Mark Corson

By G. Hurit. The Salk Institute for Biological Studies.

Westerner attending a tai chi class may come away It is well established that discount naprosyn 500 mg line, historically cheap naprosyn 250mg without prescription, towns and cities unmoved by their experience naprosyn 250mg cheap. In open-minded Westerner is likely to actually perceive the the West, such water supplies were most commonly benefit of the cultivation of chi as a result of the sanitized through distillation. In the East, water supplies interaction between increased oxygen and well-hydrated were most commonly sanitized through boiling the water cellular machinery (for further discussion of cellular and adding leaves with high antioxidant levels. Paramagnetic materials biochemical environment and is a classic example of attract and repel like normal magnets when subject to metabolic typing, or biochemical individuality in action. It is interesting to note that many natural health • Diamagnetism is a form of magnetism that is only authorities suggest that because Western social drinks exhibited in the presence of an external magnetic field. Though to some this may seem a disadvantage, it also means that people with this profile have very low risk of alcoholism. Janda (1994), for example, discusses the fact that crisis may affect the firing of the deep, local stabilizer some muscles in the neck, the levator scapulae in par- system. Since the system is tonic, we might expect that ticular, may be used to literally ‘dump’ excessive it would become facilitated and tight (as does the neural drive from the limbic-emotional system. This pectoralis minor or the levator scapulae), but this enhanced neural drive to the levator and other pos- depends on the nature of the stimulus and whether tural muscles results in the hunched, red-light or that stimulus arrives at the cord via the alpha-afferent upper crossed posture we are all familiar with in or the beta-afferent system. The former (low threshold stressed states (whether they be emotional, physical, system) may acutely alter postural reflexes, such as thermal, etc. The common outcome of this is tension in stimulus will upregulate, while a high stimulus will the tonic muscle system and relative inhibition in the inhibit physiological processes, so the response of the phasic muscle system, though there are exceptions motor nerve at any given level will depend entirely (see Table 9. The multifidus, transversus and other deep stabi- The notion of the musculoskeletal system as a damp- lizer muscles have a lower threshold to stimulus (Sahr- ener for aberrant energies from the organ systems, mann 2002) and therefore are the first muscles to be from emotional input or from pain generators is con- affected by aberrant neural events at the cord level. Chapter 9 • Rehabilitation and Re-education (Movement) Approaches 389 Psychology of corrective exercise Box 9. Bear in mind socioeconomic effects of pain: patients about their condition as well as to offer advice and coaching as to how to make better choices, • Job performance whether this involves exercise, nutrition or other life- • Sports performance style choices. Bear in mind sexual activity being affected by pain: (1999) has described some of the following concepts • Does the pain affect libido? Any other lifestyle changes or compromises due to that 85% of patients presenting for orthopedic consul- the pain tation have an unknown causative onset of their pain. Distinguish between hurt and harm: This, of course, suggests that the problem is one of • Pain during an exercise cumulative microtrauma based on dysfunctional bio- • Pain during a stretch mechanical, biochemical or emotional patterns. Manage your patient properly by offering Movement approaches and mood comprehensive information 8. Flare-ups are not failures to manage the pain, but Depressive symptomatology is more prevalent among education as to how to better manage the pain in sedentary than physically active individuals (Berlin et future al 2006). Focus your patient on function rather than pain mental health problems account for 30% of total dura- 10. Progress should be monitored every 2–4 weeks be defined as either acute or chronic. The acute effects to give patients accurate feedback of their of exercise on mood tend to focus on state anxiety. The changes/improvements vast majority of research into the effects of exercise on 13. Assess using pain provocation tests/quantifiable psychological well-being has been conducted using testing to demonstrate gains aerobic exercise. Nevertheless, activities such as weight or strength training, yoga, and other ‘non- aerobic’ exercises have produced positive effects on psychological health (Weinberg & Gould 1999). How this occurs probably involves many mecha- Higher levels of physical activity in depressed nisms, including the fact that exercise is commonly patients have been shown to be associated with less performed in an outdoor