CHRONIC ILLNESSES COME WITH SYMPTOMS. These are signals from the body that something unusual is happening. These symptoms may include fatigue, stress, shortness of breath, pain, itching, anger, depression, and sleep problems. Sometimes they cannot be seen by others, some are very difficult to describe, and we may not know when they will occur. Although some symptoms are common, the times when they occur and the ways in which they affect us are very personal. What’s more, these symptoms can interact, which may worsen existing symptoms or even lead to new symptoms or problems.
Regardless of the causes of these symptoms, the ways in which we can manage them are often similar. These are our self-management tools. This chapter discusses several common symptoms, their causes, and some of the tools you can use to manage them. Additional cognitive tools—ways you can use your mind to help deal with many of these symptoms—are discussed in Chapter 5.
Dealing with Common Symptoms
Learning to manage symptoms is very similar to problem solving, discussed in Chapter 2. First, it is important to identify the symptom you are experiencing. Next, determine why you might be having the symptom now. This may sound like a simple process, but it is not always easy.
You can experience many different symptoms, and each symptom can have various causes and interact with other symptoms. The ways in which these symptoms affect one’s life are also different. All of these factors can become very tangled, like the frayed threads of a cloth. To manage these symptoms, it is often helpful to figure out how to untangle the threads. One way to do this is to keep a daily diary or journal. This can be as simple as writing your symptoms on a calendar along with some notes about what you were doing before the symptom started or worsened, as shown in the example below. After a week or two, you may see a pattern. For example, you go out to dinner on Saturday evening and wake up in the night with stomach pain. Once you realize that when you go out, you overeat, you know to adjust what you order in the future. Or every time you go dancing, your feet hurt, but this does not occur when you walk. Could the shoes you wear account for the difference? Seeing patterns is for many people the first step in symptom self-management.
As you read through this chapter, you will note that many symptoms have the same causes. Also, one symptom may actually cause other symptoms. For example, pain may change the way you walk. This new way of walking may change your balance and cause a new pain or cause you to fall. As you gain a better understanding of the possible causes of your symptoms, you will be able to identify better ways to deal with them. You may also find ways to prevent or lessen certain symptoms.
Using Different Symptom-Management Tools
Choose a tool to try. Be sure to give this method a fair trial. We recommend that you practice it for at least 2 weeks before deciding whether or not the tool is going to be helpful.
Try some other tools, giving each a trial period. It is important to try more than one tool because some tools may be more useful for certain symptoms or you may find that you simply prefer some techniques over others.
Think about how and when you will use each tool. For example, some of these tools may require more lifestyle changes than others. The best symptom managers learn to use a variety of techniques. These depend on your condition and what you want and need to do each day.
Place some cues in your environment to remind you to practice these techniques. Both practice and consistency are important for mastering new skills. For example, place stickers or notes where you’ll see them, such as on your mirror, near the phone, in your office, on your computer, or on the car’s dashboard. Change the notes from time to time so that you’ll continue to notice them.
Try linking the practice of each new tool with some other established daily behavior or activity. For example, practice relaxation as part of your cool-down from exercise. Also, ask a friend or family member to remind you to practice each day; he or she may even wish to participate.
Let’s look at what you can do to lessen some of the more common symptoms experienced by people with particular chronic conditions.
Common Symptoms
These common symptoms are discussed in this chapter on the pages shown below.
Fatigue (p. 38)
Pain or Physical Discomfort (p. 39)
Shortness of Breath (p. 43)
Sleep Problems (p.46)
Depression (p. 50)
Anger (p. 56)
Stress (p. 58)
Memory Problems (p. 62)
Itching (p. 62)
Urinary Incontinence (p. 64)
Fatigue
A chronic condition can drain your energy. Fatigue is a very real problem for many people. It is not, as some might say, “all in the mind.” Fatigue can keep you from doing things you’d like to do. It is often misunderstood by people who do not have a chronic illness. After all, others cannot usually see your fatigue. Unfortunately, spouses, family members, and friends sometimes do not understand the unpredictable way in which the fatigue associated with your condition can affect you. They may think that you are just not interested in certain activities or that you want to be alone. Sometimes you may not even know why you feel this way.
To be able to manage fatigue, it is important to understand that your fatigue may be related to several factors, such as these:
The disease itself. No matter what illness or illnesses you have, whatever you do demands more energy. When a chronic illness is present, the body uses energy less efficiently. This is because the energy that could be going to everyday activities is being used to help heal the body. Your body may release chemical signals to conserve energy and make you rest more. Some chronic conditions are also associated with anemia (low blood hemoglobin), which can contribute to fatigue.
Inactivity. Muscles that are not used regularly become deconditioned and less efficient at doing what they are supposed to do. The heart, which is made of muscle tissue, can also become deconditioned. When this happens, the ability of the heart to pump blood, which carries necessary nutrients and oxygen to other parts of the body, is decreased. When muscles do not receive these necessary nutrients and oxygen, they cannot function properly. Deconditioned muscles tire more easily than muscles in good condition.
Poor nutrition. Food is our basic source of energy. If the fuel we take in is of inferior quality, is not consumed in the appropriate quantities, or is improperly digested, fatigue can result. Rarely are vitamin deficiencies a cause of fatigue. For some people, weight results in fatigue. Extra weight causes an increase in the amount of energy needed to perform daily activities. Being underweight can also cause problems associated with fatigue. This is especially true for individuals with chronic obstructive pulmonary disease (COPD). Many people with COPD experience weight loss because of a change in their eating habits and therefore have increased fatigue.
Not enough rest. For a variety of reasons, there are times when we do not get enough sleep or do not sleep well. This can also result in fatigue. We will discuss how to manage sleep problems in more detail later in this chapter.
Emotions. Stress, anxiety, fear, and depression can also cause fatigue. Most people are aware of the connection between stress and feeling tired, but fewer are aware of the fact that fatigue is a major symptom of depression.
Medications. Some medications can cause fatigue. If you think your fatigue is medication-related, talk to your doctor. Sometimes medications or the dose can be changed.
If fatigue is a problem, start by trying to determine the cause. Again, a journal may be helpful. And start with the easiest things that are within your control to improve. Are you eating healthy foods? Are you exercising? Are you getting enough good-quality sleep? Are you effectively managing stress? If you answer no to any of these questions, you may be well on your way to finding one or more of the reasons for your fatigue.
The important thing to remember about your fatigue is that it may be caused by things other than your illness. Therefore, to combat and prevent fatigue, you must address the possible causes of your fatigue. This may mean trying a variety of self-management tools.
If your fatigue is the result of not eating well, such as eating too much junk food or drinking too much alcohol, then the solution is to eat better-quality foods in the proper quantities or to drink less alcohol. For others, the problem may be a decreased interest in food, leading to a lack of calories and subsequent weight loss. Chapter 11 discusses some of the problems associated with eating and provides tips for healthy eating.
People often say they can’t exercise because they feel fatigued. Believing this creates a vicious cycle: people are fatigued because of a lack of exercise, and they don’t exercise because of the fatigue. Believe it or not, motivating yourself to do a little exercise might be the answer. You don’t have to run a marathon. The important thing is to get outdoors and take a short walk. If this is not possible, walk around your house or try some gentle chair exercises. See Chapter 6 for more information on getting started on an exercise program.
If emotions are causing your fatigue, rest will probably not help. In fact, it may make you feel worse, especially if your fatigue is a sign of depression. We will talk about how to deal with depression a little later in this chapter. If you feel that your fatigue may be related to stress, read the section on managing stress on pages 60–61.
Pain or Physical Discomfort
Pain or physical discomfort is a problem shared by many people with chronic illness. As with most symptoms of chronic illness, pain or discomfort can have many causes. The following are some of the most common causes.
The disease itself. Pain can come from inflammation, damage in or around joints and tissues, insufficient blood supply to muscles or organs, or irritated nerves, to name just a few sources.
Tense muscles. When something hurts, the muscles in that area become tense. This is your body’s natural reaction to pain—to try to protect the damaged area. Stress can also cause you to tense your muscles. Tense muscles can cause soreness or pain.
Muscle deconditioning. With chronic disease, it is common to become less active, leading to a weakening of the muscles, or muscle deconditioning. When a muscle is weak, it tends to complain anytime it is used. This is why even the slightest activity can sometimes lead to pain and stiffness.
Lack of sleep or poor-quality sleep. Pain often interferes with the ability to get either enough sleep or good-quality sleep. But poor sleep can also make pain worse and lessen your ability to cope with it.
Stress, anxiety, and emotions such as depression, anger, fear, and frustration. These are all normal responses to living with a chronic condition, and they can affect your pain or discomfort. When we are stressed, angry, afraid, or depressed, everything, including the pain, seems worse.
Medications. The medicine you are taking can sometimes cause abdominal or other discomfort, pain, weakness, or changes in your thinking. If you suspect that medications are the cause, talk with your doctor.
