GTD and Evernote.

Written by Ben Anderson.  

For those of you who are not familiar with GTD, it's a popular time management and organizational system that stands for "Getting Things Done".  The system was originally developed by David Allen and described in his appropriately titled book "Getting Things Done".  If you haven't read the book, I highly recommend it - it's a great book that clearly describes his system in an easy to understand manner that causes the book to go by quickly.  I'm going to touch on the basic concepts in this series of articles as I outline my implementation, however the book goes into much more detail on each aspect and provides a host of resources that will lead you through the process from start to finish. The basic idea is that we all have little things that we know we need to do that are floating around in our heads.  Our mind knows that it needs to remember to do these things and so relegates part of our brain's processing power to keeping a reminder tab floating just within consciousness.  When you add all those bits and reminders to yourself up, it ends up drawing a significant amount of your brain power.  Not to mention what it does to your stress levels. 

The idea behind GTD is to get all of those pesky little tidbits out of your head and into an organizational system that allows you to know, with confidence, that everything has been captured and will be presented to you when it's needed.  Once you are confident you've captured everything you need to do, and have organized all the bits and pieces that are floating around in your head constantly, then you can truly focus on what it is that you're working on at the time. 

It's a widely known fact that your productivity is related to your focus.  With less distractions you can get more done.  This is a system to reduce distractions, empty your head of the clutter, and focus on the things that matter.

GTD Introduction.

GTD is essentially a system of lists.  Through the organization of the various lists, you gain the ability to organize your life in such a way that the things that need to get done, get done.  Your major projects move forward and continue to make progress.  And most importantly, nothing gets lost in the shuffle - the system efficiently tracks all of the things that need doing.  It provides you with a mechanism to get your commitments and your tasks out of your head and into a reliable system.

Of course, for this system to be effective, you need a reliable list management strategy.  Something that allows you to organize the various lists that you work with throughout the GTD system.  Some people prefer paper lists, which work fine, but are ultimately somewhat clumsy, require lots of rewriting and aren't redundant.  If you lose that notebook, stack of papers, or manila folder, you're finished. 

I have to recommend a fully electronic version of the system.  With today's technology, specifically with smart phones and the Internet, you have every advantage to putting your system in digital format.  Now, I've played with several different applications and mechanisms for managing my GTD system, including Outlook and OneNote - both Microsoft products that tend to do very well.  However, those products tend to be expensive, not easily synchronized for redundancy, and lacking in some key features that can really make your system powerful.  (Yes, I'm talking about tags)

Evernote.

Enter Evernote.  Evernote is a free application rooted in the cloud.  You essentially just sign up for their service and then create all of your lists and notebooks in the cloud, on their servers.  They provide you with several mechanisms to add and edit those notebooks, including a powerful web-based interface you can use wherever you find an Internet connection, and a fat client that you can install on your primary (and other) machines that gives you a rich, application experience.  They also have a mobile web-interface, and several mobile fat clients (currently the iPhone, the Blackberry, and the Palm Pre).  You also have several additional ways to add notes into your notebooks, via sending emails to a personalized email address, SMS messaging notes to your account, or taking pictures and sending them to your account.  The fat client has a web clip feature that allows you to grab any content while you are surfing and throw it into an Evernote note.  With a free Dial2Go account, you can even transcribe notes directly into your notebook.

Inbox.

Examining the many different input methods for Evernote leads us directly into the first phase of the GTD system.  Collecting.  Since your goal with this system is to get all of the random thoughts, ideas, and tasks out of your head and into an organized system, we utilize an inbox to capture all of this information.  Your inbox is an unsorted free-for-all of notes and snippets that came out of your head.  When that information is stored safely in a trusted repository, your mind can focus purely on the task at hand without constantly spending background cycles thinking about or trying to remember these items.  In Evernote, your inbox is simply any note without a Tag.  Tags represent a list (or lists) that these notes become members of, but prior to processing, they are simply sitting in the inbox.

I won't go through the entire process of getting all of your data out of your head and into your inbox; David Allen has some really great techniques and tools for helping you do that in his book.  Suffice it to say, that's where everything starts, and as you continue to utilize the system, everything passes (even if briefly) through the inbox.

Processing.

The second phase in the GTD system is Processing.  This consists of going through your inbox and organizing it.  Each time you process, everything in your inbox has something done with it, and nothing goes back into your inbox.  When processing is complete, your inbox is empty.  The frequency at which you perform your processing is a variable of your particular style, how quickly your inbox fills up, and how you structure your time.  I find that I like to process on the fly, so I will run through the inbox at least once a day, if not a couple of times a day just sorting things out and staying on top of it.  Some people will process less frequently, nothing wrong with that, as long as you process frequently enough to trust that things you put in your inbox will be processed timely.  It is absolutely critical that you completely trust your system, that is the only way that you can clear your head and completely rely on it. 

When processing the notes in your inbox, the first decision you have to make for each note is whether or not it is actionable, whether or not the note represents a task that you need to do.  If it does not, then it goes into the trash, onto a Someday/Maybe list, or into a reference file.  In the Evernote world, your Someday/Maybe list and reference files are represented by Tags.  Someday/Maybe has it's own tag, and is the place for things that you do want to do, eventually, but are not on your immediate radar.  You'll review this list on a regular basis to decide if you actually want to do any of these things.  Your reference file can be as simple or complicated as you'd like.  Some people prefer to dump all of their reference data into a single bucket and rely on the search functionality to find what they need.  Personally I prefer more organization, and therefore have several various buckets/tags that I use to organize my reference data.

If the note is actionable, you either do it, delegate it, or defer it.  In Evernote, if the note is actionable, it gets a context tag (see next section).  This provides a way to search/filter on actions that are incomplete, and a marker to indicate that a task has been completed.  If the task takes less than 2 minutes to complete, just do it right then.  There's no point in entering it into your system when you can just knock it out right then and there.  If you can't do it right then, then you can either delegate it to someone else, or defer it until later when you have time/energy/opportunity to take care of it yourself.  If you need to delegate it, do so immediately and then tag the note with a @waiting tag. 

Context Tags.

If you are postponing the action for later, then you need to tag it with a context tag.  GTD utilizes the concept of context to organize your tasks.  This allows you to focus only on the tasks that are relevant to you in any given situation.  The context tags that I use in my system are @agenda, @errands, @home, and @computer.  The @agenda context are for actions that I need to meet with, talk to, or somehow directly interface with another person.  These are often phone calls that I need to make, or things that I need to bring up in the next meeting.  These can usually be accomplished whenever I am somewhere with my phone.  The @errands context are things that need to be done while I'm out of the house.  Things I need to grab at the grocery store, items to drop off at the post office, or an art gallery that I want to visit.  The @home context represents things that I need to do at home that aren't on the computer.  Hanging pictures, working on my truck, clean the living room, are all things that can be done during the hours I'm not in my home office.  For when I am in the office, or sitting in front of the computer, I have the @computer context. 

Note:  If something needs to be done at a specific time (i.e. go to a baseball game, pick up Fluffy from the vet, etc.), an event gets created on Google Calendar with a reminder.  You can use whatever calendaring application your currently using, as long as it has a reminder function.  Once it's captured on the calendar, it no longer needs to be maintained in Evernote, you can consider it processed and move on.

Now all of your Next Actions are sorted into context sensitive lists.  By clicking on the @errands tag just before you head out, you can review all of the things that you need to do while you're out and about.  Scanning the @computer tag list while you're sitting at your desk puts in front of you, all of the things that you can do right then and there.  When you complete an item, replace the context tag with the Done tag.  This removes it from your current to do lists and archives it.  This is analogous to checking the check box to indicate completion, but provides a way to go back and review your completed tasks if needed.

The GTD system purposely does not assign priority to your tasks.  The idea is that each time you are in a context and ready to accomplish something, you refer to your list and evaluate which items to work on.  This is done with a combination of intuition, energy level, time available, etc.  This tends to be a very effective way to process your lists, however some people will find that their lists are too long to process this way and desire some additional organization system.  We will cover this later in the article in the Advanced topics section.

Saved Searches as Dynamic To Do Lists.

It is worth mentioning here, I also created an "!INBOX" saved search that just scans for any untagged notes.  As I stated at the beginning of this article, any note that doesn't have a tag is in the Inbox and ready for processing.  As I process it and add the appropriate tags to it, it automatically falls out of the Inbox.  The !INBOX search allows you easy access to these notes for processing.  It can be accomplished with the search context of: -tag:* This tells Evernote to display any notes that aren't tagged at all.

I also find it helpful to build an "All To Do" search as well.  This just gives you an overview of all of your open actions, regardless of context.  You can build this search by using the more advanced search syntax - this is where Evernote gets really powerful.  The search string looks like this: any: tag:@home tag:@computer tag:@errands tag:@agenda 

Specialty contexts.

I would like to point out, that I employ several 'specialty' contexts for certain types of notes and actions.  These are just additional layers of description and organization that I have found useful over time to help separate out frequently used types of tasks.  The first is @dining.  This tag I use for restaurants that I want to try or recipes that I've found and want to make at some point.  I like to try different restaurants around town and so I am constantly picking up ideas for new places to eat.  This organizes them in a single list so that when I am hungry and looking for a place to eat, I can simply refer to this context and pick one from the list.  Once I've eaten there (and Yelp'ed the restaurant), then I complete the task and it gets archived. 

I also use a @read/review context tag for items that I want to spend some time studying or reviewing, this includes things that I find around the web, books, etc.  This tag doesn't get used all that often since most of my reading occurs within Google Reader, and gets starred there if it is something I want to make sure I read.  Likewise, if it is a single webpage that I'm interested in reading, it gets a specific (Read Later) bookmark in my browser that indicates I want to return to that information.  However, for things that exist outside of those two mediums, the @read/review tag captures those actions.

Lastly I use a @habit tag to indicate actions that I perform over time.  Most often these are actions that I am developing into a habit.  Once they are completely habitualized, I no longer need the reminder and can tag them Done to indicate they're completed, however during the habitualizing process I use this tag and review it daily to remind myself of the items I am working on.

Projects.

Now lets talk about projects. GTD defines a project as anything that requires more than one task to accomplish.  So if there are multiple steps to accomplishing any one thing, it's considered a project.  Using this definition, you may find that you have quite a few projects going on!  That's okay, with this system they'll all be kept track of easily and you will have a sure-fire way to ensure you're making progress on each one.

The most important concept around processing projects is that they must ALL be reviewed on a regular basis (generally weekly) and scoured for next actions.  Each project should be thought through at least enough to identify what the next action is to move that project forward.  That next action then is added to your To Do lists.

Organizationally, each project has it's own tag in Evernote.  I generally precede all of my project tags with a period (.), this is simply to identify that tag as a project tag, so that I don't mistake it for part of my reference materials or other portion of my notes system.  One note will represent the root of the project, including the overview of what you plan to accomplish, maybe a rough outline of the tasks that will be required, or any other relevant information.  That note will be tagged with the project tag, as well as the "Active Projects" tag.  This system of tagging allows for several dynamic lists to be generated.

First, the Active Projects tag will give you a simple, high-level listing of all of the active projects that you are currently working on.  This is valuable to review on a regular basis to ensure that you have next actions identified for each one.  As a project is completed, replace the Active Projects tag with the Done tag.  This will remove it from your view and store it safely away for later reference if needed.






Second, the project tag itself will give you a way to correlate any additional project support notes.  Any action items (completed or pending), future actions, random notes or web clippings that relate, notes that you jot down, or additional planning activities, can all be referenced quickly and easily via the tag for that project.





A Note on Organizing Tags.

By now you're probably thinking that you're racking up quite a few tags, and your sidebar in Evernote is getting crowded and a little out of control.  Not to mention the fact that you're having to scroll to your Saved Searches.  Evernote allows the nesting of tags, thus allowing you to create a hierarchy.  This is performed by dragging and dropping the tags onto each other.  So each of the project tabs gets made a child of the Active Projects tag (or subsequently the Done tag when completed).  This allows you to collapse all of your projects when you're not reviewing them.  I also created a 'Contexts' tag that I use to nest all of my context tags under. 

This is where the real power of Evernote comes into play.  The ability to tag notes, and with multiple tags, allows you to generate dynamic lists based on note attributes.  Since GTD is essentially a list management system, this provides you with a lot of flexibility to make your system make sense and ensure that you can get to the information you need to get to, when you need to get to it.

Below you can see how my dashboard is laid out, I've got my Saved Search "All To Do" highlighted so that I can quickly review all of my open tasks.  You can see they are easily sorted by what project they are a part of for easy comprehension.





Summary.

That completes my overview of how I use Evernote to manage my GTD system and keep my world in order.  I've really only discussed the mechanics of the system, and just enough of the theory to make it make sense.  However, I highly recommend that you read Getting Things Done by David Allen.  It's a quick read and you'll find that you breeze through it, as you will continually be saying "Ah, of course!  That makes so much sense!".  It really is a simple, common sense system, that's got just the right amount of process and guidelines to ensure that you can count on it.  And that is the key to any information management system, you have to be confident that you can get to the information you want, without missing any key elements that might be buried somewhere deep where you can find it.

Getting Things Done and Evernote provide a way to keep all of your balls in the air successfully, and ensure that you aren't spinning your wheels incessantly, but are truly moving forward and making progress on the goals that you want to accomplish.

There are several other aspects to this system that I consider advanced topics, extensions on the base system to provide more functionality, how to more fully integrate it into your life, what to do if you have too many tasks, how to integrate with your email, and how to use this to accomplish your life's ambitions.  I will be posting those topics in an upcoming article.  Stay tuned by subscribing to our RSS feed which will automatically deliver new articles to you as they are released.

Getting things done simply with Google

Ok, I’ll admit it, I’m a bit of a productivity nerd. I read some blogs on personal productivity and I like trying out the latest and greatest tools that claim to make me more productive. Over the last few years, I’ve tried out a number of different tools and techniques, but I’ve never managed to stick to anything for more than a few weeks.

My latest attempt involved using Google Calendar to keep track of events that I needed to attend and Todoist as a task manager. The setup worked pretty well for a while, but some it wasn’t quite right. For example, I liked to make a weekly plan at the start of the week. I used Todoist’s projects feature to set up a project for each week and added a bunch of tasks. I’d make a toplevel task for each major work area for the week and put eveything I needed to do under that. This worked well for a while, but problems started to crop up. If I couldn’t get things done in a certain week, I had to move them from one week-project to the next. While this was ok for one or two tasks, it would become a pain for anything more. Being the tech enthusiast that I am, I started looking around for other solutions. I tried Remember the Milk and the Things application for the Mac. I rejected Things because it costs a pretty penny and I can’t afford to be tied to my desktop. Remember the Milk looked like a good possibility, but I just couldn’t agree with the interface. I couldn’t find an easy way to see all the tasks and I was afraid that unless I meticulously tagged and timed them, I would quickly start losing things.

Then I realized…

That the only thing that I really needed to keep myself organized was… lists. So I needed a simple list tool. Something that would easily let me see all available tasks, group them, move them about and add new ones. I also wanted that was thin on ‘features’ so that I wouldn’t get tempted to be all fancy. What was the bare minimum task manager I could get that was still fairly usable?

The simplest app I could find was Tadalist. It lets you make multiple lists and reorder them. That was close to what I wanted. But I did want a grouping mechanism, so that wouldn’t work. The answer, it turned out, was right under my door. Google recently integrated a simple task management app into Gmail. It’s simple and smoothly integrated into the Gmail interface. It has simple lists. No tagging, or labels or projects or any other bells and whistles. However, it does have a simple indentation feature that lets you indent lists one level in from the task above it. That’s good enough to help me distinguish groups of tasks.

To efficiently use Tasks, I set up two separate lists. One is the ‘current’ list, which contains all the things that I will be doing within the week. It has toplevel tasks for homework, this blog, other work and other projects. Anything that needs to be done goes into one of these categories. If needed, I can quickly create another category and put things down under it. I check off things once they’re done and clear the list of completed items when it gets too full (and I don’t need to remember what I’ve done). Every morning, I look through this list and try to schedule things using Google calendar. Calendar is then set up to set me reminders at times if I feel I need them.

The second list is my ‘inbox’ (GTD style). This is for everything that I might need or want to do, but know that I won’t have time for in the near future. Once a week I’ll be going through this list and moving things to current if need be.

This setup seems to be working quite well for now. There are some distinct advantages to this: it’s right in my email and I’ve learned to look it up every time I log in. Anything that comes in by email can be turned into a task easily. There is also a simple scheduling feature though I don’t really use it that much.

