule or powder form (or in yogurt). They may help with intestinal troubles by restoring the balance of bacteria in the intestine, and possibly by affecting the immune system.

A number of small studies, as well as anecdotal reports, suggest that probiotics improve IBS symptoms for some people. However, data on their safety and effectiveness are limited.

You can find probiotic supplements in grocery stores, health food stores, and pharmacies and through Web sites. If you’re interested in trying one, talk with your doctor. She or he may be able to offer some guidance.

Serotonin-modulating drugs

One of the most promising approaches to IBS treatment involves medications that alter the action of serotonin in the colon. These drugs act on the serotonin receptors on intestinal nerves — specifically serotonin-3 (5HT3) and serotonin-4 (5HT4) receptors.

Drugs known as 5HT3 receptor antagonists inhibit the action of serotonin in the gut. Alosetron (Lotronex), the first 5HT3 receptor antagonist developed for IBS, had a rocky start. FDA-approved in 2000, Lotronex relieved symptoms for many women with diarrhea-predominant IBS. (The drug doesn’t work in men.) Constipation was the most common side effect. Several months later, reports of severe complications of constipation that resulted in 44 hospitalizations and 5 deaths prompted the manufacturer to withdraw the drug from the market. These complications included intestinal blockages, extreme inflammation and distention of the large intestine, and compromised blood flow to the colon (ischemic colitis).

It was a tremendous disappointment for the many women who benefited from Lotronex. Lobbying by patients and doctors eventually brought this drug back to market in 2002, but only under a tightly controlled prescribing program (for more information, go towww.lotronex.com).

A 5HT3 antagonist (cilansetron) is now under study. Preliminary data suggest that this drug offers benefits to both men and women with IBS.

The 5HT4 agonists have the opposite effect of 5HT3 antagonists. Like Lotronex, the 5HT4agonist tegaserod (Zelnorm) greatly improves symptoms, but this time for women with constipation-predominant IBS. It, too, is effective only in women. Tegaserod speeds up movement of bowel contents through the colon and reduces sensitivity to intestinal nerve stimulation. As you’d expect, diarrhea is the most common side effect.

 

Moving forward

Many researchers believe that the key to better IBS treatment lies in tweaking the neurotransmitters and hormones related to gastrointestinal motility and sensation. Several newer and more specific compounds are under investigation, including muscarinic-3 receptor antagonists, neurokinin receptor antagonists, and opiate agonists.

As more targeted medications become available, physicians will be able to tailor treatment to individual women. In the meantime, if you have IBS, you’ll want to collaborate with a clinician who has experience treating IBS and who can help you find the best treatment plan for you.

Antidepressants are like antibiotics

Simple analogies can sometimes be helpful when emphasizing a point with a patient.  In what ways are antidepressants like antibiotics? Each of these similarities makes an important point regarding treatment with antidepressants.

Antidepressants

1. Antidepressants are not “happy pills”

Antibiotics don’t work for all infections. When you have a sore throat, you don’t automatically take an antibiotic because most cases of sore throat are due viral infection. Similarly, not everyone who is sad or depressed should get an antidepressant. Antidepressants are effective only for certain types of depression.

2. Antidepressants take some time to work

When you take an antibiotic, you often do not feel better right away. It usually takes a little time. Similarly, when you take an antidepressant, it takes some time for it to work. Typically this is 4 to 8 weeks for a clear effect though an improvement may be felt even earlier.

3. It is not irrational to use symptomatic treatment along with an antidepressant

When a person is treated with an antibiotic, e.g., for a strep throat, it is common to take other medications for treatment of symptoms, e.g., pain, fever, etc. Similarly, with an antidepressant, it often makes sense to also take a separate medication for insomnia or for anxiety. In a few cases, other symptomatic treatments like methylphenidate or modafinil are also  used.

4. Do NOT stop taking the antidepressant just because you feel better

With antibiotics, one should not stop taking them when we feel better; we should finish the “course” of treatment, 7 days, 14 days, etc. Similarly, with antidepressants, it is very important to not stop the antidepressant even when the depression has completely resolved. Persons who took an antidepressant for an episode of major depressive disorder and benefitted must continue the antidepressants at the same dose for at least 4 to 12 months after the depression is 100% improved (“continuation treatment”). If you stop an antibiotic before the course of treatment is over, the infection may come back and may be harder to treat the next time. The same is true with antidepressants.

5. Many patients require longer-term prophylactic antidepressant treatment

When a person is at high risk of an infection or has had recurrent infections, longer-term prophylactic antidepressant treatment is sometimes given. In patients with major depressive disorder, longer-term treatment with an antidepressant (“maintenance treatment”) is often indicated, much more often than with antibiotics.


A study done in primary care populations found that about 28% of patients stopped taking antidepressants during the first month of treatment, and 44% had stopped taking them by the third month (Lin et al., 1995). However, the study found that patients who received the following 5 specific educational messages were less likely to stop taking the antidepressant during the first month of treatment:

1. Take the medication daily. (Antidepressants should not be taken only on the days when the patient is feeling worse.)

2. Antidepressants must be taken for 2 to 4 weeks for a noticeable effect

3. Continue to take medicine even if feeling better

4. Do not stop taking the antidepressant without checking with the physician

5. Specific instructions regarding what to do to resolve questions regarding antidepressants

!0 Secrets for better public speaking presentation

From time to time it’s important to take a step back and put the world of public speaking into perspective. I do take it very seriously, and I am completely passionate about it, but it’s also important to recognize that public speaking is one human activity out of many, we don’t burn people at the stake any longer for disagreeing with us, and ultimately life is about love and work, as Freud noted, so at the very most public speaking should only occupy your thinking 50% of the time. And so here are my 10 rules for thinking rationally about public speaking, whether it’s something you dread or love, whether it’s a career for you, or a religion, and whether or not you ever will consider trying to master the art and science of it.

1. A presentation is a brief phenomenon.

 

It’s measured in minutes, typically, and the trend is toward shorter and shorter speeches. Unlike, say, chess games that can go on for days, or agriculture, which is measured in seasons, speeches are planned and timed to the minute. There are many implications that follow from this simple observation, but here are three. Minutes are important, and you should always give a few of them back to the audience – end early, not late, in other words. If your speech goes badly, and inevitably some will, then realize that you will live through it. If minutes are important to this art form, then seconds are too. Good public speaking is all about timing. Use your seconds wisely. Don’t just fill them up with words – use pauses, gestures, and silence as well.

 

2. Your most important job as a speaker is to find your voice.

 

Clients often ask me if their messages are new enough. But there’s very little that’s truly new in the advice we humans give to one another. Aristotle figured out most things a couple thousand years ago. Rather than obsessing about novelty, realize that what is new is your voice. If you draw on your own experience, insight, and stories, then not only will your message be a new version of what may be an old truth, but no one will be able to say it just the way you can. Human voices, when realized, are unique. That’s your real job – finding your unique voice. Don’t quote someone else – say it the way only you can.

3. Slow down and pare down.

 

The mistake that most rookie speakers make is to try to tell their audiences too much, to cram everything in, to tell them everything they know. One thing I’ve learned over two decades of coaching is that different clients need different approaches. Brilliant advice offered to one person falls on deaf ears of someone else. They’re at different places, or differing levels of skill, or have different issues. One size most certainly doesn’t fit all, and that goes for the presentations and their audiences too. So rather than try to dump what you know on everyone, spend some time figuring out what you’re going to leave out, what you’re going to not say, and how you’re going to use silence to best effect.

