Mark Corson

By T. Fasim. Rush University.

Changes in affect and activity levels can be observed and reported by people with mania and mild to even very severe intellectual disabilities and their carers cheap leukeran 2 mg with mastercard. In Down’s syndrome buy cheap leukeran 2 mg on-line, mania is very uncommon among women discount leukeran 2mg without a prescription, whereas in the general population the male: female ratio is equal. Interestingly, those with Down’s syndrome less frequently have a positive family history. Similarly, cyclothymia (persistent mood swings not meeting severity criteria for affective disorders) has as yet received little attention in this population. High levels of anxiety are thought to be part of the behavioural psychiatric phenotype in William’s syndrome. Obsessive Compulsive Disorder Compulsive behaviours have reported frequencies of 3. Compulsions are significantly associated with stereotypies and self-injurious behaviour. Obsessions and compulsions can arise in a number of disorders other than obsessive–compulsive disorder, such as depression and pervasive developmental disorder. Some specific stereotyped movements have been associated with disorders such as Rett syndrome (hand-wringing movements in front of the body) and Smith–Magenis syndrome (body self-hugging, self-biting). Although obsessions and compulsions may need pharmacological treatment in individuals with Prader–Willi syndrome, the effectiveness of serotonin reuptake inhibitors in the treatment of stereotyped movements in Rett syndrome and Smith–Magenis syndrome is less established. The risk of posttraumatic stress disorder and adjustment disorder is therefore likely to be significantly increased. In the acute phase, management usually focuses in accessing services, ensuring safety of the patient and others and initiation of medication. After resolution of the acute phase, management is more likely to focus on maintaining good mental health, insight-related work and relapse prevention planning. Treatments should be tailored to the individual, and so take into account any co-existing medical conditions such as epilepsy, other drugs being taken and any other particular requirements. With the gradual closure of the long stay units and the focus in community care, the role of psychology has expanded enormously. Assessment and management of expressed emotion in families and professional carers can also be beneficial. Social and environmental risk factors relate to social barriers and dependence support from carers, and may include stigma and segregation, over- protection, lack of opportunities, neglect and abuse, limited social networks and poorly managed changes and losses. Respite care and rehabilitation for those with more chronic illnesses, including the use of day services, should be part of a comprehensive long-term person-centred management plan. Practical social interventions, tailored to the individual’s needs, are important in order to support both the patient and the support network. Treatment as for the general population is appropriate with the following cautions:  Treatment with medication: start low, go slow and change one medication at a time, as there is higher frequency of idiosyncratic responses to psychotropic drugs. Where different medications are being used simultaneously, the reason for each needs to be explained. It is wise therefore to have a crisis plan mapped ahead of time in order to address safety and other issues at these times. For those with the most severe forms of depression and those with suicidal intent, hospital admission needs to be considered. Treatment with selective serotonin reuptake inhibitors may be beneficial in obsessive–compulsive disorder, as may various behavioural techniques. Social treatments can include interventions in the social network and helping people to find meaningful occupation and develop their skills. It can mean ensuring that people are treated with appropriate dignity and respect and are able to make choices in their lives. This is not only confined to just those areas of the brain responsible for cognitive and social functioning but also associated to a variety of physical impairments that can lead to additional health needs over and above those experienced by the general population. For example, depression and psychosis may predispose to poor compliance with medication, and chronic psychiatric illness is associated with poor physical health and morbidity. A third of adolescents with autism develop epilepsy, and it is associated with other syndromes such as Tuberose Sclerosis, Sturge- Weber syndrome and Rett’s syndrome. That is why a thorough full psychiatric and medical history and mental state is required. An informant is essential especially as witness to the seizures and a full description of seizure is required, i. Epilepsy is associated with increased prevalence of nearly all forms of psychiatric disorder. Possible mechanisms include greater social disadvantage, chronic potentially life threatening illness, accidents, head injuries, self-esteem issues, dependency on others. Some studies report that rates of psychosis are higher in those with milder disability and epilepsy, whereas depression rates are higher in those with severe disability. A complex relationship exists between poor impulse control, epilepsy and socio-cultural factors. Interestingly, ‘Forced Normalisation’ is an uncertain phenomenon but relatives/carers frequently report that patient is improved in mental health terms when fit control not so optimal. This can impact on physical health, psychological health and mortality, and in turn also could have an impact on the families and carers of these individuals. Most antiepileptic drugs have agitation or mental illness as an associated side effect, although carbamazepine, lamotrigine and 248 sodium valproate are also used as mood stabilisers. Finally, the treatment of epilepsy may also reduce cognitive ability (both drugs and surgery). They often report feeling isolated and wanting to have friends, though they may not have the skills necessary to form relationships. Frequently, due to the “one shot learning” style of memory, one unpleasant experience may lead to avoidance and a phobic reaction.

