BLOATED FEELING, in women. Abdomen feels heavy and swollen. Helonias.
The term is also a street drug name for an amphetamine derivative, 3, 4-methylenedioxymethamphetamine or MDMA, increasingly used as a ‘recreational’ drug. It is classi?ed as a class A drug under the Misuse of Drugs Act 1971. MDMA is structurally similar to endogenous CATECHOLAMINES and produces central and peripheral sympathetic stimulation of alpha and beta ADRENERGIC RECEPTORS. It is taken into nerve terminals by the serotonin transporter and causes release of the NEUROTRANSMITTER substances serotonin and dopamine. Following this, SEROTONIN depletion is prolonged. As serotonin plays a major part in mood control, this leads to the characteristic ‘midweek depression’ experienced by MDMA users.
Several fatalities in young people have been attributed to adverse reactions resulting from MDMA use/abuse and possibly accompanying alcohol consumption. The principal effects are increase in pulse, blood pressure, temperature and respiratory rate. Additional complications such as cardiac ARRHYTHMIA, heatstroke-type syndrome, HYPONATRAEMIA and brain haemorrhage may occur. There is also concern over possible effects on the mental concentration and memory of those using ecstasy.
Management of patients who get to hospital is largely symptomatic and supportive but may include gastric decontamination, and use of DIAZEPAM as the ?rst line of treatment as it reduces central stimulation which may also reduce TACHYCARDIA, HYPERTENSION and PYREXIA.... ecstasy
The speciality of anaesthesia broadly covers its provision for SURGERY, intensive therapy (intensive care), chronic pain management, acute pain management and obstetric analgesia. Anaesthetists in Britain are trained specialists with a medical degree, but in many countries some anaesthetists may be nurse practitioners working under the supervision of a medical anaesthetist.
The anaesthetist will assess the patient’s ?tness for anaesthesia, choose and perform the appropriate type of anaesthetic while monitoring and caring for the patient’s well-being, and, after the anaesthetic, supervise recovery and the provision of post-operative pain relief.
Anaesthesia may be broadly divided into general and local anaesthesia. Quite commonly the two are combined to allow continued relief of pain at the operation site after the patient awakens.
General anaesthesia is most often produced by using a combination of drugs to induce a state of reversible UNCONSCIOUSNESS. ‘Balanced’ anaesthesia uses a combination of drugs to provide unconsciousness, analgesia, and a greater or lesser degree of muscle relaxation.
A general anaesthetic comprises induction, maintenance and recovery. Historically, anaesthesia has been divided into four stages (see below), but these are only clearly seen during induction and maintenance of anaesthesia using inhalational agents alone.
(1) Onset of induction to unconsciousness
(2) Stage of excitement
(3) Surgical anaesthesia
(4) Overdosage
Induction involves the initial production of unconsciousness. Most often this is by INTRAVENOUS injection of a short-acting anaesthetic agent such as PROPOFOL, THIOPENTONE or ETOMIDATE, often accompanied by additional drugs such as ANALGESICS to smooth the process. Alternatively an inhalational technique may be used.
Maintenance of anaesthesia may be provided by continuous or intermittent use of intravenous drugs, but is commonly provided by administration of OXYGEN and NITROUS OXIDE or air containing a volatile anaesthetic agent. Anaesthetic machines are capable of providing a constant concentration of these, and have fail-safe mechanisms and monitors which guard against the patient’s receiving a gas mixture with inadequate oxygen (see HYPOXIC). The gases are adminstered to the patient via a breathing circuit either through a mask, a laryngeal mask or via ENDOTRACHEAL INTUBATION. In recent years, concerns about side-effects and pollution caused by volatile agents have led to increased popularity of total intravenous anaesthesia (TIVA).
For some types of surgery the patient is paralysed using muscle relaxants and then arti?cially ventilated by machine (see VENTILATOR). Patients are closely monitored during anaesthesia by the anaesthetist using a variety of devices. Minimal monitoring includes ELECTROCARDIOGRAM (ECG), blood pressure, PULSE OXIMETRY, inspired oxygen and end-tidal carbon-dioxide concentration – the amount of carbon dioxide breathed out when the lungs are at the ‘empty’ stage of the breathing cycle. Analgesic drugs (pain relievers) and local or regional anaesthetic blocks are often given to supplement general anaesthesia.
Volatile anaesthetics are either halogenated hydrocarbons (see HALOTHANE) or halogenated ethers (iso?urane, en?urane, des?urane and sevo?urane). The latter two are the most recently introduced agents, and produce the most rapid induction and recovery – though on a worldwide basis halothane, ether and chloroform are still widely used.
Despite several theories, the mode of action of these agents is not fully understood. Their e?cacy is related to how well they dissolve into the LIPID substances in nerve cells, and it is thought that they act at more than one site within brain cells – probably at the cell membrane. By whatever method, they reversibly depress the conduction of impulses within the CENTRAL NERVOUS SYSTEM and thereby produce unconsciousness.
At the end of surgery any muscle relaxant still in the patient’s body is reversed, the volatile agent is turned o? and the patient breathes oxygen or oxygen-enriched air. This is the reversal or recovery phase of anaesthesia. Once the anaesthetist is satis?ed with the degree of recovery, patients are transferred to a recovery area within the operating-theatre complex where they are cared for by specialist sta?, under the supervision of an anaesthetist, until they are ready to return to the ward. (See also ARTIFICIAL VENTILATION OF THE LUNGS.) Local anaesthetics are drugs which reversibly block the conduction of impulses in nerves. They therefore produce anaesthesia (and muscle relaxation) only in those areas of the body served by the nerve(s) affected by these drugs. Many drugs have some local anaesthetic action but the drugs used speci?cally for this purpose are all amide or ester derivatives of aromatic acids. Variations in the basic structure produce drugs with di?erent speeds of onset, duration of action and preferential SENSORY rather than MOTOR blockade (stopping the activity in the sensory or motor nerves respectively).
The use of local rather than general anaesthesia will depend on the type of surgery and in some cases the unsuitability of the patient for general anaesthesia. It is also used to supplement general anaesthesia, relieve pain in labour (see under PREGNANCY AND LABOUR) and in the treatment of pain in persons not undergoing surgery. Several commonly used techniques are listed below:
LOCAL INFILTRATION An area of anaesthetised skin or tissue is produced by injecting local anaesthetic around it. This technique is used for removing small super?cial lesions or anaesthetising surgical incisions.
NERVE BLOCKS Local anaesthetic is injected close to a nerve or nerve plexus, often using a peripheral nerve stimulator to identify the correct point. The anaesthetic di?uses into the nerve, blocking it and producing anaesthesia in the area supplied by it.
SPINAL ANAESTHESIA Small volumes of local anaesthetic are injected into the cerebrospinal ?uid through a small-bore needle which has been inserted through the tissues of the back and the dura mater (the outer membrane surrounding the spinal cord). A dense motor and sensory blockade is produced in the lower half of the body. How high up in the body it reaches is dependent on the volume and dose of anaesthetic, the patient’s position and individual variation. If the block is too high, then respiratory-muscle paralysis and therefore respiratory arrest may occur. HYPOTENSION (low blood pressure) may occur because of peripheral vasodilation caused by sympathetic-nerve blockade. Occasionally spinal anaesthesia is complicated by a headache, perhaps caused by continuing leakage of cerebrospinal ?uid from the dural puncture point.
EPIDURAL ANAESTHESIA Spinal nerves are blocked in the epidural space with local anaesthetic injected through a ?ne plastic tube (catheter) which is introduced into the space using a special needle (Tuohy needle). It can be used as a continuous technique either by intermittent injections, an infusion or by patient-controlled pump. This makes it ideal for surgery in the lower part of the body, the relief of pain in labour and for post-operative analgesia. Complications include hypotension, spinal headache (less than 1:100), poor e?cacy, nerve damage (1:12,000) and spinal-cord compression from CLOT or ABSCESS (extremely rare).... anaesthesia
Uses Before the serious effects that result from its habitual use were realised, the drug was sometimes used by hunters, travellers and others to relieve exhaustion and breathlessness in climbing mountains and to dull hunger. Derivatives of cocaine are used as locally applied analgesics via sprays or injections in dentistry and for procedures in the ear, nose and throat. Because of its serious side-effects and the risk of addiction, cocaine is a strictly controlled Class A drug which can be prescribed only by a medical practitioner with a Home O?ce licence to do so.... cocaine
Doctors make the diagnosis of depression when they believe a patient to be ill with the latter condition, which may affect physical health and in some instances be life-threatening. This form of depression is common, with up to 15 per cent of the population suffering from it at any one time, while about 20 per cent of adults have ‘medical’ depression at some time during their lives – such that it is one of the most commonly presenting disorders in general practice. Women seem more liable to develop depression than men, with one in six of the former and one in nine of the latter seeking medical help.
Manic depression is a serious form of the disorder that recurs throughout life and is manifested by bouts of abnormal elation – the manic stage. Both the manic and depressive phases are commonly accompanied by psychotic symptoms such as delusions, hallucinations and a loss of sense of reality. This combination is sometimes termed a manic-depressive psychosis or bipolar affective disorder because of the illness’s division into two parts. Another psychiatric description is the catch-all term ‘affective disorder’.
Symptoms These vary with the illness’s severity. Anxiety and variable moods are the main symptoms in mild depression. The sufferer may cry without any reason or be unresponsive to relatives and friends. In its more severe form, depression presents with a loss of appetite, sleeping problems, lack of interest in and enjoyment of social activities, tiredness for no obvious reason, an indi?erence to sexual activity and a lack of concentration. The individual’s physical and mental activities slow down and he or she may contemplate suicide. Symptoms may vary during the 24 hours, being less troublesome during the latter part of the day and worse at night. Some people get depressed during the winter months, probably a consequence of the long hours of darkness: this disorder – SEASONAL AFFECTIVE DISORDER SYNDROME, or SADS – is thought to be more common in populations living in areas with long winters and limited daylight. Untreated, a person with depressive symptoms may steadily worsen, even withdrawing to bed for much of the time, and allowing his or her personal appearance, hygiene and environment to deteriorate. Children and adolescents may also suffer from depression and the disorder is not always recognised.
Causes A real depressive illness rarely has a single obvious cause, although sometimes the death of a close relative, loss of employment or a broken personal relationship may trigger a bout. Depression probably has a genetic background; for instance, manic depression seems to run in some families. Viral infections sometimes cause depression, and hormonal disorders – for example, HYPOTHYROIDISM or postnatal hormonal disturbances (postnatal depression) – will cause it. Di?cult family or social relations can contribute to the development of the disorder. Depression is believed to occur because of chemical changes in the transmission of signals in the nervous system, with a reduction in the neurochemicals that facilitate the passage of messages throughout the system.
Treatment This depends on the type and severity of the depression. These are three main forms. PSYCHOTHERAPY either on a one-to-one basis or as part of a group: this is valuable for those whose depression is the result of lifestyle or personality problems. Various types of psychotherapy are available. DRUG TREATMENT is the most common method and is particularly helpful for those with physical symptoms. ANTIDEPRESSANT DRUGS are divided into three main groups: TRICYCLIC ANTIDEPRESSANT DRUGS (amitriptyline, imipramine and dothiepin are examples); MONOAMINE OXIDASE INHIBITORS (MAOIS) (phenelzine, isocarboxazid and tranylcypromine are examples); and SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS) (?uoxetine – well known as Prozac®, ?uvoxamine and paroxetine are examples). For manic depression, lithium carbonate is the main preventive drug and it is also used for persistent depression that fails to respond to other treatments. Long-term lithium treatment reduces the likelihood of relapse in about 80 per cent of manic depressives, but the margin between control and toxic side-effects is narrow, so the drug must be carefully supervised. Indeed, all drug treatment for depression needs regular monitoring as the substances have powerful chemical properties with consequential side-effects in some people. Furthermore, the nature of the illness means that some sufferers forget or do not want to take the medication. ELECTROCONVULSIVE THERAPY (ECT) If drug treatments fail, severely depressed patients may be considered for ECT. This treatment has been used for many years but is now only rarely recommended. Given under general anaesthetic, in appropriate circumstances, ECT is safe and e?ective and may even be life-saving, though temporary impairment of memory may occur. Because the treatment was often misused in the past, it still carries a reputation that worries patients and relatives; hence careful assessment and counselling are essential before use is recommended.
Some patients with depression – particularly those with manic depression or who are a danger to themselves or to the public, or who are suicidal – may need admission to hospital, or in severe cases to a secure unit, in order to initiate treatment. But as far as possible patients are treated in the community (see MENTAL ILLNESS).... depression
Friction fremitus is a grating feeling communicated to the hand by the movements of lungs or heart when the membrane covering them is roughened, as in PLEURISY or PERICARDITIS. Vocal fremitus means the sensation felt by the hand when a person speaks; it is increased when the lung is more solid than usual. The ‘thrills’ felt over a heart affected by valvular disease are also varieties of fremitus.... fremitus
Epidemiology There has been a dramatic fall in the number of sufferers from 1986, when more than 80,000 cases were reported. This is due to the introduction in 1988 of the measles, mumps and rubella vaccine (MMR VACCINE – see also IMMUNISATION); 1990, when the proportion of children immunised reached 90 per cent, was the ?rst year in which no deaths from measles were reported. Even so, fears of side-effects of the vaccine against measles – including scienti?cally unproven and discredited claims of a link with AUTISM – mean that some children in the UK are not being immunised, and since 2002 local outbreaks of measles have been reported in a few areas of the UK. Side-effects are, however, rare and the government is campaigning to raise the rate of immunisation, with GPs being set targets for their practices.
There are few diseases as infectious as measles, and its rapid spread in epidemics is no doubt due to the fact that this viral infection is most potent in the earlier stages. Hence the dif?culty of timely isolation, and the readiness with which the disease is spread, which is mostly by infected droplets. In developing countries measles results in the death of more than a million children annually.
Symptoms The incubation period, during which the child is well, lasts 7–21 days. Initial symptoms are CATARRH, conjunctivitis (see EYE, DISORDERS OF), fever and a feeling of wretchedness. Then Koplik spots – a classic sign of measles – appear on the roof of the mouth and lining of the cheeks. The macular body rash, typical of measles, appears 3–5 days later. Common complications include otitis media (see under EAR, DISEASES OF) and PNEUMONIA. Measles ENCEPHALITIS can cause permanent brain damage. A rare event is a gradual dementing disease (see DEMENTIA) called subacute sclerosing panenecephalitis (SSPE).