environment which allows concurrent depression, even after controlling for exposure to sunlight, known to have antidepressant gender, age, medical problems and negative life effects and to help to re-regulate circadian rhythms. Physical activity counter- The exercise itself may also help to re-regulate a dis- acted the effects of medical conditions and negative rupted circadian rhythm, thereby aiding sleep and life events on depression. If the circadian rhythm is Exercise has been shown to have an irrefutable disrupted, this alone may be a major cause of depres- benefit in helping to optimize mood – both in those sion (Spiegel et al 2003). Other benefits of exercise on who are non-symptomatic and in those with clinically mood will be due to the ability of exercise to exert a defined depressive episodes (Warburton et al 2006). Some of this also known to increase opiate-like endorphin produc- evidence is described in Chapter 10. Governmental tion in the brain, and may contribute to a natural high physical activity guidelines are variable but com- from exercise – alongside the possibility of a feel-good monly fall within the approximate range of 20–30 factor from knowing that time has been used con- minutes’ duration of >60% of maximal heart rate three structively and to move towards a positive goal. Such Similar to antidepressants, exercise has been hypoth- guidelines are sufficient to elicit health benefits, espe- esized to increase the synthesis of new neurons in the cially in previously sedentary people. Studies on rats reveal a two- to threefold those unaccustomed to exercise use their lack of exer- increase in hippocampal neurogenesis with regular cise history as an excuse for not taking on the advice access to a running wheel when compared with of the clinician to do an exercise program; however, control animals (Ernst et al 2006). Recent rat studies the less conditioned they are, the greater the benefits also show that exercise (in this instance swimming) they will receive (Warburton et al 2006). Many people who suffer with depression are focused In one study (Berlin et al 2006), 40 regular exercisers on one or multiple earlier life experiences (such as were deliberately deprived of exercise across just 2 a bereavement, a divorce, or a time(s) they have felt weeks and assessed using multiple profiles and testing cheated). Alternatively, such individuals may be procedures to measure fatigue and somatic depres- focused on a kind of hopelessness about the future sive symptoms. Both fatigue and depressive symp- and how certain past (or anticipated future) events toms emerged after just 1 week of exercise withdrawal may impact the potential for future happiness. Exercise withdrawal also resulted future events that may never happen (Tolle 2001). Depressed mood and fatigue are commonly engagement in exercise encourages the participant observed in individuals deprived of usual exercise into the present, into the now, potentially decreasing activities, and the increase in fatigue may be partially pain, increasing endorphins, and enhancing self- mediated by reduced fitness levels.

Aripiprazole may normalise haloperidol-induced hyperprolactinaemia whilst the patient remains on haloperidol generic naprosyn 250 mg. Disconnection hyperprolactinaemia: pituitary tumour presses on pituitary stalk blocking tonic inhibition of dopamine from hypothalamus on secretion of prolactin buy naprosyn 500mg overnight delivery. Pseudotumour cerebri: This condition includes raised intracranial pressure discount 500 mg naprosyn otc, classically in a young obese woman. Cases are divided into 3079 primary (idiopathic intracranial hypertension) and secondary. Management of primary cases includes weight loss, repeated lumbar puncture, diuretics, 3080 topiramate, emergency steroids to save sight, and surgery. Craniopharyngioma: These tumours may affect sight (optic chiasma) and cognition, memory problems not being entirely explicable by raised intracranial pressure. Other reported findings (by some but not all studies) are excessive sleepiness and eating, bouts of aggression, and (often medication-resistant) depression. Some cases have no neuropsychiatric manifestations whereas others may have neurotic or personality problems, or psychosis. Personality change due to a medical disorder A persistent change in personality may indicate serious pathology. Abulia (mute, lacks motivation and feeling) must be distinguished from depression. Focal lesions of the hemispheres Frontal and temporal lesions are more often associated with personality change and psychosis respectively. Frontal: There may be a grasp reflex (see table), spastic paralysis and ataxia of the contralateral upper limb, anosmia, incontinence and personality change. A variety of factors influence the type of symptoms to be found with frontal lobe lesions, such as localisation, size, type, and course of lesion, as well as premorbid personality and age. Defective oxidation of