It is doubt­ ful that this will be widespread discount leukeran 2mg otc, but communities may try to treat “their own” using indigenous folk practices buy 2mg leukeran amex. T he demise of folk medicine was associated with the disin­ tegration of viable insular com m unities generic leukeran 2mg. Profes­ sionalism is incompatible with the idea of community and the egalitarianism that accompanies it. But professionalism in the sense of autonomy, to use Eliot Freidson’s concep­ tualization, is the cornerstone of the medical care system. In The Natural Mind,,21 Andrew Weil draws a distinction between “straight,” or conventional thinking, and “stoned” thinking. Straight thinking is charac­ terized as: • a tendency to know things through the intellect rather than through some faculty of mind; • a tendency to be attached to the senses and through them to external reality; • a tendency to pay attention to outw ard forms rather than to inner contents and thus to lapse into materialism; An Emerging Zeitgeist 151 • a tendency to perceive differences rather than similarities am ong phenom ena; • a tendency toward negative thinking, pessimism, and despair. Straight thinking assumes that nature is hostile and can be managed by direct application of force. Weil continues: As vigorous selective agents, insecticides in o u r w orld play a significant role in th e evolutionary developm ent o f all insect species. T h ey neatly w eed out th e susceptible n u m b er o f fam ilies co ncentrating in insect gene pools all over th e w orld th e genetic factors th at confer resistance to these chem icals. New and m ore effective insecticides are then needed and so on—an infinite regress. Weil then distinguishes straight thinking from “stoned” thinking: • a reliance on intuition as well as intellection; • an acceptance of the ambivalent nature o f things; • an experience of infinity and its positive aspects. The autonom ic nervous system, which is supposed to trigger the involuntary muscles such as the heart, illustrates stoned thinking. U nder prevailing biomedical concepts, the au­ tonomic nervous system is not “connected” to consciousness. If told that his or her skin has been touched by hot metal, a subject in full trance will blister as if burned when touched by a finger. Weil concludes that there “m ust be a channel be­ tween mind and body [that] is wide open whenever we are in 152 The Climate for Medicine an altered state o f consciousness. In The Master Game,26 one of the many books and articles on the subject, Robert S. De- Ropp argues that because hum an beings have evolved with a large brain, they should be capable of far greater powers than they have dem onstrated. DeRopp feels that, “because [man] does not know how to use this powerful machine, it tends to operate in ways not beneficial to its possessor, to generate a host of illusions am ong which he wanders. William Jam es m ade the same point in The Varieties of Religious Ex­ perience in 1929: O ne conclusion forced u p o n my m ind at th at tim e, an d my im pression o f its tru th has ever since rem ain ed unshaken. It is th at o u r norm al w aking consciousness, rational consciousness as we call it, is but one special type o f consciousness, w hilst all about it, p arted from it by the film iest o f screens, th ere lie potential form s o f consciousness entirely d ifferen t. W e m ay go th ro u g h life w ithout suspecting th eir existence, but apply the requisite stim ulus, a n d at a touch they are th ere in all their com pleteness. N o account o f th e universe in its totality can be final w hich leaves these o th e r form s o f consciousness quite d isreg ard ed. If hum an beings are capable of higher states o f consciousness, it may be possible for individuals to assume m ore responsibility for self-care than is now the case (even am ong those who have not succumbed to professional coercions). T he literature, flanked by a wealth of anecdotal accounts, is full o f descriptions of natural healings. T he mechanistic approach to health and well-being that characterizes m odern medicine is inconsistent with concepts of higher consciousness. T he m ore that is discovered about hum an potential and the powers of an evolved conscious­ ness, the less sense the prevailing medical paradigm makes. We may be at the limits o f allopathic medicine to treat and reduce disease; new approaches are needed, new ways to heal and be healed. Some diseases may result from imbal­ ances in consciousness that can only be treated through its alteration. It may then be possible to achieve improvements in health through expanding consciousness. If transform ations take place that alter the beliefs and attitudes underlying our culture, medicine will inevitably be affected. Barry Com m oner, in The Closing Circle,31 postulates four laws of ecology: “(1) everything is connected to every­ thing else; (2) everything must go somewhere; (3) nature knows best; and (4) there is no such thing as a free lunch. W e have been train ed by m od­ e rn science to think about events th at