'Методы лечения'

Основной метод лечения психогенной импотенции — разъяс­нительная терапия. Врач должен раскрыть причину заболевания, а это возможно только при очень откровенном рассказе больного о своих переживаниях накануне и в интимной ситуации половой близости. Иногда уже это восстанавливает половую способность (происходит разрядка напряжения). Нередко приходится давать совет о половом воздержании определенной продолжительности (ослабление эрекции) при обязательном сохранении хороших взаимоотношений супругов. Временное воздержание содействует усилению интенсивности влечения и этим снимаются психогенные расстройства.

При лечении нельзя рассчитывать на быстрый эффект, какие-то «чудодейственные» лекарства. Для выздоровления необходимо время, терпеливое, но оптимистическое ожидание и создание условий оптимальной сексуальной ситуации.

Для  лечения  психогенной   формы   импотенции,   особенно возникшей после неудачной попытки совершения полового акта, применяется оправдавший себя на практике психотерапевтический прием: супругам рекомендуется заранее договориться о том, что несколько ночей (до двух недель) они проводят в одной постели, но без попыток к половому сближению (взаимные ласки, воздействия на эрогенные зоны необходимы). Муж должен рассказать жене о своих волнениях, переживаниях. В такой ситуации страдающий импотенцией как бы освобождается от необходимости исполнения супружеских обязанностей, исчезает страх и половое влечение бурно проявляет себя, обеспечивая нормальный половой акт.

Конечно, такой психотерапевтический прием может быть связан с большими трудностями: не каждый решится на откровенный разговор с женой. Это возможно лишь при полном взаимопонимании. Роль женщины в этих ситуациях очень велика. Она должна знать, чем вызвано половое расстройство у мужа, еще лучше, если она вместе с ним посетит врача и получит заверение во временном характере этого явления. При длительном и безуспешном лечении психогенной импотенции это требование совершенно необходимо, так как врач сообщает жене в присут­ствии мужа общие данные о характере его заболевания, указывает на благоприятный прогноз и особо подчеркивает необходимость временного воздержания при сохранении хороших взаимоотноше­ний. Жене необходимо также дать совет о том, как ей нужно вести себя с мужем во время его лечения. Так лечатся случаи импотен­ции, когда срыв половой функции произошел по причинам психических переживаний, волнений, страхов, когда вне обста­новки полового сближения у мужчины все остается в норме (утренние эрекции, поллюции, влечения, возбуждение в подгото­вительный период). Когда этого нет, то лечение проводится другими способами.

Physiological adjustment. It has been recognised since the 1980s that overfeeding does not always result in the weight gain predicted by the physics energy balance equation. This is because in humans, the body defends itself against an imbalance between EI and EE by adjusting, within limits, the one to the other. Adjustment refers to the metabolic, physiological and behavioural changes that occur when the equilibrium, or ‘settling point’ is altered by a positive or negative energy imbalance. The adjustments tend to oppose the energy imbalance to minimise the effect on body weight changes. This helps to explain why, with such huge variations in energy intake and energy expenditure over a year, there are normally only minor fluctuations in body weight in most people. It also helps to explain the plateaus and rebounds during a fat loss program.

The popular belief (based on the physics model presented above) is that fat or weight loss can be calculated in a linear fashion from the calorie deficit. However, reducing the amount of food eaten over a set period by a total of 3500kcals, will not result in an automatic loss of 0.45kg of fat, which would be predicted as the storage equivalent of 3500kcal. Adjustment in energy expenditure through a decrease in metabolic rate in particular, would mean that the reduction in body stores is much less than expected. The opposite also holds true for a positive energy balance. When more is eaten than is used up as energy, metabolic rate increases as body mass increases and again, the fat gain will be less than predicted.

It is this physiological adjustment which has been typically under-estimated in discussions of weight control, although a range of research has now identified it as a key factor in the long term failure of many programs. Adjustment is a biological protective mechanism which prevents excessive long term gains and losses in body energy stores. It is more effective in some people than others (perhaps partly genetically determined). It may also be more strenuously invoked if the energy deficit and weight loss are large.

The short term adjustments are mainly through appetite control, although changes in the thermic effects of food (TEF) are directly related to meal size. Lethargy can be a marked feature of low energy intakes. In the longer term as fat mass and FFM decrease so do RMR and fat burning (higher RQ). Often the changes are greater than expected and this is called adaptation. For example, the fall in RMR may be much greater than expected for the loss of FFM. The adaptive changes are a sign of active mechanisms in the body opposing major shifts in body weight.

Myth-information. Arguments about the benefits of butter or margarine are largely irrelevant when considering their use in fat loss. Both have equivalent fat energy value (i.e. 9 kcal/g).

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Which of these views is right? All of them-to an extent. But a complete picture only emerges when experts pool their information and examine the problem from all points of view.