 

 

4. You’ll learn more from audiences that don’t love you than audiences that do.

 

Early on, most speakers just want to be loved. They want an endless, ongoing standing ovation from their audiences from the very start. And so presenters placate their audiences, tell them what they think the audience wants to hear, and avoid challenging their audiences really to think hard. The result is the endless stream of mediocre presentations happening day and night around the globe. It’s only when you get the courage to make your audience hate you that you’ll find out what you really need to say to them.

5. You can’t give speeches in your head.

 

Speakers run through their speeches in their head and believe that this is rehearsal. It’s not. You need to use your body to give a speech, and to rehearse one, because we embody our emotions first in order to find out what they are. In your head, you can say it quickly, smoothly – and blandly. In your body, you find the clumsy moments and the issues with connections from one part to another. Never rely entirely on the mental. Public speaking is performance art.

 

 

6. Let it go.

A speech is the product of the speaker, the message, and the audience. When it’s done, it’s gone. Let it go. Don’t let the accumulating weight of all your successes and failures become what defines you. If you do, you’ll stop being capable of being truly present and creating that performance art. You’ll just start phoning it in. Never, ever phone it in. You, your message, and your audience deserve better.

 

 

7. Not all audiences should hear you.

 

I can always tell a rookie author because when I ask him, “who’s your audience?” he says, as if it were obvious, “Well, everyone!” That’s a writer who hasn’t thought clearly enough about what he is writing about and who should read it. In the same way, not every audience will resonate with your message. It’s everyone’s job – you, the meeting planner, the speaker bureau, the organizers, whoever’s involved – to try to get this right beforehand. It’s always obvious after the fact.

8. You’ve got to take care of yourself, but not too carefully.

 

Some of my clients, when they become successful, become divas. It’s hilarious to watch, and I secretly love it precisely because it is a sign of success. You get the only-brown-M&Ms-in-the-bowl-in-the-hotel-room-which-is-set-to-69-degrees phenomenon. It happens, truly. But you’ll have more fun if you remember that you are actually just another glorious human being, with all the rights and limitations pertaining thereunto, and don’t end up taking yourself too seriously.

9. You are not your speech.

 

Along the same lines, never confuse yourself with your message. You are more (and sometimes less) than your message. The message can change. The speech should change. Speeches are not sculptured objects; they are monuments to a moment in time only. You should never give exactly the same speech for more than a few years running.  Knowledge changes, audiences change, you should too.

10. In fact, you should never give the same speech twice.

 

Speeches need to be tailored to specific audiences. The main points may be similar, or even the same, but you always need to customize your presentation to a particular audience because if you don’t it means you’re not thinking about that audience as much as you need to.

Public speaking is important, even life-changing and world-changing sometimes, but that doesn’t mean we have to take it with desperate seriousness. All human endeavor is ultimately temporary, and we are but dust in the wind. So enjoy yourself, make it as perfect as you can, and then trust to luck. Good hunting!

Yes it can be vitamin B12!

Over the course of two months, a 62-year-old man developed numbness and a “pins and needles” sensation in his hands, had trouble walking, experienced severe joint pain, began turning yellow, and became progressively short of breath.

The cause was lack of vitamin B12 in his bloodstream, according to a case report  from Harvard-affiliated Massachusetts General Hospital published in The New England Journal of Medicine. It could have been worse—a severe vitamin B12 deficiency can lead to deep depression, paranoia and delusions, memory loss, incontinence, loss of taste and smell, and more.

What does vitamin B12 do?

The human body needs vitamin B12 to make red blood cells, nerves, DNA, and carry out other functions. The average adult should get 2.4 micrograms a day. Like most vitamins, B12can’t be made by the body. Instead, it must be gotten from food or supplements.

And therein lies the problem: Some people don’t consume enough vitamin B12 to meet their needs, while others can’t absorb enough, no matter how much they take in. As a result, vitamin B12 deficiency is relatively common, especially among older people. The National Health and Nutrition Examination Survey estimated that 3.2% of adults over age 50 have a seriously low B12 level, and up to 20% may have a borderline deficiency.

Are you at risk?

There are many causes for vitamin B12 deficiency. Surprisingly, two of them are practices often undertaken to improve health: a vegetarian diet and weight-loss surgery.

Plants don’t make vitamin B12. The only foods that deliver it are meat, eggs, poultry, dairy products, and other foods from animals. Strict vegetarians and vegans are at high risk for developing a B12 deficiency if they don’t eat grains that have been fortified with the vitamin or take a vitamin supplement. People who have stomach stapling or other form of weight-loss surgery are also more likely to be low in vitamin B12 because the operation interferes with the body’s ability to extract vitamin B12 from food.

Conditions that interfere with food absorption, such celiac or Crohn’s disease, can cause B12trouble. So can the use of commonly prescribed heartburn drugs, which reduce acid production in the stomach (acid is needed to absorb vitamin B12). The condition is more likely to occur in older people due to the cutback in stomach acid production that often occurs with aging.

Recognizing a B12 deficiency

Vitamin B12 deficiency can be slow to develop, causing symptoms to appear gradually and intensify over time. It can also come on relatively quickly. Given the array of symptoms it can cause, the condition can be overlooked or confused with something else. Symptoms may include:

  • strange sensations, numbness, or tingling in the hands, legs, or feet
  • difficulty walking (staggering, balance problems)
  • anemia
  • a swollen, inflamed tongue
  • yellowed skin (jaundice)
  • difficulty thinking and reasoning (cognitive difficulties), or memory loss
  • paranoia or hallucinations
  • weakness
  • fatigue

While an experienced physician may be able to detect a vitamin B12 deficiency with a good interview and physical exam, a blood test is needed to confirm the condition.

Early detection and treatment is important. “If left untreated, the deficiency can cause severe neurologic problems and blood diseases,” says Dr. Bruce Bistrian, chief of clinical nutrition at Harvard-affiliated Beth Israel Deaconess Medical Center.

B proactive

It’s a good idea to ask your doctor about having your B12 level checked if you:

  • are over 50 years old
  • take a proton-pump inhibitor (such as Nexium or Prevacid) or H2 blocker (such as Pepcid or Zantac)
  • take metformin (a diabetes drug)
  • are a strict vegetarian
  • have had weight-loss surgery or have a condition that interferes with the absorption of food

A serious vitamin B12 deficiency can be corrected two ways: weekly shots of vitamin B12 or daily high-dose B12 pills. A mild B12 deficiency can be corrected with a standard multivitamin.

In many people, a vitamin B12 deficiency can be prevented. If you are a strict vegetarian or vegan, it’s important to eat breads, cereals, or other grains that have been fortified with vitamin B12, or take a daily supplement. A standard multivitamin delivers 6 micrograms, more than enough to cover the average body’s daily need.

If you are over age 50, the Institute of Medicine recommends that you get extra B12 from a supplement, since you may not be able to absorb enough of the vitamin through foods. A standard multivitamin should do the trick.

