Sleep Helps Protect Your Brain

Dr. Gary Small

I love the way I feel after a good night’s sleep. My body is rested; my mind feels clear and alert; and I am happy to just linger in bed and relax. Of course, this delightful state is eventually interrupted by an alarm going off or the dog barking for me to feed him.

But I continue to feel good throughout the day if I slept well the night before. It’s as if my entire system — my body and my brain — have been reset in a healthy way.

This good feeling may be a result of the anti-inflammatory effects of sleep. Chronic brain inflammation appears to contribute to cellular deterioration that can lead to Alzheimer’s disease. Getting a good night’s sleep has a positive impact on that inflammatory process and may explain why people who sleep well regularly often look younger and have more energy.

When scientists measure a volunteer’s blood markers of inflammation, they find that after the volunteer has had a restful night of sleep, those measures improve significantly. These are the same measures that improve when we eat anti-inflammatory foods like omega-3 rich fish or olive oil. Dr. Wendy Troxel and colleagues at the University of Pittsburgh have found that people with sleep problems such as difficulty falling asleep, fretful sleep, or loud snoring have a higher risk for metabolic syndrome, another condition linked to chronic inflammation that puts the brain at risk for neurodegeneration.

Scientific evidence tells us that actually sleeping on our problems is an efficient way to solve them. During sleep, our brain’s memory centers are busy consolidating recall for more effective memory when we’re awake. Sleeping well is an important way to improve your memory ability and may lower risk for cognitive decline.

About 30 percent of adults suffer from insomnia. The following are a few strategies to consider if you’re having trouble falling or staying asleep through the night.

    • Stay up during the day. A daytime nap can be invigorating, but if you already suffer from sleeplessness at night, try not to nap so you’ll feel more fatigued at bedtime.
    • Avoid evening liquids. After dinner, try not to drink large quantities of water or other drinks. A full bladder can awaken you during the night and you may have trouble getting back to sleep.
    • Stay mellow in the evening. Watching lively nighttime sports or an exciting movie thriller tends to hype some people up, making it harder for them to fall asleep.
    • Avoid caffeine at night. Whether it’s from tea, coffee, soda or even a chocolate bar, caffeine can keep us awake, so avoid it in the evenings. Try to skip coffee entirely in the late afternoon and evening.
  • Maintain good sleep habits. It helps to get into bed at the same time each night. Try to skip watching TV, eating or even reading a book. Simply turn out the light and take a few moments to get settled. If you are not asleep after 20 minutes, get out of bed and do something else until you feel tired again. Once you go back to bed, get settled, and give it another 20 minutes. Every time you get into bed to sleep, try remaining still and focus on slow, steady breathing.

For more by Gary W. Small, M.D., click here.

For more on sleep, click here.

Gary Small, MD, is director of UCLA’s Longevity Center and co-author of The Alzheimer’s Prevention Program: Keep Your Brain Healthy for the Rest of Your Life.

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Keep Walking to Stay Mentally Sharp

Dr. Gary Small

My wife’s 103-year-old grandmother lived in a third floor walk-up apartment in New York City. Every day she walked up and down those stairs several times to go shopping, to the post office, the dry cleaner’s and do other little errands. At 103, she was as sharp as a tack. She never forgot a birthday, an anniversary or a single holiday. And God forbid you forgot to send her a card or call her on her birthday — you’d hear about it for ages. The exercise she got on those stairs and errands may not only have protected her heart so she could live past 100, it may also have protected her brain.

Walking is one of the safest and easiest ways to get an aerobic workout. How much walking or exercise each person needs depends on their baseline fitness level, age and other health factors. And getting short amounts of cardio workouts throughout the week is more effective than being a weekend warrior who only exercises on Saturday and Sunday.

In a study of more than 18,000 older women, Harvard researchers found that 90 minutes a week of brisk walking, or approximately 15 minutes a day, was all one needed to delay cognitive decline and reduce possible risk for future Alzheimer’s disease. University of Pittsburgh scientists found that the more that older people walked, the better their cognitive abilities and the larger their brain. A larger brain is associated with a lower risk for Alzheimer’s disease.

Many studies have demonstrated that a lower risk for Alzheimer’s disease is associated with almost any form of physical activity, whether it’s gardening, housework, swimming, or tennis. When sedentary people start a fitness program, their brains get larger in key memory regions like the frontal lobe and hippocampus.

