MORE SPECIFIC PROBLEMS

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 Eating disorders or just overeating--see discussion and examples of 20 Methods for Controlling Behavior given above (mostly for overeating). It is estimated that 55% to 70% of us Americans are overweight, about 25%-35% of us are just plain obese (20% or more over-weight), while another 12% are classified severely overweight. An estimated 44% of us go on a diet sometime during each year, explaining the enormous amount spent on diet books. Fat, especially in our upper body, endangers our health. In women, the risk of heart disease increases with the addition of only 10 or 12 pounds above your ideal weight or your weight at 18. The obese have 3 to 5 times the risk of heart disease, 4 to 5 times the risk of diabetes, more back trouble and, in general, a lower quality of life for a shorter while. Note: being obese or even just a little over-weight is regarded negatively in our culture (Moyer calls it "demonized"). Remember, being over-weight may have physiological causes and over-eating often becomes a powerful habit that is almost impossible to conquer. Large people deserve our sympathy, not our disdain and rejection.

 Just a brief note about the prejudice against fat people: It is one of our culture's more unfair discriminations. About 16% of American parents-to-be would abort an untreatably fat child if it could be predicted, that's about the same as a retarded child. Fat people scare many children by age 3 or 4 because they look different. In grade school, children often describe their over-weight peers as dirty, lazy, ugly, stupid, sloppy, etc. Teenagers sometimes cruelly tease and insult them, often avoiding them. One study showed that college students would rather marry an embezzler, a drug user, a shoplifter, or a blind person than a obese person. The very over-weight are often denied jobs and health insurance; they earn 24% less than others; they frequently have few friends. Obesity (and the way other people react to them) often leads to low self-esteem and deep depression. (Most of this information comes from Carey Goldberg's New York Times article on 11/5/00.) As a culture, we need to find ways to control our weight and ways to curb our prejudice.

 There is clear evidence that obesity is correlated with many more medical problems and expenses than smoking or drinking, but this relationship may not be causal or as simple as it seems. Dr. Glen Gaesser (2002) reports that today's popular health literature implies that being over-weight is responsible for 300,000 deaths a year. He believes fat may not be the main villain because several other unhealthy characteristics are often associated with being over-weight, such as poor diet, lack of exercise, poor fitness, bad dieting habits, inadequate health care, and so on. Providing some confirmation of this notion, Dallas's Cooper Institute has found that the high mortality rates among the obese was explained by activity levels, not weight. Those researchers suggest that a brisk 1/2 hour walk every day will result in the same mortality rates as thin people have. Books for weight-control may be over-emphasized while books about exercise are under-emphasized. See exercise.

 Ordinary, simple overeating is very common but there are several types of quite serious eating disorders. Overeating can develop into frequent recurrent overeating episodes called Binge Eating Disorder. There is a chance that bingeing and/or very strict dieting can develop into Bulimia or Anorexia. Bulimia involves impulsive binge eating followed by harmful self-induced vomiting, laxative or diuretics use, and compulsive exercise. Anorexia involves seeing one's self as fat when in reality you are very thin; this is a dangerous disorder because anorexics may refuse to eat, eventually starving themselves to death (1 in 10 die from a related cause). About 10 million American women have an eating disorder, although it is adolescent and young women who account for 90% of the disorders--50,000 will die as a result. About 15% of teenage girls have some kind of eating disorder but only 1/3 seek help (some are embarrassed, others do not realize they have a serious problem). Bulimics often remain normal in weight, so no one else knows, but between 1% and 3% of young women suffer this disorder. Men are as over-weight as women but they do not have anorexia and bulimia nearly as often.

 Although often left untreated, eating disorders can devastate the body and the mind (depression, anxiety, addictions). I won't give details, but believe me, this is a serious matter. Eating disorders and/or being obese (say, 50+ pounds overweight) should usually be treated by professionals--these are deeply ingrained addictions and often not responsive to self-help. Ideally a team is needed: psychologist, physician, and nutritionist. Ordinary overeating or moderate overweight may be a self-help problem. But when your weight creates a physical problem or a serious psychological problem or if your self-help efforts just aren't working any more, get professional help. Some sources of information and professional treatment for eating disorders are given below, but the self-help methods and references mentioned here are for toning up and shedding up to 20-30 pounds over many weeks or months.

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 Beware of Commercial Weight-Loss Programs. There is little evidence that any commercial programs are effective. When I say “see a professional,” I mean a weight-loss experienced Psychologist, a MD who regularly deals with weight-loss, or a Professional Center specializing in Anorexia or Bulimia or extreme over-weight, NOT Jenny Craig, eDiets, Optifast, Health Management Resources, Medifast, or even self-help groups like Overeaters Anonymous, etc. The commercial programs cost between $65 and $170 for three months (most of us need more than 3 months). A medically supervised low-calorie diet might cost more than $2,000. Seeing a psychologist weekly for 3 months may cost a little less than that. If you don’t have insurance or can’t afford professional treatment, look for a counselor at your Community Mental Health Center who has an interest in losing weight.