Treatment Isolation of the patient and treatment of any secondary bacterial infection, such as pneumonia or otitis, with antibiotics. Children usually run a high temperature which can be relieved with cool sponging and antipyretic drugs. Calamine lotion may alleviate any itching.... measles
Depersonalization is often accompanied by derealization.
It is rarely serious and usually comes on suddenly and may last for moments or for hours.
Depersonalization most often occurs in people with anxiety disorders.
Other causes include drugs and temporal lobe epilepsy.... depersonalization
Paralysis due to brain disease The most common form is unilateral palsy, or HEMIPLEGIA, generally arising from cerebral HAEMORRHAGE, THROMBOSIS or EMBOLISM affecting the opposite side of the BRAIN. If all four limbs and trunk are affected, the paralysis is called quadraplegia; if both legs and part of the trunk are affected, it is called paraplegia. Paralysis may also be divided into ?accid (?oppy limbs) or spastic (rigid).
In hemiplegia the cause may be an abscess, haemorrhage, thrombosis or TUMOUR in the brain. CEREBRAL PALSY or ENCEPHALITIS are other possible causes. Sometimes damage occurs in the parts of the nervous system responsible for the ?ne control of muscle movements: the cerebellum and basal ganglion are such areas, and lack of DOPAMINE in the latter causes PARKINSONISM.
Damage or injury Damage to or pressure on the SPINAL CORD may paralyse muscles supplied by nerves below the site of damage. A fractured spine or pressure from a tumour may have this e?ect. Disorders affecting the cord which can cause paralysis include osteoarthritis of the cervical vertebrae (see BONE, DISORDERS OF), MULTIPLE SCLEROSIS (MS), MYELITIS, POLIOMYELITIS and MENINGITIS. Vitamin B12 de?ciency (see APPENDIX 5: VITAMINS) may also cause deterioration in the spinal cord (see also SPINE AND SPINAL CORD, DISEASES AND INJURIES OF).
Neuropathies are a group of disorders, some inherited, that damage the peripheral nerves, thus affecting their ability to conduct electrical impulses. This, in turn, causes muscle weakness or paralysis. Among the causes of neuropathies are cancers, DIABETES MELLITUS, liver disease, and the toxic consequences of some drugs or metals – lead being one example.
Disorders of the muscles themselves – for example, muscular dystrophy (see MUSCLES, DISORDERS OF – Myopathy) – can disturb their normal working and so cause partial or complete paralysis of the part(s) affected.
Treatment The aim of treatment should be to remedy the underlying cause – for example, surgical removal of a displaced intervertebral
disc or treating diabetes mellitus. Sometimes the cause cannot be recti?ed but, whether treatable or not, physiotherapy is essential to prevent joints from seizing up and to try to maintain some tone in muscles that may be only partly affected. With temporary paralysis, such as can occur after a STROKE, physiotherapy can retrain the sufferers to use their muscles and joints to ensure mobility during and after recovery. Patients with permanent hemiplegia, paraplegia or quadraplegia need highly skilled nursing care, rehabilitative support and resources, and expert help to allow them, if possible, to live at home.... paralysis
It usually occurs together with depersonalization and may be caused by fatigue, hallucinogenic drugs, or disordered brain function.... derealization
Information is collected by millions of sense receptors found throughout body tissues and in special sense organs, such as the eye.
Certain sensory information, mainly that from the special sense organs and skin receptors, enters the sensory cortex of the brain, where sensations are consciously perceived.
Other types of sensory information, for example about body posture, are processed elsewhere and do not produce conscious sensation.... sensation
Insomnia, malaise, agitation, and tearfulness are also common. Gradually, but usually within 2 years, the bereaved person adjusts to the loss.
Family and friends can often provide support. Outside help may be required and may be given by a social worker, health visitor, member of the clergy, or self-help group. For some people, when depression, apathy, and lethargy impede any chance of recovery, specialized counselling or psychotherapy is necessary. (See also stillbirth.)... bereavement
Habitat: Kashmir at altitudes of 1500-2100 m.
English: Wormwood, Maderwood.Unani: Afsanteen, Vilaayati Afsan- teen.Siddha/Tamil: Machipatri.Folk: Mastiyaaraa (Punjab), Titween (Kashmir).Action: Choleretic (bile and gastric juice stimulant), anthelmintic, stomachic, carminative, antispasmodic, anti-inflammatory, emme- nagogue, mild antidepressant; used in chronic fevers.
Key application: In loss of appetite, dyspepsia, biliary dyskinesia. (German Commission E.) In anorexia, for example, after illness, and dyspeptic complaints. (ESCOP.) It is contraindicated in gastric and duodenal ulcers. Excessive doses may cause vomiting, severe diarrhoea, retention of urine or dazed feeling and central nervous system disturbances. (ESCOP.)The herb contains a volatile oil of variable composition, with alpha- and beta-thujone as the major component, up to about 35%; sesquiterpene lactones (artabasin, absinthin, anab- sinthin); azulenes; flavonoids; phenolic acids; lignans.Thujone is a toxic constituent which shows hallucinogenic and addictive activity found in Indian hemp. It stimulates the brain; safe in small doses, toxic in excess. The azulenes are anti- inflammatory. The sesquiterpene lac- tones exhibit an antitumour effect and are insecticidal and anthelmintic.Essential oil from leaves—antibacterial, antifungal. The oil is toxic at 10 ml.... artemisia absinthiumNon-speci?c back pain is probably the result of mechanical disorders in the muscles, ligaments and joints of the back: torn muscles, sprained LIGAMENTS, and FIBROSITIS. These disorders are not always easy to diagnose, but mild muscular and ligamentous injuries are usually relieved with symptomatic treatment – warmth, gentle massage, analgesics, etc. Sometimes back pain is caused or worsened by muscle spasms, which may call for the use of antispasmodic drugs. STRESS and DEPRESSION (see MENTAL ILLNESS) can sometimes result in chronic backache and should be considered if no clear physical diagnosis can be made.
If back pain is severe and/or recurrent, possibly radiating around to the abdomen or down the back of a leg (sciatica – see below), or is accompanied by weakness or loss of feeling in the leg(s), it may be caused by a prolapsed intervertebral disc (slipped disc) pressing on a nerve. The patient needs prompt investigation, including MRI. Resting on a ?rm bed or board can relieve the symptoms, but the patient may need a surgical operation to remove the disc and relieve pressure on the affected nerve.
The nucleus pulposus – the soft centre of the intervertebral disc – is at risk of prolapse under the age of 40 through an acquired defect in the ?brous cartilage ring surrounding it. Over 40 this nucleus is ?rmer and ‘slipped disc’ is less likely to occur. Once prolapse has taken place, however, that segment of the back is never quite the same again, as OSTEOARTHRITIS develops in the adjacent facet joints. Sti?ness and pain may develop, sometimes many years later. There may be accompanying pain in the legs: SCIATICA is pain in the line of the sciatic nerve, while its rarer analogue at the front of the leg is cruralgia, following the femoral nerve. Leg pain of this sort may not be true nerve pain but referred from arthritis in the spinal facet joints. Only about 5 per cent of patients with back pain have true sciatica, and spinal surgery is most successful (about 85 per cent) in this group.
When the complaint is of pain alone, surgery is much less successful. Manipulation by physiotherapists, doctors, osteopaths or chiropractors can relieve symptoms; it is important ?rst to make sure that there is not a serious disorder such as a fracture or cancer.
Other local causes of back pain are osteoarthritis of the vertebral joints, ankylosing spondylitis (an in?ammatory condition which can severely deform the spine), cancer (usually secondary cancer deposits spreading from a primary tumour elsewhere), osteomyelitis, osteoporosis, and PAGET’S DISEASE OF BONE. Fractures of the spine – compressed fracture of a vertebra or a break in one of its spinous processes – are painful and potentially dangerous. (See BONE, DISORDERS OF.)
Backache can also be caused by disease elsewhere, such as infection of the kidney or gall-bladder (see LIVER), in?ammation of the PANCREAS, disorders in the UTERUS and PELVIS or osteoarthritis of the HIP. Treatment is e?ected by tackling the underlying cause. Among the many known causes of back pain are:
Mechanical and traumatic causes
Congenital anomalies. Fractures of the spine. Muscular tenderness and ligament strain. Osteoarthritis. Prolapsed intervertebral disc. Spondylosis.
In?ammatory causes
Ankylosing spondylitis. Brucellosis. Osteomyelitis. Paravertebral abscess. Psoriatic arthropathy. Reiter’s syndrome. Spondyloarthropathy. Tuberculosis.
Neoplastic causes
Metastatic disease. Primary benign tumours. Primary malignant tumours.
Metabolic bone disease
Osteomalacia. Osteoporosis. Paget’s disease.
Referred pain
Carcinoma of the pancreas. Ovarian in?ammation and tumours. Pelvic disease. Posterior duodenal ulcer. Prolapse of the womb.
Psychogenic causes
Anxiety. Depression.
People with backache can obtain advice from www.backcare.org.uk... backache
The blood pressure is biphasic, being greatest (systolic pressure) at each heartbeat and falling (diastolic pressure) between beats. The average systolic pressure is around 100 mm Hg in children and 120 mm Hg in young adults, generally rising with age as the arteries get thicker and harder. Diastolic pressure in a healthy young adult is about 80 mm Hg, and a rise in diastolic pressure is often a surer indicator of HYPERTENSION than is a rise in systolic pressure; the latter is more sensitive to changes of body position and emotional mood. Hypertension has various causes, the most important of which are kidney disease (see KIDNEYS, DISEASES OF), genetic predisposition and, to some extent, mental stress. Systolic pressure may well be over 200 mm Hg. Abnormal hypertension is often accompanied by arterial disease (see ARTERIES, DISEASES OF) with an increased risk of STROKE, heart attack and heart failure (see HEART, DISEASES OF). Various ANTIHYPERTENSIVE DRUGS are available; these should be carefully evaluated, considering the patient’s full clinical history, before use.
HYPOTENSION may result from super?cial vasodilation (for example, after a bath, in fevers or as a side-e?ect of medication, particularly that prescribed for high blood pressure) and occur in weakening diseases or heart failure. The blood pressure generally falls on standing, leading to temporary postural hypotension – a particular danger in elderly people.... blood pressure
Nutritional Profile Energy value (calories per serving): Low Protein: Trace Fat: Trace Saturated fat: None Cholesterol: None Carbohydrates: Trace Fiber: Trace Sodium: Low Major vitamin contribution: None Major mineral contribution: None
About the Nutrients in This Food Coffee beans are roasted seeds from the fruit of the evergreen coffee tree. Like other nuts and seeds, they are high in proteins (11 percent), sucrose and other sugars (8 percent), oils (10 to 15 percent), assorted organic acids (6 percent), B vitamins, iron, and the central nervous system stimulant caffeine (1 to 2 percent). With the exceptions of caffeine, none of these nutrients is found in coffee. Like spinach, rhubarb, and tea, coffee contains oxalic acid (which binds calcium ions into insoluble compounds your body cannot absorb), but this is of no nutritional consequence as long as your diet contains adequate amounts of calcium-rich foods. Coffee’s best known constituent is the methylxanthine central ner- vous system stimulant caffeine. How much caffeine you get in a cup of coffee depends on how the coffee was processed and brewed. Caffeine is Caffeine Content/Coffee Servings Brewed coffee 60 mg/five-ounce cup Brewed/decaffeinated 5 mg/five-ounce cup Espresso 64 mg/one-ounce serving Instant 47 mg/rounded teaspoon
The Most Nutritious Way to Serve This Food In moderation, with high-calcium foods. Like spinach, rhubarb, and tea, coffee has oxalic acid, which binds calcium into insoluble compounds. This will have no important effect as long as you keep your consumption moderate (two to four cups of coffee a day) and your calcium consumption high.
Diets That May Restrict or Exclude This Food Bland diet Gout diet Diet for people with heart disease (regular coffee)
Buying This Food Look for: Ground coffee and coffee beans in tightly sealed, air- and moisture-proof containers. Avoid: Bulk coffees or coffee beans stored in open bins. When coffee is exposed to air, the volatile molecules that give it its distinctive flavor and richness escape, leaving the coffee flavorless and/or bitter.
Storing This Food Store unopened vacuum-packed cans of ground coffee or coffee beans in a cool, dark cabinet—where they will stay fresh for six months to a year. They will lose some flavor in storage, though, because it is impossible to can coffee without trapping some flavor- destroying air inside the can. Once the can or paper sack has been opened, the coffee or beans should be sealed as tight as possible and stored in the refrigerator. Tightly wrapped, refrigerated ground coffee will hold its freshness and flavor for about a week, whole beans for about three weeks. For longer storage, freeze the coffee or beans in an air- and moistureproof container. ( You can brew coffee directly from frozen ground coffee and you can grind frozen beans without thawing them.)
Preparing This Food If you make your coffee with tap water, let the water run for a while to add oxygen. Soft water makes “cleaner”-tasting coffee than mineral-rich hard water. Coffee made with chlorinated water will taste better if you refrigerate the water overnight in a glass (not plastic) bottle so that the chlorine evaporates. Never make coffee with hot tap water or water that has been boiled. Both lack oxygen, which means that your coffee will taste flat. Always brew coffee in a scrupulously clean pot. Each time you make coffee, oils are left on the inside of the pot. If you don’t scrub them off, they will turn rancid and the next pot of coffee you brew will taste bitter. To clean a coffee pot, wash it with detergent, rinse it with water in which you have dissolved a few teaspoons of baking soda, then rinse one more time with boiling water.
What Happens When You Cook This Food In making coffee, your aim is to extract flavorful solids (including coffee oils and sucrose and other sugars) from the ground beans without pulling bitter, astringent tannins along with them. How long you brew the coffee determines how much solid material you extract and how the coffee tastes. The longer the brewing time, the greater the amount of solids extracted. If you brew the coffee long enough to extract more than 30 percent of its solids, you will get bitter compounds along with the flavorful ones. (These will also develop by let- ting coffee sit for a long time after brewing it.) Ordinarily, drip coffee tastes less bitter than percolator coffee because the water in a drip coffeemaker goes through the coffee only once, while the water in the percolator pot is circulated through the coffee several times. To make strong but not bitter coffee, increase the amount of coffee—not the brewing time.
