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With progression diabetes and depression discount precose, stupor or coma may occur Thiamine is found in many foods and 1–2 mg daily is gen(Wallis et al blood sugar 51 order precose once a day. Total body stores Nystagmus diabetes medications pictures cheap precose 50 mg otc, although generally horizontal blood glucose 114 buy online precose, may at times of thiamine range from 20 to 100 mg, and the half-life of be vertical. With progression, a bilateral and typically thiamine ranges from 10 to 20 days; thus, with severely asymmetric sixth cranial nerve palsy may appear and reduced thiamine intake, significant deficiency may appear patients may complain of diplopia. Once absorbed, thiamine is converted to its active form, Ataxia typically follows nystagmus and may be evident thiamine pyrophosphate; this molecule functions as an as an ataxia of gait or as a truncal ataxia, which, in turn, essential co-factor for transketolase, which plays a critical may be so severe that patients are unable to sit up in bed. With It must be emphasized that this classic triad of sympsignificant thiamine deficiency, transketolase activity is lost, toms is the exception rather than the rule. By seen in malnourished alcoholics, cases have also been noted far the most common presentation is with delirium alone, in a number of other conditions (Ogershok et al. Wernicke’s encephalopathy but these are rarely required 1999), and prolonged vomiting occurring after liver transfor the diagnosis, and, in any case, treatment of suspected plantation (DiMartini 1996) or as a side-effect of digitalis Wernicke’s encephalopathy should never wait upon test (Richmond 1959). Red blood cell thiamine intake, for example secondary to a loss of appetite transketolase activity may be decreased (Dreyfus 1962), during an upper respiratory infection (Shimomura et al. Furthermore, some individuals have flour was ‘enriched’ with niacin and the plague of endemic an inherited form of transketolase that displays a decreased pellagra was eradicated. Korsakoff’s syndrome is a chronic amnestic disorder with In acute cases petechial hemorrhages are seen in gray prominent anterograde and variable retrograde compomatter adjacent to the third ventricle, aqueduct of Sylvius, nents that occurs as sequela to Wernicke’s encephalopathy. In those who survive, neuronal loss and gliosis are tally different: Wernicke’s encephalopathy is marked by a seen in the same areas. There is an additional difficulty regarding nomenclature and this Differential diagnosis has to do with the definition of Korsakoff’s syndrome. In some texts this term is used to refer to any chronic amnestic the diagnosis of Wernicke’s encephalopathy should be disorder, regardless of cause. In this text, however, the term entertained in any malnourished patient who develops refers only to the chronic amnestic disorder that occurs as delirium; although from a diagnostic point of view it is a sequela to Wernicke’s encephalopathy. Clinical features Among alcoholics, consideration must also be given to delirium tremens, encephalopathic pellagra, and hepatic As noted in Section 13. Prominent tremor suggests delirium characterized by delirium with or without nystagmus and tremens, cogwheel rigidity points to pellagra, and myoclonus ataxia. In those who survive, the delirium gradually resolves suggests hepatic encephalopathy. These disorders, however, and patients may then be left with an amnestic disorder. They are typically able to carry encephalopathy may occur secondary to a cytomegalovirus on a conversation and may be reasonably sociable. Indeed, patients may not be Treatment able to recall a conversation they had with the physician just minutes before. A degree of disorientation to time and Whenever Wernicke’s encephalopathy is suspected, patients place inevitably accompanies this anterograde amnesia. Barring a severe degree of hypoglycemia, ent on asking patients about their lives before the food and glucose-containing fluids should be withheld for at Wernicke’s encephalopathy: answers often display a ‘temleast several hours. In questioning patients about recent events, and ataxia improve over a matter of days; maximum one often encounters the phenomenon of confabulation: improvement generally takes about a month. Thus, if a patient were asked whether he tion of Wernicke’s encephalopathy and its major sequela or she had ever met the physician before, the patient might Korsakoff’s syndrome, that governments have not manrespond in the affirmative and go on to talk about meeting dated the addition of thiamine to alcoholic beverages. The the physician at a local tavern the week before, where they results could be as spectacular as those that occurred when had a ‘few’ beers, played some pool, etc. Insomnia or hypersomnia may accomEtiology pany these changes (Abd El Naby and Hassanein 1965; Cook et al. As stressed above, Korsakoff’s syndrome occurs as a sequela the parkinsonism (Abd El Naby and Hassanein 1965; to Wernicke’s encephalopathy (Malamud and Skillicorn Calne et