Restless legs syndrome is different from another condition called nocturnal myoclonus, which means “nighttime muscle-twitching” and is the name given to the problem of frequent strong leg jerks. Sleep laboratory studies have found that some patients may have leg jerks three hundred to four hundred times a night, occurring every twenty to forty seconds. Both legs are usually involved. Unlike restless legs syndrome, myocolonus causes no unpleasant sensations in the leg. Because it occurs during sleep, episodes are seldom recalled. Myoclonus may arise from such medical problems as kidney disease, metabolic disorders, narcolepsy, drug withdrawal, or apnea. Withdrawal from medications, such as antidepressants or anticonvulsive drugs, can serve to worsen the problem. I should stress that myoclonus is not a seizure disorder like epilepsy. EEG tracings of people with myoclonus indicate that both their sleep and their waking patterns are normal (except for the nighttime arousals caused by twitching).Obviously, victims of myoclonus have trouble maintaining sleep. While they may not actually awaken during a twitching episode, these patients may perceive their sleep to be light, broken, and restless. They may also awaken feeling unrested and unrestored. Frequently, too, their bed partners complain of disturbed sleep, pointing to the bruises on their shins as evidence. Researchers estimate that as many as 10 to 15 percent of patients with a sleep disorder have nocturnal myoclonus; an estimated one out of three people over the age thought to suffer from the problem. *124\226\8*

Whenever we call on the nervous system to carry out some ne task, something it has no experience of, there will usually be an anxiety response. The first time we stand up and address the class, give a lecture, take out an appendix or get behind the wheel of the car, we experience significant anxiety. This doe not mean anything other than the fact that the nervous system has not done this thing before and therefore alerts us to its difficulty in processing the information by triggering an anxiety reaction.
In our society, therefore, we tend to recognize that anxiety is normal and expected part of learning new skills and performing new tasks. However, there should not be any anxiety in learning new information. A student would not expect to experience significant anxiety just simply from sitting in lectures listening to his teachers. This distinction, I believe, is important. Our schoolchildren these days display increasing levels of anxiety; it is important for educators to consider carefully how much of the children’s anxiety is primarily due to stress breakdown and how much is due to performing new skills.
When a normal person is suffering the adverse effects of excessive stress, the first symptoms to be experienced are the symptoms of anxiety. Anxiety is the alarm mechanism of the nervous system which alerts us to the fact that the nervous system is beginning to fail to process the information adequately.   It is possible to diagnose our anxiety symptom immediately they occur with five questions – two related to the tasks required of the brain, and three related to factors which will reduce the brain’s processing ability.
A person suffering from anxiety symptoms due to excessive stress can stop whatever he or she is doing immediately and take steps to restore the normal balance between the brain’s processing ability and the tasks required of it. These steps will prevent progression of stress breakdown beyond this first stage, the stage of anxiety symptoms.

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The first explanation of why we need to sleep is coherent with the theory of evolution and survival. Hibernation, which is like a very deep sleep in winter for some animals, has been studied extensively by biologists. It is an adaptive survival mechanism enabling certain animals to survive long snowy winters; without it, many of these animals would face extinction. The hibernating animals do not need food during the winter months, at a time when food may be scarce or unavailable. Just before winter comes, they have built up a great deal of body fat. When winter arrives, they automatically go into extremely low activity and so can survive solely on their fat reserves. There is very little movement, the body temperature is very low, the metabolism is minimal, and the breathing is slow and shallow. The brain waves of these hibernating animals are nearly silent and are in distinct contrast to those of sleep. Normally, during hibernation, the animals cannot be aroused, even if given a good shake.

Hibernation has been studied in laboratory conditions. The animals are kept inside in the warm with plenty of food throughout the winter. However, they still go into hibernation, as if there is a need for them to do so. Hibernation is an innate mechanism in these animals; they do not have to learn how to hibernate. Hence the mechanism could have been handed down from one generation to the next through the genes.

