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By: S. Thorek, M.B. B.CH. B.A.O., M.B.B.Ch., Ph.D.
Clinical Director, Virginia Tech Carilion School of Medicine and Research Institute
His problems and course in summary: Bipolar disorder: the patient was diagnosed with bipolar disorder in New York City several years ago anxiety quitting smoking purchase phenergan 25 mg without a prescription. He reports greater than 20 years of episodic severe depression anxiety genetic cheap phenergan online master card, alternating with periods of feeling invincible and starting big projects anxiety symptoms breathlessness purchase discount phenergan online. Symptoms of his disorder include anxiety with severe panic attacks, many losses including failed relationships, lost friendships, homelessness, and severe interference with his career. He reports episodes of using alcohol to blunt his feelings of irritability, depression, and anxiety. He reports being told that he might need medications to stabilize his mood but never took these nor believed he needed them. Initial attempts at prescribing Valproate (Depakote) to him were unsuccessful due to his perception of side effects. Most recently he has been restarted on Valproate which he has tolerated since he has been abstaining from alcohol. His poor insight and the presence of a co-occurring narcissistic personality style or disorder have complicated his psychiatric care. Musculoskeletal complaints: the patient reports a history of problems with his back, extremities, and "diaphragm" which result from his years as a dancer. He has received various therapies in the past for these and reports he can no longer dance professionally due to his pain but otherwise copes with his chronic pain. Alcoholism: the patient has a history of drinking in an excessive and uncontrollable manner. He has required several episodes of medically supported detoxification while under my care. He participated in a residential rehab program at Baker Places and was abstinent for 3 months but continued to have severe psychiatric symptoms and relapsed soon after completing the program. He has abstained from alcohol since that time and reports he has had 13 years of sobriety between 1989 and 2002 and feels he has the tools to do this again especially if his underlying psychiatric issues are stabilized. These do not seem to be caused by any underlying severe disorder but reflect somatization of his underlying psychiatric disorders. Observation of him during periods of abstinence strongly suggests that his psychiatric disorder is the primary diagnosis. He has been unable to engage in any Substantial Gainful Activity during the period of time I have been treating him. At times he has embarked on volunteer work or started planning for large projects but has been unable to follow through with these commitments. With continued treatment he has a guarded chance of recovery and improvement but I would expect this to require several years of adherence with medications, psychotherapy, and abstinence from alcohol. He has attempted paid or volunteer work a few times in the past year but these have ended quickly due to his inability to maintain psychiatric stability. He has had good adherence and reports the medication helps avoid what he describes as his manic episodes. He still has episodes of severe depression which have triggered relapses to drinking alcohol several times over the past 4 months. He has had less episodes of panic attacks in the past year but continues with occasional (about once a month) very debilitating panic and daily anxiety effecting his ability to function. He has had several referrals and episodes of treatment in the mental health system since the last report. He has also had conflict and increased stress related to his attempts to return to working as a ballet instructor. He was apparently accused of some type of inappropriate behavior toward a young student. These conflicts and difficulties are consistent with his diagnosis of narcissistic personality disorder. Unfortunately no psychotherapy has been effective as of yet in helping the patient cope with this problem. In the past 6 weeks the patient has had at least 6 emergency room visits due to feelings of severe depression, anxiety, and suicidal behavior or ideations. The patient is socially very isolated at this time and is markedly impaired in this area. Musculoskeletal complaints: the patient continues with complaints of back and joint pain.
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- Bindewald Ulmer Muller syndrome
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There are hundreds of studies on soy and dozens on hot flashes anxiety quotes order 25mg phenergan otc, some showing effect and others not anxiety symptoms 37 purchase generic phenergan from india, making it difficult to anxiety oils generic phenergan 25mg online make conclusions. The first systematic study was a review of the literature for the randomized controlled clinical trials on soy and perimenopausal symptoms. There were no serious safety concerns with soy products for the treatment periods, which were up to six months. In the second systematic review, 25 trials involving approximately 2,300 women met the study criteria. Only one soy food trial and two soy extract trials showed the ability to reduce hot flushes. The final report comes from a consensus opinion of the North American Menopause Society,31 which acknowledges that some data does support the efficacy of isoflavones in reducing the incidence and severity of hot flashes but that many studies have not found any difference. It also concluded that there was not adequate data to evaluate the effect of isoflavones on breast and other cancers, bone mass, and vaginal dryness but that there were convincing health benefits of isoflavones and lipids in reducing low-density lipoproteins and triglycerides and increasing high-density lipoproteins. Perhaps the best evidence that soy lowers cholesterol comes from a review of 38 scientific studies. For some women, and this has been borne out in some studies, soy protein and soy isoflavones can be helpful in reducing the frequency and severity of hot flashes. For the specifics in regard to bone effects and cardiovascular effects, please refer to the osteoporosis and heart disease chapters. If you choose to increase soy foods or take soy beverages, powders, or supplements, a word about dosages and addressing some of the highly publicized controversies about soy is important. A reasonable approach would be to ingest a daily level of isoflavones that does not exceed the amount consumed in ethnic diets that contain high amounts of isoflavones. From a review of those diets, it appears that this amount is somewhere between 50 to 150 mg of isoflavones per day for adults. A listing of the isoflavone content of some of these soy foods will offer some help in calculating your daily intake (see Table 12. There have been some controversies about soy, and based on the actual research, these negTable 12. Some have pointed out problems with thyroid function, inhibition of mineral and protein absorption, and concerns about hormonal effects. Some of the controversy about soy lies not only in its ability to bind to estrogen receptors but in its content of phytates and trypsin inhibitors, interference with thyroid function, and difficult digestibility for some individuals. Soy foods, especially cooked soybeans, are difficult for some people to digest, causing gas and stomach upset. However, many researchers believe that so few trypsin inhibitors are left behind after processing the soy food that for most people, their digestion is not affected. The phytate content in soybeans has been another cause for concern with soy foods. Phytates are compounds found in grains and legumes that can compete with the uptake of minerals such as calcium, magnesium, iron, and zinc. If you eat soy products in the context of a healthy, varied diet, you should get adequate minerals. This problem is not likely to occur with an average amount of soy in the diet and again in the context of a healthy, varied diet, especially a diet that is adequate in iodine, which is now mostly the case in this country. In some susceptible individuals, or in some who take very high doses of nutritional supplementation of soy isoflavones (above 200 mg per day) or have an extreme diet low in other nutrients and high in soy, it is prudent to be aware of potential but extremely rare problems with soy ingestion. One of the greatest fears for women contemplating menopause treatment options is the concern about estrogen replacement therapy and breast cancer. Although we will be addressing this in the hormone and conventional medicine sections of this chapter, there are several lines of evidence and logic that support the conclusion that not only is soy safe, but there is actually a relationship between increased soy intake and breast cancer prevention. Several studies concluded that Asian women who consume a traditional low-fat, high-soy diet have a four- to sixfold lower risk of developing breast cancer. The most comprehensive review of the literature on soy and its effects on the breast comes from a paper citing over 280 references. The authors concluded that moderation in intake is probably wise and should mimic the Asian soy intake of one to two servings per day. Doubts as to the significance of the breast cancer protective effects of soy and the safety of soy will remain until there has been a prospective study on soy comparing women on a high-soy diet with women on a low-soy diet over the span of many years with identical risk factors in other areas.