Equally convincing evidence of the brain benefits of physical exercise comes from studies that have monitored volunteers in exercise programs and compared them to sedentary control groups. Dr. Arthur Kramer and colleagues at the University of Illinois recruited volunteers aged 58 to 77 years, and assigned them to either a walking group or a group that did stretching and toning. After six months, the walkers had increased blood flow in brain circuits controlling spatial ability and complex thinking, compared with the stretching and toning group. Although stretching and toning are important components of a comprehensive physical fitness program, Professor Kramer’s findings demonstrate the added value of cardiovascular conditioning for maintaining brain health.

Aerobic conditioning may be improving our mental acuity in several ways. Exercise gets the heart pumping more blood to the brain, which appears to reverse cellular deterioration associated with aging. It also stimulates the growth of new synapses — the connection sites between neurons — and makes brain cells more responsive to external stimuli.

Gary Small, M.D., is director of UCLA’s Longevity Center and co-author of The Alzheimer’s Prevention Program: Keep Your Brain Healthy for the Rest of Your Life

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Mass Hysteria Can Strike Anywhere, Anytime

Dr. Gary Small

While still in my psychiatry residency training program, I was watching the news, and a story caught my attention – a bunch of grade school kids had been hospitalized because of a mystery illness.

Outbreaks of mystery illness are more common than we think – often a physical culprit is discovered, but psychological stress and anxiety are sometimes the cause.  Epidemics of hysteria have been recorded as far back as the Middle-Ages and continue to strike today.  Most often, the outbreaks afflict children and teenagers, girls more than boys, and fainting and hyperventilation are the most common symptoms.  Occasionally the illness persists for days; but usually, once the afflicted crowd disperses, symptoms tend to disappear, probably because they are only contagious when new victims observe others falling ill.  Rumors about the cause of these outbreaks tend to spring up throughout the communities.

In all the mass hysteria episodes I’ve studied and written about over the years, the lingering question for me is why they don’t happen more often.  The essential ingredients – groups under psychological and physical stress, often hungry, tired, or both – come together almost daily all around the world.  So what is that ultimate trigger that pushes some people over the edge and let’s their minds take over their bodies en masse?

When I investigate a mystery illness, many victims and their families become defensive because they think I might be accusing them of having an illness that is “only in their minds.”  It makes sense when you think about it from the victim’s point of view.  The physical symptoms are experienced as real, and when they strike, even if the victim is swept up by the excitement and anxiety of the crowd, how could their real physical experiences – hyperventilation, fainting, nausea, stomach pains – be the result of anything but an actual physical illness?

Some people are more likely to endorse a far-fetched or outlandish cause for their illness than to consider the mind-over-matter theory.  Examples of bizarre explanations for mass hysteria have included a “phantom gasser” that Mattoon, Illinois, residents believed was spraying poisonous mist into the bedroom windows of teenage girls, causing nausea, vomiting, and burning sensations in their mouths and throats.  In the early 1950s, when people in the state of Washington were nervous about nuclear testing, many believed that cosmic rays or shifts in the Earth’s magnetic field were causing previously unnoticed windshield pits or dings in their cars.  Some even blamed it on “super-natural gremlins.”  Although this is an example of collective delusion rather than mass hysteria, it shows how a worried group can over-interpret physical phenomena that were already there but went unnoticed before the spread of anxiety.

When we face uncertainty, our minds crave explanations.  If we have no way to account for symptoms, we feel out of control and our fear escalates.  And, if we learn that our own minds may have caused these very real symptoms, we tend to feel more anxiety about what our minds might do next.  People may worry that their brains are possessed by some outside spirit, or perhaps a poltergeist has taken charge of their willpower.  They’d rather latch onto something like the mysterious poisonous water theory.