al. Cogwheelmediodorsal and anterior nuclei of the thalamus (Halliday ing is often seen and, although tremor may also be present, et al. The parkinsonism may also be accompanied by dystonia, often affecting the cervical musculature or the face. The most characterisDifferential diagnosis tic feature of manganese-induced parkinsonism is, however, a distinctive dystonic gait abnormality known as a As discussed in detail in Section 5. Here, patients walk on their metatarsophais one of the chronic anterograde amnesias that also have a langeal joints as if they were wearing high heels; at times, retrograde component and as such must be distinguished the elbows may be flexed, creating the overall appearance of from other disorders capable of producing such an amnethe walk of a rooster. When the history of an immediately preceding in anywhere from a small minority (Cook et al. Treatment Psychosis, known as ‘manganese madness’, may occur, and is characterized by excitation, hallucinations, and Some form of supervision is generally required and, in severe delusions (Abd El Naby and Hassanein 1965). With cessation of exposure, however, sonism, and, less commonly, a dementia or psychosis. A similar progression has been noted for the ‘cockintravenous total parenteral nutrition with manganesewalk’ (Huang et al. Clinical features Etiology the onset of symptoms is typically gradual, occurring after Neuronal loss and gliosis, although most prominent in the months or years of exposure, and patients may present globus pallidus, are also found in the putamen, the pars with a personality change, parkinsonism, or both (Abd El reticulata of the substantia nigra, the thalamus, hypothalaNaby and Hassanein 1965). Lacking a history of manganese exposure, the differential generally involves a consideration of other causes of Course parkinsonism, as discussed in Section 3. In this regard, special attention should be given to those disorders that Acute intoxications may be fatal in up to one-tenth of can cause a combination of parkinsonism and dystonia, cases. In those who survive, there is a gradual, more or less such as late-onset pantothenate kinase-associated neurocomplete recovery; in some cases there may be persistent degeneration, Wilson’s disease, corticobasal ganglionic cognitive deficits (which may be severe enough to produce degeneration, and progressive supranuclear palsy. The general treatment of personality change, dementia, Etiology and psychosis are outlined in Sections 7. If antipsychotics are required, consideration In acute cases there is cerebral edema, often with petechial should be given to second-generation agents, such as quehemorrhages; in more gradual onset cases, and in those tiapine, in an effort to avoid exacerbating parkinsonism. In the peripheral nerves axonal degeneration in high doses of up to 3 g or more daily [Mena et al. Differential diagnosis Manganese is stored in bone and has a long half-life, extending to 1 month or more. Although the role of chelatAcute cases may be confused with arsenic intoxication or, ing agents during the first few months is not established, when symptoms are confined primarily to a polyneurocase reports suggest their utility (Discalzi et al. The eventual appearance of severe alopecia, however, indicates the correct diagnosis. Since thalThallium undergoes enterohepatic recirculation and, conlium was banned as a rodenticide, current cases generally sequently, laxatives and activated charcoal should be given. Prussian blue binds to thallium in the gut, and this is part of standard treatment. Chelation therapy is contraindicated Clinical features as it may be followed by a deterioration in the patient’s condition (Wainwright et al. The onset of symptoms may be either acute or gradual, depending on the amount ingested. Within days or a week or so, patients develop nervous system toxicity, arsenic salts are toxic; with acute a delirium and a painful peripheral sensorimotor polyneuintoxication one may see a delirium, whereas with chronic, ropathy, which may progress to a quadriplegia. Arsenic salts are neuropathies, with facial palsy or ophthalmoplegia, may found in certain herbicides and rodenticides, and ingestion also develop, and, rarely, grand mal seizures may occur. Within 1–3 weeks patients then develop the most characteristic feature of thallium intoxication, namely a severe, generalized alopecia. Clinical features Gradual intoxication presents with dementia, a sensorimotor polyneuropathy, and alopecia; gastrointestinal sympAcute ingestion is followed rapidly by delirium (Freeman tomatology may or may not be present. Classically an acute onset of delirium, accompanied by myoclonus, there is also an odor of garlic on the breath. Hyperkeratosis of the palms and soles may occur, and Mees’ lines may Course appear, which are transverse white discolorations of the nails. Arsenic may be found in a 24-hour urine sample, and, within weeks of exposure, is also found in the hair and nails. Etiology Course In one autopsied case neuronal loss was noted among the Purkinje cells of the cerebellum and in the hippocampus Acute arsenic intoxication is often fatal. When the history of bismuth ingestion is lacking, the differential includes other deliria associated with myoclonus, Etiology as discussed in Section 3. In acute cases, widespread petechial hemorrhages within the white matter are seen (Hurst 1959; Russell 1937). Treatment Clinical features Acute intoxication is treated with gastric lavage, osmotic Delirium and seizures have been reported after intoxication diuresis, and intensive supportive care. Among patients who do survive tin intoxication, residual symptoms are common and may Clinical features be severe. With high dosage, there may be temporal cortex, amygdala, basal ganglia, and cerebellum p13.
