Chapter 9 of the book Self-Help Stuff That Works

by Adam Khan:

IN 1982 STEVEN CALLAHAN was crossing the Atlantic alone in his sailboat when it struck something and sank. He was out of the shipping lanes and floating in a life raft, alone. His supplies were few. His chances were small. Yet when three fishermen found him seventy-six days later (the longest anyone has survived a shipwreck on a life raft alone), he was alive - much skinnier than he was when he started, but alive.

His account of how he survived is fascinating. His ingenuity - how he managed to catch fish, how he fixed his solar still (evaporates sea water to make fresh) - is very interesting.

But the thing that caught my eye was how he managed to keep himself going when all hope seemed lost, when there seemed no point in continuing the struggle, when he was suffering greatly, when his life raft was punctured and after more than a week struggling with his weak body to fix it, it was still leaking air and wearing him out to keep pumping it up. He was starved. He was desperately dehydrated. He was thoroughly exhausted. Giving up would have seemed the only sane option.

When people survive these kinds of circumstances, they do something with their minds that gives them the courage to keep going. Many people in similarly desperate circumstances give in or go mad. Something the survivors do with their thoughts helps them find the guts to carry on in spite of overwhelming odds.

"I tell myself I can handle it," wrote Callahan in his narrative. "Compared to what others have been through, I'm fortunate. I tell myself these things over and over, building up fortitude...."

I wrote that down after I read it. It struck me as something important. And I've told myself the same thing when my own goals seemed far off or when my problems seemed too overwhelming. And every time I've said it, I have always come back to my senses.

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The truth is, our circumstances are only bad compared to something better. But others have been through much worse. I've read enough history to know you and I are lucky to be where we are, when we are, no matter how bad it seems to us compared to our fantasies. It's a sane thought and worth thinking.

So here, coming to us from the extreme edge of survival, are words that can give us strength. Whatever you're going through, tell yourself you can handle it. Compared to what others have been through, you're fortunate. Tell this to yourself over and over, and it will help you get through the rough spots with a little more fortitude.

Tell yourself you can handle it.

Do you want to be strong? Would you like to remove a good portion of fear, shyness, and awkwardness from your life? Check out the chapter called:

 

next: Maybe it's Good

Robert Burney, author of Codependence: The Dance of Wounded Souls, calls his private practice "Counseling for Wounded Souls." He holds a Master of Arts degree in Human Relations and has experience in chemical dependence treatment programs, having worked in inpatient and outpatient settings with both adults and adolescents.

Robert is a non-clinical, non-traditional therapist a healer, teacher, and Spiritual guide whose private practice is based upon Twelve Step Recovery Principles and emotional energy release/grief process therapy. His practice is based on the belief that we are Spiritual Beings having a human experience and that the key to healing is awakening to consciousness of our Spiritual connection. He emphasizes that the purpose of healing is to learn how to enjoy being alive.

Robert is based in Cambria on the the Central Coast of California. He spends part of each week in Santa Barbara and works with clients in Los Angeles.

History of Codependence: The Dance of Wounded Souls:

In the spring of 1991, Robert Burney was asked to speak in several different venues on the subject of Codependence. In the course of those speaking engagements he heard himself making statements to a general audience that he had never considered saying in public because of their controversial nature. To his surprise he found that the practical process level tools and techniques that he utilized in his private therapy practice were merging with mystical and magical knowledge he had acquired writing a book that was an adult fable about the history of the Universe the first book of a trilogy.

Although he experienced a great deal of fear about making such controversial statements in public, he was compelled to further explore this message that he felt coming through him. He arranged dates in June of 1991 to give a talk in Cambria and Morro Bay, California. He then found he was unable to write the talk. The message that he was formulating was multileveled and nonlinear so that he found it impossible to organize his thoughts into a coherent presentation. His anxiety mounted as the date for his talk approached until in a burst of inspiration born out of desperation he wrote almost continuously for the last 48 hours prior to the talk. The presentation was scrawled on yellow legal pages that first time he presented the talk.

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As he got ready to give his talk, he was overwhelmed with feelings of dread and experienced emotional memories of being stoned to death by an angry mob. He was convinced the audience would not be able to hear his message because of the outrageously controversial aspects of it but was compelled to go forward with it because of his personal Karmic need to take responsibility and stand up for his Truth. To his amazement, the audience not only heard what he was saying but cried tears of Joy in recognition of the Truth he was sharing.

That talk formed the basis for the book Codependence: The Dance of Wounded Souls. The message evolved and expanded over the years as he refined the techniques he was developing to facilitate Codependence recovery, but the basic structure of the book was essentially born in those two days of desperation. Robert made a trip from Taos New Mexico, where he was living at the time, to the Central Coast of California in the winter of 1995 in an attempt to raise funds to publish a book based on the talk. Because of that trip (which was a real leap of faith) he did receive the financing to start the publishing process in the summer of 1995. He returned to Cambria to set up his publishing company, Joy to You & Me Enterprises, in the fall of 1995. The official publication date of the book was January of 1996.

Robert is in the process of writing six more books about the Human Condition and the recovery process. He hopes to be able to publish two of those books in the coming year.

One of those books will be a process level, how-to, book about the recovery process and his techniques for developing internal boundaries. The working title for this book is Wounded Souls Dancing in The Light (a great deal of the material for that book is being previewed in this web site.) Robert hopes to get this book in print in 1999 but that will depend on raising the financing to publish it.

The other book he hopes to publish in the coming year is the first book of the mystical fable trilogy that provided part of the inspiration for his current book. That mystical fable is entitled The Dance of the Wounded Souls Trilogy Book I - "In The Beginning..."(a preview of that book is included in this web site.) Book II - Atlantis, Mu, and Jesus Too is scheduled for publication in 2000. The third book of the trilogy is as yet untitled.

About his Work:

The focus of Robert Burney's therapy is teaching self-empowerment. He does not normally do long term individual therapy which he believes can sometimes foster dependence. The purpose of his work is helping people to access their own Spirit so that they can learn to depend on, and trust themselves. He specializes in small groups (maximum 4 people) which focus on changing the core relationship with self. These consciousness expanding process groups are designed to help people on a Spiritual Path become more aligned with the healing process so that life can become an easier, more enjoyable experience. During the course of the group process individuals learn how to: get in touch with and release childhood grief which allows emotional honesty with self; get intimately in touch with both the inner child (inner children) and Higher Self; have internal boundaries, as well as external boundaries, in order to stop being at war within and start developing a more Loving relationship with self.

It is Robert's unique approach and application of the concept of internal boundaries coupled with the Spiritual belief system he teaches that make his work so innovative and effective. The following paragraphs from one of his pamphlets exemplifies both the philosophy and goal of his therapeutic work:

"Learn how to integrate Spiritual Truth and intellectual knowledge of healthy behavior into your experience of life and find some balance in your relationships. Knowing Spiritual Truth intellectually will not make your fear of intimacy disappear or relieve you of the shame you feel deep within. Integrating Spiritual Truth into your day-to-day life process and emotional reactions is what will set you free.

It is possible to feel the feelings without being the victim of them. It is possible to change the way you think so that your mind is no longer your worst enemy. It is possible to become empowered to have choices in life at the same time you are letting go of trying to be in control. Life can be an exciting, enjoyable adventure if you stop reacting to it out of your childhood emotional wounds and attitudes."

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Personal History

His background is interesting and eclectic. He was raised on a farm in Nebraska. His childhood from all outside appearances was an idyllic, middle class, Norman Rockwell, all-American upbringing with both parents present and no overt dysfunction. He participated in 4-H and little league baseball and in sports, theater, and student government in high school. He became very interested in politics through the influence of his grandfather who was a long-time Lieutenant Governor and, due to the death of his predecessor, for several months Governor of Nebraska. The first outward sign that Robert's path was veering from the norm came as a freshman at Creighton University in Omaha when he was one of the founders of Creighton Students for Human Relations, one of the University's first Civil Rights organizations. In that freshman year, he became very involved in theater and through the influence of a dynamic French teacher made plans to study at The Sorbonne in Paris his sophomore year. Those plans were did not work out and because of that disappointment and disillusionment with the University's response to his participation in marches, protests, and attempts to reform student government, he transferred to the University of Nebraska for his sophomore year.

There he continued his activism for a while, even serving as a delegate to the state Democratic convention, but after the trauma of 1968 with assassinations, riots, and the election of Richard Nixon, he withdrew from activism and spent his remaining college days mostly drinking and partying. He was in Air Force ROTC because of a strong desire to fly (which he later realized was about his spiritual quest and not about planes) and because of the draft. Although he was opposed to the war in Viet Nam, his low number in the draft lottery convinced him to join the Air Force rather that be drafted into the army. Robert was commissioned as an Air force officer on the same day he received his Bachelor of Arts degree in Political Science.

He entered Air Force pilots training and was flying solo in jet aircraft before being medically eliminated because of allergies. He was then assigned to an Intelligence wing where he held one of the highest security clearances available. After receiving an early discharge because of the de-escalation in Viet Nam, he entered graduate school. He got involved with the American Indian Movement in the spring of 1973 during their occupation of the village of Wounded Knee in South Dakota. He left graduate school and went to South Dakota to fly an air drop of supplies but the siege ended a few days after his arrival. He remained actively involved with AIM for the rest of that year and had an extensive FBI file compiled on him for his active participation in revolutionary activities against the government. During this time more than a dozen of the people he was closely involved with were killed or went to prison. It was only through divine intervention on several occasions that he survived to return to graduate school.

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He completed his Masters Degree and was then hired by the U. S. Civil Service as a Race Relations Orientations Specialist at Edwards Air Force Base in California (a little cosmic irony here.) Robert enjoyed great success communicating with and fostering change in the attitudes and belief systems of the base personnel he was teaching but left that position in frustration over bureaucratic interference from Base authorities who thought him too radical. A brief sojourn in England rekindled his love of theater and he moved to Hollywood to pursue an acting career.

Over the course of more than a decade pursuing an acting career, he got very few parts of any consequence but was able to play out fully the role of the suffering artist, a perfect expression for his own particular brand of Codependence which also gave ample opportunity for him to fully pursue personal research in the area of substance abuse. He played the role to the hilt in all areas of his life including earning a living by parking cars, driving cabs, and waiting tables. Acting provided an invaluable emotional outlet to explore and express feelings that would otherwise have been unacceptable according to his childhood training and experiences. The personal research of substance abuse almost killed him.

Robert was introduced to Twelve Step programs through an intervention by his family on a trip home for the holidays. He started his Twelve Step Recovery in January of 1984 and remained in Nebraska for nine months. During this time he worked first in the family care section of the treatment program which he had gone through and then at a state mental hospital where he started to again utilize his training and skills in communication and counseling. He returned to Hollywood in the fall of 1984 convinced that his new found Spiritual path would facilitate his quest for an Oscar nomination. When that did not materialize in short order, he fled to South Lake Tahoe and went to work in the poker room at a casino. The Universe however had other plans for him and ended his career at the casino so that he could go to work for the Alcoholism Council of the Sierra Nevada. It was there that he started to realize and deal with how Codependent he was in his relationships with others.

When funding for his position ended, Robert returned to Southern California and gave acting one last try. It was only a short time however before he went to work in a Chemical Dependence Treatment program in Pasadena. His work as a therapist there and at a subsequent treatment program facilitated and accelerated his personal recovery process. In the spring of 1988, he had a major emotional breakthrough in his recovery and gave himself the gift of entering a thirty day treatment program for Codependence. Sierra Tucson Treatment Center in Arizona was one of the first to pioneer treatment of Codependence and it was there that he learned a great deal about the grieving process and absorbed techniques and knowledge upon which he would later expand.

He also realized what a Codependent relationship he had with the romance of Hollywood and upon completion of the program promptly moved. After brief stays in Tucson and Sedona Arizona, he lived in Taos, New Mexico, for a year until his Spiritual path led him to Cambria, California. It was in Cambria that he began a private practice specializing in Codependence Recovery and inner child healing. During almost two years on the coast he became involved in a relationship a tribute to the healing he had done to overcome his terror of intimacy. He and his new "family" (significant other and her daughter) moved back to Taos. That relationship ended after two years. Robert remained in Taos refining his practice for several more years before making a successful trip to California in the winter of 1995 to raise funds to publish his first book. He returned to Cambria to set up his publishing company, Joy to You & Me Enterprises, in the fall of 1995. He now practices in Cambria, San Luis Obispo, and Santa Barbara, with occasional forays into Los Angeles.

next: Author ´s Foreword

Thoughtful quotes about women, women's lives, and how women assess their sense of self-worth.

Words of Wisdom

"Women's lives are made up of cycles of descent and ascent." (Sue Monk Kid)

"It is observed that women are closer to the earth." (Susan Griffin)

"The queens in history compare favorably with the kings." (Susan B. Anthony)

"The woman's place of power within each of us is neither white nor surface; it is dark, it is ancient, it is deep." (Audre Lorde)

"One is not born a woman, one becomes one." (Simone de Beauvoir)

"But why didn't you leave? Why didn't you take the job? Why didn't you marry the other man? She would always insist it didn't matter, she was lucky to have my sister and me. If I pressed hard enough, she would add, 'If I'd left, you never would have been born.' I always thought but never had the courage to say: 'But you might have been born instead." (Gloria Steinhem)

"In the womb we all begin as female." (author unknown)

"Women have a tendency to assess their sense of self-worth in relation to the condition of their intimate relationships." (Maggie Scarf)

"Women can talk to each other in short hand...They possess highly tuned powers of empathy - being able to sense what another feels because they must. They have to know which way to jump; it is only dominant people who can afford to be insensitive." (Gail Sheehy)

"...many women truly cannot tolerate or allow themselves to feel that their life activities are for themselves." (Jean Baker Miller)

"And what would happen if one woman told the truth about her life? The world would split open." (author unknown)

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next:Work

Chapter 52 of the book Self-Help Stuff That Works

by Adam Khan:

ON MY PAGE-A-DAY calendar, I read this: "Render more and better service than that for which you are paid and sooner or later you'll receive compound interest on compound interest from your investment."

Of course it's ridiculous to believe there is actually compound interest accumulating somewhere in the ether, but it is extremely useful to think of your effort in that way because that thought can make itself true.

When you think that way, you will work hard and enjoy it because you are assuming you'll be compensated for any work you do. Why not work hard? Any money you're not making right away for your extra effort is earning compound interest for you. Your extra effort is an investment that will be paid to you eventually. So your attitude is good and you are willing to work long and hard. And because you do, you will be the first one to be promoted. You will be the one the customer seeks out. You will be the one who is indispensable. People will notice the extra service and it will work in your favor constantly. Your original belief in this maxim becomes true by virtue of your belief in it.

And look at what happens to a person who doesn't think that way. Imagine a person who thinks, "I'm not going to put out any more work until they pay me more." Now if you were the boss, will this be the first person you consider for a promotion? If you were the customer, is that the person you want to do business with? No! Not if there is someone down the road who is giving more and better service than you pay her for. She will get the business. She will get the promotion. She is more of a pleasure to work with. Her rewards may not be immediate, but they will come. It's the Law of Return.

It is only human nature to want to do business with someone who is trying hard and has a good attitude. It's human nature to promote someone like that. They're obviously an asset. Many many people just try to get by. So when you work to accumulate "compound interest," you stand out...and your ship comes in.

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Assume extra effort is an investment that returns to you with compound interest.

Would you like to be more productive without adding
any more stress? Check this out:
Time Management Made Simple

Would you like the charisma and good feeling that comes
with self-confidence? It's not as hard to develop as you'd think.
But there's something you must know:
Self-Confidence

next: Personality Counts

To the depression sufferer:

The more you read about depression, the more useful ideas you will pick up. And you never know when you will stumble across an idea -- which may be nothing more than everyday folk wisdom -- that will explode into a break-through for you. The asterisks next to books in this list mean that I recommend them -- and more asterisks mean a higher recommendation. I have also added brief notes next to some key items. Throughout, I have tried to refer mainly to books rather than articles so that the general reader might be able to find the referenced work in a general library. For the most recent developments in research results and depression trends, I have had to refer occasionally to the technical literature, however.