In the near future…

I hope that Tasks doesn’t go the way of some other promising Google products (such as Notebook). I would certainly like to see just a few more features added. Moving tasks between lists would be appreciated, even if it’s not drag-and-drop. Indentation is nice, but folding indented items would be nice to have. I also hope that they let Tasks talk to Calendar. It would be awesome if I could take a task, set a time for it and have it show up in my Calendar automatically.

Google Tasks provides a very lightweight task management tool. If you already have a comfortable setup with another tool, there really isn’t a compelling reason to change. Most tools have much more features. In all fairness, I could probably use Todoist the same way I use Tasks now. Also if you spend most of your time on one machine, a desktop app would be a choice worth looking into. What Tasks has going for it most at the moment is integration with Gmail and the possibility of tying into Calendar at some point in the future. Though I quite enjoy the setup, it’s certainly a set up most suited to minimalists.

Healing back pain part. 1

The Manifestations of TMS.

I have never seen a patient with pain in the neck, shoulders, back
or buttocks who didnt believe that the pain was due to an injury, a
hurt brought on by some physical activity. I hurt myself while
running (playing basketball, tennis, bowling). The pain started
after I lifted my little girl or when I tried to open a stuck window.
Ten years ago I was involved in a hit-from-behind auto accident
and I have had recurrent back pain ever since.
The idea that pain means injury or damage is deeply ingrained
in the American consciousness. Of course, if the pain starts while
one is engaged in a physical activity its difficult not to attribute the
pain to the activity. (As we shall see later, that is often deceiving.)
But this pervasive concept of the vulnerability of the back, of ease
of injury, is nothing less than a medical catastrophe for the American
public, which now has an army of semidisabled men and women
whose lives are significantly restricted by the fear of doing further
damage or bringing on the dreaded pain again. One often hears,
Im afraid of hurting myself again so Im going to be very careful
of what I do.
In good faith, this idea has been fostered by the medical
profession and other healers for years. It has been assumed that
neck, shoulder, back and buttock pain is due to injury or disease of
the spine and associated structures or incompetence of muscles
and ligaments surrounding these structureswithout scientific
validation of these diagnostic concepts.
On the other hand, I have had gratifying success in the
treatment of these disorders for seventeen years based on a very
different diagnosis. It has been my observation that the majority of
these pain syndromes are the result of a condition in the muscles,
nerves, tendons and ligaments brought on by tension. And the point
has been proven by the very high rate of success achieved with a
treatment program that is simple, rapid and thorough.
Medicines preoccupation with the spine draws on fundamental
medical philosophy and training. Modern medicine has been
primarily mechanical and structural in orientation. The body is
viewed as an exceedingly complex machine and illness as a
malfunction in the machine brought about by infection, trauma,
inherited defects, degeneration and, of course, cancer. At the same
time medical science has had a love affair with the laboratory,
believing that nothing is valid unless it can be demonstrated in that
arena. No one would dispute the essential role the laboratory has
played in medical progress (witness penicillin and insulin for
example). Unfortunately, some things are difficult to study in the
laboratory. One of these is the mind and its organ, the brain. The
emotions do not lend themselves to test tube experiments and
measurement and so modern medical science has chosen to ignore
them, buttressed by the conviction that emotions have little to do
with health and illness anyway. Hence, the majority of practicing
physicians do not consider that emotions play a significant role in
causing physical disorders, though many would acknowledge that
they might aggravate a physically caused illness. In general,
physicians feel uncomfortable in dealing with a problem that is
related to the emotions. They tend to make a sharp division between
the things of the mind and the things of the body, and only feel
comfortable with the latter.

Peptic ulcer of the duodenum is a good example. Although
some physicians would dispute the idea, there is fairly wide
acceptance among practicing doctors that ulcers are caused
primarily by tension. Contrary to logic, however, the major focus
in treatment is medical, not psychological, and drugs are
prescribed to neutralize or prevent the secretion of acid. But failure
to treat the primary cause of the disorder is poor medicine; it is
symptomatic treatment, something we were warned about in
medical school. But since most physicians see their role only as
treating the body, the psychological part of the problem is neglected,
even though its the basic cause. In fairness, some physicians make
an attempt to say something about tension, but its often of a
superficial nature like, You ought to take it easy; youre working
too hard.
Pain syndromes look so physical it is particularly difficult for
doctors to consider the possibility that they might be caused by
psychological factors, and so they cling to the structural explanation.
In doing so, however, they are chiefly responsible for the pain
epidemic that now exists in this country.
If structural abnormalities dont cause pain in the neck,
shoulder, back and buttocks, what does? Studies and clinical
experience of many years suggest that these common pain
syndromes are the result of a physiologic alteration in certain
muscles, nerves, tendons and ligaments which is called the Tension
Myositis Syndrome (TMS). It is a harmless but potentially very
painful disorder that is the result of specific, common emotional
situations. It is the purpose of this book to describe TMS in detail.
The ensuing sections of this chapter will discuss who gets it, in
what parts of the body it occurs, the various patterns of pain and
the overall impact of TMS on peoples health and daily lives.
Following chapters will talk about the psychology of TMS (which
is where it all begins), its physiology and how it is treated.
Conventional diagnosis and treatment will be reviewed and I will
conclude with a chapter on the important interaction between mind
and body in matters of health and illness.

WHO GETS TMS ?

One might almost say that TMS is a cradle-to-grave disorder since
it does occur in children, though probably not until the age of five
or six. Its manifestation in children is, of course, different from
what occurs in adults. I am convinced that what are referred to as
growing pains in children are manifestations of TMS.
The cause of growing pains has never been identified but
physicians have always been comfortable in reassuring mothers
that the condition is harmless. It occurred to me one day while
listening to a young mother describe her daughters severe leg
pain in the middle of the night that what the child had experienced
was very much like an adult attack of sciatica, and since this was
clearly one of the most common manifestations of TMS, growing
pains might very well represent TMS in children.
Little wonder that no one has been able to explain the nature
of growing pains since TMS is a condition that usually leaves no
physical evidence of its presence. There is a temporary constriction
of blood vessels, bringing on the symptoms, and then all returns to
normal.
The emotional stimulus for the attack in children is no different
from that in adults anxiety. One might say that the attack in a
child is a paranightmare. It is a substitute for a nightmare, a command
decision by the mind to produce a physical reaction rather than
have the individual experience a painful emotion, which is what
happens in adults as well.
At the other end of the spectrum, I have seen the syndrome in
men and women in their eighties. There appears to be no age limit,
and why would there be? As long as one can generate emotions
one is susceptible to the disorder.

What are the ages when it is most common, and can we learn
anything from those statistics? In a follow-up survey carried out in
1982, 177 patients were interviewed as to their then current status
following treatment for TMS. (See Follow-Up Surveys for results
of the survey.) We learned that 77 percent of the patients fell
between the ages of thirty and sixty, 9 percent were in their
twenties, and there were only four teenagers (2 percent). At the
other end of the spectrum, only 7 percent were in their sixties and
4 percent in their seventies.
These statistics suggest very strongly that the cause of most
back pain is emotional, for the years between thirty and sixty are
the ages that fall into what I would call the years of responsibility.
This is the period in ones life when one is under the most strain to
succeed, to provide and excel, and it is logical that this is when one
would experience the highest incidence of TMS. Further, if
degenerative changes in the spine (osteoarthritis, disc degeneration
and herniation, facet arthrosis and spinal stenosis, for instance)
were a primary cause of back pain, these statistics wouldnt fit at
all. In that case, a gradual increase in incidence from the twenties
on would occur, with the highest incidence in the oldest people. To
be sure, this is only circumstantial evidence, but it is highly suggestive.
So the answer to the question Who gets TMS? is Anybody.
But it is certainly most common in the middle years of life, the
years of responsibility. Lets now take a look at how TMS
manifests itself.

WHERE DOES TMS MANIFEST ITSELF?

Muscle.
The primary tissue involved in TMS is muscle, hence the original
name myositis (as mentioned, myo stands for muscle). The only
muscles in the body that are susceptible to TMS are those in the
back of the neck, the entire back, and the buttocks, known
collectively as postural muscles. They are so named because they
maintain the correct posture of the head and trunk and contribute
to the effective use of the arms.
Postural muscles have a higher proportion of slow twitch
muscle fibers than limb muscles, making them more efficient for
endurance activity, which is what is required of them. Whether or
not this is the reason why TMS is restricted to this group of muscles
we do not know. It is possible, though, since the muscles most
frequently involved have the most important jobs. These are the
buttock muscles, known anatomically as gluteal muscles. Their job
is to keep the trunk upright on the legs, to prevent it from falling
forward or to either side. Statistically, the low back–buttock area
is the most common location for TMS.
Just above the buttocks are the lumbar muscles (in the small
of the back), often involved simultaneously with buttock muscles.
Occasionally the gluteal or lumbar muscles are affected separately.
Roughly two-thirds of TMS patients will have their major pain in
this area.
Second in order of frequency of involvement are the neck and
shoulder muscles. The pain is usually in the side of the neck and
the top of the shoulder, in the upper trapezius muscle.
TMS can occur anywhere else in the back, between the
shoulders and low back, but does so far less frequently than in the
two areas mentioned.
Generally a patient will complain of pain in one of these prime
areas, as, for example, in the left buttock or the right shoulder, but
the physical examination will reveal something else of great interest
and importance. In virtually every patient with TMS one finds
tenderness when pressure is applied (palpation) to muscles in three
parts of the back: the outer aspect of both buttocks (and sometimes
to the entire buttock), the muscles in the lumbar area and both
upper trapezius (shoulder) muscles. This consistent pattern is
important because it supports the hypothesis that the pain syndrome
originates in the brain rather than in some structural abnormality of
the spine or incompetence of the muscle.

Nerve.
The second type of tissue to be implicated in this syndrome is
nerve, specifically what are known as peripheral nerves. Those
most frequently affected are located, as might be expected, in close
proximity to the muscles that are involved most often.
The sciatic nerve is located deep in the buttock muscle (one
on each side); lumbar spinal nerves are under the lumbar para-
spinal muscles; the cervical spinal nerves and brachial plexus are
under the upper trapezius (shoulder) muscles. These are the nerves
most frequently affected in TMS.
In fact, TMS looks like a regional process, rather than one
aimed at specific structures. So when it affects a given area, all
the tissues suffer oxygen deprivation so that one may experience
both muscle and nerve pain.
Varying kinds of pain may result when muscle and/or nerve
are affected. It may be sharp, aching, burning, shocklike, or it may
feel like pressure. In addition to pain, nerve involvement may
produce feelings of pins and needles, tingling and/or numbness,
and sometimes sensations of weakness in the legs or arms. In
some cases there is measurable muscle weakness. The latter can
be documented with electromyographic studies (EMG). EMG
abnormalities are often cited as evidence of nerve damage due to
structural compression, but in fact EMG changes are very common
in TMS and usually reveal involvement of many more nerves than
could be explained by a structural abnormality.
Lumbar spinal and sciatic nerve symptoms are in the legs, for
that is where those nerves are going. Involvement of cervical spinal
nerves and brachial plexus cause symptoms in the arms and hands.
Traditional diagnoses attribute leg pain to a herniated disc and arm
pain to a pinched nerve. (See chapter 5.)
TMS may involve any of the nerves in the neck, shoulders,
back and buttocks, sometimes producing unusual pain patterns.
One of the most frightening is chest pain. One immediately thinks
of the heart when there is chest pain and, indeed, it is always
important to be sure that there is nothing wrong with that organ.
Once having done so, one should keep in mind that spinal nerves in
the upper back may be suffering mild oxygen deprivation because
of TMS and that this may be the source of the pain. These nerves
serve the front of the trunk as well as the back, hence the chest
pain.
Remember: Always consult a regular physician in order to
rule out serious disorders. This book is not intended as a guide to
self-diagnosis. Its purpose is to describe a clinical entity, TMS.
One may suspect the presence of nerve involvement in TMS
through the patients history, the physical examination or both. Sciatic
pain may affect any part of the leg except the upper, front thigh.
There is considerable variability depending on how much of the
nerve trunk is affected by oxygen debt. As noted above, the person
may also complain of other strange feeings and of weakness.
On physical examination the tendon reflexes and muscle
strength are tested to determine whether oxygen deprivation has
irritated the nerve sufficiently to interfere with the transmission of
motor impulses. Similarly, sensory tests are done (for example,
ability to feel a pinprick) to determine the integrity of the sensory
fibers in the involved nerve. The major virtue of documenting
sensory or motor deficits is to be able to discuss them with patients
and reassure them that feelings of weakness, numbness or tingling
are quite harmless.
The so-called straight leg–raising test is always done when a
patient is examined, though for different reasons, depending on the
examiner. If there is a great deal of soreness in the buttocks, the
patient will be unable to elevate the straightened leg very far and
then only with a great deal of pain. The pain may be due to the
muscle, the sciatic nerve or both. What the sign does not mean in
the majority of cases is that there is a herniated disc pressing on
the sciatic nerve, as patients are often told.
When there is a shoulder-arm pain syndrome, one does similar
tests on the arm and hand.
Sometimes patients have pain on two sides; this is of no
particular significance. People will also often report that in addition
to having the major pain in the right buttock and leg, for example,
they have some intermittent pain in the neck or one of the shoulders.
This is not unexpected since TMS may involve any or all of the
postural muscles.

Tendons and Ligaments.

Following the publication of my first book describing TMS, I
gradually became aware that a variety of tendonalgias (pain in
tendons or ligaments) were probably part of the syndrome of tension
myositis. The term myositis was fast becoming obsolete, it having
been determined many years before that nerves could be implicated
in TMS, as just described. Now I was beginning to realize that still
another type of tissue might be part of the process; and as time
went by this conclusion became more and more inescapable.
What first attracted attention were reports from treated patients:
In addition to the disappearance of back pain, their tendon pain
(for example, tennis elbow) often left as well. As is well known,
tennis elbow is one of the most common of the disorders called
tendonitis. Generally, it is assumed that these painful tendons are
inflamed, presumably because of excessive activity. The routine
treatment is anti-inflammatory medication and activity restriction.
Having been alerted to the possibility that these painful tendons
might be part of TMS, I began to suggest to patients that their
tendonitis might also disappear if they allowed it to occupy the
same place in their thinking as the back pain. The results were
encouraging and over time my confidence in the diagnosis
increased. I am now prepared to say that tendonalgia is often an
integral part of TMS and in some cases is its primary manifestation.
It has become apparent that the elbow is not the most common
site of tendonalgia. In my experience, the knee has that distinction.
Some of the usual diagnoses for knee pain are chondromalacia,
unstable knee cap and trauma. However, the examination discloses
that there is tenderness of one or more of the tendons and ligaments
surrounding the knee joint and the pain usually disappears along
with the back pain.
Another common place is the foot and ankle, either the top or
bottom of the foot, or the Achilles tendon. Common foot diagnoses
are neuroma, bone spur, plantar fasciitis, flat feet and trauma due
to excessive physical activity.
The shoulder is another location for TMS tendonalgia; the usual
structural diagnosis is bursitis or rotator cuff disorder. Again, there
is usually easily identified tenderness on palpation of a tendon in
the shoulder. Wrist tendons are not uncommonly involved. It is
possible that what is known as carpal tunnel syndrome may also
be part of TMS but this cannot be stated without further observation
and study.
Recently I saw a patient who had developed pain in a new
location after a minor accident. She said the pain was in her hip
and that X rays showed that there was arthritis of the hip joints,
more on the side where she was having pain, and she had been
told that this was the cause of her pain. She had proven to be
highly susceptible to TMS in the past so I suggested she come in
for an examination. The X rays showed a very modest amount of
arthritic change in the joint in question, about what would be
expected in someone of her age. She had excellent range of motion
of the joint and no pain on weight bearing or movement of the leg.
When I asked her to touch the exact spot where she felt the pain
she identified a small area where the tendon of a muscle attaches
to bone, well above the hip joint; it was tender to pressure. I told
her I thought she had TMS tendonalgia and the pain left in a few
days.
Hip tendonalgia is most commonly attributed to what is called
trochanteric bursitis. That diagnosis was not made on this occasion
because the location of pain was above the trochanter, the bony
prominence that can be felt at the upper, outer aspect of the hip.
TMS can manifest itself in a variety of locations and it tends to
move around, particularly if something is being done to combat the
disorder. Patients often report pain in a new location as the old one
gets better. It is as though the brain is unwilling to give up this
convenient strategy for diverting attention away from the realm of
the emotions. It is, therefore, particularly important for the patient
to know where all the possible locations of pain are. My patients
are routinely instructed to call me when they develop new pain so
that we can determine whether it is part of TMS.
In summary, TMS involves three types of tissue: muscle, nerve
and tendon-ligaments. Let us now look at how TMS manifests
itself.

