Relaxation and mental imagery are among the most valuable tools we have found to help patients learn to believe in their ability to recover from cancer. In fact, we mark as the conception of our present approach the first time Carl used mental imagery with a patient. Since then, we have discovered that mental imagery is not only an effective motivational tool for recovering health, but is also an important tool for self-discovery and for making creative change in other areas of life.

We owe our discovery of the relaxation and mental imagery process to Stephanie’s background in motivational psychology. Because of her training, we were aware that this process for altering expectancies had been used by people in many different disciplines. The common thread running through these disciplines was that people created mental images of desired events. By forming an image, a person makes a clear mental statement of what he or she wants to happen. And, by repeating the statement, he or she soon comes to expect that the desired event will indeed occur. As a result of this positive expectation, the person begins to act in ways consistent with achieving the desired result and, in reality, helps to bring it about.

For example, a golfer would visualize a beautiful golf swing with the golf ball going to the desired place. A business person would visualize a successful business meeting. A stage performer would visualize a smooth opening night. A person with a malignancy would picture the tumor shrinking and his body regaining health.

As we were learning of the effectiveness of the relaxation and mental imagery process, we were also learning of the evidence that biofeedback researchers were amassing, that people could learn how to control inner physiological states, such as heart rate, blood pressure, and skin temperature. When interviewed, these people frequently stated that they had not been able to command the body to alter the internal state but instead had learned a visual and symbolic language by which they communicated with the body.

One woman, who had a dangerously irregular heartbeat, created a picture in her mind’s eye of a little girl on a swing. She would see the little girl rhythmically swinging back and forth whenever she needed to bring her heartbeat under control. Within a short time, she needed no heart medication and had; no more difficulties. Her success and the experiences of thousands of others in using mental imagery to control body states suggested to us that mental imagery—used in conjunction with standard medical treatment—might be a way cancer patients could influence their immune system to become more active in fighting their illness.

Carl first used the mental imagery technique in 1971 with a patient whose cancer was considered medically incurable. The patient practiced three times a day visualizing his cancer, his treatment coming in and destroying it, his white blood cells attacking the cancer cells and flushing them out of his body, and finally imagining himself regaining health. The results were spectacular: The “hopeless” patient overcame his disease and is still alive and healthy.

*41\347\2*

Nutrition and Exercise

Pregnant women have additional needs for protein, calories, and certain vitamins and minerals, so their diets should be carefully monitored by a qualified practitioner. Special attention should be paid to getting enough folic acid (found in dark leafy greens), iron (dried fruits, meats, legumes, liver, egg yolks), calcium (nonfat or low-fat dairy products, some canned fish), and fluids. Vitamin supplements can correct some deficiencies, but there is no true substitute for a well-balanced diet. Starting January 1, 1998, manufacturers of breads, pastas, rice, and other grain products were required to add folic acid to their products in a move to help reduce neural tube defects in newborns. Folic acid, when consumed before and during early pregnancy, reduces the risk of spina bifida, a common disabling birth condition resulting from failure of the spinal column to close. Babies born to mothers whose nutrition has been poor run high risks of substandard mental and physical development.

Weight gain during pregnancy helps nourish a growing baby. For a woman of normal weight before pregnancy, the recommended weight gain during pregnancy is 25-35 pounds. For obese or overweight women, 15-25 pounds are recommended. If one is underweight prior to pregnancy, a goal of 28-40 pounds is acceptable. Women carrying twins should gain about 35-45 pounds. Gaining too much or too little weight can lead to complications. With higher weight gains, women may develop gestational diabetes, hypertension, or increased risk of delivery complications. Gaining too little weight can increase the chances of delivering a low-birth-weight baby.

Of the total number of pounds gained during pregnancy, about 6-8 are the baby’s weight. The baby’s birth-weight is important, since low weight can mean health problems during labor and the baby’s first few months. Pregnancy is not the time to think about losing weight – doing so may endanger the baby.

As in all other stages of life, exercise is an important factor in weight control during pregnancy as well as in overall maternal health. In one study a balanced 45-minute exercise session three days per week was associated with heavier-birth weight babies, fewer surgical births, and shorter hospital stays after birth. Pregnant women should consult their physicians before starting any exercise program.