What about sleep? Sleep is distinct from hibernation. This is shown by the different brain wave pattern and the fact that an animal can always be aroused from sleep but not from hibernation. Sleep is possibly another evolutionary adaptation to survival. The earth rotates once every 24 hours and any one point on the surface is in darkness nearly half of this time. Man has been walking on the planet Earth for over a million years. Remember that artificial light such as candles, oil lamps, and electric lights are inventions only of the last few thousand years. During the long dark night, primitive man had nothing to do. In fact it could be dangerous to move around in the dark. Man could injure himself easily by tripping over in the rugged country or through meeting some vicious animal. Hence he withdrew, stayed put, closed his eyes, and slept.

The need to sleep at night not only withdraws us from a dangerous environment, but also allows us to rest and restore our energy. Sleep is an innate biological function like hibernation, and has been studied under laboratory conditions. Even if the room is continuously brightly lit without the cue of what time of day or night it is, we still feel the need to sleep once every 24 hours or so. Here, the need to sleep is very similar to the need to hibernate—an evolutionary adaptation for survival.

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At the present time there is a fashion for frequent reference to the problem of homosexuality in literature, in the theatre, in films and TV. As a result, the idea of homosexuality is brought to the minds of many sensitive young people who would otherwise never have thought of it. They begin to question themselves, and come to worry about it, and they often think back to some experience of their childhood or youth which involved some degree of examination and experimentation with another of the same sex. Such experiences are common in the youth of normal people, and in the vast majority of cases do not lead to any difficulties in later life.

The opposite set of circumstances also occurs. There are of course young men who do have homosexual traits in their personality. But many of them are not aware of any homosexual bias in themselves. These people are often chronically tense. Strangely enough their tension shows itself in different circumstances according to the degree to which their homosexual traits are repressed. They may become very tense in the company of girls of their own age, while with others the nervous tension is more marked with companions of the same sex because of the strange feeling of attraction which they do not understand or of which they may not be aware. However, the reader is warned that many sexually normal, but introvert, young people experience rather similar anxiety which is of no serious import at all.

Of course it is not uncommon for the young person of either sex to become aware that he or she is homosexually inclined, and then to marry in an attempt, as it were, to cure the homosexuality. In these circumstances a married life based on love and tenderness is virtually impossible, and both husband and wife soon develop the symptoms of nervous tension in greater or lesser degree.

This week I saw a tense young woman who was having difficulty in her marriage on account of her tension. She was working as a fully qualified professional psychologist. With a valiant effort to control her distress, she asked, “Am I a Lesbian? I have a girl friend whose company I enjoy very much.”

She was greatly relieved when I explained that we all have quite normal homosexual traits hidden within us. It is only when these are grossly exaggerated that the individual is abnormal. If she had not been concerned with psychology, the thought of her being a Lesbian would probably have never occurred to her.

An intelligent young widow, the mother of three children, was desperately lonely for adult companionship. She came to enjoy a close friendship with a woman, who unbeknown to the patient was in fact a Lesbian. The widow enjoyed the friendship, and as a result her general health, mental and physical, improved. Then suddenly the patient realized that the other woman was a Lesbian. She was overwhelmed with the most terrible panic and self-loathing in the belief that she herself must be tainted.

Tranquillizers and logical explanation did nothing to relieve her turmoil; but as she learned to relax physically she came to experience calm of her body in her mind, and over a period of some weeks she regained her equilibrium.

A young university student arrived in great distress. Before coming to the point, he had to justify himself. “The only way to have a full life is to have full experience of life.” He was rather a mixed-up youth, and had come to associate with a group of pseudo-sophisticated students who talked a lot about homosexuality. He had decided to put this theory into practice. Quite deliberately he had sought out a homosexual, had accompanied him to his flat, and had had the experience he was seeking. Now he was in a pathetic state of acute anxiety.

The theory of living the full life and of experiencing all we can of life when we are young attracts many students of both sexes. There are, however, two areas where experimentation frequently leads to disastrous results. These are in homosexuality and in taking drugs.