To the Professional Reader:

An authoritative comprehensive review by Karasu (1990a and 1990b) of the experimental and theoretical literature on depression and various therapies for it arrives at conclusions consistent with the earlier findings cited in the text, and with the theoretical ideas presented in the book. This review makes it unnecessary that the recent literature be reviewed in great detail here. For those persons wishing a quick tutorial on the state of professional thought, I would suggest turning first to Karasu's articles, and to the collection edited by Alloy (1988). *** NEW TO BE ADDED

Chevalier, Nancy Young, "When Pills, Shock Therapy Failed...I Imagined Dancing In Vienna," in Washington Post Health, January 16, 1990, p. 14.

Ben-David, Calev, "The Philosopher's Couch," in The Jerusa- lem Post International Edition, Week ending March 31, 1990, p. 13.

Ellis, Albert, How To Subbornly Refuse To Make Yourself Miserable About Anything--88--Yes, Anything! (Secaucus, New Jer- sey: Lyle Stuart Inc., 1988).

Hoffmann, Banesh, Albert Einstein - Creator & Rebel (New York: The Viking Press, Inc., 1972).

Karasu, T. Byram, "Toward a Clinical Model of Psychotherapy for Depression, I: Systematic Comparison of Three Psychothera- pies," in The American Jouranl of Psychiatry 147:2, February 1990, pp. 133-147.

Karasu, T. Byram, "Toward a Clinical Model of Psychotherapy for Depression, II: An Integrative and Selective Treatment Ap- proach," in The American Journal of Psychiatry 147:3, March 1990, pp. 269-278.

Klerman, Gerald L., "The Nature of Depression -- Mood, Symp- tom, Disorder," in The Measurement of Depression, Guilford Publications, Inc., 1987.

Kolata, Gina, "Manic-Depression Gene Tied to Chromosome 11," in Research News, March 6, 1987, pp. 1139-49.

Kovacs, Maria, et al, "Depressed Outpatients Treated With Cognitive Therapy or Pharmacotherapy," in Arch. Gen. Psychiatry, Vol. 38, January 1981, pp. 33-39.

Miller, Ivan W., et al, "Cognitive-Behavioral Treatment of Depressed Inpatients: Six- and Twelve-Month Follow-Up," in The American Journal of Psychiatry 146:10, October 1989, pp. 1274- 1279.

Oatley, Keith, Best Laid Schemes -- The Psychology of Emotions (Cambridge: Cambridge University Press, 1992).

The Philosophy of William James (Drawn from his own Works) Introduction by Horace M. Kallen (New York: The Modern Library, Inc., 1925).

Seligman, Martin E. P., Learned Optimism (New York: Alfred A. Knopf, 1991).

Selmi, Paulette M., et al, "Computer-Administered Cognitive- Behavioral Therapy for Depression," in The American Journal of Psychiatry 147:1, January 1990, pp. 51-56.

Simons, Anne D., et al, "Cognitive Therapy and Pharmaco- therapy for Depression," in Arch. Gen. Psychiatry, Vol. 43, January 1986, pp. 43-48.

Sotsky, Stuart M., et al, "Patient Predictors of Response to Psychotherapy and Pharmacotherapy: Findings in the NIMH Treatment of Depression Collaborative Research Program," in The American Journal of Psychiatry 148:8, August 1991, pp. 997-1008.

Thase, Michael E., et al, "Severity of Depression and Response to Cognitive Behavior Therapy," in The American Journal of Psychiatry 148:6, June 1991, pp. 784-789.

Wells, Kenneth B., et al, "The Functioning and Well-being of Depressed Patients," in JAMA, August 18, 1989, Vol. 262, No. 7, pp. 914-919.

Woolf, Leonard, The Journey Not the Arrival Matters (New York: Harcourt Brace Jovanovich, 1975).

****

Abraham, Karl, "Notes on the Psycho-Analytical Investigation and Treatment of Manic-Depressive Insanity and Allied Conditions," in Gaylin, cited below. Alcoholics Anonymous (New York: Alcoholics Anonymous World Services, third edition, 1976).

Alloy, Lauren B., ed., Cognitive Processes In Depression (New York: The Guilford Press, 1988).

--- and Lyn Y. Abramson, "Depressive Realism: Four Theoretical Perspectives", in Alloy (1988),223-265.

Alvarez, 1971

American Psychiatric Association, Diagnostic and Statistical Manual, (Washington: APA, 3rd edition, 1980, fourth edition (DSM-IIIR), 1987).

Andreasen, Nancy C., and Ira D. Glick, "Bipolar Affective Disorder and Creativity: Implications and Clinical Management", Comprehensive Psychiatry, Vol 29, May/June, 1988, 207-217.

Arieti, Silvano, "Manic-Depressive Psychosis", in Arieti(ed), American Handbook of Psychiatry, 2 vols. (New York: Basic Books, 1959).

**Beck, Aaron T., Depression: Clinical, Experimental, and Theoretical Aspects (New York: Harper and Row, 1967). This is still one of the two most important works in the field, and the book that saved me from depression. But it is written for the professional rather than the layman.

*Beck, Aaron T., Cognitive Therapy and the Emotional Disorders (New York: New American Library, 1976). For the professional.

Beck, Aaron T., "Cognitive Models of Depression," in Journal of Cognitive Psychotherapy, Volume 1, Number 1, 1987, pp. 5-37.

Beck, Aaron T., and David A. Clark, "Anxiety and Depression: An Information Processing Perspective," in Anxiety Research, Vol. 1, pp. 23-36, 1988.

*Beck, Aaron T., A. John Rush, Brian F. Shaw, and Gary Emery, Cognitive Therapy of Depression (New York: Guilford, 1979). For the professional, but full of helpful tips.

Beck, Aaron T., Gary Brown, Robert A. Steer, Judy I. Eidelson, and John H. Riskind, "Differentiating Anxiety and Depression: A Test of the Cognitive Content-Specificity Hypothesis," in Journal of Abnormal Psychology, Vol. 96, No. 3, pp. 179-183, 1987.

Behanan, Kovoor T., Yoga: A Scientific Evaluation (New York: Dover, 1937/1959).

Benson, Herbert, with Miriam Z. Klipper, The Relaxation Response (New York: Avon Books, 1976).

Bibring, Edward, "The Mechanism of Depression," in Gaylin, cited below.

Bonime, Walter, "The Psychodynamics of Neurotic Depression" , Chapter 18, in Vol. 3, 1966 in ?

Bowlby, John, Attachment vol I of Attachment and Loss (New York: Basic Books, 1969.

Bowlby, John, Loss: Sadness and Depression (vol III of Attachment and Loss) (New York: Basic Books, 1980)

Brickman, Philip, and Dan Coates, and Ronnie Janoff Bulman, "Lottery Winners and Accident Victims: Is Happiness Relative?", xerox, August, 1977.

Brooks, Van Wyck, The Days of the Phoenix (New York: Dutton, 1957), excerpted as "A Season In Hell," in Kaplan, 1964.

[include only if cited in text] Brussel, James A., and Theodore Irwin, Understanding and Overcoming Depression (New York: Hawthorn, 1973).

Buber, Martin, Good and Evil, (New York: Scribners, 1952). ***Burns, David D., Feeling Good -- The New Mood Therapy (New York: William Morrow and Company, Inc., 1980, also in paperback). One of the two best self-help books on the subject.

Burtt, E. A., The Teachings of the Compassionate Buddha (New York: Mentor, 1955).

*Cammer, Leonard, Up From Depression (New York: Simon and Schuster, 1969, quotes from Pocket Books ed. 1971).

Campbell, Donald T. and Julian Stanley, "Experimental and Quasi-Experimental Designs for Research in Teaching", in N. L. Gage (ed.), Handbook of Research in Teaching (Chicago: Rand McNally, 1963).

*Carnegie, Dale How to Stop Worrying and Start Living (New York: Simon and Schuster, 1944).

Collingwood, Robin G., An Autobiography (Oxford: OUP, 1939/1970).

Conze, Edward, Buddhism: Its Essence and Development (New York: Cassirer, 1951, Harper Torchbook, 1959).

*Cousins, Norman, Anatomy of an Illness as Perceived by the Patient (New York: Bantam Books, Inc., 1981).

Coyne, J. C. and Gotlib, I. H. , "The Role of Cognition in Depression: A Critical Appraisal", Psychological Bulletin, 94, 1983, pp. 472-505.

Custance in Kaplan, 1964, cited below, pp. 56-58.

Dewey, John, Experience and Nature (New York: Dover, 1929/1958).

Dobson, Keith S., ed., Handbook of Cognitive-Behavioral Therapies (New York: The Guilford Press, 1988).

Dominian, Jack, Depression (Great Britain: William Collins Sons and Co. Ltd. Glasgow, 1976).

Duval, S., and R. A. Wicklund, A Theory of Objective Self- Awareness (New York: Academic Press, 1972).

Eaves, George G., Cognitive Patterns in Endogenous and Nonendogenous Unipolar Major Depression, Ph. D. dissertation, The University of Texas at Dallas, 1981, Abstract

-----, and A. J. Rush, "Cognitive Patterns in Symptomatic and Remitted Unipolar Major Depression," in Journal of Abnormal Psychology, 33(1), 1984, pp. 31-40.

Elkin, Irene, Paul A. Pilkonis, John P. Docherty, and Stuart M. Sotsky, "Conceptual and Methodological Issues in Comparative Studies of Psychotherapy and Pharmacotherapy, I: Active Ingredients and Mechanisms of Change," in Am J Psychiatry 145:8, August, 1988, pp. 909-17.

Elkin, Irene, Paul A. Pilkonis, John P. Docherty, and Stuart M. Sotsky, "Conceptual and Methodological Issues in Comparative Studies of Psychotherapy and Pharmacotherapy, II: Nature and Timing of Treatment Effects," in Am J Psychiatry, 145:9, September, 1988, pp. 1070-76.

----- et al., "NIMH Treatment of Depression Collaborative Research Program: Initial Outcome Findings", abstract of paper given at Am. Assn. for the Adv. of Science, May, 1986.

Ellis, Albert, "Outcome of Employing Three Techniques of Psychotherapy", Journal of Clinical Psychology, 13, 1957, 344- 350.

**-----Reason and Emotion in Psychotherapy (New York: Lyle Stuart, 1962). One of the two best theoretical books for the professional.

*-----"The Use of Rational Humorous Songs in Psychotherapy", in W. F. Fry, Jr. and W. A. Salameh (eds.), Handbook of Humor in Psychotherapy: Advances in the Clinical Use of Humor (Sarasota, Fla: Professional Resource Exchange, Inc., 1987), pp. 265-285.

-----"The Impossibility of Achieving Consistently Good Mental Health", American Psychologist, 42, April, 1987, 364-375.

Ellis, Albert, How To Stubbornly Refuse to Make Yourself Miserable About Anything, Yes Anything (New York; Lyle Stuart, 1988).

***-----, and Robert A. Harper, A New Guide to Rational Living (North Hollywood, Calif: Wilshire, revised 1977 edition). One of the two best self-help books.

Elster, Jon, Multiple Selves.

**Emery, Gary, A New Beginning (New York; Simon and Schuster, 1981). Lots of valuable practical advice from a member of Beck's cognitive therapy "school."

Endler, Norman S., Holiday of Darkness: A Psychologist's Personal Journey out of His Depression (New York: Wiley, 1982). The title is apt. The author was treated only with drugs and electroshock; no psychotherapy is mentioned. His description of the side-effects of the drugs is interesting. The book is generally upbeat and hopeful.

Flach, Frederic F., The Secret Strength of Depression (New York: Bantam Books, 1975).

**Frankl, Viktor E., Man's Search For Meaning (New York: Washington Square Press, 1963). Fascinating and often useful ideas rooted in a philosophical attitude toward life and depression.

**-----The Doctor and the Soul, 2nd ed.(New York: Bantam, 1969). More excellent ideas by Frankl.

Freud, Sigmund, "Mourning and Melancholia," in Gaylin, 1968, cited below.

Gallagher, 1986

Gaylin, Willard (ed.), The Meaning of Despair (New York: Science House, Inc., 1968).

Gaylin, Willard, Feelings: Our Vital Signs (New York: Harper & Row, 1979)

Gibson, William, A Season in Heaven (New York: Bantam, 1974). Interesting description of a meditation community by a first-rate dramatist.

Gilson, M., "Depression as Measured by Perceptual Bias in Binocular Rivalry." Unpublished doctoral dissertation, Georgia State University. (University Microfilms No. AAD83-27351), 1983. Cited by Beck, 1988.

Glatzer, Nahum (ed.), The Dimensions of Job (New York: Schocken, 1969).

Goddard

Greenberg, Michael S., Carmelo V. Vazquez, and Lauren B. Alloy, "Depression versus Anxiety: Differences in Self- and Other-Schemata", in Alloy (1988), 109-142.

*Greist, John H., and James W. Jefferson, Depression and Its Treatment (Washington: Am. Psychiatric Press, 1984). A mainstream "official" medical discussion of depression.

Grinspoon, Lester (ed.), Psychiatry Update, Vol. II (Washington: American Psychiatric Press, 1983). A good review for professionals of the state of the art.

Gussow, Mel, "Elizabeth Swados - A Runaway Talent," New York Times Magazine, March 5, 1978.

Heinicke, Christoph M., "Parental Deprivation in Early Childhood", in Scott and Senay.

Hildebrand, Kenneth, Achieving Real Happiness (New York: Harper, 1955).

Hirschfeld, Robert M. A., Gerald L. Klerman, Paula J. Clayton, and Martin B. Keller, "Personality and Depression - Empirical Findings," in Archives of General Psychiatry, September, 1983, Volume 40, pp. 993-98.

Holden, Constance, "Depression Research Advances, Treatment Lags", Science, 15 August, 1986, 723-727

Honigfeld, Gilbert, and Alfreda Howard, Psychiatric Drugs, A Desk Reference (New York and London: Academic Press, 1973).

Hume, David, Essential Works (New York: Bantam, 1965)

***James, William, Varieties of Religious Experience. The all-time classic about mental illness.

-----, Psychology, one-volume edition (Greenwich, Conn: Fawcett, 1892/1963).

Janoff-Bulman, Ronnie, and Bernard Hecker, "Depression, Vulnerability, and World Assumptions", in Alloy (1988), 177-192

Johnston, Tracy, review of John Maher of Delancey Street by Grover Sales, New York Times Book Review, August 15, 1976, p. 6.

Kahneman, Daniel, and Amos Tversky, "Prospect Theory: An Analysis of Decision Under Risk," in Decision, Probability, and Utility, Peter Gardenfors and Nils-Eric Sahlin (eds.) (Cambridge: Cambridge University Press, 1988).

Kaplan, Bert, The Inner World of Mental Illness (New York, Evanston, and London: Harper and Row, 1964). Writings by people who have suffered from mental illness.

Kiev, Ari, Riding Through the Hassles, Snags, and Funks (New York: Dutton, 1980)

Killian

Klerman, G. L., "Evidence for Increase in Rates of Depression in North America and Western Europe in Recent Decades," in New Results in Depression Research, Eds. H. Hippius set al, Springer-Verlag Berlin Heidelberg, 1986.

Klerman, Gerald L., "Relationship Between Anxiety and Depression," in Handbook of Anxiety, Vol. 1: Biological, Clinical and Cultural Perspectives, Elsevier Science Publishers B.V., 1988, pp. 59-82.

Klerman, Gerald L., "Depression and Related Disorders of Mood (Affective Disorders)," in The New Harvard Guide to Psychiatry (Cambridge and London: Belknap Press of Harvard University Press, 1988).