Rogers studied motor disorders in 100 extremely chronic psychiatric in-patients blood glucose and triglycerides order precose canada, 59 women and 41 men labile diabetes definition buy generic precose on-line, with a mean length of current admission of 42 diabetes blood sugar levels precose 25mg free shipping. Ninety-two of these patients had had a diagnosis of schizophrenia at some time diabete and exercise purchase precose cheap online, and all of them showed some current motor disorder. Ninety-eight of these 100 patients had had motor disorder recorded prior to 1955, before there was any treatment with neuroleptic drugs. There was considerable variability between the type of motor disorder recorded before 1955 and observed currently. Disorder of eye movements, tone, gait and blinking were recorded less commonly in the past. Movement disorder in this group of patients was compared between those currently receiving neuroleptic drugs; those not treated for one month, one year or fve years; and those never having received medication. With the possible exception of facial movements, which were more frequent in those having received treatment in the past year, there was no difference in the frequency of abnormal movements. In addition to the description of abnormal movements above, overfow movements have been described. These are defned as involuntary movements that tend to accompany voluntary movements and are recognized as neurological soft signs and are thought to be characteristic of schizophrenia (D’Agati et al, 2012). Motor Disorder in Brain Disease the disturbance of basal ganglia resulting in parkinsonian symptoms has two main causes of relevance to psychiatry: Parkinson’s disease and symptoms secondary to exposure to psychotropic drugs. Some of the motor symptoms are similar in these two conditions, but the overall clinical picture differs. In Parkinson’s disease, as well as motor symptoms, there are often sensory, autonomic and psychiatric abnormalities. Parkinson’s original description in 1817 implied an absence of perceptual (as opposed to sensory) abnormality and does not comment on ‘psychiatric status’, which would then have been an unknown concept. Primary or secondary sensory abnormalities may occur, and there may be autonomic underor overactivity. However, the most conspicuous symptoms are in motor function: slowing of emotional and voluntary movement (Walton, 1985); muscular rigidity; akinesia; tremor; and disorders of gait, speech and posture. There is not necessarily any mental change; however, depression is very common (Mindham, 1970), intellectual deterioration may occur and personality disorder is sometimes associated. A graphic description of the symptoms and subjective experience of parkinsonism is given in Sacks’ account, Awakenings (1973). The extrapyramidal movement disorders produced by antipsychotic drugs are described in detail by Marsden et al. Akinesia varies from being mild in degree (dyskinesia), with an immobile, blank, expressionless face; limited movements with loss of such associated motor activity as the arms swinging when walking; and lack of spontaneity; to more severe and generalized absence of movement – this may start soon after beginning antipsychotic medication. Cogwheel rigidity and ‘pill rolling’ of the fngers, tremor of the hands or periorbital tremor may occur but are less common than akinesia. There is a subjective experience of motor unease, with a feeling of being unable to sit still, a need to get up and move about and to stretch the legs, tap the feet, rock the body (Box 18. Akathisia may occur at the same time as the akinesia of drug-induced parkinsonism and presents the contrasting state of a subjective urge to move and physical impairment of movement. In order to distinguish akathisia from other causes of inner restlessness, restlessness of the legs should be found to be especially prominent. Acute dystonic reactions include a variety of intermittent or sustained muscular spasms and abnormal postures. Dystonia has been defned as ‘a syndrome dominated by sustained muscle contractions, frequently causing twisting and repetitive movements, or abnormal postures’ (Fahn et al. Owens (1990) has considered the major clinical types of dystonia to be acute dystonias, oculogyric spasms, focal dystonias including torticollis, blepharospasm, writer’s cramp and other occupational dystonias, and