*29\57\2*

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No one knows the answer to this question at this time for sure. In the course of evolution, the plant appears to have developed the capacity to produce many compounds that have pharmacological effects in humans and animals. Some of these substances are toxic to animals and in this way might have served to protect the plant over millennia of evolution. We know, for example, that cattle that eat too much of the plant can develop harmful or even fatal skin reactions when they are subsequently exposed to sunlight. I should emphasize that these harmful doses are dozens of times greater than the doses used for treating depression, which are quite safe.

Most of the research on St John’s Wort, both with depressed patients and in the laboratory, has been performed with an extract of St John’s Wort called LI 160. This extract contains many active substances. Although most attention has been focused on two of these substances – hypericin and pseudohypericin – more attention is now being paid to a third substance – hyperforin – which appears to have some of the pharmacological properties thought to be responsible for the effects of the herb as a whole. In dealing with an herb containing such a complex mixture of active compounds, it is quite possible that more than one of the compounds is having a therapeutic effect and that they are acting in harmony to complement one another’s actions.

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Two recently marketed SSRIs include Zoloft (generic name setraline) and Paxil (paroxetine). Both new drugs appear to be equal to Prozac in efficacy and safety. Like Prozac, Zoloft, Paxil and Luvox have minimal side effects, compared to the older tricyclics and MAOIs.

Both Zoloft and Paxil have shorter half-lives than Prozac, which suggests that on sudden withdrawal, there is a greater likelihood of producing symptoms than with Prozac, which tapers itself off over longer period of time.

Evidence indicates that all varieties of sexual side effects occur in approximately one third of all patients taking antidepressant medications, old and new.

How do Prozac and Wellbutrin compare to other antidepressants?

Prozac and Wellbutrin do not have the same mechanism of action. Wellbutrin works mainly by blocking the uptake of the neurotransmitters dopamine and norepinephrine in the brain; Prozac and other SSRIs work by blocking the uptake of serotonin.

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Depression experts and psychopharmacologists have conceptualized the treatment of depression into three parts: the acute phase, the continuation phase, and the maintenance phase.

The acute phase of treatment begins when the patient appears in the doctor’s office showing signs or complaining of symptoms of depression. At (his point, the immediate goal is to alleviate the symptoms as quickly as possible. This might mean medication, some form of psychotherapy, or a combination of the two.

The continuation or middle phase of treatment begins once the patient has responded to treatment. Too frequently, both the patient and the physician, believing that an improvement of symptoms indicates that the depression has been defeated, discontinue the medication. This is a mistake. Although the depression may have retreated, often it has not yet been conquered. It is simply in remission. If the patient is taken off medication too soon, the depression may attack again. Even with medication, relapses are common, which is why it is important to continue treatment during this phase. To prevent a relapse after the symptoms have disappeared, one study found that patients need to continue taking medication for four or five months.

During the third or maintenance phase of treatment, the object is to prevent another acute episode of depression. The way to do this is by maintaining the medication for as long as several years—or a lifetime. Patients often don’t want to do this, sometimes because they just don’t like the idea of taking drugs and they feel that they are “cured”. Yet the unfortunate fact is that for most people, depression is not a once-in-a-lifetime event More than 50% of patients suffering from a first bout of major depression will have it again at some point, and 80% to 90% of patients having a second episode will go on to experience a third. With disorders such as major depression, preventive medicine means long-term maintenance medication.

Emerging evidence also suggests that many depressed patients do better if medication is combined with three or four months of individual psychotherapy, cognitive therapy, or behavioral therapy. When the therapy comes to an end, however, the medication should continue if the depression is recurrent.

*97\22\4*

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Increasingly, lithium and Prozac are being used together, usually in cases of bipolar manic depression where lithium alone has not controlled the depressive side of the illness and in cases of recurrent unipolar depression for long-term stabilization. (Other antidepressants have also been used with or without lithium to control recurrent depression.) Lithium can also be used as a step-up treatment when TCA, MAOI, or SSRI antidepressants don’t seem to be working on their own.