saturated very long chain fatty acids leads to their accumulation. Controversial proposed treatments include Lorenzo’s oil (mixture of glyceryl trioleate and glyceryl trierucate) and dietary fat restriction. Common 3084 symptoms are headache, epilepsy, disturbed micturition and neurological abnormalities. These symptoms are usually present at the time of diagnosis, even in those with early psychiatric problems, and should be looked for. The commonest psychiatric symptoms associated with frontal lobe tumours are impaired consciousness and progressive intellectual deterioration, followed by 3085 mood and behavioural disturbances. In some cases, especially with meningiomas , there may be no neurological symptoms until the tumours are large and causing displacement. These cases may be referred to a psychiatrist because of progressive personality change and intellectual decline. Frontal lobe release 3086 reflexes are commoner in demented than in non-demented elderly people. Sudden onset of symptoms such as forced thoughts, dreamy states, terrible fear, depersonalisation, and déjà vu should bring one to consider temporal lobe epileptic aura. If infarction occurs in one occipital lobe (posterior cerebral artery) there will be a homonymous hemianopia with sparing of the macular area (supplied by middle cerebral artery). If the pole of one occipital lobe undergoes infarction there will be a small scotomatous homonymous hemianopia. Glabellar reflex: damage to fontopontine pathways to facial nerve nucleus – Parkinson’s disease, Parkinsonism, dementia, cerebral atrophy, frontal lobe tumours – tap glabella from behind head – not common in drug-induced Parkinsonism Grope reflex: touch hand of patient and latter will reach out for your hand; extreme cases allow the examiner, by successive touching, to guide the patient’s hand through space (‘magnet reaction’) or, indeed, in the absence of touching, there may be automatic groping for objects seen by the patient Snout reflex: tap nose and look for excess facial grimacing Sucking reflex: stroke lip and look for pouting/sucking lip movements (normal in babies and gone by 18 months) Chewing reflex: put tongue depressor in mouth and look for reflex chewing movements Grasp reflex: stroke palm and patient will grasp your finger (may resist removal of your finger – 3093 sometimes, if you stroke the dorsum of his fingers, he will let go) 3094 Palmomental (palmar-mental) reflex: scratch palm and watch wrinkling/puckering of chin on same side or scratch base of thumb and look for slight downward movement of lower lip and jaw _____________________________________________________________________________________________________ Common office tests of frontal lobe functioning  Naming as many animals as possible in 60 seconds (verbal fluency)  Getting the patient to reproduce various 3 hand positions or sequentially tap with both hands (motor 3095 sequencing )  Go/no-go tasks (‘tap the table once if I tap it once, but do not tap if I tap twice’)  Abstraction (e. Astereognosia or tactile agnosia is the inability to identify simple objects placed in the hand with the eyes closed. Autopagnosia, where the patient totally 3093 This must be distinguished from the magnet reaction found in catatonic and organic brain disorders: examiner touches patient’s palm – as examiner withdraws his fingers the patient’s hand follows them. The same object may be seen repetitively or a central object may be seen even after it has been removed from view (visual perseveration). Temporal: elaborate visual sensations, epilepsy, hallucinations (auditory, gustatory, and olfactory), illusions, receptive aphasia (with dominant lesions), transient amnesias, homonymous upper quadrantanopia, and déjà vu. Occipital: crude visual hallucinations with irritative lesions, contralateral homonymous hemianopia with destructive lesions. Corpus callosum: apraxia of left hand, anomia for objects held in left hand, and alien hand syndrome. Paranoid thinking and koro have also been reported (Durst & Rosca-Rebaudengo, 1988). There is a genetic cause in a 3101 minority of cases and an association with trisomy disorders is well known. Some cases are attributable to intrauterine toxin exposure or infection to metabolic disorders such as excess glycine. Whilst the condition is usually reported in childhood it may be discovered at any stage of life, even at autopsy. Seizures, spasticity, intellectual disability (only when there are other malformations), and hydrocephalus are reported associations. It seems that the brain is able to compensate for the absence of this structure in many cases, e. Andermann syndrome, described in 1972, may run in families and consists of intellectual disability, callosal agenesis, facial dysmorphia, peripheral neuropathy, and psychosis; psychosis may relate to cerebellar atrophy. Tumours of the corpus callosum: In most cases there is a quick development of intellectual decline, with memory affected first.

