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Limb dystonia has rarely been reported following electrical injury to erectile dysfunction young age cheap 400mg levitra plus mastercard an extremity erectile dysfunction doctors boise idaho buy levitra plus 400mg lowest price, although it may result from cerebral hemisphere electrical trauma weight lifting causes erectile dysfunction order levitra plus 400 mg on-line. Actual passage of electrical current through the brain causes inflammatory changes in the blood vessels of the meninges and brain tissue erectile dysfunction 43 years old buy 400 mg levitra plus with amex. Subarachnoid hemorrhage or thrombosis of blood vessels and infarction would generally follow erectile dysfunction genetic purchase genuine levitra plus. Questions Progressive disorders may begin after electrical injury and resemble one or another (continued) of several syndromes such as Parkinsonism, cerebellar disorders, myelopathy, spinal muscular atrophy, or sensorimotor peripheral neuropathy. Frequently, the plaintiff has a pre-existing mood or anxiety disorder that may account for their current symptomatology. Refer to Chapter 6 for a list of symptoms associated with a pre-existing mental disorder, personality disorder or medical illness. They are normed on small populations that do not relate to toxic injury plaintiffs and they would not withstand a scientific (Daubert or Frye) challenge. These toxic questionnaires are given to class-action and individual plaintiffs and should raise a red flag for defense counsel. General causation is the demonstration that a given toxic substance, in the particular location and for a particular duration, can cause the type of illness or injuries alleged. Specific causation requires proof that the toxic chemical actually did cause the alleged injuries. Toxic exposure claims are relatively rare, but when they do occur, the nature of the claims require a thorough investigation into the mechanism of injury, the symptoms, and the alleged sequelae. As with electrical injury claims, cases of toxic exposure are difficult and often mismanaged by physicians with no expertise in the area. The following information and questions will focus on carbon monoxide poisoning, the most common claim of toxic (hypoxic) injury, and toxic mold. Carbon monoxide affects several different sites within the body, but the exact contribution of each pathophysiologic effect remains unclear. The lungs rapidly absorb carbon monoxide, which avidly combines with hemoglobin at 230 to 270 times greater affinity than oxygen. For average, sedentary, nonsmoking workers maximum allowable exposures (200ppm) produce 0. Perceptible clinical effects occur with a 20-hour exposure to concentrations as low as 0. Q: Please describe the mechanism of exposure (furnace, occupational exposure, etc. If the plaintiff lost consciousness, they may have relapses for several weeks and continue to suffer from headaches, fatigue, loss of memory, difficulty thinking, irrational behavior, and irritability. Carbon monoxide toxicity is increased by numerous factors, including decreased barometric pressure. For instance, a concentration of 800 ppm will cause headaches after one hour, but can lead to unconsciousness and death in 2 to 3 hours. Maximum allowable exposure is about 200 ppm, but perceptible clinical effects occur with a 20-hour exposure to concentrations as low as 0. At very low concentrations, the effects of carbon monoxide may take years to affect the body. Occupational Health and Safety limit is 50 parts per million (ppm) for our eight hour averaging time (maximum allowable exposure is much higher). Carbon monoxide detectors are required to sound an alarm when concentrations are greater than 100 ppm. Patients presenting with acute poisoning may display weakness, fatigue, and "amnestic confabulatory state," apathy, impulsiveness, and distractibility. There are often abnormal motor, sensory, and cerebellar findings, including abnormal reflexes. Three percent of those acutely poisoned develop permanent sequelae, including mental deterioration (98%), urinary and fecal incontinence (88%), and gait disturbance (81%). In the active stage of poisoning, they may have hypertension, hyperthermia, and cherry skin. One may find homonymous hemianopsia, papilledema, scotoma, and flame-shaped retinal hemorrhages. Of these, about 40% have memory impairment, including amnestic confabulatory states, and retroand anterograde amnesias. Many have cerebral, cerebellar, and midbrain damage evidenced in findings of akinetic movements, agnosia, apraxia, rigidity, and brisk reflexes. Thirty-three percent have personality changes usually including lethargy, apathy, and fatigue. They may show irritability, verbal aggression, violence, impulsiveness, moodiness, "affective incontinence," severe attention deficits, distractibility, and sexual outbursts. Dysrhythmias range from frequent premature ventricular contractions to atrial fibrillation and ventricular tachyarrhythmias. These findings are nonspecific and may be associated with barbiturate intoxications, hypoglycemia, cyanide, disulfiram, and hydrogen sulfide poisoning. Monoxide Carbon monoxide symptoms are similar to the flu and include headaches, fatigue, (continued) nausea, dizziness, confusion, and irritability. Continued exposure can lead to vomiting, loss of consciousness, brain damage, heart irregularity, breathing difficulties, muscle weakness, abortions and even death. Hyperbaric oxygen is a mode of therapy in which the patient breathes 100% oxygen at pressures greater than normal atmospheric (sea level) pressure. In contrast with attempts to force oxygen into tissues by topical applications at levels only slightly higher than atmospheric pressure, hyperbaric oxygen therapy involves the systemic delivery of oxygen at levels 2-3 times greater than atmospheric pressure. An average smoker (defined as about 1 pack per day) may have levels