Klerman, Gerald L., and Robert M. A. Hirschfeld, "Personality As a Vulnerability Factor: With Special Attention To Clinical Depression," in Handbook of Social Psychiatry, Henderson/Burrows (eds), Elsevier Science Publishers B. V. (Biomedical Division), 1988, pp. 41-53.

Klerman, Gerald L., Philip W. Lavori, John Rice, Theodore Reich, Jean Endicott, Nancy C. Andreasen, Martin B. Keller, and Robert M. A. Hirschfeld, "Birth-Cohort Trends in Rates of Major Depressive Disorder Among Relatives of Patients With Affective Disorder," in Archives of General Psychiatry, July, 1985, Volume 42, pp. 689-93.

*Kline, Nathan, From Sad to Glad (New York: Ballantine, 1975). By a pioneer in anti-depressant medication.

*Knauth, Percy, A Season in Hell (New York: Harper & Row, 1975). A depression sufferer's own well-told story.

Kovacs, Maria, "Psychotherapies for Depression", in Grinspoon, 1983, cited above.

*LaHaye, Tim, How To Win Over Depression (Grand Rapids, Mich: Zondervan, 1974).

**Lazarus, Arnold, and Allen Fay, I Can If I Want To (New York: William Morrow, 1975). Excellent common-sense advice for improving your life, consistent with the analysis given here.

***Lewinsohn, Peter M., Ricardo F. Munoz, Mary Ann Youngren, Antonette M. Zeiss, Control Your Depression (Englewood Cliffs, NJ: Prentice-Hall, Inc., 1978). One of the very best self-help books for depression, emphasizing "social learning" and behavioral exercises.

Lowen, Alexander, Depression and the Body (Baltimore: Penguin Books Inc., 1973).

Mahoney, Michael J. and Carl E. Thoresen, Self-Control: Power to the Person (Monterey, Calif: Brooks/Cole, 1974).

Maslow, 1950

Maslow, Toward a Psychology of Being 2nd ed.,(New York: Van Nostrand,1968)

McKinney, William T. Jr., Stephen J. Suomi, and Harry F. Harlow, "New Models of Separation and Depression in Rhesus Monkeys", in Scott and Senay.

Mendels, Joseph (ed.), Psychobiology of Depression (New York: SP Books Division of Spectrum Publications, distributed by Halsted Press, 1975).

Miller, Ivan W., William H. Norman, and Gabor I. Keitner, "Cognitive-Behavioral Treatment of Depressed Inpatients: Siox- and Twelve-Month Follow-up", American Journal of Psychiatry, Vol 146, October, 1989, 1274-1279.

Musson, Robert F. and Lauren B. Alloy, "Depression and Self- Directed Attention", in Alloy (1988), 193-222

Myers, Gloria, as told to Diane Clark, "Clinical Depression: Victim Recalls 'Living Death'", Champaign-Urbana News Gazette, Oct. 30, 1977. p. 10B.

Naranjo, Claudio and Robert E. Ornstein, On the Psychology of Meditation (New York: Viking, 1971).

Nelson, R. Eric, and W. Edward Craighead, "Selective Recall of Positive and Negative Feedback, Self-control Behaviors, and Depression," in Journal of Abnormal Psychology, 1977, Vol. 86, No. 4, pp. 379-88.

*NIMH, Helpful Facts About Depressive Disorders (Washington, 1987).

Ostow, Mortimer, The Psychology of Melancholy (New York: Harper and Row, 1970).

**Papalos, Dimitri I., and Janice Papalos, Overcoming Depression ( New York: Harper and Row, 1987). A practical manual for what to do when depression strikes you or a person you care about.

Peterson, Christopher, Barbara A. Bettes, and Martin E. P. Seligman, "Depressive Symptoms and Unprompted Causal Attributions: Content Analysis" in Behav. Res. Ther., Vol. 23, No. 4, pp. 379-382, 1985.

Peterson, Christopher, and Martin E. P. Seligman, "casual Explanations as a Risk Factor for Depression: Theory and Evidence," in Psychological Review, Vol. 91, No. 3, pp. 347-374, 1984.

Plath, Sylvia, The Bell Jar (New York: Bantam, 1971).

Rehm, Lynn P., "Self-management and Cognitive Processes in Depression", in Alloy (1988), 143-176

Rosenthal, D., 1970

Royko, Mike, "How To Ease That Hangover," in Chicago Daily News, Jan 1-2, 1977, p. 3.

Rubin, Theodore Isaac, Compassion and Self-Hate (New York: Ballantine, 1975).

**Russell, Bertrand, The Conquest of Happiness (New York: Signet, 1930-1951).

Scheinin, 1983

Schneider, 1962

Scott, John Paul, and Edward C. Senay (eds.), Separation and Depression (Washington: AAAS, 1973).

Scott, John Paul, John M. Stewart, and Victor J. DeGhett, "Separation in Infant Dogs", in Scott and Senay.

Seligman, Martin E. R., Helplessness: On Depression, Development, and Death (San Francisco: W. H. Freeman, 1975).

Seligman, Martin E. P., Camilo Castellon, John Cacciola, Peter Schulman, Lester Luborsky, Maxine Ollove, and Robert Downing, "Explanatory Style Change During Cognitive Therapy for Unipolar Depression," in Journal of Abnormal Psychology, Vol. 97, No. 1, 1988, pp. 1-6.

Selye, Hans, Stress Without Distress (New York: Signet, 1974).

Simon, Julian L., Basic Research Methods in Social Science (New York: Random House, 1969; second edition, 1978; third edition, [with Paul Burstein], 1985.

Simon, Julian L., Applied Managerial Economics (Englewood Cliffs: Prentice-Hall, 1975).

Simon, Julian L., The Economics of Population Growth (Princeton: Princeton University Press, 1977).

Simon, Julian L., The Ultimate Resource (Princeton: Princeton University Press, 1981).

Steer, Robert A., Aaron T. Beck, John H. Riskind, and Gary Brown, "Differentiation of Depressive Disorders From Generalized Anxiety by the Beck Depression Inventory," in Journal of Clinical Psychology, Vol. 42, No. 3, May, 1986, pp. 475-78.

Suzuki, Daisetz T., Outlines of Mahayana Buddhism (New York: Schocken, 1907/1963).

Tolstoy, Leo, A Confession, trans. Aylmer Maude (London: Oxford U. P., 1920).

Tutko, Thomas, "Winning Isn't Everything It's Cracked Up To Be," in The New York Times, July 4, 1976.

Vaillant, George E., "The `Normal Boy' in Later Life: How Adaptation Fosters Growth," Harvard Magazine, November-December 1977, pp. 46-61.

*Watts, Alan W., The Meaning of Happiness (New York: Harper and Row, 1940, Perennial Library edition, 1968).

Watts, 1972

Weil, Andrew, The Natural Mind (Boston: Houghton Mifflin Company, 1972).

Wender, Paul., and Donald F. Klein, Mind, Mood, and Medicine (New York: Farrar, Straus, and Giroux, 1981).

Wilde, Oscar, in Burnett, 1958

Zigler, Edward and Marion Glick, "Is Paranoid Schizophrenia Really Camouflaged Depression?" American Psychologist, April, 1988, 284-290.

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Exelon is a cholinesterase Inhibitor used in the treatment of Alzheimer's Disease. Usage, dosage, side-effects of Exelon.

Brand Name: Exelon
Generic Name: rivastigmine tartrate

Exelon (rivastigmine tartrate) is an Cholinesterase Inhibitor used in treatment of Alzheimer's Disease. Detailed info on uses, dosage and side-effects of Exelon below.

Contents:

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

Exelon patient information (in plain English)

Description

Exelon® (rivastigmine tartrate) is a reversible cholinesterase inhibitor and is known chemically as (S)-N-Ethyl-N-methyl-3-[1-(dimethylamino)ethyl]-phenyl carbamate hydrogen-(2R,3R)-tartrate. Rivastigmine tartrate is commonly referred to in the pharmacological literature as SDZ ENA 713 or ENA 713. It has an empirical formula of C ₁₄ H ₂₂ N ₂ O ₂ · C ₄ H ₆ O ₆ (hydrogen tartrate salt - hta salt) and a molecular weight of 400.43 (hta salt). Rivastigmine tartrate is a white to off-white, fine crystalline powder that is very soluble in water, soluble in ethanol and acetonitrile, slightly soluble in n-octanol and very slightly soluble in ethyl acetate. The distribution coefficient at 37°C in n-octanol/phosphate buffer solution pH 7 is 3.0.

Exelon is supplied as capsules containing rivastigmine tartrate, equivalent to 1.5, 3, 4.5 and 6 mg of rivastigmine base for oral administration. Inactive ingredients are hydroxypropyl methylcellulose, magnesium stearate, microcrystalline cellulose, and silicon dioxide. Each hard-gelatin capsule contains gelatin, titanium dioxide and red and/or yellow iron oxides.

Exelon Oral Solution is supplied as a solution containing rivastigmine tartrate, equivalent to 2 mg/mL of rivastigmine base for oral administration. Inactive ingredients are citric acid, D&C yellow #10, purified water, sodium benzoate and sodium citrate.

Clinical Pharmacology

Mechanism of Action

Pathological changes in Dementia of the Alzheimer type involve cholinergic neuronal pathways that project from the basal forebrain to the cerebral cortex and hippocampus. These pathways are thought to be intricately involved in memory, attention, learning, and other cognitive processes. While the precise mechanism of rivastigmine's action is unknown, it is postulated to exert its therapeutic effect by enhancing cholinergic function. This is accomplished by increasing the concentration of acetylcholine through reversible inhibition of its hydrolysis by cholinesterase. If this proposed mechanism is correct, Exelon's effect may lessen as the disease process advances and fewer cholinergic neurons remain functionally intact. There is no evidence that rivastigmine alters the course of the underlying dementing process. After a 6-mg dose of rivastigmine, anticholinesterase activity is present in CSF for about 10 hours, with a maximum inhibition of about 60% five hours after dosing.

In vitro and in vivo studies demonstrate that the inhibition of cholinesterase by rivastigmine is not affected by the concomitant administration of memantine, an N-methyl-D-aspartate receptor antagonist.

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Clinical Trial Data

The effectiveness of Exelon® (rivastigmine tartrate) as a treatment for Alzheimer's Disease is demonstrated by the results of two randomized, double-blind, placebo-controlled clinical investigations in patients with Alzheimer's Disease [diagnosed by NINCDS-ADRDA and DSM-IV criteria, Mini-Mental State Examination (MMSE) >/=10 and <!--=26, and the Global Deterioration Scale (GDS)]. The mean age of patients participating in Exelon trials was 73 years with a range of 41-95. Approximately 59% of patients were women and 41% were men. The racial distribution was Caucasian 87%, Black 4% and Other races 9%.

Study Outcome Measures: In each study, the effectiveness of Exelon was evaluated using a dual outcome assessment strategy.

The ability of Exelon to improve cognitive performance was assessed with the cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-cog), a multi-item instrument that has been extensively validated in longitudinal cohorts of Alzheimer's Disease patients. The ADAS-cog examines selected aspects of cognitive performance including elements of memory, orientation, attention, reasoning, language and praxis. The ADAS-cog scoring range is from 0 to 70, with higher scores indicating greater cognitive impairment. Elderly normal adults may score as low as 0 or 1, but it is not unusual for non-demented adults to score slightly higher.

The patients recruited as participants in each study had mean scores on ADAS-cog of approximately 23 units, with a range from 1 to 61. Experience gained in longitudinal studies of ambulatory patients with mild to moderate Alzheimer's Disease suggest that they gain 6-12 units a year on the ADAS-cog. Lesser degrees of change, however, are seen in patients with very mild or very advanced disease because the ADAS-cog is not uniformly sensitive to change over the course of the disease. The annualized rate of decline in the placebo patients participating in Exelon trials was approximately 3-8 units per year.

The ability of Exelon to produce an overall clinical effect was assessed using a Clinician's Interview Based Impression of Change that required the use of caregiver information, the CIBIC-Plus. The CIBIC-Plus is not a single instrument and is not a standardized instrument like the ADAS-cog. Clinical trials for investigational drugs have used a variety of CIBIC formats, each different in terms of depth and structure. As such, results from a CIBIC-Plus reflect clinical experience from the trial or trials in which it was used and can not be compared directly with the results of CIBIC-Plus evaluations from other clinical trials. The CIBIC-Plus used in the Exelon trials was a structured instrument based on a comprehensive evaluation at baseline and subsequent time-points of three domains: patient cognition, behavior and functioning, including assessment of activities of daily living. It represents the assessment of a skilled clinician using validated scales based on his/her observation at interviews conducted separately with the patient and the caregiver familiar with the behavior of the patient over the interval rated. The CIBIC-Plus is scored as a seven point categorical rating, ranging from a score of 1, indicating "markedly improved," to a score of 4, indicating "no change" to a score of 7, indicating "marked worsening." The CIBIC-Plus has not been systematically compared directly to assessments not using information from caregivers (CIBIC) or other global methods.

U.S. Twenty-Six-Week Study

In a study of 26 weeks duration, 699 patients were randomized to either a dose range of 1-4 mg or 6-12 mg of Exelon per day or to placebo, each given in divided doses. The 26-week study was divided into a 12-week forced dose titration phase and a 14-week maintenance phase. The patients in the active treatment arms of the study were maintained at their highest tolerated dose within the respective range.

Effects on the ADAS-cog: Figure 1 illustrates the time course for the change from baseline in ADAS-cog scores for all three dose groups over the 26 weeks of the study. At 26 weeks of treatment, the mean differences in the ADAS-cog change scores for the Exelon-treated patients compared to the patients on placebo were 1.9 and 4.9 units for the 1-4 mg and 6-12 mg treatments, respectively. Both treatments were statistically significantly superior to placebo and the 6-12 mg/day range was significantly superior to the 1-4 mg/day range.

Figure 2 illustrates the cumulative percentages of patients from each of the three treatment groups who had attained at least the measure of improvement in ADAS-cog score shown on the X axis. Three change scores, (7-point and 4-point reductions from baseline or no change in score) have been identified for illustrative purposes, and the percent of patients in each group achieving that result is shown in the inset table.

The curves demonstrate that both patients assigned to Exelon and placebo have a wide range of responses, but that the Exelon groups are more likely to show the greater improvements. A curve for an effective treatment would be shifted to the left of the curve for placebo, while an ineffective or deleterious treatment would be superimposed upon, or shifted to the right of the curve for placebo, respectively.

Effects on the CIBIC-Plus: Figure 3 is a histogram of the frequency distribution of CIBIC-Plus scores attained by patients assigned to each of the three treatment groups who completed 26 weeks of treatment. The mean Exelon-placebo differences for these groups of patients in the mean rating of change from baseline were 0.32 units and 0.35 units for 1-4 mg and 6-12 mg of Exelon, respectively. The mean ratings for the 6-12 mg/day and 1-4 mg/day groups were statistically significantly superior to placebo. The differences between the 6-12 mg/day and the 1-4 mg/day groups were statistically significant.

Global Twenty-Six-Week Study

In a second study of 26 weeks duration, 725 patients were randomized to either a dose range of 1-4 mg or 6-12 mg of Exelon per day or to placebo, each given in divided doses. The 26-week study was divided into a 12-week forced dose titration phase and a 14-week maintenance phase. The patients in the active treatment arms of the study were maintained at their highest tolerated dose within the respective range.

Effects on the ADAS-cog: Figure 4 illustrates the time course for the change from baseline in ADAS-cog scores for all three dose groups over the 26 weeks of the study. At 26 weeks of treatment, the mean differences in the ADAS-cog change scores for the Exelon-treated patients compared to the patients on placebo were 0.2 and 2.6 units for the 1-4 mg and 6-12 mg treatments, respectively. The 6-12 mg/day group was statistically significantly superior to placebo, as well as to the 1-4 mg/day group. The difference between the 1-4 mg/day group and placebo was not statistically significant.