Also naprosyn 500 mg cheap, Simms and Mulholland (2008) failed to link depression in schizophrenia to perceived lack of social support discount 500 mg naprosyn free shipping. Many researchers believe that that depression is an integral part of schizophrenia buy 250mg naprosyn with visa. It may be that dysphoric symptoms precede, coincide with (during which they may be masked), and follow the more florid illness. Whether this is due to a functional link between the two symptomatologies or due to a common physiological disturbance is still disputed. Some authors hold that verbal memory impairment in schizophrenia is explained by depression and that it is not an integral part of the disorder. Depending on how one defines such symptoms, 3-10% of cases may experience such episodes at some stage. Even when one considers bipolar disorder, schizoaffective disorder, drug- 1153 induced disorder , and somatic disorders (e. Veen 1156 ea (2004) reported a strong association between use of cannabis and earlier age at first psychotic episode in males with schizophrenia. Henquet ea (2005), in a prospective and population-based (Munich) sample, found that cannabis use in people aged 14 to 24 years moderately increased the risk for psychotic symptoms but had a much stronger effect in those with evidence of predisposition for psychosis. An increase in psychotic symptoms predicted relapse to cannabis abuse and medication adherence reduced cannabis relapse risk in a prospective post- discharge study of psychotic patients. Further work conducted by Arendt ea (2008) was suggestive of cannabis-induced psychosis being an early manifestation of schizophrenia rather than a distinct disorder. Barnett ea (2007) reported increased substance use in people with first-episode psychosis, age at first use of cannabis, cocaine, ecstasy and amphetamine being significantly associated with age at first psychotic symptoms. Moore ea (2007) performed a systematic review and concluded that cannabis increases risk of psychotic outcomes independent of confounding and transient psychotic effects. Miettunen ea (2008) found cannabis use to be associated with prodromal symptoms of psychosis in adolescence and Mata ea (2008) found that cannabis abuse was associated with 1158 impaired decision-making before onset of psychosis but could not determine direction of causality. Veling ea (2008b) conducted a study among non-Western immigrants to The Hague with first-episode schizophrenia. Cannabis use predicted schizophrenia but genetic predisposition did not predict schizophrenia. Weiser and Noy (2005) suggest that, rather than cannabis causing schizophrenia, an abnormal endogenous cannabinoid system might be common to both schizophrenia and the tendency to use cannabis. Acute cannabis use induced psychotomimetic symptoms in people prone to psychosis in a study conducted by Mason ea. Henquet ea (2010) found that patients had an acute enhancement of mood and subacute hallucinations from cannabis and, again, they found no direct connection between cannabis use and attempts at self-medication. From the most to the least common the order seems to be a mixture of the two types, type I, and type 2. Under the same nosological rubric was subsumed the occasional manic, depressive, or personality disorder. However, if standard diagnostic methods were employed then one could still 1162 demonstrate a core of patients in all centres with similar symptomatology. At the Serbsky Institute in Moscow, Snezhnevsky offered a broad concept of schizophrenia - many eccentrics and personality-disordered individuals were included in his idea of schizophrenia. Snezhnevsky took more cognisance of the course of the illness than of the manifestations. Hegarty ea (1994) reported that only 40% of subjects could be considered to have improved after follow up averaging 5. Outcome was better with broad or undefined criteria, but poorer (27%) with narrow criteria. Outcome varied for different reasons (treatment, criteria changes) at different times. In the closing years of the 19th century Kraepelin viewed schizophrenia as a disorder which always carried a poor prognosis. In the 1960s Brown and others found that after five years 56% of discharged schizophrenics made a social recovery, 35% were socially damaged but lived outside hospital, and only 11% had spent all their time in hospital. Bland and Orn (1978) found that after fourteen years about half were coping well with minimal disability, one-quarter had moderate to marked disability and a further quarter were disabled psychiatrically, socially and occupationally. Manfred Bleuler (in 1974, lived 1903-94) followed up 208 patients for over twenty years and found that there was usually no further deterioration after five years; in fact, some even improved. Also, there have been reports of a relatively good outcome for schizophrenia in some industrialised societies (Prague, Nottingham) and of a poor outcome in Cali. Three- year outcomes were similar to that of affective psychosis and significantly superior to that of schizophrenia. Also, in non-affective psychotic disorders, being a woman and having good premorbid function, but not acute onset or early remission, predicts favourable outcome at three years. Sikanerty and Eaton (1984) reported a lower prevalence for schizophrenia in the Third World. There are also reports from developing countries of symptomatic, severely disabled chronic, untreated patients living with extended families. Even the best studies fail to predict more than one-quarter of the variation in subsequent course. Wing and Brown (1970) looked at the long-stay schizophrenic patients of three different hospitals. The hospitals with the most barren, understimulating wards had the most withdrawn, silent and affectively blunted cases. While this was not borne out by a cross-sectional study conducted by Eyler Zorrilla ea (2000) it received support from a study showing an increased risk of developing dementia compared to patients with osteoarthritis and to the general population. However, more recent studies suggest that elderly schizophrenics remain symptomatic and impaired.