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By: I. Goose, M.B.A., M.D.

Program Director, University of Rochester School of Medicine and Dentistry

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If I examine my addictive behaviours without judgment and ask “Why” in the spirit of compassionate curiosity muscle relaxant otc cvs generic sumatriptan 50 mg with mastercard, what do I find? Is it that I’m a respected thirty-year veteran of medical practice muscle relaxant back pain buy sumatriptan 50 mg free shipping, spouse and parent muscle relaxant drugs cyclobenzaprine order sumatriptan 25mg with visa, counsellor, public speaker, activist and author? What about the anxious, insecure man who has often felt empty and incomplete and has looked to the outside to allay some insatiable hunger? As fellow addict and author Stephen Reid said during our conversation in the cafeteria of the William Head penitentiary: “…makes my teeth hurt, the work of pulling back from all those outside things and looking inside myself. Along with my positive qualities—intellectual confidence, strengths, passions and commitments—there has always lurked near the very core of me a churning, inchoate anxiety. Had I been able to be honest with myself and had I been prepared to accept vulnerability, I would have declared at many stages of my life, as Clarissa did: “I’m scared. I feel sure it was forged in my chest cavity somewhere between my lungs and heart long before I knew the names of things. In contrast to healthy anxiety (for which a better word is fear) felt in the face of danger—like the fear a gazelle might experience in the presence of a hungry lion or that a small child might feel when his parents are not in sight, chronic anxiety is not rooted in the experience of the moment. We may believe we’re anxious about this or that—body image, the state of the world, relationship issues, the weather—but no matter what story we weave around it, the anxiety just is. Like addiction itself, anxiety will always find a target, but exists independently of its targets. More often we repress it, bury it under ideas, identifications, deeds, beliefs and relationships. We build above it a mound of activities and attributes that we mistake for our true selves. We then expend our energies trying to convince the world that our self-made fiction is reality. As genuine as our strengths and achievements may be, they cannot but feel hollow until we acknowledge the anxiety they cover up. The addict believes—either with full awareness or unconsciously—that he is “not enough. He must escape the painful experience of the void within through any activity that fills his mind with even temporary purpose, be it work, gambling, shopping, eating or sexual seeking. In my first book, Scattered Minds, I depicted this perennial psychic hunger: the British psychiatrist R. Laing wrote somewhere that there are three things human beings are afraid of: death, other people, and their own minds. There always had to be a book in my pocket as an emergency kit in case I was ever trapped waiting anywhere, even for one minute, be it a bank lineup or supermarket checkout counter. I was forever throwing my mind scraps to feed on, as to a ferocious and malevolent beast that would devour me the moment it was not chewing on something else. My workaholism and compact disc shopping have been only the most consistent forms of escape my mind chooses when it’s uncomfortable. Emotionally they take the shape of chronic, low-grade depression and irritability. On the thought level, they manifest as cynicism—the negative side of the healthy skepticism and independent thinking I’ve always valued. Behaviourally they mask themselves as hypomanic energy or as lethargy, as the constant hankering for activity or for oblivion. When the ordinary, everyday escape mechanisms fail to satisfy, I plunge into my overtly addictive patterns. If I had greater pain and fewer resources, if I had been less fortunate in the circumstances of my nurturing environment, I might well have been impelled to turn to drugs. Once I see my anxiety and recognize it for what it is, the need to escape dwindles. It is clear to me that the sense of threat and fear of abandonment that make up anxiety were, in my case, programmed in the Budapest ghetto in 1944.