PATIENT CONCEPTS OF CAUSE AND TYPE OF ONSET.

When first seen most people are under the impression that they
have been suffering from the long-term results of an injury, a
degenerative process, a congenital abnormality or some deficiency
in the strength or flexibility of their muscles. The idea of injury is
probably the most pervasive. This often ties in with the
circumstances under which the pain begins.

According to a survey we did a number of years ago, 40 percent
of a typical group of patients reported that the pain began in
association with some kind of physical incident. For some it was a
minor automobile accident, usually the hit-from-behind type. Falls,
on the ice or down steps, were common. Lifting a heavy object or
straining was another; and, of course, running, tennis, golf or
basketball were often blamed. The pain began anywhere from
minutes to hours or days after the incident, raising some important
questions about the nature of the pain. Some of the reported
incidents were trivial, such as bending over to pick up a toothbrush
or twisting to reach into a cupboard, but the ensuing pain might be
just as excruciating as that experienced by someone who was trying
to lift a refrigerator.
I recall a young man who was sitting at his office desk writing
and experienced a spasm in his low back so severe and persistent
that he had to be taken home by ambulance. The next forty-eight
hours were agonizing; he couldnt move without setting off a new
wave of spasm.
How can such excruciating pain be set off by this great variety
of physical incidents? In view of the different degrees of severity
of the physical incidents and the great variation in when the pain
begins after the incident, the conclusion is that the physical
happening was not the cause of the pain but was merely a trigger.
Many patients apparently dont need a trigger; the pain just comes
on gradually or they awaken with it in the morning. In the survey
mentioned above, 60 percent fell into that category.
The idea that physical incidents are triggers is reinforced by
the fact that there is no way to distinguish between those pains
that start gradually and those that begin dramatically in terms of
subsequent severity or longevity of the attack. All of this makes
perfect sense when one considers the nature of TMS. Despite the
perception of injury, patients are not injured. The physical
occurrence has given the brain the opportunity to begin an attack
of TMS.
There is another reason to doubt the role of injury in these
attacks of back pain. One of the most powerful systems that has
evolved over the millions of years of life on this planet is the biologic
capacity for healing, for restoration. Our body parts tend to heal
very quickly when they are injured. Even the largest bone in the
body, the femur, only takes six weeks to heal. And during that
process there is pain for only a very short time. It is illogical to
think that an injury that occurred two months ago might still be
causing pain, not to mention one of two or ten years ago. And yet
people have been so thoroughly indoctrinated with the idea of
persistent injury that they accept it without question.
Invariably those patients who have a gradual onset of pain will
attribute it to a physical incident that may have occurred years
before, like an automobile or skiing accident. Because in their minds
back pain is physical, that is, structural, it must be due to an
injury. As far as they are concerned there has to be a physical
cause.
This idea is one of the great impediments in the way of recovery.
It must be resolved in the patients mind or the pain will persist.
Gradually, patients need to begin to think psychologically; and,
indeed, once the diagnosis of TMS is made, it is common for patients
to begin to recall all of the psychological things that were going on
in their lives when acute attacks occurred, like starting a new job,
getting married, an illness in the family, a financial crisis and so on.
Or the patient will acknowledge that he or she has always been a
worrier, overly conscientious and responsible, compulsive and
perfectionistic. This is the beginning of wisdom, the start of the
process of putting things into proper perspective. In this case, it is
the recognition that there are physical disorders that play a
psychological role in human biology. Not to be aware of that fact is
to doom oneself to perpetual pain and disability.

THE CHARACTER OF ONSET.

The Acute Attack.
Perhaps the most common, and undoubtedly the most frightening,
manifestation of TMS is the acute attack. It usually comes out of
the blue and the pain is often excruciating, as described in the case
of the young man above. The most common location for these
attacks is the low back, involving the lumbar (small of the back)
muscles, the buttock muscles or both. Any movement brings on a
new wave of terrible pain so the condition is very upsetting, to say
the least. It is clear that the involved muscles have gone into spasm.
Spasm is a state of extreme contraction (tightening, tensing) of the
muscles, an abnormal condition that may be horrifically painful.
Most everyone has experienced a leg or foot cramp (charley horse),
which is the same thing, except that the cramp will stop as soon as
the involved muscle is stretched. The spasm of an attack of TMS
does not let up. When it begins to ease, any movement can start it
up again.
As will be described in the physiology chapter (see The
Physiology of TMS), I believe that oxygen deprivation is
responsible for the spasm as well as other kinds of pain characteristic
of TMS. It is likely that common leg cramps also result from oxygen
deprivation, which is why they usually occur in bed when the
circulation of blood is slowed down and there is liable to be a
temporary, minor state of reduced oxygenation in the leg muscles.
Blood flow can be quickly restored to normal with muscle
contraction. With TMS, however, reduced blood flow is continued
by action of the autonomic nerves, and the abnormal muscle state
persists.
People often report that at the moment of onset they hear
some kind of noise, a crack, a snap or a pop. Patients often use the
phrase My back went out. They are sure that something has
broken. In fact, nothing breaks, but the patient will swear that there
has been some kind of structural damage. The noise is a mystery.
It may be that it is similar to the noise elicited by a manipulation of
the spine, which is a kind of cracking the knuckles of the joints
of the spinal bones. One thing is clearthe noise indicates nothing
harmful.

Though the low back is the most common location for an acute
attack, it can occur anywhere in the neck, shoulders or upper and
lower back. Wherever it occurs, it is the most painful thing I know
of in clinical medicine, which is ironic because it is completely
harmless.
Not uncommonly the trunk is distorted by one of these attacks.
It may be bent forward or to the side, or a bit of both. The precise
reason for and mechanism of this is not known. Naturally, its very
disturbing but it has no special significance.
These episodes last for varying periods of time and invariably
leave the person with a sense of dread and apprehension. The
common perception is that something terrible has happened and
that it is important to be very careful not to do anything that will
injure the back and bring on another attack.
If the low back pain is accompanied by pain in the leg, or
sciatica, there is even greater concern and apprehension, for this
raises the spectre of the herniated disc and the possibility of surgery.
In this media-dominated age very few people have not heard of
herniated discs and the idea arouses great anxiety, resulting in
greater pain. If, in the course of medical investigation, imaging
studies show a herniation, the apprehension is multiplied even
further. And if there should be feelings of numbness or tingling in
the leg or foot and/or weakness, all of which can occur with TMS,
because of burgeoning fear, the conditions for a very protracted
episode of pain are defined. As will be discussed later, herniated
discs are rarely the cause of the pain (see Herniated Disc).
There is not a great deal one can do to speed the resolution of
such an episode. If the person is fortunate enough to know what is
going on, that this is only a muscle spasm and there is nothing
structurally wrong, the attack will be short-lived. But this is rarely
the case. I advise my patients to remain quietly in bed, perhaps
take a strong painkiller, and not agonize over what has happened.
They are further instructed to keep testing their ability to move
around and not assume they are going to be immobilized for days
or weeks. If one can overcome ones apprehension, the duration
of the attack will be considerably shorter.

The Slow Onset of Pain.

In over half the cases of TMS the pain begins graduallythere is
no dramatic episode. In some cases there is no physical incident to
which one can attribute the pain. In others onset of pain may follow
a physical happening, but hours, days or even weeks later. This
pattern is fairly common after a so-called whiplash incident. A car
is struck from behind and your head snaps back. Examination and
X rays do not reveal a fracture or dislocation but sometime
thereafter pain begins, usually in the neck and shoulders, occasionally
in the mid or low back. Pain in an arm or hand may also occur and,
like sciatica, arouses a great deal of anxiety. Sometimes the pain
begins in the neck and shoulders and then moves down to involve
the rest of the back. If one knows that this is TMS, the course may
be relatively brief. If some sort of structural diagnosis is made,
symptoms may continue for many months, despite treatment.

THE TIMING OF ONSET.
Acute attack or slow onset, why does the pain begin when it
does? Remember, the physical incident, no matter how dramatic,
is a trigger. The answer, of course, is to be found in ones
psychological state. Sometimes the reason is obviousa financial
or health crisis, or something one ordinarily thinks of as a happy
occasion, like getting married or the birth of a child. I have had a
number of highly competitive people whose pain began in the course
of athletic competition, like a tennis match. Naturally, they assumed
that they had hurt themselves. When they realized they had TMS,
they admitted how very anxious they had been about the
competition.
It is not the occasion itself but the degree of anxiety or anger
which it generates that determines if there will be a physical reaction.
The important thing is the emotion generated and repressed, for
we have a built-in tendency to repress unpleasant, painful or
embarrassing emotions. These repressed feelings are the stimulus
for TMS and other disorders like it. Anxiety and anger are two of
those undesirable emotions that we would rather not be aware of,
and so the mind keeps them in the subterranean precincts of the
subconscious if it possibly can. All of this is discussed in detail in
the psychology chapter.
Then theres the person who says, There was absolutely
nothing going on in my life when this began. But when we begin
to discuss the trials and tribulations of daily life it is usually clear
that this person is generating anxiety all the time. I think there is a
gradual buildup in such people until a threshold is reached, at which
point the symptoms begin. Once it is pointed out to them, these
patients have little trouble recognizing that they are the kind of
perfectionist, highly responsible people who generate a lot of
subconscious anger and anxiety in response to the pressures of
everyday life.

The Delayed Onset Reaction.

There is another interesting pattern that we see very often. In
these cases patients go through a highly stressful period that may
last for weeks or months, such as an illness in the family or a
financial crisis. They are physically fine as they live through the
trouble, but one or two weeks after its all over they have an attack
of back pain, either acute or slow onset. It seems as though they
18
rise to the occasion and do whatever they have to do to deal with
the trouble, but once its over the accumulated anxiety threatens to
overwhelm them, and so the pain begins.
Another way of looking at it is that they dont have time to be
sick during the crisis; all of their emotional energy goes into coping
with the trouble.
A third possibility is that the crisis or stressful situation is
providing enough emotional pain and distraction that a physical
pain isnt necessary. The pain syndrome seems to function to divert
the persons attention away from repressed undesirable emotions
like anxiety and anger. When one is living through a crisis there is
more than enough unpleasantness going on and one has no need
for a distraction.
Whatever the psychological explanation, this is a common
pattern and it is important to recognize it so that the back pain will
not be blamed on some physical condition.

The Weekend-Vacation Syndrome.

When we generate anxiety depends mostly on the details of our
personality structure. Not uncommonly people will report that they
almost always have an attack of pain when they are on vacation,
or if they already have pain that it gets worse on weekends. For
some the reason is obvious. They are very anxious about their
work or business when they are away from it. Its a bit like the
delayed reaction; as long as they are on the job they may be burning
up the anxiety but when they are away from it, supposedly relaxing,
the anxiety accumulates.
Speaking of relaxing, one often hears the advice Relax, as
though thats something one can do voluntarily. There are also
numerous techniques around for promoting relaxation, like drugs,
meditation and biofeedback, to name a few. However, unless the
relaxation process succeeds in reducing repressed anxiety and
anger, people will develop things like TMS and tension headaches
despite the attempt to induce relaxation. Some people dont know
how to leave their daily concerns behind them and shift attention
to something pleasurable. I remember a patient who said that her
pain would invariably begin when she got herself a drink and sat
down to relax.
Recently I saw a young man who illustrated the vacation
syndrome very well. He described having been under a lot of stress
for a long time, but without any back pain. It wasnt until he was
on his honeymoon that he was awakened one night with a
nightmarish dream followed immediately by a severe back spasm
in which, he said, my back went completely out. Of course, it
might have been due to the stresses and strains of being newly
married, but he was an extremely conscientious type and I was
inclined to connect it with his work.
He was still having symptoms when I saw him three months
later, no doubt due to the fact that an MRI had shown a disc
herniation at the lower end of the spine and the possibility of surgery
had been discussed. (An MRI, or magnetic resonance imaging, is
an advanced diagnostic procedure that is capable of producing an
image of body soft tissues allowing one to detect the presence of
such things as tumors or herniated discs.)
However, he read my book on TMS, thought that he was typical
of the patients described, and came in to see me. The examination
was conclusive for TMS. In fact, it showed that his symptoms
could not be due to the herniated disc, for he had weakness in two
sets of muscles in his leg, something that the herniated disc could
not have caused. Only involvement of the sciatic nerve, as is typical
in TMS, could have produced this neurological picture. At any rate,
he was delighted to learn that TMS was the basis for his back
troubles and had a rapid recovery.
Another explanation, often difficult for people to admit to
themselves, is that there are great sources of anxiety and anger in
their personal lives, like a bad marriage, trouble with children, having
to care for an elderly parent. We have seen numerous examples
of this: women trapped in bad marriages that they cannot stand
and yet unable to break out because of their emotional and/or
financial dependence on their husbands; people who feel perfectly
competent at what they do for a living but who cannot deal with a
difficult spouse or child.
I recall a woman with a persistent pain problem who lived
with a very difficult brother. Despite psychotherapy the pain
continued. One day she told me that she had done a very unusual
thing; she had gotten furious at her brother, had shouted and ranted
at him and stormed out of the house. And with thatthe pain
disappeared. Unfortunately, she could not maintain her strong
posture and the pain returned.

The Holiday Syndrome.

One often hears or reads that holidays may be stressful. What
should be a time of relaxation and fun often turns out to be
unpleasant for some people. I have been struck by the fact that
many patients will report the onset of attacks of TMS before, during
or shortly after major holidays.
The reason is obvious: big holidays usually mean a lot of work,
particularly for women, who take the responsibility in our culture
for organizing and carrying out the festivities. And, of course, society
demands that this be done cheerfully, with a smile. Usually the
women are completely unaware that they are generating great
quantities of resentment, and the onset of pain comes as a complete
surprise.

THE NATURAL HISTORY OF TMS.

What are the common patterns of TMS? What happens over time
if one continues to be plagued by this disorder?

Conditioning.

Essential to an understanding of this subject is knowledge about a
very important phenomenon known as conditioning. A more
modern term meaning the same thing is programming. All animals,
including humans, are conditionable. The phenomenon is best known
by the experiment reported by the Russian physiologist Pavlov,
who is credited with the discovery of conditioning. His experiment
demonstrated that animals develop associations which can produce
automatic and reproducible physical reactions. In the research study
he rang a bell each time he fed a group of dogs. After repeating
this a few times he found that the dogs would salivate if he rang
the bell even without the presentation of food. They had become
conditioned to have a physical reaction at the sound of the bell.
The process of conditioning, or programming, seems to be very
important in determining when the person with TMS will have pain.
For example, a common complaint of people with low back pain is
that it is invariably brought on by sitting. This is such a benign
activity one is mystified by the fact that it initiates pain. But
conditioning occurs when two things go on simultaneously, so it is
easy to imagine that at some point early in the course of the TMS
experience the person happens to be having pain while sitting. The
brain makes the association between sitting and the presence of
pain and that person is now programmed to expect pain with sitting.
In other words, the pain occurs because of its subconscious
association with sitting, not because sitting is bad for the back.
That is one way a conditioned response may be established. There
must be others I am unaware of since sitting is such a common
problem for people with low back pain. Car seats have a bad
reputation, so a person expects to have pain when he or she gets
into a car.
Often people are programmed to have pain because of things
they have heard or been told by a practitioner. Never bend at the
waist means the onset of pain is a sure thing when they bend
from then on, although it may never have caused pain before.
Someone says that sitting compresses the lower end of the spine
so, of course, its got to hurt when you sit. Standing in one place,
lifting, carryingall have a bad reputation and will quickly be
conditioned into a patients pattern.
Many people report that the pain is relieved by walking; others
say that walking brings it on. Some have a great deal of pain at
night and cannot sleep. One man worked hard all day long with a
fair amount of heavy lifting and never a twinge of pain. Every
night he would wake up about 3:00 A.M. with severe pain that
persisted until he got out of bed. Clearly a conditioned reaction.
Others report that they sleep well but develop pain as soon as
they wake up and get out of bed. In these patients the pain usually
increases in severity as the day goes on.
Based on history and physical examination, all of these people
have TMS but are programmed to believe they suffer from
something else. What gives strong support to the idea that these
reactions are conditioned is that they disappear within a few weeks
as patients go through my treatment program. If they were
structurally based they would not go away after treatment
(consisting primarily of lecture seminars), which is what happens
with successfully treated patients. The conditioning is broken by
the educational process.
One cannot overemphasize the importance of conditioning in
TMS for it explains many of the reactions that patients dont
understand. If someone says, I can lift a very light weight but
anything over five pounds will cause pain, the pain cant be based
on structural grounds. Or this example: a woman who could bend
over and touch her palms to the floor without pain but told me she
always felt pain when she put her shoes on!
Many of these conditioned responses stem from the fear that
people develop when they have back pain, especially in the low
back. They have been told and they have read that the back is
fragile, vulnerable and easily injured, so if they try to do something
vigorous, like jog or swim or vacuum the floor, their backs begin to
hurt. They have learned to associate activity with pain; they expect
it, so it happens. That is conditioning.
The specific posture or activity that brings on the pain is not
important per se. What is essential is to know that it has been
programmed in as a part of the TMS and is, therefore, of
psychological rather than physical significance.