Not a cure

The Internet is full of articles lauding the use of vitamin B12 to prevent Alzheimer’s disease, heart disease, and other chronic conditions or reverse infertility, fatigue, eczema, and a long list of other health problems. Most are based on poor or faulty evidence.

Take Alzheimier’s disease as an example. “Although there is a relationship between low vitamin B12 levels and cognitive decline, clinical studies—including those involving people with Alzheimer’s disease—have not shown improvement in cognitive function, even doses of the vitamin as high as 1000 micrograms,” says Dr. Bistrian.

For now, it’s best to get enough vitamin B12 to prevent a deficiency, and not look to it as a remedy for what ails you.

What to do Before a Panic Attack

There are certain things you can do before a panic attack strikes that will help you better prepare yourself mentally for what’s to come. These moments you spend preparing can successfully desensitize you from the events, people, things and/or circumstances that might cause you to panic. In addition to this, the preparation you do now will help you handle stress, worry, anxiety and unexpected change with more thought and control.

Here are some suggestions to help you prepare yourself mentally and physically for the likelihood of a future panic attack:

Understand: Panic Attacks are Not Dangerous

It’s important to keep reminding yourself that panic attacks are not dangerous. Yes, the body does some strange things, and it might even feel as though you’re experiencing a heart attack, however that’s not actually the case. Your body is just responding to perceived danger by activating the fight-flight response. It sees that there is an emergency and it needs to make sure that you are aware and prepared to survive this encounter.

The excessive adrenaline that is pumped through your body at the time of a panic attack is what makes you feel on-edge and somewhat out of control. This is a natural and normal experience to a perceived threat. Yet, it’s important to remember that it’s only a “perceived” threat. You perceive things a certain way and as a result you react accordingly. Therefore, it would make sense that if you perceived things another way, that you would react differently.

If you do end up experiencing a panic attack, keep in mind that they tend to come and go in short bursts. Therefore, it’s important to feel secure in the fact that experiencing panic is natural, normal, not dangerous, and won’t last very long.

Expose Yourself to Uncomfortable Situations

You feel panic because you are potentially being thrown into an uncomfortable and unexpected situation that causes you to “freak-out” a little. This is understandable. Anything that’s new, unfamiliar or anything that you tend to fear and feel somewhat reluctant about can certainly get the adrenaline grands going and as a result you may very well experience a panic attack.

If new things can do this to us, then how about things that we’ve done numerous times before. These things are not new or unexpected. They are now familiar and we become comfortable with the things we have done time and again over an extended period of time. And within this lies the key to desensitizing yourself emotionally from uncomfortable situations.

To desensitize yourself, you must expose yourself to uncomfortable circumstances that you might fear or feel uncertain about in small doses over an extended period of time. This essentially means taking chances and risks to stretch your comfort zone using small daily steps. Yes, initially you might feel somewhat uneasy and may begin to feel that adrenaline building up inside your body. However, with continuous exposure over time, this feeling will subside and will instead be replaced with the knowledge and certainly that you can actually get through this situation successfully without losing control of your emotions.

Probably the most important thing that will come about from this daily desensitization process, is that you will begin disproving your fears. You will start becoming familiar and somewhat more comfortable with the events and circumstances you are confronting, and this will shift how you think about things. This shift in perspective will encourage you to take even greater risks the next day, and the next day after that. And before you know it you will have taken a giant leap that will give you the confidence you need to work through this situation successfully without panic or fear.

To desensitize yourself, take small progressive steps daily. When you begin losing control of your emotions, take a step back and learn from the experience. Then once you’ve gathered your thoughts, take another small step forward and try again. You might not make a lot of progress today, however with consistent effort you will make plenty of progress over the course of a week or month. The key is to try. You have absolutely nothing to lose and everything to gain.

Build Your Support Network

Everyone needs a strong support network. This is a network of friends, colleagues, family members, mentors, etc, who can help support you in times of need. Likewise, you can help support them when they need it most.

Your support network can successfully help you get through difficult emotional experiences. They can help you work through your stresses, overcome your worries, and even calm your anxieties. They can also help shift your perspective about events and circumstances. Maybe they will provide you with a new way of viewing things that will help convince you that there is nothing to worry about.

Build this support network over time by developing strong emotional bonds and connections with people. Help them out with their problems and emotional struggles, and they will likewise be there for you in your time of need. However, you have to be willing to reach out to these people and spend time growing and cultivating these relationships over many months and even years. That is when you will gain the greatest value from your support network.

Find Ways to Keep Calm

When you’re in “panic mode” the very first thing you need to do is to stay cool, calm and collected. And staying calm begins with your breath.

When you lose control of your breath, you lose control of your body, and when you lose control of your body, there is no turning back. Your first step is therefore to learn about breath control. Yes, actually jump onto the Internet and look for articles about “breath control”. Learning to control your breath will just make everything else so much easier, and will help put you in a more open and positive state-of-mind.

Another way to keep yourself calm during a panic attack is to practice progressive muscle relaxation technique. Normally when we’re in a state-of-panic, all our muscles tense up, and as a result we find it very difficult to relax and ground ourselves. However, if you take the time to learn and practice progressive muscle relaxation technique, then this can provide you with the confidence you need to use this technique during moments of an imminent panic attack.

The final way to calm yourself down comes in the form of meditation. Meditation can help you gain clarity and peace of mind in times of emotional turmoil. However, the benefits of meditation come over an extended period of time. They come after several months and years of teaching yourself how to calm your emotions and settle your mind. This calmness is initially only found while you’re meditating. However, over time after months and years of practice, this calmness will be within you throughout the day, whether you’re meditating or not.

So, jump onto the Internet and do your research. Look for articles about breath control, articles about progressive muscle relaxation, and about meditation. These three calming techniques will help you significantly as you work your way to a more calm, centered and focused state-of-mind.

Develop Your Emotional Coping Skills

Panic attacks are often triggered when you are unable to handle the less-intense emotions you experience throughout the day. For instance stress, worry, anxiety and fear are all common emotions that the typical person experiences that can often lead to a panic attack. It therefore makes sense that to ward off the possibility of experiencing a panic attack, that we must learn to better manage and cope with these four critical emotions.

Take time to gain as much knowledge as you can about each of these emotions, and then work on learning to cope with them more effectively on a day-to-day basis. Initially you might feel a little reluctant and might not make a lot of progress. However, with persistent effort and dedication over time, you will develop the necessary coping skills that will help you manage these emotions successfully. And once these emotions are under-check, then you will be less likely to experience a panic attack resulting from one of these emotional experiences.

Avoid Addictions

Addictions are never good for you. However, it’s just so easy to indulge in them when our emotions get out of hand.

Addictions such as alcohol, over-eating, caffeine, nicotine and recreational drugs have many side-effects and dangers. However, what’s less known, is that all of them will tend to raise your anxiety levels in the long-term. And when your anxiety levels are raised, this is more likely to trigger unexpected panic attacks throughout the day when you’re confronted with new or uncomfortable situations. This is very important, because under normal conditions you might not experience a panic attack, however because your anxiety levels were higher than normal, then this naturally put your emotions into a tailspin, and caused you to lose control.

Avoid addictions and give yourself a fighting chance to take control of your panic attacks.

How to Talk to Yourself??


What does it sound like in your head?