laryngopharyngeal dystonia, segmental dystonias, generalized dystonia, drug-related (symptomatic) dystonias and psychogenic dystonia. The frequency of association of so called tardive dyskinesia, in which repetitive, purposeless movements of the facial muscles, mouth and tongue occur (sometimes with choreoathetotic limb movement and respiratory grunting) with exposure to psychotropic drugs is disputed. There is no doubt that faciobuccolinguomasticatory dyskinesia occurs in many chronic, especially elderly, psychotic patients on neuroleptic medication, but is it causally connected with drugsfi The word tardive is used, as the syndrome was considered to be a late consequence of drug treatment; however, there are cases described in patients who have never received neuroleptic drugs, and the precise relationship remains to be elucidated – it may be simply a late stage of the illness. In practice, the extrapyramidal symptoms secondary to medication are diffcult to evaluate and measure by severity – problematic in accounting for aetiologically but important in the satisfactory treatment of the patient. At a three year follow-up of psychiatric patients receiving antipsychotic medication, orofacial dyskinesia increased from 39 per cent to 47 per cent of the sample, with a few individuals developing the disorder anew and a few remitting (Barnes et al. There was an association between dyskinesia and age over 50 years and the presence of akathisia, but none with the use of antipsychotic drugs; in fact, those on high dosage were unlikely to have the condition. Huntington’s Chorea this is a hereditary condition, inherited as a Mendelian dominant, which manifests usually in early middle life and is characterized by choreiform movements and dementia. Dysarthria and disorders of gait can also occur before intellectual impairment develops. The progressive dementia, with inertia and apathy, may be accompanied by irritability and occasional outbursts of excited behaviour. Various psychological abnormalities have been described in the prodromal stage before manifestation of chorea and dementia. These may be anxiety, reactive depression and the features of personality disorder, especially antisocial behaviour. It is not known if this is truly an early symptom of the illness or part of the psychosocial reaction to this appalling and doom-laden condition. Tics and Gilles De La Tourette’s Syndrome Tics are rapid, repetitive, coordinated and stereotyped movements, most of which can be mimicked, and are usually reproduced faithfully by the individual (Macleod, 1987). In Gilles de la Tourette’s syndrome, multiple tics are accompanied by forced vocalizations that often take the form of obscene words or phrases – coprolalia (Lishman, 1997). The condition starts in childhood, under the age of 16; there are multiple motor tics and unprovoked loud utterances that may amount to shouted obscenities. The condition is more common in boys than in girls and usually starts between the ages of fve and eight with simple tics. The vocalizations usually begin as unrecognizable sounds but may progress to ‘four-letter’ swear words. The subject often tries desperately hard not to vocalize the word, and this may be accompanied by considerable anxiety. An interesting study compared adult sufferers with depressed adults and normal controls on measures of obsessionality, depression and anxiety (Robertson et al. Thus with parkinsonism, and to an even greater extent catatonic schizophrenia, an individual abnormal movement may be elaborated into an abnormal pattern of behaviour. Behavioural Disorders of Schizophrenia Disorder of movement is characteristic of catatonia, in which the patient may become immobilized in one attitude because of increased muscle tone at rest; it is usually seen in schizophrenia but has been described with frontal lobe tumour and some other organic conditions. There are abnormalities of posture and of movement, frequently shown in the actions made in relation to another person – the interviewer. Thus, in waxy fexibility the posture of the limbs is so described because it is maintained indefnitely after being manipulated into that attitude by the observer. Behaviour, the composite of movements, may also be abnormal, and this is characteristic of catatonic schizophrenia, with more than just one isolated abnormality of posture. It has often been commented that the incidence of catatonic schizophrenia has markedly declined. However, Mahendra (1981) has queried the existence of catatonic schizophrenia as a condition with classic Kraepelinian schizophrenic features and catatonia in the same patient. He believes many of the patients with catatonia suffered from neurological disease, perhaps postencephalitis, following epidemic and endemic viral infections. If this were so, the presumed association between schizophrenia and catatonia was accidental. One could make a vast catalogue of the bizarre, and sometimes unpleasant, behaviour demonstrated by patients with chronic schizophrenia, but this would never be exhaustive. The patient is mute and akinetic, although from the alertness of the eyes and the occasional excursion into abrupt activity or speech he is clearly conscious. It can be distinguished from depressive or manic stupor by the obvious abnormalities of mood in the stupor of the affective psychoses. A patient with schizophrenia sat mute and motionless with her arms held in stereotyped, twisted posture for hours at a time. This symptom is almost never seen nowadays with adequate treatment of schizophrenic symptoms.