Figure 5 illustrates the cumulative percentages of patients from each of the three treatment groups who had attained at least the measure of improvement in ADAS-cog score shown on the X axis. Similar to the U.S. 26-week study, the curves demonstrate that both patients assigned to Exelon and placebo have a wide range of responses, but that the 6-12 mg/day Exelon group is more likely to show the greater improvements.

Effects on the CIBIC-Plus: Figure 6 is a histogram of the frequency distribution of CIBIC-Plus scores attained by patients assigned to each of the three treatment groups who completed 26 weeks of treatment. The mean Exelon-placebo differences for these groups of patients for the mean rating of change from baseline were 0.14 units and 0.41 units for 1-4 mg and 6-12 mg of Exelon, respectively. The mean ratings for the 6-12 mg/day group was statistically significantly superior to placebo. The comparison of the mean ratings for the 1-4 mg/day group and placebo group was not statistically significant.

U.S. Fixed Dose Study

In a study of 26 weeks duration, 702 patients were randomized to doses of 3, 6, or 9 mg/day of Exelon or to placebo, each given in divided doses. The fixed-dose study design, which included a 12-week forced titration phase and a 14-week maintenance phase, led to a high dropout rate in the 9 mg/day group because of poor tolerability. At 26 weeks of treatment, significant differences were observed for the ADAS-cog mean change from baseline for the 9 mg/day and 6 mg/day groups, compared to placebo. No significant differences were observed between any of the Exelon dose groups and placebo for the analysis of the CIBIC-Plus mean rating of change. Although no significant differences were observed between Exelon treatment groups, there was a trend toward numerical superiority with higher doses.

Age, Gender and Race: Patient's age, gender, or race did not predict clinical outcome to Exelon treatment.

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Pharmacokinetics

Rivastigmine is well absorbed with absolute bioavailability of about 40% (3-mg dose). It shows linear pharmacokinetics up to 3 mg BID but is non-linear at higher doses. Doubling the dose from 3 to 6 mg BID results in a 3-fold increase in AUC. The elimination half-life is about 1.5 hours, with most elimination as metabolites via the urine.

Absorption: Rivastigmine is rapidly and completely absorbed. Peak plasma concentrations are reached in approximately 1 hour. Absolute bioavailability after a 3-mg dose is about 36%. Administration of Exelon with food delays absorption (t max ) by 90 min, lowers C max by approximately 30% and increases AUC by approximately 30%.

Distribution: Rivastigmine is widely distributed throughout the body with a volume of distribution in the range of 1.8-2.7 L/kg. Rivastigmine penetrates the blood brain barrier, reaching CSF peak concentrations in 1.4-2.6 hours. Mean AUC 1-12hr ratio of CSF/plasma averaged 40 ± 0.5% following 1-6 mg BID doses.

Rivastigmine is about 40% bound to plasma proteins at concentrations of 1-400 ng/mL, which cover the therapeutic concentration range. Rivastigmine distributes equally between blood and plasma with a blood-to-plasma partition ratio of 0.9 at concentrations ranging from 1-400 ng/mL.

Metabolism: Rivastigmine is rapidly and extensively metabolized, primarily via cholinesterase-mediated hydrolysis to the decarbamylated metabolite. Based on evidence from in vitro and animal studies the major cytochrome P450 isozymes are minimally involved in rivastigmine metabolism. Consistent with these observations is the finding that no drug interactions related to cytochrome P450 have been observed in humans (see Drug-Drug Interactions ).

Elimination: The major pathway of elimination is via the kidneys. Following administration of 14 C-rivastigmine to 6 healthy volunteers total recovery of radioactivity over 120 hours was 97% in urine and 0.4% in feces. No parent drug was detected in urine. The sulfate conjugate of the decarbamylated metabolite is the major component excreted in urine and represents 40% of the dose. Mean oral clearance of rivastigmine is 1.8 ± 0.6 L/min after 6 mg BID.

Special Populations

Hepatic Disease: Following a single 3-mg dose, mean oral clearance of rivastigmine was 60% lower in hepatically impaired patients (n=10, biopsy proven) than in healthy subjects (n=10). After multiple 6 mg BID oral dosing, the mean clearance of rivastigmine was 65% lower in mild (n=7, Child-Pugh score 5-6) and moderate (n=3, Child-Pugh score 7-9) hepatically impaired patients (biopsy proven, liver cirrhosis) than in healthy subjects (n=10). Dosage adjustment is not necessary in hepatically impaired patients as the dose of drug is individually titrated to tolerability.

Renal Disease: Following a single 3-mg dose, mean oral clearance of rivastigmine is 64% lower in moderately impaired renal patients (n=8, GFR=10-50 mL/min) than in healthy subjects (n=10, GFR>/=60 mL/min); Cl/F=1.7 L/min (cv=45%) and 4.8 L/min (cv=80%), respectively. In severely impaired renal patients (n=8, GFR/=60 mL/min); Cl/F=6.9 L/min and 4.8 L/min, respectively. For unexplained reasons, the severely impaired renal patients had a higher clearance of rivastigmine than moderately impaired patients. However, dosage adjustment may not be necessary in renally impaired patients as the dose of the drug is individually titrated to tolerability.

Age: Following a single 2.5 mg oral dose to elderly volunteers (>60 years of age, n=24) and younger volunteers (n=24), mean oral clearance of rivastigmine was 30% lower in elderly (7 L/min) than in younger subjects (10 L/min).

Gender and Race: No specific pharmacokinetic study was conducted to investigate the effect of gender and race on the disposition of Exelon, but a population pharmacokinetic analysis indicates that gender (n=277 males and 348 females) and race (n=575 White, 34 Black, 4 Asian, and 12 Other) did not affect the clearance of Exelon.

Nicotine Use: Population PK analysis showed that nicotine use increases the oral clearance of rivastigmine by 23% (n=75 Smokers and 549 Nonsmokers).

Drug-Drug Interactions

Effect of Exelon on the Metabolism of Other Drugs: Rivastigmine is primarily metabolized through hydrolysis by esterases. Minimal metabolism occurs via the major cytochrome P450 isoenzymes. Based on in vitro studies, no pharmacokinetic drug interactions with drugs metabolized by the following isoenzyme systems are expected: CYP1A2, CYP2D6, CYP3A4/5, CYP2E1, CYP2C9, CYP2C8, or CYP2C19.

No pharmacokinetic interaction was observed between rivastigmine and digoxin, warfarin, diazepam, or fluoxetine in studies in healthy volunteers. The elevation of prothrombin time induced by warfarin is not affected by administration of Exelon.

Effect of Other Drugs on the Metabolism of Exelon: Drugs that induce or inhibit CYP450 metabolism are not expected to alter the metabolism of rivastigmine. Single dose pharmacokinetic studies demonstrated that the metabolism of rivastigmine is not significantly affected by concurrent administration of digoxin, warfarin, diazepam, or fluoxetine.

Population PK analysis with a database of 625 patients showed that the pharmacokinetics of rivastigmine were not influenced by commonly prescribed medications such as antacids (n=77), antihypertensives (n=72), (beta)-blockers (n=42), calcium channel blockers (n=75), antidiabetics (n=21), nonsteroidal anti-inflammatory drugs (n=79), estrogens (n=70), salicylate analgesics (n=177), antianginals (n=35), and antihistamines (n=15). In addition, in clinical trials, no increased risk of clinically relevant untoward effects was observed in patients treated concomitantly with Exelon and these agents.

Indications and Usage

Exelon® (rivastigmine tartrate) is indicated for the treatment of mild to moderate dementia of the Alzheimer's type.

Contraindications

Exelon® (rivastigmine tartrate) is contraindicated in patients with known hypersensitivity to rivastigmine, other carbamate derivatives or other components of the formulation (see DESCRIPTION ).

Warnings

Gastrointestinal Adverse Reactions

Exelon ® (rivastigmine tartrate) use is associated with significant gastrointestinal adverse reactions, including nausea and vomiting, anorexia, and weight loss. For this reason, patients should always be started at a dose of 1.5 mg BID and titrated to their maintenance dose. If treatment is interrupted for longer than several days, treatment should be reinitiated with the lowest daily dose (see DOSAGE AND ADMINISTRATION ) to reduce the possibility of severe vomiting and its potentially serious sequelae (e.g., there has been one post-marketing report of severe vomiting with esophageal rupture following inappropriate reinitiation of treatment with a 4.5-mg dose after 8 weeks of treatment interruption).

Nausea and Vomiting: In the controlled clinical trials, 47% of the patients treated with an Exelon dose in the therapeutic range of 6-12 mg/day (n=1189) developed nausea (compared with 12% in placebo). A total of 31% of Exelon-treated patients developed at least one episode of vomiting (compared with 6% for placebo). The rate of vomiting was higher during the titration phase (24% vs. 3% for placebo) than in the maintenance phase (14% vs. 3% for placebo). The rates were higher in women than men. Five percent of patients discontinued for vomiting, compared to less than 1% for patients on placebo. Vomiting was severe in 2% of Exelon-treated patients and was rated as mild or moderate each in 14% of patients. The rate of nausea was higher during the titration phase (43% vs. 9% for placebo) than in the maintenance phase (17% vs. 4% for placebo).

Weight Loss: In the controlled trials, approximately 26% of women on high doses of Exelon (greater than 9 mg/day) had weight loss of equal to or greater than 7% of their baseline weight compared to 6% in the placebo-treated patients. About 18% of the males in the high dose group experienced a similar degree of weight loss compared to 4% in placebo-treated patients. It is not clear how much of the weight loss was associated with anorexia, nausea, vomiting, and the diarrhea associated with the drug.

Anorexia: In the controlled clinical trials, of the patients treated with an Exelon dose of 6-12 mg/day, 17% developed anorexia compared to 3% of the placebo patients. Neither the time course or the severity of the anorexia is known.

Peptic Ulcers/Gastrointestinal Bleeding: Because of their pharmacological action, cholinesterase inhibitors may be expected to increase gastric acid secretion due to increased cholinergic activity. Therefore, patients should be monitored closely for symptoms of active or occult gastrointestinal bleeding, especially those at increased risk for developing ulcers, e.g., those with a history of ulcer disease or those receiving concurrent non-steroidal anti-inflammatory drugs (NSAIDS). Clinical studies of Exelon have shown no significant increase, relative to placebo, in the incidence of either peptic ulcer disease or gastrointestinal bleeding.

Anesthesia

Exelon as a cholinesterase inhibitor, is likely to exaggerate succinylcholine-type muscle relaxation during anesthesia.

Cardiovascular Conditions

Drugs that increase cholinergic activity may have vagotonic effects on heart rate (e.g., bradycardia). The potential for this action may be particularly important to patients with "sick sinus syndrome" or other supraventricular cardiac conduction conditions. In clinical trials, Exelon was not associated with any increased incidence of cardiovascular adverse events, heart rate or blood pressure changes, or ECG abnormalities. Syncopal episodes have been reported in 3% of patients receiving 6-12 mg/day of Exelon, compared to 2% of placebo patients.

Genitourinary

Although this was not observed in clinical trials of Exelon, drugs that increase cholinergic activity may cause urinary obstruction.

Neurological Conditions

Seizures: Drugs that increase cholinergic activity are believed to have some potential for causing seizures. However, seizure activity also may be a manifestation of Alzheimer's Disease.

Pulmonary Conditions

Like other drugs that increase cholinergic activity, Exelon should be used with care in patients with a history of asthma or obstructive pulmonary disease.

Precautions

Information for Patients and Caregivers Caregivers should be advised of the high incidence of nausea and vomiting associated with the use of the drug along with the possibility of anorexia and weight loss. Caregivers should be encouraged to monitor for these adverse events and inform the physician if they occur. It is critical to inform caregivers that if therapy has been interrupted for more than several days, the next dose should not be administered until they have discussed this with the physician.

Caregivers should be instructed in the correct procedure for administering Exelon® (rivastigmine tartrate) Oral Solution. In addition, they should be informed of the existence of an Instruction Sheet (included with the product) describing how the solution is to be administered. They should be urged to read this sheet prior to administering Exelon Oral Solution. Caregivers should direct questions about the administration of the solution to either their physician or pharmacist.

Drug-Drug Interactions

Effect of Exelon ® on the Metabolism of Other Drugs: Rivastigmine is primarily metabolized through hydrolysis by esterases. Minimal metabolism occurs via the major cytochrome P450 isoenzymes. Based on in vitro studies, no pharmacokinetic drug interactions with drugs metabolized by the following isoenzyme systems are expected: CYP1A2, CYP2D6, CYP3A4/5, CYP2E1, CYP2C9, CYP2C8, or CYP2C19.

No pharmacokinetic interaction was observed between rivastigmine and digoxin, warfarin, diazepam, or fluoxetine in studies in healthy volunteers. The elevation of prothrombin time induced by warfarin is not affected by administration of Exelon.

Effect of Other Drugs on the Metabolism of Exelon: Drugs that induce or inhibit CYP450 metabolism are not expected to alter the metabolism of rivastigmine. Single dose pharmacokinetic studies demonstrated that the metabolism of rivastigmine is not significantly affected by concurrent administration of digoxin, warfarin, diazepam, or fluoxetine.

Population PK analysis with a database of 625 patients showed that the pharmacokinetics of rivastigmine were not influenced by commonly prescribed medications such as antacids (n=77), antihypertensives (n=72), (beta)-blockers (n=42), calcium channel blockers (n=75), antidiabetics (n=21), nonsteroidal anti-inflammatory drugs (n=79), estrogens (n=70), salicylate analgesics (n=177), antianginals (n=35), and antihistamines (n=15).

Use with Anticholinergics: Because of their mechanism of action, cholinesterase inhibitors have the potential to interfere with the activity of anticholinergic medications.

Use with Cholinomimetics and Other Cholinesterase Inhibitors: A synergistic effect may be expected when cholinesterase inhibitors are given concurrently with succinylcholine, similar neuromuscular blocking agents or cholinergic agonists such as bethanechol.

Carcinogenesis, Mutagenesis, Impairment of Fertility

In carcinogenicity studies conducted at dose levels up to 1.1 mg-base/kg/day in rats and 1.6 mg-base/kg/day in mice, rivastigmine was not carcinogenic. These dose levels are approximately 0.9 times and 0.7 times the maximum recommended human daily dose of 12 mg/day on a mg/m ² basis.

Rivastigmine was clastogenic in two in vitro assays in the presence, but not the absence, of metabolic activation. It caused structural chromosomal aberrations in V79 Chinese hamster lung cells and both structural and numerical (polyploidy) chromosomal aberrations in human peripheral blood lymphocytes. Rivastigmine was not genotoxic in three in vitro assays: the Ames test, the unscheduled DNA synthesis (UDS) test in rat hepatocytes (a test for induction of DNA repair synthesis), and the HGPRT test in V79 Chinese hamster cells. Rivastigmine was not clastogenic in the in vivo mouse micronucleus test.

Rivastigmine had no effect on fertility or reproductive performance in the rat at dose levels up to 1.1 mg-base/kg/day. This dose is approximately 0.9 times the maximum recommended human daily dose of 12 mg/day on a mg/m ² basis.

Pregnancy Pregnancy Category B: Reproduction studies conducted in pregnant rats at doses up to 2.3 mg-base/kg/day (approximately 2 times the maximum recommended human dose on a mg/m ² basis) and in pregnant rabbits at doses up to 2.3 mg-base/kg/day (approximately 4 times the maximum recommended human dose on a mg/m ² basis) revealed no evidence of teratogenicity. Studies in rats showed slightly decreased fetal/pup weights, usually at doses causing some maternal toxicity; decreased weights were seen at doses which were several fold lower than the maximum recommended human dose on a mg/m ² basis. There are no adequate or well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, Exelon should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Nursing Mothers

It is not known whether rivastigmine is excreted in human breast milk. Exelon has no indication for use in nursing mothers.