Other Factors

A pregnant woman should avoid exposure to toxic chemicals, heavy metals, pesticides, gases, and other hazardous compounds. She should not clean cat-litter boxes because cat feces can contain organisms that cause a disease called toxoplasmosis. If a pregnant woman contracts this disease, her baby may be stillborn or suffer mental retardation or other birth defects.

Before becoming pregnant, a woman should be tested to determine if she has had rubella (German measles). If she has not had the disease, she should get an immunization for it and wait the recommended length of time before becoming pregnant. A rubella infection can kill the fetus or cause blindness or hearing disorders in the infant. If the woman has ever had genital herpes, she should inform her physician. The physician may want to deliver the baby by cesarean section, especially if the woman has active lesions. Contact with an active herpes infection during birth can be fatal to the infant.

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How to decrease your sugar intake

Best Choices

Fruit juices (unsweetened and in reasonable amounts), sugar-free carbonated beverages, sparkling water, fresh or unsweetened fruit (reasonable amounts), sugar-free hot chocolate, sugar-free gelatin or pudding, bread sticks, popcorn, or pretzels

Go Easy On

Plain donuts, plain cookies (such as vanilla wafers), plain cakes (such as angel food cake)

Limit or Avoid

Regular sweetened soft drinks, lemonade, and fruit drinks, cake, pie, donuts, pastries, ice cream, ice milk, sherbet, sorbet, sugar-sweetened gelatin, cereals with more than 5 grams of sucrose and other sugars per ounce, candy, chocolate, sugar, honey, jam, or jelly

Fats

Best Choices (in small amounts)

Polyunsaturated oils (safflower, corn, sunflower, soybean, sesame, or cottonseed) and monounsaturated oils (olive, canola, or peanut). Salad dressings made with unsaturated oils, margarine made from polyunsaturated oil, or margarine whose main ingredient is “liquid” oil (listed first on the label)

Go Easy On

Mayonnaise, creamy salad dressings, reduced-fat sour cream or cream cheese

Limit or Avoid

Saturated fats, including butter, lard, and bacon. Gravy and cream sauces, cream, half-and-half, sour cream, cream cheese, hydrogenated margarine and shortening, cocoa butter (found in chocolate), coconut oil, palm oil, palm-kernel oil, most nondairy creamers, and nondairy whipped toppings

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Sometimes anxiety stems from the loss of control and the extreme dependence on others imposed by the disability, regardless of how the injury occurred. Spinal cord injury caused by a vascular problem or spinal tumor (rather than an accident) may not cause posttraumatic stress, but it nevertheless results in a major loss of independent function. Basic biological functions and the simplest tasks of daily living may suddenly require the assistance of another person.

When you are no longer able-bodied, you must depend on others to take you to the bathroom, get you dressed, or help you dial the phone. You are suddenly confronted with a host of uncertainties. Will the nurse answer your call-bell in time, or will you wet the bed? Will you get help to make a call home before your wife leaves for work, or will you have to wait until visiting hours to talk to her? What if the staff doesn’t like you? What if your injury is repulsive to others? Will you still get the help you need? These uncertainties produce anxiety and feelings of helplessness in the rehabilitation hospital and often afterward, when problems become even more complex. Will my office or school be wheelchair accessible? How will I reach the files? Can I use the bathroom independently at my favorite restaurant?

Just as when you were a small child, you have to depend on the care and assistance of others for many of your basic needs. At first you may expect the hospital to take care of all your needs, but you’ll inevitably be disappointed. You’ll learn that there aren’t enough nurses, or that other patients’ needs are more urgent, or that priority is given to biological over social needs, even though the latter may be just as important to your sense of well-being.

You may feel frustrated and angry about not getting help. You may also be quite anxious and afraid – that you will never get help, that others will forget about or abandon you, or that something terrible will happen to you because you are helpless and alone (you will fall, stop breathing, or lose your sanity!). This type of anxiety, if left unchecked, can lead to disabling attacks of panic, requiring medication or other treatment. But more often, this anxiety is experienced as a humiliating regression to an infantile state of fear, frustration, and irritability, a loss of control over oneself and one’s environment, which is at best unsettling and at worst an assault on one’s dignity.