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Eine ahnliche Argumentation findet sich im Streitgesprach zwischen Singer und dem Philosophen Wingert (2000 gestational diabetes diet video discount precose 50 mg without prescription, S can you cure diabetes in dogs order precose 25mg fast delivery. Dort wird auch die entstellende Reduzierung kommunikativer Prozesse auf den Dialog von Gehirnen vermieden diabetes type 2 in older adults order discount precose online, wenn es heifit: „Die Hirnforschung kann nachvollziehen blood sugar questionnaire discount precose 25 mg otc, wie sich nach der Geburt die kognitiven Strukturen eines Kindes an die reale Welt und an das kulturelle Umfeld anpassen und von ihr geformt werden. Am Ende kommt ein Wesen heraus, das ab einem Alter von drei bis vier Jahren ‚Ich‘ sagt, ein Bewusstsein und einen eigenen Willen entwickelt – Phanomene, die in der naturwissenschaftlichen Beschreibung eigentlich nicht mehr drin sind“ (Singer, 2000, S. Singers Argumente bringen den Hirnforscher mit dem Philosophen und den Psychoanalytiker unter ein Dach: Sobald namlich der Naturwissenschaftler das Gehirn im menschlichen Lebenskreis betrachtet, verschieben sich die Abhangigkeitsverhaltnisse zugunsten des Einflusses von Poppers seelisch-geistiger Welt Zwei und Welt Drei. Unter dem Gesichtspunkt der psychosozialen Selbsterhaltung wird das Gehirn in einen Funktionskreis einbezogen, der Plastizitat voraussetzt und die Frage der Korrelation aus der monadischen Isolation 113 befreit. Das gesunde Gehirn ist zwar Herr im eigenen Haus, und unser Ich-Gefuhl ist in der abhangigen Position, aber zu neurobiologischer Selbstherrlichkeit besteht kein Grund: Das Gehirn steht im Dienste der Losung phylogenetischer und ontogenetischer Lebensprobleme und wird seinerseits von psychosozialen Bedingungen geformt. Die Abhangigkeit zerebraler Funktionen von Lernprozessen wird besonders eindrucksvoll durch folgendes Beispiel bewiesen: Der Ophtalmologe von Senden (1932) hat schon vor langer Zeit nachgewiesen, dass fruh erblindete oder aufgrund eines peripheren Defektes blind geborene Sauglinge bei voll funktionsfahiger Hirn-Sehrinde oft ihre Sehkraft nicht mehr erwerben konnen, wenn die lokale Ursache operativ zu spat das heifit etwa nach Schuleintritt beseitigt wurde. Die jahrelang funktionslose Hirnrinde ist sozusagen lernunfahig geworden (siehe hierzu Singer, 1994, S. Spitz (1974) hat diesen Befund aus der Sicht der analytischen Entwicklungspsychologie ausfuhrlich kommentiert. Die bahnbrechenden Untersuchungen von Spitz fielen noch in die Zeit verbreiteter Ablehnung psychoanalytischer Annahmen uber die fruhe Atiologie seelischer Storungen. Umso bemerkenswerter ist es deshalb, wenn nun durch neurobiologische Forschungen der Einfluss fruhkindlicher Erfahrungen auf die Reifung des Gehirns und auf die fruhe Entstehung seelischer Storungen bestatigt wird. Braun und Bogerts (2000) fassen viele Befunde zusammen, die die Hypothese unterstutzen, dass Erkrankungen wie neurotische Fehlentwicklungen, Personlichkeitsstorungen, aber auch dissoziales Verhalten ihren Ausgangspunkt in einer Storung von fruhkindlichen Erfahrungsund Lernprozessen und der damit verbundenen synaptischen Reorganisationsprozesse haben. Dies stutzt Beobachtungen, die bereits vor hundert Jahren von der Psychoanalyse und der Verhaltenstherapie auf psychodynamischer bzw. Die Aufklarung lebensgeschichtlich bis in die Kindheit zuruckreichender Lernprozesse ist nicht ihre Domane. Als Psychoanalytiker habe ich grofien Respekt vor den neurobiologischen „Constraints“ und nehme zugleich auch personlich entlastet zur Kenntnis, dass die moderne Forschung dem adulten Gehirn eine gewisse Plastizitat zuschreibt. Meine langjahrigen therapeutischen Erfahrungen haben mich gelehrt, dass Veranderungen unbewusster Schemata, die das Erleben und Verhalten bestimmen, ihre Zeit brauchen. Braun und Bogerts haben allerdings von der Psychoanalyse ein Bild, das seit den zwanziger Jahren des 20. Die beiden Autoren sprechen von Analytikern, die angeblich glauben, durch alleiniges Bewusstmachen tatsachlicher oder vermeintlicher verdrangter Konflikte die synaptischen Netzwerke der Hirnfunktion nachhaltig bessern zu konnen. Auch wenn uber die therapeutische Wirksamkeit solcher Verfahren bei bestimmten Indikationen berichtet wurde, durfte nicht selten eine erhebliche Diskrepanz zwischen therapeutischem Anspruch und dem bestehen, was aus neurobiologischer Sicht realisierbar ist. Die mit steigendem Lebensalter dramatisch nachlassende Synapsenplastizitat lasst spater nur relativ geringe Korrekturmoglichkeiten eines fehlentwickelten neuronalen