You may delay, but time will not, and lost time is never found again. That is the stage of the novice. What the master practitioner (and the accomplished family member) has learned is how to improvise from those copies, how to move beyond stereotyping and caricaturing, with all the dangers implicit in such routinization, toward healing, which is a fundamentally humanizing art. Treating hypochondriasis is notoriously difficult. It is easy to see how practitioners and family members can joke about patients in order to relieve their own sense of inadequacy and failure. Not just the patient's disease, but the practitioner's and family member's response, is a copy. That copy of the therapeutic relationship often is demeaning and rejecting. Even the best of intentions may contribute to a worsening in the patient's condition: excessive concern can encourage a trajectory of help seeking with unnecessary hospitalizations, costly tests, dangerous treatments, and frustration on all sides. What can I recommend? I have found that maintaining one's own sense of irony is a barrier to feelings of therapeutic helplessness and rage. Working with hypochondriacal patients and their families explicitly to increase their awareness of the multiple ironies we have reviewed can be a means of reducing the more disabling consequences of this chronic condition. There is a physiological component associated with dissociation that is trauma related and automatic, but there is a habitual aspect to the behavior as well. By consciously focusing on the dissociative behavior, you can begin to change it. The choice to avoid gets made at some level, often unconsciously. The problem is that if you choose to dissociate in an attempt to avoid, the fix is temporary and often creates further stress in the end. Living in the present moment means accepting your experience, moment by moment, without judgment, which takes both practice and positive intention. The first step is simply to observe your behavior, without judgment. In the case of DID, as with everyone, that means observing the behaviors of which you are aware. With time, your sphere of awareness will gradually increase. When people dissociate, they refer to it in various ways: spacing out, getting little, going away, and so on.

They often feel as if they are floating, are outside of their bodies, or are lost in a fog. What is to be done today, must be done today. There's a myth that tomorrow exists and that it's just as viable a time to do something as is today. So as we halt, stop, or even regress, time doesn't. It constantly moves forward, so to match it, we must do the same. Procrastination is laziness. It's enabled by listening to opinions in one's own mind about what should be done rather than doing what that same mind had already decided to do. How do you stop procrastinating? You stop procrastinating. In the intro of this article I talked briefly about the mindlessness of action, of how boxing and business helped me shut my brain off and just do, rather than thinking about what to do. If you've paid attention to this article you'll likely have already set your planning time. I urge that hypochondriasis be treated as a language of distress and that caregivers be taught to work within that language to use the same metaphors patients use. An approach to the language of hypochondriasis could be a useful complement to psychotherapeutic explorations of the life tensions and intimate pressures that intensify patients' fear of disease and their doubt of their own and their doctors' judgments. The systematic exploration of the meanings of hypochondriacal illness can become the basis of a therapy that also focuses on the ironical position of the protagonists as actors and onlookers simultaneously. Such therapy is still a long and difficult and uncertain passage. Many cases just barely manage to pull through, in large part because they are periodically revivified by a sense of the ironic. There is an uncommon form of hypochondriasis in which the patient lacks insight and his nosophobia has all the characteristics of a delusion (a fixed false belief that is not shared by others), namely, monosymptomatic hypochondriacal psychosis. The remarkable thing about this disorder is that the psychosis is limited to this single aspect of experience. Simulated ignorance is the original ancient Greek meaning of irony. Perhaps no other word in recent years has been more abused than holistic, which gained popularity as a gloss for psychosocially attentive as well as biomedically competent care but has been transformed tendentiously into a commercialized slogan for selling a brand name of medical care.

I use holistic in its earlier sense. When that happens to you, take some time to answer the following questions: What happened right before I started to dissociate? What was I feeling, both physically and emotionally? What is the last thing I remember? I knew that I was dissociating because I started (tapping my foot, feeling dizzy, getting a headache, etc); I stopped (talking, thinking clearly, making eye contact, etc); I started to think (I'm going to die, people can't be trusted, I never do anything right, etc). What was I trying to avoid? What else could I have done? This is when you think. This is when you determine correct action. With the choice having already been made, there is no decision when it comes time to act. What you have set out to do is what you do. Nothing gets in its way because there's nothing else you set out to get done. TV doesn't stand between you and the article you want to write. Tiredness isn't a barrier that prevents you from working out. Tomorrow isn't when you planned to do what you have on your to do list, today is. Time keeps moving.

Pushing things to tomorrow is a horrible habit to form and a very effective habit to break. Patients who begin with somatic hypochondriasis are increasingly being transformed into psychological hypochondriacs. In my experience, this is a dangerous and undesirable change, because there are so few benchmarks in psychiatry, unlike the rest of medicine, to disconfirm a patient's (or a psychiatrist's) concern that a certain disease process is present. These symptoms are all consistent with panic attacks, a form of anxiety disorder. Previously this was called hyperventilation syndrome; I thought Woody Allen's performance in the movie Hannah and Her Sisters was reminiscent of Wolf Segal, but not quite as funny. The likelihood is that Bingman never had thyroid disease, but he did have one or two abnormal results in the dozen or so thyroid tests he has undergone. This is consistent with the probability of random laboratory error. I do know from his current internist that there is no laboratory evidence of active thyroid disease or clinical reason to suspect its presence. The Healers Varieties of Experience in Doctoring Initially, you may find you need help in answering some of these questions, but with practice, you will begin to identify the patterns associated with why and how your dissociation operates. There are some positive aspects to the behavior as well. Dissociation can be soothing in much the same way that some people find a glass of wine with dinner relaxing at the end of a stressful day. Switching to a younger part can be a great escape from the adult world of responsibilities and can illicit nurturing from the people closest to you. It can also allow parts to work on issues that are important to them and that may otherwise continue to go unnoticed. Dissociation can offer an individual the chance to say no to something when she feels unable to do so in any other way. It can also keep a person safe. Many dissociators have internal parts that keep others from committing suicide or harming themselves in other ways. Some parts exist solely to self-soothe.

These aspects are good. If you genuinely want to become better, stronger, tougher, and more FREE, breaking this habit of procrastination is so necessary it's hard to overstate. To stop procrastination you depend on a few things we've covered in this article: You need to plan tomorrow at the end of today. Don't wait to the day of to plan what must be done. You need to start small, really small. Have one vital task that must be completed and for the first couple of weeks of your quest to defeat procrastination, accomplish this single thing and keep it to a single thing. This is your foundation, this one thing. Every morning you're going to do it, and you're not going to think about whether or not you have to do it. You need to set parameters. I'm writing this in a cafe that has no internet - parameter number one. To write prescriptions is easy, but to come to an understanding with people is hard. As a physician, I am aware of how draining and threatening empathy for helpless, injured people can be. I know how hard it is to hold on to compassion when all of one's invested power and energy seems helpless against the tide of fate. As a patient, I felt more alone, more helpless, more terrified, and more enraged than I now believe I had to be. Men that look no further than outside think health an appurtenance unto life and quarrel with our condition of being sick, But I who have looked at the innermost parts of man and known what tender filaments that fabric hangs on oft wonder that we are not always so, And considering the thousand doors that lead to death do thank my God that I can die but once. Eight Medical Lives The following brief sketches of the clinical lives of eight physicians can hardly do justice to the manifold work of doctoring among the chronically ill, or to the variety of practitioners routinely encountered by the chronically ill.