How Other Kinds of Processing Affect This Food Drying. Soluble coffees (freeze-dried, instant) are made by dehydrating concentrated brewed coffee. These coffees are often lower in caffeine than regular ground coffees because caffeine, which dissolves in water, is lost when the coffee is dehydrated. Decaffeinating. Decaffeinated coffee is made with beans from which the caffeine has been extracted, either with an organic solvent (methylene chloride) or with water. How the coffee is decaffeinated has no effect on its taste, but many people prefer water-processed decaf- feinated coffee because it is not a chemically treated food. (Methylene chloride is an animal carcinogen, but the amounts that remain in coffees decaffeinated with methylene chloride are so small that the FDA does not consider them hazardous. The carcinogenic organic sol- vent trichloroethylene [TCE], a chemical that causes liver cancer in laboratory animals, is no longer used to decaffeinate coffee.)
Medical Uses and/or Benefits As a stimulant and mood elevator. Caffeine is a stimulant. It increases alertness and concentra- tion, intensifies muscle responses, quickens heartbeat, and elevates mood. Its effects derive from the fact that its molecular structure is similar to that of adenosine, a natural chemical by-product of normal cell activity. Adenosine is a regular chemical that keeps nerve cell activ- ity within safe limits. When caffeine molecules hook up to sites in the brain when adenosine molecules normally dock, nerve cells continue to fire indiscriminately, producing the jangly feeling sometimes associated with drinking coffee, tea, and other caffeine products. As a rule, it takes five to six hours to metabolize and excrete caffeine from the body. During that time, its effects may vary widely from person to person. Some find its stimu- lation pleasant, even relaxing; others experience restlessness, nervousness, hyperactivity, insomnia, flushing, and upset stomach after as little as one cup a day. It is possible to develop a tolerance for caffeine, so people who drink coffee every day are likely to find it less imme- diately stimulating than those who drink it only once in a while. Changes in blood vessels. Caffeine’s effects on blood vessels depend on site: It dilates coronary and gastrointestinal vessels but constricts blood vessels in your head and may relieve headache, such as migraine, which symptoms include swollen cranial blood vessels. It may also increase pain-free exercise time in patients with angina. However, because it speeds up heartbeat, doc- tors often advise patients with heart disease to avoid caffeinated beverages entirely. As a diuretic. Caffeine is a mild diuretic sometimes included in over-the-counter remedies for premenstrual tension or menstrual discomfort.
Adverse Effects Associated with This Food Stimulation of acid secretion in the stomach. Both regular and decaffeinated coffees increase the secretion of stomach acid, which suggests that the culprit is the oil in coffee, not its caffeine. Elevated blood levels of cholesterol and homocysteine. In the mid-1990s, several studies in the Netherlands and Norway suggested that drinking even moderate amounts of coffee (five cups a day or less) might raise blood levels of cholesterol and homocysteine (by-product of protein metabolism considered an independent risk factor for heart disease), thus increas- ing the risk of cardiovascular disease. Follow-up studies, however, showed the risk limited to drinking unfiltered coffees such as coffee made in a coffee press, or boiled coffees such as Greek, Turkish, or espresso coffee. The unfiltered coffees contain problematic amounts of cafestol and kahweol, two members of a chemical family called diterpenes, which are believed to affect cholesterol and homocysteine levels. Diterpenes are removed by filtering coffee, as in a drip-brew pot. Possible increased risk of miscarriage. Two studies released in 2008 arrived at different conclusions regarding a link between coffee consumption and an increased risk of miscar- riage. The first, at Kaiser Permanente (California), found a higher risk of miscarriage among women consuming even two eight-ounce cups of coffee a day. The second, at Mt. Sinai School of Medicine (New York), found no such link. However, although the authors of the Kaiser Permanente study described it as a “prospective study” (a study in which the research- ers report results that occur after the study begins), in fact nearly two-thirds of the women who suffered a miscarriage miscarried before the study began, thus confusing the results. Increased risk of heartburn /acid reflux. The natural oils in both regular and decaffeinated coffees loosen the lower esophageal sphincter (LES), a muscular valve between the esopha- gus and the stomach. When food is swallowed, the valve opens to let food into the stomach, then closes tightly to keep acidic stomach contents from refluxing (flowing backwards) into the esophagus. If the LES does not close efficiently, the stomach contents reflux and cause heartburn, a burning sensation. Repeated reflux is a risk factor for esophageal cancer. Masking of sleep disorders. Sleep deprivation is a serious problem associated not only with automobile accidents but also with health conditions such as depression and high blood pres- sure. People who rely on the caffeine in a morning cup of coffee to compensate for lack of sleep may put themselves at risk for these disorders. Withdrawal symptoms. Caffeine is a drug for which you develop a tolerance; the more often you use it, the more likely you are to require a larger dose to produce the same effects and the more likely you are to experience withdrawal symptoms (headache, irritation) if you stop using it. The symptoms of coffee-withdrawal can be relieved immediately by drinking a cup of coffee.
Food/Drug Interactions Drugs that make it harder to metabolize caffeine. Some medical drugs slow the body’s metabolism of caffeine, thus increasing its stimulating effect. The list of such drugs includes cimetidine (Tagamet), disulfiram (Antabuse), estrogens, fluoroquinolone antibiotics (e.g., ciprofloxacin, enoxacin, norfloxacin), fluconazole (Diflucan), fluvoxamine (Luvox), mexi- letine (Mexitil), riluzole (R ilutek), terbinafine (Lamisil), and verapamil (Calan). If you are taking one of these medicines, check with your doctor regarding your consumption of caf- feinated beverages. Drugs whose adverse effects increase due to consumption of large amounts of caffeine. This list includes such drugs as metaproterenol (Alupent), clozapine (Clozaril), ephedrine, epinephrine, monoamine oxidase inhibitors, phenylpropanolamine, and theophylline. In addition, suddenly decreasing your caffeine intake may increase blood levels of lithium, a drug used to control mood swings. If you are taking one of these medicines, check with your doctor regarding your consumption of caffeinated beverages. Allopurinol. Coffee and other beverages containing methylxanthine stimulants (caffeine, theophylline, and theobromine) reduce the effectiveness of the antigout drug allopurinol, which is designed to inhibit xanthines. Analgesics. Caffeine strengthens over-the-counter painkillers (acetaminophen, aspirin, and other nonsteroidal anti-inflammatories [NSAIDS] such as ibuprofen and naproxen). But it also makes it more likely that NSAIDS will irritate your stomach lining. Antibiotics. Coffee increases stomach acidity, which reduces the rate at which ampicillin, erythromycin, griseofulvin, penicillin, and tetracyclines are absorbed when they are taken by mouth. (There is no effect when the drugs are administered by injection.) Antiulcer medication. Coffee increases stomach acidity and reduces the effectiveness of nor- mal doses of cimetidine and other antiulcer medication. False-positive test for pheochromocytoma. Pheochromocytoma, a tumor of the adrenal glands, secretes adrenalin, which is converted to VM A (vanillylmandelic acid) by the body and excreted in the urine. Until recently, the test for this tumor measured the levels of VM A in the patient’s urine and coffee, which contains VM A, was eliminated from patients’ diets lest it elevate the level of VM A in the urine, producing a false-positive test result. Today, more finely drawn tests make this unnecessary. Iron supplements. Caffeine binds with iron to form insoluble compounds your body cannot absorb. Ideally, iron supplements and coffee should be taken at least two hours apart. Birth control pills. Using oral contraceptives appears to double the time it takes to eliminate caffeine from the body. Instead of five to six hours, the stimulation of one cup of coffee may last as long as 12 hours. Monoamine oxidase (MAO) inhibitors. Monoamine oxidase inhibitors are drugs used to treat depression. They inactivate naturally occurring enzymes in your body that metabolize tyra- mine, a substance found in many fermented or aged foods. Tyramine constricts blood vessels and increases blood pressure. Caffeine is a substance similar to tyramine. If you consume excessive amounts of a caffeinated beverage such as coffee while you are taking an M AO inhibitor, the result may be a hypertensive crisis. Nonprescription drugs containing caffeine. The caffeine in coffee may add to the stimulant effects of the caffeine in over-the-counter cold remedies, diuretics, pain relievers, stimulants, and weight-control products containing caffeine. Some cold pills contain 30 mg caffeine, some pain relievers 130 mg, and some weight-control products as much as 280 mg caffeine. There are 110 –150 mg caffeine in a five-ounce cup of drip-brewed coffee. Sedatives. The caffeine in coffee may counteract the drowsiness caused by sedative drugs; this may be a boon to people who get sleepy when they take antihistamines. Coffee will not, however, “sober up” people who are experiencing the inebriating effects of alcoholic beverages. Theophylline. Caffeine relaxes the smooth muscle of the bronchi and may intensif y the effects (and/or increase the risk of side effects) of this antiasthmatic drug.... coffee
The dependence that most concerns modern society is one in which individuals become dependent on or addicted to certain substances such as alcohol, drugs, tobacco (nicotine), caffeine and solvents. This is often called substance abuse. Some people become addicted to certain foods or activities: examples of the latter include gambling, computer games and use of the Internet.
The 28th report of the World Health Organisation Expert Committee on Drug Dependence in 1993 de?ned drug dependence as: ‘A cluster of physiological, behavioural and cognitive phenomena of variable intensity, in which the use of a psychoactive drug (or drugs) takes on a high priority. The necessary descriptive characteristics are preoccupation with a desire to obtain and take the drug and persistent drug-seeking behaviour. Psychological dependence occurs when the substance abuser craves the drug’s desirable effects. Physical dependence occurs when the user has to continue taking the drug to avoid distressing withdrawal or abstinence symptoms. Thus, determinants and the problematic consequences of drug dependence may be biological, psychological or social and usually interact.’
Di?erent drugs cause di?erent rates of dependence: TOBACCO is the most common substance of addiction; HEROIN and COCAINE cause high rates of addiction; whereas ALCOHOL is much lower, and CANNABIS lower again. Smoking in the western world reached a peak after World War II with almost 80 per cent of the male population smoking. The reports on the link between smoking and cancer in the early 1960s resulted in a decline that has continued so that only around a quarter of the adult populations of the UK and USA smokes. Globally, tobacco consumption continues to grow, particularly in the developing world with multinational tobacco companies marketing their products aggressively.
Accurate ?gures for illegal drug-taking are hard to obtain, but probably approximately 4 per cent of the population is dependent on alcohol and 2 per cent on other drugs, both legal and illegal, at any one time in western countries.
How does dependence occur? More than 40 distinct theories or models of drug misuse have been put forward. One is that the individual consumes drugs to cope with personal problems or diffculties in relations with others. The other main model emphasises environmental in?uences such as drug availability, environmental pressures to consume drugs, and sociocultural in?uences such as peer pressure.
By contrast to these models of why people misuse drugs, models of compulsive drug use – where individuals have a compulsive addiction
– have been amenable to testing in the laboratory. Studies at cellular and nerve-receptor levels are attempting to identify mechanisms of tolerance and dependence for several substances. Classical behaviour theory is a key model for understanding drug dependence. This and current laboratory studies are being used to explain the reinforcing nature of dependent substances and are helping to provide an explanatory framework for dependence. Drug consumption is a learned form of behaviour. Numerous investigators have used conditioning theories to study why people misuse drugs. Laboratory studies are now locating the ‘reward pathways’ in the brain for opiates and stimulants where positive reinforcing mechanisms involve particular sectors of the brain. There is a consensus among experts in addiction that addictive behaviour is amenable to e?ective treatment, and that the extent to which an addict complies with treatment makes it possible to predict a positive outcome. But there is a long way to go before the mechanisms of drug addiction are properly understood or ways of treating it generally agreed.
Effects of drugs Cannabis, derived from the plant Cannabis sativa, is a widely used recreational drug. Its two main forms are marijuana, which comes from the dried leaves, and hashish which comes from the resin. Cannabis may be used in food and drink but is usually smoked in cigarettes to induce relaxation and a feeling of well-being. Heavy use can cause apathy and vagueness and may even cause psychosis. Whether or not cannabis leads people to using harder drugs is arguable, and a national debate is underway on whether its use should be legalised for medicinal use. Cannabis may alleviate the symptoms of some disorders – for example, MULTIPLE SCLEROSIS (MS) – and there are calls to allow the substance to be classi?ed as a prescribable drug.
About one in ten of Britain’s teenagers misuses volatile substances such as toluene at some time, but only about one in 40 does so regularly. These substances are given o? by certain glues, solvents, varnishes, and liquid fuels, all of which can be bought cheaply in shops, although their sale to children under 16 is illegal. They are often inhaled from plastic bags held over the nose and mouth. Central-nervous-system excitation, with euphoria and disinhibition, is followed by depression and lethargy. Unpleasant effects include facial rash, nausea and vomiting, tremor, dizziness, and clumsiness. Death from COMA and acute cardiac toxicity is a serious risk. Chronic heavy use can cause peripheral neuropathy and irreversible cerebellar damage. (See SOLVENT ABUSE (MISUSE).)
The hallucinogenic or psychedelic drugs include LYSERGIC ACID DIETHYLAMIDE (LSD) or acid, magic mushrooms, ecstasy (MDMA), and phencyclidine (PCP or ‘angel’ dust, mainly used in the USA). These drugs have no medicinal uses. Taken by mouth, they produce vivid ‘trips’, with heightened emotions and perceptions and sometimes with hallucinations. They are not physically addictive but can cause nightmarish bad trips during use and ?ashbacks (vivid reruns of trips) after use, and can probably trigger psychosis and even death, especially if drugs are mixed or taken with alcohol.