Psychosomatic specialists have come up with additional physiological explanations for some of the symptoms of mass hysteria outbreaks.  When people get excited and scared, they may hyperventilate or start breathing too quickly; thus, exhaling too much carbon dioxide.  Low carbon dioxide levels in the body cause muscles in the extremities to spasm, which can explain the numbness, tingling and muscle twitching that some victims experience.  If the carbon dioxide depletion is treated by simply breathing into a paper bag, the symptoms rapidly disappear.
In a heightened state of anxiety, victims often notice and misinterpret normal physical sensations.  A gurgling stomach can be mistaken for a sign of food poisoning.  And if others around you grab their stomachs and fall to the floor, your fear level may heighten, your knees might buckle, and you may fall to the floor as well.  The sheer force and power of group dynamics tends to take over, and people get swept up in the symptoms of the crowd.  The social hierarchy of the group can also play out in the spread of symptoms.  If the “popular” girls faint first, the less-popular will likely follow their lead.

In the “Fainting Schoolgirls” incident from my new book “The Naked Lady Who Stood on Her Head: A Psychiatrist’s Stories of His Most Bizarre Cases,” I was investigating a sudden outbreak of illness in a suburban grade school.  The kids were rehearsing a performance, when suddenly 30 of them grabbed their stomachs and fainted.  The principal told me that it started with one popular child who fainted and suddenly the rest of them went down like dominoes.  The health department couldn’t find a cause and gave the “all clear,” but the community was in an uproar.  The school seemed to be blocking my efforts to get to the bottom of things, and the parents took offense that a psychiatrist was suggesting that their kids might have had a psychosomatic illness.  I nearly gave up my study until I attended the actual show – a little worried that the outbreak might recur – when one of the mothers sought me out and supported my theory of mass hysteria – she was convinced that her daughter’s physical symptoms were in fact psychological.  My subsequent research proved my theory that when stressed out, the mind can make the body sick, and in a group setting, it can really get out of control.  Mass hysteria can strike anywhere, anytime.

See my new book, “The Naked Lady Who Stood on Her Head: A Psychiatrist’s Stories of His Most Bizarre Cases.”

Copyright Gary Small, M.D.

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Can Exercise Cure Depression?

Dr. Gary Small

Not long ago, a friend told me about his symptoms of depression – trouble sleeping through the night, loss of appetite, forgetfulness, and occasional comments that he might be better off dead.  It all sounded like a major depression that could have a good chance of responding to an antidepressant medication, but he was reluctant to take medicines that might “control his mind.”  Besides, he had read that getting fit at the gym or running a few laps was all he needed to beat the blues.

I am a big fan of the mental and physical benefits of exercise, but I wasn’t convinced that exercise therapy would be enough to cure my friend’s depression.  In the last few years, clinical scientists have been focusing more on the mental benefits of physical exercise.  Anyone who has run a 10-K or lifted weights knows first-hand the compelling and immediate sense of endorphin-induced euphoria.  We feel uplifted and clear-headed, but is it just a transient state – an effective but temporary treatment for depression?

A few years ago, colleagues from Duke University compared the antidepressant effects of aerobic exercise training to the popular antidepressant medicine sertraline, as well as a placebo sugar pill.  They randomized depressed patients to one of the interventions and found that after four months about 40 percent of the subjects were no longer depressed.  Those who exercised or received the medicine had higher and comparable response rates, but they were only slightly better than the placebo group.  Those who exercised at a moderate level – about 40 minutes three to five days each week – experienced the greatest antidepressant effect.  So they interpreted that to mean that exercise was just as good as medicine.  And in that particular study, the high placebo response meant that nonspecific influences like patient expectations and the attention from the study personnel during monitoring visits may have caused the therapeutic response.

Exercise not only increases blood flow to the brain, it releases endorphins, the body’s very own natural antidepressant.  It also releases other neurotransmitters, like serotonin, which lift mood.  In fact, the antidepressant in the study, sertraline, is an SSRI or a selective serotinon reuptake inhibitor – it is thought to exert its effects on body chemistry by increasing the amount of brain serotonin, a chemical that is lowered during depressed mental states.  Brain-derived neurotrophic factor, a chemical that promotes brain health and memory, is also reduced in depression, and exercise has been found to elevate levels of this neurotransmitter.  Maybe a fitness program could boost my friend’s levels in all these areas, and help his forgetfulness, too.  He could only laugh at the idea of having 40 extra minutes three times a week to exercise.  His wife was mad enough that he worked 14 hour days as it was.