Tens of thousands of bipolar patients in the United States and abroad are safely using Prozac with lithium. Frequent monitoring is necessary because there H have been infrequent reports of increased or decreased lithium levels, which may or may not be related to the Prozac.

Finally, patients diagnosed with recurrent schizoaffective disorder with prominent depressive component have sometimes been treated for long-term stabilization with a combination of lithium, Prozac, and an anti-psychotic medication. Thyroid medication may also be included in the regimen as a step-up treatment for the depression component of the illness.

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Although scientific research in this area is scanty and incomplete, the evidence so far indicates that children and adolescents can safely be given Prozac, assuming that the dosage is small and is escalated slowly. Younger patients can be given small doses of liquid Prozac, while adolescents can probably take larger regular capsular doses approaching those of adults.

However, some evidence suggests that even in their late teens and early twenties, young people may do better with smaller doses. One limited study observed the reactions of fifteen depressed, treatment-resistant young people between 16 and 24 years old to being treated with Prozac for six or seven weeks. Although they were initially put on a standard dose of 20 mg of Prozac a day or even every other day, the dose was soon reduced to 5 or 10 mg a day. For a third of the patients, that small dose was enough to create a significant shift in the depression, which suggests that young people normally might be started on 5 or 10 mg a day. Overall, seven of the eleven patients who completed this study showed a positive change according to one standard depression rating scale, and eight showed significant improvement according to another scale. Considering that these young people had been unsuccessfully treated with other antidepressants, this admittedly small study offers real hope.

However, it is absolutely essential that the prescribing physician take a detailed family history, which can reveal a genetic predisposition toward manic depression. In some cases, children taking Prozac have become agitated, and one published study described five adolescent girls, all with family histories riddled with major depression and suicide, who developed mania while taking Prozac. This is not at all surprising to me, since the family histories also revealed evidence of manic depression or one of its genetically linked illnesses such as alcohol and drug abuse, suicide, gambling, depression, or sociopathy.

The need still exists for carefully controlled clinical studies comparing the responses of children and adolescents to Prozac and other standard drugs. In the meantime, youngsters taking Prozac should be observed closely and frequently, and side effects should be reported. If the psychiatrist or the family is in doubt about the child’s response or any emerging side effects, the drug should be discontinued. A child psychopharmacologist who specializes in treating childhood depression with drugs is the most appropriate person to consult.

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Prozac is really contraindicated in cases in which the patient has been experiencing the manic or hypo-manic ups that are the most important signs and symptoms of manic-depressive illness or other bipolar disorders. With or without the depressed downs, patients with a history of clear-cut hypomanic or manic episodes should not be treated solely with Prozac or other antidepressants because these drugs can induce a full-blown manic or even psychotic episode. (The same problem may exist when a patient is diagnosed with major depressive disorder but the family history shows strong signs of bipolar disorder.)

However, Prozac can be an important part of a coordinated treatment program when combined with lithium or the alternatives Tegretol or Depakote. If the mood swings have been treated with these medications and as a result, the highs have been stabilized but the lows have not, the addition of small amounts of Prozac may help stabilize the overall manic-depressive condition.

In my experience, patients with hypomania or mania should under no circumstances take Prozac or any other antidepressant drug without first being stabilized on lithium or one of its alternatives. If such a mistake is made by the physician, the patient may report feeling supertransformed in what is becoming a manic psychosis that will require hospitalization.

Needless to say, if the Prozac patient on or, off lithium is having this reaction, the immediate discontinuation of Prozac, an increase in lithium, and possible hospitalization are required.

However, caution must be taken when combining Prozac with antimanic drugs. In three isolated instances, the so-called toxic serotonin syndrome has been reported in patients taking a combination of Prozac and Tegretol, and in one case—the only one in eight years—it appeared in a patient taking Prozac and lithium. The symptoms of the serotonin syndrome are serious and best treated in a hospital. They include shivering, m dizziness, loss of coordination, and involuntary muscle movements.

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