Common Patterns of TMS.

Perhaps the most common pattern is for the person to have
recurrent acute attacks of the kind described earlier. These may
last from days to weeks or even months, with the most acute pain
subsiding after a few days. They are traditionally treated with bed
rest, painkillers and anti-inflammatory drugs, administered by mouth
or by injection. If the patient is hospitalized, traction is often
employed, though its purpose is to immobilize the patient and not to
pull the spinal bones apart since this could not be done with the
weights used. I do not instruct my patients what to do for an acute
attack, for it is the goal of this program to see that the attacks
dont occurto prevent them. However, occasionally I am called
upon to advise someone having an acute attack; as stated earlier
in the chapter, its essentially a question of waiting it out. I may
prescribe a strong painkiller but not an anti-inflammatory drug, since
there is no inflammation.

The irony of the usual experience with one of these attacks is
that most patients would be better off if they consulted no one.
This is unwise, however, because every once in a while there may
be something physiologically important going on and so one must
be examined by a physician. Assuming nothing truly serious, like a
tumor, is present, the usual diagnosis is some spinal structural
abnormality. A scary diagnosis (degenerative disc disease, herniated
disc, arthritis, spinal stenosis or facet syndrome) plus the dire
warnings of what will happen if the patient doesnt take sufficient
bed rest and cautioning about never again jogging or using a vacuum
cleaner or bowling or playing tennis is the perfect combination for
multiplied and persistent pain.
But the human spirit is more or less indomitable and eventually
the symptoms fade, leaving someone who is essentially free of
pain but permanently scarred, not physically but emotionally. Except
for the very brave few, most people who have had such an attack
never again engage in vigorous physical activity with an easy mind.
They have been sensitized by the experience and all that it is
supposed to imply and they see themselves, to a greater or lesser
degree, as permanently altered. They fear another attack and
eventually it comes. It may be six months or a year later but the
prophecy is fulfilled and the dreaded event occurs again. As before,
the person usually attributes the attack to some physical incident.
This time there may be leg pain as well as back pain and now
there is talk of surgery should a herniated disc be found on MRI or
CT scan. (CT, or computed tomography, is an advanced X-ray
technique that can, like the MRI, give information about soft tissues
as well as bone.) This further increases anxiety and the pain may
become even more severe.
This pattern of recurrence of acute attacks is very common.
As time goes on the attacks tend to come more frequently, to be
more severe and to last longer. And with each new attack the fear
increases and there is an increased tendency to limit physical
activities. Some patients become virtually disabled as time goes
on.
In my view physical restrictions and the fear of physical activity
represent the worst aspect of these pain syndromes. They are
ever present, though the pain may come and go. They have a
profound effect on all aspects of life: work, family, leisure time.
Indeed, I have known patients with TMS who were much more
disabled in terms of their daily lives than patients who were
paralyzed in both legs. Many of the latter go to work every day on
their own, raise families and in every way lead normal lives, except
that they are in wheelchairs. The severe TMS patient may have to
stay in bed most of the day because of the pain.
Eventually most people who have recurrent attacks will develop
a chronic pattern. They will begin to have some pain all the time,
usually mild, but exacerbated by a variety of activities or postures
to which they have become conditioned. I can lie on my left side
but not on my right; I must always have a pillow between my
knees in bed; I never go anywhere without my seat cushion;
My body corset (or neck collar) is absolutely essential if I am to
remain free of pain; If I sit for more than five minutes I get
severe pain; The only chair I can sit on has to have a hard seat
and a straight back; and on and on.
And to some the pain becomes the primary focus of their lives.
It is not uncommon to hear people say that the pain is the first thing
they are aware of when they awaken in the morning and the last
thing they think about when they go to sleep. They become
obsessed with it.
There is great variety in . There
are those who have a little pain all the time with varying degrees of
physical restriction. Others have occasional acute attacks but live
essentially normal lives in between with little or no restriction.
What I have been describing are the more common
manifestations of TMS and the most dramatic, those in the low
back and legs. However, a severe episode involving the neck,
shoulders and arms can be very dramatic tooand just as physically
restricting. Here is a typical example.
The patient was a middle-aged man who had been having
recurrent attacks of pain in the neck and shoulders and pain,
numbness and tingling in his hands for about three years prior to
the time I saw him. The episode that brought him to me had begun
about eight months previously with pain in the left arm. He saw
two neurologists, had a variety of sophisticated tests and was told
that the pain was the result of a disc problem in the neck. There
was debate whether he should have immediate surgery; he was
warned that he might become paralyzed if he didnt. Not
surprisingly, the pain spread from his arm to his neck and back; he
was unable to ski or play tennis, two of his favorite sports. He was
very frightened.
My examination disclosed that he had TMS and that there
were no neurological abnormalities. Fortunately, a third neurologist
concluded that there was no structural basis for his pain so he was
able to accept the diagnosis of TMS with an easy mind. He went
through the program and in a few weeks was free of pain and able
to resume his usual athletic activities. He has not had a recurrence.
Sometimes the shoulder is the site of the trouble or the knee.
To anyone who tries to be physically active, knee pain can be very
debilitating. I have had such an episode and can attest to the fact
that it can be scary, persistent and restricting. Any of the tendons
and ligaments in the arms and legs and any of the muscles and
nerves of the neck, shoulders, back and buttocks can be involved
in TMS.
Though we must identify the structures involved in each case,
this is the least important part of the consultation. Each encounter
with a patient is an excursion into that persons life. After we have
established which body parts are involved that information must
be put aside, for we do not work on the muscles, nerves and
ligaments directly. Something in that persons emotional life that
might have played a role in producing the symptoms must be
addressed.

There comes to mind the case of a man who had found himself
financially well-off enough to retire from business at an early age
and who shortly thereafter developed the pain syndrome for which
I saw him. As we talked it became apparent that since his retirement
he had become preoccupied with a number of family problems,
there had been a number of deaths in the family, he was worried
about the health of the business he had left (in the hands of relatives),
and he had begun to wonder what his life was all about now that
he was retired and was thinking about aging and mortality for the
first time. His concern about these matters, considered consciously
and unconsciously, had produced sufficient anxiety (and anger) to
precipitate the TMS. Conventional medicine had attributed his pain
to an aging spine, and treatment for that had, naturally, failed. He
had TMS; his troubles were not in his spinethey were in his life.
To summarize, TMS may involve postural muscles, nerves that
are in and around those muscles, and a variety of tendons and
ligaments in the arms and legs. In the areas involved, the patient
has pain, possibly feelings of pins and needles and/or weakness.
There are many different patterns and locations of symptoms and
considerable variation in severity, ranging from mild annoyance to
almost total disability.
Recurrent attacks, fear of recurrence and physical activity,
and failure to find successful treatment characterize TMS.
The symptoms of pain, numbness, tingling and weakness are
intended by the brain to suggest that something is physically wrong.
To most people, practitioners and laymen alike, physically wrong
means injury, weakness, incompetence and degeneration, singly or
in combination. To further this view of the symptoms, the pain
often begins in association with some physical activity, the more
vigorous the better. The patient cant help but conclude that
something has been injured or displaced. My back went out is a
common description of the event.
Also very important to advancing the idea of structural
incompetence is the powerful tendency for people to become
programmed to fear a variety of simple, common things like sitting,
standing in one place, bending and lifting.
The net effect of symptoms, fears and alterations in life-style
and daily activities is to produce someone whose attention is strongly
focused on the body. As shall be seen in succeeding chapters, that
is the purpose of the syndrometo create a distraction so that
undesirable emotions can be avoided. It seems a heavy price to
pay, but then the inner workings of the mind are not really known,
and we can only suspect its deep aversion to frightening, painful
feelings.

CHANGE YOUR BRAIN, CHANGE YOUR WEIGHT

THE CRAVING SOLUTION,
USE YOUR BRAIN TO INCREASE YOUR WILLPOWER AND CALM THE
URGES THAT PREVENT YOU FROM ACHIEVING YOUR GOALS.

From craving
is born grief, from craving is born fear. For one freed from craving, there's no grief--so
how fear?--buddha.

I had been good all day. I had a protein-fruit shake for breakfast; a spinach salad
with turkey, blueberries, and walnuts for lunch; and sweet red bell pepper and apple
slices with a little almond butter in the afternoon. All seemed right with my relationship
with food, until I went to the Los Angeles Lakers basketball game. I know how to eat
when I am away from home. But this night my brother bought a huge caramel apple with
peanuts. I find that I now have total focus, not on the game, but on the sticky, gooey,
sweet apple.

Our grandfather was a candy maker and some of my best memories are standing
on a stool at the stove with him when I was a little boy making and then, of course, eating
candy. Sweets have always been an emotional food for me. I am named after my
grandfather, and he was my best friend growing up. Yet, I know how tired and foggy a
sugar load makes me feel twenty to thirty minutes later.

Nonetheless, I am still totally focused on my brother's caramel apple. I try not to
look at it, but the urge to look, sort of like when you are next to a very pretty woman,
nudges me in that direction. The memories of the sweet taste try to hijack my brain.
Dopamine, the pleasure and motivation brain chemical, pushes on an area in my brain
called the nucleus accumbens, in the basal ganglia, which drives me toward asking for a
piece, or heck, just getting up and buying an apple of my own. My prefrontal cortex, the
brain's brake, fights back. Eating well earlier that day has given me a good blood sugar
level, which helps to protect me against my urges. "I'll be back," I tell my brother, and I
take a brief walk to reset my brain, let him finish the apple, and get my mind back on the
game.

I come from a family of not only candy makers but also amazing cooks and
overweight people. My brother, whom I adore, is at least one hundred pounds
overweight. My grandfather, also overweight, had a heart attack in his sixties. If I was not
focused on taking care of my brain, eating well, and exercise, I would, for sure, be
overweight too. I am grateful for my neuroscience background, because it shows me how
to maintain control over my urges.

In this chapter, I will share with you what I have learned on how to have the
willpower to control your cravings to stay on track toward your goals of having a healthy
brain and a vibrant body.

THE CIRCUITRY OF CONTROL.

Understanding the brain circuits of willpower and self-control is an important step
in gaining mastery of your brain and body. There are centers in the brain responsible for
focus, judgment, and impulse control (the prefrontal cortex, in the front third of the
brain). There is also a pleasure and motivation center, called the nucleus accumbens,
which is part of the basal ganglia, large structures deep in the brain. The nucleus
accumbens provides the passion and motivation that is one of the main drivers of
behavior.

Additionally, the brain has emotional memory centers that trigger behavior.
According to my friend, addiction specialist Mark Laaser, Ph.D., "the arousal
template" in the emotional memory centers underlies many behaviors that get out of
control. It is important to understand where you were and how old you were when you
experienced your first pleasurable or arousing experience, such as standing at the stove
making fudge with my grandfather when I was four years old. This intense, emotionally
pleasurable experience often lays the neural tracks for later addictions, even if the
experience happened as early as age two or three. The first experience gets locked into
the brain, and when you get older, you seek to repeat the experience because it was the
way you had the initial arousal or pleasurable experience, like the first time you tasted
fudge, had sex, fell in love, or used cocaine. Understanding the triggers for emotional
eating, smoking, or drinking can be very helpful to breaking addictions.

Four neurotransmitters are also important to mention here.

Dopamine is often thought of as the pleasure, motivation, and drive chemical in
the brain. Cocaine and stimulants like Ritalin boost dopamine in the brain. Dopamine is
often associated with "saliency," or the relative importance of something. At the moment
I saw the caramel apple, it became much more salient or important in my mind.

Serotonin is thought of as the happy, antiworry, flexibility chemical. Most of the
current antidepressants work on this neurotransmitter. When serotonin levels are low,
people tend to suffer with anxiety, depression, and obsessive thinking.

GABA is an inhibitory neurotransmitter that calms or helps to relax the brain.
Endorphins are the brain's own natural pleasure and painkilling chemicals.

The relative strength and weakness of each of these brain areas and each of these
neurotransmitters goes a long way in determining how much control we have over
ourselves and how well we are able to stick to our plans, even around caramel apples
with peanuts at the Lakers game. They all work together symphonically to give us
beautiful control over our lives. When they are out of balance, the noise can be very
irritating.

BRAIN AREAS INVOLVED WITH CRAVING AND WILLPOWER.
Prefrontal cortex (PFC)--focus, judgment, and impulse control
Basal ganglia (nucleus accumbens)--pleasure and motivation center
Deep limbic (emotional memory centers)--triggers of behavior.

BRAIN CHEMICALS INVOLVED WITH CRAVING AND WILLPOWER
Dopamine--motivation, saliency, drive, stimulant
Serotonin--happiness, antiworrying, calming
GABA--inhibitory, calming, relaxing.

Endorphins--pleasure and painkilling properties
In a healthy brain, there is good judgment and emotional control by a competent
prefrontal cortex (PFC), but also plenty of emotion and drive from the deep limbic
system to stay on track and get things done. Figure 2.1 shows a healthy self-control
circuit. Healthy dopamine levels can drive passion, especially in the context of good
activity in the PFC, which acts as the reins or the brake so you do not get out of control.
Low levels of dopamine are associated with certain problems that rob us of motivation,
such as Parkinson's disease, some forms of depression, and ADD. Addictions occur when
the drive circuits hijack the brain and take over control.

When these chemicals and brain areas are in balance, we can be focused and goal
oriented and have control over our cravings; we can walk away from caramel apples,
chocolate cake, the bag of chips, French fries, and the myriad of other unhealthy choices.
When these chemicals and brain areas are troubled (Figure 2.2), we often get off track
and can do serious damage to ourselves.

For example, having low activity in the PFC from a head injury, poor sleep,
persistent drug or alcohol use, or inheriting ADD, makes it more likely you will have
impulse-control problems and poor self-supervision. Even though the goal would be to
stop drinking, hold the cigarettes, or maintain a healthy weight, you do not have the
willpower (or the PFC power) to say no on a regular basis.

In the healthy self-control circuit, the prefrontal cortex (PFC) is strong and there
is good balance between the chemical dopamine and the basal ganglia (BG) and limbic or
emotional circuits in the brain. In the addicted circuit, the PFC is weak, so it has little
control over unbridled passions that drive behaviors. Addiction actually changes the brain
in a negative way, making it harder to apply the brakes to harmful behaviors. In the
nonaddicted brain, the PFC is constantly assessing the value of incoming information and
the appropriateness of the planned response, applying the brakes or inhibitory control as
needed. In the addicted brain, this control circuit becomes impaired through drug abuse,
ADD, sleep deprivation, or a brain injury, losing much of its inhibitory power over the
circuits that drive response to stimuli deemed salient.

I once treated a forty-two-year-old woman who failed six alcohol treatment
programs. Her impulse control was virtually zero. She could not be given a prescription
for any medication because she would take them all at once. When I asked her initially if
she had ever had a brain injury, she said no. But when I pushed her, she remembered that
she had been kicked in the head by a horse when she was ten years old. Her brain SPECT
scan showed severe PFC damage (Image 2.1). She had virtually no supervisor in her
head. Comedian Dudley Moore once said that, "The best car safety device is a rearview
mirror with a cop in it." The PFC acts like the cop in your head, and when it shows this
level of damage, most people are in serious trouble. If I did not address the damaged
PFC, she would never be well. Giving her a medication to enhance PFC function was
very helpful to her.