Netzwerkes zu. Man kann nur hoffen, dass es nicht nochmals ein Jahrhundert dauert, bis der interdisziplinare Austausch allseitigen Bildungsmangel behoben hat. Entgegen seiner dezidierten Stellungnahme zugunsten einer Einheitssprache kann der Philosoph Herbert Feigl nicht umhin, „reasons as causes“ und damit im Prinzip psychoanalytische Erklarungen seelischer Verursachung somatischer Prozesse, also einer Erklarung von oben nach unten, anzuerkennen: Any solution of the mind-body problem worth consideration should render an adequate account of the efficacy of mental states, events, and processes in the behavior of human (. The correspondence rules in the unitary language would ultimately be statements of fi – fi correlations, i. Since precise knowledge of these correlations is only a matter of hope for a future psychophysiology, the unitary language is largely in the ‘promissory note’ stage. If this requires n-tuples of numbers, then simple expressions like ‘17–9–6–53–12’ (or even abbreviatory symbols for these) might be inculcated in the child’s language. If we took care that these expressions take the 116 place of all introspective labels for mental states, the child would immediately learn to speak about this own mental states in the language of neurophysiology. Of course, the child would not know this at first, because it would use the expression. But having acquired this vocabulary, the child, when growing up and becoming a scientist, would later have no trouble in making this terminology coherent with, and part of, the conceptual system of neurophysiology. Aus psychoanalytischer Sicht wird hierbei die unbewusste Sehnsucht nach Uberwindung aller Unterschiede wirksam. In der Einheitssprache ware das Paradies in die Zukunft projiziert, und der Sundenfall, der auch zur babylonischen Sprachverwirrung fuhrte, ware aufgehoben. Ich fasse zusammen: Freud hat die seelische Entstehung irrationaler, neurotischer Angste in wesentlichen Punkten aufgeklart. Seine Neigung zu materialistischen Erklarungen behinderte die Entwicklung der psychoanalytischern Methode als einer tiefenpsychologischen. Am Beispiel des Angstanfalls, der heute als Panikattacke bezeichnet wird, demonstrierte ich die negativen theoretischen und therapeutischen Konsequenzen von Freuds materialistischer Position. Seiner Zeit verhaftet, konnte sich auch Freud der faszinierenden monistischen Utopie nicht entziehen und erwartete sogar, dass durch die Fortschritte der Biologie eines Tages psychoanalytische Hypothesen „umgeblasen“ wurden und durch physiologische und chemische Termini die Menge psychoanalytischer Umschreibungen verschwinden wurden (Freud, 1914, S. Als Methodiker war Freud zugleich zum Gluck Dualist, sonst gabe es keine psychoanalytische Praxis mit einer eigenstandigen Methodik. Durch die Entwicklung der psychoanalytischen Methode in den letzten Jahrzehnten, die von der biologischen Psychiatrie und von der Verhaltenstherapie kaum rezipiert wird, konnte die Panikattacke als neurotische Angst 117 verstanden werden. Damit kann die Psychogenese aller psychopathologischen Angste vom Angstanfall bis zur sozialen Phobie einer allgemeinen Theorie subsumiert und fur die verschiedenen Syndrome differenziert ausgearbeitet werden. Als Therapie hat die psychoanalytische Methode anhand neuer Erkenntnisse uber die Transformation frei flottierender Angst in konkrete interaktionell entstandene Furcht Dimensionen hinzugewonnen, deren Berucksichtigung den therapeutischen Erfolg erheblich erhoht. Dass man als Hirnforscher und Psychiater der Seele den ihr gebuhrenden Raum lassen kann, hat Eric Kandel schon 1983 gezeigt. Gewiss kann man in Frage stellen, ob die Stressexperimente mit seinem „pet animal“, der Meeresschnecke Aplysia, sich in Analogie zu neurotischen Angsten setzen lassen. Entsprechend stellt er eine seiner Veroffentlichungen (1999) unter das Motto der oben erwahnten Worte Freuds (1914; 1920), die eine materialistische Position kennzeichnen. Aber Kandels Fragen und Antworten lassen dem Erleben und dem Lernen im weiteren Sinn und dessen Auswirkungen auf das Gehirn den notigen Spielraum, wie den folgenden Zitaten zu entnehmen ist: Can experience lead to enduring structural changes in the nervous systemfi Do these structural changes involve alteration of gene expression, and, if so, is psychotherapy successful only when it induces such changesfi Er hat diese und andere Fragen folgendermafien beantwortet: I have suggested that normal learning, the learning of anxiety and unlearning it through psychotherapeutic intervention, might involve long-term functional and structural changes in the brain that result from alterations in gene expression. Thus, we can look forward, in the next decade of research into learning, to a merger between aspects of molecular genetics and cellular neurobiology. This merger, in turn, will have important consequences for psychiatry – for psychotherapy on the one hand and for psychopharmacology on the other. Soweit neurophysiologische Veranderungen in der Amygdala bei Angstsyndromen zu finden sind, handelt es sich nicht um deren Ursache, sondern um