Controlling the “Pain Gates”
Research suggests that we are not helpless in the face of pain. The brain can regulate the flow of pain messages by sending electrical and chemical signals that open and close “pain gates” along nerve pathways.
For example, the brain can release powerful opiate-like chemicals—such as endorphins—that can effectively block pain. When people are very seriously injured, they sometimes experience little pain while they are focused on survival. How you focus your attention, your mood, and the way you view your situation can open or close the pain gates. The techniques in Chapter 5 can be helpful.
A Word About Chronic Pain
Chronic pain is pain that extends over months or years and is often difficult to explain. Most experts now believe that almost all unexplained chronic pain is caused by some type of physical problem: damaged or inflamed nerves, blood vessels, muscles, or other tissues. These underlying physical problems simply can’t be pinpointed. It’s not “all in your head.”
Your day-to-day pain level is based on how your mind and body respond to pain. For example, the body quickly attempts to limit the movement of the damaged area. This causes muscle tension, which can cause more pain. Chronic pain often leads to inactivity. Muscles often become weakened and may then hurt with the slightest use.
Feelings of anxiety, anger, frustration, and loss of control also amplify the experience of pain. This doesn’t mean that the pain is not real; it just means that emotions can make a painful situation worse.
Here are four examples of ways in which the mind and body interact:
Inactivity. Because of the pain, you tend to avoid physical activity, which in turn causes you to lose strength and flexibility. The weaker and more out of condition you become, the more frustrated and depressed you feel. These negative emotions can open the pain gates and cause pain levels to rise.
Overdoing. You may be determined to prove that you can still be active, so you overexert. This increases the pain and leads to more inactivity, more depression, and more pain.
Keep a Pain Diary
To get a clear understanding of how your moods, activities, and conditions affect your pain, keep a pain diary. Begin by recording your activities and pain levels 3 times a day, at regular intervals.
1. Record the date and time.
2. Describe the situation or activity (watching TV, doing housework, arguing, and so on).
3. Rate the physical sensation of pain on a scale from 0 (no pain) to 10 (worst pain).
4. Describe the pain sensation (for example, “deep aching pain in left lower back”).
5. Rate the emotional distress of pain on a scale from 0 (no distress) to 10 (terribly distressed).
6. Describe the type of emotional distress (for example, “felt very angry” or “needed to cry”).
7. Describe what you did, if anything, to alleviate the discomfort (took medication, had a massage, did a relaxation exercise, took a walk, and so on) and its effect.
Look for patterns. For example, is the pain worse after sitting for a long time? Is it less when you are engaged in a favorite hobby?
How much you notice pain may vary according to your mood, fatigue, and muscle tension. It’s important to distinguish between physical pain sensations (physical stabbing, burning, and aching sensations) and emotional pain distress (the accompanying anger, anxiety, frustration, or sadness). This is useful because even if your physical pain cannot be reduced, you may feel better about the pain and experience less distress, anxiety, helplessness, and despair.
Misunderstanding. Your friends, family, boss, and coworkers may not understand that you are suffering and may dismiss your pain as “not real.” This evokes more anger or depression.
Overprotection. Friends, family, and coworkers coddle you and make excuses for you. This can lead you to feel and act more dependent and disabled.
Fortunately, this downward spiral of mind-body interaction can be interrupted. Being told you have to learn to live with pain doesn’t have to be the end of the road. It can be a new beginning. You can learn techniques such as the following:
To redirect your attention to control pain
To challenge negative thoughts that support pain
To cultivate more positive emotions
To slowly increase your activity and recondition yourself
Tools for Managing Pain
There are many tools for managing pain. Just as one cannot build a house with one tool, one often needs several tools to manage pain.
Exercise
Exercise and physical activity can be excellent pain relievers. The benefits of exercise as well as tips for starting an exercise program are discussed in Chapters 6 through 8. If you are not able to do the things you want and need to do because of physical limitations, a physical therapist may be helpful.
Mind-made medicine
You can also use your mind to manage pain through relaxation, imagery, visualization, and distraction (see Chapter 5). Positive thinking is another powerful way to challenge pain. Learn how to monitor and challenge negative thinking or self-talk. If you find yourself waking up in pain and saying, “I’m going to be miserable all day; I won’t get anything done,” tell yourself instead, “I’ve got some pain this morning, so I’ll start with some relaxation and stretching exercises. Then I’ll do some of the less demanding things I want to get done today.” You will find more about positive thinking in Chapter 5.
Ice, heat, and massage
For pain in a local area such as the back or knee, the application of heat, cold, and massage have all been found to be helpful. These three tools work by stimulating the skin and other tissues surrounding the painful area, which increases the blood flow to these areas or blocks transmission of pain in nerve fibers.
Apply heat by using a heating pad or by taking a warm bath or shower (with the water flow directed at the painful area). You can make a substitute heating pad by placing rice or dry beans in a sock, knotting the top of the sock, and heating it in a microwave oven for 3 to 4 minutes. Before use, be sure to test the heat so as not to burn yourself. Do not use popcorn! Some people, however, prefer cold for soothing pain, especially if there is inflammation. A bag of frozen peas or corn makes an inexpensive, reusable cold pack. Whether using heat or cold, place a towel between the source and skin. Also, limit the application to 15 or 20 minutes at a time (longer can burn or freeze the skin).
Massage is one of the oldest forms of pain management. Hippocrates (c. 460–380 B.C.) said, “Physicians must be experienced in many things, but assuredly also in the rubbing that can bind a joint that is loose and loosen a joint that is too hard.” Self-massage is a simple procedure that can be performed with little practice or preparation. It stimulates the skin, underlying tissues, and muscles by rubbing with a little applied pressure. Some people like to use a mentholated cream with self-massage because it gives a cooling effect.
Massage, while relatively simple, is not appropriate for all cases of pain. Do not use self-massage for a “hot joint” (one that is red, swollen, and hot to the touch) or an infected area or if you are suffering from phlebitis, thrombophlebitis, or skin eruptions.
Medications
Acute pain usually responds to painkilling drugs, from mild over-the-counter analgesics for headaches to powerful narcotic medications for postoperative and cancer pain. Some medications can open up blood vessels in the heart or muscles that can relieve pain. Some types of chronic pain and arthritis respond well to anti-inflammatory medications. Surprisingly, some medications originally used to treat depression have been found to relieve pain in lower doses without problems of addiction. Narcotic medications are rarely suitable for chronic pain, as they can become less effective over time and require increasing doses. They can also interfere with breathing, balance, and sleep and cause disturbances in mood and the ability to think clearly. Sometimes injections of a local anesthetic or a surgical procedure can block pain signals from a painful area. This provides temporary or sometimes lasting relief from chronic pain.
Two final notes
If you have pain medication in the house, keep it in a place that will not be accessible to young people or visitors. The most common source of prescription drugs abused today in schools is the family medicine cabinet.
If you or someone you care for is nearing the end of life (estimated to have six months or less to live) and pain is a problem, consider asking for palliative or hospice care. Hospice units are staffed by special teams of health professionals who are experts in relieving end-of-life pain while allowing the patient to remain alert. At this point in life, addiction is not a concern; comfort is.
If pain continues to be a major influence in your life, discuss with your doctor your options, including referral to a pain management clinic.
Shortness of Breath
Shortness of breath, like so many other symptoms, can have several causes, all of which prevent your body from getting the oxygen it needs. (Before reading further in this section, you may wish to turn to Chapter 15, which discusses normal lung functioning as well as changes that take place in the lungs with chronic lung disease. Chapter 16 talks about heart disease, which can also cause shortness of breath.)
Excess weight can cause shortness of breath because added weight increases the amount of energy you use and therefore the quantity of oxygen you need. Weight also increases the workload for the heart. Thus if excess weight is coupled with chronic lung or heart disease, there is added difficulty in supplying the body with the oxygen it needs.
Deconditioning of muscles can also lead to shortness of breath. This deconditioning can affect the breathing muscles as well as other muscles in your body. When muscles become deconditioned, they are less efficient at doing what they are supposed to do. They require more energy (and oxygen) to perform activities. In the case of deconditioned breathing muscles, the problem is complicated. If the breathing muscles are not strong, it becomes harder to cough and clear mucus from the lungs. When there is mucus in the lungs, there is less space for fresh air.
Just as there are many causes of shortness of breath, there are many things you can do to manage this problem.
When you feel short of breath, don’t stop what you are doing or hurry up to finish, but slow down. If shortness of breath continues, stop for a few minutes. If you are still short of breath, take medication if prescribed by your provider. Shortness of breath can be frightening, and this fear can cause two additional problems. First, when you are afraid, you release hormones such as epinephrine. This causes more shortness of breath. Second, you may stop activity for fear that this will hurt you. If this happens, you will never build up the endurance necessary to help your breathing. The basic rule is to take things slowly and in steps.