in the range of 4-5% and a heavy smoker (defined as more than 1 pack per day) may have levels ranging from 8-12%. General Information Molds are simple, microscopic organisms, and are found virtually everywhere, indoors and out. Mold growths range in color from white to orange and from green to brown and black. When mold is present in large quantities, it can cause allergic symptoms similar to those due to pollen exposure. Certain molds can produce toxins, called mycotoxins, that the mold uses to inhibit or prevent the growth of other organisms. Mycotoxins are generally not volatile – a disturbance is generally required in order to trigger exposure. The most common species of mold are: Cladosporium, Pennicillium, Alternaria, Aspergillus, Mucor and Stachybotrys chartarum (which produces toxins). The unusual species include: Epicoccum, Apsergillus versicolor, Aurebasidium and Fusarium. Variations in Mold Species and Individual Reactions Mold species vary tremendously in their ability to cause health effects. A similar, almost idiosyncratic, response to mold is found among individuals: some people can withstand substantial exposure to mold, while others are more susceptible. This is one of the reasons that agencies have such difficulty establishing "safe" levels of mold. One species might not produce particularly toxic reactions standing alone, but might mix with other mold species to create a highly toxic soup. In view of the impact to different individuals, one thing is clear: the defense team should be particularly sensitive to environments where there are immune-susceptible individuals. Schools, hospitals, and health care facilities immediately come to mind because each environments house those who potentially have compromised immune systems. Depending on the type of mold, nature of exposure and individual, an individual may experience: (a) allergic / immunologic reactions; (b) infections; and (c) toxic effects. Allergic Reactions Mold Perhaps the most common health problems associated with exposure to mold are (continued) allergic reactions, which range from mildly uncomfortable to life-threatening illnesses. Common signs or symptoms of an allergic reaction to mold include: • Watery eyes • Runny nose and sneezing • Nasal congestion • Itching • Coughing • Wheezing and impaired breathing • Headache • Fatigue E. Infections While not as common as allergies, there are several types of mold-related infections. The classifications of infections caused by fungi are systemic, opportunistic and dermatophytic. Toxic Reactions Toxic reactions from exposure to molds remain one of the least studied and understood areas of human health. This area concerns exposure to toxins on the surface of mold spores, not with the growth of mold in the body. Differential Diagnosis (continued) Similar to other toxic exposure cases, plaintiffs in a mold case must address causation through a differential diagnosis employing three elements: 1. Applying the Daubert analysis, it is difficult for the plaintiff to prove that mold has the capacity to injure because of the lack of scientific knowledge, the lack of peer review, and the general level (current) of unacceptability within the scientific community. The first known human morbidity from it was identified in Chicago in 1986, when a family suffered flu symptoms (diarrhea, dermatitis and general fatigue) for five years, until the Stachybotrys was found and removed. Research is advancing in this area given the heightened level of interest from various governmental and private agencies. General Causation In a federal case, or in a jurisdiction following the federal rule, the court is required under Daubert and its progeny to be the gatekeeper to keep out unreliable expert testimony in technical or scientific areas. However, the judge has discretion here, and the following considerations may bear upon her inquiry: • whether the theory or technique in question can be tested; • whether it has been subjected to peer review and publication; • its known or potential error rate (statistical validity); and • whether it has attracted widespread acceptance within the relevant scientific community. For jurisdictions following the Frye line of cases, the standard is higher than the federal rule. Frye and its progeny mandate that the techniques or methods used be "generally accepted within the scientific community". Establishing either type of causation requires expert testimony, which is subject to exclusion or limitation under the Daubert case, and comparable rules in state courts that still follow the Frye line of cases. Exposure to Mold Does Not Equal Illness the presence of fungi on building materials, as identified by a visual assessment or by bulk/surface sampling results, does not necessarily mean that people will be exposed to mold or exhibit health effects. In order for humans to be exposed indoors, fungal spores, fragments, or metabolites must be released into the air and inhaled, physically handled (dermal exposure), or ingested. Whether symptoms develop in people exposed to fungi depends on the nature of the fungal material. For these reasons, and because measurements of exposure are not standardized and biological markers of exposure to fungi are largely unknown, it is difficult to determine "safe" or "unsafe" levels of exposure for people in general. Q: Describe any past documented or undocumented sensitivity to mold or other foods or substances. Mold (continued) Q: Describe the proximate cause linkage between the claimed exposure and the claimed symptoms, behaviors and illnesses. Q: Describe the physical and psychological evaluation techniques (clinical, laboratory, tests, etc). Q: What alternate sources of symptoms, behaviors and illnesses were considered and ruled out in the differential diagnostic processfi Q: Provide all past medical, psychological and social history records and documentation including occupational, military and litigation histories.