die Folge einer neurophysiologischen Anpassung an die standige subliminale Wahrnehmung von Gefahren. A study in experimental and social psychology, Cambridge: Cambridge University Press, Reprint 1977 Basoglu, M. Psychische Schaden als Folge der Trennung von Mutter und Kind, Munchen: Kindler Brakel, L. Eine Ubersicht zur Kombinationsbehandlung bei neurotischen und Personlichkeitsstorungen“, in: Psychotherapeut 43, S. Kritische Beitrage zur Behandlungskonzeption und Technik in der Psychoanalyse, Frankfurt am Main: Fischer Thoma, H. Dabei werden diese Sorgen und Angste von den Patienten als schwer kontrollierbar erlebt. Sie fuhren zu einer deutlichen Beeintrachtigung des Lebens der betroffenen Personen. Die Generalisierte Angsterkrankung ist demnach in der Primarversorgung eine der haufigen Storungen. Zwei Drittel der Patienten mit dieser Angsterkrankung sind weiblich (American Psychiatric Association, 1994). Das durchschnittliche Ersterkrankungsalter fur die Generalisierte Angsterkrankung liegt zwischen dem zwanzigsten und dreifiigsten Lebensjahr. Patienten mit diesem Leiden geben jedoch oftmals an, schon in der Kindheit und Jugend angstlich, schreckhaft und nervos gewesen zu sein. Etwa 66 Prozent der Patienten, die Generalisierte Angsterkrankung als primare Diagnose erhalten, weisen aktuell weitere Achse-I-Storungen auf (Wittchen et al. Dabei sind affektive Storungen, Panikerkrankungen und Agoraphobien sowie Abhangigkeitserkrankungen die haufigsten Zusatzkomplikationen. Etwa 49 Prozent der Patienten mit Generalisierter Angsterkrankung erfullen zusatzlich Kriterien fur die Diagnose einer Personlichkeitsstorung (Sanderson et al. Da Patienten mit Generalisierter Angsterkrankung im Vergleich zu Patienten mit Panikerkrankungen seltener und erst sehr spat professi128 onelle Hilfe suchen (Shores et al. Dreizehn Prozent der Patienten mit Generalisierter Angsterkrankung berichteten in dieser Studie von einem Suizidversuch im Vergleich zu sechs Prozent der Panikpatienten.
The following causes of secondary polycythaemia must be excluded: • chronic lung disease with hypoxia • cyanotic congenital heart disease • renal cysts diabetes type 1 urinary tract infection purchase precose 50 mg overnight delivery, tumours diabetes pathogenesis of type 2 diabetes mellitus order precose 25 mg with mastercard, renal transplants • hepatoma early signs diabetes feet generic 50mg precose fast delivery, cerebellar haemangioblastoma diabetic diet 2000 calories buy precose 25mg amex, uterine fibroids • Cushing’s disease. The erythropoietin level is low in polycythaemia rubra vera and high in secondary polycythaemia. The leucocyte alkaline phosphatase level is also raised in polycythaemia rubra vera. The patient should be venesected until the haematocrit is within the normal range. A variety of agents can be used to keep the haematocrit down: 32P, hydroxyurea and busulphan. The symptoms have been present for 2 months and have increased slightly over that time. He had noticed some skin lesions on the edge of the hairline and around his nostrils. Previously he had been well apart from an appendicectomy at the age of 17 years. Examination There is no deformity of the joints and no evidence of any acute inflammation. In the skin there are some slightly raised areas on the edge of the hairline posteriorly and at the ala nasae. The age is typical and sarcoidosis is more common in those of African-Caribbean origin. The blood results show a slightly raised calcium level which is related to vitamin D sensitivity in sarcoidosis where the granulomas hydroxylate 25-hydroxycholecalciferol to 1,25dihydroxycholecalciferol. The skin lesions at the hairline and the nostrils are typical sites for sarcoid skin problems. The eye trouble 6 weeks earlier might also have been a manifestation of sarcoidosis, which can cause both anterior and posterior uveitis. Tuberculosis can also cause hypercalcaemia although this is much less common than in sarcoid. Tumours, especially lymphoma, might give this X-ray appearance but would not explain the other findings. The arthralgia (pains with no evidence of acute inflammation or deformity on examination) can occur in sarcoid or tuberculosis but again they are commoner in sarcoid. The serum level of angiotensin-converting enzyme would be raised in over 80 per cent of cases of sarcoidosis but often in tuberculosis also; the granuloma cells secrete this enzyme. A bronchial or transbronchial lung biopsy at fibreoptic bronchoscopy would be another means of obtaining diagnostic histology. In patients with a cough and sarcoidosis the bronchial mucosa itself often looks abnormal, and biopsy will provide the diagnosis. Steroid treatment would not be necessary for the hilar lymphadenopathy alone, but would be indicated for the hypercalcaemia and possibly for the systemic symptoms. She also has a persistent frontal headache associated with early morning nausea. Eight years previously she had a left mastectomy and radiotherapy for carcinoma of the breast. She is a retired civil servant who is a non-smoker and drinks 10 units of alcohol per week. Her pulse