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THE BIG NO-NO’S – INTRODUCTION

Are you aware that you might be putting you and your children’s mental, emotional and physical health at risk each me you bathe, shave, and apply sunscreens, body lotion or nail polish?Or, did you know that when you clean your house, you may be creating greater toxic air pollution indoors that exists outdoors?Everyday we use products that we think are perfectly safe but the truth is that all too often they are far from it — and manufacturers don’t have to tell us so. Ever since 1938 — when the FDA granted self-regulation to the cosmetics industry — such products can be marketed, regardless of what tests show. Most of the 25,000 chemicals used have not been tested for long-term toxic effects. In a typical day, you might be exposed to over 200 different chemicals, many of which are suspected of causing cancer or disrupting hormones. The Environment Protection Agency tests conclude that ingredients in shampoos, dyes and other personal care products “May be laying havoc with hormones that control reduction and development.”*44/165/1*

DELIRIUM: DIFFERENTIAL DIAGNOSIS-SCHIZOPHRENIA

Psychiatrists are sometimes asked whether patients with hypoactive-hypoalert delirium might not have catatonic schizophrenia. It is important to remember here that catatonic phenomena occur not only in psychiatric conditions (especially affective disorders) but also in a large number of medical and neurological illnesses capable of producing delirium, such as hepatic failure, viral encephalitis, and neuroleptic malignant syndrome. Catatonia, then, does not equal schizophrenia.     In the unlikely event that the differential diagnosis cannot be resolved from the patient’s history, examination, and laboratory tests, a trial of benzodiazepines may settle the matter. When such medications are given to catatonic patients with affective disorders or schizophrenia, their motor signs and mutism almost always abate. A mental status examination will then reveal that the patients have been alert and aware of their surroundings despite their withdrawn and uncommunicative behavior. In contrast, if benzodiazepines are given to patients with hypoactive-hypoalert delirium, they may become even more obtunded and inaccessible.     Delirium tremens can initially be mistaken for paranoid schizophrenia because agitation, delusions, and hallucinations occur in both. Although it may be difficult to assess an agitated patient, it should not be hard to recognize certain features of delirium tremens that are useful in differential diagnosis. The most important of these characteristics are autonomic overactivity, tremulousness, severe insomnia, and prominent visual hallucinations.     If a patient’s agitation is due to paranoid schizophrenia, it will eventually be clear that he has no fundamental disturbance of consciousness. Even when schizophrenic patients are frightened or distracted, it is possible to “make contact” with them and to prove that they are aware of their surroundings. When I asked one such patient where he was, he replied: “You say this is Johns    Hopkins Hospital in Baltimore, but I know it’s really a police station in Washington, D.C.” The first part of his answer demonstrated that he was well oriented; the second, that he was delusional. Observations of this sort help to distinguish paranoid schizophrenia from hyperactive-hyperalert delirious states, whether or not they take the form of delirium tremens.*27\172\2*

WHY YOU CAN’T STAY AWAKE: OTHER TYPES OF DOES – KLEINE-LEVIN SYNDROME

This rare cause of hypersomnia usually affects males, most often between the ages of ten and twenty-one. Victims experience bouts of extreme daytime sleepiness coupled with unusual eating patterns. The fact that victims alternate between periods of enormous appetite and near starvation leads some authorities to suspect that the cause of the syndrome lies in a malfunctioning appetite control center in the brain. Other behavior helps differentiate this syndrome: irritability, confusion, incoherent speech, delusions, social isolation, shyness, and apathy. Victims may demonstrate exceptionally aggressive or inappropriate sexual activity, such as exhibitionism. Metabolic disturbances can be detected through urinalysis. Victims experience earlier and shorter REM periods and less deep NREM sleep. After a period of time the condition enters a stage of remission that can last months or even years. Sleep during this time is normal. Diagnosis of this unusual condition is tricky, since some of these symptoms may appear to be just part of the transition from prepubes-cence to young adulthood. Indeed, there may be some connection to the rampaging hormonal activity of this stage of life. Treatment with lithium carbonate may prevent (but not eliminate) attacks; the condition usually resolves itself spontaneously before the age of forty.*161\226\8*