Multiple systematic clinical trials of antidepressant medications have shown that they are significantly more effective than placebo in relieving symptoms in people with major depression.  To determine whether or not somebody has a major depression and will respond to an antidepressant medicine, I often use the mnemonic I learned during my psychiatry residency training, which that reminds me of eight features of major depression:  “SIG E CAPS.”  “SIG” is an abbreviation doctors use to stand for prescribe; “E” stands for energy; and “CAPS” stands for capsules.  Each letter is an abbreviation for one of the symptoms:  S—sleep decrease or increase; I—interest loss; G—guilt feelings; E—energy decline; C—concentration impairment; A—appetite change; P—psychomotor disturbance (agitation or slowed movements); and S—suicidal thinking.  Patients with three or more of these symptoms generally respond well to antidepressants.  My friend had at least five of these symptoms so I was confident he would respond to a trial of medication.

Use of antidepressants got a push back recently from a meta-analysis or a combined analysis of previous studies using another SSRI, Paxil, and an older antidepressant drug, imipramine, in a class known as tricyclics.  The study suggested that these drugs may be no better than placebo, but that study had drawbacks:  for example, it eliminated other antidepressant medicines and did not include sequential treatments.  Many patients do not respond to the first medicine they try but respond very well to a medicine from another drug group.

Research and clinical practice support the idea that antidepressant medicines often work best when combined with non-pharmacological approaches like psychotherapy, support groups, or healthy lifestyle habits.  So for my friend, he wouldn’t necessarily have to choose one approach over the other.  Since he already seemed predisposed toward exercise, I encouraged him to join a fitness center – his wife would probably come around if he cut back on work a few hours, which might also lower his stress levels and improve his mood.  But I also urged him to give medicines a try.  If he gave it a few weeks or more – antidepressants often take several weeks to have an effect and the first one may not work – there was an excellent chance that he’d have a good response.  Before I could finish my suggestions, his cell phone rang.  It was his wife reminding him that he was late for dinner.  He had to run off.  Perhaps that would be good for his mood, if he kept up a good pace.
Copyright Gary Small, M.D.

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Addicted to Therapy

Dr. Gary Small

Were decades of psychoanalysis enough to cure Woody Allen’s angst? Long-term psychotherapy seems to be on the decline these days – staying on the couch for more than five or six years is extreme, but many patients have a hard time saying goodbye to their therapist.  Often in therapy, the patient feels cared for and safe, and there is anxiety about leaving this nurturing relationship.  Many feel a lingering fear that if they were out on their own, they couldn’t hold it together.  Their emotional discomfort, relationship struggles and other symptoms would recur, and they’d feel like a failure crawling back to the couch.

A related phenomenon is the occasional “therapy hopper” – patients who jump from doctor to doctor – perhaps enjoying the thrill of the initial meetings and early sessions of psychotherapy.  Often such people are afraid to delve deeper into their own emotional life and flee before the feelings get too intense.

In one of the unusual cases I describe in “The Naked Lady Who Stood on Her Head: A Psychiatrist’s Stories of His Most Bizarre Cases,” the patient appeared to have addiction issues – not to alcohol and drugs, but first to food and then to shopping.  After what appeared to be successful therapy for her impulsive purchasing, along with the help of a 12-step debtors anonymous program, I by chance discovered that she had begun regular psychotherapy sessions on the sly with a colleague, while continuing to work each week with me.  After confronting her, she admitted that her she craved the thrill she felt when she experienced those moments of insight with me, especially when she realized that her addiction had shifted from eating to shopping.  As much as she tried, the thrill of therapy was gone so she moved on.  I had heard of serial addictions.  People who kick one habit have a tendency toward addiction so they take on a new form of addiction.  The thrill-seeking patterns are the same, but the objects of desire change.

Whether people are addicted to substances, such as alcohol or drugs, or processes, such as gambling, sex, work or spending, they suffer similar symptoms.  They become preoccupied with the experience, develop tolerance and crave higher doses, have difficulty avoiding the experience, and have withdrawal symptoms when they can get what they want.  Often they conceal their addictive behaviors and are attempting to escape or avoid uncomfortable feelings.  Not all experts agree whether some of these behaviors represent true addictions or just obsessive-compulsive behaviors.  For example, work groups for the new Diagnostic and Statistical Manual of Mental Disorders (DSM-V) have argued that there is insufficient evidence to include Internet or as a category.