Pediatric Use There are no adequate and well-controlled trials documenting the safety and efficacy of Exelon in any illness occurring in children.

Adverse Reactions

Adverse Events Leading to Discontinuation The rate of discontinuation due to adverse events in controlled clinical trials of Exelon® (rivastigmine tartrate) was 15% for patients receiving 6-12 mg/day compared to 5% for patients on placebo during forced weekly dose titration. While on a maintenance dose, the rates were 6% for patients on Exelon compared to 4% for those on placebo.

The most common adverse events leading to discontinuation, defined as those occurring in at least 2% of patients and at twice the incidence seen in placebo patients, are shown in Table 1.

Table 1
Most Frequent Adverse Events Leading to Withdrawal from Clinical Trials during Titration and
Maintenance in Patients Receiving 6-12 mg/day Exelon ^® Using a Forced Dose Titration

Study Phase	Titration		Maintenance		Overall
	Placebo (n=868)	Exelon >/=6-12 mg/day (n=1,189)	Placebo (n=788)	Exelon >/=6-12 mg/day (n=987)	Placebo (n=868)	Exelon >/=6-12 mg/day (n=1,189)
Event/% Discontinuing
Nausea	<1	8	<1	1	1	8
Vomiting	<1	4	<1	1	<1	5
Anorexia	0	2	<1	1	<1	3
Dizziness	<1	2	<1	1	<1	2

Most Frequent Adverse Clinical Events Seen in Association with the Use of Exelon

The most common adverse events, defined as those occurring at a frequency of at least 5% and twice the placebo rate, are largely predicted by Exelon's cholinergic effects. These include nausea, vomiting, anorexia, dyspepsia, and asthenia.

Gastrointestinal Adverse Reactions

Exelon use is associated with significant nausea, vomiting, and weight loss (see WARNINGS ).

Adverse Events Reported in Controlled Trials

Table 2 lists treatment emergent signs and symptoms that were reported in at least 2% of patients in placebo-controlled trials and for which the rate of occurrence was greater for patients treated with Exelon doses of 6-12 mg/day than for those treated with placebo. The prescriber should be aware that these figures cannot be used to predict the frequency of adverse events in the course of usual medical practice when patient characteristics and other factors may differ from those prevailing during clinical studies. Similarly, the cited frequencies cannot be directly compared with figures obtained from other clinical investigations involving different treatments, uses, or investigators. An inspection of these frequencies, however, does provide the prescriber with one basis by which to estimate the relative contribution of drug and non-drug factors to the adverse event incidences in the population studied.

In general, adverse reactions were less frequent later in the course of treatment.

No systematic effect of race or age could be determined on the incidence of adverse events in the controlled studies. Nausea, vomiting and weight loss were more frequent in women than men.

 

Table 2
Adverse Events Reported in Controlled Clinical Trials in at Least 2% of Patients Receiving Exelon ^®
(6-12 mg/day) and at a Higher Frequency than Placebo-treated Patients

Body System/Adverse Event	Placebo (n=868)	Exelon (6-12 mg/day) (n=1,189)
Percent of Patients with any Adverse Event	79	92
Autonomic Nervous System
Sweating increased	1	4
Syncope	2	3
Body as a Whole
Accidental Trauma	9	10
Fatigue	5	9
Asthenia	2	6
Malaise	2	5
Influenza-like Symptoms	2	3
Weight Decrease	<1	3
Cardiovascular Disorders, General
Hypertension	2	3
Central and Peripheral Nervous System
Dizziness	11	21
Headache	12	17
Somnolence	3	5
Tremor	1	4
Gastrointestinal System
Nausea	12	47
Vomiting	6	31
Diarrhea	11	19
Anorexia	3	17
Abdominal Pain	6	13
Dyspepsia	4	9
Constipation	4	5
Flatulence	2	4
Eructation	1	2
Psychiatric Disorders
Insomnia	7	9
Confusion	7	8
Depression	4	6
Anxiety	3	5
Hallucination	3	4
Aggressive Reaction	2	3
Resistance Mechanism Disorders
Urinary Tract Infection	6	7
Respiratory System
Rhinitis	3	4

Other adverse events observed at a rate of 2% or more on Exelon 6-12 mg/day but at a greater or equal rate on placebo were chest pain, peripheral edema, vertigo, back pain, arthralgia, pain, bone fracture, agitation, nervousness, delusion, paranoid reaction, upper respiratory tract infections, infection (general), coughing, pharyngitis, bronchitis, rash (general), urinary incontinence.

Other Adverse Events Observed During Clinical Trials

Exelon has been administered to over 5,297 individuals during clinical trials worldwide. Of these, 4,326 patients have been treated for at least 3 months, 3,407 patients have been treated for at least 6 months, 2,150 patients have been treated for 1 year, 1,250 have been treated for 2 years, and 168 have been treated for over 3 years. With regard to exposure to the highest dose, 2,809 patients were exposed to doses of 10-12 mg, 2,615 patients treated for 3 months, 2,328 patients treated for 6 months, 1,378 patients treated for 1 year, 917 patients treated for 2 years, and 129 treated for over 3 years.

Treatment emergent signs and symptoms that occurred during 8 controlled clinical trials and 9 open-label trials in North America, Western Europe, Australia, South Africa, and Japan were recorded as adverse events by the clinical investigators using terminology of their own choosing. To provide an overall estimate of the proportion of individuals having similar types of events, the events were grouped into a smaller number of standardized categories using a modified WHO dictionary, and event frequencies were calculated across all studies. These categories are used in the listing below. The frequencies represent the proportion of 5,297 patients from these trials who experienced that event while receiving Exelon. All adverse events occurring in at least 6 patients (approximately 0.1%) are included, except for those already listed elsewhere in labeling, WHO terms too general to be informative, relatively minor events, or events unlikely to be drug caused. Events are classified by body system and listed using the following definitions: frequent adverse events - those occurring in at least 1/100 patients; infrequent adverse events - those occurring in 1/100 to 1/1,000 patients. These adverse events are not necessarily related to Exelon treatment and in most cases were observed at a similar frequency in placebo-treated patients in the controlled studies.

Autonomic Nervous System: Infrequent: Cold clammy skin, dry mouth, flushing, increased saliva.

Body as a Whole: Frequent: Accidental trauma, fever, edema, allergy, hot flushes, rigors. Infrequent: Edema periorbital or facial, hypothermia, edema, feeling cold, halitosis.

Cardiovascular System: Frequent: Hypotension, postural hypotension, cardiac failure.

Central and Peripheral Nervous System: Frequent: Abnormal gait, ataxia, paraesthesia, convulsions. Infrequent: Paresis, apraxia, aphasia, dysphonia, hyperkinesia, hyperreflexia, hypertonia, hypoesthesia, hypokinesia, migraine, neuralgia, nystagmus, peripheral neuropathy.

Endocrine System: Infrequent: Goitre, hypothyroidism.

Gastrointestinal System: Frequent: Fecal incontinence, gastritis. Infrequent: Dysphagia, esophagitis, gastric ulcer, gastritis, gastroesophageal reflux, GI hemorrhage, hernia, intestinal obstruction, melena, rectal hemorrhage, gastroenteritis, ulcerative stomatitis, duodenal ulcer, hematemesis, gingivitis, tenesmus, pancreatitis, colitis, glossitis.

Hearing and Vestibular Disorders: Frequent: Tinnitus.

Heart Rate and Rhythm Disorders: Frequent: Atrial fibrillation, bradycardia, palpitation. Infrequent: AV block, bundle branch block, sick sinus syndrome, cardiac arrest, supraventricular tachycardia, extrasystoles, tachycardia.

Liver and Biliary System Disorders: Infrequent: Abnormal hepatic function, cholecystitis.

Metabolic and Nutritional Disorders: Frequent: Dehydration, hypokalemia. Infrequent: Diabetes mellitus, gout, hypercholesterolemia, hyperlipemia, hypoglycemia, cachexia, thirst, hyperglycemia, hyponatremia.

Musculoskeletal Disorders: Frequent: Arthritis, leg cramps, myalgia. Infrequent: Cramps, hernia, muscle weakness.

Myo-, Endo-, Pericardial and Valve Disorders:Frequent: Angina pectoris, myocardial infarction.

Platelet, Bleeding, and Clotting Disorders: Frequent: Epistaxis. Infrequent: Hematoma, thrombocytopenia, purpura.

Psychiatric Disorders: Frequent: Paranoid reaction, confusion. Infrequent: Abnormal dreaming, amnesia, apathy, delirium, dementia, depersonalization, emotional lability, impaired concentration, decreased libido, personality disorder, suicide attempt, increased libido, neurosis, suicidal ideation, psychosis.

Red Blood Cell Disorders: Frequent: Anemia. Infrequent: Hypochromic anemia.

Reproductive Disorders (Female & Male): Infrequent: Breast pain, impotence, atrophic vaginitis.

Resistance Mechanism Disorders: Infrequent: Cellulitis, cystitis, herpes simplex, otitis media.

Respiratory System: Infrequent: Bronchospasm, laryngitis, apnea.

Skin and Appendages: Frequent: Rashes of various kinds (maculopapular, eczema, bullous, exfoliative, psoriaform, erythematous). Infrequent: Alopecia, skin ulceration, urticaria, dermatitis contact.

Special Senses:Infrequent: Perversion of taste, loss of taste.

Urinary System Disorders: Frequent: Hematuria. Infrequent: Albuminuria, oliguria, acute renal failure, dysuria, micturition urgency, nocturia, polyuria, renal calculus, urinary retention.

Vascular (extracardiac) Disorders: Infrequent: Hemorrhoids, peripheral ischemia, pulmonary embolism, thrombosis, thrombophlebitis deep, aneurysm, hemorrhage intracranial.

Vision Disorders: Frequent: Cataract. Infrequent: Conjunctival hemorrhage, blepharitis, diplopia, eye pain, glaucoma.

White Cell and Resistance Disorders: Infrequent: Lymphadenopathy, leukocytosis.

Post-Introduction Reports

Voluntary reports of adverse events temporally associated with Exelon that have been received since market introduction that are not listed above, and that may or may not be causally related to the drug include the following:

Skin and Appendages: Stevens-Johnson syndrome.

Overdose

Because strategies for the management of overdose are continually evolving, it is advisable to contact a Poison Control Center to determine the latest recommendations for the management of an overdose of any drug.

As Exelon® (rivastigmine tartrate) has a short plasma half-life of about one hour and a moderate duration of acetylcholinesterase inhibition of 8-10 hours, it is recommended that in cases of asymptomatic overdoses, no further dose of Exelon should be administered for the next 24 hours.

As in any case of overdose, general supportive measures should be utilized. Overdosage with cholinesterase inhibitors can result in cholinergic crisis characterized by severe nausea, vomiting, salivation, sweating, bradycardia, hypotension, respiratory depression, collapse and convulsions. Increasing muscle weakness is a possibility and may result in death if respiratory muscles are involved. Atypical responses in blood pressure and heart rate have been reported with other drugs that increase cholinergic activity when coadministered with quaternary anticholinergics such as glycopyrrolate. Due to the short half-life of Exelon, dialysis (hemodialysis, peritoneal dialysis, or hemofiltration) would not be clinically indicated in the event of an overdose.

In overdoses accompanied by severe nausea and vomiting, the use of antiemetics should be considered. In a documented case of a 46 mg overdose with Exelon, the patient experienced vomiting, incontinence, hypertension, psychomotor retardation, and loss of consciousness. The patient fully recovered within 24 hours and conservative management was all that was required for treatment.

Dosage and Administration

The dosage of Exelon® (rivastigmine tartrate) shown to be effective in controlled clinical trials is 6-12 mg/day, given as twice a day dosing (daily doses of 3 to 6 mg BID). There is evidence from the clinical trials that doses at the higher end of this range may be more beneficial.

The starting dose of Exelon is 1.5 mg twice a day (BID). If this dose is well tolerated, after a minimum of two weeks of treatment, the dose may be increased to 3 mg BID. Subsequent increases to 4.5 mg BID and 6 mg BID should be attempted after a minimum of 2 weeks at the previous dose. If adverse effects (e.g., nausea, vomiting, abdominal pain, loss of appetite) cause intolerance during treatment, the patient should be instructed to discontinue treatment for several doses and then restart at the same or next lower dose level. If treatment is interrupted for longer than several days, treatment should be reinitiated with the lowest daily dose and titrated as described above (see WARNINGS ). The maximum dose is 6 mg BID (12 mg/day).

Exelon should be taken with meals in divided doses in the morning and evening.

Recommendations for Administration: Caregivers should be instructed in the correct procedure for administering Exelon Oral Solution. In addition, they should be directed to the Instruction Sheet (included with the product) describing how the solution is to be administered. Caregivers should direct questions about the administration of the solution to either their physician or pharmacist (see PRECAUTIONS : Information for Patients and Caregivers).

Patients should be instructed to remove the oral dosing syringe provided in its protective case, and using the provided syringe, withdraw the prescribed amount of Exelon Oral Solution from the container. Each dose of Exelon Oral Solution may be swallowed directly from the syringe or first mixed with a small glass of water, cold fruit juice or soda. Patients should be instructed to stir and drink the mixture.

Exelon Oral Solution and Exelon Capsules may be interchanged at equal doses.

How Supplied

Exelon® (rivastigmine tartrate) capsules equivalent to 1.5 mg, 3 mg, 4.5 mg, or 6 mg of rivastigmine base are available as follows:

1.5 mg Capsule - yellow, "Exelon 1,5 mg" is printed in red on the body of the capsule.

Bottles of 60 -- NDC 0078-0323-44
Bottles of 500 -- NDC 0078-0323-08
Unit Dose (blister pack) Box of 100 (strips of 10) -- NDC 0078-0323-06

3 mg Capsule - orange, "Exelon 3 mg" is printed in red on the body of the capsule.

Bottles of 60 -- NDC 0078-0324-44
Bottles of 500 -- NDC 0078-0324-08
Unit Dose (blister pack) Box of 100 (strips of 10) -- NDC 0078-0324-06

4.5 mg Capsule - red, "Exelon 4,5 mg" is printed in white on the body of the capsule.

Bottles of 60 -- NDC 0078-0325-44
Bottles of 500 -- NDC 0078-0325-08
Unit Dose (blister pack) Box of 100 (strips of 10) -- NDC 0078-0325-06

6 mg Capsule - orange and red, "Exelon 6 mg" is printed in red on the body of the capsule.

Bottles of 60 -- NDC 0078-0326-44
Bottles of 500 -- NDC 0078-0326-08
Unit Dose (blister pack) Box of 100 (strips of 10) -- NDC 0078-0326-06

Store below 25°C (77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature]. Store in a tight container.

Exelon® (rivastigmine tartrate) Oral Solution is supplied as 120 mL of a clear, yellow solution (2 mg/mL base) in a 4 ounce USP Type III amber glass bottle with a child-resistant 28 mm cap, 0.5 mm foam liner, dip tube and self-aligning plug. The oral solution is packaged with a dispenser set which consists of an assembled oral dosing syringe that allows dispensing a maximum volume of 3 mL corresponding to a 6 mg dose, with a plastic tube container.

Bottles of 120 mL -- NDC 0078-0339-31

Store below 25°C (77°F); excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature]. Store in an upright position and protect from freezing.

When Exelon Oral Solution is combined with cold fruit juice or soda, the mixture is stable at room temperature for up to 4 hours.