 Surprising as it may seem, this huge lucrative area has undertaken very few dependable studies. Researchers in this area are very blunt about the people in this business—books, special diets, supplements, weight-loss programs, exercise programs, recipe books, over-weight treatments—who generally oppose disclosing the results of any outcome study. Stockholders in these businesses are looking for profit, not science. Investors and management openly argue that “research is not our business” or “it’s too expensive to do,” or some actually admit that “we are selling a dream, so it is not in our interest to produce discouraging research findings.”.

 Apparently, we consumers are so gullible we believe the slick ads—or we feel so ineffective when dealing with big corporations that we don’t ask for more evidence or for protection from false advertising. Indeed, our government seems to side with businesses and against consumers. The Federal Trade Commission has tried (somewhat) to get data from many weight-loss companies that would enable objective researchers and customers to assess the effectiveness of specific weight-loss programs. The industry refused to cooperate with FTC and the government took no action, not even setting aside significant money for independently researching the effectiveness of these programs. It is a buyer’s beware market!.

 The situation just described has not just been uncovered; it has been reported for years. A recent big and well designed study supporting these findings has just been published by Dr. Thomas Wadden and Dr. Adam Gilden Tsai (both at University of Pennsylvania) in Annals of Internal Medicine (January, 2005). Reviewing the entire weight-loss literature from 1966 to 2003, they found 108 studies of commercial programs but only 10 of them met minimal standards for research, such as lasting 12 weeks or more and checking the weight-loss of clients for one year after the study. Even within the top 10 studies, most did not include the subjects who dropped out. Since 50% to 75% of participants in commercial weight-loss programs drop out, weighing only the ones that stay in the program is something like trying to evaluate the quality of teaching by testing only the better students.

 Another large scientific study of diet supplements (Dr. Robert Saper, in American Family Physician , November 1, 2004) did not find any that led to weight loss. Some were potentially dangerous. Yet, 7% of adults use supplements and 28.4% of young, overweight women use them..

 To their credit, Weight Watchers have published a few studies but the results have not been encouraging. Wadden and Tsai cite the Weight Watchers study published in The Journal of the American Medical Association (2003). There were 423 subjects and half were assigned to regular Weight Watchers groups and the other half were told “to try to lose weight on your own.” The average starting weight was 205 pounds and two years later the Weight Watchers group had loss an average of 6.4 pounds. That is very slow loss but the do-it-yourself-group had not lost any..

 Most other dieting programs had failed to do much if any evaluation. When a study had been done of a program, sometimes an untreated control group was encouraged to use a self-help manual. The self-help group frequently lost weight about as well or even better than the commercial program. Of course, some people do lose weight with any of these methods; however, according to Wadden & Tsai, people who lose weight will usually regain a third of what they lost in one year and regain two-thirds in two years. In three to five years most people will be back to where they started. Discouraging, isn’t it? We have to think in terms of permanently changing our eating and exercising habits, not just trying to get through a diet for two or three months..

 It is important for me to make it clear that just because a weight-loss program chooses to not evaluate the efficacy of their program, that does not mean, the weight loss method is a scam or a failure. We just don’t know its effectiveness. You can bet, however, that the producer of any program would surely do the research and publish it widely if their results were likely to be markedly better than the competition. Just keep this in mind as you develop a weight-loss plan that the big commercial systems have done little acceptable research. ^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ .

 Losing weight requires either taking in less or burning off more. The research strongly suggests that both a restricted diet (fewer calories, less fat, more fruit and vegetables, less snacking, avoiding rich foods) and an exercise program (burning 1000+ calories per week) are necessary for most overweight people. Indeed, some studies have indicated that for some people weight loss may only come with vigorous (90% of maximum) exercise for months, not light exercise. Hard exercise seldom makes you feel tired, to the contrary, exercise usually gives you energy (although you may go to sleep earlier). There are people, however, who find hard exercise so unpleasant that they would stop trying to lose weight if they had to exercise. So, adjust to your needs. Feeling tired is often actually caused by the lack of exercise, called "sedentary inertia." So, a demanding exercise program is for some a must, for others moderate exercise and a restricted diet will work. Several Web sites discuss exercise: APA Help Center and CNET: Downloads contain 50 or more software programs to aid weight loss via exercise. Many search engines will generate a few thousand weight loss and exercise sites.

 It has been demonstrated that many women are in a bad mood (more depression, insecurity, and anger) after viewing pictures of fashion models. Some therapists think the combination of envying thin models and a negative self-critical mood prompts women to binge and then purge. Note: eating disorders increased 5 fold in teenaged girls soon after TV came to Fiji. There can be no doubt that Americans are unhappy with how they look, about 65% of women are dissatisfied with their weight. How dissatisfied? Psychology Today (Jan, 1997) did a survey that showed that 24% of women and 17% of men would sacrifice three years of their life to be their desired weight. It becomes an unhealthy cycle: body loathing causes emotional distress which increases the disgust with the body. Psychology Today's suggestions for accepting and feeling better about your body are: Stop looking at fashion magazines or ads anywhere. Realize your self-concept must be much broader than looks; weight isn't what makes you a good or bad person. Appreciate all the uses, abilities, and uniqueness of your body just as it is. Do things that make you feel good about your body--exercise, dress well, have good sex, etc. Change or get out of negative relationships. Develop positive self-talk about your looks to replace the criticism. Learn people skills, especially empathy, "I" statements, and assertiveness (ch. 13), so you are more caring and likeable (counterbalancing the prejudices people have against over-weight people).