Whether we call it an obsession or an addiction, overlapping brain circuits that control pleasure-seeking are involved when people give up one addiction only to substitute another, and we know that these behaviors disrupt people’s lives.  When patients shift from one form of addiction to another, the problem can elude friends, family members and professionals.

Most specialists are aware of addiction-switching, but can someone really get hooked on therapy or develop a serial therapy addiction? What do you think?

See my new book, “The Naked Lady Who Stood on Her Head: A Psychiatrist’s Stories of His Most Bizarre Cases.”

Copyright Gary Small, M.D.

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The Mile High Therapy Club

Dr. Gary Small

Not long ago, I was on an airplane queued up on the tarmac awaiting its turn to depart, when I noticed the young woman sitting next to me.  She was hyperventilating, holding her knees to her chest in a near-fetal position, and barely masking her panicked state.  I asked if she needed help, but got no response.  I guessed that fear of flying was causing her panic so in a slow, calm voice, I suggested that she plant her feet firmly on the ground and concentrate on wiggling her toes – a technique that a commercial pilot I knew found effective for passengers with these typical symptoms.  She seemed to gain some control.  I handed her the paper bag in the seat pocket and urged her to breathe into it slowly – inhaling her own carbon dioxide back through the bag can often break the hyperventilation cycle caused by rapidly exhaling too much carbon dioxide.  Both strategies seemed to work, and she quickly gained composure.

I recalled this incident after reading Liz Galt’s interesting New York Times article, “Cornered: Therapist’s on Airplanes.”  She describes many of the challenges therapist’s experience when their seat mates learn of their profession.  Some people spill their guts jumping at the opportunity for a free session, which could be more than the standard 50 minutes depending on the duration of the flight.  Others clam up lest the therapist might attempt to delve into and analyze their deepest secrets.  And, there’s the therapist’s discomfort to consider – he may not be interested in working at 30,000 feet.  To avoid such discomfort, some therapists lie about what they do or distort how they describe their professional activities when the inevitable “And what do you do?’ comes up in casual conversation.  I have resorted to this tact when I sense a potentially loquacious neighbor and focus on my research in Alzheimer’s disease.  Of course, that may lead to a cascade of questions about the latest suspected causes and experimental treatments.  Perhaps launching into an update-on-Alzheimer’s lecture is preferable to establishing an impromptu doctor-patient relationship with the potential legal risks that might follow.

My reaction to the panicky woman in seat 11B was a knee-jerk response.  I wasn’t thinking that I’m a licensed physician and that I have not established a professional relationship with her.  I responded instinctively to someone in need and did what I could to help with her distress.  But had I opened myself up for a lawsuit? Perhaps I should have pushed the flight attendant call button when I first noticed that she might be in trouble? I suppose a part of me wanted to play the hero, but what if she had been suffering from some other cause of panic, such as hypoglycemia, a drug side effect, or psychosis?

Fortunately, in this case, it wasn’t one of these other problems, and in my defense, I was just a moment away from pushing the call button for help.  But that might have been a circular plea for assistance, leading to an overhead page of “Is there a doctor on the plane to help a passenger in distress? In particular, is there a psychiatrist in the house who might know how to help someone with a panic attack?”

I recall a related situation that a psychiatrist colleague faced on a cruise ship.  A fellow vacationer with a history of bipolar disorder developed a full-blown manic episode.  The patient was becoming dangerously hyperactive and delusional, expressing the belief that she could fly and that she needed to leave the cruise for an important meeting with the President of the United States.  My colleague was well equipped to make the diagnosis, but he didn’t have the equipment or adequate medication to treat her.  The ship’s doctor found a few minor tranquilizers in the pharmacy, but these didn’t seem to have much effect, and no lithium or antipsychotic medicines were available.  My colleague realized that he could use a drug for treating sea-sickness, compazine, to treat her mania.  Compazine is in the same class of medication originally used to treat acute manic psychosis.  Not the ideal medication, but good enough to calm the patient and make the situation safe until the ship arrived at the next port in the morning.

Whether it’s a cruise ship or an airplane, the close quarters and limited medical resources will always pose these kinds of challenges.  Such settings often loosen us up and create a sense of intimacy that we might not experience in other situations.  It can also lead to anxiety that can be a trigger for some people to start talking about their personal life to a stranger, especially if that neighbor is a therapist.  And, dealing with a chatty neighbor, whose too personal revelations create social discomfort, can be a challenge for anyone, whether it’s a therapist, rabbi, bar tender, or school teacher.