STRESS BREAKDOWN: AGGRESSION AND VIOLENCE, USE OF SEDATIVE DRUGS

Aggression and violence in stage two breakdownIt is readily obvious that where people lose emotional control in a situation of high anxiety, violence may result. This is particularly so if the person is experiencing significant threat to the integrity of his or her territory, that aspect of a person which is held inviolable by others. One’s territory might be actually one’s own backyard, and someone is intruding uninvited. Or one’s territory might be a role, or a job, or a specific responsibility. People react fairly quickly in response to others trying to take over their jobs. Territorial threat will, in ordinary circumstances, provoke defensive aggression.In stress breakdown, that defensive aggression is apt to be sudden, unpredictable, and violent, because of the loss of emotional control. Violence is even more likely if the person under stress has been using sedative drugs.
The use of sedative drugs in stress breakdownSedative drugs such as alcohol, barbiturates, chloral hydrate and the benzodiazepine drugs such as oxazepam (Serepax), diazepam (Valium) and nitrazepam (Mogadon) are able to switch off the anxiety response to nervous system overload. The person under stress, who is uncomfortable from anxiety symptoms, can temporarily feel a lot better on taking a sedative drug. The temptation is therefore to stay in the stressful situation and suppress the anxiety symptoms with drugs or alcohol. This situation is something like a motorist blocking out the oil-pressure warning light because the light is interfering with his driving, instead of stopping the car and investigating why the oil pressure has dropped. Ignoring warning signals leads to trouble.When the sedative effect of these drugs wears off, the person is left with a low-grade agitation which makes the person feel worse than he did before taking the drug. This heightened feeling of anxiety may lead to a desire for further doses of the drug to suppress the agitation; the stage is then set for continued use of the drug and the beginnings of a drug dependency problem.In my experience, the use of sedative drugs to suppress anxiety symptoms in stress breakdown lowers the inhibitory reserve and makes the stressed person more prone to aggressive outbursts and actual violence. At this point, the problems of the person with stress breakdown, complicated by continued use of drugs, begin to merge with the problems of alcoholism and sedative abuse. Sorting out the problems of a person with stress breakdown when that person has been using sedative drugs regularly, presents a complex situation requiring expert skills.
*23/129/5*

WEIGHT MANAGEMENT: DEFINING ‘MORBID OBESITY’NIC

E defines morbid obesity ‘for the purposes of the guidance’ as:A BMI either equal to or greater than 40 kg/m2, or between 35 kg/m2 and 40 kg/m2 in the presence of significant comorbid conditions that could be improved by weight loss.Other authorities use a broader definition. According to Balsiger et al:Patients have morbid obesity when they are 100% or greater above ideal body weight (IBW), are at least 100 lb above IBW or have a BMI of over 35. A strictly weight-based definition is not appropriate, however, and a better definition of morbid obesity includes patients who have direct, weight-related serious morbidity, such as mechanical arthropathy, hypertension, type 2 diabetes, lipid related cardiac disease, and sleep apnoea.
People suffering from morbid obesityIn 1998, an estimated 0.6% of men and 1.9% of women in England and Wales had a BMI of 40 kg/m2 or more – this is equivalent to 124 000 men and 412 700 women. People with a BMI >35 have a rate of mortality at any given age double that of someone with a BMI of 20-25.*55/312/5*