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The authors found a higher prevalence of cells carrying the translocation in the farmers whose blood had been drawn during a period of high pesticide use than in those whose blood had been drawn during a low-use period erectile dysfunction vasectomy purchase levitra plus 400 mg free shipping. In most cases of follicular lymphoma herbal erectile dysfunction pills review order levitra plus 400mg line, tumor cells carry the t(14;18) chromosomal translocation erectile dysfunction treatment new zealand generic levitra plus 400mg amex, and there is evidence that an increased frequency of lymphocytes from the peripheral blood carrying this tumor marker may be a necessary but not suffcient step toward the development of follicular lymphoma (Roulland et al erectile dysfunction generics purchase levitra plus 400mg without prescription. When examining immunoglobulin (IgG cialis erectile dysfunction wiki generic 400mg levitra plus otc, IgA, IgM, IgD, and IgE) and complement (C3 and C4) concentrations measures of humoral immunity, Saberi Hosnijeh et al. Limiting the analyses to workers from Factory A and examining serum concentrations of 16 cytokines, 10 chemokines, and 6 growth factors, Saberi Hosnijeh et al. The evidence was drawn from occupational and other studies in which subjects were exposed to a variety of herbicides and herbicide components. Other studies that showed positive associations have lacked exposure-specifcity in the the populations studied. Plasm a Cell Dyscrasias Plasma cell dyscrasias are a heterogeneous group of disorders characterized by the presence of monoclonal immunoglobulins in the serum, which refects a monoclonal proliferation of lymphoplasmacytic cells in the bone marrow (W ahed and Dasgupta, 2015). Plasma cell neoplasms are lymphoid neoplasms of terminally differentiated B cells, all of which exhibit the expansion of a single clone of Ig-secreting plasma cells. The condition is typically discovered as an incidental fnding when a protein electrophoresis test is performed for reasons unrelated to plasma cell dyscrasias. The presence of one of two factors (an abnormal serum free light-chain ratio and a high serum M protein level [fi 1. After an adjustment for competing causes of death, the risk of progression was 10% at 10 years, 18% at 20 years, 28% at 30 years, 36% at 35 years, and 36% at 40 years (Kyle et al. Data and biospecimens were collected prospectively from individuals to whom structured questionnaires and physical exams were given at set times over 20 years, with the fnal exam conducted in 2002. The study included 479 Ranch Hand veterans (who conducted aerial spray missions of the herbicides from 1962 to 1971) and 479 controls (comparison veterans who were also in the Air Force and had similar job duties and were deployed to Southeast Asia during the same period) who participated in the 2002 follow-up examination and had given a serum specimen and were at least 50 years old at the 2002 follow-up. Individuals with a history of multiple myeloma, W aldenstrom macroglobulinemia, solitary plasmacytoma, or amyloidosis were excluded. The Ranch Hand veterans and comparison veterans had similar demographic and lifestyle characteristics and medical histories. The incidence of multiple myeloma is highly age-dependent and is relatively low in people under 40 years old. The incidence is slightly higher in men than in women; for all races the incidence rate for 2009–2013 was 8. In the age groups that include most Vietnam veterans, the age-adjusted modeled incidence rate of myeloma for men 50–64 years old of all races combined was 13. Few studies of multiple myeloma have been conducted among Vietnam veterans, and most of them have reported no cases of or decreased risks of multiple myeloma (Akhtar et al. Follow-up analyses of the New Zealand cohort of veterans who served in Vietnam found no statistically signifcant increase in the risk of deaths from or incidence of multiple myeloma when compared to the standardized general New Zealand population (M cBride et al. M ost recently, a follow-up analysis of the Cross Canada Study of Pesticides and Health was reviewed by the Update 2014 committee. Pesticides were grouped by type, chemical class, and their carcinogenic potential. Odds ratios were calculated and adjusted for age, residence, medical history, and smoking. A statistically signifcant increased risk of multiple myeloma was observed with exposure to M ecoprop but not with exposure to 2,4-D. An evaluation of days per year of mixing or applying phenoxy herbicides was not statistically signifcant for any category (fi 2 days per year, 2–5 days, and > 5 days). It is known to be increased in B-cell neoplasms, including multiple myeloma and various lymphomas (Hussein et al. In comparing the frequency of specifc variants of several metabolic genes between multiple myeloma cases and controls, Gold et al. Most of these cancers also arise from B cells, so the committee hypothesized that it would be etiologically plausible for the association with multiple myeloma to belong with the lymphomas in the suffcient category. Two well-designed studies of well-characterized cohorts were reviewed in the current update. The conditions share several biologic features, notably the clonal hyperproliferation of B cell–derived plasma cells and the production of abnormal amounts of immunoglobulins. The pattern of organ involvement depends on the nature of the protein; some amyloid proteins are more fbrillogenic than others. Amyloidosis is classifed according to the biochemical properties of the fbril-forming protein. Excessive amyloid protein can have modest clinical consequences, or it can produce severe, rapidly progressive multiple-organ-system dysfunction. The Amyloidosis Foundation estimates that approximately 4,500 new cases are diagnosed each year (Amyloidosis Foundation, 2018). It usually affects people from ages 50 to 80 years and occurs more often in males than in females. Historically, bone marrow biopsies emphasized routine histochemical analysis, but modern immunocytochemistry and fow cytometry now commonly identify monoclonal populations of plasma cells with molecular techniques. Epidemiologic results for amyloidosis were reported for the frst time in Vietnam veterans in the publication from the Korean Veterans Health Study (Yi et al. The National Cancer Institute estimated that in the United States in 2018, 60,300 people would receive a new diagnosis of and 24,370 men and women would die from some form of leukemia. Grouping all different forms of leukemias into a single group is not informative because the different forms have different patterns of incidence and different risk factors. It is associated