a re vastly m ore sim ple— how one particle bounces o ff an o th er, o r how M olecule A reacts w ith M olecule B. C o n fro n ted by a situation as com plex as th e en v iro n m en t and its vast array o f living 154 T he Climate for Medicine inhabitants, we are likely— som e m ore than o th ers— to attem pt to red u ce it in o u r m inds to a set o f separate, sim ple events, in the hope th at th eir sum will som ehow picture the w hole. T h e existence o f the en vironm ental crisis w arns us that this is an illusory hope. For som e tim e now, biologists have studied iso­ lated anim als and plants, and biochem ists have studied m ol­ ecules isolated in test tubes, accum ulating th e vast, detailed literatu re o f m o d ern biological science. Yet these separate data have yielded no sum s th at explain th e ecology o f a lake, for instance, and its vulnerability. This is not a sim ple-minded nostrum , for upon reflection it is clear that unless ill health is the product of evil spirits, the causes of disease can be found in the ecosphere and in m an’s m anipulation of its elements. It follows that prevention and even treatm ent of disease lies in fostering conditions that are conducive to health. As our ecological knowledge grows, the im poverishm ent of our approach to health will become in­ creasingly evident. This approach to health is not novel (I discuss some of its roots later), but it has not been cogently expressed as a guide for action. In the preface to Habit and Habitat, Robert T heo­ bald distinguishes m an’s relationship to his habitat from that of other species: M an is unique. T his statem ent has been m ade so o ften — an d so incorrectly— th at we have lost sight o f th e few areas w here it is pro fo u n d ly tru e.

Patients were divided into two cancer and chemotherapy groups buy leukeran 2mg overnight delivery, with the experimental group receiving The results of a study by Andersen et al (2006) acupressure with massage discount 2mg leukeran overnight delivery, while having hemodialy- indicate that 6 weeks of a multidimensional exercise sis treatment 2 mg leukeran for sale. Findings were that those individu- are undergoing chemotherapy, can lead to a reduction als in the treatment group had significantly decreased in symptoms and side-effects. The researchers divided fatigue into different Physical medicine therapeutic categories: measures for fatigue • Physical fatigue: The sense of fatigue that • Light forms of manipulation (e. The women Fibromyalgia syndrome (see instinctive received 30 treatments, two or three times weekly. Note: A number of studies relating to the pain expe- • manipulation of the upper thoracic and cervical rienced in fibromyalgia are discussed later in this region using rotational and high velocity thrust chapter under the subheading ‘Pain’. To what reported after both 15 and 30 treatments and were extent, in any given case, the soft tissue approaches sustained for at least 1 month following the end of the alone might be responsible for the resulting benefits treatment. Among those who did not report benefit after 30 Various mechanisms could be involved. Pain inhibi- treatments it was observed that there had been a less tion may be achieved as a result of: than 35% improvement by the end of 15 treatments, and that this: ‘suggests that a minimum 35% improve- • increased spinal mobility following ment in pain intensity must be observed after 15 treat- manipulation that tends to decrease central ments or it may no longer be appropriate to pursue transmission of pain from adjacent structures this form of treatment’. However, this does not clarify following manipulation whether the ischemic pressure, which calmed the • paraspinal muscles relaxing due to stretching trigger points, would have, on its own, achieved of apophyseal joint capsules during similar results. Ten patients received treatment between teaching (learning about the condition and self- three and five times per week for 4 weeks. During this help measures) and a third group received only time the remainder (the controls) received no treat- moist-heat treatment. Treatment consisted of: noted in the self-teaching group (Jiminez et al • soft tissue massage using a counterirritant 1993). Studies which showed the greatest improvement in their compare joint manipulation with soft tissue approaches quality of life (Rubin et al 1990). There is no evidence that the underlying condition is assisted As with chiropractic evidence it appears that osteo- by these methods, although they clearly have an pathic manipulation offers relative benefits to patients important role to play in management. A gradual had six visits/treatments and it was found decline in the increased myoglobin over a 1-year period that 12 of the patients concentration was observed over repeated responded well in that their tender points massage treatments as self-reported muscle became less sensitive (14% reduction in tension decreased over time. The 15 massages resulted in a self- 458 Naturopathic Physical Medicine reported reduction