 Clearly one of the questions facing every overweight person is this: Is the problem my habitual overeating or some underlying emotions that drive me to eat? The answer is not easy. Being over-eating may upset us and emotions may cause over-eating. For example, over-weight 9 and 10-year-olds do not suffer low-esteem but by 13 or 14 they do! On the other hand, people dieting, who have a history of depression, are at risk of becoming depressed again (the same is true of people stopping smoking). So, the answer is "well, for some people it is just family customs or habits of loving beer and pizza" and for other people the answer is worry about body image, depression, marital stress, conflicts at work, workaholism, or hundreds of other possibilities. You may need to figure it out in your case.

 Capaldi (1996) tries to help us understand how eating patterns are based on life experiences and how to change those patterns. Thompson (1996) explains more about the connections between body image and eating. A good book to help you start exploring the emotional possibilities underlying eating is Abramson (1998). To consider the more psychoanalytic reasons for overeating, such as an unconscious desire to be fat or a fear of being thin and sexy, read Levine (1997). There is probably no way to determine with any certainty the role of emotions in driving your food/drink intake except by (a) keeping a diary of the events in your life, your emotional reactions and your food intake, (b) openmindedly reading therapy cases and asking yourself "Could this be true of me?" or (c) getting therapy.

 Keep in mind that although a lot of research is being done and much is thought to be known, we are still pretty ignornant about all three--weight, emotions, and changing our bodies. Many studies are small, say with 20 subjects or so, and result in conflicting "findings," other studies are suspect because they were supported by companies selling a product or people pushing a diet, and some pronouncements just aren't true. For instance, a recent study (Anderson, 1999) reported that very over-weight dieters who went on a very low calorie diet (500-800 calories per day) and lost weight quickly had kept more pounds off seven years later compared to slow losers. That is in conflict with the standard expert recommendations, like Weight Watchers, of a slow loss of weight by learning new eating habits. Likewise, it is popular to pronounce that losing weight (e.g. 5% or 10% of your weight) doesn't prolong life but exercising does. Yet, there are new findings (Scientific American Frontiers, Public Television, Jan 25, 1999) suggesting that a very low calorie but nutritious diet improves health and prolongs life by a very significant amount, at least in mice. Let's not get too certain of what we "know." One thing everyone agrees on however: consult with a doctor if you are considering an extreme diet (which may cause gallstones and perhaps other problems).

 Important health concerns and our excessive obsession with thinness result in the brisk sale of diet, cook, and weight loss books. The hundreds of new diet books every year mainly repeat each other. And nutritional theory changes like fashions from a high carbohydrate diet to high protein diet to low fat, back to a Mediterranean diet (with olive oil), and we will go to something new next year. Pritikin (1998) says there are three ways to lose weight: (1) a restricted diet (but many are always hungry), (2) high protein, low carbohydrate diet (not healthy and still hungry), and (3) low fat, high fiber diet (his diet=veggies, fruit, grain, low-fat animal foods). In any case, the food intake has to be well controlled to lose weight, so it is important to be nutritionally well informed. See Wills (1999), The Food Bible, and Food and Drug Administration, NIDDK Health Information, or Dietary Guidelines.

 Another critical skill is behavioral self-control as spelled out in the Methods for Controlling Behavior section of this chapter. Several books, some fairly old, also spell out techniques for controlling eating over the long haul. Keeping in mind that calming the emotions that trigger eating-for-comfort and using diet/exercise methods that you can enjoy for a long lifetime are important, try some of these books: Kirschenbaum, 1994; Virtue, 1989; Mahoney & Mahoney, 1976; Fanning, 1990; Jeffery & Katz, 1977; Stuart,1978; and a diet program by Marston & Marston, 1982. Now mushrooming weight loss Web sites have joined books. Here are some of the better ones: American Dietetic Assoc., Cyberdiet.com, S-H & PSY, Cyberguide to Stop Overeating, Healthtouch--Weight-Control & Dieting, National Eating Disorders, Overeaters Recovery, Growth Central ,which offers individual and group programs, and Obesity & Weight Control which is mostly about drugs for losing weight. Like the weight loss books, the Web sites are very redundant. Two or three should be enough.

 Local diet and exercise centers are also available almost everywhere. Remember before investing money that most diet programs produce weight loss but 95% fail eventually, usually within one to five years. However, the better your general coping skills, as described in the Methods section of this book or in the books cited above, the more likely you will take it off. And if you focus on relapse prevention and maintenance, you can keep the weight off. It is probably fair to say that the people who maintain their weight loss also exercise for life, have social support, understand behavioral self-control methods, and confront their personal-emotional-interpersonal problems directly.