If you have suffered an emotional trauma or you are under a lot of stress, the feel-
good chemicals, such as serotonin and GABA, may be depleted and your emotional or
limbic brain may become excessively active, making you feel sad. This makes you eat or
drink in an attempt to calm your limbic brain. MIT researchers demonstrated that simple
carbohydrates, such as cookies or candy, boost serotonin levels. Many people
unknowingly use these substances as a way to medicate their underlying negative
feelings. But as with cocaine, over time these substances lose their effectiveness, and
people engage in the corresponding behaviors not so much for the high or good feelings
as for the attempt to prevent the terrible feelings of withdrawal.

Image 2.1: Brain Injury from Horse Kick.

Marked decreased PFC
Likewise, if you have engaged in excessive amounts of pleasure or used cocaine
or too many excessively pleasurable foods, your brain may have been exposed to too
much dopamine. Over time, it becomes numb to it, and it takes more and more to get the
same pleasurable response. Keeping these brain chemicals and systems in balance is
critical to maintaining focus and control over your cravings.
Anything that decreases activity to the brain, especially to the PFC, robs you of
good judgment and self-control. Head injuries are obvious. Protect your brain. Poor sleep
has been associated with overall decreased brain activity. Strive to get at least seven
hours a night (see Chapter 10, "The Sleep Solution").
REGAINING CONTROL--BALANCE YOUR BRAIN SYSTEMS
1. Boost Your Prefrontal Cortex
To gain control over willpower and cravings, it is critical to strengthen your PFC.
To do so:
Treat any PFC problems that may exist, such as ADD, toxic exposure, or brain
trauma. (See Chapter 15, "The Brain Health Solution.")
Get good sleep--at least seven hours, more is better--to maintain adequate PFC
blood flow.
Maintain a healthy blood sugar level by eating frequent smaller meals. In a 2007
article by Matthew Gailliot and Roy Baumeister, the authors outline the critical nature of
blood sugar levels and self-control. They write that self-control failures are more likely to
occur when blood sugar is low. Low blood sugar levels can make you feel hungry,
irritable, or anxious--all of which make you more likely to make poor choices. Many
everyday behaviors can cause dips in blood sugar levels, including drinking alcohol,
skipping meals, and consuming sugary snacks or beverages, which causes an initial spike
in blood sugar then a crash about thirty minutes later.

Keeping glucose levels even throughout the day improves self-control. Several
studies have examined the relationship between glucose and smoking cessation, and the
majority of these studies have found that healthy glucose levels increase the likelihood of
successfully quitting smoking. Coping with stress requires self-control because it requires
that people make a concerted effort to control their attention, thoughts, and emotions.
People with healthy blood sugar levels are therefore also able to manage stress more
effectively than others. Maintaining your blood sugar levels with complex carbohydrates,
lean protein, and healthy fat will significantly cut down on your cravings.

Exercise to boost blood flow to the brain. Table tennis is a great choice. One
study from Japan showed that ten minutes of table tennis boosted activity in the PFC.
Practice meditation--numerous studies have found that it boosts activity and blood
flow to the PFC.

Create focused, written goals. The PFC is involved in planning and forethought. It
needs clear direction. I have my patients do an exercise called the One-Page Miracle
(OPM) because it makes such a dramatic difference in the lives of those who practice it.
Here are the steps: On a piece of paper, write down the specific goals you have for your
life, including your health, relationships, work, and money. There's a reason why your
OPM includes more than just your physical goals. As you will learn throughout this book,
your relationships, career, and financial situation--and the stress they can cause--all affect
your body and your willpower.Take your time with this exercise. Keep the paper with
you so you can jot down ideas and goals as they come to you. After you complete your
initial draft, place it somewhere where you are sure to see it every day, such as on the
refrigerator, on your bathroom mirror, or on your desk at work. This way, on a daily
basis, you will be focusing on what's important to you. When you are focused on what
you want, it makes it much easier to match your behavior to make it happen. Ask yourself
every day, Is my behavior today getting me what I want? Your mind is powerful and it
makes happen what it sees. Focus and meditate on what you want. You will find that your
willpower goes up dramatically. Here is an example.

TAMARA'S ONE-PAGE MIRACLE.

What Do I Want for My Life?RELATIONSHIPS--to be connected to those I
loveSpouse/Significant other: to maintain a close, kind, caring, loving partnership with
my husband. I want him to know how much I care about him. Family: to be a firm, kind,
positive, predictable presence in my children's lives. I want to help them develop into
happy, responsible people. To continue to keep close contact with my parents, to provide
support and love. Friends: to take time to maintain and nurture my relationships with my
siblings WORK--to be my best at work, while maintaining a balanced life. Specifically,
for my work activities to focus on taking care of my current projects, doing activities
targeted at obtaining new clients, and giving back to the community by doing some
charity work each month. I will focus on my goals at work and not get distracted by
things not directly related to my goals.MONEY--to be responsible and thoughtful and
help our resources growShort-term: to be thoughtful of how our money is spent, to
ensure it is directly related to our family's and my needs and goals Long-term: to save 10
percent of everything I earn. I pay myself and my family before other things. I'll put this
money away each month in a pension plan for retirement. HEALTH--to be the healthiest
person I can beWeight: to lose thirty pounds so my body mass index (BMI) will be in the
normal range Fitness: to exercise for at least thirty minutes three days a week and to start
taking martial arts lessons. I promise no head injuries here. Nutrition: to eat breakfast
every day so I don't get really hungry until lunchtime. To prepare a sack lunch at least
three days a week so I'm not tempted to go to the fast-food restaurant across from work.
To eliminate diet sodas and reduce the amount of sugar I eat. To take a multivitamin and
fish oil every day. Physical health: to lower my blood pressure and cholesterol levels
Emotional health: to meditate for ten minutes every day to help me calm stress.

MY ONE-PAGE MIRACLE.

What Do I Want for My Life?
Along the same lines, having a clearly written set of rules also helps to boost the
PFC.
For example, one of my rules is to stay away from mayonnaise. I like it, but not
enough to make it worth the calories. Here is an example of some helpful rules.
I treat my body with respect.
I read my One-Page Miracle daily.
I look for ways to optimize my nutrition.
I eat breakfast every day.
I eat frequently enough during the day so that I do not get hungry or a low blood
sugar level.
I get seven to eight hours of sleep at night whenever possible.
I exercise three or four times a week.
I do not poison my body with toxins such as nicotine or my mind with persistent
negative thoughts.
If I break a rule, I will not dwell on it and give up on the rest of the rules. I will be
kind and forgiving.

No more than twelve rules. I once had a patient with obsessive-compulsive
disorder who made up 108 rules.

Willpower is like a muscle. The more you use it, the stronger it gets. This is why
good parenting is essential to helping children develop self-control. If we gave in to our
six-year-old every time she wanted something, we would raise a spoiled, demanding
child. By saying no, I teach her to be able to say no to herself. To develop willpower, you
need to do the same thing for yourself. Practice saying no to the things that are not good
for you, and over time, you will find it easier to do.

Long-term potentiation (LTP) is a very important concept. When nerve cell
connections become strengthened, they are said to be potentiated. Whenever we learn
something new, our brains make new connections. At first the connections are weak,
which is why we do not remember new things unless we practice them over time.
Practicing a behavior, such as saying no to the caramel apple, actually strengthens the
willpower circuits in the brain. LTP occurs when nerve cell circuits are strengthened,
practiced, and behaviors become almost automatic. Whenever you give in to the caramel
apple, it weakens willpower and makes it more likely you will not have any. You have to
practice willpower, and your brain will make it easier for you.

ACTION STEPT improve your willpower, you have to practice it.

2. Balance the Pleasure Centers and Calm Anxiety.

As mentioned, the basal ganglia are large structures deep in the brain. They are
involved with pleasure and motivation. When the basal ganglia are healthy, we feel
happy and motivated. When they work too hard, we can be anxious or overly driven.
When they are low in activity, we may feel low or unmotivated. Here are some ways to
balance your pleasure centers.

Be careful with too much technology. In Dr. Archibald Hart's book Thrilled to
Death, he suggests that the evolution of technology in our society is wearing out our
brain's pleasure centers. I believe it is having a very negative effect on our relationships
and our bodies. With the onslaught of video games, text messaging, cell phones,
Facebook, and Twitter, as well as online dating, pornography, and gambling, our pleasure
centers are being worn out. Pretty soon, we will not be able to feel anything at all. As I
mentioned above, our pleasure centers deep within the brain operate on a chemical called
dopamine, which is the same chemical that cocaine stimulates and one of the main
chemicals of new love. Whenever a little bit of dopamine is released, we feel pleasure. If
dopamine is released too often or too strongly, we become desensitized to it and it takes
more and more excitement to get the same response. More and more, I see people coming
into our offices complaining about their partner or children being addicted to new
technology. Christina and Harold were having big problems in their relationship.
Christina wanted more time with Harold, but he spent hours hooked on his video games.
He became angry when she asked him to stop playing so much, and when he told her to
stop nagging him, she moved out. Subsequently Harold became depressed and came to
see us. This couple played out the same pattern I have seen with many other types of
addictions--she didn't want to leave, but she didn't know what else to do.ACTION
STEP Work to keep your pleasure centers healthy. Be careful with the high-excitement
activities, limit video games, and stop ALWAYS being on your computer.As a society,
we have unleashed massive amounts of technology on the population with virtually no
study on what it all does to developing brains or to our families. We need to be more
careful. Stop it. In a study sponsored by Hewlett-Packard, people who were addicted to
their cell phones or their computers lost ten IQ points over a year. Find natural sources of
pleasure, such as nature, a great conversation, and long, loving eye contact.

Use relaxation techniques to help balance and calm this part of the brain.
Engage in meaningful activities that give you motivation without putting you in
overdrive.

Use supplements to calm anxiety and balance the pleasure centers. These include
vitamin B6, magnesium, and N-acetyl-cysteine (NAC). See Appendix C, "The
Supplement Solution," for more information.

3. Calm Your Brain's Emotional Centers and Eliminate Your Triggers.

Emotional stresses and depression decrease willpower. If you have unresolved
emotional issues, it is essential to understand and work through them, otherwise they will
hijack your brain. Here are six tips to help get your emotions under control.
Talk about what bothers you to someone close or a therapist. Talking about issues
can help get them out of your head. If there has been past trauma, one of the
psychotherapies I often recommend is called EMDR (eye movement desensitization and
reprocessing). It is fast and very powerful. You can learn more about it at
www.emdria.org.

When you are upset, journal rather than eat, drink, or light up. Studies show that
writing down your bothersome thoughts and feelings can have a healing effect.
Write down five things you are grateful for every day. Our research suggests that
focusing on gratitude helps to calm the deep limbic or emotional areas of the brain and
enhances the judgment centers.

Exercise. It not only boosts PFC activity, it also calms the limbic brain by
boosting serotonin, the feel-good chemical.

Correct the ANTs, or automatic negative thoughts (see Chapter 13, "The ANT
Solution"). You do not have to believe every thought that goes through your head.
Whenever you feel sad, mad, or nervous, write down the thoughts that are bothering you
and talk back to them.

Try the supplement SAMe to help calm this area of the brain and boost the PFC.
See Appendix C, "The Supplement Solution," for more information.

REGAINING CONTROL--BALANCE YOUR BRAIN CHEMISTRY.

Beyond brain-system balancing, it is also important to balance the chemicals that
drive behavior.
1. Dopamine.

Dopamine is the chemical of motivation, saliency, drive, and stimulation. It is the
chemical that both cocaine and Ritalin stimulate in the brain. Low levels are associated
with low motivation, low energy, poor concentration, impulse-control problems, some
forms of depression, Parkinson's disease, and ADD. You can boost dopamine levels by:
Doing intense physical exercise.
Eating a protein-rich meal.
Working at a job or organization that is exciting or deeply meaningful.
Being wary of excitement-seeking behaviors, which may wear out your pleasure
centers, deplete dopamine, and make you feel numb or unable to feel pleasure.

Taking natural supplements, such as L-tyrosine or SAMe. See Appendix C, "The
Supplement Solution," for more information.

2. Serotonin
Serotonin is the chemical of feeling peaceful, happy, and flexible. When it is low,
people suffer with some forms of depression, along with anxiety, obsessive thinking
(such as about the caramel apple), or compulsive behaviors. You boost serotonin by
Engaging in physical exercise, which allows the serotonin precursor L-
tryptophan, a relatively small molecule, greater access to the brain.
Practicing willpower. Giving in to obsessive behaviors solidifies them in the brain
and establishes nerve tracks to make them more automatic. Practicing willpower actually
does the opposite and has been found to change the brain, much like serotonin
medications, such as Prozac.
Taking supplements, such as 5-hydroxytryptophan (5-HTP), L-tryptophan,
inositol, or St. John's wort. Good scientific evidence supports 5-HTP's usefulness for
helping people lose weight. Inositol is a natural chemical found in the brain that is
reported to help neurons use serotonin more efficiently. St. John's wort comes from the
flowers of the Saint-John's-wort plant and seems to increase serotonin availability in the
brain. See Appendix C, "The Supplement Solution," for more information.

3. GABA.

GABA, or gamma-aminobutyric acid, is an amino acid that helps to regulate brain
excitability and calms overfiring in the brain. GABA and GABA enhancers, such as the
anticonvulsant gabapentin and L-theanine (found in green tea), function to inhibit the
excessive firing of neurons, which results in a feeling of calm and more self-control. Low
levels of GABA have been found in many psychiatric disorders, including anxiety and
some forms of depression. Rather than overeat or drink or use drugs to calm your anxiety,
natural ways to boost GABA may help. I often recommend GABA supplements.
Glycine is also an inhibitory neurotransmitter, which means it calms brain
activity. It is an important protein in the brain, and recent studies have demonstrated its
effectiveness in the treatment of obsessive-compulsive disorder and in reducing pain.
L-theanine, one of the components of green tea, has also been shown to boost
GABA, while at the same time helping with concentration and mental alertness.

4. Endorphins.
Endorphins are chemicals linked to feeling pleasure and eliminating pain. They
are the body's own natural morphine or heroinlike substances. These substances are
heavily involved in addiction and the loss of control. Natural ways to boost endorphins
include the following:
Exercise, which is why some people feel a runner's high when they exercise
intensely.
Acupuncture, which has been found to be effective for a number of pain
syndromes. Its positive painkilling effect can be blocked by using endorphin-blocking
drugs, such as naltrexone.
Hypnosis, which has been shown to be helpful in pain syndromes.
The craving solution involves balancing the brain areas and chemistry of pleasure
and control. It involves using your PFC as the master controller and making sure there is
a bridle on the pleasure and emotional centers to help them guide you to where you want
to go.

The Craving Solution
Will power Robbers.
Willpower Boosters.

Any brain problems Brain health Brain trauma.
Focusing on brain protection Poor sleep Adequate sleep (at least seven hours) Low blood
sugar Frequent small meals with at least some protein to maintain healthy blood sugar
Poor diet Enriched diet Alcohol Freedom from alcohol ADHD Clearly focused, written
goals (see One-Page Miracle) Some forms of depression Journaling when sad or anxious
Anxiety Meditation for relaxation and to boost the PFC Negative thinking Killing the
ANTs (automatic negative thoughts) Focusing on problems and fears Gratitude practice
Bad habits, giving in Practicing willpower Too much pleasure Being careful with too
much pleasure or too much technology Artificial forms of pleasure Finding natural
sources of pleasure Negative or meaningless behaviors Engaging in positive and
meaningful activities Social isolation Social support Being in denial about problems
Effectively treating any brain problems Lack of exercise Exercise Denial of feelings
Understanding emotional triggers Decreasing cravings with B6, magnesium, and NAC
Boosting dopamine (L-tyrosine, DL-phenylalanine, SAMe) Boosting serotonin (5-HTP,
L-tryptophan, inositol, St. John's wort) Boosting GABA (GABA, glycine, L-theanine)
Boosting endorphins (exercise, acupuncture, hypnosis).
3
THE WEIGHT SOLUTION.

USE YOUR BRAIN TO ACHIEVE YOUR OPTIMAL WEIGHTI am what I ate ...
and I'm frightened.--BILL COSBY.