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Stressful life events spasms during pregnancy purchase sumatriptan 25 mg visa, changes in sleep-wake schedule spasms during sleep buy generic sumatriptan 25mg online, and current alcohol or substance abuse may affect the course of illness and lengthen the time to muscle relaxant creams over the counter discount 25 mg sumatriptan recovery (26, 71, 73, 173–175). The rapid con trol of symptoms such as agitation and aggression may be particularly important for the safety of the patient and others. Lithium Lithium has been used for the treatment of acute bipolar mania for over 50 years. Pooled data from these stud ies reveal that 87 (70%) of 124 patients displayed at least partial reduction of mania with lithi um. However, the use of a crossover design in four of these trials (176–179), nonrandom assignment in two studies (177, 178), and variations in diagnostic criteria and trial duration limit interpretation of the results of all but one trial (180). Nevertheless, in the only placebo controlled, parallel-design trial in which lithium served as an active comparator to divalproex, lithium and divalproex exerted comparable efficacy (180). In active comparator trials, lithium displayed efficacy comparable to that of carbamazepine (181, 182), risperidone (183), olanza pine (184), and chlorpromazine and other typical antipsychotics (185–190). Among active comparator trials, however, only three (185, 186, 189) were likely to be of sufficient size to detect possible differences in efficacy between treatments. Open studies (191–194) and randomized, Treatment of Patients With Bipolar Disorder 31 Copyright 2010, American Psychiatric Association. These side effects vary in clinical significance; most are either minor or can be reduced or eliminated by low ering the lithium dose or changing the dosage schedule. For example, Schou (199) reported a 30% reduction in side effects among patients treated with an average lithium level of 0. Dose-related side effects of lithium include polyuria, polydipsia, weight gain, cognitive problems. Side effects that persist despite dosage adjustment may be managed with other medications. Gastrointestinal disturbances can be managed by administering lithium with meals or changing lithium preparations (especially to lithium citrate). Less commonly, cardiac conduction abnormalities have been associated with lithium treatment. Al though the polyuria associated with early lithium treatment may resolve, persistent polyuria (ranging from mild and well tolerated to severe nephrogenic diabetes insipidus) may occur. If the polyuria persists, management includes ensuring that fluid intake is adequate and that the lithium dose is as low as possible. If these measures do not ameliorate the problem, then concurrent admin istration of a thiazide diuretic. The lithium dose will usually need to be decreased (typically by 50%) to account for the increased reabsorption induced by thiazides (198). In addition, potassium levels will need to be monitored, and potassium replacement may be necessary. Amiloride, a potassium-sparing diuretic, is reported to be effective in treating lithium-induced polyuria and polydipsia (203). Its advantages are that it does not alter lithium levels and does not cause potassium depletion. It occurs more fre quently in women, tends to appear after 6–18 months of lithium treatment, and may be associated with rapid cycling (41, 80, 198, 205). Lithium-induced hypothyroidism is not a contraindication to continuing lithium and is easily treated by the administration of levo thyroxine (198, 205). In addition to the other signs and symptoms of hypothyroidism, patients with bipolar disorder are at risk of developing depression or rapid cycling. If these symptoms occur in the presence of laboratory evidence of suboptimal thyroid functioning, then thyroid supplementation, discontinuation of lithium, or both should be considered (206–208). A small number of case reports have described exacerbation or first occurrences of psoriasis associated with lithium treatment (212). Some of these patients improved with appropriate der matologic treatment or when the lithium dose was lowered. In some cases, however, lithium seemed to block the effects of dermatologic treatment, with psoriasis clearing only after lithium was discontinued. This is in contrast to the more common mild to moderate acne that can occur with lithium treatment, which is usually responsive to standard treatments (198). These changes may be associated with impairment of water reabsorption but not with reduction in glomerular filtration rate or development of renal insufficiency (41, 198, 213–216).

Nor does she think her parents are always right spasms near ribs discount 25 mg sumatriptan amex, although she loves them as much as Hugh loves his muscle relaxant abuse order 50mg sumatriptan overnight delivery. In her own way back spasms 5 weeks pregnant purchase sumatriptan 50mg without prescription, she has turned out to be what her parents wanted-just as Hugh did. Rather than accept dominance and competition as givens in life, Lou was taught to value equality and cooperation. Lou’s parents belong to a liberal Protestant denomination, but seldom darken a church door. Lou went to Sunday school when she was young, but she came home one day asking why God got so mad at Cain for sacrificing vegetables to him, since that’s what Cain grew? While some parents would have scolded their child for asking such “impertinent” questions, Lou’s father 65 told her it was good to wonder about these things, and maybe the whole story was a fairy tale. When she was 12 she began reading the Book of Revelation because a classmate told her it “proved” the world was going to end soon. At 18 she resists going on her family’s token excursions to church on Christmas and Easter. She does not believe in God, and says that the more she talks to believers, the more she thinks one should be an atheist. Lou was not raised with well-defined in-groups, nor was she taught that “different” people were probably dangerous and evil. In fact her mother got Lou involved in various inner-city activities as a young teen so she could see how unfair life is to some. Lou has a diverse set of friends now, some of whom are almost “opposites” from one another; but she likes them all. She knows a much wider range of people than Hugh does, and sometimes, with her heart in her throat, she does new and different things just to see what they are like. Lou’s virginity disappeared when she was 16, and intercourse is a regular part of her relationship with her boyfriend. Unlike Hugh, Lou did not learn from her parents that Truth was in the bag, but that she’d have to figure it out for herself. If Hugh were to abandon his parents’ faith, he might be cast out from the family forever. So even if he somehow came to believe the family religion was wrong, he would likely keep his doubts strictly to himself as long as they were alive-and probably longer. If Lou were to become very different from her parents in religion-say she became a Protestant fundamentalist-her parents would definitely not like it. But they would recognize that Lou is entitled to make up her own mind, that in fact they raised her that way, so it serves them right. Cataclysmic events, for example, can undo everything you have learned before and throw you up on a far-away beach. But most people who end up on one extreme or the other land there because most of the influences in their life got in line and pushed in the same direction, as happened to Hugh and Lou. Most parents, for example, are not as restrictive as Hugh’s but also are not as white-knuckled permissive as Lou’s. On the other hand few parents deliberately jack up their children’s social consciousness as Lou’s did. Unconventional behaviors and strange friends from different backgrounds are accepted but not gushingly welcomed. On balance, the Moderates’ experiences in adolescence made them less authoritarian than they had been earlier. They got into disputes with their parents, teachers, the police, and often came away feeling wronged. They spotted hypocrisy in the pews, and found that a literal interpretation of Genesis made no sense at all. They may have played on a team run by a strict disciplinarian coach and kicked-ass up and down their schedule. They may have smoked a little of this and tried a little of that and drunk a whole lot of something else-and then smashed, crashed and burned. They may have met “someone different” who robbed them, or left them holding the bag when the cops 67 broke up the party. In short, their experiences generally took them away from Hugh’s domain, but were not nearly as uniform as Lou’s.

Worth syndrome