STRIKE BACK AGAINST HEART ATTACK: HOW TO SURVIVE A HEART ATTACK

Your chances of living to talk about your heart attack increase greatly if you listen when your body is trying to tell you something. Although some heart attacks occur without any symptoms at all, any one of the following symptoms is a ‘strong warning that you are probably having a heart attack:(i) Uncomfortable pressure —not necessarily pain — in yourhest, most often experienced as a deep central discomfort (or feeling of fullness or squeezing) below the breastbone. This kind ofcrushing pain or heaviness in the middle of the chest is the mostcommon symptom of a heart attack (About a quarter of patients how-ever will not experience this sensation). If it lasts more than a few minutes, or if it subsides when you rest but increases with activity, that increases the likelihood that what you are experiencing is a restriction of blood flow to the heart muscle.(ii) Chest pain that radiates to the jaw, neck, back, shoulder or arm. In some patients, the pain is experienced primarily, or even exclusively, in other locations. (iii) Chest discomfort that’s accompanied by light-headedness, nausea, sweating or shortness of breath.Chest pain is unlikely to be a heart attack if it is — “Stabbing” pain that can be localized to one small spot on the chest (about the size of a coin). For instance, a feeling as if a pencil is being poked into the chest for an instant.Pain/discomfort that lasts for less than 30 seconds.Pain that is felt exclusively” in the region of the heart itself (that is the left side of the chest).If you experience any of the main symptom syndromes, immediately call for an ambulance to take you to a hospital, then take half a tablet of soluble aspirin (even if you already are on an aspirin regimen), either chewing it or allowing it to dissolve under your tongue. This self-administered aspirin therapy can in itself cut the risk of death by 40 per cent!Though an ambulance is often the fastest and safest way to get to a hospital, a friend or relative can sometimes drive you there faster. Delay in seeking expert medical attention is the most critical risk factor when a heart attack is taking place: a delay of even one to two hours can mean the difference between a small heart attack and a big one or even the difference between life and death. Doctors today have powerful drugs to dissolve the clots in the arteries that are causing heart muscle to die. But they work best if they are administered within an hour after the first symptoms begin; after six hours, they make little difference as most of the damage is irreversible by then. That is why cardiologists say, “Time is Muscle.” So, don’t stop to rationalize away the warning symptoms you’re experiencing as something else.    More don’ts:Don’t waste time going to your family doctor’s clinic or to a small nursing home. What you need is a hospital with an 1CCU (Intensive Cardiac Care Unit) which is geared to provide specialized emergency care.(Ideally, you need to practise Early Cardiac Care: if you are at known risk for heart disease, get to know and keep a list of hospitals in your areas of residence and/or work, in advance. Also keep a list of phone numbers: ambulance services, friends, relatives).Don’t try to drive yourself to the hospital, or to go by foot, cab, bus or train.And remember:Youth is no guarantee against a heart attack. Even if you are in your 20s, a long episode of chest pressure needs to be promptly evaluated by an expert to exclude the possibility of a heart problem, even a heart attack.Many heart attacks occur in those without any of the traditional risk factors for heart disease. So even if you have no history of high blood cholesterol or hypertension, do not ignore prolonged episodes of chest discomfort.Some heart attacks are signalled by atypical symptoms, which may fun the gamut from heartburn to sudden, recurrent vomiting. Complaints that arise with activity and subside with rest often also serve as early warning signs of a heart attack.*54\332\2*

BACH FLOWER REMEDIES: WALNUT REMEDY

Walnut relates the soul quality of adjustment in transition periods of life – in beginning of new life, unaffected by links with the previous life. It is aptly called the Link Breaker.In the positive state of Walnut remedy, the person can smoothly cut himself off from previous connections, howsoever strong they may have been and make a new beginning. It makes no difference whether he has to countenance natural physical changes that come with age i.e teething puberty, pregnancy or the menopause, or a major mental decision such as change of religion or profession, breaking of old conventions or social customs, or leaving one’s country for good to settle in an unknown foreign country. He may with constancy and determination leave his age-old habit of drinking or smoking. A person in the negative Walnut state, however, lacks that iron will which can surmount all vacillations that are attendant upon such major changes.He may possess the determination and strength of purpose to carry out his normal routine of life, but when a stronger personality impresses him to break off from the old and make a new beginning, he becomes a prey of duelty in his mind. He wants to change. The stronger personality has convinced him that change is in his interest. Future wants a break from the past. The present is tied to the past, which does not loosen its hold. The facts of heredity, old conventions, age-long social customs, the thought of a secure present connected to the past, and an uncertain future envisaged in the break from the past cause painful vacillations in his mind. He wants to make a new beginning, but the previous links are too strong to be snapped.*196\308\8*