Rebecca, forty-four, couldn't stop herself from eating, especially at night. She
thought about food constantly throughout the day. The thoughts haunted her, even though
she did not want to have them. Over eight years, she had gained nearly ten pounds per
year and was now eighty pounds overweight despite trying many diets and going to
multiple weight-loss clinics. She hated how she looked and was thoroughly disgusted
with herself. The Atkins diet--very high protein and low carbohydrate--made her irritable
and emotional. Diet pills made her anxious. She felt as though she needed a glass--or two
or three--of alcohol at night to settle her worries, but the extra calories were certainly not
helping her weight problem. She came to our clinics because she was starting to have
marital problems, in part because her husband was upset about her weight, and also
because she had trouble letting go of hurts, held grudges, and worried incessantly.
Rick, thirty-seven, was growing larger by the year. At five feet eight inches tall,
he was over 250 pounds. As a highly successful salesman for a large West Coast liquor
company, he was always on the run and attended many fancy dinners and sporting events.
His wife was starting to complain about his weight, which made him angry. Why doesn't
she just love me the way I am? he thought, even though she married him when he was
nearly seventy-five pounds lighter a decade earlier. Growing up, Rick had problems with
focus and impulsivity. He barely finished his first year of college when he found a job in
the liquor industry that he loved. Rick brought his son to our clinic for school-related
problems, much like the problems Rick had experienced in school. After he saw how
much better his son was on treatment, Rick decided to get an evaluation as well.
Cherrie, fifty-two, had been bulimic as a teenager, and the hidden truth for her
was that she still had bouts of bingeing and purging, especially during times of stress.
Cherrie was chronically thirty pounds overweight and hated how she looked. She would
not undress in front of her husband and found that she often picked on him as a way to
not have to have sex or be seen naked. Her own thoughts were extremely negative, and
she vacillated between being obsessive about her work and housekeeping to being
overwhelmed and disorganized. Cherrie grew up in an alcoholic home and had trouble
talking about her feelings and trusting others.
She had tried a number of diet programs without success, until the fen-phen craze
of the 1990s. On fen-phen, a combination of medications that increased the
neurotransmitters serotonin (fenfluramine) and dopamine (phentermine), she did
amazingly well, losing the unwanted pounds and feeling more emotionally stable than at
any other time in her life. When the fen-phen was pulled from the market because
fenfluramine was associated with a deadly illness called pulmonary hypertension, Cherrie
relapsed and went back to her emotional roller coaster and lack of success at losing and
keeping off weight. Cherrie came to see us on the advice of her sister, whom we were
seeing for issues of depression.
Jerry, sixty-two, was baffled by his weight problem. As a child, he was fit,
athletic, energetic, and loved being outside in the sun. He was raised in Southern
California and made the most of the beach, surfing, and volleyball. In his thirties, still in
great shape, he got a new job in the Northwest as a supervisor at Boeing. He loved his
job, the new responsibility, and the income, but over time he noticed that particularly in
the winter, his mood and energy would lag, and he started to gain weight despite trying to
work out. Over time, he retained more of the weight he gained in the winter than what he
could manage to lose in the summer. His weight gain and loss was like a yo-yo that was
losing steam. He also complained of many more aches and pains. He came to our
Northwest clinic to get a handle on his moods and weight.
Connie, twenty-eight, seemed to be constantly eating. She munched on the way to
work, at work, on the way home, and late into the night. She found that when she tried to
go without eating for a few hours, she felt anxious and nervous. She often felt a sense of
dread and was often waiting for something bad to happen. She frequently complained of
an irritable bowel, sore muscles, and headaches. Marijuana helped to calm her down in
college, but it also gave her the munchies, so she used it only sporadically. Her weight
continued to creep up; when she reached 165 pounds on her five-foot-two-inch frame, she
knew something needed to be done. She came to our clinic because her family had
complained about her level of anxiety and irritability.
Camille, sixty-four, could not keep on any weight. Two years before seeing us,
she had gone through a difficult divorce, and the year before, her mother died. Camille
had lost twenty-five pounds during that time and now none of her clothes fit. She had felt
as if her whole system was in hyperdrive. She had trouble sleeping, her thoughts seemed
to race, she had diarrhea, and both her heart rate and blood pressure were up. She came to
our clinics to help calm her mind and body and put back on some weight.

ONE SIZE DOES NOTFIT EVERYONE.

Rebecca, Rick, Cherrie, Jerry, Connie, and Camille all struggled with their
weight. Yet they all had very different clinical presentations and brain patterns.
Rebecca was a compulsive overeater. She couldn't stop thinking about food. Her
brain SPECT study showed too much activity in the front part of her brain (in an area
called the anterior cingulate gyrus), likely due to low levels of the neurotransmitter
serotonin. On a rational weight-loss program plus a regimen of 5-HTP to boost serotonin
levels in her brain, she lost weight, felt much happier, was more relaxed, and got along
better with her husband.

Rick was an impulsive overeater. He also had trouble controlling his behavior.
His brain SPECT scan showed too little activity in his prefrontal cortex, likely due to low
dopamine levels, so he had trouble supervising his own behavior. Like his son, he was
also diagnosed with ADD. On treatment to boost his dopamine levels, he felt more
focused and in better control of his impulses. Over the first year, he lost thirty-five
pounds and was getting along better with his wife and child.

Cherrie was an impulsive-compulsive overeater. Cherrie had features of both
impulsivity (the bulimia) and compulsivity (manifested by the repetitive negative
thoughts and rigid behavior). Her brain SPECT scan showed areas in her prefrontal
cortex that were both overactive and underactive, likely due to low serotonin and
dopamine levels. In my research, I discovered that this pattern is common in children and
grandchildren of alcoholics. On treatment to raise both serotonin and dopamine levels,
she felt much more emotionally balanced and consistently lost weight.
Jerry was a SAD or emotional overeater. He struggled with his mood and
weight, but only after he moved to a place where he got little sunlight. He suffered from
seasonal affective disorder (SAD), which has been associated with low vitamin D levels,
and his brain SPECT study showed increased activity in his emotional or limbic brain and
decreased activity in his PFC. On a combination of vitamin D, bright light therapy, and
SAMe, he did much better, experienced fewer pain symptoms, and returned to his
premove weight over a two-year period.
Connie was an anxious overeater. She medicated her underlying anxiety with
food. Her brain SPECT study showed increased activity in her basal ganglia, an area
often associated with anxiety. By calming her anxiety with relaxation techniques and a
combination of B 6, magnesium, and GABA, she stopped the constant grazing, felt more
relaxed and more in control of her emotions and behavior. She lost twenty pounds over
the next year and noticed a boost in her energy.
Camille was on adrenaline overload. This was causing her to waste away. The
chronic intense stress from her divorce and the recent loss of her mother reset her brain
and body to an overactive state. Her brain SPECT study showed overall increased activity
in the deep centers of her brain, a pattern on SPECT we call the diamond pattern because
of the hyperactivity of the different structures we see. On treatments to calm her brain--
including a form of psychotherapy called EMDR for people who have been emotionally
traumatized, plus phosphatidylserine, B 6, magnesium, and GABA--she was able to
sleep, quiet her mind, and come back to a normal weight.

WHY MOST WEIGHT-MANAGEMENT APPROACHES DO NOT WORK.

Weight-loss pills, clinics, books, programs, and cookbooks are everywhere you
look. Why are there so many different approaches to weight loss and weight
management? Why do they generally have such poor results? Why are people constantly
searching for the next idea and the next fix? The problem with the whole notion of weight
management is that one treatment, one program, or one method is advertised to work for
everyone. Based on our brain imaging work with tens of thousands of patients, the
premise for most weight-management programs that promote a single path or prescription
is ridiculous. First, you need to know about your own individual brain and then target the
interventions in a way that fits your own specific needs.
Looking at the descriptions below and taking the brief questionnaire in Appendix
B, plus the extended online version at www.amenclinics.com/my-brain-health/online-
tests-calculators/cyb-questionnaire, you will get an idea about how your own brain works
and what specific needs you may have. Then, based on your answers, you will be better
able to target the treatment interventions. Of course, you should do this in consultation
with your own health-care provider.

SUMMARY OF THE AMEN CLINICS: SIX TYPES OF WEIGHT-
MANAGEMENT ISSUES.

Type 1: The Compulsive Overeater.

People with this type have trouble shifting their attention and tend to get stuck on
thoughts of food or compulsive eating behaviors. They may also get stuck on anxious or
depressing thoughts. The basic mechanism of this type is that they tend to get stuck or
locked into one course of action. They tend to have trouble seeing options and want to
have things their way. They struggle with cognitive inflexibility. This type is also
associated with worry, holding grudges, and having problems with oppositional or
argumentative behavior. Nighttime-eating syndrome, where people tend to gorge at night
and not be hungry early in the day, usually fits this pattern.
The most common brain SPECT finding in this type is increased anterior
cingulate gyrus activity, which is most commonly caused by low brain serotonin levels.
High-protein diets, diet pills, and stimulants, such as Ritalin, usually make this type
worse. Interventions to boost serotonin in the brain are generally the most helpful. From a
supplement standpoint (see Appendix C), 5-HTP, L-tryptophan, St. John's wort, and the
B vitamin inositol are helpful, as are the serotonin-enhancing medications, such as
Prozac, Zoloft, and Lexapro. In fact, 5-HTP has good scientific evidence that it helps
with weight loss, and in my experience, I have found that it works best for this type.
ACTION STEP Behavioral interventions that boost serotonin to help
compulsive overeaters:
Exercise to allow more of the serotonin precursor, L-tryptophan, to get into the
brain.
If you get a negative or food-oriented thought in your head more than three times,
get up and go do something to distract yourself.
Make a list of ten things you can do instead of eating so you can distract yourself.
People with this type always do better with choices, rather than edicts. Do not tell
them where you are going to eat or what they are going to eat; give them choices.
Avoid automatically opposing others or saying no, even to yourself.
If you have trouble sleeping, try a glass of warm milk with a teaspoon of vanilla
and a few drops of stevia.

Type 2: The Impulsive Overeater.

People with this type struggle with impulsivity and trouble controlling their
behavior, even though nearly every day they intend to eat well. "I am going to start my
diet tomorrow" is their common mantra. This type results from too little activity in the
brain's PFC. The PFC acts as the brain's supervisor. It helps with executive functions,
such as attention span, forethought, impulse control, organization, motivation, and
planning. When the PFC is underactive, people complain of being inattentive, distracted,
bored, off task, and impulsive. This type is often seen in conjunction with ADD, which is
associated with long-standing issues of short attention span, distractibility,
disorganization, restlessness, and impulsivity.

Research published in the July 2008 issue of Pediatrics found that children and
adolescents with ADD who do not currently take medications are at 1.5 times the risk of
being overweight than non-ADD children. These individuals are more likely to be
impulsive overeaters. On the other hand, those taking medication for ADD had 1.6 times
more risk of being underweight compared to children without ADD, which is a side
effect of their medication, which decreases appetite.

Impulsive overeaters may also be the result of some form of toxic exposure, a
near-drowning accident, a brain injury to the front part of the brain, or a brain infection,
such as chronic fatigue syndrome. The most common brain SPECT finding in this type is
decreased activity in the PFC, which is most commonly associated with low brain
dopamine levels. High-carbohydrate diets and serotonin-enhancing medications, such as
Prozac, Zoloft, or Lexapro, or supplements, such as 5-HTP, usually make this type worse.
Interventions to boost dopamine in the brain are generally the most helpful. From a
supplement standpoint, green tea and rhodiola are helpful, as are stimulant medications,
such as phentermine, Adderall, and Ritalin, which are commonly used to treat
ADD.ACTION STEPBehavioral interventions that boost dopamine to help
impulsive overeaters:
Exercise, which helps increase blood flow and dopamine in the brain--especially
doing an exercise you love.
Clear focus--make a list of weight and health goals displayed where you can see it
every day.
Outside supervision--someone you trust checking in with you on a regular basis to
help you stay focused.
Avoid impulsively saying yes to offers for more food or drink and practice saying,
"No, thank you, I'm full."

Type 3: The Impulsive-Compulsive Overeater.

People with this type have a combination of both impulsive and compulsive
features. The brain SPECT scans tend to show low activity in the PFC (associated with
impulsivity, likely due to low dopamine levels) and high activity in the anterior cingulate
gyrus (associated with compulsivity and low serotonin levels). This pattern is common in
the children or grandchildren of alcoholics. People with this mixed type tend to have
done very well emotionally and behaviorally on the fen-phen combination, which raised
both dopamine and serotonin in the brain.
Using serotonin or dopamine interventions by themselves usually makes the
problem worse. For example, using a serotonin medication or supplement helps to calm
the compulsions but makes the impulsivity worse. Using a dopamine medication or
supplement helps to lessen the impulsivity but increases the compulsive behaviors.
Treatments to raise dopamine and serotonin together, with either a combination of
supplements, such as green tea and 5-HTP, or medications, such as Prozac and Ritalin,
have worked the best in my experience.

ACTION STEP Behavioral interventions that boost both serotonin and
dopamine to help impulsive-compulsive overeaters:
Exercise.
Set goals.
Avoid automatically opposing others or saying no, even to yourself.
Avoid impulsively saying yes.
Have options.
Distract yourself if you get a thought stuck in your head.

Type 4: The SAD or Emotional Overeater.
People with this type often eat to medicate underlying feelings of boredom,
loneliness, or depression. Their symptoms can range from winter blues to mild chronic
sadness (termed dysthymia) to more serious depressions. Other symptoms may include a
loss of interest in usually pleasurable activities; decreased libido; periods of crying;
feelings of guilt, helplessness, hopelessness, or worthlessness; sleep and appetite
changes; low energy levels; suicidal thoughts; and low self-esteem. The SPECT findings
that correlate with this type are markedly increased activity in the deep limbic areas of
the brain and decreased PFC activity.
When this type occurs in the winter, it is usually in more northern climates, where
there is often a deficiency in sunlight and vitamin D levels. Low vitamin D levels have
been associated with depression, memory problems, obesity, heart disease, and immune
suppression. In recent years, there is an increase in vitamin D deficiencies even in
southern and western states in the summer. There are two reasons for this: People are
wearing sunscreen more than ever, so they are not being exposed to the sun even when
they are outside, and they are spending more and more time indoors on their computers or
watching TV. Some researchers believe nearly half of the U.S. population suffers from a
vitamin D deficiency. I screen all of my patients for it by ordering a 25-hydroxy vitamin
D level. To treat SAD or emotional overeaters, check vitamin D levels and correct them
when low by taking a vitamin D supplement. Bright light therapy may be helpful to
correct vitamin D problems, help with mood states, and help people lose weight.
There is evidence that bright light therapy might also enhance the effectiveness of
physical activity for weight loss. In studies, it significantly reduced the binge-eating
episodes in people with bulimia and is an effective treatment for SAD. Research studies
have also shown it to be more effective than Prozac for these patients. Using bright light
therapy in the workplace was effective in improving mood, energy, alertness, and
productivity.ACTION STEPBehavioral interventions that boost mood to help SAD
or emotional overeaters:
Exercise to increase blood flow and multiple neurotransmitters in the brain.
Kill the ANTs (automatic negative thoughts) that steal your happiness.
Write down five things you are grateful for every day (this has been shown to
increase your level of happiness in just three weeks).
Volunteer to help others, which helps to get you outside of yourself and less
focused on your own internal problems.
Surround yourself with great smells, such as lavender.
Try melatonin to help you sleep.
Work to improve your relationships.
Also, make sure to check your DHEA blood levels. DHEA is a master hormone
that has been found to be low in many people with depression and obesity.
Supplementing with DHEA has good scientific evidence that it is helpful for weight loss
in certain patients. Another helpful treatment for emotional overeaters is the natural
supplement SAMe, in dosages of 400 to 1,600 mg. Be careful with SAMe if you have
ever experienced a manic episode, and take it early in the day as it has energizing
properties and may interfere with sleep. I like the medication Wellbutrin for this type,
which has been shown to have weight-reducing properties.

Type 5: The Anxious Overeater.

People with this type tend to use food to medicate underlying feelings of anxiety,
tension, nervousness, and fear. They tend to feel uncomfortable in their own skin. They
may be plagued by feelings of panic, fear, and self-doubt, and suffer physical symptoms
of anxiety as well, such as muscle tension, nail biting, headaches, abdominal pain, heart
palpitations, shortness of breath, and sore muscles. It is as if they have an overload of
tension and emotion. People with this type tend to predict the worst and look to the future
with fear. They may be excessively shy, easily startled, and freeze in emotionally charged
situations. The SPECT finding in this type is increased activity in the basal ganglia,
which is commonly caused by low levels of the calming neurotransmitter GABA.
Interventions to boost GABA, by using B6, magnesium, and GABA, are generally
the most helpful. From a medication standpoint, the anticonvulsant Topamax has strong
evidence that it is helpful for weight loss, and in my experience, it is especially helpful
for this type. Relaxation therapies can also be helpful to calm this part of the brain.
ACTION STEPBehavioral interventions that boost GABA and calm the brain to
help anxious overeaters:
Exercise.
Try relaxation exercises, such as: meditation prayer hypnosis deep
diaphragmatic breathing exercises hand-warming techniques
Kill the anxious ANTs.
For sleep, try self-hypnosis, kava kava, or valerian root.