Sometimes I wish I could hop into someone’s head to hear what they are really thinking. Our thoughts are secret—and it’s a good thing too. We are far more brutal in our minds than in reality.

As a man thinketh, so is he.

Here are the major questions I have for you:

  • When you talk to yourself, are you nicer? Meaner? Harsher? Sweeter?
  • Do your thoughts match your actions?
  • Do you speak your mind?

 

Over the past few years running the Science of People, I have shared with you my readers and students that I am a ‘recovering awkward person.’ Most people immediately ask me two questions following this statement: How were you awkward? And how are you recovering?

This blog is filled with many of the practical tips I use to fight awkwardness and successfully interact with people. But I rarely get into the mindset of behavior change. This post is the first time I will go in depth into the thoughts behind the behavior. So before we get started…

A Warning: This post is a bit softer than my normal posts. It’s because I am exploring an idea out loud (or out loud for you on my blog)—I am wondering if these tips resonate with you. If not, no worries; thanks for going down a mental path with me. If so, let me know in the comments.

Here are some of the most common bad habits:

____ Procrastinating
____ Eating Badly
____ Smoking
____ Not Exercising
____ Working Too Much
____ Working Too Little
____ Watching Too Much TV
____ Drinking
____ Losing Things
____ Gossip
____ Being Disorganized
____ Forgetting Things
____ Lying
____ Complaining
____ Ignoring Problems
____ Starting But Never Finishing

Any of these look familiar? Let’s examine how your thoughts are tied to your actions.

#1: The Brain Believes What You Tell It Most

I recently picked up the book What to Say When You Talk to Your Self by Shad Helmstetter. Dr. Helmstetter argues that we are programmed by our thoughts. His ideas are very similar to the process I use when interacting with people and overcoming social anxiety. While the neurological evidence in the book is scant, I did want to use it as a springboard for discussing mindset. In fact, this is something I run into all the time in our lab. Specifically, our self-truths:

#2: Self-Truths

Self-Truths: The ideas we tell ourselves. The beliefs we carry around whether they are true or not.

Sometimes we learn self-truths from life experiences, other times we pick them up from those around us and other times we believe what we are told by parents, bosses and teachers.

For example, I had no chance to be good at math. From a young age, I was told ‘it wouldn’t come naturally to me’ or that ‘math will be your worst subject’ and sometimes even, ‘math is hard for girls.’ And guess what? It was! (And is). I wonder what would have happened if I had been told the opposite?

Here are some other common negative self-truths I hear people say all the time:

____ I am horrible at remembering faces
____ I never get a break
____ I have terrible luck
____ I can’t remember names
____ I’m awful with people
____ I’m so awkward
____ I’ll never fit in
____ I’m not creative
____ Mondays are always slow
____ I’m no good at …
____ Things never work out for me
____ I’m just not the type of person who …
____ I’m so clumsy

Do any of these sound familiar? I want to take a moment and have you think about some of your self-truths. What are some limiting beliefs you say to yourself?

  • I’m not good at _______________________________________
  • I always _______________________________________
  • I never_______________________________________
  • I’m just not the type of person who ________________________________
  • I’m not very _______________________________________

*If nothing comes to mind with these, DON’T fill them in! But if one instantly pops into your head, you might have just learned something interesting about yourself. Read on…

#3: Contextual Self-Truths

The other kind of self-talk can come up around certain people or in specific situations. For example, I feel very out of place in nightclubs and loud bars. My self-talk sounds something like, “I am so uncool!” or “I don’t belong here.” This is probably a learned self-truth. I had a few bad experiences early on and now I can’t shake them.

A friend of mine tends to chastise herself whenever she is around her mother. Before driving over to her parents’ for dinner, she will sit in the car and agonize, “I’m always so late… I never have my s*** together.” And the sad thing is her Mom says the same thing the moment she walks in the door. “Honey, you’re always late—you have to be more organized!” This is probably a taught self-truth. Her mom reaffirmed the behavior at a young age and she held onto it.

Do you have contextual self-truths?

  • Around Your Parents:
  • With Your Friends:
  • At Work:
  • With Your Boss:
  • At School:
  • With Technology:

#4: Limiting Wishes

Sometimes self-truths come in the form of limiting wishes.

Limiting Wishes: A future state that we hope will solve all of the problems from our current lacking self.

For example, one woman came into our lab and told us that the reason she can’t make friends is because of her horrible nose. “I look like a tucan,” she said. “When I am talking to people, I know all they are thinking about is my nose. As soon as I get it fixed, it will be so much easier to meet people.”

Let me ask you a question. Have you EVER not been able to talk to someone because you didn’t like their nose? No. Absolutely not. We tried explaining this to her every way possible. We even had people watch videos of her and rate her on a variety of personality traits. Not one single person mentioned her nose in the comments, in the post-interview, nothing. However, she was convinced of this limiting wish. Her limiting wish was, “If only my nose was smaller, I would be able to make friends.”

Here are common limiting wishes:

____ If only I was thinner
____ If only I was taller
____ If only I was richer
____ If only I was funnier
____ If only I was smarter
____ If only I got that promotion
____ If only I could move to that city
____ If only I could find a significant other
____ If only I was older
____ If only I was younger

Do you have any limiting wishes? Any desires that are holding you hostage?

  • If only I was _______________________________________
  • I wish I _______________________________________
  • Everything would be better if I_______________________________________

#5: Changing Self-Talk

Dr. Helmstetter breaks down being able to change your self-talk into 5 levels which I found interesting:

Level 1: The Level of Negative Acceptance

“I can’t _____ .”

  • The fill-in the blank statements you put in for your self-truths and limiting wishes are the current negative ideas you have accepted about yourself.

Level 2: The Level of Recognition and Need to Change

“I need to …” , “I should …”

  • *Hopefully* this is where you are now. The first half of this post was getting you to think about changing some of your negative self-truths and limiting wishes.

Level 3: The Level of Decision to Change

“I no longer …”

  • When you’re here, you have decided to change some of the limiting beliefs you have (see Step #6 next).

Level 4: The Level of the Better You

“I am …”

  • Once you have retired a limiting belief or changed it you then have a new self-vision and concept.

Level 5: The Level of Universal Affirmation

“It is …”

  • Lastly, you see the world differently. You have changed your own belief and the world around you.

Deciding to Change

In What to Say When You Talk to Your Self, Dr. Helmstetter breezed through Level #3—deciding to change. Changing your self-talk is hard—in fact, I think it takes a lifetime. It’s something I have been working on since I turned 17 and was lovingly called on some of my own limiting beliefs by a mentor. My hope with this post is that I am doing the same for you. Let’s start here:

#6: What Do You Sound Like?

This is kind of a weird question, but go with me for a second:

What does your internal voice sound like?

For just a moment, think about the voice in your head. You know the one that comments on your actions or makes little observations about the world around you. Does that voice sound like the voice you use in real life? Over the last few years, I have talked to people about their own ‘self-talk’ and more often than not I would hear them mention ‘how mean’ the voice in their head is. “But that’s you!?” I would say. “That voice is you!” But they would explain that sometimes the way they talk to themselves is much harsher than the way they would speak to anyone else.

Would you speak to someone else the same way you speak to yourself?