When does it make sense for a psychiatrist or any professional therapist to practice mile high therapy? What do you think?

See my new book, “The Naked Lady Who Stood on Her Head: A Psychiatrist’s Stories of His Most Bizarre Cases.”

Copyright Gary Small, M.D.

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Falling in Love with Your Psychiatrist

Dr. Gary Small

Her psychiatrist knows her inner thoughts and feelings better than anyone.  She can say anything to him and he doesn’t judge her, but only seems to understand her better.  She feels safe and comforted whenever she sees him.  He knows just when to hand her a tissue when she’s about to cry, and they share laughs together because her sense of humor is so like his.  She finds herself looking forward to sessions and even wondering what to wear.  She daydreams about him and wonders if he feels the same special connection to her.  Perhaps she’s become his favorite patient.

She feels guilty when her husband asks how therapy is going, and tells herself that her feelings about her psychiatrist can’t be real.  After all, she’s paying for his time and damn it, he’s never late with a bill, and there’s no special discount for these special feelings.

So what if she’s in love with him? It happens.  She didn’t plan it that way.  And he may even love her back.  Jason Robards was a psychologist in Tender is the Night and married his patient, Jennifer Jones.  And in Spellbound, Ingrid Bergman fell in love with her patient Gregory Peck.  Maybe she should just come out with it and tell him how she really feels, but what if he rejects her?

This patient’s experiences are typical of what occurs in many forms of psychotherapy that focus on exploring and understanding the patient’s inner psychological life.  Known as transference, it means that the patient is transferring feelings she has toward a parent or authority figure, onto the therapist.  A therapist who can remain neutral by not expressing his own issues and emotional reactions during treatment will allow the patient to fill in what she imagines to be the therapist’s reaction.  When the time comes for the therapist to point out the reality of the relationship, the patient will hopefully gain insight into her distortions, and realize how she transfers past distortions onto other relationships in her life.  With the psychiatrist’s help, the patient can come to grips with this pattern, put her distortions into perspective, and move on with her life.

This process can be particularly challenging when the patient’s transference is eroticized.  And if the therapist is experiencing emotional issues in his own personal life, it can lead to a dangerous romantic liaison as it is often depicted in films.  An ethical, well-trained psychiatrist, however, knows how to deal with his own emotional reactions to his patient’s expressions of transference.

Freud used the term countertransference to refer to the therapist’s emotional responses to a patient during psychotherapy.  An effective therapist has the capacity for empathy and will experience countertransference feelings, but should not allow them to interfere with the therapy.  In fact, for psychiatrists who maintain perspective on these reactions and their distortions, countertransference offers an important opportunity to explore the patient’s inner emotional world.  It helps the therapist understand how the patient’s behaviors affect others in her life, and how these distortions can create dysfunctional interpersonal patterns.

Anyone who has positive or negative feelings towards her psychiatrist during therapy should discuss those feelings, no matter how uncomfortable that discussion may be.  For many patients, it provides an opportunity to gain greater understanding of themselves, offering a path to emotional health.

However, some patients can’t handle this kind of exploratory insight-oriented psychotherapy.  The psychiatrist’s silence or probing questions may stir up so much anxiety that it distorts the patient’s reality and imposes other dangers.

In the “Sexy Stare” incident in my new book, I was still a young psychiatrist-in-training when I first had to deal with a patient who had an eroticized transference towards me.  Insight-oriented therapy had pushed her into such a distorted transference state that she believed I had made love to her by staring into her eyes.  Once I realized that her transference feelings had morphed into dangerously psychotic romantic desires, I quickly changed my therapy strategy.  I stopped probing her past and helped her cope with her current anxieties.  I continued to work with this patient for another year or so, and she improved.  I tried never to stare into her eyes again.

So falling in love with your psychiatrist can be a normal part of therapy.  A few people can’t handle it, and an experienced psychiatrist knows how to spot them and help them deal with their problems in the present.  For most patients, talking about those feelings with the therapist and learning how they relate to past relationships often speeds up emotional growth, recovery and health.

See my new book, “The Naked Lady Who Stood on Her Head: A Psychiatrist’s Stories of His Most Bizarre Cases.”

Copyright Gary Small, M.D.

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