with an acquired chromosomal translocation known as the Philadelphia chromosome, for which exposure to high doses of ionizing radiation is a known risk factor. Additional information available to the committees responsible for Update 1996 through Update 2010 did not change that conclusion. In Update 2014, the committee assessed two cohorts of veterans who served in Vietnam. They also reported the incidence of 21 leukemias overall, which resulted in a statistically signifcantly elevated standaridized incidence ratio. Results were stratifed by incident non-lymphoid and lymphoid leukemias, but only the lymphoid leukemia standardized incidence ratio was statistically signifcant. The small number of low-exposure deaths makes the reported estimates quite unstable. Other Identifed Studies Several other studies (occupational, environmental, and case-control designs) were identifed that examined leukemia outcomes, but all lacked suffcient exposure specifcity. Biologic Plausibility Leukemia is a relatively rare spontaneous neoplasm in mice, but it is less rare in some strains of rats. In this context, information in a letter to the editor of the American Journal of Hematology from Nguyen-Khac et al. Vietnam veterans, fndings have been null, and risk estimates have been less than 1. No new studies of leukemia in Vietnam veterans were identifed for the current update. Two mortality updates of occupational cohorts were reviewed that examined all leukemia and subtypes. Likewise, a statistically signifcant increased risk of death compared with the standardized U. M ost involve the number of cytopenias, dependence on transfusion, cytogenetic abnormalities, and the number of blasts in the marrow. For low-risk disease, the median survival is about 7 years; for high risk, it is less than 1 year. Exposures to radiation, a number of drugs, and some industrial chemicals (such as benzene) are recognized as risk factors for this condition, but it may also arise from an autoimmune disease. They followed Ahr-null mice, showing that they have diminished survival, splenomegaly, leukocytosis, and anemia. The hematopoetic stem cells showed diminished selfrenewal capacity, with somatic changes compatible with a profle of accelerated aging and hematopoetic stem cell exhaustion. The adverse outcomes evaluated in this chapter are male reproductive health effects such as alterations in sperm quality, semen, sex ratio, or hormonal levels; female reproductive health effects, including endometriosis and outcomes related to alterations in hormonal levels such as polycystic ovary syndrome and gestational diabetes; increased fetal loss (spontaneous abortion and stillbirth); neonatal and infant mortality; the adverse gestational outcomes of low birth weight and preterm delivery; and the possibility of adverse health outcomes (birth defects, cancer; and changes in growth and physical parameters and in immune, allergic, motor development, cognitive, behavioral and socio-emotional outcomes) at any time during the lives of all progeny of Vietnam veterans. The committee responsible for Updates 2012 and 2014 separated those outcomes most directly related to reproductive health and to the health of progeny into separate chapters. This report combines them because the committee believes that reproduction-related effects are best understood as a continuum. Whenever the information was available, an attempt has been made to evaluate the effects of exposure on males and females separately. In addition, for published epidemiologic or experimental results to be fully relevant to the evaluation of the plausibility of reproductive effects in Vietnam veterans, whether female or male, the veterans’ exposure needs to have occurred before the conception of the child. With the exception of female veterans who became pregnant while serving in Vietnam, pregnancies that might have been affected occurred after deployment, when primary exposure had ceased but fetal exposure via dioxin stored in maternal tissue was possible. In the case of pregnancies of women who have previously been substantially exposed to the lipophilic dioxins, the direct exposure of the fetus throughout gestation is possible through the mobilization of toxicants from the mother’s adipose tissue. The categories of association and the approach to categorizing the health outcomes are discussed in Chapter 3. To reduce repetition throughout the report, Chapter 5 characterized study populations and presents design information related to new publications that report fndings or that revisit study populations considered in earlier updates. If a person had a high exposure, then high amounts of dioxins may still be stored in fat tissue and be mobilized, particularly at times of weight loss. That would not be expected to be the case for nonlipophilic chemicals, such as cacodylic acid. Dioxin exposure has the potential to disrupt male reproductive function by altering the expression of genes that are pertinent to spermatogenesis and by altering steroidogenesis (Wong and Cheng, 2011); it has the potential to disrupt female reproductive function by altering the expression of genes relevant to ovarian follicle growth and maturation, uterine function, placental development, and fetal morphogenesis and growth (Bruner-Tran et al. The core histones that are retained in human sperm carry epigenetic modifcations to maintain open nucleosomes, which permits the transcription of genes that are important during embryo development (Casas and Vavouri, 2014). The mobilization of dioxin during pregnancy may be increased because the body is drawing on fat stores to supply nutrients to the developing fetus. Thus, dioxin in the mother’s bloodstream could cross the placenta and expose the developing embryo and fetus. Data indicate that dioxin can accumulate in placental tissue and that dioxin can transfer from the placenta to the developing fetus (M ose et al. Experiments with 2,4-D and 2,4,5-T indicate that these chemicals have subcellular effects that could constitute a biologically plausible mechanism for reproductive and gestational effects. However, the preponderance of evidence from animal studies indicates that these chemicals do not have reproductive effects. There is insuffcient information on picloram and cacodylic acid to assess the biologic plausibility of their potential reproductive or gestational effects. The sections on the biologic plausibility of the specifc outcomes considered in this chapter present more detailed toxicologic fndings that are of particular relevance to the outcomes discussed. Several of these components and some health outcomes related to male fertility, including reproductive hormones and sperm characteristics, can be studied as indicators of fertility.