Increase your activity gradually, generally by not more than 25% each week. Thus, if you are now able to garden comfortably for 20 minutes, next week increase it by a maximum of 5 minutes. Once you can garden comfortably for 25 minutes, you can again add a few more minutes.
Don’t smoke, and—equally important—avoid smokers. This may sometimes be difficult because smoking friends may not realize how they are complicating your life. Your job is to tell them. Explain that their smoke is causing breathing problems for you and that you would appreciate it if they would not smoke when you are around. Also, make your house and especially your car “no smoking” zones. Ask people to smoke outside.
If mucus and secretions are a problem, drink plenty of fluids (unless your doctor has told you to limit what you drink). This will help thin the mucus and make it easier to cough up. Using a humidifier may also be helpful.
Use your medications and oxygen as prescribed. We often hear that drugs are harmful and should not be used. In many cases this is correct. However, when you have a chronic disease, drugs are often very helpful, even life savers. Don’t skimp, cut down, or go without. Likewise, more is not better, so don’t take more than the prescribed amount. If adjustments need to be made, let your health care provider make that decision.
Breathing Self-Management Tools
Here we’ll discuss several tools that can help with better breathing; you will find more tools described in Chapter 15.
Diaphragmatic breathing (“belly breathing”)
Diaphragmatic breathing is also called belly breathing because when you do it properly, the diaphragm descends into the abdomen. One of the problems that cause shortness of breath, especially for people with emphysema, chronic bronchitis, or asthma, is deconditioning of the diaphragm and chest breathing muscles. When deconditioning occurs, the lungs are not able to function properly. That is, they do not fill well, nor do they get rid of old air.
Most of us use mainly our upper lungs and chest for breathing. Because diaphragmatic or belly breathing goes deeper, it requires a little practice to learn to fully expand the lungs. This deep breathing strengthens the breathing muscles and makes them more efficient, so breathing is easier. These are the steps for diaphragmatic breathing:
1. Lie on your back with pillows under your head and knees.
2. Place one hand on your stomach (at the base of your breastbone) and the other hand on your upper chest.
3. Breathe in slowly through your nose, allowing your stomach to expand outward. Imagine that your lungs are filling with fresh air. The hand on your stomach should move upward, and the hand on your chest should not move or should move only slightly.
4. Breathe out slowly, through pursed lips. At the same time, use your hand to gently push inward and upward on your abdomen.
5. Practice this technique for 10 to 15 minutes, three or four times a day, until it becomes automatic. If you begin to feel a little dizzy, rest or breathe out more slowly.
You can also practice diaphragmatic breathing while sitting in a chair:
1. Relax your shoulders, arms, hands, and chest. Do not grip the arms of the chair or your knees.
2. Put one hand on your abdomen and the other on your chest.
3. Breathe in through your nose, filling the area around your waist with air. Your chest hand should remain still and the hand on your abdomen should move.
4. Breathe out without force or effort.
Once you are comfortable with this technique, you can practice it almost anytime, while lying down, sitting, standing, or walking. Diaphragmatic breathing can help strengthen and improve the coordination and efficiency of the breathing muscles, as well as decrease the amount of energy needed to breathe. In addition, it can be used with any of the relaxation techniques that use the power of your mind to manage your symptoms (described in Chapter 5).
Pursed-lip breathing
A second technique, pursed-lip breathing, usually happens naturally for people who have problems emptying their lungs. It can also be used if you are short of breath or breathless.
1. Breathe in, and then purse your lips as if to blow across a flute or into a whistle.
2. Using diaphragmatic breathing, breathe out through pursed lips without any force.
3. Remember to relax the upper chest, shoulders, arms, and hands while breathing out. Check for tension. Breathing out should take longer than breathing in.
By mastering this technique while doing other activities, you will be better able to manage your shortness of breath.
The next two techniques may be helpful for removing secretions (mucus, phlegm).
Huffing
This technique combines one or two forced huffs (puffs of breath) with diaphragmatic breathing. It is useful for removing secretions from small airways.
1. Take in a breath as you would for diaphragmatic breathing.
2. Hold your breath for a moment.
3. Huff—keep your mouth open while squeezing your chest and abdominal muscles to force out the air (this is a little like panting).
4. If possible, do another huff before taking in another breath.
5. Take two or three diaphragmatic breaths.
6. Huff once or twice.
Positions That Will Help If You Are Breathless or Short of Breath
Controlled cough
This helps remove secretions (phlegm) from larger airways.
1. Take in a full, slow diaphragmatic breath.
2. Keep shoulders and hands relaxed.
3. Hold the breath for a moment.
4. Cough (tighten the abdominal muscles to force the air out).
You can find more about controlled coughing in Chapter 15.
Note: If you have a bout of uncontrolled coughing, this may help:
Avoid very dry air or steam.
Swallow as soon as the bout starts.
Sip water.
Suck on lozenges or hard candy.
Try diaphragmatic breathing, being sure to breathe in through your nose.
Sleep Problems
Sleep is a time during which the body can concentrate on healing. Little energy is required to maintain body functioning when we sleep. When we do not get enough sleep, we can experience a variety of other symptoms, such as fatigue, inability to concentrate, irritability, increased pain, and weight gain. Of course, this does not mean that all these symptoms are always caused by a lack of sleep. Remember, the symptoms associated with chronic disease can have many causes. Nevertheless, improving the quality of your sleep can help you manage many of these symptoms, regardless of the cause.
How Much Sleep Do You Need?
The amount of sleep needed varies from person to person. Most people do best with 7½ hours. Some feel refreshed with just 6, but others need 8 to 10 to function well. If you are alert, feel rested, and function well during the day, chances are you’re getting enough sleep.
Sleep is a basic human need, like food and water. Getting less sleep one night is not a big problem. But if you get less sleep than you require night after night, your quality of life and mood may suffer.
Getting a Good Night’s Sleep
The self-management techniques we offer here are clinically proven, with a 75% to 80% success rate. They are not “quick fixes” like sleep medications, but they’ll give you more effective (and safer) results in the long run. Allow yourself at least 2 to 4 weeks to see some positive results and 10 to 12 weeks for long-term improvement.
Things to do before you get into bed
Get a comfortable bed that allows for ease of movement and good body support. This usually means a good-quality, firm mattress that supports the spine and does not allow the body to stay in the middle of the bed. A bed board, made of ½- to ¾-inch (1 to 2 cm) plywood, can be placed between the mattress and the box spring to increase the firmness. Heated waterbeds, airbeds, or foam mattresses are helpful for some people with chronic pain because they support weight evenly by conforming to the body’s shape. If you are interested, try one out at a friend’s home or a hotel for a few nights to decide if it is right for you. An electric blanket or mattress pad, set on low heat, or a wool mattress pad are also effective at providing heat while you sleep, especially on cool or damp nights. If you decide to use electric bedding, be sure to follow the instructions carefully to prevent getting burned.
Warm your hands and feet with gloves or socks. For painful knees, it often helps to cut the toes off warm stockings and use the remainders as sleeves over the knees.
Find a comfortable sleeping position. The best position depends on you and your condition. Sometimes the use of small pillows placed in the right places can relieve pain and discomfort. Experiment with different positions and the use of pillows. Also check with your health care provider for specific recommendations given your condition.
Elevate the head of the bed 4 to 6 inches on wooden blocks to make breathing easier. This is especially helpful if you have heartburn or gastric reflux.
Keep the room at a comfortable temperature. This can be either warm or cool. Each of us is different.
Use a vaporizer if you live where the air is dry. Warm, moist air often makes breathing and sleeping easier.
Make your bedroom safe and comfortable. Keep a lamp and telephone by your bed, within easy reach. If you use a cane, keep it by the bed where you will not trip over it. This way you can use it when you get up during the night.
Keep eyeglasses by the bed when you go to sleep. This way, if you need to get up in the middle of the night, you can easily put on your glasses and see where you are going!
Things to avoid before bedtime
Avoid eating. You may feel sleepy after eating a big meal, but that is not an appropriate way to help you fall asleep and get a good night’s sleep. Sleep is supposed to allow your body time to rest and recover, and when it is busy digesting food, this takes valuable time and attention away from the healing process. If you find that going to sleep feeling hungry keeps you awake, try drinking a glass of warm milk at bedtime.
Avoid alcohol. You may think that that alcohol helps you sleep better because it makes you feel relaxed and sleepy, but in fact, alcohol disrupts your sleep cycle. Alcohol before bedtime can lead to shallow sleep and frequent awakenings throughout the night.
Avoid caffeine late in the day. Caffeine is a stimulant, and it can keep you awake. Coffee, tea, colas and other sodas, and chocolate all contain caffeine, so go easy on them as evening approaches.
Avoid smoking to help you sleep. Aside from the fact that smoking itself can cause complications and a worsening of your chronic disease, falling asleep with a lit cigarette can be a fire hazard. Furthermore, the nicotine contained in cigarettes is a stimulant.
Avoid diet pills. Diet pills often contain stimulants, which may interfere with falling asleep and staying asleep.