Take a look at this spectrum. When you talk to yourself, where do you fall:

spectrum

I am extremely critical of myself. When I don’t get something right, I internally berate myself and my abilities. If I mess up playing soccer or have a bad workout day, I internally chastise my laziness and lack of willpower. This self-talk gives me my drive, but it is often exhausting and demoralizing.

However, it has gotten better—slowly. I want to share with you the only way I know how to change self-talk.

How to Talk to Yourself

Do these 3 steps with me now before trying them practically:

Step #1: Hear Yourself

Most of this post has been dedicated to examining, identifying and calling out your self-truths. Why? That is the first step to changing them. We very rarely actually listen to what we say to ourselves. Please spend some time with the self-truth, limiting wish and contextual self-truth exercises. I want you to take out a sheet of paper and draw three columns. In the first one, write down all of your limiting beliefs. It might look like this:

 

hear yourself chart

Step #2: Reverse

It seems silly, but sometimes we have been thinking something for so long that we have forgotten what made us believe it in the first place. And we certainly no longer challenge it. I want you to go through your self-truth list and write down its reverse in a column called ‘Opposite.’ It should look like this:

 

opposite chart

Step #3: Gather the Evidence

This is the hard part. I want you to write down all of the reasons why the opposite is true. Sometimes this means finding learning experiences from hard memories—that’s ok.

 

evidence chart

#7: Your Choice

Now you have a choice. You can live automatically, easily, by default. Or you can live purposefully, with challenges and hard truths. I do not believe ignorance is bliss. I think truly living is embracing truth—about yourself, about the people around you, about how we work. But only you can decide to do this. If you want to try purposeful self-talk all you have to do is complete the 3 steps above when you begin to be self-critical. I can’t do this all the time, but it is what I try most of the time. This is how I have overcome a lot of my social anxiety. When I find myself in a bar for a friend’s bachelorette party, I go through these three steps:

  • I don’t belong.
  • I belong.
  • My best friends are here. I love celebrating people, especially the bachelorette. I love the song they are playing.

And so it goes. It’s not easy. It doesn’t happen all the time. But it’s exactly what it sounds like in my head.

What does it sound like in yours?

How To Use eBooks In eLearning

 

 

 

 

eBooks are portable, printable, and multiplatform-friendly. When they first arrived on the literary scene they were merely electronic copies of the original text. Today, they are fully interactive and immersive, making them a welcome addition to eLearning courses. At a moment’s notice, online learners can download an eBook onto their laptop, tablet, or mobile device in order to explore the subject matter at their leisure. This offers the all-important convenience factor, thereby enhancing their motivation and participation. Here are 7 tips for using eBooks in eLearning.

1. Offer A Variety Of Formats

Online learners are accessing your eLearning course on a broad range of platforms. Therefore, you must offer your eBooks in a variety of different formats. Some eBook publishers prefer ePub, while others use PDF. It’s best to survey your audience beforehand to narrow down your list of formats. In addition, research some of the top eBook converters, paying close attention to their supported formats. If you are going to offer your eBook on third-party sites, such as Amazon, then check their guidelines, as well.

2. Add Text-To-Speech Features

The thing that most eBooks lack is immersiveness. Online learners are being asked to simply read about the topic and then let their imagination take over. But that can be challenging for those who aren’t creatively-inclined. That’s when music becomes a valuable tool. Background audio, sound effects, and even audio narrations can make your eBooks more interactive and engaging. For example, instead of reading about what the eLearning characters are saying, you can offer them voice-acted dialogue. Bear in mind that your online learners are used to technology. It’s not uncommon for them to jump into online videos or opt for amazing eLearning games. Thus, static eBooks simply won’t suffice. They need to grab your audience’s attention and appeal to their senses.

3. Find The Ideal Level Of Interactivity

While we’re on the subject, adding interactivity is one of the most effective ways to make your eBook multi-sensory. In particular, it incorporates the all-important tactile elements that online learners crave. Rather than passively observing the subject matter while they read, online learners have the power to dive into the eBook story. They must click on links, drag and drop objects, and take notes in order to complete the in-book eLearning activities. For example, instead of telling them how to complete a task you can incorporate a link to an eLearning simulation. That being said, it’s essential to find the ideal level of interactivity. Tech-savvy online learners may love media-rich eLearning activities, but others might just be looking for a good read. Survey your online learners to determine what they need and how you can provide it through your eBook. Pay close attention to their tech experience, knowledge base, and learning preferences.

4. Incorporate Skill-Building eLearning Activities

One of the most significant benefits of using eBooks in eLearning is that they can contain multimedia. eLearning professionals have the ability to incorporate eLearning videos, articles, and other eLearning aids within the document. Likewise, online learners also have the opportunity to upload their own creations based on what they’ve read. For example, an online learner is able to record a video summarizing the eLearning content to share with their peers. This improves their communication and technical skills, while helping others to enhance their understanding of the topic. In fact, you might even consider creating a social media page for your eBook where online learners can share their insights.

5. Include Links To Online Resources

Your online learners may require more information after reading a section of the eBook. This usually prompts them to scour the internet for helpful eLearning resources. However, you can include links within the eBook itself to make the eLearning process much more convenient. For instance, they can simply click on the link in order to watch a tutorial or read a related news article. You may also include a master resource list at the end for those who want to explore sub-topics. Divide it into categories so that online learners can quickly find the information they need. Also, periodically check your links to ensure that they’re still active.

6. Include A Clickable Table Of Contents

This tip applies to all eBooks, no matter the page length. Online learners don’t have the time nor patience to skim through the entire eBook looking for key information. As such, you must provide them with a clickable table of contents in the beginning that redirects to individual sections. You can do this by simply creating bookmarks throughout the document that link back to the table. In addition, make sure that all of your pages are clearly numbered and include the chapter heading. Online learners should be able to pause and then return to where they left off with ease.

7. Typography Is Tantamount

Some eBook publishers get creative when choosing their fonts. They opt for fancytypography that adds a certain flair. However, this may actually be doing more harm than good. This is due to the fact that certain fonts are illegible, particularly on smaller screens. For this reason, it’s wise to stick with standard font types. Convey your creativity in other areas, such as adding appealing images or borders. If you do want to use non-traditional typography, then only use it in small doses. For example, make the chapter headers stand out or spruce up your table of contents with specialty fonts.

From eReaders to smartphones, eBooks in eLearning are accessible on a broad range of platforms. This makes them ideally suited for tech-savvy online learners who need constant access to information, even when they aren’t connected. Read these 7 tips and tricks to use eBooks in eLearning and create dynamic, interactive, and media-rich “must-reads” for your audience.

Rediscovering clozapine: Adverse effects develop—what should you do now?