Stimulant drugs such as amphetamine and cocaine act like adrenaline and speed up the central nervous system, making the user feel con?dent, energetic, and powerful for several hours. They can also cause severe insomnia, anxiety, paranoia, psychosis, and even sudden death due to convulsions or tachycardia. Depression may occur on withdrawal of these drugs, and in some users this is su?ciently deterrent to cause psychological dependence. Amphetamine (‘speed’) is mainly synthesised illegally and may be eaten, sni?ed, or injected. Related drugs, such as dexamphetamine sulphate (Dexedrine), are prescribed pills that enter the black market. ECSTASY is another amphetamine derivative that has become a popular recreational drug; it may have fatal allergic effects. Cocaine and related drugs are used in medicine as local anaesthetics. Illegal supplies of cocaine (‘snow’ or ‘ice’) and its derivative, ‘crack’, come mainly from South America, where they are made from the plant Erythroxylon coca. Cocaine is usually sni?ed (‘snorted’) or rubbed into the gums; crack is burnt and inhaled.
Opiate drugs are derived from the opium poppy, Papaver somniferum. They are described as narcotic because they induce sleep. Their main medical use is as potent oral or injectable analgesics such as MORPHINE, DIAMORPHINE, PETHIDINE HYDROCHLORIDE, and CODEINE. The commonest illegal opiate is heroin, a powdered form of diamorphine that may be smoked, sni?ed, or injected to induce euphoria and drowsiness. Regular opiate misuse leads to tolerance (the need to take ever larger doses to achieve the same e?ect) and marked dependence. A less addictive oral opiate, METHADONE HYDROCHLORIDE, can be prescribed as a substitute that is easier to withdraw.
Some 75,000–150,000 Britons now misuse opiates and other drugs intravenously, and pose a huge public-health problem because injections with shared dirty needles can carry the blood-borne viruses that cause AIDS/HIV and HEPATITIS B. Many clinics now operate schemes to exchange old needles for clean ones, free of charge. Many addicts are often socially disruptive.
For help and advice see APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELF-HELP – National Dugs Helpline.
(See ALCOHOL and TOBACCO for detailed entries on those subjects.)... dependence
Habitat: Cultivated in Punjab, Uttar Pradesh and Tamil Nadu.
English: Black Mustard.Ayurvedic: Banarasi Raai, Raajika (var.).Unani: Khardal Siyah. Siddha/Tamil: Kadugu. Folk: Raai.Action: Seeds are used for treating coryza with thin excoriating discharge with lacrimation, sneezing and hacking cough, nostril blockage and dry and hot feeling of pharyngitis.
The seeds contain glucosinolate sin- igrin, which produces allyl isothio- cyanate when mixed with warm water. Allyl isothiocynate acts as a counterir- ritant when diluted (1:50).Brayera anthelmintica Kunth.Synonym: Hagenia abyssinica (Bruce) J. F. Gmelin.Family: Rosaceae.Habitat: Indigenous to north-east Africa. Imported into Mumbai.
English: Cusso, Brayera.Folk: Kusso.Action: Anthelmintic. Administered in the form of an infusion for the expulsion of tapeworm (ineffective against hookworm, roundworm, whipworm). Irritant to mucous membrane; produces nausea, vomiting and colic in large doses.... brassica nigra
Clinical psychologists are involved in health care in the following ways: (1) Assessment of thoughts, emotions and behaviour using standardised methods. (2) Treatment based on theoretical models and scienti?c evidence about behaviour change. Behaviour change is considered when it contributes to physical, psychological or social functioning. (3) Consultation with other health-care professionals about problems concerning emotions, thinking and behaviour. (4) Research on a wide variety of topics including the relationship between stress, psychological functioning and disease; the aetiology of problem behaviours; methods and theories of behaviour change. (5) Teaching other professionals about normal and dysfunctional behaviour, emotions and functioning.
Clinical psychologists may specialise in work in particular branches of patient care, including surgery, psychiatry, geriatrics, paediatrics, mental handicap, obstetrics and gynaecology, cardiology, neurology, general practice and physical rehabilitation. Whilst the focus of their work is frequently the patient, at times it may encompass the behaviour of the health-care professionals.... clinical psychology
Constipation is a chronic condition and must be distinguished from the potentially serious disorder, acute obstruction, which may have several causes (see under INTESTINE, DISEASES OF). There are several possible causes of constipation; those due to gastrointestinal disorders include:
Dietary: lack of ?bre; low ?uid consumption.
Structural: benign strictures (narrowing of gut); carcinoma of the COLON; DIVERTICULAR DISEASE.
Motility: poor bowel training when young; slow transit due to reduced muscle activity in the colon, occurring usually in women; IRRITABLE BOWEL SYNDROME (IBS); HIRSCHSPRUNG’S DISEASE.
•Defaecation: anorectal disease such as ?ssures, HAEMORRHOIDS and CROHN’S DISEASE; impaction of faeces. Non-gastrointestinal disorders causing constipation include:
Drugs: opiates (preparations of OPIUM), iron supplements, ANTACIDS containing aluminium, ANTICHOLINERGIC drugs.
Metabolic and endocrine: DIABETES MELLITUS, pregnancy (see PREGNANCY AND LABOUR), hypothyroidism (see under THYROID GLAND, DISEASES OF).
Neurological: cerebrovascular accidents (STROKE), MULTIPLE SCLEROSIS (MS), PARKINSONISM, lesions in the SPINAL CORD. Persistent constipation for which there is no
obvious cause merits thorough investigation, and people who experience a change in bowel habits – for example, alternating constipation and diarrhoea – should also seek expert advice.
Treatment Most people with constipation will respond to a dietary supplement of ?bre, coupled, when appropriate, with an increase in ?uid intake. If this fails to work, judicious use of LAXATIVES for, say, a month is justi?ed. Should constipation persist, investigations on the advice of a general practitioner will probably be needed; any further treatment will depend on the outcome of the investigations in which a specialist will usually be involved. Successful treatment of the cause should then return the patient’s bowel habits to normal.... constipation
Psychiatrists like to categorise mental illnesses because mental signs and symptoms do occur together in clusters or syndromes, each tending to respond to certain treatments. The idea that illnesses can be diagnosed simply by recognising their symptom patterns may not seem very scienti?c in these days of high technology. For most common mental illnesses, however, this is the only method of diagnosis; whatever is going wrong in the brain is usually too poorly understood and too subtle to show up in laboratory tests or computed tomography scans of the brain. And symptom-based definitions of mental illnesses are, generally, a lot more meaningful than the vague lay term ‘nervous breakdown’, which is used to cover an attack of anything from AGORAPHOBIA to total inability to function.
There is still a lot to learn about the workings of the brain, but psychiatry has developed plenty of practical knowledge about the probable causes of mental illness, ways of relieving symptoms, and ways of aiding recovery. Most experts now believe that mental illnesses generally arise from di?erent combinations of inherited risk and psychological STRESS, sometimes with additional environmental exposure – for example, viruses, drugs or ALCOHOL.
The range of common mental illnesses includes anxiety states, PHOBIA, DEPRESSION, alcohol and drug problems, the EATING DISORDERS anorexia and bulimia nervosa, MANIC DEPRESSION, SCHIZOPHRENIA, DEMENTIA, and a group of problems related to coping with life that psychiatrists call personality disorders.
Of these mental illnesses, dementia is the best understood. It is an irreversible and fatal form of mental deterioration (starting with forgetfulness and eventually leading to severe failure of all the brain’s functions), caused by rapid death of brain cells and consequent brain shrinkage. Schizophrenia is another serious mental illness which disrupts thought-processes, speech, emotions and perception (how the brain handles signals from the ?ve senses). Manic depression, in which prolonged ‘highs’ of extremely elevated mood and overexcitement alternate with abject misery, has similar effects on the mental processes. In both schizophrenia and manic depression the sufferer loses touch with reality, develops unshakeable but completely unrealistic ideas (delusions), and hallucinates (vividly experiences sensations that are not real, e.g. hears voices when there is nobody there). This triad of symptoms is called psychosis and it is what lay people, through fear and lack of understanding, sometimes call lunacy, madness or insanity.
The other mental illnesses mentioned above are sometimes called neuroses. But the term has become derogatory in ordinary lay language; indeed, many people assume that neuroses are mild disorders that only affect weak people who cannot ‘pull themselves together’, while psychoses are always severe. In reality, psychoses can be brief and reversible and neuroses can cause lifelong disability.
However de?ned and categorised, mental illness is a big public-health problem. In the UK, up to one in ?ve women and around one in seven men have had mental illness. About half a million people in Britain suffer from schizophrenia: it is three times commoner than cancer. And at any one time, up to a tenth of the adult population is ill with depression.
Treatment settings Most people with mental-health problems get the help they need from their own family doctor(s), without ever seeing a psychiatrist. General practictitioners in Britain treat nine out of ten recognised mental-health problems and see around 12 million adults with mental illness each year. Even for the one in ten of these patients referred to psychiatrists, general practitioners usually handle those problems that continue or recur.
Psychiatrists, psychiatric nurses, social workers, psychologists, counsellors and therapists often see patients at local doctors’ surgeries and will do home visits if necessary. Community mental-health centres – like general-practice health centres but catering solely for mental-health problems – o?er another short-cut to psychiatric help. The more traditional, and still more common, route to a psychiatrist for many people, however, is from the general practititioner to a hospital outpatient department.
Specialist psychiatric help In many ways, a visit to a psychiatrist is much like any trip to a hospital doctor – and, indeed, psychiatric clinics are often based in the outpatient departments of general hospitals. First appointments with psychiatrists can last an hour or more because the psychiatrist – and sometimes other members of the team such as nurses, doctors in training, and social workers – need to ask lots of questions and record the whole consultation in a set of con?dential case notes.
Psychiatric assessment usually includes an interview and an examination, and is sometimes backed up by a range of tests. The interview begins with the patient’s history – the personal story that explains how and, to some extent, why help is needed now. Mental-health problems almost invariably develop from a mixture of causes – emotional, social, physical and familial – and it helps psychiatrists to know what the people they see are normally like and what kind of lives they have led. These questions may seem unnecessarily intrusive, but they allow psychiatrists to understand patients’ problems and decide on the best way to help them.
The next stage in assessment is the mental-state examination. This is how psychiatrists examine minds, or at least their current state. Mental-state examination entails asking more questions and using careful observation to assess feelings, thoughts and mental symptoms, as well as the way the mind is working (for example, in terms of memory and concentration). During ?rst consultations psychiatrists usually make diagnoses and explain them. The boundary between a life problem that will clear up spontaneously and a mental illness that needs treatment is sometimes quite blurred; one consultation may be enough to put the problem in perspective and help to solve it.
Further assessment in the clinic may be needed, or some additional tests. Simple blood tests can be done in outpatient clinics but other investigations will mean referral to another department, usually on another day.
Further assessment and tests
PSYCHOLOGICAL TESTS Psychologists work in or alongside the psychiatric team, helping in both assessment and treatment. The range of psychological tests studies memory, intelligence, personality, perception and capability for abstract thinking. PHYSICAL TESTS Blood tests and brain scans may be useful to rule out a physical illness causing psychological symptoms. SOCIAL ASSESSMENT Many patients have social diffculties that can be teased out and helped by a psychiatric social worker. ‘Approved social workers’ have special training in the use of the Mental Health Act, the law that authorises compulsory admissions to psychiatric hospitals and compulsory psychiatric treatments. These social workers also know about all the mental-health services o?ered by local councils and voluntary organisations, and can refer clients to them. The role of some social workers has been widened greatly in recent years by the expansion of community care. OCCUPATIONAL THERAPY ASSESSMENT Mental-health problems causing practical disabilities – for instance, inability to work, cook or look after oneself – can be assessed and helped by occupational therapists.
Treatment The aims of psychiatric treatment are to help sufferers shake o?, or at least cope with, symptoms and to gain or regain an acceptable quality of life. A range of psychological and physical treatments is available.
COUNSELLING This is a widely used ‘talking cure’, particularly in general practice. Counsellors listen to their clients, help them to explore feelings, and help them to ?nd personal and practical solutions to their problems. Counsellors do not probe into clients’ pasts or analyse them. PSYCHOTHERAPY This is the best known ‘talking cure’. The term psychotherapy is a generalisation covering many di?erent concepts. They all started, however, with Sigmund Freud (see FREUDIAN THEORY), the father of modern psychotherapy. Freud was a doctor who discovered that, as well as the conscious thoughts that guide our feelings and actions, there are powerful psychological forces of which we are not usually aware. Applying his theories to his patients’ freely expressed thoughts, Freud was able to cure many illnesses, some of which had been presumed completely physical. This was the beginning of individual analytical psychotherapy, or PSYCHOANALYSIS. Although Freud’s principles underpin all subsequent theories about the psyche, many di?erent schools of thought have emerged and in?uenced psychotherapists (see ADLER; JUNGIAN ANALYSIS; PSYCHOTHERAPY). BEHAVIOUR THERAPY This springs from theories of human behaviour, many of which are based on studies of animals. The therapists, mostly psychologists, help people to look at problematic patterns of behaviour and thought, and to change them. Cognitive therapy is very e?ective, particularly in depression and eating disorders. PHYSICAL TREATMENTS The most widely used physical treatments in psychiatry are drugs. Tranquillising and anxiety-reducing BENZODIAZEPINES like diazepam, well known by its trade name of Valium, were prescribed widely in the 1960s and 70s because they seemed an e?ective and safe substitute for barbiturates. Benzodiazepines are, however, addictive and are now recommended only for short-term relief of anxiety that is severe, disabling, or unacceptably distressing. They are also used for short-term treatment of patients drying out from alcohol.
ANTIDEPRESSANT DRUGS like amitriptyline and ?uoxetine are given to lift depressed mood and to relieve the physical symptoms that sometimes occur in depression, such as insomnia and poor appetite. The side-effects of antidepressants are mostly relatively mild, when recommended doses are not exceeded – although one group, the monoamine oxidase inhibitors, can lead to sudden and dangerous high blood pressure if taken with certain foods.
Manic depression virtually always has to be treated with mood-stabilising drugs. Lithium carbonate is used in acute mania to lower mood and stop psychotic symptoms; it can also be used in severe depression. However lithium’s main use is to prevent relapse in manic depression. Long-term unwanted effects may include kidney and thyroid problems, and short-term problems in the nervous system and kidney may occur if the blood concentration of lithium is too high – therefore it must be monitored by regular blood tests. Carbamazepine, a treatment for EPILEPSY, has also been found to stabilise mood, and also necessitates blood tests.