 The strength and tenacity of bad eating habits is shown by Perri's (1998) review of the effectiveness of weight loss programs with obese patients. Most programs take off some weight and some programs continue the maintenance of weight loss by extending the treatment and using phone calls as follow up. But, as Perri says, maintenance effectiveness tends to dissolve after termination. That means that you have to pay as much attention to relapse prevention as to weight loss. See Relapse Prevention in chapter 11 to control your impulse eating and re-start the weight loss plan as soon as you regain two pounds!

 Opinions differ about dieting. The professionals who work with anorexics and bulimics caution against diets because severe dieting is seen so often in their clients' history (they favor exercise rather than diets). To prove their point a recent study found that the 8%-10% of teenage girls who dieted severely were eighteen times more likely to develop an eating disorder than girls who had not dieted. (It shouldn't surprise anyone that diets are the first step but the study underscores that severe dieting may serve as a warning sign.) Another group of professionals simply say all diets are bad because they don't work in the long run. On the other hand, professionals dealing with very overweight clients consider diets to be a main solution to serious health problems. The facts are: obesity is certainly a health risk; weight loss is usually beneficial but can increase certain risks, e.g. yo-yo dieting year after year is associated with certain chronic diseases; diets do work (maintenance often fails); learning how to maintain weight loss is badly needed (Brownell & Rodin, 1994).

 Many diet centers and hospitals offer classes for extremely overweight people which provide detailed knowledge about how the body uses food, the role of fiber and fat, how to prepare better meals, and how much exercise is needed. Many (indeed, most) people don't know these things about nutrition, but once they know exactly how their diet and exercise program needs to be changed, they will often do it. I urge you to get that knowledge. Two of the better current books about fat and nutrition are by Bailey (1991, 1999) and Ornish (1993). Bailey also has four PBS videos (1-800-645-4PBS). It is commonly thought that very strict diets will be so unpleasant that people will not stick with them, but research has shown that stricter diets are actually more effective. Strict diets tend to be simpler and easier to follow.

 Losing weight may require attention to your feelings and interpersonal relationships. Obviously, if overeating is a misguided attempt to handle some emotional pain, the emotions need to be dealt with. See Abramson (1993) for ordinary "emotional eating" and Sandbeck (1993) for the shame, guilt and low self-esteem that often underlie bulimia or anorexia. Virtue (1989) and LeBlanc (1992) also address this specific situation. Farrell's Lost for Words, a psychoanalytic view, is online. Empty lives can cause cravings for food; unhappy spouses gain two to three times the weight that happy spouses do! For the various unhealthy psychological uses of fat in a marriage, see Stuart & Jacobson (1987). Therapists report that over-eaters often need unusual attention, nurturance, and warmth. Roth (1989, 1993), a good writer, and Greeson (1994) have written that food is used to replace the love that is missing. It has been reported that depression may increase while dieting but people are usually happier after the fat is gone (Brownell & Rodin, 1994). Interestingly, interpersonal therapy focusing on relationships and attitudes toward weight has been just as effective as cognitive-behavioral therapy focusing on eating habits. Self-help groups are often helpful, too (Weiner, 1999). To find a support group online: Mental Earth Community, Grohol's Forums, Support Groups, Support Path.com, Eating Disorder Recovery Online, and a newsgroup at alt.support.eating-disordFAQ. Support groups are also discussed in the next chapter. Another resource you should consider seriously is Overeaters Anonymous, a world-wide organization. To find a local group see Overeaters Anonymous in your White or Yellow Pages or email overeatr@technet.nm.org for information. There are two OA Web sites: Recovery and Overeaters Anonymous. Keep in mind that 12-step programs, like OA and AA, need to be supplemented with nutritional information and cognitive-behavioral self-help methods. A caution: it has been reported that some anorexics become more anorexic after interacting with fellow anorexics in support groups or chat groups.

 Since most people try to lose weight on their own, it is to be expected that self-help programs and methods will appear. Fairburn (1995) has developed a science based self-help program for overcoming the binge eating. Crisp, Joughin, Halek & Bowyer (1997) offer self-help to anorexics. Schmidt & Treasure (1994) describe self-help methods for bulimics. Remember, serious eating disorders need professional help too. Peterson, et al (1998) found that a structured group self-help approach was as effective with binge eaters as therapist lead psychoeducational and discussion groups. Burnett, Taylor & Agras (1985) and, more recently, Personal Improvement Computers have developed small hand-held computers that assist moderately overweight patients to control and monitor their food intake.