Avoid sleeping pills. Although the name “sleeping pills” sounds like the perfect solution for sleep problems, these remedies tend to become less effective over time. Also, many sleeping pills have a rebound effect—that is, if you stop taking them, it is more difficult to get to sleep. Thus, as they become less effective, you can have even more problems than you had when you first started taking the pills. All in all, it is best to use other approaches and to avoid using sleeping pills.
Avoid using a computer or watching TV for about an hour before you go to bed. The light from computer and TV screens can disrupt your natural sleep rhythms.
Avoid diuretics (water pills) before bedtime. You may want to take them in the morning so that your sleep is not interrupted by frequent trips to the bathroom. Unless your doctor has recommended otherwise, don’t reduce the overall amount of fluids you drink, as these are important for your health. However, you may want to limit the amount you drink right before you go to bed.
How to develop a routine
Maintain a regular rest and sleep schedule. Try to go to bed at the same time every night and get up at the same time every morning. If you wish to take a brief nap, take one in the afternoon, but do not take a nap after dinner. Stay awake until you are ready to go to bed.
Reset your sleep clock when necessary. If your sleep schedule gets off track (for example, you go to bed at 4:00 A.M. and sleep until noon), you’ll have to reset your internal sleep clock. To do so, try going to bed an hour earlier or later each day until you reach the hour you want to go to sleep. This may sound strange, but it seems to be the best way to reset your sleep clock.
Exercise at regular times each day. Not only will the exercise help you obtain better-quality sleep, but it will also help set a regular pattern for your day. However, avoid exercising immediately before bedtime.
Get out in the sun every morning, even if it is only for 15 or 20 minutes. This helps regularize your body clock and rhythms.
Do the same things every night before going to bed. This can be anything from listening to the news to reading a chapter of a book to taking a warm bath. By developing and sticking to a “get ready for bed” routine, you will be telling your body that it’s time to start winding down and relax.
Use your bedroom only for sleeping and sex. If you find that you get into bed and you can’t fall asleep, get out of bed and go into another room until you begin to feel sleepy again. Keep the lighting there low.
What to do when you can’t get back to sleep
Many people can get to sleep without a problem but then wake up with the “early morning worries” and can’t turn off their minds. Then they get more worried because they cannot go back to sleep once they have awakened. Keeping your mind occupied with pleasurable or interesting thoughts will ward off the worries and help you get back to sleep. For example, try a distraction technique such as quieting your mind by counting backward from 100 by threes or by naming a flower for every letter of the alphabet. The relaxation techniques described in Chapter 5 may also be helpful. If after a while you really can’t sleep, get up and do something—read a book, wash your hair, play a game of solitaire (not on the computer). After 15 or 20 minutes, go back to bed.
It can also help to set a “worry time.” Does a racing mind keep you awake? If it does, designate a “worry time” well before bedtime, during which you write down your problems and concerns, and then make a to-do list to get them off your mind. Then you can relax and sleep well at night, knowing that you can worry again during tomorrow’s worry time.
Don’t worry about not getting enough sleep. If your body needs sleep, you will sleep. Also, remember that people tend to need less sleep as they get older.
Sleep Apnea and Snoring
If you fall asleep “as soon as your head hits the pillow” or fall asleep regularly in front of the TV and are tired when you wake up in the morning, even after a full night’s sleep, you may have a sleep disorder. People who have the most common sleep disorder, obstructive sleep apnea, often do not know it. When they are asked about their sleep, they respond, “I sleep just fine.” Sometimes the only clue is that others complain about their loud snoring. Sleep specialists believe that obstructive sleep apnea is very common and alarmingly underdiagnosed.
With sleep apnea, the soft tissue in the throat or nose relaxes during sleep and blocks the airway, requiring extreme effort to breathe. The person struggles against the blockage for up to a minute, then wakes just long enough to gasp air, and falls back to sleep to start the cycle all over again. The person is rarely aware that he or she has awakened dozens of times during the night and does not get the deep sleep needed to restore the body’s energy and help with the healing process. This, in turn, leads to more symptoms such as fatigue and pain.
Sleep apnea can be a serious or even life-threatening medical problem. It has been linked to heart disease and stroke and is thought to be the cause of death for many people who die in their sleep after a heart attack. Sleep experts suggest that people who are tired all the time in spite of a full night’s sleep or who find that they need more sleep now than when they were younger should be evaluated for sleep apnea or other sleep disorders, especially if they (or their spouses) report snoring. You can find more about sleep apnea in Chapter 15.
Getting Professional Help
The majority of sleep problems can be solved with the techniques just mentioned, but there are times when you need professional assistance. When should you get help?
If your insomnia persists for 6 months or is seriously affecting your daytime functioning (your job or your social relationships), despite faithfully following the self-help program described here
If you have great difficulty staying awake during the day, especially if your daytime sleepiness causes or comes close to causing an accident
If your sleep is disturbed by breathing difficulties, including loud snoring with long pauses, chest pain, heartburn, leg twitching, excessive pain, or other physical conditions
If your difficulty sleeping is accompanied by depression, problems with alcohol, sleeping medications, or addictive drugs
Don’t put off asking for help. Most sleep problems can be solved. Once they’re gone, you’ll enjoy a better night’s sleep and better health.
Depression
Most people with a chronic illness sometimes feel depressed. As with pain, there are different degrees of depression. These can range from being occasionally sad or blue to serious clinical depression. Sometimes we do not know we are depressed. More often we may not want to admit it. How you handle depression makes the difference.
Depression and Bad Moods
Feeling sad sometimes is natural. “Normal” sadness is a temporary feeling, often linked to a specific event or loss. We sometimes use the word depressed to describe feeling sad or disappointed: “I’m really depressed about missing out visiting with my friends.” In these circumstances we feel sad, but we can still relate to others and find joy in other areas of our lives.
Sometimes depression lasts longer, as when we lose a loved one or are diagnosed with a serious illness.
If your depressed or sad feelings are severe, long-lasting, and recurrent, you may be experiencing clinical depression. It drains the pleasure out of life, leaving you feeling hopeless, helpless, and worthless. With severe depression, feelings may become numb, and even crying brings no relief.
Depression affects everything: the way you think, the way you behave, the way you interact with others, and even the way your body functions.
What Causes Depression?
Depression is not caused by personal weakness, laziness, or lack of willpower. Heredity, your chronic illness, and your medications may all play a role in depression. The way you think, especially negative thoughts, can also produce and sustain a depressed mood. Negative thoughts can be automatic, recur endlessly, and are often not linked to any event or triggering cause. Certain feelings and emotions also contribute to depression.
Fear, anxiety, or uncertainty about the future. Feelings that result from worries about finances, your disease or treatment, or concerns about your family can lead to depression. By facing these issues as soon as possible, both you and your family will will spend less time worrying and have more time to enjoy life. This can have a healing effect. We talk more about these issues and how to deal with them in Chapter 19.
Frustration. Frustration can have many causes. You may find yourself thinking, “I just can’t do what I want,” “I feel so helpless,” “I used to be able to do this myself,” or “Why doesn’t anyone understand me?” The longer you accept these feelings, the more alone and isolated you are likely to feel.
Loss of control over your life. Many things can make you feel like you are losing control. These include having to rely on medications, having to see a doctor on a regular basis, or having to count on others to help you do things like bathing, dressing, and preparing meals. This feeling of loss of control can make you lose faith in yourself and your abilities. Even though you may not be able to do everything yourself, you can still be in charge. You are the coach for your team.
Not all depression behavior is negative. Sometimes unrealistic cheeriness will mask what the person is really feeling, and the wise observer will recognize the brittleness or phoniness of the mood. Refusal to accept offers of help, even in the face of obvious need for it, is a frequent symptom of unrecognized depression.
Depressed feelings can lead to such behaviors as withdrawal, isolation, and lack of physical activity. These behaviors can cycle back to create more depressed feelings. The paradox of depression-related behavior is that the more you engage in the behavior, the more likely it is that you will drive away the people who can support and comfort you. Most of our friends and family want to help us feel better, but often they don’t really know what to do to help. As their efforts to comfort and reassure us are frustrated, they may at some point throw up their hands and quit trying. Then the depressed person winds up saying, “See, nobody cares.” This again reinforces the feelings of loss and loneliness.
All these factors, along with others, can contribute to an imbalance in the chemicals in your brain (neurotransmitters). This imbalance can result in changes in the way you think, feel, and act. Changing the way you think and behave can be a powerful and effective way of changing your brain chemistry, lightening depression, and improving an ordinary bad mood.
Am I Depressed?
Here is a quick test for depression: Ask yourself what you do to have fun. If you do not have a quick answer, consider the additional possible symptoms of depression listed here.
Consider your mood over the past two weeks. Which of the following have you experienced?
Little interest or pleasure in doing things. Not enjoying life or other people may be a sign of depression. Symptoms include not wanting to talk to anyone, to go out, or to answer the phone or doorbell.