Current Psychiatry 2016 August;15(8):40-46,48-49.
Brianne M. Newman, MD
Associate Professor of Psychiatry
Department of Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri

William J. Newman, MD
Associate Professor of Psychiatry
Department of Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri
Member of the Editorial Board of Current Psychiatry

 

Clozapine is a highly effective antipsychotic with superior efficacy in treatment-resistant schizophrenia, but its side effect profile is daunting (Figure 1).1 Adverse reactions lead to approximately 17% of patients who take clozapine eventually discontinuing the medication.1 As we noted in Part 1 of this 3-part series,2 clozapine remains the most efficacious, but most tedious, antipsychotic available to psychiatrists because of its monitoring requirements and potential side effects.

clozapine3

A powerful rationale for prescribing clozapine, despite its drawbacks, is its association with a reduced risk of all-cause mortality.3,4 People with serious mental illness, including schizophrenia, have a median 10-year shorter life expectancy than the general population.5
A recent cohort study6 examined electronic health records to test whether intensive monitoring or lower suicide risk might account for the reduced mortality with clozapine. The authors found that the reduced mortality rate was not directly related to clozapine’s clinical monitoring or other confounding factors. They did find an association between clozapine use and reduced risk of death from both natural and unnatural causes.

clozapine2
This second article in our series examines clozapine’s adverse effects from a systems perspective. Severe neutropenia, myocarditis, sedation, weight gain, orthostatic hypotension, and sialorrhea appear to be the most studied adverse effects, but myriad others can occur.7 We offer guidance to help the astute clinician continue this effective antipsychotic by monitoring carefully, treating side effects early, and managing potential drug interactions (Table 1).8

Hematologic events
Severe neutropenia, defined as absolute neutrophil count (ANC) <500/µL, is a well-known adverse effect of clozapine that requires specific clinical monitoring, a requirement that was updated by the FDA in 2015.2 The incidence of severe neutropenia peaks in the first 2 months of clozapine therapy and tapers after 6 months, but some risk always remains.

clozapin
Older efficacy studies in the United States gauged the 1-year cumulative incidence of severe clozapine-induced neutropenia to be 2%.9 A 1998 study of the effects of using a clozapine registry reported a lower incidence—0.38%—than the 2% noted above.10 Early recognition and recommended interventions can improve clinical outcomes.2

 

Drug interactions and neutropenia. A retrospective study of mental health inpatients taking clozapine concurrently with oseltamivir during an influenza outbreak found a statistically significant—but not clinically significant—change in ANC values.11 The authors noted that viral infection might lead to blood dyscrasia early in illness, and that oseltamivir has been associated with a small incidence of blood dyscrasia.11-13 This information might be useful when treating influenza in patients taking clozapine, although no specific change in management is recommended.
Similarly, concomitant treatment with clozapine and lithium can affect both white blood cell and ANC values.14,15 Lithium-treated patients often demonstrate increased circulating neutrophils via enhancement of granulocyte-colony stimulating factor.16 Case studies describe how initiating lithium treatment enabled some patients to continue clozapine after developing neutropenia.14,17 Leukocytosis can affect blood monitoring, possibly masking other blood dyscrasias, when lithium is used concurrently with clozapine.
Eosinophilia (blood eosinophil count >700/µL) occurs in approximately 1% of clozapine users, usually in the first 4 weeks of treatment.18 It can be benign and transient or a harbinger of a more rare adverse reaction such as myocarditis, pancreatitis, hepatitis, colitis, or nephritis.19 If a patient taking clozapine develops eosinophilia, clozapine’s package insert recommends that you:
evaluate promptly for other systemic involvement (rash, other evidence of allergic reaction, myocarditis, other organ-specific disease)
stop clozapine immediately if any of these are found.
If other causes of eosinophilia are identified (asthma, allergies, collagen vascular disease, parasitic infection, neoplasm), treat these and continue clozapine.
The manufacturer also mentions the occurrence of clozapine-related eosinophilia without organ involvement that can resolve without intervention, with careful monitoring over several weeks.8 In this scenario, there is flexibility to judge whether clozapine should be stopped or re-challenged, or if close monitoring is adequate. Consulting with an internal medicine or hematology specialist might be helpful.
Cardiovascular side effects

 

Most common events. Three of the 10 most common clozapine side effects are cardiac: tachycardia, hypotension, and hypertension (Figure 1).1 Orthostatic hypotension, bradycardia, and syncope also can occur, especially with rapid clozapine titration. Baseline electrocardiogram (ECG) can help differentiate whether abnormalities are clozapine-induced or related to a preexisting condition.
Reducing the dosage of clozapine or slowing titration could reverse cardiac side effects.8 If dosage reduction is not an option or is ineffective, first consider treating the side effect rather than discontinuing clozapine.20
Sinus tachycardia is one of the most common side effects of clozapine. First, rule out serious conditions—myocarditis, cardiomyopathy, neuroleptic malignant syndrome (NMS)—then consider waiting and monitoring for the first few months of clozapine treatment. If tachycardia continues, consider dosage reduction. Slower titration, or treatment with a cardio-selective beta blocker such as atenolol.21,22 Note that a recent Cochrane Review concluded that there is not enough randomized evidence to support any particular treatment for clozapine-induced tachycardia; the prescriber must therefore make a case-by-case clinical judgment.22

 

Similarly, orthostatic hypotension can be managed with a reduced dosage of clozapine or slower titration. Increased fluid intake, compression stockings, and, if necessary, fludrocortisone also can be initiated.20
Rare, potentially fatal events. Myocarditis, pericarditis, and cardiomyopathy are among the rare but potentially fatal adverse effects of clozapine. A recent study reported the incidence of myocarditis with clozapine at a range of 0.015% to 1.3%; cardiomyopathy was even more rare.23 Pulmonary embolism and deep venous thrombosis also are very rare possibilities; keep them in mind, however, when patients taking clozapine report new cardiovascular symptoms.

 

 

Patients with clozapine-induced cardiovascular effects most commonly report shortness of breath (60%), palpitations (36%), cough (16%), fatigue (16%), and chest pain (8%).7,24
Clozapine’s “black-box” warning specifically recommends discontinuing clozapine and consulting cardiology when myocarditis or cardiomyopathy is suspected. In 50% of cases, myocarditis symptoms present in the first few weeks of clozapine treatment.23 The manufacturer states that myocarditis usually presents in the first 2 months, and cardiomyopathy after 8 weeks of treatment; however, either can present at any time.8 Figure 2 provides a clinical reference for monitoring a clozapine patient for cardiomyopathy.24

 

 