Antipsychotic drugs, also called neuroleptics, and major tranquillisers are the only e?ective treatments for relieving serious mental illnesses with hallucinations and delusions. They are used mainly in schizophrenia and include the short-acting drugs chlorpromazine and clozapine as well as the long-lasting injections given once every few weeks like ?uphenazine decanoate. In the long term, however, some of the older antipsychotic drugs can cause a brain problem called TARDIVE DYSKINESIA that affects control of movement and is not always reversible. And the antipsychotic drugs’ short-term side-effects such as shaking and sti?ness sometimes have to be counteracted by other drugs called anticholinergic drugs such as procyclidine and benzhexol. Newer antipsychotic drugs such as clozapine do not cause tardive dyskinesia, but clozapine cannot be given as a long-lasting injection and its concentration in the body has to be monitored by regular blood tests to avoid toxicity. OTHER PHYSICAL TREATMENTS The other two physical treatments used in psychiatry are particularly controversial: electroconvulsive therapy (ECT) and psychosurgery. In ECT, which can be life-saving for patients who have severe life-threatening depression, a small electric current is passed through the brain to induce a ?t or seizure. Before the treatment the patient is anaesthetised and given a muscle-relaxing injection that reduces the magnitude of the ?t to a slight twitching or shaking. Scientists do not really understand how ECT works, but it does, for carefully selected patients. Psychosurgery – operating on the brain to alleviate psychiatric illness or di?cult personality traits – is extremely uncommon these days. Stereo-tactic surgery, in which small cuts are made in speci?c brain ?bres under X-ray guidance, has super-seded the more generalised lobotomies of old. The Mental Health Act 1983 ensures that psychosurgery is performed only when the patient has given fully informed consent and a second medical opinion has agreed that it is necessary. For all other psychiatric treatments (except another rare treatment, hormone implantation for reducing the sex drive of sex o?enders), either consent or a second opinion is needed – not both. TREATMENT IN HOSPITAL Psychiatric wards do not look like medical or surgical wards and sta? may not wear uniforms. Patients do not need to be in their beds during the day, so the beds are in separate dormitories. The main part of most wards is a living space with a day room, an activity and television room, quiet rooms, a dining room, and a kitchen. Ward life usually has a certain routine. The day often starts with a community meeting at which patients and nurses discuss issues that affect the whole ward. Patients may go to the occupational therapy department during the day, but there may also be some therapy groups on the ward, such as relaxation training. Patients’ symptoms and problems are assessed continuously during a stay in hospital. When patients seem well enough they are allowed home for trial periods; then discharge can be arranged. Patients are usually followed up in the outpatient clinic at least once.
TREATING PATIENTS WITH ACUTE PSYCHIATRIC ILLNESS Psychiatric emergencies – patients with acute psychiatric illness – may develop from psychological, physical, or practical crises. Any of these crises may need quick professional intervention. Relatives and friends often have to get this urgent help because the sufferer is not ?t enough to do it or, if psychotic, does not recognise the need. First, they should ring the person’s general practitioner. If the general practitioner is not available and help is needed very urgently, relatives or friends should phone the local social-services department and ask for the duty social worker (on 24-hour call). In a dire emergency, the police will know what to do.
Any disturbed adult who threatens his or her own or others’ health and safety and refuses psychiatric help may be moved and detained by law. The Mental Health Act of 1983 authorises emergency assessment and treatment of any person with apparent psychiatric problems that ful?l these criteria.
Although admission to hospital may be the best solution, there are other ways that psychiatric services can respond to emergencies. In some districts there are ‘crisis intervention’ teams of psychiatrists, nurses, and social workers who can visit patients urgently at home (at a GP’s request) and, sometimes, avert unnecessary admission. And research has shown that home treatment for a range of acute psychiatric problems can be e?ective.
LONG-TERM TREATMENT AND COMMUNITY CARE Long-term treatment is often provided by GPs with support and guidance from psychiatric teams. That is ?ne for people whose problems allow them to look after themselves, and for those with plenty of support from family and friends. But some people need much more intensive long-term treatment and many need help with running their daily lives.
Since the 1950s, successive governments have closed the old psychiatric hospitals and have tried to provide as much care as possible outside hospital – in ‘the community’. Community care is e?ective as long as everyone who needs inpatient care, or residential care, can have it. But demand exceeds supply. Research has shown that some homeless people have long-term mental illnesses and have somehow lost touch with psychiatric services. Many more have developed more general long-term health problems, particularly related to alcohol, without ever getting help.
The NHS and Community Care Act 1990, in force since 1993, established a new breed of professionals called care managers to assess people whose long-term illnesses and disabilities make them unable to cope completely independently with life. Care managers are given budgets by local councils to assess people’s needs and to arrange for them tailor-made packages of care, including services like home helps and day centres. But co-ordination between health and social services has sometimes failed – and resources are limited – and the government decided in 1997 to tighten up arrangements and pool community-care budgets.
Since 1992 psychiatrists have had to ensure that people with severe mental illnesses have full programmes of care set up before discharge from hospital, to be overseen by named key workers. And since 1996 psychiatrists have used a new power called Supervised Discharge to ensure that the most vulnerable patients cannot lose touch with mental-health services. There is not, however, any law that allows compulsory treatment in the community.
There is ample evidence that community care can work and that it need not cost more than hospital care. Critics argue, however, that even one tragedy resulting from inadequate care, perhaps a suicide or even a homicide, should reverse the march to community care. And, according to the National Schizophrenia Fellowship, many of the 10–15 homicides a year carried out by people with severe mental illnesses result from inadequate community care.
Further information can be obtained from the Mental Health Act Commission, and from MIND, the National Association for Mental Health. MIND also acts as a campaigning and advice organisation on all aspects of mental health.... mental illness
Cystitis is a common problem; more than half the women in Britain suffer from it at some time in their lives. The cause of the disease is a bacterial infection of the bladder, the germs having entered the urethra and ascended into the bladder. The most common organism responsible is called Escherichia coli. This organism normally lives in the bowel where it causes no harm. It is therefore likely to be present on the skin around the anus so that there is always a potential for infection. The disease is much more common in women because the urethra, vagina and anus are very close together and the urethra is much shorter in the female than it is in the male. It also explains why women commonly suffer cystitis after sexual intercourse and honeymoon cystitis is a very common presentation of bladder in?ammation. In most cases the in?ammation is more of a nuisance than a danger but the infection can spread up to the kidneys and cause PYELITIS which is a much more serious disorder.
In cases of cystitis the urine should be cultured to grow the responsible organism. The relevant antibiotic can then be prescribed. Fluids should be taken freely not only for an acute attack of cystitis but also to prevent further attacks, because if the urine is dilute the organism is less likely to grow. Bicarbonate of soda is also helpful as this reduces the acidity of the urine and helps to relieve the burning pain, and inhibits the growth of the bacteria. Careful hygiene, in order to keep the PERINEUM clean, is also important. (See URINARY BLADDER, DISEASES OF.)... cystitis
Pregnancy lasts about 280 days and is calculated from the ?rst day of the last menstrual period – see MENSTRUATION. Pregnancy-testing kits rely on the presence of the hormone beta HUMAN CHORIONIC GONADOTROPHIN (b HCG) which is excreted in the woman’s urine as early as 30 days from the last menstrual period. The estimated date of delivery can be accurately estimated from the size of the developing fetus measured by ULTRASOUND (see also below) between seven and 24 weeks. ‘Term’ refers to the time that the baby is due; this can range from 38 weeks to 41 completed weeks.
Physical changes occur in early pregnancy – periods stop and the abdomen enlarges. The breasts swell, with the veins becoming prominent and the nipples darkening. About two in three women will have nausea with a few experiencing such severe vomiting as to require hospital admission for rehydration.
Antenatal care The aim of antenatal care is to ensure a safe outcome for both mother and child; it is provided by midwives (see MIDWIFE) and doctors. Formal antenatal care began in Edinburgh in the 1930s with the recognition that all aspects of pregnancy – normal and abnormal – warranted surveillance. Cooperation between general practitioners, midwives and obstetricians is now established, with pregnancies that are likely to progress normally being cared for in the community and only those needing special intervention being cared for in a hospital setting.
The initial visit (or booking) in the ?rst half of pregnancy will record the history of past events and the results of tests, with the aim of categorising the patients into normal or not. Screening tests including blood checks and ultrasound scans are a routine part of antenatal care. The ?rst ultrasound scan is done at about 11 weeks to date the pregnancy, with a further one done at 20 weeks – the anomaly scan – to assess the baby’s structure. Some obstetric units will check the growth of the baby with one further scan later in the pregnancy or, in the case of twin pregnancies (see below), many scans throughout. The routine blood tests include checks for ANAEMIA, DIABETES MELLITUS, sickle-cell disease and THALASSAEMIA, as well as for the blood group. Evidence of past infections is also looked for; tests for RUBELLA (German measles) and SYPHILIS are routine, whereas tests for human immunode?ciency virus (see AIDS/ HIV below) and HEPATITIS are being o?ered as optional, although there is compelling evidence that knowledge of the mother’s infection status is bene?cial to the baby.
Traditional antenatal care consists of regular appointments, initially every four weeks until 34 weeks, then fortnightly or weekly. At each visit the mother’s weight, urine and blood pressure are checked, and assessment of fetal growth and position is done by palpating the uterus. Around two-thirds of pregnancies and labours are normal: in the remainder, doctors and midwives need to increase the frequency of surveillance so as to prevent or deal with maternal and fetal problems.
Common complications of pregnancy
Some of the more common complications of pregnancy are listed below.
As well as early detection of medical complications, antenatal visits aim to be supportive and include emotional and educational care. Women with uncomplicated pregnancies are increasingly being managed by midwives and general practitioners in the community and only coming to the hospital doctors should they develop a problem. A small number will opt for a home delivery, but facilities for providing such a service are not always available in the UK.
Women requiring more intensive surveillance have their management targeted to the speci?c problems encountered. Cardiologists will see mothers-to-be with heart conditions, and those at risk of diabetes are cared for in designated clinics with specialist sta?. Those women needing more frequent surveillance than standard antenatal care can be looked after in maternity day centres. These typically include women with mildly raised blood pressure or those with small babies. Fetal medicine units have specialists who are highly skilled in ultrasound scanning and specialise in the diagnosis and management of abnormal babies still in the uterus. ECTOPIC PREGNANCY Chronic abdominal discomfort early in pregnancy may be caused by unruptured ectopic pregnancy, when, rarely, the fertilised OVUM starts developing in the Fallopian tube (see FALLOPIAN TUBES) instead of the uterus. The patient needs hospital treatment and LAPAROSCOPY. A ruptured ectopic pregnancy causes acute abdominal symptoms and collapse, and the woman will require urgent abdominal surgery. URINARY TRACT INFECTIONS These affect around 2 per cent of pregnant women and are detected by a laboratory test of a mid-stream specimen of urine. In pregnancy, symptoms of these infections do not necessarily resemble those experienced by non-pregnant women. As they can cause uterine irritability and possible premature labour (see below), it is important to ?nd and treat them appropriately. ANAEMIA is more prevalent in patients who are vegetarian or on a poor diet. Iron supplements are usually given to women who have low concentrations of HAEMOGLOBIN in their blood (less than 10.5 g/dl) or who are at risk of becoming low in iron, from bleeding, twin pregnancies and those with placenta previa (see below). ANTEPARTUM HAEMORRHAGE Early in pregnancy, vaginal bleedings may be due to a spontaneous or an incomplete therapeutic ABORTION. Bleeding from the genital tract between 24 completed weeks of pregnancy and the start of labour is called antepartum haemorrhage. The most common site is where the PLACENTA is attached to the wall of the uterus. If the placenta separates before delivery, bleeding occurs in the exposed ‘bed’. When the placenta is positioned in the upper part of the uterus it is called an abruption. PLACENTA PRAEVIA is sited in the lower part and blocks or partly blocks the cervix (neck of the womb); it can be identi?ed at about the 34th week. Ten per cent of episodes of antepartum bleeding are caused by placenta previa, and it may be associated with bleeding at delivery. This potentially serious complication is diagnosed by ultrasound scanning and may require a caesarean section (see below) at delivery. INCREASED BLOOD PRESSURE, associated with protein in the urine and swelling of the limbs, is part of a condition known as PRE-ECLAMPSIA. This occurs in the second half of pregnancy in about 1 in 10 women expecting their ?rst baby, and is mostly very mild and of no consequence to the pregnancy. However, some women can develop extremely high blood pressures which can adversely affect the fetus and cause epileptic-type seizures and bleeding disorders in the mother. This serious condition is called ECLAMPSIA. For this reason a pregnant woman with raised blood pressure or PROTEIN in her urine is carefully evaluated with blood tests, often in the maternity day assessment unit. The condition can be stopped by delivery of the baby, and this will be done if the mother’s or the fetus’s life is in danger. If the condition is milder, and the baby not mature enough for a safe delivery, then drugs can be used to control the blood pressure. MISCARRIAGE Also called spontaneous abortion, miscarriage is the loss of the fetus. There are several types:
threatened miscarriage is one in which some vaginal bleeding occurs, the uterus is enlarged, but the cervix remains closed and pregnancy usually proceeds.
inevitable miscarriage usually occurs before the 16th week and is typi?ed by extensive blood loss through an opened cervix and cramp-like abdominal pain; some products of conception are lost but the developing placental area (decidua) is retained and an operation may be necessary to clear the womb.
missed miscarriages, in which the embryo dies and is absorbed, but the decidua (placental area of uterine wall) remains and may cause abdominal discomfort and discharge of old blood.
THERAPEUTIC ABORTION is performed on more than 170,000 women annually in England and Wales. Sometimes the woman may not have arranged the procedure through the usual health-care channels, so that a doctor may see a patient with vaginal bleeding, abdominal discomfort or pain, and open cervix – symptoms which suggest that the decidua and a blood clot have been retained; these retained products will need to be removed by curettage.