Learning to manage anxiety is an important task for every person, regardless of circumstances. Most people need some predictability and some sense of control over their bodies, their behavior, and their environment in order to feel secure and confident. We all learn ways to manage anxiety about new situations: by learning about what to expect (knowledge), developing skills to meet the new demands (mastery), gradually imposing some regularity or predictability (control), and allowing for periods of rest or “down time” when we temporarily set aside the new demands (pacing). These strategies are also helpful in coping with the anxiety generated by disability and dependence.

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While each step in the process of evaluation of a child for surgery requires careful thought, it is at this point, when all the available information has been collected, that reconsideration of the potential risks and benefits is necessary. We accomplish this with a meeting of the whole team that has been involved in the evaluation. This team includes the epilepsy specialist who has been your child’s primary physician, our group of monitoring specialists, those who have carefully assessed language and intellectual function, our counsellor who has been working closely with the child and the family, and the surgeon who will be performing the operation. At this conference we carefully assess where the seizures appear to be coming from, what surgery can be done to eliminate them, what normal functions might be damaged by the surgery, and the risks and the potential benefits of the surgery. At times we decide that, despite all our careful evaluation, surgery should not be performed. After the group reaches consensus, we then present our opinions to the patient and family, who must make their independent decision on whether or not to proceed with surgery, whether their perception of the risks and benefits is similar to ours.

*160\208\8*

Most people with insulin-treated diabetes first learn that they have diabetes while they are school-children. Most people with maturity onset diabetes discover their diabetes when they are working or after they have retired. Whether you are sixteen or sixty years old, the news that you have diabetes comes as a shock. It is important to get back to your usual daily routine as quickly as possible and thereafter not to allow your diabetes to get in your way. Being diabetic should not prevent you from achieving what you want from life, whether it is a senior management position, a holiday in the sun, a job as a sales assistant or a college education.

Life at school usually has a regular pattern and times of energy output (whether mental or physical) are predictable. This means that you can adjust your food and insulin pattern to suit your activities with a reasonable amount of accuracy.

It is probably easier to take a constant dose of insulin and alter your food intake according to what you will be doing next. However, if you have a very energetic morning or afternoon on the same day every week, it may be helpful to reduce your insulin on that day. For example, you could reduce short-acting for morning activity and intermediate-acting for the afternoon in addition to eating more.

Tom is fourteen years old and takes twelve units of Actrapid (short-acting insulin) and twenty units of Monotard (long-acting insulin) in the morning before breakfast and eight units of Actrapid before his main evening meal. On Tuesdays he has history and geography before break-time, woodwork until lunch-time and football all afternoon. He has had a couple of mild hypoglycemic episodes during football in the past, so he reduces his Monotard insulin to seventeen units on Tuesday mornings, but still takes twelve units of Actrapid. He has his normal breakfast but eats an extra apple at break-time if he is going to do a lot of sawing in woodwork. At lunch-time he has an extra helping of potato and a double portion of dessert. Half-way through football he has a chocolate bar and an apple. He also has a couple of biscuits or crackers before he changes after the lesson, because he will be riding his bicycle home. On some Tuesdays he checks his blood glucose level several times during the day to see if his dietary and insulin changes are being successful.

*41/102/5*

The question the reader will ask at this point is ‘Given all this epidemiological study, do we know the causes of cancer?’ Broadly the answer is ‘yes’ in many circumstances and for many cancers, and the opportunities for prevention that this understanding generates are there to be taken. We do not always know how the factors that have been identified by the epidemiological studies discussed in this chapter link up to what is being learned in the laboratories of the molecular biologists. This connection is being made rapidly and will be increasingly clear by the end of the century. Epidemiology has been very successful in discovering or confirming which features of our lives in the Western world can be now identified as causes of cancer.

