The viruses that cause influenza are genetically unstable. They change both gradually and abruptly, and each change may enable the virus to skirt around previously acquired immunity, invade the respiratory tract, and cause the flu. This genetic instability is why people can get influenza over and over again, why they get it some years and not others, why some attacks make them much sicker than others, and why it’s necessary to get a new flu shot every year for maximum protection.
The gradual changes in the virus, called antigenic drift, may or may not be enough to override most people’s immunity to it. But when the abrupt changes known as antigenic shift occur, large numbers of people—and sometimes the entire population—have no protection. Such shifts usually result in worldwide epidemics, or pandemics, and, when they involve type A flu viruses, they are often highly lethal.
Type A flu viruses have two major antigens on their surface called H and N (the “H” stands for hemagglutinin and the “N” for neuraminidase). When they encounter a person’s immune system, these antigens trigger the production of antibodies that protect the person against the viral infection. When major changes occur in H and/or N, most people have no preexisting antibody protection, and so they are susceptible to an invasion by the new form of the virus. The following table shows the major shifts that have occurred in the type A influenza virus during this century. The pandemics are usually named for the area where the virus was first isolated.
There is evidence that during the last decade of the nineteenth century, a type A virus very similar to the H2N2 Asian flu virus prevailed, and that during the first seventeen years of the twentieth century a virus similar to the H3N2 Hong Kong virus was the primary troublemaker.
The Spanish flu A-H1N1 virus that first appeared in 1918 lingered in the population until 1957, when the Asian virus, A-H2N2, emerged and supplanted it. However, in 1977 a virus reappeared that was virtually identical to the A-H1N1 that had circulated at least until 1950. Most people born before 1950 had immunity to the 1977 virus, but those who were younger or who had missed being exposed to the original cause of Spanish flu had no natural protection, and many became very ill.
In 1992, the type A virus genetically rearranged some of its attire, but did not do a total costume switch. A variant known as Beijing arose, an A-H3N2 virus that was a kissing cousin of the A-H3N2 virus that caused the Hong Kong flu in 1968. Thus, many people had at least a partial immunity to it because they had encountered its close relative in the past. In the 1994-95 flu season, yet another A-H3N2 virus called Shandong was a leading troublemaker.
What will come along next is anybody’s guess. But the nation’s flu watchers are always on guard, and as soon as any new variant arises that causes a significant outbreak of influenza anywhere in the world, the manufacturers of flu vaccine will be ready to add it to their mix.
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If you feel a sense of dread as bedtime approaches or as you enter the bedroom, consider your feelings about death and dying. You may wish to discuss these feelings with a professional counselor. There are also a few simple things you can do yourself to make your bedroom more attractive and less “cryptlike.” Use of a night-light can help. Not only is the presence of light reassuring as you fall asleep, it can help orient you and provide comfort should you awaken during the night. Also, make your bedroom a warm and inviting place. Don’t be hesitant to wear luxurious and comfortable sleep garb or to indulge in beautiful and sensual bedclothes. If you find silk sheets to be the height of luxury, and can sleep on them without slipping out onto the floor, by all means use them. Make sure your bedroom is clean, uncluttered, and decorated with objects or artwork you find attractive and appealing. Even the use of mild incense or air scents may improve the ambience. I’ll have more to say about the bedroom environment later in this chapter.
Often the mental and emotional causes of sleep disturbance are deeply rooted and need more aggressive treatment than the simple steps I’ve just described. For example, earlier we discussed the role depression can play in causing insomnia.
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An allergist is a physician who, on completing medical school, trained at least three years and passed an examination to become a fully qualified specialist in either internal medicine or in pediatrics. After that, he or she must undergo at least two years of highly specialized training in allergy and immunology. Mere completion of this training does not qualify one as a specialist. To be recognized as a specialist in allergy, a physician must next become certified by the American Board of Allergy and Immunology, a conjoint board of the American Board of Internal Medicine and the American Board of Pediatrics. This requires the passing of a comprehensive examination that assesses the doctor’s basic knowledge as well as diagnostic and treatment skills with a variety of allergy and immunology problems. All told, specialists in allergy and immunology are required to complete five years of training and pass two difficult specialty examinations before they can be recognized as allergy specialists. Your county/parish medical society should be able to provide you with a list of board-certified specialists in allergy and immunology.