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Buprenorphine is less dangerous than methadone in overdose with a lower risk of respiratory depression impotence 101 trusted 400 mg levitra plus. Concurrent use of benzodiazepines or alcohol however significantly increases the risk of death from respiratory depression(Megarbane erectile dysfunction fast treatment quality levitra plus 400 mg, Hreiche et al erectile dysfunction icd 10 cheap levitra plus 400mg free shipping. When used in outpatient treatment buprenorphine is combined with the opioid antagonist naloxone and administered sublingually erectile dysfunction in young guys buy levitra plus amex. Naloxone is added to erectile dysfunction test yourself order generic levitra plus canada discourage intravenous abuse of this medication: if this combination is misused intravenously, the naloxone effect predominates and blocks any opioid effect. Buprenorphine may also be beneficial in chronic pain patients who are at risk of opioid dependence; higher doses may be needed when buprenorphine is used as an analgesic. It disrupts ethanol metabolism by irreversibly inhibiting aldehyde dehydrogenase, thereby leading to a significant accumulation of ethanol metabolite acetaldehyde which is associated with severely unpleasant adverse effects (and cardiac stress). Although there is no evidence that it helps maintain abstinence over the long run, it may be useful as a disincentive to ethanol use in the short term. Ultimately however, most patients who wish to drink do so by discontinuing disulfiram, and many drink while still on it, placing themselves at severe risk. Therefore, like all pharmacotherapies for ethanol dependence, external supports (such as family supervision of medication adherence) and nonpharmacological therapies (such as ongoing counseling and behavioral therapies) are needed for continued effectiveness. Disulfiram is not recommended for patients with cardiac disease, significant liver disease, peripheral neuropathy or psychosis. Acamprosate may increase the number of abstinence days and decrease overall alcohol consumption long-term in alcohol dependent patients. Alcohol can increase the release of endogenous opioids in the brain which may contribute to its euphoric effects. Patients on naltrexone must not be given opiates for pain management: overdose and death can result from the high opiate doses needed to override the effect of naltrexone. Some studies have suggested superior efficacy of naltrexone as compared to acamprosate. It also found that the meetings with a healthcare provider increased the likelihood of abstinence. Bupropion, an antidepressant with possible dopaminergic effects (see section on antidepressants), is also efficacious for smoking cessation. The addition of nicotine replacement therapy to bupropion can increase the chances of abstinence compared to the use of either drug alone. It may have effectiveness that is comparable to, or greater than that of bupropion for smoking cessation. Table 6 summarizes the characteristics of medications used for substance abuse/dependence disorders. Treatment-emergent neuropsychiatric Varenicline (Nicotine symptoms and suicidality reported. Anxiolytics, including benzodiazepines and non-dependence-producing alternatives, are available for the treatment of severe anxiety disorders. First and second generation antipsychotics with different receptor profiles and side effect profiles have expanded the choices for patients with psychotic disorders. Lithium and other medications with mood stabilizing properties are available for use in patients with bipolar disorder. New formulations of stimulants and nonstimulant agents can be used in adults with attention-deficit/hyperactivity disorder. Finally, pharmacological therapies for the treatment of substance abuse and dependence disorders have been greatly expanded in recent years. Medical students and physicians should become familiar with these medications and obtain some facility in using them. As always, the science and art of medicine comprise the ability to appropriately and carefully apply that which is learned in textbooks to a specific patient. In the clinical setting, pharmacotherapeutic treatments should be used judiciously: the risks and benefits of treatments should be considered so that every effort is made to "first do no harm. The goal is to provide relief and lessen suffering, preferably in the most evidence-based and cost-effective manner possible. Finally, students and clinicians should keep in mind that for pharmacotherapeutic interventions to be successful there must also be appropriate psychosocial support and treatment. Journal of Clinical Psychiatry 65:267-272, 2004 Alda M: Pharmacogenetics of lithium response in bipolar disorder. Journal of Clinical Psychiatry 66:195-198, 2005 Ansari A: the efficacy of newer antidepressants in the treatment of chronic pain: a review of current literature. Journal