Exelon® (rivastigmine tartrate) Oral Solution Instructions for Use

	1. Remove oral dosing syringe from its protective case. Push down and twist child resistant closure to open bottle.
	2. Insert tip of syringe into opening of white stopper.
	3. While holding the syringe, pull the plunger up to the level (see markings on side of syringe) that equals the dose prescribed by your doctor
	4. Before removing syringe containing prescribed dose from bottle, push out large bubbles by moving plunger up and down a few times. After the large bubbles are gone, pull the plunger again to the level that equals the dose prescribed by your doctor. Do not worry about a few tiny bubbles. This will not affect your dose in any way. Remove the syringe from the bottle.
	5. You may swallow Exelon Oral Solution directly from the syringe or mix with a small glass of water, cold fruit juice or soda. If mixing with water, juice or soda, be sure to stir completely and to drink the entire mixture. DO NOT MIX WITH OTHER LIQUIDS.
	6. After use, wipe outside of syringe with a clean tissue and put it back into its case. Close bottle using child resistant closure

Store Exelon Oral Solution at room temperature (below 77°F) in an upright position. Do not place in freezer.

Capsules manufactured by:
Novartis Farmacéutica S.A.
Barcelona, Spain

Oral Solution manufactured by:
Novartis Consumer Health, Incorporated
Lincoln, Nebraska 68517

Distributed by:
Novartis Pharmaceuticals Corporation
East Hanover, New Jersey 07936

Exelon patient information (in plain English)

IMPORTANT: The information in this monograph is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects. This information is generalized and is not intended as specific medical advice. If you have questions about the medicines you are taking or would like more information, check with your doctor, pharmacist, or nurse. Last updated 6/06.

Source: Novartis Pharmaceuticals, U.S. distributor of Exelon.

back to: Psychiatric Medications Pharmacology Homepage

Dr. Kluft is Assistant Clinical Professor Psychiatry, Temple University School of Medicine, and Attending Psychiatrist, The Institute of the Pennsylvania Hospital, Philadelphia.

Overview of Treatment

This is an exciting but confusing epoch in the history of the treatment of Multiple Personality Disorder (MPD). On the one hand, as noted in the first part of this lesson, an increasing number of MPD patients are being identified, and seeking psychiatric help. On the other hand, despite the upsurge in the literature on their treatment remains in a pioneering phase. The first outcome studies are quite recent; controlled studies are not available. A considerable number of articles offer advice generalized from single cases or from small or unspecified data bases. Since MPD patients are quite diverse, it is not surprising to find that citations can be found which appear to argue both for and against many therapeutic approaches. "Multiple personality disorder delights in puncturing our generalizations, revels in shattering our security about our favorite techniques and theories, and exhilarates in the role of gadfly and disturber of the peace." In contrast, among those workers who have seen many patients with MPD, most of whom taught their techniques in workshops but were unpublished prior to the 1980's, fascinating convergence's as well as differences have been noted. Braun, observing commonalties of videotaped therapeutic behavior among experienced MPD therapists who professed different theoretical orientations, inferred that the clinical realities of MPD influenced clinicians from diverse backgrounds toward similar approaches and conclusions. He offered the hypothesis that in actual treatment settings experienced workers behaved much more alike than their own statements would suggest. Many authorities concur. There is also increasing agreement that the prognosis for most patients with MPD is quite optimistic if intense and prolonged treatment from experienced clinicians can be made available. Often logistics rather than untreatability impede success.

Despite these encouraging observations, many continue to question whether the condition should be treated intensively or discouraged with benign neglect. Concern has been expressed that naive and credulous therapists may suggest or create the condition in basically histrionic or schizophrenic individuals, or even enter a folie á deux with their patients. Arguments to the contrary have been offered. Over a dozen years, this author has seen over 200 MPD cases diagnosed by over 100 separate clinicians in consultation and referral. In his experience, referral sources have been circumspect rather than zealous in their approach to MPD, and he cannot support the notion that iatrogenic factors are major factors. Although no controlled trials compare the fates of MPD patients in active treatment, placebolike treatment, and no treatment cohorts, some recent data bears on this controversy. The author has seen over a dozen MPD patients who declined treatment (approximately half of whom know the tentative diagnoses and half who did not) and over two dozen who entered therapies in which their MPD was not addressed. On reassessment, two to eight years later, all continued to have MPD. Conversely, patients reassessed after treatment for MPD have been found to hold onto their rather well.

Treatment Goals

MPD does not exist in the abstract or as a freestanding target symptom. It is found in a diverse group of individuals with a wide range of Axis II or character pathologies, concomitant Axis I diagnoses, and many different constellations of ego strengths and dynamics. It may take many forms and express a variety of underlying structures. Generalizations drawn from the careful study of single cases may prove grossly inaccurate when applied to other cases. Perhaps MPD is understood most parsimoniously as the maladaptive persistence, as a post-traumatic stress disorder, of a pattern which proved adaptive during times when the patient was overwhelmed as a child.

In general, the tasks of therapy are the same as those in any intense change-oriented approach, but are pursued, in this case, in an individual who lacks a unified personality. This precludes the possibility of an ongoing unified and available observing ego, and implies the disruption of certain usually autonomous ego strengths and functions, such as memory. The personalities may have different perceptions, recollections, problems, priorities, goals, and degrees of involvement with and commitment to the therapy and one another. Therefore, it usually becomes essential to replace this dividedness with agreement to work toward certain common goals, and to achieve treatment to succeed.Work toward such cooperation and the possible integration of the several personalities distinguishes the treatment of MPD from other types of treatment. Although some therapists argue that multiplicity should be transformed from a symptom into a skill rather than be ablated, most consider integration preferable. (I the typer of this page and the creator of this website, Debbie would like to add a note right here: As an MPD patient and one who talks with many other MPDs, I personally feel that it should be transformed from a symptom into a skill rather than be ablated......most MPD patients that I speak with do not consider integration preferable. thank you for allowing me to interrupt.) In a given case, it is hard to argue with Caul's pragmatism: "It seems to me that after treatment you want a functional unit, be it a corporation, a partnership, or a one-owner business."

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In this lesson, the terms "unification," "integration" and "fusion" are used synonymously, and are understood to connote the spontaneous or facilitated coming together of personalities after adequate therapy has helped the patient to see, abreact, and work through the reasons for being of each separate alter. Consequently, the therapy serves to erode the barriers between the alters, and allow mutual acceptance, empathy, and identification. It does not indicate the dominance of one alter, the creation of a new "healthy" alter, or a premature compression or suppression of alters into the appearance of a resolution. Operationally.

"Fusion was defined on the basis of three stable months of 1) continuity of contemporary memory, 2) absence of overt behavioral signs of multiplicity, 3) subjective sense of unity, 4) absence of alter personalities on hypnotic re-exploration (hypnotherapy cases only), 5) modification of transference phenomena consistent with the bringing together of personalities, and 6) clinical evidence that the unified patient's self-representation included acknowledgment of attitudes and awareness which were previously segregated in separate personalities."

Such stability usually follows the collapse of one or more short-lived "apparent fusions." and subsequent further work in treatment. Post-fusion therapy is essential.

Modalities of Treatment

Many pioneers in the field of MPD developed their techniques in relative isolation and had difficulty publishing their findings. For example, Cornelia B. Wilbur had extensive experience with MPD and her work was popularized in Sybil, published in 1973, however, her first scientific article on treatment did not appear until 1984. There developed two "literature's," which overlapped only on occasion. The published scientific literature slowly amassed a body of (usually) single case applications of particular approaches, while an oral tradition developed in workshops, courses, and individual supervisions. In the latter, clinicians who had worked with many cases shared their insights. This "oral literature" remained largely unpublished until several special journal issues in 1983-1984.

Psychoanalytic approaches to MPD have been discussed by Ries, Lasky, Marmer, and Lample-de-Groot. It seems clear that some patients with MPD who have the ego strengths to undertake analysis, who are not alloplastic, whose personalities are cooperative, and who are completely accessible without hypnosis can be treated with analysis. However, these constitute a small minority of MPD patients. Some diagnosis being suspected; others also undiagnosed, have had their analyses interrupted by regressive phenomena not recognized as manifestations of the MPD condition. While psychoanalytic understanding is often considered desirable in work with MPD, formal psychoanalysis ought to be reserved for a small number cases. Psychoanalytic psychotherapy, with or without facilitation by hypnosis, is widely recommended. Bowers et al. Offered several useful precepts, Wilbur described her approaches, and Marmer discussed working with the dreams of dissociating patients. Kluft's articles on treatment described aspects of work in psychoanalytic psychotherapy facilitated by hypnosis, but their emphasis was on the hypnosis and crisis management aspects rather than the application of psychodynamic precepts. Kluft described the problems and impairment of ego functions suffered by MPD patients by virtue of their dividedness, and showed how they render the application of a purely interpretive psychoanalytic paradigm problematic.

Behavioral treatments have been described by Kohlenberg, Price and Hess, and most elegantly by Klonoff and Janata. There is no doubt that behavioral regimens can make dramatic transient impacts on MPD's manifest pathology, but there is no extant case report of a behavioral regimen's effecting a successful long-term cure. Klonoff and Janata found that unless the underlying issues were resolved, relapse occurred. Many workers think that behavioral approaches inadvertently replicate childhood traumas in which patients' pain was not responded to, or in confined or bound rather than allowed freedom. In fact, many patients experience them as punitive. Klonoff and Janata are currently working to improve their behavioral regimens to adjust for these problems. At this point in time, the behavioral therapy of MPD per se must be regarded as experimental.

Family interventions have been reported by Davis and Osherson, Beale, Levenson and Berry, and Kluft, Braun, and Sachs. In sum, although MPD is all too often an aftermath of family pathology, family therapy is rately successful as a primary treatment modality. It often can be a valuable adjunct. Empirically, treatment of an adult MPD patient with a traumatizing family of origin frequently does no more than result in retraumatization. However, family interventions may be essential to treat or stabilize a child or early adolescent with MPD. Family work with the MPD patient, spouse, and/or children may allow relationships to be saved and strengthened, and protect the children from incorporating or being drawn in to some aspects of the MPD parent's psychopathology. In general, the concerned others in an MPD patient's family may require considerable education and support. They must bear difficult and crisis-filled cases, their support of the or with a colleague's cooperation, can be critical to the treatment's outcome.

Group treatment of the MPD patient can prove difficult. Caul has summarized the difficulties such patients experience in and impose upon hererogeneous groups. In brief, unintegrated MPD patients may be scapegoated, resented, disbelieved, feared, imitated, and, in many ways, require so much attention at times of switching or crisis that they may incapacitate the group's productivity. The materials and experiences they share may overwhelm the group members. MPD patients often are exquisitely sensitive and become engulfed in other's issues. They are prone to dissociate in and/or run from sessions. So many therapists have reported so many misadventures of MPD patients in heterogeneous groups that their inclusion in such a modality cannot be routinely recommended. They work more successfully in task-oriented or project-oriented groups such as that which occupational therapy, music therapy, movement therapy, and art therapy may provide. Some anecdotally describe their successful inclusion in groups with a shared experience, such as those that have been involved in incestuous relationships, rape victims, or adult children of alcoholics. Caul has proposed a model for undertaking an internal group therapy among the alters.

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A number of workers have described the facilitation of treatment with amobarbital and/or videotaped interviews. Hall, Le Cann, and Schoolar describe treating a patient by retrieving material in amytal in treatment. Caul has described taping hypnotically- facilitated sessions, and offered cautions about the timing of playing back such sessions to the patient. While there are some patients whose personalities tolerate videotaped confrontation with evidence and alters from which they were profoundly dissociated, many are overwhelmed by such data or re-repress it. Such approaches are best considered on a case-by-case basis, and cannot be regarded as uniformly advisable or effective. Caul recognizes this and seems to advocate a version of what hypnotherapists refer to as "permissive amnesia," i.e., the patient can see the tape when he is ready to see it (an analogy to the suggestion the patient will remember a traumatic even when he or she is ready to do so).

Hypnotherapeutic interventions have an established role in the contemporary treatment of MPD despite the controversy which surrounds their use. On the one hand, a large number of clinicians have helped a good many MPD patients using such interventions. On the other hand, many prominent and eloquent individuals have raised concerns that hypnosis can concretize, exacerbate, or even create MPD (as noted in the first part of this lesson). Often the debate becomes arcane to those unfamiliar with the literature of hypnosis, and the specialized concerns of forensic hypnosis, in which workers struggle to guard against the induction of confabulated or false memories which are perceived as concrete reality, and, if so reported, can impede the judicial process. The thrust of the clinical literature is that judicious hypnotherapeutic interventions thoughtfully integrated into a well-planned psychotherapy, individualized to a particular patient and oriented toward integration, can be extremely productive and helpful, and that ill-advised hypnotic work, like any other inappropriate steps, may well miscarry. The use of hypnosis in exploration, in accessing personalities for therapeutic barriers, in encouraging alters communication, and in encouraging alters communication, and documented by Allison, Bowers et al., Braun, Caul, Erickson and Kubie, Gruenewald, Horevitz, Howland, Kluft, Ludwig and Brandsma, and Spiegel, among others.

A number of clinicians advocate the provision of a very tangible corrective emotional experience, under rubric of reparenting. They undertake to create experiences within the treatment which offer to nurture the patient through a more positive recapitulation of various developmental issues and to provide more positive interjects. No published article addresses this approach. It is the author's experience that successful treatment does not necessitate such measures.

Also not available in the literature are papers on the successful approaches involving the coordinated efforts of a team of therapists employing several modalities in conjunction. This approach was pioneered by B. G. Braun and R. G. Sachs of Chicago.

Useful Principles and Caveats

According to an empirically-derived model, the patient who develops MPD had (1) the capacity to dissociate, which becomes enlisted as a defense in the face of (2) life experiences (usually of severe abuse) which traumatically overwhelm the nondissociative adaptive capacities of a child's ego. A number of (3) shaping influences, substrates, and developmental factors determine the form taken by the dissociative defenses (i.e., personality formation). Those who remain dissociated are given (4) inadequate stimulus barriers, soothing, and restorative experiences, and are exposed to pressures and further traumatization which reinforce the need for and shape of the dissociative defenses. The elements of the Four-Factor Theory of Etiology have certain implications for treatment. Whether or not a clinician elects to use hypnosis, he ought to be aware of its phenomena, and of how dissociative manifestations may express themselves in clinical settings, especially as psychosomatic and quasi-psychotic presentations. The patient brings his dissociative defenses into the therapy. One must "be gentle, gradual, and avoid imposing upon the patient any overwhelming experience that is not an inevitable concomitant of dealing with painful material. The material to be recovered brings with it the certainty of reliving anguish, and explains these patients' frequent evasiveness, protracted resistance's, and mistrust of the therapist's motives. The patient needs to be empathetically understood across and within all personalities; the therapist must deal with all with an "evenhanded gentle respectfulness, but help the patient protect himself from himself. A mutuality of working together and recognition of the difficult nature of the job to be done is essential. These treatments "sink or swim on the quality of the therapeutic alliance established with the personalities."

Certain principles advocated by Bowers et al. have stood the test of time. In summary, the therapist must remain within the limits of his competence and not rush to apply incompletely-understood and partially-mastered principles and techniques. The therapist must give integration priority over exploring fascinating phenomena and differences. He should help all alters understand themselves as more or less dissociated sides of a total person. The personalities names are accepted as labels, not as guarantees or individual rights to irresponsible autonomy. All alters must be heard with equal empathy and concern. Often one or more will be especially helpful in advising the therapist about readiness to proceed into painful areas. "Encourage each personality to accept, understand, and feel for each other personality, to realize each is incomplete so long as it is separated from the rest of the individual, and to unite with the others in common interests." Respect the patient's distress over facing painful material and the alters' misgivings over integration. Therapy must be gentle. ECT is contraindicated. Psychodynamic psychotherapy is the treatment of choice. Within its context, hypnosis may be valuable for dealing with serious conflicts among alters and, when used synthetically, to help the individual "recognize, consider, and utilize his various past and present experiences, impulses, and purposes for better self-understanding and increased self-direction." Intervene therapeutically with concerned others when necessary. Do not dramatize amnesia; assure the patient he will recover his past when he is able. Bowers et al. cautioned against irresponsible misuse of hypnosis, lest splitting be worsened, yet their classic article did not list "acceptable techniques" as there was a lack of space. Bowers and two co-authors, Newton and Watkins, in personal communications in a recent source within the rubric of the constructive use of hypnosis.