THE CARBOHYDRATE ADDICT’S PROFILE: CAUSES OF ADDICTION

The events of any given day may bring on a desire to eat. The familiar and obvious smell of fresh baked goods when you walk past a bakery can trigger an addictive attack, as can a more subtle (and seemingly irrelevant) event like a disagreement with a colleague at your place of work.We call these day-to-day experiences “addiction triggers.” Here is a list of some of the most common triggers we have observed in the carbohydrate addicts we have treated at the Carbohydrate Addict’s Center.
EMOTIONAL STATES The following feelings may provoke a desire to eat:Anger you can’t expressA sense of being out-of-control or of being powerlessDepressionExcitementFrustrationSelf-blame
DAY-TO-DAY ACTIVITIESMany quite unexceptional day-to-day activities can cause the carbohydrate addict to progress to higher addiction levels. These include:Changes in home lifeChanges in working conditionsExerciseIllnessPregnancyPremenstrual changesQuitting smoking• Stressful situations of almost any kind EATING HABITSNot surprisingly, a range of dietary and nutritional factors can also trigger addictive response’s. Among them are:Extreme dietingThe sight or smell of foodRapid weight gainRapid weight loss
HIGH-CARBOHYDRATE FOODSConsuming high-carbohydrate foods is another surefire way to trigger the desire for more carbohydrates. Among the foods that most of our dieters have found trigger their addictions are:Bread and other grain products, including bagels, cookies, cereals, cakes, crackers, pastries, doughnuts, and rolls.Fruit of all kinds, including grapes (and raisins), bananas, cherries, date’s, apples, and oranges. Juices too.Sweet dessert foods, including ice cream, chocolate, candy, puddings, sherbets.Snack foods like popcorn, potato chips, pretzels, cheese puffs, and nuts.And other foods, too. including some beans (Boston baked beans, rich with molasses, is a classic trigger); all kinds of pasta, from simple spaghetti and egg noodles to ziti and ravioli; rice (alone and in other dishes); French fries; and—don’t forget— plain sugar, too, even just a spoonful of it in your coffee or tea.*22\236\2*

THE KINDS OF SEIZURE: GENERALIZED SEIZURES – THE FRONTAL LOBES

Areas of the frontal lobes other than the motor strip are less well defined; they have to do with personality, memory, anxiety, alertness, and awareness. With many connections to the temporal lobes, it is often difficult to determine from the way the seizure looks whether the function (or the dysfunction of seizures) comes from the frontal or the temporal lobes. Some areas near the “motor strip” (supplementary motor area) seem to control the coordination of movements of groups of muscles. Electrical stimulation of the supplementary motor area (or seizures) thus may cause the eyes, head, and body to turn away from the side stimulated. Other seizures originating here may appear to cause a brief staring and loss of awareness before some of the stereotyped seizures called complex partial seizures appear.*67\208\8*

APPROACH TO PATIENTS WITH ACUTE CONJUNCTIVITIS: PRINCIPLES OF MANAGEMENT

HistoryCertain historical features can help narrow the diagnostic etiology of a red eye and rapidly determine the need for patient referral. The medical history should include questions regarding the following:- Change of vision (“Can you read ordinary print with the affected eye?”)- Eye pain- Photophobia- History of eye trauma- Contact lens use- Time course of illness- Environmental or work-related exposures- Eye itching- Eye discharge- History of upper respiratory tract infection- Sexual history/history of sexually transmitted diseases- Medication history- Allergies- History of eye disease
Ocular ExaminationThe patient with a red eye should be examined in a well-lit room. The physician should carefully observe and examine the face and eyelids and search for regional lymphadenopathy. The ocular examination should focus on the following:- Measurement of visual acuity – If acuity is diminished, the physician should suspect a more worrisome diagnosis (angle closure glaucoma, infectious keratitis, uveitis) and immediately refer the patient to an ophthalmologist.- Examination of the pupils – The size and reactivity of the pupils should be closely observed. A fixed or nonreactive pupil should prompt immediate referral to an ophthalmologist.- Examination of the anterior segment – The clinician should note the presence of any discharge, appearance of the cornea, and pattern of redness. If either ciliary flush (circumcorneal injection) or hypopyon (a layer of leukocytes in the anterior chamber) are seen, urgent referral to an ophthalmologist is required.- Fundoscopic examination – This is usually not helpful in the differential diagnosis of the red eye.*32/348/5*