 Web sites providing information for losing weight were given above but even more sites are offered for understanding the more serious eating disorders: Eating Disorders (see "Best on the Net"), MHN-Eating Disorders, ivillage diet, Eating Disorders, Futter Eating Disorders, Lucy Serpells Eating Disorder Resources, American Anorexic Bulimia Association, Concerned Counseling Eating Disorders, Surgeon General, Assoc of Anorexia Nervosa & Associated Disorders, Something Fishy's Eating Disorders, and, lastly, more treatment programs for serious eating conditions, Binge Eating. Bulimics and anorexics usually have additional psychological and interpersonal problems beyond the abnormal eating. They often have poor social skills and are frequently in conflict with family members. Young bulimic women tend to be dependent and have trouble separating from their mothers. Judi Hollis (1994) says she has never met a starving or bingeing woman who wasn't raging inside, usually at her mother. Serious eating disorders require professional treatment.

 People with eating disorders need to learn better communication and problem-solving skills and, then, change their eating-exercise habits, such as having regular meals that include previously avoided foods, learning new ways of handling the bingeing-purging situations, and modifying their attitudes towards their shape and weight (see the previous section in this chapter). This usually means therapy. Thus far, the cognitive-behavioral methods are only fairly effective with bulimia by persuading the patient to stop dieting since bingeing is a natural reaction to starving the body (Wilson, 1993). Also, after the binge-purge cycles stop, the person needs to cognitively accept his/her "natural weight," based on healthy food and exercise. Keep in mind, serious eating disorders are remarkably resistant to change; only half of patients in treatment will be fully recovered in five years (American Journal of Psychiatry, 1997, vol 153). Like all long-term disorders, bulimia and anorexia place great stress on the family; they all may need help (Sherman & Thompson, 1997). Unfortunately, the prevention programs for young at risk women have, thus far, not been effective. These urges are hard to change.

 There are many additional sources of help. See Bennion, Bierman & Ferguson (1991) for a factual discussion of weight control. Parents worry about their children's weight too; there is help (Archer, 1989). Perri, Nezu, & Viengener (1992), Epstein, et al (1994), and Brownell & Wadden (1992) provide therapists with guidelines for managing serious obesity. For information and referrals about anorexia and/or bulimia, call 847-831-3438. For more information about locating Cognitive-Behavioral therapists, call 212-647-1890 or try the Web site for abbt. All obese people and persons with an eating disorder should have a psychological or psychiatric evaluation, including an assessment of the family. Most importantly, you must realize that extreme anorexia, called "the fear of being fat," can be fatal (5% die, half from complications and half from suicide); don't put off getting professional treatment for anorexia and bulimia, three-quarters can be helped by behavioral therapy. See eating disorders at the end of the next chapter.

Guidelines for Losing Weight if Moderately Overweight

 1. Remember the expertise of three disciplines are involved: psychology, nutrition, and medicine. You need to know some of all three.

 2. Become familiar with the 20 Methods for Controlling Behavior described above.

 3. Realize that good weight loss is probably not starving, a crash diet, pills, or a special “program,” it is simply acquiring the habits to eat good tasting, healthy food in the right amount for the rest of your life. For some dieters, especially those with a lot to lose, a special diet is necessary to get satisfying results. Get your "bulk," as my Grandmother used to say. That means high fiber--vegetables, beans, fruit, nuts, and grains--which give you only half as many calories as meat, sugars, cheeses, and fried foods. An occasional "day off" may make a long diet more tolerable.

 4. Weight loss almost always involves increased exercise. Be active, move around even in sedentary jobs; it’s good for you. If exercise is hard for you and you do little, read Fenton & Bauer (1995) who recommend walking. Also, strength training ("pumping iron") will add muscle as fat comes off; muscle burns more calories and keeps your metabolic rate high (Nelson, 1999). If you are not used to hard exercise, see a physician, build up gradually, and guard against injuries.

 5. To drop one pound of weight each week: Cut 250-300 calories per day (1 candy bar, 2 light beers or soft drinks, 3-4 oz. of meat or cheese) AND exercise more each day (1 hour walking or yard work, 1/2 hour jog or bike ride, 1/2 hour swim). One pound=3500 calories.

 6. Find a time of relative quiet in your life to start your new eating/exercise habits. Once started, avoid missing any days (if it happens, get back on schedule as soon as possible).

 7. Eat at times and in sufficient amount so you don’t get hungry. Relax and enjoy eating. Don’t let your calorie intake drop below 1100 calories per day.

 8. Your genes may be a factor. Eating Disorders and being overweight tend to run in families (that doesn’t prove it is genetic). However, depression, low self-esteem, helplessness, poor body image, anxiety, obsessive-compulsive habits, and sometimes perfectionism, addictions, and impulsiveness also run in families with Eating Disorders. Histories including teasing, rejection, abuse, death of a loved one, and giving birth are common. These factors make losing weight a little harder but they won’t stop a determined self-helper.

 9. Realize that medication can be of help with certain eating disorders, especially bulimia.

 10. If changing your eating habits seems to be impossible after several weeks of trying, get serious about discovering the emotions and needs underlying your overeating (see the books and Web sites listed above). If that doesn’t work, get professional help from a psychologist with experience in this area.

 11. Find the emotional roots of your urge to eat. What are the psychological concerns (relationships, frustrations, needs) underlying the eating problem. If you can reduce those concerns, you have a better chance of stopping overeating and of avoiding relapse (The Weight Control Digest, May/June, 1997).