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A General Outline of Treatment

Virtually every aspect of treatment depends on the strength of the therapeutic alliance which must be cultivated globally and with each individual alter. In the face of severe psychopathology, painful material, crises, difficult transferences, and the likelihood that, at least early in treatment, the alters may have grossly divergent perceptions of the psychiatrist and test him rigorously, the patient's commitment to the task of therapy and collaborative cooperation are critical. This emphasis is implicit in a general treatment plan outlined by Braun, which has sufficient universality to be applied in most therapy formats. Braun enumerates 12 steps, many of which are overlapping or ongoing rather than sequential.

Step 1 involves the development of trust, and is rarely complete until the end of therapy. Operationally, it means "enough trust to continue the work of a difficult therapy."

Step 2 includes the making of the diagnosis and the sharing of it with the presenting and other personalities. It must be done in a gentle manner, soon after the patient is comfortable in the therapy and the therapist has sufficient data and/or has made sufficient observations to place the issue before the patient in a matter-of-fact and circumspect way. Only after the patient appreciates the nature of his situation can the true therapy of MPD begin.

Step 3 involves establishing communication with the accessible alters. In many patients whose alters rarely emerge spontaneously in therapy and who cannot switch voluntarily, hypnosis or hypnotic technique without hypnosis may be useful.

Upon gaining access to the alters, Step 4 concerns contracting with them to attend treatment and to agree against harming themselves, others, or the body they share. Some helper personalities rapidly become allies in these matters, but it is the therapist's obligation to keep such agreements in force.

History gathering with each alter is Step 5 and encompasses learning of their origins, functions, problems, and relations to the other alters.

In Step 6 work is done to solve the alters' problems. During such efforts prime concerns are remaining in contact, sticking with painful subjects, and setting limits, as difficult times are likely.

Step 7 involves mapping and understanding the structure of the personality system.

With the previous seven steps as background, therapy moves to Step 8 which entails enhancing interpersonality communications. The therapist or a helper personality may facilitate this. Hypnotic interventions to achieve this have been described, as has an internal group therapy approach.

Step 9 involves resolution toward a unity, and facilitating blending rather than encouraging power struggles. Both hypnotic and non-hypnotic approaches have been described. Some patients appear to need the latter approach.

In Step 10 integrated patients must develop new intrapsychic defenses and coping mechanisms, and learn adaptive ways of dealing interpersonally.

Step 11 concerns itself with a substantial amount of working-through and support necessary for solidification of gains.

Step 12 follow-up, is essential.

The Course and Characteristics of Treatment

It is difficult to conceive of a more demanding and painful treatment, and those who must undertake it have many inherent vulnerabilities. Dissociation and dividedness make insight difficult to attain. Deprived of a continuous memory, and switching in response to both inner and outer pressures and stressors, self-observation and learning from experience are compromised. The patients' alters may alienate support systems as their disruptive and inconsistent behaviors and their memory problems may cause them to appear to be unreliable at best. Traumatized families may openly reject the patient and/or disavow everything the patient has alleged.

The alters' switching and battles for dominance can create an apparently never-ending series of crises. Alters identifying with aggressors or traumatizers may try to suppress those who want to cooperate with therapy and share memories, or punish those they dislike by inflicting injury upon the body. Battles between alters may result in hallucinations and quasipsychotic symptoms. Some alters may suddenly withdraw the patient from therapy.

Painful memories may emerge as hallucinations, nightmares, or passive influence experiences. In order to complete the therapy, long-standing repressions must be undone, and dissociative defenses and switching must be abandoned and replaced. The alters also must give up their narcissistic investments in separateness, abandon aspirations for total control, and "empathize, compromise, identify, and ultimately coalesce with personalities they had long avoided. opposed and rejected."

In view of the magnitude of the changes required and the difficulty of the materials which must be worked through, therapy may prove arduousfor patient and therapist alike. Ideally, a minimum of two sessions a week is desirable, with the opportunity for prolonged sessions to work on upsetting materials and the understanding that crisis intervention sessions may be needed. Telephone accessibility is desirable, but firm nonpunitive limit-setting is very much in order. The pace of therapy must be modulated to allow the patient respite from an incessant exposure to traumatic materials. the therapist should bear in mind that some patients, once their amnestic barriers are eroded, will be in states of "chronic crisis" for long periods of time.

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The Therapist's Reactions

Working to cure MPD can be arduous and demanding. Most therapists feel rather changed by the experience and believe their overall skills have been improved by meeting the challenge of working with this complex psychopathology. A smaller number feel traumatized. Certain initial reactions are normative: excitement, fascination, over investment, and interest in documenting the panoply of pathology. These reactions are often followed by bewilderment, exasperation, and a sense of being drained. Many feel overwhelmed by the painful material, the high incidence of crises, the need to bring to bear a variety of clinical skills in rapid succession and/or novel combinations, and the skepticism of usually supportive colleagues. Many psychiatrists, sensitive to their patients isolation and the rigors of therapy, find it difficult both to be accessible and to remain able to set reasonable and non-punitive limits. They discover that patients consume substantial amounts of their professional and personal time. Often the therapist is distressed to find his preferred techniques ineffective and his cherished theories disconfirmed. As a result, the therapist may become exasperated with some alters' failure to cooperate with or value the goals of the therapy, and/or their incessant testing of his or her trustworthiness and goodwill.

The psychiatrist's empathic tendencies are sorely taxed. It is difficult to feel along with the separate personalities, and to remain in touch with the "red thread" of a session across dissociative defenses and personality switches. Furthermore, the material of therapy is often painful, and difficult to accept on an empathic level. Four reaction patterns are common. In the first, the psychiatrist retreats from painful affect and material into a cognitive stance and undertakes an intellectualized therapy in which he plays detective, becoming a defensive skeptic or an obsessional worrier over "what is real." In the second, he or she abandons a conventional stance and undertakes to provide an actively nurturing corrective emotional experience, in effect proposing to "love the patient into health." In the third, the therapist moves beyond empathy to counter-identification, often with excessive advocacy. In the fourth, the psychiatrist moves toward masochistic self-endangerment and/or self-sacrifice on the patient's behalf. These stances, however they are rationalized, may serve the therapist's counter-transference needs more than the goals of the treatment.

Therapists who work smoothly with MPD patients set firm but non-rejecting boundaries and sensible but non-punitive limits. They safeguard their practice and private lives. They know therapy may be prolonged, thus they avoid placing unreasonable pressures upon themselves, the patients, or the treatment. They are wary of accepting an MPD patient whom they do not find likable, because they are aware that their relationship with the patient may become quite intense and complex and go on for many years. As a group, successful MPD therapists are flexible and ready to learn from their patients and colleagues. They are comfortable in seeking rather than allowing difficult situations to escalate. They neither relish nor fear crises and understand them to be characteristic of work with MPD patients. They are willing to be advocates on occasion.

Hospital Treatment

An MPD patient may require hospitalization for self-destructive episodes, severe dysphoria, fugues, or alters' inappropriate behaviors. Sometimes a structured environment is advisable for difficult phases of treatment; an occasional patient must seek treatment far from home. Such patients can be quite challenging, but if the hospital staff accepts the diagnosis and is supportive of the treatment, most can be managed adequately. Failing these conditions, an MPD patient's admission can be traumatizing to the patient and hospital alike. An MPD patient rarely splits a staff splits itself by allowing individual divergent views about this controversial condition to influence professional behavior. Unfortunately, polarization may ensue. MPD patients, experienced as so overwhelming as to threaten the sense of competence of that particular milieu. The staff's sense of helplessness vis-à -vis the patient can engender resentment of both the patient and the admitting psychiatrist. It is optimal for the psychiatrist to help the staff in matter-of-fact problem-solving, explain his therapeutic approach, and be available by telephone.

The following guidelines emerge from clinical experience:

1. A private room offers the patient a place of refuge and diminishes crises.
2. Treat all alters with equal respect and address the patient as he or she wishes to be addressed. Insisting on a uniformity of name or personality presence on a uniformity of name or personality presence provokes crises or suppresses necessary data.
3. Make it clear that the staff is not expected to recognize each alter. Alters must identify themselves to staff members if they find such acknowledgment important.
4. Anticipate likely crises with staff; emphasize one's availability.
5. Explain ward rules personally, having requested all alters to listen, and insist on reasonable compliance. If problems emerge, offer warm and firm responses, eschew punitive measures.
6. As such patients often have trouble with verbal group therapy, encourage art, movement, or occupational therapy groups, as they tend to do well in these areas.
7. Encourage a cooperative therapeutic thrust despite staff member's disagreement about MPD; emphasize the need to maintain a competent therapeutic environment for the patient.
8. Help the patient focus on the goals of the admission rather than succumb to a preoccupation with minor mishaps and problems on the unit.
9. Clarify each staff member's role to the patient, and emphasize that all members will not work in the same way. For example, it is not unusual for patients whose therapists elicit and work intensively with various alters to misperceive staff as unconcerned if they do not follow suit, even though it usually would be inappropriate if they did so.

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Medications

It is generally agreed that medication does not influence the core psychopathology of MPD, but may palliate symptomatic distress or impact upon a co-existing drug-responsive condition or target symptom. Many MPD patients are treated successfully without medication. Kluft noted six patients with MPD and major depression, and found treating either disorder as primary failed to impact on the other. However, Coryell reported a single case in which de conceptualized MPD as an epiphenomenon of a depression. While most MPD patients manifest depression, anxiety, panic attacks, and phobias, and some show transient (hysterical) psychoses, the drug treatment of such symptoms may yield responses which are so rapid, transient, inconsistent across alters, and/or persistent despite the discontinuation of the medication, that the clinician cannot be sure an active drug intervention rather than a placebo-like response has occurred. It is known that alters within a single patient may show different responses to a single medication.

Hypnotic and sedative drugs are often prescribed for sleep disturbance. Many patients fail to respond initially or after transient success, and try to escape from dysphoria with surreptitious overdosage. Most MPD patients suffer sleep disruption when alters are in conflict and/or painful material is emerging, i.e., the problem may persist throughout treatment. Often one must adopt a compromise regimen which provides "a modicum of relief and a minimum of risk." Minor tranquilizers are useful, but tolerance can be expected, and occasional abuse is encountered. Often high doses become a necessary transient compromise if anxiety becomes disorganizing or incapacitating. In the absence of coexisting mania or agitation in affective disorder, or for transient use with severe headaches, major tranquilizers should be used with caution and generally avoided. A wealth of anecdotal reports describe serious adverse effects; no documented proof of their beneficial impact has been published. Their major use in MPD is for sedation when minor tranquilizers fail or abuse/tolerance has become problematic. Many MPD patients have depressive symptoms, and a trial of tricyclics may be warranted. In cases without classic depression, results are often equivocal. Prescription must be circumspect, since many patients may ingest prescribed medication in suicide attempts. Monoamine oxidose inhibitor (MAOI) drugs give the patient the opportunity for self-destructive abuse, but may help atypical depressions in reliable patients. Patients with coexistent bipolar disorders and MPD may have the former disorder relieved by lithium. Two recent articles suggested a connection between MPD and seizure disorders. Not with standing that the patients cited had, overall, equivocal responses to anticonvulsants, many clinicians have instituted such regimes. The author has now seen two dozen classic MPD patients others had placed on anticonvulsants, without observing a single unequivocal response.

Postfusion Therapy

Patients who leave treatment after achieving apparent unity usually relapse within two to twenty-four months. Further therapy is indicated to work through issues, prevent repression of traumatic memories, and facilitate the development of non-dissociative coping strategies and defenses. Patients often wish and are encouraged by concerned others to "put it all behind (them)," forgive and forget, and to make up for their time of compromise or incapacitation. In fact, a newly-integrated MPD patient is a vulnerable neophyte who has just achieved the unity with which most patients enter treatment. Moratoria about major life decisions are useful, as is anticipatory socialization in potentially problematic situations. The emergence of realistic goal-setting, accurate perception of others, increased anxiety tolerance, and gratifying sublimations augur well, as does a willingness to work through painful issues in the transference. Avoidance coping styles and defenses require confrontation. Since partial relapse or the discovery of other alters are both possible, the integration per se should not be regarded as sacrosanct. An integration's failure is no more than an indication that it's occurrence was premature, i.e., perhaps it was a flight into health or it was motivated by pressures to avoid further painful work in treatment.

Many patients remain in treatment nearly as long after integration as they required to achieve fusion.

Postfusion Therapy

Patients who leave treatment after achieving apparent unity usually relapse within two to twenty-four months. Further therapy is indicated to work through issues, prevent repression of traumatic memories, and facilitate the development of non-dissociative coping strategies and defenses. Patients often wish and are encouraged by concerned others to "put it all behind (them)," forgive and forget, and to make up for their time of compromise or incapacitation. In fact, a newly-integrated MPD patient is a vulnerable neophyte who has just achieved the unity with which most patients enter treatment. Moratoria about major life decisions are useful, as is anticipatory socialization in potentially problematic situations. The emergence of realistic goal-setting, accurate perception of others, increased anxiety tolerance, and gratifying sublimations augur well, as does a willingness to work through painful issues in the transference. Avoidance coping styles and defenses require confrontation. Since partial relapse or the discovery of other alters are both possible, the integration per se should not be regarded as sacrosanct. An integration's failure is no more than an indication that it's occurrence was premature, i.e., perhaps it was a flight into health or it was motivated by pressures to avoid further painful work in treatment.

Many patients remain in treatment nearly as long after integration as they required to achieve fusion.

Follow-up Studies

Case reports and a recent study of the natural history of MPD suggest that untreated MPD patients history of MPD suggest that untreated MPD patients do not enjoy spontaneous remission, but instead many (70-80%) appear to shift to a one-alter predominant mode with relatively infrequent or covert intrusions of others as they progress into middle age and senescence. Most case reports do not describe complete or successful therapies. Many of those which appear "successful" have no firm fusion criteria, unclear follow-up, and offer confusing conceptualizations, such as describing "integrations" in which other alters are still occasionally noted. Using operational fusion criteria defined above, Kluft has followed a cohort of intensively-treated MPD patients and periodically studied the stability of their unification. The 33 patients averaged 13.9 personalities (there was from 2 personalities to as many as 86) and 21.6 months from diagnosis to apparent integration. Reassessed after a minimum of 27 months after apparent fusion (two years after fulfilling fusion criteria), 31 (94%) had not relapsed into behavioral MPD and 25 (75.8%) showed neither residual nor recurrent dissociative phenomena. No genuine full relapse was noted. Of the two with MPD, one had feigned integration and the other had a brief reactivation of one of 32 previously integrated alters when her spouse was found to be terminally ill. Six had alters which had not assumed executive control, and were classified as intrapsychic. Of these, two had new entities: one formed upon a lover's death, the other upon the patient's return to college. Three patients showed layering phenomena, groups of preexisting alters which had been long-suppressed, but were beginning to emerge as other alters were solidly integrated. The other relapse events were partial relapses of previous alters under stress, but those alters remained intrapsychic. Object loss, rejection, or the threat of those experiences triggered 75% of the relapse events. Four of these eight patients were reintegrated and have been stable after another 27 months of follow-up. Three remain in treatment for the newly-discovered layers of alters, and all are approaching integration. One individual worked years to initiate a relapse autohypnotically, and only recently returned for treatment. In sum, the prognosis is excellent for those MPD patients who are offered intensive treatment and are motivated to accept it.

Summary

MPD appears to be quite responsive to intense psychotherapeutic interventions. Although its treatment may prove arduous and prolonged, results are often gratifying and stable. The most crucial aspects of treatment are an open-minded pragmatism and a solid therapeutic alliance.

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next:   Uses Of Hypnosis with Multiple Personality

As a professional relationship coach, over the years I have listened as partners pour out their hearts to me, justifying their position to the detriment of the relationship.