Type 6: The Adrenaline-Overload Anorexic.
For most people, excess stress leads to weight gain. But some people have trouble
keeping a healthy weight on their bodies when they're under a lot of stress. The stress
causes them to go into an emotional overload state, and they start to waste away.
Typically, these people's thoughts often go too fast, they tend to have trouble sleeping,
they may experience diarrhea, and they often complain of memory problems. Their brain
SPECT studies show overall increased activity, especially in the deep centers of their
brains, similar to what I see with post-traumatic stress syndrome.
Treatments to calm the brain are generally the most helpful, including EMDR--
eye movement desensitization and reprocessing (see www.emdria.org for more
information)--hypnosis, and cognitive therapy. The supplements phosphatidylserine (PS),
B 6, magnesium, and GABA are also helpful to calm the stress. There are not any current
medications I use to help people gain weight. Any medications I prescribe depend on
what other factors may be contributing to the current stress. ACTION STEPBehavioral
interventions--the same as those recommended for anxious overeaters--that boost
GABA and calm the brain to help adrenaline overload anorexics:
Exercise.
Try relaxation exercises, such as: meditation prayer hypnosis deep
diaphragmatic breathing hand-warming techniques
Kill the anxious ANTs.
For sleep, try self-hypnosis, kava kava, or valerian root.
Knowing your brain type is essential to the Weight Solution and getting the right
help for yourself. For any weight solution to be effective, it must be centered on your
particular brain, your particular problems, and your particular needs. Any program that
gives you a one-size-fits-all approach is destined to fail.
Do You Have More Than One Type?
Having more than one type is common, and it just means that you may need a
combination of interventions. Type 3 Impulsive-Compulsive Overeaters is actually a
combination of Type 1 Compulsive Overeater and Type 2 Impulsive Overeater. It is
common to have Type 1 mixed with Type 4 SAD or emotional overeater or with Type 5
Anxious Overeater. In those cases, we may mix 5-HTP for Type 1 with SAMe for Type 4
or GABA with Type 5. Again, it is always smart to discuss these options with your
health-care provider. If he or she does not know much about natural treatments, consult a
naturopath or a physician trained in integrative medicine or natural treatments.

WEIGHT CONTINUES TO BE A RISING PROBLEM.
Our poor eating habits are making us one of the fattest nations on the planet. More
than half of American women have a waistline greater than thirty-five inches, while half
of their male counterparts measure in at more than forty inches around the belly. Obesity
is becoming an epidemic with a devastating impact on our health and our brains.
Research from 2005 and 2006 indicates that fully one-third of adult men and more than
35 percent of adult women in the United States are obese. About six million people are
considered to have morbid obesity, which is defined as being at least 100 pounds
overweight. Obesity is determined by a person's body mass index (BMI), which is a ratio
of their weight and height.

Body Mass Index (BMI) Categories.
Underweight:
Normal weight: 18.5-24.9.
Overweight: 25-29.9.
Obese: 30 or higher.
Morbid obesity: 40 or higher.
Sources: National Institutes of Health and American Society for Metabolic &
Bariatric Surgery.
Here are the steps to calculate your BMI: weight in pounds x 703/height in
inches.
Multiply your weight in pounds times 703.
Multiply your height (in inches) times your height (in inches).
Divide the number in step 1 by the number in step 2 to get your BMI.
For example: If you weigh 148 pounds and you are five feet six inches tall, the
calculation would look like this:
148 pounds x 703 = 104,044.
66 x 66 = 4,356.
104,044/4,356 = 23.9 BMI (normal).
Or, if you weigh 260 pounds and you are five feet six inches tall, the calculation
would look like this:
260 pounds x 703 = 182,780.
66 x 66 = 4,356.
3.182,780/4,356 = 42.0 BMI (morbidly obese).

Morbid obesity is associated with more than thirty medical conditions and
diseases, including type 2 diabetes, heart disease, and high blood pressure, as well as
brain-related conditions, such as stroke, chronic headaches, sleep apnea, and Alzheimer's
disease. These diseases can devastate a person's life. Diabetes is a disease that occurs
when blood sugar levels in the body aren't right. The high blood sugar level causes small
blood vessels in the body to become fragile and break, which can lead to terrible
consequences. I have a friend who is diabetic, and due to the disease, he has lost his sight
and has had to have both of his legs amputated. If you have a disease such as diabetes or
heart disease, it is even more important for you to eat right in order to prevent or delay
progression of the disease. Obesity is also associated with significantly longer hospital
stays for comparable conditions. Ultimately, obesity puts you at increased risk for death.
A review of several long-term studies on obesity and longevity found that the risk of
death rises as weight increases above normal weights.
People who are obese or overweight also have smaller brains than lean people,
according to new research in the journal Human Brain Mapping. Scientists used brain
scans to determine the amount of brain tissue in ninety-four people over the age of
seventy. They found that obese individuals had 8 percent less brain tissue and their brains
looked sixteen years older than the brains of people at normal weights. Overweight
people had 4 percent less brain tissue and their brains appeared eight years older.
The loss of tissue occurred in several important areas of the brain. In obese
people, losses affected the frontal lobes, anterior cingulate gyrus, hippocampus, temporal
lobes, and basal ganglia. In the overweight crowd, brain loss occurred in the basal
ganglia, corona radiata (white matter that speeds communication between different areas
of the brain), and parietal lobe. Overall, the loss of brain tissue puts overweight and obese
people at increased risk for Alzheimer's disease, dementia, and other brain disorders.
As if we needed more proof that gaining weight is bad for our health, researchers
at the University of Pittsburgh used brain imaging to examine the effects of increases in
BMI on forty-eight otherwise healthy postmenopausal women. They found that women
whose BMI went up following menopause were more likely to have a reduction in gray
matter.
What is even worse is that our kids are becoming overweight or obese at an
alarming rate. Studies show that a whopping 34 percent of children and teens are either
currently overweight or at risk of becoming overweight, and more than 16 percent of kids
ages two to nineteen are obese. Among younger children, obesity is skyrocketing. This is
putting our children at greater risk for a variety of diseases and conditions that negatively
affect brain function.
If you are overweight or love someone who is overweight, it is important to think
of this as a life-threatening problem. Mind-set here is critical. Some anxiety, or brain
alarm, is often necessary for people to take the actions needed to be healthy. I think it is
also important to treat obesity like a chronic disease, because it is. And we need to think
about being on healthy diets for life, not just for a few months to fit into a wedding dress
or a suit for a special occasion.
When it comes to the brain, size matters. A smaller brain means reduced brain
function, which can affect every aspect of your life--your relationships, your career, and
your mood.

FAT IS MORE THAN JUST FAT.

I remember the first day of my anatomy dissection lab in medical school like it
was yesterday. Some of my fellow students had weak stomachs and had to get the mop.
Even before the vomit, there was a smell in the room unlike anything most of us had ever
experienced. Some of the students were nervous. I was excited and fascinated. Anatomy
and neuroanatomy were my favorite subjects. Irma was the woman who donated her
cadaver so that my colleagues and I could become skilled physicians. Irma and I spent
many, many hours together. I remember when I cut through her skin how amazed I was
to see the bright yellow, greasy layer of fat below. I had no idea at the time that fat was
anything more than, well, fat. Since that day in the fall of 1978, fat has taken on a whole
new meaning. The fat on your body is not just an energy-storage reservoir; it is a living,
biologically active, toxin-storing, hormone-producing factory, and more fat is definitely
not better.

Fat produces the hormone leptin, which usually turns off your appetite.
Unfortunately, when people are overweight, the brain becomes sensitized to leptin, and it
no longer has a positive effect on curbing hunger cravings. Fat cells also produce the
hormone adiponectin, which also helps to turn off appetite and increases fat burning. As
fat stores increase, adiponectin levels drop, and the process of burning fat as fuel actually
becomes less efficient. In addition, fat cells pump out immune-system chemicals called
cytokines, which increase the risk of cardiovascular disease, insulin resistance, and high
blood sugar, diabetes, and low-level chronic inflammation.

Inflammation is at the heart of many chronic illnesses. The level of fat on your
body, especially abdominal fat, is also directly linked with higher total cholesterol and
LDL (bad) cholesterol and lower HDL (good) cholesterol. Together, insulin resistance,
high blood sugar, excess abdominal fat, unfavorable cholesterol and triglyceride levels,
and high blood pressure constitute the metabolic syndrome, a major risk factor for heart
disease, stroke, depression, and Alzheimer's disease.
In recent years, it has been found that fat stores toxic materials, so that the more
fat on your body, the more toxins you have. The more animal fat you eat, the more toxins
you have as well. Also, fat tends to increase the amount of estrogen in your body,
especially if you are male. Fat cells store estrogen. They contain an enzyme that converts
several other steroid hormones to estrogen. Having increased estrogen makes it difficult
to lose fat. Estrogen binds with a receptor on the surface of fat cells, which promotes the
growth and division of fat cells, especially in your butt and thighs.

THIRTEEN THINGS ALL OF US SHOULD DO TO MAINTAIN A
HEALTHY WEIGHT.

Know your type(s).
Get a complete physical and focus on having healthy vitamin D, DHEA, and
thyroid levels.
Know your BMI and caloric need numbers.
Know the approximate number of calories you eat a day by keeping a food journal
and calorie log and work on getting "high-quality calories in versus high-quality energy
out."
Exercise four or five times a week, starting with walking fast and light strength
training.
Optimize your hormone levels.
Get great sleep.
Use simple stress-management techniques.
Stop believing every negative thought that goes through your brain.
Use hypnosis to help keep you slim.
Take supplements to keep your brain healthy.
Using the advice in this book, keep your brain young and active in order to lose
ten pounds.

Take control of your weight and do not let other people make you fat.
1. Know your type(s). From the more than 55,000 scans we have performed at
the Amen Clinics, it is clear that not everyone with the same problem, such as obesity or
depression, has the same brain pattern. The descriptions above and the questionnaire in
Appendix B or at www.amenclinics.com/my-brain-health/online-tests-calculators/cyb-
questionnaire will help you know your type or types.

2. Get a complete physical. Not the five-minute type, but a real physical where
you spend time talking to your doctor about your health. Medical problems, such as being
on certain medications or having a low or suboptimal thyroid, vitamin D, DHEA, or
testosterone levels, or being depressed or anxious, can seriously sabotage any attempt to
lose, maintain, or be at your ideal weight.

3. Know your BMI and daily caloric need numbers. This is critical. The basic
principle of weight loss or weight gain is about energy balance. The BMI formula is
given above. The Harris Benedict Formula is commonly used to help people understand
the approximate number of calories a day they need to maintain their current weight. This
is a key number for you to understand, because it will serve as a guide to help you lose or
gain weight.

To find out your basic calorie needs without any exercise, your resting basal
metabolic rate (BMR), fill out the following equation on yourself:Women: 655 + (4.35 x
weight in pounds) + (4.7 x height in inches)--(4.7 x age in years)Men: 66 + (6.23 x
weight in pounds) + (12.7 x height in inches)--(6.8 x age in years)Take that number and
multiply it by the appropriate number below.1.2--if you are sedentary (little or no
exercise)1.375--if you are lightly active (light exercise/sports 1 to 3 days/week)1.55--if
you are moderately active (moderate exercise/sports 3 to 5 days/week)1.75--if you are
very active (hard exercise/sports 6 or 7 days a week)1.9--if you are extra active (very
hard exercise/sports and a physical job or strength training twice a day).
The total is the number of calories a day you need to maintain your current
weight. Put this number where you can see it. This number helps to give you control over
your health.

4. Know the approximate number of calories you eat a day by keeping a food
journal and calorie log and work on getting " high-quality calories in versus high-
quality energy out." People lie to themselves constantly about their food intake. They
underestimate the number of calories they eat and subsequently, through ignorance or
denial, ruin their brains and their bodies. I am not suggesting you count every calorie for
the rest of your life, but I am suggesting that you use your brain to become educated
about the calories and nutrition you put in your body, and then take control over them.
ACTION STEPRemember that it is the little decisions about food that you make every
day that often determine whether you are fat or trim. See the list of "100 Ways to Leave
Your Blubber" for tips on cutting calories at www.amenclinics.com/my-brain-
health/brain-health-club/100-ways-to-leave-your-blubber/.

New York State recently passed a law making restaurants put the calories of their
offerings on the menu. I love it! Why? It allows people to be informed consumers, to use
their thoughtful brains rather than just impulsively ordering something because it looks
good when their blood sugar and willpower are low. For example, when you look at the
calories and fat in a Caesar salad, you realize it is not a healthy choice. Or, take one
Cinnabon; it has 730 calories. My daily caloric intake needed to maintain my current
weight is about 2,100 calories. If I have one Cinnabon a day, it fills more than 33 percent
of my caloric needs with virtually no nutrition. Just knowing this fact will make me reach
for a banana.
Likewise, knowing the calorie content of what you eat can help you make small
adjustments that will make a big difference. Take having a Venti Peppermint White
Chocolate Mocha at Starbucks. If you have them make it with whole milk and whipped
cream, it is 700 calories! If you get a tall size of the same drink with nonfat milk and no
whipped cream, it is only 320 calories, less than half.
To really know your calorie intake without cheating, keep a food journal where
you write down absolutely everything you put in your mouth. Get a small weight scale
and measure your portions of food. I can promise you that your idea of a serving will
almost certainly vary substantially from what the food manufacturer puts on the label.
Some of you may be thinking this is too much work. Yet I promise you it is worth the
effort.
In our high school course Making a Good Brain Great, we have a lesson on
nutrition. We teach the students that people gain weight when they eat more calories than
they burn.Calories in versus calories out.Calories in = what you eat.Calories out = level
of exercise.
The average male teen burns about 2,500 calories a day, while the average female
teen burns about 2,000 calories a day. If you eat more calories than you burn, you gain
weight. If you eat fewer calories than you burn, you lose weight. Calories are key.1
pound (lb) = 3,500 calories (cals)1 lb weight gain = eat 3,500 cals more than burn1 lb
weight loss = eat 3,500 cals less than burnFor example, if you eat 500 extra cals a day
(about one cheeseburger), you will gain a pound a week
You need to know approximately how many calories you eat on a regular basis,
otherwise they can seriously get away from you.
You cannot change what you do not measure.
In one of the laboratory exercises for the high school course, we have students
write down the foods they typically order from their favorite fast-food restaurants and
then have them go online to www.chowbaby.com to find the nutritional value of those
meals. Most students are shocked by what they are putting in their bodies. When my son-
in-law Jesse did this exercise (he helped me develop the course and did his master's thesis
showing that it is highly effective in helping teens develop pro-social attitudes), he found
out that for lunch alone he was eating almost 100 percent of his daily allotted calories.
This knowledge encouraged him to make some simple adjustments that have helped him
stay within his allotted calories and maintain a healthier weight.
You typically hear doctors talk about "calories in" versus "calories out." To be
brain healthy, we must significantly upgrade this concept and think of " high-quality
calories in" versus " high-quality energy out." For example, having 300 calories from Red
Vines licorice or 730 calories from one Cinnabon is not the same as 500 calories from a
piece of wild Alaskan Copper River Salmon, grilled veggies, and a sweet potato. I
consider Red Vines and Cinnabon antinutrition, while the wild salmon, veggies, and a
sweet potato are nutrition powerhouses. Likewise, "calories out" can come through taking
supplements, such as caffeine or ephedra, to rev your metabolism and increase your stress
hormones and anxiety and insomnia, or they can come from coordination exercises that
burn calories and boost brain function. Aim for "high-quality calories in" versus "high-
quality energy out"!
5. Exercise four or five times a week. One of the best exercises is walking fast.
Walk like you are late, with periodic one-minute bursts of high-intensity walking or
running. Some studies have shown that exercise can be as effective as antidepressant
medications. The usual side effects of exercise are more energy and a healthier body. See
Chapter 5, "The Exercise Solution," for more information. Coordination exercises, such
as dance or table tennis, are also great for your brain and body.
6. Optimize your hormone levels. Much more information on this topic is found
in Chapter 7, "The Hormone Solution." For now, let's look at three essential weight-
management hormones: insulin, leptin, and ghrelin.
Insulin is produced by the pancreas and is considered a storage hormone. It gets
stimulated primarily in response to a rise in blood sugar. Its function is to take nutrients
from the bloodstream and store them in the body's cells. Insulin increases the uptake of
glucose into the liver and muscles for storage as a substance called glycogen, and it also
helps store excess glucose in fat cells. Since insulin is a storage hormone and not a
mobilizing hormone, it also stops the body from mobilizing and using fat as a fuel source.
Too much insulin stops fat burning. To maintain a healthy weight and burn fat
adequately, it is important to keep insulin properly balanced.ACTION STEPFour tips
to keep your insulin levels balanced:
Have frequent small meals throughout the day rather than a few large meals.
Larger meals tend to cause a greater insulin response.
Control your carbohydrate intake. The more carbohydrates in a meal, the greater
the insulin response.
Emphasize more low-density carbohydrates and fewer high-density ones. The
low-density carbohydrates, such as broccoli, cauliflower, green beans, and carrots, have
more fiber and fewer carbohydrates than high-density carbohydrates, such as bread,
pasta, rice, and cereals.
Glucose-balancing agents--such as chromium, alpha-lipoic acid, cinnamon, and
ginseng--may help. Chromium is a micronutrient (meaning that the human body doesn't
need very much of it) that enhances the action of insulin and is involved in the
metabolism of carbohydrates, fat, and protein. Alpha-lipoic acid is an antioxidant that
may lower blood glucose levels.
ACTION STEP.
Ways to boost leptin levels without causing leptin resistance:
* Improve your sleeping habits.
* Avoid excess sugar and bad fats.
* Exercise regularly.
* Take supplements, such as melatonin and omega-3 fatty acids.
Leptin is a hormone produced by fat cells that tells your body it is full. The more
fat cells you have on your body, the more leptin you tend to have. Leptin works on the
brain's hypothalamus to reduce your appetite when fat stores are high. When fat stores are
low, such as after dieting, leptin levels are diminished, which causes a spike in appetite
and sabotages weight loss. Leptin has been described as an antistarvation hormone
because low levels lead to increased hunger. In the past, leptin was described as an
antiobesity hormone, but researchers have since discovered that obese people, who
produce large amounts of leptin, are often resistant to its effect in a similar way that some
people are resistant to insulin. Leptin resistance may also result from over eating, as the
hypothalamus becomes desensitized to its effects so you never know when you are full.
Poor sleep also decreases leptin levels, which is interesting because many overweight
people suffer from sleep apnea, a condition where people snore loudly, stop breathing
frequently during sleep, and are chronically tired during the day. The lack of oxygen from
sleep apnea is likely involved in lowering leptin levels. Poor sleep also impairs melatonin
production, which can also lower leptin levels.