 12. Keeping a food diary is very helpful, especially if you record the circumstances in which the urge occurs, what you were thinking, feeling, and doing immediately before hand, and how you responded to the urge to eat. A graph showing your progress can be very satisfying. A recent study at Duke University shows that bingeing by women is triggered by depression, getting off their diets, gaining weight, low self-esteem, and anxiety. Bingeing by men is preceded by anger, getting off their diets, thoughts of food, conflicts, and fasting. Plans ways of dealing with your triggers to binge.

 13. Celebrate and brag when your pants are loose and slipping down. (Actually it is important to reward in some brief way the achievement of each daily and weekly goal.)

 14. Make plans to maintain your gains. Use relapse prevention if needed. In any case, get serious about your weight whenever you gain 2-3 pounds over your desired weight, taking into account your normal weight changes by time of day and, for women, time of month.

 15. Live a long, active, healthy life.

 Gambling: Many people occasionally gamble small amounts at a local state-approved casino or on trips to Atlanta or Las Vegas. They are social gamblers, like social drinkers, and some spend quite a bit of time in a casino but they are not out of control. Most people gamble for excitement, novelty, and fun; some do it to escape stress. Unfortunately, the people who need money the most, gamble the most. People who make less than ten to fifteen thousand dollars a year gamble six times more often than those who earn over fifty thousand dollars a year. About 1/3 of problem gamblers are women.

 We aren't talking about gambling for fun here; we are discussing a powerful habit or mindset that occupies most of your free time, wipes out your savings, leads to stealing, writing bad checks, and neglecting your children, and destroys relationships. Gamblers drop over 50 billion dollars every year, 30% comes from problem gamblers. That's more money than spent on movies, recorded music, theme parks, and sports events combined! That's huge. Ironically, gambling brings in 12 billion to 37 state governments, but those states spend only 20 million to help the addicts, with ruined lives, get treatment, education or prevention.

 Robert Custer, MD, writing for the Illinois Institute for Addiction, describes three common phases in gambling addiction. First, there is a winning experience or phase, a happy time that hooks them into hoping for more windfalls. They quickly become unduly optimistic (“I have a feeling I’m going to win”) and start betting larger amounts. Second, is the inevitable losing phase. Still bragging about previous winnings, they now start to gamble alone and obsess more about winning back their losses. The problem, as they now see it, is how to get more money so they can recoup their losses. They start lying about their activities and losses; they raid or beg for spouse’s and relative’s money; they may become withdrawn, anxious, and irritable when they can’t pay their debts. Last is the desperation phase. Many feel hopeless panic knowing they are in an impossible economic situation. They may blame others or get very depressed, about half abuse alcohol or drugs. Divorce, arrests (2/3’s commit crimes), mental breakdowns, etc. are not uncommon.

 The Illinois Addiction Recovery web site (see above) has a test to help you determine if you have a gambling problem. Over 85% of Americans have gambled at least once, so remember it is causing problems and getting into trouble that defines a serious addiction. Gamblers with significant problems make up only about 1%-2% of the American population. It is important to note, however, that teenagers are three times more likely than adults to become problem gamblers. Each “problem gambler” costs the taxpayers about $3000 a year, according to the University of Chicago’s National Opinion Research Council. Moreover, as the state-run lotteries become more popular with huge payoffs, addiction rates go up. Every gambler in some part of his/her mind recognizes that in the course of time he/she will almost certainly lose money. Yet, gambling enthusiasts somehow contort their minds into believing that they not only can win but have a “good chance” of winning. It is very irrational thinking.

 There is evidence that Cognitive-Behavioral treatment focusing on correcting misconceptions about gambling (as well as teaching problem-solving, social skills, and relapse prevention) can be successful (Sylvain, Ladouceur & Boisvert, 1997). However, most of the gambling treatment centers associated with hospitals and psychiatrists are, like alcohol programs, associated with 12-step programs (see Gamblers Anonymous or call 1-213-386-8789). The Gambling Help Line (1-800-522-4700 or 1-800-GAMBLER) offers crisis counseling and information, including treatment and GA group locations. Gam-Anon can be reached at 718-352-1671. The search engines, such as Yahoo and Alta Vista, list some of the gambling treatment programs available around the country. Few treatment centers will serve gamblers who have lost their savings and health insurance, and can't pay for the services. Gamblers in serious trouble only have Gamblers Anonymous.

 More information is available from the National Council on Problem Gambling. Also, some states have comprehensive Web sites concerned with several types of addiction, such as the Illinois site cited above and the Michigan Compulsive Gaming Help Line. Other Web information sources include Gambling Treatment which is just one of about 10,000 treatment centers (see the search engines).