There are as many relationship issues as there are people, however if I were going to make a list of the most frequent issues I would say that money, in-laws, sex, control issues, unfulfilled expectations and a lack of effective communication top the list.

It is one thing to know there is a problem and it is quite another to not do anything about it. You must first acknowledge that a problem exists before it can be fixed. Part of the healing is to acknowledge that there are indeed problems that you may be responsible for. Knowing that is not enough. DOING something different is!

Relationship derailment is a troubling phenomenon. However, it's time for the death of finger pointing. Blame in a love relationship doesn't work!

There is a payoff for everything you do. The payoff for pointing a finger at your partner and blaming him or her for your relationship condition is: you don't have to take responsibility for your share of the problem.

Although blaming has no redeeming value, if you must place blame, you would be wise to accept responsibility and know that the blame goes to the person looking back at you in the mirror.

Relationship problems are shared problems. To manage the complexity of a stormy relationship you must accept responsibility for your share of the problem. When you can do that, the problem is half solved. Not only will this change you, it will change your relationship with your partner.

It is time to STOP blaming someone else for the misery you are creating for yourself. It's time to forgive yourself and your partner so the hurt will heal. The hurts won't heal until you allow yourself to forgive.

Perhaps your relationship deserves a powerful new focus. The responsibility of both partners is to acknowledge that there is a problem, talk about it in the most loving way you can and reach a conclusion with a workable solution that will benefit both of you.

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Ideally, having a partner who understands the concept of team and the responsibility that goes with it contributes greatly to creating a greater attitude of team, which sheds light on solutions instead of keeping the focus on the problem.

True love allows for disagreements. Problems are not there to break you. They help make you a better partner; they help you grow. Acknowledging when you are wrong is not a sign of weakness; it is a sign of strength.

If your relationship is off track, the cost of complacency is obviously substantial. Waiting for your partner to "come around," may prove futile. Go first. You must take the first step while you are still afraid. Doing so helps to inoculate your relationship against a relapse.

Your relationship priorities are clear now, right? Go first. Say it.

"I was wrong and I am sorry."

It probably doesn't need to be said, however I will say it anyway. Saying "I'm sorry" over and over for the same mistake doesn't work! Not making the same mistake again does. It demonstrates your sincerity and respect for your partner and makes a significant contribution to your relationship.

Do what's right!

Those seven words will help make your perceptions clearer, your judgments sounder, your relationship and your life work better and you will be closer to your heart's desire; a healthy love relationship and marriage.

Do you want to be happy or do you want to be right?

next: Are You Being Authentic in Your Relationship?

As society has become increasingly aware of the prevalence of child abuse and its serious consequences, there has been an explosion of information on posttraumatic and dissociative disorders resulting from abuse in childhood. Since most clinicians learned little about childhood trauma and its aftereffects in their training, many are struggling to build their knowledge base and clinical skills to effectively treat survivors and their families.

Understanding dissociation and its relationship to trauma is basic to understanding the posttraumatic and dissociative disorders. Dissociation is the disconnection from full awareness of self, time, and/or external circumstances. It is a complex neuropsychological process. Dissociation exists along a continuum from normal everyday experiences to disorders that interfere with everyday functioning. Common examples of normal dissociation are highway hypnosis (a trance-like feeling that develops as the miles go by), "getting lost" in a book or a movie so that one loses a sense of passing time and surroundings, and daydreaming.

Researchers and clinicians believe that dissociation is a common, naturally occurring defense against childhood trauma. Children tend to dissociate more readily than adults. Faced with overwhelming abuse, it is not surprising that children would psychologically flee (dissociate) from full awareness of their experience. Dissociation may become a defensive pattern that persists into adulthood and can result in a full-fledged dissociative disorder.

The essential feature of dissociative disorders is a disturbance or alteration in the normally integrative functions of identity, memory, or consciousness. If the disturbance occurs primarily in memory, Dissociative Amnesia or Fugue (APA, 1994) results; important personal events cannot be recalled. Dissociative Amnesia with acute loss of memory may result from wartime trauma, a severe accident, or rape. Dissociative Fugue is indicated by not only loss of memory, but also travel to a new location and the assumption of a new identity. Posttraumatic Stress Disorder (PTSD), although not officially a dissociative disorder (it is classified as an anxiety disorder), can be thought of as part of the dissociative spectrum. In PTSD, recall/re-experiencing of the trauma (flashbacks) alternates with numbing (detachment or dissociation), and avoidance. Atypical dissociative disorders are classified as Dissociative Disorders Not Otherwise Specified (DDNOS). If the disturbance occurs primarily in identity with parts of the self assuming separate identities, the resulting disorder is Dissociative Identity Disorder (DID), formerly called Multiple Personality Disorder.

The Dissociative Spectrum

The dissociative spectrum (Braun, 1988) extends from normal dissociation to poly-fragmented DID. All of the disorders are trauma-based, and symptoms result from the habitual dissociation of traumatic memories. For example, a rape victim with Dissociative Amnesia may have no conscious memory of the attack, yet experience depression, numbness, and distress resulting from environmental stimuli such as colors, odors, sounds, and images that recall the traumatic experience. The dissociated memory is alive and active--not forgotten, merely submerged (Tasman Goldfinger, 1991). Major studies have confirmed the traumatic origin of DID (Putnam, 1989, and Ross, 1989), which arises before the age of 12 (and often before age 5) as a result of severe physical, sexual, and/or emotional abuse. Poly-fragmented DID (involving over 100 personality states) may be the result of sadistic abuse by multiple perpetrators over an extended period of time.

Although DID is a common disorder (perhaps as common as one in 100) (Ross, 1989), the combination of PTSD-DDNOS is the most frequent diagnosis in survivors of childhood abuse. These survivors experience the flashbacks and intrusion of trauma memories, sometimes not until years after the childhood abuse, with dissociative experiences of distancing, "trancing out", feeling unreal, the ability to ignore pain, and feeling as if they were looking at the world through a fog.

The symptom profile of adults who were abuse as children includes posttraumatic and dissociative disorders combined with depression, anxiety syndromes, and addictions. These symptoms include (1) recurrent depression; (2) anxiety, panic, and phobias; (3) anger and rage; (4) low self-esteem, and feeling damaged and/or worthless; (5) shame; (6) somatic pain syndromes (7) self-destructive thoughts and/or behavior; (8) substance abuse; (9) eating disorders: bulimia, anorexia, and compulsive overeating; (10) relationship and intimacy difficulties; (11) sexual dysfunction, including addictions and avoidance; (12) time loss, memory gaps, and a sense of unreality; (13) flashbacks, intrusive thoughts and images of trauma; (14) hypervigilance; (15) sleep disturbances: nightmares, insomnia, and sleepwalking; and (16) alternative states of consciousness or personalities.

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Diagnosis

The diagnosis of dissociative disorders starts with an awareness of the prevalence of childhood abuse and its relation to these clinical disorders with their complex symptomatology. A clinical interview, whether the client is male or female, should always include questions about significant childhood and adult trauma. The interview should include questions related to the above list of symptoms with a particular focus on dissociative experiences. Pertinent questions include those related to blackouts/time loss, disremembered behaviors, fugues, unexplained possessions, inexplicable changes in relationships, fluctuations in skills and knowledge, fragmentary recall of life history, spontaneous trances, enthrallment, spontaneous age regression, out-of-body experiences, and awareness of other parts of self (Loewenstein, 1991).

Structured diagnostic interviews such as the Dissociative Experiences Scale (DES) (Putnam, 1989), the Dissociative Disorders Interview Schedule (DDIS) (Ross, 1989), and the Structured Clinical Interview for Dissociative Disorders (SCID-D) (Steinberg, 1990) are now available for the assessment of dissociative disorders. This can result in more rapid and appropriate help for survivors. Dissociative disorders can also be diagnosed by the Diagnostic Drawing Series (DDS) (Mills Cohen, 1993).

The diagnostic criteria for the diagnosis of DID are (1) the existence within the person of two or more distinct personalities or personality states, each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self, (2) at least two of these personality states recurrently take full control of the person's behavior, (3) the inability to recall important personal information that is to extensive to be explained by ordinary forgetfulness, and (4) the disturbance is not due to the direct physiological effects of a substance (blackouts due to alcohol intoxication) or a general medical condition (APA, 1994). The clinician must, therefore, "meet" and observe the "switch process" between at least two personalities. The dissociative personality system usually includes a number of personality states (alter personalities) of varying ages (many are child alters) and of both sexes.

In the past, individuals with dissociative disorders were often in the mental health system for years before receiving an accurate diagnosis and appropriate treatment. As clinicians become more skilled in the identification and treatment dissociative disorders, there should no longer be such delay.

Treatment

The heart of the treatment of dissociative disorders is long-term psychodynamic/cognitive psychotherapy facilitated by hypnotherapy. It is not uncommon for survivors to need three to five years of intensive therapy work. Setting the frame for the trauma work is the most important part of therapy. One cannot do trauma work without some destabilization, so the therapy starts with assessment and stabilization before any abreactive work (revisiting the trauma).

A careful assessment should cover the basic issues of history (what happened to you?), sense of self (how do you think/feel about yourself?), symptoms (e.g., depression, anxiety, hypervigilance, rage, flashbacks, intrusive memories, inner voices, amnesias, numbing, nightmares, recurrent dreams), safety (of self, to and from others), relationship difficulties, substance abuse, eating disorders, family history (family of origin and current), social support system, and medical status.

After gathering important information, the therapist and client should jointly develop a plan for stabilization (Turkus, 1991). Treatment modalities should be carefully considered. These include individual psychotherapy, group therapy, expressive therapies (art, poetry, movement, psychodrama, music), family therapy (current family), psychoeducation, and pharmacotherapy. Hospital treatment may be necessary in some cases for a comprehensive assessment and stabilization. The Empowerment Model (Turkus, Cohen, Courtois, 1991) for the treatment of survivors of childhood abuse--which can be adapted to outpatient treatment--uses ego-enhancing, progressive treatment to encourage the highest level of function ("how to keep your life together while doing the work"). The use of sequenced treatment using the above modalities for safe expression and processing of painful material within the structure of a therapeutic community of connectedness with healthy boundaries is particularly effective. Group experiences are critical to all survivors if they are to overcome the secrecy, shame, and isolation of survivorship.

Stabilization may include contracts to ensure physical and emotional safety and discussion before any disclosure or confrontation related to the abuse, and to prevent any precipitous stop in therapy. Physician consultants should be selected for medical needs or psychopharmacologic treatment. Antidepressant and antianxiety medications can be helpful adjunctive treatment for survivors, but they should be viewed as adjunctive to the psychotherapy, not as an alternative to it.

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Developing a cognitive framework is also an essential part of stabilization. This involves sorting out how an abused child thinks and feels, undoing damaging self-concepts, and learning about what is "normal". Stabilization is a time to learn how to ask for help and build support networks. The stabilization stage may take a year or longer--as much time as is necessary for the patient to move safely into the next phase of treatment.

If the dissociative disorder is DID, stabilization involves the survivor's acceptance of the diagnosis and commitment to treatment. Diagnosis is in itself a crisis, and much work must be done to reframe DID as a creative survival tool (which it is) rather than a disease or stigma. The treatment frame for DID includes developing acceptance and respect for each alter as a part of the internal system. Each alter must be treated equally, whether it presents as a delightful child or an angry persecutor. Mapping of the dissociative personality system is the next step, followed by the work of internal dialogue and cooperation between alters. This is the critical stage in DID therapy, one that must be in place before trauma work begins. Communication and cooperation among the alters facilitates the gathering of ego strength that stabilizes the internal system, hence the whole person.

Revisiting and reworking the trauma is the next stage. This may involve abreactions, which can release pain and allow dissociated trauma back into the normal memory track. An abreaction might be described as the vivid re-experiencing of a traumatic event accompanied by the release of related emotion and the recovery of repressed or dissociated aspects of that event (Steele Colrain, 1990). The retrieval of traumatic memories should be staged with planned abreactions. Hypnosis, when facilitated by a trained professional, is extremely useful in abreactive work to safely contain the abreaction and release the painful emotions more quickly. Some survivors may only be able to do abreactive work on an inpatient basis in a safe and supportive environment. In any setting, the work must be paced and contained to prevent retraumatization and to give the client a feeling of mastery. This means that the speed of the work must be carefully monitored, and the release painful material must be thoughtfully managed and controlled, so as not to be overwhelming. An abreaction of a person diagnosed with DID may involve a number of different alters, who must all participate in the work. The reworking of the trauma involves sharing the abuse story, undoing unnecessary shame and guilt, doing some anger work, and grieving. Grief work pertains to both the abuse and abandonment and the damage to one's life. Throughout this mid-level work, there is integration of memories and, in DID, alternate personalities; the substitution of adult methods of coping for dissociation; and the learning of new life skills.

This leads into the final phase of the therapy work. There is continued processing of traumatic memories and cognitive distortions, and further letting go of shame. At the end of the grieving process, creative energy is released. The survivor can reclaim self-worth and personal power and rebuild life after so much focus on healing. There are often important life choices to be made about vocation and relationships at this time, as well as solidifying gains from treatment.

This is challenging and satisfying work for both survivors and therapists. The journey is painful, but the rewards are great. Successfully working through the healing journey can significantly impact a survivor's life and philosophy. Coming through this intense, self-reflective process might lead one to discover a desire to contribute to society in a variety of vital ways.

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References

Braun, B. (1988). The BASK model of dissociation. DISSOCIATION, 1, 4-23. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Loewenstein, R.J. (1991). An office mental status examination for complex chronic dissociative symptoms and multiple personality disorder. Psychiatric Clinics of North America, 14(3), 567-604.

Mills, A. Cohen, B.M. (1993). Facilitating the identification of multiple personality disorder through art: The Diagnostic Drawing Series. In E. Kluft (Ed.), Expressive and functional therapies in the treatment of multiple personality disorder. Springfield: Charles C. Thomas.

Putnam, F.W. (1989). Diagnosis and treatment of multiple personality disorder. New York: Guilford Press.

Ross, C.A. (1989). Multiple personality disorder: Diagnosis, clinical features, and treatment. New York: Wiley.

Steele, K., Colrain, J. (1990). Abreactive work with sexual abuse survivors: Concepts and techniques. In Hunter, M. (Ed.), The sexually abused male, 2, 1-55. Lexington, MA: Lexington Books.

Steinberg, M., et al. (1990). The structured clinical interview for DSM III-R dissociative disorders: Preliminary report on a new diagnostic instrument. American Journal of Psychiatry, 147, 1.

Tasman, A., Goldfinger, S. (1991). American psychiatric press review of psychiatry. Washington, DC: American Psychiatric Press.

Turkus, J.A. (1991). Psychotherapy and case management for multiple personality disorder: Synthesis for continuity of care. Psychiatric Clinics of North America, 14(3), 649-660.

Turkus, J.A., Cohen, B.M., Courtois, C.A. (1991). The empowerment model for the treatment of post-abuse and dissociative disorders. In B. Braun (Ed.), Proceedings of the 8th International Conference on Multiple Personality/Dissociative States (p. 58). Skokie, IL: International Society for the Study of Multiple Personality Disorder.

Joan A. Turkus, M.D., has extensive clinical experience in the diagnosis and treatment of post-abuse syndromes and DID. She is the medical director of The Center: Post-Traumatic Dissociative Disorders Program at The Psychiatric Institute of Washington. A general and forensic psychiatrist in private practice, Dr. Turkus frequently provides supervision, consultation, and teaching for therapists on a national basis. She is co-editor of the forthcoming book, Multiple Personality Disorder: Continuum of Care.

* This article has been adapted by Barry M. Cohen, M.A., A.T.R., for publication in this format. It was originally published in the May/June, 1992, issue of Moving Forward, a semi-annual newsletter for survivors of childhood sexual abuse and those who care about them. For subscription information, write P.O. Box 4426, Arlington, VA, 22204, or call 703/271-4024.

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