Most anorexics are teenagers, and I believe that for them anorexia represents a way to avoid maturity. By maturity I mean not just physical or sexual development, but psychological and social development as well. A woman can translate her fear of growing up into a loss of body weight. If she can keep the same weight she had at age ten, maybe she can stay ten forever. Achieving thinness lets her turn back the clock and revert to a childlike physical appearance. Even more important, loss of body weight causes the menstrual cycle to shut down. The patient gains control over one of the most powerful-and perhaps frightening-signs of womanhood. (For males, of course, the issue is different, as I’ll explain later.) Thus anorexia can reflect problems in making the transition from childhood to adolescence.

In contrast, bulimia can reflect difficulty growing from adolescence into adulthood. Here the problem isn’t so much one of achieving maturity, but of handling its responsibilities: separating from the family; controlling oneself and others; assuming an identity through marriage or career; defining oneself through relationships with others.

A person with an eating disorder struggles with these deep and troubling issues. The pressures combine and drive her to create an identity based on her ability to control food and eating. Through such control she achieves something that everybody desires, something that society values: the ability to be seen as special.

Everyone wants to be special in some way. It’s a natural human trait. We seek distinction through our talents, achievements, or personalities. Some of us take jobs and provide things that people want. Others express themselves through the arts. Still others devote themselves to the care of their families. Rewards for our efforts come in many forms: a paycheck, applause, a child’s hug.

But victims of an eating disorder look for a different reward. They believe that the only way they can be special is to control their weight and eating habits-to starve themselves if they have to. An anorexic patient might say to me, «I want to be the thinnest person in my school,» or, «the thinnest in the world.»

Of course, many people realize that true self-esteem is based not just on physical appearance, but on other innate qualities. These are the people who answer the question, «Why must we be thin?» by saying, «I don’t have to be.»

As a specialist in eating disorders, I work to convince patients that defining self-worth through abnormal eating is a dangerously unhealthy business. To pursue the «ideal body shape» is to pursue a myth.

I see these myths every day in countless guises. I don’t know how many times I have heard my patients say, «I always felt that if I was thin I would be happy,» or, «If people really loved me then I wouldn’t binge out,» or, «Being fat lets people see me for the loser I am.»

Some people believe that someone with an eating disorder won’t get better unless she wants to. Wrong! For families to embrace this myth is to run the risk that their daughter will starve to death before she gets the help she needs. Many times, families refuse to get help for their daughter because they believe she can get better on her own. «Recovery is just a matter of willpower,» they claim. People who believe this graduated from the «Just snap out of it» school of thinking. An eating-disordered girl can’t «will» herself out of her condition any more than people can «will» themselves out of the flu.

Helping a patient to want to get better is actually part of the first stage of therapy. Once she has learned the importance of changing, she has reached a point where other types of therapy have a chance of succeeding. Patients need sensitive, thoughtful treatment to help them break the vicious cycle of disturbed eating, correct their faulty thinking, improve their eating behavior and resolve their difficulties in relationships with friends and family.

To me, the most frustrating thing about these myths is how deeply rooted they have become. Many people accept them as reality. Thus the first important step in treatment is to uproot these myths and correct them.

No patient is «typical.» Many share certain traits or experiences, but each patient has a different history-and a different future. Keeping that in mind, here are scenarios describing the course of these illnesses.

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As the owner of an agency that provides makeup artists for stage actors and TV personalities, Juanita Dillard was constantly surrounded by thin, gorgeous women—and free buffets. The ever-present food proved to be too much of a temptation for Juanita, especially in such a high-pressure environment.

«I’d eat all day, then help the caterers clean up just so I could take home the leftovers,» says the 37-year-old Cheverly, Maryland, resident. Before she knew it, she weighed 274 pounds.

It took a souvenir photo from a vacation in the Cayman Islands to persuade Juanita to slim down. «The photo was taken in late 1989. When I saw how I looked, I became determined to lose weight in the new year,» she says. «I was tired of compliments that stopped at my face. There I was, surrounded by gorgeous women. I wanted g to be one, too.»

Juanita stopped cruising the big buffets and instead signed up for Weight Watchers, where she learned about portion control and the importance of filling up on vegetables. But the most valuable lesson she learned was how to journal. When she started writing about her stress instead of feeding it, the weight rolled off. In a year-and-a-half, she lost 137 pounds.

The biggest test of her weight-loss success came when her dog, Nikki, was killed by a car. Distraught, Juanita grabbed a block of American cheese, a box of Saltines, a jar of black-bean salsa, a super-size bag of Tostitos, and a bottle of blueberry wine—all the fixings for a binge. Before long, tears were rolling down her cheeks. The jar of salsa was empty; the bag of tortillas, half-eaten.

By chance, Juanita reached into her purse and felt her journal. She took it out and started writing about how much she missed Nikki. When she was through, she felt better, and her desire to eat was gone.

«Stress was what made me fat before, and I wasn’t going to let it happen again,» she says. «Now, journaling is my zero-calorie stress buster.»

WINNING A C T I O N

Put your feelings on paper. The next time you’re inclined to pick up a fork, grab a pen instead and start writing. Research shows that journaling when you’re tense can help avoid emotional eating.

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