 Hazelden offers several books about this addiction, mostly testimonials, inspirational, or informational, not many explicit self-help approaches. Indeed, the general view seems to be that gambling addicts with serious problems must seek treatment, not try to do self-help themselves. Walker’s (1996) book while descriptive does not offer a lot about treatment and even less about self-help methods. Of course, self-control is probably possible for most people who are just starting into the losing phase. This entails just staying away from gambling, i.e. cutting your losses, and avoiding, at all costs, the temptation to “chase” your losses (trying to recoup your losses by betting more). If that doesn’t work, get help.

 Hairpulling (trichotillomania) becomes a strong habit, often resulting in bald spots. A recent study (Keuthen, O'Sullivan & Sprich-Buckminster, 1998) has reviewed several approaches and found that the treatment of choice, at this time, is habit reversal training described above. Other treatments were less successful: Cognitive-behavioral, punishment, and psychiatric drugs.

 Internet addiction is a new affliction for human-kind. With millions of people around the world, including 60 million Americans, logging onto the Internet, there is bound to be some addiction. Like workaholism, Internet “addiction” is not using the Internet for many hours of work and pleasure. To be an addict, as I'm using the term, the logging on has to cause problems, such as in the 5% to 8% who become so “hooked” that they spend almost all their spare time online, even going without sleep. Other Internet users (about 15% of total Internet users and far more men than women) become attracted to pornography online, some of them spend a lot of time and money being a voyeur and avoiding real relationships. (Keep in mind that about 80% of Internet users are married, committed, or dating someone.) Still others, twice as many women as men, spend inordinate hours seeking friendships, support, emotional exchanges, and/or flirtatious-sexual interactions in newsgroups, forums, and chat rooms. Some young people spend hours with interactive computer games. All this time spent online reduces the time available for face to face relationships, for productive work and learning, and for recreation/leisure/physical activities. Therapists working in this area observe that addicts frequently deny any problem until confronted with a personal crisis, like doing poorly in school, getting caught misusing a computer at work, or facing criticism from a partner. If you spend more than a couple of hours per day on the Internet playing games, flirting, or seeking sexual-pleasure, you should ask yourself if this is the best use of your time.

 Probably thousands of married people have had emotionally involved “affairs” online, some even sneaked out to rendezvous. When caught, these online relationships can devastate a marriage. Other examples of problems: parents have been charged with child neglect caused by this addiction. One study found that people judged to be Internet addicts averaged (in excess of work hours) 30 hours per week online (for a few it was 100 hours per week). Students have flunked out of college because they were online so much. Contrary to what you might believe, the average Internet addict is not a teenager, but 30 to 40 years old, 40% are women, and one third earn over $40,000 a year. A surprisingly high percentage of Internet addicts have a psychiatric disorder, often manic-depression, anxiety, low self-esteem, anorexia, an impulse control disorder or a substance abuse problem (Shapira, et al., 1998).

 Another survey of Internet users (Cooper, Scherer, Boies & Gordon, 1999) also found that the people who frequently logged onto sex-oriented sites often have psychological problems and stress, including running risks to real relationships. However, these authors believe occasional visits to sex or flirtation sites may be harmless entertainment for most people. Yet, they say that the 8% of heaviest users of such sites (11+ hours/week) may be harmed, primarily by exacerbating their sexual compulsions. The study also noted that about 60% of the respondents using sex related sites didn’t tell the truth about their age, almost 40% had pretended to be a different race, and 75% kept secret how much time they spent on such sites while denying any guilt about the activity.

 For those of you interested in more information about the connection between pornography and sexual activities or acting-out, see Dr. Cline's powerful statement. The Surgeon General's Office has also produced an unclear report on the effects of pornography (the scientists on the commission disagreed with each other). Not all researchers believe that pornography is a consistant cause of sexual aggression. Often aggressive tendencies are seen before the offender started looking an pornography (Seto, Maric & Barbaree, 2001, in Aggression & Violent Behavior, 35-53); likewise, the offender had often been abused himself as a child before he got access to pornography, so we don't know for sure what the primary causes are. Keep in mind, too, that many writers of the material cited in this section are therapists or evaluators working with addicts who have gotten into deep psychological, interpersonal or legal trouble because of sexual addiction. These writers have found and report that people who cheat on their spouses, who abuse children, who rape do not restrain themselves from looking at pornography. No surprise there. What we don't know for sure, yet, is if there are avid viewers of pornography who never mistreat or abuse anyone...and who have good healthy sex lives and loving relationships. If such people exist, we don't have professional experts writing about that group yet.

 A psychiatrist, Dr. Kimberly Young (1998; 2001), has done a three year study of Internet addiction, written two or more books, and developed a Web site, Center for On-line Addiction. The Web site is mostly ads for her books and services but there is a test for Internet addiction there. Her focus in her first book is on who gets hooked, why and how, and what can be done about various kinds of addiction. She, like other investigators, believes that persons with psychiatric histories seek out newsgroups, forums, chat rooms, or interactive games hoping for relief, but the old emotional problems lead to Internet addiction. Her more recent book is about cybersex and provides more specific steps to extricate oneself from porn and affairs. Another book (Gwinnell, 1999) focuses more specifically on the seductive falling-in-love experience of some Net addicts. Both of the above authors and Dr. Orzack at the Internet Addiction Services recommend keeping careful records of your time online, setting time limits for the pornography or in chat groups, cutting back on email lists, rewarding keeping to the schedule, and so on. Success is reported in 6 to 8 therapy sessions, but some ex-addicts state that total abstinence from their online temptations were necessary for them; otherwise, like the ex-smoker, one brief experience hooks them again. As one relapsing addict commented, “...I thought I had broken the compulsive habit, but once I returned to my favorite sites, I immediately experienced the same “buzz” and “high” that had lead me into difficulty...” Some people will just have to stay completely away from parts of the Internet.