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The clinical hallmarks of acute viral encephalitis include fever, headache, and an altered level of consciousness. Other common clinical findings include behavioral changes, speech disturbances, and focal or diffuse neurologic signs such as seizure or hemiparesis.
Establishing a diagnosis of viral encephalitis may be difficult, so clinicians should inquire about certain epidemiologic features:
- Season of the year
- Prevalent diseases within the community
- History of travel
- Recreational activities
- Occupational exposures
- Animal contacts (insects or animal bites)
The use of neurodiagnostic tests, including electroencephalogram
(EEG), computed tomographic scan, and magnetic resonance imaging (MRI), can provide useful information in the evaluation of encephalitis. Although only herpes simplex encephalitis has specific treatment, the confirmation of other viral causes can provide helpful prognostic information and minimize unnecessary and ineffective therapies. Evaluation and management of acute viral encephalitis can be complex, and practitioners should seek consultation with an infectious diseases specialist for assistance.
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Melanie similarly described the difference between her appearance concerns and those of other people. “My concern is totally obsessive—it’s on my mind for hours a day—and it makes me miserable. Other peoples’ appearance concerns don’t make them so depressed, stop them from walking out the door, or make them unable to laugh at a joke. My concerns take all of my concentration, and they take over my life.”
Kathleen’s and Melanie’s BDD concerns echoed normal concerns echoed normal concerns, but they were more intense and severe. They worried too much, and they suffered. Many people with BDD have some additional normal concerns about their appearance, which they can usually easily differentiate from their BDD concerns.
Thus, BDD appears to differ quantitatively—by a matter of degree—from normal appearance concerns, lying at the severe end of a continuum or dimension of appearance preoccupation and dissatisfaction. But does BDD also differ from normal concerns in a more substantial and fundamental way? Is it also qualitatively different from normal appearance concerns? In other words, is there a point of rarity or discontinuity that suggests a natural cutoff point between BDD and health?
The answer to this question is probably yes. BDD does seem to differ from normal appearance concerns in ways other than its severity. One difference is that BDD appears to affect an approximately equal number of men and women, whereas studies of the general population indicate that more women than men are unhappy with how they look. In addition, surveys of the general population have generally found that people usually dislike their weight or weight-related aspects of appearance, such as the size of their abdomen, hips, or thighs. For example, in a 1972 Psychology Today survey, 48% of women were dissatisfied with their weight, 50% with their abdomen, and 49% with their hips and upper thighs. Only 11% were dissatisfied with their face. And in the 1997 Psychology Today survey I previously mentioned, 44% of women said that looking at their stomach in the mirror was very upsetting, whereas only 16% said this about their face. Among people with BDD, however, facial concerns are most common.
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Just because you have nose symptoms that act like allergy doesn’t mean that you are allergic. The first step in determining whether or not your nasal symptoms would benefit from immunotherapy is to be certain that you have allergic rhinitis. That requires your doctor to ensure that you actually make IgE antibodies (allergic antibodies) to the common airborne allergens and that it is these allergens that are causing your symptoms. To do this your doctor must take a very detailed medical history, perform a physical examination, and then do skin or serological (blood) tests to confirm the presence of IgE antibodies to common airborne allergens. Once these allergy tests are obtained, they are correlated with the history and physical examination findings and a treatment program is planned.
The steps that should be taken prior to your beginning any immunotherapy program are summarized below:
Before Beginning Immunotherapy
Be sure that your nose problem is allergic and not some other problem that causes similar symptoms.
Be sure that you have IgE antibodies to airborne allergens (pollens, dust mites, animals, etc.).