Feeling down, depressed, or hopeless. Feeling persistently blue can be a symptom of depression.
Trouble falling or staying asleep or sleeping too much. Awakening and being unable to return to sleep or sleeping too much and not wanting to get out of bed can signal a problem.
Feeling tired or having little energy. Fatigue—feeling tired all the time—is often a clear-cut symptom of depression.
Poor appetite or overeating. This change may range from a loss of interest in food to unusually erratic or excessive eating.
Feeling bad about yourself. Have you felt that you are a failure or have let yourself or your family down? Have you had a feeling of worthlessness, a negative image of your body, or doubts about your own self-worth?
Trouble concentrating. Have you found it hard to do such things as reading the newspaper or watching television?
Lethargy or restlessness. Have you been moving or speaking so slowly that other people could have noticed? Or the opposite, have you been so fidgety or restless that you have been moving around a lot more than usual? Either can be a sign of depression.
Wishing yourself harm or worse. Thoughts that you would be better off dead or of hurting yourself in some way are often the hallmark of severe depression.
Depressed people may also experience weight gain or loss, loss of interest in sex or intimacy, loss of interest in personal care and grooming, inability to make decisions, and more frequent accidents.
If several of these symptoms seem to apply to you, please get some help from your doctor, good friends, a member of the clergy, a psychologist, or a social worker. Do not wait for these feelings to pass. If you are thinking about harming yourself or others, get help now. Don’t let a tragedy happen to you and your loved ones.
Fortunately, the treatments for depression, including antidepressant medications, counseling, and self-help, are highly effective in decreasing the frequency, length, and severity of depression. Depression, like other symptoms, can be managed.
How to Lighten Depression and Bad Moods
The most effective treatments for depression are medications, counseling, and self-help.
Medications
Antidepressant medications that help balance brain chemistry are highly effective. Most anti-depressant medications take from several days to several weeks before they begin to work. Then they usually bring significant relief. Don’t be discouraged if you don’t feel better immediately. Stick with it. To get the maximum benefit you may need to take certain medications for 6 months or more.
Side effects are usually most noticeable in the first few weeks and then lessen or go away. If the side effects are not especially severe, continue to take your medication. As your body gets used to the medication, you will begin to feel better. It is important to remember to take your medication every day. If you stop the medication because you’re feeling better (or worse), you may relapse. Antidepressant medications are not addictive, but talk with your doctor before stopping or changing the dose.
Counseling
Several types of psychotherapy can also be highly effective, relieving symptoms up to 60% to 70% of the time. As with medications, counseling rarely has an immediate effect. It may be weeks (or longer) before you see improvement. Therapy can be brief, usually involving one to two sessions a week for several months. By learning new skills for ways to think and relate, psychotherapy may also help reduce the risk of recurrent depression.
Self-help
Self-help can also be surprisingly effective. You can learn many successful psychotherapy techniques on your own. For mild to moderate depression or just to lift your mood, the self-help strategies discussed here can sometimes be very productive. One study showed that reading and practicing self-help advice improved depression in nearly 70% of patients.
These skills and strategies can be used alone or to supplement medications and counseling.
Eliminate the negative. First let’s talk about what does not help depression or bad moods. Being alone and isolating yourself, crying a lot, getting angry and yelling, blaming your failure or bad mood on others, or using alcohol or other drugs usually leaves you feeling worse. Are you taking tranquilizers or narcotic painkillers such as Valium, Librium, Restoril, codeine, Vicodin, sleeping medications, or other “downers”? These drugs intensify depression or may cause depression as a side effect. However, do not stop taking the medication before first talking with your doctor, as there may be important reasons for continuing its use or you may experience withdrawal reactions.
Do you drink alcohol to feel better? Alcohol is also a downer. There is virtually no way to escape depression unless you unload these negative influences from your brain. For most people, one or two drinks in the evening is not a problem, but if your mind is not free of alcohol during most of the day, you are having trouble with this drug. Talk this over with your doctor or call Alcoholics Anonymous.
Plan for pleasure. When you are feeling blue or depressed, the tendency is to withdraw, isolate yourself, and restrict activities. That is, in fact, the wrong thing to do. Maintaining or increasing activities is one of the best antidotes for depression. Going for a walk, looking at a sunset, watching a funny movie, getting a massage, learning another language, taking a cooking class, or joining a social club can all help keep your spirits up and keep you from falling into a situation where you can get depressed.
But sometimes having fun isn’t such an easy prescription. You may have to make a deliberate effort to plan pleasurable activities. Even if you don’t feel like doing it, try to stick to the schedule. You may find that the nature walk, cup of tea, or half hour of listening to music will improve your mood despite your initial misgivings. Don’t leave good things to chance. You might want to make up a schedule for your free time during the week and what you’d like to do with it.
If you are feeling hardly any emotion and the world seems devoid of color, make an effort to put some sensation back into your life. Go to a bookstore and look through your favorite section. Listen or dance to some upbeat music. Exercise or ask someone to give you a massage so you can reconnect with your body. Eat some spicy food. Treat yourself to a very hot bath, or try a cold shower. Go to a garden center and smell all the flowers.
Make plans and carry them out. Look to the future. Plant some young trees. Look forward to your grandchildren’s graduation from college even if your own kids are in high school. If you know that one time of the year is especially difficult, such as Christmas or a birthday, make specific plans for that period. Don’t wait to see what happens. Be prepared.
Take action. Continue your daily activities. Get dressed every day, make your bed, get out of the house, go shopping, walk your dog. Plan and cook meals. Force yourself to do these things even if you don’t feel like it. Taking action to solve the problems immediately facing you provides the surest relief from a bad mood. More important than what you change or how much you change are the confidence-building feelings that come from successfully changing something—anything! Taking action is the important thing. Incorporating some simple things into your life can boost your mood. You might decide to clean or reorganize a room, for instance, or a closet or even a desk drawer. Or get a new magazine subscription or call an old friend.
Be careful not to set yourself difficult goals or take on a lot of responsibility. Break large tasks into small ones, set some priorities, and do what you can as best you can. Learn some of the proven steps for taking successful action (see chapter 2). It may be wise when you are feeling depressed not to make big life decisions. For example, don’t move to a new setting without first visiting for a few weeks and learning about the resources available to you in this new community. Moving can be a sign of withdrawal, and depression often intensifies when you are in a location away from friends and acquaintances. Besides, many troubles may move with you. At the same time, the support you may need to deal with your troubles may have been left behind.
Socialize. Join a group. Get involved in a church group, a book club, a community college class, a self-help class, or a senior nutrition program. If you can’t get out, consider a group on the Internet. If you do this, be sure that the Internet group is moderated, that is, that someone is in charge to enforce the rules of the group. Don’t isolate yourself. Try to seek out positive, optimistic people who can lighten your heavy feelings.
Move your mood. Physical activity lifts depression and negative moods. Depressed people often complain that they feel too tired to exercise. But the feelings of fatigue associated with depression are not due to physical exhaustion. Try to get at least 20 to 30 minutes a day of some type of exercise, from chair dancing to walking. If you can get yourself moving, you may find that you have more energy (see chapter 7).
Think positive. Many people tend to be excessively critical of themselves, especially when they’re depressed. You may find yourself thinking groundless, untrue things about yourself.
As you challenge your automatic negative thoughts, begin to rescript the negative stories you tell yourself (see Chapter 5). For example, one of your underlying beliefs may be “Unless I do everything perfectly, I’m a failure.” Perhaps this belief could be revised to “Success is doing the best that I can in any situation.” Also, when you are depressed, it’s easy to forget that anything nice has happened at all. Make a list of some of the good or positive events in your life.
Do something for someone else. Lending a helping hand to someone in need is one of the most effective ways to change a bad mood, but it is one of the least commonly used. Arrange to baby-sit for a friend, read a story to someone who is ill, or volunteer at a soup kitchen. When you’re depressed, you may greet the advice of helping others with thoughts like “I’ve got enough troubles of my own. I don’t need anyone else’s.” But if you can bring yourself to help someone else, even in a small way, you’ll feel better about yourself. Feeling useful is good for self-esteem, and you will be temporarily distracted from your own problems. Helping others needier than yourself can help you appreciate your own assets and capabilities. By comparison, your problems and difficulties may not appear as overwhelming. Sometimes helping others is the surest way to help yourself.
Don’t be discouraged if it takes some time to feel better. If these self-help strategies alone are not sufficient, seek help from your physician or a mental health professional. Often some “talk therapy” or the use of antidepressant medications (or both) can go a long way toward relieving depression. Seeking professional help and taking medications are not signs of weakness. They are signs of strength.
Anger
Anger is one of the most common responses to chronic illness. The uncertainty and unpredictability of living with a chronic disease may threaten your independence and control. At times you may find yourself asking, “Why me?” This is a normal response to chronic illness.