 I would caution you, however, that even some of the writers in this area, including Young (1998), seem to feel negative about online relationships, implying that trustworthy, intimate, devoted friends must be face to face (what about letter writers and phone callers?). Dr. John Grohol writes about this bias in his (MHN Internet Addiction) review of Dr. Young’s book. To the contrary, one reason why people are attracted to the Internet is so they can get and give support, empathy, and advice. Sometimes it is easier to “open up,” perhaps anonymously, on the Internet than in person. It is true that one has to guard against getting excessively “hooked,” just as we need to keep under control watching TV, talking on the phone, listening to music, socializing instead of working/studying, etc. Mentalhelp Net lists several web sites about this addiction in MHN Internet Addiction and Dr. Grohol does in Psych Central. For several more articles go to Self-Help and Psychology Magazine and type in “Internet addiction.” For many good Web sites go to Yahoo Internet Addiction Sites.

 Lack of Exercise can become a serious health problem, especially if you are over weight. If you are a couch potato, a regular exercise routine is hard to start. Many never start. About 50% drop out of a new exercise program within the first three months. Think about the negative consequences of not exercising and the positive ones of exercising. Arrange things so you will start; make it fun, then a habit. But once established as a consistent habit, a "need" for exercise develops which makes it easy to continue exercising. Professionals consider Cooper's books (1970; 1988), one for men and another for women, to be the best guides to exercising. Dishman (1993) focuses on learning to stick with an exercise program. More discussion and references are in exercise.

 Homosexual tendencies have been reduced by punishment (Feldman & MacCulloch, 1971), by increasing heterosexual interests and skills, and by religion. But it is rare to change sexual orientation. It would usually be easier to accept the sexual behavior and focus on coping with the problems of being gay or lesbian, especially if there are physiological predilections. Each person must choose. Homosexuality is discussed in chapter 10.

 Lack of motivation and underachievement have been covered in the motivation section in this chapter. Miller & Goldblatt (1991) and Mandel & Marcus (1995) also discuss psychological reasons for advantaged young people underachieving. Covey's (1989) The 7 Habits of Highly Effective People is recommended by professionals (Santrock, Minnett, & Campbell, 1994). His new book, First Things First, emphasizes developing a "mission statement" for your life and, thus, having worthwhile goals to work toward (Covey, 1994). Also see chapter 3 and Method #7 in chapter 14.

 Lonely and want to find love? Look over chapters 9 and 10 (see Raphael & Abadie, 1984).

 Nail biting and thumb sucking have been punished with a bitter substance from the drug store applied to the fingers. The bad taste is also a warning signal to stop.

 Obsessive-compulsive disorders often involve obsessions that lead to ritualistic behaviors, like hand washing. The rituals relieve the worry for a short while, and the obsessions begin again. The disorder may be genetically or chemically caused to some extent (relatives of these patients are five times more likely--10%--than normal--1 or 2%--to have similar symptoms); the symptoms tend to develop before 18. Drug treatment, such as Anafranil or Prozac, helps about 60% of the time (see a MD). Known as the "doubting disease," these patients can't be sure they have washed all the germs off their hands or that they have locked all the doors and windows. The obsessions are frequently "primitive," i.e. about being clean or safe, and, thus, may be a throwback to early ancestors.

 Another factor in this disorder is the impact the compulsions have on family members, e.g. certain family members may help the patient with the excessive cleaning or arranging, others might avoid using a part of the house to accomodate the patient and make him/her more comfortable, they could become a part of the patient's rituals, they often give in to the patient's unreasonable demands (Calvocorressi, 1995). It is unknown, at this time, how much this accommodation by the family reinforces the compulsive behavior. Behavior therapy usually involves deliberately getting your hands dirty and not washing all day or intentionally leaving doors and windows unlocked for a few nights (Baer, 1991). This could be done as self-help.

 Since it usually causes great anxiety if the compulsion is not performed, we will deal with this disorder in chapter 5.

 Passivity is covered in chapters 8 and 13 (Method #3).

 Procrastination is dealt with extensively earlier in this chapter.

 Psychotic behavior is not something the person, friends, or relatives can ordinarily deal with; professional help at a Mental Health Center is needed right away. Medication and psychotherapy can help.

 Satisfying but unwanted responses, e.g. critical or bragging comments, being loud, flirtatious, or bossy, can be replaced with more desirable behaviors. Coaching and practice are needed.


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