Clozapine and the heart

Laboratory findings that support a diagnosis of clozapine-related myocarditis include:
elevated C-reactive protein
elevated troponin I or T
elevated creatine kinase-MB
peripheral eosinophilia.8,25
ECG, echocardiography, and cardiac MRI can be helpful in diagnosis, in consultation with a cardiologist.
Neurologic side effects
Seizures are listed in the “black-box” warning for clozapine. Seizure incidence with clozapine is 5% per year, with higher incidence at dosages ≥600 mg/d.8 Because clozapine-induced seizures are dosage-dependent, slow titration can mitigate this risk. Tonic-clonic seizures are the most common type associated with clozapine.
The manufacturer recommends caution when using clozapine in patients with a known seizure disorder, alcohol use disorder, or other CNS pathology.8 Patients with a seizure disorder may be at increased risk of experiencing clozapine-induced seizures, but this is not an absolute contraindication.26 Smoking cessation increases clozapine blood levels by an average of 57.4%, further increasing seizure risk.26,27
Discontinuing clozapine is unnecessary when a patient experiences a seizure. Instead, you can:
halve the dosage prescribed at the time of the seizure (or at least reduce to the last seizure-free dosage)
consider any medications or medical problems that might have contributed to a lower seizure threshold
consider prophylaxis with an antiepileptic medication (eg, valproic acid has efficacy for both myoclonic and tonic-clonic seizures).20,26
Sedation is the most common side effect of clozapine.1 Patients experiencing severe sedation should not drive or operate heavy machinery. To reduce sedation, consider instructing the patient to take all or most of the clozapine dosage at bedtime. A critical review of modafinil for sedation caused by antipsychotics in schizophrenia found only 1 open-label study that showed any positive effects; the authors concluded that further study is needed.28
Cognitive and motor slowing are possible neurologic side effects of clozapine. Caution patients about the risk of participating in activities that require cognitive or motor performance until the individual effects of clozapine are known.8
Tardive dyskinesia. Clozapine carries some risk of tardive dyskinesia, although that risk is lower than with other antipsychotics. Similarly, all antipsychotics including clozapine are associated with a risk of NMS. In the rare case of clozapine-induced NMS, stop clozapine immediately and initiate supportive therapy. Clozapine-induced NMS is not an absolute contraindication to re-challenging a patient with clozapine, however, if doing so is clinically appropriate.20
Cerebrovascular events. In older people with dementia, the use of antipsychotics—including clozapine—has been shown to increase the risk of cerebrovascular events. Because most antipsychotics are not FDA-approved for treating psychosis associated with dementia (only pimavanserin is FDA-approved for symptoms of psychosis in Parkinson’s disease), a risk-benefit analysis should be documented when prescribing any antipsychotic in this population. In practice, clozapine’s benefits may outweigh the mortality risks in specific situations.29,30
CASE Sialorrhea puts progress at risk
Ms. B, age 40, has a history of treatment-resistant schizophrenia and is starting clozapine because of residual psychosis during trials of other antipsychotics. She develops severe persistent drooling, mostly at night, during clozapine titration. Sugar-free candy, multiple bed pillows, and changing the dosing schedule do not significantly improve the sialorrhea.
As a result, Ms. B is embarrassed to continue her usual activities. She asks to stop clozapine, even though her psychotic symptoms have improved and she is functioning at her highest level in years.
Ms. B already is taking trihexyphenidyl, 5 mg, 3 times daily, to manage extrapyramidal symptoms related to haloperidol decanoate treatment. After discussing other medication options for sialorrhea, she agrees to a trial of glycopyrrolate, 1 mg, twice daily. She experiences significant improvement and continues taking clozapine.
Sialorrhea develops in 13% of patients taking clozapine.1 As in Ms. B’s case, this side effect can be embarrassing, can limit social or occupational functioning, and might lead patients to discontinue clozapine treatment despite efficacy. Nonpharmacotherapeutic options include covering the pillow with a towel, lowering the clozapine dosage or titrating slowly (or both), and using sugarless gum or candy to increase swallowing.
If the benefits of additional medications targeting side effects outweigh the risks, pharmacotherapeutic intervention may be appropriate. Options include the tricyclic antidepressant amitriptyline31; alpha-adrenergic agonists or antagonists (clonidine, terazosin); and anti-muscarinic medications (benztropine, atropine, trihexyphenidyl, glycopyrrolate) (Table 231). Scopolamine transdermal patch is another possible treatment strategy; however, the scopolamine patch was used for clozapine-induced sialorrhea in only a few case reports, and it is not considered a first-line treatment choice.30

When prescribing, consider the possibility of combined side effects with clozapine and adjunct medications having antimuscarinic or alpha-adrenergic activity, or both. Even atropine ophthalmic drops, administered sublingually, are readily absorbed and cross the blood–brain barrier.31 Another antimuscarinic agent, glycopyrrolate, is less likely to cross the blood–brain barrier and therefore is less likely to cause cognitive side effects. Glycopyrrolate is 5 times more potent at blocking the muscarinic receptor than atropine.31,32 Ipratropium bromide, another nonselective muscarinic receptor antagonist, has less systemic absorption than atropine drops, with less anticholinergic side effects when administered sublingually.
Limited evidence supports the efficacy of alpha-adrenergic medications for managing clozapine-induced sialorrhea. Monitor blood pressure when prescribing terazosin or clonidine, which could potentiate clozapine’s hypotensive effects.
Endocrine side effects
Among antipsychotics, clozapine is associated with the greatest weight gain—averaging nearly 10% of body weight.33,34 Similarly, the risk of new-onset diabetes mellitus is highest with clozapine in relation to other antipsychotics: 43% reported in a 10-year naturalistic study.35 The risk of hyperlipidemia also increases with clozapine treatment.36 These metabolic changes increase the risk of cardiovascular-related death, with a 10-year mortality rate from cardiovascular disease reported at 9% in clozapine-treated patients.35
Despite clozapine’s metabolic side effects, patients with schizophrenia who are treated with clozapine show a significant reduction in overall mortality compared with patients not treated with clozapine.6 Effective identification and management of metabolic side effects can prevent the need to discontinue clozapine.
Behavioral weight management and exercise are recommended as initial therapy.20 If, based on clinical judgment, these alone are insufficient, data support the use of pharmacotherapeutic interventions. Metformin demonstrates a positive effect on body weight, insulin resistance, and lipids, making it the first choice for adjunctive treatment of clozapine-induced metabolic side effects.37-39
Gastrointestinal side effects
Clozapine’s anticholinergic activity can lead to serious gastrointestinal (GI) side effects, including constipation, intestinal obstruction, fecal impaction, and paralytic ileus.8 Ileus has produced more fatal adverse reactions with clozapine than has severe neutropenia.20,40 Co-administered anticholinergic medications could increase the risk of ileus. Obtaining a GI review of systems and monitoring bowel movements (in inpatient or residential facilities) can aid in early identification and limit morbidity and mortality from GI adverse events. A high-fiber diet, adequate hydration, bulk laxatives in patients who can reliably maintain hydration, and GI consultation (if needed) may help manage GI side effects.20
Constitutional side effects
Fever can occur with clozapine, most often in the first month of treatment, but the incidence is quite variable (0.5% to 55%).20,41 Although benign fever is common, agranulocytosis with infection, NMS, and other systemic illness must be ruled out. The recommended workup when a patient develops fever while taking clozapine includes physical examination and relevant testing (urinalysis, measurement of ANC and serum creatine kinase, chest radiograph, ECG, and, possibly, blood cultures).41
If evidence supports a serious adverse reaction, stop clozapine immediately.20 If benign clozapine-related fever is suspected, acetaminophen or another antipyretic might provide symptomatic relief; discontinuing clozapine is then unnecessary.41
Pregnancy. When a patient with schizophrenia requires clozapine treatment during pregnancy, reliable clinical guidance is limited. The American College of Obstetricians and Gynecologists Practice Bulletin on the use of psychiatric medications during pregnancy and lactation can be a useful resource.42
Be aware that the FDA very recently made major changes to the format and content of pregnancy and lactation labeling, removing the letter categories that have been used for medications approved on or after June 30, 2001. The manufacturers of medications (such as clozapine) that were approved before June 30, 2001, have 3 years to comply with new requirements.43
The FDA had rated clozapine a pregnancy risk category B medication, meaning no evidence of risk in humans. In 2011, the FDA issued a general warning that antipsychotic use in pregnancy can cause extrapyramidal symptoms and discontinuation symptoms in newborns.44,45
A 2015 review of psychotropic medications and pregnancy noted that approximately 60% of women with schizophrenia became pregnant, with an increased incidence of unplanned pregnancy. A high risk of psychotic relapse (65%) during pregnancy and in the postpartum period may lead to insufficient prenatal care, drug use, and obstetric complications.45 Some data suggest low fetal birth weight and an increased rate of therapeutic abortions in women with schizophrenia.42,46
When treating a pregnant patient, weigh the benefits of clozapine against the risks of adverse events, and clearly document the analysis. Clozapine treatment is not recommended during breast-feeding because of the risk of side effects for newborns.8
We highly recommend keeping updated on the literature regarding pregnancy and lactation information with antipsychotics, including clozapine, because prescribing information will likely be updated in the near future to comply with recent FDA labeling changes.
Final installment: Using clozapine off-label
Clozapine is FDA-approved for refractory schizophrenia and for reducing the risk of recurrent suicidal behavior in schizophrenia or schizoaffective disorder. In Part 3 of this series, we review off-label uses—such as managing bipolar disorder, borderline personality disorder, and aggressive behavior—that have varying degrees of scientific support.
BOTTOM LINE
Clozapine is highly efficacious but requires greater clinician monitoring than most other psychotropics. Early identification and management of side effects can help patients continue clozapine, which is associated with reduced risk of mortality from natural and unnatural causes.