in pain in 85% of the on treatment with connective tissue massage (30% patients and a reduction in analgesic use by and 10%). Depression and self-rated One of the main findings in this pilot study of women quality of life improved but no improvements with initially severe pain due to long-standing and inca- were observed in sleep, ability for activities pacitating fibromyalgia was that they experienced a sub- and anxiety. Previously, it has been reported in a consisting of medical care from the clinic nurse double-blind study of 48 women with fibromyalgia or physician (Alnigenis et al 2001). However, that connective tissue massage gives pain relief in no impact on pain, depression, well-being and one-third of the treated women (Brattberg 1999). The greatest benefits were Exercise and fibromyalgia noted in areas of mood and depression, as well as in reduced pain levels (Field et al 2003). All symptoms showed favorable progress during a Supervised and graduated exercise 4-week period with manual lymph drainage therapy. Fibro- Relaxation and flexibility comprised upper and myalgia patients who attempt to begin an exercise lower limb stretches and relaxation techniques. As the program often experience an increase in muscle classes continued, more techniques were introduced, pain which may discourage them from continuing to progressing through progressive muscle relaxation, work on improving their level of fitness. Pellegrino release-only relaxation and visualization, cue- (1997) notes that a prescribed, supervised exercise controlled relaxation and differential relaxation. This program is beneficial for fibromyalgia patients, and occupied the whole 1-hour class. It is worth noting, however, that in both only groups the tender point counts had fallen significantly 2. Such a program After 12 months fewer participants in the aerobic can include walking, water aerobics, using an exercise group fulfilled the criteria for fibromyalgia; exercise bicycle, or performing a low impact by this time only 75 (55%) participants still met these aerobic program diagnostic criteria. The goal is to achieve improvement, but also to achieve a stable baseline For people with fibromyalgia prescribed graded aerobic exercise is an effective treatment that leads to 4. Compliance is a consider- relaxation and flexibility able problem, giving high dropout rates. Future strategies to (male and female, age range 18–70 years), evaluated increase the efficacy of exercise as an intervention the effect on their conditions of either graded cardio- should confront the issue of compliance. Potential vascular fitness exercise or relaxation and flexibility strategies include additional cognitive behavioral activities, to which they were randomly assigned. Both forms of intervention helped a good number Exercise therapy comprised an individualized of participants, although clearly aerobic activity pro- aerobic exercise program, mostly walking on tread- duced the most benefit. When people first started classes cost, high-benefit outcome should be seen as offering they usually did two periods of exercise per class a beacon for individuals in chronic pain. Sadly, despite periods of 25 minutes at an intensity that made them obvious benefits, individuals commonly slip back into sweat slightly while being able to talk comfortably in old habits, abandon exercise regimes and return to complete sentences. Exercise routines should be introduced condition and how to manage it, with a group who gradually – see the protocol used by Richards & Scott attended these same lectures but who also received (2002) described above (page 458) – with caution and six 1-hour sessions of physical training. Unsupervised home exercising is probably with doing nothing in similar patients) were untreated unwise until the individual has attended classes during this entire study but received treatment after where the degree, intensity and timing of exercise can it was over. Patients participated Fitness, flexibility and strengthening in the study for 3 weeks (total of 15 sessions). Patients were evaluated by the number In another study (Martin et al 1996) the benefits of of tender points, visual analog scale for pain, exercise (fitness, flexibility and strengthening) pro- Beck’s Depression Index and Fibromyalgia grams were compared with relaxation exercises in a Impact Questionnaire for functional capacity. In Both groups of patients (those doing active exercise, group 1, there were statistically significant and those doing relaxation) met three times a week differences in number of tender points, visual for 6 weeks to carry out their routines under supervi- analog scores, Beck’s Depression Index and sion. At the start, both groups had the same amount Fibromyalgia Impact Questionnaire scores after of pain, stiffness, etc. Six months exercises, 18 completed the course, along with 20 (of later, in group 1, there was still an the 30) in the relaxation group. Both groups showed improvement in the number of tender points (p an improvement in the number and sensitivity of <0.