Simple infections do not cause cancer. Pneumonias and urinary infections, for instance, are usually caused by bacteria and there is no evidence that such infections predispose to cancer in any way. Animal cancers can be caused by viruses but human cancers are not usually caused by viruses. There are, however, some notable exceptions to this general statement. The virus described by Epstein and Barr (Epstein-Barr virus, EBV) probably causes a rare cancer of the lymph glands, particularly in Africa, and may cause cancer of the nasal passages among the Chinese. Hepatitis B virus infection, when chronic, probably contributes to the high incidence of liver cancers in the Far East, the evidence for this being a most convincing cohort study in Taiwan. Rare types of leukaemia, particularly in Japan and the Caribbean, have been linked to infection with a particular kind of virus (human T lymphotrophic virus type 1), which seems to be spread early in life but which may alio, like AIDS, be spread by sexual activity and drug abuse. AIDS infection predisposes patients to a number of cancers of a rare kind which may be very difficult indeed to treat. As indicated above, viruses are being investigated as a possible explanation for a link between cancer of the neck of the womb and multiple sexual partners. It should be emphasized that human cancer is not in any simple way an infectious disease, that patients with cancer do not require isolation and that people need not be concerned about sharing homes or workplaces with cancer patients.

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One of the factor in apnea is the horizontal position we assume during sleep, which can lead to narrowing of the air passage. The breathing tube collapses somewhat because of the weight of the body pressing down from above, and it is further obstructed to a degree because the tongue moves from its usual waking position to a position farther back in the throat. Also, during the night the coughing mechanism is somewhat suppressed, and the lungs are less able to clear themselves of secretions. All of these slowdowns in breathing function are normal and pose no threat to the majority of people. When complicated by other factors, however, they can result in OSA.

Results of the physical examination of an apnea victim are often relatively normal. I may, and often do, find elevated blood pressure, or I may notice that the mouth and pharynx are smaller than normal or “crowded” due to some kind of unusual structural formation. On listening to the neck I may hear stridor—the harsh, high-pitched sound associated with obstruction of the larynx. In cases where the heart has been affected, I may detect signs of right ventricular failure, such as distension of the jugular vein or swelling of the ankles. Analysis of gasses in the blood may reveal a high level of carbon dioxide; if so, I will want to rule out some other form of lung disease by ordering further pulmonary tests.

*137\226\8*

Red, scaling patches, most frequently on the scalp, face, ears, chest, and genitals, are symptoms of seborrhea. Some people have the patches symmetrically on both cheeks, in what is called a “butterfly” distribution. Many people simply have seborrhea on the scalp, where it is referred to as dandruff.

Seborrhea has no specific cause, generally involves only the skin, and, at least when severe, is usually cared for by dermatologists. Seborrhea occurs in 50 percent to 80 percent of people with HIV infection. As the infection progresses, seborrhea occurs more frequently and more severely.

The treatment of seborrhea of the scalp is to use shampoos containing coal tar, available without prescription at drugstores. Seborrhea on the rest of the skin can be treated with ointments containing cortisone. Cortisone ointments are available without prescription, but severe or persistent cases of seborrhea are best treated with stronger concentrations of cortisone, which require a prescription.

*115\191\2*

Oral drugs for psoriasis

Oral medications are used in severe cases of psoriasis. The most common of these is Methotrexate. Methotrexate is extremely effective but does carry a small risk of long-term liver damage. Nonetheless, if it is used in low doses, and the liver is carefully monitored, it can be relatively safely used.

Tigason, which is a vitamin A derivative, is another newer drug used in treating psoriasis. It is best used in combination with PUVA (Oral Psoralen plus ultraviolet A light), not being terribly effective on its own. Tigason seems to protect the skin from developing skin cancers, which is a particular advantage when it is combined with ultraviolet light. On the other hand, Tigason must never be used in women of child-bearing age, as it is a major cause of birth defects.

New therapies for psoriasis

There has been something of an explosion in the search for new psoriasis treatments. Recent developments include:

- Vitamin D creams. The last five years have seen the emergence of vitamin D creams in the treatment of mild psoriasis. Although vitamin D tablets were used initially, they were found to be too toxic, producing high levels of calcium in the bloodstream. Vitamin D creams, however, are safe and are as effective as strong cortisone creams, without the risk of skin thinning. Vitamin D creams are currently available in Europe and hopefully will be on the Australian market within a few years.

- Cyclosporin. This drug is extremely effective for treating severe forms of psoriasis, but at the present time is used exclusively in organ transplantation. Cyclosporin acts on the immune system, preventing rejection of foreign organs, yet how it works in psoriasis remains a mystery. The main problem with Cyclosporin is the long-term risk of kidney damage and this requires further investigation.

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