You may be angry with yourself, family, friends, health care providers, God, or the world in general. For example, you may be angry at yourself for not taking better care of yourself. You may be angry at your family and friends because they don’t do things the way you want. Or you might be angry at your doctor because he or she cannot fix your problems. Sometimes your anger may be misplaced, as when you find yourself yelling at the cat or dog.
Sometimes the health condition itself causes anger. For example, a stroke or Alzheimer’s disease can affect someone’s emotions, leading the person to cry inappropriately or have temper flare-ups. Some people who are depressed or have anxiety disorders express their depression or anxiety through anger.
Aristotle (c. 384–322 B.C.) observed, “Anyone can get angry—that is easy— … but to do this to the right person, to the right extent, at the right time, with the right motive, and in the right way, that is not for everyone, nor is it easy.”
The first step is recognizing or admitting that you are angry and identifying why or with whom. These are important steps to learning how to manage your anger effectively. This task also involves finding constructive ways to express your anger.
Defusing Anger
Research now suggests that people who vent their anger actually get angrier. But suppressing anger isn’t the answer either. The angry feelings often smolder, only to flare up later. There are a couple of strategies you can use to reduce hostile feelings:
You can raise your anger threshold—that is, allow fewer things to trigger your anger in the first place.
You can choose how to react when you get angry—without either denying your feelings or giving in to the situation.
This sounds simple enough, but what gets in the way is our tendency to see anger as coming from outside ourselves—something over which we have little control. We see ourselves as helpless victims. We blame others and say, “You make me so angry!” We explode and then say, “I couldn’t help it.” We see friends as selfish and insensitive, bosses as snobs or bullies, friends as unappreciative. So it seems that our only choice is an outburst of hostility. But with a little practice, even a seasoned hothead can master a new repertoire of healthy and more effective responses.
There are several things you can do to help manage your anger.
Reason with yourself
How you interpret and explain a situation determines whether you will feel angry or not.
You can learn to defuse anger by pausing and questioning your anger-producing thoughts. If you change your thoughts, you can change your response. You can decide whether or not to get angry and then decide whether or not to act.
At the first sign of anger, count to three and ask yourself the following questions:
Is this really important enough to get angry about? Maybe this incident isn’t serious enough to merit the time and energy. Consider if the issue will likely make a big difference in your life.
Am I justified in getting angry? You may also need to gather more information to really understand the situation to counteract jumping to conclusions or misinterpreting the intentions or actions of others.
Will getting angry make a difference? More often than not, getting angry and losing your cool does not work and may even be punishing. Exploding or venting increases your angry feelings, puts a strain on your relationships, and potentially damages your health.
Cool off
Any technique that relaxes or distracts you—such as meditating or taking a long walk—can help you put out the fire within. Slow, deep breathing is one of the quickest and simplest ways to cool off (see page 129). When you notice anger building, take ten slow, relaxed breaths before responding. Sometimes withdrawing and buying some alone time can defuse the situation. Also, physical exercise provides a good natural outlet for stress and anger.
Verbalize without blame
One important technique is to learn how to communicate your anger out loud, preferably without blaming or offending others. This can be done by learning to use “I” (rather than “you”) messages to express your feelings. (Refer to Chapter 9 for a discussion of “I” messages.) However, if you choose to express your anger verbally, know that many people will not be able to help you. Most of us are not very good at dealing with angry people. This is true even if the anger is justified. Therefore, you may also find it useful to seek counseling or join a support group. Voluntary organizations, such as the various heart, lung, liver, and diabetes associations and the Arthritis Foundation, may be useful resources in this area.
Modify your expectations
You may also find that you would benefit from modifying your expectations. You have done this throughout your life. For example, as a child you thought you could become anything—a fireman, a ballet dancer, a doctor, and so on. As you grew older, however, you reevaluated these expectations, along with your capabilities, talents, and interests. Based on this reevaluation, you modified your plans.
This same process can be used to deal with the effects of chronic illness on your life. For example, it may be unrealistic to expect that you will get “all better.” However, it is realistic to expect that you can still do many pleasurable things. You have the ability to affect the progress of your illness by slowing your decline or preventing it from becoming worse. Changing your expectations can help you change your perspective. Instead of dwelling on the 10% of things you can no longer do, think about the 90% of things you can still do.
In short, anger is a normal response to having a chronic condition. Part of learning to manage the condition involves acknowledging this anger and finding constructive ways to deal with it.
Stress
Stress is a common problem. But what is stress? In the 1950s, the physiologist Hans Selye described stress as “the nonspecific response of the body to any demand made upon it.” Others have expanded this definition to explain that the body adapts to demands, whether pleasant or unpleasant. For example, you may feel stress after experiencing negative events, such as the death of a loved one, or even joyful events such as the marriage of a child.
How Does Your Body Respond to Stress?
Your body is used to functioning at a certain level. When there is a need to change this level, your body must adjust to meet the demand. It reacts by preparing to take some action: Your heart rate increases, your blood pressure rises, your neck and shoulder muscles tense, your breathing becomes more rapid, your digestion slows, your mouth becomes dry, and you may begin sweating. These are signals of what we call stress.
Why does this happen? To take an action, your muscles need to be supplied with oxygen and energy. Your breathing increases in an effort to inhale as much oxygen as possible and to get rid of as much carbon dioxide as possible. Your heart rate increases to deliver the oxygen and nutrients to the muscles. Furthermore, body functions that are not immediately necessary, such as the digestion of food and the body’s natural immune responses, are slowed down.
How long will these responses last? In general, they are present only until the stressful event passes. Your body then returns to its normal level of functioning. Sometimes, though, your body does not return to its former comfortable level. If the stress is present for any length of time, your body begins adapting to it. This chronic stress can contribute to the onset of some chronic conditions and can make the symptoms more difficult to manage.
Common Stressors
Regardless of the type of stressor, the changes in the body are the same. Stressors, however, are not completely independent of one another. In fact, one stressor can often lead to other stressors or even magnify the effects of existing stressors. Several stressors can also occur at the same time. For instance, shortness of breath can cause anxiety, frustration, inactivity, and loss of endurance. Let’s examine some of the most common sources of stress.
Physical stressors
Physical stressors can range from something as pleasant as picking up your new grandchild to everyday grocery shopping or the physical symptoms of your chronic illness. What they have in common is that all of these stressors increase your body’s demand for energy. If your body is not prepared to deal with this demand, the results may be anything from sore muscles to fatigue to a worsening of some disease symptoms.
Mental and emotional stressors
Mental and emotional stressors can also be either pleasant or uncomfortable. The joys you experience from seeing a child get married or meeting new friends may induce a similar stress response as feeling frustrated or worried because of your illness. Although this fact may seem surprising, the similarity comes from the way your brain perceives the stress.
Environmental stressors
Environmental stressors, too, can be both good and bad. They may be as varied as a sunny day, uneven sidewalks that make it difficult to walk, loud noises, bad weather, a snoring spouse, or secondhand smoke. Each creates a pleasurable or apprehensive excitement that triggers the stress response.
Isn’t “Good Stress” a Contradiction?
As noted earlier, some types of stress can be good, such as a job promotion, a wedding, a vacation, a new friendship, or a new baby. These stressors make you feel happy but still cause the changes in your body that we have just discussed. Another example of a good stressor is exercise.
When you exercise or do any type of physical activity, there is a demand placed on the body. The heart has to work harder to deliver blood to the muscles; the lungs are working harder, and you breathe more rapidly to keep up with your muscles’ demand for oxygen. Meanwhile, your muscles are working hard to keep up with the signals from your brain, which are telling them to keep moving.
As you maintain an exercise program for several weeks, you will begin to notice a change. What once seemed virtually impossible now becomes easier. Your body has adapted to this stress. There is less strain on your heart, lungs, and other muscles because they have become more efficient and you have become more fit. The same can happen with psychological stresses. Many people become more resilient and stronger emotionally after experiencing emotional challenges to which they need to learn to adapt.
Recognizing When You Feel Stressed
Everyone has a certain need for stress. It helps your life run more efficiently. As long as you do not go past your body’s breaking point, stress is helpful. You can tolerate more stress on some days than on others. But sometimes, if you are not aware of the different types of stress, you can go beyond your breaking point and feel that your life is out of control. Often it is difficult to recognize when you are under too much stress. The following are some of the warning signs:
Biting your nails, pulling your hair, tapping your foot, or other repetitive habits
Grinding your teeth or clenching your jaw
Tension in your head, neck, or shoulders
Feeling anxious, nervous, helpless, or irritable
Frequent accidents
Forgetting things you usually don’t forget
Difficulty concentrating
Fatigue and exhaustion
Sometimes you can catch yourself when you are behaving or feeling stressed. If you do, take a few minutes to think about what it is that is making you feel tense. Take a few deep breaths and try to relax. Also, a quick body scan (described in Chapter 5) can help you recognize stress in your body. You will find additional good ideas for coping with stress in that chapter.
Let us now examine some tools for dealing with stress.