rate is 72/min, blood pressure 120/84 mmHg, jugular venous pressure is not raised, heart sounds are normal and she has no peripheral oedema. It is more likely that she has polyuria due to neurogenic diabetes insipidus as a result of secondary metastases in her hypothalamus. The hypercalcaemia and raised alkaline phosphatase are suggestive of bony metastases secondary to her breast carcinoma. The recent-onset headache, worsened by coughing and lying down and associated with vomiting is characteristic of raised intracranial pressure, which is confirmed by the presence of papilloedema. In some tumours around the pituitary there may be compression of the optic nerve causing visual field abnormalities. The remaining causes are neoplastic, infectious, inflammatory (granulomas), traumatic (neurosurgery, deceleration injury) or vascular (cerebral haemorrhage, infarction). Patients with central diabetes insipidus typically describe an abrupt onset of polyuria and polydipsia. A water-deprivation test should be performed in this patient, measuring the plasma sodium, urine volume and urine osmolality until the sodium rises above 146 mmol/L, or the urine osmolality reaches a plateau and the patient has lost at least 2 per cent of body weight. An increase in urine osmolality #50 per cent indicates central diabetes insipidus and! She should be referred to an oncologist for treatment of her metastatic carcinoma. Otherwise, examination of his cardiovascular, respiratory, abdominal and neurological systems is unremarkable. The high gamma-glutamyl transpeptidase level is compatible with liver disease related to a high alcohol intake. Commonest glomerular causes of microscopic haematuria • Immunoglobulin A (IgA) nephropathy • Thin basement membrane disease • Alport’s syndrome (predominantly affects males) IgA nephropathy is the commonest glomerulonephritis in developed countries, and is characterized by diffuse mesangial deposits of IgA. Patients often have episodes of macroscopic haematuria concurrent with upper respiratory tract infection. Most cases of IgA nephropathy are idiopathic, but this it is also commonly associated with Henoch–Schonlein purpura and alcoholic cirrhosis. About 20 per cent of patients with IgA nephropathy will develop end-stage renal failure after 20 years of follow-up. Thin basement membrane disease is a familial disorder which presents with isolated microscopic haematuria, minimal proteinuria and normal renal function that does not deteriorate. Electron microscopy shows diffuse thinning of the glomerular basement membranes (the width is usually between 150 and 225 nm versus 300–400 nm in normal subjects). Alport’s syndrome is a progressive form of glomerular disease, associated with deafness and ocular abnormalities and is usually inherited as an X-linked dominant condition so that males are more seriously affected. As the patient is over 50 years old he should have urine cytology/prostate-specific antigen/cystoscopy performed to exclude concurrent bladder and prostatic lesions. The patient should be advised to abstain from alcohol, and needs his blood pressure controlling. He needs regular follow-up as he is at risk of progressing to dialysis and/or renal transplantation. The raised creatinine appears modest in terms of the actual figures, but as plasma/serum creatinine does not begin to rise until the glomerular filtration rate is reduced to 50 per cent of normal (irrespective of the patient’s age), the raised creatinine in this case indicates a serious loss of renal function to approximately 40 per cent of normal. There is no convincing evidence for immunosuppression retarding the progression into renal failure in most patients with IgA nephropathy. This has been associated with a decrease in appetite and an increasing problem with vomiting. During the last month he has noticed some weakness, particularly in his legs, climbing hills and stairs. He is a smoker of 20 cigarettes per day and drinks around 10 units of alcohol each week. His past medical history consists of hypertension which was treated for 2 years with beta-blockers. There are no abnormalities to find on examination of the cardiovascular and respiratory systems. There are no masses to feel in the abdomen and no tenderness, but a succussion splash is present. This would be compatible with vomiting of residual food some time after eating and the succussion splash from the retained fluid and food in the stomach. In compensation, hydrogen ions are retained by exchange for potassium in the kidney and across the cell membranes, so leading to hypokalaemia, and carbonic acid dissociates to hydrogen ions and bicarbonate. The hypokalaemia indicates a considerable loss of total body potassium, which is mostly in the skeletal muscle, and explains the patient’s recent weakness. The most likely cause would be a carcinoma of the stomach involving the pyloric antrum and producing obstruction to outflow. A chronic gastric ulcer in this area could produce the same picture from associated scarring, and gastroscopy and biopsy would be necessary to be sure of the diagnosis.