of Clinical Psychiatry 60 (Suppl 2):77-84, 1999 Banerjee S, Shamash K, et al. Biological Psychiatry 62:7-16, 2007 Bertilsson L: Geographical/interracial differences in polymorphic drug oxidation. Progress in Neuropsychopharmacology and Biological Psychiatry 31:539-540, 2007 Cuijpers P, Van Straten A, et al. British Journal of Psychiatry 185:196-204, 2004 De Berardis D, Campanella D, et al. Journal of Clinical Psychiatry 63(Suppl 1):10-17, 2002 Dutra L, Stathopoulou G, et al. American Journal of Psychiatry 163:2090-2095, 2006 Faggiano F, Vigna-Taglianti F, et al. New England Journal of Medicine 355:365-374, 2006 Fishbain D: Evidence-based data on pain relief with antidepressants. Proceedings of the National Academy of Sciences of the United States of America 105: 20522057, 2008 Freedman R: Exacerbation of schizophrenia by varenicline. Biological Therapies in Psychiatry Newsletter 25, 2002 Gerstner T, Teich M, et al. Journal of the American Medical Association 296:47-55, 2006 Grunder G, Fellows C, et al. American Journal of Health-System Pharmacy 65:611-618, 2008 Harada T, Sakamoto K, et al. Neurochemistry International 37:103-110, 2000 Johannessen Landmark C: Antiepileptic drugs in non-epilepsy disorders: relations between mechanism of action and clinical efficacy. Journal of the American Medical Association 296:1609-1618, 2006 King M, Sibbald B, et al. Journal of Clinical Psychopharmacology 28:392-400, 2008 Kintz P: Deaths involving buprenorphine: a compendium of French cases. Journal of the American Medical Association 288:351-357, 2002 Kohen I, Kremen N: Varenicline-induced manic episode in a patient with bipolar disorder. Alcoholism: Clinical and Experimental Research 25:1335-1341, 2001 Kuhn R: the treatment of depressive states with G 22355 (imipramine hydrochloride). American Journal of Psychiatry 115:459-464, 1958 Laaksonen E, Koski-Jannes A, et al. Journal of Clinical Psychiatry 61(Suppl 9):5-15, 2000 Lepkifker E, Sverdlik A, et al. Drug Safety 5:195-204, 1990 Littleton J, Zieglgansberger W: Pharmacological mechanisms of naltrexone and acamprosate in the prevention of relapse in alcohol dependence. American Journal of Human Genetics 78:804-814, 2006 Megarbane B, Hreiche R, et al. Schizophrenia Bulletin 33:1379-1387, 2007 Onghena P, Van Houdenhove B: Antidepressant-induced analgesia in chronic non-malignant pain: a meta-analysis of 39 placebo-controlled studies. Journal of Clinical Psychopharmacology 14:230-240, 1994 Perucca E: Clinically relevant drug interactions with antiepileptic drugs. 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Generally, neurostimulation techniques can be defined as using a variety of different methods of stimulating the brain. In the past, there have been a variety of methods used, which are no longer used such as Cardiazol Shock Therapy, Insulin Coma Therapy, etc. Sometimes these treatment methods are referred to as biological treatment, as opposed to psychological treatment (psychotherapy) or pharmacological therapy (psychopharmacological agents). In this chapter, we will look in more detail at Electroconvulsive Therapy and Transcranial Magnetic Stimulation. A convulsion (seizure) is induced by the application of electrical current to the brain by using 2 electrodes. The position of the electrodes is important and the most commonly used positions currently are (1) bilateral position, where the electrodes are placed symmetrically on both sides of the head. It can further be subdivided to (a) bitemporal placement when the 2 electrodes are positioned on both temporal areas and (b) bifrontal positioning where the electrodes are positioned on the forehead. More recently in the last 20-30 years, this has been modified to monophase brief pulse electrical current. Current is measured in ampers and the most commonly used range is between 500 to 800 milliampers. Frequency of the brief pulse is typically anywhere between 20 to 120 Hz (pulse/sec). The total charge of electricity delivered at one stimulation is measured in coulombs and it is derived by the combination of different stimulus parameters. The actual energy delivered depends on the charge and impedance; it is measured in jolts. Seizure threshold is defined as the minimal charge (combination of individual parameters) able to produce a seizure. Once the threshold is established, the actual stimulus can be delivered at low dose (at seizure threshold), moderate dose (1. As this paralysis may be associated with significant fear and an anxiety response, the use of short acting general anaesthesia has been incorporated into the treatments. There might have been suggestion that treatments delivered 3 times per week may be associated with faster response, but with more side effects, and this could be used by individual practitioners in order to make determination of the actual frequency. Treatments delivered every day and even more than 1 treatment per day are virtually no longer used.