O Psychiatrists Screen for abnormal blood glucose, diabetes!

USPSTF update:
Screen all adults, ages 40 to 70 years, who are overweight or obese. Consider screening younger patients who have specific personal or family risk factors.
J Fam Pract. 2016 July;65(7):481-483.
Doug Campos-Outcalt, MD, MPA
Medical Director, Mercy Care Plan, Phoenix, Ariz
[email protected]

In December 2015, the United States Preventive Services Task Force updated its recommendation on screening for abnormal blood glucose and diabetes to say that clinicians should screen all adults ages 40 to 70 years who are overweight or obese as part of a cardiovascular risk assessment.1 This recommendation carries a B grade signifying a moderate certainty that a moderate net benefit will be gained by detecting impaired fasting glucose (IFG), impaired glucose tolerance (IGT), or diabetes, and by implementing intensive lifestyle interventions. In this article, as in the Task Force recommendation, the term diabetes means type 2 diabetes. Obesity is defined as a body mass index (BMI) of ≥30 kg/m2, and overweight as a BMI >25.
How the Task Force recommendation evolved
The previous Task Force recommendation on this topic, made in 2008, advised screening only adults with hypertension because there was no evidence that any other group benefited from screening. In subsequent years, there were calls for the Task Force to revise its recommendation to bring it more in line with that of the American Diabetes Association (ADA).2 While this new recommendation does add more adults to the cohort of those the Task Force believes should be screened, it is still not totally in concert with the ADA, which recommends screening all adults 45 years or older and those who are younger if they have multiple risk factors.3
Both the Task Force and the ADA acknowledge there is no direct evidence for any benefit in screening for diabetes in the general, asymptomatic population. The Task Force, with its standard of making recommendations only when good evidence supports them, has opted to address screening for abnormal glucose levels in the context of cardiovascular risk reduction and persuasive evidence that lifestyle interventions can reduce cardiovascular risks and slow progression to diabetes.
The ADA is willing to rely on less rigorous evidence of benefit in screening, diagnosing, and treating undetected diabetes. It believes that morbidity and mortality from this pervasive chronic disease can be reduced with early detection and treatment.
Still the Task Force and ADA agree more than they differ
While it appears that significant differences exist between the recommendations of the Task Force and the ADA, a closer look shows they actually have much in common; and, as they pertain to daily practice, any remaining differences are primarily ones of emphasis. For instance, the Clinical Considerations section of the Task Force recommendation acknowledges that certain people are at increased risk for diabetes at younger ages and at a lower BMI, and that clinicians should “consider” screening them earlier than at age 40 years. The risks listed include a family history of diabetes or a personal history of gestational diabetes or polycystic ovarian syndrome; or being African American, Hispanic, Asian American, American Indian, Alaskan Native, or Native Hawaiian.

 

DM-Lab
The Task Force statement seems to imply—although this is not entirely clear—that those who have these risks should also be screened if they are older than age 40 years even if they are not obese. So, although the ADA would screen everyone ages 45 and older, the Task Force would screen everyone ages 40 and older, except for non-Hispanic whites who are not overweight or obese, and who have no other risk factors. TABLE 11,3 details the Task Force and the ADA screening criteria and how they differ.

DM_lab2
USPSTF and ADA screening recommendations for abnormal blood glucose in adults: How they compare image
The Task Force and the ADA also agree on the 3 tests acceptable for screening and the test values that define normal glucose, IGT, IFG, and diabetes (TABLE 2).1,3 The tests are a randomly measured glycated hemoglobin level, a fasting plasma glucose level, and an oral glucose tolerance test performed in the morning after an overnight fast, with glucose measured 2 hours after a 75-g oral glucose load. If a screening result is abnormal, confirmation should be sought by repeating the same test. And both organizations suggest that, following a normal test result, the optimal interval for retesting is 3 years.
Normal and abnormal test values for glucose metabolism image
Intervening to delay progression to diabetes

 
For anyone with a confirmed abnormal blood glucose level, the Task Force advises referral for intensive behavioral interventions—ie, multiple counseling sessions over an extended period on a healthy diet and optimal physical activity. These types of interventions can reduce blood glucose levels and lower the risk of progression to diabetes, and can help with lowering weight, blood pressure, and lipid levels. The evidence report that preceded the recommendation pooled the results from 10 studies on lifestyle modification.4 The length of follow-up in these studies ranged from 3 to 23 years, and the number needed to treat to prevent one case of progression to diabetes ranged from about 5 to 20.4
Medications such as metformin, thiazolidinediones, and alpha-glucosidase inhibitors can also reduce blood glucose levels and slow progression to diabetes. However, the Task Force says there is insufficient evidence that pharmacologic interventions have the same multifactorial benefits—weight loss or reductions in glucose levels, blood pressure, and lipid levels—as behavioral interventions.1
As for the other modifiable risk factors for cardiovascular disease—obesity, lack of physical activity, high lipid levels, high blood pressure, and smoking—the Task Force has developed recommendations on screening for and treating each of them,5 which supplement the recommendations discussed in this article.

 

 

 

 

References

1. U.S. Preventive Services Task Force. Abnormal blood glucose and type 2 diabetes mellitus: screening. Available at:http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes. Accessed May 20, 2016.

2. Casagrande SS, Cowie CC, Fradkin JE. Utility of the US Preventive Services Task Force criteria for diabetes screening. Am J Prev Med. 2013;45:167-174.

3. American Diabetes Association. Standards of medical care in diabetes – 2016. Diabetes Care. 2016;39(Suppl 1):S1–S112.

4. Selph S, Dana T, Bougatsos C, et al. A systematic review to update the 2008 U.S. Preventive Services Task Force recommendation [Agency for Healthcare Research and Quality]. 2015. Available at: http://www.ncbi.nlm.nih.gov/books/NBK293871/. Accessed May 20, 2016.

5. U.S. Preventive Services Task Force. Healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: behavioral counseling. Available at: http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/healthy-diet-and-physical-activity-counse