Your symptoms should be uncomfortable and poorly controlled by avoidance measures and medications.
Be sure that you are willing to take the time to participate in the treatments.
Be sure that the physician giving your immunotherapy is experienced in the diagnosis and treatment of allergic rhinitis.
Anyone who embarks on a course of immunotherapy should make a commitment to complete the entire course of therapy. Taking a course of immunotherapy for a few months, stopping it, and then starting it again is a waste of your time and money. If immunotherapy is to be effective, a high dose of allergen extract must be given regularly over a prolonged period of time. If you stop and start on the program, you will never achieve the dose needed, nor will you take it long enough for it to help.
Immunotherapy is time consuming and expensive. If you are going to make such a commitment to time and funds, then for goodness’ sake seek out a specialist in allergic diseases. Ask for references from your regular physician or friends who have undergone immunotherapy.
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Fuller Torrey, who was at one time reserved about the direction of psychiatry (1974), today fully supports the biomedical approach (1983). Yet the vagueness of DSM III is apparent in his work.
Unfortunately, many patients have symptoms which place them somewhere on a spectrum between schizophrenia and manic-depressive illness. Most psychiatrists have seen individual patients who fit only one of these disease entities perfectly, but most have also seen patients with a confusing melange of symptoms of both diseases. Textbooks of psychiatry are written as if patients had one disease or the other and imply that all patients can be placed under one of the two disease categories. It has been facetiously suggested that we need either to insist that patients read the books and choose which disease they wish to have or we need to become more flexible in our psychiatric thinking. I personally have seen patients with virtually every possible combination of schizophrenic and manic-depressive symptoms.
To resolve some of the overlap between categories, ‘schizoaffective disorders’ have been defined. Treatment is somewhere in between that for schizophrenia and manic-depressive illness. This category demonstrates the lack of congruency in psychiatric treatment and its dependency upon the personality of the psychiatrist in the choice of drugs. According to Torrey,
Those who are carefully diagnosed as schizoaffective are more likely to have a good outcome to their illness, especially if they are properly treated. And proper treatment means a trial of lithium, the drug which has been used so successfully to treat manic-depressive illness. Any person with a schizoaffective disorder who has not responded to other treatment deserves a trial of lithium, and relatives of such a patient should continue shopping for a psychiatrist until they find one who uses lithium in such cases.
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In everyday life, perhaps no ailment is as bothersome as the common cold, with its irritating symptoms of runny nose, itchy eyes, and generally uncomfortable sensations. Colds are responsible for more days lost from work and more uncomfortable days spent at work than any other ailment.
Caused by any number of viruses (some experts claim there may be over 100 different viruses responsible for the common cold), colds are endemic (always present to some degree) among peoples throughout the world. Current research indicates that otherwise healthy people carry cold viruses in their noses and throats most of the time. These viruses are held in check until the host’s resistance is lowered. In the true sense of the word, it is possible to “catch” a cold – from the airborne droplets of another person’s sneeze or from skin-to-skin or mucous membrane contact – though recent studies indicate that the hands may be the greatest avenue of colds and transmission of other viruses. Obviously, then, covering your mouth with a tissue or handkerchief when sneezing is better than covering it with your bare hand, particularly if you next use your hand to touch food in a restaurant, shake your friend’s hand, or open the door.
Although numerous theories exist concerning how to “cure” the common cold, including the ingestion of mega-doses of vitamin C, little hard evidence supports any of them. The best rule of thumb is to keep your resistance level high. Sound nutrition, adequate rest, stress reduction, and regular exercise appear to be the best bets in helping fight off infection. Also, avoiding people with newly developed colds (colds appear to be most contagious during the first 24 hours of onset) is advisable. Once you contract a cold, bed rest, plenty of fluids and aspirin for relief of pain and discomfort are the tried-and-true remedies for adults. Children should not be given aspirin for colds or the flu because of the possibility that this may lead to a potentially fatal disease known as Reye’s syndrome. Several over-the-counter preparations have proved effective for alleviating certain cold symptoms.