Dealing with Stress
Dealing effectively with stress need not be complicated. In fact, it can start with a simple three-step process:
1. Identify your stressors by making a list. Consider every area of your life: family, relationships, health, financial security, living environment, and so on.
2. Sort your stressors. For each stressor, ask yourself, Is it important or unimportant? and, Is it changeable or unchangeable? Then place each of your stressors in one of four categories:
Important and changeable
Important and unchangeable
Unimportant and changeable
Unimportant and unchangeable
For example, needing to quit smoking is changeable and, for most people, important. Loss of a loved one or a job is important and unchangeable. The bad record of your favorite sports team, a traffic jam, or bad weather is unchangeable and may or may not be important. What really counts is what you think about each stressor.
3. Match your strategy to each stressor. Different strategies work for different stressors. Following are some strategies to help you be more effective in managing each type of problem.
Important and changeable stressors. These types of stressors are best managed by taking action to change the situation and to reduce the stress associated with them. Useful problem-solving skills include planning and goal setting (see Chapter 2); imagery (page 77); positive, healthy thinking (page 75), effective communication (see Chapter 9), and seeking social support.
Important and unchangeable stressors. These stressors are often the most difficult to manage. They can make you feel helpless and hopeless. No matter what you do, you cannot make another person change, bring someone back from the dead, or delete traumatic experiences from your life. Even though you may not be able to change the situation, you may be able to use one or more of the following strategies:
1. Change the way you think about the problem. For example, think how much worse it could be, focus on the positive and practice gratitude (see page 86), deny or ignore the problem, distract yourself (see page 74), accept what you can’t change.
2. Find some part of the problem that you can reclassify as changeable (you can’t stop the hurricane, but you can take steps to rebuild).
3. Reassess how important the problem is in light of your overall life and priorities (maybe your neighbor’s criticism isn’t so important after all).
4. Change your emotional reactions to the situation and thereby reduce the stress (you can’t change what happened, but you can help yourself feel less distressed about it). Try writing or confiding your deepest thoughts and feelings (see page 87), seeking social support, helping others, enjoying your senses, relaxing, using imagery, enjoying humor, or exercising.
Unimportant and changeable stressors. If the stressor is unimportant, first try just letting it go. But if you can control it with relatively little effort, go ahead and deal with it. Solving small problems helps build your skills and confidence to tackle bigger ones. Use the same strategies as described for important and changeable problems.
Unimportant and unchangeable stressors. The best solution for these problems is to ignore them. Starting now, you are given permission to let go of unimportant concerns. These are common hassles, and everybody has their share of them. Don’t let them bother you. You can distract yourself with humor, relaxation or imagery, or focusing on more pleasurable things.
Using Problem Solving
There are some situations that you recognize as stressful, such as being stuck in traffic, going on a trip, or preparing a meal. First, look at what it is about the particular situation that is stressful. Is it that you hate to be late? Are trips stressful because of uncertainty about your destination? Does meal preparation involve too many steps and demand too much energy?
Once you have determined what the problem is, begin looking for possible ways to reduce the stress. Can you leave earlier? Can you let someone else drive? Can you call someone at your destination and ask about wheelchair access, local mass transit, and other concerns? Can you prepare food in the morning? Can you take a short nap in the early afternoon?
After you have identified some possible solutions, select one to try the next time you are in the situation. Then evaluate the results. (This is the problem-solving approach that was discussed in Chapter 2.)
Managing the Stress
Whereas you can successfully manage some types of stress by modifying the situation, other types of stress seem to sneak up on you when you don’t expect them. The approach to dealing with these types of stress also involves problem solving.
If you know that certain situations will be stressful, develop ways to deal with them before they happen. Try to rehearse, in your mind, what you will do when the situation arises so that you will be ready.
Certain chemicals you ingest can also increase stress. These include nicotine, alcohol, and caffeine. Some people smoke a cigarette, drink a glass of wine or beer, eat chocolate, or drink a cup of coffee to soothe their tension, but this may actually increase stress. Eliminating or cutting down on these stressors can help.
As noted earlier, other tools for dealing with stress include getting enough sleep, exercising, and eating well. Sometimes stress is so overwhelming that these tools are not enough. These are times when good self-managers turn to consultants such as counselors, social workers, psychologists, or psychiatrists.
In summary, stress, like every other symptom, has many causes and can therefore be managed in many different ways. It is up to you to examine the problem and try to find solutions that meet your needs and suit your lifestyle.
Memory Problems
Many people worry about changes in their memory, particularly as they age. Although all of us are sometimes forgetful, there are serious illnesses that cause memory loss, including Alzheimer’s disease and other types of dementia. These are not a normal part of aging. Although symptoms can vary widely, the first problem many people notice is forgetfulness severe enough to affect their ability to function at home or at work or to enjoy lifelong hobbies. Alzheimer’s and similar diseases may cause a person to become confused, get lost in familiar places, misplace things, or have trouble with language. The disease gets worse over time.
If you suspect that you or someone you know is experiencing symptoms, it is important to seek a diagnosis as soon as possible. There is currently no cure for dementia, but early detection allows you to get the maximum benefit from available treatments—treatments that may relieve some symptoms and help you maintain your independence longer. An early diagnosis allows you to take part in decisions about care, transportation, living options, and financial and legal matters. You can also start building a social network sooner and increase your chances of participating in clinical drug trials that help advance research.
If you are concerned about Alzheimer’s or a similar condition, contact the Alzheimer’s Association. Help is available 24 hours a day, 7 days a week. Contact information is provided at the end of this chapter.
Itching
Itching is one of the most difficult symptoms to understand. It is any sensation that causes an urge to scratch. Like other symptoms, it can have many different causes. Some of these we understand. When you get an insect bite or come in contact with poison ivy, your body releases histamines, which irritate nerve endings and cause itching. When the liver is damaged, it cannot remove bile products, and these are deposited in the skin, causing itching. In kidney disease, itching may be severe, but the exact cause is not clear. There are also other conditions, such as psoriasis, in which the causes of itching are not easily explained. We do know that other factors such as warmth, wool clothing, and stress can make itching worse. The following are some ways that may help you relieve your itching.
Moisture
Dry skin tends to be itchy; therefore, keep the skin moisturized by applying moisturizing creams several times a day. When you choose a moisturizer, be careful. Be sure to read the list of ingredients when buying a cream or lotion. Avoid products that contain alcohol or any other ingredient that ends in -ol, as they tend to dry the skin. In general, the greasier the product, the better it works as a moisturizer. Creams are better moisturizers than lotions, and products such as Vaseline, olive oil, and vegetable shortening are also very effective.
When taking a bath or shower, use warm water and soak for not less than 10 or more than 20 minutes. You also may want to add bath oil, baking soda, or “Sulzberger’s household bath oil” to the water. To make this bath oil, stir 2 teaspoons of olive oil into a large glass of milk and add it to your bath. When you get out of the water, pat yourself dry immediately and apply your cream.
If your itching is caused by the release of histamines during an allergic reaction or from having had contact with an irritating substance, wash off the oils or offending agent, apply cold compresses, and take Benadryl or another anti-histamine to help stop the reaction.
During cold weather it can be especially difficult to deal with itching because indoor heating tends to dry the skin. If this is a problem for you, the use of a humidifier might help. Also try to keep your home and office as cool as you can without being uncomfortable.
Clothing
The type of clothing you wear can also add to the itching sensations. Obviously, the best rule of thumb is to wear what is comfortable. This is usually clothing made from material that is not scratchy. Most people find that natural fibers such as cotton allow the skin to “breathe” better and are the least irritating to the skin.
Medications
Antihistamines will help if your itching is caused by the release of histamines. You can buy many of these products over the counter. They include triprolidine (Actifed), diphenhydramine (Benadryl), chlorpheniramine maleate (Chlor-Trimeton), cetirizine (Zyrtec), and loratidine (Claritin).
You can also buy creams that help soothe the nerve endings, such as Ben Gay and Vicks Vap-o-Rub. If you want an anti-itch cream, look for one that contains benzocaine, lidocaine, or pramoxine. However, be careful, because some people can have allergic reactions to these creams, especially benzocaine. Capsaicin creams may also help itching, although they will cause a burning sensation. Steroid creams that contain cortisone can also help control some types of itching. If you are confused about what over-the-counter products to buy, ask your doctor or pharmacist.
With the exception of moisturizing creams, no cream should be used on a long-term basis without talking to your doctor. If your itching continues with use of these over-the-counter products, you may want to talk to your doctor about trying the stronger prescription versions of these medications.
Stress
Anything that you can do to reduce the stress in your life will also help reduce the itching. We have already discussed some of the ways to deal with stress earlier in this chapter, and some additional techniques are described in Chapter 5.
Scratching
While our natural tendency is to scratch what itches, this really does not help, especially for chronic itching. Rather, it leads to a vicious cycle whereby the more you scratch, the more you tend to itch. Unfortunately, it is hard to resist scratching. However, you might try rubbing, pressing, or patting the skin when you feel the need to scratch. If you are not able to break this cycle yourself, consult a dermatologist, who may be able to help you find alternative ways to control the itching.