Septic abortions are now much less common in Britain than before the Abortion Act (1967) permitted abortion in speci?ed circumstances. The cause is the passage of infective organisms from the vagina into the uterus, with Escherichia coli and Streptococcus faecalis the most common pathogenic agents. The woman has abdominal pain, heavy bleeding, usually fever and sometimes she is in shock. The cause is usually an incomplete abortion or one induced in unsterile circumstances. Antibiotics and curettage are the treatment. INTRAUTERINE GROWTH RETARDATION describes a slowing of the baby’s growth. This can be diagnosed by ultrasound scanning, although there is a considerable margin of error in estimates of fetal weight. Trends in growth are favoured over one-o? scan results alone. GESTATIONAL DIABETES is a condition that is more common in women who are overweight or have a family member with diabetes. If high concentrations of blood sugar are found, e?orts are made to correct it as the babies can become very fat (macrosomia), making delivery more di?cult. A low-sugar diet is usually enough to control the blood concentration of sugars; however some women need small doses of INSULIN to achieve control. FETAL ABNORMALITIES can be detected before birth using ultrasound. Some of these defects are obvious, such as the absence of kidneys, a condition incompatible with life outside the womb. These women can be o?ered a termination of their pregnancy. However, more commonly, the pattern of problems can only hint at an abnormality and closer examination is needed, particularly in the diagnosis of chromosomal deformities such as DOWN’S (DOWN) SYNDROME (trisomy 21 or presence of three 21 chromosomes instead of two).
Chromosomal abnormalities can be de?nitively diagnosed only by cell sampling such as amniocentesis (obtaining amniotic ?uid – see AMNION – from around the baby) done at 15 weeks onwards, and chorionic villus sampling (sampling a small part of the placenta) – another technique which can be done from 12 weeks onwards. Both have a small risk of miscarriage associated with them; consequently, they are con?ned to women at higher risk of having an abnormal fetus.
Biochemical markers present in the pregnant woman’s blood at di?erent stages of pregnancy may have undergone changes in those carrying an abnormal fetus. The ?rst such marker to be routinely used was a high concentration of alpha-fetol protein in babies with SPINA BIFIDA (defects in the covering of the spinal cord). Fuller research has identi?ed a range of diagnostic markers which are useful, and, in conjunction with other factors such as age, ethnic group and ultrasound ?ndings, can provide a predictive guide to the obstetrician – in consultation with the woman – as to whether or not to proceed to an invasive test. These tests include pregnancy-associated plasma protein assessed from a blood sample taken at 12 weeks and four blood tests at 15–22 weeks – alphafetol protein, beta human chorionic gonadotrophin, unconjugated oestriol and inhibin A. Ultrasound itself can reveal physical ?ndings in the fetus, which can be more common in certain abnormalities. Swelling in the neck region of an embryo in early pregnancy (increased nuchal thickness) has good predictive value on its own, although its accuracy is improved in combination with the biochemical markers. The e?ectiveness of prenatal diagnosis is rapidly evolving, the aim being to make the diagnosis as early in the pregnancy as possible to help the parents make more informed choices. MULTIPLE PREGNANCIES In the UK, one in 95 deliveries is of twins, while the prevalence of triplets is one in 10,000 and quadruplets around one in 500,000. Racial variations occur, with African women having a prevalence rate of one in 30 deliveries for twins and Japanese women a much lower rate than the UK ?gure. Multiple pregnancies occur more often in older women, and in the UK the prevalence of fertility treatments, many of these being given to older women, has raised the incidence. There is now an o?cial limit of three eggs being transferred to a woman undergoing ASSISTED CONCEPTION (gamete intrafallopian transfer, or GIFT).
Multiple pregnancies are now usually diagnosed as a result of routine ultrasound scans between 16 and 20 weeks of pregnancy. The increased size of the uterus results in the mother having more or worse pregnancy-related conditions such as nausea, abdominal discomfort, backache and varicose veins. Some congenital abnormalities in the fetus occur more frequently in twins: NEURAL TUBE defects, abnormalities of the heart and the incidence of TURNER’S SYNDROME and KLINEFELTER’S SYNDROME are examples. Such abnormalities may be detected by ultrasound scans or amniocentesis. High maternal blood pressure and anaemia are commoner in women with multiple pregnancies (see above).
The growth rates of multiple fetuses vary, but the di?erence between them and single fetuses are not that great until the later stages of pregnancy. Preterm labour is commoner in multiple pregnancies: the median length of pregnancy is 40 weeks for singletons, 37 for twins and 33 for triplets. Low birth-weights are usually the result of early delivery rather than abnormalities in growth rates. Women with multiple pregnancies require more frequent and vigilant antenatal assessments, with their carers being alert to the signs of preterm labour occurring. CEPHALOPELVIC DISPROPORTION Disparity between the size of the fetus and the mother’s pelvis is not common in the UK but is a signi?cant problem in the developing world. Disparity is classi?ed as absolute, when there is no possibility of delivery, and relative, when the baby is large but delivery (usually after a dif?cult labour) is possible. Causes of absolute disparity include: a large baby – heavier than 5 kg at birth; fetal HYDROCEPHALUS; and an abnormal maternal pelvis. The latter may be congenital, the result of trauma or a contraction in pelvic size because of OSTEOMALACIA early in life. Disproportion should be suspected if in late pregnancy the fetal head has not ‘engaged’ in the pelvis. Sometimes a closely supervised ‘trial of labour’ may result in a successful, if prolonged, delivery. Otherwise a caesarean section (see below) is necessary. UNUSUAL POSITIONS AND PRESENTATIONS OF THE BABY In most pregnant women the baby ?ts into the maternal pelvis head-?rst in what is called the occipito-anterior position, with the baby’s face pointing towards the back of the pelvis. Sometimes, however, the head may face the other way, or enter the pelvis transversely – or, rarely, the baby’s neck is ?exed backwards with the brow or face presenting to the neck of the womb. Some malpositions will correct naturally; others can be manipulated abdominally during pregnancy to a better position. If, however, the mother starts labour with the baby’s head badly positioned or with the buttocks instead of the head presenting (breech position), the labour will usually be longer and more di?cult and may require intervention using special obstetric forceps to assist in extracting the baby. If progress is poor and the fetus distressed, caesarean section may be necessary. HIV INFECTION Pregnant women who are HIV positive (see HIV; AIDS/HIV) should be taking antiviral drugs in the ?nal four to ?ve months of pregnancy, so as to reduce the risk of infecting the baby in utero and during birth by around 50 per cent. Additional antiviral treatment is given before delivery; the infection risk to the baby can be further reduced – by about 40 per cent – if delivery is by caesarean section. The mother may prefer to have the baby normally, in which case great care should be taken not to damage the baby’s skin during delivery. The infection risk to the baby is even further reduced if it is not breast fed. If all preventive precautions are taken, the overall risk of the infant becoming infected is cut to under 5 per cent.
Premature birth This is a birth that takes place before the end of the normal period of gestation, usually before 37 weeks. In practice, however, it is de?ned as a birth that takes place when the baby weighs less than 2·5 kilograms (5••• pounds). Between 5 and 10 per cent of babies are born prematurely, and in around 40 per cent of premature births the cause is unknown. Pre-eclampsia is the most common known cause; others include hypertension, chronic kidney disease, heart disease and diabetes mellitus. Multiple pregnancy is another cause. In the vast majority of cases the aim of management is to prolong the pregnancy and so improve the outlook for the unborn child. This consists essentially of rest in bed and sedation, but there are now several drugs, such as RITODRINE, that may be used to suppress the activity of the uterus and so help to delay premature labour. Prematurity was once a prime cause of infant mortality but modern medical care has greatly improved survival rates in developing countries.
Labour Also known by the traditional terms parturition, childbirth or delivery, this is the process by which the baby and subsequently the placenta are expelled from the mother’s body. The onset of labour is often preceded by a ‘show’ – the loss of the mucus and blood plug from the cervix, or neck of the womb; this passes down the vagina to the exterior. The time before the beginning of labour is called the ‘latent phase’ and characteristically lasts 24 hours or more in a ?rst pregnancy. Labour itself is de?ned by regular, painful contractions which cause dilation of the neck of the womb and descent of the fetal head. ‘Breaking of the waters’ is the loss of amniotic ?uid vaginally and can occur any time in the delivery process.
Labour itself is divided into three stages: the ?rst is from the onset of labour to full (10 cm) dilation of the neck of the womb. This stage varies in length, ideally taking no more than one hour per centimetre of dilation. Progress is monitored by regular vaginal examinations, usually every four hours. Fetal well-being is observed by intermittent or continuous monitoring of the fetal heart rate in relation to the timing and frequency of the contractions. The print-out is called a cardiotocograph. Abnormalities of the fetal heart rate may suggest fetal distress and may warrant intervention. In women having their ?rst baby (primigravidae), the common cause of a slow labour is uncoordinated contractions which can be overcome by giving either of the drugs PROSTAGLANDIN or OXYTOCIN, which provoke contractions of the uterine muscle, by an intravenous drip. Labours which progress slowly or not at all may be due to abnormal positioning of the fetus or too large a fetus, when prostaglandin or oxytocin is used much more cautiously.
The second stage of labour is from full cervical dilation to the delivery of the baby. At this stage the mother often experiences an irresistible urge to push the baby out, and a combination of strong coordinated uterine contractions and maternal e?ort gradually moves the baby down the birth canal. This stage usually lasts under an hour but can take longer. Delay, exhaustion of the mother or distress of the fetus may necessitate intervention by the midwife or doctor. This may mean enlarging the vaginal opening with an EPISIOTOMY (cutting of the perineal outlet – see below) or assisting the delivery with specially designed obstetric forceps or a vacuum extractor (ventouse). If the cervix is not completely dilated or open and the head not descended, then an emergency caesarean section may need to be done to deliver the baby. This procedure involves delivering the baby and placenta through an incision in the mother’s abdomen. It is sometimes necessary to deliver by planned or elective caesarean section: for example, if the placenta is low in the uterus – called placenta praevia – making a vaginal delivery dangerous.
The third stage occurs when the placenta (or afterbirth) is delivered, which is usually about 10–20 minutes after the baby. An injection of ergometrine and oxytocin is often given to women to prevent bleeding.
Pain relief in labour varies according to the mother’s needs. For uncomplicated labours, massage, reassurance by a birth attendant, and a warm bath and mobilisation may be enough for some women. However, some labours are painful, particularly if the woman is tired or anxious or is having her ?rst baby. In these cases other forms of analgesia are available, ranging from inhalation of NITROUS OXIDE GAS, injection of PETHIDINE HYDROCHLORIDE or similar narcotic, and regional local anaesthetic (see ANAESTHESIA).
Once a woman has delivered, care continues to ensure her and the baby’s safety. The midwives are involved in checking that the uterus returns to its normal size and that there is no infection or heavy bleeding, as well as caring for stitches if needed. The normal blood loss after birth is called lochia and generally is light, lasting up to six weeks. Midwives o?er support with breast feeding and care of the infant and will visit the parents at home routinely for up to two weeks.
Some complications of labour All operative deliveries in the UK are now done in hospitals, and are performed if a spontaneous birth is expected to pose a bigger risk to the mother or her child than a specialist-assisted one. Operative deliveries include caesarean section, forceps-assisted deliveries and those in which vacuum extraction (ventouse) is used. CAESAREAN SECTION Absolute indications for this procedure, which is used to deliver over 15 per cent of babies in Britain, are cephalopelvic disproportion and extensive placenta praevia, both discussed above. Otherwise the decision to undertake caesarean section depends on the clinical judgement of the specialist and the views of the mother. The rise in the proportion of this type of intervention (from 5 per cent in the 1930s to its present level of over 23 per cent
P
of the 600,000 or so annual deliveries in England) has been put down to defensive medicine
– namely, the doctor’s fear of litigation (initiated often because the parents believe that the baby’s health has suffered because the mother had an avoidably di?cult ‘natural’ labour). In Britain, over 60 per cent of women who have had a caesarean section try a vaginal delivery in a succeeding pregnancy, with about two-thirds of these being successful. Indications for the operation include:
absolute and relative cephalopelvic disproportion.
placenta previa.
fetal distress.
prolapsed umbilical cord – this endangers the viability of the fetus because the vital supply of oxygen and nutrients is interrupted.
malpresentation of the fetus such as breech or transverse lie in the womb.
unsatisfactory previous pregnancies or deliveries.
a request from the mother.
Caesarean sections are usually performed using regional block anaesthesia induced by a spinal or epidural injection. This results in loss of feeling in the lower part of the body; the mother is conscious and the baby not exposed to potential risks from volatile anaesthetic gases inhaled by the mother during general anaesthesia. Post-operative complications are higher with general anaesthesia, but maternal anxiety and the likelihood that the operation might be complicated and di?cult are indications for using it. A general anaesthetic may also be required for an acute obstetric emergency. At operation the mother’s lower abdomen is opened and then her uterus opened slowly with a transverse incision and the baby carefully extracted. A transverse incision is used in preference to the traditional vertical one as it enables the woman to have a vaginal delivery in any future pregnancy with a much smaller risk of uterine rupture. Women are usually allowed to get up within 24 hours and are discharged after four or ?ve days. FORCEPS AND VENTOUSE DELIVERIES Obstetric forceps are made in several forms, but all are basically a pair of curved blades shaped so that they can obtain a purchase on the baby’s head, thus enabling the operator to apply traction and (usually) speed up delivery. (Sometimes they are used to slow down progress of the head.) A ventouse or vacuum extractor comprises an egg-cup-shaped metal or plastic head, ranging from 40 to 60 mm in diameter with a hollow tube attached through which air is extracted by a foot-operated vacuum pump. The instrument is placed on the descending head, creating a negative pressure on the skin of the scalp and enabling the operator to pull the head down. In mainland Europe, vacuum extraction is generally preferred to forceps for assisting natural deliveries, being used in around 5 per cent of all deliveries. Forceps have a greater risk of causing damage to the baby’s scalp and brain than vacuum extraction, although properly used, both types should not cause any serious damage to the baby.
Episiotomy Normal and assisted deliveries put the tissues of the genital tract under strain. The PERINEUM is less elastic than the vagina and, if it seems to be splitting as the baby’s head
moves down the birth canal, it may be necessary to cut the perineal tissue – a procedure called an episiotomy – to limit damage. This is a simple operation done under local anaesthetic. It should be done only if there is a speci?c indication; these include:
to hasten the second stage of labour if the fetus is distressed.
to facilitate the use of forceps or vacuum extractor.
to enlarge a perineum that is restricted because of unyielding tissue, perhaps because of a scar from a previous labour. Midwives as well as obstetricians are trained
to undertake and repair (with sutures) episiotomies.