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Syndromes

Personal constructs were proposed by George Kelly (1955) as the individual theories which people use to erectile dysfunction vegan levitra plus 400mg lowest price generated hypotheses in order to erectile dysfunction caused by high blood pressure medication discount levitra plus 400mg with amex explain their experience Kelly’s model of the person was of ‘man as-scientist’ that the person was actively making sense of the world by formulating hypotheses about it erectile dysfunction vitamin discount levitra plus 400mg online, and then testing them erectile dysfunction otc discount 400 mg levitra plus otc, much as a scientist investigates their chosen subject area no xplode impotence 400 mg levitra plus. By identifying the special, personal set of constructs which the individual uses, a therapist would be far better placed to understand that person and to assist them with their problems in living. Kelly’s was thus an idiographic theory, concerned with the uniqueness of the individual and how he understood his world. The form of assessment known as the repertory grid, which Kelly developed, allows the therapist to utilize the individual’s own constructs in analyzing their experience. Personal space: the distance which people keep between themselves and others during everyday activities. The distance will vary depending on the individual’s culture, on the circumstances, and on their relationship with the other person; we tend to position ourselves more closely to intimate friends than we do to strangers. Personal space is a manifestation of proxemics, and an important Dictionary of Psychology & Allied Sciences 307 non-verbal cue; it is often described in terms of territoriality. Personality: Characteristic configuration of behaviourresponse patterns that each person evolves as a reflection of his individual adjustment to life. Personality, dependent: A personality disorder, with or without asthenic features, with a low degree of self-esteem, a persistent tendency to avoid the assumption of responsibility, and an inclination to subordinate personal drives to those of other people. Personality disorder: Mental disorder characterized by inflexible, deeply ingrained, maladaptive patterns of adjustment to life that cause either subjective distress or significant impairment of adaptive functioning. The types of personality disorders include paranoid, schizoid, schizotypal, histrionic, narcissistic, antisocial, borderline, avoidant, dependent, compulsive, passive-aggressive, and atypical. Personality disorder, affective: A condition characterized by lifelong predominance of a pronounced mood which may be persistently depressive, persistently elated, or alternately one then the other. During periods of elation there is unshakable optimism and an enhanced zest for life and activity, whereas periods of depression area marked by worry, pessimism, low output of energy and a sense of futility. Such individuals are prone to manic depressive psychosis but it does not occur inevitably. Synonym: cycloid personality; cyclothymic personality; depressive personality; dysthymic personality; hyperthymic personality. Personality disorder, anankastic: A lifelong pattern of personality organization characterized by feeling of personal insecurity, doubt and incompleteness leading to excessive conscientiousness, stubbornness and caution. There may be insistent and unwelcome thoughts or impulses which do not 308 Dictionary of Psychology & Allied Sciences attain the severity of an obsessive compulsive disorder. There is perfectionism and meticulous accuracy and a need to check repeatedly in an attempt to ensure this. Personality disorder, asthenic: Personality disorder characterized by passivity and a weak or inadequate response to the demands of daily life. Lack of vigour may show itself in the intellectual or emotional spheres; there is little capacity for enjoyment. Personality, explosive: Personality disorder characterized by instability of mood with liability intemperate outbursts of anger, hate, violence or affection. The outbursts cannot readily be controlled by the affected person, who is not otherwise prone to antisocial behaviour. Personality disorder, hysterical: A personality pattern characterized by shallow, labile affectivity, dependency on others, craving for appreciation and attention, suggestibility and theatricality. Personality disorder, schizoid: Personality disorder in which there is withdrawal from affection, and social and other contacts, with autistic preference for fantasy and introspective reserve. Behaviour may be slightly eccentric or indicate avoidance of competitive situations. Personality disorder with predominantly sociopathic or a social manifestations: Personality disorder characterized by disregard for social obligations, Dictionary of Psychology & Allied Sciences 309 lack of feeling for others, and impetuous or callous unconcern. People with this personality are often affectively could and may be abnormally aggressive or irresponsible. Their tolerance to frustration is low; they blame others or offer plausible rationalizations for the behaviour which brings them into conflict with society. Synonyms: amoral personality; antisocial personality disorder; a social personality; moral insanity; socio pathic personality. Personality dynamics: An approach to understanding behaviour in terms of the active interplay of aspects of the personality structure. Freud’s account of personality in terms of interactions between the id, ego, and super-ego is the classic example. Personality eccentric: A personality disorder characterized by an overvalued private system of beliefs or habits which are exaggerated in nature, sometimes fantastic and held with fanatical conviction. Personality fanatic: A personality pattern dominated by overvalued ideas that are held tenaciously and may be extensively elaborated without qualifying for delusional status. Individuals may pursue their idea combatively in defiance of social norms or adopt more private, often eccentric ways of life. Personality hyperthymic: A variant of personality characterized by cheerfulness and high level of activity without the morbid overtones of hypomania. Hyperthymia and dysthymia constitute the cyclothymic personality type which is associated with manic-depressive disease. Personality immature: A personality disorder characterized by conduct and emotional response that suggest a failure or lag in psychobiological development. A constitutional basis for this anomaly has 310 Dictionary of Psychology & Allied Sciences been suggested by electroencephalographic abnormality in the form of slow, paroxysmal theta or delta wave activity, mostly in the temporooccipital