Itching is a common and undoubtedly very frustrating symptom for both patients and physicians to manage. If the self-management tips described here do not seem to help, it may be time to seek the help of a physician. Often he or she can prescribe medications that can help with some specific types of itching.
Urinary Incontinence: Loss of Bladder Control
Urinary incontinence means you have trouble controlling your bladder and accidentally leak urine. If you have trouble controlling your bladder, you are not alone. Many people are coping with this problem. Although urinary incontinence can occur in both men and women, it is more common in women. In many cases, incontinence can be controlled, if not cured outright.
It is common to experience incontinence during or after pregnancy or with menopause, aging, or weight gain. Activities that put increased pressure on the bladder, such as coughing, laughing, sneezing, and physical activity, can cause urine leakage. Incontinence can be related to changes in your hormones, weakening muscles or ligaments in the pelvic area, or the use of certain medications. Infections in the bladder can also cause temporary incontinence.
Urinary incontinence can affect your quality of life and lead to other health problems. Feeling embarrassed by urinary incontinence causes some people to avoid social activities or sex. Some people experience loss of confidence or depression as a result of incontinence. Leaked urine may also cause skin irritation and infections. The frequent urge to urinate can interfere with sound, restorative sleep. Slipping and falling on leaked urine when rushing to the bathroom can result in injury.
The good news is that there are many treatments that can control or even cure this condition. It may be reassuring to know that many of these are small things you can do at home. If none of the following solves the problem, talk to your doctor about other treatments. Don’t be embarrassed. Your doctor has heard it all before.
There are three types of persistent or chronic loss of bladder control:
Stress incontinence refers to small amounts of urine leaking out during exercise, coughing, laughing, sneezing, or other movements that squeeze the bladder. Kegel exercises (described under “Home Treatments”) often improve this condition.
Urge incontinence, or overactive bladder, happens when the need to urinate comes on so quickly that you don’t have enough time to get to the toilet.
Overflow incontinence occurs when the bladder cannot empty completely.
Home Treatments
Small, effective changes to your lifestyle or behavior are the first treatments for urinary incontinence. For many people, these treatments effectively control or cure the problem.
Kegel exercises strengthen your pelvic floor muscles. This allows better control of your urine flow and prevents leaking. Learning Kegel exercises takes a bit of practice and patience. It may take a few weeks to feel an improvement in your symptoms.
Here is how to do Kegel exercises:
1. First, find the muscles that stop your urine. You can do this by repeatedly stopping your urine in midstream and starting again. Focus on the muscles that you feel squeezing around your urethra (opening for the urine) and anus (opening for your bowels).
2. Practice squeezing these muscles when you are not urinating. If your stomach or buttocks move, you’re not using the right muscles.
3. Squeeze the muscles, hold for 3 seconds, and then relax for 3 seconds.
4. Repeat the exercise 10 to 15 times per session.
Complete at least 30 Kegel exercises every day. The wonderful thing about Kegels is that you can do them anywhere and anytime. No one will know what you are doing except you.
With urge incontinence, retraining your bladder may help.
Practice “double-voiding.” Empty your bladder as much as possible, relax for a minute, and try to empty it again. This helps empty your bladder completely.
It sometimes helps to practice waiting a specified amount of time before urinating. This gradually retrains your bladder to require emptying less often.
Train yourself to urinate on a regular schedule, about every 2 to 4 hours during the day, whether or not you feel the urge. If you now need to urinate every 30 minutes, perhaps you can start by waiting to every 40 minutes and gradually work your way up to every 2 to 4 hours.
Consuming fewer beverages that stimulate the bladder and urine production, such as alcohol, coffee, tea, and other drinks that contain caffeine, can reduce your trips to the toilet.
If you carry extra weight, losing weight can reduce the pressure on your bladder. Studies show that a loss of just 10 percent of total body weight improves incontinence problems for many people.
Wearing absorbent pads or briefs does not cure incontinence but helps manage the condition.
Treatments and Medications
If changes in your lifestyle or behavior do not relieve your urinary incontinence, discuss with your doctor other treatments such as the use of medication, a pessary (a thin, flexible ring that can be worn inside the vagina to support the pelvic area), or, in some cases, surgery. You don’t have to suffer in silence if you have urinary incontinence. Talk with your doctor.
In this chapter we have discussed common causes of some of the most common symptoms experienced by people with chronic conditions. In addition, we have described some tools that you can use to cope with your symptoms. Taking action to deal physically with your symptoms is necessary in coping with your illness on a day-to-day basis. But sometimes this just doesn’t seem to be enough. There are times when you may wish to escape from your surroundings and just have “your time”—a time that allows you to clear your mind and gain a fresh perspective. The following chapter presents different ways to complement your physical-symptom management with thinking techniques—using the power of your mind—to help reduce and even prevent some of the symptoms you may experience.
Suggested Further Reading
Bourne, Edmund. Coping with Anxiety: 10 Simple Ways to Relieve Anxiety, Fear, and Worry. Oakland, Calif.: New Harbinger, 2003.
Carter, Les. The Anger Trap: Free Yourself from the Frustrations That Sabotage Your Life. San Francisco: Jossey-Bass, 2004.
Casarjian, Robin. Forgiveness: A Bold Choice for a Peaceful Heart. New York: Bantam Books, 1993.
Caudill, Margaret. Managing Pain Before It Manages You, 3rd ed. New York: Guilford Press, 2008.
David, Martha, Elizabeth Robbins Eshelman, and Matthew McKay. The Relaxation and
Stress Reduction Workbook. Oakland, Calif.: New Harbinger, 2008.
DePaulo, J. Raymond, and Leslie Alan Horvitz. Understanding Depression: What We Know and What You Can Do About It. New York: Wiley, 2003.
Donoghue, Paul J., and Mary E. Siegel. Sick and Tired of Feeling Sick and Tired: Living with Invisible Chronic Illness, 2nd ed. New York: Norton, 2000.
Gordon, James S. Unstuck: Your Guide to the Seven-Stage Journey Out of Depression. New York: Penguin, 2008.
Hankins, Gary, and Carol Hankins. Prescription for Anger, 3rd ed. Newberg, Ore.: Barclay Press, 2000.
Hauri, Peter, and Shirley Linde. No More Sleepless Nights. New York: Wiley, 1993.
Jacobs, Gregg D. Say Good Night to Insomnia. New York: Holt, 2009.
Kabat-Zinn, Jon. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York: Delta, 2005.
Kabat-Zinn, Jon. Mindfulness for Beginners: Reclaiming the Present Moment—and Your Life. Louisville, Colo.: Sounds True, 2011.
Klein, Donald F., and Paul H. Wender. Understanding Depression: A Complete Guide to Its Diagnosis and Treatment, 2nd ed. New York: Oxford University Press, 2005.
Kleinke, Chris L. Coping with Life Challenges, 2nd ed. Pacific Grove, Calif.: Brooks/Cole, 2002.
McGonigal, Kelly. The Willpower Instinct: How Self-Control Works, Why It Matters, and What You Can Do to Get More of It. New York: Avery, 2011.
McKay, Matthew, Peter D. Rogers, and Judith McKay. When Anger Hurts, 2nd ed. Oakland, Calif.: New Harbinger, 2003.
Natelson, Benjamin H. Facing and Fighting Fatigue: A Practical Approach. New Haven, Conn.: Yale University Press, 1998.
Sobel, David, and Robert Ornstein. The Healthy Mind, Healthy Body Handbook (also published under the title The Mind and Body Health Handbook). Los Altos, Calif.: DRX, 1996.
Stahl, Bob, and Elisha Goldstein. A Mindfulness-Based Stress Reduction Workbook. Oakland, Calif.: New Harbinger, 2010.
Torburn, Leslie. Stop the Stress Habit: Change Your Perceptions and Improve Your Health. Bloomington, Indiana: iUniverse, 2008.
Turk, Dennis, and Justin Nash. “Chronic Pain: New Ways to Cope.” In Daniel Goleman and Joel Gurin, eds., Mind/Body Medicine. New York: Consumer Reports Books, 1993.
Williams, Redford, and Virginia Williams. Anger Kills: Seventeen Strategies for Controlling the Hostility That Can Harm Your Health. New York: Random House, 1998.
Williams, Redford, and Virginia Williams. Lifeskills: 8 Simple Ways to Build Stronger Relationships, Communicate More Clearly, and Improve Your Health. New York: Three Rivers Press, 1998.
Other Resources
American Chronic Pain Association: http://www.theacpa.org/
National Sleep Foundation: http://www.sleepfoundation.org/
The Alzheimer’s Association’s 24/7 Helpline provides information, referrals, and care consultation in 140 languages: (800) 272-3900; http://www.alz.org/
National Association for Continence: http://www.nafc.org/