(For organisations which o?er advice and information on various aspects of childbirth, including eclampsia, breast feeding and multiple births, see APPENDIX 2: ADDRESSES: SOURCES OF INFORMATION, ADVICE, SUPPORT AND SELF-HELP.)... pregnancy and labour
Habitat: Native to East Asia; cultivated in Assam, Vadodara, Tamil Nadu, Bengal and Madhya Pradesh.
English: Wild Yam, Greater Yam, Asiatic Yam.Ayurvedic: Kaashthaaluka. Aaluka (var.). Aalukas (yams) of Ayurvedic texts, belong to Dioscorea spp.Siddha/Tamil: Perumvalli kizhangu.Folk: Kathaalu.Action: Even the best among the cultivated yams causes irritation in the throat or a feeling of discomfort when eaten raw. Wild yams—cholagogue, antispasmodic, anti-inflammatory, antirheumatic, diuretic. Also used for painful periods, cramps and muscle tension.
Key application: Dioscorea villosa L., Wild Yam—as spasmolytic, anti-inflammatory. (The British Herbal Pharmacopoeia.)The edible tubers of Dioscorea alata are purple-coloured and contain an- thocyanins, cyanidin and peonidin- 3-gentiobioside acylated with sinapic acid. The tubers contain surcose, while leaves contain large quantities of D- fructose, D-glucose and the polyols, 2-deoxyribitol, 6-deoxysorbitol and glycerol.Mouldy yams are reported to contain a compound ipomeanol which is being tested against human lung cancer. (J. Am Med Assoc, 1994,15, 23.)Diosgenin obtained from Dioscorea species was used in the first commercial production of oral contraceptives, topical hormones, systemic corticos- teroids, androgens, estrogens, pro- gestogens and other sex hormones.The chemical transformation of di- osgenin to estrogen, progesterone or any other steroidal compound does not occur in human body. Topically applied Wild Yam does not appear to cause changes in serum FSH, estradi- ol or progesterone. (Natural Medicines Comprehensive Database, 2007.)Diosgenin, combined with the drug clofibrate, caused a greater decrease in LDL than either substance alone in rats. (Sharon M. Herr.)... dioscorea alataA number of co-factors are necessary for AIDS to develop: diet, environment, immoral lifestyle, drugs, etc also dispose to the disease which, when eliminated, suggest that AIDS needs not be fatal. However, there is no known cure. Smoking hastens onset. Causes include needle-sharing and sexual contacts. Also known as the ‘Gay Plague’ it can be transmitted from one member of the family to another non-sexual contact.
The virus kills off cells in the brain by inflammation, thus disposing to dementia.
Symptoms. Onset: brief fever with swollen glands. “Feeling mildly unwell”. This may pass off without incident until recurrence with persistent diarrhoea, night sweats, tender swollen lymph nodes, cough and shortness of breath. There follows weight loss, oral candida. Diagnosis is confirmed by appearance of ugly skin lesions known as Kaposi’s sarcoma – a malignant disease. First indication is the appearance of dark purple spots on the body followed by fungoid growths on mouth and throat.
While some cases of STDs have been effectively treated with phytotherapy, there is evidence to suggest it may be beneficial for a number of reasons. Whatever the treatment, frequent blood counts to monitor T-4 cells (an important part of the immune system) are necessary. While a phytotherapeutic regime may not cure, it is possible for patients to report feeling better emotionally and physically and to avoid some accompanying infections (candida etc).
Treatment. Without a blood test many HIV positives may remain ignorant of their condition for many years. STD clinics offer free testing and confidential counselling.
Modern phytotherapeutic treatment:–
1. Anti-virals. See entry.
2. Enhance immune function.
3. Nutrition: diet, food supplements.
4. Psychological counselling.
To strengthen body defences: Garlic, Echinacea, Lapacho, Sage, Chlorella, Reisha Mushroom, Shiitake Mushroom. Of primary importance is Liquorice: 2-4 grams daily.
Upper respiratory infection: Pleurisy root, Elecampane.
Liver breakdown: Blue Flag root, Milk Thistle, Goldenseal.
Diarrhoea: Bayberry, Mountain Grape, American Cranesbill, Slippery Elm, lactobacillus acidophilus.
Prostatitis: Saw Palmetto, Goldenrod, Echinacea.
Skin lesions: External:– Comfrey, Calendula or Aloe Vera cream.
To help prevent dementia: a common destructive symptom of the disease: agents rich in minerals – Alfalfa, Irish Moss, Ginkgo, St John’s Wort, Calcium supplements.
Nervous collapse: Gotu Kola, Siberian Ginseng, Oats, Damiana.
Ear Inflammation: Echinacea. External – Mullein ear drops.
With candida: Lapacho tea. Garlic inhibits candida.
Anal fissure: Comfrey cream or Aloe Vera gel (external).
Practitioner: Formula. Liquid extract Echinacea 30ml (viral infection) . . . Liquid extract Poke root 10ml (lymphatic system) . . . Liquid extract Blue Flag root 10ml (liver stimulant) . . . Tincture Goldenseal 2ml (inflamed mucous membranes) . . . Liquid extract Guaiacum 1ml (blood enricher) . . . Decoction of Sarsaparilla to 100ml. Sig: 5ml (3i) aq cal pc.
Gargle for sore throat: 5-10 drops Liquid extract or Tincture Echinacea to glass water, as freely as desired.
Abdominal Castor oil packs: claimed to enhance immune system.
Chinese medicine: Huang Qi (astragalus root).
Urethral and vaginal irrigation: 2 drops Tea Tree oil in strong decoction Marshmallow root: 2oz to 2 pints water. Inject warm.
Diet. Vitamin C-rich foods, Lecithin, Egg Yolk, Slippery Elm gruel, Red Beet root, Artichokes. Garlic is particularly indicated as an anti-infective.
Nutrition. Vitamin A is known to increase resistance by strengthening the cell membrane; preferably taken as beta carotene 300,000iu daily as massive doses of Vitamin A can be toxic. Amino acid – Glutathione: Garlic’s L-cysteine relates.
Vitamin C. “The virus is inactivated by this vitamin. Saturating cells infected with the HIV virus with the vitamin results in 99 per cent inactivation of the virus. The vitamin is an anti-viral and immune system modulator without unwanted side-effects. The ascorbate, when added to HIV cells, substantially reduced the virus’s activity without harming the cells at specific concentrations. Patients taking large doses report marked improvement in their condition. Minimum daily oral dose: 10 grams.” (Linus Pauling Institute, Science and Medicine, Palo Alto, California, USA)
Periwinkle. An anti-AIDS compound has been detected in the Madagascan Periwinkle (Catharanthus roseus), at the Chelsea Physic Garden.
Mulberry. The black Mulberry appears to inhibit the AIDS virus.
Hyssop. An AIDS patient improved to a point where ulcers were healed, blood infection eliminated, and Kaposi’s sarcoma started to clear when her mother gave her a traditional Jamaican tea made from Hyssop, Blessed Thistle and Senna. From test-tube research doctors found that Hyssopus officinalis could be effective in treatment of HIV/AIDS. (Medical Journal Antiviral Research, 1990, 14, 323-37) Circumcision. Studies have shown that uncircumcised African men were more than five to eight times more likely to contract AIDS than were circumcised men; life of the virus being short-lived in a dry environment. (Epidemiologist Thomas Quinn, in Science Magazine)
Study. A group of 13 HIV and AIDS patients received 200mg capsules daily of a combination of Chelidonium (Greater Celandine) 175mg; Sanguinaria (Blood root) 5mg; and Slippery Elm (Ulmus fulva) 20mg. More than half the patients enjoyed increased energy and improved immune function with reduction in both size and tenderness of lymph nodes. (D’Adamo P. ‘Chelidonium and Sanguinaria alkaloids as anti-HIV therapy. Journal of Naturopathic Medicine (USA) 3.31-34 1992)
Bastyr College of Naturopathy, Seattle, MA, USA. During 1991 the College carried out a study which claimed that a combination of natural therapies including nutrition, supplements, herbal medicine, hydrotherapy and counselling had successfully inhibited HIV and other viral activity in all patients in controlled trials lasting a year.
Patients chosen for the trial were HIV positive, not on anti-viral drugs and showing symptoms of a compromised immune system, but without frank AIDS (generally taken to be indicated by Karposi’s sarcoma and/or PCP-pneumocystitis carinii pneumonia).
Symptoms included: Lymphadenopathy in at least two sites, oral thrush, chronic diarrhoea, chronic sinusitis, leukoplakia, herpes, night sweats and fatigue.
Assessment was subjective and objective (including T-cell ratio tests). The patients did better than comparable groups in published trials using AZT.
Treatment was naturopathic and herbal. Patients receiving homoeopathy and acupuncture did not do as well as those receiving herbs.
Best results with herbs were: Liquorice (1g powder thrice daily); St John’s Wort (Yerba prima tablets, 3, on two days a week only). Patients reported a great increase in the sense of well-being on St John’s Wort. An equivalent dose of fresh plant tincture would be 10ml. The tincture should be of a good red colour. The College did not use Echinacea, which would stimulate the central immune system and which would therefore be contra-indicated.
Supplements given daily. Calcium ascorbate 3g+ (to bowel tolerance). Beta-carotene 300,000iu. Thymus gland extract tablets 6. Zinc 60mg (with some Copper). B-vitamins and EFAs.
To control specific symptoms: most useful herbs were: Tea Tree oil for fungal infections; Goldenseal and Gentian as bitters. Ephedra and Eyebright for sinusitis. Carob drinks for non-specific enteritis. Vitamin B12 and topical Liquorice for shingles.
Counselling and regular massage were used to maintain a positive spirit. Studies show all long term HIV positive survivors have a positive attitude and constantly work at empowering themselves.
Results showed significant improvements in symptoms suffered by HIV patients despite a slow deterioration in blood status. Methods used in the study had dramatically reduced mortality and morbidity. A conclusion was reached that AIDS may not be curable but it could be manageable. (Reported by Christopher Hedley MNIMH, London NW1 8JD, in Greenfiles Herbal Journal) ... aids
Symptoms: blurred speech, stumbling gait, fatigue on effort, inability to concentrate, feeling of isolation and weakness – cannot fight back.
Causes: vitamin deficiency, overwork, excess physical and mental activity. Multiple sclerosis.
Symptom relief only. Tea: equal parts, Mistletoe, Skullcap, Valerian. 1 heaped teaspoon to each cup water; bring to boil; simmer one minute; infuse 15 minutes. Half-1 cup thrice daily.
Ginseng. Kola. Saw Palmetto. Ginkgo. Tablets, capsules, tinctures, etc. Symptomatic relief. CEREBRAL HAEMORRHAGE. See: STROKE. ... cerebellar ataxia
Fennel eye compress. Steep teabag in cold water and apply.
Chickweed Lotion. Take a handful of Chickweed, wash well, crush with a rolling pin, infuse in two cups boiling water until cool. Use as a compress or in an eye bath two or more times daily.
Supplements. Daily. Vitamin A 7500iu. Vitamin B2 10mg. Vitamin C 1g. Vitamin E 400iu. Zinc.
Palming. Bilberries.
If persistent, consult eye specialist. ... eyes – sore
It is a recurrent and paroxysmal disorder starting suddenly and ceasing spontaneously due to occasional sudden excessive rapid and local discharge of the nerve cells in the grey matter (cortex) of the BRAIN. Epilepsy always arises in this way from the brain, but its origin is often of microscopic size. It is diagnosed by the clinical symptoms based on the observations of witnesses. Its cause can sometimes be established by laboratory tests, and brain scanning. Fits can be the ?rst sign of a tumour, or follow a stroke, brain injury or infection, but in the large majority no underlying cause is found – so-called idiopathic epilepsy.
A single epileptic ?t is not epilepsy. Of those people who have a single seizure, a signi?cant minority (20 per cent) have no further attacks.
Major (generalised) seizures have a sudden, often unprovoked onset; the patient emits a cry, then falls to the ground, rigid, blue, and then twitching or jerking both sides of the body: the tonic-clonic convulsion. Drowsiness and confusion may last for some hours after recovering consciousness. Some experience a momentary warning (AURA): a smell, or sensation in the head or abdomen, vision, or déjà vu.
Partial seizures: focal motor (Jacksonian) begin with twitching of the angle of the mouth, the thumb, or the big toe. If the seizure discharge then spreads, the twitching or jerking spreads gradually through the limbs. Consciousness is preserved unless the seizure spreads to produce a secondary generalised ?t. In some attacks the eyes and head may turn, the arm may rise, and the body may turn, while some patients feel tingling in the limbs.
Complex partial seizures (temporal lobe epilepsy) The patient usually appears blank, vacant and may be unable to talk, or may mumble or chatter – though later they often have no memory of this period. They may be able to carry out complex tasks, taking o? gloves or clothes, and may smack their lips or rub repeatedly on one limb (automatisms). A sense of strangeness supervenes: unreality, or a feeling of having experienced it all before (déja vu). There may be a sense of panic. Strange unpleasant smells and tastes are olfactory and gustatory hallucinations. The visual hallucinations evoke complex scenes. An initial rising sense of warmth or discomfort in the stomach, or ‘speeding-up’ of thoughts are common psychomotor symptoms. All these strange symptoms are brief, disappearing within a few seconds or up to 3–4 minutes.
Minor seizures (petit mal) Attacks start in childhood. They last a few seconds. The child ceases what he or she is doing, stares, looks a little pale, and may ?utter the eyelids. The head may drop forwards. Attacks are commonly provoked by overbreathing. The child and parents may be unaware of the attacks
– ‘just daydreaming’. Major ?ts develop in one-third of subjects. By contrast with other types of epilepsy, the ELECTROENCEPHALOGRAM (EEG) is diagnostic.
Precautions Children with epilepsy should take normal school exercises and games, and can swim under supervision. Adults must avoid working at heights, with exposed dangerous machinery, and driving vehicles on public roads. Current legislation allows driving after two years of complete freedom from attacks during waking hours; those who for more than three years have had a history of attacks only while asleep may also drive.