areas of the brain, which is commonly associated with behavioural disorders of children and criminals. Personality, multiple: A rare condition in which an individual exhibits two or more relatively separate, alternating personalities. Dissociation, suggestibility, and role playing are all regarded as psychopatholigically significant factors in the genesis of the disorder. It is usually viewed as hysterical but has been reported in organic states, especially epilepsy. Personality, passive-aggressive: A personality disorder characterized by a pattern of aggressive feelings expressed covertly by various forms of passivity. Personality, psychasthenic: A form of personality disorder characterized by an asthenic physique, a low level of energy, a proneness to fatigue, lassitude, lack of conative drive, and sometimes an over sensitivity associated with obsessional traits, Comment: the term drives from the concept of neurasthenia, introduced by Beard in 1869. Personology: Term borrowed by Marjorie Brierley from General Smuts to describe the study of the personality ‘not as an obstruction or bundle of psychological abstractions, but rather as a vital organism, as the organic psychic whole which par excellence it is’ (smuts) and used by her to distinguish the science of personality from Metapsychology, the two differing in that the former retains the person and his experience while the latter conceives of it as the result of the interaction of personal structures. Dictionary of Psychology & Allied Sciences 311 Pervasive developmental disorder: A disorder characterized by severe distortions in the development of social skills, language, and contact with reality. Many psychological functions are involved, and a child with a pervasive developmental disorder displays abnormalities that are not normal for any stage of development. During this period, sexual interest, curiosity, and pleasurable experiences are centered on the penis in boys and the clitoris in girls. The resolution of Oedipus complex is the dominant developmental conflict during this stage; it is thus also referred to an Oedipal stage. See also Anal phase, Genital phase, Infantile sexuality, Latency phase, Oral phase, Psychosexual development. Phantom limb: False sensation that an extremity that has been lost is, in fact, present. Phenomenology: the study of events or happenings in their own right, rather than from the point of view of inferred causes. It is associated with existential psychiatry and reflects the theory that behaviour is determined by the way the person perceives reality, rather than by external reality in objective terms. The word came into use in philosophy after publication of Hegel’s “phenomenology of the spirit”. In exception to the usual; conditioned reflex experiments occurring in some phobic patients in which the conditioning stimulus. Pheromone: Chemical signal that a person releases into the external environment and that affects the behaviour or physiological states of other persons. Phi phenomenon: An illusion of movement brought about by the sequencing in illumination of adjacent lights. If one light comes on when the other goes off, and the light next to it goes on when that goes off, what is perceived (assuming it happens reasonable quickly) is an impression of one light moving across from the location of the first one to the location of the last. This phenomenon is widely used in illuminated advertising signs, and can sometimes be very convincing. Should the lights be arranged in a circle, the perceived circular motion is seen as describing a circle of smaller diameter than the actual arrangement of the lights. It is thought that the phi phenomenon is a manifestation of the Gestalt psychologists’ principle of closure occurring with dynamic stimuli rather than with static ones. Phobia: An obsessive, persistent, unrealistic, intense fear of an object or situation. The fear is believed to arise through a process of displacing an internal (unconscious) conflict to an external object symbolically related to the conflict. Some of the common phobias are (add “abnormal fear of” to each entry): achluophobia: Darkness. Phobic disorder: An anxiety disorder characterized by intense specific fear of an object or situation. Phonemes are not the same as syllables: a one-syllable word, like ‘cat’ for instance, is made up of three distinct phonemes, which are combined to produce the syllable, or morpheme. Phonemics: the study of regularities and distinctive patterns in the combination of phonemes in spoken language. Phrenology: the study of the bony conformation of the skull in the belief that it is related to mental faculties and traits. Phyloanalysis: Term adopted by Trigant Burrow to describe type of behaviour analysis conducted in groups. Burrow was a pioneer in the study of human 314 Dictionary of Psychology & Allied Sciences behaviour in groups, but his chief interest was in understanding human evolutionary status, rather than in developing techniques of group psychotherapy. Because the earlier term for his work, “group analysis” led to confusion with analytic group psychotherapy, Burrow dropped the term and spoke, instead, of phyloanalysis. Physical disorder: A disorder of body function whose manifestations are not primarily behavioural or psychological. Physiological correlate: A physical change which accompanies a behavioural or psychological response. It may be recognized, for instance, that a cognitive event such as concentration or sleep is accompanied by physiological correlated is adopted as a description. Physiological need: Identified by Maslow as ebbing the lowest level in his hierarchy of needs; physiological need are the requirements for physical functioning, such as the needs for food, water, etc. Physiological psychology: the study of the way in which human behaviour and cognition are influenced or performed by processes which take place physically within the body. The term ‘physiological’ is preferred to ‘biological’ because such influences are usually exerted by whole systems of physical functioning operating together, such as is demonstrated in the fight or flight response, or the sensory information processing systems. Physiological psychology is often seen as being inherently reductionist as it explains behaviour in terms of the actions of neurons and chemicals, but many physiological psychologists maintain an interaction’s approach to the subject, in which physiological factors are sent as contributing to or influencing behaviour, but necessarily determining it. Dictionary of Psychology & Allied Sciences 315 Piaget, Jean (1896–1980): Swiss psychologist noted for his research on cognitive development in children.

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