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As we have seen, emotional and mental turbulence can disrupt the process of sleep. The death of a spouse, child, relative, or close friend is an obvious and understandable cause of anguish. In addition, stress-related insomnia can be triggered by a disruption or a change in virtually any aspect of your daily life, including the following.
* Marital: marriage, separation, divorce, reconciliation
* Domestic: birth of a child, moving to a new location, child leaving home, conflict between spouses or siblings
* Financial: sudden loss (or increase) of income, unexpected expenses
* Employment: new job, promotion, loss of job, turmoil or discord within your company, pressure, competition
* Health: illness, injury, or hospitalization, your own or that of someone in the family
* Social: retirement, involvement in a legal conflict, jail term
Certain behavior patterns or emotional habits can also affect your ability to get a good night’s rest.
* Feelings of anger, frustration, hostility, competitiveness, aggression
* Repression or suppression of such feelings
* Inability to relax
* Tendency to ruminate, especially while in bed
* Sexual fears or frustrations
* Other fears, especially of darkness or death
If you are unable to sleep, take some time to look carefully at your situation. Think back over the last few weeks, or the past year, and determine if any events or feelings similar to the ones mentioned above might be playing some role in your current sleep difficulty. Sometimes just becoming*aware of a problem, acknowledging its impact or realizing a pattern of events, can be the first step in resolving the crisis. Fortunately, much of the sleeplessness arising from such situations is transient and will pass within a few days or a few weeks. As a physician, I am constantly amazed at the human ability to absorb the blows dealt out by life in the modern world, then to bounce back within a relatively short period. If you experience a traumatic change in your life, one that disturbs your ability to sleep, rest assured that in most cases time will provide the cure as you learn to recognize, adjust to, and cope with your new circumstances.
As we have seen, in some cases insomnia may stem from a deep-seated fear of death. Sleep is sometimes referred to poetically as “the little death.” The comparison is apt: when we sleep, we enter a dark environment, lie down, close our eyes, and surrender conscious control of our senses to a mysterious and little-understood force.
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Allergy shots, desensitization, hyposensitization, and immunotherapy are different terms for the same thing. Immunotherapy is the term allergists use when referring to allergy shots.
Immunotherapy is the process by which a series of injections of gradually increasing doses of extracts of airborne allergens is taken. Only the allergens to which you are allergic are used in immunotherapy. These may include dust mites, mold spores, and grass, tree, or ragweed pollens. Each injection received is just a little stronger than the preceding one until you reach the highest dose that will be given. This dose is frequently called the maintenance dose, because it is the dose that will be repeated, weekly or every other week, throughout your course of immunotherapy. Ordinarily, it will take about three months of regularly administered injections to reach your maintenance dose. This maintenance dose is then continued at regular intervals until you have obtained your maximum relief. An immunotherapy program for airborne allergens generally requires a minimum of three years of injections.
Immunotherapy works by producing very specific immune changes in your body. Allergic conditions responding to immunotherapy include the following:
- Seasonal Allergic Rhinitis
- Perennial Allergic Rhinitis
- Insect Sting Allergy
- Allergic Asthma
Most people with perennial allergic rhinitis have non-allergic triggers of their nasal symptoms as well. For example, you might have PAR and be using nasal decongestant sprays too often as well as suffering nasal congestion whenever you are around cigarette smoke, perfumes, or the smell of cleaning chemicals. Your chronic nasal symptoms are in fact caused by the interaction of three different types of rhinitis: allergen triggered rhinitis (PAR), nose-spray triggered rhinitis (chemical rhinitis) and irritant triggered rhinitis (irritant rhinitis). Immunotherapy will help protect you against the allergens causing your perennial allergic rhinitis. It won’t help you break the nose- spray habit or keep cigarette smoke from twitching your nose. Other measures will have to be used to help you break the nose-spray habit and reduce your response to irritating odors.
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