WHAT YOU CAN CHANGE WHAT YOU CANNOT CHANGE There are things we can change about ourselves and things we cannot Concentrate your energy on what is possible too much time has been wasted This is the age of psychotherapy and the age of self improvement Millions are struggling to change We diet we jog we meditate We adopt new modes of thought to counteract our depressions We practice relaxation to curtail stress We exercise to expand our memory and to quadruple our reading speed We adopt draconian regimens to give up smoking We raise our little boys and girls to androgyny We come out of the closet or we try to become heterosexual We seek to lose our taste for alcohol We seek more meaning in life We try to extend our life span Sometimes it works But distressingly often self improvement and psychotherapy fail The cost is enormous We think we are worthless We feel guilty and ashamed We believe we have no willpower and that we are failures We give up trying to change On the other hand this is not only the age of self improvement and therapy but also the age of biological psychiatry The human genome will be nearly mapped before the millennium is over The brain systems underlying sex hearing memory left handedness and sadness are now known Psychoactive drugs quiet our fears relieve our blues bring us bliss dampen our mania and dissolve our delusions more effectively than we can on our own Our very personality our intelligence and musical talent even our religiousness our conscience or its absence our politics and our exuberance turns out to be more the product of our genes than almost anyone would have believed a decade ago The underlying message of the age of biological psychiatry is that our biology frequently makes changing in spite of all our efforts impossible But the view that all is genetic and biochemical and therefore unchangeable is also very often wrong Many people surpass their IQs fail to respond to drugs make sweeping changes in their lives live on when their cancer is terminal or defy the hormones and brain circuitry that dictate lust femininity or memory loss The ideologies of biological psychiatry and self improvement are obviously colliding Nevertheless a resolution is apparent There are some things about ourselves that can be changed others that cannot and some that can be changed only with extreme difficulty What can we succeed in changing about ourselves What can we not When can we overcome our biology And when is our biology our destiny I want to provide an understanding of what you can and what you can t change about yourself so that you can concentrate your limited time and energy on what is possible So much time has been wasted So much needless frustration has been endured So much of therapy so much of child rearing so much of self improving and even some of the great social movements in our century have come to nothing because they tried to change the unchangeable Too often we have wrongly thought we were weak willed failures when the changes we wanted to make in ourselves were just not possible But all this effort was necessary Because there have been so many failures we are now able to see the boundaries of the unchangeable this in turn allows us to see clearly for the first time the boundaries of what is changeable With this knowledge we can use our precious time to make the many rewarding changes that are possible We can live with less self reproach and less remorse We can live with greater confidence This knowledge is a new understanding of who we are and where we are going CATASTROPHIC THINKING PANIC S J Rachman one of the world s leading clinical researchers and one of the founders of behavior therapy was on the phone He was proposing that I be the discussant at a conference about panic disorder sponsored by the National Institute of Mental Health NIMH Why even bother Jack I responded Everyone knows that panic is biological and that the only thing that works is drugs Don t refuse so quickly Marty There is a breakthrough you haven t yet heard about Breakthrough was a word I had never heard Jack use before What s the breakthrough I asked If you come you can find out So I went I had known about and seen panic patients for many years and had read the literature with mounting excitement during the 1980 s I knew that panic disorder is a frightening condition that consists of recurrent attacks each much worse than anything experienced before Without prior warning you feel as if you are going to die Here is a typical case history The first time Celia had a panic attack she was working at McDonald s It was two days before her 20th birthday As she was handing a customer a Big Mac she had the worst experience of her life The earth seemed to open up beneath her Her heart began to pound she felt she was smothering and she was sure she was going to have a heart attack and die After about 20 minutes of terror the panic subsided Trembling she got in her car raced home and barely left the house for the next three months Since then Celia has had about three attacks a month She does not know when they are coming She always thinks she is going to die Panic attacks are not subtle and you need no quiz to find out if you or someone you love has them As many as five percent of American adults probably do The defining feature of the disorder is simple recurrent awful attacks of panic that come out of the blue last for a few minutes and then subside The attacks consist of chest pain sweating nausea dizziness choking smothering or trembling They are accompanied by feelings of overwhelming dread and thoughts that you are having a heart attack that you are losing control or that you are going crazy THE BIOLOGY OF PANIC There are four questions that bear on whether a mental problem is primarily biological as opposed to psychological Can is be induced biologically Is it genetically heritable Are specific brain functions involved Does a drug relieve it Inducing panic Panic attacks can be created by a biological agent For example patients who have a history of panic attacks are hooked up to an intravenous line Sodium lactate a chemical that normally produces rapid shallow breathing and heart palpitations is slowly infused into their bloodstream Within a few minutes about 60 to 90 percent of these patients have a panic attack Normal controlssubjects with no history of panic rarely have attacks when infused with lactate Genetics of panic There may be some heritability of panic If one of
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