Treatment identi?es, and avoids where possible, any factors (such as shortage of sleep or excessive ?uids) which aggravate or trigger attacks. If ?ts are very infrequent, treatment may not be recommended. However, frequent ?ts may be embarassing, may cause injury or may cause long-term brain damage so treatment is advisable. Anti-epileptic drugs are usually necessary for several years under medical supervision. Carbamazepine and sodium valproate are the most frequently prescribed. The dose is governed by the degree of control of ?ts and sometimes drug levels can be monitored by blood tests to check on dosage. Strict adherence to the drug schedule gives a reasonable chance of total suppression of ?ts, especially in younger patients whose ?ts have started recently. The table summarises anticonvulsant drugs in use. Interactions can occur between anti-epileptics and, if drug treatment is changed, the patient needs careful monitoring. In particular, abrupt withdrawal of a drug should be avoided as this may precipitate severe rebound seizures.
Indications First-choice drugs: Ethosuximide PM, JME Phenobarbitone M, P Phenytoin M, P, CP Carbamazepine M, P, CP Valproate M, PM, JME Second-line drugs: Primidone M, P, CP Clobazam M, CP Vigabatrin M, P, CP Lamotrigine M, P, CP Gabapentin M, P, CP Topirimate P
M = major generalised tonic-clonic; P = partial or focal; CP = complex partial (temporal lobe); PM = petit mal; JME = juvenile myoclonic epilepsy.
Anticonvulsant drugs
As all anticonvulsant drugs have an e?ect on the brain, it is not surprising that there may be side-effects, especially inolving alertness or behaviour. In each case careful assessment is necessary for doctor and patient to agree on the best compromise between stopping ?ts and avoiding ill-effects of medication.
Patients who have an epileptic seizure should not be restrained or have a gag or anything else placed in their mouths; nor should they be moved unless in danger of further injury. Any tight clothing around the neck should be loosened and, when the seizure has passed, the person should be placed in the recovery position to facilitate a return to consciousness (see APPENDIX 1: BASIC FIRST AID).
Patients with epilepsy and their relatives can obtain further advice and information from the British Epilepsy Association or Epilepsy Action Scotland.... epilepsy
See: FLATULENCE. ... meteorism
(e.g. arsenic, mercury and thallium). Treatment is unsatisfactory but aspirin provides sympomatic relief.... erythromelalgia
Chronic fatigue is a symptom of some illnesses such as ANAEMIA, CHRONIC FATIGUE SYNDROME (CFS), HYPOTHYROIDISM, MONONUCLEOSIS, MOTOR NEURONE DISEASE (MND), MYASTHENIA GRAVIS, MYALGIC ENCEPHALOMYELITIS (ME) and others. Some drugs may also produce a feeling of fatigue.... fatigue
Habitat: Extensively farmed for the brewing industry, and is found growing wild in hedges and open woods.
Features ? Stem rough, very long, will twist round any adjacent support. Leaves in pairs, stalked, rough, serrate, cordate, three- or five-lobed. Flowers or catkins (more correctly called strobiles) consist of membranous scales, yellowish-green, roundish, reticulate-veined, nearly half-inch long, curving over each other. These are the fertile flowers which are used medicinally and industrially.Action: Tonic, diuretic.
As a tonic in prescriptions for debility, nervous dyspepsia, and general atony. Although usually given in combination with other herbs, the ounceto pint infusion of hops taken thrice daily makes quite a good tonic medicine for those feeling "run-down." Lying on a pillow stuffed with hops is an old-fashioned way of dealing with insomnia.... hopsCommon features of IBS include:
abdominal distension.
altered bowel habit.
colicky lower abdominal pain, eased by defaecation.
mucous discharge from rectum.
feelings of incomplete defaecation.
Investigations usually produce normal results. Positive diagnosis in people under 40 is usually straightforward. In older patients, however, barium ENEMA, X-rays and COLONOSCOPY should be done to exclude colorectal cancer.
Reassurance is the initial and often e?ective treatment. If this fails, treatment should be directed at the major symptoms. Several months of the antidepressant amitriptyline (see ANTIDEPRESSANT DRUGS) may bene?t patients with intractable symptoms, given at a dose lower than that used to treat depression. The majority of patients follow a relapsing/remitting course, with episodes provoked by stressful events in their daily lives. (See also INTESTINE, DISEASES OF.)... irritable bowel syndrome (ibs)
People who have an antisocial personality lack a sense of guilt and cannot tolerate frustration.
They may have problems with relationships and are frequently in trouble with the law.
Behaviour therapy, and various forms of psychotherapy, may help to improve integration.
In general, the effects of this disorder decrease with age.... antisocial personality disorder
be replaced by unrelated new ones.
(See also psychotherapy.)... blocking
cachexia A condition of severe weight loss and decline in health caused by a serious underlying disease, such as cancer or tuberculosis, or by starvation.... byssinosis
It usually begins at puberty – although young children can be affected – and tends to stop in middle age: in women, for example, attacks often cease after MENOPAUSE. It frequently disappears during pregnancy. The disorder tends to run in families. In susceptible individuals, attacks may be provoked by a wide variety of causes including: anxiety, emotion, depression, shock, and excitement; physical and mental fatigue; prolonged focusing on computer, television or cinema screens; noise, especially loud and high-pitched sounds; certain foods – such as chocolate, cheese, citrus fruits, pastry; alcohol; prolonged lack of food; irregular meals; menstruation and the pre-menstrual period.
Anything that can provoke a headache in the ordinary individual can probably precipitate an attack in a migrainous subject. It seems as if there is an inherited predispostion that triggers a mechanism whereby in the migrainous subject, the headache and the associated sickness persist for hours, a whole day or even longer.
The precise cause is not known, but the generally accepted view is that in susceptible individuals, one or other of these causes produces spasm or constriction of the blood vessels of the brain. This in turn is followed by dilatation of these blood vessels which also become more permeable and so allow ?uid to pass out into the surrounding tissues. This combination of dilatation and outpouring of ?uid is held to be responsible for the headache.
Two types of migraine have been recognised: classical and common. The former is relatively rare and the headache is preceded by a slowly extending area of blindness in one or both eyes, usually accompanied by intermittent ‘lights’. The phenomenon lasts for up to 30 minutes and is followed by a bad, often unilateral headache with nausea, sometimes vomiting and sensitivity to light. Occasionally, passing neurological symptoms such as weakness in a limb may accompany the attack. The common variety has similar but less severe symptoms. It consists of an intense headache, usually situated over one or other eye. The headache is usually preceded by a feeling of sickness and disturbance of sight. In 15–20 per cent of cases this disturbance of sight takes the form of bright lights: the so-called AURA of migraine. The majority of attacks are accompanied by vomiting. The duration of the headache varies, but in the more severe cases the victim is usually con?ned to bed for 24 hours.
Treatment consists, in the ?rst place, of trying to avoid any precipitating factor. Patients must ?nd out which drug, or drugs, give them most relief, and they must always carry these about with them wherever they go. This is because it is a not uncommon experience to be aware of an attack coming on and to ?nd that there is a critical quarter of an hour or so during which the tablets are e?ective. If not taken within this period, they may be ine?ective and the unfortunate victim ?nds him or herself prostrate with headache and vomiting. In addition, sufferers should immediately lie down; at this stage a few hours’ rest may prevent the development of a full attack.
When an attack is fully developed, rest in bed in a quiet, darkened room is essential; any loud noise or bright light intensi?es the headache or sickness. The less food that is taken during an attack the better, provided that the individual drinks as much ?uid as he or she wants. Group therapy, in which groups of around ten migrainous subjects learn how to relax, is often of help in more severe cases, whilst in others the injection of a local anaesthetic into tender spots in the scalp reduces the number of attacks. Drug treatment can be e?ective and those a?icted by migraine may ?nd a particular drug or combination of drugs more suitable than others. ANALGESICS such as PARACETAMOL, aspirin and CODEINE phosphate sometimes help. A combination of buclizine hydrochloride and analgesics, taken when the visual aura occurs, prevents or diminishes the severity of an attack in some people. A commonly used remedy for the condition is ergotamine tartrate, which causes the dilated blood vessels to contract, but this must only be taken under medical supervision. In many cases METOCLOPRAMIDE (an antiemetic), followed ten minutes later by three tablets of either aspirin or paracetamol, is e?ective if taken early in an attack. In milder attacks, aspirin, with or without codeine and paracetamol, may be of value. SUMATRIPTAN (5-hydroxytryptamine [5HT1] AGONIST – also known as a SEROTONIN agonist) is of value for acute attacks. It is used orally or by subcutaneous injection, but should not be used for patients with ischaemic heart disease. Naratriptan is another 5HT1 agonist that is an e?ective treatment for acute attacks; others are almotriptan, rizariptan and zolmitriptan. Some patients ?nd beta blockers such as propranolol a valuable prophylactic.
People with migraine and their relatives can obtain help and guidance from the Migraine Action Association.... migraine
An excessive accumulation of monoamines can induce a dangerous reaction characterised by high blood pressure, palpitations, sweating and a feeling of su?ocation. Hence the care with which MAOI drugs are administered. What is equally important, however, is that in no circumstances should a patient receiving any MAOI drug eat cheese, yeast preparations such as Marmite, tinned ?sh, or high game. The reason for this ban is that all these foodstu?s contain large amounts of tyramine which increases the amount of certain monoamines such as noradrenaline in the body. (See MENTAL ILLNESS.)
There are also certain drugs, such as AMPHETAMINES and PETHIDINE HYDROCHLORIDE, which must not be taken by a patient who is receiving an MAOI drug. The MAOIs of choice are phenelzine or isocarboxazid because their stimulant effects are less than those of other MAOIs, making them safer.... monoamine oxidase inhibitors (maois)
Depression, giddiness, nausea and vomiting are the most prominent.
Causes Although the vast majority of people appear to be liable to this ailment at sea, they do not all suffer alike. Many endure acute distress, whilst others are simply conscious of transient feelings of nausea and discomfort. A smaller proportion of people suffer from air and car sickness. The symptoms are a result of over-stimulation of the organs of balance in the inner EAR by continuous changes in the body’s position. The movements of the horizon worsen this situation.
Symptoms The symptoms generally show themselves soon after the journey has started, by the onset of giddiness and discomfort in the head, together with a sense of nausea and sinking at the stomach, which soon develops into intense sickness and vomiting. Most people recover quickly when the motion stops.
Treatment Innumerable preventives and remedies have been proposed. Cinnarizine 30 mg orally is useful 2 hours before travel, then 15 mg every 8 hours during the journey if necessary. Dimenhydrinate and promethazine are also commonly taken for motion sickness.... motion (travel) sickness
Causes As a rule, a person is not conscious of the beating of the heart except when the nervous system is unduly excited. A disorder of the rhythm of the heart (ARRHYTHMIA) may cause palpitations. Sudden emotions, such as fright, or overuse of tobacco, tea, co?ee or alcohol may bring it on. Sometimes it may appear in people with organic heart disease.
Symptoms There may simply be a ?uttering of the heart and a feeling of faintness, or the heart may be felt pounding and the arteries throbbing, causing great distress. The subject may be conscious of the heart missing beats.
Treatment Although these symptoms can be unpleasant, they do not necessarily signify serious disease. Moderate exercise is a good thing. If the person is a smoker, he or she should stop. Tea, co?ee, alcohol or other stimulants should be taken sparingly. If symptoms persist or are severe, the individual should see a doctor and any underlying disorder should be investigated – including by exercise ECG – and treated. The BETA-ADRENOCEPTOR-BLOCKING DRUGS are the most useful drugs in controlling the palpitations of anxiety and those due to some cardiac arrhythmias.... palpitation
Catharsis is used to refer to the process of cleaning out the bowels.
Sigmund Freud used the term in psychoanalytic theory to describe the expression of repressed feelings and memories.... catharsis
This is usually performed consciously to obtain emotional relief in a manner that will not cause harm to oneself or to another person.
Some psychotherapists believe that displacement is an unconscious defence mechanism, which prevents disturbing feelings from entering consciousness.... displacement activity
First developed by Sigmund Freud, it is based on the idea that repressed feelings and thoughts are revealed, in a disguised manner, in dreams.... dream analysis
Dreams usually closely mirror the day’s preoccupations.
Dreaming can be seen as a process in which the mental impressions, feelings, and ideas are sorted out.
People roused during sleep report especially vivid dreams.... dreaming
(4) Absence of any other form of mental disorder that would explain the unusual behaviour. The corresponding American terminology is ‘antisocial personality disorder’. (See MENTAL ILLNESS.)... psychopathic
In girls, puberty is marked by the onset of MENSTRUATION and development of the BREASTS. The latter is usually the ?rst sign of puberty to appear, and may occur from nine years onwards; most girls show signs of breast development by the age of 13. The time from the beginning of breast development to the onset of menstruation is usually around two years but may range from six months to ?ve years. The ?rst sign of puberty in boys is an increase in testicular and penile size (see TESTICLE; PENIS) between the age of ten and 14. The LARYNX enlarges in boys, so that the voice – after going through a period of ‘breaking’ – ?nally assumes the deep manly pitch. Hair appears on the pubis and later in the armpits in both boys and girls, whilst in the former it also begins to grow on the upper lip, and skin eruptions are not uncommon on the face (see ACNE).
The period is one of transition from a physical and mental point of view. Puberty is not to be regarded as a physiological ‘coming of age’, for full development is usually achieved in the early 20s.... puberty
Gender identity is not necessarily the same as biological sex.
It is fixed within the first 2–3 years of life and is reinforced during puberty; once established, it cannot usually be changed.
Gender identity problems, such as transsexualism, occur when a person has persistent feelings of discomfort about his or her sexual identity.... gender identity
Guilt is self-inflicted, unlike shame, which depends on how other people view the transgression.
Some psychoanalysts view guilt as a result of the prohibitions of the superego instilled by parental authority in early life.
Others see guilt as a conditioned response to actions that in the past have led to punishment.
Feeling guilty for no reason or for an imagined crime is one of the main symptoms of psychotic depression.... guilt
Hunger due to a low blood sugar level can also occur in thyrotoxicosis, and in diabetes mellitus when an incorrect balance between insulin and carbohydrate intake causes hypoglycaemia.... hunger
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