Ghrelin is a hormone secreted by the stomach that tells your brain you are hungry.
I think of ghrelin as gremlins that force you to eat. In one study, when people were given
ghrelin injections and then offered a buffet meal, they ate 30 percent more than they
normally would! One of the main reasons it is thought that people tend to put weight back
on after a diet is that ghrelin levels increase during dieting. This results in uncontrolled
hunger and subsequent overeating. Naturally reducing ghrelin, keeping the gremlins
away, is essential to maintaining a healthy weight. The substance peptide YY3-36 or
PYY3-36, which is also produced in the stomach, blunts the effects of ghrelin. PYY3-36
is increased by having frequent small meals.ACTION STEPTo stimulate the secretion of
PYY3-36 in your stomach and help keep hunger at bay, eat with the acronym CRON
(calorie restricted but optimally nutritious) in mind. For example, eating a 500-calorie
spinach-and-salmon salad will keep you feeling full much longer than a 700-calorie
cinnamon roll.ACTION STEPPay attention to Chapter 13, "The ANT Solution," to clean
up the ANTs that are stealing your happiness and increasing your waistline.
7. Get great sleep. For all of the brain types, being sleep deprived ultimately will
make you fat and less intelligent. See Chapter 10 for more information.
8. Use simple stress-management techniques. Chronic, unrelenting stress upsets
everything in your body, from your weight to your immune system to your memory. See
Chapter 11 for more information.
9. Stop believing every negative thought that goes through your brain. People
with weight issues typically are infested with a lot of ANTs. See Chapter 13 for more
information. For many, these negative thinking patterns are one of the primary sources of
worry, stress, depression, and anxiety, which often contribute to overeating or erratic
eating.
A former professional football player who came to see us as part of a brain
imaging study I am conducting on retired NFL athletes was six feet two inches and
struggled at a weight of 365 pounds. When I asked him about it, he said, "I have no
control over food." I asked, "Is that really true?" He said, "No, it isn't really true." I told
him, "By saying or thinking that thought, I have no control over food, you just gave
yourself permission to have no control over food and eat whatever you want."
In the same way, I was recently at dinner with a friend who was morbidly obese
and ordered a large plate of nachos smothered in cheese. His wife was trying to get him
on a healthy food plan, but he said, "I don't like any of that rabbit food." I responded by
asking him what he meant. He said, "You know, all those vegetables and fruits." I told
him that his way of thinking was giving himself permission to eat anything he wanted,
and was going to kill him. "I don't like paying taxes," I said, "but I do it because I know
there are consequences if I don't." Pay attention to your thoughts. They can help keep you
on track toward your goals or completely give you permission to fail.
10. Use hypnosis to help keep you slim. When I was an intern at the Walter
Reed Army Medical Center in Washington, D.C., one of my favorite teachers was the
noted psychologist Harold Wain. He was the president of the American Society for
Clinical Hypnosis and the chief of our Consultation-Liaison Service, the group of
psychologists and psychiatrists who helped patients on medical wards who had
psychiatric issues. Harold was a wonderful teacher. When he would use hypnosis for
weight loss, he would help patients take their time to savor their food and drink. To
patients in a trance he could describe drinking a cup of coffee in such a seductive way
that it made them think drinking was as pleasurable as sex. He pointed out that people
typically inhale their food and take little time to actually enjoy it. By using a simple,
descriptive hypnotic technique, he could get people to slow down, feel full faster, and
really start to enjoy the energy they put into their bodies.
I have personally been using hypnosis in my practice with patients for thirty
years. To use it effectively for weight loss, it needs to be used in combination with a
responsible weight-management program. There is also significant scientific evidence
that suggests that hypnosis can be a powerful aid to weight loss. In one scientific review
comparing a series of weight-loss studies with and without hypnosis, it was found that
adding hypnosis significantly improved weight loss. The average post-treatment weight
loss was 6.0 pounds without hypnosis and 11.83 pounds with hypnosis, nearly double. In
a further follow-up period, the mean weight loss was 6.03 pounds without hypnosis and
14.88 pounds with hypnosis. The benefits of hypnosis increased over time.
Hypnosis can help people learn positive eating behaviors and create healthy long-
term patterns of food intake. Some common hypnotic suggestions I give to patients
include "feel full faster ... eat more slowly ... savor and enjoy each bite of your food ...
visualize yourself at your ideal weight and body ... see the behaviors you need to do to
get the body you want."
In addition, hypnosis has been found to be helpful to decrease stress, anxiety,
insomnia, pain, and negative thinking patterns, all conditions that increase the potential
for weight gain. Brain imaging studies have also shown that hypnosis boosts overall
blood flow to the brain, which, as you will see below, helps to keep the brain young and
may help you burn more calories. On our website (www.amenclinics.com), you can find
a series of hypnosis CDs and downloads that I have created for you.
11. Take supplements to keep your brain healthy. Taking nutritional
supplements can make a big difference in your efforts to reach your ideal weight. To all
of my patients, I recommend taking a daily multiple vitamin/mineral supplement. Studies
have reported that they help prevent chronic illness. In addition, people with weight-
management issues often are not eating healthy diets and have vitamin and nutrient
deficiencies.
I also recommend fish oil. Increased blood levels of omega-3 fatty acids from fish
or fish oil have been recently linked to a lower incidence of obesity. Research results
reported in the British Journal of Nutrition indicate that overweight and obese people
have blood levels of omega-3 fatty acids that are lower than those of people with a
healthy weight.
A considerable number of studies already support the benefits of the omega-3
fatty acids for heart, skin, eye, joint, brain, and mood health. In this particular study,
researchers recruited 124 people of varying weights: 21 were classified as having a
healthy weight, according to their body mass index (BMI); 40 were classed as
overweight; and 63 were obese. People who consumed omega-3 supplements were
excluded from the study. Blood samples were taken after the subjects fasted for at least
ten hours. Researchers reported an inverse relationship between total omega-3 blood
levels with BMI, the subjects' waist size, and their hip circumference. The researchers
suggested that a diet rich in omega-3 fatty acids or omega-3 supplementation may play an
important role in preventing weight gain and improving weight loss when used in
combination with a structured weight-loss program.
Results from animal studies suggested that omega-3s may increase the production
of heat by burning energy (thermogenesis). Another study suggested a role of omega-3s
in boosting the feeling of fullness after a meal, and may help regulate the levels of hunger
hormones like ghrelin and leptin, which impact appetite.
In addition, I recommend a craving supplement containing chromium picolinate,
N-acetyl-cysteine, L-glutamine, and vitamin D and DHEA if levels of these are low. (See
more about these supplements in Appendix C, "The Supplement Solution," and on our
website: www.amenclinics.com.) Then, depending on your brain type, choose the
supplements, if needed or desired, that best fit your brain. See the table at the end of this
chapter.
I only consider recommending medication or surgery for weight loss if nothing
else is working. People who have mild to moderate weight issues are often able to get a
handle on the problem through natural means, but sometimes medications--especially
those targeted to your type--or even surgery may be needed to save your life. The
medications for each type are listed in the Summary Table of the Six Types of Weight-
Management Issues at the end of this chapter. Obesity is a life-threatening problem, and
sometimes lifesaving means are necessary. My friend Anthony Davis, a College Football
Hall of Fame running back from USC, had bariatric surgery with great success.
There are several new weight-loss treatments currently being studied. For
example, scientists are working on developing drug treatments that target abdominal fat.
Another breakthrough technique involves brain surgery to treat obesity. Called deep brain
stimulation, it delivers electricity to specific areas of the brain and has proved successful
in eliminating or reducing tremors and tics in people with epilepsy, Parkinson's disease,
and other neurological conditions. It has also been found to be useful in resistant
depression and obsessive-compulsive disorder.
12. Using the advice in this book, keep your brain young and active in order
to lose ten pounds. The brain uses 20 to 30 percent of the calories you consume each
day. It is the major energy consumer in your body. Based on tens of thousands of brain
scans that we have performed at the Amen Clinics, we have seen that the brain becomes
dramatically less active as we age. In Image 3.1, you can see that the activity of the PFC
peaks around age ten and then becomes less and less active. This happens in part because
nerve cells are being wrapped with the white fatty substance myelin, which helps them
work more efficiently, and brain connections that are not being used are pruned away.
But this also happens because later in life there is overall decreased blood flow to the
brain, which contributes to aging. This finding has also been reported by other
researchers and may be one of the reasons why people need fewer calories with age.

This graph shows increased
activity in the prefrontal cortex early in life, but dramatic decreased activity after age ten
over the life span.
One way to lose ten pounds is to keep your brain young, healthy, and always
challenged. By encouraging a youthful activity pattern and continually learning new
things, you will keep your brain active, which will help you better manage your weight.
So, learning a language or a musical instrument, playing bridge, or learning a new dance
step all contribute to keeping your brain young.
13. Take control of your weight and do not let other people make you fat. My
heritage is Lebanese. Like many cultures, Lebanese gatherings are often centered around
and focused on food--usually tasty, high-calorie foods such as baklava, butter cookies,
and rice fried in butter topped with tomatoes, green beans, and lamb. Too often, well-
meaning, sweet people sabotage your efforts to maintain a healthy weight. "Eat this ... try
that... this is so amazing, you need to try just a bite ... you are too skinny, eat more ...
here, have more or we will have to throw it away." Your own lack of focus, anxiety, and
desire to please others allows these people to contribute to your early demise.
I see these interactions nearly everywhere I go. We were in Subway for lunch on a
recent vacation and the store had run out of the little toys that come with the children's
meal for our five-year-old. The clerk asked me if he could replace it with a cookie. I said,
"No. Let's do an apple."
I was once at a store with a friend who asked me if I wanted an ice cream cone. I
told her, "No."
She said, "Are you sure?"
"As sure as I can be," I replied.
When she came back, she had an ice cream cone for me.
"What part of no did you not understand?"
"The ice cream was on sale. I would get two cones for five dollars," she said
innocently.
"Toss it or give it to the poor," I replied with a smile. "I get to have control over
what goes into my body."
She didn't believe I would turn it down, but never disrespected my wishes again
when it came to food.
Other people, at home, at parties, or in restaurants, often sabotage our efforts at
health. Most of the times the behavior is innocent. Some of the time, it is because they
feel uncomfortable being overweight and they would like you to join them. It is critical, if
you want to be healthy, for you to be in control. Here are five ways to deal with people
who, unknowingly or not, try to make you fat:
Be focused on your health goals. Before you go to a restaurant, party, or family
gathering, know the approximate number of calories you want to spend on yourself.
Practice saying no, nicely at first: "No, thank you, I am full."
If the other person persists, add a little more detail: "No, thank you, I am on a
special program, and it is really working for me."
If the other person is still persistent, pause, look them in the eye, and smile. Say
something like, "Why do you want me to eat more than I want to?" That usually gets their
attention. I was recently at the house of a friend who was very persistent. She asked me
six times if I wanted something to eat. When I finally smiled and said, "Why do you want
me to eat more than I want to?" she replied, "I am sorry, I just wanted to help." She then
realized she was not being helpful, but irritating, and stopped.
Be persistent. We train other people how to treat us. When we just give in to their
offers for food--so that they can feel helpful and important, or so we do not feel anxious--
we train them to invade our health. When we are firm and kind, most people get the
message and respect our wishes. Additionally, it may give you an opportunity to tell them
about the exciting new information you are learning in this book.

IS FAT CONTAGIOUS?

A study published in the New England Journal of Medicine shows that one of the
strongest associations in the spread of obesity is whom you spend time with. It is not a
new virus that has been discovered, but the social and behavioral influence of your
friends. The study was conducted using information gathered from more than twelve
thousand people who had participated in a multigenerational heart study collected from
1971 to 2003. The study showed that if a subject had a friend who became obese, he had
a 57 percent higher chance of becoming obese himself. That went up to a 171 percent
higher chance if both friends identified each other as very close friends. Friendship was
apparently the strongest correlation, and it didn't matter how far away geographically the
friends were. Distance did not have a notable influence on the results. Sibling influence
was also ranked high, with a 40 percent greater chance of becoming obese if another
sibling was obese.
The study highlights the social network effect on health issues and makes an
important point: Our health is heavily influenced by many factors, not the least of which
are the role models around us. Whom you spend time with matters to the health of your
brain and your body. This powerful influence works both ways, it seems, as the study's
authors also stated that the same network effect showed up between friends who were
losing weight. Health-conscious friends improve their health and their friends' health as
well. By taking the information in this book seriously, you can influence your whole
network of friends and family.
If you lead the way to better health in your circle of friends, your friends may also
benefit. The author of the study said, "People are connected, and so their health is
connected."

The Weight Solution.
Weight Boosters.
Weight Trimmers.
Thoughtless eating Restricted and optimally
nutritious calories Low vitamin D level Adequate vitamin D Compulsive eating Thought-
stopping techniques SAD eating Finding healthier ways to be happy Anxious eating Deep
relaxation Adrenaline overload Dealing with emotional issues Only one diet tried
Tailoring the plan to your type Low thyroid Optimal thyroid Ignorance/lying to self on
calories consumed Knowledge and honesty Low blood sugar, which leads to impulsivity
Consistent blood sugar Insomnia or low sleep Adequate sleep, at least seven hours/night
Negative thinking, i.e., "I have no control" Honest, optimistic thinking, i.e., "I do have
control" Sluggish brain Active brain Lack of exercise Physical activity at least four or
five times a week Being unaware of calorie content Counting calories Hormonal
imbalances Balanced hormones Chronic stress Stress-management techniques
See www.amenclinics.com/my-brain-health/brain-health-club/100-ways-to-leave-
your-blubber/ for "100 Ways to Leave Your Blubber."