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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.
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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*

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*